Every finding on record at Salem Springlake Health & Rehabilitation Center

Based on observation, interview and review of the facility policy, the facility failed to store, label and date food in accordance with professional standards for food service safety. The findings include: Review of the facility policy titled, Storage Procedures, revised 01/2025 revealed, refrigeration equipment was to be routinely cleaned and defrosted, foods should be covered and dated, leftovers were to be refrigerated immediately and used within five (5) days with a used by date clearly marked. Continued policy review revealed, Individual frozen supplements must be dated if being stored in refrigerators on designated nurses' stations kitchen refrigerator. Observation of the Nutritional Room refrigerator located on the 100 hall, on 09/24/2025 at 1:40 PM, with Registered Nurse (RN) 1, revealed a peanut butter and jelly sandwich that was not labeled or dated, and the bread was hard. Continued observation revealed a loosely wrapped, partially eaten restaurant sandwich, not labeled or dated, a bagged meal from a fast-food restaurant with a receipt dated 09/16/2025. Further observation revealed a plastic container of leftover food, not labeled or dated; three bottles of coconut water with an expiration of July 2025; and eight Magic Cups (frozen nutritional supplement), that were melted, and not labeled or dated. In interview with the Dietary Manager (DM) on 09/26/2025 at 11:30 AM, she stated she and the DON were responsible for the nutrition room. She said she tried to check the nutrition room refrigerator weekly; however, did not do it as much as she should. The DM further stated items stored in the refrigerator should have been labeled and dated when stored there.During interview with the Director of Nursing (DON) on 09/26/2025 at 11:42 AM, she stated the DM and herself were responsible for checking the refrigerator in the nutrition room. She said the refrigerator had not been checked daily. The DON further stated she expected items stored in the refrigerator to be labeled and dated. During interview with the Administrator on 09/26/2025 at 12:30 PM, she stated she expected the refrigerator in the nutrition room to be checked daily as required. She further stated any food items not labeled or dated were to be discarded.

Based on observation, interview and review of facility policy, it was determined the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. for five (5) of fourteen (14) sampled residents(Resident #8, Resident #23, Resident #38, Resident #42 and Resident #203). Observation of a dinner meal in the dining room, on 12/04/2023, revealed Unit Manager #1 was standing over Resident #8 as she provided feeding assistance. Additionally, observations of Resident's #42, #23, #38, and #203, revealed staff failed to ensure the resident's bare bodies were not exposed to others. The findings include: Review of the facility's policy, Resident Rights, updated 09/20/2022, revealed it was the policy of the facility to ensure residents had the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside of the facility. Review of the facility's policy, Privacy, Dignity, and Confidentiality, dated 01/2011 and reviewed 01/2022, revealed residents had the right to privacy with whomever the resident desires. The resident had the right to personal privacy, which included accommodations, medical treatment, written and telephone communication, personal care, visits, and meetings of the family and resident groups. 1. Review of Resident #42's Admission Record revealed the facility admitted Resident #42 on 08/31/2023 with diagnoses which included Cerebral Infarction due to Unspecified Occlusion of the Cerebral Artery, Aphasia, and Hemiplegia/Hemiparesis following Cerebral Infarction. Review of Resident #42's Admission Minimum Data Set (MDS) Assessment, dated 09/05/2023 revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of six (6) of fifteen (15), indicating Resident #42 had severe cognitive impairment. Observation of Resident #42 on 12/05/2023 at 11:18 AM, revealed his/her door was open, and he/she was laying in bed and had no sheet or blanket covering him/her. Resident #42's legs were exposed. Further observation revealed Resident #42's gown was not in place causing his/her brief to be visible to others. During an interview with Certified Nurse Aide (CNA) #3 on 12/06/2023 at 10:40 AM, she stated Resident #42 would often remove his sheet or blanket. She stated they usually kept the door pulled closed. CNA #3 further stated it could be a dignity issue if a resident was exposed. 2. Review of Resident #8's Admission Record revealed the facility admitted the resident on on 05/28/2021 with diagnoses which included Alzheimer's, Dementia, and Hypertension. Review of Resident #8's Quarterly Minimum Data Set (MDS) Assessment, dated 11/03/2023, revealed a the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of ninety-nine (99), indicating that Resident #8 was unable to complete the assessment. Further view of the MDS assessment, Section GG, revealed Resident #8 was a dependent dinner. Observation of a dinner meal in the dining room, on 12/04/2023 at 5:15 PM, revealed Unit Manager #1 was standing over Resident #8 as she provided feeding assistance to the resident, while he/she was seated. In an interview with the Unit Manager #1 on 12/06/2023 at 10:28 AM. she stated she was not aware that standing while feeding a resident was a dignity issue. She stated she was in a standing position so that she could observe the other residents in the dining room. 3. Review of Resident #38's Admission Record revealed the facility admitted the resident on 10/27/2022, with diagnoses which included Diabetes Mellitus, Atrial Fibrillation, and Depression. Review of Resident #38's Annual Minimum Data Sets (MDS) Assessment, dated 2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of ten (10) of fifteen (15), which indicated the resident was interviewable. Observation of Resident #38 on 11/29/2023 at 2:20 PM, revealed his/her door was open, and he/she was lying in bed with no clothing or blanket covering his/her body. 4. Review of Resident #23's Admission Record revealed the facility admitted the resident on 11/23/2018 with diagnoses which included Gastroesophageal Reflux Disease (GERD), Dementia, and Depression, Review of Resident #23's Quarterly Minimum Data Sets (MDS) Assessment, dated 11/01/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of two (2) of fifteen (15), which indicated severe cognitive impairment. Observation of lunch meal pass, on 12/05/2023 at 12:05 PM, revealed Certified Nurse Aide (CNA) #3, and CNA #2 passing lunch meal trays to resident's rooms. Further observation revealed Resident #23 who had a BIMS of two (2) and required feeding assistance, had his/her meal tray left on the bedside table while staff continued to pass other residents' food trays. In an interview with CNA #3, on 12/05/23 at 12:10 PM, she stated it had been normal practice for Resident #23's meal tray to be left on bedside table until assistance was provided. She stated had not been aware that the meal tray should be left on the enclosed cart until staff were ready to assist the resident. In an interview with CNA #2, on 12/05/23 at 12:15 PM, she stated she not aware the tray should not be left on the food cart to keep it warm until staff were ready to assist the resident. She further stated she would ensure that did not happened again. 5. Review of Resident #203's Admission Record revealed the facility readmitted the resident on 07/18/2023, with diagnoses which included Unspecified Dementia, Psychotic Disturbance, and Anxiety. Review of Resident #203's Quarterly Minimum Data Sets (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of three (3) of fifteen (15) indicating the resident was not interviewable. Observation on 12/05/2023 at 11:01 AM and 12/07/2023 at 11:54 AM, revealed Resident #203's door was open, the resident was laying in bed asleep. Resident #203 was wearing a T-shirt and a brief, with only a sheet covering his/her feet, leaving his/her body exposed to others. During an interview with Registered Nurse (RN) #5 on 12/06/2023 at 12:12 PM, she stated residents should be covered in a dignified way at all times and if she saw a resident with a body part exposed, she would ask the resident if she could cover them with a blanket or close their door. In an interview with the Director of Nursing ( DON), on 12/08/023 at 3:50 PM, she stated staff were expected to cover residents with a blanket, or ask to pull the curtain, and check room temperatures, prior to exiting the resident's room, if they were exposed to others. She further stated staff could only close the door if residents had permitted them to close it. The DON stated staff should assist resident's with their meal trays timely. In an interview with the Administrator, on 12/08/2023 at 4:15 PM, she stated staff were expected to honor resident rights and dignity always. She further stated if a Residen were uncovered, she would expect staff to cover the resident or at least pull the curtain to ensure they were not exposed. Additionally, the Administrator stated all residents should be served at the same table at the same time, and no meal tray should be dropped off in resident's room until staff were ready to assist them with the meal. 45914 47798

Based on observation, interview, record review and review of facility policy, it was determined the facility failed to revise the care plan following a significant weight change for four (4) of fourteen (14) sampled residents (Resident #22, Resident #42, Resident #18 and Resident #203). Review of Resident #22's, #42's, #28's, and #203's care plans revealed the care plans were not revised to include interventions for weight loss and supplements. The findings include: Review of the facility policy titled, Resident Assessment Comprehensive Care Plans, updated on 05/24/2022, revealed the facility would develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet a residents medical, nursing and mental and psychosocial needs, that were identified in the comprehensive assessment. Continued review revealed that the comprehensive care plan must describe the residents medical, nursing, physical, mental and psychosocial needs and preferences on how the facility would assist in meeting those needs and preferences. The care plan must reflect interventions to enable each resident to meet their objectives. The care plan must reflect changes in the residence preferences and goals as they change throughout their stay. Further review revealed that updates would be made to the Comprehensive Care Plan as needed. 1. Review Resident #18's Admission Record revealed the facility admitted the resident on 06/04/2018 with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD), Type 2 Diabetes Mellitus and Adult failure to Thrive. Review of Resident #18's Significant Change in Status Minimum Data Set (MDS) Assessment, dated 11/16/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of twelve (12) of fifteen (15), indicating the resident had moderate cognitive impairment. Review of Resident #18's weight June 2023 through December 2023 revealed that on 06/14/2023, Resident #18 weighed one hundred twenty six (126) pounds (lbs) and on 12/05/2023, Resident #18 weighed one hundred two point eight (102.8) lbs. On 12/07/2023 the Surveyor requested and observed staff as Resident #18's weight was obtained at 98.8 lbs. This reflected a significant weight loss of twenty one point five percent (21.5 %) in one hundred eighty (180) days. Review of Resident #18 Comprehensive Care Plan dated 06/05/2018, revealed a focus problem of Nutritional Status, that indicated Resident #18 was at risk related to lack of coordination, type 2 diabetes mellitus, essential hypertension, atherosclerotic heart disease, schizophrenia, altered texture diet, thickened liquids, and pour intakes. Continued review revealed that the Comprehensive Care Plan was last reviewed and revised on 11/22/2023 by the MDS Coordinator. However, further review revealed no new interventions had been added to the care plan since 01/23/2023. Review of care plan approaches revealed the following; diet per physician orders, med pass supplement as ordered, encourage resident to eat meals in the dining room for increased socialization and pleasant dining experience, encourage increased intake of meals, provide cues as needed, assist with meals as needed, encourage fluids per physician order, honor likes and dislikes and medications as ordered to increase appetite. 2. Review of Resident #22's Admission Record revealed the facility admitted the resident on 02/17/2023 with diagnoses which included Congestive Heart Failure, Cognitive Communication Deficit, and Personal History of Transient Ischemic Attack. Review of Resident #22's Quarterly Minimum Data Set MDS) Assessment, dated 10/16/2023, revealed the resident assessed the resident to have a Brief Interview for Mental Status (BIMS) score of three (3) of fifteen (15), indicating the resident had severe cognitive impairment. Review of Resident #22's Physician orders revealed a diet order of Puree diet with Magic Cup (supplement) as an evening snack. Further, Resident #22 received Remeron seven point five milligrams (7.5mg) at bedtime for appetite stimulant Review of Resident #22's Comprehensive Care Plan for Nutritional Status dated 02/18/2023, revealed that the resident was at risk for altered nutritional status related to, congested heart failure, hyperglycemia, anemia, diuretic use, and edema. Further review revealed interventions dated 02/18/2023, included, assist with meals as needed, diet per order, encourage fluids, honor likes and dislikes, medications as ordered, monitor for labs as needed, monitor meal intake and record, monitor tolerance to diet texture, offer substitutes if consumes less than 50% of meals, therapy or restorative screen and treat as needed, weigh every month or as needed, notify physician of significant change. The care plan did not reflect that Resident #22 was receiving supplements (health shakes) or that weekly weights were being obtained. 3. Review of Resident #42's Admission Record revealed the facility admitted Resident #42 on 08/31/2023 with diagnoses which included Cerebral Infarction due to Unspecified Occlusion of the Cerebral Artery, Aphasia, and Hemiplegia/Hemiparesis following Cerebral Infarction. Review of Resident #42's Admission Minimum Data Set (MDS) Assessment, dated 09/05/2023 revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of six (6) of fifteen (15), indicating Resident #42 had severe cognitive impairment. Review of Resident #42's Comprehensive Care Plan dated 09/02/2023, revealed that Resident #42 was at risk for Nutritional Status related to diabetes mellitus, obesity, history of stroke, hypertension, and chronic kidney disease. Continued review of the care plan revealed, interventions, dated 09/02/2023, included, assist with meals as needed, diet per order, encourage fluids, honor likes and dislikes, medications as ordered, monitor for signs and symptoms of fluid imbalance, monitor labs as needed, monitor meal intake and record, monitor tolerance to diet texture and adjust as needed, offer substitutes if consumes less than 50% of meals, therapy, restorative, screen and treat as needed. weight every month and or as needed, notify physician if significant change. In an interview with Unit Manager (UM) #1, on 12/08/2023 at 3:30 PM, she stated CNAs would report to her if there were concerns with residents not consuming meals and had potential weight loss. She stated she would notify would report to an RN or the ADON if available and then either she or another nursing staff member would contact the physician for orders. She stated weight loss would be recognized as a change of condition. She stated she recalled all nursing staff being allowed to make changes on resident care plans, but she stated she had not made those changes without consulting with her superiors or the physician and being given consent. In an interview with Registered Nurse (RN) #1 on 12/08/2023 at 3:20 PM, she stated she does not usually do anything with the care plan, but she probably could update it, she stated the MDS or DON would be responsible for updating a care plan. The RN stated if a resident had a change in condition or a new intervention was added, she would notify the oncoming shift and/or CNA's verbally either during the current shift or at change of shift. In an interview with the Minimum Data Set (MDS) Coordinator on 12/08/2023, at 2:20 PM, she stated she had been at the facility for two (2) years. She stated the purpose of the care plan was to guide care. She stated information came from resident interviews, staff interviews, the clinical record, and observations. The MDS coordinator stated she was responsible for updating all areas of the Comprehensive Care Plan. She stated the Registered Dietitian initiated the nutrition care plan, but she was responsible for doing any updates. She stated that weight loss, could be addressed on the nutrition care plan, or a resident may have a specific care plan for weight loss. The MDS nurse stated care plans were reviewed and revised quarterly or with a significant change of status. 4) Review of Resident #203's Admission Record revealed the facility readmitted the resident on 07/18/2023, with diagnoses which included Unspecified Dementia, Psychotic Disturbance, and Anxiety. Review of Resident #203's Quarterly Minimum Data Sets (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of three (3) of fifteen (15) indicating the resident was not interviewable. Review of Resident #203's Weight Record revealed on 07/25/2023, the resident weighed 178.8 pounds and on 11/28/2023 he/she weighed 140 pounds indicating a -21.70% loss for the one hundred and eighty (180) day period. On 10/25/2023 the resident weighed 157 pounds and on 11/28/2023 he/she weighed 140 pounds indicating a -10.83% loss for thirty (30) days. Review of Resident #203's Comprehensive Care Plan for nutritional status revealed it was implemented on 01/14/2023. However there were no revisions to address the resident's documented weight loss. During an interview with Registered Nurse (RN) #1 on 12/08/2023 at 3:20 PM, she stated she usually does not have any responsibilities related to a care plan but she could probably update it if needed. RN #1 stated the MDS coordinator or the DON would be responsible for updating a care plan. She stated if a resident had a change in condition or a new intervention was added, she would notify the oncoming shift verbally. During an interview with the Director of Nursing (DON) on 12/08/2023 at 3:52 PM, she stated the MDS coordinator was responsible for implementing a care plan but any nurse could also do that. The DON stated she expected floor nurses, the MDS or herself to ensure the resident's care plans were updated and revised. During an interview with the Administrator on 12/08/2023 at 4:13 PM, she stated the resident's care plans were the facility's guide to providing care and if something was not added to the care plan then staff would not be aware of what needed to be done. The Administrator stated the Care Plan had to be updated. 47798

Based on observation, interviews, record review and review of facility policy, it was determined the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, unless the resident's clinical condition demonstrates that this is not possible, for two (2) of fourteen (14) sampled residents (Resident #22 and Resident #42). 1. Review of Resident #42's weight beginning 09/04/2023, revealed an admission weight of 233.5 pounds (lbs). On 12/06/2023 at 10:30 AM, the Surveyor requested and observed staff obtain Resident #42's weight using a mechanical lift scale and weight was observed to be 187 lbs. This reflected a significant weight loss of 19.91% in ninety (90) days. 2. Review of recorded weights for Resident #22 revealed that on 06/14/2023, the resident weighed 131.4 lbs. On 12/08/2023 at 10:00 AM, the Surveyor requested and observed staff obtain Resident #22's weight and the weight was one hundred eight point six (108.6) lbs, indicating Resident #22 had a significant weight loss of seventeen point four percent (17.4%) in one-hundred an eighty (180) days. The findings include: Review of facility policy titled, Residents at Nutritional Risk, revised 08/2023, revealed any resident identified as being at nutritional risk would have a problem of, Alteration in Nutrition, identified on the care plan. The physician would be informed, and a dietary consultation requested. Continued review revealed criteria to help identify nutritionally at risk residents included, a resident consistently refuses twenty-five (25%) percent or more of a meal, undesirable weight loss or gain of three (3) pounds (lbs.) if under one hundred lbs., and five (5) lbs., if over one hundred (100) lbs. or more in one month. Progressive weight loss ten percent (10%) in six (6) months or gain over several months, difficulties in swallowing or chewing. Non compliance with diet order. Further, based on nutritional assessment, many nutrition assessment section. If a resident score is less than nine, would indicate a risk or is malnourished. Timely assessment and implementation of a plan was crucial in proper care of the resident at risk. Review of facility policy titled, Weight Monitoring, dated 01/2019 and reviewed 01/2022, revealed all residents height and weight would be determined by the appropriate method and recorded within twenty four (24) hours of admission. Weight would be measured monthly and weight changes of all residents would be monitored. Percentage weight changes would be determined for a 30 day, 90 day and a 180 day. Continued review revealed residents that triggered for a significant weight loss, more than 5% from the previous month, would be placed on weekly weights and each resident would be reviewed by the interdisciplinary team (IDT) committee and appropriate interventions would be put in place. 1. Review of Resident #42's Admission Record revealed the facility admitted Resident #42 on 08/31/2023 with diagnoses which included Cerebral Infarction due to Unspecified Occlusion of the Cerebral Artery, Aphasia, and Hemiplegia/Hemiparesis following Cerebral Infarction. Review of Resident #42's Admission Minimum Data Set (MDS) Assessment, dated 09/05/2023 revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of six (6) of fifteen (15), indicating Resident #42 had severe cognitive impairment. Review of Resident #42's Physician orders revealed that Resident #42 received a Regular diet with sugar substitutes and sugar free health shakes four times a day. Review of Resident #42's Weight Record revealed an admission weight of 233.5 lbs on 09/04/2023. Continued review revealed on 10/09/2023, weight was 217 lbs., on 11/08/2023, weight was 189 lbs., on 11/30/2023, Resident #42 returned from the hospital and weight was recorded at 212 lbs. Additionally, weight on 12/05/2023, was 191 lbs. On 12/06/2023 at 10:30 AM, the Surveyor requested and observed staff obtain Resident #42's weight using a mechanical lift scale and weight was observed to be 187 lbs. This reflected a significant weight loss of 19.91% in 90 days. Review of Resident #42's meal intakes for December 1st through December the 6th, revealed there was an opportunity for eighteen (18) meals. Resident #42 had one meal where 26 to 50% of the meal was consumed, eight (8) meals that 1-25% was consumed and there were seven (7) meals that were documented as not taken. Further, there were two (2) meals that no documentation was available Review of the Initial Nutritional assessment dated , 08/31/2023, and signed by the Registered Dietician (RD), revealed the resident had a history that included stroke, diabetes, and hypertension. Resident triggers for nutrition risk related to obesity, decreased meal intake. Weekly weights for four (4) weeks, then monthly if stable. Review of Nutrition Note dated, 11/11/2023 and signed by the RD, revealed Resident #42 received a regular diet with finger foods, and a sugar free health shake daily. Resident #42 triggered for nutrition risk related to obesity. Decreased intake and recent weight loss of 12.9% in 30 days. Recommend continuing weekly weights then monthly of stable. Also recommend adding an additional sugar free shake daily at lunch. Current intakes average 25%. Review of Interdisciplinary Team (IDT) Note dated 11/15/2023 and signed by the Administrator, revealed that Resident #42 continued with weekly weights and weight was stable. Review of Resident #42's Comprehensive Care Plan dated 09/02/2023, revealed the resident was at risk for Nutritional Status related to diabetes mellitus, obesity, history of stroke, hypertension, and chronic kidney disease. Continued review of the care plan revealed, interventions included, assist with meals as needed, diet per order, encourage fluids, honor likes and dislikes, medications as ordered, monitor for signs and symptoms of fluid imbalance, monitor labs as needed, monitor meal intake and record, monitor tolerance to diet texture and adjust as needed, offer substitutes if consumes less than 50% of meals, therapy, restorative, screen and treat as needed. weight every month and or as needed, notify physician if significant change. Observation on 12/05/2023 at 12:27 PM, Kentucky Medication Aide (KMA) #10 was observed exiting Resident #42's room with lunch tray and the surveyor asked to see what was consumed. KMA #10 removed lid and Resident #42's food looked to be untouched. In an interview during observation with KMA #10 on 12/05/2023 at 12:27 PM, she stated Resident #42 was independent with eating after set up. She stated Resident #42 ate the cookie and drunk the tea. KMA #10 stated she did not offer Resident #42 anything else to eat. She stated she would inform the nurse of Resident #42's not eating. She further stated she would document that Resident #42 ate 0-25% of the meal. Observation on 12/06/2023, at 9:20 AM, revealed Resident #42 was awake with head of bed elevated Surveyor entered room and noted breakfast tray remains at bedside. The breakfast meal consisted of scrambled eggs, biscuit and gravy, oatmeal and 1/2 glass of liquid. There are no condiments (butter, sugar, salt pepper) or finger foods on the tray and the meal is untouched as the utensils are unused. Resident #42 was a dependent diner and no staff were present. Unit Manager entered room, saw Resident #42 had not eaten and offered him/her a peanut butter and jelly sandwich to which he refused. Further the Unit Manager made no attempt to assist Resident #42 with his/her meal. 2. Review of Resident #22's Admission Record revealed the facility admitted the resident on 02/17/2023 with diagnoses which included Congestive Heart Failure, Cognitive Communication Deficit, and Personal History of Transient Ischemic Attack. Review of Resident #22's Quarterly Minimum Data Set MDS) Assessment, dated 10/16/2023, revealed the resident assessed the resident to have a Brief Interview for Mental Status (BIMS) score of three (3) of fifteen (15), indicating the resident had severe cognitive impairment. Review of Resident #22's Weight Record revealed the resident weighed 131.4 lbs on 06/14/2023. Continued review revealed that on 07/07/2023, the resident weighed 111.2 lbs., a significant weight loss of 15.37% in 30 days. Further weights were recorded on 08/08/2023, at 108 lbs., on 09/05/2023, 111 lbs., on 10/03/2023, 109.6 lbs., and on 11/08/2023, Resident #22 weighed 108.2 lbs. On 12/08/2023 at 10:00 AM, the Surveyor requested and observed staff obtain Resident #22's weight and the weight was one hundred eight point six (108.6) lbs, indicating Resident #22 had a significant weight loss of seventeen point four percent (17.4%) in 180 days. Review of Resident #22's Physician orders revealed a diet order of Puree diet with Magic Cup (supplement) as an evening snack. Further, Resident #22 received Remeron seven point five milligrams (7.5mg) at bedtime for appetite stimulant Review of record revealed no documentation of Interdisciplinary Team (IDT) or Nutrition notes could be located for June or July 2023, when Resident #22 was first noted with a significant weight loss. Review of a Nutrition Note dated 08/01/2023, and signed by the RD, revealed Resident #22 received a Puree diet with snacks twice a day. Average meal intake was 76%. Weight on 07/11/2023 was 111 lbs, and indicated a loss of 15.4% in 30 days, and 11.3% in 90 days. Resident was placed on weekly weights for 4 weeks to monitor, recommend adding magic cups for added calories. In an interview with the Certified Dietary Manager (CDM) on 12/07/2023, at 4:07 PM, she stated she had been the CDM for five years. The CDM stated she attended care plan meetings and the weekly IDT meetings. She stated she updated the care plan if needed. She further stated she made the RD aware if a resident was having weight loss. She stated residents having weight loss were discussed in the weekly IDT meeting and notes were made. In an interview with Certified Nurse Aide (CNA) #6 on 12/08/2023 at 9:00 AM, he stated if a resident was not eating he would report it to the charge nurse. He further stated he would let the kitchen know and get a sandwich. He stated he was not aware of anything the kitchen offered other than sandwiches. In an interview with Certified Nurse Aide (CNA) #8 on 12/08/2023 at 9:33 AM, she stated she had been at the facility for eight (8) years. and normally works 400,500 and 600 halls. She stated if a residents appetite changed and the resident was not eating she would notify the nurse. She stated residents with weight loss received shakes or magic cups. She stated there were limited options when residents did not like or want what was served. She stated the kitchen would serve left overs or sandwiches. In an interview with the Registered Dietician (RD) (contract) on 12/08/2023 at 10:18 AM, she stated she came to the facility weekly on Saturday. She stated the Certified Dietary Manager (CDM), leaves her a list of things she needs to look at. She reviews residents on weekly weights and residents being followed in the weekly meeting. She stated the menus came from corporate and there was no alternative menu or an always available menu. She stated she did not know what was available to the residents as she was only at the facility once a week. In an interview with Kentucky Medication Aide (KMA) #10 on 12/08/2023 at 3:10 PM, she stated CNAs would report to her if they had concerns with resident weight loss or not eating meals. She stated she would notify the Unit Manager (UM) or charge nurse about the concerns. She stated weight loss would be considered a change of condition and the charge nurse or UM on duty would notify the physician. She further stated she was not been involved with care plans. In an interview with Unit Manager (UM) #1 on 12/08/2023 at 3:30 PM, she stated CNA's would report to her if there were concerns with residents not consuming meals and had potential weight loss. She stated she would notify would report to an RN or the Assistant Director of Nursing (ADON) if available and then either she or another nursing staff member would contact the physician for orders. She stated weight loss would be recognized as a change of condition. She stated she recalled all nursing staff being allowed to make changes on resident care plans, but she stated she had not made those changes without consulting with her superiors or the physician and being given consent. During an interview with Registered Nurse (RN) #1 on 12/08/2023 at 3:20 PM, she stated the Certified Nursing Assistant (CNA) would notify her if meal intakes were less than fifty percent (50%). She stated weights were reported to the MDS nurse. She also stated that if a resident was not consuming at least 50% of meals, that would be a decline and a significant change in condition and should be reported to the physician; She stated the DON was responsible for notifying the doctor. RN #1 stated she would notify the residents provider and DON within two days if a resident continued not to consume their meals. In an interview with the Director of Nursing (DON) on 12/08/2023 at 3:50 PM, she stated with weight loss and feeding, the guidelines were listed on the resident care guide. She stated she expected the CNA or KMA to report to the nurse if a resident was not eating. She further stated the NP or physician should be made aware. She stated the MDS Coordinator and the CDM followed resident weights and that the Dietician also followed residents with weight loss. She further stated, residents with weight loss were placed on weekly weights and followed weekly until stable. In an interview with the Administrator, on 12/08/2023 at 4:15 PM, she stated she was part of the IDT team. She stated the IDT team followed residents with weight loss weekly by making notes in the chart. The Administrator stated the facility did not offer a second options for meals but soup and sandwiches were always available to residents.

Based on observation, interview, record review, and facility document review, it was determined the facility failed to ensure services were provided by sufficient competent staff, including but not limited to licensed nurses and nurse aides, on a 24-hour basis to provide nursing and related services to residents for four (4) of fourteen (14) sampled residents (Resident's #4, #6, #16, and #26). Interviews revealed nursing staff was slow to answer resident call lights. The findings include: Review of the Facility Assessment Tool, revised 10/23/2023, revealed the facility staffing plan was based on resident population and their identified needs for care and support. The facility determined the following approach to staffing to ensure that the facility had sufficient staff to meet the needs of the residents at any given time. The facility completed an evaluation of overall number of facility staff needed to ensure a sufficient number of qualified staff were available to meet each resident's needs. Continued review revealed that the total number of full-time equivalents needed on a daily basis for nursing, based on a twelve (12) hour shift was, Licensed Nurses, four to five (4-5) staff per twelve (12) hour shifts, Certified Nurse Aides (CNAs), six to eight (6-8) staff per twelve (12) hour shifts. Review of the facility policy titled, Standards of Nursing Practices, revised 05/2018, revealed residents requiring help with meals would be provided the necessary needed help. Further review revealed staff would respond to residents request for assistance by answering call lights within a reasonable amount of time, per policy, was no longer than a ten (10) minute period of time. 1. Review of Resident #26's Admission Record revealed the facility readmitted the resident on 02/23/2022 with diagnoses which included Hypertension, Dementia, and Arthritis. Review of Resident #26's Quarterly Minimum Data Set (MDS) Assessment, dated 09/25/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of five (5) of fifteen (15) which indicated severe cognitive impairment. In an interview with Resident #26, on 12/05/2023 at 10:02 AM, he/she stated the call lights were not always answered timely especially during meal times. He/she stated staff had provided good care as best as they could. He/she stated he/she could ambulate on his/her own, but getting into his/her wheelchair required at least one staff member to be with him/her. (Resident #26 had a low BIMS score but demonstrated knowledge regarding his/her care) 2. Review of Resident #16's Admission Record revealed the facility readmitted the resident on 12/18/2021 with diagnoses which included Atrial Fibrillation, Anxiety Disorder, and Asthma. Review of Resident #26's Quarterly Minimum Data Set(MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of eleven (11) of fifteen (15) which indicated the resident was interviewable. In an interview with Resident #16, on 12/05/2023 at 10:30 AM, he/she stated staff had not always answered call lights timely when assistance was needed. Resident #16 had pressed call light and after ten (10) minutes staff had not come to assist him/her. On 12/05/23 at 10:42 AM, State Surveyor (SS) had gone to the nurse station to interview to why the call light for Resident #16 had not been answered and observed no staff at the nurse station. Observation of Certified Nurse Aide (CNA)#3, who arrived to answer call light for Resident #16 after fifteen (15) minutes was informed that Resident #16's call light was a test call. In an interview with Licensed Practical Nurse (LPN), Unit Manager (UM) #1, on 12/05/23 at 11:08 AM, she stated to her knowledge, fifteen (15) minutes was the state maximum wait time for call lights to be answered, but residents had not typically waited that long to get assistance. LPN/UM #1 further stated she didn't believed the facility was short staffed because resident's received good care. 3. Review of Resident #4's Admission Record revealed the facility readmitted the resident on 08/09/2016 with diagnoses which included Heart Failure, Diabetes Mellitis, and Depression. Review of Resident #4's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of four (4) of fifteen (15), which indicated severe cognitive impairment. In an interview with Family Member #3, on 12/06/2023 at 9:25 AM, he stated he had visited Resident #4 everyday and only lived about a block away from the facility. He stated if he had not been close enough to visit daily, Resident #4 would not be in that facility. He stated Resident #4 stated to him that call lights were not answered timely and stated staff were unable to assist all residents appropriately. He stated Resident #4 had called him when he/she needed something and if staff had not answered his/her call light, he had come to the facility to assist Resident #4. Resident #4 had stated to him the wait time to get assistance going to the bathroom had sometimes been an hour or an hour and a half, but noted unsure if Resident #4's perception of time was exact. He stated Resident #4 was unable to walk and was fully dependent on staff to assist him/her to the wheelchair and then assist him/her onto the toilet. In an interview with Certified Nurse Aide (CNA) #3, on 12/05/2023 at 10:00 AM, she stated that staffing had been okay most days, but they had a staff member quit recently and weekends were about the same. CNA #3 stated she had worked on both sides of the facility, depending on where she had been assigned, but had been able to complete her assigned tasks during her shift. 4. Review of Resident #6's Admission Record revealed the facility readmitted the resident on 07/05/2018 with diagnoses which included Hyperlipidemia, Heart Failure, and Depression. Review of Resident #6's Quarterly Minimum Data Sets (MDS) Assessment, dated 10/31/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of thirteen (13) of fifteen (15) which indicated no cognitive impairment. In an interview with Resident #6, on 12/08/23 at 11:26 AM, he/she stated that breakfast was normally good and most of the time, he/she had been able to feed him/herself. Resident #6 stated it had taken him/her a long time to eat without assistance, and he/she had trouble with eating sausage sometimes. Resident #6 stated that staff had not always assisted him/her with meals. He/she stated sometimes they had come to assist after passing all other trays. and other times staff would be busy picking up trays and at those times he/she had no assistance with feeding at all. Resident #6 further stated he/she was able to press the call light button and it was in reach, but stated staff had not always answered the call light timely. He/she felt there was not enough staff available at times because the call lights weren't answered timely. In an interview with Assistant Director of Nursing (ADON), on 12/01/2023 at 2:53 PM, she stated call lights should be answered within five (5) minutes, but no later then ten (10) unless there was an emergency, and she would typically let residents know why there was a delay. In an interview with Director of Nursing (DON), on 12/08/023 at 3:50 PM, she stated staff expectations for answering call lights timely was less than fifteen (15) minutes. In an interview with the Administrator, on 12/08/2023 at 4:15 PM, she stated call lights should be answered as soon as staff were physically able to get out of the room noting staff may be tied up in another room. She stated facility policy stated ten (10) minutes to answer resident's call lights, but she stated that was a little harsh. The Administrator stated expectations were that staff would at least acknowledge the light and tell the resident they would be back as soon as possible. Further, she stated staff should acknowledge the light is on then to get to it as soon as they can. Additionally, she stated all staff had worked together, and sometimes staff were pulled from other areas of the facility if necessary to provide the best care for residents. She stated when staff had called out and the facility required other staff to come in, staff members were responsible to assist with filling their positions for that shift.

Based on observation, interviews, record review, and review of facility policy, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (1) of fourteen (14) sampled residents (Resident #42). Observation on 12/06/2023 at 10:20 AM, revealed Certified Nursing Assistant (CNA) #3 failed to remove her soiled gloves prior to picking up and offering Resident #42 a glass of water. The findings include: Review of the facility policy titled, Infection Control Program, reviewed on 03/20/2023, revealed the major purpose of infection control program in the nursing facility were to minimize the effects of infections on residents and employees and to educate the staff. Review of Resident #42's Admission record revealed the facility admitted Resident #42 on 08/31/2023 with diagnoses which included Cerebral Infarction due to Unspecified Occlusion of the Cerebral Artery, Aphasia, and Hemiplegia/Hemiparesis following Cerebral Infarction. Review of Resident #42's Admission Minimum Data Set (MDS) Assessment, dated 09/05/2023 revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of six (6) of fifteen (15), indicating Resident #42 had severe cognitive impairment. During observation of care on 12/06/2023 at 10:20 AM, Certified Nursing Assistant (CNA) #3 and Unit Manager (UM) were providing incontinent care to Resident #42. CNA #3 and the UM washed their hands and donned gloves prior to care. However, following care, CNA #3 moved Resident #42's bedside table closer to the resident, picked up the glass of water and offered the resident a drink. CNA #3 had not removed her soiled gloves or washed her hands prior to offering Resident #42 a drink of water. In an interview with CNA #3 at the time of observation, on 12/06/2023 at 10:20 AM, she stated she should have removed her gloves and washed her hands prior to giving Resident #42 a drink of water. In an interview with the Director of Nursing/Infection Preventionist on 12/08/2023 at 3:50 PM, she stated her expectations on hand hygiene following incontinent was for staff to remove gloves and wash their hands. She stated potential outcomes could be spreading infection to themselves or other residents. During an interview with the Administrator on 12/08/2023 at 4:13 PM, she stated staff should always remove gloves and do hand hygiene following any care with a Resident.

Based on observation, interview, record review and review of the facility policy, it was determined the facility failed to conduct regular inspections of all bed frames, mattresses, and bed rails, if any, as part of a regular maintenance program to identify areas of possible entrapment for one (1) of fourteen (14) sampled residents (Resident #42). Observation of Resident #42's bed on 12/07/2023, revealed there was a large gap between the side rails and bed mattress. The findings include: Review of the facility policy titled, Bed/Side Rail Use, dated 04/2018 and reviewed on 01/2022, revealed the facility would attempt to use appropriate alternatives prior to installing a bed rail or side rail. If a bed or side rail was used, the facility would ensure correct installation, use and maintenance of bed rails, including but not limited to the following elements, assess the resident for risk of entrapment from bedside rail prior to installation, review the risk and benefits of bedrails with the resident or resident representative, and obtain informed consent prior to installation, ensure that the beds dimensions were appropriate for the resident size and weight and follow the manufacturers recommendation and specification for installing and maintaining bed rails. During observation of care on 12/07/2023 at 10:55 AM, revealed Resident #42 had 1/4 rails on his/her bed with a large gap between the right rail and the mattress. The Maintenance Director measured the right-side rail and it was five point five (5.5) inches from the mattress. The left-side rail measured three point seven five (3.75) inches from the mattress. Further observation revealed the mattress was too small for the bed frame. In an interview with Maintenance Director at time of observation revealed,, he stated the bed frame was adjustable and he would adjust the frame. He stated he does nothing to the beds except add rails when he was asked. In an interview with Unit Manager #1 on 12/07/2023 at 10:15 AM, she stated assessments were completed when a resident used a bed rail as an enabler. She stated she was unaware of what maintenance did with beds. In an interview with the Maintenance Supervisor on 12/07/2023 at 10:55 AM, he stated he was not aware of any assessments or inspections he was supposed to be doing on beds, mattresses, or rails. He stated he does not do anything with the beds except put rails on when asked. He stated Resident #42's bed frame was adjustable and he adjusted the frame on 12/07/2023. During an interview with the Director of Nursing (DON) on 12/08/2023 at 3:52 PM, she stated she thought maintenance was supposed to inspect the beds. She stated nursing checked that beds were functioning, such as a broken rails. The DON stated a device assessment was completed when resident required or requested rails as enablers. In an interview with the Administrator on 12/08/2023 at 4:13 PM, she stated the Maintenance Supervisor had just completed training as of 12/07/2023 on bed assessments, to include rails and mattresses's. She stated going forward when residents were admitted , the facility would inspect beds and mattresses to ensure guidelines were being followed. The Administrator further stated a monthly audits would be completed.

Based on interview, record review, and facility policy review, it was determined the facility failed to notify the representative of one (1) of three (3) sampled residents of a change in condition (Resident #2). On 03/26/2021 and 04/01/2021, an order to initiate a new form of treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: Review of the facility's policy titled, Notification Of Change, dated July 2017, revealed the resident's physician and responsible party must be notified when an event involving the resident occurs or when the resident experiences a change in condition, potential discharge, room transfer or death. The resident's legal representative or interested family member is notified of a significant change in the resident's condition unless the resident has specified otherwise. Record review revealed the facility readmitted Resident #2 on 06/12/19, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Sets (MDS) assessment, dated 01/14/21, revealed the facility assessed Resident #2's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of two (2) which indicated the resident was not interviewable. Further review of the record revealed the resident had a legal family guardian. Review of Resident #2's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review revealed on 04/01/21, an order to clean sacrum with NS, apply Santyl to wound bed, and cover with bordered foam dressing daily. However, review of the Progress Notes, dated 03/26/21 and 04/01/21, revealed no documented evidence that Resident 2's family was made aware of the sacral pressure wound, treatment ordered, and deteriorating conditions of the wound. Interview with Resident #2's Responsible Party on 05/26/21 at 10:10 AM, revealed facility staff notified him/her on 04/02/21 and stated Resident #2 was being transferred to the hospital for dehydration. Further interview revealed the Responsible Party was informed of the patient's sacral pressure wound when he/she was hospitalized . Responsible Party stated, I was not notified he/she had skin breakdown again, no one from the nursing home ever called me or any other family member to let us know, and from the size of the pressure sore, it had been there a while. Interview with the Director of Nursing (DON), on 05/28/2021at 1:20 PM, revealed she expected nursing staff to notify the resident's representative of a significant change in a resident's condition and/or new physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure a resident's medical record reflected the resident's condition in accordance with accepted professional standards, practices, and maintained medical records on each resident that were complete, accurately documented, and accessible for three (3) of 3 sampled residents (Resident #1, #2, and #3). Review of Resident #1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Wound Care Advanced Practice Registered Nurse (APRN) assessed, measured, and documented characteristics of the pressure ulcers weekly. However, the last documented wound assessments by the APRN in the resident's medical record was 03/31/21. Review of Resident #2's closed clinical record (Physician Orders) revealed a treatment order for a sacral pressure ulcer. However, the last documented wound assessment by the APRN in the resident's medical record was 03/18/21. Review of Resident #3's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . However, the last documented wound assessments by the APRN in the resident's medical record was 03/31/21. The findings include: Review of the facility's policy titled, Content of the Clinical Record, dated June 2016, revealed a separate clinical record shall be maintained for each resident admitted to the facility with specific sections of the records established to ensure complete and accurate record keeping. Resident medical records will be in paper/hard copy and also in the facility electronic medical record (EMR) system. In the resident's medical record as events occur in each facility department, documents will be authenticated and dated, and may include the following items: m) description of any decubitus ulcer or skin breakdown including measurements and care given. 1. Record review revealed the facility admitted Resident #1 on 09/17/2020 [CONDITION(S)], Cerebral Infarction, Acute Kidney Failure, [CONDITION(S)], Moderate Protein-Calorie Malnutrition, Heart Failure, [CONDITION(S)], and [CONDITION(S)]. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of three (3) which indicated the resident was not interviewable. Review of Resident #1's Treatment Administration Record (TAR), dated 05/01/21 through 05/31/21, revealed treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review revealed treatment to Stage 3 Sacral Pressure Ulcer to cleanse with NS and pat dry, apply Santyl (wound [MEDICATION(S)] agent) to wound bed, pad with foam dressing to alleviate pressure and cover with bordered foam dressing. 2. Record review (closed) revealed the facility readmitted Resident #2 on 06/12/19, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS, dated [DATE], revealed the facility assessed Resident #2's cognition as severely impaired with a BIMS score of two (2) which indicated the resident was not interviewable. Review of Resident #2's TAR, dated 03/26/21, revealed treatment to Unstageable Pressure Ulcer on sacrum to cleanse with NS, apply bordered foam dressing, change every 3 days and PRN. Continued review revealed on 04/01/21, a new order was obtained due to pressure ulcer declined, to cleanse with NS, apply Santyl to wound bed, and cover with bordered foam dressing daily. 3. Record review revealed the facility admitted Resident #3 on with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Annual MDS, dated [DATE], revealed the facility assessed the resident's cognition as severely impaired with a BIMS of zero (0) which indicates the resident was not interviewable. Review of Resident #3's TAR, dated 05/01/21 through 05/31/21, revealed treatment to Stage 3 Pressure Ulcer on right hip and right buttock to cleanse with NS, pat dry, saturate Calcium Alginate (absorbent dressing) rope with Santyl (wound [MEDICATION(S)] agent) and pack down into each wound tunnel to base, cover with 2 foam dressings, cut center out to off-load wound daily. Interview with the Wound Care APRN, on 05/28/21 at 10:42 AM, revealed all resident's wound care consist of pictures, measures, and treatment which is entered into the Wound Care Providers EMR. Interview revealed the Director of Nursing (DON) access the Wound Care Providers EMR system which is in PDF format and contains all wound care orders, progress notes, measurements, characteristics and ensures the records are entered into each resident's EMR. Continued interview revealed the DON of each facility is responsible to merge residents wound care information into the facility's EMR (Matrix) system. Interview with the DON, on 05/28/21 at 1:20 PM, revealed she logged into the Wound Care Provider EMR system and printed off the APRN Wound Care Notes. Interview revealed the DON put each resident's wound care notes in the Medical Record Clerk's box which is filed in each residents overflow medical record in the medical record clerk's office. Continued interview revealed residents care, provided by the Wound Care Provider APRN, wound care notes are not accessible in the resident's physical and/or EMR although, are maintained in the Medical Clerk's office in each resident's overflow medical record.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to treat each resident with respect, dignity, and care in a manner that promotes maintenance or enhancement of his/her quality of life, recognizing each resident's individuality, for two (2) of twelve (12) sampled residents (Residents #11 and #14). Staff failed to close the blinds/curtain when providing a skin assessment for Resident #11, leaving the resident's buttocks exposed to anyone who could have looked in the window. In addition, staff placed Resident #14's medication in his/her mouth with her bare hand and the resident stated it made him/her feel like a child. The findings include: Review of the facility's policy titled, Dignity, not dated, revealed the policy of the facility is to care for residents in a manner and in an environment that promotes maintenance or enhancement of each resident's quality of life, dignity, and respect in full recognition of his or her individuality. Dignity means that in their interactions with residents, staff carries out activities that assist the Resident to maintain and enhance his/her self-esteem and self worth. 1. Record review revealed the facility admitted Resident #11 on 11/17/2015 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of zero (0), which indicated the resident was rarely/never understood. Observation of Resident #11's skin assessment, on 03/30/2021 at 1:20 PM, performed by Registered Nurse (RN) #1 and State Registered Nurse Aide (SRNA) #1, revealed the staff failed to close the privacy curtain and window blinds. Further observation revealed the resident's buttocks were exposed to the window and could be viewed from the outside. In addition, observation revealed a staff member entered Resident #11's room while the skin assessment was being conducted although staff at the bedside stated, resident care. Interview with SRNA #1 on 03/30/2021 at 1:30 PM, revealed the window blinds and privacy curtains should be closed before providing resident care to ensure the resident's privacy and dignity. Interview with RN #1 on 03/30/2021 at 1:30 PM, revealed she expected staff to ensure each resident's privacy when care was provided. RN #1 stated she and SRNA #1 should have closed Resident #11's window blinds and privacy curtain although they failed to do so. She states, We just got in a hurry. 2. Record review revealed the facility admitted Resident #14 on 08/09/2017 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS assessment, dated 03/12/2021, revealed the facility assessed Resident #14's cognition as intact with a BIMS score of fifteen (15), which indicated the resident was interviewable. Observation on 03/30/2021 at 9:40 AM, revealed Resident #14 received [MEDICATION(S)] (pain medication) and [MEDICATION(S)] XL (hypertension) by mouth which was administered by the Assistant Director of Nursing (ADON). The ADON was observed to remove both pills from the medicine cup with her bare hand and place them in the resident's mouth. Interview with Resident #14 on 03/31/2021 at 1:05 PM, revealed the ADON was the only staff that administered his/her medications with bare hands. Resident #14 stated, Although she washes her hands, it makes me feel like a child when she put the pills in my mouth bare handed. Interview with the ADON on 04/01/2021 at 2:05 PM, revealed Resident #14 asked her one (1) time to wear gloves when administering his/her medication although he/she did not say why. The ADON further revealed she gave the resident's medication either bare handed or with a spoon. She stated, I am not the only nurse that gave the resident medication bare handed. Interview with the Director of Nursing (DON) on 04/01/2021 at 2:40 PM, revealed staff should ensure privacy when resident care was provided. She stated, privacy was provided when privacy curtain and window blinds are closed. Further interview revealed Resident #14 preferred his/her medications to be given with a spoon. She stated, I would expect staff to administer )(his/her medications with a spoon or gloved hand, not bare handed.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment for two (2) of twelve (12) sampled residents, (Residents #11 and #29), related to oxygen administration, and stoma/suctioning. Resident #11 was care planned for oxygen at 2 Liters [MEDICAL CONDITION] at 35% humidified oxygen air. However, observations on 03/30/2021 revealed Resident #11's oxygen humidification container was empty and the oxygen was not humidified at 35%, per the care plan. In addition, Resident #29 was admitted on oxygen; however, review of the comprehensive care plan revealed the facility failed to develop a care plan to address the resident being on oxygen. The findings include: Review of the facility's policy titled, Resident Assessment Comprehensive Care Plans, dated 11/28/2017, revealed the facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at 483.10 (c)(2) and 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. Each resident will have a person-centered comprehensive care plan developed and implemented to meet preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs. 1. Record review revealed the facility admitted Resident #11 on 11/17/2015 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of zero (0), which indicated the resident was rarely/never understood. Review of Resident #11's Comprehensive Care Plan titled, Potential for Complications related to History of Pneumonia and Compromised Respiratory System related to [MEDICAL CONDITION] dated 11/30/2015, revealed an intervention for oxygen at 2 Liters [MEDICAL CONDITION] at 35% humidified oxygen air. However, observations on 03/30/2021 at 10:08 AM, 11:30 AM, and 1:20 PM revealed Resident #11 was receiving oxygen at two (2) liters [MEDICAL CONDITION] collar and the humidification container was empty and was not providing humidified oxygen as care planned. Interview with Registered Nurse (RN) #1, on 03/31/2021 at 1:30 PM, revealed Resident #11 was care planned for humidified oxygen. RN #1 stated humidification container should not be empty and the licensed staff was responsible to ensure the resident's oxygen was humidified with an oxygen saturation greater than 92%. She stated without oxygen humidification the resident was at risk for alteration in his/her respiratory status and decrease in his/her oxygen saturation. Interview with the Director of Nursing (DON), on 04/01/2021 at 2:05 PM, revealed she expected Resident #11's oxygen to be humidified as care planned. 2. Record review revealed the facility admitted Resident #29 on 02/05/2021 with [DIAGNOSES REDACTED]. Review of the Admission MDS Assessment, dated 02/10/2021, revealed the facility assessed Resident #29's cognition as intact with a BIMS score of 14 which indicated the resident was interviewable. Further review of the MDS revealed Resident #29 had a [MEDICAL CONDITION], but it did not indicate suctioning. Review of a physician's orders [REDACTED]. In addition, observations on 03/29/2021 at 11:10 AM, 03/30/2021 at 9:20 AM and 03/30/21 at 3:30 PM revealed there was an uncovered suction machine on Resident #29's bedside table and the canister was dated 02/25/2021. Continued observation revealed liquid contents in the canister. However, review of Resident #29 Comprehensive Care Plan, dated 02/05/2021- 03/03/2021 revealed there was no care plan to address Resident #29's [MEDICAL CONDITION] and the use of suction equipment. Interview with the DON on 03/31/2021 at 2:15 PM revealed care plans were printed from the Matrix following the MDS assessment period. The DON stated the care plans were kept in a binder at the desk for updating changes. She revealed Resident #29 should have had a Respiratory care plan.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to update and revise the comprehensive nursing care plan for one (1) of (12) sampled residents (Resident #34) Resident #34 was readmitted to the facility on [DATE] with a new indwelling urinary catheter and was on oxygen therapy. However, review of Resident #34's Comprehensive Care Plan revealed the facility failed to revise the care plan to reflect the use and/or care of the indwelling urinary catheter and oxygen. The findings include: Review of the facility's policy, titled Resident Assessment Care Plan Development, effective 11/28/2017 revealed a comprehensive care plan must be reviewed and revised based on changing goals, preferences and needs of the resident and in response to current interventions Record review revealed the facility admitted Resident #34 on 02/25/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) assessment, dated 03/02/2021, revealed Resident #34 had an indwelling urinary catheter present on admission. However, review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Progress Notes dated 03/18/2021, revealed Resident #34 was sent to an acute care facility and returned on 03/26/2021 with oxygen and an indwelling catheter in place. Observations on 03/29/2021 at 11:10 AM, 03/30/2021 at 9:20 AM and 03/30/2021 at 3:30 PM, revealed Resident #34 had a indwelling urinary catheter and was receiving oxygen via nasal cannula at 2 liters. However, review of Resident #34's Comprehensive Care Plan dated 02/25/2021-03/19/2021 revealed there was no care plan to address the resident's use of an indwelling urinary catheter or oxygen. Interview with Registered Nurse (RN) #1 on 03/31/2021 at 1:47 PM, revealed she had completed Resident #34's readmission assessment on 03/26/2021. RN #1 stated Resident #34 had a catheter and was using oxygen. The RN further stated usually two (2) nurses completed admissions, one to complete the assessment and the other nurse to enter physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the Director of Nursing (DON) on 03/31/2021 at 230 PM, revealed she expected the resident's care plan to include the catheter and oxygen. She further stated the care plan should be updated and revised when a resident returned from the hospital to reflect their true status.

Based on observation, interview, record review, and facility policy review, it was determined two (2) residents in the selected sample of twelve (12) were identified on the facility's Census and Condition to have a urinary catheters. The facility failed to have an effective system in place to ensure appropriate treatment and services was provided to one (1) of twelve (12) sampled residents (Resident #34). Resident #34 was readmitted to the facility on [DATE] with an indwelling urinary catheter in place. However, the facility failed to ensure the resident had a valid justification for use, a physician's orders [REDACTED]. The findings include: Review of the facility's policy, titled Urinary Catheters, dated January 2019, revealed a physician's orders [REDACTED]. Review of the facility's policy, titled Resident Assessment Care Plan Development, effective 11/28/2017 revealed a comprehensive care plan must be reviewed and revised based on changing goals, preferences and needs of the resident and in response to current interventions Record review revealed the facility admitted Resident #34 on 02/25/2021 and discharged the resident to hospital on [DATE]. Further review revealed the facility readmitted him/her on 03/26/2021 with diagnoses of Pneumonia. However, there were no diagnoses to support the use of a catheter, per facility policy. Review of the Admission Minimum Data Set (MDS) assessment, dated 03/02/2021, revealed Resident #34 was rarely/never understood. Further review revealed Resident #34 required total care with the assistance of two (2) for toileting and the extensive assistance of one (1) for hygiene. Interview with Registered Nurse (RN) #1 on 03/31/2021 at 1:47 PM, revealed she had completed Resident #34's readmission assessment on 03/26/2021 and Resident #34 had a catheter. Review of Resident #34's, 03/26/2021 Readmission orders [REDACTED]. Observations on 03/29/2021 at 11:10 AM, 03/30/2021 at 9:20 AM, and 03/30/2021 at 3:30 PM, revealed Resident #34 was in bed and had an indwelling urinary catheter. Further observation revealed the urinary catheter bag was lying on the floor. Interview with State Registered Nurse Aide (SRNA) #3,who was assigned to Resident #34, on 03/31/2021 at 1:27 PM, revealed the resident did not have a catheter when he/she went to hospital. SRNA stated she did not recall noticing the position of the bedside drainage bag or if it was on the floor. Interview with Registered Nurse (RN) #1 on 03/31/2021 at 1:47 PM, revealed she had completed Resident #34's readmission assessment on 03/26/2021 and Resident #34 had a catheter. She revealed two (2) nurses completed admissions, one to complete the assessment and the other nurse to enter physician's orders [REDACTED].#1 stated she did not enter Resident #34's orders and was not sure why the catheter order was not placed on his/her care plan. She stated she was not aware Resident #34's catheter drainage bag was on the floor. The RN stated she would expect staff to ensure drainage bags were kept off the floor at all times. Interview with the Director of Nursing (DON) on 03/31/2021 at 230 PM, revealed she expected Resident #34's care plan to include the catheter. The DON stated the care plan should be updated and revised when a resident returned from the hospital to reflect their true status. She stated she was responsible for entering Resident #34's admission orders [REDACTED]. The DON further stated catheter bags should be kept off the floor to prevent infection control issues.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to have an effective system to ensure oxygen therapy was provided according to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observations on 03/30/2021 at 10:08 AM, 11:30 AM, and 1:20 PM revealed Resident #11's oxygen humidification container was empty and not dated. The findings include: Interview with the Director of Nursing (DON), on 03/30/2021 revealed the facility did not have a policy for oxygen humidification. However, the facility referenced the Lippincott Manual of Nursing Practices procedures in providing nursing care for residents with a [CONDITION(S)]. Review of the Lippincott Manual of Nursing Practices 11th Edition, dated 2018, Nursing Care for Residents with Artificial Airways revealed to ensure adequate ventilation and oxygenation through the use of supplemental oxygen or mechanical ventilation as indicated. Assess breath sounds every two (2) hours, note evidence of ineffective secretion clearance (rhonchi, crackles), which suggest need for suctioning. Provide adequate humidity when the natural humidifying pathway of the oropharanyx is bypassed. Record review revealed the facility admitted Resident #11 on 11/17/2015 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of zero (0), which indicated the resident was rarely/never understood. Review of Resident #11's Physician Orders, dated 12/30/2019, revealed an order to administer oxygen per [CONDITION(S)] Mask 35% humidified air to keep saturation greater than 92% every shift. Review of Resident #11's Comprehensive Care Plan titled,Potential for Complications related to History of Pneumonia and Compromised Respiratory System related to [CONDITION(S)] dated 11/30/2015, revealed a goal: resident will not exhibit signs of pneumonia or complications from respiratory compromise. Further review revealed an intervention for oxygen at 2 Liters per [CONDITION(S)] mask at 35% humidified oxygen air. Observations on 03/30/2021 at 10:08 AM, 11:30 AM, and 1:20 PM revealed Resident #11 received oxygen at two (2) liters per [CONDITION(S)] mask collar. However, the oxygen humidification container was empty and humidified oxygen was not provided, as ordered. Interview with Registered Nurse (RN) #1, on 03/31/2021 at 1:30 PM, revealed Resident #11 had humidified oxygen ordered. RN #1 stated the humidification container should not be empty and the licensed staff was responsible to ensure the resident's oxygen was humidified with an oxygen saturation greater than 92%. She stated without oxygen humidification, the resident was at risk for alteration in his/her respiratory status and decrease in his/her oxygen saturation. Interview with the Director of Nursing (DON), on 04/01/2021 at 2:05 PM, revealed Resident #11's oxygen should always be humidified as ordered.

Based on observation, interview, and review of the facility's policy and procedure, it was determined the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable. Observation on 03/30/2021 revealed there were two (2) expired medications stored in the facility's medication refrigerator. The findings include: Review of the facility's policy, Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles, last revised 10/28/2019, revealed the facility should ensure medications and biologicals have an expired date on the label; have been retained no longer than recommended by the manufacturer or supplier's guidelines; or if contaminated or deteriorated were stored separate from other medications until destroyed or returned to the pharmacy. Observation of the one (1) medication refrigerator on 03/31/2021 at 10:25 AM, revealed one (1) unopened, expired vial of [MEDICATION(S)] (Pneumonia Vaccine) with an expiration date of September 2020; and an opened bottle of Magic Mouthwash with an expiration date of 03/05/2021. Interview with Registered Nurse (RN#1) on 03/31/2021 at 10:40 AM revealed expired drugs should be removed from cart or refrigerator. Interview with the Director of Nursing (DON) on 03/31/2021 at 10:50 AM revealed nurses and medication techs should remove expired medications from the medication cart/refrigerator. She stated the nightshift nurses should check the medication room refrigerator weekly on Sundays, but she had no tracking system to ensure this had been done.

Based on observation, interview, facility policy review, and review of the Centers for Disease Control (CDC) and Prevention guidelines, it was determined the facility failed to ensure staff followed standard and transmission-based precautions to prevent the spread of infections; and, hand hygiene procedures when involved in direct resident contact. Resident #34 was on contact and droplet precautions due to being readmitted to the facility from hospital, however, observation revealed staff provided incontinent care to the resident without wearing a gown and shield. In addition, licensed staff placed Resident #14's medication in his/her mouth with her bare hand. The findings include: Review of the facility's policy on 2019 Novel Coronavirus (COVID19), last revised March 2021 under Transmission and Control Strategies revealed a health care provider (HCP) should wear a face mask at all times while they are in the facility. Further review revealed all newly admitted residents should be placed in Standard, Contact, and Droplet precautions; and be closely monitored in a private room, if possible. Review of the guidance from the Centers for Disease Control (CDC) Prevention revealed Standard Precautions were used for all patient care. They are based on a risk assessment and make use of common sense practices and personal protective equipment use that protect healthcare providers from infection and prevent the spread of infection from patient to patient. Further review revealed Contact Precautions requires the use of Personal Protective Equipment (PPE), including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Wear PPE upon room entry and properly discard before exiting. Droplet Precautions requires the use of a mask upon entry into the patient room or patient space. 1. Record review revealed the facility readmitted Resident #34 on 03/26/2021 with [DIAGNOSES REDACTED]. Observation on 03/29/2021 at 10:15 AM revealed Resident #34 had an isolation cart outside the door of his/her room with no visible signage indicating precautions were in place, and there were no receptacles for trash or soiled linens in the room. Further observation on 03/29/2021 at 2:30 PM revealed there were signs for contact precautions visible at door, and trash and linen receptacles were inside the doorway. Observation on 03/30/2021 at 9:30 AM revealed State Registered Nurse Aide (SRNA) #3 entered Resident #34's room and closed the door. Further observation revealed SRNA #3 was not wearing a gown or face shield. She proceeded to provide incontinent care and reposition the resident. Interview with SRNA #3 outside Resident #34's room on 03/30/2021 at 9:40 AM, related to the signage on the wall, she stated, I should have used a gown. SRNA #3 stated Resident #34 was not there the last time she worked. She further revealed new admissions/readmissions were placed in isolation and staff should wear PPE in those rooms when providing direct care. Interview with the Director of Nursing (DON), on 03/31/2021 at 2:28 PM revealed new admissions and re-admissions were placed on the observation unit. The DON stated residents should have isolation carts outside the door, signs that tell what type of precaution, and containers in the room for soiled linens and trash. She further revealed Personal Protective Equipment should be worn as long as a resident was on isolation. She stated the facility's policy mimicked the CDC guidelines 2. Record review revealed the facility admitted Resident #14 on 08/09/2017. Review of the Quarterly MDS assessment, dated 03/12/2021, revealed the facility assessed Resident #14's cognition as intact with a BIMS score of fifteen (15), which indicated the resident was interviewable. Observation on 03/30/2021 at 9:40 AM, revealed the Assistant Director of Nursing administered Resident #14 [MEDICATION NAME] (pain medication) and [MEDICATION NAME] XL (hypertension) by removing both pills from the medicine cup with her bare hand and placing them in the resident's mouth. Interview with the Assistant Director of Nursing (DON) on 04/01/2021 at 2:05 PM, revealed Resident #14 asked her one (1) time to wear gloves when administering his/her medication although he/she did not say why. The DON stated she gave the resident's medication either bare handed or with a spoon. Interview with the Director of Nursing (ADON) on 04/01/2021 at 2:40 PM, revealed she stated, I would expect staff to administer his/her medications with a spoon or gloved hand, not bare handed due to infection control.

Based on interview, record review, facility policy review, facility Event Report review, and Hospital Record review, it was determined the facility failed to ensure services provided or arranged by the facility met professional standards of quality for one (1) of three (3) sampled residents, (Resident #1). On 04/17/2020, Licensed Practical Nurse (LPN) #1 failed to obtain vital signs, and assess for pain and injury per facility care standards after Resident #1 was found on the floor. In addition, licensed staff failed to assess the resident each shift on 04/18/2020 and 04/19/2020, per facility care standards to determine the resident's status after the incident. These failures resulted in Resident #1's treatment being delayed and on 04/20/2020, it was determined the resident had a fractured right hip. The Resident was admitted to the hospital and required surgery. The findings include: Review of the facility's policy titled, Care Standards, dated July 2017, revealed when made aware of a change in condition of a resident the Licensed nurse will perform an assessment based on their professional judgement that may include: vital signs, skin inspection, pain level as pertinent, voiced complaints by the resident if any, and actions already taken. Review of the facility's policy titled, Care Standards, dated November 2019, revealed all incidents or accidents (regardless of how minor they may present) must be reported to the Charge Nurse immediately upon discovery with a completed applicable event report and communicated to the on-coming shift. Further review of the policy revealed following an incident/accident event, the charge nurse shall complete an Event in the resident's medical record before leaving the facility. If a Fall Event has occurred, ensure immediate interventions were in place to prevent re-occurrence. Report off to the next shift or on-coming shift of the event to alert nursing that documentation related to the resident's status following the accident/incident is required every shift for seventy-two (72) hours. Closed record review revealed the facility admitted Resident #1 on 04/10/2020 and discharged on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 04/15/2020 revealed the facility assessed Resident #1's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of five (5) which indicated the resident was not interviewable. Review of Resident #1's Progress Notes revealed a late entry was completed by LPN #1, on 04/20/2020 at 4:04 AM, for an unwitnessed fall that occurred on 04/17/2020. LPN #1 documented, Resident had been combative and appeared he/she had sat him/herself in the floor beside his/her bed, states no pain at this time. There was no evidence LPN #1 followed the facility's care standards related to assessing the resident or documenting the incident and completing an event report. The event report included an area to document nursing resident assessment and interventions put in place to address the incident; and, reporting the incident to the oncoming shift on 04/17/2020. In addition, there was no evidence in the Progress Notes, dated 04/17/2020-04/19/2020 that licensed staff completed nursing assessments of the resident every shift for seventy-two (72) hours after the incident, per facility care standards. Review of Resident #1's Falls Event Report revealed LPN #1 did not complete the event report related to being found on the floor, on 04/17/2020 until 04/20/2020 at 1:29 AM. Review of Progress Notes, dated 04/20/2020 at 9:58 AM, revealed the resident complained of pain to right hip and leg, and an x-ray was conducted. Review of Resident #1's Hospital Record, dated 04/20/2020, revealed the resident sustained [REDACTED]. Interview with LPN #1, on 11/12/2020 at 10:41 AM, revealed on 04/17/2020, Resident #1 refused his/her medications twice and was asking staff to leave his/her room. She stated after the nighttime medication pass she found Resident #1 sitting in the floor beside his/her bed. She revealed she asked Resident #1 what happened and the Resident stated, I sat in the floor because I don't need help. She stated the resident denied any pain and denied injury. LPN #1 revealed she failed to complete a Fall Event report because she felt it was not a fall but the resident chose to place him/herself in the floor. She stated she failed to document the incident in the progress notes. Further interview with LPN #1 revealed she called the Director of Nursing (DON) late Sunday evening on 04/19/2020, and explained the incident. She stated the DON instructed her to complete a Falls Event Report and a late entry in the Progress Notes. Interview with Certified Nurse Aide (CNA) #2 on 11/10/2020 at 1:07 PM, revealed she had worked dayshift on 04/18/2020, and taken care of Resident #1. She stated the resident had complained of pain to either the right or left hip area and she reported the resident's complaints of pain to the nurse. Interview with CNA #1, on 11/12/2020 at 1:26 PM, revealed she worked dayshift on 04/18/2020 and 04/19/2020 and provided care to Resident #1. She stated Resident #1 required more assistance going back to the bed after using the bedside commode and the nurse came to help but she could not remember which nurse. She revealed Resident #1 seemed tired and could not help as much during the transfer. Interview with Licensed Practical Nurse (LPN) #3 on 11/12/2020 at 10:10 AM, revealed she provided care to Resident #1 on 04/18/2020. She stated the resident required more assistance during a transfer from the bedside commode back to bed and she assessed the resident after the resident was placed in bed. She stated the resident complained of general pain but to no certain area so she offered him/her some pain medication and the resident declined. LPN #3 further stated she failed to document Resident #1's assessment but was aware the resident placed him/herself in the floor. Interview with LPN #2, on 11/12/2020 at 1:05 PM, revealed she had only worked with Resident #1 briefly on 04/19/2020 and did not recall anyone reporting the resident complained of pain. She stated she did not remember anything because it was in April 2020 and she had no documentation. Interview with Registered Nurse (RN) #1, on 11/10/2020 at 2:03 PM, revealed during dayshift on 04/20/2020, Resident #1 complained of pain to his/her legs. She stated she notified the physician and received an order for [REDACTED]. Telephone nterview with the Director of Nursing (DON) on 11/12/2020 at 4:11 PM, revealed LPN #1 called her late on 04/19/2020 and stated she had found Resident #1 sitting on the floor beside his/her bed on 04/17/2020. She stated LPN #1 felt it was not considered a fall because the resident stated he/she had placed him/herself in the floor and had no complaints of pain. The DON revealed she instructed LPN #1 to complete a Fall Event Report because Resident #1's cognition was moderately impaired. She stated she expected licensed staff to complete a Fall Event Report with any fall and document continuous assessments of the resident's status for at least seventy-two (72) hours, per facility care standards. Telephone interview with the facility Administrator, on 11/12/2020 at 4:15 PM, revealed new hires are educated on the facility falls policy and she would expect staff to monitor the resident per the policy and document their findings. She further stated the DON is available if a nurse needs guidance on any situation regarding a resident.

Based on interview, record review, facility policy review, facility Event Report review, and hospital record review, it was determined the facility staff failed to identify one (1) of three (3) sampled residents had a fall and thoroughly investigate the fall and monitor the resident to ensure no injury (Resident #1) Licensed Practical Nurse (LPN) #1 failed to identify Resident #1 had an unwitnessed fall when found on floor at his/her bedside, and failed to complete a Fall Event Report at that time which would have included an assessment of resident for injuries, conditions surrounding the event, and interventions put in place to try to prevent further incidents, per facility policy. In addition, licensed staff failed to assess the resident every shift on 04/18/20 and 04/19/20 to identify if any change in resident's condition occurred, due to the fall, per facility policy. On 04/20/2020, x-ray results revealed Resident #1 had a right femoral fracture and was hospitalized for [REDACTED]. The findings include: Review of the Resident Assessment Instrument User's Manual, Version 3.0, Chapter 3, page J-27 revealed unless there was evidence suggesting otherwise, when a resident was found on the floor, a fall was considered to have occurred. Review of the facility's policy titled, Falls Prevention and Management Program, dated June 2016, revealed key components for the management of falls and injuries must include investigations conducted thoroughly, accurately, and timely. All factors that contributed to the event have been identified. The process of an effective root cause analysis was to first gather and document initial information, fill in the gaps, analyze, develop an action plan, implement new interventions and evaluate results. Review of the facility's policy titled, Care Standards, dated November 2019, revealed all incidents or accidents (regardless of how minor they may present) must be reported to the Charge Nurse immediately upon discovery with a completed applicable event report and communicated to the on-coming shift. Further review of the policy revealed following an incident/accident event, the charge nurse shall complete an Event in the resident's medical record before leaving the facility. If a Fall Event has occurred ensure immediate interventions are in place to prevent re-occurrence. Report off to the next shift or on-coming shift of the event to alert nursing that documentation related to the resident's status following the accident/incident is required every shift for seventy-two (72) hours. Review of a blank Fall Event Report, revealed it gathers information to include assessments for pain, injury, neurological checks, mental status, possible contributing factors to fall, and risks involved. Further review of the Report revealed care plan interventions with a box for nurse to choose which one to put in place at that time. Closed record review revealed the facility admitted Resident #1 on 04/10/2020 and discharged on [DATE], with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 04/15/2020, revealed the facility assessed Resident #1's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of five (5) which indicated the resident was not interviewable. Further review of the MDS revealed the resident required an assist of one (1) staff for transfers, extensive assist of two (2) staff with walking, required the use of a walker or wheelchair for mobility, and balance during transitions and walking was not steady only able to stabilize with human assistance. The MDS further indicated the resident had fallen in the last month prior to admission. Review of the Comprehensive Care plan Falls dated 04/16/2020 revealed Resident #1 was at risk for falls due to confusion, decreased mobility and weakness related to recent hospitalization with interventions to evaluate a need for bed/chair alarm, implement exercise program that targets strength, gait and balance; increased staff supervision with intensity based on resident need, comprehensive medication review by pharmacist, and provide individualized toileting interventions based on needs/patterns. Interview with Resident #1's Responsible Party, on 11//10/2020 at 9:39 AM, revealed he received a call from the facility, on 04/18/2020, stating Resident #1 had a fall and there was no injury. He stated Resident #1 spoke to a family member on the phone either on 04/18/2020 or 04/19/2020, and he/she told them he/she had fallen and was hurting. He stated when he was notified of Resident #1's injury on Monday (04/20/2020) he was very upset and notified the Ombudsman. He stated because of visitation restrictions at that time, he could only go on the word of the facility staff and felt treatment was delayed. Review of the Resident #1's Progress Notes, revealed a late entry was completed by LPN #1, on 04/20/2020 at 4:04 AM, related to the resident being found in the floor, on 04/17/2020. LPN #1 documented, Resident had been combative and appeared he/she had sat him/herself in the floor beside his/her bed, states no pain at this time. There was no documented evidence an incident report was completed, nor of a resident assessment for injury. In addition, no interventions wer put in place to address the resident's getting out of bed without assistance, per facility policy; on 04/17/20 at time of fall. Review of the Falls Event Report revealed LPN #1 had not completed the event report for Resident #1's fall on 04/17/2020 until 04/20/2020 at 1:29 AM. Further review of the report revealed LPN #1 documented Resident #1 appeared to have sat him/herself in the floor on 04/17/2020 at 10:28 PM. At time of fall, the Resident had access to equipment and care items, living space was free of clutter, there were clear pathways, and adequate lighting. In addition, she documented Resident #1 had no complaints of pain, no injury was noted, range of motion (ROM) was completed without limitations, no rotation/deformity/shortening of extremities was noted, and Resident was alert with clear speech. Continued review of the Falls Event Report revealed she documented contributing factors to the fall included incontinence, balance problem, and hypertension; and there were no risk factors identified related to the fall. The immediate intervention was to reposition for comfort; however, there was no intervention to address the resident getting up without assistance. Further review of the Progress Notes dated 04/18/2020 - 04/20/2020 revealed there was no documented evidence nursing assessments were completed each shift for seventy-two (72) hours after the incident to monitor Resident #1's status after the fall, per facility policy until 04/20/2020 at 9:58 AM, when the resident complained of pain to right hip and leg. The Advanced Practice Registered Nurse (APRN) was notified and an order received for an x-ray. Review of Progress Notes dated 04/20/2020 at 1:14 PM, revealed x-ray results received and the resident was identified to have a right femoral fracture (right [MEDICAL CONDITION]). The APRN was notified and an order was received to send the resident to the hospital for evaluation. Review of Resident #1's Hospital Record, dated 04/20/2020, revealed the resident sustained [REDACTED]. Further review of the Hospital Record revealed Resident #1 required a right trochanteric fixation nailing (surgery). Interview with LPN #1, on 11/12/2020 at 10:41 AM, revealed on 04/17/2020, Resident #1 refused his/her medications twice and told staff to leave his/her room. LPN #1 stated she documented the resident was combative because the resident did not want medications and wanted staff to leave him/her alone. She revealed she found Resident #1 sitting in the floor bedside his/her bed after the nighttime medication pass. She stated she asked Resident #1 what happened and the Resident stated I sat in the floor because I don't need help. LPN #1 revealed the resident took her hands and she assisted Resident #1 back on to the bed by sliding the resident's bottom up on to the low positioned bed. She stated the resident denied any pain and was assessed with [REDACTED].#1 further revealed she failed to complete a Fall Event Report because she felt it was not a fall but the resident chose to place him/herself in the floor. She stated she failed to document the incident in the nurses notes but did pass it on to the next shift. Further interview (Post Survey) by telephone with LPN #1 on 11/19/2020 at 3:16 PM, revealed LPN #1 felt it was not a fall because the resident's cognition level at the time was not impaired when the resident stated, I sat myself in the floor; however, per the MDS assessment dated [DATE], the resident's cognition was severely impaired. She stated she did not put an intervention in place to address the resident getting up without assistance because she felt an alarm would only agitate the resident because he/she had refused his/her night time medications. Interview with Certified Nurse Aide (CNA) #1, on 11/12/2020 at 1:26 PM, revealed she worked dayshift on 04/18/2020 and 04/19/2020, and provided care to Resident #1. She stated Resident #1 required more assistance going back to the bed after using the bedside commode and the nurse came to help but she could not remember which nurse. She revealed Resident #1 seemed tired and could not help as much during the transfer. CNA #1 further stated she did not remember the resident ever trying to get up without assistance. Interview with CNA #2, on 11/10/2020 at 1:07 PM, revealed she had worked dayshift on 04/18/2020 and taken care of Resident #1. She stated the resident had complained of pain to either the right or left hip area and she reported the resident's complaints of pain to the nurse. CNA #2 stated she was unable to recall any further details at this time. Interview with Licensed Practical Nurse (LPN) #3, on 11/12/2020 at 10:10 AM, revealed she had provided care to Resident #1, on 04/18/2020. She stated the resident had required more assistance during a transfer from the bedside commode back to bed. She revealed after the resident was placed in bed, she assessed him/her and saw no redness or bruising. She stated the resident complained of general pain but to no certain area, so she offered him/her some pain medication and the resident declined. LPN #3 further stated she failed to document Resident #1's assessment but was aware the resident placed him/herself in the floor. LPN #3 stated Resident #1 required assistance with transfers and had not made any attempts to self-transfer during her shift. Interview with LPN #2, on 11/12/2020 at 1:05 PM, revealed she had been told the resident had put him/herself in the floor. She stated she only worked with Resident #1 briefly on 04/19/2020, and did not recall anyone reporting the resident complained of pain. LPN #2 stated she could not offer much else because the resident was only in the facility briefly. Interview with Registered Nurse (RN) #1, on 11/10/2020 at 2:03 PM, revealed during dayshift on 04/20/2020, Resident #1 complained of pain to his/her legs. She stated she notified the physician and received an order for [REDACTED]. Telephone interview with the Director of Nursing (DON), on 11/12/2020 at 4:11 PM, revealed LPN #1 called her late on 04/19/2020, and stated she had found Resident #1 sitting on the floor beside his/her bed on 04/17/2020. She stated LPN #1 felt it was not considered a fall because the resident stated he/she had placed him/herself in the floor and had no complaints of pain. The DON instructed LPN #1 to complete a Fall Event Report because Resident #1's cognition was moderately impaired. She stated she expected licensed staff to complete a Fall Event Report with any fall, and document continuous assessments of the residents status for at least seventy-two (72) hours. Telephone interview with the facility Administrator, on 11/12/2020 at 4:15 PM, revealed new hires are educated on the facility falls policy and she would expect staff to monitor the resident. She further stated the DON is available if a nurse needs guidance on any situation regarding a resident.

Based on interview, record review, and facility policy review, it was determined the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete and accurately documented for one (1) of three (3) sampled residents (Resident #1). Record review reveal Resident #1 was found on the floor beside his/her bed on 04/17/2020, however, Licensed Practical Nurse (LPN) #1 failed to document the event until 04/20/2020. In addition, licensed staff failed to document nursing assessments of Resident #1 after the fall. The findings include: Telephone interview (Post Survey) with the Director of Nursing (DON) on 11/19/2020 at 9:45 AM, revealed the facility does not have a documentation policy. She stated the facility follows federal and state regulations related to documentation in the resident's clinical record. Closed record review revealed the facility admitted Resident #1 on 04/10/2020 and discharged on [DATE] with [DIAGNOSES REDACTED]. Review of Progress Notes, dated 04/20/2020 at 4:04 AM, revealed LPN #1 completed a late entry for Resident #1's fall on 04/17/2020. Further review of the Progress Note revealed, resident had been combative and appeared to have sat him/herself on the floor beside his/her bed, no pain at this time. Interview with LPN #1, on 04/12/2020 at 10:41 AM, revealed she failed to document the incident in the progress notes because she felt it was not a fall. She stated only after speaking to the Director of Nursing (DON) on Sunday evening did she document a late entry in the progress notes for Resident #1's fall that occurred on 04/17/2020. LPN #1 stated she worked the nights of 04/18/2020 and 04/19/2020, and frequently checked on Resident #1. She further stated Resident #1 had no complaints of pain. LPN #1 stated she failed to document the fall, vital signs, and nursing assessments because she felt the resident had not fallen but rather sat him/herself in the floor. Interview with Licensed Practical Nurse (LPN) #3, on 11/12/2020 at 10:10 AM, revealed she had provided care to Resident #1 on 04/18/2020. She stated she knew the resident had slipped out of bed on 04/17/2020, and when the resident required more assistance during a transfer, she assessed the resident's skin for injury and none was noted. LPN #3 revealed she failed to document her assessment in the Progress Notes because she did not notice any bruising or redness. Telephone interview with the Director of Nursing (DON), on 11/12/2020 at 4:11 PM, revealed licensed staff should document falls and ongoing assessments of the resident in the progress notes. Telephone interview with the facility Administrator, on 11/12/2020 at 4:15 PM, revealed new hires are educated on the facility falls policy and she would expect nursing staff to document a fall in the resident's medical record. She further stated the DON is available if a nurse needs guidance on any situation regarding a resident.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure medications were given in a timely manner to one (1) of three (3) sampled residents (Resident #2). The findings include: Review of facility policy titled, Medication Administration Times, revealed the facility should ensure that authorized personnel, as determined by applicable law, administer medication according to times of administration as determined by facility's pharmacy committee and/or physician/prescriber. Facility should commence medication administration within (60) sixty minutes before the designated times of administration and complete by (60) sixty minutes after the designated times of administration. Record review revealed the facility admitted Resident #2 on 07/03/18 with [DIAGNOSES REDACTED]. Review of Resident #2's Comprehensive Care Plan for Resident has [MEDICAL CONDITION] and is at risk for complications, dated 07/12/18, revealed to administer medication as ordered. Review of Resident #2's Medication Flow sheet revealed to administer [MEDICATION NAME] 40 milligrams (mg) twice a day (8:00 AM and 2:00 PM). The order was initiated on 01/02/19. Observation of a medication pass on 12/17/19 at 9:20 AM revealed Registered Nurse (RN) #1 administered Resident #2, [MEDICATION NAME] 40 mg at approximately 9:20 AM (twenty (20) minutes after 60 minute timeframe ended) Interview with RN #1 on 12/17/19 at approximately 9:30 AM revealed Resident #2's [MEDICATION NAME] 40 mg should have been administered at 8:00 AM and she did not know the policy related to administration of medication in a timely manner. Interview with the Director of Nursing (DON) on 12/17/19 at approximately 11:00 AM, revealed the medication error was a transcription error and the time had defaulted to 8:00 AM and 2:00 PM as the times of administration; however, Resident #2 hall's medication pass was to be completed a 9:00 AM. She stated staff should have identified this and corrected it. Review of form provided by facility on 12/17/19 revealed Medication pass times on Hall 600 (Resident 2's hall) were 9:00 AM/1:00 PM/5:00 PM/and 9:00 PM.

Based on interview, record review, and facility policy review, it was determined the facility failed to consult with the resident's physician when there was a significant change and a need to alter treatment significantly for one (1) of eighteen (18) sampled residents (Resident #35). Resident #35 refused breakfast and lunch on 10/14/18, 10/15/18, 10/17/18 and 10/18/18 and only ate twenty-five (25) percent at supper; and his/her twenty-four (24) hour intake totaled 600 milliliters (mL) 10/14/18; 580 mL on 10/15/18; 600 mL on 10/16/18; and, 420 mL on 10/17/18 and 10/18/18; however, the facility failed to make the Physician/APRN aware of the resident's continued refusals of meals and decrease in fluid intake per facility policy. On 10/18/18 at 8:09 AM, Resident #35 experienced an episode of vomiting, he/she did not eat or drink at breakfast and would not take his/her morning medications. At 9:44 AM on 10/18/18, the resident experienced another episode of vomiting. Additionally, the resident's blood pressure was low, and a urinalysis (UA) was ordered on [DATE] but was not obtained prior to the resident's transport to the emergency roiagnom on [DATE]. However, there was no documented evidence of Physician/APRN notification of the resident's continued vomiting on 10/18/19, low blood pressure, or that staff were unable to obtain the 10/16/18 ordered UA, so treatment could be altered; per facility policy. The findings included: Review of facility policy titled Nonfiction of Change, dated (MONTH) (YEAR), revealed the residents' physician and responsible party must be notified when an event involving the resident occurs or when the resident experiences a change in condition, potential discharge, room transfer or death. The facility has adopted the current INTERACT Tools Change in Condition: When to report to the Physician, Physician Assistant (PA) or Advanced Practice Registered Nurse (APRN). The program is an evidence based program that may be utilized by the nurse when needed and does not supersede the clinical judgement of the licensed nurse. Review of the INTERACT Version 4.0 Tool, updated June, (YEAR), revealed the Physician, PA or APRN should be notified immediately for any symptom, sign or apparent discomfort that is acute or sudden in onset; and a marked change in relation to usual symptoms and signs; or unrelieved by measures already prescribed. Non-immediate notification would be for new or worsening symptoms that do not meet the above criteria. Additional review revealed a listed sign or symptom to report included diminished appetite, with immediate notification for no oral intake two (2) consecutive meals; and non-immediate notification would be for significant decline in food and fluid intake in the resident with marginal hydration and nutritional status. A second listed symptom to report was vomiting with immediate notification if persistent or recurrent (two (2) or more within twelve (12) hour) vomiting, with or without abdominal pain, bleeding, distention/fever; and non-immediate notification would be for intermittent recurrent vomiting without immediate notification criteria met. Record review revealed the facility admitted Resident #35 on 03/09/18 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set, dated dated [DATE], revealed the facility assessed Resident #35's cognition as severely impaired as the resident was unable to complete a Brief Interview of Mental Status (BIMS) exam indicating the resident was not interviewable. Further review of the Quarterly MDS revealed Resident #35 required total care with all activities of daily living (ADL's); and the resident was incontinent of bowel and bladder. Review of the Intake and Output Record for October, (YEAR), revealed Resident #35 had refused breakfast and lunch on 10/14/18, 10/15/18, 10/17/18 and 10/18/18 and only ate twenty-five (25) percent at supper on each of these days. On 10/16/18, the resident ate fifty (50) percent of breakfast and twenty-five (25) percent of lunch and dinner. Further review revealed the resident's fluid intake was poor. On 10/14/18, twenty-four (24) hour intake totaled 600 milliliters (mL); on 10/15/18: 580 mL; on 10/16/18: 600 mL; and, on 10/17/18 and 10/18/18: 420 mL for each day. The resident's usual average fluid intake for twenty-four (24) hours was 1000 ml per day. Review of the Nurse's Progress Notes dated 10/17/18 at 4:14 PM revealed RN #1 was alerted Resident #35 wasn't acting right. Vital signs were, blood pressure 102/48 (base line 128/68), temperature 103.3 degrees Fahrenheit, heart rate 120 (base line 65), resident awake and alert, grinding teeth at times. At 4:37 PM, RN #1 telephoned the Physician's Assistant (PA) (who was back-up call for the Advanced Practice Registered Nurse {APRN}) and received orders for Tylenol 650 mg suppository to be given then and every six (6) hours as needed for elevated temperature; and a UA per in and out catheterization. Further review of the Nurse's Progress Notes revealed an in and out catheterization (cath) was not attempted until 10/17/18 at 9:00 PM by RN #3 , almost five (5) hours after the order was received. The attempt was unsuccessful due to only a scant amount of urine obtained. Further review revealed there were two (2) other entries made in the Nurse's Progress Notes, on 10/17/18 at 6:26 PM and on 10/18/18 at 9:44 AM by RN #1 revealing the resident had incontinent episodes and staff were unable to obtain a urine specimen. Review of the Nurse's Progress Notes, dated 10/18/18 at 8:09 AM, by Registered Nurse (RN) # 1 revealed Resident #35 did not eat any breakfast this morning or drink any fluid. He/she would not take morning medications with liquids or food. The RN documented she was informed by a nurse assistant that the resident has vomited greenish fluid earlier that morning. and the resident's temperature was 99.1 degrees Fahrenheit. Further review of the Nurse's Progress Notes, dated 10/18/18 at 9:44 AM, by RN #1, revealed Resident #35 vomited greenish bile fluid, approximately 100 milliliters (mL). However, further clinical record review revealed there was no documented evidence the Physician, PA, or APRN was notified of the severe decrease in food or fluid intake; that the resident had two (2) episodes of vomiting on 10/18/18 at 8:09 AM and 9:44 AM; or that the staff had not obtained the UA ordered on [DATE]. Review of the Clinical Situation, Background, Assessment and Review (SBAR) Form for Resident #35, dated 10/18/18 at 4:30 PM, (almost seven (7) hours after the last documented emesis) completed by RN #1, revealed under 'Situation', 'The change in condition, symptoms, or signs I am calling about is/are', Resident has been vomiting green bile looking fluid X 3 over 2 days; just not acting right in general; not eating or drinking; was given an enema earlier today due to constipation and temp of as high as 103.3 however now is 99.2. The APRN was notified and orders received to notify the resident's family and let them decide if they want the resident sent to the emergency room (ER) for evaluation. Review of the Nurse's Progress Notes dated 10/18/18 at 6:57 PM, by RN #1, revealed Resident #35 was transported, by family in a private vehicle, to the ER. Review of the Hospital Discharge Summary revealed Resident #35 was admitted to the hospital on [DATE] at 9:00 PM with [DIAGNOSES REDACTED]. Review of the Discharge Physician's Note revealed, on admission, the resident was also hemoconcentrated initially and with hydration, labs improved. After treatment, the resident was discharged from the hospital on [DATE]. Interview with RN #1 on 01/11/18 at 2:22 PM and on 01/23/19 at 11:41 AM (Post Survey) revealed she worked day shift on 10/17/18 and 10/18/18. RN #1 stated she had not been monitoring the Intake and Output sheets as she did not know where they were located and no one had told her she needed to do so. Interview (Post Survey) with the APRN on 01/25/19 at 9:33 AM revealed she knew Resident #35 had been having some vomiting because she ordered [MEDICATION NAME] on 10/16/18, however, she was not aware the resident had vomited two (2) times on 10/18/18 (8:09 AM and 9:44 AM). The APRN further stated she was aware the resident had not been eating well, however, she was not made aware of how poor the resident's food and fluid intake had been. Additionally, the APRN stated had she been made aware of the severity of the resident's illness (more vomiting, severity of lack of food and fluid intake, and low blood pressure) she would have initiated intravenous fluids or sent the resident to the ER sooner. The APRN further stated had she been contacted by the facility, it probably would have made a difference in the severity of the resident's illness and the outcome as well. Interview (Post Survey) with the Director of Nursing (DON) on 01/24/19 at 8:52 AM revealed she felt like RN #1 completed a full assessment and she trusted the RN nursing judgment on when to notify or not notify the physician.

Based on interview, record review and review of facility policy, it was determined the facility failed to ensure the residents received treatment and care in accordance with professional standards of practice to prevent hospitalization for one (1) of eighteen (18) sampled residents (Resident #35). Record review revealed Resident #35 had a decline in intake, episodes of vomiting from 10/14/18-10/16/18, and constipation. The Advanced Practice Nurse Practitioner (APRN) saw Resident #35 on 10/16/18 and ordered a stool softener for constipation and an antiemetic for nausea and vomiting. On 10/17/18 at 4:14 PM, the resident had symptoms of temperature of a 103.3 degrees Fahrenheit, heart rate 120 (base line 65), blood pressure 102/48 (base line 128/68) and was grinding his/her teeth at times. The Physician Assistant and APRN were contacted with orders received for labs and Tylenol. However ,further record review revealed there was no evidence a complete nursing assessment was completed per facility policy when the resident's change in condition was first identified on 10/16/18 and no evidence ongoing assessments were completed per policy due to the resident's continued refusal of meals, vomiting, and lack of bowel movements. The resident was hospitalized [DATE] to 10/22/18 with [DIAGNOSES REDACTED]. The findings included: Review of the facility policy titled, Standard of Nursing Practice, last revised (MONTH) (YEAR), revealed residents having any change in condition will have a complete nursing assessment performed and documented. A complete nursing assessment may include but is not limited to: vital signs with temperature, bowel sounds, lung sounds, oxygen saturation level, skin appearance, mental status, review of meal intakes over a twenty-four hour period, and review of bowel elimination record over the last three (3) days. On-going monitoring may be required to identify the resident's response to clinical interventions and if resolution is achieved. The resident's response will determine the frequency of the assessment. Reasons to assess the resident's condition more frequently include vomiting and/or diarrhea, new onset or increased complaints of pain, increased confusion. Monitoring a change in condition requires the nurse to include an entry in the progress notes. Communication to the physician will require completion of a SBAR (Situation, Background, Assessment, Recommendation) tool. Monitoring a resident's condition may have multiple entries in the resident's medical record and include progress notes, observations, and assessment tools. Record review revealed the facility admitted Resident #35 on 03/09/18 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 01/07/19, revealed the facility assessed Resident #35's cognition as severely impaired as the resident was unable to complete a Brief Interview of Mental Status (BIMS) exam indicating the resident was not interviewable. Further review of the Quarterly MDS revealed Resident #35 required total care with all activities of daily living (ADL's); and the resident was incontinent of bowel and bladder. Review of the Intake and Output Record for October, (YEAR), revealed Resident #35 started having a decreased intake of food and fluid on 10/14/18. On 10/14/18 and 10/15/18, the resident refused breakfast (prior average intake 40%), only had bites for lunch (prior average intake 50%), and only ate twenty-five (25) percent for supper (prior average intake 35%), each day. The resident drank 120 milliliters (mL) of fluid for each of the six (6) meals on these two (2) days (average prior fluid intake was 240 mL each meal). On 10/16/18, the resident ate fifty (50) percent of breakfast, and twenty-five (25) percent for lunch and supper; and, drank 120 ml fluid with each meal. Further review of the Intake and Output Record revealed the resident had one (1) small bowel movement on 10/14/18, none on 10/15/18 and one (1) small on 10/16/18. Review of the Nursing Progress Notes dated 10/14/18-10/16/18 revealed there was no documented evidence the resident was assessed related to having any decline in his/her food and fluid intake, being constipated, or having nausea/vomiting peer facility policy. However, further review of the Nurse's Progress Notes revealed on 10/16/18 at 10:57 AM, the APRN assessed Resident #35 and ordered [MEDICATION NAME] (stool softener) two times a day for constipation and [MEDICATION NAME] (antiemetic) 4 milligrams (mg) every four (4) hours as needed for nausea and vomiting. In addition, there was no evidence a SBAR was completed per facility policy to ensure the Nurse Practitioner had all the information of an assessment. Review of the APRN's Progress Note dated 10/16/18 revealed nursing staff stated Resident #35 had only two (2) bowel movements in the last fourteen (14) days and was also having some issues with occasional vomiting. On physical exam, the APRN assessed the resident to have pale, warm and dry skin; bowel sounds present, abdomen was soft, round and nontender. Orders were given for [MEDICATION NAME] Sodium ten (10) mL orally two (2) times per day and [MEDICATION NAME][MEDICATION NAME] (4) mg every six (6) hours as needed. Interview with Registered Nurse (RN) #4 on 01/23/19 at 6:33 PM, revealed she worked on 10/15/18, day shift. RN #4 did not recall why the [MEDICATION NAME] was increased or why [MEDICATION NAME] was ordered on [DATE]. The RN stated she thought the resident had a history of [REDACTED]. Interview (Post Survey) with RN #2 on 01/24/19 at 9:03 AM, revealed she documented the APRN's visit on 10/16/18 at 10:57 AM. She stated she did not recall the reason for the increase in [MEDICATION NAME] or the new order for [MEDICATION NAME]. RN #2 further stated if the [MEDICATION NAME] was increased, the resident was probably having problems with constipation. The RN did not recall if the resident was having nausea or vomiting at that time. Further review of the Intake and Output Record for October, (YEAR) revealed on 10/17/18 the resident refused food and fluid for both breakfast and lunch and ate fifty percent of supper on 10/17/18. His/her fluid continued to decline with daily, twenty-four (24) hour, fluid intake total of 420 mL (normal fluid intake averaged one-thousand (1000) mL per day or more). In addition, the resident had one (1) medium bowel movement on 10/17/18. Review of the Nursing Notes dated 10/17/18 at 3:21 AM revealed Resident #35 was tolerating the increase in [MEDICATION NAME] without adverse effects and the resident did not request [MEDICATION NAME] this shift. Further review revealed there was no documented evidence the resident was assessed again due to the resident refusal of both breakfast and lunch, and decline in fluid intake per facility policy. On 10/17/18 at 4:14 PM (approximately thirteen (13) hours after last assessment), the nurse was alerted the resident wasn't acting right and the resident's vital signs were blood pressure: 102/48 (base line 128/68), temperature: 103.3 degrees Fahrenheit, heart rate: 120 (base line 65), with resident awake and alert, and grinding teeth at times. Registered Nurse (RN) #1 attempted to contact the APRN two (2) times and text her as well with no response. RN #1 telephoned the Physician's Assistant (PA) and received orders for Tylenol 650 mg suppository to be given then and every six (6) hours as needed for elevated temperature and a UA per in and out catheterization. Tylenol was given at that time. Further review of the Nursing Notes revealed on 10/17/18 at 4:46 PM, the APRN returned telephone calls with orders for a CBC, CMP, and to check bowel sounds. Temperature at that time was 102.3 degrees Fahrenheit and bowel sounds were positive in all four (4) abdominal quadrants. Review of the Nurse's Progress Notes revealed Resident #35 had emesis of greenish fluid, did not eat any breakfast or drink any fluid, and would not take his/her morning medications with food or fluid on 10/18/18 at 8:09 AM, and was given an enema at 9:12 AM with only small results. At 9:44 AM, the resident had emesis of green fluid again. Further review of the Intake and Output Record for October, (YEAR) revealed on 10/18/18 the resident refused food and fluid for lunch. Further review of the Nursing Notes revealed there was no documentation of the resident's condition or of ongoing assessments per facility policy from 10/18/18 at 9:44 AM to 2:37 PM. On 10/18/18 at 2:37 PM vital signs were: blood pressure 92/42, heart rate 109, respirations 22 and temperature 99.8 degrees Fahrenheit Review of the facility's Observation Detail List Report (Situation, Background, Assessment, Recommendation, SBAR) completed on 10/18/18 at 5:10 PM by RN #1 revealed the ARPN was notified on 10/18/18 at 4:30 PM regarding Resident #35's condition. The report revealed the resident's symptoms started on 10/17/18 and it was reported to the ARPN the resident had vomited green bile three (3) times over two (2) days; the resident had not been acting right in general; the resident was not eating or drinking; and, was having fever and had been given Tylenol Suppositories two (2) times. Vital signs were blood pressure 94/68; heart rate 109; respirations 18; and temperature 99.3 degrees Fahrenheit. The SBAR indicated there were no gastrointestinal/abdomen or gastrourinary changes and revealed the resident was not having pain. The APRN gave an order to let the family decide if they wanted the resident sent to the ER. Review of the Nurse's Notes, revealed RN #1 spoke to Resident #35's brother on 10/18/18 at 5:52 PM and at 6:27 PM, Resident #35 was in stable condition and was transported to the hospital ER in a private vehicle by his/her brother. Review of the Hospital Labs obtained at the hospital dated 10/18/18 revealed Resident #35's Blood Urea Nitrogen (BUN) was 38 (7-25); Creatinine 2.9 (0.6-1.2); and White Blood Cells (WBC) 33.9 (4.0-10.0); and review of the UA results revealed the urine was dark yellow, cloudy with moderate amount of blood, with 3+ Bacteria (normal is none). Review of the Hospital Discharge Summary revealed Resident #35 was admitted to the hospital on [DATE] at 9:00 PM with [DIAGNOSES REDACTED]. Review of the Discharge Physician's Note revealed, on admission, the resident was also hemoconcentrated initially and with hydration, labs improved. After treatment, the resident was discharged from the hospital on [DATE]. Interview with RN #1 on 01/11/18 at 2:22 PM and on 01/23/19 at 11:41 AM (Post Survey) revealed she worked day shift on 10/17/18 and 10/18/18. RN #1 stated Resident #35 was one to get constipated very easily, but she was not sure exactly the circumstances surrounding the increase in the [MEDICATION NAME] or the [MEDICATION NAME] because she had only recently started working at the facility. RN #1 revealed she could not recall if the resident was having bowel movements at the time she administered the enema on 10/18/18 at 9:12 AM. Additionally, RN #1 stated she was not made aware of the resident being constipated or that the resident had decreased food and fluid intake. RN #1 stated she had not been monitoring the Intake and Output sheets as she did not know where they were located and no one had told her she needed to do so. Interview (Post survey) with RN #3 on 01/24/18 at 8:07 AM, revealed she worked 10/16/18 through 10/18/18, night shift. RN #3 stated she does not recall why the [MEDICATION NAME] was increased nor did she have to give Resident #35 [MEDICATION NAME] for nausea or vomiting. RN #3 further stated she could not recall if anyone alerted her to the resident's decreased food and fluid intake, however, she monitored the Intake and Output sheets as often as she could. Additionally, RN #3 stated a small bowel movement was normal for the resident. Interview with the Physician's Assistant (PA) on 1/11/19 at 2:08 PM revealed a reasonable time to obtain a straight cath UA would have been two (2) to four (4) hours. Interview with the APRN on 01/11/19 at 2:41 PM revealed she would have expected the UA and the results to be called back her within three (3) to four (4) hours after the UA was ordered, and if the UA could not be obtained, she would have expected the facility to notify her. The APRN further stated if the UA had been obtained quicker with the results called to her, she would have ordered intravenous fluids and antibiotics and possibly avoided hospitalization . She revealed she always tries to treat the residents at the facility first before sending out. Further interview (Post Survey) with the APRN on 01/25/19 at 9:33 AM revealed she knew Resident #35 had been having some vomiting because she ordered [MEDICATION NAME] on 10/16/18, however, she was not aware the resident had vomited two (2) times on 10/18/18 (8:09 AM and 9:44 AM). The APRN further stated she was aware the resident had not been eating well, however, she was not made aware of how poor the resident's food and fluid intake had been. Additionally, the APRN stated had she been made aware of the severity of the resident's illness (vomiting, poor food and fluid intake, and low blood pressure) she would have initiated intravenous fluids or sent the resident to the ER sooner. The APRN further stated had she been contacted by the facility, it probably would have made a difference in the severity of the resident's illness and the outcome as well. Interview with the Director of Nursing (DON) on 01/11/19 at 11:33 AM and on 01/24/19 (Post Survey) at 8:52 AM revealed Resident #35 was having, what staff thought was, regular bowel movements, but after talking with the family, discovered the resident normally had extra large bowel movements. The DON stated RN #1 completed a full assessment of Resident #35 on 10/17/18 at 4:14 PM when the change occurred. The DON stated that RN #1 documented an assessment in the progress notes and notified the physician but failed to complete a SBAR per policy. The DON stated the expectation would have been for RN #1 to complete a SBAR per policy. Additionally, the DON stated that a full assessment was completed on 10/18/18 at 4:30 PM and a SBAR was completed but not documented in the nurse's notes. She would have expected the assessment to be documented in the nurse's progress notes as well as on the SBAR.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections for two (2) of eighteen (18) sampled residents (Resident #44 and #35). On 10/17/18 at 4:37 PM the Physician's Assistant was contacted regarding Resident #35's change in condition. an order for [REDACTED]. On 10/18/18, the resident was hospitalized with [DIAGNOSES REDACTED]. In addition, observation of incontinent care on 01/10/19 for Resident #44 revealed the Certified Nurse Aide (CNA) failed to wash the buttocks and rectal area and, also, did not change gloves or wash her hands when going from a dirty to clean area. The findings include: Review of the facility policy titled Standard of Nursing Practice, last revised (MONTH) (YEAR), revealed the licensed nurse that receives an order and notes the order is responsible to carry the order through by placing in the achieve Matrix, on the (Medication Administration Record [REDACTED]. Review of the facility policy titled Laboratory Test, dated 06/2008, revealed the licensed nurse receiving the order for any laboratory test will document the order on the appropriate Physician's order form, transcribe the order onto the the tracking log, include the type of laboratory test to be done; the licensed nurse working night shift will review the log for all labs to be done; once the lab is completed, the licensed nurse on duty will enter the date the lab was obtained onto the tracking log. The licensed nurse receiving the lab results will complete the tracking form by entering the date the lab result was received and physician notification. Record review revealed the facility admitted Resident #35 on 03/09/18 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set, dated dated [DATE], revealed the facility assessed Resident #35's cognition as severely impaired as the resident was unable to complete a Brief Interview of Mental Status (BIMS) exam indicating the resident was not interviewable. Further review of the Quarterly MDS revealed Resident #35 required total care with all activities of daily living (ADL's); and the resident was incontinent of bowel and bladder. Review of the Nurse's Progress Notes dated 10/17/18 at 4:14 PM revealed Registered Nurse (RN) #1 was alerted Resident #35 wasn't acting right. Vital signs were, blood pressure 102/48 (base line 128/68), temperature 103.3 degrees Fahrenheit, heart rate 120 (base line 65), resident awake and alert, grinding teeth at times. At 4:46 PM, RN #1 telephoned the Physician's Assistant (PA) (who was back-up call for the Advanced Practice Registered Nurse {APRN}) and received orders for Tylenol 650 mg suppository to be given then and every six (6) hours as needed for elevated temperature; and a UA per in and out catheterization. Review of the facility Lab Tracking Form dated 10/18/18 revealed an entry for Resident #35 with ordered tests of CBC and CMP, and was collected at 2:02 AM; however, there was no entry for the UA order or collection per facility policy. Further review of the Nurse's Progress Notes revealed an in and out catheterization (cath) was not attempted until 10/17/18 at 9:00 PM by RN #3 , almost five (5) hours after the order was received. The attempt was unsuccessfully due to only a scant amount of urine obtained. Further review revealed there were two (2) other entries made in the Nurse's Progress Notes, on 10/17/18 at 6:26 PM and on 10/18/18 at 9:44 AM by RN #1 revealing the resident had incontinent episodes and staff were unable to obtain a urine specimen. However, there was no documented evidence staff attempted to conduct an in and out cath from 10/17/18 at 9:00 PM until 10/18/18 at 6:27 PM, after the order was obtained and prior to going to the hospital. Review of the facility's Observation Detail List Report (Situation, Background, Assessment, Recommendation, SBAR) completed on 10/18/18 at 5:10 PM by RN #1 revealed the resident's symptoms started on 10/17/18 and it was reported to the ARPN the resident had vomited green bile three (3) times over two (2) days; the resident had not been acting right in general; the resident was not eating or drinking; and, was having fever and had been given Tylenol Suppositories two (2) times. Vital signs were blood pressure 94/68; heart rate 109; respirations 18; and temperature 99.3 degrees Fahrenheit. The APRN gave an order to let the family decide if they wanted the resident sent to the ER. Review of the Nurse's Notes, revealed RN #1 spoke to Resident #35's brother on 10/18/18 at 5:52 PM and at 6:27 PM, Resident #35 was in stable condition and was transported to the hospital ER in a private vehicle by his/her brother. Review of the Hospital laboratory results dated [DATE] for a Complete Blood Count (CBC), Comprehensive Metabolic Profile (CMP) and a Urinalysis (UA) revealed the resident's BUN was 38 (7-25); Creatinine was 2.9 (0.6-1.2); WBC was 33.9 (4.0-10.0); and the UA results indicated the urine was dark yellow, cloudy with moderate amount of blood, with 3+ Bacteria (normal is None). Review of the Hospital Discharge Summary revealed Resident #35 was admitted to the hospital on [DATE] at 9:00 PM with [DIAGNOSES REDACTED]. After treatment, the resident was discharged from the hospital back to the nursing home on 10/22/18. Interview (Post Survey) with RN #3 on 01/24/18 at 8:07 AM, revealed she worked 10/16/18 through 10/18/18, night shift. The RN stated she attempted to obtain a urine specimen on 10/17/18 at 9:00 PM, but was unsuccessful because the resident was always incontinent of urine and there was no urine in the bladder. The RN stated she did not make another attempt to obtain the specimen. Interview with RN #1 on 01/11/18 at 2:22 PM and on 01/23/19 at 11:41 AM (Post Survey) revealed she was not aware of the lab process according to policy, and could only report what she had done when she received the order for the UA. RN #1 stated when she received orders, I can hope that I get to it and if not, I pass it to the next shift. RN #1 stated she received the order for the UA on 10/17/18 at 4:46 PM, but did not attempt to obtain the UA that day and reported the need to get the UA to the oncoming RN (RN #3). RN #1 further stated she did not know why she did not obtain the specimen at that time. RN #1 revealed on 10/18/18 she attempted to get the UA but was unsuccessful and when she removed the catheter, there was a mucous plug on end of of the catheter, so she completed the SBAR and called the APRN. She revealed she contacted Resident #35's brother per the APRN's directive. RN #1 stated she did not make another attempt to obtain a specimen before the resident went to theER on [DATE] at 6:27 PM. Interview with the Physician's Assistant (PA) on 1/11/19 at 2:08 PM revealed a reasonable time to obtain a straight cath UA would have been two (2) to four (4) hours. Interview with the APRN on 01/11/19 at 2:41 PM revealed she would have expected the UA and the results to be called back her within three (3) to four (4) hours after the UA was ordered, and if the UA could not be obtained, she would have expected the facility to notify her. The APRN further stated if the UA had been obtained quicker with the results called to her, she would have ordered intravenous fluids and antibiotics and possibly avoided hospitalization . She stated she always tries to treat the residents at the facility first before sending out. Interview with the Director of Nursing (DON) on 01/11/19 at 11:33 AM revealed she expected staff to obtain a straight cath UA in a timely manner and to keep the APRN or doctor informed if they were unable to obtain the specimen. The DON further stated the APRN should have been notified that they were unable to obtain the specimen. 2. Review of the facility Certified Nurse Aide (CNA) form titled Perineal Male Care Competency, not dated, revealed: 9. Expose perineum only. 10. Retract foreskin if resident uncircumcised, grasp penis, cleaning tip, using circular motion, using water and soapy washcloth. Starting at meatus of the urethra and working outward. 11. Rinse the area with another washcloth, using the same circular motion. 12. Return foreskin to its natural position immediately after rinsing. 13. Clean shaft of penis. Rinse and dry the area. 14. Assist the resident to flex knees and spread legs as much as possible. Clean the scrotum. Rinse well pat dry. 15. Assist resident to turn side to side, away from the CNA. 16. With a new soapy washcloth, clean rectal area. 17. Using washcloth clean from scrotum to rectal area in a single stroke, using clean area of washcloth with each stroke. Record review revealed the facility admitted Resident #4 on 01/03/18 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 12/15/18 revealed the facility assessed the resident was unable to complete a Brief Interview for Mental Status (BIMS) which indicated the resident's cognition was severely impaired and he/she was not interviewable. Further review of the MDS revealed the resident required extensive assist of two (2) for toileting and extensive assist of one (1) with hygiene. Observation on 01/10/19 at 4:40 PM revealed CNA #2 performed peri care and she was accompanied by the Unit Manager and Registered Nurse (RN) #2. Further observation revealed each of the staff washed their hands, applied gloves, and CNA #2 cleaned the peri area per protocol and policy, but failed to wash the buttocks and rectal area. In addition, observation revealed when cleaning of the peri area was completed, CNA #2 did not wash her hands or change gloves but continued with applying the resident's brief, clothing, and assisted him/her out of bed without ever washing her hands or changing gloves. Interview with CNA #2 on 01/11/19 at 5:41 PM revealed she realized after finishing, she failed to wash the rectal area, and also she knew to always wash her hands and change her gloves after completing the cleaning procedure but just forgot. Interview with the Unit Manager on 01/11/19 at 5:45 PM revealed the CNA said she should have cleaned the buttocks area, washed hands and changed gloves when going from dirty to clean. Interview with the DON, on 01/11/19 at 5:50 PM revealed she expected the nursing staff to follow policy and CNA competency check off list while providing incontinent care, and to wash the buttocks as well as the peri area. She stated staff should wash hands and change gloves after providing incontinent care, and before applying a clean brief, clothing, and bed linen.