Every finding on record at Signature Healthcare of Georgetown

Based on observation and interview, the facility failed to provide a safe, clean, comfortable, and homelike environment for 2 out of 4 hallways, 100 Hall and 400 Hall.Observations on 07/07/2025 revealed the drain access covers on the 100 and 400 Hall were loose, creating a possible tripping hazard.The findings include:Observation on 07/07/2025 at 2:05 PM revealed the drain cover at the end of 100 Hall outside room [ROOM NUMBER] was loose and slid side to side.Observation on 07/07/2025 at 3:58 PM revealed plates (covers) on 400 Hall were loose and spun around.In an interview on 07/08/2025 at 9:15 AM, Resident (R) 44 stated it was nice the drain cover was screwed down better now and did not move around when he wheeled over it. He stated it had been loose for a while.In an interview on 07/10/2025 at 10:10 AM, the Maintenance Director stated the process for routine maintenance in the building was to schedule tasks in the maintenance computer program. He further stated he was aware the drain covers periodically came loose and created tripping hazards. Per interview, the Maintenance Director stated he did not schedule checking the drain covers as part of routine maintenance and only addressed the issue if he noticed it during a walk-through.In an interview on 07/10/2025 at 11:10 AM, the Director of Nursing (DON) stated she expected the building to be maintained in a manner to keep residents safe. She stated she had not noticed the plate on 100 Hall that slid around, and she did not know why the plates had been loose. In further interview, the DON stated an uneven area in the floor created a tripping hazard for residents. In an interview on 07/10/2025 at 11:35 AM, the Administrator stated he expected the building to be kept safe for residents. He further stated he believed the machine used to clean the floors had loosened the plates, which were not on the routine maintenance list. In continued interview, the Administrator stated it was important for the plates to remain secure because a loose plate could create a tripping hazard for residents.

Based on observation, interview, record review, and review of guidelines from the Centers for Disease Control and Prevention (CDC), the facility failed to follow infection control precautions for 1 of 9 sampled residents under Enhanced Barrier Precautions (EBP), Resident (R) 58. Observation on 07/08/2025 revealed Certified Nurse Aide (CNA) 1 changing linens and removing garbage for a resident under EBP precautions (R58) without wearing appropriate personal protective equipment (PPE).The findings include: Review of the facility provided signage for Enhanced Barrier Precautions (EBP) revealed the signage followed the guidelines from the United States Department of Health and Human Services, Centers for Disease Control and Prevention (CDC). The EBP signage, posted on R58's door, directed that everyone must clean their hands before entering and before leaving the room; providers and staff were directed to wear gloves and a gown for the following high contact resident care activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy) and wound care (any skin opening requiring a dressing). Review of R58's admission Record revealed the facility admitted the resident on 06/18/2025 with diagnoses of sepsis, chronic prostatitis, meningitis, lung cancer, pressure ulcer of the sacrum, and gastrostomy status (feeding tube). Review of R58's admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 06/26/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 12 out of 15, indicating moderate cognitive impairment.Review of R58's Clinical Orders, dated 06/18/2025 revealed an order for Enhanced Barrier Precaution (EBP) for his gastrostomy tube and wounds. Further review revealed an order for an enteral feeding tube, dated 06/18/2025, and an order for a suprapubic urinary catheter, dated 06/19/2025.Review of R58's Comprehensive Care Plan [CCP], dated 06/19/2025, revealed an active care plan for requiring EBP related to a gastrostomy tube, wounds, and a catheter. The documented goal of the care plan was the resident would not experience any adverse outcomes related to EBP. The documented approaches were to disinfect high touch surfaces as able as needed, attempt to maintain environmental cleanliness, staff to wear personal protective equipment (PPE) as indicated, and report to physician signs and symptoms of infection as needed. On 07/08/25 at 8:17 AM (CNA)1 was observed in R58's room, which had a sign on the door indicating R58 was on EBP, with Occupational Therapist (OT)1, changing linens and removing garbage. CNA1 was observed with gloves on but did not have a gown on. Upon interview, CNA1 stated she had been working at the facility for two weeks and had received some training on hire, but no one had explained EBP to her and she had not seen the signage on the door. CNA1 further stated she was not sure of the importance of EBP.During an interview on 07/08/2025 at 8:40 AM with the Regional Clinical Consultant (RCC), she stated CNA1 had just received an on the spot training session for EBP. The RCC further stated CNA1 had been scheduled for additional in person education that morning when she arrived, and as CNA1 was a very helpful person and wanted to do everything for everyone, she began resident care immediately and before the IP could meet with her and provide the training.During an interview on 07/09/2025 at 3:28 PM with the IP, she stated all staff received training upon hire via an hour-long infection control (IC) video, and then periodic education, quarterly and as needed, was provided to staff as a refresher. The IP stated the IC education included a return demonstration portion in which staff would show her how to wash hands and put on and remove PPE. The IP also stated new staff orientation included walking staff through handwashing, the donning (put on) and doffing (remove) of PPE, and a checklist was completed. The IP further stated CNA1 was not out of her orientation period yet, and her orientation checklist was not complete. The IP stated her expectation was that all staff used PPE appropriately and every time. The IP stated when CNA1 arrived yesterday morning she began her work before she met with her to complete her education. The IP stated it was her expectation that all staff looked at infection control signage on a resident's door and followed the directions provided every time.During an interview on 07/10/2025 at 11:02 AM with the Director of Nursing (DON), she stated she had been at the facility for two years. The DON stated for new referrals, if a resident had tubes or wounds, the room was set up for EBP immediately, and the facility process was to put EBP in as an order for all residents that needed it. The DON stated if a resident had an event that made EBP necessary after admission, an order would be written, and staff would be made aware and instructed by nursing leadership to post signage and put the three drawer PPE bin near the door of the resident's room. The DON stated nursing leadership then rounded and made sure the signs were posted, and PPE was available. The DON also stated Infection Control (IC) training was offered to staff upon hire, quarterly, and as needed and included a return demonstration by the employee. The DON stated she expected staff to follow the guidance on the posted signage for all precautions for all residents, so residents did not end up with a facility acquired infection.During an interview on 07/10/2025 at 11:55 PM with the Administrator with the RCC present, he stated he had been at the facility for almost three years. He stated the facility ensured residents were safe from any additional infection by using EBP, following signage for precautions, and using the provided PPE. He stated housekeeping was expected to keep the room and environment clean, and staff was expected to do their best to keep the residents clean. He stated all residents were assessed for the need of EBP on admission and as needed as new issues arose. He stated new orders were discussed in the morning stand up clinical meeting and stand down meeting. He stated staff received training on infection control during orientation and as needed based on the education guidelines provided by CDC. He stated EBP orders were placed in the resident chart for all residents that required them. The Administrator stated it was his expectation that staff used the provided PPE and followed the signage. He stated the precautions were in place for the protection of the residents.

Based on interview, record review, and review of the facility's policy, the facility failed to follow its Abuse Policy when an employee did not immediately report an allegation of abuse to the Administrator or his designee for 1 of 2 residents reviewed for reporting alleged sexual abuse, Resident (R) 28.On 07/07/2025 at 2:10 PM a housekeeper (HK) 1 reported to the State Survey Agency (SSA) Surveyor that on approximately 07/05/2025, she overheard Certified Nurse Aide (CNA) 2 having a sexually inappropriate conversation with R28. However, that incident was not reported and investigated.The findings include:Review of the facility's policy titled, Abuse, Neglect and Misappropriation of Property, last revision date 09/15/2023, revealed the definition of abuse was willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also included the deprivation by an individual, including a caretaker, of goods or services that were necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, caused physical harm, pain, or mental anguish. It included verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled by technology. Per the policy, Every stakeholder shall immediately report any allegation of abuse, injury of unknown origin or suspicion of a crime, as those terms are defined above, to the Facility Administrator or designee as assigned by the Facility Administrator in his/her absence.Review of R28's Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 06/21/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of eight out of 15, indicating moderate cognitive impairment.During an interview on 07/07/2025 at 2:10 PM with HK1, she approached the SSA Surveyor in the hall and stated, on 07/05/2025, she overheard CNA2 speak to R28 about sex and dead people. HK1 stated she approached CNA2 and told her she felt the conversation was inappropriate. She stated CNA2 told HK1 the resident did not even know what she was talking about, to which HK1 replied, But you do. HK1 stated she immediately reported her concerns to her housekeeping supervisor (HKS).During an interview on 07/08/2025 at 3:08 PM with CNA2, she stated R28 was often confused. CNA2 stated R28 told her, I would like to have [NAME]. CNA2 stated she told R28 she thought the actor was dead. Then CNA2 stated R28 told her that it did not matter to her. CNA2 stated she then told R28, That ain't right! CNA2 was asked to give examples of abuse, and if she saw or heard something that she felt was abuse what would she do about it. CNA2 gave appropriate examples and stated she would make sure the resident was safe, then tell a nurse and/or the Director of Nursing/Administrator immediately. She stated the best way to deal with a difficult resident was to walk away and reapproach or have someone else work with that resident. During an interview on 07/07/2025 at 2:17 PM, the Housekeeping Supervisor (HKS) stated she was aware of the allegation reported by HK1. She stated she recalled some of the verbiage used by HK1, specifically the part where HK1 told CNA2 that R28 did not know what was being talked about, and HK1 said, But you do. The HKS stated she could not hear HK1 very well, and she did not follow up with HK1.During an interview on 07/07/2025 at 4:56 PM with the HKS, she stated she had not told anyone about the incident with R28 because it just happened the previous weekend, and she had not had time to follow up. Regarding HK1, she stated HK1 was new but a good housekeeper. She stated she had no concerns regarding her work. She stated HK1's personal views could have caused her to read into the conversation more than what was said. During an interview on 07/07/2025 at 4:05 PM, the Social Services Director (SSD) stated she knew nothing about the allegation of abuse between CNA2 and R28.During an interview on 07/07/2025 at 2:19 PM, the Administrator stated he was not aware of the incident with R28 and had been on vacation at that time. He stated the incident had not been reported to anyone, and it had not gone any further than the HKS.During an attempted second interview with HK1 on 07/09/2025, it was reported she was not scheduled to work. However, the HK District Manager (HKDM) stated HK1 was in the building, but HK1 then exhibited strange behaviors and abruptly left. HK1 never returned to work and did not answer her phone for the remainder of the survey.During an interview on 07/10/2025 at 10:50 AM with the Director of Nursing (DON), she stated she expected staff to report allegations of abuse immediately to the supervisor or abuse coordinator. She stated the reporting process was to immediately report to the supervisor, and the supervisor would call the Administrator. She stated the supervisor, clinical manager, or DON would be notified. She stated, if the manager felt it was egregious or substantiated, they called the Administrator immediately. She stated all concerns were always taken seriously. During an interview on 07/10/2025 at 11:34 AM with the Administrator and the Regional Corporate Consultant, the Administrator stated it was his expectation that the staff would follow the Abuse policy. He stated to ensure the policy and procedures were followed, the SDC provided education and re-education. He stated his expectation for the reporting process would be for the staff member to report immediately. He stated clinical staff would go to the Assistant Director of Nursing (ADON) and/or the DON. He stated nonclinical staff would report to the ADON or shift supervisor. He stated there should be no variance in reporting regardless of the resident's cognition, and all reports were taken seriously.

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to ensure residents had the right to examine the results of the facility's most recent survey and Plan of Correction. Observations on 11/30/2021 through 12/02/2021, revealed the survey results were not readily accessible to the resident, family members and legal representatives of the resident. In addition residents voiced that they were unaware they could view the latest survey results and did not know where the results were kept for them to view. The findings include: Review of the facility policy titled, Resident Rights, revised 08/16/2018, revealed residents were entitled to exercise his/her rights and privileges as a resident of the facility and as a citizen of the United States, to the fullest extent possible without interference, coercion, discrimination, or reprisal. Observation on 11/30/2021 at 9:45 AM, revealed the front lobby and the Transitional Care Unit (TCU) was separated from the main clinical hallways by a door which required a digital code to be entered into a keypad which was approximately four (4) to five (5) feet from the ground. Observation on 11/30/2021 at 3:40 PM, revealed a sign on the wall located in the front lobby beside the facility's main entrance which stated, KRS (Kentucky Revised Statutes) 217.54 requires state inspection reports on this facility to be made available to you upon request. Further observation revealed the Federal and State survey results were located in a white binder in the facility front lobby, under a table, stacked on other books and not accessible to residents without staff assistance. Review of the facility Census, dated 11/30/2021, revealed there were forty-seven (47) residents in the facility; however, interview with the Administrator, on 11/30/2021 at 9:00 AM, revealed there were no residents in the Transitional Care Unit (TCU). During a Resident Group Interview, on 11/30/2021 at 2:00 PM, with seven (7) facility residents, Residents #2, #20 and #23, expressed they were unaware they could view the latest survey inspection results. Additionally, they did not know where the results were kept for them to view. The other residents in the group left early or did not respond when asked about the survey inspection results. Interview with Resident #23, on 11/30/2021 at 2:15 PM, revealed he/she wasn't sure where the survey book was located and had never examined the survey book. Resident #23 was assessed as having a Brief Interview for Mental Status (BIMS) score of fourteen (14) out of fifteen (15) indicating intact cognition on the most recent Quarterly MDS assessment dated [DATE]. Interview with Resident #2, on 11/30/2021 at 2:16 PM, revealed he/she had never examined the survey book and was not sure where it was located. Resident #2 was assessed as having a BIMS score of fifteen (15) out of fifteen (15) indicating intact cognition on the most recent Quarterly MDS assessment dated [DATE]. Interview with Resident #20, on 11/30/2021 at 2:17 PM, revealed he/she had never examined the survey book and was not sure where it was located. Resident #20 was assessed as having a BIMS score of fifteen (15) out of fifteen (15) indicating intact cognition on the most recent Quarterly MDS assessment dated [DATE]. Interview with State Registered Nurse Aide (SRNA) #5, on 12/02/2021 at 5:33 PM, revealed she had worked at the facility for two (2) years. She stated residents had a right to be informed of survey results to ensure they were aware of what was going on in their home. Per interview, SRNA #5 was unaware of the location of the survey results. Additionally, SRNA #5 stated residents were not allowed access to the front lobby of the facility unless they were accompanied by staff or family. Further, she stated a digital code was necessary to unlock the door going from the resident living area to the front lobby. Interview with Licensed Practical Nurse (LPN) #2, on 12/03/2021 at 10:52 AM, revealed he had worked at that facility for nine (9) months. He stated the binder with survey results was located in the facility entrance lobby and he was unaware of any other location where the survey results were kept. Additionally, he stated the survey results should be easily accessible to the residents because they had a right to know what was going on where they lived. Interview with Assistant Director of Nursing (ADON) #1, on 12/03/2021 at 11:25 AM, revealed she had been employed by the facility since 2010 and started in the role of ADON in 2016. Per interview, residents had the right to know the survey results and the results should be accessible to them. The ADON stated survey results were currently kept in the Administrator's office and in the front lobby entrance. She further stated a survey results binder was kept on the Transitional Care Unit (TCU) until the unit was changed over to a COVID-19 unit. The ADON stated residents did not have the code that allowed them to gain access to the front lobby. Additionally, she stated residents did not have full access to the Administrator's office. However, she stated she felt the survey results were readily accessible to the residents because if a resident requested to view the survey results binder, staff would assist the resident with getting the binder. Interview with the Director of Nursing (DON), on 12/03/2021 at 12:15 PM, revealed she had worked at the facility as DON since 11/29/2021. Interview further revealed it was her expectation that survey results would be readily accessible to the residents. Additionally, she stated she felt the survey results were readily accessible to the residents because if a resident requested to see them, the staff would make sure they had access to the survey results binder. Interview with the Administrator, on 12/03/2021 at 12:37 PM, revealed there was a survey results binder in the front lobby and as of the morning of 12/03/2021, there was another survey binder on a table at the back door entrance, on TCU. Additionally, he stated an additional survey results binder had been provided at the back door entrance on TCU in the past, but the binder was removed when the TCU was changed over to a COVID-19 unit. Per interview, residents were made aware of the location of the survey results binder by the Activities Director and the Ombudsman. Interview further revealed it was his expectation the facility made survey results readily available to the residents. He stated staff would provide the survey results binder to residents whenever they asked to see them.

Based on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) Healthcare Providers Clean Hands Count for Healthcare Providers guideline, review of the nursing manual Potter and Perry. (n.d.). Fundamentals of Nursing, and review of the facility's policies, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent and control the development and transmission of communicable diseases, including COVID-19, and to implement interventions per the Centers for Medicare and Medicaid Services (CMS), the CDC, and the Kentucky Department for Public Health (Health Department) State guidelines for COVID-19 for two (2) of twenty-two (22) sampled residents, Resident #18 and Resident #37. Observation, on 12/01/2021, during medication administration revealed Registered Nurse (RN) #1 broke a pill with her unsanitized bare hands and placed it in a medication cup for administration to a resident. Observation, on 12/02/2021, revealed an RN failed to maintain sterility during suprapubic catheter irrigation. Observation, on 12/03/2021, revealed a visitor standing at the nurse's station donned in personal protective equipment (PPE) after exiting a droplet/contact isolation room. Additional observation revealed a staff member failed to disinfect her face shield after leaving a droplet/contact isolation room. The findings include: Review of the facility's policy titled, Novel Coronavirus (COVID-19), revised 11/15/2021, revealed the facility should always maintain an Infection Prevention and Control (IPC) program. An IPC program aimed to provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of communicable diseases and infections. Review of the facility's policy titled, Coronavirus (COVID-19) - Screening of Visitors, revised 03/11/2021, revealed visitors would be provided with a copy of the Visitor COVID-19 Education and Rules, which visitors were required to review and sign. Visitors must adhere to the principles of the COVID-19 infection prevention policy. Additionally, the policy stated facility staff must escort visitors to and from the resident's room. Review of the facility's policy titled, Coronavirus (COVID-19) - Resident Visitation, Dining, Activities, revised 11/15/2021, revealed visitors must always adhere to the principles of the COVID-19 infection prevention and best practices in all places to help reduce the risk of potential COVID-19 exposure and transmission. Additionally, the facility should communicate and educate all residents, family, and others on the Core Principles of the policy well in advance of a visitation. Review of the facility's policy titled, Infection Control, revised 10/2018, revealed all personnel would be trained on IPC policies and practices upon hire and periodically throughout employment. Review of the facility's policy titled, Handwashing/Hand Hygiene, revised 08/2019, revealed the facility considered hand hygiene as the primary means to prevent the spread of disease and infections. Further review revealed the clinical indications for the use of hand hygiene included immediately before touching a patient, after touching a patient or the patient's immediate environment, and before preparing or handling medications. Furthermore, the policy stated all facility personal shall follow hand washing/hand hygiene procedures to help prevent the development and transmission of communicable diseases and infections. Review of the facility's policy, Isolation-Categories of Transmission-Based Precautions, dated October 2018, revealed Transmission-Based Precautions (TBP) were initiated when a resident developed signs and symptoms of a transmissible infection, arrived for admission with symptoms of an infection; or had laboratory confirmed infection and was at risk for transmitting the infection to other residents. Additionally, standard precautions were used when caring for residents at all times regardless of their suspected or confirmed infection status. Per the policy, TBP were additional measures that protected staff, visitors, and other residents from becoming infected, and were determined by how specific pathogens spread from person to person. Continued review revealed when a resident was placed on TBP, appropriate notification was placed on the room entrance and on the front of the chart so personnel and visitors were aware of the need for and the type of precaution. The signage informed the staff of the type of CDC precautions, instructions for use of PPE, and/or instructions to see the nurse before entering the room. Further, when TBP's were in effect, if resident-care equipment items required re-use and could not be dedicated to a single resident, then the item would be cleaned and disinfected according to current guidelines before use with another resident. Continued review of this policy revealed Droplet Precautions would be implemented for an individual documented or suspected to be infected with microorganisms transmitted by droplets that could be generated by the individual coughing, sneezing, talking, or by the performance of procedures. Additionally, mask, gloves, gown, and goggles should be worn when entering a resident's room with Droplet Precautions. Review of the guideline Centers for Disease Control and Prevention (CDC) Healthcare Providers Clean Hands Count for Healthcare Providers, reviewed 01/08/2021, revealed hand hygiene reduced the spread of infection and disease to patients. Alcohol-based hand rub (ABHR) and washing hands with soap and water were the two (2) methods for hand hygiene. Further review revealed the clinical indications for the use of hand hygiene included immediately before touching a patient, after touching a patient or the patient's immediate environment, when hands were visibly soiled, and before preparing or handling medications. Review of Potter and Perry. (n.d.). Fundamentals of Nursing. (9 ed.). page 1143, revealed, when instilling fluid into a suprapubic catheter, to ensure the irrigation or installation fluid remained sterile and to reduce the transmission of infection to the resident, the injection port should be thoroughly cleansed with an antiseptic swab and allowed to dry. Next, the prescribed amount of sterile solution should be drawn up in a sterile syringe, and the tip of the needleless syringe should be capped with a sterile cap. Finally, the syringe should be withdrawn, and the catheter port should be cleansed with an antiseptic swab. Review of the facility's policy, Suprapubic Catheter Care, reviewed 08/16/2021, revealed suprapubic catheter care was provided to maintain catheter patency, facilitate frequent bladder irrigations, and prevent infection. Review of the facility's employee orientation checklist, Infection Control Program Employee Orientation Checklist, revised 06/2005, revealed all employees were educated by an instructor and checked off for understanding and proper technique on isolation precautions, standard precautions, using protective equipment, and hand hygiene. 1. Review of Resident #37's medical record revealed the facility admitted Resident #37, on 02/26/2019. Further review revealed Resident #37 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 10/22/2021, revealed the facility assessed the resident to have a Brief Interview of Mental Status (BIMS) score of three (3) out of fifteen (15), indicating the resident was cognitively impaired. Observation, on 12/01/2021 at 9:03 AM, revealed RN #1 removed her gloves after giving insulin to Resident #37 and failed to sanitize her hands. Continued observation revealed at 9:05 AM, RN #1 broke a pill for Resident #37 with her bare hands and place it in a medication cup to administer to the resident. Interview with the Assistant Director of Nursing/Infection Preventionist (ADON/IP), on 12/03/2021 at 11:25 AM, revealed she expected staff to use proper hand hygiene techniques routinely, which included before and after each medication administration and direct patient care. 2. Review of Resident #18's Electronic Medical Record (EMR) revealed the facility admitted the resident, on 01/27/2017, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #18's Quarterly Minimum Data Set (MDS) Assessment, dated 11/01/2021, revealed Resident #18 had an indwelling suprapubic catheter (a surgically created connection between the urinary bladder and the skin to drain urine in individuals with an obstruction of normal urinary flow) . Review of Resident #18's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #18's Comprehensive Care Plan (CCP), dated 10/18/2021, revealed the resident was at risk for infection related to the suprapubic catheter and a [CONDITION(S)] bladder. Long-term goals, with a target date of 01/18/2022, were that the resident would remain free of infection, as evidenced by normal vital signs and absence of pain or retention. Interventions included providing catheter care as ordered. Observation of RN #1 performing Resident #18's suprapubic catheter irrigation, on 12/02/2021 at approximately 10:00 AM, revealed RN #1 failed to thoroughly clean the suprapubic catheter's injection port with an antiseptic wipe or allow it to dry prior to beginning the sterile instillation. Furthermore, RN #1 failed to ensure the [MEDICATION(S)] instillation solution remained sterile. RN #1 set up her supplies on a towel on the resident's bedside table. She obtained a vial of [MEDICATION(S)] from a bag located on the treatment cart. RN #1 snapped off the top of a contaminated thirty (30) milliliter vial of [MEDICATION(S)] and placed it directly into the catheter port without first transferring the solution to a sterile capped syringe. Next, RN #1 failed to clean the catheter port with an antiseptic wipe and let dry it before placing the catheter tubing back in place. Interview with RN #1, on 12/02/2021 at approximately 10:30 AM, revealed she obtained the [MEDICATION(S)] from the resident's medications located on the treatment cart. The vials of solution were stored in a labeled bag from pharmacy. When asked if the tip of the vial was sterile, RN #1 stated, It is clean. She further stated that she always performed the suprapubic catheter irrigation using the pre-packaged vial of [MEDICATION(S)] and did not transfer the irrigation solution to a sterile tipped syringe. RN #1 stated it was important to clean and disinfect the catheter port before and after the procedure and to use a sterile tipped syringe to prevent infection. Interview with the Director of Nursing (DON), on 12/03/2021 at 12:15 PM, revealed it was not her expectation for a nurse to be checked off on every procedure he/she performed; however, it was her expectation that Potter and Perry Fundamentals of Nursing, the facility's standard of care reference, was used if the nurse was unfamiliar with a procedure. She further stated that it was her expectation that a nurse would not perform any procedure he/she was uncomfortable doing without instruction. She stated it was her expectation that nurses maintain sterility during suprapubic irrigation, and a nurse doing any procedure to be able to perform it correctly. The DON stated when procedures were performed improperly, the quality of care decreased, and there was the potential for injury and infection. 3. Observation on Unit 4, on 12/03/2021 at 11:45 AM, revealed Visitor #1 exiting an isolation room, room [ROOM NUMBER], in contaminated personal protective equipment (PPE). Visitor #1 was fully donned in a gown, gloves, face mask, and face shield. He walked out of room [ROOM NUMBER] to the nurse's station. Registered Nurse (RN) #4 and State Registered Nurse Aide (SRNA) #10 were observed talking to Visitor #1. Per the observation, neither RN #4 nor SRNA #10 attempted to educate Visitor #1 about being outside an isolation room in contaminated PPE. When the State Survey Agency (SSA) Surveyor came into view, RN #4 instructed Visitor #1 to go back into room [ROOM NUMBER]. Interview with RN #4, on 12/03/2021 at 11:55 AM, revealed she was an agency staff nurse and had been on duty for four (4) hours. RN #4 denied talking to Visitor #1. However, she stated that should she see anyone come out of isolation still wearing contaminated PPE, she would educate him/her on the proper donning and doffing of PPE and instruct the visitor to follow appropriate IPC techniques. RN #4 revealed she received education on IPC policies and procedures through her agency. Interview with SRNA #10, on 12/03/2021 at 1:10 PM, revealed she received education upon hire on IPC policies and procedures. She stated she and RN #4 talked to Visitor #1 while he was at the nurse's station. SRNA #10 stated neither she nor RN #4 instructed the visitor about doffing PPE before coming out of an isolation room. SRNA #10 further stated that she should have educated the visitor immediately. She stated it was important to prevent the spread of infectious diseases. Interview with Visitor #1, on 12/03/2021 at 1:20 PM, revealed he had been screened at the front entrance. He stated he did not recall receiving any education related to the facility's IPC policies for family and visitors when he was screened. He stated he was not escorted back to room [ROOM NUMBER]. In addition, Visitor #1 stated he followed the signs on the door to determine what PPE to wear before entering the room. Per the interview, Visitor #1 stated he forgot to doff his PPE before leaving the room, but stated, The nurses didn't say anything to me about it when I came out. Continued interview with the Assistant Director of Nursing/Infection Preventionist (ADON/IP), on 12/03/2021 at 11:25 AM , revealed all staff was updated on operational changes related to IPC via word of mouth from facility leadership, including the Administrator, DON, and Unit Managers, and through in-service training. She stated leadership staff audited and monitored staff for IPC compliance. She stated the facility followed State and County IPC guidelines. She stated it was her expectation that all nursing staff followed IPC guidelines to decrease the chance of the spread of infections and for the safety of residents and staff. Continued interview with the DON, on 12/03/2021 at 12:15 PM, revealed family and visitors were not allowed to go into an isolation room without first stopping at the nurse's station; and, it was her expectation that nursing staff did not allow visitors in or out of isolation rooms without first donning or doffing PPE. She stated if visitors were not using proper IPC practices, nurses should intercept them and reeducate immediately. Furthermore, the DON stated it was her expectation that all visitors should be screened and educated in the lobby by front office staff before entering patient care areas or an isolation room. Per interview, it was her expectation that all staff followed IPC procedures to prevent the spread of infection. Additionally, the DON stated following the correct IPC policies and procedures were important for the safety of the residents and staff. Interview with the Administrator, on 12/03/2021 at 12:37 PM, revealed he expected IPC guidelines to be maintained at all times in the facility to decrease the potential spread of infection. Surveyor: [NAME], Lillian Gale

Based on observation, interview, record review, review of the Centers for Medicare and Medicaid's (CMS) Resident Assessment Instrument (RAI) 3.0 Manual, and review of the facility's policy, it was determined the facility failed to develop and implement a person-centered Comprehensive Care Plan (CCP) for each resident's care needs for six (6) of twenty-two (22) sampled residents (Resident #11, #14, #18, #27, #29, and #38). 1. Resident #29's CCP, initiated on 03/12/2019, revealed the facility failed to develop a care plan related to care measures for a resident with a [CONDITION(S)] upon return to the facility from the hospital. Additionally, the facility failed to develop the CCP related to incontinence care for a dependent resident. 2. Resident #38's CCP, initiated on 06/16/2021, revealed the facility failed to develop a care plan related to his/her Foley catheter. 3. Resident #14's CCP, initiated on 07/09/2021, revealed the facility failed to develop a care plan related to his/her oxygen therapy. 4. Resident #27's CCP, initiated on 10/13/2021, revealed the facility failed to develop a care plan related to his/her oxygen therapy. 5. Resident #18's CCP, dated 10/18/2021, directed staff to float heels to relieve pressure on the heels. However, per observation on 12/01/2021 at 2:04 PM, the staff failed to implement this action. 6. Resident #11's CCP, initiated on 04/04/2016, directed staff to ensure the resident was sitting in an upright position when eating. However, per observation on 11/30/2021 at 9:30 AM, the staff failed to implement this action. In addition, Resident #11 had a self-care deficit in feeding, but the CCP was not developed with interventions to address the deficit. The findings include: Review of the facility's policy titled, Comprehensive Care Plans, last revised 07/19/2018, revealed a person-centered Comprehensive Care Plan (CCP) that included measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs was developed for each resident. Additionally, the care plan would include how the facility would assist the resident to meet their needs, goals, and preferences. Further, the policy revealed the CCP was based on a thorough assessment that included, but was not limited to, the Resident Assessment Instrument. Review of CMS's Resident Assessment Instrument (RAI) 3.0 Manual, Version 3.0, dated 10/2019, revealed the Minimum Data Set (MDS) viewed the resident in distinct functional areas to gain knowledge of the resident's functional status. Per the RAI, the facility should develop and implement an interdisciplinary care plan based on assessment information gathered throughout the RAI process. Further RAI review revealed the facility should re-evaluate the resident's status at prescribed intervals and modify the individualized care plan as appropriate. 1. Review of Resident #29's Electronic Medical Record (EMR) revealed the facility admitted the resident, on 03/17/2015, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #29's Gastrointestinal (GI) Consult History and Physical from an acute care hospital, dated 10/29/2021, revealed the resident was sent to the ED for a critically low hemoglobin on 10/28/2021. Further review revealed, Patient admitted due to [CONDITION(S)] suspected to be due to GI blood loss, positive occult stool test yesterday. During hospitalization , the resident was transfused with two (2) units of packed red blood cells. The resident returned to the facility on [DATE]. Review of Resident #29's Quarterly Minimum Data Set (MDS) Assessment, dated 11/08/2021, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15), indicating the resident was cognitively intact. Per the MDS Assessment, the resident required the extensive assist of two (2) caregivers for transfers and toileting. Further review of the MDS Assessment, revealed the resident was frequently incontinent of bowel and bladder, indicating a decline from the previous MDS Assessment which revealed the resident was frequently incontinent of bladder and always continent of bowel. Review of Resident #29's Comprehensive Care Plan (CCP), initiated on 03/12/2019 and last reviewed on 11/11/2021, revealed a focus of Activities of Daily Living (ADL) Function and Rehabilitation Potential identifying the resident was ADL deficient and required extensive assistance with toileting and personal hygiene. The goal stated the resident would maintain ADL self-performance levels as evidenced by no decline in ADL level. Interventions included, but were not limited to, use of a wheelchair for mobility, assistance of two (2) staff with transfers and bed mobility, use of partial side rails to assist with bed mobility, and encourage resident to participate in ADL's with staff support. However, there was no documented evidence the CCP was developed with interventions related to toileting or bowel and bladder incontinence care of a dependent resident. Furthermore, the CCP was not developed to denote problems, goals or interventions related to the care or monitoring of a resident who had been recently readmitted to the facility after being hospitalized and receiving a blood transfusion related to a [CONDITION(S)]. Interview with State Registered Nurse Aide (SRNA) #5, on 12/02/2021 at 5:33 PM, revealed Resident #29 seemed to be urinating in his/her brief more frequently, but further stated the resident would call for help if he/she had to have a bowel movement. Additionally, she stated the resident did have episodes of diarrhea a few months ago and had a bowel movement in his/her brief. Further interview revealed the resident required extensive assistance with toileting and personal hygiene. Interview with the MDS Nurse, on 12/02/2021 at 9:20 AM, revealed Resident #29's CCP should have been developed to include the amount and type of ADL support needed related to toileting and incontinence. Interview with the Assistant Director of Nursing (ADON)/Unit Manager of the Transitional Care Unit (TCU), on 12/03/2021 at 11:25 AM, revealed if a resident returned to the facility following a hospitalization for a [CONDITION(S)], and the resident received a blood transfusion, it would be her expectation that the care plan would be developed to address the resident's additional needs. 2. Review of Resident #38's EMR revealed the facility admitted the resident, on 06/16/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #38's Quarterly MDS Assessment, dated 10/30/2021, revealed the facility assessed the resident to have a BIMS score of fifteen (15) out of fifteen (15), indicating no cognitive deficits. Further review revealed the facility assessed the resident as requiring limited assistance with toileting, and extensive assistance with dressing, personal hygiene, and transfers. Additionally, the MDS Assessment revealed the resident was continent of bowel and occasionally incontinent of bladder. Review of Resident #38's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional orders, dated 11/08/2021, included recording output and providing catheter care every shift. Review of the Certified Nursing Assistant (CNA) Care Report, undated, revealed the resident's elimination status was marked as continent. However, there was no check mark in the box marked F/C (Foley catheter). The State Survey Agency (SSA) Surveyor requested a copy of this document. On the document copy received, the box indicating the resident had a Foley catheter was checked. Review of Resident #38's Comprehensive Care Plan (CCP), initiated on 06/16/2021, revealed there was no problem, goal, or interventions related to the Foley catheter care needs of the resident. Interview with SRNA #5, on 12/02/2021 at 5:33 PM, revealed Resident #38 had a Foley catheter. Additionally, she stated she provided catheter care and recorded urinary output every shift. Interview with the MDS Nurse, on 12/02/2021 at 9:20 AM, confirmed Resident #38's CCP did not address his/her Foley catheter. Additionally, she stated it was important for the Foley catheter to be included on the CCP because everyone needed to know how to care for the resident. Interview with Licensed Practical Nurse (LPN) #2, on 12/03/2021 at 10:52 AM, revealed if a resident had a Foley catheter, this information should be included on the CCP. Interview with Assistant Director of Nursing (ADON), on 12/03/2021 at 11:25 AM, revealed Resident #38's Foley catheter should have been included on the resident's CCP. Interview with the Director of Nursing (DON), on 12/03/2021 at 12:15 PM, revealed Resident #38's Foley catheter should have been included on the resident's CCP. 3. Review of Resident #14's Electronic Medical Record (EMR), revealed the facility admitted the resident on 07/09/2021. Resident #14's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #14's Quarterly MDS Assessment, dated 09/10/2021, revealed the facility assessed the resident to have a BIMS Score of nine (9) out of fifteen (15) indicating moderate cognitive impairment. Further review revealed the resident required extensive assistance with toileting, transfers, bed mobility, and personal hygiene. Additionally, the MDS Assessment revealed the resident received oxygen therapy. Review of Resident #14's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional orders, dated 11/01/2021, included oxygen saturation to be checked every shift, and oxygen saturation without supplemental oxygen for fifteen (15) minutes, to be checked every week on Wednesday. Review of Resident #14's CCP, initiated on 07/09/2021, revealed there was no documented evidence the CCP was developed to include problems, goals or interventions related to the resident's oxygen therapy. Observation of Resident #14, on 11/30/2021 at 9:07 AM, revealed the resident was in bed with oxygen applied via nasal cannula. 4. Review of Resident #27's EMR revealed the facility admitted the resident, on 10/13/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #27's Admission MDS Assessment, dated 10/20/2021, revealed the facility assessed the resident to have a BIMS score of eight (8) out of fifteen (15) indicating moderate cognitive impairment. Further review revealed the resident received oxygen therapy. Additionally, the MDS Assessment revealed the resident required extensive assist with transfers, bed mobility, dressing, toileting, and personal hygiene. Review of Resident #27's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #27's CCP revealed there was no documented evidence the CCP included problem, goal, or interventions related to oxygen therapy. Observation of Resident #27, on 11/30/2021 at 9:11 AM, revealed the resident was in his/her room with oxygen therapy applied via nasal cannula. Interview with LPN #2, on 12/03/2021 at 10:52 AM, revealed the CCP should include care needed to take care of the residents, including transfer status, toileting needs, nutritional needs, communication problems, oxygen use, and any other special needs. Additionally, he stated the nurses were responsible for developing the CCP. Per the interview, it was important the CCP was developed to address the residents' individualized needs in order for staff to be aware of how to provide care. 5. Review of Resident #18's EMR revealed the facility admitted the resident, on 01/27/2017, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #18's Quarterly MDS Assessment, dated 11/01/2021, revealed the facility did not assess Resident #18's BIMS due to the resident being rarely/never understood. A continued review of the MDS Assessment revealed the resident had modified independence related to Cognitive Skills for Daily Decision Making. Resident #18 was totally dependent on staff for all Activities of Daily Living (ADL). Further review revealed Resident #18 had current skin issues and pressure ulcer/injury care. Review of Resident #18's Wound Care Progress Note, dated 11/18/2021, revealed that modifying factors included off-loading the resident's heels by floating them. Review of Resident #18's CCP, dated 10/18/2021, revealed the resident was care planned for pressure ulcers related to decreased mobility. Long-term goals, with a target date of 01/18/2022, were that there would be signs of healing, through the next review. Interventions included keeping bony prominences from direct contact with each other; float heels to relieve pressure on the heels; and treatment to pressure area as ordered. Observation of Resident #18, on 12/01/2021 at 2:04 PM, revealed the resident's heels were not floated as per order. Interview with Resident #18, on 12/01/2021 at 3:17 PM, revealed nursing staff turned him regularly while in bed. However, the resident shook his head, No, when asked if staff positioned his/her heels off the mattress while the resident was in bed. Interview with SRNA #1, on 12/01/2021 at 3:25 PM, revealed aides performed checks and changed all residents every two (2) hours. She stated Resident #18 would let staff know if he/she needed changing or repositioning. She could not say for sure if Resident 18's heels needed to be off-loaded. Interview with RN #1, on 12/01/21 at 2:04 PM, revealed Resident #18's heels were not floated while the resident was in bed. When asked what interventions were in place to prevent pressure wounds on Resident #18's heels, she stated nursing provided treatments to pressure areas as ordered. Per the interview, RN #1 stated it was important that a CCP was developed and implemented to address the residents' individualized needs. She further stated nursing staff was responsible to update the CCP for staff to be aware of how to provide care. 6. Review of Resident #11's EMR revealed the facility admitted the resident, on 04/14/2016, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #11's Quarterly MDS Assessment, dated 11/04/2021, revealed the facility did not assess Resident #11's BIMS due to the resident being rarely/never understood. A continued review of the MDS Assessment revealed the resident was independent related to Cognitive Skills for Daily Decision Making. Resident #11 required extensive assistance of staff for all Activities of Daily Living (ADL). Further review of the MDS, revealed Resident #11 was coded as needing setup by staff and supervision was required with eating and drinking. Review of Resident #11's CCP, initiated on 04/14/2016, revealed the resident was care planned for self-care deficits. Long-term goals, with a target date of 12/21/2021, included to have no decline through the next review. Interventions included: report changes in ADL self-performance to the nurse. Further review revealed Resident #11 had a potential nutritional risk related to the need for a mechanically altered diet. Interventions included encourage oral intake of food and fluids; and to ensure resident was sitting in an upright position when eating. Review of Resident #11's CNA Care Report, on 12/01/2021 at 3:25 PM, revealed the Feeds Self box was checked. Review of Resident #11's CNA Care Report, on 12/02/2021 at 9:25 AM, revealed the Feeds Self box was crossed out (date and time was not noted) and the Dependent box was checked, with assist written to the side. Continued review of Resident #11's medical record revealed an Occupational Therapy (OT) evaluation, with a start date of 11/30/2021, to address the need for assistance with self-care related to eating. Further review of the OT evaluation revealed Resident #11 was spilling fifty (50) percent of liquids and only consumed twenty-five (25) percent of his/her meal. Per the evaluation, OT recommended weighted utensils in order to self-feed seventy-five (75) percent of the meal to maintain nutrition. Continued review of Resident #11's medical record revealed an OT Treatment Encounter Note, dated 11/30/2021, which revealed the OT reviewed self-care performance with SRNA's, stating the resident required assistive equipment to aid in grasping and a visual target tracking to gain independence in self-feeding. Further review revealed the resident still had excessive spillage of liquids. Continued review of Resident #11's medical record revealed an OT Treatment Encounter Note, dated 12/01/2021, which stated that Resident #11 was repositioned in bed to optimize eating. Furthermore, weighted utensils, bowls, and dycem (non-slide mats) were utilized to assist the resident to grasp and visually track food and to avoid excessive spillage of liquids. Observation of Resident #11, on 11/30/2021 at 9:30 AM, revealed the resident lying in bed at an approximate thirty (30) degree angle with food on his/her mustache, shirt, and sheets. His/her sheets were wet with a large dark liquid substance. His/her hands and nails were soiled with food particles. Resident #11 nodded, Yes, when the SSA Surveyor asked if he/she had spilled his breakfast. Observation of Resident #11, on 11/30/2021 at 12:30 PM, revealed the resident was self-feeding, attempting to get food from a plate. He/she was not wearing his/her dentures. The coffee cup was not a two-handled cup, and the resident was using regular utensils. His/her food tray had been set on the bedside table, but the table was not positioned directly in front of the resident. Interview with Resident #11, on 11/30/2021 at 9:33 AM, revealed Resident #11 stated he/she was not assisted with meals. Interview with SRNA #1, on 12/01/2021 at 3:25 PM, revealed there was a Care Plan binder, located at the nurse's station, which held a CNA Care Report for each resident to refer to regarding resident care. SRNA #1 stated the binder was updated by nursing staff. SRNA #1 stated aides were updated about special feeding instructions during report at shift change or by looking at updates from the nurses in the CNA Care Report. Interview with the OT, on 12/01/21 at 1:31 PM, revealed she had evaluated Resident #11 during lunch. Further interview revealed OT referrals were made by nursing. When asked if nursing had made the referral for OT to evaluate Resident #11's need for feeding assistance, she stated they had not. She further stated that while assisting Resident #11's roommate, she observed Resident #11 having difficulty with self-feeding, so she made the referral for an OT evaluation. Interview with the Speech Language Pathologist (SLP), on 12/01/2021 at 4:36 PM, revealed Resident #11 had been evaluated; however, he/she was not currently receiving services. Interview with RN #1, on 11/30/2021 at 2:31 PM, revealed aides round every two (2) hours. She stated if a resident was ordered supervision during meals, it meant that someone must be in the room to monitor for choking. She further stated that nurses updated changes in the CNA Care Report, and the Charge Nurse monitored SRNA's to ensure the CCP is followed. RN #1 stated it was her expectation that the CCP's were updated, and that staff assisted with feeding according to the CCP. Per the interview, she stated the nurses were responsible for developing the CCP. RN #1 stated it was important that a CCP was developed for staff awareness of how to provide care and to address the individualized needs of the residents. Interview with the MDS Coordinator, on 12/01/21 at 5:14 PM, revealed the facility acted as a team and each discipline updated the CCP. She stated changes in condition were discussed at care plan meetings, and each team member contributed to developing an individualized care plan. She further stated Resident #11's CCP should have been developed to reflect the resident's change in ability to feed self, and supervision and set up should have been added. Interview with the MDS Nurse, on 12/02/2021 at 9:20 AM, revealed the CCP should be developed with specific information on how to take care of each resident. Per the interview, the interdisciplinary team reviewed Nurse's Notes from the previous day(s) every morning, and information acquired during this meeting, including any new orders or a change in a resident's condition, was used to develop the CCP. Per the interview, the Resident Assessment Instrument (RAI) was the guideline utilized during CCP development. Interview the ADON, on 12/03/2021 at 11:25 AM, revealed the CCP was based on the resident's needs at admission and developed or evolved as needed. The ADON stated the MDS Nurse and nursing staff were responsible for developing the CCP as needed. The ADON stated it was important for the CCP to be up-to-date to direct staff on how to care for the residents' individual needs. Per the interview, it was her expectation the CCP would be developed as necessary and followed accordingly. Interview with the Director of Nursing (DON), on 12/03/2021 at 12:15 PM, revealed she had worked at the facility as DON since 11/29/2021. Further interview revealed the CCP would be developed by the nurses including the MDS Nurse. She stated the CCP was a working document and was to reflect the resident's current status. Additionally, she stated the CCP was the guide staff used to provide care to residents. Interview with Administrator, on 12/03/2021 at 12:37 PM, revealed it was his expectation that staff develop, update, and follow the CCP to provide individualized care to meet the residents' needs.

Based on interview and record review, it was determined the facility failed to ensure sufficient nursing staff to provide nursing services and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for seven (7) of twenty-two (22) sampled residents (Resident's #2, #6, #20, #23, #27, #29, and #30). Interviews with Resident #6, Resident #20, and Resident #27, on 11/30/2021, revealed they had to wait up to an hour for their call bell to be answered. In addition, interview with Resident #23, on 11/30/2021, revealed it may take up to thirty (30) to forty-five (45) minutes for call lights to be answered during mealtimes During Resident Group Interview conducted on 11/30/2021, Residents #2 and #29, revealed they had to wait extended wait periods for assistance after the call lights were activated. Additional interview with Resident #29, on 12/01/2021, revealed approximately two (2) months ago he/she activated the call light, but staff did not answer call light timely and he/she soiled himself/herself. Furthermore, Resident #30 complained that on 11/29/2021, he/she had to call his/her friend in order for his/her friend to call the nurse's station because the staff did not answer the call bell. The findings include: Review of the facility's Census and Condition, dated 11/30/2021, revealed the facility had 47 residents. Review of the Facility Assessment, dated 2021, under the Acuity-Quality Assuance Performance Improvement/Plan Summary revealed the facility currently had Performance Improvement Plans (PIP) for fall, infection control, care plans, assessments, and wounds, however there was no documented evidence of a PIP for call lights or staffing. Further review under the Acuity-Sufficency Analysis Summary section, revealed the facility would follow acuity based staffing criteria and the staffing schedules were based on the census in order to have adequate Per Patient Day (PPD) staffing. Additional review of the Facility Assessment revealed the facility assessed the overall staffing, staff competencies and services as being sufficient with no need for an action plan in the areas of Activities of Daily Living (ADL). Review of the facility's document titled, Answering Call Lights, undated, revealed it addressed if unable to meet resident's need and leave call light on until the need had been met. Continued review revealed staff should identify self and call the resident by name. It addressed to listen to the resident's request do what the resident asks if if permitted. It addressed that if staff promised to return to the resident they should do so promptly. Finally it stated that if assistance was needed when entering the room to summon help by initiating the call light. However, there was no documented evidence the policy addressed the timeliness of answering the call lights. Review of the facility Resident Rights Policy, revised 08/16/2018, revealed all residents would be treated in a manner and in an environment that promotes maintenance or enhancement of quality of life. Review of the facility's daily staffing assignment sheets for the month of November 2021 revealed the facility had an average of twelve (12) SRNAs, two and one half (2.5) LPNs, one and a half (1.5) RN's on the schedule per day (24 hours). Continued review revealed there were three (3) days in November 2021 with only eleven total staff members. On two (2) of the three (3) days that only had eleven (11) staff, there were nine (9) SRNAs and two (2) LPNs for the twenty-four (24) hour period. The other day there were ten (10) SRNAs and one (1) LPN for the twenty-four (24) hour period. There was no other RN on those days except the Director of Nursing. 1. Review of Resident #30's medical record revealed the facility admitted the resident on 12/16/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #30's Quarterly Minimum Data Set (MDS) Assessment, dated 09/19/2021, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of thirteen (13) out of fifteen (15) indicating the resident was cognitively intact. Additionally, the facility assessed the resident as requiring the assist of two (2) plus caregivers for transfers and toileting. Further review of the MDS Assessment, revealed the resident was totally dependent on staff for assistance with ADLs and was incontinent of bowel and bladder. Interview with Resident #30, on 11/30/2021 at 10:51 AM, revealed staff did not answer the call light in a timely manner. Continued interview revealed last night (on 11/29/2021) he/she had to phone his/her friend to call the nurse's station because the staff did not answer the call bells when he/she needed assistance. Interview with State Registered Nurse Assistant (SRNA) #1, on 12/01/2021 at 3:27 PM, revealed she was usually assigned to sixteen (16) residents and usually worked day shift. She stated she often felt rushed. Further interview revealed oral care was hard to do sometimes, especially if the resident requested oral care three(3) times a day. Continued interview revealed the facility had been utilizing agency staff to help with the staffing situation. Continued interview with State Registered Nursing Assistant (SRNA) #1, on 12/2/2021 at 8:41 AM, revealed she attempted to answer resident call lights within five (5) minutes, but during meals, it was harder to assist residents in a timely manner and there were times she felt she could not give the residents the time and care they needed. 2. Review of Resident #29's medical record revealed the facility admitted the resident on 03/17/2015. Resident #29's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #29's most recent Quarterly Minimum Data Set (MDS) Assessment, dated 11/08/2021, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fifteen (15), out of fifteen (15) indicating the resident was cognitively intact. Additionally, the facility assessed the resident as requiring extensive assist of two (2) plus caregivers for transfers and toileting. Further review of the MDS Assessment, revealed the resident was frequently incontinent of bowel and bladder. Interview with Resident #29, on 11/30/2021 at 9:00 AM, revealed he/she has had to wait for long periods of time for the call light to be answered, and this was on all shifts. Additionally, Resident #29 voiced this same concern during Resident Council Meeting on 11/30/2021 at 2:30 PM and requested the State Survey Agency (SSA) Representative to discuss this further with him/her privately. Additional interview with Resident #29, on 12/01/2021 at 10:13 AM, revealed he/she had diarrhea approximately two (2) months ago and needed to have a bowel movement. The resident stated he/she activated the call light, but staff did not answer the call light for a long time. The resident further stated he/she was not able to wait any longer for help and soiled himself/herself. Resident #29 was observed closing his/her eyes, tilting head down and shaking head back and forth as he/she voiced being very embarrassed about this occurrence. Phone interview with Resident #29's daughter, on 12/02/2021 at 2:05 PM, revealed the resident had complained to her that call lights take a long time to be answered. Resident #29's daughter stated the resident told her he/she would push the call light and if no one came to answer it, then the resident would have his/her roommate check the light on the wall to ensure the call light was on. The resident's daughter stated she felt the resident never had enough help. 3. Review of Resident #2's medical record revealed the facility admitted the resident on 08/24/2017 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Quarterly MDS Assessment, dated 11/14/2021, revealed the facility assessed the resident to have a BIMS score of fifteen (15) out of fifteen (15), which indicated he/she was cognitively intact. Additionally, the MDS Assessment revealed the resident required supervision and one (1) person assist with transfers, toileting, bed mobility and ambulation. The MDS further revealed the resident was occasionally incontinent of bladder and always continent of bowel. Interview with Resident #2, on 11/30/2021 at 9:10 AM, revealed it could take up to an hour for staff to answer call lights and it was the same for any time day or night. Additionally, he/she stated the delay in answering call lights happened on all shifts. Further interview with Resident #2 during Resident Group Interview, on 11/30/2021 at 2:22 PM, revealed he/she felt the facility was understaffed at times. The resident did not elaborate when asked what he/she usually needed assistance with when using the call light. 4. Review of Resident #27's medical record revealed the facility admitted the resident on 10/13/2021. Resident #27's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #27's Admission MDS Assessment, dated 10/20/2021, revealed the facility assessed the resident as having a BIMS score of eight (8) out of fifteen (15), indicating moderate cognitive impairment. Further, the facility assessed the resident as requiring extensive assist of one (1) caregiver for transfers, bed mobility, dressing and toileting. Additionally, the MDS Assessment revealed the resident was frequently incontinent of bowel and bladder. Interview with Resident #27, on 11/30/2021 at 9:17 AM, revealed it could take up to an hour for the call light to be answered. Additionally, the resident stated it took the longest for staff to answer the call light during night shift. 5. Review of Resident #6's medical record revealed the facility admitted the resident on 06/11/2021. Resident #6's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #6's Quarterly MDS Assessment, dated 08/31/2021, revealed the facility assessed the resident as having a BIMS score of eleven (11), out of fifteen (15) indicating moderate cognitive impairment. Further, the facility assessed the resident as requiring extensive assist of two (2) plus caregivers for bed mobility and dressing. Continued review revealed the resident was completely dependent on staff and required two (2) plus person assist for toileting and transfers. Additionally, the MDS Assessment revealed the resident was always incontinent of bowel and bladder. Interview with Resident #6, on 11/30/2021 at 12:06 PM, revealed he/she had to wait up to an hour for his/her call bell to be answered. Additionally, the resident stated that there was no specific day or shift when call bells took longer to answer. The resident stated he/she knew it took up to an hour because he/she could see the time on the clock. During the interview, the State Survey Agency (SSA)Representative observed a large clock on the resident's wall. Interview further revealed the resident was able to accurately report time to the SSA Representative. 6. Review of Resident #23's medical record revealed the facility admitted the resident on 06/26/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #23's Quarterly MDS Assessment, dated 09/30/2021, revealed the facility assessed the resident as having a BIMS score of fourteen (14), out of fifteen (15) indicating intact cognition. Further review revealed the facility assessed the as requiring extensive assist with bed mobility, transfers, dressing and toileting. Additionally, the MDS Assessment revealed the resident was always incontinent of bowel and bladder. Interview with Resident #23, on 11/30/2021 at 2:27 PM, revealed it may take up to thirty (30) to forty-five (45) minutes for call lights to be answered during mealtimes. He/she further stated there were staffing problems because of COVID-19. 7. Review of Resident #20's medical record revealed the facility admitted the resident on 06/18/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #20's Quarterly MDS Assessment, dated 10/08/2021, revealed the facility assessed the resident as having a BIMS score of fifteen (15), out of fifteen (15) indicating intact cognition. Further, the facility assessed the resident as requiring extensive assist with bed mobility, transfers, dressing and personal hygiene. Further, the resident required limited assist with toileting. Additionally, per the MDS Assessment, the resident was always incontinent of bowel and occasionally incontinent of bladder. Interview with Resident #20, on 11/30/2021 at 2:24 PM, revealed he/she had to wait up to one (1) hour for call lights to be answered if something else was going on at the time. The resident stated he/she would get aggravated sometimes, but further stated he understood because of the number of people staff have to take care. Interview with State Registered Nursing Assistant (SRNA) #1, on 12/02/2021 at 8:41 AM, revealed she tried to answer call lights within five (5) minutes, but during meals, it was difficult to assist residents in a timely manner. Additionally, she stated there were times she felt she could not give the residents the time and care they needed and little things, like mouth care, were hard to fit in. Interview with SRNA #5, on 12/02/2021 at 5:33 PM, revealed she worked day shift and had about sixteen (16) residents to care for daily. She further stated that some days were more difficult than others to get everything completed, but she usually had enough time to get everything done. Further interview revealed call lights sometimes took a while to answer, especially during meals, but she did not give a specific amount a time a resident would have to wait. Per interview, no other disciplines besides SRNAs would answer the call lights. Interview further revealed she had taken call light concerns to the Assistant Director of Nursing (ADON) #1 and the Administrator and she had not identified any improvement with this concern. Interview with Licensed Practical Nurse (LPN) #2, on 12/03/2021 at 10:52 AM, revealed he typically worked day shift. He stated it was important to answer call lights quickly for safety reasons and further explained if a resident was in pain or was a fall risk, it would be important to have their needs met quickly. He further reported residents did not have to wait a long time to have their call light answered, but did not give a specific amount of time they might have to wait. Interview with Assistant Director of Nursing (ADON) #1, on 12/03/2021 at 11:25 AM, revealed everyone was responsible for answering call lights and a call light should be answered in three (3) to five (5) minutes because the resident might have an urgent need. Additionally, she stated she was not aware of any resident having to wait longer than three (3) to five (5) minutes to have their call light answered and she was unaware of any concerns related to call lights. She further stated she did not feel the facility had a staffing problem. Interview with the Director of Nursing (DON), on 12/03/2021 at 12:15 PM, revealed it was everyone's responsibility to answer call lights. She further stated an acceptable time for call lights to be answered depended on the situation, but further stated that an hour was excessive. Additionally, it was important to answer call lights within a reasonable amount of time in order to meet resident needs. Further interview revealed she just started auditing call lights, three (3) days ago, and the longest time a resident had to wait for the call light to be answered was four (4) minutes. She further stated she was not aware of call light audits done before she started at the facility on 11/29/2021. Interview with the Administrator, on 12/03/2021 at 12:37 PM, revealed the amount of time to answer a call light was individualized to the situation, but further stated a thirty (30) minute wait to have a call light answered was unreasonable. Further, he stated it was his expectation that call lights were answered in a reasonable amount of time in order for residents to receive necessary care and services upon request. Further the Administrator stated he felt the staffing levels were adequate.

Based on observation, interview, review of the document from the Centers for Disease Control and Prevention (CDC) Vaccine Storage and Handling, review of the product insert instructions for Imdevimab (monoclonal antibodies), review of the product insert instructions for [MEDICATION(S)] vaccine (influenza vaccine), and review of the facility's policies, it was determined the facility failed to store medications according to appropriate environmental controls to preserve their integrity, affecting two (2) unopened boxes of influenza vaccine, one (1) opened and used vial of influenza vaccine, and one (1) box of [CONDITION(S)]-CoV-2 monoclonal antibodies. In addition, the facility failed to ensure drugs and biological's were stored to ensure the safety of residents and the integrity of the medication for one (1) of twenty-two (22) sampled residents, Resident #30. Observation of the Medication Storage room for Units 1, 2, and 3 revealed medication was stored in the refrigerator door. Further observation revealed a refrigerator in the Staff Development Coordinator's (SDC) office, which stored vaccines, that was not monitored for temperature controls. Observation of Resident #30's room revealed four (4) different medications located on the resident's dresser. The findings include: Review of the facility's Medication Storage policy, reviewed [DATE], revealed the purpose of the policy was to ensure medications were stored safely, securely, and appropriately, following manufacturer's recommendations, to ensure the integrity of the medications and the safety of the residents. Further review revealed daily refrigerator temperatures were documented on the temperature log. In addition, the policy stated all medications, including over-the-counter, were kept in locked storage at all times, either in the medication room or Medication Cart. Review of the facility's Influenza Vaccine policy, revised ,d+[DATE], revealed all residents and employees shall be offered the influenza vaccine annually to promote the benefits associated with the influenza vaccination. Additional review revealed documentation of the date of vaccination, lot number, expiration date, person administering, and the site of the vaccination would be kept in the resident's/employee's file. Furthermore, the policy stated administration of the influenza vaccine would be made in accordance with current CDC recommendations. Review of the CDC's document Vaccine Storage and Handling, updated [DATE], revealed proper vaccine storage and handling play critical roles in efforts to prevent vaccine-preventable diseases. Vaccines exposed to storage temperatures outside the recommended ranges might have decreased efficacy, creating limited protection, and exposure to temperatures thirty-two (32) degrees Fahrenheit or colder could destroy potency. The document stated best practices for storage of vaccines included: 1) do not over-pack the refrigeration unit; 2) place vaccine packages in such a way that air could circulate around the compartment to promote air flow; 3) leave two (2) to three (3) inches between vaccine containers, and the refrigerator's walls; 4) and do not use the top shelf, floor, or door for vaccine storage as the temperature in these areas may differ significantly from the temperature in the body of the unit. Per the CDC recommendations, vaccine temperatures should be monitored and documented at least twice daily if the temperature monitoring device did not read minimum and maximum temperatures. Further review revealed vaccine storage and monitoring should be delegated to competently trained staff. Review of the product insert instructions for Imdevimab ,d+[DATE].1, (Antiviral Monoclonal Antibodies-SAR-CoV-2 Coronavirus), given to treat COVID-19, revealed the medication should be stored in a refrigerator at a temperature between 35.6- and 46.4-degrees Fahrenheit. In addition, the manufacturer's guidelines state Imdevimab should not be frozen. Review of the product insert instructions for [MEDICATION(S)] vaccine (Influenza Vaccine), revealed temperature storage should be between thirty-six (36) and forty-six (46) degrees Fahrenheit. Per the manufacturer's recommendations, the vaccine should not be frozen. 1. Observation of the medication storage room utilized by Units 1, 2, and 3, on [DATE] at 9:00 AM, revealed the medication refrigerator's temperature was at forty-two (42) degrees Fahrenheit. Further observation revealed one (1) unopened box of Imdevimab ,d+[DATE].1 - [CONDITION(S)]-CoV-2 monoclonal antibodies stored on the top shelf of the refrigerator door directly adjacent to the freezer. In addition, the freezer compartment had approximately three-quarters of an inch of ice build-up on all sides of the freezer. In addition, there was a temperature log for this refrigerator, which had the correct temperature range on it of thirty-six (36) to forty-six (46) degrees Fahrenheit for reference. Observation of the vaccine storage refrigerator, on [DATE] at 9:45 AM, located in the Staff Development Coordinator's (SDC) office, revealed the thermometer located inside the body of the refrigerator unit read the internal temperature at thirty (30) degrees Fahrenheit. The refrigerator contained two (2) unopened boxes of [MEDICATION(S)] and one (1) opened vial of [MEDICATION(S)], which was used and approximately half full. In addition, there was not a temperature log for the vaccine refrigerator in the SDC's office, which had the correct temperature range on it for reference. Interview with the SDC, on [DATE] at 9:45 AM, revealed it was her responsibility to monitor the vaccine temperatures once daily. When asked by the State Survey Agency (SSA) surveyor for temperature logs for the vaccine refrigerator, the SDC stated she had no documentation. She stated further that she had not yet checked the temperature of the vaccine refrigerator for the day. When asked what the optimal temperature of the refrigerator should be maintained for proper influenza vaccine storage, the SDC stated, About thirty-two (32) degrees Fahrenheit to forty-two (42) degrees Fahrenheit. Per the interview, she stated she had no training specific to vaccine storage and monitoring. She further stated the vaccine stored in the refrigerator would be used for staff immunizations. Additional interview revealed residents received their influenza vaccinations last week; however, the SDC did not know who received vaccinations from the opened vial of [MEDICATION(S)]. Interview with Registered Nurse (RN) #1, on [DATE] at 10:45 AM, revealed it was the responsibility of the nursing staff to ensure medications were stored according to facility policy to ensure the safety of all residents. Interview with Licensed Practical Nurse (LPN) #2, on [DATE] at 10:52 AM, revealed staff was to ensure medications were stored according to facility policy. Per the interview, storing drugs according to manufacturer's recommendations and CDC guidelines were necessary for the safety of all residents. Interview with the Assistant Director of Nursing/Infection Preventionist (ADON/IP), on [DATE] at 9:00 AM, revealed she was unaware medications should not be stored on shelves in the refrigerator door. The ADON/IP stated the Imdevimab was house stock and had been removed already from the refrigerator and discarded because it had been stored improperly, and she was unsure of its efficacy. According to the ADON/IP, all vaccines were stored in the SDC's office, and the SDC was responsible for monitoring the vaccines and documenting temperatures on the temperature log. Further interview revealed staff members who received vaccine deliveries, as well as those who handled or administered vaccines, were not all trained in vaccine-related practices to include storage and monitoring. Additional interview with the ADON/IP, on [DATE] at 10:15 AM, revealed the vaccine stored in the refrigerator would be discarded because it had been stored in a refrigerator without proper temperature control monitoring, and the noted temperature was below the CDC's temperature guidelines. She stated all the residents requesting the influenza vaccine had been given the immunization. The ADON/IP further stated the facility had not yet offered the influenza vaccine to staff. She stated she would make the Administrator aware and contact the pharmacy regarding the vaccine's efficacy and for further instructions. Additional interview with the ADON/IP, on [DATE] at 9:00 AM, regarding the compromised vaccines, revealed the compromised influenza vaccine was only used on staff, and she would provide a list of those employees. However, the documentation was never provided. 2. Review of Resident #30's medical record revealed the faciity admitted the resident on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #30's Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility asessed the resident as having a Brief Interview for Mental Status (BIMS) score of thirteen (13) out of fifteen (15) indicating the resident was cognitively intact. Additionally, the facility assessed the resident as requiring the assist of two (2) plus caregivers for transfers and toileting. Observation of Resident #30's room, on [DATE] at 12:10 PM and again at 3:00 PM, revealed a tube of [MEDICATION(S)] (an antibacterial ointment), a tube of [MEDICATION(S)] (an anti-fungal ointment), a tube of Derma Fungal (2% Miconazole, an anti-fungal ointment), and a bottle of [MEDICATION(S)] nasal spray (an antihistamine used to treat allergies) which were placed on the top of Resident #30's dresser, which was in the back left side of the room. Additional interview with the ADON/IP, on [DATE] at 11:25 AM, revealed it was her expectation that all nursing staff follow facility policy and procedures related to medication administration and storage. The ADON/IP stated, if an item was found to be expired, labeled, and/or stored improperly, it was her expectation that nursing staff return or discard the medication according to facility policy. Additionally, the ADON/IP stated it was her expectation that all medication refrigerators were checked and logged daily to maintain the integrity of medications. Continued interview revealed it was important to ensure the efficacy of the medications and vaccines for the safety of all residents. Interview with the DON, on [DATE] at 12:15 PM, revealed it was her expectation that all nursing staff follow facility policy and procedures related to medication administration and storage. Additionally, the DON stated it was her expectation that all medication refrigerators were checked and logged daily to maintain the integrity of medications and for the safety of all residents. Interview with the Administrator, on [DATE] at 12:37 PM, revealed it was his expectation for medication to be stored appropriately by CDC and manufacturer's guidelines and facility policy. Furthermore, he expected nursing staff to follow current medication policies and protocols. The Administrator further stated this was important to ensure the safety of all residents.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure two (2) of twenty-two (22) sampled residents' care plans, Resident #11 and #33, were revised to reflect the care needs of the residents. 1. Review of Resident #33's Comprehensive Care Plan (CCP), initiated on 07/18/2020, revealed the facility failed to revise the resident's Nutritional Status focus area to ensure the staff was provided Resident #33's correct feeding instructions. 2. Review of Resident #11's (CCP), initiated on 04/14/2016, revealed the facility failed to revise the resident's Nutritional Status focus area to ensure the staff was provided Resident #11's correct feeding instructions, as directed by the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The findings include: Review of the facility's policy titled, Comprehensive Care Plans, revised on 07/19/2018, revealed the CCP included how the facility would assist the resident to meet their needs, goals, and preferences. Further review of the policy revealed the care plans were ongoing and revised as information about the resident and the resident's condition changed. 1. Review of Resident #33's medical record revealed the facility admitted the resident on 07/18/2020. Resident #33's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #33's Quarterly Minimum Data Set (MDS) Assessment, dated 10/15/2021, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15) which indicated severe cognitive impairment. Further review of the MDS Assessment, revealed the facility assessed the resident to require extensive assist with bed mobility, transfers, toilet use, and dressing. Additionally, the facility assessed the resident as completely dependent on staff for eating. Review of Resident #33's Comprehensive Care Plan (CCP), initiated on 07/18/2020, revealed the resident was at nutritional risk related to a mechanically altered diet, decreased meal and fluid intake, and a significant weight loss. The goals, dated 08/16/2021, revealed the resident's weight would remain greater than 100.4 pounds, and the resident would tolerate the mechanically altered diet through the next review. Interventions, dated 7/30/2021, included: Mechanically altered diet as ordered, monitor for signs and symptoms of chewing and swallowing difficulties, and consult the Speech Language Pathologist (SLP) as needed. No special feeding instructions were detailed on the CCP. Review of the Speech Therapy Treatment Encounter Note, dated 10/07/2021, revealed the Speech Language Pathologist (SLP) educated staff to provide Resident #33 with his/her preferred food item (pudding) at the beginning of his/her meal to prevent the resident from holding food in his/her mouth. The Note further revealed staff verbalized understanding of the feeding instructions. Review of the Speech Therapy Treatment Encounter Note, dated 10/12/2021, revealed the SLP placed a visual aid in Resident #33's closet for staff to review with directions on feeding the resident. Review of Resident #33's visual aid, located inside of Resident #33's closet, revealed Feeding Recommendations For, with the resident's initials, undated, revealed the feeding recommendations for the resident included staff was to provide the resident food before his/her drink; drinks were provided at the end of the resident's meal (which would allow the resident to consume more food and hopefully decrease weight loss); to be fed in the dining room as he/she was able; ensure the resident was seated in an upright position and lights were on prior to feeding; pudding or ice cream was provided at the beginning of his/her meal; and the resident was to spit out food or drink if he/she held food or drink in his/her mouth. Review of the SLP Discharge Summary, dated 10/15/2021, revealed Resident #33 received Dysphagia therapy from 09/20/2021 through 10/15/2021. Further review revealed the discharge recommendations included: resident to be fed in dining room as able, position and environment modified to promote alertness, and drinks provided at the end of the resident's meal. Review of the Certified Nurse Assistant (CNA) Care Report, undated, revealed Resident #33 was to receive a pureed diet with honey thickened liquids. There were no special feeding instructions detailed on the CNA Care Report. Observation of Resident #33, on 11/30/2021 at 12:38 PM, revealed the resident was in bed, being fed by State Registered Nurse Aide (SRNA) #5. The resident was fed one (1) opportunity of thickened beverage, followed by five (5) spoons of pureed solid food, followed by one (1) opportunity of thickened liquid, during assistance with his/her meal. Interview with SRNA #5, on 11/30/2021 at 12:45 PM, revealed she was unaware of specific instructions on how Resident #33 was to be fed. SRNA #5 revealed she was not previously aware of these special feeding instructions. Observation, on 12/03/2021 at 8:42 AM, revealed Resident #33's visual aid was located inside of Resident #33's closet. Interview with the Speech Language Pathologist (SLP), on 12/01/2021 at 1:10 PM, revealed she evaluated Resident #33 in 09/2021, and she reported the resident's feeding recommendations to the nurses and SRNA's caring for the resident. Further interview revealed she posted the recommendations on the inside of the resident's closet door for staff to review. Interview with SRNA #9, on 12/02/2021 at 5:33 PM, revealed she had recently fed Resident #33 and was aware the resident needed to be seated in an upright position when being fed. She stated there were instructions for feeding Resident #33 on the inside of the resident's closet door. Interview with Licensed Practical Nurse (LPN) #2, on 12/03/2021 at 10:52 AM, revealed he was not sure of Resident #33's diet order or any special feeding instructions. Interview further revealed that special feeding instructions for a resident should be included on the CCP. Additionally, he stated this was important to ensure the resident's CCP was up to date to ensure the residents were treated according to their current needs. 2. Review of Resident #11's medical record revealed the facility admitted the resident, on 04/14/2016, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #11's Quarterly Minimum Data Set (MDS) Assessment, dated 11/04/2021, revealed the facility did not assess Resident #11's BIMS due to the resident being rarely/never understood. A continued review of the MDS Assessment revealed the resident was independent related to Cognitive Skills for Daily Decision Making. Further review of the MDS, revealed Resident #11 assessed as needing setup by staff and supervision was required with eating and drinking. Review of Resident #11's current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #11's Comprehensive Care Plan (CCP), initiated on 04/14/2016, revealed the resident was care planned for self-care deficits. Long-term goals, with a target date of 12/21/2021, revealed no decline through the next review. Further review revealed Resident #11 had a potential nutritional risk related to the need for a mechanically altered diet. Interventions included to encourage oral intake of food and fluids; and to ensure the resident was sitting in an upright position when eating. Further review of Resident #11's CCP revealed no documented evidence the facility revised the resident's Nutritional Status Care Plan, to ensure the resident received the correct feeding instructions for staff to assist the resident with his/her meals, reflecting the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #11's Occupational Therapy (OT) evaluation, with a start date of 11/30/2021, revealed the resident was referred to OT to address the resident's need for assistance with self-care related to eating. Further review revealed Resident #11 spilled fifty (50%) percent of his/her liquids and only consumed twenty-five (25 %) percent of his/her meal. Per the evaluation, OT recommended weighted utensils in order for the resident to self-feed seventy-five (75%) percent of his/her meal, to maintain his/her nutrition. Review of Resident #11's OT Treatment Encounter Note, dated 11/30/2021, revealed Resident #11 was sitting up in his/her wheelchair when OT entered the room. OT charted she reviewed self-care performance with SRNA's, stating the resident required assistive equipment to aid in grasping and visual target tracking to gain independence in self-feeding. Further review revealed the resident continued to have excessive spillage of liquids. Review of Resident #11's OT Treatment Encounter Note, dated 12/01/2021, revealed the resident was repositioned in bed to optimize eating. Furthermore, weighted utensils, bowls, and dycem non-slide mats were utilized to assist resident to grasp and visually track food and to avoid excessive spillage of liquids. Review of Resident #11's Registered Dietician (RD) Progress Note, dated 12/01/2021, revealed the resident was at risk related to the need for a mechanically altered diet, the need for dietary supplements, and not meeting his/her fluid needs. Review of Resident #11's RD's Mini Nutritional Assessment, dated 12/01/2021, revealed the resident was assessed to be malnourished. Per the RD progress notes, dated 12/01/2021, she requested the physician to add the malnutrition diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #11's CNA Care Report, on 12/01/2021 at 3:25 PM, revealed the Feeds Self box was checked. Review of Resident #11's CNA Care Report, on 12/02/2021 at 9:25 AM, revealed the Feeds Self box was crossed out (date and time was not noted) and the Dependent box was checked, with assist written to the side. Observation of Resident #11, on 11/30/2021 at 9:30 AM, revealed the resident was lying in bed with food on his/her mustache, shirt, and sheets. His/her sheets were wet with a large dark liquid substance that had spilled. Resident #11's hands and nails were soiled with food residue. Resident #11 nodded, Yes, when the State Survey Agency (SSA) Surveyor asked if he/she had spilled his/her breakfast and coffee. Observation of Resident #11, on 11/30/2021 at 12:30 PM, revealed the resident was self-feeding, attempting to get food from a plate. He/she was not wearing his/her dentures. The coffee cup was not a two-handled cup, and the resident was using regular utensils. His/her food tray had been set on the bedside table, but the table was not positioned directly in front of the resident. Interview with Resident #11, on 11/30/2021 at 9:33 AM, revealed Resident #11 stated he/she was not assisted with meals. Interview with SRNA #1, on 12/01/2021 at 3:25 PM, revealed there was a Care Plan binder, located at the nurse's station, which held a CNA Care Report for each resident to refer to regarding resident care. SRNA #1 stated the binder was updated by nursing staff. SRNA #1 stated aides were updated about special feeding instructions during report at shift change or by looking at updates from the nurses in the CNA Care Report. Interview with the OT, on 12/01/2021 at 1:31 PM, revealed she had evaluated Resident #11 during lunch. Per the interview, the OT stated she did offer substitutions, but Resident #11 did not want anything more. Further interview revealed OT referrals are made by nursing. When asked if nursing had made the referral for OT to evaluate Resident #11's need for feeding assistance, she stated they had not. She stated that while she was assisting Resident #11's roommate, she observed Resident #11 having difficulty with self-feeding, so she made the referral for an OT evaluation. Interview with RN #1, on 11/30/2021 at 2:31 PM, revealed aides round every two (2) hours. She stated if a resident was ordered supervision during meals, it meant that someone must be in the room to monitor for choking. If a nurse observed a resident was having difficulty with swallowing, he/she would write a referral for speech language pathology (SLP) or occupational therapy (OT). RN #1 stated Resident #11 was changed after breakfast, and a skin assessment done. She further stated that nurses updated changes in the CNA Care Report. She stated the Charge Nurse monitored SRNA's to ensure the CCP was followed. RN #1 stated it was her expectation that the CCP's were updated and that staff assisted with feeding according to the CCP. Per the interview, she stated the nurses were responsible for developing the CCP. Further, she stated it was important that a CCP was developed for staff awareness of how to provide care and to address the individualized needs of residents. Interview with the Minimum Data Set (MDS) Coordinator, on 12/01/21 at 5:14 PM, revealed the facility acted as a team, and each discipline worked to update the CCP. She stated changes in condition were discussed at care plan meetings, and each team member contributed to developing an individualized care plan. She further stated Resident #11's CCP should have been updated to reflect the resident's change in ability to feed self, and supervision and set up should have been added. Interview with the MDS Nurse, on 12/02/2021 at 9:20 AM, revealed the CCP should include specific information on how to take care of each resident. She further stated the ADON printed off the Nurse's Notes from the previous day(s), and the interdisciplinary team reviewed the information in a clinical meeting every morning. Additionally, she stated the CCP should be updated with information acquired during this meeting, including any new physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She further stated it was important the CCP was updated so staff would know how to take care of the residents. Per the interview the Resident Assessment Instrument (RAI) was the guideline utilized during CCP development. Interview with the Assistant Director of Nursing (ADON), on 12/03/2021 at 11:25 AM, revealed it was her expectation that any special feeding instructions would be documented in the resident's CCP. Further interview revealed the CCP was based on the resident's needs at admission and updated as needed. The ADON stated the MDS Nurse and nursing staff were responsible for developing and updating the CCP as needed. Additionally, she stated it was important for the CCP to be up-to-date because it instructed staff on how to provide for the resident's needs. Interview with the Director of Nursing (DON), on 12/03/2021 at 12:15 PM, revealed it was her expectation that staff was aware of any current specific feeding instructions for the residents. She stated the CCP was a working document and was to be revised and updated as changes in the resident's condition occurred. Additionally, she stated it was important the CCP was up-to-date because it was the guide staff used to care for the residents. Per the interview, it was her expectation that the CCP was revised as necessary when a resident had a change in condition or with a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Interview with the Administrator, on 12/03/2021 at 12:37 PM, revealed it was his expectation that staff update the CCP to provide individualized care to meet the residents' needs.

Based on observation, interview, record review, facility policy review, review of Potter and Perry. (n.d.). Fundamentals of Nursing, and review of the Kentucky Board of Nursing (KBN) Advisory Opinion Statement (AOS) #14, it was determined the facility failed to follow professional standards of practice for two (2) of twenty-two (22) sampled residents, Residents #18 and #30. 1. Observation of Registered Nurse (RN) #1, on [DATE] at approximately 10:30 AM, revealed she performed the incorrect wound care to Resident #18's left great toe. Further observation revealed RN #1 administered a discontinued medication to the skin rash on Resident #18's face. Additionally, observation of RN #1 performing Resident #18's suprapubic catheter (a surgically created connection between the urinary bladder and the skin used to drain urine from the bladder) irrigation, on [DATE] at approximately 10:00 AM, revealed RN #1 failed to use appropriate infection control techniques. 2. Observation on [DATE] at 11:00 AM, revealed Registered Nurse (RN) #1 gave a medication to State Registered Nurse Aide (SRNA) #1 with instructions to give to and tell Resident #30 it would help with the itch on his/her toe. SRNA #1 left the medication unattended on the dresser in Resident #30's room. Further, the medication given and left in the room was not prescribed for Resident #30. Additionally, observation on [DATE] at 12:10 PM, in Resident #30's room revealed five (5) medications left in the resident's room unattended. The findings include: Review of the KBN, AOS #14, Roles of Nurses in the Implementation of Patient Care Orders, revised [DATE], revealed nurses were responsible and accountable for making decisions based upon the individual's educational preparation and current clinical competence in nursing and required licenses to practice nursing with reasonable skill and safety. Further review revealed licensed nurses should administer medication and treatment as prescribed by the Physician, Physician Assistant, Dentist, or Advanced Practice Registered Nurse (APRN). This included preparing and administering medications in the prescribed dosage, route, and frequency. Review of the facility's policy titled, Medication Administration, dated ,d+[DATE], revealed prior to administration, staff were to review and confirm medication orders. Medications were to be administered in accordance with the written orders of the prescriber. Continued review revealed the person who prepared the dose for administration was the person who administered the dose. In addition, the policy stated medications supplied for one (1) resident were never administered to another resident. Further review revealed staff was to remain with the resident until all medications had been taken. Review of Potter and Perry. (n.d.). Fundamentals of Nursing. (9 ed.). page 1143, revealed to ensure the irrigation or installation fluid remained sterile and to reduce the transmission of infection to the resident, the injection port of the suprapubic catheter should be thoroughly cleansed with an antiseptic swab and allowed to dry. Next, the prescribed amount of sterile solution should be drawn up in a sterile syringe, and the tip of the needleless syringe should be capped with a sterile cap. Finally, the syringe should be withdrawn, and the catheter port should be cleansed with an antiseptic swab. 1. Review of Resident #18's Electronic Medical Record (EMR) revealed the facility admitted the resident, on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #18's Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility did not assess Resident #18's BIMS due to the resident being rarely/never understood. A continued review of the MDS Assessment revealed the resident had modified independence related to Cognitive Skills for Daily Decision Making. Resident #18 required total dependence on staff for all Activities of Daily Living (ADL). Further review revealed Resident #18 had current skin issues, pressure ulcer/injury care, and a suprapubic catheter. Review of Resident #18's Wound Care Progress Note, dated [DATE], revealed modifying factors, which included open sores and a [CONDITION(S)] skin rash to various areas. Review of Resident #18's CCP, dated [DATE], revealed the resident was care planned for a drug regimen review with the goal of identifying and actual or potential medications issues and address with the physician or designee in a timely manner. Interventions included keeping the resident free of any actual or clinically significant medication issues. Review of Resident #18's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A second order, dated [DATE], revealed to paint the left great toe with [MEDICATION(S)] and cover with a band-aid daily; once a day at night. Further review of Resident #18's active physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #18's Medication/Treatment Administration Records (MAR/TAR) revealed two (2) active orders for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . A second order, dated [DATE], revealed to paint the left great toe with [MEDICATION(S)] and cover with a band-aid daily; once a day at night. Review of Resident #18's MAR/TAR, dated [DATE] - [DATE] revealed Hydrocortisone ointment (a corticosteriod) one percent (1%), apply topically to the face twice daily, was ordered with a start date of [DATE] and was open ended. Review of Resident #18's MAR/TAR, dated [DATE] - [DATE] revealed [MEDICATION(S)] topical cream one percent (1%), apply topically to affected areas (face), was ordered on [DATE] and discontinued on [DATE]. Observation of Registered Nurse #1, on [DATE] at approximately 10:30 AM, with Resident #18, revealed RN #1 performed the evening shift treatment to paint the left great toe with [MEDICATION(S)] and cover with a band-aid daily, once a day, at night. Further observation revealed RN #1 administered a discontinued medication, [MEDICATION(S)] topical cream. During observation of RN #1 performing wound care on Resident #18, RN #1 placed a liberal amount of [MEDICATION(S)] topical cream into a thirty (30) millimeter medicine cup, which already contained Hydrocortisone cream. RN #1 mixed the two (2) creams together and used the cream on Resident #18's face. Interview with RN #1, on [DATE] at approximately 10:30 AM, revealed she checked the treatment orders before performing every treatment. She stated she had done Resident #18's treatments and knew the orders. She stated she was not aware the [MEDICATION(S)] topical cream had been discontinued. Furthermore, RN #1 stated she was not aware that there were two (2)different orders for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she performed the evening treatment instead of the daytime treatment. RN#1 also stated when an order was confusing or needed to be explained, the nurse should contact the physician for clarification. Continued observation of RN #1, on [DATE] at approximately 10:00 AM, while she was performing Resident #18's suprapubic catheter irrigation, revealed RN #1 failed to thoroughly clean the suprapubic catheter's injection port with an antiseptic wipe and allowed it to dry prior to beginning the sterile instillation. Furthermore, RN #1 failed to ensure the [MEDICATION(S)] instillation solution (used to prevent encrustations in suprapubic catheters) remained sterile. RN #1 set up her supplies on a towel on the resident's bedside table. She obtained a vial of [MEDICATION(S)] from a bag located on the treatment cart. The Assistant Director of Nursing/Infection Preventionist (ADON/IP) later brought in a sterile, needleless, capped syringe, which RN #1 did not use. RN #1 snapped off the top of a contaminated thirty (30) milliliter vial of [MEDICATION(S)] and placed it directly into the catheter port without first transferring the solution to a sterile capped syringe. Next, RN #1 failed to clean the catheter port with an antiseptic wipe and let it dry before placing the catheter tubing back in place. Continued interview with RN #1, on [DATE] at approximately 10:30 AM, revealed she had obtained the [MEDICATION(S)] from the resident's medications located on the treatment cart. The vials of solution were stored in a labeled bag from pharmacy. RN #1 stated the tip of the vial of [MEDICATION(S)] was not sterile but was clean. She further stated that she always performed the suprapubic catheter irrigation using the pre-packaged vial of [MEDICATION(S)] and did not transfer the irrigation solution to a sterile tipped syringe. RN #1 stated it was important to prevent infection with bladder irrigations to clean and disinfect the catheter port before and after the procedure and to use a sterile tipped syringe. Interview with the ADON/IP, on [DATE] at 11:25 AM, revealed it was her expectation that all nursing staff followed infection prevention and control (IPC) guidelines to decrease the chance of the spread of infections and for the safety of residents and staff. Interview with the Director of Nursing (DON), on [DATE] at 12:15 PM, revealed it was her expectation that all staff followed IPC procedures to prevent the spread of infection. Per the interview, the DON stated that it was not her expectation for a nurse to be checked off on every procedure he or she performed; however, it was the DON's expectation that Potter and Perry Fundamentals of Nursing, the facility's standard of care reference, was used if the nurse was unfamiliar with a procedure. She further stated it was her expectation that a nurse would not perform any procedure he/she was uncomfortable doing without instruction. Additionally, she stated it was her expectation that nurses maintain sterility during suprapubic irrigation. She stated she expected a nurse doing any procedure to be able to follow the correct procedure. The DON stated that when procedures were performed improperly, the quality of care decreased, and there was the potential for injury and infection. Additionally, the DON stated following the correct IPC policies and procedures were important for the safety of the residents and staff. Interview with facility Administrator, on [DATE] at 12:37 PM, revealed he expected IPC guidelines to be always maintained in the facility to decrease the potential spread of infection. 2. Observation, on [DATE] at 11:00 AM, revealed RN #1 went to the medication cart, opened Resident #18's drawer, removed a large jar of medication cream, scooped out a moderate amount of the cream, and placed it into a thirty (30) milliliter (ml) medication cup. RN #1 then gave SRNA #1 the medication cup and told her it was Hydrocortisone cream (corticosteroid) and to tell Resident #30 it would help with the itch on his/her toe. SRNA #1 took the medication cup into Resident #30's room and explained she had some medication to help with the itch on the resident's toe. Resident #30 asked what the medication was and SRNA #1 responded, It is Hydrocortisone cream to put on your toe to stop the itch. The resident asked SRNA #1 to put the cup on the dresser. The SRNA then placed the medicine cup with Hydrocortisone cream on Resident #30's dresser and left the room, leaving the medication unattended. Further observation, on [DATE] at 12:10 PM and 3:00 PM, revealed a cup with an opaque ointment was noted to be at the foot of Resident #30's bed. On top of the dresser in the back left side of the room, there was a tube of [MEDICATION(S)] (antibacterial), a tube of [MEDICATION(S)] (antifungal), a tube of Derma Fungal (2% Miconazole-antifungal) and a bottle of [MEDICATION(S)] Nasal Spray (antihistamine). There was also a medicine cup with approximately twenty (20) ml of an opaque ointment on top of the dresser. Review of Resident #30's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with RN #1, on [DATE] at 12:15 PM, revealed she had placed the Hydrocortisone cream in a medicine cup and left it on Resident #30's bedside table. The State Survey Agency Surveyor then asked RN #1 where she obtained the Hydrocortisone cream for Resident #30. RN #1 stated she borrowed the Hydrocortisone cream from another resident and asked if she was going to get in trouble for doing this. RN #1 stated it was not appropriate to use another resident's medication or to use a medication for a resident that had not been prescribed. Continued interview with the ADON/IP, on [DATE] at 11:25 AM, revealed it was her expectation that all nursing staff follow facility policy and procedures related to medication administration and storage. The ADON/IP stated, if an item was found to be expired, labeled, and/or stored improperly, it was her expectation that nursing staff return or discard the medication according to facility policy. Continued with the DON, on [DATE] at 12:15 PM, revealed it was her expectation that all nursing staff follow facility policy and procedures related to medication administration and storage. Continued interview with the Administrator, on [DATE] at 12:37 PM, revealed he expected nursing staff to follow current medication policies and protocols. The Administrator further stated this was important to ensure the safety of all residents.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure a resident who was unable to carry out Activities of Daily Living (ADL) received necessary services for two (2) of twenty-two (22) sampled residents (Resident #11 and Resident #29). Interview with Resident #29, on 12/01/2021, revealed approximately two (2) months ago, he/she used the call light to request staff assistance with toileting. However, the resident stated he/she had a bowel movement and soiled self because he/she had to wait an extended time for the call light to be answered by staff. Further, the resident stated he/she was very embarrassed about the incident. Observation of Resident #11, on 11/30/2021, after the breakfast meal, revealed the resident was lying in bed with food and drink spilled on his/her hands, moustache, clothes, and bed linens. The findings include: Interview with the Assistant Director of Nursing (ADON), on 12/02/2021 at 2:41 PM, revealed the facility did not have a policy related to care for dependent residents. Review of the facility's policy titled, Resident Rights, revised 08/16/2018, revealed all residents have the right to be treated with respect and dignity. 1. Review of Resident #29's Electronic Medical Record (EMR), revealed the facility admitted the resident, on 03/17/2015, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #29's Quarterly Minimum Data Set (MDS) Assessment, dated 11/08/2021, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15), out of fifteen (15), indicating intact cognitive skills for daily decision making. Additionally, the facility assessed the resident as requiring extensive assist of two (2) staff for transfers and toileting. Further, the resident was assessed as having a decline in bowel and bladder functioning; and was frequently incontinent of bowel and bladder. Review of Resident #29's Comprehensive Care Plan (CCP), initiated 03/12/2019, reviewed 11/11/2021, revealed the focus of Activities of Daily Living (ADL) Function and Rehabilitation Potential because the resident was ADL deficient and required extensive assistance with toileting and personal hygiene. The goal stated the resident would maintain ADL self-performance levels as evidenced by no decline in ADL level. Interventions included, but were not limited to: assistance by two (2) staff with transfers and bed mobility; use partial side rails to assist with bed mobility, and encourage resident to participate in ADL's with staff support. However, there was no documented evidence of interventions related to toileting. (Refer to F-656) Interview with Resident #29, on 12/01/2021 at 10:13 AM, revealed approximately two (2) months ago (the resident was unable to recall a specific date or time) he/she had multiple episodes of diarrhea, and on one (1) day, he/she pushed the call light when he/she felt the urge to have a bowel movement. The resident stated on that day, when he/she used the call light for assistance to go to the bathroom, the call light was not answered for a long time. The resident could not state the length of time he/she considered a long time. Further, the resident stated he/she was not able to wait any longer for staff assistance and had a bowel movement in his/her brief. Per the interview, it was very embarrassing to need to go to the bathroom but have to soil self because assistance was not provided. When discussing the incident, the resident was observed to close his/her eyes, tilt his/her head down, and shake his/her head back and forth. Interview with State Registered Nurse Aide (SRNA) #5, on 12/02/2021 at 5:33 PM, revealed she was assigned to Resident #29, and he/she would use the call light when needing assistance to go to the bathroom to have a bowel movement. Per the interview, a few months ago, Resident #29 had episodes of diarrhea, and the resident soiled his/her brief before staff could provide the needed assistance to the resident. Further, she stated Resident #29 told her that he/she was embarrassed about the incident because he/she had a bowel movement in his/her brief waiting for staff assistance. Additionally, SRNA #5 stated she worked day shift and was usually assigned to about sixteen (16) residents to care for daily. She further stated call lights sometimes took a while to answer, especially during meals, but she did not give a specific amount of time residents had to wait for assistance once the call light was activated. Per the interview, usually only the SRNA's would answer the call lights and not the nurses. Telephone interview with Resident #29's daughter, on 12/02/2021 at 2:05 PM, revealed the resident told her it took staff a long time to answer/respond to call lights. Additionally, the resident told her he/she would push the call light, and if no one came to answer it, the resident would have his/her roommate check the light on the wall to ensure the call light was on. Further, the resident's daughter stated she felt the resident never had enough help. Interview with Licensed Practical Nurse (LPN) #2, on 12/03/2021 at 10:52 AM, revealed it was important that call lights were answered quickly because the residents could be in pain or could fall if not assisted timely. Further, he stated he was assigned to Resident #29 on the day in which he/she soiled himself/herself, and the resident was embarrassed. LPN#2 stated he did not know if the reason the resident soiled himself/herself was because the call light had not been answered timely. Additional interview with the ADON, on 12/03/2021 at 11:25 AM, revealed everyone was responsible for answering call lights, which should be answered in three (3) to five (5) minutes because the resident might have an urgent need. Interview with the Director of Nursing, on 12/03/2021 at 12:15 PM, revealed she had worked at the facility since 11/29/2021. She stated it was everyone's responsibility to answer call lights, and it was her expectation call lights were answered timely and residents had their care needs met. Additionally, she stated an acceptable amount of time a resident should have to wait for a call light to be answered would depend on the situation. Interview with the Administrator, on 12/03/2021 at 12:37 PM, revealed it was everyone's responsibility to answer call lights. Further, he stated an acceptable amount of time to answer a call light was individualized, but thirty (30) minutes would be unreasonable. Additionally, he stated it would be important for call lights to be answered in a reasonable time so staff could provide necessary care and assistance to the residents. 2. Review of Resident #11's EMR revealed the facility admitted the resident, on 04/14/2016, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #11's Quarterly MDS Assessment, dated 11/04/2021, revealed the facility did not assess Resident #11's BIMS due to the resident being rarely/never understood. A continued review of the MDS Assessment revealed the resident was independent related to Cognitive Skills for Daily Decision Making. Resident #11 required extensive assistance of staff for all ADL's. Further review of the MDS revealed Resident #11 was assessed as requiring setup by staff and supervision with eating and drinking. Review of Resident #11's CCP, initiated on 04/14/2016, revealed the resident was care planned for self-care deficits. Long-term goals, with a target date of 12/21/2021, were that there would be no decline through the next review. Interventions included: report changes in ADL self-performance to the nurse. Further review revealed Resident #11 had a potential nutritional risk related to the need for a mechanically altered diet. Interventions included encourage oral intake of food and fluids; and to ensure resident was sitting in an upright position when eating. However, there was no documented evidence of specific interventions related to staff assisting the resident with feeding . (Refer to F-656) Review of Resident #11's Certified Nursing Assistant (CNA) Care Report, on 12/01/2021 at 3:25 PM, revealed the Feeds Self box was checked. Review of Resident #11's CNA Care Report, on 12/02/2021 at 9:25 AM, revealed the Feeds Self box was crossed out (date and time was not noted) and the Dependent box was checked, with assist written to the side. Continued review of Resident #11's medical record revealed an Occupational Therapy (OT) evaluation, with a start date of 11/30/2021, for OT to address the need for assistance with self-care related to eating. Further review of the OT evaluation stated Resident #11 was spilling fifty (50) percent of liquids and only consumed twenty-five (25) percent of his/her meal. Per the evaluation, OT recommended weighted utensils in order to self-feed seventy-five (75) percent of the meal to maintain nutrition. Continued review of Resident #11's medical record revealed an OT Treatment Encounter Note, dated 11/30/2021, which revealed the Occupational Therapist (OT) reviewed self-care performance with SRNA's, stating the resident required assistive equipment to aid in grasping and a visual target tracking to gain independence in self-feeding. Further review revealed the resident still had excessive spillage of liquids. Continued review of Resident #11's medical record revealed an OT Treatment Encounter Note, dated 12/01/2021, which revealed that Resident #11 was repositioned in bed to optimize eating. Furthermore, weighted utensils, bowls, and dycem non-slide mats were utilized to assist the resident to grasp and visually track food and to avoid excessive spillage of liquids. Observation of Resident #11, on 11/30/2021 at 9:30 AM, revealed the resident lying in bed at an approximate thirty (30) degree angle with food on his/her mustache, shirt, and sheets. His/her sheets were wet with a large dark liquid substance. His/her hands and nails were soiled with food. Resident #11 nodded, Yes, when the SSA Surveyor asked if he/she had spilled his breakfast. Additional observation of Resident #11, on 11/30/2021 at 12:30 PM, revealed the resident was self-feeding, attempting to get food from a plate. He/she was not wearing his/her dentures. The coffee cup was not a two-handled cup, and the resident was using regular utensils. His/her food tray had been set on the bedside table, but the table was not positioned directly in front of the resident. Interview with Resident #11, on 11/30/2021 at 9:33 AM, revealed Resident #11 was not assisted by staff with meals. Interview with SRNA #1, on 12/01/2021 at 3:25 PM, revealed there was a Care Plan binder, located at the nurse's station, which holds a CNA Care Report for each resident to refer to regarding resident care. SRNA #1 stated the binder was updated by nursing staff. SRNA #1 stated aides were updated about special feeding instructions during report at shift change or by looking at updates from the nurses in the CNA Care Report. Interview with the OT, on 12/01/2021 at 1:31 PM, revealed she had evaluated Resident #11 during lunch. Further interview revealed OT referrals were made by nursing. When asked if nursing had made the referral for OT to evaluate Resident #11's need for feeding assistance, she stated they had not. She explained, that while assisting Resident #11's roommate, she observed Resident #11 having difficulty with self-feeding, so she made the referral for an OT evaluation. Interview with RN #1, on 11/30/2021 at 2:31 PM, revealed aides rounded every two (2) hours. She stated if a resident was ordered supervision during meals, it meant that someone must be in the room to monitor for choking. If a nurse observed a resident was having difficulty with swallowing or eating, he/she would write a referral for speech language pathology (SLP) or occupational therapy (OT). RN #1 stated Resident #11 was changed after breakfast, and a skin assessment was done. She further stated that nurses updated changes in the CNA Care Report. Interview with the MDS Coordinator, on 12/01/2021 at 5:14 PM, revealed the facility staff acted as a team. She further stated Resident #11's CCP should have been updated to reflect the resident's change in ability to feed self and supervision, set up, and assistance with feeding should have been added to provide direct care staff with information to effectively care for Resident #11. Continued interview with the ADON, on 12/03/2021 at 11:25 AM, revealed the MDS Nurse and nursing staff were responsible for for directing SRNA's on how to care for the residents' individual needs. Per the interview, it was her expectation that residents received the ADL support needed. Continued interview with the DON, on 12/03/2021 at 12:15 PM, revealed it was her expectation that a resident who was unable to carry out ADL's received necessary care and services in a timely manner. Continued interview with the Administrator, on 12/03/2021 at 12:37 PM, revealed all residents needed to receive necessary care and assistance from staff, especially those that had self-care deficits.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure support for residents in their choice of activities, both facility-sponsored group and individual activities for one (1) of twenty-two (22) residents, Resident #21. There was no documented evidence Resident #21 participated in his/her preferred activities in August, September, October, or November of 2021, and he/she only attended and participated in minimal activities during the last four (4) months at the facility. Observation of Resident #21, on 11/30/2021, 12/01/2021, 12/02/2021, and 12/03/2021, revealed the resident was in his/her room, in bed with the lights dimmed. The television was on and tuned to an action/adventure television station. There was no radio observed in the room. The findings include: Review of the facility's policy titled, Resident Rights, revised 08/16/2018, revealed when providing care, the facility would respect the resident's individuality. Interview with the Activities Director (AD), on 12/03/2021 at 11:40 AM, revealed the facility did not have a written policy or protocol related to the Activities Department's programming of activities for residents. Review of Resident #21's Electronic Medical Record (EMR) revealed the facility admitted the resident, on 03/27/2018, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #21's Comprehensive Care Plan (CCP), dated 10/28/2021, revealed Resident #21 was at risk, or had a decline in previous recreational activities and interests. It was noted that the resident liked to listen to Bluegrass music. Further review of the CCP revealed the goal was staff would take necessary actions to accommodate the resident's routines and preferences to satisfy and engage the resident in activity opportunities. Additionally, the CCP stated it was important to the resident to have opportunities to engage in activities, meaningful to the resident. The interventions included but were not limited to: provide the resident with opportunities to hear/listen to music, allowing access to Bluegrass music. Review of Resident #21's Quarterly Minimum Data Set (MDS) Assessment, dated 11/24/2021, revealed the resident had adequate hearing. Continued review revealed the facility was unable to assess for a Brief Interview for Mental Status (BIMS) score due to a decline in his/her condition. Additional review revealed preferences, indicated at admission, for activities that were important to the resident included listening to music. Furthermore, the resident was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #21's Electronic Medical Record (EMR), dated November 2021, revealed there was no documented evidence the resident was offered Bluegrass music, per the resident's choice/preference of activities. Review of Resident #21's Certified Nurse Aide (CNA) Care Report, no date, revealed there was no documentation of the resident's preferred activities. Observation, on 11/30/2021 at 9:15 AM, revealed Resident #21 was lying in bed, with no lights on in the room. The privacy curtain was drawn, blocking light from the outside window. Continued observation revealed the resident's television (TV) was turned on a nature documentary on crocodile hunting. Further, there was no radio visible in the resident's room. Additional observation revealed the resident was lying on his/her back. Further, the resident's eyes were open; however, he/she did not respond to the State Survey Agency (SSA) Surveyor. Observation of Resident #21, on 11/30/2021 at 12:18 PM, revealed the resident lying in bed, on his/her back. The room was dim, and the resident's eyes were closed. Additional observation revealed the TV was turned on. Further, there was no radio in the resident's room. Observation of Resident #21, on 11/30/2021 at 3:20 PM, revealed the resident was lying in bed on his/her left side, facing the wall. The room light was on above the bed, and the resident's eyes were closed. Further, the TV was turned on, and there was no source of music in the room. Observation, on 11/30/2021 at 5:16 PM, revealed Resident #21 was lying in bed on his/her back. Further, the resident's eyes were open, and when the SSA Surveyor spoke to the resident, the resident did not respond to the questions. The room was dim. Additional observation revealed the TV was turned on, and there was no radio in the resident's room. Observation of Resident #21, on 12/01/2021 at 8:34 AM, revealed the resident was in bed lying on his/her back. The resident's eyes were closed. Further, the TV was turned off, and there was no source of music in the room. Observation of Resident #21, on 12/01/2021 at 10:10 AM, revealed the room was dim. Further, the TV was turned on to a western action program without sound. There was no music source in the room. Observation of Resident #21, on 12/02/2021 at 4:18 PM, revealed the resident lying in bed, on his/her back. The room was dim, and the resident's eyes were closed. Additional observation revealed the TV was turned on. Further, there was no music source in the room. Observation, on 12/03/2021 at 11:10 AM, revealed Resident #21 was lying in bed on his/her left side, facing the wall. The room light was on above the bed and the resident's eyes were closed. Further the TV was turned on, and there was no source of music in the room. Observation, on 12/03/2021 at 2:20 PM, revealed Resident #21 was lying in bed on his/her right side, toward the door. Additional observation revealed the resident's eyes were close. The room was brightly lit, and the TV was turned on without sound. There was no source of music in the room. Observation, on 12/03/2021 3:14 PM, revealed Resident #21 was lying in bed with his/her eyes closed, on his/her back. The room was dim, the lights were off. Further observation revealed the resident's TV was turned on without sound. Bluegrass music was not playing in the room. Interview with State Registered Nurse Aide (SRNA) #1, #6, and #8, on 12/03/2021 at 11:10 AM, revealed Resident #21 loved Bluegrass music, and he/she listened to it on his/her radio. When asked if the resident had a radio, SRNA #1 stated he/she did. Additional interview revealed the staff turned on his/her TV in the past but could not recall what type of television programs the resident liked to watch. Interview with the Activities Director (AD), on 12/03/2021 at 11:40 AM, revealed the facility did not have a written policy or protocol related to the Activities Department's programming of activities for residents. Further interview revealed the AD provided oversight over activities by assessing resident needs related to activities and asking residents what they liked to do for fun. He stated he did this on admission, with significant change, quarterly, and as needed. He stated these preferences should be noted on the MDS Assessment and the CCP. Further interview revealed the AD was familiar with Resident #21's activity preferences of listening to Bluegrass music and to the reading of the Bible and prayer; however, the AD admitted he failed to document these activities. Continued interview with the Activities Director (AD), on 12/03/2021 at 11:40 AM, revealed he tried to do the Activities [section] of the CCP, which the MDS Nurse used to do. He further stated the Corporate Regional Director was working with him on getting his documentation concerns met. He stated that documentation was his weakest area. Further interview revealed the AD read and prayed with Resident #21, on a one-to-one (1:1) basis because the resident no longer came to group activities. He stated that Resident #21 loved Bluegrass music, and when Resident #21's spouse was a resident in the facility, he/she would visit, and they would dance to Bluegrass music. The AD stated activities staff was expected to follow-up with all residents to encourage participation in activities. He stated it was important to engage residents to participate in activities of their preference to enrich their lives, which prevented depression and increased their quality of life/care. The AD stated Resident #21 should be provided opportunities to engage in activities of his/her preference, however his/her decline in health prevented him/her from engaging in group activities. Also, the AD Director stated he was responsible to provide activities to residents and to ensure other staff provided them. Interview with the Director of Nursing (DON), on 12/03/2021 at 12:15 PM, revealed activities were important for all residents. Per the interview, she expected residents would be engaged in preferred activities throughout the day. Continued interview revealed it was the responsibility of the whole Interdisciplinary Team (IDT), consisting of the Administrator, Physician/Nurse Practitioner, DON, ADON, and the Head of Departments, to interact and identify what resident needs and preferences were and engage/promote these activities. Further, she stated it was the IDT's responsibility to ensure activities were provided through daily rounds. Per the interview, engaging residents in activities ensured a better quality of life for the resident. Interview with the Administrator, on 12/03/2021 at 12:37 PM, revealed the facility should offer/provide scheduled activities as well as individualized activities to each resident per their choices and preferences. Further interview revealed it was important to honor resident choices for activities.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one (1) of twenty-two (22) sampled residents (Resident #33). Record review revealed Resident #33 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . However, current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to ensure the correct feeding instructions were followed for this resident, as observation and staff interviews revealed discrepancies in feeding procedures. The findings include: Review of the facility's policy titled, Assistance with Meals, reviewed by the facility on 06/27/2018, revealed residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Additionally, residents who could not feed themselves would be fed with attention to safety, comfort, and dignity. Review of Resident #33's medical record revealed the facility admitted the resident on 07/18/2020. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #33's Comprehensive Care Plan (CCP), initiated on 07/18/2020, revealed the resident was at nutritional risk related to mechanically altered diet, decreased meal and fluid intake, and a significant weight loss. The goals, dated 08/16/2021, revealed the resident's weight would remain greater than 100.4 pounds and the resident would tolerate mechanically altered diet through next review. Interventions dated 7/30/2021 included: Mechanically altered diet as ordered, monitor for signs and symptoms of chewing and swallowing difficulties, and consult Speech Language Pathologist (SLP) as needed. No special feeding instructions were documented in the CCP. Review of the Certified Nurse Assistant (CNA) Care Report, undated, revealed Resident #33 was to receive a pureed diet with honey thickened liquids. No special feeding instructions were documented on the CNA Care Report. Review of Resident #33's Speech Therapy Treatment Encounter Note, dated 10/07/2021, revealed the Speech Language Pathologist (SLP) educated staff to provide resident with preferred food item (pudding) at the beginning of meal to prevent the resident from holding food in his/her mouth. The Note further revealed staff verbalized understanding of feeding instructions. Review of Resident #33's Speech Therapy Treatment Encounter Note, dated 10/12/2021, revealed the SLP placed a visual aid in the resident's closet for staff review with directions on feeding the resident. Review of a facility document titled Feeding Recommendations for with the resident's initials, undated, found on the inside of Resident #33's closet, revealed feeding recommendations which included: most (if not all) food provided before drink; drinks provided at end of meal which would allow resident to consume more food and hopefully decrease weight loss; to be fed in dining room as able; ensure resident seated in an upright position and all lights on prior to feeding; pudding or ice cream provided at beginning of meal; and request resident to spit out food or drink if he/she held food or drink in mouth. Review of Resident #33's SLP Discharge Summary, dated 10/15/2021, revealed the resident received Dysphagia therapy from 09/20/2021 through 10/15/2021. Further review revealed discharge recommendations included: resident to be fed in dining room as able, position and environment modified to promote alertness, and drinks provided at the end of meal. Review of Resident #33's Quarterly Minimum Data Set (MDS) Assessment, dated 10/15/2021, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15) indicating severe cognitive impairment. Further review of the MDS Assessment, revealed the facility assessed the resident as requiring extensive assist with bed mobility, transfers, toilet use, and dressing. Additionally, the resident was was assessed as completely dependent on staff for eating. Review of current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Nurse's Progress Notes, dated 09/01/2021 through 12/02/2021, revealed an entry dated 10/27/2021, stating Magic Cup (nutritional supplement) was discontinued because of adequate intake. Additionally, an entry dated 11/17/2021, revealed the resident refused meals when in bed. Further review of Nurse's Progress Notes, dated 11/20/2021, revealed the resident was taking ProMod (protein supplement) and Vitamin E Oil. There was no documentation related to special feeding instructions for Resident #33 during this three (3) month review. However, review of the residents weights revealed the weights were steady and the resident was not losing weight. Review of Resident #33's Medication Administration Records (MARs), and Treatment Administration Records (TARs), dated 10/01/2021 through 11/30/2021, revealed the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #33's weekly weights, revealed the resident's weight had remained under ninety (90) pounds since 10/27/2021, with the most current weight on 12/01/2021 of 87.6 pounds. Further review revealed from 11/24/2021 to 12/01/2021 the weight stayed steady at 87.6 pounds. Observation on 11/30/2021 at 12:38 PM, revealed Resident #33 was in bed, being fed by State Registered Nurse Aide (SRNA) #5. The resident was provided one (1) opportunity of thickened beverage, followed by five (5) spoons of pureed solid food, followed by one (1) opportunity of thickened liquid, during assistance with the meal. Interview with SRNA #5, on 11/30/2021 at 12:45 PM, revealed she was not aware of any specific instructions on how Resident #33 was to be fed. However, SRNA #5 then removed the meal lid from the resident's bedside table, and read a bright, orange paper taped to the top side of the resident's bedside table. This orange paper included the resident's name and specific instructions for feeding the resident that included: watch for pocketing of food; alternate between solids and liquids with each bite; and alternate between hot and cold foods and liquids. SRNA #5 stated she was not previously aware of these special feeding instructions. Interview with SRNA #4, on 11/30/2021 at 3:44 PM, revealed she had not fed Resident #33 recently and was not familiar with his/her current specific feeding needs. However, she stated she was aware the resident had special feeding instructions taped on his/her bedside table. Additional observation on 12/01/2021 at 4:00 PM, revealed the document was no longer on the resident's bedside table. The State Survey Agency (SSA) Surveyor requested a copy of the orange paper which was taped to the top side of the resident's bedside table paper from management three (3) times between 11/30/2021 and 12/01/2021; however, a copy of the document was not received. Interview with the Administrator, on 12/01/2021 at 3:43 PM, revealed he was unaware of this document. Interview with SRNA #9, on 12/2/2021 at 5:33 PM, revealed special feedings instructions for a resident should be in the CNA Care Report binder or in Matrix. Additionally, she stated any special instructions or changes in feeding instructions were provided to SRNAs by the nurse or therapy staff. Further interview revealed she had recently fed Resident #33 and was aware the resident needed to be seated in an upright position when being fed. She stated she was also aware the resident needed to have food and drink alternated while being fed. She further stated there were instructions for feeding Resident #33 on the inside of the resident's closet door. (However, the instructions on the inside of the closet were NOT to alternate food/drink, but rather to hold drink until the end of the meal). Interview with MDS Nurse, on 12/2/2021 at 9:20 AM, revealed the facility used a team approach when updating a resident's care plan. Additionally, she stated that any new Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . She further stated it was important the CCP was up to date because staff used the care plan to guide resident care. Interview with Licensed Practical Nurse (LPN) #2, on 12/03/2021 at 10:52 AM, revealed SRNAs were informed of any special feeding instructions for a resident in the report given at the beginning of the shift. He further stated SRNAs would also have access to any special feeding instructions on the CNA Care Report. Interview further revealed, LPN #2 was not sure of Resident #33's diet order or any special feeding instructions; however, he did state Resident #33 had to be fed. Additionally, LPN #2 stated it was important to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the SLP, on 12/01/2021 at 1:10 PM, revealed she evaluated Resident #33 in 09/2021 and the resident was found to be pocketing liquids and foods while eating and drinking. She further explained, feeding the resident dessert first, and holding liquids till the end of the meal provided the most benefit to the resident. Additionally, she stated she reported these feeding recommendations to the nurses and SRNAs caring for the resident and posted the recommendations on the inside of the resident's closet door for staff to review. Further interview revealed SRNAs reported back to the SLP about one (1) month later that the resident was eating better and the resident was discharged from therapy. During the interview, the State Survey Agency (SSA) Surveyor inquired about the instructions found on the orange paper taped to Resident #33's bedside table which included alternating food, drink, and temperatures. The SLP stated she was unaware of those instructions and those were not the instructions she had put into place. Interview with Assistant Director of Nursing (ADON) #1, on 12/03/2021 at 11:25 AM, revealed the SLP would communicate any needed changes in the feeding instructions for a resident to staff. She also stated the nurses were to update the CNA Care Report to include these changes. Additionally, ADON #1 stated the charge nurse was responsible for monitoring the SRNAs to ensure they were following any special feeding instructions for the residents. During the interview, ADON #1 further revealed it was her expectation staff would be aware of and implement the latest special feeding instructions. Further, if there was a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the Director of Nursing (DON), on 12/03/2021 at 12:15 PM, revealed if a resident had special feeding instructions, SRNAs and Nurses would receive that information in report at the beginning of the shift, in the CNA Care Report book, or the instructions would be listed inside the resident's wardrobe. Further, she stated nurses were responsibile to ensure special feeding instructions were followed. She stated it was her expectation that the most recent physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the Administrator, on 12/03/2021 at 12:37 PM, revealed it was his expectation that a resident who had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, interview, and record review, it was determined the facility failed to provide or ensure each resident received necessary treatment and services, such as off-loading heels from the mattress, following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: Review of the facility's Pressure Ulcer/Injury Risk Evaluation Policy, revised on 01/08/2020, revealed the purpose was to provide guidelines for evaluation and identification of residents at risk of developing pressure ulcers. Further review of the policy revealed a skin evaluation would be done to assess for the risk of developing pressure ulcer and skin alterations on a weekly basis. Under the monitoring section of the policy it stated staff would perform routine skin inspections with daily care. Nurses would conduct skin evaluations at least weekly to identify changes. Continued review of the policy revealed at risk residents should have interventions in place and implemented promptly. Additionally, the policy stated that the facility would proceed to care planning and interventions individualized for the resident and their particular risk factor. Interview with the Director of Nursing (DON), on 12/03/2021 at 12:15 PM, revealed the facility had no formal policy related to following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #18's Electronic Medical Record (EMR) revealed the facility admitted the resident, on 01/27/2017, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #18's Quarterly Minimum Data Set (MDS) Assessment, dated 11/01/2021, revealed the facility did not assess Resident #18's Brief Interview for Mental Status (BIMS) score due to the resident being rarely/never understood. A continued review of the MDS Assessment revealed the resident had modified independence related to Cognitive Skills for Daily Decision Making. Resident #18 required total dependence on staff for all Activities of Daily Living (ADL). Further review revealed Resident #18 had current skin issues and was ordered to have pressure ulcer/injury care. Review of Resident #18's Comprehensive Care Plan (CCP), dated 10/18/2021, revealed the resident was care planned for pressure ulcers related to decreased mobility. Long-term goals, with a target date of 01/18/2022, indicated there would be signs of healing, through the next review. Interventions included keeping bony prominence's from direct contact with each other; float heels to relieve pressure on the heels; and treatment to pressure areas as ordered by the physician. Review of the active Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A second order, dated 11/11/2021, revealed to paint the left great toe with [MEDICATION(S)] and cover with a band-aid daily; once a day at night. Review of Resident #18's Wound Care Progress Note, dated 11/18/2021, revealed an assessment of Wound #7 Left Hip - unstageable pressure injury, with status of not healed; Wound #13 Great Toe - full thickness trauma wound, with a status of not healed; and Wound #15 Buttocks - partial thickness with dermatological rash, with a status of improving; and modifying factors which included open sores and [CONDITION(S)] skin rash to various areas. Continued review of the Wound Care Progress Note revealed the Physician stated modifying factors included off-loading pressure areas and dressing changes. Review of Resident #18's Medication/Treatment Administration Records (MAR/TAR) revealed two active orders for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . A second order, dated 11/11/2021, revealed to paint the left great toe with [MEDICATION(S)] and cover with a band-aid daily; once a day at night. The Wound Care physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Furthermore, the Wound Care physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the ordered Weekly Skin Assessments revealed some skin assessments were complete, which were done on 09/01/2021, 09/06/2021, 09/08/2021, 09/15/2021, 09/22/2021, 09/29/2021, 10/06/2021, 10/18/2021, 10/24/2021, 11/02/2021, and 11/23/2021. Two (2) assessments, on 11/15/2021 and 11/28/2021, had no assessment documentation. Further, there was no documented skin assessment the week of 10/10/2021 through 10/16/2021. Interview with RN #1 on 12/01/2021 at approximately 10:30 AM, revealed skin assessments were to be completed weekly. She said she was not always assigned to complete Resident #18's skin assessment, but the skin assessments were to be completed weekly by the assigned nurse. Observations of Resident #18, on 11/30/2021, 12/01/2021, 12/02/2021, and 12/03/2021, while the resident was in bed, revealed his/her heels were not floated off the mattress, and there was skin to skin contact of the bony prominence of both ankles. Observation of Registered Nurse (RN) #1, on 12/01/2021 at approximately 10:30 AM, revealed RN #1 performed the evening shift treatment to paint the left great toe with [MEDICATION(S)] and cover with a band-aid daily, once a day, at night. However, RN #1 stated she was unaware Resident #18's heels should be off-loaded. Interview with Resident #18, on 12/01/2021 at 3:17 PM, revealed the resident nodded his/her head, No, when asked if the nurses kept his/her heels from touching the mattress. Interview with State Registered Nurse Aide (SRNA) #1, on 12/01/2021 at 3:25 PM, revealed check and change of all residents was done every two (2) hours. She further stated Resident #18 would let staff know if he/she needed changing or repositioning. SRNA #1 stated she did not float the resident's heels. She stated she was unaware of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with Registered Nurse (RN) #1, during treatment observation, on 12/01/2021 at 2:04 PM, revealed Resident #18's heals were not being floated or off loaded as per the care plan. Interview with the Assistant Director of Nursing (ADON), on 12/03/2021 at 11:25 AM, revealed it was her expectation care be provided as per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated it was her expectation wound and skin assessments be completed weekly so that any new areas of skin breakdown would be quickly identified, and any existing wounds would be monitored for healing or decline. Further interview revealed if skin treatments were not completed, this could lead to further skin impairment. Interview with the Director of Nursing (DON), on 12/03/2021 at 12:15 PM, revealed skin assessments were to be completed weekly and documented on the Weekly Skin Review Form by the staff nurses, and the Wound Nurse was to assess wounds weekly and document the findings on the Wound Evaluation Flow Sheet. She stated it was important to complete wound assessments in order to track a resident's skin integrity and ensure the interventions in place were effective. Continued interview revealed it was her expectation physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Furthermore, she stated it was her expectation that nurses implemented care plan interventions. Per the interview, it was imperative that treatments and interventions be completed as ordered to ensure there was not a deterioration in the wounds. Interview with the Administrator, on 12/03/2021 at 12:37 PM, revealed staff should follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Per the interview, it was the Administrator's expectation that all physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to restore continence for resident with urinary incontinence for one (1) of twenty-two (22) sampled residents (Resident #2). Review of Resident #2's Quarterly Urinary Continence Evaluation, dated 07/12/2021, revealed the resident was continent of bladder. However, review of the Quarterly Minimum Data Set (MDS) Assessment, dated 08/14/2021, and 11/14/2021, revealed the resident was occasionally incontinent of bladder. Although there was a change in the resident's ability to maintain urinary continence, there was no documented evidence the resident received appropriate treatment and services to restore continence to the extent possible. Interview with Resident #2, on 12/01/2021, revealed he/she had occasional episodes of urinary incontinence. The resident further stated, he/she was never offered any type of program to help restore continence, but was trying to do his/her own pelvic strengthening exercises. The findings include: Review of the facility's policy titled, Bowel and Bladder Management, last revised 07/19/2018, revealed the interdisciplinary team (IDT) would review bowel and bladder data to determine if retraining was an option or a pattern had been identified. Additionally, if retraining was indicated, the resident's care plan would be updated to reflect results and intervention(s). Further, the policy revealed if a pattern of incontinence was identified, the IDT would implement a voiding plan based on times indicated, cognition, functional ability, and habits. Additionally, the care plan would be updated to reflect the interventions. Review of Resident #2's medical record revealed the facility admitted the resident on 08/24/2017 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Quarterly Minimum Data Set (MDS) Assessment, dated 08/14/2021, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15), which indicated he/she was cognitively intact. Additionally, the MDS Assessment revealed the resident required supervision with transfers, toileting, bed mobility and ambulation. The MDS further revealed the resident was occasionally incontinent of bowel and bladder. Further review of the MDS Assessment revealed a trial toileting program was NOT attempted. Review of Resident #2's Quarterly Urinary Continence Evaluation, dated 07/12/2021, revealed the resident had no history of bladder incontinence; no history of urinary tract infections; was continent of urine during the previous seven (7) days prior to assessment; and did not have a urinary catheter in place. Continued review revealed no problems were identified in communication or mental/behavior status. The evaluation further revealed the resident was independent with bed mobility, required supervision in transfers, walking/locomotion and toileting, and required an assist of one (1) caregiver with personal hygiene. Additional review revealed the resident was taking medication that may affect his/her urinary continence. The evaluation revealed no problems were identified in emptying his/her bladder and a pattern of urinary elimination was identified. Although the Quarterly Minimum Data Set (MDS) Assessment, dated 08/14/2021, revealed the resident was now occasionally incontinent of bowel and bladder, which was a change from the Quarterly Urinary Continence Evaluation, dated 07/12/2021, there was no documented evidence the facility completed another Quarterly Urinary Continence Evaluation in order to identify the nature and pattern of incontinence; identify if voiding patterns needed to be established; and to determine if retraining was an option. Review of the Quarterly MDS Assessment, dated 11/14/2021, revealed the facility assessed the resident to have a BIMS score of fifteen (15) out of fifteen (15), which indicated he/she was cognitively intact. Additionally, the MDS Assessment revealed the resident required supervision and one (1) person assist with transfers, toileting, bed mobility and ambulation. The MDS further revealed the resident was occasionally incontinent of bladder and always continent of bowel. Further review of the MDS Assessment revealed a trial toileting program was NOT attempted. Review of Resident #2's Comprehensive Care Plan (CCP), under the category of Activities of Daily Living (ADL) Function and Rehab Potential, initiated on 08/11/2020, revealed the resident had a self-care deficit and was at risk for complications related to deficit. The goal for this section of the care plan, revised 05/21/2021, revealed the resident would maintain ADL self-performance levels as evidenced by no decline in stated level through next review date. However, there were no documented evidence of interventions related to bowel or bladder continence or a toileting program in this section of the CCP. Additional review of Resident #2's CCP, initiated on 08/11/2020, revealed the resident had a deep brain stimulator related to [CONDITION(S)]. The goal for this problem, last revised on 05/21/2021, revealed the resident would remain free of injury. Interventions included providing toileting assistance every two (2) hours. Further review of Resident #2's CCP, initiated on 08/11/2020, revealed the resident was at risk for falls due to [CONDITION(S)] and recent falls with injury. The goal, dated 08/21/2021, revealed the resident would be free from major injury with falls. Interventions dated 08/11/2020, included providing resident with an individualized toileting plan based on needs and patterns which included: toilet before and after meals, at bedtime and as needed. Review of the Certified Nursing Assistant (CNA) Care Report, undated, revealed Resident #2 was independent with elimination and was continent of bowel and bladder. Interview with Resident #2, on 12/01/2021 at 9:07 AM, revealed he/she was continent of bowel, but had occasional episodes of urinary incontinence. The resident further stated he/she was never offered any type of program to help restore continence, but was trying to do his/her own pelvic strengthening exercises to maintain urinary continence. Interview with State Registered Nursing Assistant (SRNA) #5, on 12/02/2021 at 5:33 PM, revealed she was familiar with Resident #2 and was assigned to the resident. SRNA #5 stated the resident was continent and independent with toileting and was not on a toileting program. Interview on 12/03/2021 at 10:52 AM, with Licensed Practical Nurse (LPN) #2, who was assigned to Resident #2, revealed residents on a bowel and bladder program were offered the opportunity to go to the restroom in advance of their need. He further stated there were two (2) residents on the bowel and bladder program, but he did not identify Resident #2 as being one of them. Interview with the MDS Nurse, on 12/02/2021 at 10:34 AM, revealed she was not aware of any actual bowel and bladder policy. Interview further revealed the bowel and bladder evaluation was only done on admission or if a concern came up where the resident might benefit from the assessment. However, she stated it was important to have an ongoing bowel and bladder assessment in order for residents to remain independent. Interview with Assistant Director of Nursing (ADON) #1/Unit Manager of the Transitional Care Unit, on 12/03/2021 at 11:25 AM, revealed bowel and bladder assessments were to be completed on admission, quarterly and if there was a change in a resident's condition by the Unit Managers. She further stated, the resident's ADL status helped determine if the resident was a candidate to participate in the bowel and bladder program. Additionally, she stated it was her expectation that if a resident met the criteria for the bowel and bladder program, he or she would be started on one. Interview with the Director of Nursing (DON,) on 12/03/2021 at 12:15 PM, revealed she just started at the facility as DON on 11/29/2021. The DON stated it was her expectation that a bowel and bladder assessments were completed at least quarterly or if there was a change identified. Further interview revealed if a resident needed bowel or bladder training, the facility should provide the training. Interview with the Administrator, on 12/03/2021 at 12:37 PM, revealed it was his expectation that an ongoing assessment of bowel and bladder was completed in order to meet the individual needs of the resident.

Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to maintain the usual body weight or the desirable body weight range for one (1) of twenty-two (22) sampled residents, Resident #11. Resident #11's weight was not rechecked after a documented significant weight change. The findings include: Review of the facility's policy titled, At Risk Meeting, revised 09/05/2018, revealed At Risk Meetings were to be used to focus the Interdisciplinary Team (IDT) care standards, and to recognize and intervene when there was a change in a resident's condition. The At Risk Meeting included the Director of Nursing (DON); Assistant Director of Nursing (ADON); Social Services; representatives from the Activities, Dietary, Restorative, and Rehabilitation departments; and Licensed Nurses and State Registered Nurse Aides (SRNA). Each resident discussed would have his/her care plan brought to the meeting. Review of the facility's policy titled, Assistance with Meals, revised 06/27/2018, revealed the purpose of the policy was to ensure residents would receive assistance with meals consistent with his/her individual needs. Further review revealed residents who could not feed themselves would be fed by staff, with attention to safety, comfort, and dignity. Review of Resident #11's Electronic Medical Record (EMR) revealed the facility admitted the resident, on 04/14/2016, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #11's Quarterly Minimum Data Set (MDS) Assessment, dated 11/04/2021, revealed the facility did not assess Resident #11's Brief Interview for Mental Status (BIMS) score due to the resident being rarely/never understood. A continued review of the MDS Assessment revealed the resident was independent related to Cognitive Skills for daily decision making. Further review of the MDS, revealed Resident #11 was assessed as needing setup by staff, and supervision was required with eating and drinking. Review of Resident #11's Comprehensive Care Plan (CCP), initiated on 04/22/2019, under the focus area of Nutrition, revealed the resident had a potential nutrition risk related to the need for a mechanically altered diet, need for nutritional supplementation to meet needs, and a Basic Metabolic Index (BMI) score of less than eighteen and one half (18.5), with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The long-term goal, edited on 09/30/2021, with a target date of 12/24/2021, revealed the resident's weight would remain within five (5) pounds of the current weight through the next review date. Interventions included encourage oral intake of food and fluids, dated 02/14/2020; ensure the resident was sitting in an upright position and was alert and ready to consume food and fluid by mouth, dated 03/29/2021; and monitor and report to the physician any signs and symptoms of malnutrition, chewing problems, or swallowing problems, dated 04/22/2019. There was no documented evidence the facility updated the resident's care plan after the significant weight loss recorded on 10/15/2021. Review of Resident #11's active physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Orders, dated 11/16/2021, also included nectar thick liquids and a Dysphagia Advanced Diet with special instructions for double desserts at lunch and dinner. Additionally, an order on 11/16/2021, revealed the resident was to have no liver or seafood, and dycem was to be placed under bowls on table or tray. Further review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Dietary Progress Note, dated 12/01/2021, revealed Resident #11's current diet order was a Dysphagia Advanced diet with thickened liquids, a bedtime snack, frozen nutritional treat for lunch and dinner, and double desserts. Dietary progress notes further revealed Resident #11 had a low BMI and a gradual weight gain would be beneficial. Additionally, there was a request from the Registered Dietician (RD) to add the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed there was no weight obtained in November 2021, and the RD requested Resident #11's weight be obtained and updated as soon as possible. Continued review of Resident #11's EMR revealed his/her recorded weight was 131.4 pounds on 07/14/2021. There was no documented evidence a weight was taken in August 2021. Review of the EMR revealed Resident #11 weighed 129 pounds on 09/03/2021. Resident #11 weighed 89.2 pounds on 10/05/2021 with no documented evidence a re-weight was completed despite a significant thirty (30) percent indicated weight loss in one month. Per review, Resident #11 weighed 121 pounds on 10/15/2021, indicating a five (5) percent weight loss from 09/03/2021 to 10/15/2021; however, no weight was taken in November 2021. Further review revealed Resident #11 weighed 125.4 pounds on 12/02/2021. Continued review of Resident #11's EMR revealed there were no corresponding nursing progress notes, which indicated communication of the significant weight loss or reasons for not obtaining consistent monthly weights as per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Observation of Resident #11, on 11/30/2021 at 9:30 AM, revealed the resident was lying in bed at an approximate thirty (30) degree angle with food on his/her mustache, shirt, and sheets. His/her sheets were wet with a large dark liquid substance. His/her hands and nails were soiled with food. Resident #11 nodded, Yes, when the State Survey Agency (SSA) Surveyor asked if he/she had spilled his/her breakfast. Additional observation of Resident #11, on 11/30/2021 at 12:30 PM, revealed the resident was self-feeding, attempting to get food from a plate. He/she was not wearing his/her dentures. The coffee cup was not a two-handled cup, and the resident was using regular utensils. His/her food tray had been set on the bedside table, but the table was not positioned directly in front of the resident. Interview with Resident #11, on 11/30/2021 at 9:33 AM, revealed he/she was not assisted with meals. Additional observation of Resident #11, on 12/01/2021 at 12:50 PM, revealed the Occupational Therapist (OT) was helping Resident #11 with his/her lunch meal. Resident #11 refused several items on the lunch tray. Interview with SRNA #1, on 12/01/2021 at 3:25 PM, revealed there was a binder, located at the nurse's station, which held a Certified Nursing Assistant (CNA) Care Report for each resident. SRNA #1 stated SRNAs should refer to the report regarding resident care. SRNA #1 stated the binder was updated by nursing staff. SRNA #1 stated aides were updated about special feeding instructions during report at shift change or by looking at updates from the nurses in the CNA Care Report. Interview with the OT, on 12/01/2021 at 1:31 PM, revealed she had evaluated Resident #11 during lunch on 12/01/2021. Per the interview the OT stated she did offer substitutions, but Resident #11 did not want anything more. Further interview revealed OT referrals were usually made by nursing. However, the OT stated nursing had not made the referral for OT to evaluate Resident #11's need for feeding assistance. She stated while assisting Resident #11's roommate, she observed Resident #11 having difficulty with self-feeding, so she made the referral for an OT evaluation. Interview with the Registered Dietician (RD), on 12/02/2021 at 1:06 PM, revealed she assessed Resident #11, on 12/01/2021, after noting inconsistencies in Resident #11's weight. She documented in the RD Progress Note a request for nursing staff to re-weigh the resident. Per the interview, the RD stated that if a resident had any special dietary needs, they should be noted on the resident's meal ticket. She stated SRNA's were informed of special feeding instructions and special dietary needs, communicated to the nursing staff during shift change. Continued interview with the RD, on 12/02/2021 at 1:06 PM, revealed that if a resident's weight was noted to be out of parameters, the nursing staff should reweigh the resident. The RD also stated, for a resident with a significant change in weight, the facility held weekly meetings to discuss those residents who were nutritionally at risk (NAR). Per the interview, the RD was required to attend all NAR meetings, and any concerns were communicated to her during the weekly meeting. Additionally, the RD stated she ran reports to find at risk residents, and those residents were flagged and discussed in the NAR meetings. Per interview, the RD stated that nurses should do nutrition and weight monitoring per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated if a resident refused to be weighed, it should be charted in a progress note. She further stated that it was important for the nursing staff to follow dietary care plans. She stated it was her expectation that any significant weight change would be reported, as it was important for the resident's quality of life and to maintain proper nutrition requirements. Interview with Registered Nurse (RN) #1, on 11/30/2021 at 2:31 PM, revealed that SRNAs obtained weights and documented them in the resident's chart. Per interview nurses should review the weights and notify the RD of any significant change. Interview with the Assistant Director of Nursing (ADON), on 12/03/2021 at 11:25 AM, revealed nursing was to communicate to the RD about residents who were nutritionally at risk. Nurses should review the weights and notify the RD of any significant change. She further stated that nursing staff should re-weigh a resident if there was a significant change from the previous weight. She did not know why the resident was not re-weighed after the documented thirty-nine (39) pound weight loss. She stated Resident #11 was not weighed in November 2021 due to testing positive for COVID-19, on 10/28/2021, and being moved to the COVID Isolation Unit. However, the ADON stated there was a scale for weighing residents on the isolation unit. Further interview revealed it was the ADON's expectation that physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the Director of Nursing (DON), on 12/03/2021 at 12:15 PM, revealed nursing was to communicate significant changes in a resident's weight, and residents who were nutritionally at risk to the RD. She stated those concerns were addressed at the NAR meeting. She further stated nurses should follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the Administrator, on 12/03/2021 at 12:37 PM, revealed staff should follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, interview, record review and review of the facility's Oxygen Administration - Nasal Cannula, Clinical Practice Guideline, it was determined the facility failed to ensure respiratory care was provided consistent with professional standards of practice for three (3) of twenty-two (22) sampled residents (Resident #7, Resident #14, and Resident #27). Observation on 11/30/2021 of Resident #7, Resident #14, and Resident #27, revealed their oxygen tubing was unlabeled. Additional observation revealed Resident #27's humidification bottle on the oxygen concentrator was dated 11/16/2021. The findings include: Review of the facility's Oxygen Administration - Nasal Cannula, Clinical Practice Guideline, dated 10/23/2020, revealed the entire oxygen tubing set up should be replaced every seven (7) days, dated, and stored in a treatment bag when not in use. Further, humidification bottles should be changed every seven (7) days. 1. Review of Resident #14's Electronic Medical Record (EMR), revealed the facility admitted the resident on 07/09/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #14's Quarterly Minimum Data Set (MDS) Assessment, dated 09/10/2021, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) Score of nine (9) out of fifteen (15) indicating moderate cognitive impairment. Additionally, the Assessment revealed the resident required extensive assistance with bed mobility, toileting, and personal hygiene. Further review revealed the resident received oxygen therapy. Review of Resident #14's current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed additional orders, dated 11/01/2021, for oxygen saturation to be checked every shift and oxygen saturation without supplemental oxygen for fifteen (15) minutes to be checked every Wednesday. Review of Resident #14's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of Resident #14, on 11/30/2021 at 9:07 AM, revealed the resident was in bed with supplement oxygen applied via nasal cannula as per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Review of Resident #27's EMR revealed the facility admitted the resident on 10/13/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #27's Admission MDS Assessment, dated 10/20/2021, revealed the facility assessed the resident to have a BIMS Score of eight (8) out of fifteen (15) indicating moderate cognitive impairment. Additional review revealed the resident required extensive assist with transfers, bed mobility, dressing and toileting. Further review revealed the resident received oxygen therapy. Review of Resident #27's current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #27's MAR, dated 11/01/2021 through 11/30/2021, revealed all oxygen orders had been initialed by licensed nurses, which indicated the orders were followed. Observation of Resident #27, on 11/30/2021 at 9:11 AM, revealed the resident was in his/her room with oxygen therapy applied via nasal cannula at 3 Liters (L) per minute. Further observation revealed the tubing was not dated or labeled. Additionally, the humidification bottle was dated 11/16/2021, which indicated the humidification bottle had been in use for fourteen (14) days contradictory to the facility's Guideline. 3. Review of Resident #7's EMR, revealed the facility admitted the resident on 07/21/2016, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #7's Quarterly MDS Assessment, dated 11/01/2021, revealed the facility assessed the resident to have a BIMS score of fifteen (15) out of fifteen (15) indicating no cognitive impairment. Continued review of the MDS Assessment, revealed the resident required partial to moderate assist with bed mobility, toileting, and personal hygiene. Further review revealed Resident #7 received oxygen therapy. Review of Resident #7's current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #7's MAR, dated 11/01/2021 through 11/30/2021, revealed all oxygen orders had been initialed by licensed nurses, which indicated the orders were followed. Observation of Resident #7, on 11/30/2021 at 9:40 AM, revealed the resident was sitting up in bed in no acute distress. Resident #7 was observed to receive oxygen at two (2) Liters per minute via nasal cannula. Observation of the oxygen tubing, revealed it was dated 11/28/2021; however, the humidification bottle was not dated or labeled. Interview with Resident #7 during the observation, on 11/30/2021 at 9:40 AM, revealed he/she did not remember when the humidifier bottle had last been changed. Interview with Licensed Practical Nurse (LPN) #2, on 12/03/2021 at 10:52 AM, revealed the Unit Manager/Assistant Director of Nursing or the Infection Preventionist changed the resident's oxygen tubing weekly. Additionally, he stated humidification bottles were changed weekly and as needed. Per interview, oxygen tubing and oxygen humidification bottles should be dated, and nurses were also responsible for checking the oxygen humidification bottles and tubing every shift. Further it was important for oxygen tubing and humidification bottles to be changed weekly for infection control. Interview with Registered Nurse (RN) #1, on 11/30/2021 at 10:52 AM, revealed oxygen tubing and oxygen humidification bottles should be labeled with the change date. Furthermore, it was the nurse's responsibility to check the portable oxygen concentrator, liters of oxygen being administered, and the humidification bottles and tubing every shift. RN #1 stated Unit Managers changed the residents' oxygen tubing and humidification bottles weekly. RN #1 stated management of oxygen therapy administration was important to prevent the spread of infection. Interview with Assistant Director of Nursing (ADON) #1, who was also the Infection Preventionist, and the Unit Manager for the Transitional Care Unit (TCU), on 12/03/2021 at 11:25 AM, revealed oxygen tubing and humidification bottles should be dated when changed. Additionally, it was important to date the oxygen tubing and humidification bottles for infection control and to ensure staff were aware of when they were last changed. Further, it was her expectation that oxygen tubing and humidification bottles were dated and changed weekly, per the facility policy/guidelines. She further stated humidification bottles were dated and changed sooner if they were running low. Additional interview revealed the Unit Managers were responsible for changing out and dating oxygen tubing and humidification bottles, but floor nurses were responsible for checking the oxygen concentrators for correct liters per minute and checking on tubing and humidification bottles as needed. Interview with the Director of Nursing (DON), on 12/03/2021 at 12:15 PM, revealed she had worked at the facility as DON since 11/29/2021. Further interview revealed oxygen tubing and humidification bottles should be dated; however, she was unaware of the facility's policy on how often tubing and humidification should be changed or who was responsible because she was so new to the facility. Further, it was her expectation that oxygen tubing and humidification bottles would be changed per facility policy/guidelines and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Interview with the Administrator, on 12/03/2021 at 12:37 PM, revealed it was his expectation that oxygen tubing and humidification bottles would be dated and changed per policy/guidelines and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to establish mechanisms for documenting and communicating the resident's choices to the interdisciplinary team and to the staff responsible for the resident's care for one (1) of twenty-two (22) sampled residents (Resident #42). Record review revealed Resident #42 was admitted to the facility on [DATE], with a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Advance Directive/Informed Consent form for Resident #42 had Full Code handwritten in large letters, in the top right corner. However, the resident's most recent Advance Directives/Informed Consent form, dated [DATE], revealed the resident's code status was DNR. Additionally, although Resident #42's Advance Directive/Informed Consent was obtained on [DATE] for Do Not Intubate and the most recent Advance Directive/Informed Consent was obtained on [DATE] for DNR, physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: Review of the the facility's Advance Directives Procedure Policy, revised [DATE], revealed if the resident or the resident's representative stated that the resident had completed an advance directive, it shall be documented in the medical record. Review of Resident #42's Electronic Medical Record (EMR) revealed the facility admitted the resident on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional review revealed the resident's Responsible Party/Legal Oversight Guardian was the resident's granddaughter. Review of Resident #42's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE], new orders were received for a Do Not Resuscitate (DNR) code status. However, Resident #42's Advance Directive/Informed Consent form, dated [DATE], signed by the resident's Power of Attorney (POA), revealing Code status:Full Code, was observed, on [DATE] at 3:30 PM, to be at the nurse's station in a binder, with information used by staff to provide care, in the cabinet accessible to staff. Further, record review revealed there was a discrepancy in Code status for Resident #42 in comparing Advance Directives and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #42's Advance Directive/Informed Consent form, dated [DATE]; signed by the resident's POA, revealed the resident's Code status was Do Not Intubate. Additionally, review of the Kentucky Emergency Medical Services DNR Order, dated [DATE], revealed Resident #42's Code status was DNR; review of the Advanced Practice Registered Nurse's (APRN) Note, dated [DATE], revealed the resident's Code status was DNR; and review of the Advance Directives/Informed Consent form, dated [DATE], revealed the resident's code status was DNR. Review of Resident #42's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with Registered Nurse (RN) #2, on [DATE] at 4:12 PM, revealed if the computers were down, the nurse was to look at the binder with the Advance Directives/Informed Consent forms and perform Cardiopulmonary Resuscitation (CPR) if the chart stated a resident was a full code. Interview with Licensed Practical Nurse (LPN) #1, on [DATE] at 10:26 AM, revealed she looked for the code status in the computer. Per interview, if the computer was down, she would look in the hard chart. However, she stated she did not know where the hard charts were located. She further stated she would need to ask the Assistant Director of Nursing (ADON), the Director of Nursing (DON), or the Administrator where the code status was located. Interview with State Registered Nurse Aide (SRNA) #7, on [DATE] at 4:45 PM, revealed she checked the resident's code status in the computer. She further stated if the computers were down, there was a binder at the nurse's station that included the residents' code status. Interview with SRNA #2, on [DATE] at 10:30 AM, revealed he looked for the code status in Matrix, which was a computer program the facility utilized. He stated if the computers were down, he would ask the nurse the resident's code status. Interview with SRNA #3, on [DATE] at 10:36 AM, revealed she looked in the cabinet at the nurse's station for the binder which included the resident's code status and if it was not there, she would ask a nurse. Interview with the Social Worker, on [DATE] at 11:00 AM, revealed the daughter who was Resident #42's POA had passed away and the resident's granddaughter was now the resident's POA. Further interview revealed the granddaughter requested to continue the code status as the daughter had documented. Additional interview revealed the Social Worker was not aware there was a discrepancy in the code status for Resident #42 in comparing the code status in the computer and the Advance Directive/Informed Consent form which was kept in a binder at the nurse's station. Further, the Social Worker was unaware of the discrepancies in the Advance Directives and the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the Assistant Director of Nursing (ADON), on [DATE] at 10:38 AM, revealed she would look for the code status in the computer Matrix, and there was a backup computer in the conference room. Observation during the interview, revealed the ADON was attempting to access the backup computer which was stored in a drawer in the conference room; however, the computer was not charged. The ADON plugged in the computer. She attempted to sign into the computer; however, she was not successful. The ADON then asked Medical Records for the paper copy of Resident #42's code status, which was in the file cabinet. The Advance Directive/Informed Consent form, dated [DATE] that was in the file cabinet had Full code written on the top right hand corner of the form. However, the Directive/Informed Consent form was incorrect or outdated since there were orders since [DATE] for DNR status. Interview with the Director of Medical Records, on [DATE] at 10:50 AM, revealed nurses were responsible for documenting the code status of a resident, and the ADON was to ensure the Advance Directive/Informed Consent form was signed. Further, Medical Record's role for keeping records was to input the Advanced Directive codes in Matrix; and then place the paper form of the Advance Directive in the file cabinet. Further interview revealed she attended the morning clinical meetings where Advanced Directives were checked for new admissions; however, the Advanced Directives were not checked again during these meetings. Interview with the Staff Development Coordinator, on [DATE] at 2:35 PM, revealed staff checked the Matrix program in the computer for code status, and if the computers were down, they had a backup computer. She stated there should not be a book at the nurse's station to determine code status. Interview with Registered Nurse (RN) #2, on [DATE] at 11:40 AM, revealed if the computer was not working, she would look in the binder at the nurse's station for the Advance Directive/Informed Consent form to find out a resident's code status. Interview with the Director of Nursing (DON), on [DATE] at 12:30 PM, revealed staff checked the computer for a resident's code status. However, she stated if the computers were down when a resident became unresponsive or went into [CONDITION(S)], there was a binder at the nurse's station which included the Advance Directive/Informed Consent form which would indicate a resident's code status. Continued interview revealed the consequences of having the wrong Code status information in the binder at the nurse's station, the DON stated, in the rare instance that there was a discrepancy, a resident might receive CPR against his/her wishes or not receive CPR as desired. Interview with the Administrator, on [DATE] at 12:52 PM, revealed if the computers were not functioning, the staff could identify the code status of the resident by looking in the binder at the nurse's station.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure the environment remained free of accident hazards and failed to ensure each resident received adequate supervision and monitoring to prevent accidents for one (1) of three (3) sampled residents (Resident #1). On the 03/27/2020, during the 7:00 PM to 7:00 AM shift, the Power of Attorney (POA) for Resident #1 requested a hot water bottle be placed on Resident #1's abdomen. When staff removed the hot water bottle from the resident's abdomen, the towels used as skin barrier to protect the skin from the water bottle had shifted and a red area to the right upper abdomen with a small open blister was noted. The blister measured fourteen (14) cm (centimeters) in length by four (4) cm in width. Further, interviews with nursing staff revealed Resident #1 had used the hot water bottle for at least two (2) years. The facility failed to identify and eliminate the accident hazard or decrease the risk for an accident with its use. There was no evidence of a physician's order, assessment, evaluation, or care plan for the use of the hot water bottle. Further, there was no evidence the facility was monitoring the use of the hot water bottle. (Refer to F-656) The findings include: Review of the facility's policy, Accidents and Incident Investigation Reporting, revised 11/06/2019, revealed accidents and incidents involving residents would be investigated and reported to the Administrator. Additionally, a thorough investigation of the accident/incident would be completed including circumstances surrounding the accident, the names of witnesses and their accounts of the accident/incident, corrective action taken, follow up information, and other pertinent data as necessary or required. Further, the incident would be reported to the Administrator and/or the Director of Nursing. Interview with the Director of Nursing (DON), on 10/29/2020 at 1:42 PM, revealed the facility did not have a policy related to the use of devices including monitoring devices while in use. Review of Resident #1's medical record revealed the facility originally admitted the resident, on 08/01/2012, and readmitted the resident, on 08/13/2020, with [DIAGNOSES REDACTED]. Review of Resident #1's Comprehensive Care Plan (CCP), dated 10/28/2019, revealed the resident was at risk for developing skin breakdown related to immobility, percutaneous endoscopic gastrostomy (PEG, feeding tube) stoma, and total dependence on staff for bed mobility. The long-term goal was the resident would have intact skin, free of redness, blisters, or discoloration. Further, the short-term goal stated the area of redness and blister to the abdomen would be healed in thirty (30) days, and the target date was 04/28/2020. However, the CCP was not developed to include the use of the hot water bottle. (Refer to F-656) Record review revealed no documented evidence the facility conducted an assessment or evaluated the use of the hot water bottle. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 03/06/2020, revealed the facility assessed the resident as having both short-term and long-term memory loss and as rarely understood. There was no Brief Interview for Mental Status (BIMS) conducted. Further review revealed the facility assessed the resident as requiring total physical assistance of two (2) persons for all activities of daily living (ADL). Continued review revealed the resident had no skin impairment prior to this MDS Assessment. Review of Resident #1's Certified Nursing Assistant (CNA) Skin Care Alert form, dated 03/27/2020 for the 7:00 AM to 7:00 PM shift, signed by Licensed Practical Nurse (LPN) #2, revealed the resident's skin condition was clear, with no bruises, skin tears, reddened areas, rashes, blisters, pressure ulcers, or other skin impairment. Review of Resident #1's recorded revealed a progress noted, made by the Medical Director, dated 03/27/2020, which noted the resident was resting in bed and did not appear to be in any acute distress, was nonverbal, and had no signs or symptoms of pain or discomfort. Additionally, the note stated neither nursing nor the facility reported any concerns with the resident. Continued review revealed the resident had no jaundice or rashes of the skin. Further, the note stated other chronic co-morbidities were stable, and there was no indication to change the current treatment plan or regimen for chronic conditions. Review of Resident #1's Safety Events-Burns Report, dated 03/28/2020 at 4:50 AM, completed by Licensed Practical Nurse (LPN) #3, revealed the resident sustained [REDACTED]. Additionally, per the report, earlier on the 03/27/2020, 7:00 PM to 7:00 AM shift, the Power of Attorney (POA) and resident requested the application of a hot water bottle to the abdomen (towels were placed between the bottle and skin). However, the towels had shifted and when removing the hot water bottle, a red area to the right upper abdomen with a small open blister was noted, fourteen (14) cm (centimeters) in length by four (4) cm in width. Further, the report stated the MD, family/guardian, Administrator, and DON (Director of Nursing) were notified, and the nursing intervention included topical treatment and discontinued use of the hot water bottle. Continued review of Resident #1's Safety Events-Burns Report revealed the POA and family frequently requested a hot water bottle to be applied to the resident's abdomen due to discomfort for a twenty (20) to thirty (30) minute timeframe. Per the report, the family was visiting the resident through the window, on 03/27/2020, from 7:00 PM to 7:45 PM; and, prior to the family leaving the parking lot, the POA requested the hot water bottle be applied to the resident's abdomen. Continued review revealed the State Registered Nurse Aide (SRNA- wasn't identified in the report) folded two (2) towels and placed them onto the resident's skin as a barrier to protect the skin from the water bottle. Further, the possible burn was noted at 4:00 AM, on 03/28/2020. Review of Resident #1's Physician's Orders, revealed an order, with a start date of 03/28/2020, and a discontinue date of 04/16/2020, for [MEDICATION NAME] (Silver [MEDICATION NAME], a topical antibiotic used for burns) cream, one (1) percent, apply a liberal amount topically to the blistered area on the right upper abdomen, three (3) times a day and as needed; leave open to air. Review of Resident #1's Progress Notes, dated 03/28/2020 at 3:30 PM, by Registered Nurse (RN) #1, revealed, upon morning report from the night shift nurse, LPN #2, reported that Resident #1 had a red, blistered area to his/her right upper abdomen. Additionally, the Assistant Director of Nursing (ADON), the POA, and the Physician were notified. Further, a new order was received for [MEDICATION NAME] and to continue to monitor the burn. Review of Resident #1's Treatment Administration Record (TAR), dated March 2020, and the TAR, dated April 2020, revealed the resident received [MEDICATION NAME] cream, one (1) percent, topically to the blistered area on the right upper abdomen, three (3) times a day, from 03/28/2020 until 04/16/2020. Additionally, there was no documented evidence in the medical record of a medical provider's assessment of Resident #1's burn/blister to the right abdomen, until 04/16/2020, nineteen (19) days after the injury. Further, the Medical Director (MD) Progress Note, dated 04/16/2020, revealed the resident's left mid-abdomen region had a healed scar with a small scab from a prior burn mark, and wound care was no longer necessary. However, Resident #1's burn, acquired on 03/28/2020, was on the right abdomen. Interview with SRNA #3, on 10/28/2020 at 3:30 PM, revealed she was assigned to Resident #1, on 03/27/2020, for the 7:00 PM to 7:00 AM shift, and had worked at the facility for two (2) years. Per interview, since she had worked at the facility, Resident #1's POA had requested the red rubber hot water bottle be applied to the resident's abdomen. Additionally, it was common practice for nursing staff to apply the hot water bottle, filled with hot water from the tap, to the resident's abdomen at the POA's request. SRNA #3 stated there was a towel placed under and above the water bottle. She stated the bottle would be left on the resident until the POA requested it be removed. However, the hot water bottle practice was not included on the CCP. Review of the facility's Logbook Documentation, for hot water temperatures, dated 03/27/2020, revealed the hot water temperature in Resident #1's room was one hundred and ten (110) degrees Fahrenheit. Continued interview with SRNA #3 on 10/28/2020 at 3:303 PM revealed, on 03/27/2020 at 7:00 PM, she went into Resident #1's room right away to check him/her because she knew the POA came for a window visit around that time every day, and the resident was prone to [MEDICAL CONDITION]. SRNA #3 stated the hot water bottle was warm to touch and was on the resident's abdomen with a towel underneath the bottle and a towel over the bottle to hold it in place. SRNA #3 stated during the next resident round, at approximately 9:00 PM, the hot water bottle was cool and the nurse directed her to refill the hot water bottle with hot water from the tap and reapply the bottle to the resident's abdomen. Continued interview revealed she next checked on Resident #1 at approximately 11:00 PM, the resident was asleep, and the hot water bottle was cool; she removed the water bottle and towels. Further interview revealed she noted redness to the right side of the resident's abdomen, and reported it to the nurse. SRNA #3 stated she did not check Resident #1 at 4:00 AM resident rounds, on 03/28/2020. LPN #2, the night shift nurse on duty when the burn occurred, and the Assistant Director of Nursing (ADON)/LPN #3 were no longer employed by the facility and were unavailable for interviews. Interview with LPN #1, on 10/29/2020 at 10:15 AM, revealed she was assigned to Resident #1, on 03/28/2020 at 7:00 AM, and she had worked at the facility for ten (10) months. Per interview, before COVID-19 restrictions, the resident's POA was at the facility every day and would apply the hot water bottle and towel to the resident's abdomen. LPN #1 stated it was a long standing practice that was ongoing when she started working at the facility. Further interview revealed with visitation restrictions, the POA could not come into the facility to visit and would call and request nursing staff apply the hot water bottle for thirty (30) minutes; then, the POA would call back and request the water bottle be removed. Additionally, she stated staff filled the water bottle with hot water from the sink in the resident's restroom. The resident's PEG (feeding tube) was on the left side of the abdomen, and staff would fold the PEG tube into a washcloth and lay it to the left side of his/her abdomen, before they placed the water bottle in the middle of the abdomen on a towel. However, LPN #1 stated she had no knowledge of a physician's order, assessment, evaluation, or care plan for the hot water bottle use for Resident #1. Continued interview with LPN #1 revealed the night shift nurse (LPN #2) passed on in report, before 7:00 AM on 03/28/2020, Resident #1 had a burn on his/her abdomen from the hot water bottle used during the shift. Continued interview revealed LPN #2 did not report specifics of who applied the hot water bottle or the time the hot water bottle remained on the resident. Additional interview revealed both LPN's went into the resident's room and assessed his/her abdomen; there were two (2) intact fluid filled blisters, approximately fourteen (14) cm in length by four (4) cm in width. Further, she called the ADON/LPN #3, the MD, and the POA during her shift to notify them of the injury. Per interview, the hot water bottle should have been assessed for safety, prior to its initial use, and there should have been an ongoing evaluation, to ensure the resident received safe care. LPN #1 stated there should have been a physician's order and a care plan, with parameters set, on when to use the hot water bottle and the frequency the hot water bottle could be applied, to ensure proper monitoring was in place and to decrease the risk for injury/burn. Interview with RN #1, on 10/29/2020 at 11:36 AM, revealed she had worked at the facility for two (2) years. Per interview, she heard LPN #2's report, to LPN #1, on 03/28/2020 at 7:00 AM. Continued interview revealed Resident #1's hot water bottle was a common practice nursing implemented, per the POA's request, for as long as she had worked at the facility. However, there was no Physician's Order for the use or monitoring of the hot water bottle. Additionally, she stated LPN #2 reported the night shift aide, SRNA #3, filled the hot water bottle and placed it on Resident #1's abdomen, and LPN #2 was not aware the hot water bottle had stayed on the resident's abdomen until the blister was discovered during rounds, on 03/28/2020 at 4:00 AM. Further, she stated a Physician's Order for the hot water bottle would have ensured consistent care with monitoring and reduced the risk for accidents/injury. Post-Survey interview with the MDS Nurse, on 11/02/2020 at 4:00 PM, revealed she had worked at the facility for one (1) year. She stated she attended the Interdisciplinary Team (IDT) Morning Meetings, held Monday through Friday, and the weekly At Risk Meeting, which included participants such as the Administrator, Director of Nursing (DON), Unit Managers, and a representative from the Therapy Department. During these meetings, new admissions, readmissions, and resident changes in conditions were discussed, as well as a review of safety measures to implement for devices. Additionally, she stated, with the MDS schedule, she reviewed the medical record, spoke with staff and residents' representatives, and completed face-to-face assessments and observations of each resident. Per interview, during the MDS assessment period, she would review all devices to ensure they were in place and functioning properly; however, there was not an assessment or evaluation to document the review of devices, and she did not routinely document that she reviewed the devices. Continued interview revealed the use of devices required a Physician's Order. However, she stated Resident #1's hot water bottle did not have a Physician's Order, and the facility's systemic approaches, including the IDT meeting, the At Risk Meeting, and the ancillary MDS reviews had not identified the hot water bottle as an accident hazard nor had they implemented interventions to decrease the risk for accidents with its use. Further interview revealed to ensure the resident received consistent care and had a safe environment to meet his/her individual needs, the hot water bottle should have had a Physician's Order; been addressed in the CCP with documentation as to why it was used with safety measures; and, had an ongoing evaluation of whether it was an effective intervention. Interview with the DON, on 10/29/2020 at 1:42 PM, revealed she had been in the position for eight (8) months. The DON stated residents should receive adequate supervision and assistive devices to prevent accidents. Per interview, staff should consistently monitor the use of devices to ensure they were functioning properly and used correctly, to ensure a resident's safety. Continued interview revealed LPN #3 notified her two (2) days after the incident, on 03/30/2020, that Resident #1 had received a burn from the use of a water bottle, on 03/28/2020. Additionally, the DON, stated she was not aware the hot water bottle existed until she was notified of the 03/28/2020 occurrence. Per interview, when she became aware of the hot water bottle, she immediately removed it from Resident #1's room. The DON stated the incident with Resident #1 was an avoidable accident, and there should have been an order and a care plan that specified parameters for use of the hot water bottle. Per interview with the DON revealed, when a resident or resident's representative requested an assistive device, the assigned nurses were expected to obtain a Physician's Order for the device, initiate a care plan for the device, and notify the DON of the request for the device. However, she stated Resident #1 did not have an order or a care plan for the hot water bottle. Additional interview revealed the facility had a daily, Monday through Friday, IDT Meeting and, a weekly At Risk Meeting, where the DON, Administrator, MDS Nurse, Social Worker and Therapy Department representative discussed devices/equipment that were low use/high risk and changes in residents' conditions. The DON stated the MDS Nurse also assessed the risk, benefit, and effectiveness of devices with the MDS schedule for quarterly and comprehensive assessments and ensured they were care planned. However, the DON stated the facility did not identify and eliminate the accident hazard for the hot water bottle or decrease the risk for accidents while using the hot water bottle. Further interview with the DON revealed after she was notified that Resident #1 received the second degree burn related to the hot water bottle, she verbally provided education with the nurses in the facility. The DON stated the education she provided on 03/30/2020, included that devices require orders and consistent supervision. However, she stated there was no documented evidence she had provided this education. She stated a medical provider had not assessed Resident #1's burn until 04/16/2020, nineteen (19) days after the injury. Additionally, the DON stated she expected a timely assessment by the medical provider after all incidents/accidents involving residents; but, Resident #1's assessment was not timely and should have been completed before 04/16/2020, to ensure quality care and treatment. Interview with the Administrator, on 10/29/2020 at 2:32 PM, revealed he had worked at the facility for ten (10) months. Per interview, residents should receive adequate supervision and assistive devices to prevent accidents. Additionally, he stated he was notified by the DON, on 03/30/2020, two (2) days after the accident, that Resident #1 had acquired a second degree burn due to the use of a hot water bottle. Continued interview with the Administrator revealed he acknowledged the facility did not identify Resident #1's hot water bottle as an accident hazard until after the resident acquired an injury (second-degree burn) from the hot water bottle. Interview revealed the IDT discussed devices in use by residents in the morning meetings and the At Risk Meetings. However, Resident #1's hot water bottle had not been discussed in the meetings, and he was not aware the resident used the hot water bottle until after the injury occurred. Per interview, he stated the facility had failed to identify the use of the hot water bottle as an accident hazard; and failed to obtain a Physician's Order; and, develop a care plan so safety interventions could have been implemented when using the hot water bottle for Resident #1. Further, the Administrator revealed, through the facility's investigation, the root cause of the injury to Resident #1 was the use of the hot water bottle without adequate supervision. Per interview, the hot water bottle should have had an order and care plan developed to ensure its safe and consistent use. Further, he stated there was no documented evidence of education provided to nursing staff after the accident with injury to Resident #1, on 03/28/2020. The Administrator stated there had been no changes in the facility's systemic approach to identify devices or situations with potential accident hazards, eliminate accident hazards, or decrease the risk for accidents with their use.

Based on interview, record review, review of the Centers for Medicare and Medicaid Services (CMS), Resident Assessment Instrument (RAI) Manual 3.0, and review of the facility's policy, it was determined the facility failed to develop and implement the Comprehensive Care Plan (CCP) in accordance with each resident's individualized care needs/preferences related to accident hazards/devices for one (1) of three (3) sampled residents (Resident #1). According to the Comprehensive Care Plan (CCP), dated 10/28/2019, Resident #1 had a short-term goal for the area of redness and blister to the abdomen to be healed in thirty (30) days, and the target date was 04/28/2020. However, prior to this, the CCP had not been developed, to include the use of the hot water bottle. Interviews with nursing staff revealed for at least two (2) years, Resident #1 had routinely used a hot water bottle. However, there was no evidence the CCP was developed to include the hot water bottle. Due to the facility's failure to care plan the hot water bottle as an accident hazard and provide adequate supervision, Resident #1 acquired a second degree burn to his/her abdomen, on 03/28/2020. (Refer to F689) The findings include: Review of the facility's policy, Comprehensive Care Plan, dated 07/19/2018, revealed a person-centered Comprehensive Care Plan (CCP), to meet the resident's medical, nursing, mental, and psychological needs would be developed for each resident. Per policy, the Interdisciplinary Team (IDT) was responsible for review and updating of the care plan. Additionally, the care plan should reflect the current status of the resident and be updated with significant change, re-admission to the facility, and at least quarterly. Continued review revealed the care plan would include how the facility would assist the resident to meet their needs, goals, and preferences. Per policy, the CCP was based on a thorough assessment, not limited to the Resident Assessment Instrument (RAI). Further, the policy stated care plan interventions were implemented after consideration of the resident's problems and their causes. Continued review revealed interventions would address the underlying source(s) of the problem area(s), rather than addressing only symptoms or triggers and would address actions, treatments, and/or procedures. Review of the Centers for Medicare and Medicaid Services (CMS), Resident Assessment Instrument (RAI) Manual 3.0, dated October 2016, revealed the care plan must be reviewed and revised periodically, and the services provided or arranged should be consistent with each resident's written plan of care. Continued review revealed the care plan was driven, not only by identified resident issues and/or conditions, but also by a resident's unique characteristics, strengths, and needs. Furthermore, a care plan based on a thorough assessment and effective clinical decision making, was compatible with current standards of clinical practice that provided a strong basis for optimal approaches to quality of care and quality of life needs of individual residents. In addition, a well developed and executed assessment and care plan re-evaluated the resident's status at prescribed intervals (quarterly, annually, or if a significant change in status occurred) using the RAI and then modified the individualized care plan as appropriate and necessary. Review of Resident #1's medical record revealed the facility originally admitted the resident, on 08/01/2012, and readmitted the resident, on 08/13/2020, with [DIAGNOSES REDACTED]. Review of Resident #1's Comprehensive Care Plan (CCP), dated 10/28/2019, revealed the resident was at risk for developing skin breakdown related to immobility, percutaneous endoscopic gastrostomy (PEG, a feeding tube) stoma, and total dependence on staff for bed mobility. The long-term goal was the resident would have intact skin, free of redness, blisters, or discoloration. Further, the short-term goal was the area of redness and blister to the abdomen would be healed in thirty (30) days, and the target date was 04/28/2020. However, the CCP had not been developed to include the use of the hot water bottle. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 03/06/2020, revealed the facility assessed the resident as having both short-term and long-term memory loss and as rarely understood. There was no Brief Interview for Mental Status (BIMS) conducted. Further review revealed the facility assessed the resident as requiring total physical assistance of two (2) persons for all activities of daily living (ADL). Continued review revealed the resident had no skin impairment prior to this MDS Assessment. Review of Resident #1's Safety Events-Burns Report, dated 03/28/2020 at 4:50 AM, completed by Licensed Practical Nurse (LPN) #3, revealed the resident sustained [REDACTED]. Further review revealed that earlier, on the 7:00 PM to 7:00 AM shift, beginning on 03/27/2020, the Power of (POA) and resident had requested the application of a hot water bottle to the abdomen, towels were placed between the bottle and skin. However, the towels had shifted and when removing the hot water bottle, a red area to the right upper abdomen with a small open blister was noted. This area measured fourteen (14) centimeters (cm) in length by four (4) cm in width. Further, the report stated the MD (medical doctor), family/guardian, Administrator, and Director of Nursing (DON) were notified, and the nursing intervention included topical treatment and discontinued use of the hot water bottle. Continued review of Resident #1's Safety Events-Burns Report, dated 03/28/2020 at 4:50 AM, revealed the POA and family frequently requested a hot water bottle to be applied to the resident's abdomen due to discomfort for a twenty (20) to thirty (30) minute timeframe. Per the Report, the family was visiting the resident through the window, on 03/27/2020 from 7:00 PM to 7:45 PM; and, prior to the family leaving the parking lot, the POA requested the hot water bottle be applied to the resident's abdomen. Continued review revealed the State Registered Nurse Aide (SRNA, the report did not indicate a specific SRNA), folded two (2) towels and placed them onto the resident's skin as a barrier to protect the skin from the water bottle. Further, the possible burn was noted, on 03/28/2020 at 4:00 AM. Interview with SRNA #3, on 10/28/2020 at 3:30 PM, revealed she was assigned to Resident #1, on 03/27/2020 for the 7:00 PM to 7:00 AM shift, and had worked at the facility for two (2) years. SRNA #3 stated Resident #1's POA routinely requested the red rubber hot water bottle be applied to the resident's abdomen, and it was common practice for nursing staff to apply the hot water bottle, filled with hot water from the tap, to the resident's abdomen at the POA's request. However, the hot water bottle practice was not included on the CCP. SRNA #3 stated she used the CCP to know how to provide care to each resident, and it was important for the CCP to be developed to include all devices and approaches a resident needed to ensure their care needs were met. Further, she stated she had not been provided education on care plans including devices/supervision. Licensed Practical Nurse (LPN) #2, assigned to Resident #1, on 03/27/2020 during the 7:00 PM- 7:00 AM shift, and the Assistant Director of Nursing (ADON)/LPN #3, who LPN #2 reported the incident to on 03/28/2020, were no longer employed by the facility and were unavailable for interviews. Interview with LPN #1, on 10/29/2020 at 10:15 AM, revealed she was assigned to Resident #1, on 03/28/2020 at 7:00 AM, and she had worked at the facility for ten (10) months. LPN #1 stated that before COVID-19 restrictions, the resident's POA was at the facility every day and would apply the hot water bottle and towel to the resident's abdomen; it was a long standing practice that was ongoing when she started working at the facility. Continued interview revealed that with the visitation restrictions, the POA could not come into the facility to visit and would call and request nursing staff apply the hot water bottle for thirty (30) minutes, and then call back to request the water bottle be removed. Additionally, LPN #1 stated she used the CCP as a guide on how to provide care to each resident to meet their needs. Further interview with LPN #1, revealed the hot water bottle should have been care planned to ensure continuity of care. She stated the CCP was a guide all staff utilized, and if the CCP had included the hot water bottle and interventions for proper monitoring, the facility could have decreased the risk for injury/burn; the resident would have received safe care. Per interview, she had not received training related to the CCP, including use of devices with supervision. Interview with Registered Nurse (RN) #1, on 10/29/2020 at 11:36 AM, revealed she had worked at the facility for two (2) years. RN #1 stated she heard LPN #2's report, to LPN #1, on 03/28/2020 at 7:00 AM. Continued interview revealed Resident #1's hot water bottle was a common practice nursing had implemented, per the POA's request, for as long as she had worked at the facility. However, she stated the resident's CCP was not developed for the use or monitoring of the hot water bottle. Additionally, she stated a care plan for the hot water bottle would have ensured consistent care and monitoring and reduced the risk for accidents/injury for Resident #1. Further, RN #1 stated she had not received education related to devices being care planned. Post-Survey interview with the MDS Nurse, on 11/02/2020 at 4:00 PM, revealed she had worked at the facility for one (1) year. She stated she attended the Interdisciplinary Team (IDT) Morning Meetings, held Monday through Friday, and the weekly At Risk Meeting, which included the Administrator, the DON, Unit Managers, and a representative from the Therapy Department. Further interview revealed that during these meetings, new admissions, readmissions and residents' changes in conditions were discussed, as well as a review of safe measures to implement, including with devices. Additionally, with the MDS schedule, she reviewed the medical record, spoke with staff and resident representatives, and completed face-to-face assessments and observations of each resident. The MDS Nurse stated during the MDS assessment period, she would review all devices to ensure they were in place and functioning properly; however, there was not an assessment or evaluation to document the review of devices, and she did not routinely document that she reviewed the devices. She stated the use of devices required a physician's orders [REDACTED]. [REDACTED]. its use. Further interview revealed to ensure the resident received consistent care and had a safe environment to meet his/her individualized needs, the hot water bottle should have had a physician's orders [REDACTED]. Interview with the Director of Nursing (DON), on 10/29/2020 at 1:42 PM, revealed she had been in the position for eight (8) months. The DON stated residents should have care plans developed for devices to ensure they received adequate supervision with the assistive devices to prevent accidents. Additionally, she stated when implementing the CCP for devices and supervision, staff would consistently monitor the use of devices to ensure they were functioning properly and used correctly, to ensure the resident's safety. The DON stated when a resident or resident's representative requested the use of a device, the assigned nurses were expected to initiate a care plan for the device. However, she stated Resident #1 did not have a care plan developed for the hot water bottle. Continued interview with the DON, on 10/29/2020 at 1:42 PM, revealed the facility had a daily, Monday through Friday, IDT Meeting and a weekly, At Risk Meeting, where the DON, Administrator, MDS Nurse, Social Worker, and Therapy Department representative, discussed devices/equipment that were low use/high risk and changes in residents' conditions. Per interview, the MDS Nurse also assessed the risk, benefit, and effectiveness of devices with the MDS schedule for quarterly and comprehensive assessments and ensured they were care planned. However, the DON stated the facility did not identify Resident #1's CCP was not developed to eliminate the accident hazard (hot water bottle) or decrease the risk for accidents while using the hot water bottle. She further stated the IDT was responsible for ensuring CCP were developed. Continued interview with the DON revealed, on the morning of 03/30/2020, after notification that Resident #1 received the second degree burn related to the hot water bottle, she verbally provided education to nurses in the facility about the initiation of a CCP for all devices. However, there was no documented evidence she had provided this education. Interview with the Administrator, on 10/29/2020 at 2:32 PM, revealed he had worked at the facility for ten (10) months. Per interview, the CCP should be developed to include adequate supervision with assistive devices to prevent accidents. Additional interview revealed the IDT discussed devices in use by residents in the morning meetings and the At Risk Meetings. However, the facility had failed to identify the hot water bottle as an accident hazard and failed to develop a care plan and implement interventions to ensure Resident #1 received close supervision/monitoring when using the hot water bottle. Continued interview with the Administrator revealed the hot water bottle should have had a care plan developed to ensure its safe and consistent use. Additionally, he stated there was no evidence of CCP education provided to nursing staff after the accident with injury to Resident #1, on 03/28/2020. The Administrator stated there had been no changes in the facility's systemic approach to identify or care plan devices with the potential for accident hazards or to decrease the risk for accidents with their use.

Based on interview, record review, review of facility policy and review of the Lippincott Manual of Nursing Practice, it was determined the facility failed to ensure the Physician was notified when there was a change in condition, for one (1) of seven (7) sampled residents (Resident #3). On 06/19/16 at approximately 1:00 PM, Resident #3 reported leaking around his/her indwelling urinary catheter. Without informing the Physician, or obtaining procedure orders, Licensed Practical Nurse (LPN) #7 attempted to irrigate the resident's catheter, and proceeded to make multiple attempts to replace the catheter. Throughout the procedure, Resident #3 complained of pain, begged the nurse to stop, and experienced bleeding. Furthermore, when the resident's ex-wife, who sat with the resident throughout the night of 06/19/16 into 06/20/16, reported the resident did not feel well and had no urine output, staff on duty still did not notify the Physician. On 06/20/16 at approximately 10:00 AM, the nurse did obtain an order to transfer Resident #3 to the hospital at the ex-wife's insistence. Review of the hospital record revealed Resident #3 was noted by the Urologist to have scant urine output, bleeding secondary to trauma sustained during catheterization attempts at the facility, and a Urinary Tract Infection [MEDICAL CONDITION]. (Refer also to F281, F282, F315, F441, and f514) The findings include: The facility did not provide a specific written policy regarding physician notification. Interview with the Director of Nursing (DON), on 06/23/16 at 11:00 AM, revealed the facility followed nursing practice standards outlined in Lippincott and Potter & Perry manuals. She stated the facility did not have a copy of the reference manuals, but could access them on-line if information was needed. Review of the Lippincott Manual of Nursing Practice Standards, Ninth Edition, revealed professional nursing standards set minimum levels of acceptable performance for which its practitioners were accountable. Continued review revealed the failure to perform proper assessments, notify physicians of changes in condition, and obtain orders for care could result in adverse outcomes. Review of the medical record revealed Resident #3 was admitted by the facility on 05/11/16, with [DIAGNOSES REDACTED]. Review of the nursing Admission Assessment revealed the resident had an indwelling urinary catheter connected to a bedside drainage bag. Review of the Admission Minimum Data Set (MDS) Assessment, dated 05/18/16, revealed the facility assessed Resident #3 to have a Brief Interview for Mental Status (BIMS) score of twelve (12), which indicated the resident was cognitively intact, and therefore interviewable. Continued review of the MDS revealed the resident was assessed to have an indwelling catheter; however, there was no documented medical [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan, dated 05/20/16, revealed Resident #3 was at risk for complications associated with bladder elimination related to an indwelling urinary catheter. The stated goal was for the resident to have a reduced risk of complications due to the catheter through the next review date of 08/18/16. Approaches included a directive to monitor bladder status and report any changes such as low urine output, discolored urine, and pain to the Physician. Interview with State Registered Nurse Assistant (SRNA) #8, on 06/24/16 at 11:30 AM, revealed Resident #3 reported to SRNA #8, on 06/19/16, that his/her catheter was leaking. Continued interview revealed SRNA #8 informed Licensed Practical Nurse (LPN) #7 of the resident's complaint. He stated when he re-entered the resident's room, observed LPN #7 remove the indwelling catheter and proceed to insert a new catheter. SRNA #8 further stated when the nurse tried to put the new catheter in, the resident cried out, Stop! Stop!, and the SRNA noted the resident was bleeding a lot. Further interview revealed LPN #7 stated she couldn't get the catheter in, so she got another one, and inserted it. The resident was crying, and told the nurse he couldn't stand it and to take it out. According to SRNA #8, the nurse removed the newly placed catheter, handed the original catheter, which had been removed, to the SRNA and directed him to rinse it off in the bathroom. LPN #7 re-inserted the used catheter into the resident's bladder. Telephone interview with LPN #7, on 06/23/16 at 6:45 PM, regarding the catheter change for Resident #3 on 06/19/16, revealed she made a mistake and was terminated by the DON. LPN #7 acknowledged she put in the wrong size catheter without a physician's orders [REDACTED]. She further stated when she inserted the larger catheter, the resident bled and she panicked. She did not acknowledge her attempt to flush the catheter when the resident reported leaking around it, or removal of the larger catheter and re-insertion of the used catheter. Interview with the ex-wife of Resident #3, on 06/23/16 at 5:20 PM, revealed she stayed throughout the night of 06/19/16 into 06/20/16 because the resident did not feel well and she knew something was wrong. She stated the resident had no urine output all night, was very sore, reported feeling like a panic attack, and did not seem as alert as usual. Continued interview revealed the ex-wife described her concerns to the nurse on duty and expressed her feeling the resident should go to the hospital. She further stated the nurse said he didn't need to go because his vital signs were fine. Further interview revealed on the day shift of 06/20/16, the ex-wife insisted the resident be sent to the Emergency Department (ED). She reported she was informed in the ED the resident had suffered trauma due to repeated catheterization attempts, with resultant internal swelling and the presence of blood clots. Review of the Nurses Notes and nursing assessments for 06/19/16 and 06/20/16 revealed no documented evidence of the events surrounding the catheter change for Resident #3. Furthermore, there was no documented evidence of a call to the Physician related to the events, including the resident's bleeding and subsequent lack of urine output, or the receipt of any new treatment orders. Review of the Intake/Output Record, dated 06/19/16 and 06/20/16, revealed no documented evidence of any urine output for Resident #3 after 11:00 PM on 06/19/16. Review of the Nursing Home to Hospital Transfer Form, dated 06/20/16 at 10:00 AM, revealed the nurse noted Resident #3 had had no urine output for twelve (12) hours, and exhibited a decreased level of consciousness and generalized weakness. Review of the resident's physician's orders [REDACTED]. Continued review revealed a verbal order, dated 06/20/16, to transfer the resident to the hospital Emergency Department for an evaluation per family request. Further interview with the DON, on 06/23/16 at 11:00 AM, revealed when she questioned LPN #7, the nurse reported Resident #3's catheter was not draining so she tried to flush it without success. The nurse decided to replace the catheter. The DON stated LPN #7 further reported the resident bled a lot during the procedure. Continued interview revealed LPN #7 should have called the Physician and obtained an order prior to flushing or changing the indwelling catheter. The DON expressed her expectation that a nurse never flush or change a catheter without obtaining an order, and stated decisions regarding Resident #3's catheter should have been made by the Physician, not the nurse. Review of hospital records revealed Resident #3 was admitted on [DATE] with [DIAGNOSES REDACTED].#3 had remarkably infected urine and a Urology consult was ordered to address the resident's hematuria (blood in the urine). Review of the Urology consult note, dated 06/21/16, revealed the physician specialist documented the presence of gross hematuria, likely secondary to multiple traumatic attempts at catheterization at the facility. Continued review revealed the presence of a UTI, low urine output and acute renal (kidney) failure. Interview with the Administrator, on 06/24/16 at 3:30 PM, revealed he expected nursing staff to notify the Physician for changes in condition. A post-exit telephone interview with Resident #3's Physician, on 06/29/16 at 11:15 AM, revealed he would have expected the nurses to notify him of changes in the resident's urinary status, including leaking, obstruction, decreased urinary output, or the need for irrigation or replacement of the catheter. Continued interview revealed he would have expected to be immediately notified of a traumatic catheter insertion, such as occurred with Resident #3. The Physician stated he would have cultured the urine, verified placement and initiated precautions to monitor the resident for complications. Further interview revealed the Physician was not notified of any catheter problems for Resident #3 until the resident was on the way out of the facility to the hospital. He further stated the nurse re-using a catheter was bizarre behavior and showed negligence in the nurse's thought processes we don't re-use needles or catheters.

Based on interview, record review, review of the facility's policy and review of the Lippincott Manual of Nursing Practice, it was determined the facility failed to ensure services provided met professional standards of quality for one (1) of seven (7) sampled residents (Resident #3). When the resident had leakage of urine from around an indwelling urinary catheter on 06/19/16, the nurse did not notify the Physician of the resident's change in condition, attempted to flush the catheter, and ultimately replaced the catheter without a physician's orders [REDACTED]. When the resident cried in pain, experienced bleeding, and insisted the nurse remove the catheter, she instructed the State Registered Nurse Assistant (SRNA) to rinse the original catheter which had been removed, then reinserted the non-sterile, used catheter into the resident's bladder. Later that night, and into the morning of 06/20/16, the resident's ex-wife noticed a decline in the resident, including lethargy and a lack of urine output, and expressed her concerns to the nurse, who did not address the concerns. On the day shift of 06/20/16, at the insistence of the ex-wife, Resident #3 was sent to the hospital. Review of the Emergency Department (ED) record revealed the resident had minimal or no urine output since the urinary catheter was changed the day before, and lab results revealed a severe urinary tract infection [MEDICAL CONDITION]. According to the Urology Consult report, Resident #3 had gross hematuria (large amount of blood in the urine), most likely caused by multiple, traumatic catheterizations at the facility, with subsequent low urine output and acute renal (kidney) failure. (Refer also to F157, F282, F315, F441 and F514) The findings include: Review of the facility's policy titled Catheterization Policy, undated, revealed catheterizations should be completed using sterile technique. Continued review revealed if problems were encountered during the procedure, the nurse should stop and notify the Physician. Interview with the Director of Nursing (DON), on 06/23/16 at 11:00 AM, revealed the facility did have a written policy regarding nursing standards of care; however, the facility followed nursing practice standards outlined in the Lippincott and Potter & Perry nursing manuals. She stated the facility did not have a current copy of the nursing reference. Further interview with the DON revealed the facility followed the Centers for Disease Control (CDC) recommendations for changing indwelling urinary catheters. She stated catheters were changed as ordered by the Physician. Review of the Lippincott Manual of Nursing Practice Standards, Ninth Edition, revealed professional nursing standards of practice were minimum levels of acceptable performance for which its practitioners were accountable. Continued review revealed patients were at risk for adverse outcomes when nurses failed to assess properly, failed to notify the Physician of changes and obtain orders for care, failed to adhere to facility policy or procedure, and failed to document relevant information in the medical record. Further review of the Lippincott Manual, related to Standards for Catheterization, revealed irrigation of the catheter and catheterization should be performed using sterile technique, utilizing the smallest catheter capable of draining the bladder adequately. Continued review revealed the Physician should be notified if bloody urine developed. Review of the medical record revealed the facility admitted Resident #3 on 05/11/16 with [DIAGNOSES REDACTED]. Review of the nursing Admission Assessment revealed Resident #3 had an indwelling urinary catheter connected to a bedside drainage bag. Review of the Admission Minimum Data Set (MDS) Assessment, dated 05/18/16, revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of twelve (12), which indicated the resident was assessed to be cognitively intact and interviewable. Continued review of the MDS revealed the resident was assessed to have an indwelling catheter; however, continued review revealed no medical [DIAGNOSES REDACTED]. Telephone interview with Resident #3's ex-wife, on 06/23/16 at 5:20 PM, revealed the resident came to the facility from the hospital with the urinary catheter in place because Resident #3 was very obese, could only urinate when standing up, and was too weak to stand while in the hospital. Review of the Comprehensive Care Plan, dated 05/20/16, revealed Resident #3 was at risk for complications associated with bladder elimination related to an indwelling urinary catheter. The stated goal was for the resident to have a reduced risk of complications due to the catheter through the next review date of 08/18/16. Approaches included an intervention to monitor bladder status and report any changes such as low urine output, discolored urine, and pain to the Physician. Interview with SRNA #8, on 06/24/16 at 11:30 AM, revealed on 06/19/16 at approximately 1:00 PM, Resident #3 told him that his/her catheter was leaking. The SRNA reported to the Charge Nurse/Licensed Practical Nurse (LPN) #7, who gathered supplies and entered the resident's room. When SRNA #8 returned to the room, LPN #7 had taken the old catheter out and was in the process of inserting a new one. SRNA #8 said he noticed the new catheter was larger in diameter than the old one, and asked the nurse about it. He said LPN #7 stated the resident required a larger catheter because there was leaking around the smaller one. When the nurse tried to put the new catheter in, the resident cried out, Stop! Stop! and began bleeding. The nurse stopped, obtained another catheter and inserted it. Resident #3 started crying and told the nurse to take it out because he/she couldn't stand it. SRNA #8 stated, LPN #7 removed the newly placed catheter and handed the original catheter to the SRNA and directed him to rinse it off in the bathroom. The nurse then, reinserted the used catheter and secured it, and left the resident's room. SRNA #8 knew the pain and the bleeding wasn't right and stated he meant to report the incident to the DON, but he got busy and did not report it. Telephone interview with LPN #7, on 06/23/16 at 6:45 PM, regarding the catheter change for Resident #3 on 06/19/16, revealed she made a mistake and was terminated by the facility. LPN #7 stated she put in the wrong size catheter without a physician's orders [REDACTED]. She further stated when she inserted the larger catheter, the resident bled and she panicked. She did not acknowledge her attempt to flush the catheter when the resident reported leaking around it, or removal of the larger catheter and re-insertion of the used catheter. Review of the Job Description for Position of Charge Nurse, signed by LPN #7, revealed essential duties and responsibilities included notifying the Physician when there was a change in a resident's condition. Interview with SRNA #7, on 06/23/16 at 4:00 PM, revealed the SRNA was familiar with Resident #3, and had provided direct care to the resident on the 06/19/16 evening shift. The SRNA stated Resident #3 complained of being dirty and not feeling well. SRNA #7 stated at about 9:00 PM, she assisted the resident's ex-wife to clean the resident up. SRNA #7 further stated the resident had old, dried blood on his/her abdomen. Interview with LPN #6, on 06/24/16 at 1:00 PM, revealed she cared for Resident #3 from 7:00 PM to 11:00 PM on 06/19/16. She stated she noted the resident had a blue indwelling catheter which was the type present when the resident was admitted by the facility. She further stated the facility did not have blue catheters, only tan ones, so she knew it was the same catheter. However, she revealed, LPN #7 had reported she had tried to change Resident #3's catheter without success, so she flushed the catheter because it was clogged, and just changed the bag. Continued interview revealed Resident #3 told LPN #6 the day shift nurse (LPN #7) tried to put in a new catheter multiple times and couldn't, so she put the old catheter back in. The resident further reported LPN #7 took a syringe out of the trash can and tried to flush the catheter. Further interview with LPN #6 revealed the facility had no policy for flushing or changing catheters; however, she stated, neither procedure should be performed without a physician's orders [REDACTED].#3's catheter. Telephone interview with Registered Nurse (RN) #1, on 06/24/16 at 12:30 PM, revealed on 06/19/16 at change of shift for the 11-7 shift, LPN #6 reported LPN #7 tried to change Resident #3's catheter, but replaced the used catheter. LPN #7 stated she cleaned it first, but RN #1 didn't know how, since the facility had no sterilizing machine. Continued interview revealed Resident #3 had the same blue indwelling catheter in place, and RN #1 confirmed the facility did not stock blue catheters. Further interview with Resident #3's ex-wife, on 06/23/16 at 5:20 PM, revealed she was very upset about the problems resident had regarding the catheter. She stated the resident told her the nurse hurt him/her when she changed the catheter. He/she reported the catheter was leaking urine bad, and after the catheter was changed, there was blood all over his/her belly, the diaper, the towel and the pad underneath him/her. The ex-wife further stated she did not know why the catheter was changed; the resident was not having any pain until after the nurse tried to change it. Continued interview revealed Resident #3 told the ex-wife he/she kept telling the nurse she was hurting him/her but she continued. According to the ex-wife, after the incident Resident #3 said he/she felt the needed to urinate, but it hurt, and he/she thought the catheter was clogged. Further interview with the ex-wife revealed she stayed with the resident all night, and the resident had no urine output. She stated the resident reported feeling shaky, like he/she was having a panic attack. Furthermore, Resident #3 complained of pain in his/her chest, arm and back, and wasn't as alert as normal. The ex-wife reported the resident acted the same way before when he/she had kidney failure; she kept telling the night nurse something was wrong, but the nurse said the resident's vital signs were fine and did not need to go out to the hospital. The ex-wife decided if the facility did not call the doctor, she would. She reported the day shift nurse on 06/20/16 did call the Physician and made arrangements to send the resident to the hospital. She further stated in the Emergency Department (ED), the nurse told her the catheter from the nursing home was not working and had to be replaced. The ex-wife also stated she was told the resident was very swollen inside, and had blood clots. Review of the Intake/Output Record, dated 06/19/16 and 06/20/16, revealed no documented evidence of any urine output for Resident #3 after 11:00 PM on 06/19/16. Review of the Nurses Notes and nursing assessments for 06/19/16 and 06/20/16 revealed no documented evidence of the events surrounding the catheter change for Resident #3. Furthermore, there was no documented evidence of a call to the Physician related to the events, including the resident's bleeding and subsequent lack of urine output, or the receipt of any new treatment orders. Telephone interview with LPN #3, on 06/24/16 at 1:15 PM, revealed he worked the day shift on 06/20/16. He stated he was told in shift report that Resident #3's catheter was changed the day before. He further stated the resident's ex-wife had been at the facility all night and she told LPN #3 about the circumstances surrounding the catheter change, and that the resident had not had any urine output all night and she wanted the resident sent to the hospital. Continued interview revealed LPN #3 asked Resident #3 how he/she was feeling and Resident #3 said he/she wasn't peeing. Further interview revealed LPN #3 called the Physician to let him know the resident's ex-wife wanted Resident #3 sent to the hospital, and he gave a verbal order to send the resident out. LPN #3 stated Resident #3 left the facility at approximately 10:00 AM on 06/20/16, for transport to the Emergency Department (ED) by the ambulance service. Review of the resident's physician's orders [REDACTED]. Continued review revealed a verbal order, dated 06/20/16, to transfer the resident to the hospital Emergency Department for an evaluation per family request. Review of the Transfer Form, dated 06/20/16 at 10:00 AM, revealed the nurse noted Resident #3 had had no urine output for twelve (12) hours, and exhibited a decreased level of consciousness and generalized weakness. Review of the hospital History and Physical, signed by the admitting Physician and dated 06/20/16, revealed in the ED, Resident #3 was moderately distressed with increased respiratory effort. The resident required intubation and mechanical ventilation, and was transferred to the Intensive Care Unit (ICU), where Resident #3 continued with low urine output that was very bloody in nature. Continued review revealed a [DIAGNOSES REDACTED]. Review of the Urology consult note, dated 06/21/16, revealed the Physician specialist documented the presence of gross hematuria, likely secondary to multiple traumatic attempts at catheterization at the facility. Continued review revealed the presence of a UTI, low urine output and acute renal (kidney) failure. Interview with Licensed Practical Nurse (LPN)/Assistant Director of Nursing (ADON), on 06/23/16 at 11:10 AM, in regards to a urinary catheter that was not working properly, or not draining, revealed she would not flush or change a catheter without a physician's orders [REDACTED]. She further stated if she was unable to insert a catheter without difficulty, she would notify the Physician. Interview with the DON, on 06/23/16 at 11:00 AM, revealed Resident #3 came to the facility from the hospital with an indwelling catheter. The DON stated she questioned LPN #7 about the events on 06/19/16, who reported the resident's catheter was not draining. She said LPN #7 reported to her that she tried unsuccessfully to flush the catheter, and made the decision to replace it. LPN #7 told the DON she must have broken through a clot because there was a lot of blood. Continued interview with the DON revealed LPN #7 should have called the Physician and obtained an order prior to flushing or changing the indwelling catheter, and the nurse should not have reinserted the used catheter, because catheterization should be completed under sterile technique. The DON expressed her expectation that a nurse never flush or change a catheter without a physician's orders [REDACTED].#3's catheter should have been made by the Physician, not the nurse. Interview with the Administrator, on 06/24/16 at 3:30 PM, revealed he expected nursing staff to notify the Physician for changes in condition, obtain Physician orders [REDACTED]. A post-exit telephone interview with Resident #3's Physician, on 06/29/16 at 11:15 AM, revealed he would have expected the nurse to notify him of changes in the resident's urinary status, including leaking, obstruction, decreased urinary output, or the need for irrigation or replacement of the catheter. Continued interview revealed he would have expected to be immediately notified of a traumatic catheter insertion, such as occurred with Resident #3. The Physician stated he would have cultured the urine, verified placement and initiated precautions to monitor the resident for complications. Further interview revealed the Physician was not notified of any catheter problems for Resident #3 until the resident was on the way out of the facility to the hospital. He further stated the nurse re-using a catheter was bizarre behavior and showed negligence in the nurse's thought processes we don't re-use needles or catheters.

Based on interview and record review, it was determined the facility failed to ensure services were provided in accordance with each resident's written plan of care, for two (2) of seven (7) sampled residents (Residents #1 and #3). The nursing staff did not follow the Care Plan when they failed to inform the Physician of a change in the condition of Resident #3 related to his urinary status and an indwelling urinary catheter. Resident #3 experienced leaking around the catheter. Without notifying the Physician and obtaining care orders, the nurse attempted to flush the catheter, then changed the catheter. Furthermore, the nurse did not notify the Physician when the resident had pain and bleeding related to her attempts to insert a catheter. The following day, Resident #3 was admitted to the hospital with [REDACTED]. In addition, Resident #1 was assessed to be require two (2) staff for assistance with transfers; however, the resident was transferred by one staff member on two (2) occasions on 06/08/16. The resident complained of pain and a bruise was observed on the left shoulder. Resident #1 sustained a fracture to the left humerus (upper arm). (Refer also to F157, F281, F315, F441, and F514) The findings include: Interview with the Director of Nursing (DON), on 06/24/16 at 2:45 PM, revealed the facility did not have a written policy related to following the Care Plan. She stated it was her expectation for the nurses to follow the Care Plan as it had been developed. Review of the Job Description for Position of Charge Nurse (LPN or RN), revealed Essential Duties and Responsibilities included review of the Care Plan daily to confirm that appropriate care was being delivered. 1. Review of the medical record revealed the facility admitted Resident #3 on 05/11/16 with [DIAGNOSES REDACTED]. Review of the nursing Admission Assessment revealed Resident #3 had an indwelling urinary catheter connected to a bedside drainage bag. Review of the resident's Admission Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of twelve (12), which indicated the resident was assessed to be cognitively intact and interviewable. Continued review of the MDS revealed the resident was assessed to have an indwelling urinary catheter. Review of the Comprehensive Care Plan, dated 05/20/16, revealed Resident #3 was at risk for complications related to bladder incontinence and an indwelling urinary catheter. The stated goal was for the resident to have a reduced risk of complications due to the catheter through the next review date of 08/18/16. Specific interventions included the following: report changes in bladder status to the Physician; and monitor and report any symptoms of a Urinary Tract Infection [MEDICAL CONDITION], such as discolored urine, pain on urination, and [MEDICAL CONDITION] (low urine output). Telephone interview with Licensed Practical Nurse (LPN) #7, on 06/23/16 at 6:45 PM, regarding the catheter change for Resident #3 on 06/19/16, revealed she made a mistake and was terminated by the DON. She stated the resident told her he was wet and a towel underneath the resident was soaked, and there was no urine in the bag. LPN #7 further stated the drainage bag was hazy and discolored and needed to be changed. The nurse acknowledged she did not notify the Physician of the condition change related to Resident #3's catheter and urinary status, as directed by the Care Plan, and did not obtain any orders because she knew he would okay it. Interview with LPN #3, on 06/23/16 at 11:20 AM, revealed the nurse should follow the Care Plan related to urinary catheters, and notify the Physician if symptoms indicated a problem, and obtain an order before proceeding to other interventions. Review of hospital records revealed Resident #3 was admitted on [DATE] with [DIAGNOSES REDACTED].#3 had remarkably infected urine and a Urology consult was ordered to address the resident's hematuria (blood in the urine). Review of the Urology consult note, dated 06/21/16, revealed the physician specialist documented the presence of gross hematuria, likely secondary to multiple traumatic attempts at catheterization at the facility. Continued review revealed the presence of a UTI, low urine output and acute renal (kidney) failure. Post-Survey Interview by phone with the Physician for Resident #3, on 06/29/16 at 11:15 AM, revealed he would have expected to be notified, (as directed by the Care Plan), when the resident developed problems associated with his catheter. He stated if he had been made aware of the leaking, bleeding, low urine output and difficulty flushing and changing the catheter, he would have cultured the resident's urine, verified placement and taken precautions to monitor the resident for further complications. 2. Review of the medical record revealed the facility admitted Resident #1 on 09/05/12 with [DIAGNOSES REDACTED]. Review of the Annual MDS Assessment, dated 04/06/16, revealed the facility assessed Resident #1 to have a BIMS score of (0), which indicated the resident was severely cognitively impaired. Continued review of the MDS revealed Resident #1 required extensive physical assistance of two persons for transfers. Review of the comprehensive Care Plan, dated 04/19/16, revealed Resident #1 was at risk for complications related to a self-care deficit. Continued review revealed interventions included staff assist of two (2) for transfers. Review of the care directives utilized by the SRNAs, for June 2016, revealed Resident #1 required the assistance of two (2) staff when transferring. Review of the Nurses Notes, dated 06/09/16 at 5:54 AM, revealed Resident #1 complained of left arm pain, and had a bruise on the left shoulder. Continued review revealed a portable x-ray was obtained, which showed a [MEDICAL CONDITION] humerus (upper arm). Review of the hospital radiology report, dated 06/09/16, revealed Resident #1 sustained a proximal left humerus fracture. Record review of the documented interview between the facility's Assistant DON (ADON) and SRNA #1, dated 06/09/16, revealed SRNA #1 acknowledged she had provided care to Resident #1 during her 3:00 PM to 11:00 PM shift on 06/08/16. Further review revealed the SRNA also acknowledged she transferred Resident #1 without other staff assistance on two (2) occasions during the 06/08/16 shift. The SRNA described the transfer as standing in front of the resident, wrapping her arms around the resident, grabbing the back of the the resident's pants, and lifting and pivoting the resident. Continued review revealed SRNA #1 did not ask other staff for assistance. Telephone interview with SRNA #1, on 06/23/16 at 3:11 PM, revealed she was assigned to care for Resident #1 on 06/08/16. She acknowledged she transferred the resident by herself, and without the use of a gait belt. She further stated the other SRNA was at lunch, so she just picked the resident up by the back of her pants and moved her, from the bed to the chair, and from the chair to the bed. Interview with the DON, on 06/24/16 at 2:45 PM, revealed SRNA #1 did not transfer Resident #1 appropriately when she did not obtain assistance. She stated the Care Plan was not followed regarding the directive to transfer with the assist of two (2) staff. The DON further stated the SRNA reported she thought she could do it by herself because the resident was little. Interview with the Administrator, on 06/24/16 at 3:30 PM, revealed once the Care Plan is developed by the Interdisciplinary Team, he expected staff to follow it. Regarding Resident #1, the Administrator stated the stakeholder transferred the resident improperly. Further interview revealed the SRNA did a return demonstration of that transfer and it was improper. The Administrator additionally stated the x-ray ruled out the resident's fracture was caused from impact because it was a [MEDICATION NAME] fracture, so it must have occurred during the transfer. Continued interview revealed the Administrator expected the nursing staff to follow the Care Plan for each resident, to ensure all needs were met.

Based on observation, interview, record review, review of the facility's policy and the Resident Assessment Instrument (RAI) Manual, it was determined the facility failed to ensure an indwelling urinary catheter was not used unless there was valid medical justification. In addition, the facility failed to ensure services were provided to prevent Urinary Tract Infections (UTIs), and restore or improve normal bladder function to the extent possible, for one (1) of seven (7) sampled residents (Resident #3). On 05/11/16, Resident #3 was admitted to the facility with an indwelling urinary catheter without a supportive medical [DIAGNOSES REDACTED].#3's catheter. Furthermore, there was no evidence of re-assessment or bladder training in an attempt to restore or improve normal bladder function. On 06/19/16, Resident #3 developed complications related to the catheter which were exacerbated by the nurse's improper management and failure to notify the Physician. Resident #3 experienced pain, bleeding, and decreased urine output, which required admittance to the hospital, with gross hematuria (large amount of blood in the urine), UTI and Acute Kidney Failure. (Refer also to F157, F281, F282, F441, and F514) The findings include: The facility provided no written policy related to assessment and management of residents admitted to the facility with an indwelling urinary catheter. Interview with the Director of Nursing (DON), on 06/24/16 at 2:45 PM, revealed the facility uses the Resident Assessment Instrument (RAI) Manual to assess residents who are admitted to the facility with an indwelling urinary catheter. Review of the RAI Manual, Version 3.0, revealed indwelling catheters should not be used unless there is valid medical justification. Assessment should include consideration of the risk and benefits of the catheter, the anticipated duration of use, and consideration of complications, which can include an increased risk of UTI, blockage of the catheter, pain and bleeding. Review of the facility's Policy titled Bladder Retraining & Toileting, dated 09/17/2015, revealed guidelines included the following: assess the resident to determine if the resident is capable of retraining and will cooperate with retraining; fill out the retraining document; and include the retraining on the Care Plan. Review of the medical record revealed the facility admitted Resident #3 on 05/11/16 with [DIAGNOSES REDACTED]. Review of the nursing Admission Assessment revealed Resident #3 had an indwelling urinary catheter connected to a bedside drainage bag on admission; however, the section titled Indwelling Catheter Evaluation was not completed by the nurse. Continued medical record review revealed no documented medical justification for the urinary catheter, and no documented bladder retraining assessment completed according to facility policy. Review of the Admission Minimum Data Set (MDS) Assessment, dated 05/18/16, revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of twelve (12), which indicated the resident was assessed to be cognitively intact and interviewable. Continued review of the MDS revealed the resident was assessed to have an indwelling catheter; however, there was no documented evidence of a supporting medical diagnosis. Review of the physician's orders [REDACTED]. Telephone interview with Resident #3's ex-wife, on 06/23/16 at 5:20 PM, revealed the resident came to the facility from the hospital with the urinary catheter in place. She stated the catheter was placed at the hospital because the resident was too weak to stand up to urinate, and no one ever took the catheter out. Review of the Comprehensive Care Plan, dated 05/20/16, revealed Resident #3 was at risk for complications related to bladder elimination and presence of an indwelling urinary catheter. The care plan goal stated the resident would have reduced risk of complications from the catheter through the next review date. Approaches included to monitor and report any changes in bladder status. Continued review of the Care Plan revealed no individualized interventions related to a medical justification for the catheter, no interventions for determining if the underlying reason for the catheter could be reversed, and no plan for bladder retraining and possible removal of the catheter. Telephone interview with Licensed Practical Nurse (LPN) #5, on 06/24/16 at 2:15 PM, revealed the process for determining if a urinary catheter was medically necessary was to read the resident's History and Physical to see why the catheter was placed. She stated there were various reasons for a catheter, e.g. wounds, [MEDICAL CONDITION] and immobility, but she could not provide the medical justification for Resident #3's catheter. Interview with LPN #2, on 06/24/16 at 2:00 PM, revealed she and LPN #5 had completed the admission process and paperwork for Resident #3. She stated the admitting nurse should take report from the hospital, and ask questions regarding the catheter, e.g. what size it was, when and why it was placed. She further stated the information should be documented. Continued interview revealed the facility had a protocol for bladder retraining, but Resident #3 did not have an order for [REDACTED].>Further interview with the DON, on 06/24/16 at 2:45 PM, revealed a resident admitted with an indwelling catheter was assessed and care planned with interventions for maintaining the catheter, or the catheter was discontinued if there was not a [DIAGNOSES REDACTED]. The DON stated the IDT looked for supporting [DIAGNOSES REDACTED]. If the Physician did not provide a diagnosis, the facility followed their protocol for bladder retraining. Further interview revealed Resident #3 should have been re-assessed for a medical reason to continue the catheter. She acknowledged there was no documented evidence the resident was re-assessed since admission. Regarding the nursing Admission Assessment, the DON stated it was the responsibility of the admitting nurse to ensure the Indwelling Catheter Evaluation section was completed and documented. She stated the evaluation should identify exclusions; if there were no exclusions, the resident should be re-assessed for discontinuing the catheter. Post-survey telephone interview with the MDS nurse, on 06/28/16 at 11:40 AM, revealed residents admitted with an indwelling urinary catheter were evaluated by the IDT to identify the medical justification for the catheter. She explained if there was not an appropriate diagnosis, the doctor was notified to ensure the catheter was medically necessary. She stated our doctor (Resident #3's doctor) would not write a [DIAGNOSES REDACTED]. Continued interview revealed the IDT followed up for re-evaluations of the need for a catheter, and stated there was not a specific timeframe for follow-up because every resident was different. The MDS nurse responded, No, an inability to urinate unless standing up was not a qualifying [DIAGNOSES REDACTED]. Post-survey telephone interview by phone with the Staff Development Coordinator (SDC), on 07/01/16 at 1:00 PM, revealed she was not an official part of the IDT. She stated her responsibilities were predominantly related to staff orientation and training, and she had little involvement in the resident admission evaluation process. She further stated she was aware an indwelling catheter required a medical diagnosis, and the IDT had to take further steps if there was not a qualifying reason for the catheter, but she could not say what the exact process was. Interview with SRNA #8, on 06/24/16 at 11:30 AM, revealed on 06/19/16 at approximately 1:00 PM, Resident #3 reported his/her catheter was leaking. The SRNA informed LPN #7, who gathered supplies and entered the resident's room. When SRNA #8 returned to the room, he observed LPN #7 had taken the old catheter out and was having a difficult time inserting a new one. He stated when the nurse tried to put the new catheter in, the resident cried out, Stop! Stop! and began bleeding. The nurse stopped, obtained another catheter and inserted it. Resident #3 started crying and told the nurse to take it out because he/she couldn't stand it. SRNA #8 stated, LPN #7 removed the new catheter and handed the original catheter to the SRNA and directed him to rinse it off in the bathroom. The nurse reinserted the used catheter and secured it, and left the resident's room. Telephone interview with Licensed Practical Nurse (LPN) #7, on 06/23/16 at 6:45 PM, revealed Resident #3 reported being wet. She stated a towel underneath the resident was soaked, and there was no urine in the drainage bag. LPN #7 further stated the drainage bag was hazy and discolored and the catheter needed to be changed. The nurse acknowledged she did not notify the Physician of the condition change related to Resident #3's catheter leaking, and did not notify the Physician when the resident had bleeding associated with repeated attempts by the nurse to flush the catheter, and change the catheter. Post-Survey telephone interview with Resident #3's Physician, on 06/28/16 at 11:15 AM, revealed if a resident was admitted to the facility with an indwelling catheter, he would rely on the Discharge Summary from the prior facility to determine the medical justification for continuing the catheter. He stated the resident should be care planned based on the diagnosis, and re-assessment determined if bladder training was possible. Continued interview revealed he would have expected the nurses to notify him of changes in the resident's urinary status, including leaking, obstruction, decreased urinary output, or the need for irrigation or replacement of the catheter. Furthermore, he would have expected to be immediately notified of a traumatic catheter insertion, such as occurred with Resident #3. The Physician stated he would have cultured the urine, verified placement and initiated precautions to monitor the resident for complications. Further interview revealed the Physician was not notified of any catheter problems for Resident #3 until the resident was on the way out of the facility to the hospital. Review of the hospital History and Physical, signed by the admitting Physician and dated 06/20/16, revealed a [DIAGNOSES REDACTED]. Review of the Urology consult note, dated 06/21/16, revealed the Physician specialist documented the presence of gross hematuria, likely secondary to multiple traumatic attempts at catheterization at the facility. Continued review revealed the presence of a UTI, low urine output and acute renal (kidney) failure. Interview with the Administrator, on 06/24/16 at 3:30 PM, revealed he expected nursing staff to follow facility policy and adhere to accepted standards of practice as it related to residents with indwelling urinary catheters.

Based on interview, record review, review of the facility's policy and review of the Centers for Disease Control (CDC) Guidelines, it was determined the facility failed to ensure safe and sanitary practices to prevent the development and transmission of disease and infection for one (1) of seven (7) sampled residents (Resident #3). Licensed Practical Nurse (LPN) #7 did not follow professional nursing standards on 06/19/16 when Resident #3 had a change in bladder status and leakage of urine from around the indwelling urinary catheter. After attempting to irrigate the catheter with no success, LPN #7 removed the existing urinary catheter, and attempted to insert another, larger catheter. When that failed, the nurse instructed the State Registered Nurse Assistant (SRNA) to wash the old catheter, and the nurse re-inserted the un-sterile, used catheter into the resident's bladder. Later that night, and into the morning of 06/20/16, the resident's ex-wife, who visited the resident often, noticed a decline in the resident and expressed her concerns to the nurses on duty. On 06/20/16, at the insistence of the ex-wife, Resident #3 was sent to the hospital. Review of the hospital emergency room (ER) record revealed the resident had minimal or no urine output since the urinary catheter was changed the day before, and lab results revealed a severe urinary tract infection (UTI). Resident #3 was diagnosed in sepsis and septic shock, which is a serious medical condition where organs are injured or damaged in response to infection. The primary infection is most commonly caused by bacteria, and can be located in any part of the body, but most commonly in the lungs, brain, urinary tract or abdominal organs. It can cause multiple organ failure and death. Resident #3 experienced a rapid decline in the ER which resulted in not being able to breathe on independently. Resident #1 was intubated, (which means a tube was placed down the throat into the lungs) and was put on a mechanical ventilator machine. According to the Urology Consult report, Resident #3 had gross hematuria, which is a large amount of blood in the urine. The report stated this was mostly likely caused by multiple, traumatic catheterizations, which was followed by low urine output, difficulty breathing and sepsis. (Refer also to F157, F281, F282, F315, and F514) The findings include: Review of the facility's policy titled Catheterization Policy, undated, revealed steps which included Open the sterile catheterization tray and establish a sterile field, and Open the catheter of proper diameter and balloon size and drop it on the sterile field. The facility did not provide a policy for Infection Control. The facility provided a sheet of paper with the statement Infection Control Program. Signature Healthcare of Georgetown follows CDC Guidelines and Heaton manual for Infection Control Policies and Procedures. Review of the CDC Guideline recommendations regarding catheter changes revealed only properly trained persons who knew the correct technique of aseptic, or sterile method, of catheter insertion were given the responsibility to perform catheterizations. Continued review revealed sterile technique and equipment was necessary to prevent harmful organisms from entering the body and causing infection. Review of Resident #3's medical record revealed the resident was admitted by the facility on 05/11/16, with [DIAGNOSES REDACTED]. Review of the nursing admission assessment revealed the resident had an indwelling urinary catheter connected to a bedside drainage bag. Review of Resident #3's Admission Minimum Data Set (MDS) Assessment, dated 05/18/16, revealed Resident #13 was assessed to have a Brief Interview for Mental Status (BIMS) score of twelve (12), which indicated the resident was cognitively intact and interviewable. Continued review of the MDS revealed the resident was assessed to have an indwelling catheter, but no documented medical [DIAGNOSES REDACTED]. Review of the Transfer Form, dated 06/20/16 at 10:00 AM, revealed the nurse noted Resident #3 had had no urine output for twelve (12) hours, and exhibited a decreased level of consciousness and generalized weakness. Review of the hospital History and Physical, signed by the admitting Physician and dated 06/20/16, revealed in the ED, Resident #3 was moderately distressed with increased respiratory effort. The resident required intubation and mechanical ventilation, and was transferred to the Intensive Care Unit (ICU), where Resident #3 continued with low urine output that was very bloody in nature. Continued review revealed a [DIAGNOSES REDACTED]. Review of the Urology consult note, dated 06/21/16, revealed the Physician specialist documented the presence of gross hematuria, likely secondary to multiple traumatic attempts at catheterization at the facility. Continued review revealed the presence of a UTI, low urine output and acute renal (kidney) failure. Interview with State Registered Nurse Assistant (SRNA) #8, on 06/24/16 at 11:30 AM, regarding the catheter change Licensed Practical Nurse (LPN) #7 performed for Resident #3 on 06/19/16, revealed the resident had urine leakage from around the catheter. LPN #7 removed the existing catheter, attempted to replace it with a bigger catheter and was unsuccessful, had the SRNA wash off the used catheter in the bathroom. The nurse then reinserted the used, un-sterile catheter into the resident's bladder and connected to the bedside drainage bag. Interview by phone with Registered Nurse (RN) #1, on 06/24/16 at 12:30 PM, regarding Resident #3's catheter change revealed on 06/19/16, the evening shift nurse/LPN #6 said in shift report, that LPN #7 tried to change the catheter, but ended up putting the same catheter back in. She stated LPN #7 said she cleaned the used catheter before she put it back in. RN #1 further stated, I wondered how she did it, because we don't have an autoclave (sterilizing machine). Interview with the Director of Nursing (DON), on 06/24/16 at 2:45 PM, revealed the facility followed the CDC Guidelines for infection control and frequency of changing catheters. The DON stated she expected nurses to follow Professional Standards and facility policy, and nurses should never re-use a catheter. Interview with the Administrator, on 06/24/16 at 3:30 PM, revealed he expected the nurses to follow Professional Standards and absolutely not re-use a catheter that had been removed. A post-exit interview by phone with Resident #3's Physician, on 06/28/16 at 11:15 AM, revealed he would have expected the nurses to notify him of any changes in resident's urinary status, which would have included leakage, obstruction, decreased urinary output and need for irrigation or catheter change orders. Continued interview revealed the physician would have expected to be notified immediately of an improper catheter insertion, such as occurred with Resident #3. The physician stated, he would have cultured the urine, verified placement and took precautions to monitor the resident for complications. He stated the nurse re-inserting a catheter that had been in the trash is bizarre behavior, and shows the nurse was negligent in her thought processes. He stated you should never re-use needles or catheters.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure two (2) of four (4) sampled residents, (Resident's #1 and #4) received adequate supervision to prevent falls. The facility failed to follow their Resident Alarm and Incident Reporting Policy/Protocol related to maintaining assistive devices in working order to allow for adequate supervision. The facility failed to ensure care plan interventions were implemented to prevent falls. Furthermore, the facility failed to ensure their investigations of falls identified all causal factors in order to ensure appropriate interventions would be implemented. The facility assessed Resident #1 as being at risk for falls, requiring assistance with ambulation and the use of bed/chair alarms to alert staff when the resident attempted to rise unassisted. On 04/28/11, Resident #1 ambulated independently without staff knowledge or assistance at which time he/she fell in the bathroom and sustained a left hip fracture. Three (3) facility staff heard no alarm sounding and the monthly alarm checks noted on the Treatment Administration Record (TAR) had not been signed five (5) months indicating the alarm had been checked for . Resident #4's monthly alarm check had not been completed for one (1) month. The findings include: Review of the facility's policy titled "Incident Reporting", dated 12/10, revealed the facility shall ensure that the resident's environment shall remain as free of accident hazards as possible, and that each resident shall receive adequate supervision and assistive devices that shall reduce accidents. The procedure included the Charge Nurse/designee will add interventions to the care plan as needed. Review of the facility's policy titled "Resident Alarms", dated 12/10, revealed resident alarms may be used for residents as a non-restraining device that alerts staff to a resident rising from a bed or chair without assistance. The procedure included identifying residents at risk for falls, those who would benefit from the use of an alarm device, and checking the battery for strength or need of changing. Review of the TAR revealed the facility had a system to document monthly that alarms had been checked regarding functionality of the device and strength of the battery. Interview with Licensed Practical Nurse (LPN) #2, on 07/26/11 at 2:50 PM, revealed LPN #1 normally checked the alarms. Interview with LPN #4, on 07/26/11 at 3:00 PM, revealed the Charge Nurses were responsible for checking the alarms for functioning but all nursing staff checked them. 1. Review of the medical record revealed the facility admitted Resident #1 on 11/19/09 with [DIAGNOSES REDACTED]. Review of the Annual Resident Assessment Instrument (RAI), dated 10/28/10, revealed the facility assessed the resident as having severely impaired cognition, wandering behaviors which occurred four (4) to six (6) days a week and would intrude on others. The resident also required setup help, one (1) person assist with transfers, and was continent of bowel and bladder. Review of the resident's Comprehensive Plan of Care revealed the facility had determined Resident #1 was at risk for falls and on 11/11/10 developed Care Plan interventions to address injuries from falls related to the resident's weakness and lack of safety awareness. The interventions included the facility were to provide the resident with a sensor pad alarm to the bed to alert staff of the resident's attempts to transfer without assistance, staff were to assist with locomotion as needed, staff were to monitor use of adaptive devices and offer cues as needed. Interview with the Certified Medication Technician (CMT), on 07/20/11 at 2:30 PM, revealed the resident would often get up and attempt to go to the bathroom on his/her own. Interview with State Registered Nursing Assistant (SRNA) #4, on 07/20/11 at 2:55 PM, the reason the resident had the alarm was because he/she would attempt to transfer independently. Interview on with the Rehab Services Manager, on 07/25/11 at 2:17 PM, revealed sometimes Resident #1 would try to ambulate on his/her own. Interview with SRNA #3, on 07/26/11 at 10:02 AM, revealed Resident #1 would try to ambulate on his/her own and that was why the resident had alarms on his/her bed and chair so staff could be aware when he/she was trying to ambulate. Review of Resident #1's TARs revealed there was no documented evidence the facility had checked/changed the resident's alarm device batteries during the months of January 2011, February 2011, March 2011 and April 2011, as per the facility's policy. Review of the Nursing note, dated 04/28/11 at 10:40 AM, revealed Resident #1 was found on the floor lying on his/her back with complaints of left hip pain. Interview with the CMT, on 07/20/11 at 2:30 PM, revealed the resident had said he/she had gotten up from using the commode, was going back to bed and then fell . Interview with SRNA #4, on 07/20/11 at 2:55 PM, revealed she was passing ice and heard a resident call out, she entered the room and found Resident #1 lying on the bathroom floor. She further indicated she did not recall Resident #1's pressure alarm sounding when she entered the room. Interview with SRNA #6, on 07/21/11 at 2:30 PM, revealed she had been assigned to care for Resident #1 on 04/28/11. She stated she noticed people going in and out of the resident's room saying he/she had fallen. She stated she had not heard the alarm sounding. Review of staff statements taken after the incident revealed LPN #3 stated the alarm was not sounding when she entered the resident's room. Further record review revealed a Hospital Discharge Summary, dated 05/02/11, revealed Resident #1 was admitted to the hospital on [DATE] with the [DIAGNOSES REDACTED]. Review of the TAR dated May 2011 revealed the facility had no documented evidence that staff had checked/changed the battery for the alarm device. Review of the resident's RAI, dated 05/22/11, revealed the resident was assessed as having wandering behaviors which occurred daily, and was assessed as needing extensive assistance with transfers and one (1) person total assistance with toileting. Interviews with the Social Services Director on 07/20/11 at 1:06 PM, Previous DON on 07/26/11 at 1:40 PM and with the Administrator on 07/25/11 at 3:30 PM revealed the facility's incident investigation had identified the only causal factor of the fall was due to a sticky substance on the floor keeping the resident from moving his/her feet. There was no evidence that the facility had identified that staff had not assisted the resident to the bathroom, that the bed alarm was not sounding, and that the facility staff had not been checking the battery strength monthly for four (4) months prior to the incident or for the month following the incident. Interview with the previous Administrator, on 07/26/11 at 11:05 AM, and the previous DON at 1:40 PM, revealed he didn't know whether the resident's alarm had been checked and she had no recollection of whether the alarm was sounding at the time of the fall. Furthermore there was no evidence the facility had established any new interventions after the residents fall on 04/28/11. 2. Review of Resident #4's medical record revealed the facility admitted the resident on 06/17/10 with [DIAGNOSES REDACTED]. Review of the resident's Comprehensive Plan of Care, dated 03/17/11, revealed the facility was to provide a sensor pad alarm to the resident's bed to alert staff of the resident's attempts to transfer without assistance, which was put into place on 12/04/10. Review of Resident #4's TAR's revealed no evidence the resident's alarm batteries had been checked/changed during the month of May 2011. Interview with LPN #1, on 07/26/11 at 9:50 AM, revealed she had identified the problem of the resident's TARs not being signed off on in relationship to the alarm batteries in the month of March 2011 and had begun a tracking tool in March, which meant she evaluated a percentage of the residents' chart, ten (10) percent, to determine if the documentation was being completed on the residents' TARs; however, there was no evidence that the tracking tool had corrected the problem for Residents #1 and #4.