Every finding on record at The Methodist Hospital SNF

Based on interview and record review, the facility failed to ensure MDS data was transmitted within 14 days of completion for 1 of 10 residents (CR #4), in that: - CR #4's discharge assessment was never completed and submitted following discharge on 12/12/2022. This failure could place residents at risk for receiving unnecessary services or inadequate care. Finding included: Record review of CR #4's face sheet, printed 6/8/2023 revealed an [AGE] year-old female who was admitted on [DATE] and discharged [DATE]. Record review of CR #4's MDS section I, dated revealed the resident had diagnoses including osteoporosis and hypertension. Record review of CR #4's MDS, dated [DATE], revealed the resident MDS OBRA assessment completed but not a discharge assessment. In an interview with the MDS Coordinator on 06/09/2023 at 7:11AM, the MDS Coordinator stated CR #4 was only in the facility for 5 days and on the 5th day, she completed the OBRA and admission assessment but forgot to check off that she discharged . She also stated per policy of the RAI manual, the rule was to transmit completed assessments within 14 days. The MDS Coordinator stated she did not know what the implications were because this was the first this had happened to her. In an interview with the Program Director on 06/09/23 at 09:57AM, she stated she monitors information she receives from feedback reports, and provider reports and 5-star reports provided by CMS. She stated there was not necessarily a report to see missed MDS assessments. She also said she was not too familiar with all the types of MDS assessments, but in this case believes the MDS Coordinator made an honest mistake but had corrected the issue today. Record review of the RAI Manual, revised October 2019, stated, . Short-term or respite residents: An RAI must be completed for any individual residing more than 14 days on a unit of a facility that is certified as a long-term care facility for participation in the Medicare or Medicaid programs. If the respite resident is in a certified bed, the OBRA assessment schedule and tracking document requirements must be followed. If the respite resident is in the facility for fewer than 14 days, an OBRA Admission assessment is not required; however, an OBRA Discharge assessment is required.

Based on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 10%, based on 3 errors out of 30 opportunities, which involved 1 of 4 residents (Resident #7) and 1 of 3 staff (RN A) reviewed for medication errors in that: -RN A failed to administer Resident #7's medications via G-Tube ( A tube inserted into the abdomen directly into the stomach to provide nutrition, liquid and medications) individually and failed to administer a water flush between each medication. These failures could place residents who receive medications via gastrostomy tube by placing them at risk of inadequate therapeutic outcomes and a decline in health. Findings included: Record review of Resident #7's admission face sheet dated 05/15/2023 revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: malignant neoplasms (cancer) of the tongue, head, neck and face, respiratory failure (lungs cannot get enough oxygen into the blood), tracheostomy (an opening surgically created through the neck into the windpipe to allow air to fill the lungs), chronic heart failure, and G-Tube. Record review of Resident #7's Admission MDS dated [DATE] revealed in part: Resident #7's speech clarity the resident was absent of spoken words. The resident's BIMS was 14 to indicate he was cognitively intact. Resident # 7 was totally dependent by one staff for eating. The resident's active diagnoses were medically complex to include cancer, heart failure, tracheostomy. Record review of Resident #7's care plan dated 05/27/2023 revealed in part: Focus: Nutrition; Goal: To achieve/improve and maintain an adequate nutritional status; to administer tube feeding safely; to administer medications without complications; Interventions: If more than one medication was being administered, flush with 10ml of water between each medication. Record review of Resident #7's physician's order report dated June 2023 revealed the following orders: Multiple vitamin one tablet by feeding tube daily, order start date 05/16/2023; Entresto 24-26Mg (medication to treat chronic heart failure) one tablet by feeding tube two times daily, order start date 05/17/2023; Plavix 75 Mg (medication to prevent blood platelets from clumping together to form clots) one tablet by feeding tubes daily, order start date 05/24/2023. Record review of the unit training titled Feeding Tubes: Nasoenteral (Tube inserted through the nose to the stomach to administer medications, nutrition) , Gastrostomy and Small Bowel, dated 02/06/2023 read in part: Administer each medication separately, flush the tube after each medication administered with 30ml of water. In an observation on 06/07/2023 at 11:51 AM, Resident # 7 was sitting up in bed awake, alert and nonverbal. RN A checked Resident # 7's blood pressure which was 115/54. RN A returned to the medication cart. RN A placed the resident's multiple vitamin, entrestro and Plavix in the pill crusher. RN A crushed the three tablets together. RN A added the crushed medications to a cup with 280 ml of water. The three mediations were dissolved in the cup of water. RN A returned to the resident. RN A checked Resident #7's stomach residual (purpose of checking stomach residual was to check the amount of liquid in the stomach prior to medications and feedings). RN A flushed Resident #7's G-Tube with 15ml water. RN A added the three dissolved mediations in to a 60 ml syringe. The mediations were administered by gravity flow into the G-Tube. RN A administered all three medications at one time. In an interview on 06/07/2023 at 12:05 PM immediately after the medication administration RN A stated she did mix Resident #7s multiple vitamin, Plavix and entrestro together. RN A stated this was how she gave the resident his medications. RN A stated she administered the medications this way to prevent the G-Tube form clogging. In a follow up interview on 06/07/2023 at 1:15 PM RN A stated she did crush resident #7's Multiple vitamin, Plavix and entrestro together. RN A stated she put them together in one cup of water to dissolve the medications. The RN stated she wanted to prevent the resident's G-Tube from clogging. RN A stated each medication should have been crushed separate. She continued and stated she should have flushed after each medication with water. RN A stated the risk of not separating the medication was the possibility of an interaction between the medications. In an interview on 06/08/2023 at 12:22 PM, the Unit Manager stated her expectations were G-Tube medications were crushed and administered separately. The Unit Manager stated each medication was to be separated with a water flush. The Unit Manager stated each mediation was to be crushed separate then dissolved in water. She continued and stated G-Tube crushed medications were not to be administered together. The Unit Manager stated one risk of the medications administered together was a possible interaction between medications. The Unit Manager stated another risk was if the tube clogged during administration the nurse would not be able to determine which mediation had been administered. The Unit Manager stated to prevent this from occurring again all staff would be in serviced on G-Tube medication administration. The Unit Manager stated the nurse who administered the medication would be in serviced one on one. In an interview on 06/08/223 at 2:12 PM, the Director stated her expectations for G-Tube medications were crushed and administered separately. The Director stated each medication was dissolved in water. She continued and stated a water flush was to be given between each medication. The Director stated a risk of combining the mediations were compatibility. The Director stated another risk of combining the medication was not knowing what or how much of a medication was administered if the tube became clogged. The Director stated the plan to prevent this from occurring again was staff education. The Director stated the monitoring of medication administration was done by the Hospital Pharmacy Technician. The Director stated the Hospital Pharmacy Technician monitors medication administration. The Directory stated the Hospital Pharmacy Technician audited the staff by observing mediation administration monthly. In an interview on 06/09/2023 at 8:17 AM, the Hospital Pharmacy Technician stated she did monthly observations of medication administration to audit the staff's medication administration. The Pharmacy Technician stated she had not had any issues with her observation. The Pharmacy Technician stated she had not done any recent G-Tube administration observation. The Pharmacy Technician stated she followed the nurse and what medication that was scheduled. The Pharmacy Technician stated the correct way to administer the G-tube mediations was separately with a water flush between each medication to prevent them from mixing together. The Pharmacy technician stated if she observed a problem during her audits, she notified the Unit Manager for additional education. Record review of the policy titled Feeding Tube: Medication Administration dated February 2023 read in part .22. Administer liquid or dissolved medications by pouring it into the syringe and flush. A. After the administration of medications or formula, clear the tube by flushing it with a minimum of 15 ml of purified water .

Based on observation, interview and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infects for one 1 of 1 resident (Resident #63) reviewed for incontinence, in that; RN #21 handed the indwelling urinary catheter bag to PCA #9 above the bladder which resulted in back flow of urine. RN #21 did not perform hand hygiene during incontinent care for Resident #63 These failures affect 1 resident and placed him at risk of infection . Findings include: Resident #63 Record review of Resident #63's face sheet revealed admitted [DATE], 69yrs old with [DIAGNOSES REDACTED]. Record review of Resident #63's electronic record revealed he did not have a completed MDS or Care Plan for his Foley catheter. Resident #63 admitted [DATE]. Observation on 10/18/19 at 2:45 P.M. of Resident #63's incontinent and buttock wound care provided by RN #21 and PCA # 9 assisting revealed RN #21 had already set up her supplies on a white chux, on the resident's overbed table. RN #21 with assistance from PCA #9 turned Resident #63 to his left side facing the window, removed his indwelling foley catheter bag from the right side and passed it to PCA #9 who was positioned on the left of the bed. During this time surveyor noted yellow urine in the catheter tubing and 50cc in the outer collection measuring meter. Surveyor asked RN #21 if there was urine in the tubing that back flowed and RN #21 and PCA #9 responded simultaneously Yes. RN #21 unfastened the resident's brief and bowel movement approximately half dollar coin diameter with 1 inch depth was noted at the rectum. RN #21 opened a new package of wipes and removed 1wipe, cleaned the anus area one swipe and bowel movement got on her gloved index finger. RN #21 went back into wipe package with the bowel movement on her glove and removed another wipe and wiped his anus area again. RN #21 went back into the wipe package 5 times with the bowel movement on her glove and the last time used the same wipe for the left and right side of his buttocks wiping up and around the wound dressing to his right buttock, with same bowel movement soiled gloves on. RN #21 then washed her hands and double gloved them. RN #21 opened her wound care supplies that was on the table, removed his old dressing and removed her top/first layer of gloves (provided no hand hygiene), cleaned the stage 2 (dime size)wound to the right buttock and proceeded with the wound care treatment, never changing her gloves. RN #21 folded the old brief, that had scant bowel movement on it, inward toward Resident #63 and applied the new brief. RN #21 and PCA #9 then rolled him to the right side where PCA #9 further removed old brief and applied new brief then, removed his indwelling foley catheter bag from the left side and passed it to RN #21 who was positioned on the right of the bed during this time surveyor noted yellow urine in the catheter tubing again that back flowed. RN #21 and PCA #9 repositioned him, adjusted Resident #63's clothing and his bed linens, while wearing the same soiled gloves used to remove the old brief, then they washed their hands. Upon cleaning Resident #63's over bed table RN #21 picked up the unused wipes package, unused gauze, zinc tube and placed them in her left hand and used her right hand to remove the white chux and pushed it down X 2 in the same trash bag used to throw away the bowel movement wipes, old wound care dressing and old brief. RN #21 then without washing her hands used both her hands to place Resident #63's unused supplies, she had in her left hand, on his handwashing sink counter. RN #21 washed her hands and left the room. During an interview on 10/18/19 at 3:00 P.M., RN #21 stated she had been working for the facility for approximately one year and had not had an in-service on infection control but has had one on hand washing. She stated that she was taught to wash her hands before and after patient procedures and after changing gloves. RN #21 agreed that she should have done some type of hand hygiene after changing gloves. She further stated she double gloved to save time in changing gloves and that she should have changed her gloves when going into the wipe pack to prevent contamination of the other unused wipes in the packet. RN #21 stated she did not realize that she used the same gloves to remove the soiled brief and apply the new brief. RN #21 also said that if urine is in the tubing of the Foley catheter and goes back in the bladder it can cause infection, and that the tubing should be drained of urine then pass it over him. During an interview on 10/18/19 at 5:00 PM, the Nurse Educator stated she expected staff to do hand hygiene before donning and removing gloves, can use soap and water or alcohol based products. Nurse Educator said if gloves are soiled with poop, they change the gloves, if no bowel movement was on the gloves , they can continue with the same gloves and there was no need to change gloves with each new wipe until you get to a different Zone (body area). Nurse Educator further stated the expectation is to change gloves with a new brief because that is a clean item and should be clean. She continued to say before moving the foley catheter, urine in the tubing should be drained first to prevent re-entry of urine up-stream to the bladder. During an interview on 10/18/19 at 5:20 PM, with Director ED present , the DON stated she expected gloves to be changed with each wipe usage especially if soiled, staff should use clean to dirty technique. She stated that she probably would have done it differently, remove dirty then to clean and would have drained the urine out of the catheter tubing then move the bag. During an interview on 10/18/19 at 5:25 PM, the Director ED stated nurses can double glove, and taking off both gloves would be a glove change. Director ED said she expected staff to remove their gloves and either wash or sanitize their hands after touching a dirty area prior to moving to a clean area when performing incontinent care. Page #197, PR[NAME]EDURAL GUIDELINE #35 - INDWELLING URINARY CATHETER CARE, revealed the following elements: [NAME] Purpose 2. To help avoid urinary tract infections. B. Guidelines for Maintaining the Urinary Drainage System 5. Check that urine is draining freely through the system. 7. Keep the urine-collecting bag below the level of the bladder at all times to prevent backflow of old urine into the bladder. Maintain position of urine-collecting bag according to manufacture guidelines. Record review of facility policy and procedure titled _PCPS134 Hand Hygiene and Artificial Nails revised date 1/19/18 revealed in part:, Appropriate hand hygiene practice is the single most important factor in preventing the transmission of pathogens, some of which could be multi-drug resistant organisms, in healthcare settings. Strict adherence to hand hygiene practices has a direct correlation with reduction in incidence of healthcare acquired infections (HAIs), and therefore, directly contributes to patient safety. Proper use of gloves during patient care can also prevent transmission of infectious agents in high-risk situations. 4.1 Hand Hygiene is indicated 4.1.3 Patient Zone. 4.1.3.3 After body fluids exposure risk- After contact with body fluids or excretions mucous membranes, non-intact skin, and wound dressings; even if gloves were worn. 4.1.4 Before donning gloves and after glove removal, even if there was no patient contact. 4.1.5 Before moving from a contaminated-body site to a clean-body site during patient care, even if gloves were worn. 4.7 Glove Use 4.7.1 In no way does glove use modify hand hygiene indications or replace hand hygiene practices by using alcohol-based products or by hand washing with soap and water. 4.7.3 Change gloves during patient care if moving from a contaminated body site to another body site. Hand hygiene must be performed when changing gloves. 4.7.7 Double gloving for routine patient care(even when caring for patients on contact isolation) is not recommended. However, id double gloving is practiced, the healthcare provider must remove both sets of gloves and perform hand hygiene when changing gloves between tasks or upon completion of patient care. Review of the Texas Curriculum for Nurse Aides in Long Term Care Facilities (Fifth Edition (YEAR)): Page #145, Section II - Infection Control, Procedural Guideline Section #6 Hand Washing, revealed the following elements: B. Guidelines and Precautions 2. Hand-washing should be done at the following times: e. After contact with blood, body fluids and contaminated items (Procedural Guideline #7). f. Whenever hands are obviously soiled.

Based on observation, interview and record review, the facility failed to maintain an effective infection control program to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection for one of one resident (Resident #63) reviewed for infection control as evidenced by: RN #21 did not perform hand hygiene during incontinent care for Resident #63 This deficient practice affected one resident and placed him at risk of infections from cross contamination. Findings include: Resident #63 Record review of Resident #63's face sheet revealed admitted [DATE], 69yrs old with [DIAGNOSES REDACTED]. Record review of Resident #63's electronic record revealed he did not have a completed MDS or Care Plan for his Foley catheter. Resident #63 admitted [DATE]. Observation on 10/18/19 at 2:45 P.M. of Resident #63's incontinent and buttock wound care provided by RN #21 and PCA # 9 assisting revealed RN #21 had already set up her supplies on a white chux, on the resident's overbed table. RN #21 with assistance from PCA #9 turned Resident #63 to his left side facing the window, removed his indwelling foley catheter bag from the right side and passed it to PCA #9 who was positioned on the left of the bed. During this time surveyor noted yellow urine in the catheter tubing and 50cc in the outer collection measuring meter. Surveyor asked RN #21 if there was urine in the tubing that back flowed and RN #21 and PCA #9 responded simultaneously Yes. RN #21 unfastened the resident's brief and bowel movement approximately half dollar coin diameter with 1 inch depth was noted at the rectum. RN #21 opened a new package of wipes and removed 1wipe, cleaned the anus area one swipe and bowel movement got on her gloved index finger. RN #21 went back into wipe package with the bowel movement on her glove and removed another wipe and wiped his anus area again. RN #21 went back into the wipe package 5 times with the bowel movement on her glove and the last time used the same wipe for the left and right side of his buttocks wiping up and around the wound dressing to his right buttock, with same bowel movement soiled gloves on. RN #21 then washed her hands and double gloved them. RN #21 opened her wound care supplies that was on the table, removed his old dressing and removed her top/first layer of gloves (provided no hand hygiene), cleaned the stage 2 (dime size)wound to the right buttock and proceeded with the wound care treatment, never changing her gloves. RN #21 folded the old brief, that had scant bowel movement on it, inward toward Resident #63 and applied the new brief. RN #21 and PCA #9 then rolled him to the right side where PCA #9 further removed old brief and applied new brief then, removed his indwelling foley catheter bag from the left side and passed it to RN #21 who was positioned on the right of the bed during this time surveyor noted yellow urine in the catheter tubing again that back flowed. RN #21 and PCA #9 repositioned him, adjusted Resident #63's clothing and his bed linens, while wearing the same soiled gloves used to remove the old brief, then they washed their hands. Upon cleaning Resident #63's over bed table RN #21 picked up the unused wipes package, unused gauze, zinc tube and placed them in her left hand and used her right hand to remove the white chux and pushed it down X 2 in the same trash bag used to throw away the bowel movement wipes, old wound care dressing and old brief. RN #21 then without washing her hands used both her hands to place Resident #63's unused supplies, she had in her left hand, on his handwashing sink counter. RN #21 washed her hands and left the room. During an interview on 10/18/19 at 3:00 P.M., RN #21 stated she had been working for the facility for approximately one year and had not had an in-service on infection control but has had one on hand washing. She stated that she was taught to wash her hands before and after patient procedures and after changing gloves. RN #21 agreed that she should have done some type of hand hygiene after changing gloves. She further stated she double gloved to save time in changing gloves and that she should have changed her gloves when going into the wipe pack to prevent contamination of the other unused wipes in the packet. RN #21 stated she did not realize that she used the same gloves to remove the soiled brief and apply the new brief. RN #21 also said that if urine is in the tubing of the Foley catheter and goes back in the bladder it can cause infection, and that the tubing should be drained of urine then pass it over him. During an interview on 10/18/19 at 5:00 PM, the Nurse Educator stated she expected staff to do hand hygiene before donning and removing gloves, can use soap and water or alcohol based products. Nurse Educator said if gloves are soiled with poop, they change the gloves, if no bowel movement was on the gloves , they can continue with the same gloves and there was no need to change gloves with each new wipe until you get to a different Zone (body area). Nurse Educator further stated the expectation is to change gloves with a new brief because that is a clean item and should be clean. She continued to say before moving the foley catheter, urine in the tubing should be drained first to prevent re-entry of urine up-stream to the bladder. During an interview on 10/18/19 at 5:20 PM, with Director ED present , the DON stated she expected gloves to be changed with each wipe usage especially if soiled, staff should use clean to dirty technique. She stated that she probably would have done it differently, remove dirty then to clean and would have drained the urine out of the catheter tubing then move the bag. During an interview on 10/18/19 at 5:25 PM, the Director ED stated nurses can double glove, and taking off both gloves would be a glove change. Director ED said she expected staff to remove their gloves and either wash or sanitize their hands after touching a dirty area prior to moving to a clean area when performing incontinent care. Record review of facility policy and procedure titled _PCPS134 Hand Hygiene and Artificial Nails revised date 1/19/18 revealed in part:, Appropriate hand hygiene practice is the single most important factor in preventing the transmission of pathogens, some of which could be multi-drug resistant organisms, in healthcare settings. Strict adherence to hand hygiene practices has a direct correlation with reduction in incidence of healthcare acquired infections (HAIs), and therefore, directly contributes to patient safety. Proper use of gloves during patient care can also prevent transmission of infectious agents in high-risk situations. 4.1 Hand Hygiene is indicated 4.1.3 Patient Zone. 4.1.3.3 After body fluids exposure risk- After contact with body fluids or excretions mucous membranes, non-intact skin, and wound dressings; even if gloves were worn. 4.1.4 Before donning gloves and after glove removal, even if there was no patient contact. 4.1.5 Before moving from a contaminated-body site to a clean-body site during patient care, even if gloves were worn. 4.7 Glove Use 4.7.1 In no way does glove use modify hand hygiene indications or replace hand hygiene practices by using alcohol-based products or by hand washing with soap and water. 4.7.3 Change gloves during patient care if moving from a contaminated body site to another body site. Hand hygiene must be performed when changing gloves. 4.7.7 Double gloving for routine patient care(even when caring for patients on contact isolation) is not recommended. However, id double gloving is practiced, the healthcare provider must remove both sets of gloves and perform hand hygiene when changing gloves between tasks or upon completion of patient care. Review of the Texas Curriculum for Nurse Aides in Long Term Care Facilities (Fifth Edition (YEAR)): Page #145, Section II - Infection Control, Procedural Guideline Section #6 Hand Washing, revealed the following elements: B. Guidelines and Precautions 2. Hand-washing should be done at the following times: e. After contact with blood, body fluids and contaminated items (Procedural Guideline #7). f. Whenever hands are obviously soiled. Page #197, PR[NAME]EDURAL GUIDELINE #35 - INDWELLING URINARY CATHETER CARE, revealed the following elements: [NAME] Purpose 2. To help avoid urinary tract infections. B. Guidelines for Maintaining the Urinary Drainage System 5. Check that urine is draining freely through the system. 7. Keep the urine-collecting bag below the level of the bladder at all times to prevent backflow of old urine into the bladder. Maintain position of urine-collecting bag according to manufacture guidelines.

Based on observation, interview and record review, the facility failed to develop and/or implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and time frames to meet residents' mental and psychosocial needs for 1 of 8 Residents (Resident #165) reviewed for comprehensive care plans, in that: Resident #165 use of feeding tube was not included in his care plan. This failure affected 1 resident and placed him at risk of not having his needs met. Findings include: Resident #165 Record review of Resident #165's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #165's Admission's MDS dated [DATE] revealed a BIMS score of 5 indicating severe cognitive impairment. Further review of the MDS revealed he did not have a feeding tube and had a that therapeutic diet. Record review of Resident #165's care plan dated 9/21/19 revealed a problem area of nutrition that revealed he was on a heart healthy diet and has episodes of nausea. The nutrition care plan further stated he needs limited assistance to eat. His interventions included: 1. Assess patients' nutritional status and monitor for associated complications. 2. Monitor glucose, serum [MEDICATION NAME] levels and report abnormalities. 3. Medicate as prescribed for nausea and vomiting. 4. Refer to Dietary/Nutritional Consult for thorough nutritional assessment and planning. 5. Assess awareness and understanding of patients and/or caregiver regarding the importance of adequate nutritional intake and with their disease process. Further review of the care plan revealed no mention of care for Resident #165's feeding tube. Record review of Resident #165's [MEDICATION NAME] radiology (IR) Feeding Tube results dated 10/14/19 revealed study results, Examination: IR Gastrostomy Catheter Initial Placement, Clinical History: Dysphagia Malnutrition needing PEG, Procedure: Gastrostomy tube placement, Complication: No immediate Complications, Impression: Percutaneous placement of 16 French push-type gastrostomy tube, Plan: Okay to use gastrostomy tube in 6 hours. Record review of Resident #165's nursing note date 10/14/19 at 10:32AM revealed the resident was received status [REDACTED]. Record review of Resident #165's nutritional evaluation dated 10/14/19 at 1:57PM revealed recommendations, in part, .1. When PEG cleared for use. EN regimen as followed: - [MEDICATION NAME] 1.5 with goal rate at 50ml/hr. Initiate at 30ml/hour and advance 10 every 4 hours to goal rate . - Regular fluid flushed per MD to maintain tube patency and adequate hydration. Suggest 75 ml every 4 hours to provide additional 450Mls fluid daily. - When tolerating continuous regimen for > 24 hours, can advance to bolus regimen: 1 carton [MEDICATION NAME] 1.5 at 5 times daily . Further review of the evaluation revealed an assessment with details, in part, .Patient with confusion and difficulty swallowing, MBS (modified [MEDICATION NAME] Swallow)10/2 and 10/7. Per Speech Language Pathologist (SLP), patient not safe for PO (by mouth) diet at this time. Per MD, to continue pleasure feeds with nectar thick liquids. Patient started on TPN (Total [MEDICATION NAME] nutrition) due to family not being ready for PEG 10/10. PEG placed on 10/14 . The evaluation also reviewed diet orders that were ordered on [DATE] and started on 10/14/19 of, NPO effective Midnight Diet effective midnight, Comments: PEG insertions 10/14/19 Question: NPO Answer: Except Meds. Record review of Resident #165's physician progress notes [REDACTED]. Record review of Resident #165's nursing notes dated 10/15/19 at 8:10AM revealed, Hand off received from Night RN, Patient supposed to get PEG tube feeding from midnight, but per Night RN, waiting for kangaroo pump to start feeding. Tried to start feeding now but PEG tube is clogged, found granules in the PEG tube. Record review of Resident #165's TPN Progress note dated 10/15/19 at 3:25PM revealed in part, .-Changes today: clogged PEG tube - unable to start tube feed today, continue TPN at current rate . Record review of Resident #165's Nursing note dated 10/15/19 at 4:27PM revealed in part, .Tried to start feeding via PEG, but its clogged . Record review of Resident #165's Nursing note dated 10/15/19 at 7:32PM revealed in part, Spoke to Doctor regarding PEG tube clogged, MD will put the order to reinsert the PEG. Record review of Resident #165's imaging for IR [DEVICE] Exchange/Replace dated 10/16/19 at 6:31PM revealed an impression of, Uncomplicated gastrostomy tube exchange. The new Gastrostomy tube is ready for use. Record review of Resident #165's nursing note dated 10/16/19 at 6:18PM revealed in part, .Currently patient OFF unit. At 6:30PM received report from RN that patient has new PEG tube because de-clogging was not successful . Record review of Resident #165's nursing note dated 10/16/19 at 6:18PM revealed in part, .Procedure completed . Patient to be transferred back to SNF . Record review of Resident #165's Plan of Care note dated 10/17/19 at 1:58AM revealed in part, .patient tolerating PGT feedings . Observation and interview on 10/17/19 at 12:39PM, Resident #165 said he was doing okay and said he'd been at the facility for a few weeks, the resident was pleasantly confused. Resident #165 was attached to [DEVICE] feeding machine that was on and set to feed 50ml every hour and to flush 75ml every 4hrs. the machine read that 541Ml had been fed and 806ml had been flushed. The formula bag that was being administered was dated 10/16/19 and had 50ml/hr written on the bag. Observation on 10/18/19 at 10:19AM, Resident #165 was sleeping, his [DEVICE] was attached and running to the settings of feed 50ml every hour and to flush 75ml every 4hrs. The formula bag being administered was dated 10/17/19 at 9:00PM. Record review of Resident #165's Plan of Care note dated 10/18/19 at 2:19AM revealed in part, .patient tolerating tube feedings . Interview on 10/18/19 at 3:00PM, the MDS Coordinator reviewed the care plan on her computer and could not find where in the care plan it addressed Resident #165's feeding tube. She searched Resident #165's clinical record and said the resident did not come to the unit with [DEVICE] and said it was placed after he admitted . She said he had the [DEVICE] placed on 10/16/19 and started feedings yesterday (10/17/19). Interview on 10/18/19 at 5:30PM, Nurse Manager said she expects the care plans to be updated immediately after a change or if a new problem presents. The Nurse Manager said the care plans should be every shift. Interview on 10/18/19 at 5:52PM, MDS Coordinator said the care plan should be updated immediately when a new care area develops. The MDS Coordinator said herself and nurses are able to update the care plans. Record review of the facility's Assessment and Reassessment and Planning of Care policy (Revised 1/31/19) revealed in part, .The plan of care should be based upon needs identified during the admission assessment. The plan of care should be revised every shift and as necessary to reflect the changing needs of the patient and the patient's condition. Initiate planning for each active problem/condition/ comorbidity/ or care need which may affect or be affected by the course of hospitalization .The frequency of reassessment will be based on the patients diagnosis, condition and needs but a complete reassessment should occur at least every eight hours .

Based on observation, interviews, and record reviews the facility failed to provide services as outlined by the comprehensive care plan to meet professional standards of quality for 1 of 9 residents (Resident #165) during medication administration, in that: 1. RN #1 failed to completely administer thru the gastrostomy tube, [MEDICATION NAME] (Vitamin D3) 2,000 units as ordered by physician for Resident #165. This deficient practice affected 1 resident and placed him at risk of not receiving the intended therapeutic benefit of his medication. The findings were: Resident #165 Record review of Resident #165's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #165's Admission's MDS dated [DATE] revealed a BIMS score of 5 indicating severe cognitive impairment. Further review of the MDS revealed he did not have a feeding tube and had a that therapeutic diet. Record review of Resident #165's [MEDICATION NAME] radiology (IR) Feeding Tube results dated 10/14/19 revealed study results, Examination: IR Gastrostomy Catheter Initial Placement, Clinical History: Dysphagia Malnutrition needing PEG, Procedure: Gastrostomy tube placement, Complication: No immediate Complications, Impression: Percutaneous placement of 16 French push-type gastrostomy tube, Plan: Okay to use gastrostomy tube in 6 hours. Record review of Resident #165's care plan dated 9/21/19 revealed a problem area of nutrition that revealed he was on a heart healthy diet and has episodes of nausea. The nutrition care plan further stated he needs limited assistance to eat. His interventions included: 1. Assess patients' nutritional status and monitor for associated complications. 2. Monitor glucose, serum [MEDICATION NAME] levels and report abnormalities. 3. Medicate as prescribed for nausea and vomiting. 4. Refer to Dietary/Nutritional Consult for thorough nutritional assessment and planning. 5. Assess awareness and understanding of patients and/or caregiver regarding the importance of adequate nutritional intake and with their disease process. Further review of the care plan revealed no mention of care for Resident #165's feeding tube. Record review of Resident #165's Medication orders dated (MONTH) 2019 indicated Resident #165's Order [MEDICATION NAME] (vitamin D3) tablet 2,000 units oral daily start 10/18/19. During an observation of the medication pass on 10/18/19 at 11:45 a.m., RN #1 removed two [MEDICATION NAME] 1,000 unit tablets from her Medication WOW(Workstation On Wheels). She scanned Resident #165's arm identification bracelet, the 2 [MEDICATION NAME] packets, put the 2 white tablets into a silent night pill pouch, crushed the two white tablets with the silent night and poured the powdered white medication into a 30cc clear medication cup. RN #1 stopped Resident #165's feeding pump and disconnected the tubing, assessed the placement via aspiration with a 60cc irrigation syringe thru the lopez valve and then removed the syringe. RN #1 left the 60cc syringe attached to the tube, poured 20-25cc of water into the medication cup, stir the medication using the syringe tip(med was white powdered consistency that floated on top of water), connected the syringe to the lopez valve, poured the medication in the syringe which flowed thru via gravity and poured 20-30 cc of water thru the syringe via gravity. Surveyor noted there were 2-3 clumps of the white medication residue in the bottom of the syringe. RN #1 placed the residue syringe back in the syringe container and stated back in 1hour to turn pump on as she was walking out Resident #165 door. Surveyor intervened and asked to see the syringe in the container. Surveyor asked about the white clumps, RN #1 picked up the syringe agreed there were white clumps of mediation still in the syringe and that she did not see the medication that before disconnecting. RN #1 attached the syringe to the lopez valve and poured 20-30cc of water thru the syringe via gravity with twirling the syringe to facilitate the white medication going down the feeding tube, and disconnected the empty syringe from the tube placing it in the container. During an interview on 10/18/19 at 12:00 p.m., RN #1 confirmed there were white clumps of medication left in the medication syringe and that she didn't know how much of the [MEDICATION NAME] the resident actually got, maybe half of it she said. RN #1 further stated Resident #165 was ordered [MEDICATION NAME] for his bones for debility and would finish clean the meds from the syringe to ensure the resident was given all of the ordered dosage. Interview on 10/18/19 with the facility Nurse Educator at 4:40 p.m. revealed the expectation for administering medications thru a feeding tube is to make sure no mediation is left in the syringe and to flush the syringe until the medication passes thru. She agree that resident #165 did not receive the complete dosage of [MEDICATION NAME] the first time before surveyor intervention with RN #1. Interview on 10/18/19 with Nurse Manager at 5:20 p.m. revealed she agreed RN #1 did not administer the total dosage of [MEDICATION NAME] to Resident #165 as ordered by the physician and that was a medication error. Nurse Manager further stated RN #1 should have made sure the mediation had all passed thru the gastrostomy tube. Record review of facility's policy Skills; Feeding Tube: Medication Administration Quick Sheet revealed in part: Take steps to eliminate interruptions and distractions during medication preparation. 19. Prepare Medications for instillation into the feeding tube. b. Tablet: Crush the tablet using a pill-crushing device to grind it into a fine powder. Mix and dilute it in at least 30 ml of purified or sterile water. Fore more that one tablet, crush and dilute each individually. 27. Administer liquid or dissolved medication b pouring it into the syringe and flush. a. Following the administration of medications or formula, clear the tube by flushing with a minimum of 15ml of purified or sterile water. i. if water or medication does not flow freely, raise the height of the syringe to increase the rate of flow or have the patient change position slightly . ii. if these measures do not improve the flow, a gentle push with the bulb or plunger of the oral syringe may facilitate the flow. b. If administering more than one medication, give each separately and flush between medications with at least 15ml of purified or sterile water. c. Follow the last dose of medication with at least 15ml of purified or sterile water.

Based on interview and record review, the facility failed to ensure residents had right to organize and participate in resident groups in the facility for two of two confidential residents reviewed for residents right. Two of two confidential residents were unaware that they had the right to organize and participate in a group meeting. This failure affected 2 residents who could not participate in a resident council meeting without interference. Findings include: In an interview on 10/10/2018 at 11:24am, the Activities Director stated, the facility did not have Resident Council meetings because the Residents are not here long. In an interview on 10/11/2018 at 2:43pm, the Director of Rehabilitation stated the facility did not have Resident Council meetings because the Residents do not stay at facility long, but staff does go around daily and ask Residents if they have complaints. In an interview on 10/11/2018 at 2:43pm, the Nurse Manger said the facility did not have Resident Council because the Residents did not stay at the facility long. The facility's policy on resident council was requested but was not provided for review. In an interview on 10/11/2018 at 2:45pm, Confidential Resident #1 stated she has not heard of or know about a Resident Council at facility. In an interview on 10/11/2018 at 2:45pm, Confidential Resident #2 stated he has not been told about Resident Council meeting. The facility's CMS form 672 dated 10/10/2018 indicated the facility's census was 17 residents.

Based on observation, interview and record review, the facility failed to maintain an effective infection control program to help prevent the development and transmission of disease and infection for one of two halls reviewed for infection control as evidenced by: A bag of linen was on the floor by the elevator. This failure could affect eleven rooms on the left hall by placing at risk of infections and diseases. Findings included: Observation on 10/10/18 at 9:15 AM, on the left side of the facility main entrance elevator revealed a clear trash bag containing linen was found on the floor. Further observation on at 9:30 AM, revealed the clear trash bag was still in the same location. Interview on 10/11/18 at 10:19 AM with Nurse manager, she stated the expectation was when staff removed linen from the residents' rooms, the bag was to be tied, and placed in a bin, then transported to the first floor. The Nurse manager further stated she did not know why the bag would have been left on the floor by the elevator. She said maybe the bag fell off the cart during transport. The Nurse manager explained she did not know how long the bag was on the floor, but it was not supposed to be there. Interview on 10/11/18 at 4:19 PM, with PCA #5, she stated dirty linens are bagged, tired up and placed in dirty linen closet. PCA#5 further stated dirty linen bags are never placed on the floor or left unattended because someone could think it was something else. PCA#5 said she did not have any knowledge of the clear trash bag with linens in- front of the elevator. Record review of facility's policy titled Infection Prevention and Control (revised 01/31/2018) revealed in part .Policy and General Statement: The mission of (facility) is to provide the best care and service in a spiritual environment. In keeping with this mission, the infection prevention and control program provides a systematic, coordinated process to improve performance and to identify, prevent or control transmission of infection among patients, staff and visitors. The facility's CMS form 672 dated 10/10/18 indicated a census of 17.

Based on observation, interview and record review, the facility failed to ensure the facility records reflected the choices of formulated advance directive for one of eight residents (Resident 260) reviewed for advance directives. The facility failed to update Resident #260's chart to reflect an advance directive on file. This failure affected one resident by placing him at risk of not having his advance directive wishes honored by staff in emergency. Findings include: Record review of Resident #260's face revealed a [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Resident #260 Admission MDS was not completed at time of survey. Record review of Resident #260's electronic medical chart under code status revealed documentation This patient does not have an advance directive on file. Record review of Resident #260's electronic medical chart revealed a blue link to an advance directive attachment. Further review of link revealed a valid DNR that was signed and dated on (MONTH) 8, 2008. Observation on 10/10/2018 at 9:48am revealed Resident #260 was in his bed and dressed in a hospital gown. His bed was in a low position while he ate his meal. In an interview on 10/10/2018 at 4:05pm, Resident #260 stated he does have an advance directive which he provided at the time of his admission to hospital. Interview on 10/11/2018 at 1:00pm, the Rehabilitation Director stated she saw the conflicting information about Resident 260's advance directive on file. The Rehabilitation Director said the resident's time of entry (7:00pm) may be why it is entered wrong. The Rehabilitation Director stated she expects nurses who admit patients to go in the code status tab in the Resident's chart and see if the advance directives are in the system. The Rehabilitation Director stated she will look into why Resident #260's chart indicated no Advance Directive when he had one. Record review of the facility policy titled Official Policy and Procedures System . subject: Advance Directives (revised (MONTH) 1, 2014) read in part: .With regard to a Directive to Physicians, staff should be aware of the following: *When a patient has a Directive to a Physician .Place the copy of the Advance Directive in a prominent place .Medical Records Personnel a. Ensure the availability of completed Advance Directive from former and prospective patients. Such directives are received with the medical record when the patient is admitted , and should be scanned into Horizon Patient Folder . The CMS 672 dated 10/10/2018 indicated the facility census was 17 residents.

Based on interview, and record review, the facility failed to ensure all alleged violations involving neglect or abuse were reported immediately to the State survey and certification agency for one of nine residents (CR #2) reviewed for abuse or neglect. The facility did not report immediately to the State agency when CR #2 alleged that male staff touched her inappropriately. This failure could place the census of 18 residents at risk for neglect or abuse. Findings included: Record review of CR #2's face-sheet revealed a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of CR #2's MDS dated [DATE] revealed she was able to make self-understood, and had a BIMS score of 15, indicating she was cognitively intact. Further review of CR#2's MDS revealed she had no behaviors. Record review of the facility's investigation of CR #2's incident entitled Corrective Action Form dated 3/31/16 revealed CR #2 made an allegation that male staff touched her inappropriately. Review of facility's Investigation Finding within this Corrective Action Form read in part .Per Social Worker, pt has a history of sexual abuse as a child. Pt states three physicians roughed her up while on the(NAME)unit before coming to SNF while under anesthesia (unable to determine a time/day of this) Stated a PCA washed her breast too long . Further review of facility's Preventive Department Actions within this Corrective Action Form revealed .Management has removed all male caregivers from her care, including students and asked all care providers, physicians included, to not enter room without a female witness . During an interview on 9/8/16 at 11:50 AM the Nurse Manager stated complaints were reported to the SW, and the SW investigated and interviewed. The Nurse Manager stated the incident where CR #2 accused male staff of being inappropriate with her was reported to the SW. During an interview on 9/8/16 at 12:15 PM the SW stated she was unsure if the incident was reported to DADS. When asked if she was the facility designated abuse coordinator, she was unsure. She said the staff reported complaints or allegations to her. During an interview on 9/8/16 at 2:10 PM the Nurse Manager stated the incident with CR #2 was not reported to DADS. Interview on 9/9/16 at 11:00 a.m., the DON said the facility did not report CR#2's allegation of abuse to DADS. She stated the in-house investigation found the allegation to be unsubstantiated so they had no reason to believe the resident was abused or neglected. The DON said the facility's policy required them to report if they had cause to believe that a resident had been abused, neglected or exploited. Record review of the facility's Official Policy And Procedure, Subject: Patients and Legally Authorized Representative Grievance (Revised April 30, 2014) revealed .III. Procedure A. The hospital's grievance process is approved by the governing body. The hospital's governing body is responsible for the effective operation of the grievance process, which includes the hospital's compliance with all the CMS grievance process requirement . Record review of facility's official Procedure for Abuse and Neglect And Misappropriations (Revised 7/2016) revealed in part .G. Reporting - The following incidents must be reported to the Texas Department of Human Services State Office,(NAME) TX, immediately upon learning of the incident: 1. Abuse, witnessed and/or alleged. 2. Neglect .The Social Service Department will facilitate the formal reporting of incidents to the TDHS . The facility 672 dated 9/7/16 indicated the census was 18 residents.

Based on observation, interview and record review, the facility failed to develop and implement written policies and procedures that prohibit mistreatment, neglect and abuse of residents for one of nine residents (CR #2) reviewed for abuse or neglect. The facility failed to designate a person responsible for the oversight of abuse prevention. The facility failed to implement and follow its policy on reporting allegations of abuse made by CR#2. This failure could affect 18 residents, placing them at risk of abuse, neglect and misappropriation of their funds by denying them the opportunity of having an allegation or incident reported and investigated by outside officials to prevent reoccurrence. Findings include: Record review of facility's policy on abuse, neglect and misappropriation dated 7/2016 revealed the policy did not identify a person designated for abuse, neglect and misappropriation coordination. Further record review of the facility's policy on abuse, neglect and misappropriation dated 7/2016 read in part .patients will have the right to be free from verbal, sexual physical and mental abuse corporal punishment and involuntary seclusion. Implementation of this policy will be accomplished through the following: Prevention - patients, family, family members and staff will be provided information about and to whom to report concerns, incidents and grievance without fear of retribution. If concerns, incidents, or grievances are reported, the patient/family member/staff member will be given feedback regarding the concerns that have been expressed. Investigation - the social worker/designee shall conduct a thorough investigation with written documentation detailing such investigation. This includes situations in which a staff member receives a complaint alleging acts or omissions that may constitute abuse, neglect exploitation, misappropriation of property or illegal or unprofessional or unethical conduct. Reporting - the following incidents must be reported to Texas Department of Human Services state office Austin TX, (DBA DADS since 09/01/04), immediately upon learning of the incident: abuse, witnessed and/or alleged, neglect, exploitation, death and missing patients, misappropriation of patient's property and drug diversion. The social service department will facilitate the formal reporting of incidents to the TDHS . Observation on 9/7/16 between 8:30 a.m. and 10:30 a.m. during initial tour revealed the facility had posted signs in all residents' rooms indicating all complaints should be reported to the Resident Liaison, with her phone number. Interview on 9/7/16 at 9:30 a.m., during entrance conference, the Nurse Manager reported the facility did not have a designated abuse/neglect coordinator. She further said the facility had a patient liaison who rounded daily, and patients could report their grievances or concerns to. During a confidential group interview on 9/8/16 at 10:00 a.m., four of four residents had no knowledge of any designated person responsible for abuse prevention coordination. Four of four residents said they would call the number of the Resident Liaison posted in their room to report any concerns. Interview on 9/8/16 at 1:50 p.m., the Resident Liaison said she rounded daily and followed up with complaints from residents in the unit. She further said she involved the unit manager to investigate residents' concerns. She did not know DADS' requirements for reporting certain incidents. Interview on 9/8/16 at 3:15 p.m., the Social Worker said the facility staff would automatically report complaints from the residents to her. She stated she would follow up and involve other hospital staff, and depending on the complaint, APS would be notified. The Social Worker did not know certain incidents needed to be reported to DADS and did not know what criteria made an incident a reportable. When asked if she was the facility designated abuse coordinator, she was unsure. She said the staff reported complaints or allegations to her. Interviews with 12 alert and oriented confidential residents on 9/9/16 from 9:50 a.m., to 10:30 a.m., all 12 residents reported no knowledge of any facility designated person who coordinated abuse prevention. They said they would tell the nurses or the Resident Liaison if they had allegations of abuse or neglect. CR#2 Record review of CR #2's face-sheet revealed [AGE] year old female admitted to facility on 3/15/16 and discharged on [DATE]. Her [DIAGNOSES REDACTED]. Record review of CR #2's MDS dated [DATE] revealed CR #2 was able to make self-understood, and had a BIMS score of 15. Further review of CR#2's MDS revealed she had no behaviors. Record review of the facility's investigation of CR #2's incident entitled Corrective Action Form dated 3/31/16 revealed CR #2 made an allegation that male staff touched her inappropriately. Review of facility's Investigation Finding within this Corrective Action Form read in part .Per Social Worker, pt has a history of sexual abuse as a child. Pt states three physicians roughed her up while on the Dunn unit before coming to SNF while under anesthesia (unable to determine a time/day of this) Stated a PCA washed her breast too long . Further review of facility's Preventive Department Actions within this Corrective Action Form revealed .Management has removed all male caregivers from her care, including students and asked all care providers, physicians included, to not enter room without a female witness . Interview on 9/8/16 at 11:50 a.m., the Nurse Manager, said complaints were reported to the Social Worker (SW), and the SW investigated and interviewed. The Nurse Manager also said the incident of CR #2 accusing male staff of being inappropriate with her was reported to the SW. Interview on 9/8/16 at 12:15 p.m. the SW, she stated she was unsure if the incident was reported to DADS. Interview on 9/8/16 at 2:10 p.m. the Nurse Manager said the incident with CR#2 was not reported to DADS. Interview on 9/9/16 at 11 a.m., the DON said the facility did not report CR#2's allegation of abuse to DADS. She stated the in-house investigation found the allegation to be unsubstantiated so they had no reason to believe the resident was abused or neglected. The DON said the facility's policy required them to report if they had cause to believe that a resident had been abused, neglected or exploited. Record review of the facility's Official Policy And Procedure, Subject: Patients and Legally Authorized Representative Grievance (Revised April 30, 2014) revealed .III. Procedure A. The hospital's grievance process is approved by the governing body. The hospital's governing body is responsible for the effective operation of the grievance process, which includes the hospital's compliance with all the CMS grievance process requirement . Record review of facility's official Procedure for Abuse and Neglect And Misappropriations (Revised 7/2016) revealed in part .G. Reporting - The following incidents must be reported to the Texas Department of Human Services State Office, Austin, TX, immediately upon learning of the incident: 1. Abuse, witnessed and/or alleged. 2. Neglect .The Social Service Department will facilitate the formal reporting of incidents to the TDHS . The facility 672 dated 9/7/16 indicated the census was 18 residents.

Based on interview and record review the facility failed to complete assessments accurately to reflect the status of one of eight residents (Resident #1) reviewed for accurate assessments. Resident #1's initial assessment MDS did not identify all active diagnoses. This failure affected one resident and placed 17 other residents at risk of a decreased quality of care and not having their individualized needs met or communicated accurately to staff. Findings include: Resident #1 Record review of Resident #1's face sheet revealed a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #1's initial assessment MDS, dated [DATE], revealed the following active diagnoses; cancer, hypertension, diabetes mellitus, malnutrition, chronic lymphocytic [MEDICAL CONDITION] of b-cell type not having achieved remission. Graft-verse-host disease, [MEDICAL CONDITION] and other malaise, long term (current) use of non-steroidal anti-inflammatories. Further review of this MDS revealed it did not identify the resident's other active [DIAGNOSES REDACTED]. Observation on 9/7/16 at 3:10 p.m. revealed Resident #1 in his room, alert, oriented, with a physical therapist. The resident's skin to his upper body was reddened and peeling off, with [MEDICAL CONDITION] all over his upper body. Interview on 9/8/16 at 11:40 a.m., the MDS coordinator said another staff completed the MDS for Resident #1. She further said all active [DIAGNOSES REDACTED]. She said active [DIAGNOSES REDACTED]. Interview on 9/9/16 at 10:00 a.m., the MDS coordinator said the facility used the MDS 3.0 manual for guidelines as the policy for MDS completion. Facility's CMS form 672 dated 9/7/16 revealed a census of 18 residents.

Based on observation, interview and record review the facility failed to promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect for two of 18 residents (Resident #3 and #15) reviewed for dignity. Residents #3 and 15 were not provided assistance with nail care despite their requests, in violation of facility protocol. These failures affected two residents and placed 12 other residents who needed assistance maintaining personal hygiene and grooming at risk of health and psychological decline. The findings include: Resident # 3 Record review of Resident #3's face-sheet revealed a [AGE] year old female, admitted to facility on 9/1/16. Her [DIAGNOSES REDACTED]. Observation and interview on 9/7/16 at 9:00 a.m., revealed Resident #3 dressed in a gown, lying in bed. Her fingernails on both hands were long. When asked about her nails, Resident #3 stated she did not like having long fingernails, but would cut them when she returned home, because the facility did not cut fingernails. Observation and interview on 9/8/16 at 12:23 p.m., Resident #3 was in bed ready for wound care to sacral stage III. She was alert and oriented. Resident # 3 had very long untrimmed fingernails. She reported sacral stage III was itching last night and she scratched the area with her nails which caused the wound to bleed. Resident #3 said she had been hospitalized since May and had not been able to trim and cut down her long fingernails. Resident #3 stated her fingernails were too long and she would like to have them trimmed. Interview on 9/8/16 at 12:25 p.m., RN #22 said the facility did not provide nail care during a patient's stay. She further said some patients were referred to the podiatrist when needed but fingernails were not trimmed. Interview on 9/9/16 at 12:40 p.m., the DON said the facility tried to accommodate the needs of the residents during their stay. She further said she looked at Resident #3's nails yesterday and she was working on getting them trimmed. The DON stated the unit did not have a policy on nail care and had no system in place to address nail care. She said in the past, such needs were addressed when they came up by sending patients to nail salon across the street to get nail care. Resident #15 Record review of Resident #15's face-sheet revealed a [AGE] year old male, admitted to facility on 8/31/16. His [DIAGNOSES REDACTED]. Observation and interview on 9/7/16 at 9:20 a.m., revealed Resident #15 dressed in a gown, sitting on his bed. Spouse visiting with the Resident. His fingernails on both hands were long. Resident #15 stated he had asked the facility staff for assistance with cutting his fingernails, but had not yet been assisted. Interview on 9/7/16 at 9:05 a.m. the NT (Night) Manager stated the facility staff did not cut Residents' fingernails. The NT Manager further stated Residents had the option to go to the salon to have their nails cut at their own expense. Interview on 9/8/16 at 2:15 p.m. the Nurse Manager, stated the facility did not have a policy and procedure on nail care. The Nurse Manager further stated the facility had a Clinical Skills - Nail and Foot Care Quicksheet. Record review of facility's Clinical Skills - Nail and Foot Care Quicksheet (Reviewed March 2016) revealed in part .24. File and trim the fingernails using the patient's specifications regarding shape and length . Facility CMS form 672 dated 9/7/16 revealed a census of 14 residents required assistance with ADLs.

Based on observation interview and record review the facility failed to store, prepare and distribute food under sanitary conditions. The walk-in freezer was not operating at the appropriate temperature. The stove burners were black and the back splash was not clean. Foods stored in the cooler and freezer were not labeled and dated. The smoker with racks was not clean. The pureed foods that were stored in the freezer were not labeled and dated. These failures affected 16 residents who ate food prepared in the kitchen by placing them at risk of food borne illness or disease. Findings include: Observation of the walk-in freezer on 10/29/2013 at 9:50 A.M. revealed several small circles of ice formation around the two fans and thick layer of ice on the poles that held the shelves. One thermometer in the freezer located high on around the fans revealed -20 degrees Fahrenheit to -30 degrees Fahrenheit. The thermometer was read by an unidentified cook who was working in the kitchen. Interview on 10/29/2013 at 9:30 A.M. the Director of Food and Nutrition Services revealed the freezer condition had been referred to the outside contractor. At this time a copy of the requisition showing when the outside contractor was contacted was requested. Record review on 10/29/2013 at around 3:15 P.M. revealed a copy of the outside contractor ' s invoice dated 10/29/2013 which read the walk-in freezer had been repaired on 10/29/2013. The evaporation motor had been changed Observation in the kitchen on 10/29/2013 at 9:45 A.M. of the stove revealed a black area on the back splash and a thick black crust on the burners. Observation in the kitchen on 10/29/2013 at 10:05 A.M. revealed in the cold storage area on the shelf was Salsa in a large steam table pan covered with plastic wrap not labeled and dated. Interview with the Chef on 10/29/2013 at 10:05 A.M. stated he did not know why the salsa was not marked and he would have to check with my cook. Observation in the kitchen on10/29/2013 at 10:07 A.M. revealed 2 meat smokers with 3 racks in each. All the racks had a brown substance stuck to the racks. There were several racks stored on top of the smoker which were also covered with the brown substance. Three steam table pans on the floor in front of the roaster were observed at the same time which contained a black substance with some liquid. There was nothing cooking in the smoker. Interview on 10/29/2013 at 10:10 A.M. the Divisional Manager and the Dietitian revealed there was no cleaning schedule. They both stated that cleaning was a part of the daily duties of the steward. Observation in the kitchen on 10/29/2013 at 10:30 A.M. revealed in cardboard boxes stored in the freezer: Pureed Green Beans (opened) individual servings sealed in plastic Sheets with no receiving date. Two bags of Burger Patties in an open cardboard box with both bags opened with 4 Burger Patties in each not labeled and dated Pureed Roast Pork 7 individual servings sealed in plastic in an opened box no date to indicate when received and when opened. Pureed Roast Beef 2 sheets of 6 each individual servings sealed in plastic in an opened box not dated as to when it was opened. Pureed Peas 2 sheets of 3 individual servings sealed in plastic in an opened box not dated as to when it was opened. Pureed Pears 19 individual servings sealed in plastic in an opened box not dated as to when it was opened. Pureed Bread 2 sheets of individual servings, one sheet with 1 pureed serving and another with 10 individual servings sealed in plastic not dated as to when it was opened. Chicken Pureed 8 individual servings sealed in plastic not dated as to when it was opened. Interview on 10/29/2013 at 10: 40 A.M the Chef stated the food should have been labeled and dated. Observation and interview on 10/29/2013 at 10:50 A.M. revealed the bottom of the inside freezer had a dried substance stuck on the side . The Divisional Manager stated the freezer should be cleaned on regular basis. Record review of the facility ' s Food Labeling Policy title: Official Procedure- FNS-PR-203 not dated revealed all foods must be labeled in compliance with the City of Houston Department and the Texas Department of Health. To maintain the quality throughout the department, all foods must be labeled . This included raw food, frozen food, ingredients, cooked food, processed food, prepared food and leftovers. The same policy revealed all in-use and stored foods must be labeled with product name, opening or preparation date, use by date and associate initials. Record review of cleaning schedule provided by the facility on 10/30/2013 revealed cleaning schedule title: Room Service Cleaning Schedule was dated 10/28/2013 through 11/02/2013. The scheduled showed which staff member was responsible for cleaning which item but no signatures or check off system was noted on the form. Record review of the freezer temperature log dated September 2013 revealed the temperature to be between - 4 and 3 degrees Fahrenheit. The same form dated October 2013 revealed temperatures from -4 to 7 degrees Fahrenheit. Facility Form CMS 672 dated10/29/2013 revealed a census of 20 with 4 residents being nourished by feeding tubes.

Based on observation, interview, and record review the facility failed to be free of a medication error rate of 5% or greater. The medication error rate was 9 % involving 1 staff (RN#15) and 1 resident (Resident # 8) There were 3 errors with 31 opportunities. RN #15 did not provide a water flush between the first and second and seventh and eighth medications administered through the feeding tube of Resident # 8 . RN #15 did not stop the tube feeding at least 30 minutes prior to administering Resident #8's medication [MEDICATION NAME]. These failures affected 1 resident and placed 19 residents at risk of medication errors which could result in physical complications and a decline in health. Findings include: Resident #8 Record review of Resident #8 ' s admission information revealed the resident was admitted to the facility on [DATE]. His date of birth was 10/21/40. Resident #8 ' s admission [DIAGNOSES REDACTED]. Record review of Resident # 8 ' s admission MDS identified the resident ' s cognitive status as cognitively intact. Record review of Resident #8 ' s Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Observation on 10/30/13 at 8:55 A.M. revealed RN# 15 crushed Resident #8 ' s medication and carried them to the bedside. RN#15 administered the first and second crushed medications without a flush between them. The observation continued and RN#15 did not flush between the seventh and eighth medications administered through the resident ' s tube. Observation on 10/30/13 at 8:55 A.M. revealed the resident ' s tube feeding was running via pump. It was turned off when RN#15 was ready to start administering the medications. [MEDICATION NAME] 600 mg was crushed and administered through the nasal feeding tube. Interview on 10/30/13 immediately following the observation RN #15 stated she did not know the order she gave the medications. She stated she did not know which medications were given first, second seventh and eighth. She stated she did not flush between some of the medications. Interview on 10/30/13 at 12:40 P.M. when asked about the medication being given before meals, RN#15 stated before a meal sounded confusing and that she did not understand what that meant. She continued and stated I guess the pump should have been turned off an hour before giving. She stated she was going to call the pharmacist because she did not understand exactly what she was to do. Interview on 10/30/13 at 12:40 P.M. after a phone conversation with the hospital pharmacist who was unidentified, RN #15 stated the [MEDICATION NAME] was to be given 30 minutes before a meal. Interview on 10/30/13 at 1:45 P.M. the Nursing Director stated when a medication was to be given before a meal and if the resident had a tube feeding running she would expect the tube feeding to be stopped for a period of time prior to the medication being administered. Record review of MedicineNet.com revealed [MEDICATION NAME] recommended dose is 30 minutes before breakfast and dinner. Record review of the facility policy and procedure titled ... " Medication Administration by Nurses " Date revised 6/1/13 revealed " The purpose of this policy and procedure is to promote the safe administration of medication by nurses within their scope of practice ... A 30 ml water flush should be administered before and after the medication ... " Review of the policy did not reveal turning off the tube feeding before administering medications when indicated. Record review of the facility patient education form provided by the Nursing Director titled " Taking Medication Through a Feeding Tube " dated 2000-2013 revealed "...Be sure to flush your tube with 5 ml (about 1 teaspoon) or more of warm water between all medications. Take each medication by itself. Never mix medication together in the syringe ..." The facility CMS form 672 listed 20 residents in the facility.

Based on observation, interview and record review the facility failed to ensure staff provided services that met professional standards of quality for nursing care to 1 of 6 residents (# 8) reviewed for professional standards concerning medication administration. RN #15 did not obtain an apical heart rate for Resident # 8 prior to administration [MEDICATION NAME] (cardiac medication which slows the heart rate). This failure affected 1 resident and placed 19 residents at risk of not receiving the correct nursing interventions which could result in an abnormally lower heart rate. Findings Include: Texas Administrative Code Title 22 Examining Boards Part 11 Texas Board of Nursing Chapter 217 Licensure, Peer Assistance and Practice Rule 217.11 Standards of nursing Practice The Texas Board of nursing is responsible for regulating the practice of nursing within the State of Texas for Vocational Nurses, Registered Nurses, and Registered Nurses with advanced practice authorization. The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure or advanced practice authorization. Failure to meet these standards may result in action against the nurse ' s license even if no actual patient injury results. (1) Standards Applicable to all nurses. All vocational nurses, registered and registered nurses with advanced practice authorization shall: (A) Know and conform to the Texas Nursing Practice Act and the boards rules and regulations as well as all federal, stated, or local laws, rules or regulations affecting the nurse ' s current area of nursing practice;... (C) Know the rational for and the effects of medications and treatments and shall correctly administer the same; (iv) Administration of medications and treatments; Resident #8 Record review of Resident #8 ' s admission information revealed the resident was admitted to the facility on [DATE]. His date of birth was 10/21/40. Resident #8 ' s admission [DIAGNOSES REDACTED]. Record review of the resident ' s Admission Minimal Data Set (MDS) revealed he was cognitively intact. Record review of the physician's orders dated October 25, 2013, revealed [MEDICATION NAME] 0.125 mg daily monitor heart rate and rhythm. Interview on 10/30/13 at 8:50 A.M. RN#15 stated she reviewed Resident #8 ' s vital signs which had been given to her 30 minutes prior. The vital signs had been taken by the CNAs but she did not know when they were actually obtained. Observation on 10/30/13 at 8:55 A.M. revealed RN#15 crushed the medication [MEDICATION NAME] 0.125 mg and administered it to Resident # 15 through his feeding tube without obtaining a heart rate at the time of the administration. Interview on 10/31/13 at 12:00 P.M. RN#15 stated she did not realize that an apical heart rate should be done prior to giving the [MEDICATION NAME]. Interview on 10/30/13 at 2:33 P.M. the Nurse Director stated the apical heart rate should have been taken by the nurse prior to giving the [MEDICATION NAME]. The vital signs that were taken by the CNA ' s were taken off a machine. Record review of " Lippincott ' s Nursing Drug Guide " dated 2005 revealed "[MEDICATION NAME] ... Therapeutic actions decreases heart rate ... Interventions ...monitor apical pulse for 1 minute before administering hold if pulse is < 60 beats per minute wait 1 hour and retake ..." Record review of the facility policy and procedure titled ... " Medication Administration by Nurses " Date revised 6/1/13 revealed " The purpose of this policy and procedure is to promote the safe administration of medication by nurses within their scope of practice ..." Continued review of this policy did not reveal specific [MEDICATION NAME] administration nursing interventions. Record review of the facility policy and procedure titled "... IV Drips and High-Risk Medications in the Acute Care Setting: Administration and Patient Placement " revise dated 12/1/11 did not reveal specific [MEDICATION NAME] administration nursing interventions. CMS form 672 revealed the census was 20 residents.

Based on observation, interview and record review the facility failed to provide safe storage of resident medications for 1 of 6 residents (Residents #8) reviewed for safe storage of medications. Resident #8 medications were not properly secured in the medication cart. This failure affected 1 resident and placed 19 residents at risk of drug diversion and not having their medications available, resulting in a physical or psychosocial decline in health. Findings include: Resident #8 Record review of Resident #8 ' s admission information revealed the resident was admitted to the facility on [DATE]. His date of birth was 10/21/40. Resident #8 ' s admission [DIAGNOSES REDACTED]. Observation on 10/30/13 at 8:55 A.M. revealed RN #15 rolled the medication administration computer to Resident #8 ' s room and left it in the hall at the door. RN #15 walked into the room turned her back on the computer and was talking to the resident. RN#15 washed her hands. Unattended on top of the computer stand were the following medications: [REDACTED] Coreg, Vitamin B, Digoxin, Lasix, Zestril, Aldactone, Lopid, a vials of Novolog insulin and a tube of Zinc Oxide cream. Observation on 10/30/13 at 9:22 A.M. revealed RN #15 removed the tube of Zinc Oxide cream from the top of the computer stand and reentered the resident ' s room. RN#15 pulled the privacy curtain around the resident to apply the cream. The vial of Novolog Insulin was left unattended on top to the computer stand out in the hall. Interview on 10/30/13 immediately after the observation RN#15 stated the first time she left the medicine because the surveyor was there. She continued and stated she usually rolls the computer into the room. She then stated " you got me " . Interview on 10/30/13 at 1:45 P.M. The Nurse Director stated medications should be secured and not left unattended. Record review of the facility policy titled " Medication Storage and Handling Prior to Administration to Patients " Date Revised/Reviewed 1/1/12 revealed ... " Appropriate medication storage increases patient safety. Medication storage is designed to assist in maintaining medication integrity, promote the availability of medications when needed, minimize the risk of medication diversion, and reduce potential dispensing errors. This policy addresses the safe storage and handling of medication between receipt of a medication by an individual health care provider and medication administration ... Security ... Once the medication is removed, the medication should remain with the individual at all times and should not be left unattended .If medications are left in a room, they should be secured. A staff member must always be present in a room containing medications when there are patients in the area." The facility ' s CMS 672 revealed census was 84 residents.

Based on observation, interview, and record review, the facility failed to maintain an infection control program that provided a safe environment that would assist in the prevention of infection from occurring to 5 of 10 sampled residents ( Residents # 4, # 8, # 15, #16, and # 22) and 1 random resident ( Resident # 11) that received care. The facility failed to ensure that: RT # 1 established a clean work surface prior to providing tracheostomy care to Resident # 16, performed hand-hygiene between glove changes, and did not double-glove. CNA # 1 performed hand hygiene between glove changes during perineal care to Resident # 22. CNA # 1 sanitized the Blood Glucose Kit prior to taking it into Resident # 22's room. RN # 2 performed hand hygiene between a glove change after administering an ointment to Resident # 11's feet. RT # 1 performed hand-hygiene between glove changes during the provision of tracheostomy care to Resident # 8. RT # 2 performed hand-hygiene between glove changes and did not double-glove during the provision of tracheostomy care to Resident # 8. CNA # 3 performed hand hygiene in between glove changes during the provision of indwelling catheter care to Resident # 8. CNA # 2 performed hand hygiene between glove changes during provision of indwelling catheter care to Resident # 8. CNA # 4 did not use contaminated gloves and performed hand hygiene between glove changes during the provision of peri-care to Resident # 15. RN # 3 performed hand hygiene between glove changes during the provision of wound care to Resident # 4. The failure to use appropriate hand hygiene and proper cleaning of equipment affected 6 residents and placed 16 residents at risk of facility-acquired infections. Findings include: Resident #16: Record review of Resident #16 ' s admission information revealed he was admitted on [DATE] for Ventriculopertoneal Shunt replacement. Resident #16 was [AGE] years old. Observation on 9/27/11 at 11:30 A.M. of Resident #16 revealed the resident was resting in bed with his eyes closed. The head of his bed was elevated. He had oxygen administered via the tracheostomy (trach) collar going into a trach in his neck. The resident was non verbal. Observation on 9/28/11 10:15 A.M. revealed RT #1 preparing to perform Tracheostomy(trach) care to Resident #16. RT#1 performed hand hygiene and gloved. He placed a trach care kit on the resident ' s unclean over bed table. He used his arm to slide the resident ' s tray down a little which provided a corner of the table to work from. The table was cluttered with the resident ' s breakfast tray, a water pitcher and water glasses. During the procedure RT #1 cleaned around the outside of the resident ' s trach and changed his gloves without performing hand hygiene. RT #1 poured hydrogen peroxide into the trach kit then donned another pair of sterile gloves on top of the unsterile gloves. RT #1 cleaned around the trach and removed the inner cannula. He removed the sterile gloves and inserted the new inner cannula while wearing the unsterile gloves. Interview on 9/28/11 at 3:15 P.M. RT #1 stated he double gloved as protection if one glove tore. Interview on 9/28/11 at 4:00 P.M. the RT Director stated double gloving was not the facility's practice. Double gloving was not acceptable and it would be corrected. Resident # 22 Record review of Resident #22 ' s admission sheet revealed she was admitted to the facility on [DATE]. Resident was a [AGE] year old female. Her admitting [DIAGNOSES REDACTED]. Stage 4 [DIAGNOSES REDACTED]. Observation on 9/27/11 at 9:40 AM of Resident #22 revealed she was alert and oriented. The resident was sitting up in bed on an air mattress. Intravenous fluids were infusing along with the pain medication [MEDICATION NAME] to a catheter in her chest. The resident had a splint and support strap to her right arm which was bent at the elbow and held tight against her chest. Resident #22 had an indwelling catheter to bedside drainage with clear yellow urine. Observation on 9/28/11 at 11:00 revealed CNA #1 preformed perineal care to Resident #22. After CNA #1 cleaned the resident ' s perineal area she removed her gloves and donned new gloves with out hand hygiene. CNA #1 cleaned around the resident ' s indwelling catheter and changed her gloves without hand hygiene. Observation on 9/28/11 at 11:45 A.M. revealed CNA #1 carried the glucose monitoring kit into Resident #22 ' s room and placed it on her unclean bed side table. After taking Resident #22 ' s blood glucose level CNA #1 removed the glucose monitoring kit from the resident ' s beside and returned all the equipment to the nurses station without cleaning it. Interview on 9/28/11 at 3:10 P.M. CNA #1 stated she was to wash her hands when her gloves were changed. As the interview continued she stated the blood glucose kit was to be cleaned between patients and since she did not go to another room she did not feel cleaning the machine was needed. She stated she took the machine to the nurse ' s station and that it should be cleaned before being used on another patient. Resident #11 Observation on 9/27/11 at 8:15 A.M. revealed RN #2 applied lotion to Resident #11 ' s feet. RN# 2 removed her gloves and donned new gloves without performing hand hygiene. RN # 2 continued to administer Resident #11 ' s oral medications to her. Resident # 8 Record review of Resident # 8 admission sheet revealed she was admitted to the facility on [DATE]. Resident was a [AGE] year old female. Her admitting [DIAGNOSES REDACTED]. Record review of Resident # 8 ' s admission assessment MDS dated [DATE] revealed Resident # 8 had an indwelling catheter for urinary elimination and an ostomy for bowel elimination. The same MDS identified Resident # 8 was receiving trach care and was on oxygen therapy. Observation on 09/28/11 at 9:25 A.M., RT # 1 was observed performing tracheostomy care and suctioning to Resident # 8. RT # 1 changed gloves multiple times with no hand hygiene. He was observed donning two pairs of gloves at one time (double gloving). He wore regular gloves and then wore sterile gloves on top. After cleaning the trachaeostomy's outer area, he removed the first glove and continued to suction Resident # 8 ' s mouth. There was no hand hygiene observed with six glove changes done throughout the procedure. Observation on 09/27/11 at 2:00 P.M. RT # 2 was observed providing tracheostomy care to Resident # 8. She wore sterile gloves and was observed cleaning the resident ' s tracheostomy's outer area. She changed her gloves and donned clean gloves without any hand hygiene. RT # 2 continued care, using regular gloves to remove the inner tracheostomy cannula, and re-inserted the same cannula. She stated at this same time that the inner cannula was still clean. She removed her gloves and donned clean gloves without any hand hygiene. She proceeded to suction Resident # 8 ' s mouth with an oral suction catheter. Throughout the procedure RT # 2 did not perform any hand hygiene. Observation on 09/28/11 at 9:30 A.M., during indwelling catheter care on Resident # 8, CNA # 3 started by putting a towel in a bowl of water on the resident's over the bed table. She used a bar of soap to make water lather and soapy. CNA # 3 wiped Resident # 8 ' s perinael area and catheter, discarded the used towel, grabbed another clean towel and applied soap on it. She repeated this five times and then turned Resident # 8 over to clean the sacral area. CNA # 3 left the room once and left the resident's bedside twice to obtain supplies and then returned to provide care. She changed her gloves at these times but did not perform any hand hygiene. Interview on 9/28/11 at 9:40 A.M. CNA # 3 said she forgot to wash her hands with the glove changes and said she was to sanitize her hands. Observation on 9/27/11 at 1:50 P.M., CNA # 2 provided a bed bath and incontinent care to Resident # 8. CNA #2 did not perform hand hygiene between glove changes throughout the procedure. She removed used gloved three times during the provision of the care and donned clean gloves without any hand hygiene. Resident # 15 Record review of Resident # 15 face sheet revealed he was admitted to the facility on [DATE] and was [AGE] years old. His medical history included the following: Traumatic Brain Injury and Vascular/ Mutli-Infarct Dementia. Record review of Resident # 15 ' s admission MDS, dated [DATE] revealed he was non-verbal but able to understand others. He required total assistance from staff for most ADLs and transfers and received 100% of his nutrition via [DEVICE]. Resident # 15 had an external urinary catheter and was incontinent of bowel. Observation on 09-27-11 at 12:00 P.M. revealed CNA # 4 answered Resident # 15 ' s door while wearing gloves. CNA # 4 stated she was just getting ready to begin incontinent care on Resident # 4. Continued observation revealed CNA # 4, while wearing the same gloves in which she answered the door; moved the trash can away from the bed. With the same contaminated gloves, CNA # 4 proceeded to perform incontinent care to Resident # 15, cleansing his groin area and penis. CNA # 4 then re-positioned Resident # 15 to his right side and cleansed his buttocks area. During the procedure CNA # 4 changed her gloves three (3) times and failed to perform hand hygiene between glove changes. Resident # 4 Record review of Resident # 4 face sheet revealed he was admitted to the facility on [DATE] and was [AGE] years old. His medical history included the following: Retroperitoneal Abscess, DM, Atrial Fibrillation, [DIAGNOSES REDACTED], HTN, Left BKA, and Right Malleous Stasis Ulcer Record review of Resident # 4 admission Care Plan, undated, read: " Risk for Actual Infection ...4. Promote proper hygiene (e.g...handwashing ...) ...4. Prevent /reduce entry of organisms (e.g. aseptic practices, clean to dirty ...) ... " Review of Resident # 4 ' s computerized " Adult Plan of Care, " dated 07-21-11 read: " Goals: (PT/OT/Rehab only): PT Wound Care ...Promote healthy wound healing environment ... " Observation on 09-28-11 at 10:00 A.M. revealed Resident # 4 lying in bed, awake and alert, receiving oxygen via nasal cannula at 2 LPM. At this same time, RN # 3 donned a pair of gloves without performing hand hygiene and proceeded to sanitize the overbed table in preparation to perform wound care. RN # 3 left the room to obtain additional needed supplies. RN # 3 re-entered Resident # 4 ' s room while cutting the top off of a Styrofoam cup using a pair of scissors. RN # 3 informed the surveyor the cup was filled with sanitizing gel she obtained from the hallway. RN # 3 proceeded to dip her fingers into the cup, obtain gel and wiped her hands; she then donned a pair of gloves. She re-dipped her hand into the cup of gel and wiped the scissors with it. Continued observation revealed RN # 3 providing wound care to Resident # 4 ' s right lower abdominal area (I & D previously done at this site for a ruptured abscess). RN # 3 changed her gloves 3 to 4 times during the wound care observation. Between each glove change, RN # 3 dipped her fingers into the cup of gel and wiped her hands. Interview on 09-28-11 at 3:00 P.M. the Nursing Director stated her expectation of the staff was to sanitize their hands between glove changes. She went on to say that using gel from a cup was not an acceptable method of hand hygiene. The Nursing Director said the staff should carry a bottle of hand sanitizer or wash their hands at the sink. Review of staff education revealed "When to Sanitize ...After removal of any protective equipment, especially gloves ..." Review of facility policyStandard Precautions, date revised March 2011, Section A. Barrier Precautions, read: " ...Change gloves between tasks and procedures on the same patient after contact with material that may contain a high degree of microorganisms ...wash hands or use alcohol hand sanitizer until handwashing is feasible after removing gloves ... " The facility CMS Form 672 listed a census of 22 residents.

Based on observation, interview, and record review, the facility failed to promote care for 4 of 10 sampled residents (Resident #4, #8, #11, #22) and one random resident (Resident # 3) that maintained or enhanced each resident ' s dignity. RN # 4 knocked at the door but failed to wait for response or permission to enter Resident # 8 ' s room during incontinent care. RN # 4 referred to Resident # 3 as a " PEG tube" and a "total feed." RT # 1 referred to Resident # 11 by her room number. Recreation Therapist entered Resident # 11 ' s room without knocking while resident was receiving care. RN # 1 referred to Resident # 22 by her room number while talking to surveyor. RN # 3 failed to knock at the door of Resident #4 twice ; RN # 5 failed to knock and entered Resident #4's room during wound care. RN # 3 spoke to Resident # 4 in a chastising manner. RN # 5 knocked at the door but failed to wait for response or permission to enter Resident # 8 ' s room during incontinent care. RT # 1 referred to Resident # 11 by her room number This failure to promote dignity and respect affected 5 residents and placed 17 residents at risk for low self-esteem, feelings of helplessness, and emotional distress by not providing dignity and privacy during care and "labeling" residents. Findings include: Resident # 8 Record review of Resident # 8's admission sheet revealed she was admitted to the facility on [DATE]. Resident #8 was a [AGE] year old female. Her admitting [DIAGNOSES REDACTED]. Record review of Resident # 8 ' s admission assessment MDS dated [DATE] revealed Resident # 8 had an indwelling catheter for urinary elimination and an ostomy for bowel elimination. The same MDS identified Resident # 8 was receiving Trcaheostomy care, was on Oxygen therapy, was cognitively intact and able to make her needs known. Observation on 09/28/11 at 9:30 A.M, during indwelling catheter /incontinent care, RN # 4 knocked at the door and immediately opened the door while CNA # 3 was still asking who it was. RN # 4 was attending to Resident # 8 ' s room mate. Observation on 9/28/1 at 9:30 A.M., CNA # 3 during indwelling catheter and incontinent care left the room to get more supplies. She failed to draw the privacy curtain in order to provide privacy to Resident # 8 who was in the middle of receiving incontinent care and had her private area uncovered. Resident # 8 ' s bed was very close to the door and was exposed. CNA # 3 returned and continued care. She left the bed side and walked to the sink area to get needed supplies. CNA # 3 again failed to draw the privacy curtain. Resident # 8 was making signs to remind her to close curtain but CNA #3 failed to realize this. Resident # 8 appeared uncomfortable and asked CNA # 3 to close curtain at this time. Interview on 9/28/11 at 10:56 A.M. Resident # 8 said the facility staff never cared about the privacy of the patients when they provide care. She said they don't knock and if they do, before you give permission, they had already entered. She said since her admission, she had not seen any staff ask for permission before entering her room. Resident # 8 said the staff did this even when she was receiving a bed bath or incontinent care. She said it was sad that staff treated people that way. Observation on 09/28/11 at 9:25 A.M., Respiratory Therapist # 1 was performing [MEDICAL CONDITION] care and suctioning to Resident # 8. RT# 1 told CNA # 3 that he wanted to get done here and go to the other side because " room [ROOM NUMBER]" was waiting on him. He was asked what he meant and he explained that he was going to provide care to the resident in room [ROOM NUMBER]. Resident # 11 Observation on 9/27/11 at 8:15 A.M. Resident #11 was in her bed. RN # 2 entered the room and closed the door to administer medications. The privacy curtain was left opened. The Recreation Therapist opened the resident ' s door without knocking. She walked into the room and did not introduce herself or explain her reason for being in the room. She stocked supplies in the closet and left with out saying anything. Resident # 22 Record review of Resident #22 ' s admission sheet revealed she was admitted to the facility on [DATE]. Resident was a [AGE] year old female. Her admitting [DIAGNOSES REDACTED]. Stage 4 [MEDICAL CONDITION]. Interview on 09-27-11 at 4:10 P.M., RN # 1 stated "You wanted to know when 32 went back to bed." When asked RN # 1 stated she was referring to Resident # 22 and that 32 was a room number. Resident # 3 Interview during initial tour of the facility on 09-27-11 at 9:50 A.M. RN # 4 gave report on the condition of Resident # 3. During this report, RN # 4 stated: " He is a PEG tube. He is a complete feed." Observation at this same time revealed Resident # 3 lying in bed. Resident # 3 was awake, alert, oriented and spoke freely. He denied pain or other issues at this time. Further observation revealed a catheter drainage bag attached to the bed frame draining clear yellow urine. Resident # 4 Record review of Resident # 4's admission information revealed he was admitted to the facility on [DATE] and was [AGE] years old. His medical history included the following: Retroperitoneal Abscess, DM, [MEDICAL CONDITION] Fibrillation, [MEDICAL CONDITION], HTN, Left BKA, and Right Malleous Stasis Ulcer. Observation on 09-28-11 at 10:00 A.M. revealed Resident # 4 lying in bed, awake and alert, and receiving oxygen via nasal cannula at 2 LPM. Further observation revealed RN # 3 entered the room without knocking or announcing herself to Resident # 4. RN # 3 was observed providing treatment to Resident # 4 ' s wounds. RN # 5 entered the room to assist with the care and failed to knock on the door. Further observation during the wound care revealed Resident # 4 said CNA # 1 had changed his dressings the day before and "signed them. "RN # 3 told Resident # 4 in a chastising-type tone : "Now you know better than that Mr.( ) ; the nurses are the ones who always do the wound care." Resident # 4 said " I'm sorry; I was just trying to help." Interview on 09-28-11 at 3:00 P.M. the Nursing Director stated it was her expectation that staff knock on resident's room doors and wait for permission to enter. The Nursing Director went on to say it was not acceptable to refer to residents by their [DIAGNOSES REDACTED]. Review of facility's patient information guide, revealed the facility's Mission /Vision/Values. The guide read: "...Our values are easily remembered using the acronym I CARE. ...Respect: we treat every individual as a person of worth, divinity and value..." Review of the facility resident admission packet revealed Statement of Resident Rights, undated, read: " ...You have the right to: ...(4) be treated with courtesy and respect...(6)privacy..." CMS form 672 listed a census of 22 residents.

Based on observation, record review and interview the facility failed to develop, update and individualize care plans based upon the assessed needs of 4 of 10 sampled residents (# ' s 4, 8, 16 and 22). The facility failed to review, update and individualize: Resident #22 ' s care plan to address the pathological fracture to her right arm and provide interventions to care for her indwelling catheter. Resident #16's care plan to address an artificial airway. Resident #4 ' s care pan to address the need for oxygen, blood transfusion, and stasis ulcer. Resident #8 ' s care plan to address her current status with blood transfusion, bowel and bladder elimination and functional limitations in range of motion. This failure affected 4 residents and placed 18 at risk of physical decline due to not receiving care as assessed. Findings include: Resident # 22 Record review of Resident #22 ' s admission sheet revealed she was admitted to the facility on [DATE]. Resident #22 was a [AGE] year old female. Her admitting [DIAGNOSES REDACTED]. Stage 4 [MEDICAL CONDITION]. Record review of Resident #22 ' s undated care plan titled Mobility, Impaired Physical, provided by staff for review, revealed Goals/Outcomes "...9. State/demonstrate appropriate exercises to improve functional joint mobility and strength... Interventions / Process ...2. Plan with patient/family goals to progress/maintain level of mobility (example stretching, number of repetitions of exercise, ambulation distance, stair climbing ...) ..." Review of Resident #22 ' s care plan obtained from the computer revealed an undated care plan titled Impaired Physical Mobility Left Hip Open Reduction Internal Fixation (ORIF) "...Goal patient will improve mobility and activities of daily living ...Self performance to maximum potential with out fall and injury by discharge date ..." Record Review of Resident #22 ' s undated Care Plan titled Urinary Elimination, provided by staff for review revealed Alteration in patterns Goals/Outcomes " ...6. State factors that enhance urinary elimination and reduce residual ...Empty bladder every 2 hours during the day ...wipe from front to back, taking a shower vs. tub bath, using techniques to stimulate urination ( Crede, Valsalva, pouring warm water over the perineum and running the water ...) ... Interventions / Process ...1.Correlate urinary elimination pattern to intake and output, residual urine, post voided symptoms ...3. position for ease in voiding (sitting (female) ...4. establish elimination pattern in relation to intake/sleep pattern/lifestyle ..." Review of Resident #22 ' s care plan obtained from the computer revealed an undated care plan titled Urinary Elimination Alteration in pattern ...Goal-patient will remain free from the Foley catheter complication to extent possible ...Intervention provide Foley care every shift. Interview on 9/27/11 at approximately 9:40 AM RN #1 stated Resident #22 had multiple tumors in her bones which caused her to have a pathological fracture to her right arm. The patient had to be lifted by the physical therapy department carefully using a sheet. She stated nursing staff could not use the Hoyer lift on her because the compression of the lift jacket could cause more fractures. Interview on 9/28/11 at 8:30 A.M. Resident #22 stated she never gets into the shower or tub. She stated she must have a bed bath. Interview on 9/28/11 at 3:45 PM RN #1 stated the care plan for Resident #22 was not individualized for her. She stated the resident had a fracture to her right arm. RN#1 stated the resident did not have a current ORIF and that maybe the care plan was addressing an old surgery, not a current one. RN #1 stated Resident #22 was unable to perform any exercises. The resident had an indwelling catheter and the elimination care plan was not individualized and accurate. Observation on 9/27/11 at 9:40 AM of Resident #22 revealed she was alert and oriented. The resident was sitting up in bed on an air mattress. Intravenous fluids were infusing along with the pain medication [MEDICATION NAME] to a catheter in her chest. The resident had a splint and a support strap to her right arm which was bent at the elbow and was held tight against her chest. Resident #22 had an indwelling catheter hooked to a bedside drainage with clear yellow urine. Resident # 16 Record review of Resident #16 ' s admission information revealed he was admitted on [DATE] for Ventriculopertoneal Shunt replacement. Resident #16 was [AGE] years old. Review of the resident ' s undated care plan titled Care of the Patient with an Artificial Airway which was provided by staff revealed Goals/outcome "...1. State the basic anatomy and physiology of the respiratory system..." Observation on 9/27/11 at 11:30 A.M. of Resident #16 revealed the resident was resting in bed with his eyes closed. The head of his bed was elevated. He had oxygen by [MEDICAL CONDITION] (trach) collar going into [MEDICAL CONDITION] his neck. The resident was non verbal. Interview on 9/28/11 at 3:45 P.M. RN#1 stated care plans were completed by the nurse initially. The care plans were to be updated daily and at least weekly and as needed. RN #1 stated the printed out care plan was not what staff used, it was a guide. She stated the care plan was the map of care for the resident. Resident # 4 Record review of Resident # 4 admission information revealed he was admitted to the facility on [DATE] and was [AGE] years old. His medical history included the following: Retroperitoneal Abscess, DM, [MEDICAL CONDITION] Fibrillation, [MEDICAL CONDITION], HTN, Left BKA, and Right Malleous Stasis Ulcer. Observation on 09-28-11 at 10:00 A.M. revealed Resident # 4 lying in bed, awake and alert, and receiving oxygen via nasal cannula at 2 LPM. During observation of wound care at this same time, RN # 3 stated Resident # 4 had a stasis ulcer to his right foot and a left BKA. Record review of Resident # 4 ' s September 2011 physician orders revealed an order dated 09-20-11 that read " T & C and transfuse one unit of PRBC today ...transfuse over 3 hours.. " Further review of Resident # 4 ' s record revealed the blood was transfused that day. Further review of the September 2011 physician orders for Resident # 4 revealed an order dated 09-30-11 that read "O2 at 3 LPM." Record review of Resident # 4 ' s printed Care Plan , undated, provided by the staff, along with the computerized Flowsheet " Adult Plan of Care " for Resident # 4 failed to reveal any problems, interventions or goals related to oxygen therapy or blood transfusion. Further review of the undated Care Plan revealed Resident # 4 had " pressure ulcer " identified as a problem. Record review of Resident # 4 ' s MDS, dated [DATE] revealed he had no pressure ulcer. Interview on 09-28-11 at 4:45 P.M RN # 3 stated care plans were updated when a resident ' s condition changed and as needed. RN # 3 was unable to locate oxygen therapy or blood transfusion as identified problems in Resident # 4 ' s Care Plan. She went on to say that oxygen and blood transfusion should have been addressed on the care plan. RN # 3 said Resident # 4 did not have a pressure ulcer; the care plan should have addressed a stasis ulcer and not a pressure ulcer. Resident # 8. Record review of Resident # 8 admission sheet revealed she was admitted to the facility on [DATE]. Resident was a [AGE] year old female. Her admitting [DIAGNOSES REDACTED]. Record review of Resident # 8 ' s admission assessment MDS dated [DATE] revealed Resident # 8 had an indwelling catheter for urinary elimination and an ostomy for bowel elimination. The same MDS revealed Resident # 8 was receiving trcaheostomy care and was on oxygen therapy. The MDS revealed Resident # 8 was transfused with blood on 8/17/11 and 8/31/11. Record review of Resident # 8 ' s care plan dated 8/25/11 failed to identify Resident # 8 ' s blood [MEDICAL CONDITION] on 8/17/11 and 8/31/11. Record review of Resident # 8 ' s care plan dated 8/25/11 identified Resident # 8 had impaired physical mobility of the bilateral shoulder with decreased range of motion. Goals and intervention were outlined. Record review of Resident # 8 ' s physical therapy evaluation note dated 8/25/11 under range or motion assessment revealed bilateral upper extremities within functional limits, tightness at end range elbow extension. Under strength assessment it was documented that Resident # 8 had bilateral upper Extremities "...3 to 3 plus in a given rage of 5..." and Resident # 8 was able to reach out and do a slight pull. Physical therapy notes revealed that Resident #8 had tightness to her elbow but her upper extremities were within functional limits. Resident #8's care plan incorrectly identified she had bilateral shoulder decreased range of motion. Record review of Resident # 8 ' s care plan dated 8/25/11 revealed skin integrity impairment of actual/potential. Goals and interventions were outlined. Intervention # 6 " continue to promote continence by promoting assistance with toileting needs. " Record review of Resident # 8 ' s care plan dated 8/25/11 identified urinary elimination, alteration in patterns: Goal: Resident # 8 will be free from complications from "Foley" to extent possible. Interventions were outlined. This care plan documented signs/symptom/defining characteristics to altered elimination pattern as incontinence. There were discrepancies in documentations to Resident # 8 ' s urinary and bowel elimination. This care plan failed to be individualized reflecting Resident # 8 ' s status. Observation on 9/27/11 at 1:50 P.M., CNA # 2 performed a bed bath and incontinent care to Resident # 8 who was able to move side to side in bed and assisted in repositioning her self using side rails throughout the care. Observation on 09/27/11 at 2:00 P.M., RT # 2, was observed performing tracheotomy care to Resident # 8. Throughout the procedure Resident # 8 was able to assist in repositioning herself moving about in bed. She was observed suctioning her mouth with a yanker handed to her by RT # 1. Observation on 09/28/11 at 9:30 A.M., during catheter care, Resident # 8 was observed cleaning her face with towel handed her by CNA # 3. She was observed assisting in repositioning herself throughout care. Interview on 9/28/11 at 4:40 P.M. RN # 3 said the care plan was developed based on assessments and review of documentation from other disciplines. She said the care plan should be individualized to reflect the current status of a resident. She said Resident # 8 was able to do things for herself when she wanted. She explained that she refused care and refused to get out of bed sometimes so it was hard to assess her. Review of the facility Policy and Procedure NU401" ...Subject: Assessment/Reassessment and Planning of Care ...Effective date 4/1/1989, Date Revised/Reviewed 2/1/2010 ...1.Policy and General Statement ...The purpose of this policy and procedure is to help guide the nurse in determining the patient ' s need for immediate intervention and to develop a plan of care based on a list of identified problems ...Procedure ...D. Individualized Plan of Care ...An individualized plan of care will be initiated by the Registered Nurse (RN) within a time frame appropriate to the patient ' s [DIAGNOSES REDACTED]. The plan of care should be based upon needs identified during the admission assessment. The plan of care should be revised as necessary to reflect the changing needs of the patient and the patient ' s conditions ...E. Reassessment ... the frequency of reassessment should be based on the patient ' s diagnosis, condition and needs and should occur at least every eight (8) hours ..." The facility CMS form 672 identified the census was 22 residents.