Every finding on record at Telford Terrace

Based on observation, interview, review of facility recipes, and review of facility Policy, the facility failed to ensure food was prepared by methods that conserve nutritive value, flavor and appearance for pureed foods. Observation during lunch tray line, on 02/22/2023, during preparation of the lunch puree meal revealed the CDM used hot water to puree the macaroni and cheese and hot water to blend the barbecue chicken. However, review of the facility Puree Mac [Macaroni]-Cheese recipe, revealed directions to blend with milk and some of the juice from the Mac-Cheese. Additionally, review of the facility Puree BBQ [Barbecue] Chicken recipe, revealed directions to blend with BBQ sauce or chicken broth. The findings include: Review of the facility Policy titled, Food: Quality and Palatability, revised 09/2017, revealed, Food will be prepared by methods that conserve nutritive value, flavor and appearance. Food will be palatable, attractive and served at a safe and appetizing temperature. Food and liquids are prepared and served in a manner, form, and texture to meet resident's needs. Review of the facility's Diet Master, printed 02/21/2023, revealed two (2) residents received a pureed diet. Interview with the Certified Dietary Manager (CDM), on 02/21/2023 at 11:08 AM, revealed the facility had two (2) residents who received a pureed diet texture. Interview with Resident #8's family member, on 02/21/2023 at 2:11 PM, revealed the resident's diet had just been upgraded from a pureed textured diet. Per interview, the pureed foods had no flavor, and Resident #8 nodded his/her head in agreement. Review of the facility's planned menu indicated the puree lunch meal for 02/22/2023 consisted of puree barbecue chicken, puree oven fried fish, puree baked macaroni and cheese, puree rice with gravy, puree beets, puree fruit, puree bread and lemon pudding. Review of the Puree Mac [Macaroni]-Cheese recipe, undated, revealed blend with milk and some of the juice from the Mac-Cheese. If thin, add thickener to a smooth puree. Review of the Puree BBQ [Barbecue] Chicken recipe, undated, revealed, blend with BBQ sauce or chicken broth until smooth If thin add thickener to a smooth puree. During an observation of the preparation of the lunch puree meal, on 02/22/2023 at 11:46 AM, the CDM used hot water to blend the barbecue chicken until smooth and used cooking water to puree the beets until the beets were smooth and consistent. Further observation revealed the CDM used hot water from the coffee pot to puree the macaroni and cheese until the macaroni and cheese was smooth and consistent. Additional observation revealed the CDM used hot water to puree the bread. Interview with the CDM during the observations revealed she used hot water to puree meats and the vegetable cooking water to puree vegetables. Interview with Cook #14, on 02/22/2023 at 11:55 AM, revealed he had worked at the facility for four (4) months. Cook #14 stated he used hot water to puree meats and added thickener to get the food item to the proper consistency. According to Cook #14, broth could be used to puree meats and he would have used barbecue sauce to puree barbecue chicken, instead of hot water. Cook #14 stated, adding only water to puree foods could affect the flavor of the food served. During observation of the lunch tray line on 02/22/2023 at 12:22 PM, revealed Cook #14 commented the color of puree food items served up on the plates was bland. During observation of the lunch tray line with the CDM, on 02/22/2023 at 12:41 PM, the CDM revealed she could not identify the barbecue chicken among the puree food items. Observation on 02/22/2023 at 12:57 PM, revealed the test tray was retrieved from the delivery cart and sampled in the conference room. The puree macaroni and cheese was thick and pasty, without the taste of cheese or seasoning. Further, the puree barbecue chicken was flavorless and bland, without the taste of barbecue sauce or seasoning of any kind. During a follow-up interview with the CDM, on 02/22/2023 at 3:18 PM, CDM stated she used a barbecue sauce liquid and hot water mixture to puree the chicken and used only hot water for the macaroni and cheese during the lunch meal service on 02/22/2023. The CDM further stated milk could have been used in place of hot water for the macaroni and cheese to add more flavor. Per the CDM, she usually tasted the pureed foods before meal service, but did not taste the pureed food at lunch on 02/22/2023. Interview with the Registered Dietitian (RD), on 02/23/2023 at 10:44 AM, revealed puree foods should be blended with natural juices, gravies, broths, or cream sauces to preserve the flavor and nutritive value of texturized foods. Interview was conducted with the Assistant Director of Nursing (ADON), Director of Nursing (DON), and the Administrator, on 02/24/2023 at 11:29 AM. The DON stated pureed diet foods should taste the same or similar to regular food items. Additionally, the DON stated water should not be used to blend puree food items, but broth, soup, gravy, or sauce should be used to enhance the flavor of the foods. The ADON and the Administrator were in agreement with the DON's comments. Further, the DON stated the RD was in the facility weekly and would sample the food and provide feedback to the CDM.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (2) of eighteen (18) sampled residents (Residents #217 and #218). Observation, on 01/12/2022 at 10:45 AM, revealed Certified Nurse Aide (CNA) #1 walked out of room [ROOM NUMBER], where Resident #218 had been moved, after testing positive for COVID, and walked up the hallway. CNA #1 was observed to be wearing the contaminated full personal protective equipment (PPE) of gown, mask, eye protection, and shoe covers that had been worn while in room [ROOM NUMBER]. Continued observation revealed CNA #1 walked up the hallway and touched the community linen cart with a contaminated gloved hand. Additionally, CNA #1 was observed to wear the contaminated shoe covers from room [ROOM NUMBER] up the hallway and into the community nourishment room. Additional observations, on 01/11/2022 and 01/12/2022, revealed Licensed Practical Nurse (LPN) #1, while performing pre-meal blood glucose tests, either failed to wash her hands before donning gloves to conduct the testing, and/or failed to allow the glucometer to air dry after disinfection, as required before storage. Additional observations, on 01/11/2022, revealed CNA #3 and Kentucky Medication Aide (KMA) #2 failed to don (put on) appropriate PPE when giving care to Resident #217, who was on transmission based precautions (TBP) related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The facility's failure to maintain an infection prevention and control program to prevent unnecessarily exposing residents to COVID-19 has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) was identified, on 01/12/2022, and was determined to exist on 01/12/2022, at 42 CFR 483.80 Infection Prevention and Control (F-880) at a Scope and Severity (S/S) of a J. The facility was notified of the Immediate Jeopardy on 01/12/2022. The facility provided an acceptable Immediate Jeopardy Removal Plan, on 01/14/2022, alleging removal of the IJ on 01/15/2022. The State Survey Agency determined the IJ had been removed on 01/15/2022, as alleged, prior to exit on 01/15/2022. The findings include: Review of the facility's policy titled, Policy and Procedure COVID-19, undated, revealed the facility would follow the current Centers for Disease Prevention and Control (CDC) guidelines for the evaluation, prevention, and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review revealed if a resident had a positive COVID-19 test or signs and symptoms of a respiratory [CONDITION(S)] infection, standard, contact and droplet precautions were to be maintained. Additional review revealed the facility would ensure all its staff were educated on hand hygiene and appropriate donning and doffing (putting on and taking off) of PPE. Review of the facility's Infection Prevention and Control Assessment Tool, undated, revealed the facility had Environmental Protection Agency (EPA) registered, hospital-grade disinfectants with an emerging [CONDITION(S)] pathogens claim against SAR-CoV-2 (COVID-19) available for frequent cleaning of high-touch surfaces and shared resident care equipment. Continued review revealed the facility's practice was for staff to perform hand hygiene in the following situations: before resident contact, even if gloves were worn; after contact with the resident; after contact with blood, body fluids or contaminated surfaces or equipment; before performing an aseptic task; and after removing PPE. 1. Observation, on 01/12/2022 at 10:45 AM, revealed CNA #1 walking on the 100 Hallway after exiting room [ROOM NUMBER], where Resident #218, who had tested positive for COVID, resided. Per observation, CNA #1 was wearing the full PPE he/she had worn in Resident #218's room, which was contaminated. Observation revealed CNA #1 walked to the linen cart where the CNA touched the top right corner of the community linen cart with his/her contaminated gloves. Further observation revealed the Director of Nursing (DON), instructed CNA #1 to go back down the hallway to room [ROOM NUMBER], which was being used as the nurse's station for the COVID area of the facility, and remove the contaminated PPE. Continued observations on 01/12/2022 from 10:45 AM until 11:32 AM, revealed the door to room [ROOM NUMBER] remained open until 11:29 AM, with no protective barrier in place to prevent transmission of the COVID virus. Additional observation revealed the Housekeeping Director exited COVID positive room [ROOM NUMBER] which he had been assisting with cleaning (room [ROOM NUMBER] was where Resident #218, the COVID positive resident, resided prior to being moved to room [ROOM NUMBER]). Further observation revealed the Housekeeping Director obtained linen from the linen cart that CNA #1 had previously contaminated and walked toward the clean room. However, the Housekeeping Director was stopped by the State Survey Agency (SSA) Surveyor, prior to re-entering room [ROOM NUMBER], which had been cleaned. Interview with the Housekeeping Director, on 01/12/2022 at 11:32 AM, revealed he did not know the linen cart had been contaminated by CNA #1, as he was in room [ROOM NUMBER], assisting to clean that room. The Housekeeping Director stated if he had known the cart had been contaminated, he would have ensured the cart and linens on it were taken out of service and disinfected appropriately. Interview with CNA #1 on 01/12/2022 at 10:57 AM, revealed the CNA had exited Resident #218's room wearing contaminated PPE. Per the CNA, while wearing the contaminated PPE, which included gloves, he/she had touched the community linen cart contaminating it. Observation, on 01/12/2022 at 10:57 AM, revealed CNA #1 entered Resident #218's room, the COVID positive resident, and pulled the room curtain back without wearing the required gloves. Observation, on 01/12/2022, at 12:32 PM, revealed CNA #1 exited room [ROOM NUMBER] and walked up the 100 Hallway with contaminated shoe covers and face shield still in place. Continued observation revealed CNA #1 entered the community nourishment room wearing the contaminated shoe covers and face shield. The DON was notified of this information by the State Survey Agency (SSA) Surveyor performing the observation. Further observation revealed the DON immediately went to the nourishment room where CNA #1 was located. Interview, on 01/14/2022 at 1:40 PM, with CNA #1, via telephone, revealed on 01/12/2022, he/she had not realized he/she had come out of room [ROOM NUMBER], which was COVID positive, wearing contaminated PPE. Per the interview, CNA #1 stated he/she had not realized he/she touched the linen cart while wearing the contaminated PPE on that date. Further, the CNA stated he/she was unaware his/her contaminated shoe covers were still in place when he/she went to the nourishment room. The CNA stated staff had recently, in December 2021, received Infection Control education that covered everything from proper hand hygiene, donning/doffing PPE, to appropriate door signage for the type of isolation for the resident. Interview with the DON, on 01/12/2022 at 12:45 PM and 2:12 PM, revealed she had re-educated CNA #1 on the facility's infection control protocol, when she went into the community nourishment room where the CNA had been wearing contaminated PPE. The DON stated it never occurred to her, that instead of waiting on Maintenance to erect a barrier, the most immediate solution would have been to ensure Resident 218's door, remained closed. Additional interview with the DON, on 01/15/2022 at 5:55 PM, revealed it was her expectation that staff adhered to all components of the facility's infection control policy. The DON stated the facility's Infection Preventionist (IP) had quit on 01/13/2022. Further interview revealed, until 01/12/2022, there had not been a COVID positive resident in the facility since October 2021. Interview with the Administrator, on 01/15/2022 at 6:25 PM, revealed his involvement with infection control had been to direct all the facility's Department Heads to come together to create an after action plan regarding the errors that occurred during the establishment of the COVID Unit that week (01/12/2022) and to address what would be done to correct those errors. He stated it was his expectation all staff would follow the recommended guidelines for infection control and isolation. 2. Review of the facility's Advocate (brand) glucometer manufacturer's instructions, undated, revealed the meter was to be cleaned and disinfected before use. The review revealed a commercially available disinfectant towelette could be used on the device for sanitizing. Continued review revealed the meter was to be wiped down and allowed to air dry; after air-drying the disinfection process for the meter was to be followed. Further review revealed the disinfection steps included to: discard the used disinfectant towelette; and obtain a new disinfectant wipe to wipe down the body of the meter enough to thoroughly wet the surface. Further review revealed the disinfection process included continuing to wipe the meter six (6) times, three (3) passes horizontally and three (3) passes vertically, and allow the devices to remain wet for a 2 minute-contact time. Additionally, the review revealed the used disinfectant wipe was to be discarded in the trash, and the user was to wash their hands thoroughly with soap and water after handling the meter. Review of the Professional Disposables International (PDI) Sani-Hands wipes use and directions, revealed it was intended for handwashing to decrease bacteria on the skin. Further review revealed the wipe was for a single use and was to be removed from the packet, used once, and then discarded in a trash receptacle. Review of the Super Sani-Cloth germicidal disposable wipe directions revealed each wipe was to be used as directed and discarded after a single use. Continued review of the wipe directions revealed the wipes were to be used for disinfecting non-food contact surfaces only. Further review revealed the user was to unfold a clean wipe to thoroughly wet the non-food contact surface, allow the treated surface to remain wet for a full two (2) minutes, and then allow the treated surface to air dry. Observation, on 01/11/2022 at 11:46 AM, of Licensed Practical Nurse (LPN) #1, while performing a pre-meal blood glucose test, revealed she failed to wash her hands before donning gloves to conduct the testing. Continued observation, after the test was done, revealed after removing her gloves and washing her hands, LPN #1 placed the glucometer on a barrier towel she laid on the medication cart. Observation revealed LPN #1 cleaned the glucometer with a PDI Sani-Hands 70% Alcohol towelette (sanitizing towelettes), wrapped the wipe around the glucometer, placed it on the barrier towel and wrapped the same barrier towel around the wipe covered glucometer. Interview, at the time of observation, revealed LPN #1 stated the facility's policy was to clean multi-use equipment with a sanitizing wipe, then leave the glucometer wrapped in the sanitizing towelette for 5-10 minutes before putting it away in the cart. Further observation revealed LPN#1 failed to allow the glucometer to air dry before storing. Observation, on 01/12/2022 at 8:25 AM, of LPN #1 after performing a pre-meal blood glucose testing prior to the morning meal, revealed she placed the glucometer on the barrier towel while she obtained a Sani Wipe from the container with which to clean the meter. Observation revealed the LPN cleansed the glucometer with the Sani Wipe, wrapped the meter in the same Sani Wipe and placed it on the same barrier towel. Continued observation revealed LPN #1 wrapped the barrier towel around the Sani Wipe, covered the glucometer and placed the meter on the cart. Further observation revealed LPN #1 left the meter on the medication cart to go administer the resident's scheduled insulin dose. Observation further revealed LPN #1 returned to the cart after approximately four (4) minutes, and removed the glucometer from the barrier towel and sanitizing wipe, disposed of those items and placed the glucometer in the medication cart drawer failing to allow the meter to air dry as required. Interview with the Director of Nursing (DON), on 01/12/2022 at 5:18 PM and, on 01/13/2022 at 12:02 PM, revealed Sani Cloth wipes were located on all the medication carts and were to be used by staff to clean multi-use equipment, such as glucometers or blood pressure cuffs. She stated the facility's policy was to disinfect the equipment by wiping it down and cleaning it well with a sani wipe. Continued interview revealed the equipment was to then be left sitting for two (2) minutes to dry before using it again. Per the DON, multi-use equipment, such as a blood pressure cuff should be sanitized with a sani wipe, allowed to air dry for ninety (90) seconds, then be placed in a case before it was stored away. Further interview revealed for glucometers staff should follow the process for sanitizing the meter, allow it to air dry, and place the meter in a case or bag before storing it in the medication cart. The DON revealed she was not sure how staff referenced the facility's policies regarding sanitizing multi-use equipment. She further stated she believed there was a policy book staff could use; however, she was not sure where it was stored. 3. Review of Resident #217's medical record revealed the facility admitted the resident, on 12/15/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review revealed Resident #217 was placed on transmission based precautions (TBP) on admission related to the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Interview with the Registered Nurse (RN) Infection Preventionist (IP), on 01/11/2022 at 8:45 AM, confirmed Resident #217, who resided in room [ROOM NUMBER], had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Observation, on 01/11/2022 at 9:30 AM, revealed Resident #217's room had a sign posted on the door to, See the nurse prior to entering the room. Continued observation revealed a three (3) drawer container, with various PPE stored in it, located next to the door of room [ROOM NUMBER]. Observation of CNA #3, on 01/11/2022 at 12:05 PM, revealed she entered Resident #217's room, who was on TBP, without donning gloves. Continued observation revealed she washed her hands, doffed her gown and rolled it inside out. She then washed her hands again. Continued observation of CNA #3, on 01/12/2022 at 8:30 AM, revealed she took the breakfast tray into Resident #217's room. CNA #3 did not don any type of PPE before entering the room. Interview with CNA #3, on 01/11/2022 at 12:08 PM and, on 01/12/2022 at 8:32 AM, revealed she was not wearing gloves and was just trying to assist with giving water to the resident. However, she stated she should have donned gloves because she touched a wash cloth to take to the soiled linen. CNA #3 stated she was told Resident #217 was removed from TBP precautions, and it was okay to just take the tray in and leave the tray without donning or doffing any PPE. She further explained she just asked the nurse what the needed precautions were, per the sign posted on the door. Observation of Kentucky Medication Aide (KMA) #2, on 01/11/2022 at 12:30 PM, during medication administration on the 100 Hall revealed KMA #2 entered TBP Resident #217's room to give medications and did not don gloves. Interview with KMA #2, on 01/11/2022 at 12:32 PM, revealed she should have worn gloves to give medication. She stated KMA's just ask the nurse about the required PPE for that room/patient. Interview with the DON, on 01/12/2022 at 12:09 PM, on 01/13/2022 at 12:03 PM, and on 01/15/2022 at 6:02 PM, revealed Resident #217 should remain in TBP until the Medical Doctor cleared it and provided an order to do so. She stated the CNA and KMA should have donned PPE including a gown, mask, gloves, face shield or goggles while taking in the breakfast tray and to administer medication. The DON revealed her expectation was for staff to don PPE prior to entering the TBP room along with a proper sign on the door to explain PPE precautions and how to don/doff PPE. Interview with the Administrator, on 01/15/2022 at 6:04 PM, revealed his expectation was that staff would follow the recommended guidelines for infection control related to TBP and COVID precautions. The facility provided an acceptable Immediate Jeopardy Removal Plan, on 01/14/2022, that alleged removal of the Immediate Jeopardy (IJ) on 01/15/2022. The facility implemented the following: 1. On 01/12/2022 at 9:00 AM, Resident #218 was determined to have a positive COVID test. Residents in room [ROOM NUMBER] were moved to other rooms and Resident #218 was moved into room [ROOM NUMBER]. Per interview with the DON, room [ROOM NUMBER] was chosen because it was at the end of the hall and near the exit door that could be used for entry/exit by staff. 2. Staff, including agency personnel, were re-educated by nurse management on appropriate usage of PPE to include gloves, gown, eye protection, and face masks. This included return demonstration to ensure understanding. Education was conducted, on 01/12/2022 through 01/14/2022. 3. Staff, including agency personnel, were re-educated by nurse management on transmission based precautions (TBP) including signage, usage of PPE, proper handwashing, and donning and doffing of PPE. This included return demonstration to ensure understanding. Education was done, on 01/12/2022 through 01/14/2022. 4. Staff, including agency personnel, were re-educated by nurse management on proper handwashing performance with a questionnaire and quiz given and reviewed by nurse management to ensure understanding or need for further education. Education began on 01/12/2022. 5. Additional education was provided to staff including agency personnel, by nurse management for proper glove usage and proper donning/ doffing measures. Education began on 01/12/2022. The State Survey Agency validated the implementation of the facility's Immediate Jeopardy Removal Plan as follows: 1. Interview with the DON and the Administrator, on 01/15/2022 at 5:55 PM and 6:25 PM, respectively, revealed they identified that all residents had the potential to be affected by the deficiencies in infection control practices. Observation, on 01/12/2022, at 1:35 PM, revealed the facility created a dedicated COVID-19 Care Unit on the 100 Hall. The COVID-19 Care Unit was physically separated from other rooms by a temporary zippered barrier wall. In addition, the facility was staffing the unit with dedicated staff: one (1) RN or LPN, and one (1) CNA, who would not work on both the COVID-19 Care Unit and other units during the same shift. To the extent possible, there was restricted access of ancillary personnel (e.g., dietary) to the unit. Meals were handed through the plastic barrier. An environmental services (EVS) staff member would be dedicated to the COVID-19 Care Unit. All dedicated staff would enter through a clean area where staff doff PPE. Staff exited the facility through the back door. Observation and interview with LPN #1 and CNA #1, on 01/14/2022, at 1:40 PM, revealed they had been assigned as dedicated staff to the COVID-19 Care Unit. Both stated they received re-education on transmission based precautions (TBP) including signage, usage of PPE, proper handwashing performance, and donning and doffing of PPE. LPN #1 and CNA #1 stated they were required to demonstrate donning and doffing PPE and hand hygiene. Both stated they were educated to not leave the unit during their shift, except on breaks, in which they exited though the back stairwell. Both stated meals were passed through the zippered barrier. Observation revealed both LPN #1 and CNA #1 performed proper hand hygiene technique and were wearing the appropriate PPE. 2. Observation, interview, and record review revealed nursing management completed re-education of all scheduled staff on appropriate usage and storage of PPE to include gloves, gown, eye protection, and face masks. Further observation revealed training by nursing management, which included return demonstration from staff. Education occurred from 01/12/2022 through 01/14/2022. Record review revealed education sheets, sign-in logs, and the post-test were completed by staff during the day and evening shifts prior to being allowed to work to ensure understanding or the need for further education. 3. Interviews with CNA/KMA #2, CNA #3/Billing, CNA #4, CNA #5, CNA #6, CNA #7, CNA #8, CNA #9, Resident Assistant (RA) #1, RA #2, LPN #1, LPN #2, RN #1, RN #2 and RN #3, on 01/15/2022 between 10:58 AM and 3:08 PM, revealed they were re-educated by nurse management on transmission based precautions (TBP) including signage, usage of PPE, proper handwashing performance, and donning and doffing of PPE. Interviews were continued with Dietary Aides #1 and #2; Cook #1, and the Dietary Manager, on 01/15/2022 between 10:58 AM and 3:39 PM, which revealed they had also received infection control education for COVID and their department. Observations of training by nursing management, on 01/12/2022 through 01/14/2022, revealed they provided re-education and return demonstration of donning and doffing full PPE and hand hygiene. Record review revealed education sheets, sign-in logs, and posttests were completed by day and evening staff, and graded by nursing management, prior to being allowed to work to ensure understanding or the need for further education. 4. Interviews with CNA/KMA #2, CNA #3/Billing, CNA #4, CNA #5, CNA #6, CNA #7, CNA #8, CNA #9, Resident Assistant (RA) #1, RA #2, LPN #1, LPN #2, RN #1, RN #2 and RN #3, on 01/15/2022 between 10:58 AM and 3:08 PM, revealed they were re-educated by nurse management on proper handwashing performance with a questionnaire and quiz taken. Record review revealed education sheets, sign-in logs, and posttests were completed by day and evening staff, and graded by nursing management, prior to staff being allowed to work. Interview with the DON, on 01/14/2022 at 1:13 PM, revealed staff, including agency personnel, were re-educated by nurse management on proper handwashing performance, with questionnaire and quiz, and reviewed by nurse management to ensure understanding or the need for further education. 5. Interviews with CNA/KMA #2, CNA #3/Billing, CNA #4, CNA #5, CNA #6, CNA #7, CNA #8, CNA #9, Resident Assistant (RA) #1, RA #2, LPN #1, LPN #2, RN #1, RN #2 and RN #3, on 01/15/2022 between 10:58 AM and 3:08 PM revealed they were re-educated by nurse management on proper glove usage and proper donning/doffing measures. Record review revealed education sheets and sign-in logs were completed by staff during the day and evening shifts prior to being allowed to work. Interview with the DON, on 01/14/2022 at 1:13 PM, revealed staff that were off would be re-educated prior to his/her shift. No staff member would be allowed to work until all his/her re-education was completed.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to serve food in a safe manner. Observations, on 01/11/2022, of the resident tray line revealed Cook #1 picked up an alcohol wipe from the floor with a gloved hand. Cook #1 proceeded to wash off the thermometer in the hand sink while wearing the contaminated glove. Continued observation revealed Cook #1 then used an alcohol wipe to sanitize the thermometer and continued to use the same wipe on the thermometer after each food on the tray line. In addition, Cook #1 was observed, on 01/11/2022, walking toward the facility from the parking lot wearing his apron and hairnet. Observation, on 01/12/2022 at 8:45 AM, in the resident nourishment room revealed food items were not labeled or dated in the freezer, cabinets, and on the countertop. The findings include: Review of the facility's policy titled, Food Preparation, dated 09/2017, revealed for all staff to practice proper hand washing techniques and glove use. All food contact equipment would be cleaned and sanitized after every use. 1. Observation of the resident tray line, on 01/11/2022 at 11:45 AM, revealed the Dietary Manager handed alcohol wipes to Cook #1 from the drawer next to the hand sink. The wipes fell to the floor, and Cook #1 picked up the alcohol wipes with a gloved hand. He washed the thermometer in the hand sink under water wearing the same gloves. Continued observation of Cook #1 revealed he used one (1) alcohol wipe for the thermometer between all foods on the lunch tray line wearing the same gloves. Observation of Cook #1, on 01/11/2022 at 12:40 PM, revealed he returned to the facility from the side parking lot, entering the kitchen through the back door, wearing an apron and hair net. Interview with Cook #1, on 01/14/2021 at 10:07 AM, revealed he should have changed his gloves after touching the floor, washed hands, and put on new gloves because there was the potential he could have spread germs and bacteria to the food. He stated the thermometer was cleaned using a alcohol wipe between all foods to not cross contaminate between food items. He stated he should not have worn Personal Protective Equipment (PPE) when going outside to smoke to prevent cross contamination of food. Cook #1 stated he should have removed his gloves, apron, and mask when he exited the building. He further stated he should wash his hands and put on the apron and a new pair of gloves when he entered the kitchen. Interview with the Dietary Manager (DM), on 01/14/2022 at 10:20 AM and 2:36 PM, revealed staff had received on-line training for hand hygiene, when to change gloves, and when to wash hands. The DM stated there was a potential for cross contamination when Cook #1 retrieved the alcohol wipe from the floor, so Cook #1 should have removed his gloves, washed his hands, and put on a new pair of gloves. She stated Cook #1 should have used a separate alcohol wipe to sanitize the thermometer between each food on the resident tray line. In addition, the DM revealed her expectations for staff was to remove their apron and gloves, prior to going outside, and wash their hands upon return to the kitchen, put on their apron and a new pair of gloves. Interview with the Director of Nursing (DON), on 01/15/2022 at 6:00 PM, revealed her expectation was for food to be handled appropriately. She stated staff should sanitize the thermometer appropriately between each food temp. Per the interview, staff should wash their hands and change gloves if they touched the floor to prevent the potential of cross contamination. Additionally, she stated staff should not wear an apron to smoke outside and reenter the facility without washing their hands, gloving, and putting on a new apron. Interview with the Administrator, on 01/15/2022 at 6:05 PM, revealed his expectation was for food service staff to follow safe food handling practices and to change their gloves and wash their hands after touching the floor with gloves. Additionally, he stated staff should not wear an apron outside to smoke. 2. Observation, on 01/12/2022 at 8:45 AM, of the resident nourishment room revealed, in the freezer, a frozen Life Water purified full bottle 23.7 ounces, two (2) cold packs, one (1) comfort Jell Cold Pack, and two (2) frozen packaged sausage packs with no resident identification or date. Continued observation of the nourishment room revealed three (3) drinks located in an upper cabinet on a shelf to the right of the refrigerator behind the cabinet door with no identification or date. The drinks observed included: one (1) cup with initials and a symbol, one (1) Propel Grape with approximately 5 of 20 fluid ounces left, and one (1) peach nectarine 250 milliliters (ml) with a straw. Observation of the upper cabinet over the refrigerator revealed two (2) uncovered styrofoam cups not labeled or dated. One (1) cup contained 1/2 cup of salted almonds, and the other cup contained 1/2 cup of cranraisins. Further observation of the tray on the countertop revealed seven (7) packages of peanut butter crackers, not dated, and five (5) oatmeal creme cookies, not dated. Observation of the nourishment room drawers revealed numerous oatmeal creme cookies not dated and three (3) packets of hot cocoa mix not dated. Continued observation revealed staff's jackets were kept in the lower cabinets. Interview with the DM, on 01/14/2022 at 10:20 AM, revealed the residents' snacks were labeled with the resident's name and dated when sent to the nurses' station. The DM further revealed she thought staff saved the snacks refused by residents, removed the label, and placed the food in the nourishment room. Interview with Certified Nurse Aide (CNA) #4, on 01/14/2022 at 2:53 PM, revealed staff's drinks should not be kept in the nourishment room to prevent the possible or potential for cross contamination. CNA #4 stated staff should keep food and drink or any personal items in the staff lounge. Interview with Registered Nurse #1, on 01/15/2022 at 10:58 AM, revealed staff should not put personal drinks in the resident nourishment room because it was not sanitary and could get mixed up with the residents' food items. Interview with CNA #5, on 01/15/2022 at 11:51 AM, revealed staff removed the label from the snack item if the resident refused it, and placed the snack in the nourishment room. Interview with the Director of Nursing, on 01/15/2022 at 6:00 PM, revealed her expectation was that staff should store personal food items in the staff room and not in the residents' nourishment room to prevent potential cross contamination. She stated resident food in the nourishment room should be labeled and dated, and it was the facility's practice to do so. Interview with the Administrator, on 01/15/2022 at 6:05 PM, revealed his expectation that all food in the nourishment room should be labeled and dated. He stated staff was to keep personal items and food in the staff designated areas and not in the resident nourishment room.

Based on interview, record review, and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.17.1, dated 10/2019, it was determined the facility failed to complete the Minimum Data Set (MDS) assessments at least quarterly for four (4) of eighteen (18) sampled residents (Residents #3, #12, #16, and #167). The findings include: Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1, dated 10/2019, under the section 5.2: Timeliness Criteria revealed the completion date for all non-Admission OBRA (Omnibus Budget Reconciliation Act) and Prospective Payment System (PPS) assessments, the Quarterly Minimum Data Set (MDS) Assessments must be completed not less frequently than every three (3) months. 1. Review of Resident #3's electronic medical record (EMR) revealed the facility admitted the resident, on 03/04/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional review of Resident #3's EMR revealed Resident #3's latest Quarterly MDS Assessment was dated 09/05/2021. Further review revealed the Quarterly MDS Assessment, for Quarter #3, which was due 12/05/2021, was overdue by thirty-seven (37) days, on 01/11/2022, and had not been completed. 2. Review of Resident #12's EMR revealed the facility admitted the resident, on 10/21/2019, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional review of Resident #12's EMR revealed his/her latest Significant Change MDS Assessment was dated 09/06/2021. Resident #12's next required Quarterly MDS assessment, due on 12/06/2021, was thirty-six (36) days overdue on 01/11/2022 and had not been completed. 3. Review of Resident #16's EMR revealed the facility admitted the resident, on 03/19/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional review of Resident #16's EMR revealed his/her latest Quarterly MDS Assessment, dated 10/15/2021, was in-progress and had not been completed. This Quarterly Assessment was overdue by eighty-eight (88) days as of 01/11/2022. 4. Review of Resident #167's EMR revealed the facility admitted the resident, on 01/19/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional review of Resident #167's EMR revealed his/her last Quarterly MDS was dated 10/03/2021 but had not been completed by 01/11/2022. Therefore, this Quarterly Assessment was overdue by one hundred (100) days as of 01/11/2022. Interview with the Licensed Practical Nurse (LPN)/MDS Coordinator, on 01/15/2022 at 10:23 AM, revealed she had no MDS experience prior to starting her position, on 10/18/2021, and has had no formal MDS training. She further stated she was aware of the overdue MDS assessments, and had been working through them with great effort to complete the late ones. Interview with the Director of Nursing (DON), on 01/15/2022 at 5:59 PM, revealed her expectation was for the MDS Coordinator to complete the MDS assessments timely according to the RAI Guidelines. The DON revealed she was responsible to ensure the MDS assessments were a complete and accurate record. Interview with the Administrator, on 01/15/2022 at 6:08 PM, revealed the plan was for the LPN/MDS Coordinator to work with the former MDS Coordinator to receive on-the-job training. He stated he was aware of the lateness of the MDS assessments, and his expectation was for all MDS assessments to be completed in a timely fashion according to the RAI manual.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted standards of practice. Observation revealed the medication storage room contained expired and discontinued medications, as well as medications of residents who had expired. The findings include: Review of the facility's policy titled, Storage of Medication, undated, revealed the facility would store all drugs and biologicals in a secure and orderly manner without crowding. Further review revealed the facility would not keep drugs on hand after the expiration date which appeared on the label. Additional review of the policy revealed external medications should be stored separately from internal medications. Observation of the Medication Storage Room, on [DATE] at 10:05 AM, revealed three (3) 1.0 liter (L) bags of Normal Saline (NS) that expired on [DATE]. Further observation revealed multiple medications stored loosely, and in no particular order, in a cabinet above the sink that also contained intravenous (IV) medication administration supplies. The medications included two (2) vials of expired IV [MEDICATION(S)] (pain medication), expired IV Vitamin K, and a partially used card of discontinued [MEDICATION(S)] (a statin to treat high cholesterol) labeled for Resident #221. In addition, medications that belonged to deceased residents were also present in the medication storage room. These medications included: [MEDICATION(S)] (antibiotic), Glycemic gel/[MEDICATION(S)] (used to treat low blood sugar), Hycosamine (an anticholinergic agent that decreased stomach acid) and Triamicinolone topical cream (a steroid cream used to treat itching and skin inflammation). Interview with Registered Nurse (RN) #2, on [DATE] at 10:05 AM, revealed any medications no longer in use should be returned when the pharmacy courier delivered medications. Further interview revealed RN #2 did not know why these medications were stored in the cabinet instead of the bin where they were supposed to be stored. Interview with the Director of Nursing (DON), on [DATE] at 11:13 AM, revealed the facility typically would have a tote from pharmacy to store expired or discontinued medications or those that belonged to discharged residents. Further interview revealed she was unaware of the location of the tote. Additionally, she stated nursing staff should follow the facility's policy for disposing of these medications. Interview with the Administrator, on [DATE] at 6:25 PM, revealed his expectation was that staff followed the facility's policy and accepted standards of practice for safe medication administration and storage.

Based on interview, record review, and review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1, dated 10/01/2019, it was determined the facility failed to complete the Annual Minimum Data Set (MDS) Assessments in a timely manner as determined by the Resident Assessment Instrument (RAI) Guidelines for one (1) of eighteen (18) sampled residents (Resident #2). The findings include: Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.17.1 dated 10/01/2019 under the Section 5.2: Timeliness Criteria revealed the completion date for all non-Admission OBRA (Omnibus Budget Reconciliation Act) and Prospective Payment System (PPS) assessments, the MDS assessment completion date must be no later than fourteen (14) days after the Assessment Reference Date (ARD). Review of Resident #2's medical record revealed the facility admitted the resident, on 12/03/2019, with Alzheimer's Disease, [CONDITION(S)], Dysphagia, and Hypertension. Review of Resident #2's Annual MDS Assessment, in the electronic medical record (EMR), revealed it had a due date for completion of 11/29/2021 but had not been completed as of 01/14/2022 . This Annual MDS Assessment was overdue for completion by forty-seven (47) days and was listed in the EMR as in progress. Interview with Licensed Practical Nurse (LPN)/MDS Coordinator, on 01/15/2022 at 10:23 AM, revealed she only received on-the-job training and had no formal MDS training. She stated she was aware of the outstanding MDS assessment for Resident #2 and was trying to catch up to complete the MDS assessments. Interview with the Director of Nursing (DON), on 01/15/2022 at 5:59 PM, revealed her expectation was to complete the MDS assessments according to the RAI guidelines. Interview with the Administrator, on 01/15/2022 at 6:08 PM, revealed he was aware of the lateness of the MDS assessments. He stated his expectation was for all MDS assessments to be completed in a timely fashion according to the RAI manual.

Based on interview, record review, and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 Manual, Version 1.17.1, dated 10/2019, it was determined the facility failed to complete a Significant Change Minimum Data Set (MDS) Assessment in a timely fashion for one (1) of eighteen (18) sampled residents (Resident #1). The findings include: Review of the Long-Term Care Facility RAI 3.0 User's Manual, Version 1.17.1, dated 10/2019, Section 5-2: Timeliness Criteria revealed that for other comprehensive MDS assessments, Significant Change in Status Assessment and Significant Correction to Prior Comprehensive Assessment, the CAA (Care Area Assessment) completion date must be no later than fourteen (14) days from the determination date of the significant change in status or the significant error, respectively. Review of Resident #1's medical record revealed the facility admitted the resident, on 05/11/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's medical record revealed a Significant Change in Status MDS Assessment, dated 10/08/2021 for the start of the assessment and the significant change, still in progress, on 01/11/2022. According to the RAI Guidelines, this assessment was overdue for completion by eighty-one (81) days. Interview with Licensed Practical Nurse (LPN)/MDS Coordinator, on 01/15/2022 at 10:25 AM, revealed she had no MDS experience prior to starting her position on 10/18/2021. She stated she has had no formal MDS training, only on-the-job training. Further interview revealed she was aware of the overdue MDS assessments. She stated she had been working to catch up and complete the late MDS assessments. Interview with the Director of Nursing (DON), on 01/15/2022 at 5:59 PM, revealed her expectation was for the MDS Coordinator to complete the MDS assessments in accordance with the RAI Guidelines. Interview with the Administrator, on 01/15/2022 at 6:08 PM, revealed he was aware of the overdue MDS assessments. He stated his expectation was for all the MDS assessments to be completed timely within the RAI Guidelines.

Based on observation, interview, and review of facility policy it was determined the facility failed to ensure each resident was treated with dignity and respect and cared for in a manner that promoted or enhanced the resident's quality of life for one (1) of eight (8) sampled residents (Resident #165). On 01/03/18, Resident #165's privacy bag utilized to conceal the drainage bag of the resident's indwelling catheter was observed to be torn and soiled. The findings include: Review of the facility's policy and procedure titled Foley Catheter Care Policy, undated, revealed a privacy bag would be utilized to conceal indwelling catheter drainage bags. In addition, review of facility documentation titled 11-7 Shift Duties, revealed staff working on the 11PM-7AM shift would change the privacy bags at a minimum monthly and as needed. Review of Resident #165's medical record revealed the facility admitted the resident on 10/27/15 with [DIAGNOSES REDACTED]. The review also revealed Resident #165 had a suprapubic catheter in place. Review of Resident #165's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status score of 10, indicating the resident was moderately cognitively impaired. Observation of Resident #165 on 01/03/18 at 11:55 AM revealed the resident had an indwelling catheter and the drainage bag used to conceal the catheter's drainage bag was soiled and torn down the side. Interview on 01/04/18 at 2:00 PM with State Registered Nursing Assistant (SRNA) #1 revealed she had worked the 11PM-7AM shift on 01/02/18 and 01/03/18. SRNA #1 stated she had cared for the resident's catheter when working on 01/02/18 and 01/03/18, but did not observe any concerns with the resident's privacy bag. SRNA #1 stated she did not know who was responsible for changing privacy bags. Interview on 01/04/18 at 2:30 PM with Licensed Practical Nurse (LPN) #1 revealed she worked the 11PM-7AM shift on 01/03/18, but did not observe any concerns with Resident #165's privacy bag. LPN #1 stated it was the responsibility of the SRNAs to change resident privacy bags monthly and as needed. LPN #1 stated that she routinely observed resident privacy bags during rounds and immediately addressed any concerns. Interview on 01/04/18 at 3:05 PM with the Director of Nursing (DON) revealed it was the responsibility of all nursing staff to ensure privacy bags were clean and in good repair. The DON stated she observed Resident #165's privacy bag on 01/03/18, and changed the bag due to it being soiled and torn.

Based on observation, interview, and review of the facility policy it was determined the facility failed to ensure the safe administration of medications for two (2) of eight (8) sampled residents (Resident #1 and Resident #9) who had expired medications available for use in the medication cart. Review of the facility policy, Nursing Services Medication, not dated, revealed nursing staff were responsible to remove any discontinued or expired medications from the medication cart. Observation on 01/04/18 at 1:53 PM revealed the medication cart on the 100 Hall contained an open bottle of Milk of Magnesium, labeled for Resident #1, which had an expiration date of August 2017. Further observation revealed an open bottle of [MEDICATION NAME]-DM, labeled for Resident #9, which had an expiration date of 11/22/17. Interview with Licensed Practical Nurse (LPN) #3 on 01/04/18 at 2:01 PM, revealed nursing staff were required to check the expiration date on each medication prior to administration, and any medication found to be expired should be removed from the cart. The LPN further stated the Quality Assurance (QA) nurse routinely performed audits of the medication carts to ensure the carts contained no expired medications. Interview with the QA Nurse on 01/04/18 at 2:01 PM revealed he performed weekly audits of medication carts which included checking for expired medications. The QA nurse also stated he must have missed the expired medications in the cart for Resident #1 and Resident #9.

Based on observation, interview, record review, and review of facility policies, it was determined the facility failed to ensure services were provided in accordance with the written plan of care for two (2) of eight (8) sampled residents (Residents #2 and #4). Residents #2 and #4 both had physician's orders to receive wound care and had interventions on their Comprehensive Care Plan addressing the wound care. However, observations during the survey revealed Resident #2 and Resident #4 were not receiving wound care as directed by their Comprehensive Plans of Care. The findings include: Review of the facility policy titled Care Plan Policy, (undated) revealed daily care and documentation would be consistent with the resident's care plan. 1. Review of the medical record for Resident #2 revealed the facility admitted the resident on 04/03/14, with [DIAGNOSES REDACTED]. Review of Resident #2's Comprehensive Plan of Care dated 02/08/16 revealed the facility would provide wound care treatment as directed by the physician. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had been assessed to have a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident was not interviewable. The MDS also revealed Resident #2 required the total assistance of two persons for bed mobility and toileting. In addition, the MDS revealed Resident #2 had been assessed to be incontinent of both urine and bowel. Review of a discharge summary for Resident #2 dated 11/07/16 revealed the resident was admitted to an acute care facility from 11/04/16 to 11/07/16 with a [DIAGNOSES REDACTED]. Continued review of the discharge summary revealed Resident #2 had developed a hematoma to the right forearm while he/she had been a patient at the acute care facility. Review of a readmission nursing assessment completed for Resident #2 dated 11/07/16 revealed the hematoma to the resident's right forearm had been assessed to be an open wound measuring 6.4 centimeters (cm) in length and 3.9 cm in width. Review of Resident #2's physician's orders dated 11/07/16 revealed an order for [REDACTED]. Observations of Resident #2 on 11/10/16 at 11:00 AM revealed Licensed Practical Nurse (LPN) #2 was observed to cleanse the wound to Resident #2's right forearm with normal saline saturated gauze, cover with dry gauze wrap, and secure with self-adhesive dressing. Interview with LPN #2 on 11/10/16 at 4:53 PM revealed she was unsure how often she was required to check a resident's care plan. LPN #2 also revealed she should have checked the physician's orders prior to providing wound care. Interview with the Director of Nursing (DON) on 11/10/16 at 4:47 PM revealed staff was required to check every resident's comprehensive plan of care at the beginning of every shift. The DON stated she had not identified any concerns with staff not providing care as directed in the resident's comprehensive plan of care. 2. Record review revealed the facility readmitted Resident #4 on 09/12/16, with [DIAGNOSES REDACTED]. Review of a facility assessment titled Weekly Skin/Wound Measurement, dated 10/20/16, revealed Resident #4 was identified to have a Stage II pressure ulcer to his/her left buttock. Further review revealed the pressure ulcer measured 3 cm wide, 3 cm long, and was superficial in depth. Review of a Comprehensive Care Plan updated 10/20/16, revealed Resident #4 had a new open area to his/her buttock and was at risk for infection. Further review revealed interventions to provide treatments as ordered by the physician. Review of a Physician's Order dated 11/02/16 revealed new orders to cleanse the Stage II pressure ulcer to Resident #4's left buttock with normal saline, apply Santyl ointment (prescription ointment used to remove dead tissue from the wound bed), cover with gauze, and secure with tape. The order further revealed the treatment was to be performed daily and as needed. Observation on 11/09/16 at 3:32 PM revealed State Registered Nurse Aide (SRNA) #1 performed incontinence care for Resident #4. Further observation revealed Resident #4 had a Stage II pressure ulcer to his/her buttock with no dressing intact. Interview with SRNA #1 on 11/10/16 at 3:42 PM, revealed she had worked with Resident #4 on 11/09/16 and provided his/her care. SRNA #1 stated she did not report to the nurse that the dressing had been removed and needed to be replaced. Further interview with SRNA #1 revealed she was aware of the care plan interventions and stated she should have notified the nurse so the dressing could have been applied as the care plan directed. Interview with the Director of Nursing (DON) on 11/10/16 at 4:55 PM revealed it was her expectation that the staff follow all policy and procedures and perform all treatments as ordered by the physician and as directed by the care plan. Further interview with the DON revealed the SRNA should have reported the dressing was removed to the nurse so the nurse could replace the dressing.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure necessary care and services to attain the highest practical physical well-being were provided for one of eight (8) sampled residents (Resident #2). Review of the medical record for Resident #2 revealed a physician's orders [REDACTED]. However, the facility failed to provide the services as ordered by the physician to Resident #2. The findings include: Review of the facility's policy titled, Treatment Administration, (undated) revealed a treatment procedure was to be developed according to the physician's orders [REDACTED]. Review of the medical record for Resident #2 revealed the facility readmitted the resident on 11/07/16, with [DIAGNOSES REDACTED]. The medical record revealed a discharge summary from an acute care facility, which revealed Resident #2 had a hematoma to the right forearm upon his/her discharge from the acute care facility. Review of Resident #2's nurse's readmission notes dated 11/07/16 revealed the resident had been assessed to have an open wound to the right forearm. Review of the physician's orders [REDACTED]. Observations of Resident #2 on 11/10/16 at 11:00 AM revealed Licensed Practical Nurse (LPN) #2 was observed to clean the wound with normal saline saturated gauze, and wrap the wound with gauze wrap followed by a self-adhesive dressing. Interview conducted with LPN #2 on 11/10/16, at 4:53 PM, revealed when she provided wound care to Resident #2, she was aware she had not followed physician's orders [REDACTED].#2 stated she should have read the physician's orders [REDACTED].#2 and had just been nervous. Interview conducted with the Director of Nursing (DON) on 11/10/16, at 4:47 PM, revealed all staff was required to read and follow physician's orders [REDACTED].

Based on observation, interview, record review, and review of the facility's policy and procedures it was determined the facility failed to ensure a resident having pressure sores received adequate care to promote healing and prevent infection for one (1) of eight (8) sampled residents (Resident #8). Record review revealed Resident #4 had a Stage II pressure ulcer to his/her left buttock with orders for Santyl ointment and a dry dressing to be performed every day and as needed; however, observation during wound care on 11/09/16 revealed the dressing was not intact per the physician's orders [REDACTED]. The findings include: Review of the facility's policy and procedure titled, Treatment Administration, not dated, revealed treatments would be provided to residents according to the physician's orders [REDACTED]. Record review revealed the facility readmitted Resident #4 on 09/12/16 with [DIAGNOSES REDACTED]. Review of a facility assessment titled Weekly Skin/Wound Measurement, dated 10/20/16, revealed Resident #4 was identified to have a Stage II pressure ulcer to his/her left buttock. Further review revealed the pressure ulcer measured 3 centimeters (cm) wide, three 3 cm long, with superficial depth. Review of a Comprehensive Care Plan updated 10/20/16 revealed Resident #4 had a new open area to his/her buttock and was at risk for infection. Further review revealed interventions to provide treatments as ordered by the physician. Review of a physician's orders [REDACTED].#4's left buttock with normal saline, apply Santyl ointment (prescription ointment used to remove dead tissue from the wound bed), cover with gauze and secure with tape, to be performed daily and as needed. Observation on 11/09/16 at 3:32 PM revealed State Registered Nurse Aide (SRNA) #1 performed incontinence care for Resident #4. Further observation revealed Resident #4 had a Stage II pressure ulcer to his/her buttock with no dressing intact. Interview with SRNA #1 on 11/10/16 at 3:42 PM, revealed she had worked with Resident #4 on 11/09/16 and provided his/her care. SRNA #1 stated she did not report to the nurse that the dressing had been removed and needed to be replaced. Further interview with SRNA #1 revealed she knew she should have reported this to Resident #4's nurse but stated, I guess I just got busy and forgot. Interview with Licensed Practical Nurse (LPN) #3 revealed she had worked on 11/10/16 and was Resident #4's nurse. LPN #3 stated SRNA #1 did not report to her that the dressing had been removed. Interview with the Director of Nursing (DON) on 11/10/16 at 4:55 PM, revealed it was her expectation that the staff follow all policy and procedures and perform all treatments as ordered by the physician. Further interview with the DON revealed the SRNA should have reported the dressing was removed to the nurse so the nurse could replace the dressing.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure an infection control program was established and maintained to provide a sanitary environment and help prevent the development and transmission of diseases and infection for one (1) of ten (10) sampled residents (Resident #6) and one (1) unsampled resident (Resident A). Observation during the medication pass on 11/09/16 revealed Kentucky Medication Aide (KMA) #1 administered a nose spray to Resident #6 without wearing gloves. Additionally, LPN #3 cleansed the nebulizer mask and administered a nebulizer treatment to Resident A without wearing gloves. The findings include: Review of the facility's policy and procedure titled, Universal Precautions, not dated, revealed gloves would be worn any time it was likely the hands would come in contact with body substances such as oral secretions or sputum. 1. Record review revealed the facility admitted Resident #6 on 08/22/14 with [DIAGNOSES REDACTED]. Review of the monthly Physician order [REDACTED].#6 had orders to receive Deep Sea 0.65% Nasal Spray, one (1) drop to each nostril four (4) times a day. Observation during the medication pass on 11/09/16 at 4:40 PM revealed KMA #1 administered the Deep Sea Nasal Spray to Resident #6. Additional observation revealed KMA #1 did not wear gloves. Interview with KMA #1 on 11/10/16 at 4:08 PM revealed she normally wore gloves when she administered the nose spray due to the potential to come into contact with nasal secretions. KMA #1 stated, I was distracted because I was being watched. 2. Observation during medication pass on 11/09/16 at 4:17 PM revealed LPN #3 removed the nebulizer mask from Resident A's nebulizer (medication delivery device used to deliver medication into the lungs via a mist inhaled into the lungs) and washed the mask at the sink in the resident's room. Further observation revealed after cleaning the mask, LPN #3 connected the face mask to the machine and administered a nebulizer treatment to Resident #A. However, observations revealed LPN #3 did not wear gloves while she washed the nebulizer mask and while she administered the nebulizer treatment. Interview with LPN #3 on 11/10/16 at 4:20 PM revealed LPN #3 stated she normally wore gloves while handling the nebulizer mask and while administering the nebulizer treatment due to the risk of her hands coming into contact with oral secretions and to prevent the spread of infection. LPN #3 stated, I knew I was forgetting something. Interview with the Director of Nursing (DON) on 11/10/16 at 4:55 PM revealed she expected all staff to wear gloves per the policy and procedure. The DON stated she has performed audits recently and had not identified a concern with infection control practices.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to store, prepare, and serve food under sanitary conditions for twenty-three (23) of twenty-three (23) residents who received meal trays from the kitchen. Observations on 09/08/15 revealed unlabeled and undated foods were being stored in the walk-in cooler. In addition, a container of cocktail sauce was observed to be stored in the walk-in cooler with a gray substance observed on the outside of the container. The findings include: Review of the facility's policy titled Cold Food Storage, dated 07/10/14, revealed all shelf stable items requiring refrigeration after opening were required to be marked with the date the container was opened. The policy also revealed all surfaces would be cleaned and sanitized and staff putting away stock would conduct a sanitation audit every delivery day. Observations on 09/08/15 at 11:10 AM revealed a container of mayonnaise, one (1) container of honey mustard salad dressing, one (1) container of maraschino cherries, and one (1) container of barbecue sauce opened, unlabeled, and undated in the walk-in cooler. In addition, a container of cocktail sauce was observed to be stored in the walk-in cooler with a gray substance observed on the outside of the container. Interview conducted with the Dietary Manager on 09/10/15 at 11:00 AM revealed he was responsible for putting up stock and monitoring to ensure all items had been labeled and dated when opened. The Dietary Manager stated he had completed the last audit on 09/02/15 and had not identified the containers being opened and undated, nor had he identified the gray substance on the outside of the cocktail sauce. The Dietary Manager stated all foods were required to be labeled and dated prior to being placed in the walk-in cooler. Interview conducted with the Registered Dietitian (RD) on 09/10/15 at 11:20 AM revealed she was required to do a monthly audit of the kitchen, and she had not identified any concerns with sanitation. The RD stated all foods should be labeled and dated when opened and containers should be clean.

Based on observation, interview, record review, and facility policy review it was determined the facility failed to ensure and provide appropriate treatment and services to prevent infections of the urinary tract for two (2) of ten (10) sampled residents (Resident #3 and Resident #8). During observations of catheter care for Resident #3, facility staff failed to change gloves and wash hands as required during the provision of incontinence care to Resident #3. In addition, during observation of incontinence care for Resident #8, facility staff placed clean soapy washcloths directly on the resident's headboard before using them to provide incontinence care for Resident #8. The findings include: Review of the facility's policy titled Foley Catheter Care Policy, with a revision date of 01/04/12, revealed staff would remove gloves, discard the gloves into the designated container, wash and dry hands thoroughly, and then put on clean gloves when performing catheter care. 1. Review of the medical record revealed Resident #3 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #3 to require total assistance with toileting needs and to require an indwelling catheter. Review of the comprehensive care plan dated 04/14/15 revealed the resident required an indwelling catheter with catheter care to be provided every shift and as needed. Review of September 2015 Physician order [REDACTED]. Observation of catheter care for Resident #3 on 09/08/15 at 3:50 PM with Certified Nurse Aide (CNA) #1 revealed the CNA washed her hands, put on gloves, and removed the resident's incontinence brief that was soiled with feces. Further observation revealed the CNA cleaned the resident's coccyx area that was soiled with feces. CNA #1 then proceeded to clean the indwelling catheter tubing without washing her hands or applying clean gloves. Interview with CNA #1 on 09/08/15 at 4:00 PM revealed she had been trained to change gloves and wash hands after cleaning a resident's bowel movement and before performing catheter care. The CNA stated she forgot, but should have washed her hands and changed gloves while providing catheter care for Resident #3. 2. A review of the facility's policy titled Bowel and Bladder Incontinence, (not dated) revealed staff would ensure that each resident received the appropriate treatment and services to prevent urinary tract infections. Further review of the policy revealed the policy did not address the procedure for staff to follow to prepare supplies prior to providing incontinence care. Review of the medical record revealed the facility admitted Resident #8 on 09/14/12 with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated [DATE] revealed Resident #8 required total assistance from staff for toileting. Review of the care plan revealed perineal care should be prompt after each incontinence episode. Observation of incontinence care on 09/10/15 at 3:10 PM revealed Certified Nurse Assistant (CNA) #2 placed clean soapy washcloths on the headboard of the resident's bed before using them to provide incontinence care for Resident #8. Interview with CNA #2 on 09/10/15 at 3:20 PM revealed she had been trained to place the clean washcloths on a clean plastic bag or another type of clean barrier before using them to clean the resident. She further revealed she was nervous and just forgot. Interview with the Director of Nursing (DON) on 09/10/15 at 5:15 PM revealed competency checks were done yearly with all SRNAs for catheter care. The DON further revealed staff was trained to wash hands and change gloves while cleaning catheter tubing. The DON further stated that staff was trained to place clean washcloths on a clean plastic bag before using them for incontinence care. Additional interview with the DON revealed the facility's quality assurance conducted weekly audits with all SRNAs regarding catheter care and no concerns had been identified.

Based on interview, record review, and a review of the facility abuse policy and procedure it was determined the facility failed to protect residents from abuse and ensure allegations of abuse were reported to state agencies for one (1) of three (3) sampled residents (Resident #1). Resident #1's responsible party notified the facility Administrator on 02/06/15 that a State Registered Nurse Aide cursed Resident #1, showered the resident in cold water, and threatened to not allow the resident to visit with his/her pet. The facility failed to remove the SRNA from resident care duties during the investigation and failed to report the allegation to appropriate state agencies as required. The findings include: A review of the facility policy for abuse and neglect (untitled and undated) revealed any alleged violations involving mistreatment, neglect, or abuse must be reported to the Administrator and/or his/her designee immediately and to appropriate agencies when an allegation of abuse occurs. Further review of the facility policy revealed while an investigation is being conducted facility employees who have been accused of resident abuse would be removed from resident care duties or suspended depending on the severity of the alleged offense until the results of the investigation had been reviewed by the Administrator. A review of the medical record for Resident #1 revealed the resident was admitted to the facility on [DATE]. A review of the resident's current [DIAGNOSES REDACTED]. Additional review revealed a comprehensive Minimum Data Set (MDS) assessment dated [DATE] in which the resident was assessed to require the extensive assistance of two people for bathing. In addition, the resident was assessed to have moderately impaired cognition. Further review of the record revealed Resident #1 struck a staff member while the staff was attempting to bathe the resident on 02/04/15 at 6:00 AM and twisted another staff member's arm at 11:00 AM the same day. The resident's physician was contacted and orders received to transfer the resident to a psychiatric hospital for evaluation. The resident was admitted to the psychiatric hospital on [DATE] and remained in the hospital at the time of the investigation. A review of a facility investigation completed by the Director of Nursing (DON) on 02/09/15 for Resident #1 revealed an allegation that State Registered Nurse Aide (SRNA#1) cursed at Resident #1 on 02/04/15. The investigation further revealed SRNA #1 told Resident #1 he/she would never be able to see his/her dog again if he/she didn't "straighten up" and also gave the resident a cold shower. An interview conducted with the Director of Nursing (DON) on 02/20/15 at 2:05 PM, revealed the Administrator informed the DON of an allegation of abuse on 02/06/15. The interview further revealed the DON was instructed to conduct an investigation regarding the allegation of abuse of Resident #1. The DON stated she conducted an investigation of the allegation. The DON further stated she did not suspend the employee or remove the employee from resident care during the investigation and did not report the allegation to state agencies. The DON stated she was new to the job and this was her first allegation of abuse to investigate. An interview conducted with the Administrator on 02/20/15 at 2:30 PM, revealed the Administrator was contacted by Resident #1's Responsible Party (RP) on 02/06/15 by phone. The Administrator stated the Responsible Party informed the Administrator that Resident #1 was upset because a staff member left the resident alone in the shower for a long time and sprayed the resident with cold water. Further interview revealed the Administrator instructed the DON to conduct an investigation of the allegation. The Administrator stated he did not report the allegation to the state agencies or remove/suspend the employee because the allegation was unsubstantiated and he felt abuse did not occur.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure one dietary staff member's beard was covered. Observation of the lunch tray line on 06/30/14 revealed Cook Aide #1 walked in front of the tray line while residents' food trays were being prepared with his beard uncovered. The findings include: Review of the facility policy titled, "Appropriate Attire," dated January 2002, revealed all food service personnel with beards were required to wear beard nets during food serving or preparation. Observation of the lunch tray line on 06/30/14, at 12:03 PM, revealed Cook Aide #1 walked in front of the tray line while residents' food trays were being prepared with no beard cover over his beard. Interview with Cook Aide #1 on 06/30/14, at 12:05 PM, revealed he was unaware he was required to wear a beard cover unless his beard was longer than one inch in length. He stated since his beard was approximately one-half inch long he did not think a beard was required. Interview conducted with the Dietary Manager on 06/30/14, at 12:07 PM, revealed Cook Aide #1 should have worn a beard net when he was in the food preparation and serving area. The Dietary Manager stated he monitored staff for hairnets, beard covers, and hand washing every time he came into the kitchen and had not identified any concerns.

Based on observation, interview, and record review, the facility failed to ensure that a plan of care was developed for three (3) of ten (10) sampled residents. Resident #2 and Resident #8 were assessed by the facility to have incontinence and require incontinence care. However, the facility failed to develop individualized care plans for each of these residents that addressed their toileting needs. In addition, Resident #2 sustained eight falls at the facility from 01/28/14 through 06/16/14. The facility failed to assess each fall and revise Resident #2's plan of care to prevent further falls (refer to F272, F315, and F323). Resident #6 received hospice services and the facility failed to develop a care plan to include the resident's hospice needs. The findings include: 1. A review of the facility's "continence program" (no date) revealed the facility was to assess each resident's elimination status and develop an appropriate care plan and interventions within seven to ten days after admission. Resident #2 was observed on 07/01/14 at 9:45 AM and 07/02/14 at 10:15 AM ambulating in the hallway with the assistance of a walker and one staff member. An interview conducted with Resident #2 on 06/30/14 at 3:05 PM revealed that the resident was aware when he/she needed to urinate or have a bowel movement and requested assistance from staff to the restroom; however, at times staff told the resident that he/she had to wait for assistance. Resident #2 stated that usually when he/she fell it was because he/she got up without assistance to go to the restroom. Record review revealed that Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #2's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #2 to have a Brief Interview for Mental Status (BIMS) score of 13, which indicates no cognitive impairment. Further review of the MDS revealed the facility assessed Resident #2 as being frequently incontinent of urine and always continent of bowel. However, a review of the Care Area Assessment (CAA) summary for urinary incontinence dated 12/31/13 revealed the facility assessed Resident #2 as being incontinent of bowel and bladder and utilized adult briefs to manage incontinence episodes. A review of the care plan for Resident #2 dated 01/03/14 and updated 04/03/14 revealed the facility assessed the resident to have problems with urinary incontinence. The care plan stated that Resident #2 was occasionally incontinent of bowel and bladder and utilized adult briefs to manage incontinence episodes. In addition, the care plan stated facility staff would provide perineal care after each incontinence episode and staff would assist the resident with toileting before and after meals. However, a review of the nurse aide assignment sheets for June 2014 revealed that Resident #2 was continent every day. An interview with the direct care staff, CNA (certified nurse aide) #6, on 07/02/14 at 10:00 AM revealed that Resident #2 was often continent, but had incontinence episodes at times. She also stated that the resident called for staff assistance with going to the restroom. An interview with CNA #7 on 07/01/14 at 1:15 PM revealed that Resident #2 was aware when he/she needed to use the restroom and usually rang his/her call light for assistance when she needed help. In addition, CNA #7 stated the resident was offered assistance with toileting every two hours. An interview with the MDS nurse on 07/03/14 at 10:00 AM revealed that when a resident triggered for incontinence, like Resident #2, the resident was placed on a two-hour toileting plan. She stated that they did not assess Resident #2 for patterns of incontinence or develop an individualized plan for Resident #2 to address his/her elimination needs. 2. Resident #8 was observed on 07/03/14 at 11:15 AM ambulating in the hallway with the assistance of a walker and two staff members. The resident's sister was observed to be pushing a wheelchair behind the staff members. A review of the record for Resident #8 revealed that the facility admitted the resident on 03/20/14 with [DIAGNOSES REDACTED]. The admission MDS dated [DATE] revealed that Resident #8 had a BIMS score of 6, which indicated cognitive deficits. Resident #8 was also assessed to be frequently incontinent of urine and bowel. A review of the CAA summary dated 03/27/14 revealed Resident #8 was frequently incontinent of bowel and bladder, and that he/she was toileted before and after meals. The "Assessment for Bowel and Bladder Training," dated 03/20/14 revealed the facility assessed Resident #8 as being "unable to recognize the urge to urinate or defecate" due to a [DIAGNOSES REDACTED]. The care plan for Resident #8 stated that the resident was frequently incontinent of bowel and bladder and utilized adult briefs to manage incontinence episodes. The interventions were to toilet the resident before and after meals, utilize adult briefs, and monitor for signs and symptoms of infections. An interview conducted on 07/03/14 at 12:18 PM with direct care staff, CNA #1, revealed that Resident #8 often asked to go to the restroom and recognized the urge to go. CNA #1 further stated that the resident was both incontinent and continent at times. An interview with the MDS nurse on 07/03/14 at 10:00 AM revealed that when a resident triggered for incontinence, they were placed on a two-hour toileting plan. She stated that they did not assess Resident #2 and Resident #8 for patterns of incontinence or develop an individualized plan to address Resident #2 and Resident #8's elimination needs. 3. A review of the facility's "Fall Policy," dated 08/16/13, revealed that after a resident fall occurred, a Fall Risk Evaluation and a Fall Assessment must be completed by the nurse and upon completion of the Fall Risk Assessment and a Fall Assessment, an intervention would be initiated. A review of the facility's "Comprehensive Care Plans" policy, not dated, revealed a care plan would be developed for each resident with measurable objectives to meet the resident's medical, nursing, and psychological needs. The policy also stated care plans were revised as changes in a resident's condition dictated. On 07/01/14 at 9:45 AM and 07/02/14 at 10:15 AM Resident #2 was observed ambulating in the hallway with the assistance of a walker and one staff member. An interview conducted with Resident #2 on 06/30/14 at 3:05 PM revealed the resident sustained [REDACTED]. Record review revealed that Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #2's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #2 to have a BIMS score of 13, which indicates no cognitive impairment. The facility identified the resident had sustained a fall in the last month prior to admission without fracture. The Care Area Assessment (CAA) summary for falls dated 12/31/13 revealed Resident #2 was non-ambulatory and utilized a wheelchair for mobility. The CAA summary for urinary incontinence dated 12/31/13 stated that Resident #2 was incontinent of bowel and bladder and utilized adult briefs to manage incontinence episodes. The quarterly MDS assessment that was completed on 06/16/14 for Resident #2 revealed the facility assessed Resident #2 to require extensive physical assistance from one person for transfers and ambulation. The MDS from 06/16/14 revealed the facility also assessed the resident as always being incontinent of urine and bowel, and to have had two or more falls without injury since the previous assessment. A review of the care plan for Resident #2 dated 01/03/14 and updated 04/03/14, revealed the facility identified the resident had problems including urinary incontinence and a risk for falls. The approach was to assist the resident to toilet before and after meals. The care plan also stated that Resident #2 had a history of [REDACTED]. The approaches included assisting the resident with bed mobility and transfers as needed. Further review of Resident #2's record revealed the resident had sustained eight falls since admission to the facility (01/28/14, 02/14/14, 02/23/14, 03/03/14, 03/12/14, 03/14/14, 04/22/14, and 06/16/14). A review of the incident reports for each of the falls revealed that the resident was trying to get up unassisted during each of the incidents, however, the facility failed to address why the resident was attempting to get up unassisted. Further review of Resident #2's care plan revealed no evidence the resident's care plan was revised with fall interventions since the care plan was initially developed on 01/03/14, even though the resident had sustained eight falls since the care plan was initiated. An interview with the Quality Assurance (QA) nurse on 07/03/14 at 9:00 AM revealed that the Interdisciplinary Team (IDT) met to discuss Resident #2's falls. He stated that he followed up on falls sustained by the resident, tracked all falls in the facility as part of QA, and tried to determine the cause of falls. He stated that he had determined that Resident #2's falls were due to the resident's refusal to request help and the need to be independent. He stated that the resident was on a toileting plan that all residents of the facility were on (toileting every two hours), but the facility had not developed an individualized toileting plan for Resident #2 to assure that he/she did not get up unassisted to go to the restroom in an attempt prevent falls. 4. Review of Resident #6's medical record revealed the facility admitted the resident on 05/24/13 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #6's BIMS score was 4, which indicated the resident's cognition was severely impaired. Review of the Hospice Contract titled, "Contract for Services Between Hospice Care Plus, INC. and Telford Terrace," dated 2009, revealed the Plan or Hospice Plan would include a detailed description of the scope and frequency of hospice care, services, equipment, therapies, and supplies to be provided by Hospice and to meet the resident's needs. Further review of the policy revealed both Hospice and the facility in conjunction with one another would develop the Plan for each Hospice patient, and the Plan would be updated by Hospice two times per month. A review of Resident #6's care plan dated 09/13/13 revealed no evidence that a plan of care for Hospice had been developed for Resident #6. Interview with the Hospice Nurse on 07/03/14 at 3:45 PM revealed she was the nurse who provided Hospice services for Resident #6. She stated she saw Resident #6 once a week and a Certified Nurse (CNA) visited the resident twice a week. The hospice nurse stated a care plan was completed weekly, but she did not check the resident's medical record to ensure a copy of the care plan was on the chart. The Hospice nurse stated she usually talked with nursing staff when at the facility. Interview with the MDS Coordinator on 07/03/14 at 3:15 PM revealed she was responsible for developing the care plan for each resident. She stated Hospice did not contribute to residents' care plans and only participated in a resident's care plan meeting if they had concerns. Interview with the Director of Nursing (DON) on 07/03/14 at 3:50 PM revealed she had not been monitoring to ensure Hospice care plans were in the medical record. The DON stated the care plan should have been in the resident's chart.

Based on observation, interview, record review, and facility policy review it was determined that the facility failed to ensure that appropriate treatment and services were provided for two (2) of ten (10) sampled residents (Residents #2 and #8) to prevent urinary tract infections and promote as much normal bladder function as possible. The facility assessed Resident #2 and Resident #8 to be incontinent of bowel and bladder. However, a review of the resident's record revealed that he/she was often continent. Resident #8 had a bowel and bladder assessment that stated that he/she was occasionally incontinent, but was unable to participate in a program due to the inability to recognize the urge to urinate or defecate. Record review and interview revealed that Resident #8 was often continent of bowel and bladder. The facility failed to assess Residents #2 and #8 for individualized continence needs and develop an individualized care plan to address Resident #2 and #8's continence needs to maintain bowel and bladder function (refer to F272, F279, and F323). The findings include: 1. A review of the facility's "continence program" (no date) revealed the facility was to assess each resident's elimination status and develop an appropriate care plan and interventions within seven to ten days after admission. Resident #2 was observed on 07/01/14 at 9:45 AM and 07/02/14 at 10:15 AM ambulating in the hallway with the assistance of a walker and one staff member. An interview conducted with Resident #2 on 06/30/14 at 3:05 PM revealed that the resident was aware when he/she needed to urinate or have a bowel movement and sometimes called out for assistance to go to the restroom and was told by staff that he/she had to wait. The resident stated that it was most often after meals that staff did not answer call lights timely. Resident #2 stated that usually when he/she was trying to get up without assistance, it was because he/she needed to go to the restroom. Record review revealed that Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #2's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #2 to have a Brief Interview for Mental Status (BIMS) score of 13, which indicates no cognitive impairment. The MDS also stated that Resident #2 was frequently incontinent of urine and always continent of bowel. The Care Area Assessment (CAA) summary for urinary incontinence dated 12/31/13 stated that Resident #2 was incontinent of bowel and bladder and utilized adult briefs to manage incontinence episodes. The quarterly MDS assessment that was completed on 06/16/14 revealed the facility assessed Resident #2 to be always incontinent of urine and always incontinent of bowel. Further review of the record revealed that the "Assessment for Bowel and Bladder Training" had been completed on 12/18/13 and again on 03/19/14 and 06/17/14. The 12/18/13 and 03/19/14 assessments stated that the resident was unable to participate in a training program due to weakness and requiring assistance. The plan for management was to toilet the resident before and after meals, at bedtime, and as needed. The 06/17/14 assessment stated that the resident was able to participate in a training plan due to occasional incontinence secondary to weakness and that the resident knew when he/she needed to go to the restroom. The plan for management was to toilet the resident before and after meals, at bedtime, and as needed. A review of the care plan for Resident #2 dated 01/03/14 and updated 04/03/14 revealed the facility assessed the resident to have problems with urinary incontinence. The care plan stated that Resident #2 was occasionally incontinent of bowel and bladder and utilized adult briefs to manage incontinence episodes. In addition, the care plan stated facility staff would provide perineal care after each incontinence episode and staff would assist the resident with toileting before and after meals. However, a review of the nurse aide assignment sheets for June 2014 revealed that Resident #2 was continent every day. An interview with the direct care staff, CNA (certified nurse aide) #6, on 07/02/14 at 10:00 AM revealed that Resident #2 was often continent, but had incontinence episodes at times. She also stated that the resident called for assistance when needing to go to the restroom. An interview with CNA #7 on 07/01/14 at 1:15 PM revealed that Resident #2 was aware when he/she needed to use the restroom and usually rang her call light for assistance when she needed help. In addition, CNA #7 stated the resident was offered assistance with toileting every two hours. 2. Resident #8 was observed on 07/03/14 at 11:15 AM ambulating in the hallway with the assistance of a walker and two staff members. The resident's sister was observed to be pushing a wheelchair behind the staff members. A review of the record for Resident #8 revealed that the facility admitted the resident on 03/20/14 with [DIAGNOSES REDACTED]. The admission MDS dated [DATE] revealed that Resident #8 had a BIMS score of 6, which indicates cognitive deficits. Resident #8 was also assessed to be frequently incontinent of urine and frequently incontinent of bowel. A review of the CAA summary dated 03/27/14 revealed that Resident #8 was alert and oriented with confusion. Furthermore, the CAA summary stated that Resident #8 was frequently incontinent of bowel and bladder, and that he/she was toileted before and after meals. The "Assessment for Bowel and Bladder Training," dated 03/20/14 revealed the facility assessed Resident #8 as being "unable to recognize the urge to urinate or defecate" due to a [DIAGNOSES REDACTED].#8 stated that the resident was frequently incontinent of bowel and bladder and utilized adult briefs to manage incontinence episodes. The interventions were to toilet the resident before and after meals, utilize adult briefs, and monitor for signs and symptoms of infections. An interview conducted on 07/03/14 at 12:18 PM with direct care staff, CNA #1, revealed that Resident #8 often asked to go to the restroom and recognized the urge to go. CNA #1 further stated that the resident was both incontinent and continent at times. On 07/02/14 at 3:27 PM, an interview conducted with the DON (Director of Nursing) revealed that the Assistant Director of Nursing (ADON) or the nurse that admitted the resident completed the "Assessment for Bowel and Bladder Training." The DON reviewed the assessments that had been completed for Resident #2 and Resident #8 and stated that she felt that the staff had incorrectly assessed the residents. The DON stated that the residents should be able to participate in a training or continence program. An interview was conducted with the ADON (Assistant Director of Nursing) on 07/03/14 at 9:35 AM. The ADON stated that she usually completed bowel and bladder assessments for the residents of the facility. She stated that residents who were alert and oriented like Resident #2 were not placed on a bowel and bladder training program because they did not need to be "retrained." She stated that they were placed on a toileting plan that every resident in the facility used, which was an every two-hour toileting schedule. She stated that they do not have residents on an individual toilet schedule. The ADON further stated that for Resident #2, it was "not an urgency problem (sudden urge to urinate), but getting her there quick enough." An interview with the MDS nurse on 07/03/14 at 10:00 AM revealed that when a resident triggered for incontinence, they were placed on a two-hour toileting plan. She stated that they did not assess Resident #2 or Resident #8 for patterns of incontinence or develop an individualized plan for Resident #2 or Resident #8 to address his/her incontinence.

Based on observation, interview, and record review the facility failed to complete an accurate comprehensive assessment for two (2) of ten (10) sampled residents. Resident #2 was admitted to the facility on [DATE] and an admission MDS (Minimum Data Set) was done on 12/25/13. Resident #2 was assessed to be frequently incontinent of bladder and always continent of bowel. However, the CAA (Care Area Assessment) summary stated that Resident #2 was incontinent of bowel and bladder and failed to assess the resident's continence and a toileting plan to meet the resident's needs. Resident #2 had a quarterly MDS assessment completed on 06/16/14 that stated that Resident #2 was always incontinent of bowel and always incontinent of bladder. However, a review of the nurse aide assignment sheets revealed that Resident #2 was often continent during the assessment period. Resident #8 was admitted to the facility on [DATE] and was assessed on the admission MDS dated [DATE] to be frequently incontinent of bowel and bladder. The CAA summary dated 03/27/14 stated that the resident was frequently incontinent of bowel and bladder, but did not address that the resident was continent at times and failed to accurately assess Resident #8's toileting needs (refer to F279, F315, and F323). The findings include: A review of the facility's "Continence Program" (no date) revealed that the facility was required to assess each resident's elimination status and develop an appropriate care plan and interventions within seven to ten days after admission. 1. Resident #2 was observed on 07/01/14 at 9:45 AM and 07/02/14 at 10:15 AM ambulating in the hallway with the assistance of a walker and one staff member. An interview conducted with Resident #2 on 06/30/14 at 3:05 PM revealed the resident was aware when he/she needed to urinate or have a bowel movement and called for staff assistance to the restroom. However, staff did not always assist the resident timely and the resident attempted to go to the restroom without assistance at times. Record review revealed that Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #2's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #2 to have a Brief Interview for Mental Status (BIMS) score of 13, which indicates no cognitive impairment. The MDS also stated that Resident #2 was frequently incontinent of urine and always continent of bowel. The Care Area Assessment (CAA) summary for urinary incontinence dated 12/31/13 stated that Resident #2 was incontinent of bowel and bladder and utilized adult briefs to manage incontinence episodes. The quarterly MDS assessment that was completed on 06/16/14 revealed the facility assessed Resident #2 to be always incontinent of urine and always incontinent of bowel. However, a review of the nurse aide assignment sheets for June 2014 revealed that Resident #2 was continent every day. Further review of the record revealed that the "Assessment for Bowel and Bladder Training" had been completed on 12/18/13 and again on 03/19/14 and 06/17/14. The 12/18/13 and 03/19/14 assessments stated that the resident was unable to participate in a training program due to weakness and requiring assistance. The plan for management was to toilet the resident before and after meals, at bedtime, and as needed. The 06/17/14 assessment stated that the resident was able to participate in a training plan due to occasional incontinence secondary to weakness and that the resident knew when he/she needed to go to the restroom. The plan for management was to toilet the resident before and after meals, at bedtime, and as needed. An interview with the direct care staff, CNA (Certified Nurse Aide) #6, on 07/02/14 at 10:00 AM revealed that Resident #2 was often continent, but had incontinence episodes at times. She also stated that the resident called for assistance when needing to go to the restroom and had always done so since being at the facility. An interview with CNA #7 on 07/01/14 at 1:15 PM revealed that Resident #2 was aware of the need to use the restroom and usually rang her call light for assistance to the restroom. CNA #7 stated staff offered to assist Resident #2 with going to the restroom every two hours. 2. Resident #8 was observed on 07/03/14 at 11:15 AM ambulating in the hallway with the assistance of a walker and two staff members. The resident's sister was observed pushing a wheelchair behind the staff members. A review of the record for Resident #8 revealed that the facility admitted the resident on 03/20/14 with [DIAGNOSES REDACTED]. The admission MDS dated [DATE] revealed that Resident #8 had a BIMS score of 6 which indicates cognitive deficits. Resident #8 was also assessed to be frequently incontinent of urine and frequently incontinent of bowel. A review of the CAA summary dated 03/27/14 revealed that Resident #8 was alert and oriented with confusion. Furthermore, the CAA summary stated that Resident #8 was frequently incontinent of bowel and bladder, and that he/she was toileted before and after meals. The "Assessment for Bowel and Bladder Training" dated 03/20/14 stated that Resident #8 was "unable to recognize the urge to urinate or defecate" due to a [DIAGNOSES REDACTED]. An interview conducted on 07/03/14 at 12:18 PM with direct care staff, CNA #1, revealed that Resident #8 often asked to go to the restroom and recognized the urge to go. CNA #1 further stated that the resident was both incontinent and continent at times. On 07/02/14 at 3:27 PM, an interview with the Director of Nursing (DON) revealed that the Assistant Director of Nursing (ADON) or the nurse who admits the resident completed the "Assessment for Bowel and Bladder Training." The DON reviewed the assessments for Resident #2 and Resident #8 and stated that she felt that the staff had incorrectly assessed the residents and that the residents should be able to participate in a training or continence program. An interview with the MDS nurse on 07/03/14 at 10:00 AM revealed that when a resident triggered for incontinence, they were placed on a two-hour toileting plan. She stated that the facility did not assess Resident #2 or Resident #8 for patterns of incontinence or develop an individualized plan for Resident #2 or Resident #8 to address his/her incontinence.