Every finding on record at Wolfe County Health & Rehabilitation Center

Based on observation, interview, record review, and facility policy review, the facility failed to ensure the baseline care plan was developed and implemented with current instructions necessary to provide effective, person-centered care for one of 31 sampled residents Resident(R) 88. Record review revealed a physician order dated 03/24/2026 for a secure care bracelet. However, this intervention was not added to the care plan or Kardex until 04/01/2026. The failure to maintain an accurate and timely baseline care plan had the potential to affect staff awareness of the residents' current risks and needed safety interventions.Review of facility policy dated September 2024 titled, Baseline Care Policy and Protocol, revealed that a baseline care plan would be developed and implemented to promote continuity of care and communication among facility stakeholders to increase resident safety and safeguard against adverse events that are most likely to occur right after admission. The policy also indicated that the baseline care plan would be developed and implemented within 48 hours of a resident's admission.Review of R88's Face Sheet, indicated the facility admitted R88 on 03/23/2026 with diagnoses including Alzheimer's Disease.Review of R88's care plan revealed no documented evidence the care plan was updated to reflect the Secure Care Bracelet. The facility also failed to update Kardex. Review of R88's Kardex revealed no documentation regarding the Secure Care Bracelet.Review of R88's 48-Hour Baseline Care Plan dated 3/24/2026 revealed it did not indicate the resident's use of a Secure Care Bracelet.Review of R88's physician orders revealed an order dated 03/24/2026 for a secure care bracelet. However, this intervention was not added to the care plan or Kardex until 04/01/2026. Review of R88's progress note dated 3/27/2026 revealed R88 had sustained a fall and the facility failed to update the care plan. In an interview with Unit Manager on 04/01/2026 at 1:45 PM, she stated she did not understand what could have happened to the care plan. She further stated the care plan was needed to provide safe resident care and was the blueprint for resident needs and care areas.In an interview with Care Coordinator on 04/02/2026 at 11:30 AM, she stated I missed writing that intervention on the care plan which should have been updated on 03/24/2026.In an interview with Director of Nursing (DON) on 04/02/2026 at 5:28 PM, she stated the Secure Care Bracelet should be care planned if residents were at risk for wondering and they should have a fall care plan created if they had a fall. She stated they should have a care plan so if a nurse goes from one unit to another, they can see what is in place to ensure continuity of resident care and safety. The DON further stated the care plans should be updated as necessary and should be accurate.

Based on observation, interview and facility policy review, the facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety. Observations of dietary staff during a meal service on 03/31/2026 revealed staff failed to perform hand hygiene and wear hair nets. Review of facility policy Dietary infection control, undated, revealed all staff members were to wear hair nets or caps in the food service areas.Review of facility policy Hand Washing' undated, revealed all staff were to wash their hands During food preparations, as often as necessary to remove soil or contamination and to prevent cross contamination when changing tasks, after engaging in other activities that contaminate the hands.Observation on 03/31/2026 at 12:25 PM, revealed the dietary manager in the kitchen work area without appropriate hair restraints.Observation on 03/31/2026 at 2:07 PM revealed the dietary manager in the kitchen work area without a hair net or other appropriate hair restraint.Observation on 03/31/2026 at 4:38 PM, dietary staff were observed wiping food debris from their gloved hands onto the side of their uniform pants and then continuing to prepare food for residents without changing gloves or performing hand hygiene.Observation on 03/31/2026 at 4:40 PM, dietary staff were observed leaving the tray line area and returning to the food service area without changing gloves or washing hands.During an interview on 03/31/2026 at 4:45 PM with [NAME] Registered Dietician (RRD) stated that her expectation was staff was to change gloves and wash hands anytime they left their work position or touched items that could contaminate their gloves. RRD also stated that at no time should anyone be in the kitchen area without a hair net or a beard guard.During an interview, on 04/01/2026 at 1:50 PM, the Dietary Manager stated all staff were expected to wear a hair net when in the food prep area. If hair go into food, it could contaminate it and make someone sick.During an interview on 04/01/2026 at 1:55 PM with Dietary Aide (DA)10 stated staff were expected to wear hair net at all times in the kitchen to keep hair from getting into the food or on the plates. Further stated staff were expected to wash their hands and change gloves whenever they left the tray line.During an interview on 04/01/2026 at 1:57 PM with Dietary [NAME] (DC)12 stated staff always need to wear a hair net. Further stated it was important because hair could get into the food and make someone sick. DC12 additionally stated staff must wash their hands and change gloves if staff left the tray line, used the trash or touched any part of themselves, gloves should be changed, and wash their hands. During an interview on 04/01/2026 at 2:40 PM with Director of Nursing (DON) stated the expectation was that anytime staff was the kitchen workspace, they would wear a hair net. The DON further stated that anytime staff left the steam table or touched themselves the expectation would be for staff to change gloves and wash their hands.

Based on interview, facility policy review, facility investigation review, it was determined the facility failed to ensure an allegation involving misappropriation of resident property was reported to the state survey agency and other officials in accordance with State Law. Review of a facility investigation revealed on 03/03/2021, at 9:45 PM, the Staff Development Coordinator (SDC) received an anonymous phone call stating Registered Nurse (RN) #1 was stealing narcotics and pain patches from the facility. The SDC notified the Director of Nursing (DON) and the Administrator. However, there was no evidence the required state agencies had been notified. The findings include: Review of the facility's policy, Abuse, Neglect, Misappropriation and Exploitation Policy, with a revision date of January 2018, revealed alleged violations that involved abuse, neglect, misappropriation or exploitation including injuries of unknown origin, shall be reported immediately but not later than two (2) hours after the allegation was made. The policy further stated the Administrator, DON, or Designee would report the allegations to the appropriate state and federal agencies, including law enforcement as required. Review of a facility investigation revealed on 03/03/2021, at 9:45 PM, the SDC received an anonymous phone call stating Registered Nurse (RN) #1 who was the Clinical Coordinator for the 100 Wing, was stealing narcotics and pain patches from the facility. The SDC notified the Director of Nursing (DON) and the Administrator who were not at the facility. The investigation revealed on 03/03/2021 at approximately 10:00 PM, the DON, Clinical Coordinator #2, and the Administrator arrived at the facility. The DON and the Clinical Coordinator counted all narcotics and ensured residents with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The investigation revealed all narcotics were accounted for at that time. The investigation revealed the DON informed RN #1 on 03/04/2021 at 5:30 AM of the allegation, asked RN #1 to come to the facility to submit to a drug screen and to discuss the situation. The RN told the DON she would not be able to make it to the facility until 03/04/2021 at 9:00 AM. RN #1 called on 03/04/2021 at approximately 9:10 AM, and stated she was too upset too drive and it would be 12:00 PM to 2:00 PM before she could come to the facility. The investigation revealed on 03/04/2021 at approximately 12:00 PM, the DON found RN #1's office keys and resignation on her desk. However, there was no evidence documented in the facility's investigation the state agencies had been notified. Interviews conducted with the SDC, on 05/26/2021 at 2:00 PM, revealed she had received an anonymous phone call on 03/03/2021 at approximately 9:45 PM. The SDC stated the caller stated RN #1 was stealing narcotics and pain patches. The SDC stated she had immediately notified the DON and the Administrator who were not at the facility. Interview conducted with Clinical Coordinator #2, on 05/27/2021 at 11:03 AM, revealed she had received a phone call from the DON to come into the facility to assist with an investigation regarding RN #1. The Clinical Coordinator stated she had assisted with counting all narcotics in the building and checking to ensure residents with pain patches had them in place. The Clinical Coordinator stated all narcotics and pain patches had been accounted for. Interview conducted with the DON, on 05/27/2021 at 11:30 AM, revealed she had been notified by the SDC of an anonymous call alleging RN #1 was stealing narcotics and pain patches. The DON stated after talking with the Administrator, it was decided another nurse needed to be called in to assist with checking narcotics and pain patches and she had called in Clinical Coordinator #2. The DON stated all narcotics and pain patches had been accounted for. Interview conducted with the Administrator, on 05/27/2021 at 11:45 AM, revealed she had not reported the allegation against RN #1 because after investigating the allegation, she had thought it was a false allegation. The Administrator stated since nothing was missing and the RN was no longer employed by the facility, she did not report. The Administrator revealed she was responsible for reporting allegations of abuse to state agencies.

Based on observation, interview, record review, and facility policy review, it was determined that the facility failed to ensure an allegation of misappropriation of resident property was thoroughly investigated per the facility's policy for one (1) of five (5) sampled residents (Resident #1). The facility received an allegation of misappropriation of resident property on 04/23/2021, which alleged Registered Nurse (RN) #1 and the Infection Control Nurse (ICN) Assistant had received narcotics from Resident #1. According to the allegation, Resident #1 was holding the medication in his/her cheek, and staff was buying the narcotics from the resident. The facility failed to thoroughly investigate Resident #1's allegation in accordance with facility policy/procedure. The findings include: Review of the facility's policy, Abuse, Neglect, Misappropriation and Exploitation Policy, with a revision date of January 2018, revealed each resident had the right to be free from abuse and the facility did not condone abuse by anyone, including staff members. According to the policy, the Administrator or DON would appoint a representative to investigate the incident. The policy also revealed a thorough investigation shall be completed. Review of Resident #1's closed medical record revealed the facility admitted the resident on 07/18/2019 and the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was interviewable. Review of Resident #1's nurse's notes revealed on 04/23/2021 at 10:30 AM, Resident #1 had alleged to the DON that RN #1 and the ICN Assistant had received narcotics from the resident which the resident had been holding in his/her cheek, and RN #1 had been buying them from the resident. The Resident stated RN #1 had been purchasing the medications from him/her for approximately six (6) months and had left employment in March 2021. Resident #1 had alleged after RN #1 had left employment, the ICN Assistant had been the go between, taking the medications to RN #1 and returning the money to Resident #1. Per the nurse's note, the resident stated he/she just could not live on $20.00 per month. The nurse's note revealed the state police, and state agencies had been notified and an investigation was ongoing. The nurse's note also revealed the ICN Assistant had resigned her position and had left immediately. Further review of the nurse's notes for Resident #1 revealed an entry dated 04/28/2021 at 1:10 PM, which stated the resident was discharged to the acute care hospital and was then to be transferred to drug rehabilitation center. The facility investigation dated 04/23/2021, involving Resident #1's allegation of misappropriation of property was reviewed. The Resident stated RN #1 had been purchasing the medications from him/her for approximately six (6) months and had left employment in March 2021. Resident #1 had alleged after RN #1 had left employment the ICN Assistant had been the go between, taking the medications to RN #1 and returning the money to Resident #1. The facility's investigation included the interview for Resident #1, alert and oriented residents, other staff. However, there was no evidence the facility had attempted to interview RN #1 nor the ICN Assistant. The facility failed to thoroughly investigate Resident #1's allegation in accordance with facility policy/procedure. Interview conducted with the ICN Assistant, on 05/26/2021 at 5:15 PM, revealed she had been asked to submit to a drug screen by the DON on 04/23/2021, but had not been told why. The ICN Assistant stated when she asked the DON, why she was not given an answer so she quit. The ICN Assistant stated she had not wanted to submit to a drug screen without knowing the reason why. The ICN Assistant stated she had never been interviewed about the allegation of her transporting narcotics and selling them. The ICN Assistant denied transporting medication from Resident #1 to RN #1 and bring money back to the resident. Interview conducted with RN #1, on 05/27/2021 at 9:30 AM, revealed nobody from the facility had contacted her about the allegations and stated she was unaware of what had transpired with Resident #1. The RN denied ever purchasing drugs from any resident. Interview conducted with the DON, on 05/27/2021 at 11:20 AM, revealed she had not interviewed the ICN Assistant. The DON stated after the ICN Assistant refused to submit to a drug screen, the ICN Assistant had quit and left immediately. Interview conducted with the Administrator, on 05/27/2021 at 11:45 AM, revealed she had conducted the investigation regarding Resident #1, RN #1, and the ICN Assistant. The Administrator stated she had not interviewed the employees due to they were no longer employed by the facility. The Administrator stated the ICN Assistant could have been interviewed prior to leaving the facility. The Administrator stated the immediate concern was to get the employee out of the building. The Administrator stated the facility did not contact employees after they were no longer employed by the facility.

Based on interview, record review, and review of facility policy, it was determined the facility failed to ensure that one (1) resident (Resident #1) was free from misappropriation of property. On [DATE], Resident #1 reported to facility staff that he/she had not received his/her scheduled [MEDICATION NAME] (narcotic pain medication) on 12/20/2019 at 6:00 PM and on [DATE] at 12:00 AM. Licensed Practical Nurse (LPN) #2 administered Resident #1's medications on 12/20/2019 at approximately 5:30 PM and 9:30 PM; however, she replaced the resident's prescribed [MEDICATION NAME] with [MEDICATION NAME] (a controlled substance prescribed to treat anxiety). The findings include: Review of the facility polity titled Abuse, Neglect, Misappropriation and Exploitation, last revised January 2018, defined misappropriation as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Further review of the policy revealed the facility intention was to prevent occurrences of misappropriation of resident property and to assure that all allegations were investigated and reported immediately to state agencies. Review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/30/2019, revealed the resident was assessed to have a Brief Interview for Mental Status (BI[CONDITION]) score of fifteen (15), indicating the resident was cognitively intact and interviewable. Review of Resident #1's physician orders [REDACTED]. Interview with Resident #1 on 01/18/2020 at 10:55 AM revealed LPN #2 delivered his/her medications to him/her on 12/20/2019 at approximately 5:30 PM and he/she discovered that she had not given him/her the scheduled [MEDICATION NAME] that he/she received four (4) times per day. The resident said the LPN brought a different pill that she attempted to pass off as his/her [MEDICATION NAME]. The resident stated he/she questioned LPN #2 about his/her pain medication and she stated that it was in with the pills that she had brought to him/her. Resident #1 stated he/she did not mention the incident; however, he/she did not take the pill that was not his/her [MEDICATION NAME], but threw it in the trash. The resident stated that at approximately 9:30 PM that night, LPN #2 brought his/her medications again and she had brought the same pill as earlier and told him/her that it was his/her [MEDICATION NAME]. Resident #1 stated that he/she knew what his/her [MEDICATION NAME] looked like and he/she knew that the pill she brought was not it. The resident stated he/she kept the pill and presented it to LPN #3 later that night at approximately 1:30 AM and reported to her that LPN #2 attempted to administer the pill to him/her instead of [MEDICATION NAME]. Review of the facility investigation dated [DATE] revealed on [DATE] Resident #1 reported to LPN #3 that LPN #2 did not administer his/her scheduled [MEDICATION NAME] on the 3:00 PM to 11:00 PM shift on 12/20/2019. During the investigation it was determined that LPN #2 attempted to administer [MEDICATION NAME] to Resident #1 at 5:30 PM and again at 9:30 PM instead of the resident's scheduled [MEDICATION NAME]. LPN #2 was suspended pending the facility's investigation and ultimately terminated by Administration on 12/23/2019. Further review of the investigation revealed the facility could not determine that any other residents were affected by LPN #2. Review of email correspondence from the facility's pharmacists to the Administrator on [DATE]19 and 12/30/2019 revealed that a pharmacist performed narcotic reconciliation of all narcotics in the facility on 12/26/2019 and 12/30/2019 and could not find any discrepancies. Interview with LPN #2 on [DATE]20 at 3:16 PM revealed she was assigned to Resident #1 on 12/20/2019. She stated she administered the resident's medications as ordered, which included the resident's scheduled [MEDICATION NAME]. She stated Resident #1 did not discuss with her that she (LPN #2) had failed to administer the resident's [MEDICATION NAME] at 6:00 PM and 12:00 AM. Per the LPN, she was educated regarding resident abuse and misappropriation upon hire and numerous times throughout the year. Interview with LPN #3 on [DATE]20 at 3:42 PM revealed Resident #1 reported to her on [DATE] at approximately 1:30 AM that LPN #2 attempted to administer a different medication to him/her and pass it off as his/her [MEDICATION NAME]. She stated the resident gave her the pill that he/she was given by LPN #2 at approximately 9:30 PM on 12/20/2019 and she discovered the medication was [MEDICATION NAME]. She stated Resident #1 was not prescribed [MEDICATION NAME]; therefore, she contacted the resident's physician and obtained an order for [REDACTED].#1 had communicated to her. Continued interview with LPN #3 revealed she performed a narcotic count at the beginning of her shift with LPN #2 and the narcotic count was correct. Interview with the Clinical Coordinator on [DATE]20 at 3:58 PM revealed she was notified of the allegation of misappropriation on [DATE] at approximately 1:45 AM. She stated she notified the Director of Nursing (DON) of the allegation and an investigation was initiated. She stated that she assisted with resident interviews regarding their narcotic medications and pain management and assisted with narcotic reconciliation, and stated that no other residents were affected. Interview with the Staff Development Coordinator (SDC) on [DATE]20 at 4:46 PM revealed she was the on-call supervisor for the weekend and she came in and began the investigation on [DATE]. She stated she observed all residents to determine if their pain was controlled and performed resident interviews to ensure no other residents were affected. She stated she began staff interviews regarding LPN #2 and resident behaviors and pain management and no concerns were identified. She stated that after conferring with the DON she contacted LPN #2 and communicated to her that she was suspended pending the outcome of the investigation. Continued interview with the SDC revealed that all staff were educated on narcotic administration, abuse, and misappropriation upon hire and numerous times throughout the year. She stated she began re-education with all staff regarding narcotic administration, abuse, and misappropriation on [DATE]. Review of LPN #2's employee file revealed she began employment as an LPN on 08/30/2017. The facility performed all required screenings prior to her hire and no concerns were identified. Interview with the DON on [DATE]20 at 5:16 PM revealed she was contacted at approximately 2:40 AM by the Clinical Coordinator regarding the allegation against LPN #2 and she then contacted the required state agencies. She stated she also contacted the Administrator and reported the allegation. The DON stated she performed narcotic counts and resident and staff interviews to ensure no other residents were affected. She stated all staff received education regarding narcotic administration, abuse, and misappropriation and were administered a post-test. She stated it was determined that LPN #2 attempted to administer [MEDICATION NAME] to Resident #1 on 12/20/2019 at 6:00 PM and [DATE] at 12:00 AM; however, they were unable to determine where the [MEDICATION NAME] was taken from because the narcotic counts were accurate and no residents were observed to be exhibiting anxiety or behaviors. Interview with the Administrator on [DATE]20 at 5:30 PM revealed she was notified by the DON of the allegation against LPN #2 on [DATE] at approximately 3:15 AM. She stated she contacted local law enforcement regarding the allegation and the DON had already performed all other required notifications to state agencies. She stated LPN #2 was suspended immediately and during an interview with her on 12/23/2019, she stated she administered Resident #1's medications per the physician's orders [REDACTED].#2 and referred her to the state licensing agency.

Based on observation, interview, and facility policy review, it was determined that the facility failed to conduct an accurate Minimum Data Set (MDS) assessment for one (1) of twenty-three (23) sampled residents. Resident #72 was noted to have dental caries (tooth decay); however, the facility failed to document that the resident had dental caries on the resident's 09/13/19 annual MDS. The finding include: Review of the facility policy titled, MDS, with a revision date of (MONTH) (YEAR), revealed, The facility will conduct a comprehensive, accurate, standardized and reproducible assessment that describes the resident's capability to perform daily life functions including oral/dental status. Record review revealed the facility admitted Resident #72 on 08/24/18 with [DIAGNOSES REDACTED]. Observation of Resident #72 on 10/24/19 at 4:18 PM revealed the resident had several visible dental caries (broken teeth with dark discoloration). Review of Resident #72's Comprehensive Care Plan, initiated on 09/10/18 for oral/dental status, revealed the resident was noted to have broken or carious teeth. Further review of the care plan revealed the resident was seen by a dentist in-house on 08/06/19. Review of the dental consultation note for 08/06/19 revealed Resident #72 had missing teeth and a retained root. Restorative charting was completed and treatment needed was noted. A follow-up dental consultation note for 09/19/19 revealed the resident had a complete series of radiographic images with recommendation for all remaining teeth to be extracted by an oral surgeon due to the remaining teeth being broken with gross decay and periodontal disease. However, a review of Resident #72's annual Minimum Data Set (MDS) assessment dated [DATE], in Section L Oral/Dental Status, revealed the resident did not have any cavities or broken natural teeth. Interview on 10/24/19 at 5:00 PM with the facility MDS Coordinator confirmed Resident #72 had cavities and broken teeth. The MDS Coordinator stated the MDS should have indicated the resident's cavities and broken natural teeth. The MDS Coordinator revealed she had just overlooked it and made an error on the MDS. Interview with the Director of Nursing (DON) on 10/24/19 at 5:58 PM revealed she does random checks of the MDS's to ensure accuracy. The DON further revealed it was just an oversight and should have been marked to indicate the resident had cavities and broken natural teeth. The DON further revealed she had not identified any concerns with the accuracy of the residents MDS's.

Based on interview, record review, and review of facility policy it was determined the facility failed to notify the legal representative of a change in the resident's condition for one (1) of three (3) sampled residents (Resident #1). Review of the chest x-ray report, dated 09/19/16, revealed Resident #1 had experienced a right glenohumeral (shoulder) dislocation. Interview with facility staff revealed the resident's legal representative was not notified of the x-ray results until the following day, 09/20/16. The findings include: Review of the facility policy titled Notification of Change in Resident's Status, date unknown, revealed the attending physician or their alternate, along with the resident's responsible party, is to be notified of any change in the resident's condition. The policy did not specify when the notification was to occur. Medical record review for Resident #1 revealed the facility admitted the resident on 01/24/14, with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident's Brief Interview for Mental Status (BIMS) score to be 8 indicating the resident was moderately cognitively impaired and interviewable. Further review of the MDS assessment revealed the resident required limited assistance with ambulation and extensive assistance with transfers. Review of the nurse's notes dated 09/18/16 revealed the resident was assessed to have symptoms of cough and fever. Further review revealed the resident's physician was notified of the assessment and an order was received to obtain a chest x-ray. Review of the chest x-ray results, dated 09/19/16, revealed a right glenohumeral (shoulder) dislocation was identified. Review of the nurse's notes, dated 09/19/16, revealed an order for [REDACTED]. Interview with Registered Nurse (RN) #1 on 09/27/16 at 3:41 PM revealed she was responsible for Resident #1's care on 09/19/16 and received the chest x-ray results. The RN stated she had been trained to notify the resident's responsible party with changes in condition, but forgot to notify Resident #1's family member regarding the x-ray results. Interview with the Director of Nursing (DON) and facility Administrator on 09/27/16 at 5:15 PM revealed they would have expected facility staff to notify the resident's responsible party of the x-ray results.

Based on observation, interview, record review, and review of the facility's care plan policy it was determined the facility failed to revise a plan of care with interventions for oxygen use for one (1) of twenty (20) sampled residents (Resident #4). Resident #4 had a physician's order for oxygen at two (2) liters per minute continuously; however, the facility failed to develop a comprehensive care plan with interventions for oxygen use. The findings include: Review of the facility policy, Care Plan Policy & Protocol, with a revision date of August 2012, revealed, The facility shall develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs. The care plan will be updated as indicated with changes in condition, physician orders, etc. The Kardex will also be utilized as a guide for Nurse Aides in providing care on a daily basis. This is a working tool and revisions will be made when indicated. Observations of Resident #4 conducted on 06/07/16 at 11:30 AM, 2:22 PM, 3:25 PM, 4:44 PM, and 5:41 PM, and on 06/08/16 at 9:30 AM, 10:22 AM, and 1:21 PM revealed the resident had an oxygen condenser at the bedside; however, the condenser was turned and the resident was not wearing oxygen. The oxygen tubing was draped over the side rail of the resident's bed. Review of the medical record for Resident #4 revealed the facility admitted the resident on 08/11/15 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3, which indicates severely impaired cognition. The care plan did not include interventions for the use, care, or monitoring of the resident's oxygen. Review of the resident's physician orders dated 05/10/16 revealed an order for [REDACTED]. Interview with the Minimum Data Set (MDS) Coordinator on 06/09/16 at 2:19 PM revealed she only revised residents' care plans during the MDS assessment period. She stated that since Resident #4's oxygen was ordered on [DATE], after the Quarterly MDS was completed on 05/06/16, she was not responsible for revising the resident's comprehensive care plan. She stated the nurse who took the physician's order was responsible for revising the resident's care plan with the correct information.

Based on observation, interview, record review, and facility policy review it was determined that the facility failed to follow the written plan of care for one (1) of twenty (20) sampled residents (Resident #8) related to oxygen administration. The facility developed a care plan for Resident #8 to administer oxygen as ordered. Resident #8 was ordered to have oxygen administered at three (3) liters per minute. However, observations on 06/07/16 and 06/08/16 revealed Resident #8's oxygen was set at four (4) liters per minute. The findings include: Review of the facility policy titled Care Plan Policy & Protocol, undated, revealed the policy did not address following the resident care plan. Observations of Resident #8 on 06/07/16 at 11:25 AM, 2:19 PM, 3:20 PM, 4:16 PM, and 5:57 PM, and on 06/08/16 at 9:21 AM, 10:28 AM, and 1:15 PM revealed Resident #8 was receiving oxygen via nasal cannula at four (4) liters per minute. Review of Resident #8's medical record revealed the facility initially admitted Resident #8 on 08/21/15 with readmission on 03/17/16, with [DIAGNOSES REDACTED]. Review of Resident #8's Annual Minimum Data Set ((MDS) dated [DATE] revealed the resident was assessed with [REDACTED]. Review of Resident #8's Comprehensive Care Plan dated 05/20/16 revealed an intervention for Resident #8 to receive oxygen therapy as ordered. Review of Resident #8's physician orders dated 03/17/16 revealed an order for [REDACTED]. Interview with State Registered Nurse Aide (SRNA) #2 on 06/09/16 at 1:36 PM revealed nurses were responsible for ensuring the resident's oxygen level was set at the correct flow rate. Further interview revealed that each resident had a Kardex (care guide) that the SRNAs followed and the flow rate for any resident that required oxygen was on the Kardex. She further stated that if she noticed a resident's oxygen was set on the incorrect flow rate she would notify the nurse. Interview with Licensed Practical Nurse (LPN) #2 on 06/09/16 at 1:57 PM revealed the nurse was responsible for ensuring a resident's oxygen was set on the correct flow rate. Continued interview with LPN #2 revealed she had been assigned to provide care for Resident #8 on 06/09/16 and stated she observed that the resident's oxygen was set at the correct flow rate, three (3) liters per minute. Interview with Unit Coordinator #1 on 06/09/16 at 2:25 PM revealed that it was the nurses' responsibility to ensure the resident was receiving oxygen at the correct rate. She further stated that nurses were expected to check the oxygen flow rate of any resident receiving oxygen each time the nurse administered medications to the resident or any time the nurse was in the resident's room. Interview with the Director of Nursing (DON) on 06/09/16 at 2:35 PM revealed that the nurse caring for the resident was responsible for ensuring the resident was receiving oxygen at the prescribed rate at least once a shift. She stated they should check it every time they enter the resident's room.

Based on observation, interview, record review, and facility policy review it was determined the facility failed to ensure two (2) of twenty (20) sampled residents (Residents #4 and #8) received proper treatment and care related to the administration of oxygen therapy. Resident #4 had an order for [REDACTED].#8 had an order for [REDACTED]. The findings include: Review of facility policy titled Respiratory Services, undated, revealed, Oxygen will be monitored each shift by the nurse to ensure administration per MD order. 1. Observations of Resident #4 on 06/07/16 at 11:30 AM, 2:22 PM, 3:25 PM, 4:44 PM, and 5:41 PM, and on 06/08/16 at 9:30 AM, 10:22 AM, and 1:21 PM revealed that Resident #4 had an oxygen concentrator (machine that supplies oxygen) in his/her room turned off and the oxygen tubing was draped across the resident's side rail of the bed. Review of the medical record for Resident #4 revealed the facility admitted the resident on 08/11/15 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3, which indicates severely impaired cognition. The care plan did not include interventions for the use, care, or monitoring of the external catheter. Review of the resident's physician orders [REDACTED]. Interview with State Registered Nurse Aide (SRNA) #1 on 06/09/16 at 1:30 PM revealed that Resident #4 removed his/her oxygen nasal cannula all the time. However, she did not notice that the resident's oxygen condenser was turned off. Furthermore, she stated if she had noticed the oxygen condenser was turned off she would have informed the nurse so that she could adjust it to the proper setting. Interview with Licensed Practical Nurse (LPN) #1 on 06/09/16 at 1:40 PM revealed nurses were responsible for ensuring the residents with oxygen received the prescribed rate. She stated nurses were required to check residents' oxygen during medication pass and any time they entered the resident's room. She further stated that she had not seen Resident #4's oxygen condenser turned off. 2. Observations of Resident #8 on 06/07/16 at 11:25 AM, 2:19 PM, 3:20 PM, 4:16 PM, and 5:57 PM, and on 06/08/16 at 9:21 AM, 10:28 AM, and 1:15 PM revealed that Resident #8 was wearing his/her oxygen and it was set at four (4) liters per minute. Review of Resident #8's medical record revealed the facility initially admitted Resident #8 on 08/21/15 with readmission on 03/17/16, with [DIAGNOSES REDACTED]. Review of Resident #8's Annual Minimum Data Set ((MDS) dated [DATE] revealed the resident was assessed with [REDACTED]. Review of Resident #8's admission physician's orders [REDACTED]. Interview with State Registered Nurse Aide (SRNA) #2 on 06/09/16 at 1:36 PM revealed nurses were responsible for ensuring the resident's oxygen level was set at the correct flow rate. She stated they had a Kardex (care guide) for each resident that listed the flow rate for any resident with oxygen. She further stated that if she noticed a resident's oxygen was set on the incorrect flow rate she would notify the nurse. Interview with Licensed Practical Nurse (LPN) #2 on 06/09/16 at 1:57 PM revealed the nurses were responsible for ensuring a resident's oxygen was set on the correct flow rate. Continued interview with LPN #2 revealed she had been assigned to provide care for Resident #8 on 06/09/16 and that it was set at three (3) liters per minute. She further stated that the nurses were responsible for checking the resident's oxygen flow rate every time they passed medications during their shift. Interview with Unit Coordinator #1 on 06/09/16 at 2:25 PM revealed that it was the nurses' responsibility to ensure residents received oxygen at the correct rate. She further stated that the nurses were expected to check the oxygen flow rate any time the nurse was in the resident's room. Interview with the Director of Nursing (DON) on 06/09/16 at 2:35 PM revealed that the nurse caring for the resident was responsible for ensuring the resident was receiving oxygen at the prescribed rate at least once per shift and should check it every time they entered the resident's room.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure foods were palatable and at the proper temperature for residents on the 100 Hall during the lunch meal on 05/13/15. A test tray conducted for a regular, chopped meat tray on 05/13/15 revealed food items were not palatable and not at the appropriate temperature. The findings include: Review of the Meal Pass policy (no date) revealed residents' meals would be delivered timely so that foods would be served to residents with cold food temperatures at 41 degrees Fahrenheit or below and hot foods at 135 degrees Fahrenheit or above. Observation of the lunch meal on 05/13/15 revealed a closed cart containing seven meal trays was transported from the kitchen to the 100 Hall of the facility at 11:53 AM. The last tray was intercepted at 12:21 PM (28 minutes later) and food temperatures were obtained with facility staff. The temperature of the potatoes was 101 degrees Fahrenheit and they tasted tepid, the steak was 92 degrees Fahrenheit and tasted cold, the seven-layer salad was 47 degrees Fahrenheit and tasted cool, the strawberry salad was 50 degrees Fahrenheit and tasted cool, and the apple juice was 55 degrees Fahrenheit and tasted cool. Interview with Resident #2 on 05/12/15 at 2:30 PM, revealed sometimes his/her food was cool and not at the proper temperature. Interview conducted with the Dietary Manager (DM) on 05/13/15, revealed the hot food temperatures were expected to be 140 degrees Fahrenheit or above at the point of service. The DM further stated that 20 minutes after leaving the kitchen was too long for meal trays to remain on the food tray cart prior to being served to residents. The DM also stated she conducted at least eight test trays monthly from all meals to monitor food temperatures and palatability and no consistent problems had been identified. Interview with the Director of Nurses (DON) on 05/13/15 at 4:00 PM, revealed the food carts were arranged to be delivered in room order and a small number of trays was delivered from the kitchen on each cart to enable staff to deliver the trays in a timely manner. The DON stated she monitored tray delivery service and had not identified any problems with food temperatures or palatability.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure staff implemented the care plan for one (1) of twenty (20) sampled residents (Resident #6). A review of the Care Plan for Resident #6, revised on 01/24/14, revealed the resident was at risk for pressure sores related to the resident's self-care deficit with elimination. Review of the "Resident Kardex" (undated) that was included as part of the care plan revealed the resident had a Stage II pressure sore to the right buttock. Physician orders [REDACTED]." dressing. According to the care plan, staff was to observe the resident during personal care for problem areas such as redness, bruising, skin tears, "etc." A review of the "treatment record" revealed staff had provided wound care and applied a dressing to Resident #6's wound on the second shift on 03/11/14. However, observations during a skin assessment conducted on 03/12/14, at 11:10 AM revealed the pressure sore to the resident's right buttock was uncovered and did not have a dressing intact. The findings include: A review of the facility's policy entitled "Protocol for Care Planning" (undated) revealed all residents would have a plan of care that would be reviewed and updated at least quarterly with the completion of the Minimum Data Set (MDS) assessments. The plan of care was to be updated with changes in condition, physician's orders [REDACTED]. A review of the facility's policy entitled "Resident Status Kardex" (undated) revealed a care plan update form would be placed in front of the Kardex to address any needs/problems not on the Kardex and that it would be the responsibility of the licensed nurse to update the Kardex as changes occurred or as needed. According to the policy, it was the responsibility of the State Registered Nurse Aide (SRNA) to review the Kardex to ensure appropriate care was provided. A review of the policy titled "Wound Care Protocols and Procedures," undated, revealed for Stage II (draining) sores, staff was required to assess for pain, cleanse the area with normal saline, and apply "[MEDICATION NAME]" to the area as a primary dressing and cover with "DuoDerm Signal." A review of Resident #6's medical record revealed the facility admitted the resident on 04/04/12 with [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS) quarterly assessment dated [DATE], revealed Resident #6 had been assessed to have a Brief Interview for Mental Status (BIMS) of 3, which indicated the resident's cognition was severely impaired. The facility assessed the resident to require total support from staff for bed mobility, transfers, locomotion, dressing, eating, personal hygiene, bathing, and toileting. A review of the Care Plan, revised 01/24/14, revealed Resident #6 was incontinent of bladder and bowel and required incontinence care every two hours and PRN. Review of physician's orders [REDACTED].#6's right buttock area with normal saline and cover the area with an "[MEDICATION NAME] Foam" dressing every three days and as needed. A review of the "treatment record" revealed staff had provided wound care and applied a dressing to Resident #6's pressure sore on the second shift on 03/11/14. However, observations during a skin assessment conducted by Licensed Practical Nurse (LPN) #1 on 03/12/14, at 11:10 AM revealed the pressure sore to the resident's right buttock was uncovered and did not have a dressing intact. Due to Resident #6's severely impaired cognition status, an interview with the resident was not conducted. Interview conducted with LPN #1 on 03/12/14, at 11:50 AM, revealed she was not aware Resident #6's pressure sore was uncovered. According to the LPN, she had not conducted an observation of the resident's dressing during her shift on 03/12/14 and stated the SRNAs were to inform Nursing if they had observed the pressure sore had been uncovered when they provided personal/incontinence care. LPN #1 stated she was not always assigned to provide care to Resident #6 but had provided care to the resident the previous week and the dressing had remained intact with no problems identified. Interview conducted with State Registered Nursing Assistant (SRNA) #5 on 03/12/14, at 11:40 AM, revealed she had provided incontinence care to Resident #6 on the morning of 03/12/14 and had not observed a dressing over the resident's wound. SRNA #5 stated she had "assumed" the order had been discontinued and thought the nurse was aware. SRNA #5 stated she was required to review the Kardex prior to the shift to determine the resident's care needs and to report any changes to the nurse assigned to provide care to the resident. In addition, SRNA #5 stated nursing staff usually provide a verbal report at the beginning of the shift to inform the SRNAs if a resident has a dressing that needs to be monitored. Interview conducted with Registered Nurse (RN) #2 on 03/12/14 at 4:35 PM revealed she had provided direct care to Resident #6 on the second shift on 03/11/14, had changed the resident's dressing, and stated the resident's dressing was intact during her shift. RN #2 stated it was the responsibility of the nurse on each shift to check dressings to ensure they were clean, dry, and intact and changed timely. RN #2 stated the SRNAs were to inform the nurse if the resident's dressing was observed to be soiled or off during incontinence or personal care. Interview conducted with RN #1 on 03/13/14, at 3:52 PM, revealed she was a Unit Manager at the facility, and stated she "makes rounds constantly" to ensure that staff provides care in accordance with the care plan of each resident. RN #1 stated the nurses and the SRNAs were to review the plan of care for each resident every shift; and stated the SRNAs were responsible to report to the nurse on duty if a dressing was found to be soiled or off during incontinence care. Interview conducted with the Director of Nursing (DON) on 03/13/14 at 4:07 PM, revealed staff was required to review the care plan at the beginning of every shift to ensure care was provided in accordance with the care plan. In addition, the DON stated the Kardex was updated daily. The DON stated the Unit Manager was required to check skin assessments on a weekly basis and report any issues at the weekly Quality Assurance (QA) meetings. The DON stated she was not aware of any concerns related to staff not providing care in accordance with the care plan.

Based on observation, interview, and review of facility policies, it was determined the facility failed to ensure effective maintenance and housekeeping services were provided to maintain a sanitary, orderly, and comfortable interior. The armrest on Resident #1's geri-chair was observed to be torn and jagged and the armrest on unsampled Resident A's wheelchair was torn and needed to be replaced. In addition, the gastric feeding pump used to administer tube feedings to unsampled Resident B, as well as the pole the pump was secured to, were observed to have dried tube feeding on the surfaces. The findings include: 1. Review of a worksheet tool (undated) utilized by maintenance staff revealed maintenance staff was to conduct observations of resident rooms, including wheelchairs/geri-chairs, on a weekly basis to identify any needed repairs. Observations during the environmental tour on 02/22/13 at 3:15 PM revealed the armrest on Resident #1's geri-chair was torn and jagged. In addition, the armrest on Resident A's wheelchair was observed to be worn/torn. Resident #1 did not respond to questions appropriately when an interview was attempted on 02/22/13 at 3:15 PM. Interview with Resident A on 02/22/13 at 3:15 PM revealed the resident wanted the wheelchair arm repaired; however, the resident stated, "I can't afford to pay for the repairs." Interview with the Maintenance Supervisor on 02/22/13 at 3:30 PM revealed the wheelchairs and geri-chairs were checked on a weekly basis and should have been identified by the Maintenance Supervisor. The Maintenance Supervisor said a repair requisition could be filled out by staff for any needed repairs and placed in a box at the nurses' stations. The Maintenance Supervisor was unaware of any requisitions for wheelchairs or geri-chairs to be repaired. 2. Review of the facility policy, Room Duties (undated), revealed cleaning gastric tube feeding pumps and poles was to be done every day by housekeepers. Observation on 02/20/13 at 3:15 PM of Resident B's gastric feeding pump and the pole the feeding pump was attached to revealed dried tube feeding on the right side of the pump and on the pole holding the pump. An interview was attempted with Resident B on 02/20/13 at 3:15 PM; however, the resident did not respond to questions appropriately. Interview with the Housekeeping Supervisor on 02/20/13 at 3:30 PM revealed housekeeping staff was assigned to clean resident rooms, including gastric feeding pumps and the poles they are attached to, on a daily basis. According to the Housekeeping Supervisor, Housekeeper #1 had been assigned to clean Resident B's room; however, Housekeeper #1 had left the facility for the day and an interview was not conducted. The Housekeeping Supervisor said, "I monitor daily for cleanliness and had not identified any issues with gastric pumps or poles until now." Interview with the Administrator on 02/22/13 at 3:40 PM revealed she was unaware the armrest on Resident #1's geri-chair was torn or that dried tube feeding was on the gastric feeding pump and pole observed in Resident B's room. The Administrator said the feeding pumps and poles should be cleaned daily, and wheelchairs/geri-chairs should be maintained in good working condition.

Based on observation, interview, and record review, the facility failed to ensure services provided met professional standards of quality for one of twenty sampled residents (Resident #6). Resident #6 had physician's orders [REDACTED]. The findings include: A review of the facility protocol for physician's orders [REDACTED]. A review of the medical record revealed the facility admitted Resident #6 on 10/11/11 with [DIAGNOSES REDACTED]. A review of the February 2013 physician's orders [REDACTED].#6. Observations conducted on 02/20/13 at 3:40 PM, 5:00 PM, and 5:50 PM, revealed Resident #6 was lying in bed and was receiving at 3.5 liters per nasal cannula. On 02/21/13 at 8:40 AM, 9:15 AM, 10:30 AM, and 11:25 AM, the resident was observed to continue to receive oxygen at 3.5 liters per minute per nasal cannula. On 02/22/13, at 9:45 AM, the resident was observed to be receiving oxygen at 2 liters per minute per nasal cannula. Interview conducted with Licensed Practical Nurse (LPN) #1 on 02/2213, at 9:50 AM, revealed the nurses were supposed to check the resident's oxygen setting two to three times during their assigned shift. LPN #1 stated she did not check Resident #6's oxygen setting until the afternoon of 02/21/13. The LPN stated she had identified the resident's oxygen was set on 3 liters per minute at approximately 2:00 PM on 02/21/13 and adjusted the oxygen setting to 2 liters. Interview with the Director of Nurses (DON) on 02/22/13, at 2:55 PM revealed nurses were responsible to check the resident's oxygen setting whenever they went in each resident's room to ensure the oxygen was administered in accordance with physician's orders [REDACTED]. setting and no problems had been identified.

Based on observation and interview, the facility failed to provide effective housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Observations throughout the facility revealed a door with splintered edges, a bedside commode with chipped covering on the seat, and a wheelchair and geri-chair in need of repair. The findings include: A review of the facility's monthly maintenance calendar (no date) revealed resident rooms were to be checked for needed repairs every Wednesday, Thursday, and Friday. However, no log was available to verify resident room checks were made and needed repairs were performed. Observations of the facility from 01/18/12 through 01/19/12, revealed the following areas were in need of repair: 1. The bathroom door in resident room 215 had rough edges that exposed splintered wood. 2. A bedside commode with chipped covering on the seat was observed in the bathroom of room 207. 3. The wheelchair in room 215 was observed to have a torn armrest. Several layers of transparent tape were observed on the wheelchair armrest. 4. A geri-chair in room 125 was observed to have a torn/worn armrest. An interview conducted with the Maintenance Director on 01/19/12, at 11:15 AM, revealed staff was to complete a work order and place in the Maintenance Director's box when they observed anything in need of repair. According to the Maintenance Director, work orders were reviewed every morning (Monday through Friday) and repairs that affected residents and their safety were completed before other repairs. The Maintenance Director reported he was unaware of any of the items that were identified in need of repair.

Based on observation and interview it was determined the facility failed to ensure the residents' environment remained as free from accident hazards as possible. Observation during the environmental tour of the 100 Unit on 01/18/12 through 01/19/12, revealed the facility failed to ensure over-the-counter medications, scissors, and a vegetable peeler were secured/locked and not accessible to residents. The findings include: An interview conducted with the Facility Administrator on 01/19/12, at 9:10 AM, revealed the facility did not have a policy specific to medications/personal items residents were allowed to keep at their bedside. The Administrator further stated over-the-counter medications and potentially hazardous items such as scissors or a vegetable peeler that are allowed to be kept in a resident's room are determined on an individual basis, due to some residents' ability to perform their own personal care. However, the Administrator further stated medications and/or potentially hazardous items should not be left out in open view, but should be placed in a drawer or a closet after use. 1. Observation on 01/18/12, at 2:45 PM, revealed an unopened Fleet brand enema on the bedside table in resident room 120. The package contained a warning label which read, "Keep out of children's reach. Harmful if swallowed." 2. Observation on 01/19/12, at 9:00 AM, revealed opened bottles of throat spray, saline nasal spray, and a vegetable peeler on the bedside table in resident room 108-2. 3. Further observation on 01/19/12, at 10:25 AM, revealed a pair of scissors on the bedside table in resident room 105-1. A "STOP" sign barrier affixed with Velcro tabs was observed across the doorway entrance to room 105. The resident in 105-1 reported that on occasion other residents have come into the room uninvited. A review of the "Alarms" book at the 100 Unit nurses' station revealed 22 residents on the 100 Unit have a wandering bracelet alarm. The Unit Manager (UM)/Licensed Practical Nurse (LPN) #3 stated the list of wandering residents was current. An interview conducted with State Registered Nursing Assistant (SRNA) #11 on 01/19/12, at 9:20 AM, revealed Fleet Enemas should not be kept on a resident's bedside table, but should be locked up out of residents' reach. Further interview with SRNA #11 revealed she had been trained to observe for potentially hazardous items in the residents' rooms each time she enters a resident's room to provide care. An interview with the Director of Nursing (DON) on 01/19/12, at 11:05 AM, revealed staff was trained to observe for potentially hazardous items each time they entered the residents' rooms to provide care. If items are noted they should be put away in the resident's bedside drawer or the resident's closet. Further interview revealed that those residents who have been assessed on admission and determined to be competent to self-administer their own over-the-counter medication and/or keep sharp objects at their bedside, should be reminded by staff to keep medication and potentially hazardous items in a drawer or in the closet.

Based on observation, interview, and review of the facility's policy it was determined the facility failed to prepare and distribute food in a sanitary manner. Observation of the tray line for the evening meal on 01/16/12, revealed a cook failed to wash her hands between glove changes. The findings include: Review of the facility dietary policies titled Proper Use of Gloves for Food Handling and Handwashing (not dated) revealed hands were to be washed before and after removing gloves and gloves should be changed frequently. The policies also directed staff to change gloves after touching any unsanitary item such as an oven door or refrigerator. Observation of the tray line for the evening meal on 01/16/12, revealed the cook left the tray line to obtain frozen french fries from the freezer. The cook was observed to open the walk-in freezer door with her gloved hands. The cook then opened the bag of frozen french fries by handling scissors with her gloved hands, placed the fries in a basket, and lowered the basket in the deep fryer. The cook removed her gloves and placed the empty bag from the french fries and her gloves in a large garbage can. The cook handled the lid of the trash can with her bare hands. The cook then donned clean gloves but failed to wash her hands between glove changes and after handling soiled/unsanitary items. Interview on 01/17/12, at 3:15 PM, with the cook revealed she was knowledgeable of the requirement to change gloves and wash hands after touching any contaminated surface. The cook stated she should have washed her hands before applying the clean gloves. Interview on 01/18/12, at 9:30 AM, with the Dietary Manager (DM) revealed gloves should be removed any time a cook needed to leave the serving line and hands should be washed before applying clean gloves. The DM stated staff should remove gloves and wash hands if any soiled item was touched.

Based on observations, interview, and facility policy, it was determined the facility failed to provide appropriate treatment and services to prevent urinary tract infections for one resident (Resident #8) in the selected sample of twenty residents. Observations during the provision of indwelling catheter care for Resident #8 revealed Certified Nurse Aide (CNA) #1 failed to follow facility policy and cleansed the indwelling catheter tubing toward the insertion site of the resident's indwelling urinary catheter and cleansed the perineal area in upward [MEDICAL CONDITION]. The findings include: A review of the facility's policy titled Giving Catheter Care (not dated) revealed staff was to expose the urinary catheter insertion site. While holding the catheter tubing at the insertion site staff was to cleanse the catheter tubing with soap/water/washcloth from the insertion site out to at least four inches with one stroke. The policy further directed staff to rinse the catheter using the same method. Observation on 01/17/12, at 3:00 PM, of incontinence care for Resident #8 revealed CNA #1 failed to cleanse the catheter tubing in an outward motion from the insertion site when she cleansed the catheter tubing and failed to cleanse the resident's perineal area with downward motions from the catheter insertion site. The CNA used upward [MEDICAL CONDITION] when she cleansed the sides of the catheter insertion site and moved toward the insertion site when she cleansed the catheter tubing. CNA #1 was observed to use a towel to dry the areas but failed to rinse the areas clean. CNA #1 failed to rinse the catheter as directed by the facility's policy. An interview on 01/18/12, at 2:00 PM, with CNA #1 revealed she realized she had failed to use appropriate technique when she provided catheter care to Resident #8. CNA #1 stated she failed to wipe in downward motions and failed to cleanse the catheter away from the resident as trained. CNA #1 stated she was nervous during the procedure and failed to provide the catheter care correctly. CNA #1 stated residents were more likely to have infections if staff did not use appropriate technique when cleaning catheters. Interview on 01/18/12, at 2:35 PM, with the 200 Hall Supervisor revealed staff was expected to provide catheter care as outlined in the facility policy. The Supervisor stated staff should always cleanse the catheter tubing by cleansing away from the resident and cleanse the perineal area using downward [MEDICAL CONDITION].

Based on observation, interview, and policy review, it was determined the facility failed to provide foods that were palatable and at a preferable temperature during the evening meal on the 100 Unit of the facility on 01/16/12. The findings include: A review of the facility's policy entitled "Meal Pass" (no date) revealed residents' meal delivery would be served timely so that foods were received by residents at appropriate temperatures. The policy also revealed cold foods would be served at 41 degrees Fahrenheit or below, and hot foods would be served at 135 degrees or above. Observation of the evening meal service on 01/16/12, at 5:25 PM, revealed meals were delivered from the kitchen in a closed, unheated cart to the 100 Unit of the facility. At 6:00 PM, 35 minutes after the food cart was delivered to the floor, three trays remained on the cart. Temperatures were obtained and a food palatability test was performed on one of the three remaining trays. The temperatures and food palatability tests revealed the cabbage tasted lukewarm at 99 degrees Fahrenheit, the catfish tasted lukewarm at 96 degrees Fahrenheit, and the french fries tasted lukewarm at 93 degrees Fahrenheit. The food temperatures obtained were noted to be below the facility's policy of 135 degrees Fahrenheit or above. A group interview conducted with five alert and oriented residents on 01/17/12, at 10:00 AM, revealed foods they received at the facility that should be hot were not always served hot. The residents had not reported the issue to the facility, and had not addressed the issue in the Resident Council meetings. An interview conducted with State Registered Nursing Assistant (SRNA) #7 on 01/16/12, at 6:20 PM, revealed it usually took 20 to 30 minutes per food cart to pass the meal trays to the residents. The SRNA also stated she had been told to send a tray back if it had been on the meal cart for too long. The SRNA stated a tray should not sit on the meal cart for longer than 15 minutes before notifying the dietary staff to replace the tray. The SRNA stated she was unsure why it had taken them so long to pass the trays and she should have had the trays replaced. An interview conducted with SRNA #8 on 01/16/12, at 6:28 PM, revealed it usually took 15 to 20 minutes to pass meal trays. The SRNA stated she had been told by the facility not to leave a tray on the cart for longer than 15 minutes before notifying the dietary staff to replace the tray. The SRNA stated she was unsure why it took them so long to pass the trays, and revealed she should have called the Dietary Department and had the trays replaced. An interview conducted with the Dietary Manager (DM) on 01/18/12, at 9:25 AM, revealed a tray should not sit on the meal cart for more than 20 minutes. According to the DM, if a tray has been on the meal cart 20 minutes or more, dietary staff should be notified to replace the tray. The DM stated she audited test trays for quality two to three times every month.

Based on interview and record review, it was determined the facility failed to timely complete a quarterly Minimum Data Set (MDS) assessment for one (1) of twenty-one (21) sampled residents (resident #2). The findings include: A record review conducted for resident #2 revealed the resident had an admission MDS assessment completed on July 15, 2010, and was due to have a quarterly assessment completed with an assessment reference date of October 15, 2010. Further record review revealed resident #2 had a 14-day Medicare assessment completed on October 18, 2010. There was no evidence the facility had completed the required assessment. An interview conducted with the Registered Nurse (RN) responsible for completing the MDS assessment for resident #2 revealed the resident had been out of the facility and had returned. Further interview revealed the RN had completed an assessment but had not coded the assessment correctly and was not aware that resident #2 did not have the required quarterly assessment completed.