Every finding on record at Wooldridge Place Nursing Center

Based on record review and interviews, the facility failed to ensure nursing staff had the appropriate competencies and skill sets to provide nursing and related services to assure resident's safety and attain or maintain the highest practicable physical, mental and psychosocial well-being for each resident for one resident (Resident #5) of five residents reviewed for effective implementation of Physician's Orders. The facility failed to ensure that Nurse A had the specific competencies, and skill sets necessary to care for resident's' needs, specifically she failed to entered the physician's order for Resident #5's intravenous antibiotic when she was admitted [DATE] from the hospital. Nurse A's actions resulted in Resident #5 not receiving her antibiotic until 48 hours after admission to the facility 06/03/26. This failure could place residents at risk for worsening infection and not receiving the proper care required to attain and maintain the highest practicable physical mental and psychosocial well-being. The findings included: Record review of Resident's #5's admission record, dated, revealed Resident #5 was a [AGE] year-old female with an admission date of 06/03/26. Pertinent diagnoses included: Peripheral Vascular Disease (a slow and progressive disorder of the blood vessels outside the heart), Type II Diabetes ( a chronic condition where the body resists insulin or does not make enough of it, causing sugar to build up in the blood) and Surgical amputation of her right leg (the planned removal of all or part of a limb or extremity, such as an arm, leg, hand, or toe, to save a life). Record review of Resident's #5's admission MDS assessment dated [DATE] revealed a BIMS Score of 8; indicating a moderate cognitive impairment. Record review of Resident #5's Hospital Discharge Medications List, dated 06/03/26, revealed a physician's order for Daptomycin 4mg/kg q24h to be started upon discharge with last dose administered on 06/07/26. Record review of Resident #5's Hospital Discharge summary, dated [DATE], revealed a discharge date of 06/03/26. Record review of Resident #5's June 2026 MAR printed on 08/25/26 revealed Daptomycin antibiotic initial dose was administered on 06/05/26 at 5 p.m. In a telephone interview on 08/25/26 at 9:45 a.m. the RP stated Resident #5 was sent to the facility for antibiotic treatment related to a severe foot infection. RP stated the SW told her the facility's pharmacy was located out of town which might cause a delay in receiving the medication. In an interview on 08/25/26 at 1:30 p.m., Resident #5 stated she was sent to the facility for antibiotic treatment. She stated she was scheduled to have received antibiotic treatment intravenously upon her arrival at the facility. In an interview on 08/25/26 at 4:24 p.m., the ADON stated Resident #5 was admitted on [DATE]. The ADON stated Resident 16's antibiotic was not entered into the pharmacy database until 06/04/26. She stated Nurse B discovered the discrepancy and corrected it on 06/04/26. ADON stated she entered another order for the same antibiotic but changed the time of administration to 5 p.m. so the initial dose would be given immediately upon delivery of the medication. She stated the antibiotic was delivered on 06/05/26 at 5:00 p.m. She stated the admitting nurse was responsible for completing the admission process which included entering the physician's orders into the pharmacy's database. She stated Nurse A was the admitting nurse for Resident #5 on 06/03/26. She stated the Nurse received training on hire and quarterly on the admission process. The DON stated the last in service was done in June 2026. In an interview on 08/25/26 at 5:00 p.m. the DON stated the Charge Nurse/admission Nurse was responsible for processing admissions including entering physician's orders into the pharmacy database. She stated on 06/03/26 that responsibility fell on Nurse A. She stated Nurse A was trained on the admission process when she was oriented upon hire. The DON could not provide a facility policy on the admission process specifically inputting physician's orders in the pharmacy database and confirmation the task was completed. In an interview on 08/25/26 at 5:42 p.m. Nurse A stated she was the admitting nurse for Resident #5 on 06/03/26. She stated part of the admission process was entering physician's orders into the pharmacy database. Nurse A stated it was her responsibility as the admitting nurse to enter the physician's orders. She stated she did not know why she had not entered the physician's order for the antibiotic. Nurse A stated her last competency training was 1.5 years ago and she had not had any training or in-services in the admission process since then. She stated she would have no way of knowing if the admission process changed or was updated. In an interview on 08/25/26 at 6:15p.m., the Adm. stated the Charge Nurse who admitted Resident #5 should have entered the order. He stated the error was discovered and corrected on 06/04/26. The Adm. stated the antibiotic arrived and was administered on 06/05/26. He stated Nurse A was trained on the admission process and resident evaluations during the annual competency provided every year by the facility. Review of facility's Medication Reconciliation Evaluation for Nurse A dated 07/15/26 revealed the absence of competency-based training/demonstration for the admission process specifically inputting physician's orders in the pharmacy database and confirmation task was completed. Review of the facility's On the Spot Inservice dated 02/19/26 reflected an absence of subject matter related to the admission process specifically inputting physician's orders in the pharmacy database and confirmation task was completed. Review of admission Process instructions provided by the facility reflected an absence of date implemented and an absence of the admission process specifically inputting physician's orders in the pharmacy database and confirmation task was completed.

Based on interview and record review, the facility failed to ensure residents were free from any significant medication errors for two of 5 residents (Resident #1 and Resident #2) reviewed for medication errors. 1. The facility failed to hold Resident #1's midodrine (medication that raises blood pressure) when Resident #1's blood pressure was outside of physician's parameters on 06/01/26 and 06/11/26. 2. The facility failed to administer Resident #2's midodrine when Resident #2's blood pressure was inside of physician's parameters on 06/05/26. These failures could place residents at risk for complications such as increased blood pressure, decreased blood pressure, exacerbation of symptoms, and potential hospitalization.The findings include: 1. Record review of Resident #1's face sheet dated 06/16/26 revealed a [AGE] year-old female with an initial admission date of 05/15/26 and a current admission date of 02/01/26. Resident #1's pertinent diagnosis included hypertensive heart disease with heart failure (years of unmanaged high blood pressure force your heart muscle to thicken and strain). Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 14 indicating her cognition was intact. Record review of Resident #1's Comprehensive Care Plan dated 06/16/26 revealed the focus The resident has hypertension (elevated blood pressure) / hypertensive heart disease. She also has had episodes of hypotension (low blood pressure) initiated on 07/07/23 and revised on 06/13/26. An intervention listed for the focus included Administer medications as ordered for hypotension PRN initiated on 06/13/26. Record review of Resident #1's order summary dated 06/16/26 revealed an active order for midodrine 10 MG give 1 tablet by mouth every 8 hours for Hypotension Hold for SBP (top number of a blood pressure) >120 and check BP manually initiated on 02/09/26. Record review of Resident #1's MAR for June 2026 revealed midodrine was administered at the following dates and times with associated blood pressures:06/01/26 at 2:00 PM - 123/75 by CMA A06/11/26 at 2:00 PM - 122/67 by CMA A 2. Record review of Resident #2's face sheet dated 06/16/26 revealed a [AGE] year-old female with an admission date of 06/03/26. Resident #2's pertinent diagnosis included Essential Hypertension (high blood pressure without a single identifiable medical cause). Further review revealed Resident #2 resided on the 300 hall. Record review of Resident #2's Comprehensive MDS assessment dated [DATE] revealed a BIMS score of 13 indicating her cognition was intact. Record review of Resident #2's Comprehensive Care Plan dated 06/17/26 revealed the focus The resident has hypertension. Resident may also experience hypotensive episodes initiated on 06/07/26 and revised on 06/17/26. An intervention listed for the focus included Give anti hypertensive medications as ordered. initiated on 06/07/26. Record review of Resident #2's order summary dated 06/16/26 revealed an active order for midodrine 5 MG Give 1 tablet by mouth every 8 hours as needed for hypotension for SBP < 100 initiated on 06/05/26. Record review of Resident #2's blood pressure history revealed the following blood pressure:06/05/26 at 9:39 AM - 96/45 by CMA AFurther review revealed Resident #2's blood pressure was only checked once on 06/05/26. Record review of Resident #2's MAR for June 2026 revealed midodrine was not administered on 06/05/26. Record review of the floor schedule for nurses and CNAs on 06/17/26 revealed RN A was the floor nurse covering the 300 hall on 06/05/26 During an interview with CMA A at 7:51 AM on 06/17/26, CMA A stated midodrine was a medication used to raise a resident's blood pressure. CMA A stated she always measured a resident's blood pressure before administering any medication that may alter it to ensure it was within the physician's parameters. CMA A stated it appeared on the MAR for Resident #1 that she administered midodrine outside of physician's parameters on 06/01/26 and 06/11/26. CMA A stated she did not administer PRN medications, so she would not have administered the midodrine to Resident #2 when her systolic blood pressure was below 100 on 06/05/26. CMA A stated she remembered telling a nurse that Resident #2's blood pressure was low on that day but did not remember which nurse she told. CMA A stated she did not document anywhere that she informed a nurse about Resident #2's systolic blood pressure being less than 100 on 06/05/26. CMA A stated administering midodrine outside of parameters could cause a resident's blood pressure to increase too much leading to headaches, or chest pains. CMA A stated not administering midodrine when appropriate could lead to hypotension in a resident causing dizziness or light-headedness. During an interview with RN A at 9:42 AM on 06/17/26, RN A stated the medication aides did not administer PRN medications. RN A stated he was working on 06/05/26 covering the 300 hall. RN A stated no one told him Resident #2's systolic blood pressure was below 100 on 06/05/26. RN A stated if he had been told he would have re-measured her blood pressure and then administered midodrine if appropriate. RN A stated not administering midodrine when appropriate could lead to blood pressure dropping further and causing hypotension symptoms like sleepiness or dizziness. During an interview with the DON at 12:26 PM on 06/17/26, the DON stated a resident's blood pressure should be measured before administering any blood pressure altering medication to ensure it was within the physician's parameters. The DON stated according to the MAR for Resident #1 she should not have been administered midodrine on 06/01/26 and 06/11/26 with the blood pressures that were documented. The DON stated Resident #2 should have been administered midodrine on 06/05/26 by the nurse based on the blood pressure that was documented on that day. The DON stated she was not aware of any documentation that CMA A notified anybody of Resident #2's blood pressure being low on 06/05/26. The DON stated not administering midodrine when appropriate could lead to hypotension and administering it when it was not appropriate could lead to hypertension. Record review of the facility's policy General Dose Preparation and Medication Administration effective 12/01/07 and last revised 11/15/24 revealed the following policy: .3. Prior to administration of medication, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following:3.1 Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident.3.5 If necessary, obtain vital signs.

Based on observation, interview and record review, the facility failed to maintain medical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 of 5 residents (Resident #5) reviewed for documentation. The facility failed to ensure Resident # 5's medication orders were complete and accurate on 1 occasion for June 10, 2026. This failure could place residents at risk for errors in care and treatment and not receiving the services needed to attain or maintain their highest practicable physical well-being. The findings included: Record review of Resident # 5's face sheet dated 06/16/26 indicated a [AGE] year-old-female with an original admission date of 05/09/26 and a readmission date of 06/09/26 with the diagnoses of Joint Replacement Surgery (replacement of damaged or arthritic joint surfaces with artificial implants), Rheumatoid Arthritis ( a chronic autoimmune disease where the immune system mistakenly attacks the lining of the joints), Chronic Obstructive Pulmonary Disease ( a progressive lung disease that blocks airflow and makes breathing difficult). Record review of Resident # 5's Care Plan indicated there was no current care plan initiated as resident had been admitted for less than 24 hours. Record review of Resident # 5's order summary report dated June 17, 2026, revealed no physician's order for Tylenol. Record review of Resident # 5's Medication Administration Record dated June 17, 2026, indicated there was no physician's order for Tylenol. Record review of standing orders signed by the NP on 06/17/26 revealed a standing order for Tylenol 500mg oral every 8 hours as needed for pain scale equal to or greater than 4 out of 10. During an interview with LVN D on 06/17/26 at 7:00 am, LVN D stated she had dispensed Tylenol to Resident #5 at approximately 2:00 am on 06/10/26. LVN C stated she recalled documenting the Tylenol in her shift report, but she failed to document as given in the MAR. She stated the resident had a standing order for Tylenol, but she had failed to write the order for the Tylenol in the MAR. LVN D stated Resident #5 continued to request something for pain after Tylenol had been dispensed. She stated Resident #5's medications were coming from another city which was causing the delay in her getting a stronger pain medication. LVN C stated she should have called the physician and requested a pain medication the facility had in stock. Interview with CNA C on 06/17/26 at 1:00 pm she stated Resident # 5 was given Tylenol by LVN D on 06/10/26 at approximately 2:00 am. During an interview with the DON on 06/17/26 at 12:24 pm, the DON stated the facility had standing orders for Tylenol. She stated LVN D did not transcribe the orders from the standing orders to Resident # 5's electronic health record and LVN D failed to document she had dispensed Tylenol to Resident #5. The DON stated failure to document administered medications could lead to medication errors to include but not limited to overdosing the resident. Record review of facility's Administering Medication Policy 6.0 General Dose Preparation and Medication Administration revised 11/15/24 indicated Prior to administration of medication, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following 3.2 Confirm that the MAR reflects the most recent medication order.

Based on observation, interview, and record review, the facility failed to maintain a comprehensive prevention and control program that included employing proper signage on the doors of resident's room to prevent the transmission of communicable diseases and infections for 1 of 16 residents (Resident #4) reviewed for infection control. The facility failed to place a readily visible EBP sign outside the room of Resident's #4 who had an active order for EBP. This failure could place residents at risk of cross contamination, infection, and illness.The findings include: Record review of Resident's #4's face sheet dated 06/17/26 revealed a [AGE] year-old female with an initial admission date of 01/11/24 and a readmission date of 05/11/26. Pertinent diagnoses include End Stage Renal Disease (the final stage of chronic kidney disease), Acute Pyelonephritis (a sudden, severe bacterial infection of the kidneys) and Pyelitis Cystica (a benign, chronic condition of the urinary tract characterized by the formation of multiple tiny, fluid filled cysts in the lining of the renal pelvis).Record review of Resident #4's MDS dated [DATE] reflected a BIMS score of 15 (cognition shows no signs of impairment). Record review of Resident #4's Comprehensive Care Plan dated 05/12/26 revealed Resident # 4 had an indwelling catheter for 24-hour urine collection. Record review of Resident #4's Order Summary Report dated 06/17/26 reflected Resident #4 required a catheter for a 24-hour Urine Collection for Creatinine Clearing starting Tuesday 06/16/26 to 06/17/26. During an observation on 06/17/26 at 6:30 am outside Resident's #4's room, it was noted that assorted PPE was placed in a plastic drawer organizer outside her room. No sign was visible from the hallway advising visitors or staff to wear PPE before entering Resident #4's room or when performing care on Resident #4. In an interview with CNA B on 06/17/26 at 6:40 AM, CNA B stated any resident with a catheter was on EBP. CNA B stated she knew which rooms required her to wear EBP because there was an EBP sign outside their door and PPE outside their room. In an interview with LVN B on 06/17/26 at 9:25 AM, LVN B stated Resident # 4 was on EBP. LVN B stated the proper PPE to wear for anyone providing care for Resident # 4 was a gown and gloves. LVN B stated it was her responsibility to ensure all residents that required EBP had the appropriate sign outside their door and it was plainly visible. LVN B stated the failure could place residents at risk of cross contamination, infection, and illness. In an interview with LVN C on 06/17/26 at 10:07 AM, LVN C stated Resident # 4 was on EBP due to utilizing a catheter and staff were required to wear gowns and gloves when providing care for Resident #4. LVN C stated the failure could place residents at risk of cross contamination, infection, and illness. In an interview with RN A on 06/17/26 at 9:42 AM, RN A stated Resident # 4 was on EBP, and that gown and gloves were required when providing care for Residents on EBP. RN A stated the failure could place residents at risk of cross contamination, infection, and illness. In an interview with the DON on 06/17/26 at 12:24 PM, the DON stated the Resident # 4 was currently on EBP. The DON stated that a gown and gloves were required when providing care. The DON stated an EBP sign should have been posted outside of the door of all residents that were on EBP. The DON stated the signs were in place to prevent infection from potentially spreading from one resident to another. The DON said the failure could place residents at risk of cross contamination, infection, and illness. Review of the CDC document: Long-Term Care Facilities: Implementation of Personal Protective Equipment Use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms, dated 04/02/2024 revealed, The use of gown and gloves for high-contact resident care activities was indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE (e.g., gown and gloves); For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that required the use of gown and gloves; Make PPE, including gowns and gloves, available immediately outside of the resident room. Review of facility's Enhanced Barrier Precautions Policy revised 08/19/25 revealed, The facility should use EBP as an additional MDRO mitigation strategy for residents that meet the following criteria during high contact resident care activities. EBP are indicated for residents with any of the following: Infection or colonization with CDC-targeted MDRO when Contact Precautions do not otherwise apply; orWounds and or indwelling medical devices even if the resident is not known to be infected or colonized with MDRO.Wounds generally include chronic wounds.Indwelling medical devices examples include . urinary catheters, . EBP should be used for any resident who meets the above criteria, wherever they reside in the facility.Record review of CDC guidance 483.80(a)(1) on EBP:A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to S483.70(e) and following accepted national standards.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 2 residents (Resident #1 and Resident #5) of 5 residents whose care plans were reviewed. 1. The facility failed to ensure Resident #1's care plan addressed her sexual relationship with Resident #5. 2. The facility failed to ensure Resident #5's care plan addressed his sexual relationship with Resident #1. This deficient practice could place residents in the facility at risk of not being provided with the necessary care or services, and the implementation of personalized plan of care developed to address their specific needs. The findings included: 1. Record review of Resident #1's admission record on 05/28/26 reflected an [AGE] year-old female resident initially admitted to the facility on [DATE] with most recent admission on [DATE]. Her diagnoses included chronic obstructive pulmonary disease (a progressive, incurable lung disease that causes inflammation and difficulty breathing), unspecified dementia (loss of memory, language, problem solving and other thinking abilities which significantly impair a person's ability to perform daily activities), nontraumatic intracerebral hemorrhage (a spontaneous bleed directly into the brain tissue not caused by a head injury), cognitive communication deficit (difficulty with communication, muscle weakness, and difficulty in walking. Record review of Resident #1's quarterly MDS dated [DATE] reflected a BIMS score of 8 which indicated she had moderate cognitive impairment. Record review of Resident #1's care plan dated 12/08/23 reflected her sexual relationship with Resident #5 was not addressed. Record review of Resident #1's progress notes reflected a note dated 04/24/26 by the DON that stated, DON spoke with resident RP [name]. Informed RP of resident's sexual relationship with another male resident. RP verbalized understanding of situation and stated the resident is going to do what she wants to do and its ok. Physician aware as well. 2. Record review of Resident #5's admission record reflected a [AGE] year-old male resident admitted to the facility on [DATE]. His diagnoses included chronic obstructive pulmonary disease (a progressive, incurable lung disease that causes inflammation and difficulty breathing), alcohol dependence with alcohol induced persisting dementia (damage done to nerve cells in the brain caused by long term alcohol consumption in unsafe amounts), muscle weakness, hypertension (high blood pressure), and generalized anxiety disorder (mental disorder characterized by excessive and persistent worry, fear, or anxiousness which significantly interferes with daily life). Record review of Resident #5's quarterly MDS dated [DATE] reflected a BIMS score of 9 which indicated he had moderate cognitive impairment. Record review of Resident #5's care plan dated 08/14/25 reflected his sexual relationship with Resident #1 was not addressed. In an interview on 05/28/26 at 1:15 pm, LVN A stated Resident #1 and Resident #5 have had a sexual relationship for months. She stated Resident #5 said things about Resident #1 such as he did not want to leave her and wanted to make sure she was taken care of. LVN A stated she had gone into Resident #5's room once and he and Resident #1 joked with her about their sexual relationship. In an interview on 05/28/26 at 2:05 pm, Resident #5 stated he and Resident #1 were in a romantic relationship and they were engaged. He stated the relationship was okayed by the Adm and the SW. Resident #5 stated he and Resident #1 frequently were in his room watching movies and so on. He stated he and Resident #1 would eventually move into a place together. In an interview on 05/28/26 at 2:32 pm, Resident #1 stated she did not have a boyfriend. She stated she did have a male friend but denied a sexual relationship with him and denied that she had sex at all. In an interview on 05/28/26 at 2:49 pm, Resident #1's RP stated she was made aware of a sexual relationship between Resident #1 and a male resident. She stated the DON let her know about the relationship shortly before Easter. The RP stated she felt that Resident #1 was able to say, no if she did not want to do anything or be with Resident #5. In an interview on 05/28/26 at 4:30 pm, MA B stated Resident #1 spent a lot of time in Resident #5's room. She stated she never walked in on them doing anything other than talking or watching tv. If there was a sexual relationship between two residents that she witnessed, she would tell her nurse right away. If it was not something she witnessed, she stated she would probably find out in shift report. She stated he had heard about Resident #1 and Resident #5 from other staff several days ago but had not seen anything. MA B named the abuse coordinator, types and examples of abuse and neglect, what to do if she saw, heard, or suspected abuse, and when and who to report to. In an interview on 05/28/26 at 4:40 pm, LVN C stated she had worked at the facility for about a year. She stated Resident #1 and Resident #5 had a sexual relationship. She stated she walked into Resident #5's room about 2 months ago on evening shift and Resident #1 was touching Resident #5 in a sexual manner. LVN C stated the entire staff was aware of the sexual relationship and they made it a point to educate new staff to knock and wait before entering Resident #5's room. She stated she had not seen anything in writing about their sexual relationship and other staff were made aware by word of mouth. She stated she did not report it to anyone since she was already aware of the relationship. LVN C stated if she had not known about Resident #1 and Resident #5's sexual relationship and walked in on it, she would have notified the ADON or DON and Resident #1's RP and provider. LVN C named the abuse coordinator, types and examples of abuse and neglect, what to do if she saw, heard, or suspected abuse, and when and who to report to. In an interview on 05/28/26 at 5:04 pm, LVN D stated she started working at the facility on 03/10/26. She stated all she knew about Resident #1 and Resident #5 was what she had heard from other staff. She stated she had not seen anything herself. She stated if she walked in on residents in a compromising position, she would separate them, talk to them to see if it was consensual, contact the DON and the Resident's RPs and let the provider know. LVN D named the abuse coordinator, types and examples of abuse and neglect, what to do if she saw, heard, or suspected abuse, and when and who to report to. In an interview on 05/28/26 at 5:16 pm, CNA E stated she had worked at the facility since October 2025. She stated she did not work with Resident #1 and Resident #5. She stated she had not heard anything about a sexual relationship between them, but she did not work their hall. She stated if she walked in on something sexual between 2 residents, she would shut the door and tell the nurse immediately, as that was what she was taught to do. CNA E named the abuse coordinator, types and examples of abuse and neglect, what to do if she saw, heard, or suspected abuse, and when and who to report to. She stated the last in-service on abuse and neglect was about 2 days ago and they were usually about 2 times a month. In a telephone interview on 05/28/26 at 5:31 pm, the SW stated she had heard from other people that Resident #5 said he was an attorney and he was representing Resident #1 and that they had a relationship. She stated she had not witnessed any type of sexual relationship between them. She stated she never talked to Resident #5 about a relationship with Resident #1. The SW stated if she knew of a sexual relationship between residents, she would notify the administrator. She stated a sexual relationship between Resident #1 and Resident #5, or any resident, should have been care planned. She stated if she walked in on something sexual between 2 residents, she would shut the door and tell the nurse immediately, as that was what she was taught to do. The SW named the abuse coordinator, types and examples of abuse and neglect, what to do if she saw, heard, or suspected abuse, and when and who to report to. She stated the last in-service on abuse and neglect was about 2 days ago and they were usually about 2 times a month. In a telephone interview on 05/28/26 at 5:45 pm, the MDS nurse stated she was not 100% sure what type of relationship Resident #1 and Resident #5 had. She knew they seemed to enjoy spending time together. She stated she had seen them hanging out in his room and her room and in activities together. He also pushed her wheelchair around. She stated care plans were normally updated every 3 months and as needed and any of the nurses could update them. She stated if Resident #1 and Resident #5 were in a sexual relationship it should be care planned. She stated if she witnessed sexual abuse, she would provide privacy and tell the DON as long as it did not seem nonconsensual. The MDS nurse named the abuse coordinator, types and examples of abuse and neglect, what to do if she saw, heard, or suspected abuse, and when and who to report to. She stated the last in-service on abuse and neglect was about 2 days ago and they were usually quarterly and as needed. In an interview on 05/28/26 at 6:05 pm, the ADON stated she had never seen any sexual interaction between Resident #1 and Resident #5. She stated she had seen them together holding hands, but nothing more. The ADON stated she had heard that Resident #1 and Resident #5 had a sexual relationship from other staff. She stated the ombudsman also knew about it. She stated she heard about it 2 to 3 weeks ago. The ADON stated if she walked in on residents in a consensual sexual situation, she would provide privacy and report it to the DON and the Adm. The ADON stated a sexual relationship between residents should be care planned. The ADON named the abuse coordinator, types and examples of abuse and neglect, what to do if she saw, heard, or suspected abuse, and when and who to report to. She stated the last in-service on abuse and neglect was about 2 days ago and they were usually quarterly and as needed. In interview on 05/28/26 at 6:27 pm, the DON stated she had not seen Resident #1 and Resident #5 in a sexual situation, but she heard about it, so she notified Resident #1's RP about it a few weeks ago. She stated Resident #5 was his own RP. The DON stated she spoke to Resident #1 when she found out about the relationship with Resident #5. She stated she wanted to ensure Resident #1 was able to consent to a sexual relationship. The DON stated Resident #1 told her she was in a sexual relationship with Resident #5 and she enjoyed spending time with him. The DON stated the Adm told her to have the SW notify the ombudsman. She stated the facility had not in-serviced the staff about the relationship, but they probably should have so that everyone was aware. The DON stated she did not care plan it because she just did not think about it as it was not a common occurrence. She stated if she walked in on any other 2 residents in a sexual situation and she knew they were both able to consent, she would provide privacy, document, and care plan it. If it involved a resident who was not able to consent, she would separate them, notify the Adm, the RPs, the provider, and the police. In an interview on 5/28/26 at 6:35 pm, the Adm stated he was aware of the relationship between Resident #1 and Resident #5. He stated had spoken to both residents about it and they both confirmed the relationship. He stated he spoke to Resident #1 alone and she told him she was ok with her relationship with Resident #5. Record review of the facility's Area of Focus: Care Planning- Baseline, Comprehensive, and Routine Updates policy dated 01/04/22 and reviewed on 12/04/25 reflected in part: WhyComprehensive Care PlanFederal regulation. requires the facility to develop and implement a comprehensive person-centered care plan for each resident.that includes measurable objectives and time frames to meet a residents medical nursing, and mental and psychosocial needs that are identified in the comprehensive assessment (MDS). HowComprehensive Care Plan2. The comprehensive care plan must include problem/focus statement, measurable goals, and interventions.Process Step/Objective- Recognition/Assessment: Gather information about the individual.Key Tasks- Identify and collect information that is needed to identify and individual's conditions that enables proper definition of their conditions, strengths, needs, risks, problems, and prognosis.Process Step/ Objective- Problem definition: Define the individual's problems, risks, and issues.Key Tasks- Identify any current consequences and complications of the individual's situation, underlying condition, and illnesses, etc. Clearly state the individual's issues and physical, functional, and psychosocial strengths, problems, needs, deficits, and concerns. Define significant risk factors.Process Step/ Objective- Identifying goals and objectives of care: Clarify purpose of providing care and of specific interventions, and the criteria that will be used to determine whether the objectives are being met.Key Tasks- Clarify prognosis. Define overall goals for the individual. Identify criteria for meeting goals.Process Step/ Objective- Selecting interventions/ planning care: Identify and implement interventions and treatments to address the individual's physical, functional, and psychosocial needs, concerns, problems, and risks.Key Tasks- Identify specific symptomatic and cause-specific interventions (physical, functional, and psychosocial). Identify how current and proposed treatments and services are expected to address causes, consequences, and risk factors, and help attain overall goals for the individual. Defne anticipated benefits and risks of various interventions. Clarify how specific treatment and services will be evaluated for their effectiveness and possible adverse consequences.Process Step/ Objective- Monitoring of progress: Review individual's progress towards goals and modify approaches as needed.Key Tasks- Identify the individual's response to interventions and treatments. Identify factors that are affecting progress towards achieving goals. Define or redefine the prognosis. Define or redefine when to stop or modify interventions. Review effectiveness and adverse consequences related to treatments. Adjust interventions as needed. Identify when care objectives have been achieved sufficiently to allow for discharge, transfer or change in level of care. WhenComprehensive Care Plan2. The comprehensive care plan must be updated with each MDS assessment and periodically.

Based on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 5 of 8 (Resident #82, Resident #21 , Resident #53 , Resident #32, and Resident #1) residents reviewed for respiratory care. 1. The facility failed to ensure Resident #82's oxygen was administered at the correct setting of 3 liters per minute on 2/24/2026 as ordered by the physician. 2. The facility failed to ensure Resident #21's oxygen was administered at the correct setting of 2 liters per minute on 2/24/2026 as ordered by the physician. 3. The facility failed to ensure Resident #53's oxygen was administered at the correct setting of 4 liters per minute on 2/24/2026 as ordered by the physician. 4. The facility failed to post an Oxygen sign indicating Resident #32 received oxygen on 2/24/2026. 5. The facility failed to ensure Resident #1's oxygen was administered at the correct setting of 2 liters per minute on 2/24/2026 as ordered by the physician. These deficient practices could place residents who receive respiratory care at an increased risk of developing respiratory complications, a decreased quality of care, and at risk of fire hazards by not posting oxygen signs outside the residents' rooms. The findings included: Record review of Resident #82's admission record dated 2/24/2026 reflected an [AGE] year-old female with an admission date of 02/17/2026. Pertinent diagnoses included Shortness of Breath, Chronic Obstructive Pulmonary Disease (a progressive lung condition causing airflow blockage, making breathing difficult, and includes emphysema and chronic bronchitis). Record review of Resident #82's person-centered care plan, initiated date 2/17/2026 reflected Resident #82 used oxygen therapy related to respiratory illness. Intervention included: Observe for s/sx of respiratory distress and report to MD PRN: Respirations, Pulse oximetry, Increased heart rate (Tachycardia), Restlessness, Diaphoresis (excessive, abnormal sweating), Headaches, Lethargy, Confusion, Atelectasis (the partial or complete collapse of one or more lobes of the lung), Hemoptysis (coughing up blood), Cough, Pleuritic pain a sharp, stabbing, or piercing chest pain that intensifies when breathing deeply), Accessory muscle usage (the recruitment of neck, chest, and abdominal muscles to assist with breathing when primary muscles are insufficient), Skin color. Record review of Resident #82's Order Summary dated 2/24/2026, reflected Oxygen at 3 liters per minute continuously per nasal cannula every shift. Record review of Resident #82's admission MDS assessment, dated 02/17/2026 reflected in progress. During an observation of Resident #82 on 2/24/2026 at 10:12 a.m. the oxygen level on the oxygen concentration machine was at 2 Liters Per Minute via nasal cannula. Observation of Resident #82 revealed the resident was in bed with head of the bed slightly elevated. No signs of respiratory distress noted. During an interview on 2/24/2026 at 10:20 a.m. LVN D stated she was the nurse for Resident #82. LVN D agreed that the Oxygen setting was set at 2 Liters Per Minute. She stated the oxygen setting was supposed to be at 3 Liters Per Minute per physician orders. She stated that she checked the settings at the beginning of her shift. She was not sure who might have moved it. LVN D stated that she checked Resident #82's oxygen tubing and saturation in the mornings. LVN D stated that the negative outcome of keeping Resident# 82's oxygen setting at 2 Liters Per Minute was that the resident could go to respiratory distress, shortness of breath or hypoxia (low oxygen levels). During an interview on 2/26/2026 at 2:40 p.m. the DON, stated that the nurses assigned to that hall were responsible for checking the Oxygen settings. She stated that the nurses were to check the setting twice per shift and as needed. The DON stated they were to follow oxygen settings on physician orders. The DON stated that the negative outcome could be that the resident could have difficulty breathing and hypoxia (low oxygen levels). Record Review of the facility's Oxygen Administration policy, revised 09/30/2025, revealed Definitions Oxygen Therapy- is the administration of oxygen at concentrations greater than that in ambient air (20.9%) with the intent of treating or preventing the symptoms and manifestations of hypoxia. Procedure: Oxygen Administration: 1. Oxygen orders should include the specific liter flow required by the resident. General Safety Guidelines 1. Post a NO SMOKING sign on the outside of door to the residents room before starting use of oxygen. Oxygen Signage Guidelines 1. NO SMOKING sings (and/or the international symbol for no smoking), readable from a distance of 5ft, need to be posted where supplemental oxygen is in use. The findings included: Record review of Resident #21's face sheet, dated 02/26/2026, revealed a [AGE] year-old male with an admission date of 12/06/2024. Pertinent diagnosis included Diffuse Traumatic Brain Injury (severe brain injury characterized by widespread damage to the brain). Record review of Resident #21's Annual MDS assessment, dated 12/01/2025, revealed no BIMS conducted as Resident #21 was rarely or never understood. MDS Diagnoses revealed Traumatic Brain Injury. Record review of Resident #21's physician orders, started 12/06/2024, revealed an order for Oxygen at 2 liters per minute continuously per nasal cannula. Record review of Resident #21's care plan for Oxygen therapy, initiated 12/09/2024, revealed an intervention to give medications as ordered. An observation on 02/24/2026 at 3:42 PM revealed Resident #21's oxygen concentrator was set at 1.5 liters per minute. In an interview on 02/24/2026 at 8:27 AM, the DON stated Resident #21's oxygen should be set on 2 liters per minute, or it can be titrated up to 3 to 4 liters per minute if his oxygen saturation dropped below 90%. She also stated Resident #21's oxygen concentrator settings should not be set lower than 2 liters per minute because if a residents' oxygen saturation dropped too low they could experience hypoxia, or not enough oxygen to meet the demand of the body. Record Review of the facility's Oxygen Administration policy, revised 09/30/2025, revealed Procedure: Oxygen Administration: 1. Oxygen orders should include the specific liter flow required by the resident. 3. Record review of Resident #53's face sheet, dated 02/24/2026, revealed an [AGE] year-old male with an admission date of 05/02/2025 and an initial admission date of 12/27/2024. Pertinent diagnosis included Acute and Chronic Respiratory Failure with Hypoxia (when the tissues of your body don't have enough oxygen) and Chronic Obstructive Pulmonary Disease (lung disease that causes obstructed airflow from the lungs). Record review of Resident #53's Quarterly MDS assessment, dated 02/06/2026, revealed a BIMS score of 03 indicated he had severe cognitive impairment. MDS Additional active Diagnoses revealed Dependence of Supplemental Oxygen. Record review of Resident #53's physician orders, started 05/03/2025, revealed an order for Oxygen at 4 liters per minute continuously per nasal cannula. An observation on 02/24/2026 at 11:20 a.m. revealed Resident #53's oxygen concentrator was set at 3 liters per minute. In an interview on 02/24/2026 at 11:30 a.m., LVN D stated that she was the nurse for Resident #53. She stated that she was not sure if Resident #53's oxygen was supposed to be at 3 or 4 liters per minute. LVN D stated that she checks the oxygen setting twice during her shift. If the resident goes out to therapy or out with family, she checks it again when they return. She stated that she checked the oxygen setting this morning. LVN D then logged into the computer, reviewed Resident #53's oxygen setting physician order and stated that it was supposed to be at 4 liters per minute. LVN D verified that the oxygen setting was set at 3 liters per minute. She checked Resident #53's SPO2 and it was 95%. LVN D stated the negative outcome to keeping Resident #53's oxygen setting at 3 liters per minute was that he could have altered mental status. 4. Record review of Resident #32's face sheet, dated 02/24/2026, revealed a [AGE] year-old male with an admission date of 12/30/2025. Pertinent diagnoses included Chronic Obstructive Pulmonary Disease (lung disease that causes obstructed airflow from the lungs), Primary Spontaneous Pneumothorax (the sudden onset of a collapsed lung without any apparent cause), and Congestive Heart Failure. Record review of Resident #32's Comprehensive MDS assessment, dated 01/05/2026, revealed a BIMS score of 11 indicated he had moderate cognitive impairment. Section O-Special Treatments, Procedures, and Programs indicated he was on Oxygen Therapy. Record review of Resident #32's physician orders, started 12/31/2025, revealed an order for Oxygen at 3 liters per minute continuously per nasal cannula. An observation on 02/24/2026 at 2:30 p.m. revealed Resident #32 was in his room lying on his bed. He was wearing a nasal canula and was receiving oxygen at 3 liters per minute. There was no oxygen sign posted outside of his room. In an interview on 02/24/2026 at 2:25 p.m., LVN D stated that she was the nurse for Resident #32. She stated that all the staff were responsible for posting the oxygen sign outside the residents' rooms. LVN D verified that Resident #32 did not have an oxygen sign posted outside his room. She stated that all residents who wereon oxygen regardless of needing it continuously or prn, they all need a sign. LVN D stated that it was important for posting an oxygen sign outside the resident's rooms, so no one smokes and to make everyone who went into the facility aware that there was oxygen in use inside the room. 5. Record review of Resident #1's face sheet, dated 02/24/2026, revealed a [AGE] year-old female with an admission date of 02/03/2026 and an initial admission date of 12/24/2025. Pertinent diagnoses included Chronic Obstructive Pulmonary Disease (lung disease that causes obstructed airflow from the lungs) and Congestive Heart Failure. Record review of Resident #1's MDS assessment, dated 02/06/2026, revealed a BIMS score of 14 indicated she had no cognitive impairment. Section O-Special Treatments, Procedures, and Programs indicated he was on Oxygen Therapy. Record review of Resident #1's physician orders, started 02/24/2026, revealed an order for Oxygen at 2 liters per minute continuously per nasal cannula. An observation on 02/24/2026 at 3:30 p.m. revealed Resident #1's oxygen concentrator was set at 1.5 liters per minute. In an interview on 02/24/2026 at 3:35 p.m., LVN C stated that he was the nurse for Resident #1. He stated that he checks the oxygen setting once during his shift. He stated that he checked it this morning, 2/24/2026. He stated that he was not sure if Resident #1's oxygen was supposed to be at 2 liters per minute. LVN C verified that the oxygen setting was set at 1.5 liters per minute. He checked Resident #1's SPO2 and it was 95%-97%. He then logged into the computer, reviewed Resident #1's oxygen setting physician order, and stated that it was supposed to be at 2 liters per minute. LVN C stated the negative outcome to keeping Resident #1's oxygen setting at 1.5 liters per minute was that he could desaturate (decrease amount of oxygen), become short of breath, get confused and lead to a fall. In an interview on 02/26/2026 at 8:47 a.m., the ADON stated that the floor nurses were responsible for verifying the oxygen order and the oxygen setting every shift. She stated that anybody could post the oxygen sign on the outside of the residents' room, but it was the responsibility of the admitting nurse. The ADON stated that it was important for the oxygen sign to be posted for everyone to know that there was oxygen in use in that room. She stated that she does random compliance rounds. She stated that if the oxygen setting was low then the resident could get hypoxic (the tissues of the body do not have enough oxygen). The ADON stated that the oxygen saturations were checked every shift. In an interview on 02/26/2026 at 3:22 p.m., the DON stated that it was the responsibility of the nurse who gets the order to post the oxygen sign on the outside of the resident's room. She stated that the oxygen signs were easily accessible for the nurses to get. The DON stated that compliance rounds were completed once a week by their administrative team. She stated that the oxygen sign should be posted so that people going into that room know there was oxygen in use. The DON stated that the nurses do ongoing monitoring of the oxygen setting. She stated that training was provided for oxygen administration annually at the end of the year. Record Review of the facility's Oxygen Administration policy, revised 09/30/2025, revealed Definitions Oxygen Therapy- is the administration of oxygen at concentrations greater than that in ambient air (20.9%) with the intent of treating or preventing the symptoms and manifestations of hypoxia. Procedure: Oxygen Administration: 1. Oxygen orders should include the specific liter flow required by the resident. General Safety Guidelines 1. Post a NO SMOKING sign on the outside of door to the residents room before starting use of oxygen. Oxygen Signage Guidelines 1. NO SMOKING signs (and/or the international symbol for no smoking), readable from a distance of 5ft, need to be posted where supplemental oxygen is in use.

Based on interview and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 5 residents (Resident #8) reviewed for pharmacy services. The facility failed to ensure Resident #8's blood pressures were assessed prior to administering Lisinopril (a medication used to treat high blood pressure) per the prescribed order and blood pressure parameters in February of 2026. This failure could have placed residents at risk for complications and jeopardize their health and safety.The findings Included: Record review of Resident #8's face sheet, dated 02/26/2026, revealed an [AGE] year-old female with an admission date of 02/05/2026 and a discharge date of 02/25/2026. Pertinent diagnosis included Essential Primary Hypertension (high blood pressure).Record review of Resident #8's physician orders, started 02/07/2026, revealed an order for Lisinopril 40 MG, give one tablet by mouth daily for Hypertension. Hold for blood pressure less than 110/60 and/or pulse less than 60.Record review of Resident #8's care plan for hypertension, initiated 02/15/2026, revealed Resident #8 will remain free of complications related to hypertension through review, and an intervention to give anti-hypertensive medications as ordered and observe for side effects such as orthostatic hypotension (low blood pressure which could happen when standing after sitting or lying down) and increased heart rate. Record review of Resident #8's February 2026 MAR revealed Lisinopril 40 MG, give one tablet by mouth daily for Hypertension at 8:00 AM. Hold for blood pressure less than 110/60 and/or pulse less than 60. There were no blood pressures listed in the MAR to coincide (reflect or occur at the same time) with the medication. The MAR also revealed the Lisinopril was administered on all days from 02/06/2026 - 02/24/2026.Record review of Resident #8's vital signs revealed no blood pressures taken in the mornings to coincide with the blood pressure medication on the following dates: 02/05/2026, 02/06/2026, 02/07/2026, 02/08/2026, 02/09/2026, 02/10/2026, 02/11/2026, 02/12/2026, 02/14/2026, 02/15/2026, 02/16/2026, 02/17/2026, 02/18/2026, 02/19/2026, 02/21/2026, 02/22/2026, and 02/23/2026. In an interview on 02/26/2026 at 8:27 AM, the DON stated nurses should always check the blood pressure prior to administering the blood pressure medication. The DON also stated if a blood pressure was already low, and the blood pressure medication was administered, the blood pressure could have continued to drop, and the resident's blood pressure could have bottomed out, causing potential health risks for the resident such as dizziness, blurred vision, fainting, or even possibly shock. She stated she could not find any blood pressure listed in Resident #8's February MAR to coincide with the blood pressure medication, but she was able to find possibly two blood pressures listed in the February vital signs, and given the times they were taken, could possibly coincide with Resident #8's blood pressure medication. In an interview on 02/26/2026 at 2:55 PM, MA-B stated he only worked PRN, but thought he recalled Resident #8, but did not recall her blood pressure medication or any of her blood pressures. MA-B stated if Resident #8 was on a blood pressure medication he would have taken the blood pressure prior to administering the medication because he always checked blood pressures prior to blood pressure medications. He stated he may not have recorded or written down the blood pressures when he took them, or he may have recorded them at a different time which did not coincide with the blood pressure medication, but he stated he would not have administered the blood pressure medication without the blood pressure. He also stated it was important to check the blood pressure because if a resident's blood pressure dropped too low it could make them feel sick. In an interview on 02/26/2026 at 3:00 PM, LVN-C stated he recalled Resident #8 and her blood pressure medication. He stated he thought the reason there were no blood pressures to coincide with the blood pressure medication was because there was no place or line on the MAR to record the blood pressures. He stated usually with blood pressure medications on the MAR there was a place to enter the blood pressure next to where you sign off which you gave the blood pressure medication, but he did not recall there being one on Resident #8's MAR. He stated he always took the residents' blood pressure prior to administering blood pressure medication because if the blood pressure was too low, the medication needed to be held because it could make the resident feel sick if it continued to drop. Record Review of the facility's Medications Administration policy, revised 05/05/2022, revealed Policy: The facility will ensure medications are administered safely and appropriately per physician order to address residents' diagnoses and signs and symptoms. Procedure: 2. Staff who are responsible for medication administration will adhere to the 10 rights of medication administration: f. Right Assessment: Note the resident's history and any parameters around drug administration.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were labeled and stored appropriately for 3 of 4 medication carts (100 Hall Nurse Med-Cart and 200/400 Hall and 300 Hall Medication Carts) reviewed for labeling and storage. 1. The facility failed to ensure the 100 Hall Nurse Med-Cart was locked and secured. 2. The OTC medications in the 200/400 Hall and 300 Hall Medication Carts did not have an open date written on the liquid and powder bottles. 3. The facility failed to ensure a (diabetic) lancet, sitting on top the unattended 200 hall medication cart, was used. These failures could have placed residents at risk of gaining access to unlocked medications which were not prescribed to them and could have caused them harm and not receiving the therapeutic effects of the medication and could place residents at risk of access or injury to a lancet. The findings included: 1.An observation on 02/26/2026 at 2:41 PM of the 100 Hall Nurse Med-Cart belonging to LVN-A parked at the nurses' station revealed an unlocked medication cart. The lock on the med-cart was popped out, and all drawers, except the narcotic drawer, were able to be accessed. An observation on 02/26/2026 at 2:42 PM of the 100 Hall Nurse Med-Cart parked at the nurses' station revealed the keys to the 100 Hall medication cart belonging to LVN-A were sitting on the 100 Hall medication cart in the binder that contained the narcotic and controlled count sheets. In an interview on 02/26/2026 at 2:42 PM, LVN-A stated the 100 Hall Nurse Med-Cart belonged to her. She stated she knew the med-cart should not be left unlocked because residents could have gotten into the med-cart and taken medications which had not belonged to them, and this could have caused them harm. She stated she had been in-serviced on this previously, but she could not recall when the in-service was. She stated the keys to the med-cart were in her pocket, but upon looking for them, she could not find them in her pocket or at the nurse's station. She then stated she remembered she had placed them inside the narcotic binder but stated they should have been in her pocket so no one could have gained access to the medication cart. Record review of the facility's Storage of Medications policy, dated 12/01/07, revealed Med-Carts are locked when unattended. Med storage keys are retained by designated staff. Controlled medication must be stored separately, double locked, permanently affixed compartments. 2. An observation on 02/25/2026 at 3:32 p.m., of the 200/400 Hall Medication Cart with LVN G, revealed the following over the counter (OTC) medications which did not have an opened date written on the bottles -Tussin Guaifenesin Oral Solution 8oz, Enulose (Lactulose Solution) 10g/15ml 473mls, Milk of Magnesium 16oz, and 2 bottles of Polyethylene Glycol 3350 Powder for solution Osmotic Laxative 8.3oz. An observation on 02/25/2026 at 3:42 p.m., of the 300 Hall Medication Cart with LVN H, revealed the following over the counter (OTC) medications which did not have an opened date written on the bottles –Mylanta Liquid 12oz and Polyethylene Glycol 3350 Powder for solution Osmotic Laxative 8.3oz. In an interview on 02/25/26 at 3:34 p.m., LVN G stated that the liquid OTCs should be labeled with an open date. She stated that the person responsible for labeling the bottles was the person who initially opened them. LVN G stated that they need to know when the bottle was opened, so they know when it expires. She stated that it was important for them to label the bottles with an open date to know when to get rid of them and so the resident does not get sick. In an interview on 02/25/2026 at 3:42 p.m., LVN H stated that she did not realize that the bottles did not have an open date. She stated that the person who opened the bottle was responsible for labeling it with the date. LVN H stated that this was important, so they know if it was outdated and effective. She stated that the negative outcome was that it could be spoiled, and they continue to administer it to the residents, causing them to have a side effect. In an interview on 02/26/2026 at 8:47 a.m., the ADON stated that they go off the expiration date on the MiraLAX bottle and the eyedrops. She stated that the milk of magnesium did need an open date. The ADON stated that the person who opens the bottles was responsible for labeling them with the open date. She stated that this was important, so they know when it expires, either within 30 or 90 days. The ADON stated that the negative outcome of not having an open date was that it would not be effective. In an interview on 02/26/2026 at 3:22 p.m., the DON stated that only the multidose bottles needed an open date. She stated that she was not sure if the milk of magnesium needed to be labeled with an open date because it has an expiration date. She stated they had in service on medication storage at the end of last year, 2025. 3.During an observation on 02/24/2026, at 5:52 PM, revealed on top of the 200 hall medication cart unattended, there was a diabetic lancet. During an interview on 02/24/2026 at 5:53 PM, LVN G walked up to cart. LVN G stated the (diabetic) lancet was supposed to be secured in the medication cart. LVN G stated the negative outcome could be someone could come by and grab it off the cart. During an interview on 02/26/2026 at 3:34 PM, the DON stated the lancet should be kept in the medication cart until use. She said it would be a safety issue if it were left on top the medication cart unattended and anyone could grab it. Record review of the facility's Storage of Medications policy, dated 12/01/07, revealed Med-Carts are locked when unattended. Med storage keys are retained by designated staff. Controlled medication must be stored separately, double locked, permanently affixed compartments. Record review of the facility's Storage and Expiration Dating of Medications and Biologicals, revised date 6/30/2025, revealed 11. Facility should record the date opened on the primary medication container (i.e., vial, bottle, inhaler) when the medication has a shortened expiration dated once opened or opened. 11.1 Facility staff may record the calculated expiration date based on date opened on the primary medication container.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for sanitation. The facility failed to properly label and date open, shelf stable food.The facility failed to dispose of expired shelf stable and refrigerated food.The facility failed to ensure boxes containing jugs of water were not on the floor.The facility failed to clean the filters on the ice machine.The facility failed to sweep, mop, and clean the floors and counters in the kitchen. The facility failed to ensure the refrigerators, as well as the trays inside the refrigerators, were clean. The facility failed to ensure the juice dispenser was clean. The facility failed to ensure the utensil drawer was clean. The facility failed to ensure under the sink and dishwasher were clean.These failures could have placed residents at risk of foodborne illnesses, as well as placed staff at risk for falls and injuriesThe findings included:Observations and initial tour of the kitchen on 02/24/2026 at 8:26 AM revealed the filters on the ice machine to be extremely dirty with thick build-up noted. the outsides of refrigerators were dirty and had spill lines down them. Inside of a refrigerator there was a large container of thick, yellow, substance with a use by date of 02/21/2026. There were trays inside the refrigerator which were dirty with particles and drips of old food on them. There were large containers of condiments sitting on the trays which were covered in a build-up of a sticky substance. The juice dispenser had a sticky build-up on and around the nozzles, as well as sticky build-up on the stainless backsplash of the juice dispenser. The floors in the kitchen had dirt, food, and grime built up on them with molded vegetables, silverware, and other trash under the shelves and counters. The counters and sinks were dirty with build-up and food particles. There were opened and unlabeled packages of bread, cereal, cookies, chips and peanut butter. The drawer which held the clean spoons and utensils was dirty with old food particles and splatters. Under the sink and dishwasher there was built up grime, dirt, as well as a black substance. There were boxes containing jugs of water stored on the floor in the kitchen storage room. The pans being utilized in the kitchen were scraped to the point of the Teflon scraped off, as well as burned to the point of black chips breaking off. In an interview on 02/24/2026 at 08:29 AM, the Food Services Director stated the filters, floors, counters, walls, equipment and sinks were cleaned daily, and she was not sure how all the dirt, grime, and particles had built up on the floor in one day. She also stated the juice machine was supposed to be cleaned daily as well, but she could tell it had not been cleaned. She stated if things were not cleaned and disinfected appropriately mold could grow and end up in the residents' drinks or food, and this could make them sick. She also stated if food was not dated or discarded appropriately it could make the residents sick as well. The Food Services Director stated she knew there was not supposed to be anything stored on the floor because it was a hazard, and they were in the process of disposing of the boxes full of water jugs but had not finished disposing of them yet. The Food Services Director also stated she knew the kitchen staff were not supposed to cook with pans which had burned stuff breaking off or were scraped so badly the Teflon was coming off because it could end up in the residents' food and make them sick. In an interview on 02/26/2026 at 8:45 AM, the cook stated the kitchen staff should not be cooking on pans which were extremely burned, or the Teflon was scraping off because it could end up in the residents' food and make them sick. Record review of the facility's Food Safety Policy, revised 04/26/2023, revealed Food is stored and maintained in a clean, safe and sanitary manner following federal, state and local guidelines to minimize contamination and bacterial growth. Procedure: 1. Food is stored at a minimum of six inches off the floor. 2. Pre-packaged food is placed in a leak-proof, pest-proof, non-absorbent, sanitary container with a tight-fitting lid. The container is labeled with the name of the contents and date (when item is transferred to the new container). Use by Date is noted on the label or product when applicable. Cold Food Storage: Leftovers are dated properly and discarded after 72 hours unless otherwise indicated. Dry Storage: 2. Opened packages of food are resealed tightly to prevent contamination of the food item and use by date will be used when applicable. 5. Shelves have a cleanable surface; Food Service/Meal Service: 1. Foods are prepared and served with clean tongs, scoops, forks, spoons, spatulas, or other suitable implements so as to avoid manual contact with prepared foods.

Based on interviews, observations and record review, the facility failed to ensure the resident had the right to personal privacy during medical treatment for 3 (Resident #15, Resident #82, and Resident #21) of 5 Residents reviewed for Privacy. The facility failed to ensure MA E closed the door or the curtain during medication administration for Resident #15 and Resident #82 on 02/25/2026. The facility failed to ensure LVN F closed the door, the curtain or the blinds during medication administration via gastrostomy tube for Resident #21 on 02/25/2026. These failures could place the residents at risk of not having their personal privacy maintained during medical treatment.The Findings included: During an observation on 02/25/2026 at 6:49 a.m., MA E kept the door and the curtain open while checking Resident #15's blood pressure. She then proceeded to administer his medications. During an observation on 02/25/2026 at 7:06 a.m., MA E kept the door and the curtain open while checking Resident #82's blood pressure. She then proceeded to administer his medications. During an observation on 02/25/2026 at 1:27 p.m. LVN F kept the door, the curtain, and the blinds open while administering medications via G-tube (a soft, flexible tube into the stomach to deliver liquid nutrition, fluids, and medications directly to the digestive tract). In an interview on 02/25/2026 at 7:12 a.m., MA E stated that she was supposed to close the door and the curtain before checking the blood pressures and administering medications to both Resident #15 and Resident#82. She stated that she forgot to do it. MA E stated that closing the door and the curtain was important to provide the residents with privacy.In an interview on 02/25/2026 at 1:35 a.m., LVN F stated that she forgot to close the door, the curtain and the blinds while administering medications to Resident #21. She stated that she got sidetracked looking for the soap to wash her hands with. LVN F stated that she should have closed the curtain and the door because you never knew who would walk in while she was providing care. She stated that she should have provided the resident with privacy. LVN F stated that she had been trained in resident dignity and privacy less than a month ago.In an interview on 02/26/2026 at 8:47 a.m., the ADON stated that staff should close the door, pull the curtain, and close the blinds to provide privacy when administering medications. She stated that the staff had been trained. The ADON stated that this was important because this was the patient's home, and they should provide dignity and privacy.In an interview on 02/26/2026 at 3:22 p.m., the DON stated that MA E and LVN F should have closed the door, the curtain, and the blinds prior to administering medications to residents. She stated that the staff should provide privacy when providing care. The DON stated that staff were trained annually and as needed. She stated that it was important for staff to provide privacy because that was a resident's right.Record review of the facility's policy, Resident Rights review date 11/24/2025, revealed At the time of admission, a resident is afforded certain rights while residing in a Long-Term Care Facility. The facility and its associated have the responsibility to ensuring the rights are always upheld the resident is in their care. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promote maintenance or enhancement of his or her quality of life .

Based on record reviews and interviews, the facility failed to send a copy of the residents ' discharge notice, including the reason for transfer or discharge, prior to discharge, to the representative of the Office of the State Long-Term Care (LTC) Ombudsman for 1 of 2 residents (Resident #3) reviewed for notifying the LTC Ombudsman of the residents ' discharge. Resident #3 was discharged home on [DATE] without a notice to the LTC state ombudsman. These failures could place residents at risk of not knowing their rights and receiving the services of the state LTC Ombudsman.Findings were: 1. Record review of Resident #3 ' s admission record dated 02/26/26 with an admission date 1/26/26 revealed Resident #3 was a [AGE] year-old male with diagnoses of Acute Respiratory Failure with Hypoxia (lungs cannot supply oxygen to blood), Type 2 Diabetes Mellitus without Complications (high blood sugar levels), Chronic Obstructive Pulmonary Disease (lung disease that causes obstructed airflow from lungs), Essential (Primary) Hypertension (high blood pressure), Muscle Weakness (Generalized). Record review of Resident #3 ' s latest MDS dated [DATE] revealed a BIMS score of 14 indicating intact cognition. Record review of Resident #3 ' s order summary revealed discharge home with medications on 2/5/26. Home health for patient, occupational skilled nursing follow up with primary care physician. Record review of Resident #3 ' s electronic medical record from 02/5/26 to 02/26/26 revealed no evidence of notice given to the LTC Ombudsman pertaining to Resident #3 ' s discharge home. During an interview on 02/26/26 at 9:00 a.m. the SSD stated she was not in charge of notifying ombudsman whenever a resident is discharged from the facility. She said that the BOM was in charge of notifying the Ombudsman. During an interview on 02/26/26 at 9:05 a.m. the state LTC Ombudsman representative for the facility stated she had not received any discharge notices. During an interview on 02/26/26 at 9:15 a.m. BOM said she was not aware that she needed to notify the Ombudsman when a resident was discharged from the facility. She said that she only notified the Ombudsman when there was a thirty day notification for the resident to leave the facility. Record review of the facility's policy titled Discharge Process and Bed Holds, date revised: 12/1/2025 revealed; The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #82) of 4 residents reviewed for medications.The facility failed to administer Carvedilol for Resident #82 per physician's order on 02/25/2026. This failure could place the residents at risk of not receiving therapeutic doses of their medication. Findings include Record review of Resident #82's admission record dated 2/24/2026 reflected an [AGE] year-old female with an admission date of 02/17/2026. Pertinent diagnoses included Essential Hypertension (high blood pressure), Hypertensive Heart Disease (a constellation of changes affecting the left ventricle, left atrium, and coronary arteries resulting from chronic elevation of blood pressure), and Cardiac Pacemaker. Record review of Resident #82's person-centered care plan, initiated date 2/17/2026 reflected Resident #82 has hypertension. Intervention included administer medications as ordered. Record review of Resident #82's Order Summary dated 2/24/2026, reflected Carvedilol 12.5mg oral tablet give 1 tablet by mouth two times a day for HTN. Hold if SBP less than 100 or pulse less than 60. Give with snack or meals to avoid rapid drop in BP. Record review of Resident #82's admission MDS assessment, dated 02/17/2026 reflected in progress. An observation on 02/25/2026 at 7:07 a.m., revealed MA E checked Resident #82's blood pressure and reading was 107/63 pulse 63. She grabbed a plastic pouch and said she would destroy Carvedilol and the other two blood pressure medications properly. In an interview on 02/25/2026 at 7:20 a.m, MA E stated that she was not going to administer Carvedilol because it was out of parameters along with two other blood pressure medications for Resident #82. Surveyor had her review physician's order for these medications. MA E verified Carvedilol was supposed to be given because it was within parameters. She stated that she thought that all of the medications had the same parameters. MA E stated that the negative outcome of not administering the Carvedilol would be that Resident #82's blood pressure can get too high and cause her to feel dizzy. In an interview on 02/26/2026 at 3:22 p.m., the DON stated that all three blood pressure medications were supposed to have the same parameters. She stated that MA E should have administered the blood pressure medication that was within parameters. The DON stated that the negative outcome of not receiving the medication as per physician orders could cause Resident #82s blood pressure to be raised. Record Review of the facility's Medications Administration policy, revised 05/05/2022, revealed Policy: The facility will ensure medications are administered safely and appropriately per physician order to address residents' diagnoses and signs and symptoms. Procedure: 2. Staff who are responsible for medication administration will adhere to the 10 rights of medication administration: f. Right Assessment: Note the resident's history and any parameters around drug administration.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #21 and Resident #87) of 5 residents reviewed for infection control practices, in that: 1. The facility failed to ensure LVN F followed enhanced barrier precautions while administering medications via gastrostomy for Resident #21. 2. CNA I failed to remove contaminated gloves after catheter care prior placing clean brief on Resident #87 on 02/25/2026. This failure could place residents at risk for healthcare associated cross contamination and infections. 2. Record review of Resident #87's face sheet dated 2/26/26 revealed an [AGE] year-old female admitted originally on 2/17/26. Her diagnoses included, pressure ulcer of sacral region, stage 4 (a severe, medical emergency involving full-thickness tissue loss with directly palpable or visible bone, tendon, or muscle), muscle weakness. Record review of Resident #87's Comprehensive Care Plan initiated 02/18/2026 revealed, Focus: [Resident #87] has an indwelling catheter due to sacral wound. Interventions: [Resident #87] needs enhanced barrier precautions. Record review of Resident #87's MDS dated [DATE] reflected it was in progress. During an observation on 02/25/2026 at 10:50 AM, CNA I entered Resident #87's room after knocking. CNA I began with washing hands for 30 seconds, gloved up, and prepared table of needed supplies. CNA I continued by raising bed and then discarded gloves. After discarding the gloves, CNA I continued with applying hand sanitizer and she did apply new gloves. CNA I proceeded with catheter care and proceeded placed a new brief on resident, using same pair of gloves, catheter care, and applied new brief. During an interview on 02/25/2026 at 11:00 AM with CNA I stated that they should have changed those gloves after cleaning the foley catheter, for the reason to minimize contraction of infection. CNA I stated they should have washed hands/use hand sanitizer and changed gloves, before, during, and after care to minimize chance of infection. CNA I stated that resident could get an infection because she did not changed gloves when changing from one area to another area. During an interview on 02/26/26 at 3:05 PM with the DON, The DON stated that after perineum care, hand hygiene should have been performed prior to moving to the second part of applying the new brief. The DON stressed the importance of infection prevention and stated that personnel were educated and observed by her performing specific care during checkoffs, before being allowed to work on the floor independently. DON stated this practice could put Resident #87 at risk for infection. Record review of policy titled Transmission-based Precautions and Isolation Procedures revealed: the facility will implement and utilize transmission-based precautions to ensure the mitigation of infection spread and to ensure standards of infection prevention and control are followed. Findings include: 1.Record review of Resident #21's face sheet, dated 02/26/2026, revealed a [AGE] year-old male with an admission date of 12/06/2024. Pertinent diagnoses included Gastrostomy Status (opening in the stomach to insert a tube for nutritional support), Dysphagia (difficulty swallowing), Type 2 Diabetes Mellitus, Spastic Quadriplegic Cerebral Palsy (early brain damage, resulting in extreme stiffness in all four limbs, the trunk, and the face). Record review of Resident #21's Annual MDS assessment, dated 12/01/2025, revealed no BIMS conducted as Resident #21 was rarely or never understood. Further review revealed nutritional status was feeding tube (PEG). Record review of Resident #21's physician orders, started 11/10/2025, revealed an order for Enhanced Barrier Precautions Diagnosis: G-tube every shift. Record review of Resident #21's Care Plan for the resident requiring tube feeding r/t Dysphagia. Enhanced Barrier Precautions, initiated 12/09/2024, revealed an intervention of Enhanced barrier precautions. During an observation on 02/25/2026 at 1:35 p.m., LVN F donned gloves but did not wear a PPE gown when she administered medications via G-tube for Resident #21. In an interview on 2/25/26 at 1:40 p.m., LVN F stated that she was supposed to put on a gown along with the gloves when she entered Resident #21's room, but she forgot. She stated that EBP was indicated for residents who have gastrostomy tubes, foley catheters, wounds, or who have an infection. She stated that EBP requires the use of a gown and gloves during contact with patient care. LVN F stated that it was important to wear the required PPE when providing care to EBP patients to prevent the spread of infection and to protect themselves. In an interview on 02/26/2026 at 8:47 a.m., the ADON stated that EBP was to be used on high contact care for patients with G-tubes, foley catheters, and trachs. She stated that EBP requires the use of a gown and gloves during contact with patient care. The ADON stated that it was important if the nurse were to get splashed on her when checking the residual. She stated that it was protecting patients from any bacteria. The ADON stated that it was also important to prevent infection from one patient to the other. In an interview on 02/26/2026 at 3:22 p.m., the DON stated that EBP patients were identified as anyone who has a foley catheter, a G-tube, IV's, and wounds because they have a portal for infection. She stated that the staff needed to wear gowns and gloves. The DON stated that PPE for EBP was for patients' protection, so they are not exposing germs to them. Record review of policy titled Transmission-based Precautions and Isolation Procedures, revised date 12/23/2025 revealed: the facility will implement and utilize transmission-based precautions to ensure the mitigation of infection spread and to ensure standards of infection prevention and control are followed. 5. Enhanced Barrier Precautions Refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing .

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments for 2 of 4 medication carts reviewed for labeling and storage. The facility failed to ensure the 100 Hall Nurse Medication Cart belonging to LVN-A and the 100 Hall Nurse Medication Cart belonging LVN-B were locked and secured. This failure could place the residents at risk of gaining access to unlocked medications which were not prescribed to them.The findings included:Observation on 12/17/2025 at 8:14 AM revealed an unlocked med-cart belonging to LVN-A parked in the 100 Hall with no nurses or other staff around it. The keys for the medication cart were sitting on top of the medication cart. There were residents noted to be walking and passing by. The med-cart lock was popped out, and all drawers were able to be opened and accessed. The med-cart was full of medications, including narcotics.In an interview on 12/17/2025 at 8:15 AM, LVN-A stated the med-cart observed unlocked was her med-cart, and she had forgotten to lock it and put the keys away before she walked away. She stated the med-cart should always be locked when not in use because if it was left unlocked residents could get into it and get medications out which did not belong to them, which could cause them harm. She stated the keys left in the med-cart contained the regular med-cart key, as well as the key to the narcotic box inside the med-cart. LVN-A stated it was the responsibility of the nurse who was working the med-cart to keep up with the keys for this med-cart and to ensure the med-cart remained locked when not in use.Observation on 12/17/2025 at 4:36 PM revealed an unlocked med-cart belonging to LVN-B parked in the 100 Hall with no nurses or other staff around it. The keys for the medication cart were sitting on top of the medication cart. There were residents noted to be walking and passing by. The med-cart lock was popped out, and all drawers were able to be opened and accessed. The med-cart was full of medications, including narcotics.In an interview on 12/17/2025 at 4:36 PM, LVN-B stated the med-cart observed unlocked at this time was her med-cart, and she got in a hurry to check on a resident, and she had forgotten to lock the cart and put the keys away before she walked away. She stated the med-cart should always be locked when not in use because if it was left unlocked residents could get into it and ingest medications which did not belong to them, and this could cause them harm, or even death. LVN-B stated the keys left on the med-cart contained the regular med-cart key, as well as the key to the narcotic box inside the med-cart. LVN-A stated it was the responsibility of the nurse who was working the med-cart this shift to keep up with the keys for their med-cart and to ensure the med-cart remained locked when not in use.In an interview on 12/17/2025 at 2:02 PM, the ADON stated it was the nurse's responsibility to keep her medication cart locked and keep up with the keys which went to her medication cart. She stated if the medication carts were left unlocked, residents could have gotten into the carts and taken medication which did not belong to them, and it could have harmed them. She stated the nurses knew this because they had been in-serviced over this topic.In an interview on 12/18/2025 at 8:35 AM, the Administrator stated he had been made aware of the medication carts being left unlocked. He stated it was the nurse's responsibility to keep up with the keys for their med-cart they were working with for that shift, as well as be sure the med-cart was locked every time they stepped away from it. The Administrator stated if the med-carts were not kept locked then residents or anyone else could have gained access to the cart and taken medication which did not belong to them, which could harm them, or even cause death. The Administrator stated the nurses had recently been in-serviced regarding this, and he had already started another in-service regarding the issues with locking the med-carts and wearing/protecting the keys to the med-carts. Record review of the facility's Storage and Expiration Dating of Medications and Biologicals Policy, revised August 2022, revealed Medication and Storage Quick Reference Guide: Medication Cart Security and HIPAA: Med-carts were locked when unattended. Med storage keys were retained by designated staff. Controlled medication must be stored separately, double locked, permanently affixed compartments.

Based on interviews and record review, the facility failed to report an alleged violation of abuse for (1 of 4 residents) in a timely manner.The facility failed to report to the state of Texas within 24 hours indicating Resident #1 hit her head, in a timely manner. R#1 hit her head during transport on March 7, 2005, the facility reported the incident 3 months later.This failure could place residents at risk for abuse and neglect. Findings included:Record review of Resident #1's face sheet dated June 30, 2025, revealed she was an [AGE] year-old female, admitted on [DATE], Resident #1 had a medical dx of Dementia (a group of thinking and social symptoms that interferes with daily function), Alzheimer's (a progressive disease that destroys memory and other important functions), Hypothyroidism ( condition in which the thyroid gland doesn't produce enough thyroid hormone), Muscle Weakness, Abnormal Gait (abnormal way of walking), and Lack of Coordination.An MDS assessment dated [DATE], revealed Resident #1 had a BIMS (brief interview of mental status) score of 15 (indicating resident is cognitively intact) and needed help with transferring and toileting. The MDS also indicated Resident #1 used a walker to assist with ambulation. Resident #1 was mostly independent in activities of daily living other than shower and toileting with minimal assistance. Record review of Resident #1's care plan, undated, revealed The resident has impaired cognitive ability /impaired thought processes related to Dementia. Interventions included: Allowing extra time for resident to respond to questions and instructions and to speak clearly when talking with the resident. During an interview on June 30, 2025, at 3:30 p.m., Resident #1 stated she was with one of the CNAs and the van driver going to an eye appointment, or coming back, and when she was walking into the van, she hit her head on the ceiling of the van. Resident #1 stated she could not remember the date it happened. Resident #1 stated it didn't hurt and she was okay. Resident #1 stated hitting her head surprised her. Resident #1 stated the van driver looked at her head, but it was fine. Resident #1 stated that is all she can recall from hitting her head; everything else went okay. During an interview on June 30, 2025, at 11:15 a.m., the facility Van Driver stated Resident #1 informed him she hit her head on the van ceiling when getting into the van. The Van Driver stated, CNA A and myself were telling her to duck down when walking into the van, but he did not see her hit her head. The Van Driver stated it happened just as hewas walking around the van. The van driver stated when she told me, he looked at her head and he didn't see any redness, bruising, or bump, and the resident said she was okay. The Van Driver stated he did not report the incident because the resident said she was okay. The Van Driver stated he was trained on abuse, neglect and exploitation and should have reported it to the nursing staff and to the Administrator. During an interview on June 30, 2025, at 11:45 a.m., CNA A stated while escorting Resident #1 to an eye appointment on March 7th, 2025, the resident claimed she hit her head on the ceiling of the van when walking with a walker to get into the van. CNA A stated she did not see it happen, but the resident said she was okay and there was no bump, bruise or abrasion on the resident's head and there were not any issues later. CNA A stated we told Resident #1 to duck down and to watch out for the low part of the ceiling. CNA A stated she did not report it to my manager or the Administrator because she just didn't. CNA A stated she should have reported it and she knew she should have but she didn't report it. CNA A stated she was trained on abuse, neglect, and exploitation. During an interview on 7/11/25 at 1:35 p.m., with the Administrator, he stated he found out Resident #1 hit her head while being transported to her eye doctor 3 months after the incident happened. The Administrator stated his expectations were to be to be informed of any resident hitting their head, or any occurrence immediately. The Administrator also stated staff did not connect that even though they didn't see anything (redness, abrasion and /or bruising) they did need to report this incident occurred. The Administrator stated the staff (Van driver and CNA A ) rationalized that because they did not see any injury and the resident stated she was fine, they did not need to report it. They should have reported it because there was still a possibility that she was injured. The Administrator stated Resident #1 was assessed and no head injuries noted. The Administrator stated it was and is my responsibility to complete the investigation of abuse or neglect and our findings were unfounded for the allegation of neglect or abuse, however we still did a thorough investigation including reviewing the resident's full chart. We (myself and the DON) interviewed all residents that traveled with both staff members during the time this occurred in March up until then. There were 7 residents, and all residents reported feeling safe around the staff, and no one has hit their head on the ceiling of the van. The Administrator also stated both staff members were suspended during this investigation and both staff members received corrective action because of not reporting this incident. The Administrator stated, It is my expectation that staff will follow the Abuse and Neglect Policy and report accordingly. During an interview on July 17, 2025, at 2:40 p.m., the DON stated I was made aware Resident #1 bumping her head on the ceiling in the van on June 30, 2025, but the incident occurred back in March. The DON stated this incident should have been reported to me or/and the Administrator as soon as it happened. The DON stated she assisted in the investigation for abuse and neglect by reviewing the residents record, interviewing the resident, and performing a head-to-toe assessment on the resident. The DON stated Resident #1 could not remember details of the situation, and even said she may have dreamed it happened. The DON also stated the head-to-toe assessment revealed no bruises, redness or abrasions and nothing beyond the resident's baseline of forgetfulness. The DON stated we expect our staff to follow the proper policy and protocol regarding abuse and neglect. Record review of the facility's policy titled, Protecting the Residents: Reducing the threat of Abuse and Neglect, revised 8/10/2021 revealed Each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation of any type by anyone. The policy verbiage also stated, the facility must: ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source are reported immediately, but not later than 2 hours after the allegation is made.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen and 1 of 1 nutrition room (ice room) reviewed for sanitation in that: 1.The facility failed to ensure the convection oven was opening properly and safely. 2.The facility failed to ensure [NAME] A did not place personal items on prep tables. 3.The facility failed to ensure [NAME] A were washing their hands. 4.The facility failed to ensure prep tables, the underside of the steam table shelf, and the underside of the stove shelf was clean and sanitized. 5.The facility failed to ensure a dented can of fruit was removed from the in-use shelf of cans. 6.The facility failed to ensure dry goods were sealed properly. 7.The facility failed to ensure items in the refrigerator were labeled and dated. 8.The facility failed to ensure trash bins in the kitchen were covered. 9.The facility failed to ensure trash was not on a prep table. 10.The facility failed to ensure the daily cleaning schedule of the kitchen was followed. 11.The facility failed to ensure boxes of frozen food in the walk-in freezer were not stacked to the ceiling. 12.The facility failed to ensure temperatures of the ice room refrigerator were documented properly. 13.The facility failed to ensure the ice room freezer had a thermometer. 14.The facility failed to ensure items in the ice room refrigerator were not expired. 15.The facility failed to ensure items in the ice room refrigerator and freezer were labeled and dated. 16.The facility to ensure the ice room refrigerator and freezer logs were not missing data. These failures could place residents at risk of foodborne illnesses. Findings included: Observation and initial tour of the kitchen on [DATE] at 7:05 AM revealed the right-side door of the convection oven did not open without extreme force as demonstrated by [NAME] A. The convection oven tipped back and forth when [NAME] A tried to open the right-side door. There was an eyeglasses case and partially empty 16 oz. bottle of water and a 1-gallon bag of chips that was open to air on a prep table next to the microwave. [NAME] A removed the items with a gloved hand and did not change her gloves or wash her hands before handling food (a biscuit) to place on a plate for breakfast. The bottom shelf of the steam table had dried, reddish brown discolorations that resembled leaking water. The underside of the shelf directly above the steam table had a thick dark brown substance on it directly above the food in the steam table. The substance was in the form of thick droplets. The underside of the shelf directly above food in a pan on the stove had a thick dark brown substance in the form of droplets. There was a dented 6.5 pound can of fruit on the shelf with other canned foods that were in use in the dry storage room. There was a carton type container of powdered mashed potatoes that was not sealed in the dry storage room. There was a partially full 3.5-liter container of a light tannish substance in the refrigerator that was unlabeled and undated. There was a tray in the refrigerator with 1 bowl, 1 Styrofoam cup, and 3 glasses of juice that were unlabeled and undated. There was a cardboard box with what appeared to be trash in it on the drink prep table. There was a case of food in the walk-in freezer stacked on the top shelf that was less than 6 inches below the ceiling and obstructing the water sprinklers. There was a trash bin near the 3-compartment sink that had trash in it but was not actively in use and was not covered. Observation of the nutrition room (ice room) on [DATE] at 8:50 AM revealed the temperature reading from the thermometer inside the ice room refrigerator was 29F. There was no thermometer in the freezer. There were no freezer temperatures logged on the refrigerator/freezer temperature template. There was a 1-pint container of ice cream that was unlabeled and undated in the freezer. There was thick ice build-up covering the back wall of the refrigerator. There was an unremovable 330 ml carton of an unknown substance frozen into the ice in the refrigerator. There was a sticky, thick brown substance spilled on the shelf of the door of the refrigerator. There was a 10 oz. jar of jelly, a plastic container with 8 shriveled strawberries, a drinking glass with an unknown brown substance and frozen, a large bowl full of an unknown semi liquid reddish substance, and a15 oz. partially full jar of cheese that was frozen, all unlabeled and undated in the refrigerator. There was a 46 oz. carton of liquid with an expiration date of [DATE], a full, 1-pint take-out container dated [DATE], and a 46 oz. frozen container of thickened liquid with an expiration date of [DATE] in the refrigerator. Return visit and observation of the kitchen on [DATE] at 2:45 PM revealed 6 cases of frozen food in the walk-in freezer stacked on the top shelf that were less than 6 inches below the ceiling and obstructing the water sprinklers. 5 of 5 steam table wells were crusted and flaking a whitish yellow substance approximately 2 inches up the insides and bottoms of each one. There was debris floating in the water of the steam table wells. The dented can of fruit remained on the shelf intended for use. The carton of powdered mashed potatoes that was open to air on [DATE] was in a large zip top type bag that was not sealed, leaving the carton exposed and open to air. In an interview with [NAME] B on [DATE] at 7:10 AM, she said the cardboard box on the drink prep table should not have been there because trash was not supposed be on a prep table at all and she said it could cause cross contamination and make residents sick. She said the uncovered trash bin was supposed to be covered unless they were actively using. She moved it without covering it underneath the 3-compartment sink. In an interview with [NAME] A on [DATE] at 7:15 AM, she said the door on the convection oven had been that way for about a month. [NAME] A said the eyeglasses and water on the prep table belonged to her. She said there were cubbies in the DM's office with their names on them to store personal items. She said she should have had her glasses and water in her cubby. She said she cross contaminated the biscuit by not changing gloves and not washing her hands. She said she contaminated the food and that was bad because the residents could get sick. She said she did not usually do that (not change her gloves and wash her hands after touching a contaminated item while serving food). She said she was in a hurry at that time. She said she was always in a hurry. In an interview with the FSM on [DATE] at 2:30 PM, she said the convection oven door had been hard to open for about a month. She said she started working at this facility on [DATE]. She said she told the MS about it a couple of weeks ago and he told her he was looking into the parts for it. She said the process for having equipment repaired was to let the MS know verbally. She said there were certain things he could do, otherwise the company for a particular piece of equipment did the repair, such as the dishwasher. She said personal items were never allowed in the kitchen because of sanitation issues and could contaminate food being prepped. She said hand washing rules were staff had to wash their hands as soon as they came into the kitchen and every time they touched something other than food. She said kitchen staff were required to wear gloves for all food preparations. She said if they changed gloves, they were required to wash their hands again and put on fresh gloves. She said contamination and bacteria could be transferred from the hands to the food and that was how germs were spread. She said the residents were already compromised and if they got something in them, one of the residents could easily get sick. She said there was a specific area for dented cans in the dry storage room that was labeled Dented Cans and did not know why or how the dented can was placed on the shelf with cans that were to be used for service. She said she and the rest of the kitchen staff were responsible for placing dented cans in the dented can area. She said once the cans were dented, the food inside could go bad. She said the trash on the prep table should have never been there because of cross contamination. She said the uncovered trash can was supposed to be covered unless it was actively being used and moving the trash bin under the 3-compartment sink did not count as covering it-it needed to have the lid on it. She said keeping trash cans covered was necessary because there was food scraps in there and could cause cross contamination and attract gnats, roaches or other bugs. She said the carton of powered mashed potatoes in the dry storage room should have been sealed with the date, labeled, and in a bag big enough to seal it properly. She said sealing dry storage items was important because the items could go bad or attract flies, gnats, roaches, etc. She said the items in the refrigerator should have been labeled and dated, always. She said it was important for food to be labeled and dated because they needed to know the date to tell if it was bad. She said 4 days was the cut-off for leftover food and then it should be discarded. She said the shelves over the stove and steam table were very hard to clean and it was cleaned weekly. She said the shelves were on the weekly cleaning schedule. She said the shelves did not look like they had been cleaned regularly. She said food was not allowed to be within 13 inches of the ceiling in the walk-in freezer because it could get contaminated from pipes above if they broke, and in the freezer, food would not get the circulation necessary to keep it at temp (frozen). She said frozen cases of food stacked to the ceiling in the walk-in freezer could also be a safety hazard in that it would be hard to reach and could fall on someone or catch fire because the boxes were blocking the fire sprinklers. The facility policy for personal items, handwashing, cleaning schedule, disposal of garbage, food storage, trainings and in-services were requested. In an interview with the FSM on [DATE] at 2:45 PM, she said the steam table wells were supposed to be cleaned weekly but did not look like they had been cleaned regularly. She said the open carton of powdered mashed potatoes was not sealed properly within the zip top type bag and was still open to air. In an interview with the MS on [DATE] at 2:52 PM, he said he knew nothing about the convection oven door. He said the process the kitchen was supposed to follow for repairs was they were supposed to write it in the work order book at the nurse's station. In an interview with the DON on [DATE] at 9:11 AM, she said the housekeeping supervisor was responsible for the ice room. She said he was responsible for logging the temperatures, cleaning the refrigerator, and checking the temperatures for the logbook for. She said resident families put items in the ice room refrigerator without labeling or dating them. She said there was no process in place to educate staff, families, or the housekeeping supervisor about regulations regarding nutrition room refrigerators. In an interview with the ADM on [DATE] at 9:19 AM, he said the HSK S was responsible for the ice room that included cleaning the refrigerator and freezer and logging the temperatures. He said his expectations were that the HSK S was doing his due diligence and should notify him if anything was going on with the ice room. Observation of the ice room refrigerator and freezer and interview with the HSK S on [DATE] at 9:19 AM, he said he had been working at the facility for approximately 3 years and was assigned as the housekeeping supervisor in March of 2024. He said he started taking the temperatures of the ice room refrigerator in [DATE]. He said his responsibility for the ice room included checking the refrigerator and freezer for cleanliness and expired items, defrosting as needed, cleaning the refrigerator and freezer, and logging the temperatures daily. He said the refrigerator and freezer temperature logs should have included the freezer temp. He said resident's food was kept in the refrigerator and the freezer. He said there was no thermometer in the freezer. He said he did not know how cold freezing was. He said the ice room refrigerator and freezer template for logging temperatures was titled, Refrigerator/Freezer Temperature Log and the note below the title described the temperature ranges for the refrigerator and freezer and who to notify if the temperatures were out of range (the FSM or MS). He was informed the refrigerator temperature was 29F. He said that would explain the ice inside the refrigerator. He said he was responsible for defrosting. He said the facility got new refrigerator in [DATE]. He said he delegated his staff to log the temperatures and he had not looked inside the ice room or monitored his staff. Observation of the ice room refrigerator with HSK S revealed he said it needed to be defrosted and could not remove or identify the item that was frozen into the back of the refrigerator wall. He said he had 6 staff and there were 2 that switched for the ice room. He said, They were supposed to look inside, log the correct temp and clean and or defrost it. He said he was not sure of their names. He said he did not have any policy on the upkeep of the ice room. He said he did not know where the temperature log template came from. He said he did not know who was responsible for labeling and dating resident items. He said he did not know how to educate families and residents on labeling and dating foods in the ice room refrigerator and freezer. Record review of the monthly ice room refrigerator/freezer logs dated [DATE]-Nov. 2024 revealed The frozen temperature must remain 0 F or below, and the refrigerator temperature should be between 34F and 38F but no greater than 40F. If the temperatures are not within these ranges, notify the Director of Food and Nutrition Services or Maintenance immediately. New fridge was written [DATE]. Temperatures from [DATE]-[DATE] and [DATE]-[DATE] were marked at 40F except [DATE] the temperature documented was 48F. Temperatures from [DATE]-[DATE] were the same at 39F. The month of [DATE] was missing temperatures every day except [DATE] was 43F. [DATE] and [DATE] were marked 44F. Each day for the month of [DATE] was marked 40F. The month of [DATE] temperatures ranged from 37F to 40F. Each day for the months of Aug. 2024 and Sept. 2024 were marked 39F. Temperatures for the month of Oct. 2024 were marked 40F from Oct.1-Oct.21 and marked 34F to 35F from Oct. 22-Oct. 31. The month of Nov. 2024 temperatures ranged from 35F to 38F. No temperatures for the freezer in any month were documented. Record review of the kitchen daily cleaning log listed 20 opportunities for daily cleaning including can opener, blender, steam table, slicer, table surfaces, stove top and grill, plate warmer, food processor, knife rack, floors (each shift), all sinks, cabinet area in dining room, beverage area, microwaves, ice machine scoops, utility carts (after each use), food carts (after each meal), mop bucket (empty and clean), mop heads and rags (sent to laundry), garbage cans and lids. The partial month of Sept. 2024 indicated for the week of [DATE]-[DATE], the steam table, slicer, knife rack, floors (each shift), garbage cans and lids were not done daily. Mop heads sent to laundry was done once on [DATE]. For the week of [DATE]-[DATE], the floors (each shift), all sinks, garbage cans and lids were not done daily. Mop heads sent to laundry was done once on [DATE]. For the week of [DATE]-[DATE], the steam table, stove top and grill, plate warmer, knife rack, floors (each shift), all sinks, cabinet area in dining room-now crossed off the list, beverage area, ice machine scoops, utility carts (after each use), food carts (after each meal), mop bucket (empty and clean), mop heads and rags (sent to laundry), and garbage cans and lids were not done daily. For the week of [DATE]-[DATE], [DATE]-[DATE], [DATE]-[DATE], and [DATE]-[DATE] none of the 20 opportunities were completed daily. For the week of [DATE]-[DATE], only 2 opportunities were missed daily- garbage cans and lids. For the week of [DATE]-[DATE], the kitchen daily cleaning log was revised at this time to list only 16 opportunities. The can opener, floors (each shift), all sinks, beverage area, microwaves, ice machine scoops, mop bucket (empty and clean), and garbage cans and lids were not done daily. For the week of [DATE]-[DATE] (only including to ,d+[DATE]), there were no concerns identified. Record review of the facility policy revised [DATE] and reviewed [DATE], titled Cleaning Schedule under Policy revealed .to ensure that the food and nutrition services department remains clean and sanitary at all times. Record review of the undated facility policy titled Chapter 9: Food and Nutrition Services revealed under Sanitation .It is necessary for the highest sanitary standards to be maintained throughout the department. Under bacteria and food-borne illness prevention .It is imperative that food-handling equipment and all persons associated with the handling of food be trained in this area. All foods are properly stored at the required temperatures. Refrigerators should be maintained between 34F to 38F to keep the temperature from reaching 45F or higher when the door is opened .Freezers are to be maintained at 0 F or lower. Under Garbage and waste disposal .Garbage cans are routinely cleaned and kept covered when not in use .keeping garbage areas clean and covered at all times will help prevent issues from arising. Under Hand washing/proper use of gloves .It is important that hands be properly washed .Hands are washed before beginning any job requiring food handling, after breaks, sneezing, etc. Proper use of gloves is as important as hand washing since they can become contaminated as easily as the hands .they are changed between tasks to prevent the contamination of food. Under refrigeration: Any food not in its original container must be labeled with the date and contents and must be securely covered.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program, including hand hygiene, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections, for two residents (Resident #26 and Resident #118) of six residents observed for infection control practices in that: The facility failed to ensure the WCN performed adequate hand hygiene by scrubbing hands with soap for at least 20 seconds or greater before and after performing wound care on Resident # 26 and Resident #118. This failure could place residents that require wound care at risk for healthcare associated cross-contamination and infections. The findings included: Record review of Resident #26 ' s face sheet dated 11/14/24 reflected an [AGE] year-old- female with an admitted [DATE]. Diagnoses included Alzheimer ' s disease (gradual decline in memory, thinking, behavior and social skills), type 2 diabetes (insufficient production of insulin in the body), and heart failure. Record review of Resident #26 ' s care plan dated 9/6/24 stated Resident #26 had a wound infection. Interventions included enhanced barrier precautions. Record review of Resident #118 ' s face sheet dated 11/14/24 reflected a [AGE] year-old-female with an admitted [DATE]. Diagnoses included end stage renal (kidney) disease, type 2 diabetes (insufficient insulin production in the body), and aftercare following surgical amputation (right 5th toe). Record review of Resident #118 ' s care plan dated 11/12/24 stated Resident #118 had actual impairment to skin integrity due to surgical wound. Interventions included enhanced barrier precautions (risk-based approach to personal protective equipment to reduce the spread of multidrug-resistant organisms). During an observation on 11/14/24 at 9:36 AM of wound care, the WCN performed hand hygiene for 17 seconds prior to Resident #118 ' s wound care. After wound care was performed as ordered, the WCN performed hand hygiene for 12 seconds. During an observation on 11/14/24 at 10:02 AM of wound care, the WCN performed hand hygiene for 17 seconds prior to Resident #26 ' s wound care. After wound care was performed as ordered, the WCN performed hand hygiene for 10 seconds. In an interview on 11/14/24 at 10:19 AM the WCN stated it was important to wash and lather hands for 20 seconds or greater to prevent infection and stop the spread of germs. The WCN stated by not washing hands for the appropriate amount of time, it could put residents at risk of getting their wounds infected or slow the healing process. The WCN stated she was nervous and did not realize she was not washing her hands for at least 20 seconds. The WCN could not state when the last in-service on performing hand hygiene was. In an interview on 11/14/24 at 10:24 AM the DON stated all staff are expected to wash hands for at least 20 seconds or greater to maintain infection control measures and stop the spread of germs. The DON stated not performing hand hygiene as recommended could cause the residents wounds to get infected. The DON stated the last skills check off for hand hygiene was around May of 2024. The DON stated she was going to conduct a one-on-one training with the WCN and in-service all staff on hand washing. Record review of the facility ' s Infection Prevention and Control Program and Plan dated 6/13/24 stated: Policy The facility has an ongoing infection prevention and control program (IPCP) to prevent, recognize, and control the onset and spread of infection to the extent possible and reviews and updates the IPCP annually and as necessary. This would include revision of the IPCP as national standards change; Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

Based on observations, interviews, and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents for one (Resident #1) of 1 resident reviewed for supervision. The facility failed to ensure Resident #1 received adequate supervision while Resident #1 was unaccounted for approximately 15 minutes from 6:00 PM to 6:15 PM on 10/07/24 before a 3rd party called to notify the facility that Resident #1 was walking through a field adjacent to the facility. On 10/18/24 at 2:27 PM, an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 10/19/24 at 1:25 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy due to the facility's continuing to monitor the implementation and evaluate the effectiveness of their Plan of Removal. This failure could place residents requiring supervision at risk for injury and accidents with potential for more than minimal harm. Findings included: Record review of Resident #1's face sheet revealed an [AGE] year-old male with an original admitted [DATE] and a current admitted [DATE]. Pertinent diagnoses included Alzheimer's disease, Dementia, and Unsteadiness on Feet. Record review of Resident #1's Comprehensive MDS assessment section C, cognitive patterns, dated 10/01/24 revealed a BIMS score of 3 (severe impairment). Record review of Resident #1's care plan revealed the focus Resident is at risk for falls D/T CONFUSION initiated on 10/15/22 and revised on 10/17/22. Interventions listed for this focus included: Assist with ADLs as needed initiated on 10/15/22. Call light within reach initiated on 10/15/22. Complete fall risk assessment initiated on 10/15/22. Orient resident to room initiated on 10/15/22. Provide adaptive equipment or devices as needed initiated on 10/17/22. Pt evaluate and treat as ordered or PRN initiated on 10/17/22. SIDE RAILS: quarter rails up as ordered initiated on 10/17/22 and revised on 10/17/22 Further record review of Resident #1's care plan revealed the focus The resident has had an actual fall with no injury, d/t poor balance initiated on 05/18/24 and revised on 05/20/24. Interventions listed for this focus included: For no apparent acute injury, determine and address causative factors of the fall initiated on 05/18/24 and revised on 05/20/24. Neuro-checks as per protocol initiated on 05/18/24 and revised on 05/20/24. Observe/report PRN x 72h to MD for s/sx: Pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation initiated on 05/18/24 and revised on 05/20/24. Physician ordered UA&C/S for resident initiated on 05/18/24. Resident education on using his cane for support initiated on 05/18/24 and revised on 05/20/24. Record review revealed Resident #1's elopement risk assessment dated [DATE] indicated he was not a risk for elopement at that time. Further record review revealed Resident #1's elopement risk assessment dated [DATE] indicated he was a risk for elopement at that time. Record review of the provider investigation report dated 10/11/24 revealed the following narrative: Resident was seen by charge nurse a few minutes before 6pm walking from dining room down the hallway. At 615pm Charge nurse received a call from a woman stating there was an elderly man looking like a patient of ours walking in the back field towards the fire station all in brown and was he ours? Charge nurse [LVN K] asked the 2nd charge nurse if she was missing anyone and both nurses started looking at their residents. As the staff kept looking [LVN K] quickly got in her car and drove down the street and a fireman and the lady were sitting with the resident unharmed and he stated that he was looking for his work. [LVN K] brought him safely back. Resident was in the facility at 643pm. [QAPI] and CP updated for Elopement. Elopement audit for all residents. Code change for doors and ambulance door change to lobby door. 1x1 [one to one monitoring of the resident by facility staff]. Further review of the provider investigation report revealed a witness statement written as follows by LVN C on 10/08/24: 330pm- [Resident #1] came to nurses station to ask for coffee, we told him it was not ready yet and he left the nursing area. Approx 615pm- I was coming up from the 300hall and [LVN K] told me a lady just called and said she saw a man wearing brown walking through the grassy area by our building. Went down my hall to look for all my residents, I looked out the back door and I did not see anything. Spoke with [CNA L] and he stated the alarm had sounded but he did not notice anything unusual, thought it was a family member. I went back to nurses station and saw [Unknown CNA] come back from the dining room and then we went to go look outside the facility at this time. We did not notice any residents in the surrounding area. I came back in and notified [LVN K] I did not have any missing residents and I didn't see anyone outside. Further review of the provider investigation report revealed a witness statement written as follows by LVN K on 10/08/24: Approx 6pm I saw [Resident #1] coming up 400 hall. Approx 615pm I answered the phone and it was a lady stating she saw an older gentlemen walking through the grassy area by our building wearing brown. We started checking the building for any missing residents. I took off in my vehicle to go drive around and look for him. I found him down [local road] with some fire fighters right passed the fire station. Resident was placed back in my vehicle and returned to facility. I assessed the resident from head to toe and notified all proper channels. Further review of the provider investigation report revealed in-services covering Missing Residents/Actual Elopement Event were conducted for 65 staff members between 10/07/24 and 10/09/24 by the ADON. In an interview with the DON on 10/27/24 at 2:25 PM, the DON stated Resident #1 had no history of exit seeking behavior prior to the elopement incident. The DON stated Resident #1 did not typically go outside. The DON stated Resident #1 was not allowed to go outside unsupervised. The DON stated LVN K called her after she had already found Resident #1 by the first station. The DON stated she did not know which exit Resident #1 used to leave the facility but was most likely the 100 hall exit door. The DON stated the alarm sounded on the 100 hall exit door around the time of the elopement. The DON stated she did not know who called the facility to report the elopement. The DON stated nobody in the facility was aware Resident #1 was missing until the facility was notified by the caller. The DON stated all exit doors in the facility had an electronic lock that required a code to exit. The DON stated since the incident the staff had been told not to use any of the exit doors at the rend of any residential halls. The DON stated they had an elopement drill on 10/08/24 at around 10:00 AM and they will continue to do them weekly for the next 4 weeks. The DON stated the emergency code for a missing resident was purple. The DON stated if purple was called, the charge nurse split up the staff with half of them searching outside the facility and the other half searching inside. The DON stated if they did not find the resident in a timely manner, they would notify the police. The DON stated all staff take part in the search for the missing resident. The DON stated there would be 25 to 30 staff members at the facility during the day and about 6 at night. The DON stated only staff should know the codes to the exit doors. The DON stated the last fall risk assessment performed on Resident #1 before the elopement was on 10/07/24 and received a score of 16. The DON stated a score of 10 or higher meant interventions should be initiated for the resident related to falls. During an observation on 10/17/24 at 3:00 PM, this state surveyor walked from the 100 hall exit door to the local fire station where the missing resident was located. The distance across the field just outside the 100 hall was approximately 650 feet to a residential road, and then another 350 feet after crossing the road to the fire station. In an interview with LVN C on 10/17/24 at 3:36 PM, LVN C stated the emergency color code for a missing resident was pink. LVN C stated a code pink indicated the staff should start looking everywhere for the missing resident. LVN C stated she would go through the rooms to see who was there or not. LVN C stated one of the nurses would delegate some people to go outside and others to stay inside. LVN C stated she would notify the police immediately after the resident was missing. LVN C stated she had not been part of an elopement drill since she had been working at the facility for 2 years. LVN C stated it had been weeks since her last in-service on elopements. In an interview with HK L on 10/17/24 at 3:40 PM, HK L stated he had never taken from in an elopement drill at the facility. HK L stated he had an in-service 2 days ago covering elopement. HK L stated someone goes outside to look for the resident while others stay inside. HK L stated someone needed to notify the administrator and nurse. HK L stated the emergency color code for an elopement was silver. In an interview with CNA M on 10/17/24 at 3:43 PM, CNA M stated the emergency color code for a missing resident was grey. CNA M stated a code grey indicated to all staff they needed to start looking for a missing resident. CNA M stated she would look in the rooms in her hall first. CNA M stated the charge nurse would be in charge during the elopement. CNA M stated some staff would search inside while others searched outside. CNA M stated she received an in-service 2 or 3 days ago covering elopements. CNA M stated she took part in an elopement drill 3 days ago. In an interview with the AD on 10/17/24 at 3:43pm, the AD stated the code called overhead for a missing resident was Code Purple, and if it was called, all staff were to meet at the nurse's station where the DON or the ADM would let everyone know who they were looking for and assign tasks. The AD stated if the resident was not found within 25 minutes, the police department was to be called, and the resident reported missing. The AD stated the last drill and in-service were done last Thursday or Friday (10/10/24 or 10/11/24). The AD stated for the drill, the van driver went and hid, a code purple was called overhead, and everyone was assigned a task/area to look. The van driver was found outside hiding behind a bush. In an interview with the SW on 10/17/24 at 3:49 PM, the SW stated she had only had one elopement drill since she had been working at the facility starting on 12/01/10. The SW stated when it first occurred, someone would get over the intercom and call out a code purple. The SW stated someone would go out the door that alarmed and look for the resident. The SW stated the administrator and RP were to be notified. The SW stated all the door codes had recently been changed and staff were no longer to use the exit doors on the resident's halls. In an interview with RN N on 10/17/24 at 3:50, RN N stated the emergency color code for a missing resident was purple. RN N stated they would check outside while combing the patients inside and inform the DON. RN N stated whoever found out the resident was missing would be the one to take charge. RN N stated they would search inside and outside the facility at the same time. RN N stated if they could not find the resident within 10 minutes they would notify the police. RN N stated she received an elopement in-service 2 days ago. RN N stated it had been a few months since her last elopement drill. In an interview with the MS on 10/17/24 at 3:53 PM, the MS stated he had worked at the facility for [AGE] years and that he had always conducted an elopement drill once every 3 months. The MS stated he conducted an elopement drill on 10/08/24 with all staff who were present on shift at 10:35 AM. The MS stated he had no records of ever conducting an elopement drill during night shift. The MS stated he checked the door locks and alarms weekly on all exit doors. The MS stated during door checks he pressed on the push bar from the inside for 15 seconds to ensure the alarm sounded and that the door would open. The MS stated after the door opened, he closed it back and entered the code to shut off the alarm. The MS stated he did not check the door functionality from the outside. The MS stated he was aware the door could be held open indefinitely without the alarm sounding if no one touched the push bar after the code was input. In an interview with the ADM on 10/17/24 at 3:55 PM, the ADM stated they conducted an elopement in-service with 100% staff over the course of 10/07/24 and 10/08/24 right after the elopement occurred. The ADM stated she conducted another in-service with staff on 10/15/24. The ADM stated when an alarm went off, staff were supposed to go outside and check to make sure no residents went out. The ADM stated staff should notify the charge nurse the alarm went off to initiate a head count. The ADM stated she had the alarm codes changed after the incident, along with an elopement assessment conducted on every resident in the facility. The ADM stated the elopement assessment was changed to immediately notify them if it triggered. The ADM stated the most recent elopement drills were done on 10/08/24, 09/18/24 and 06/26/24. The ADM stated she did not know the last time night shift had an elopement drill. The ADM stated the emergency code for an elopement was purple. The ADM stated Resident #1 was put on a 1 to 1 a few months ago because he talked about wanted to leave for work. The ADM stated during that time Resident #1 never attempted to leave the facility or went near an exit door. The ADM stated it turned out Resident #1 had a urinary tract infection at that time, and once it was cleared up his behaviors improved and was taken off the 1 to 1. The ADM stated she did everything she could to prevent an immediate jeopardy situation. In an interview with LVN Y on 10/18/24 at 9:45 AM, LVN Y stated resident elopement assessments were completed on entry, re-entry, after an event, quarterly, and annually. LVN Y stated the charge nurse on the floor should conduct the elopement risk assessment. LVN Y stated if the resident was overdue for an elopement risk assessment the nurse would see it in their chart as red indicating it was overdue. In an interview with CNA L on 10/18/24 at 10:50 AM, CNA L stated he was in room [ROOM NUMBER] at the end of the hall when the alarm for the exit door on hall 100 sounded at approximately 6:00 PM on 10/07/24. CNA L stated he saw a family member at the other end of the hall and assumed they opened the door but came back inside. CNA L stated he did not recognize the visitor and never spoke to them. CNA L stated he did not look outside at that time. CNA L stated he received an in-service on elopements on 10/08/24. CNA L stated he did not know the emergency color code for a missing resident. CNA L stated he had not taken part in any elopement drills at the facility. CNA L stated the alarm was going off for about 10 minutes before he turned it off around 6:10 PM. CNA L stated he was not aware of anyone else checking on the alarm. CNA L stated LVN K saw him turn the alarm off. CNA L stated he did not know the elopement policy and he did not know Resident #1 was missing until LVN K had already brought him back in the building. In an interview with LVN K on 10/18/24 at 3:40 PM, LVN K stated she was sitting at her computer in the nurse's station when she saw Resident #1 walking towards his room on the 200 hall. LVN K stated she received a call from a lady driving by the facility that stated she saw a male wearing all brown walking in the field adjacent to the facility. LVN K stated she remembered the alarm going off on the 100 hall but could not remember the time it occurred. LVN K stated the alarm went off 5 to 10 minutes before she received the phone call. LVN K stated the alarm sounded for a 1 to 2 minutes at the most. LVN K stated she observed CNA L go towards the 100 hall exit door, turned off the alarm and looked out the window. LVN K stated she did not speak to CNA L at that time. LVN K stated once she was informed that a resident was missing, CNA L and LVN C looked around the rooms while other staff started looking in common areas. LVN K stated no one went outside to look for Resident #1 at that time. LVN K stated since Resident #1 liked to wander into other resident's rooms they began looking for him there. LVN K stated Resident #1 had not been known to try to go outside or display exit seeking behaviors. LVN K stated after they could not find Resident #1 in the facility, she got in her personal vehicle and drove around the facility. LVN K stated she found the resident at a local fire station near the facility talking to firemen about trying to get to work. LVN K stated she thought someone might have let Resident #1 out a back door since family and visitors would use those exit doors on the halls. LVN K stated it took a while to get back to the facility because there was a lot of traffic at the time. LVN K stated she performed a head-to-toe assessment on Resident #1 once she got back to the facility and noted bruising to the left side of his head and bruising to his left elbow due to a fall earlier in the day. LVN K stated the bruising on Resident #1 did not look brand new. LVN K stated a code purple was not called during this incident because staff were around the nurse's station when the call came in and were aware Resident #1 was missing. LVN K stated she believed RN A did the assessment on Resident #1 after his fall earlier in the morning. LVN K stated she believed she had seen the bruise to Resident #1's head earlier in the day. In an interview with RN A on 10/18/24 at 3:54 PM, RN A stated he did the head-to-toe assessment on Resident #1 after his fall earlier in the day on 10/07/24. RN A stated he did not find any injuries on Resident #1 during his assessment. Record review of the facility policy Missing Resident/Actual Elopement Event revised on 04/05/23 and reviewed on 04/03/24 revealed the following: 1. A facility head count should be conducted whenever the following occurs; a. When a door alarm has sounded, but there was no witness to the reason for the sounding of the alarm. b. When the fire alarm goes into alarm to verify that all residents are accounted for. c. Anytime the alarm system for the doors is not operational 2. If during a facility head count a resident is unaccounted for, proceed to step 4 3. If staff cannon account for the whereabouts of a resident, during the course of the day proceed to step 4. 4. The sign out log should be reviewed to determine if the resident or resident representative has signed out of the facility. 5. The time and location the resident was last seen and the clothing the resident was wearing should be determined. 6. The Executive Director or representative and all department heads are notified that the resident cannot be located. The executive Director may need to initiate a facility lockdown if determined it is needed by the Executive Director. 7. The charge nurse will assign staff to begin a coordinated search of the facility and facility grounds. Search the facility's grounds for the resident. If necessary, distribute copies of the resident's photograph to the staff searching the grounds. Keep a record of the areas searched. 8. Staff will be assigned to remain on the unit(s) and to utilize the roster/census sheet to establish the unit census and confirm the whereabouts of all other residents. 9. If the resident cannot be located, the charge nurses or designee will notify law enforcement immediately. Law enforcement personnel will then coordinate the search efforts. 10. The charge nurse or designee will notify the responsible party, the physician, and the medical director that the resident is missing. Record review of the facility policy Unsafe Wandering and Elopement Prevention revised on 08/22/22 and reviewed on 09/25/24 revealed the following: 1. Accurate and thorough assessment of the resident is fundamental in determining indicators for unsafe wandering and elopement. Not all resident exhibit unsafe wandering behaviors or verbalize the desire to leave the facility unplanned. a. A situation in which a resident with decision-making capacity leaves the facility intentionally would generally not be considered an elopement unless the facility is unaware of the resident's departure and/or whereabouts. Record review of the undated facility policy Emergency Code Words revealed the following: Code Purple - Missing Resident An Immediate Jeopardy was identified on 10/18/24 at 2:27 PM. The IJ template was presented to the ADM, and a plan of removal was requested. This was determined to be an Immediate Jeopardy (IJ) on 10/18/24 at 2:27 PM. The Administrator was notified. The IJ template was presented to the ADM on 10/18/24 at 2:27 PM. The following Plan of Removal was submitted by the facility and was accepted on 10/18/24 at 4:27 PM. PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY Plan of Removal: Regarding: IJ 10/18/2024 F 689 Free of Accidents / Hazards / Supervision Failure: The facility failed to ensure the safety of Resident #1 by not providing supervision to prevent Resident #1 from eloping from the facility. On 10/7/2024 Resident #1 exited from the facility and was found near the fire department Corrective action for those found to be affected by the alleged deficient practice: o Identified resident was discharged to a secured unit on 10/9/2024. o Clinical assessment of the resident after return to the unit was completed. o Completed incident report within the PCC system o Notified Medical Director and family of event. o Ensured all residents are present and in the building o Completed/ updated elopement assessment for resident that exited facility and updated his care plan. Identification of others residents having the potential to be affected: o Elopement risk assessments were completed for all residents in the building. Measures/Systemic Changes to ensure the deficient practice does not recur: o Complete elopement assessments for all residents that reside in the facility today, quarterly, significant change and new admissions to the facility. o Elopement drill was completed on 10/8/202 and will be completed weekly. o Obtained statements from staff members that were present during the incident o The following in-services were completed for staff on 10/7/24, 10/8/2024 and 10/15/2024 -Residents at risk for elopement -What to do if a resident elopes -Door security-with alarms, how to ensure door alarms are in place, how often to monitor door alarms, ensuring alarms are turned back on after turning off and exiting and ensuring doors are secure. -Reporting guidelines with elopement -Completing elopement assessments and updating care plans o A list of residents with potential for elopement will be placed at the nurse's station and reception desk, pictures of residents and information will be placed in that book to identify who is at risk. This will be updated quarterly and PRN o AD-hoc QAPI completed by DON-ED and Medical Director o Check all exterior doors to ensure alarms are functioning properly and document. This will be complete weekly and as needed. o Elopement drill to be completed weekly to include all 3 shifts. o Complete elopement assessments for all residents that reside in the facility quarterly, significant change and new admissions to the facility. o Door codes were changed on all exit doors. o Doors at the end of hallways are no longer used. o Further education initiated on 10/18/2024 to include Policy on unsafe wandering and Elopement Prevention. o Elopement drill completed on night shift 10/17/2024. On going monitoring: o Elopement drills will be reviewed in monthly QAPI. o Elopement assessments will be reviewed 2-3 times per week in morning meeting. o All components of this plan of correction will be submitted to the facility QAPI committee meeting and additional recommendations will be made until substantial compliance has been achieved. Verification of Plan of Removal Interviews were conducted with RN O, CNA P, HK Q, CNA R, LVN J, RN A, RN S, CNA T, CNA U, CNA H, CNA G, CNA V, CNA W, DA X on 10/19/24 from 10:00 AM through 12:00 PM. All staff were able to identify the proper emergency color code for a missing resident. All staff stated the proper procedures if they responded to an elopement. All staff were knowledgeable on the changes implemented in the plan of removal. In an interview with the MS on 10/19/24 at 12:03 PM, the MS stated all shifts were getting elopement drills once a week until all staff were knowledgeable, and administration felt all staff were competent on elopement procedures. In an interview with the DON on 10/19/24 at 12:08 PM, the DON stated elopement drills were being conducted once per week for all 3 shifts. The DON stated elopement assessments were reviewed 2 to 3 times per week in the morning meetings to verify elopement drills were done and staff were knowledgeable on all elopement procedures. The DON stated the elopement procedures and implementation of training had been added to QAPI for review. Record review and verification of the accepted POR: Identified resident was discharged to a secured unit on 10/09/24 - Verified by record review through discharge list and interview with DON on 10/18/24. Clinical assessment of the resident after return to the unit was completed - Verified by record review of progress notes and nurse assessments on 10/18/24. Completed incident report within the PCC system - Verified by record review of incident reports on 10/18/24. Notified Medical Director and family of event - Verified by record review of progress notes and interview with DON on 10/18/24. Ensured all residents are present and, in the building - Verified by observation of all residents on a walkthrough of the facility on 10/18/24. Completed/updated elopement assessment for resident that exited facility and updated his care plan - Verified by record review of Resident #1's elopement assessment and interview with DON on 10/18/24. Identification of other residents having the potential to be affected - Verified by interview with DON on 10/18/24. Elopement risk assessments were completed for all residents in the building - Verified by interview with DON on 10/18/24. Measures/Systemic Changes to ensure the deficient practice does not recur - Verified by interview with DON on 10/18/24. Complete elopement assessments for all residents that reside in the facility today, quarterly, significant change and new admissions to the facility - Verified by interview with DON on 10/18/24. Elopement drill was completed on 10/18/24 and will be completed weekly - Verified by record review of elopement drill documentation sheet and interview with MS on 10/18/24. Obtained statements from staff members that were present during the incident - Verified by record review of provider investigation and interviews of relevant staff on 10/18/24. The following in-services were completed for staff on 10/7/24, 10/08/24, 10/15/24, and 10/18/24 - Verified by record review of in-service sign-in sheets and interviews with staff on 10/18/24 and 10/19/24: What to do if a Resident Elopes Door Security Reporting Guidelines with Elopement Complete Elopement Assessments and Updating Care Plans Employees given a quiz beginning on 10/18/24 on Elopement Procedures - Verified by record review of the quiz and interview with ADM on 10/19/24. A list of residents with potential for elopement will be placed at the nurse's station and reception desk, pictures of residents and information will be placed in that book to identify who is at risk. This will be updated quarterly, and PRN - Verified by observation of the new binder on 10/19/24. Emergency QAPI was completed with Medical Director - Verified by record review of the QAPI minutes on 10/19/24. Checking of all exterior doors to ensure alarms are functioning properly and document. This will be complete weekly and as needed - Verified by record review of the maintenance logs and interview with MS on 10/18/24 and 10/19/24. Elopement drills to be completed weekly to include all 3 shifts - Verified by interview with MS on 10/19/24. Complete elopement assessments for all residents that reside in the facility quarterly, significant change and new admissions to the facility - Verified by interview with DON on 10/18/24. Door codes were changed on all exit doors. Verified by observation of input of old door codes and interview with MS on 10/18/24. Doors at the end of hallways were no longer used. Verified by interviews with DON and ADM on 10/18/24. Elopement drill completed on night shift 10/17/24 - Verified by record review of elopement drill documentation sheet and interview with MS on 10/18/24. On going monitoring - Verified by interviews with DON and ADM on 10/19/24 Elopement drills will be reviewed monthly in QAPI - Verified by interview with DON on 10/19/24. Elopement assessments will be reviewed 2-3 times per week in morning meetings - Verified by interviews with DON and ADON on 10/18/24. All components of this plan of correction will be submitted to the facility QAPI committee meeting and additional recommendations will be made until substantial compliance has been achieved - Verified by interviews with DON and ADON on 10/19/24. The Administrator was informed the Immediate Jeopardy (IJ) was removed on 10/19/24 at 1:25 PM. The facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy because of the facility's need to monitor and evaluate the effectiveness of the corrective systems.

Based on interviews and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented, in accordance with accepted professional standards and practices for 7 (Resident #2, Resident #4, Resident #5, Resident #7, Resident #8, Resident #9, and Resident #10) of 7 residents reviewed for clinical records. 1a. The facility failed to ensure that RN A documented Resident #2's blood pressure on the MAR (medication administration record) or in the vital signs when Resident #2 was given medication that would decrease her blood pressure in 5 of 16 opportunities reviewed for medication administration. 1b. The facility failed to ensure that LVN E documented Resident #2's blood pressure on the MAR when Resident #2's medication that would decrease her blood pressure was not given due to her vital signs being outside of parameters for blood pressure medication administration in 4 of 38 opportunities reviewed for medication administration. 1c. The facility failed to ensure that RN J documented Resident #2's blood pressure on the MAR or in the vital signs when Resident #2 was given medication that would decrease her blood pressure in 1 of 1 opportunity reviewed for medication administration. 2a. The facility failed to ensure that RN A documented Resident #4's blood pressure and/or pulse on the MAR or in the vital signs when Resident #4 was given medication that would decrease her blood pressure and/or pulse in 44 of 61 opportunities reviewed for medication administration. 2b. The facility failed to ensure that LVN E documented Resident #4's blood pressure and/or pulse on the MAR or in the vital signs when Resident #4 was given medication that would decrease her blood pressure and/or pulse in 81 of 132 opportunities reviewed for medication administration. 2c. The facility failed to ensure that RN J documented Resident #4's blood pressure and/or pulse on the MAR or in the vital signs when Resident #4 was given medication that would decrease her blood pressure and/or pulse in 2 of 2 opportunities reviewed for medication administration. 3a. The facility failed to ensure that RN A documented Resident #5's blood pressure in the vital signs when Resident #5 was given medication that would decrease his blood pressure in 14 of 17 opportunities reviewed for medication administration. 3b. The facility failed to ensure that LVN E documented Resident #5's blood pressure in the vital signs when Resident #5 was given medication that would decrease his blood pressure in 1 of 35 opportunities reviewed for medication administration. 3c. The facility failed to ensure that RN J documented Resident #5's blood pressure in the vital signs when Resident #5 was given medication that would decrease his blood pressure in 1 of 1 opportunity reviewed for medication administration. 3d. The facility failed to ensure that LVN C documented Resident #5's blood pressure in the vital signs when Resident #5 was given medication that would decrease his blood pressure in 1 of 1 opportunity reviewed for medication administration. 4a. The facility failed to ensure that RN A documented Resident #7's blood pressure in the vital signs when Resident #7 was given medication that would decrease her blood pressure in 22 of 35 opportunities reviewed for medication administration. 4b. The facility failed to ensure that LVN F documented Resident #7's blood pressure in the vital signs when Resident #7 was given medication that would decrease her blood pressure in 12 of 12 opportunities reviewed for medication administration. 4c. The facility failed to ensure that LVN E documented Resident #7's blood pressure in the vital signs when Resident #7 was given medication that would decrease her blood pressure in 2 of 69 opportunities reviewed for medication administration. 4d. The facility failed to ensure that LVN E documented Resident #7's blood pressure in the vital signs when Resident #7's medication that would decrease her blood pressure was not given due to her vital signs being outside of parameters for blood pressure medication administration. 4e. The facility failed to ensure that LVN L documented Resident #7's blood pressure in the vital signs when Resident #7 was given medication that would decrease her blood pressure in 1 of 1 opportunity reviewed for medication administration. 5. The facility failed to ensure that RN A documented Resident #8's blood pressure and pulse on the MAR or in the vital signs when Resident #8 was given medication that would decrease her blood pressure and pulse in 6 of 16 opportunities reviewed for medication administration. 6a. The facility failed to ensure that RN A documented Resident #9's blood pressure in the vital signs when Resident #9 was given medication that would decrease his blood pressure in 14 of 15 opportunities reviewed for medication administration. 6b. The facility The facility failed to ensure that LVN E documented Resident #9's blood pressure in the vital signs when Resident #9 was given medication that would decrease his blood pressure in 4 of 38 opportunities reviewed for medication administration. 6c. The facility The facility failed to ensure that LVN C documented Resident #9's blood pressure in the vital signs when Resident #9 was given medication that would decrease his blood pressure in 1 of 1 opportunity reviewed for medication administration. 6d. The facility The facility failed to ensure that RN J documented Resident #9's blood pressure in the vital signs when Resident #9 was given medication that would decrease his blood pressure in 1 of 1 opportunity reviewed for medication administration. 7a. The facility failed to ensure that RN A documented Resident #10's blood pressure and pulse in the vital signs when Resident #10 was given medication that would decrease her blood pressure and pulse in 14 of 16 opportunities reviewed for medication administration. 7b. The facility failed to ensure that LVN E documented Resident #10's blood pressure and pulse in the vital signs when Resident #10 was given medication that would decrease her blood pressure and pulse in 1 of 37 opportunities reviewed for medication administration. 7c. The facility failed to ensure that LVN C documented Resident #10's blood pressure and pulse in the vital signs when Resident #10 was given medication that would decrease her blood pressure and pulse in 1 of 1 opportunity reviewed for medication administration. 7d. The facility failed to ensure that RN J documented Resident #10's blood pressure and pulse in the vital signs when Resident #10 was given medication that would decrease her blood pressure and pulse in 1 of 1 opportunity reviewed for medication administration. This deficient practice could affect residents whose records are maintained by the facility and could place them at risk for errors in care and treatment. The findings included: 1. Record review of Resident #2's admission record reflected at [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included non-traumatic brain hemorrhage (brain bleed not caused by a head injury), left hemiplegia and hemiparesis (weakness and paralysis) following cerebral infarction (brain bleed), essential (primary) hypertension (high blood pressure), unspecified dementia, and cognitive communication deficit. Record review of Resident #2's quarterly MDS dated [DATE] reflected Resident #2 had a BIMS score of 15 which indicated she was cognitively intact. Record review of Resident #2's provider order summary report reflected the following orders for medications that would decrease blood pressure: Amlodipine Besylate tablet 10mg. Give 1 tablet PO (by mouth) one time a day for HTN (high blood pressure). Hold for BP (blood pressure) < (under)120/60. (No space to document blood pressure on the MAR) Lisinopril tablet 20mg. Give 1 tablet PO one time a day for HTN. Hold for BP <120/60. (There was a space to document blood pressure on the MAR) Record review of Resident #2's vital signs in the September 2024 and October 2024 MARs reflected the following: RN A documented NA in the space where Resident #2's blood pressure was supposed to be documented when Lisinopril was administered on 9/4/24, 9/22/24, 10/10/24, and 10/16/24. LVN E documented an x in the space where Resident #2's blood pressure was supposed to be documented when Lisinopril was not administered due to her vital signs being outside of parameters for blood pressure medication administration on 9/24/24, 10/2/24, 10/7/24 and 10/20/24. RN J documented NA in the space where Resident #2's blood pressure was supposed to be documented when Lisinopril was administered on 9/10/24. Record review of Resident #2's September 2024 and October 2024 vital signs in the EHR reflected the following: RN A did not document Resident #2's blood pressures on 9/4/24, 9/22/24, 10/10/24 and 10/16/24. LVN E documented Resident #2's blood pressures on 9/24/24, 10/2/24, 10/7/24 and 10/20/24. RN J did not document Resident #2's blood pressure on 9/10/24. 2. Record Review of Resident #4's admission record reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included chronic systolic (congestive) heart failure (the heart does not pump blood effectively and causes fluid build up in the lungs), atrial fibrillation (the upper chambers of the heart beat out of coordination with the lower chambers and causes poor blood flow), unspecified dementia, and essential (primary) hypertension (high blood pressure). Record review of Resident #4's quarterly MDS dated [DATE] reflected Resident #4 had a BIMS score of 13 which indicated she was cognitively intact. Record review of Resident #4's provider order summary report reflected the following orders for medications that would decrease blood pressure and/or pulse: Amiodarone Hcl tablet 100mg. Give 1 tablet PO one time a day for arrhythmia (irregular heartbeat). Hold for HR <60. (No space to document HR on the MAR) Carvedilol tablet 3.125mg. Give 1 tablet PO BID (2 times a day) for HTN. Hold for BP <120/60, HR <50. (No space to document BP or HR on the MAR) Digoxin tablet 125mcg. Give 1 tablet PO in the morning every other day for CHF. Check pulse and hold for HR <60. (No space to document HR on the MAR) Losartan Potassium tablet 100mg. Give 1 tablet PO HS (at bedtime) for HTN. Hold for BP <120/60, HR <50. (There was space to document the BP and HR on the MAR). Record review of Resident #4's vital signs in the September 2024 and October 2024 MARs reflected the following: RN A documented NA in the space where Resident #4's blood pressure and pulse were supposed to be documented when Losartan was administered on 9/11/24, 9/29/24, 10/4/24, 10/9/24, and 10/16/24. (1 medication = 5 of 12 opportunities) Record review of Resident #4's vital signs in the EHR for September 2024 and October 2024 reflected the following: RN A did not document Resident #4's blood pressure with the morning administration of blood pressure decreasing medications on 9/4/24, 9/5/24, 9/11/24, 9/22/24, 9/23/24, 9/28/24, 9/29/24, 10/3/24, 10/4/24, 10/8/24, 10/10/24, 10/16/24, 10/17/24, and 10/22/24. (1 medication = 14 of 15 opportunities) RN A did not document Resident #4's heart rate with the morning administration of heart rate decreasing medications on 9/4/24, 9/5/24, 9/11/24, 9/22/24, 9/23/24, 9/28/24, 9/29/24, 10/4/24, 10/5/24, 10/8/24, 10/10/24, 10/16/24, 10/17/24, and 10/22/24. (3 medications = 18 of 18 opportunities) RN A did not document Resident #4's blood pressure with the bedtime administration of blood pressure decreasing medications on 9/11/24, 9/29/24, 10/4/24, 10/9/24, and 10/16/24. (2 medications = 6 of 16 opportunities) LVN E did not document Resident #4's blood pressure with the morning administration of blood pressure decreasing medications on 9/1/24, 9/2/24, 9/3/24, 9/7/24, 9/8/24, 9/9/24, 9/12/24, 9/13/24, 9/14/24, 9/15/24, 9/16/24, 9/17/24, 9/18/24, 9/19/24, 9/20/24, 9/21/24,9/24/24, 9/25/24, 9/26/24, 9/27/24, 9/30/24/24, 10/1/24, 10/2/24, 10/3/24, 10/6/24, 10/7/24, 10/9/24, 10/11/24, 10/12/24, 10/13/24, 10/14/24, 10/15/24, 10/18/24, and 10/24/24. (1 medication = 34 of 37 opportunities) LVN E did not document Resident #4's heart rate with the morning administration of heart rate decreasing medications on 9/1/24, 9/2/24, 9/3/24, 9/7/24, 9/8/24, 9/9/24, 9/12/24, 9/13/24, 9/14/24, 9/15/24, 9/16/24, 9/17/24, 9/18/24, 9/19/24, 9/20/24, 9/21/24, 9/24/24, 9/25/24,9/26/24, 9/27/24, 9/30/24, 10/2/24, 10/3/24, 10/6/24, 10/7/24, 10/9/24, 10/12/24, 10/13/24, 10/14/24, 10/15/24, 10/18/24, 10/19/24, 10/22/24, and 10/24/24. (3 medications = 105 of 108 opportunities) LVN E did not document Resident #4's heart rate when heart rate decreasing medications were not administered in the morning due to her vital signs being outside of parameters for heart rate decreasing medication administration on 9/27/24, 10/1/24 and 10/11/24. (1 medication = 3 of 7 opportunities) LVN F did not document Resident #4's blood pressure with the morning administration of blood pressure decreasing medications on 9/6/24. (1 medication = 1 of 1 opportunity) LVN F did not document Resident #4's heart rate with the morning administration of heart rate decreasing medications on 9/6/24. (2 medications = 2 of 2 opportunities) RN J did not document Resident #4's blood pressure with the morning administration of blood pressure decreasing medications on 9/10/24. (1 medication = 1 of 1 opportunity) RN J did not document Resident #4's heart rate with the morning administration of heart rate decreasing medications on 9/10/24. (2 medications = 2 of 2 opportunities) LVN K did not document Resident #4's blood pressure with the morning administration of blood pressure decreasing medications on 9/19/24. (1 medication = 1 of 1 opportunity) LVN K did not document Resident #4's heart rate with morning administration of heart rate decreasing medications on 9/19/24. (3 medications = 3 of 3 opportunities) 3. Record review of Resident #5's admission record reflected a [AGE] year-old male that was originally admitted to the facility on [DATE] an readmitted on [DATE]. Resident #5's diagnoses included atrial fibrillation, essential (primary) hypertension, and dementia. Record review of Resident #5's quarterly MDS dated 10.4.24 reflected Resident #5 had a BIMS score of 11 which indicated moderate cognitive impairment. Record review of Resident #5's provider order summary report reflected the following order for a medication that would decrease blood pressure: Metoprolol Tartrate tablet 25mg. Give 1 tablet PO one time a day for HTN. Hold for BP<120/60. Record review of Resident #5's vital signs in the EHR for September 2024 and October 2024 reflected: RN A did not document Resident #5's blood pressure with the morning administration of a blood pressure decreasing medication on 9/4/24, 9/5/24, 9/11/24, 9/22/24, 9/23/24, 9/28/24, 9/29/24, 10/4/24, 10/5/24, 10/8/24, 10/10/24, 10/16/24, 10/17/24 and 10/23/24. (1 medication = 14 of 17 opportunities) LVN E did not document Resident #5's blood pressure with the morning administration of a blood pressure decreasing medication on 9/1/24. (1 medication = 1 of 35 opportunities) RN J did not document Resident #5's blood pressure with the administration of a blood pressure decreasing medication on 9/10/24. (1 medication = 1 of 1 opportunity) LVN C did not document Resident #5's blood pressure with the morning administration of a blood pressure decreasing medication on 10/22/24. (1 medication = 1 of 1 opportunity) 4. Record review of Resident #7's admission record reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #7's diagnoses included persistent atrial fibrillation and chronic kidney disease stage 4. Record review of Resident #7's admission MDS reflected Resident #7 had a BIMS score of 15 which indicated she was cognitively intact. Record review of Resident #7's provider order summary report reflected the following orders for medications that would decrease blood pressure and pulse: Isosorbide Mononitrate Extended Release 24 hour tablet 30mg. Give 1 tablet PO one time a day for HTN. (No hold parameters indicated. No place to document BP or HR on the MAR. Discontinued 9/28/24) Metoprolol Tartrate tablet. Give 12.5mg PO BID for HTN. (No hold parameters indicated. No place to document BP or HR on the MAR.) Record review of Resident #7's September 2024 and October 2024 vital signs in the EHR reflected: RN A did not document Resident #7's blood pressure and heart rate with the morning administration of blood pressure and heart rate decreasing medications on 9/22/24, 9/23/24, 10/4/24, 10/8/24, 10/10/24, 10/16/24, 10/17/24, 10/22/24, and 10/23/24. (2 medications = 11 of 19 opportunities) RN A did not document Resident #7's blood pressure and heart rate with the evening administration of a blood pressure and heart rate decreasing medication on 9/8/24, 9/10/24, 9/11/24, 9/20/24, 9/23/24, and 10/4/24, 10/5/24(BP), 10/6/24(HR), 10/11/24, 10/16/24, 10/17/24, 10/19/24, 10/22/24, and 10/24/24. (1 medication = 14 of 18 opportunities) LVN E did not document Resident #7's blood pressure and heart rate with the evening administration of a blood pressure and heart rate decreasing medication on 10/1/24 and 10/23/24. (1 medication = 2 of 10 opportunities) LVN E did not document Resident #7's blood pressure and heart rate in the evening when a heart rate and blood pressure decreasing medication was documented as not given due to her vital signs being outside of parameters for blood pressure and heart rate decreasing medication administration on 10/12/24 and 10/23/24. (1 medication = 2 of 8 opportunities) LVN F did not document Resident #7's blood pressure and heart rate with the evening administration of a blood pressure and heart rate decreasing medication on 9/14/24, 9/15/24, 9/17/24, 9/26/24, 9/27/24, 10/2/24, 10/3/24, 10/8/24, 10/14/24, 10/15/24, 10/20/24, and 10/21/24. (1 medication = 12 of 12 opportunities) 5. Record review of Resident #8's admission record reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #8's diagnoses included essential (primary) hypertension, occlusion (blockage) and stenosis (hardening) of unspecified carotid artery (artery in the neck that helps supply the brain with blood) and unspecified heart failure. Record review of Resident #8's annual MDS dated [DATE] reflected that Resident #8 had a BIMS score of 5 which indicated she had severe cognitive impairment. Record review of Resident #8's provider order summary report reflected the following orders for blood pressure and heart rate decreasing medications: Digoxin tablet 125mcg. Give 1 tablet PO one time a day for heart failure. Hold for HR <60. (No place to document HR on the MAR) Metoprolol Tartrate tablet 50mg. Give 1 tablet PO one time a day for HTN. Hold for BP <120/60 or HR <60. (There are places to document the BP and HR on the MAR) Lisinopril tablet 20mg. Give 1 tablet PO one time a day for HTN. Hold for BP <120/60. (No place to document BP on the MAR) Record review of Resident #8's September 2024 and October 2024 MARs reflected the following: RN A documented NA in the space for BP and NA in the space for HR on the MARs with the morning administration of a blood pressure and heart rate decreasing medication on 9/4/24, 9/22/24, 9/29/24, 10/10/24, and 10/26/24. (1 medication = 5 of 15 opportunities) RN J documented NA in the space for BP and NA in the space for HR on the MARs with the morning administration of a blood pressure and heart rate decreasing medication on 10/10/24. (1 medication = 1 of 1 opportunity) Record review of Resident #8's September 2024 and October 2024 vital signs in the EHR reflected: RN A did not document Resident #8's blood pressure and heart rate with the morning administration of blood pressure and heart rate decreasing medications on 9/4/24, 9/22/24, 9/29/24, 10/10/24, and 10/16/24. (3 medications = 15 of 45 opportunities) RN J did not document Resident #8's blood pressure and heart rate with the morning administration of blood pressure and heart rate decreasing medications on 9/10/24. (3 medications = 3 of 3 opportunities) 6. Record review of Resident #9's admission record reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #9's diagnoses included essential (primary) hypertension, dementia, and chronic kidney disease. Record review of Resident #9's quarterly MDS dated [DATE] reflected Resident #9 had a BIMS score of 13 which indicated he was cognitively intact. Record review of Resident #9's provider order summary report reflected an order for the following blood pressure decreasing medication: Lisinopril oral tablet 20mg. Give 20mg PO one time a day for HTN. Hold for BP <110/50. (No place to document BP on the MAR) Record review of Resident #9's September 2024 and October 2024 vital signs in the EHR and September 2024 and October 2024 MARs reflected the following: RN A did not document Resident #9's blood pressure with the morning administration of a blood pressure decreasing medication on 9/4/24, 9/5/24, 9/11/24, 9/22/24, 9/23/24, 9/28/24, 9/29/24, 10/4/24, 10/5/24, 10/8/24, 10/10/24, 10/16/24, 10/17/24, and 10/23/24. (1 medication = 15 of 16 opportunities) LVN E did not document Resident #9's blood pressure with the morning administration of a blood pressure decreasing medication on 9/25/24 and 10/14/24, 10/21/24, and 10/25/24. (1 medication = 4 of 38 opportunities) RN J did not document Resident #9's blood pressure with the morning administration of a blood pressure decreasing medication on 9/10/24. (1 medication = 1 of 1 opportunity) LVN C did not document Resident #9's blood pressure with the morning administration of a blood pressure decreasing medication on 10/22/24. (1 medication = 1 of 1 opportunity) 7. Record review of Resident #10's Admission record reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #10's diagnoses included chronic systolic (congestive) heart failure, essential (primary) hypertension, and dementia. Record review of Resident #10's quarterly MDS reflected Resident #10 had a BIMS score of 6 which indicated she had severe cognitive impairment. Record review of Resident #10's provider order summary report reflected an order for the following blood pressure and heart rate decreasing medication: Metoprolol Tartrate tablet 25mg. Give 1 tablet PO one time a day for HTN. Hold for BP <120/60, HR <50. (There were no places to document the BP or HR on the MAR) Record review of Resident #10's September 2024 and October 2024 vital signs in the EHR and September 2024 and October 2024 MARs reflected the following: RN A did not document Resident #10's blood pressure and heart rate with the morning administration of a blood pressure and heart rate decreasing medication on 9/4/24, 9/5/24, 9/11/24, 9/22/24, 9/23/24, 9/28/24, 9/29/24, 10/4/24, 10/5/24, 10/8/24, 10/10/24, 10/16/24, 10/17/24, 10/19/24(HR), and 10/23/24. (1 medication = 15 of 16 opportunities) LVN E did not document Resident #10's blood pressure and heart rate with the morning administration of a blood pressure and heart rate decreasing medication on 10/24/24. (1 medication = 1 of 37 opportunities) RN J did not document Resident #10's blood pressure and heart rate with the morning administration of a blood pressure and heart rate decreasing medication on 9/10/24. (1 medication = 1 of 1 opportunity) LVN C did not document Resident #10's blood pressure and heart rate with the morning administration of a blood pressure and heart rate decreasing medication on 10/22/24. (1 medication = 1 of 1 opportunity) In an interview on 10/18/24 at 1:26pm LVN I stated vital signs were done by whoever was passing the medications and they were usually in the morning from 7am to 9am. LVN I stated, On the long-term residents sometimes you get all the blood pressures first, document, and then give the medications. Medications are documented as they are given. LVN I stated if the BP was not checked before giving a BP medication and the resident's BP was low, it could cause the resident to have hypotension (low blood pressure), which could lead to distress or hospitalization . LVN I stated it was important to document accurately and timely so that they would know what information to give the provider if something happened to the resident. LVN I stated if things were not documented accurately, it could lead to inaccurate information being passed along. In an interview on 10/18/24 at 2:43pm RN A stated he checked vital signs before he gave medications to make sure they were within the parameters to be given. RN A stated he would check vital signs as he went along, document them (the vital signs) as soon as they were done, give the med, then document the med right after it was given. RN A stated if a BP was not checked before a BP med was given, it could drop the pressure too low and the resident could have an adverse reaction such as syncope (fainting), falls, or dizziness. RN A stated if he found a resident with a BP too low, he would assess the resident and notify the provider. RN A stated if vital signs or medications were not documented correctly, another nurse might medicate the resident again. RN A stated, On 10/10 and 10/16 I know I took a bp before I gave the meds. I don't know if I clicked something that made it show NA and not record the bp, but I know that I took them because otherwise I wouldn't know if it was ok to give the BP meds. I will make sure from now on that it is documented correctly. RN A stated occasionally if the resident was not in the room (out to an appt or something) then the vital signs and the medication administration might get documented later on when the resident returned. In an interview on 10/18/24 at 3:35pm LVN E stated blood pressures were checked right before he gave the medications, and the blood pressure was usually documented when he put it in the computer after he gave the medication. LVN E stated he could not think of any reason why the BP and meds would be documented at a later time. LVN E stated if a medication had 8:00am, it could be given between 7am and 9am. LVN E stated if he did not check a blood pressure before giving a blood pressure med, it could cause the resident to become hypotensive which could lead to dizziness, falls, hospitalization or even death if the blood pressure got too low. LVN E stated it was important to document accurately and timely so that something was not forgotten and so that another nurse did not medicate a resident again because it appeared they had not been medicated. LVN E stated, I don't dispute the documented times on 10/11-10/15 for Resident #2's blood pressures. I documented the blood pressures once I got all the meds passed and had a chance to sit down and put the information in the computer. LVN E further stated, I have about 60 (or more) residents to medicate in a 2 hour time span. I start medicating at 6:15am and usually finish around 11:00am and that's just medicating- that's not documenting. I don't document the actual times I checked BPs, I just put them in when I get the chance to document. I've told administration that there's no way to get that many residents medicated in that amount of time. In an interview on 10/17/24 at 4:13pm, the DON stated the person giving the medication checked the BP and pulse and was supposed to document the BP and pulse at the same time the medication was given and documented. In a follow up interview on 10/25/24 at 12:42pm, the DON stated there were 2 primary people who did medication pass- RN A and LVN E and that only 1 medication aide was scheduled at a time. The DON stated the medication aide passed medications to all of the residents except the ones with G tubes because the floor nurses did those. The DON stated on average the medication aide passed medications to 58 residents. RN A and LVN E usually worked 6am to 10pm. LVN F usually worked evening shift, 2pm to 10pm, as a medication aide or 3p to 11p as a nurse. When asked about the medication aide having to pass medications to approximately 58 residents in a 2 hour time span the DON stated, I think that it CAN be done. It looks like what they are doing is signing off after medications were done. The DON further stated, I talked to my corporate nurse and we are looking at ways to change 2 of the halls to a 9am medication pass so the medication aides have a little better time frame to pass medications. The DON stated it was very important to check and document blood pressures and pulses when giving certain cardiac medications because if the med aide or nurse did not check blood pressures and/or pulses prior to medication administration, it could lower the resident's BP or HR to a dangerous level. The DON further stated when blood pressures and heart rates were checked, they should have been documented in the vitals and on the MAR. The DON stated if the vital signs were not documented where they were supposed to be, the next nurse would not know what the most recent vital signs were. The DON stated, The 3 primary medication aides were probably last in-serviced on medication administration and documentation of vital signs at the skills check off which was either March or May this year. The DON also stated, I guess I would be in charge of making sure that the medications were given and documented correctly. There probably should be an audit on medication and vital sign documentation. When asked if there any monitoring being done to ensure that medications are being given and documented correctly, the DON stated, We verbally discuss any issues that the nurses are having with residents refusing meds or any other issues that may be going on in morning meeting, but no, there is not any official monitoring or audits regarding medication administration or documentation of administration and/or vital signs. In a phone interview on 10/25/24 at 2:43pm the RPh stated this was his 3rd month to cover onsite at this facility as they were looking for a permanent pharmacist. The RPh stated he was in another city but came to the facility on ce a month to do narcotic audits and narcotic destruction. The RPh stated he checked 1 medication cart a month and looked at medication storage, expiration dates, and such. The RPh stated he had not watched medication pass because it was something that was requested by the facility and was an extra charge. The RPh stated the Pharm D was doing the reviews- including dose recommendations and admission reviews and that she would be the one to look at the blood pressures and BP medication administration. In a phone interview on 10/25/24 at 3:05pm the MD stated when residents were on cardiac medications that had hold parameters, she would expect that vital signs were checked before medications were administered to ensure that the resident's blood pressure and/or pulse were not too low. The MD stated if vital signs were not checked prior to medication administration, it could cause the resident to have hypotension or bradycardia which could lead to hospitalization or death. The MD stated she was going to contact the DON on 10/25/24 to set up an in service with the facility to cover her expectations regarding checking and documenting vital signs prior to medication administration. In a phone interview on 10/25/24 at 3:27pm the Pharm D stated she did not come to the facility as she was in another state. The Pharm D stated this was the 3rd month that she was working with this facility and that she and the RPh were covering because there was not a permanent pharmacist for the facility. The Pharm D stated when she was doing her remote review, she could go into the EHR, but there was nothing on the landing page that would specifically flag her that a medication was held for some reason. The Pharm D stated she would sometimes go in and spot check a resident's MAR but that she would have to dig deeper into the re

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program, including hand hygiene, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for one (Resident #2) of three residents, one of one Central Supply Rooms, and one of twelve rooms on the 400 hall reviewed for infection control. 1.) The facility failed to ensure resident briefs were properly stored and out of reach from other residents, staff, and visitors to prevent possible cross-contamination. 2.) The facility failed to ensure Resident #2 was placed on transmission-based precautions when her urine culture result was positive for Klebsiella pneumoniae (a bacteria). 3.) There were 4 boxes of sterile urinary catheters containing 12 each, that were expired in the Central Supply room. This failure could place residents that require assistance with personal care at risk for healthcare associated cross-contamination and infections. The Findings included: 1.) During an observation on [DATE] at 9:58 pm this state surveyor observed resident briefs in open packages on the CNA linen cart and two loose briefs on top of a plastic three drawer infection control storage bin outside a room on the 400 hall. During an observation on [DATE] at 4:07 pm this state surveyor observed an open package of resident briefs on the CNA linen cart on the 400 hall. In an interview on [DATE] at 3:15pm the DON stated she did not think resident briefs should be left open on the CNA linen carts or the infection control three drawer cart. The DON stated open briefs should not be left out on carts due to infection control and possible cross-contamination. The DON stated she was going to in-service staff on infection control immediately. In an interview on [DATE] at 3:33pm LVN C stated she had been working since 7:00 am that morning and stated she did see the briefs on the CNA linen carts but got distracted and did not put them away. LVN C stated resident briefs should not be left out on the CNA linen carts because she felt it would be infection control issue. LVN C stated she had just started working the day shift and had not really seen resident briefs on the CNA linen carts but when she did, she had not reported it to anyone because she was not sure if it was ok to have briefs out or not. LVN C could not state when the last infection control in-service was. In an interview on [DATE] at 3:44pm CNA D stated resident briefs should not be on the carts due to cross-contamination and infection control reasons. CNA D stated when she arrived on shift at 2:00pm that day, she saw the resident briefs and started to put them away. CNA D Stated she threw away the loose briefs that were left on the plastic 3 drawer infection control bin. CNA D stated the last in-service on infection control was about a week ago. 2.) Record review of Resident #2's admission record reflected at [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included non-traumatic brain hemorrhage (brain bleed not caused by a head injury), left hemiplegia and hemiparesis (weakness and paralysis) following cerebral infarction (brain bleed), essential (primary) hypertension (high blood pressure), unspecified dementia, and cognitive communication deficit. Record review of Resident #2's quarterly MDS dated [DATE] reflected Resident #2 had a BIMS score of 15 which indicated she was cognitively intact. Record review of Resident #2's laboratory results reflected Resident #2 had a urine culture collected on [DATE] and resulted on [DATE] that showed that Resident #2 had Klebsiella pneumoniae bacteria in her urine. Observation of Resident #2's room on [DATE] at 3:45pm reflected no TBP (transmission-based precaution) signage on the door or wall next to the door and no PPE (personal protective equipment) outside the room. Observation of Resident #2's room on [DATE] at 1:54pm reflected no TBP signage on the door or wall next to the door and no PPE outside the room. In an interview on [DATE] at 1:26pm, LVN I stated she knew that someone was supposed to be on TBP by diagnoses, lab results, and report. LVN I stated if a resident was supposed to be on TBP, the nurse would put an order in the computer that usually came from a telephone order from the provider. LVN I stated they would get the signage to place on the door and the PPE cart to place in the hall outside the door. LVN I stated if someone was supposed to be on TBP but was not, it could potentially cause the spread of whatever bacteria or virus that resident had which could lead to hospitalization or worse for the other residents. In an interview on [DATE] at 2:43pm RN A stated, We know if someone was supposed to be on isolation by looking for the isolation cart or go into the computer and look for the order for isolation. The order was entered by the nurse or the provider from information from the sending entity (if the resident is coming from another facility or hospital) or from lab results. RN A stated the provider was the one to make the decision on TBP. RN A stated if someone was not on isolation that should have been, infection could be spread to other residents, family or visitors which could result in illness or death. RN A stated he knew Resident #2 recently had a UTI, but did not know what the organism was. After RN A was informed it was Klebsiella pneumoniae, he stated that she should have been on contact precautions, and he did not know why she was not. In an interview on [DATE] at 3:35pm LVN E stated that they knew by the signage on the door that a resident was on transmission-based precautions and what type. LVN E stated if a resident was supposed to be on contact precautions but was not, it could spread the bacteria to other residents which could cause an outbreak resulting in hospitalization or death. In an interview on [DATE] at 4:09pm the MD stated for any infection, the resident should be put on standard contact precautions. The MD stated, I thought it was standard (automatic) for residents to be put on contact precautions for any type of infection. I did not think I would need to give orders for that. In reference to Resident #2's Klebsiella pneumoniae in her urine, the MD stated, I wouldn't have necessarily treated this particular UTI with antibiotics because the bacteria count was under 100,000. In an interview on [DATE] at 4:59pm, the IP stated a resident would be placed on contact precautions for ESBL (Extended Spectrum Beta-Lactamase. An enzyme produced by some bacteria that makes them resistant to many antibiotics) in the urine if they were incontinent without a foley and if they had a foley they would be on EBP (Enhanced Barrier Precautions). The IP stated once the physician put a resident on antibiotics it would trigger her to look at cultures. The IP stated some physicians did not want to prescribe an antibiotic if it was under 10,000 CFUs (Colony Forming Units) on the culture. In reference to Resident #2, the IP stated, With her klebsiella pneumoniae, I did not put her on contact precautions until I talked to the MD to see if she wanted to put her on EBP -vs- contact precautions. I also just do not want to fight with the family member because she got very mad when we put the resident on c diff precautions while testing for it. It came back negative, so we took her off precautions, but the family member was upset that she was on precautions in the first place. The IP stated in general, if a resident had positive urine or blood cultures they would be put on some type of precautions. The IP stated if a resident was put on precautions, the facility had batch orders to put in the computer and then it would go on her surveillance. The IP stated if someone needed to be on contact precautions but was not, infection could spread. 3.) Four full boxes of sterile urinary catheters in different sizes were expired in the Central Supply room. One box of 22fr urinary catheters had an expiration date of [DATE]. One box of 26fr urinary catheters expired on [DATE]. Two boxes of 24fr urinary catheters expired on [DATE]. In an interview with the DON on [DATE] at 9:15 am, she stated she was unaware of the expired urinary catheters. She said the catheters were sterile and should have been discarded. She said the catheters were not safe to use after the expiration date because they were most likely no longer sterile. In an interview with the CS on [DATE] at 3:02 pm, she said she was responsible for the central supply room and its contents. She said her responsibility included ordering supplies, not storing anything on the ground, nothing could be expired, and she had to keep it stocked. She said the door was supposed to be closed and locked at all times. She said she was unaware of the expired catheters. She said she did not know what could happen to the residents if sterile catheters were used to replace per doctor orders. In an interview with the DON and ADON on [DATE] at 3:10 pm, they said the facility did not have a specific policy on general supplies. They both said the only policy they could find was Storage of Chemicals and they would look for something more appropriate for storage of supplies. They said the policies they had were from corporate. In an interview with the RCNS on [DATE]/ at 3:50 pm, she stated, The facility did not have their own policies, that under the definition of the policy on what they had, implied what the facility was compliant with regulations. The RCNS then provided an eleven-page document from Lippincott procedures titled, Indwelling urinary catheter (Foley) insertion, assigned male at birth. She stated, We just don ' t have policies. Record review of the facility policy titled; Licensure and compliance with Federal, State, Local Laws, and Professional Standards reviewed [DATE] revealed it quoted Federal regulations F836 483.70(b) Compliance with Federal, State, and Local Laws and Professional Standards. Under Policy, the facility will provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to any professional providing services in the facility, whether temporary or permanent. Record review of the facility's Infection Prevention and Control Program (IPCP) and Plan policy dated [DATE] and revised on [DATE] stated: The facility has systems for the prevention, identification, reporting, investigating and control of infections and communicable disease of residents, staff, and visitors. This system includes an ongoing system of surveillance designed to identify possible communicable diseases and infections before they can spread to other persons in the facility and procedures for reporting possible incidents of communicable disease or infections. Establishing Priorities and Setting Goals 5. Examples of goals might include the following: a. Decreasing the risk of infection spreading b. Enhancing hand hygiene c. Minimizing the risk of transmitting infections associated with the use of procedures, medical equipment, and medical devices Implementing Strategies to Achieve the Goals 4. Methods to reduce the risks associated with procedures, medical equipment, and medical devices, including the following: a. Appropriate storage, cleaning, disinfection, and/or disposal of supplies and equipment. 5. Applicable precautions, as appropriate, based on the following: a. The potential for transmission b. The mechanism of transmission c. The care, treatment, and services setting

Based on observation, interviews and record review the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice for 1 of 3 residents (Resident #2) reviewed for NPO status. The facility failed to intervene timely and appropriately when Resident #2 obtainted food and began to choke. On [DATE], during lunch service about 12:00 p.m., Resident #2 obtained access to Resident #1's food, staff did not provide timely interventions which led to Resident #2 choking and expiring. Resident #2 had a g-tube and was on NPO status. An IJ was identified on [DATE]. The IJ templates were provided to the facility on [DATE] at 5:30 PM. While the IJ was removed on [DATE] at 7:18PM. The facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. This failure could place residents at risk of choking or death. Findings included: Record review on [DATE] of self-reported incident report dated [DATE] revealed Resident #2 was up and wheeling around as normal. He saw another patient eating some pie at the table near the nursing station and grabbed it from him and put it in his mouth. CNA went to get it (the pie) and he started to have difficulty breathing. Director of Nursing took him to the room and suctioned, performed the Heimlich maneuver, and provided Oxygen. Family did not want him sent out but rather stay here since he was a DNR. Record review of Resident #2's face sheet dated [DATE], revealed he was a [AGE] year-old male, admitted on [DATE]. Resident #2 had a medical dx of OTHER SEQUELAE FOLLOWING NONTRAUMATIC SUBARACHNOID HEMORRHAGE (bleeding in the space between the brain and the tissue covering the brain), DYSPHAGIA (difficulty swallowing), COGNITIVE COMMUNICATION DEFICIT (difficulty thinking and how someone uses language), BIPOLAR DISORDER (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), SCHIZOPHRENIA (serious mental illness that affects how a person thinks, feels, and behaves), AND DEMENTIA (a group of thinking and social symptoms that interferes with daily functioning). Record review of Resident #2's admission MDS assessment dated [DATE], revealed Resident #2 had a BIMS score of 09 which indicated Resident #2 was moderately cognitively impaired and needed help at times with indoor mobility. MDS indicates Resident #2 coughs and chokes during meals or when swallowing medication and has a feeding tube, Record review of Resident #2's care plan dated [DATE], stated Resident requires tube feeding with an initiated date of [DATE]. Interventions for this tube feeding included anticipating Resident #2's needs, assisting Resident #2 to develop appropriate methods of coping and interacting. Encourage Resident #2 to express feelings appropriately. Record review of Resident #2's physician orders revealed an order for an NPO diet with an initiated date of [DATE]. Record review of Resident #1's face sheet dated [DATE], revealed he was a [AGE] year old, admitted on [DATE] for Coronary Hear Disease, Hypertension, Dementia, Glaucoma, and Depression. Record review of Resident #1's admission MDS assessment dated [DATE], revealed Resident #1 had a BIMS score of 03 which indicated Resident #1 was severely cognitively impaired. Resident #1 was able to use suitable utensils to bring food and liquid to the mouth and swallow food/liquid once without assistance once the meal is placed before the resident. During an interview on [DATE] at 11:45a.m., the Administrator and the Director of Nursing stated, Resident #2 was seen at a table with another resident. Resident #2 was on NPO status. Resident #2 was seen with a pie plate with pie from the other resident at the table. CNA A removed the pie plate and informed the nurse at the nurse's station. LVN B (nurse at nurses' station) instructed CNA A to mov. Resident #2 from the table. CNA A was moving Resident #2 when she noticed he had changed in his demeanor and informed LVN B. LVN B then instructed CNA A to take Resident #2 to his room for an assessment. The Director of Nursing states I was called to Resident #2's room to assist LVN B with Resident #2. Resident #2 was unresponsive but still breathing when we transferred him to his bed. I did the Heimlich maneuver while sitting on the bed behind him. We did suction him with no residual. The Hospice nurse walked in while Resident #2 was being suctioned. Resident #2 did eventually expire, and the Hospice nurse called the time and date of [DATE] at 12:38p.m. During an interview on [DATE] at 11:45 a.m., with CNA D she stated she placed Resident #1 at a table in front of the nurse's station for monitoring of his food intake. CNA D stated she did not see anyone at the nurse's station at the moment she placed the tray of food in front of Resident #1 and left to pass the other trays for her hall. During a phone interview on [DATE] at 1:18 p.m., with CNA A she stated she saw Resident #1 and Resident #2 sitting at a table together. CAN A stated Resident #2 was seen with a pie plate from Resident #1. CNA A stated He did have crumbs on his clothes CNA A stated the plate was removed from Resident #2 due to his NPO status. CNA A stated she informed LVN B of Resident #2 having wheeled himself to a table and getting a pie plate with pie. Resident #2 got the pie by being at the table while Resident #1 has his lunch tray and LVN B instructed CNA A to move Resident #2 away from the table. Immediately after informing LVN B of Resident #2 having the pie, CNA A stated she was moving Resident #1 and noticed he was pale in color and was not responding to her. CNA A stated after informing LVN B, LVN B instructed CNA A to take the Resident #2 to his room. CNA A stated she is unsure how much time passed because it happened so quickly. During an Interview on [DATE] at 12:53 p.m., LVN B stated she instructed CNA A to escort Resident #2 to his room for an assessment. LVN B stated she called out for RN to assist in Resident #2's room. LVN B stated she is unsure how much time passed because it all happened so quickly. During an interview on [DATE] at 12:30 p.m., RN C stated she entered the room of Resident #2 and when he stopped breathing, she initiated the Heimlich maneuver and eventually suctioned Resident #2. RN C stated Resident #2 was on Hospice and the family did not want emergency services called. Resident #2 did expire with the Hospice nurse in the room and the Hospice nurse pronounced time of expiration. During a phone interview on [DATE] at 5:34pm, the Hospice Nurse said, Resident #2 was lying in his bed with the head of the bed elevated upright to what appeared to be the highest position, there were four to five nurses surrounding patients' bed, patient is noted with the pulse ox monitor to his right hand and electronic blood pressure monitor to right arm. At this time the nurse (unknown which nurse) tells me the patient who has a dx of dysphagia grabbed a pie from another patient and ate it. Resident #2's skin is cyanotic, and eyes are partially open, patient had an oxygen mask on and one of the floor nurses was attempting to perform deep oral suction. I then grabbed my phone to attempt to call patients sister from my work phone but was unable to find her number at this time one of the nurses states she was going to call the patient's family member and inform her of the situation, I then called Nurses on wheels office to get the caregivers number but at this time the nurse reentered the room and stated that the patients sister did not want to revoke the Do Not Resuscitate order and refused to have patient sent to the hospital. I did see some particles in the suction machine canister. At 12:37pm - 12:38pm I attempted to obtain a manual BP reading. I was unable to auscultate a BP reading or an apical pulse. Pupils assessed and were fixed and dilated. I then waited 1 full minute to obtain a second set of vitals, upon second attempt no BP, no pulse and no respirations. I then pronounced Resident #2 at 12:38pm. During an interview on [DATE] at 12:15 p.m., CNA C stated when she arrived yesterday ([DATE]), she was told of the choking event that led to Resident #2 expiring at the facility and stated that Resident #2 consistently would ask to eat food, however CNA C stated she would redirect Resident #2 to participate in activities during mealtimes. During an interview on [DATE] at 12:31 p.m., RN C stated the facility has provided education on abuse and neglect, Heimlich maneuver, time management, and during emergent situations do not waste time and must immediately call 911. During an interview on [DATE] at 12:56 p.m., CNA E stated she had worked with Resident #2 prior and saw a tube feeding pump and would monitor him and stated Resident #2 would ask for food consistently in a form of hand gesture and this resident could self-propel his wheelchair. Record review of facility policy titled, Removing Foreign Body Airway Obstruction-Heimlich Maneuver and dated [DATE] included verbiage that stated, If severe airway obstruction develops, quick intervention is necessary to relieve the obstruction. Anoxia resulting from such obstruction may cause brain damage and death. There was no policy provided regarding residents on NPO status. This was determined to be an Immediate Jeopardy (IJ) on [DATE]. The Administrator and the Director of Nursing were notified. The IJ template was provided to the facility on [DATE] at 5:30 PM. The following Plan of Removal submitted by the facility was accepted on [DATE] at 6:27 p.m. The following plan of action outlines immediate interventions employed by the facility to remove any further concerns surrounding the alleged issue of professional standards of practice. Identification of other residents having the potential to be affected: o Audit completed of all residents' diets and NPO status. o The facility has a binder at the nurse's station that identifies residents that have an NPO status. o Residents who are identified to be at risk for potential hazards related to NPO status will be monitored for potential risk of harm. Measures/Systemic Changes to ensure the deficient practice does not recur: All licensed staff will be re-educated on responding timely to emergent situations by DON and/or IP nurse. DON was reeducated by the Regional Director of Clinical Services on [DATE]. In-servicing by administrative nursing staff on Heimlich Maneuver per policy to be done facility wide. NPO book will be reviewed and updated as needed by DON and /or IP nurse Monday - Friday. In-servicing by administrative nursing staff (DON and/or IP nurse) on resident assessment and response to emergencies in a timely manner. Ongoing Monitoring: Daily rounding during mealtimes by administrative staff to ensure dining room supervision until compliance is achieved. All components of this plan of correction will be submitted to the facility QAPI committee meeting for three months and additional recommendations will be made until substantial compliance has been achieved. The Medical Director was notified and agrees with the plan of correction. The Admin Nursing Staff to include, Don, Infection Prevention Coordinator, Regional Director of Clinical Services, Executive Director, or designee are responsible for the corrections and continued monitoring. Completion date: [DATE] Verification of the facility's Plan of Removal Included: Record review, the facility conducted 100% review of all residents identified with gastric tubes and NPO status, as well as reviewed all residents with modified/restrictive diets. Record review of Resident #1's physician dietary orders, audited on [DATE], revealed order dated [DATE] for Resident #1 to receive regular diet, easy to chew texture, thin consistency. There were no concerns noted. Record review of Resident #3's physician dietary orders, audited on [DATE], revealed order dated [DATE], enteral feeding documented Resident #3 to receive Glucerna 1.2, 55 ml/ hour for 22 hours. 100mL water flush Q4hr - There were no concerns noted. Record review of Resident #4's physician dietary orders, audited on [DATE], order dated [DATE], regarding enteral feeding documented Resident #4 to receive Fibersource at 70 ml/hour x 20 hours via pump, with 150mls water flush Q4 hours. There were no concerns noted. Record review of Resident #5's physician's dietary modification orders was audited on [DATE], order dated [DATE], documented Resident #5 to receive sodium restricted diet, regular texture, thin consistency. There were no concerns noted. During an observation and interview on [DATE] at 4:47PM observed Resident #3's tube feeding. Resident #3 had Glucerna 1.2 infusing at 55mL/HR, with a scheduled 100ml water flush Q4hr. Resident #3 stated she did not have any concerns regarding her tube feedings. Resident #3 stated she knew why she was receiving tube feedings, and that the clinical staff attend to her needs when she requests assistance. During an observation on [DATE] at 5:13PM Resident #1 was in the dining room eating his easy to chew meal which consisted of chicken, mashed potatoes, carrots, a slice of bread and tea. Resident #1 was able to ingest his food with no issues observed. No observable concern. During an observation on [DATE] at 5:23PM, Resident #4 was receiving tube feeding. Resident #4 had Fiber source infusing at 70 ml/hour via pump with 150mL water flush Q4hr. Resident #4 did not exhibit any signs of distress. No concerns observed. During an interview on [DATE] at 12:15PM, CNA C CNA C stated if she were to encounter a person with a change in color, she has been educated to call immediately for assistance, and will stay with patient until nurse arrives. CNA C stated if she were to experience a resident choking, she will initiate a Heimlich maneuver, and position her hands within the abdomen area and thrust upward. CNA C stated she has been also taught another way to alarm the nursing staff was to call for help loudly, to signify that a person was in distress and needs emergency assistance, that could potentially lead to death. CNA C stated the CNAs were usually supervising residents eating and observe how they eat and how much they eat and will report to the nurses any irregularities with eating/ eating behaviors. CNA C stated she has been instructed to set up a tray properly, which would involve cutting the proteins in bite size measurements, and will continue to observe residents eating, however if she must vacate area, she will return immediately to ensure the resident's safety, and will make sure the resident eats a good percentage of their meal. CNA C stated when she arrived yesterday ([DATE]), she was told of the choking event that led to Resident #2 expiring and stated that Resident #2 consistently would ask to eat food, however CNA C stated she would redirect Resident #2 to participate in activities during mealtimes. CNA C stated she has been educated on types of abuse which would encompass forcefully inflicting pain, and would report to the charge nurse, DON, and Administrator. CNA C stated she was last in-serviced about Code Blue, Heimlich Maneuvers, Abuse and Neglect, and Falls on [DATE]. During an interview on [DATE] at 12:31PM, RN Charge Nurse; RN C stated the facility has provided education on abuse and neglect, and Heimlich maneuver, time management, and during emergent situations do not waste time and must immediately call 911. RN C stated for a full code blue, she has been educated on the proper procedures on how to conduct CPR and to always notify the chain of command. RN C stated Resident #2 was her patient on [DATE] and she was on break when choking/expiration happened. RN C stated she was very sad about event. RN C stated Resident #2 was NPO due to dysphagia and had difficulty swallowing. RN C stated that Resident #2 was mobile via wheelchair and was able to wheel himself throughout the facility. RN C stated Resident #2 never requested food, and when she would ask if he was hungry, once the tube feeding was complete, he would state he was full. RN C stated Resident #2 was not impulse and enjoyed counting monopoly money. RN C said while she was on break, LVN A and the floor CNAs were the ones who were watching her residents. RN C stated Resident #2's behavior never made her believe that he would take something that was not his. RN C stated she administered Resident #2's gastric tube feed at 10AM on [DATE]. RN C stated once she returned Resident #2 had passed away. RN C stated family had already been notified. RN C stated she has been educated to initiate Heimlich maneuver immediately and call out for help, the helpers would be the ones contacting chain of command as well as calling for Emergency assistance, while she continues to attempt to dislodge any particles or foreign substances out of the resident's oral cavity. RN C stated that she will begin the Heimlich maneuver to ensure resident's safety followed by then assessing the oral cavity, all as preventative measure to maintain the resident's safety and wellbeing. RN C stated in her professional opinion, the treatment nurse was wrong, and should have acted immediately because time was very important. RN C stated privacy can be maintained later, life is what is important. During an interview on [DATE] at 12:56PM, CNA D, CNA E, both stated they were in-serviced about abuse, neglect, when to report abuse and neglect, NPO definition, change in condition, and to report any immediate changes. Both stated they performed the Heimlich maneuver. Both stated to perform the Heimlich maneuver will situate hands under rib cage, and in an upward motion will thrust. Both stated they were comfortable with performing the Heimlich maneuver on heavier set people. CNA D stated she observed to her left Resident #1, crumbs on chest, thighs, and plate right in front of him. CNA D stated she knew that Resident #1 was NPO and there was nothing on the plate. CNA D notified the Treatment nurse, who instructed CNA D to take the plate away from him, and foot was caught in wheelchair and saw resident leaning to right side, and picked up his hat and his eyes were drifted to the right. The treatment nurse instructed CNA D to take to his room, and CNA D asked LVN A and Resident #1 was breathing lightly slow breathes, and while in front of an office and LVN A looked at him, then instructed to take Resident #1 into his room which was position 3 room down in 106A. CNA D stated the treatment nurse, LVN A, MDS Coordinator, and DON entered Resident #2's room. CNA D stated it could not be more than 2 minutes between the time she returned Resident #2 from the table to his room. CNA E stated that fall risk patients were positioned near the nurse's station to ensure there were people watching. CNA E stated she had worked with Resident #2 prior and saw a tube feeding pump and would monitor him and would ask for food consistently in a form of hand gesture. CNA E stated she was in his room on the day in question, and hospice nurse had just bathed Resident #2, and Resident #2 had wheeled himself out of his bedroom. Both stated they have been educated to stay with the patient and yell out for help from all clinical staff and have also been instructed to perform the Heimlich maneuver immediately. Both stated types of abuse they have been educated on were emotional, physical, and mental, if they notice a new bruise, abrasions, skin tears, and color will notify charge nurse and administrator if they suspect abuse. Both stated they attended in-services [DATE]- [DATE]. During an interview on [DATE] at 1:28PM, CNA F, CNA G, CNA H, CNA I; all have stated they have been educated on Abuse and Neglect and NPO precautions, Heimlich maneuver. All stated NPO precautions were implemented for those residents that have gastric tubes that do not allow them to eat through their oral cavities. All stated they will advocate for a nurse to intervene by calling out for help and would initiate the Heimlich maneuver immediately if a resident was witnessed choking and knows that it may be due to eating/choking issue. All stated to position hands above the gastric tubes and as close to the rib cage/abdomen area and will conduct an upward thrust and will stay with the resident until the nurse arrives and will await their instructions. Resident #1was CNA I's resident and was able to eat by himself and was in the front so that there were more eyes to watch him. All stated Resident #2 had dementia but was able to eat on his own and does not allow people to eat from his tray. All stated facility has implemented that all residents that need assistance to eat will be assisted in the dining room area, snack cart was now put behind nurses' station, as well as coffee station was now served only in dining area. CNA E stated she had seen Resident #2use a hand to mouth gesture that indicated he was hungry and wanted to eat. All stated, types of abuse they have been educated on were physiological, physical, sexual, verbal, abandonment, and misappropriation of property. All stated, signs and symptoms of abuse could be sad, crying, grimacing of pain, skin coloration, bruises, behavioral abnormalities, or resident verbalizes allegation. All stated if they do suspect abuse, they will report immediately to the charge nurse and administrator. During an interview on [DATE] at 1:55PM, LVN A stated on [DATE] around lunch time, she was at the nurse's station, on the phone getting a surgery date for another resident, when she was alerted by CNA D that help was needed. LVN A stated she then got her pulse oximeter and saw Resident #2 in distress in his room. LVN A stated she also saw the DON, MDS Coordinator, and CNA D. LVN A saw the DON performing the Heimlich maneuver. LVN A stated the treatment nurse was at the nurse's station conducting some form of documentation on the computer. LVN A stated she did not see anything going on, and once CNA D alerted her, she then reacted and went to Resident #2's room. LVN A stated she was focused on her trying to get her own resident a follow up appointment for surgery, she did not hear CNA D speak with the treatment nurse. LVN A stated it was no more than a minute from when LVN A was alerted to the time she entered Resident #2's room. LVN A stated, while the Director of Nursing was performing the Heimlich maneuver, saw some particles come out of Resident #2's mouth, but nothing else was coming up. LVN A stated the MDS Coordinator went to get a suction. LVN A stated she felt Resident #2's pulse and was gasping for air, and multiple times tried to get a blood pressure on Resident #2 but was not reading, and the pulse oximeter oxygen reading was in the 70's and administered oxygen through a simple mask, not a non-rebreather mas. LVN A stated the MDS Coordinator then returned and suctioned some particles with yanker and deeper suctioned, but nothing was working. LVN A stated they actively tried to suction and could hear Resident #2's heartbeat and was told by an unknown staff member that Resident #2's family member did not want to send Resident #2 into the hospital. LVN A stated she was positioned on the right side of Resident #2 and the hospice nurse was in the room standing to the further part of the room. LVN A stated she asked/told the hospice nurse to check pulse, and throughout the incident Resident #2's face would turn blue then return to normal skin color. LVN A stated Resident #2 was not exhibiting signs of choking. LVN A stated for sure the Heimlich maneuver should have been conducted as well as an assessment on scene, as opposed to having the resident taken to their room because maintaining the life of a patient was more important than maintaining their privacy for emergent situations. LVN A stated Resident #2 was sitting at the edge of bed and the DON performed Heimlich maneuver for approximately ,d+[DATE]minutes, nothing substantial came out, followed by the staff member placing him back in bed with the head of the bed raised, eyes were not open, and body would sporadically jerk and when performing sternal rub Resident #2's body would jerk but then stop. LVN A stated Resident #2's breathing was light/labored breathing, then stop and then would twitch/jerk sporadically. LVN A stated she has been educated to perform an assessment immediately once it was known there was cause of an emergent situation as well as to begin a Heimlich maneuver immediately when a resident was choking. During an interview on [DATE] at 2:36PM, Laundry Attendant A, Laundry Attendant B; Both stated that if they witness a resident actively choking and were standing up, they will immediately perform the Heimlich maneuver, or if they were in a wheelchair, they will call out for help from the clinical. Both stated they were in-serviced about abuse, neglect, reporting of abuse/neglect reporting, where the NPO book was located and the definition of NPO which means nothing by mouth. Both stated they were also in-serviced about the Heimlich maneuver and how to perform the Heimlich maneuver by placing both hands under the rib cage and thrusting in an upwards motion. During an interview on [DATE] at 2:45P, CNA J, CNA K, CNA L, CNA M, all stated if they were to encounter a resident that was showing signs of pallor or change in condition they will call out for the nurses' help. All stated that they will immediately commence the Heimlich maneuver, would perform the Heimlich maneuver by placing their hands on the resident's abdomen and performing a forceful upward thrust. All stated, as a collaborative effort if a resident needed to be observed while eating, the CNAs were primarily the people to do the observation, and if they must leave for any reason the nurses will take over. All stated, those residents that need assistance eating were now located in the dining room area. All stated, the snack carts were located behind the nurse's station now, and coffee station was now behind the nurses' stations as well. All stated, those residents that were NPO were now updated according in the POC as well as inputted in the NPO book that was located at the nurse's station. All stated, they were in-serviced about NPO definition, abuse and neglect, Heimlich maneuver. All stated, the facility has instructed to be more observant of the NPO residents that were mobile. All stated, abuse and neglect, encompass verbal, mental, physical, isolation, and emotional abuse. All stated, if they suspect abuse, they will report suspicion to the charge nurse and administrator. All stated they were in-services from [DATE]-[DATE]. During an interview on [DATE] at 3:02PM, LVN B stated she was (8YEARS) full time: LVN B stated she worked the second shift (,d+[DATE]PM) on [DATE]. LVN B stated Resident #2 was impulsive and would consistently ask to eat actual food and would also exhibit frustration when told he was not allowed to eat via oral cavity due to swallowing issues. LVN B stated Resident #2's mental compacity could have limited him in understanding why he could not eat through oral cavity. LVN B stated she has been educated that if she were to see a resident actively choking, she would immediately perform the Heimlich maneuver, and stated she would immediately assess the resident if the resident was exhibiting signs of distress, change in condition, or change in skin coloration. LVN B stated as a nurse, she will always prioritize the safety and well-being of a resident before maintaining their privacy because she believes, in her professional opinion, that keeping her residents' lives and thriving was the most important reason, the well-being of her residents come before maintaining their privacy because resident's lives were more important. LVN stated she was educated that a nurse needs to always stay in the dining room while residents were in the dining room, also on abuse, neglect, NPO definition (make sure no foods available to them for their safety), and Heimlich maneuver. LVN stated the facility has instructed the clinical staff to be more vigilant, LVN B caught Resident #1 walking and was very mobile and stressed that Resident #1 was impulsive. LVN stated Resident #2 was very determined. LVN stated there are all types of abuse including physical, sexual, verbal, monetary. LVN stated she was looking out for signs of symptoms of abuse by being observant of bruises, behavioral abnormalities, and family hostile dynamics, [DATE] and [DATE]. During an interview on [DATE] at 3:36PM, LVN C stated she worked here for8years; (,d+[DATE]PM) LVN C stated that Resident #2 would state he was hungry all the time. LVN C stated Resident #2 was active and would administer bolus feeds 5 times a day. LVN C stated she worked on [DATE] the evening shift (,d+[DATE]PM). LVN C stated the facility implemented a new process of the medication aides will be observing residents eat/assisting residents to eat within the dining room area solely. LVN C stated that the event with Resident #2 on [DATE] potentially was avoidable, and continued by stating the nursing staff should have reacted immediately to render aide to Resident #2, not remove Resident #2 from the table area, in front of the nurse's station, to his room. LVN C stated the time it took for Resident #2 to be transported to his room, the clinical staff could have assessed the resident and immediately started to perform the Heimlich maneuver. LVN C stated in NPO residents should be given multiple diverting activities during mealtimes as a preventative measure to keep them from being around others that were eating actual food. LVN C stated she would in her professional opinion, as a nurse, if she were to encounter a choking resident, she would immediately assess the residents, perform vital signs and begin an investigation immediately to advocate for the residents' health and well-being. LVN C stated that residents' lives were more important than maintaining a resident's privacy. LVN C stated she was educated/in-serviced about NPO definition, NPO book, abuse, neglect, Heimlich maneuver. LVN C stated all residents that need feeding assistance will be assisted in the dining room, and all snack carts will be positioned in the nursing station. During an interview on [DATE] at 4:06PM, LVN D (11PM-7PM) LVN D stated he was educated on the importance of reporting abuse and neglect, reporting any allegation of abuse, completing incident reports, specialized diets, NPO status, and Heimlich maneuver. LVN D stated if resident was actively exhibiting signs of distress including choking, he would act upon the concern immediately. LVN D stated a resident's life was more important than maintaining privacy during an emergent situation. LVN D stated if he were to be notified of a resident's change of condition, he would immediately assess the resident, attain vital signs, and if it determined they are choking, he would immediately perform the Heimlich maneuver. LVN D stated the tables that were initially in the front of the nurses' station were used for residents to eat at when the dining room was overly loud and stimulating. LVN D stated the facility has now instructed the clinical staff that residents that need to be assisted to eat, will now be solely done in the dining room. LVN D stated the facility has implemented 1 nurse will be in the dining room during mealtimes and will stay till the last resident finishes. LVN D stated he was in-serviced on the multiple topics yesterday, [DATE]. During an interview on [DATE] at 4:21PM, (10PM-7A night shift) CNA M stated she was educated/in-serviced about if there was an incident, she must notify the nurse staff immediately. CNA M stated she has been instructed to assist residents that need assistance with eating, to be assisted to eat solely in the dining room. CNA M stated she was in-serviced on how to perform the Heimlich maneuver, and what to do in an emergent situation. CNA M stated she would perform the Heimlich maneuver immediate [TRUNCATED]

Based on interviews and record review the facility failed to ensure residents receive adequate supervision to prevent accidents for 1 of 3 residents reviewed for NPO status. The facility failed to ensure Resident #1 was adequately supervised while eating lunch. On [DATE], during lunch service about 12:00 p.m., CNA D did not ensure adequate supervision of Resident #1 while eating. Resident #2 obtained access to Resident #1's food, choked and died . Resident #2 had a g-tube and was on NPO status. An IJ was identified on [DATE]. The IJ templates were provided to the facility on [DATE] at 5:30 PM. While the IJ was removed on [DATE] at 7:18PM. The facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. This failure could place residents at risk of choking or death. Findings included: Record review on [DATE] of self-reported incident report dated [DATE] revealed Resident #2 was up and wheeling around as normal. He saw another patient eating some pie at the table near the nursing station and grabbed it from him and put it in his mouth. CNA went to get it (the pie) and he started to have difficulty breathing. Director of Nursing took him to the room and suctioned, performed the Heimlich maneuver, and provided Oxygen. Family did not want him sent out but rather stay here since he was a DNR. Record review of Resident #2 face sheet revealed he was a [AGE] year-old male, admitted on [DATE], Resident #2 had a medical dx of OTHER SEQUELAE FOLLOWING NONTRAUMATIC SUBARACHNOID HEMORRHAGE (bleeding in the space between the brain and the tissue covering the brain), DYSPHAGIA (difficulty swallowing), COGNITIVE COMMUNICATION DEFICIT (difficulty thinking and how someone uses language), BIPOLAR DISORDER (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), SCHIZOPHRENIA (serious mental illness that affects how a person thinks, feels, and behaves), AND DEMENTIA (a group of thinking and social symptoms that interferes with daily functioning). Record review of Resident #2's admission MDS assessment dated [DATE], revealed Resident #2 had a BIMS score of 09 which indicated Resident #2 was moderately cognitively impaired and needed help at times with indoor mobility. MDS indicates Resident #2 coughs and chokes during meals or when swallowing medication and has a feeding tube, Record review of Resident #2's care plan dated [DATE], stated Resident requires tube feeding with an initiated date of [DATE]. Interventions for this tube feeding included anticipating Resident #2's needs, assisting Resident #2 to develop appropriate methods of coping and interacting. Encourage Resident #2 to express feelings appropriately. Record review of Resident #2's physician orders revealed an order for an NPO diet with an initiated date of [DATE]. Record review of Resident #1's face sheet dated [DATE], revealed he was a [AGE] year old, admitted on [DATE] for Coronary Hear Disease, Hypertension, Dementia, Glaucoma, and Depression. Record review of Resident #1's admission MDS assessment dated [DATE], revealed Resident #1 had a BIMS score of 03 which indicated Resident #1 was severely cognitively impaired. Resident #1 was able to use suitable utensils to bring food and liquid to the mouth and swallow food/liquid once without assistance once the meal is placed before the resident. During an interview on [DATE] at 11:45a.m., the Administrator and the Director of Nursing stated, Resident #2 was seen at a table with another resident. Resident #2 was on NPO status. Resident #2 was seen with a pie plate with pie from the other resident at the table. CNA A removed the pie plate and informed the nurse at the nurse's station. LVN B (nurse at nurses' station) instructed CNA A to mov. Resident #2 from the table. CNA A was moving Resident #2 when she noticed he had changed in his demeanor and informed LVN B. LVN B then instructed CNA A to take Resident #2 to his room for an assessment. The Director of Nursing states I was called to Resident #2's room to assist LVN B with Resident #2. Resident #2 was unresponsive but still breathing when we transferred him to his bed. I did the Heimlich maneuver while sitting on the bed behind him. We did suction him with no residual. The Hospice nurse walked in while Resident #2 was being suctioned. Resident #2 did eventually expire, and the Hospice nurse called the time and date of [DATE] at 12:38p.m. During an interview on [DATE] at 11:45 a.m., with CNA D she stated she placed Resident #1 at a table in front of the nurse's station for monitoring of his food intake. CNA D stated she did not see anyone at the nurse's station at the moment she placed the tray of food in front of Resident #1 and left to pass the other trays for her hall. During a phone interview on [DATE] at 1:18 p.m., with CNA A she stated she saw Resident #1 and Resident #2 sitting at a table together. CAN A stated Resident #2 was seen with a pie plate from Resident #1. CNA A stated He did have crumbs on his clothes CNA A stated the plate was removed from Resident #2 due to his NPO status. CNA A stated she informed LVN B of Resident #2 having wheeled himself to a table and getting a pie plate with pie. Resident #2 got the pie by being at the table while Resident #1 has his lunch tray and LVN B instructed CNA A to move Resident #2 away from the table. Immediately after informing LVN B of Resident #2 having the pie, CNA A stated she was moving Resident #1 and noticed he was pale in color and was not responding to her. CNA A stated after informing LVN B, LVN B instructed CNA A to take the Resident #2 to his room. During an Interview on [DATE] at 12:53 p.m., LVN B stated she instructed CNA A to escort Resident #2 to his room for an assessment. LVN B stated she called out for RN to assist in Resident #2's room. During an interview on [DATE] at 12:30 p.m., RN C stated she entered the room of Resident #2 and when he stopped breathing, she initiated the Heimlich maneuver and eventually suctioned Resident #2. LVN E stated she did see the suctioning process produce some residual particles of something. RN C stated Resident #2 was on Hospice and the family did not want emergency services called. During a phone interview on [DATE] at 5:34pm, the Hospice Nurse said, Resident #2 was lying in his bed with the head of the bed elevated upright to what appeared to be the highest position, there were four to five nurses surrounding patients' bed, patient is noted with the pulse ox monitor to his right hand and electronic blood pressure monitor to right arm. At this time the nurse (unknown which nurse) tells me the patient who has a dx of dysphagia grabbed a pie from another patient and ate it. Resident #2's skin is cyanotic, and eyes are partially open, patient had an oxygen mask on and one of the floor nurses was attempting to perform deep oral suction. I then grabbed my phone to attempt to call patients sister from my work phone but was unable to find her number at this time one of the nurses states she was going to call the patient's family member and inform her of the situation, I then called Nurses on wheels office to get the caregivers number but at this time the nurse reentered the room and stated that the patients sister did not want to revoke the Do Not Resuscitate order and refused to have patient sent to the hospital. I did see some particles in the suction machine canister. At 12:37pm - 12:38pm I attempted to obtain a manual BP reading. I was unable to auscultate a BP reading or an apical pulse. Pupils assessed and were fixed and dilated. I then waited 1 full minute to obtain a second set of vitals, upon second attempt no BP, no pulse and no respirations. I then pronounced Resident #2 at 12:38pm. During an interview on [DATE] at 12:15 p.m., CNA C stated when she arrived yesterday ([DATE]), she was told of the choking event that led to Resident #2 expiring at the facility and stated that Resident #2 consistently would ask to eat food, however CNA C stated she would redirect Resident #2 to participate in activities during mealtimes. During an interview on [DATE] at 12:31 p.m., RN C stated the facility has provided education on abuse and neglect, Heimlich maneuver, time management, and during emergent situations do not waste time and must immediately call 911. During an interview on [DATE] at 12:56 p.m., CNA E stated she had worked with Resident #2 prior and saw a tube feeding pump and would monitor him and stated Resident #2 would ask for food consistently in a form of hand gesture and this resident could self-propel his wheelchair. Record review of facility policy titled, Removing Foreign Body Airway Obstruction-Heimlich Maneuver and dated [DATE] included verbiage that stated, If severe airway obstruction develops, quick intervention is necessary to relieve the obstruction. Anoxia resulting from such obstruction may cause brain damage and death. There was no policy provided regarding residents on NPO status. Record review of facility dining, and meal service policy titled, Meal Service and Resident Dining Services dated [DATE] and [DATE] does not indicate monitoring or supervision of residents during mealtimes. This was determined to be an Immediate Jeopardy (IJ) on [DATE]. The Administrator and the Director of Nursing were notified. The IJ template was provided to the facility on [DATE] at 5:30 PM. The following Plan of Removal submitted by the facility was accepted on [DATE] at 6:27 p.m. The following plan of action outlines immediate interventions employed by the facility to remove any further concerns surrounding the alleged issue of professional standards of practice. Identification of other residents having the potential to be affected: o DON updates NPO book in morning meeting which is shared with all staff. o This will be reviewed Monday - Friday and updates as needed. o Residents who are identified to be at risk for potential hazards related to NPO status will be monitored for potential risk of harm. Measures/Systemic Changes to ensure the deficient practice does not recur: Daily rounding during mealtimes by administrative staff to ensure adequate dining room supervision. Supervision will be done by nursing staff with direct over-sight while feeding assistants assist with feeding patients that will need it. In-services and education for all staff will be completed by [DATE] by Admin Nursing Staff to include, DON, , Infection Prevention, , , Regional Director of Clinical Services, , RN. In-service topics will include the following: Specialized Diets/NPO Binder Abuse and Neglect DON/ADON re-in serviced nursing staff of supervisory schedule of one dining room for all three meals on [DATE]. Meal assignments Ongoing Monitoring: Department heads making dining room rounds ensuring supervision in dining area. All components of this plan of correction will be submitted to the facility QAPI committee meeting for three months and additional recommendations will be made until substantial compliance has been achieved. The Medical Director was notified and agrees with the plan of correction. The Admin Nursing Staff to include, Don, Infection Prevention Coordinator, Regional Director of Clinical Services, Executive Director, , LNFA, are responsible for the corrections and continue monitoring. Completion date: [DATE] Verification of the facility's Plan of Removal Included: Record review, the facility conducted 100% review of all residents identified with gastric tubes and NPO status, as well as reviewed all residents with modified/restrictive diets. Record review of Resident #1's physician dietary orders, audited on [DATE], revealed order dated [DATE] for Resident #1 to receive regular diet, easy to chew texture, thin consistency. There were no concerns noted. Record review of Resident #3's physician dietary orders, audited on [DATE], revealed order dated [DATE], enteral feeding documented Resident #3 to receive Glucerna 1.2, 55 ml/ hour for 22 hours. 100mL water flush Q4hr - There were no concerns noted. Record review of Resident #4's physician dietary orders, audited on [DATE], order dated [DATE], regarding enteral feeding documented Resident #4 to receive Fibersource at 70 ml/hour x 20 hours via pump, with 150mls water flush Q4 hours. There were no concerns noted. Record review of Resident #5's physician's dietary modification orders was audited on [DATE], order dated [DATE], documented Resident #5 to receive sodium restricted diet, regular texture, thin consistency. There were no concerns noted. During an observation and interview on [DATE] at 4:47PM observed Resident #3's tube feeding. Resident #3 had Glucerna 1.2 infusing at 55mL/HR, with a scheduled 100ml water flush Q4hr. Resident #3 stated she did not have any concerns regarding her tube feedings. Resident #3 stated she knew why she was receiving tube feedings, and that the clinical staff attend to her needs when she requests assistance. During an observation on [DATE] at 5:13PM Resident #1 was in the dining room eating his easy to chew meal which consisted of chicken, mashed potatoes, carrots, a slice of bread and tea. Resident #1 was able to ingest his food with no issues observed. No observable concern. During an observation on [DATE] at 5:23PM, Resident #4 was receiving tube feeding. Resident #4 had Fiber source infusing at 70 ml/hour via pump with 150mL water flush Q4hr. Resident #4 did not exhibit any signs of distress. No concerns observed. During an interview on [DATE] at 12:15PM, CNA C CNA C stated if she were to encounter a person with a change in color, she has been educated to call immediately for assistance, and will stay with patient until nurse arrives. CNA C stated if she were to experience a resident choking, she will initiate a Heimlich maneuver, and position her hands within the abdomen area and thrust upward. CNA C stated she has been also taught another way to alarm the nursing staff was to call for help loudly, to signify that a person was in distress and needs emergency assistance, that could potentially lead to death. CNA C stated the CNAs were usually supervising residents eating and observe how they eat and how much they eat and will report to the nurses any irregularities with eating/ eating behaviors. CNA C stated she has been instructed to set up a tray properly, which would involve cutting the proteins in bite size measurements, and will continue to observe residents eating, however if she must vacate area, she will return immediately to ensure the resident's safety, and will make sure the resident eats a good percentage of their meal. CNA C stated when she arrived yesterday ([DATE]), she was told of the choking event that led to Resident #2 expiring and stated that Resident #2 consistently would ask to eat food, however CNA C stated she would redirect Resident #2 to participate in activities during mealtimes. CNA C stated she has been educated on types of abuse which would encompass forcefully inflicting pain, and would report to the charge nurse, DON, and Administrator. CNA C stated she was last in-serviced about Code Blue, Heimlich Maneuvers, Abuse and Neglect, and Falls on [DATE]. During an interview on [DATE] at 12:31PM, RN Charge Nurse; RN C stated the facility has provided education on abuse and neglect, and Heimlich maneuver, time management, and during emergent situations do not waste time and must immediately call 911. RN C stated for a full code blue, she has been educated on the proper procedures on how to conduct CPR and to always notify the chain of command. RN C stated Resident #2 was her patient on [DATE] and she was on break when choking/expiration happened. RN C stated she was very sad about event. RN C stated Resident #2 was NPO due to dysphagia and had difficulty swallowing. RN C stated that Resident #2 was mobile via wheelchair and was able to wheel himself throughout the facility. RN C stated Resident #2 never requested food, and when she would ask if he was hungry, once the tube feeding was complete, he would state he was full. RN C stated Resident #2 was not impulse and enjoyed counting monopoly money. RN C said while she was on break, LVN A and the floor CNAs were the ones who were watching her residents. RN C stated Resident #2's behavior never made her believe that he would take something that was not his. RN C stated she administered Resident #2's gastric tube feed at 10AM on [DATE]. RN C stated once she returned Resident #2 had passed away. RN C stated family had already been notified. RN C stated she has been educated to initiate Heimlich maneuver immediately and call out for help, the helpers would be the ones contacting chain of command as well as calling for Emergency assistance, while she continues to attempt to dislodge any particles or foreign substances out of the resident's oral cavity. RN C stated that she will begin the Heimlich maneuver to ensure resident's safety followed by then assessing the oral cavity, all as preventative measure to maintain the resident's safety and wellbeing. RN C stated in her professional opinion, the treatment nurse was wrong, and should have acted immediately because time was very important. RN C stated privacy can be maintained later, life is what is important. During an interview on [DATE] at 12:56PM, CNA D, CNA E, both stated they were in-serviced about abuse, neglect, when to report abuse and neglect, NPO definition, change in condition, and to report any immediate changes. Both stated they performed the Heimlich maneuver. Both stated to perform the Heimlich maneuver will situate hands under rib cage, and in an upward motion will thrust. Both stated they were comfortable with performing the Heimlich maneuver on heavier set people. CNA D stated she observed to her left Resident #1, crumbs on chest, thighs, and plate right in front of him. CNA D stated she knew that Resident #1 was NPO and there was nothing on the plate. CNA D notified the Treatment nurse, who instructed CNA D to take the plate away from him, and foot was caught in wheelchair and saw resident leaning to right side, and picked up his hat and his eyes were drifted to the right. The treatment nurse instructed CNA D to take to his room, and CNA D asked LVN A and Resident #1 was breathing lightly slow breathes, and while in front of an office and LVN A looked at him, then instructed to take Resident #1 into his room which was position 3 room down in 106A. CNA D stated the treatment nurse, LVN A, MDS Coordinator, and DON entered Resident #2's room. CNA D stated it could not be more than 2 minutes between the time she returned Resident #2 from the table to his room. CNA E stated that fall risk patients were positioned near the nurse's station to ensure there were people watching. CNA E stated she had worked with Resident #2 prior and saw a tube feeding pump and would monitor him and would ask for food consistently in a form of hand gesture. CNA E stated she was in his room on the day in question, and hospice nurse had just bathed Resident #2, and Resident #2 had wheeled himself out of his bedroom. Both stated they have been educated to stay with the patient and yell out for help from all clinical staff and have also been instructed to perform the Heimlich maneuver immediately. Both stated types of abuse they have been educated on were emotional, physical, and mental, if they notice a new bruise, abrasions, skin tears, and color will notify charge nurse and administrator if they suspect abuse. Both stated they attended in-services [DATE]- [DATE]. During an interview on [DATE] at 1:28PM, CNA F, CNA G, CNA H, CNA I; all have stated they have been educated on Abuse and Neglect and NPO precautions, Heimlich maneuver. All stated NPO precautions were implemented for those residents that have gastric tubes that do not allow them to eat through their oral cavities. All stated they will advocate for a nurse to intervene by calling out for help and would initiate the Heimlich maneuver immediately if a resident was witnessed choking and knows that it may be due to eating/choking issue. All stated to position hands above the gastric tubes and as close to the rib cage/abdomen area and will conduct an upward thrust and will stay with the resident until the nurse arrives and will await their instructions. Resident #1was CNA I's resident and was able to eat by himself and was in the front so that there were more eyes to watch him. All stated Resident #2had dementia but was able to eat on his own and does not allow people to eat from his tray. All stated facility has implemented that all residents that need assistance to eat will be assisted in the dining room area, snack cart was now put behind nurses' station, as well as coffee station was now served only in dining area. CNA E stated she had seen Resident #2use a hand to mouth gesture that indicated he was hungry and wanted to eat. All stated, types of abuse they have been educated on were physiological, physical, sexual, verbal, abandonment, and misappropriation of property. All stated, signs and symptoms of abuse could be sad, crying, grimacing of pain, skin coloration, bruises, behavioral abnormalities, or resident verbalizes allegation. All stated if they do suspect abuse, they will report immediately to the charge nurse and administrator. During an interview on [DATE] at 1:55PM, LVN A stated on [DATE] around lunch time, she was at the nurse's station, on the phone getting a surgery date for another resident, when she was alerted by CNA D that help was needed. LVN A stated she then got her pulse oximeter and saw Resident #2 in distress in his room. LVN A stated she also saw the DON, MDS Coordinator, and CNA D. LVN A saw the DON performing the Heimlich maneuver. LVN A stated the treatment nurse was at the nurse's station conducting some form of documentation on the computer. LVN A stated she did not see anything going on, and once CNA D alerted her, she then reacted and went to Resident #2's room. LVN A stated she was focused on her trying to get her own resident a follow up appointment for surgery, she did not hear CNA D speak with the treatment nurse. LVN A stated it was no more than a minute from when LVN A was alerted to the time she entered Resident #2's room. LVN A stated, while the Director of Nursing was performing the Heimlich maneuver, saw some particles come out of Resident #2's mouth, but nothing else was coming up. LVN A stated the MDS Coordinator went to get a suction. LVN A stated she felt Resident #2's pulse and was gasping for air, and multiple times tried to get a blood pressure on Resident #2 but was not reading, and the pulse oximeter oxygen reading was in the 70's and administered oxygen through a simple mask, not a non-rebreather mas. LVN A stated the MDS Coordinator then returned and suctioned some particles with yanker and deeper suctioned, but nothing was working. LVN A stated they actively tried to suction and could hear Resident #2's heartbeat and was told by an unknown staff member that Resident #2's family member did not want to send Resident #2 into the hospital. LVN A stated she was positioned on the right side of Resident #2 and the hospice nurse was in the room standing to the further part of the room. LVN A stated she asked/told the hospice nurse to check pulse, and throughout the incident Resident #2's face would turn blue then return to normal skin color. LVN A stated Resident #2 was not exhibiting signs of choking. LVN A stated for sure the Heimlich maneuver should have been conducted as well as an assessment on scene, as opposed to having the resident taken to their room because maintaining the life of a patient was more important than maintaining their privacy for emergent situations. LVN A stated Resident #2 was sitting at the edge of bed and the DON performed Heimlich maneuver for approximately ,d+[DATE]minutes, nothing substantial came out, followed by the staff member placing him back in bed with the head of the bed raised, eyes were not open, and body would sporadically jerk and when performing sternal rub Resident #2's body would jerk but then stop. LVN A stated Resident #2's breathing was light/labored breathing, then stop and then would twitch/jerk sporadically. LVN A stated she has been educated to perform an assessment immediately once it was known there was cause of an emergent situation as well as to begin a Heimlich maneuver immediately when a resident was choking. During an interview on [DATE] at 2:36PM, Laundry Attendant A, Laundry Attendant B; Both stated that if they witness a resident actively choking and were standing up, they will immediately perform the Heimlich maneuver, or if they were in a wheelchair, they will call out for help from the clinical. Both stated they were in-serviced about abuse, neglect, reporting of abuse/neglect reporting, where the NPO book was located and the definition of NPO which means nothing by mouth. Both stated they were also in-serviced about the Heimlich maneuver and how to perform the Heimlich maneuver by placing both hands under the rib cage and thrusting in an upwards motion. During an interview on [DATE] at 2:45P, CNA J, CNA K, CNA L, CNA M, all stated if they were to encounter a resident that was showing signs of pallor or change in condition they will call out for the nurses' help. All stated that they will immediately commence the Heimlich maneuver, would perform the Heimlich maneuver by placing their hands on the resident's abdomen and performing a forceful upward thrust. All stated, as a collaborative effort if a resident needed to be observed while eating, the CNAs were primarily the people to do the observation, and if they must leave for any reason the nurses will take over. All stated, those residents that need assistance eating were now located in the dining room area. All stated, the snack carts were located behind the nurse's station now, and coffee station was now behind the nurses' stations as well. All stated, those residents that were NPO were now updated according in the POC as well as inputted in the NPO book that was located at the nurse's station. All stated, they were in-serviced about NPO definition, abuse and neglect, Heimlich maneuver. All stated, the facility has instructed to be more observant of the NPO residents that were mobile. All stated, abuse and neglect, encompass verbal, mental, physical, isolation, and emotional abuse. All stated, if they suspect abuse, they will report suspicion to the charge nurse and administrator. All stated they were in-services from [DATE]-[DATE]. During an interview on [DATE] at 3:02PM, LVN B stated she was (8YEARS)full time: LVN B stated she worked the second shift (,d+[DATE]PM) on [DATE]. LVN B stated Resident #2 was impulsive and would consistently ask to eat actual food and would also exhibit frustration when told he was not allowed to eat via oral cavity due to swallowing issues. LVN B stated Resident #2's mental compacity could have limited him in understanding why he could not eat through oral cavity. LVN B stated she has been educated that if she were to see a resident actively choking, she would immediately perform the Heimlich maneuver, and stated she would immediately assess the resident if the resident was exhibiting signs of distress, change in condition, or change in skin coloration. LVN B stated as a nurse, she will always prioritize the safety and well-being of a resident before maintaining their privacy because she believes, in her professional opinion, that keeping her residents' lives and thriving was the most important reason, the well-being of her residents come before maintaining their privacy because resident's lives were more important. LVN stated she was educated that a nurse needs to always stay in the dining room while residents were in the dining room, also on abuse, neglect, NPO definition (make sure no foods available to them for their safety), and Heimlich maneuver. LVN stated the facility has instructed the clinical staff to be more vigilant, LVN B caught Resident #1 walking and was very mobile and stressed that Resident #1 was impulsive. LVN stated Resident #2 was very determined. LVN stated there are all types of abuse including physical, sexual, verbal, monetary. LVN stated she was looking out for signs of symptoms of abuse by being observant of bruises, behavioral abnormalities, and family hostile dynamics, [DATE] and [DATE]. During an interview on [DATE] at 3:36PM, LVN C stated she worked here for8years; (,d+[DATE]PM) LVN C stated that Resident #2 would state he was hungry all the time. LVN C stated Resident #2 was active and would administer bolus feeds 5 times a day. LVN C stated she worked on [DATE] the evening shift (,d+[DATE]PM). LVN C stated the facility implemented a new process of the medication aides will be observing residents eat/assisting residents to eat within the dining room area solely. LVN C stated that the event with Resident #2 on [DATE] potentially was avoidable, and continued by stating the nursing staff should have reacted immediately to render aide to Resident #2, not remove Resident #2 from the table area, in front of the nurse's station, to his room. LVN C stated the time it took for Resident #2 to be transported to his room, the clinical staff could have assessed the resident and immediately started to perform the Heimlich maneuver. LVN C stated in NPO residents should be given multiple diverting activities during mealtimes as a preventative measure to keep them from being around others that were eating actual food. LVN C stated she would in her professional opinion, as a nurse, if she were to encounter a choking resident, she would immediately assess the residents, perform vital signs and begin an investigation immediately to advocate for the residents' health and well-being. LVN C stated that residents' lives were more important than maintaining a resident's privacy. LVN C stated she was educated/in-serviced about NPO definition, NPO book, abuse, neglect, Heimlich maneuver. LVN C stated all residents that need feeding assistance will be assisted in the dining room, and all snack carts will be positioned in the nursing station. During an interview on [DATE] at 4:06PM, LVN D (11PM-7PM) LVN D stated he was educated on the importance of reporting abuse and neglect, reporting any allegation of abuse, completing incident reports, specialized diets, NPO status, and Heimlich maneuver. LVN D stated if resident was actively exhibiting signs of distress including choking, he would act upon the concern immediately. LVN D stated a resident's life was more important than maintaining privacy during an emergent situation. LVN D stated if he were to be notified of a resident's change of condition, he would immediately assess the resident, attain vital signs, and if it determined they are choking, he would immediately perform the Heimlich maneuver. LVN D stated the tables that were initially in the front of the nurses' station were used for residents to eat at when the dining room was overly loud and stimulating. LVN D stated the facility has now instructed the clinical staff that residents that need to be assisted to eat, will now be solely done in the dining room. LVN D stated the facility has implemented 1 nurse will be in the dining room during mealtimes and will stay till the last resident finishes. LVN D stated he was in-serviced on the multiple topics yesterday, [DATE]. During an interview on [DATE] at 4:21PM, (10PM-7A night shift) CNA M stated she was educated/in-serviced about if there was an incident, she must notify the nurse staff immediately. CNA M stated she has been instructed to assist residents that need assistance with eating, to be assisted to eat solely in the dining room. CNA M stated she was in-serviced on how to perform the Heimlich maneuver, and what to do in an emergent situation. CNA M stated she would perform the Heimlich maneuver immediat [TRUNCATED]

Based on Interview and Record Review, the facility failed to provide access to clinical records to the Guardian of one Resident, R#1, out of four Residents reviewed for Resident Rights, within 24 hours of the request; and the facility failed to provide photocopies of the clinical records of R#1 within two working days of the request for R#1's clinical records. The facility did not allow R#1's Guardian to look at all portions of R#1's chart when the Guardian requested to review the chart on [DATE]. When R#1's Guardian requested copies from R#1's chart on [DATE], the facility did not provide them until she received them on [DATE], 31 working days after the request. The Guardian had to make decisions about R#1's health status without having full access to his medical records. This failure adversely affected one Resident identified as not having access to clinical records. The findings were: Review of R#1's undated Face Sheet revealed he was admitted to the facility on [DATE] and readmitted after hospitalization on [DATE]. His [DIAGNOSES REDACTED]. R#1 was [AGE] years old. Review of Letters of Guardianship found in R#1's Facility 1 clinical chart dated [DATE] and in effect until [DATE] revealed Family Member (FM) A was appointed as guardian for R#1. The Letter of Guardianship said that FM A had full guardianship over the Person and Estate of R#1, and had the power to review, to take possession of and consent to the disclosure of R#1's medical, dental and psychological records and the power to consent or object to all medical and dental treatment and procedures for R#1, unless prohibited by law. Review of Quarterly Minimum Data Set (MDS), dated [DATE], revealed R#1 had a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. R#1 had unclear speech but usually understood others and could make himself understood. Review of R#1's Facility 1 Clinical Record revealed the following Progress Notes: [DATE] at 11:57 a.m. by DON Spoke with resident due to roommate's family had reported to staff member that he was angry and possibly depressed and wanted to die--upon speaking with other staff members, resident had stated he had pain and had already been medicated approx. ,[DATE] min prior--I spoke with resident and he stated frustrated--reviewed his disease process and explained that with his therapy and disease process his swallow may or may not get better--he stated I know--resident patted self on shoulder and leg, reviewed given pain medication and staff monitoring--no statements or signs resident wants to hurt self or others [DATE] at 1:06 p.m. by DON initiated 1:1 supervision due to received drawing that (R#1) had drew for roommate's son--drawing is a stick figure man with a scribble around neck that appears to be a rope and the word help at the top of the page--this drawing was done prior to my conversion (conversation) with him earlier, but I did not have drawing--resident denies plan to harm self, but 1:1 initiated d/t (due to) drawing. [DATE] at 1:11 p.m. by DON notified (FM A) of 1:1 supervision due to drawing from resident--discussed that resident will be under 1:1 until cleared by psychiatric services and (FM A) acknowledged understanding--explained that I had spoken with resident (R#1) prior to receiving drawing and that resident had not expressed intentions to harm himself, but with the drawing resident would need to be cleared by psych services--(FM A) acknowledged understanding. In an email received by surveyor on [DATE], FM A wrote that when she was notified that R#1 drew the stick figure, Facility 1 told her that they called for a psychiatric evaluation and if he could not be seen that day at the facility, R#1 would have to be sent out to the hospital. FM A said she called the Corporate Vice President because she was concerned that if R#1 was sent out to the hospital, Facility 1 would refuse to take him back. FM A said the Corporate Vice President told her that if R#1 got sent out to the hospital he would absolutely be able to come back. FM A said the psychiatrist office sent someone that day and they said R#1 was not a threat to himself but was frustrated with all of the commotion. FM A said she had previously heard nurses at the Nurses Station talking openly about R#1 in her earshot. FM A said that they were discussing R#1, her family member, with FM A standing in plain sight. Review of an email received by FM A from SW C on [DATE] revealed the following: I asked about sending a copy of the picture (R#1) drew and was informed it is a part of his chart and you would have to request it through medical records. You can call medical records and speak to (Medical Records (MR) D). In an interview on [DATE] at 4:50 p.m., FM A said on [DATE] (Monday) she asked the Director of Nurses (DON) if she could look at R#1's clinical record. FM A said she wanted to review the chart before R#1 left the faciity on [DATE]. FM A said she had previously asked to look at the clinical record and was told she had to look at the chart during business hours. FM A said she lived six hours away from the facility and sometimes was unable to be at the facility during the week during business hours. In the interview on [DATE] at 4:50 p.m., FM A said she met with the DON on [DATE] in the DON's office. FM A said the DON told her she could not look at R#1's chart and the DON said she would have to read information from the chart to FM A. FM A said it was hard to see what was being read from where she was sitting and she had to cock her head to one side to see a picture of a stick figure that she had been told R#1 had drawn as a representation of how he was feeling. FM A said R#1 was an accomplished artist and she was surprised that he would have drawn a stick figure. FM A said she had been told the stick figure was of a person hanging himself and the word HELP was written next to it. In the interview on [DATE] at 4:50 p.m., FM A said in the meeting with the DON on [DATE] the DON asked her specifically what she wanted to review in the chart, but FM A said she did not know what all the chart contained and wanted to look at all of it. FM A said the DON denied her request to look at the entire chart and told her she would have to complete a medical records request form that was available from the Medical Records office. FM A said she felt frustrated that she could not see the record for herself. FM A said she had a medical transcription business and had good understanding of medical terminology and did not require assistance to read any documentation in the chart. FM A said the DON paraphrased some physician documentation and the DON told her that Physician B documented that she had called State, Corporate and the Ombudsman. FM A said she could not see the record that the DON was reading from very well from where she was sitting. FM A said the DON told her Corporate would have to approve the release of any of R#1's records to her. FM A said she went to the Medical Records office and completed a Request for Medical Records form on [DATE]. FM A said she had previously asked for a copy of the stick figure that R#1 drew and was told by the Social Worker (SW) C that she needed to talk with medical records. FM A said she felt concerned that the facility was not being cooperative in sending what she requested and she was very worried about R#1's physical and emotional state. Review of Admission Record for Facility 2, dated [DATE], revealed R#1 was admitted to Facility 2 on [DATE]. Review of Physician Note written by Physician B regarding R#1 and dated [DATE], found in Facility #2's record on [DATE] at 4:00 p.m., revealed the following: (FM A) did not wish to proceed with hospice at that time. (FM A) had agreed to a DNR (Do Not Resuscitate) status. (FM A) stated that she understood that (R#1) might develop an aspiration pneumonia secondary to eating and drinking. (FM A) has since called state inspectors, the local ombudsman and the Corporate compliance office for (Facility 1) with allegations that hospice was forced upon her and that the facility has decided to allow (R#1) to die by refusing to supply him with speech therapy services. My recommendation for this patient is that he be transferred to a facility in the same city as (FM A). I will, unfortunately, no longer be able to provide medical services for (R#1) as his family has made it clear that they are unhappy with his care. I will transfer his care to another physician as soon as possible. In an interview in his room at Facility 2 on [DATE] at 3:45 p.m., when asked how he liked being at Facility 2, R#2 turned his hand from side to side. Surveyor could not understand R#1's verbal answers to questions due to garbled speech. Review of letter from Physician B to FM A dated [DATE], found in R#1's Facility 1 clinical record, revealed Please be advised that I will no longer be able to provide medical treatment for [REDACTED].The termination of our physician/patient relationship will be effective 30 days from receipt of this letter. His medical condition requires continued physician supervision, it is important that you select another physician as soon as possible. I will remain available for emergent medical treatment in the interim. Review of DON's Progress Note dated [DATE] revealed reviewed chart with (FM A) per her request and notified medical records that she stated that she did not receive the medical records request form--I explained to (FM A) that she could go to medical records and ask for form while she was here visiting, but that I would also notify med records that she had not received form in the mail. In an interview on [DATE] at 10:20 a.m., Medical Records (MR) D said the procedure to request medical records was to get residents or their responsible parties to sign a records release and then she would send the release to the corporate office for review. MR D said corporate office would review the record to determine whether they had everything that was requested. MR D said she would offer to fax or scan in and email the request form if the request came from someone who was out of town. MR D said she thought 30 days were allowed to provide the requested documentation if the resident was still in the facility, and the maximum time to provide records for discharged or expired residents was 30 days. MR D said the DON handled requests from residents and representatives to look at their clinical records. MR D said the DON had to protect the integrity of the chart and reviewed the clinical record with the requestor so she could answer any questions that came up. In an interview on [DATE] at 10:40 a.m., the DON said she went through their medical records with the resident and family members when they asked to look at their records. The DON said she could interpret labs for them and said that most people did not understand medical terminology and needed help to understand what was in their medical records. The DON said residents and family members had to be supervised because they may remove medical records. When asked if she allowed FM A to review R#1's chart, the DON said she reviewed R#1's chart with FM A the day R#1 left the facility. The DON said I flipped through and helped her find the picture in the chart. (R#1) had a noose around his neck. He was distraught .I showed her the picture. I helped her find the progress notes . I read it to her and she took it and looked at the note .I said Let me find it for you and Anything I can help her find. The DON said one of the physician progress notes [REDACTED]. In an interview on [DATE] at 3:00 p.m., MR D said she received a call from FM A once requesting medical records and MR D asked her assistant to fax the release form that was required to be signed by FM A to FM A. MR D said she did not know the date that FM A made this call to her and did not know when the release form was faxed to FM A. MR D said she would check with her assistant to see if she retained the fax confirmation. No fax confirmation was provided to surveyor prior to exit on [DATE]. In the interview on [DATE] at 3:00 p.m., MR D said FM A was the POA (Power of Attorney) for R#1. She said she did not know FM A was the guardian for R#1. MR D said she received a completed Request for Medical Records form from FM A on [DATE] and sent this request to Corporate. MR D said she did not know if these records had been provided yet. In an interview on [DATE] at 10:52 a.m., FM A said she was seeing a pattern of retaliation from the facility because she had called State and a previous surveyor had come out to investigate an earlier complaint. FM A said she was concerned that the stick figure drawing she asked to see on [DATE] was interpreted as her father being suicidal and would be a reason for getting him out of the facility. FM A said she wanted to review the Physician Notes because Physician B had issued a discharge notice to R#1. FM A said she was not allowed to look at any other documentation in the record and the DON said FM A was not allowed to read the chart and the DON would have to read the chart to FM A. In the interview on [DATE] at 10:52 a.m., FM A said she felt the DON was denying her right to access information about R#1. FM A said the DON put her hand up like a stop sign and would talk over her. FM A said she felt bullied by the DON. FM A said there had been a pattern of requesting information and records about R#1 that had been denied by the facility. These included concerns she had in March, 2016, when R#1 was losing weight and she asked for his weight records and was denied them; and in October, 2015, when R#1 fell and had a head injury. FM A said she asked to look at the incident report to find out what happened in the incident in October, 2015 and was told she could not see it. FM A said she did not report these earlier concerns to anyone in an effort to ensure there was no retaliation to R#1. In an interview on [DATE] at 11:11 a.m., FM A said she had just received the documents from Facility 1 that she had requested originally on [DATE], and again on [DATE]. Review of facility Confidentiality, Release of Information, and HIPAA policy dated September, 2013 revealed the following: If the requester has the legal authority to view the record, a meeting should be set up within 24 hours, excluding weekends and/or holidays, as required by law. If the requester cannot accommodate a meeting within the 24-hour time frame, the review should be set up at a mutually agreed upon time. Since the resident or personal representative has the right to review his or her records under federal law, it is not necessary to get approval from the attending physician. During the meeting, a staff member should be in attendance at all times. The staff member can be from the HIM department or a designee such as Nursing/Social Services personnel. The staff member present at the meeting is there to answer questions and to ensure that the record is not altered in any way or that documents are not removed/destroyed. The resident/personal representative should be allowed to review, read, and record without intervention from the staff member present. A licensed nurse should be consulted if the resident/representative has medical-related questions. Requested copies should be provided within two working days (excluding weekends and/or holidays) unless state law mandates a shorter period. In an interview at 4:45 p.m. on [DATE], the DON said that requests for medical records came in periodically and she did not have a way to identify the number of residents who had requested copies of their records, or had requested to review their clinical charts. Review of Facility 1 Grievance/Complaint Log on [DATE] revealed no additional concerns regarding Resident Rights being violated.

Based on Interview and Record Review, the facility failed to provide 30 days notice of transfer/discharge to the legal representative of one Resident, R#1, of four Residents reviewed for transfer/discharge, when the facility determined R#1's needs could no longer be met by the facility. R#1 was transferred from the facility that had been his home since 01/12/15 without receiving required information related to his discharge. The facility did not issue a notice of transfer/discharge that included the reason for transfer/discharge, the effective date of transfer/discharge, the location to which the resident was transferred/discharged , the right to appeal, and instructions on how to notify the ombudsman after verbally notifying the legal representative that R#1 was going to be discharged due to lack of a physician. This failure placed one Resident at risk of having their right to a fair hearing and their right to be notified of the reason for transfer/discharge from a facility revoked. The findings were: Review of R#1's undated Face Sheet revealed he was admitted to the Facility 1 on 01/12/15 and readmitted after hospitalization on [DATE]. His [DIAGNOSES REDACTED]. R#1 was [AGE] years old. Review of Letters of Guardianship found in R#1's Facility 1 closed record, dated 07/27/15 and in effect until 12/10/16, revealed Family Member (FM) A was appointed as guardian for R#1. The Letter of Guardianship said that FM A had full guardianship over the Person and Estate of R#1, and had the power to review, to take possession of and consent to the disclosure of R#1's medical, dental and psychological records and the power to consent or object to all medical and dental treatment and procedures for R#1, unless prohibited by law. Review of Quarterly Minimum Data Set (MDS), dated [DATE], revealed R#1 had a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. R#1 had unclear speech but usually understood others and could make himself understood. In an interview on 08/01/16 at 4:50 p.m., FM A said that she moved R#1 to Facility 2 on 07/26/16. FM A said that she was forced to move R#1 from Facility 1 where R#1 had resided since 01/12/15 because R#1 was retaliated against after a State Surveyor came into the facility and investigated complaints. FM A said she had not wanted to move R#1 to another facility because Facility 1 was his home. In an interview at 4:50 p.m. on 08/01/16, FM A said the retaliation began when she refused hospice services because R#1 wanted to have more speech therapy to practice swallowing. FM A said she tried repeatedly to talk to Physician B about the referral to hospice services but Physician B would not call her back, and she wanted more information about hospice because she was not familiar with hospice services, and thought it might be too early to place R#1 on this service. FM A said she did finally get to speak with Physician B about the decision not to refer R#1 to hospice. In the interview at 4:50 p.m. on 08/01/16, FM A said she asked for copies of R#1's medical records on several occasions and had not received them. FM A said she spoke to the Administrator at Facility 2 (FAC 2 ADMIN) to try to give them a better understanding of what had occurred with R#1 and Physician B. FM A said FAC 2 ADMIN gave her the opportunity to talk and she told FM A that the picture she painted of the facility was different than the picture Facility 1 painted. In the interview at 4:50 p.m. on 08/01/16, FM A said the Facility 1 Administrator told her that they did not have to issue 30 days notice of discharge because R#1 was a private pay resident. FM A said she received the 30 day notice from Physician B on 06/30/16 and had 30 days from that date to get R#1 out of the facility. FM A said she almost ran out of time in finding a place for R#1 to go but felt she had no choice and had to move R#1. In an email received by surveyor on 08/04/16, entitled, Retaliation Complaint, FM A said the following: I realized that (Facility 1) was trying to build a case with their documentation to support getting rid of (R#1) after I called (outside resources) to get someone to help me with (R#1). As I mentioned, I didn't want him to die and I was told he was going to be placed on hospice, I needed to sign the paperwork for that and the doctor was not returning any phone calls or requests to speak to me about the reason or the decision to put him on hospice. All I knew is that they had a conversation with (R#1) without me (as his legal guardian participating at all) and they decided hospice is where (R#1) needed to be. After a few weeks of trying to help (R#1) .I was getting more desperate every passing day that (R#1) might die (since I didn't know or understand the medical reasons for this decision that was made) that I gave up on anyone at the facility helping .and reached out to someone who would . I then began seeing retaliation issues happen .but was able to stay one step ahead of them trying to protect (R#1) from getting kicked out of (Facility 1) because I was trying to help him. In an email received by surveyor on 08/03/16, FM A said R#1 was having difficulty swallowing and had failed a swallow study with all consistencies and on all levels, and was aspirating (getting fluid in the lungs) before and after each swallow. FM A said that she was told R#1 had pneumonia. The nurse who called, Licensed Vocational Nurse (LVN) RR said that FM A may need to consider feeding tube placement due to R#1's difficulty swallowing food. FM A said she responded that it looked like the only alternative would be to place a feeding tube to protect his (R#1's) lungs, to protect his airway and allow the pneumonia to heal and then to do speech therapy to strengthen his swallow. But I wanted to talk to the doctor about it. FM A said that this call came from a Facility 1 nurse, LVN RR, around May 8, 9 or 10, 2016, sometime around R#1's failed swallow study. HOSPICE REFERRAL In the email received by surveyor on 08/03/16, FM A said that she was then told that there was a meeting between Physician B, MR D, and R#1 that she was not invited to. FM A did not give a date for this meeting. FM A said at this meeting, R#1 indicated he did not want a feeding tube and it was decided he needed to sign himself into hospice. FM A said she wanted to talk with Physician B about this suggestion but he would not return her calls. FM A said she did not get to talk with Physician B until he called on 05/23/16 at 7:30 p.m. During the time she was waiting for his call, FM A said she was very worried about R#1's condition and thought he might expire suddenly due to his swallowing difficulties. During this conversation, Physician B agreed to refer R#1 to Speech Therapist (ST) M, a speech therapist whose techniques in Vitalstim (muscle therapy for swallowing) had previously been effective with improving R#1's ability to swallow. Review of Nurse Progress Note dated 05/23/16 at 11:03 p.m. revealed, (Physician B) and (MR D) had detailed conversation with pt. Patient wants a Hospice eval and does not want to be placed on Gtube feeding. In the email received by surveyor on 08/03/16, FM A said on 5/19/16 she received a phone call from Hospice K and she felt it was even more urgent to try to discuss R#1's options with Physician B. Review of email received from FM A on 08/03/16, dated 05/26/16, revealed FM A responded and said she talked with R#1 and Physician B and she was not going to sign R#1 up for hospice yet. SPEECH THERAPY Review of Plan of Treatment with a start of care date of 05/11/16, to be provided through 05/24/16, revealed a plan to provide speech therapy five times a week for two weeks to R#1 with goals being to improve ability to swallow liquids and solids. Review of Plan of Treatment with a start of care date of 05/25/16, to be provided through 06/07/16, revealed a plan to provide speech therapy five times a week for two weeks, with goals to include improved swallowing of liquids and solids. Review of Telephone Physician order [REDACTED]. PT (patient) noncompliant with ST recs (recommendations). Licensed Vocational Nurse (LVN) I marked a box indicating she notified R#1's family on 05/28/16 of his discontinuation of speech therapy. In an interview on 08/01/16 at 4:50 p.m., Family Member (FM) A said she had been told by a previous State Surveyor that LVN I said she (LVN I) notified FM A of R#1's discontinuation of speech therapy after two sessions because R#1 would not participate in the therapy. FM A said that it was very important that she was notified of any changes in R#1's condition, especially discontinuation of speech therapy because she was thinking that R#1 was working at overcoming his dysphagia. FM A said she was not notified on 05/28/16 by LVN I that R#1's speech therapy was discontinued. Once she was informed that R#1 refused to participate in the speech therapy and was discharged from speech therapy without her knowledge, she grew very concerned that he might be aspirating because he wanted to drink liquids but may not have been able to do so safely. FM A said Physician B also referred R#1 for hospice services around this time and she had difficulty getting him to return her calls. FM A said she grew concerned about R#1's overall condition, because of poor communication with facility staff and Physician B, and thinking R#1 was showing rapid decline and running the risk of aspiration. In the email received on 08/03/16 by surveyor, FM A said she called Facility 1's Rehabilitation Director (RD) N on 05/25/16 to request speech therapy for R#1 to be provided by ST M, who had been successful in working with R#1 in the past. In an email received on 08/08/16 by surveyor, FM A said RD N was argumentative when she spoke with her on 05/25/16. FM A said she reminded Facility 1 Administrator that R#1 was aspirating and it was important to see if there was any help to prevent more damage from occurring to R#1's lungs. FM A said she told Facility 1 Administrator it was an urgent issue. FM A said she was not called by Facility 1 Administrator to give her any more information on this request, although she called the facility and asked to speak to Facility 1 Administrator about this at least once after she had not heard from Facility 1 Administrator. FM A said she then reached out for assistance through available channels outside the nursing home. Review of Plan of Treatment by ST M dated 06/15/16 revealed speech therapy was authorized five times a week for four weeks, 06/15/16 through 07/12/16. Review of Plan of Treatment by ST M dated 07/15/16 revealed the following discharge summary: MBSS (swallow study) completed 7-13-2016, the evaluation demonstrated that the patient (R#1) made improvements in swallowing safety and efficiency as compared to initial evaluation yet those improvements were not significant enough to allow for a diet and liquids recommendation of least restrictive at this time. The recommendations are NPO with consideration for PEG placement due to need for alternative means of nutrition and hydration. TERMINATION OF PHYSICIAN Review of Social Worker (SW) C Progress Note dated 06/06/16 revealed Ombudsman (OMB) O came to visit R#1 and stated (FM A) had called with some concerns. The Progress Note continued to document what was discussed with OMB O. Review of Facility #1 Progress Notes written by SW C, dated 06/23/16, revealed Spoke to (FM A) about the order (Physician B) wrote about finding another physician for resident. (FM A) asked why the doctor did this and SW (C) told her he didn't write an explanation. She asked if she could speak to him about this. SW gave her the exchange number so (Physician B) could call her back. She said she would call SW back with results from the conversation. In the interview on 08/01/16 at 4:50 p.m., FM A said that she talked with an employee of Physician B's office, Physician Employee (PE) F on 06/24/16 at 1:08 p.m., regarding Physician B's decision to terminate R#1 as his patient. FM A said PE F told her that Physician B did not feel like he was the right physician for R#1. FM A said PE F told her, it was my understanding based on what the facility told me, that you called the State of Texas on them .and so, I mean, obviously everybody's got their back up, and so it's just .one of those things. In the interview on 08/01/16 at 4:50 p.m., FM A said that she had a transcript of the phone call of 06/24/16 at 1:08 p.m. with PE F as the call was recorded. Review of Facility 1 closed record for R#1 on 08/03/16 revealed Physician B's Progress Note dated 06/22/16, which said FM A had called state inspectors, the local ombudsman and the Corporate compliance office with allegations that hospice was forced upon her . Review of Admission Record for Facility 2, dated 07/27/16, revealed R#1 was admitted to Facility 2 on 07/26/16. Review of Physician Note written by Physician B regarding R#1 and dated 06/22/16, found in Facility #2's record on 08/01/16 at 4:00 p.m., revealed the following: (FM A) did not wish to proceed with hospice at that time. (FM A) had agreed to a DNR status. (FM A) stated that she understood that (R#1) might develop an aspiration pneumonia secondary to eating and drinking. (FM A) has since called state inspectors, the local ombudsman and the Corporate compliance office for (Facility 1) with allegations that hospice was forced upon her and that the facility has decided to allow (R#1) to die by refusing to supply him with speech therapy services. My recommendation for this patient is that he be transferred to a facility in the same city as (FM A). I will, unfortunately, no longer be able to provide medical services for (R#1) as his family has made it clear that they are unhappy with his care. I will transfer his care to another physician as soon as possible. In an interview in his room at Facility 2 on 08/01/16 at 3:45 p.m., when asked how he liked being at Facility 2, R#2 turned his hand from side to side. Surveyor could not understand R#1's verbal answers to questions due to garbled speech. Review of letter from Physician B to FM A dated 06/28/16, found in R#1's Facility 1 clinical record, revealed Please be advised that I will no longer be able to provide medical treatment for [REDACTED].The termination of our physician/patient relationship will be effective 30 days from receipt of this letter. His medical condition requires continued physician supervision, it is important that you select another physician as soon as possible. I will remain available for emergent medical treatment in the interim. In an interview on 08/03/16 at 3:23 p.m., SW C said representatives from Facility 2, Facility 3, and Facility 4 came to review R#1's chart at Facility 1, and made copies of whatever they needed. SW C said the facility record contained the physician progress notes [REDACTED]. SW C said it was difficult to find a nursing facility to accept R#1. In an interview on 08/08/16 at 5:00 p.m., Facility 1's Director of Nurses (DON) said their procedure when transferring a resident to another facility was to allow a representative of the potentially gaining facility to come review the resident's records and see the patient for themselves. The DON said if the resident was seeking placement at a facility that was out of town, the records might be faxed to the facility. Review of Facility 1 Progress Notes dated 06/23/16 at 10:54 a.m. revealed SW C spoke to FM A about order Physician B wrote about finding another physician for resident. FM A asked to speak to Physician B about why he did this and was given phone number to his exchange. Review of Progress Notes dated 06/23/16 at 1:06 p.m. by the DON revealed: initiated 1:1 supervision due to received drawing that (R#1) had drew for roommate's son--drawing is a stick figure man with a scribble around neck that appears to be a rope and the word help at the top of the page--this drawing was done prior to my conversion (conversation) with him earlier, but I did not have drawing--resident denies plan to harm self, but 1:1 initiated d/t (due to) drawing. In an email on received by surveyor on 08/04/16, FM A wrote that when she was notified that R#1 drew the stick figure, Facility 1 told her that they called for a psychiatric evaluation and if he could not be seen that day at the facility, R#1 would have to be send out to the hospital. FM A said she called the Corporate Vice President because she was concerned that if R#1 was sent out to the hospital, Facility 1 would refuse to take him back. FM A said the Corporate Vice President told her that if R#1 got sent out to the hospital he would absolutely be able to come back. Review of Facility 1 SW C Progress Note dated 06/24/16 revealed FM A requested a list of physicians that could be the attending physician for R#1 at Facility 1. FM A also requested medical records for R#1 and was told to contact the Medical Records office. Review of Facility 1 SW C Progress Note dated 06/30/16 revealed SW C was attempting to help FM A find a physician for R#1. Review of Facility 1 SW C Progress Notes dated 06/30/16, 07/06/16 and 07/13/16 revealed discussion between FM A and SW C regarding attempts to find a physician. Review of Facility 1 SW C Progress Note dated 07/13/16 revealed Facility 1 would ask physicians on behalf of FM A whether they would accept R#1 as a patient. Review of Facility 1 SW C Progress Note dated 07/15/16 at 1:12 p.m. revealed Spoke to (FM A) again to ask if she is okay with staff here looking for placement at our sister facility at (Facility 5). (FM A) did say she was fine with us looking for him. She did say she wasn't happy with the decision to move him. SW did tell her she could look at other doctors as long as the doctor will take call after hours. Will call (Facility 5) to have them come out and evaluate resident. Review of Facility 1 SW C Progress Note dated 07/15/16 at 5:06 p.m. revealed Spoke to (FM A) again to inform her that our sister facility denied resident due to doctor conflict. Asked her if we could look at other facilities in the area .to see if someone would accept. She did agree to let us call other facilities. (FM A) is very upset over the fact that resident is unable to stay in this facility. She feels the doctor is not being fair to (R#1). SW did tell her that whatever the issue was we still need to move forward with finding a doctor and facility for him. Called (Facility 6) and (Facility 3) to come out and evaluate resident. Review of Facility 1 SW C Progress Note dated 07/18/16 revealed FM A called this date and talked with SW C about not receiving a 30 day notice from the facility. SW C advised FM A that the 30 day notice came from Physician B, not Facility 1. FM A said she had spoken with OMB O and was told the facility should have issued a 30 day notice as well, and she wanted to know about her right to appeal the termination of services. Facility 1 SW C Progress Note dated 07/18/16 further stated, SW explained that the appeal would be to keep him here but he doesn't have an accepting doctor, he would still need to find another facility with an accepting doctor. (FM A) understands that he needs a doctor but feels that this is retaliation from the doctor because of her calling the state and corporate. SW let her know that this is an issue between her and the doctor. Called (FM A) back to let her know (Facility 3) staff came out to evaluate resident. She is ok with this but is still wanting him to stay here. SW let her know even if another 30 day notice is given, which one will be, he will still need an accepting doctor. Let her know if another facility accepts she needs to seriously consider transferring. SW let her know that we will continue to call other facilities if (Facility 3) denies. (FM A) would rather resident stay in this facility and said she will continue to call doctors in the community. Review of Facility 1 SW C Progress Note dated 07/18/16 revealed OMB O requested a copy of Physician B's letter sent to FM A discharging R#1 as a patient in 30 days. SW C documented that OMB O told her the facility needed to send FM A a 30 day notice of discharge from the facility. SW C said she advised OMB O that it was not the facility who wanted to discharge R#1. SW C noted that OMB O told her that the 30 day discharge notice needed to be given. Review of Facility 1 SW C Progress Note dated 07/19/16 revealed SW C advised FM A that Facility 3 might be accepting R#1. FM A said she was not ready to move R#1 at this time as she had done research on Facility 1 and did not want to move R#1. FM A requested information about the appeal process and SW informed her that the facility here would not be sending the notice because resident is not on Medicaid and doesn't fall into the category to make an appeal. All current physicians at the facility were contacted but all declined patient. Patient is required to have a physician follow him in the facility. SW explained that the facility is assisting her with finding a facility and physician which is what we would do if a notice were to be given. Asked her to please speak to the staff at (Facility 3) and make a decision because of bed availability. Review of Facility 1 SW C Progress Note dated 07/22/16 revealed SW C spoke with Facility 2 and Facility 4 and both were willing to accept R#1. (The Administrator) of Facility 2 and FM A had a very in depth conversation about expectations and care for R#1. In an interview on 08/02/16 at 4:15 p.m., Facility 2 Admissions Director (AD G) said the referral to their facility was made by SW C. AD G said that the staff at Facility 2 knew R#1 had problems with a physician at Facility 1. AD G said FM A was given a choice of three physicians who saw patients at Facility 2 and Physician H agreed to take R#1 as a patient. In an interview on 08/02/16 at 5:30 p.m., OMB O said she followed up on a complaint regarding R#1 and advised the complainant to call State about her concerns. OMB O said she was given a copy of the letter from Physician B about discharging R#1 from his service, and the letter did not say why he was dropping R#1 as a patient. OMB O said she thought the facility should have issued a 30 day notice of termination of their services so that FM A could appeal the termination on behalf of R#1. OMB O said the discharge appeared in her opinion to be retaliation. Review of Facility 1 Grievance/Complaint Log on 08/03/16 revealed no additional concerns regarding Transfer/Discharge Rights being violated.

Based on observation, interview and record review, the facility failed to implement their policy and procedure that prohibits neglect for eight Residents (R #1, R #2, R #3, R #4, R #5, R #7, R #8 and R #9) of nine Residents reviewed for indwelling urinary catheter care. The facility failed to assess and provide care to R #1's indwelling urinary catheter. As a result, R #1 was sent to the hospital on [DATE] with penile erosion, blackened areas on his penis, drainage from his penis, swollen testicles and was missing part of his penile head. R #1 was diagnosed with [REDACTED]. The facility failed to anchor R #1, R #2, R #3, R #4, R #5, R #7, R #8 or R #9's indwelling urinary catheters, placing them at risk for urethral damage. These failures resulted in identification of an Immediate Jeopardy (IJ) on 09/05/14. While the IJ was removed on 09/05/14, the facility remained out of compliance for actual harm at a scope of pattern due to the facility was continuing to in-service staff and monitoring the Plan of Removal. These deficient practices placed eight residents with indwelling urinary catheters at risk of neglect due to not receiving proper assessments and care and services required to prevent delay in treatment, complications, hospitalization , or possible harm. Findings were: R #1 R #1's undated Face Sheet revealed a [AGE] year old male admitted to the facility on [DATE]. R #1's Admission Minimum Data Set ((MDS) dated [DATE] revealed R #1 had the [DIAGNOSES REDACTED]. R #1's Admission MDS dated [DATE] revealed R #1 had clear speech; made self understood and understood others; had intact cognition; did not have behavioral symptoms; required extensive assistance with bed mobility, dressing, eating, toilet use and personal hygiene; was totally dependent with bathing; and had an indwelling urinary catheter (a tube inserted into the bladder to enable urination.) R #1's Care Plans dated 08/05/14 revealed R #1 had an indwelling urinary catheter and interventions included "(indwelling urinary) catheter care protocol (policy)." The facility's undated "Daily Catheter Care" Policy included: "...In order to prevent infection, the daily catheter care procedure was developed...15. The catheter should be loosely taped to the resident's inner thigh to keep it from being pulled from the bladder or a catheter strap may be used with frail skin..." R #1's Physician order [REDACTED]. R #1's "Catheter Justification" Form dated 08/05/14 revealed R #1 had an indwelling urinary catheter due to non-healing pressure ulcers. R #1's Telephone Order dated 09/03/14 at 4:00 p.m. revealed an order to send R #1 to the hospital for evaluation and treatment. R #1's Emergency Provider Report from Hospital "AA" dated 09/03/14 revealed: "...Patient is a distressed, toxic looking 76 (year old) male...has a (indwelling urinary catheter) with severe catheter induced urethral (tube that drains urine from the bladder) erosion...appears septic (infection)..." According to www.ncbi.nlm.nih.gov on 09/18/14, entitled "Urethral erosion: a case for prevention, ... Existing research suggests that negative outcomes associated with urethral and meatal erosions can be prevented by properly securing the indwelling catheter..." R #1's History and Physical from Hospital "AA" dated 09/04/14 revealed: "...Assessment/Plan: Urosepsis-likely from UTI (urinary tract infection), with (indwelling urinary catheter) that was not properly cared for...penile meatus erosion and scrotal swelling..." According to www.sepsisalliance.org on 09/18/14, [MEDICAL CONDITION] and Urinary Tract Infections, "...An untreated (urinary tract infection) may spread to the kidney, causing more pain and illness. It can also [MEDICAL CONDITIONS] is the body's often deadly response to infection or injury. [MEDICAL CONDITION] kills and disables millions and requires early suspicion and rapid treatment for [REDACTED]. R #1's documented photographs from Hospital "AA" dated 09/03/14 of R #1's perineal area revealed: -White to yellow drainage from his penis, -The scrotum was swollen and red in color, -On the meatus of R #1's penis and on the underside of the urethra, an approximate one centimeter diameter area of skin was missing from the urethra, -The urethra was swollen and the approximate size of one centimeter, with an approximate 0.5 centimeter indentation at the bottom of the urethra where the indwelling urinary catheter rested against it, -Approximately four black colored areas with erosion approximately 0.125 centimeters in diameter on the tip of the penis, and along the right side of the urethra. Observation of R #1 in the Intensive Care Unit at Hospital "AA" on 09/04/14 at 3:15 p.m. revealed R #1 was unresponsive to investigator's questions. R #1 moaned when repositioned by hospital staff. On 09/04/15 at 3:10 p.m., Family Member (FM) "BB" stated R #1 had an indwelling urinary catheter inserted on or around 08/01/14 due to surgery and R #1's perineal area was "normal" when the urinary catheter was inserted. R #1's "Medication Record" dated 08/05/14 revealed facility nurses documented by initialing R #1 received indwelling urinary catheter care every day from 08/06/14 through 08/31/14 on the 7:00 a.m. to 3:00 p.m. shift, the 3:00 p.m. to 11:00 p.m. shift and the 11:00 p.m. to 7:00 a.m. shift. R #1's Treatment Record dated September 2014 revealed facility nurses documented by initialing R #1 received indwelling urinary catheter care on 09/01/14, 09/02/14 and 09/04/14 on the 11:00 p.m. to 7:00 a.m. shift. The sections for the 7:00 a.m. to 3:00 p.m. and the 3:00 p.m. to 11:00 p.m. shifts were left blank. R #1's Telephone Order dated 08/21/14 at 3:30 p.m. revealed an order to obtain a wound culture to "penial area" and an order for [REDACTED]. R #1's physician progress notes [REDACTED]. -08/22/14: "...(R #1) has no complaints...Nurses called (and) reported drainage out of penis around catheter...Penile discharge culture pending..." There was no evidence R #1's catheter or penis was assessed. R #1's Medication Administration Record [REDACTED]. Review of R #1's entire clinical record, including R #1's Nurses Notes, revealed there was no evidence R #1's penis was assessed from 08/21/14 through 09/02/14. R #1's physician progress notes [REDACTED]. -08/26/14: "...(R #1) has no complaints..." There was no evidence R #1's catheter or penis was assessed, -08/29/14: "(R #1) up in wheelchair. He has no complaints..." There was no evidence R #1's catheter or penis was assessed. R #1's Nurses Notes revealed: -08/30/14 at 7:41 a.m.: "...Resident difficult to arouse or unresponsive during the night. Blood pressure 69/45. Blood sugar 120. Respiratory very shallow...Call (sic) 911. Resident awakened on paramedic arrival and refused to be transferred to hospital for evaluation. Stated, 'I'm okay, nothing is wrong with me, I heard when you were calling me. I feel like not answering you.' Encouraged fluid intake and continue to monitor vital signs through the night. Blood pressure around 7:25am (sic) is 125/63...Notify the oncoming nurse to monitor resident vital signs and notify MD..." There was no evidence the other shifts on 08/30/14 monitored R #1's vital signs or notified R #1's physician. -08/31/14 at 6:45 a.m.: "...Alert and oriented x3...Continue to run low blood pressure during the night shift. Blood pressure around the 2am (sic) was 65/45...Noted in 24 hours (sic) report for morning nurse to notify MD..." There was no evidence the other shifts on 08/31/14 monitored R #1's blood pressure or notified R #1's physician. -09/01/14 at 8:20 a.m.: "...Alert and oriented x3 (A&Ox3)...Continue to rung (sic) low blood pressure. Notified morning nurse to monitor blood pressure. Poor pulses at extremities..." There was no evidence the other shifts on 09/01/14 monitored R #1's blood pressure. -09/02/14 at 10:10 a.m.: "...Pt is A&Ox3..." There was no evidence R #1's vital signs were monitored or R #1's physician was notified, and no other entries on 09/02/14. -09/03/14 at 2:21 p.m.: "...(indwelling urinary catheter) in place, dark yellow urine, with no odor...(complaining of) pain, medicated for pain as ordered as needed. Will continue to monitor. Assessed patient had red colored loose stools with foul odor, and head of penis has a hole on the left side. Called (MD "A's") office immediately to notify Dr..." R #1's physician progress notes [REDACTED]. -09/03/14: "(R #1) makes no complaints. He insists on going home in 2 days. He has developed erosion of urethra due to (indwelling urinary catheter)...His urine output is decreased...VSS (vital signs stable)...Penis with erosion of urethra (approximately) 1/2 penis...Consider suprapubic cath...He is high risk for hospitalization ." R #1's Nurses Notes dated 09/03/14: -11:03 p.m.: "(R #1) found unresponsive at 4:45 (p.m.), able to get patient to respond after 1-2 minutes. B/P (blood pressure) 74/58...(on-call for MD "A") notified of pt. status, orders given to transfer to the ER...Rechecked on patient (every) 30 minutes, pt. (patient) has a glassy look to his face, response is sluggish, B/P remained low..." On 09/05/14 at 8:55 a.m., MD "A" stated he assessed R #1's catheter on 08/12/14 and found no abnormalities. MD "A" stated "within a couple of days after he got (to the facility), we cultured (the penis) and started antibiotics." MD "A" stated he assessed R #1's catheter on 08/26/14 and "the discharge was gone. At that point, there was no change (to R #1's penis)." MD "A" stated he assessed R #1's penis on 09/03/14 and saw the "erosion" after the facility nurses reported the erosion to MD "A" and before R #1 was sent to the hospital. MD "A" stated R #1's erosion was caused from having a "chronic catheter." When investigator showed MD "A" Hospital "AA's" documented photographs dated 09/03/14 of R #1's perineal area, MD "A" said nothing. On 09/05/14 at 11:30 a.m., Licensed Vocational Nurse (LVN) "B" stated she routinely provided care to R #1. LVN "B" stated it was the facility's policy to provide residents with indwelling urinary catheter care every shift and as needed; to use an indwelling urinary catheter strap for stabilization; and to assess the catheter and surrounding tissue during care. LVN "B" stated she assessed R #1 on or around 08/23/14 and R #1 had "pus/yellowish clearish" coming from the tip of R #1's penis. LVN "B" stated R #1 received an antibiotic daily for the drainage, R #1's penis was "normal" in appearance every day she worked until 09/03/14 and she documented the condition of R #1's penis in the Nurses Notes. LVN "B" stated on 09/03/14, she assessed R #1 and "It was the first time he had a change." LVN "B" stated the "left side" on the "tip" of R #1's penis "was open. There was no skin there...It looked red. I didn't see any black areas." LVN "B" stated she notified MD "A." LVN "B" stated the Certified Nurse Aides (CNAs) provided R #1 with catheter care and LVN "B" ensured the catheter care was done daily on her shift as ordered by making rounds. LVN "B" stated she documented by initialing R #1's Treatment Administration Record R #1 received catheter care and if there were no initials, "you didn't do it." LVN "B" stated an indwelling urinary catheter strap's purpose was for "safety...Penis could break down." LVN "B" stated she did not "recall" R #1 having an indwelling urinary catheter strap and the "nurses" were "responsible" to ensure residents' indwelling urinary catheters were anchored. On 09/05/14 at 12:00 p.m., CNA "C" stated it was the facility's policy to provide indwelling urinary catheter care every shift and to report to the nurses "anything that doesn't look normal." CNA "C" stated the purpose of an indwelling urinary catheter strap was "so it doesn't pull on the urethra. Pressure could cause infection and pain and could cause skin to tear." CNA "C" stated R #1 "refused to let us do his catheter (care) most of the time. I would report it to (LVN "B")." CNA "C" stated R #1 had refused catheter care for approximately two weeks. On 09/05/14 at 12:20 p.m., LVN "B" stated she did not "remember being told about (R #1) refusing catheter care." On 09/05/14 at 12:25 p.m., the Director of Nurses (DON) stated it was the facility's policy to provide indwelling urinary catheter care "every shift and as needed." The DON stated, "The nurses should be making sure the catheters are cleaned during rounds and document on the Treatment Administration Record it was done." The DON stated if there was no documentation on the Treatment Administration Record, "It may not have been done." The DON stated she expected the nurses to assess a resident who had a change in condition and notify the physician. The DON stated if a resident refused care, the nurse should "talk" to the resident and "try again." The DON stated she was not aware R #1 refused catheter care and on 09/03/14, staff reported to her R #1's penis "didn't look right." The DON stated she assessed R #1 before he went to the hospital and saw that "part of the head of the penis was gone....(the) scrotum was swollen and raw. I didn't see any black areas." The DON stated she instructed staff to notify MD "A" and MD "A" assessed R #1 at approximately 3:30 p.m. on 09/03/14 but did not order R #1 to be sent to the hospital. The DON stated R #1 was sent to the hospital after R #1 became unresponsive on 09/03/14. The DON stated "My nurses dropped the ball" when asked if staff monitored R #1's indwelling urinary catheter. The Administrator was on leave during the investigation. On 09/05/14 at 1:50 p.m., CNA "D" stated R #1 would "put his hands in front of his penis" when CNA "D" attempted to provide indwelling urinary catheter care. CNA "D" stated she reported this to LVN "B." On 09/05/14 at 3:00 p.m., Registered Nurse (RN) "E" stated it was the facility's policy to provide indwelling urinary catheter care "daily." RN "E" stated nurses were responsible to provide indwelling urinary catheter care and to document the care was provided on the residents' Treatment Administration Record. RN "E" stated if there were no initials on the Treatment Administration Record, "It wasn't done." RN "E" stated she provided indwelling urinary catheter care for R #1 every day she worked. RN "E" stated R #1's penis was "normal" until 09/03/14, when she assessed R #1 and found it "looked like one half of his (penile) head was missing..." after getting report from LVN "B." RN "E" stated she sent R #1 to the hospital on [DATE] because R #1 became unresponsive. RN "E" stated R #1 never refused catheter care. On 09/05/14 at 4:50 p.m., CNA "F" stated he routinely provided care for R #1. CNA "F" stated providing indwelling urinary catheter care for R #1 was "hard because he was in pain...I didn't want to hurt him, so I stopped because he moaned." CNA "F" stated this occurred for approximately "one to two weeks" before R #1 was sent to the hospital on [DATE]. CNA "F" stated he reported R #1 was in pain to LVN "B" and RN "E." CNA "F" stated R #1 had "gunk" on the tip of his penis and it had been "getting worse" and "getting harder to remove and it was turning black." CNA "F" stated, "I don't remember telling the nurse it was black." On 09/05/14 at 5:20 p.m., CNA "G" stated she routinely provided care for R #1. CNA "G" stated approximately "one to two weeks" before R #1 was sent to the hospital on [DATE], CNA "G" noticed the "top of (R #1's) penis was red with pus...There was a piece of skin hanging and it started to bleed. I saw black areas." CNA "G" stated R #1 "started refusing catheter care" and she reported this to LVN "B" and RN "E." CNA "G" stated R #1 did not have an indwelling urinary catheter tubing strap "the whole time he was here." CNA "G" stated if a residents' indwelling urinary catheter tubing was not anchored, a residents' urethra "can get infected, start eating from the inside the urethra, could cause damage." R #1's Nurses Notes dated 08/05/14 through 09/03/14 revealed no evidence R #1 refused catheter care. R #2 R #2's undated Face Sheet revealed an [AGE] year old female admitted on [DATE] with the [DIAGNOSES REDACTED]. R #2's Quarterly MDS dated [DATE] revealed R #2 usually made self understood; usually understood others; was totally dependent on staff for toilet use and personal hygiene; and had an indwelling urinary catheter. R #2's Physician order [REDACTED]. R #2's "Catheter Justification" Form dated 06/11/14 revealed R #2 had an indwelling urinary catheter due to non-healing pressure ulcers. R #2's Treatment Administration Record dated August, 2014 revealed no evidence R #2 received indwelling urinary catheter care on the 7:00 a.m. to 3:00 p.m. shift on 08/08/14, 08/09/14, 08/14/14, 08/15/14, 08/20/14, 08/21/14, 08/26/14 and 08/27/14. R #2's Treatment Administration Record dated September, 2014 revealed no evidence R #2 received indwelling urinary catheter care on 09/03/14, 09/04/14 and 09/05/14 on the 3:00 p.m. to 11:00 p.m. shift; and on 09/01/14, 09/02/14, 09/03/14 and 09/04/14 on the 11:00 p.m. to 7:00 p.m. shift. Observation of R #2 on 09/05/14 at 8:52 a.m. revealed R #2's urinary catheter was not anchored. R #3 R #3's undated Face Sheet revealed a [AGE] year old female admitted on [DATE] with the [DIAGNOSES REDACTED]. R #3's Admission MDS dated [DATE] revealed R #3 understood others and made self understood; required extensive assistance with toilet use and personal hygiene; and did not have an indwelling urinary catheter. R #3's Telephone Order dated 09/04/14 revealed an order for [REDACTED]. Observation of R #3 on 09/05/14 at 9:20 a.m. revealed R #3's indwelling urinary catheter was not anchored. R #4 R #4's undated Face Sheet revealed a [AGE] year old female admitted on [DATE] with the [DIAGNOSES REDACTED]. R #4's Quarterly MDS dated [DATE] revealed R #4 usually understood others; usually made self understood; required extensive assistance with toileting and personal hygiene; and had an indwelling urinary catheter. R #4's Physician order [REDACTED]. R #4's "Catheter Justification" Form dated 02/11/14 revealed R #4 had an indwelling urinary catheter for comfort at end of life. R #4's Treatment Administration Record dated August, 2014 revealed no evidence R #4 received indwelling urinary catheter care on the 7:00 a.m. to 3:00 p.m. shift on 08/01/14; on the 3:00 p.m. to 11:00 p.m. on 08/08/14 and 08/09/14; and on the 11:00 p.m. to 7:00 p.m. shift on 08/07/14. R #4's Treatment Administration Record dated September, 2014 revealed no evidence R #4 received indwelling urinary catheter care on the 7:00 a.m. to 3:00 p.m. shift on 09/03/14, 09/04/14 and 09/05/14. Observation of R #4 on 09/05/14 at 9:22 a.m. revealed R #4's indwelling urinary catheter was not anchored. R #5 R #5's undated Face Sheet revealed a [AGE] year old male admitted on [DATE] with the [DIAGNOSES REDACTED]. R #5's Quarterly MDS dated [DATE] revealed R #5 understood others and made self understood; required extensive assistance with toileting and personal hygiene; had an indwelling urinary catheter. R #5's Physician order [REDACTED]. R #5's "Catheter Justification" Form dated 06/10/14 revealed R #5 had an indwelling urinary catheter due to urine retention. Observation of R #5 on 09/05/14 at 9:30 a.m. revealed R #5's indwelling urinary catheter was not anchored. R #7 R #7's undated Face Sheet revealed a [AGE] year old female admitted on [DATE] with the [DIAGNOSES REDACTED]. R #7's Admission MDS dated [DATE] revealed R #7 understood others and made self understood; required extensive assistance with toileting and personal hygiene; and had an indwelling urinary catheter. R #7's Physician order [REDACTED]. R #7's "Medication Record" dated August, 2014 revealed no evidence R #7 received indwelling urinary catheter care on the 7:00 a.m. to 3:00 p.m. shift on 08/31/14; and the 3:00 p.m. to 11:00 p.m. shift on 08/26/14 and 08/28/14. Observation of R #7 on 09/05/14 at 9:15 a.m. revealed R #7's indwelling urinary catheter was not anchored. R #8 R #8's undated Face Sheet revealed an [AGE] year old female admitted on [DATE] with the [DIAGNOSES REDACTED]. R #8's Annual MDS dated [DATE] revealed R #8 usually made self understood; usually understood others; required extensive assistance with toileting and personal hygiene; and had an indwelling urinary catheter. R #8's Physician order [REDACTED]. R #8's Treatment Administration Record dated August, 2014 revealed no evidence R #8 received indwelling urinary catheter care on the 7:00 a.m. to 3:00 p.m. shift on 08/08/14, 08/09/14, 08/14/14, 08/15/14, 08/20/14, 08/21/14, 08/26/14 and 08/27/14; and the 11:00 p.m. to 7:00 a.m. shift on 08/03/14 and 08/16/14. R #8's Treatment Administration Record dated September, 2014 revealed no evidence R #8 received indwelling urinary catheter care on the 3:00 p.m. to 11:00 p.m. shift on 09/01/14, 09/02/14, 09/03/14 and 09/05/14; and the 11:00 p.m. to 7:00 a.m. shift on 09/03/14. Observation of R #8 on 09/05/14 at 9:10 a.m. revealed R #8's indwelling urinary catheter was not anchored. R #9 R #9's undated Face Sheet revealed a [AGE] year old man admitted on [DATE] with the [DIAGNOSES REDACTED]. R #9's MDS dated [DATE] revealed R #9 understood others and made self understood; required extensive assistance with toileting and personal hygiene; and did not have an indwelling urinary catheter. R #9's Physician order [REDACTED]. Observation of R #9 on 09/05/14 at 9:40 a.m. revealed R #9's indwelling urinary catheter was not anchored. The facility's undated "Protection of Residents: Reducing the Threat of Abuse & Neglect" revealed: "...Charges of abuse and/or neglect are among the most serious allegations that can occur in a nursing home...It is the policy and practice of (this fill-in-the-blank section was left blank) that all residents will be protected from abuse and/or neglect...The facility must develop and operationalize policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect...The purpose is to assure that the facility is doing all that is within its control to prevent occurrences...Every resident in a long term care facility may be at risk for abuse and/or neglect due to the potential for diminished capacity ... Residents have the right to be treated by caring and [MEDICATION NAME] staff who have adequate knowledge to appropriately respond to residents with diverse behaviors and dependencies, facilitating a protective environment for both residents and staff...This facility does not condone resident abuse and/or neglect by anyone...Our residents and families depend on us to provide a safe and caring environment. This responsibility carries with it a number of factors. Residents and families look to us not only for physical care but also for emotional support...Our role is to reassure them that we have created a 'safe' and [MEDICATION NAME] place for care...Neglect is the failure to provide goods and services to avoid physical harm, mental anguish, or mental illness..." Lippincott's Nursing Procedures, Sixth Edition, pages 380 and 381, entitled Indwelling Urinary Catheter Insertion indicates: "...(For a female) Tape the catheter to the patient's thigh to prevent possible tension on the urogenital trigone...(For a male) Tape the catheter to the patient's abdomen or thigh to prevent pressure on the urethra at the penoscrotal junction, which can lead to formation of urethrocutaneous fistulas. Taping this way also prevents traction on the bladder and alteration in the normal direction of urine flow in males. As an alternative, secure the catheter to the patient's thigh using a leg band with a Velcro closure..." According to Lippincott's Nursing Procedures, Sixth Edition, pages 374-375, entitled Indwelling Urinary Catheter Care and Removal: "...the equipment and the patient's genitalia require inspection twice daily...Inspect the outside of the catheter where it enters the urinary meatus for encrusted material and suppurative drainage. Also inspect the tissue around the meatus for irritation or swelling...NURSING ALERT Provide enough slack before securing the catheter to prevent tension on the tubing, which could injure the urethral lumen or bladder wall..." The facility's undated "Daily Catheter Care" Policy revealed: "...In order to prevent infection, the daily catheter care procedure was developed...15. The catheter should be loosely taped to the resident's inner thigh to keep it from being pulled from the bladder or a catheter strap may be used with frail skin...Reporting procedures: Upon completion of giving catheter care, the nurse assistant should report the following to the staff/charge nurse: 1. That the catheter care had been given. 2. The time the care was given. 3. How the resident tolerated the procedure. 4. Any complaints the resident may have of burning, tenderness, pain in the urethral area, or changes in the appearance of the urine. 5. If the resident refused the treatment, the reason(s) why. 6. Your observations of anything unusual...Infection Control: To assure that infection control practices are being maintained:...9. Wash the perineal area daily with soap and water...Assessment: The assessment should include the following:...2. The resultant problems or limitations..." On 09/05/14 at 4:15 p.m., an IJ was identified and the DON was informed at 4:15 p.m. of the IJ due to the above failures. On 09/05/14 at 7:07 p.m., the facility's third Plan of Removal was accepted and contained the following: "This will serve as our allegation of compliance 1. What are we going to do for the resident affected a. The individual affected was sent out to hospital and remains hospitalized 2. What are we going to do for all others who have the potential to be affected a. All other residents who have the ability to be impacted by this allegation would be those residents who have a catheter i. All residents with catheters will immediately be assessed for proper placement, security, signs and symptoms of infection and drainage ii. Catheter justification worksheets will be completed on all residents with catheters immediately iii. All assessments will be documented in the clinical record 3. How are we going to address these systematic issues a. Immediately for those on shift and prior to providing care for those who are not on shift. All clinical staff will be trained on the following. i. Male and Female catheter care ii. S/S (signs and symptoms) of infection iii. Notification regarding change of condition, resident refusal of care. Nurse will be notified and will document in clinical record the refusal and notify the MD and family. The staff will attempt to render care at a later time. We will educate the resident on the risk of refusing care. We will constantly assess and document the residents condition. iv. Interact 3 to include 'stop and watch' and SBAR v. Shift to shift communication vi. Skills and competency check lists will be conducted on all clinical staff regarding pericare and catheter care as well as S/S of infection 4. How will we monitor ongoing compliance a. The charge nurse will document on the TAR every shift regarding i. Foley catheter placement ii. Security iii. Drainage iv. Signs and symptoms of infection b. The Director of Nursing/designee will review the TAR daily to ensure that documentation is present c. The Director of Nursing/designee will monitor residents with foley catheters daily to ensure that all care has been rendered and documentation is accurate. This will occur daily for seven days, after which time this will occur five times a week for seven days, after which time this will occur three times a week for seven days after which this will occur weekly ongoing. d. A log of monitoring will be maintained and shared with the Performance Improvement Committee for review and recommendations as applicable." End of Plan of Removal. Through observations, interviews and record reviews, surveyors determined that inservicing was initiated, residents with catheters were assessed and staff followed the residents at risk for catheter complications monitoring that was documented in the facility's Plan of Removal were implemented. On 09/05/14 at 8:00 p.m., the DON was informed the IJ was removed. However, the facility remained out of compliance at a level of severity for actual harm with a scope identified as pattern. The facility was still monitoring the Plan of Removal. The facility's Centers for Medicare and Medicaid Services Form CMS-802 dated 09/05/14 revealed eight residents with indwelling urinary catheters. Throughout the survey and during the exit conference, the facility was given the opportunity to provide additional information related to providing care and services to prevent urinary catheter complications. As of exit on 09/06/14 at 4:10 p.m., the facility provided no further information.

Based on observation, interview and record review, the facility failed to implement their written policy and procedure that prohibits neglect for eight Residents (R #1, R #2, R #3, R #4, R #5, R #7, R #8 and R #9) of nine Residents reviewed for indwelling urinary catheter care. The facility failed to assess and provide care to R #1's indwelling urinary catheter. As a result, R #1 was sent to the hospital on [DATE] with penile erosion, blackened areas on his penis, drainage from his penis, swollen testicles and was missing part of his penile head. R #1 was diagnosed with [REDACTED]. The facility failed to anchor R #1, R #2, R #3, R #4, R #5, R #7, R #8 or R #9's indwelling urinary catheters, placing them at risk for urethral damage. These failures resulted in identification of an Immediate Jeopardy (IJ) on 09/05/14. While the IJ was removed on 09/05/14, the facility remained out of compliance for actual harm at a scope of pattern due to the facility was continuing to in-service staff and monitoring the Plan of Removal. These deficient practices placed eight residents with indwelling urinary catheters at risk of neglect due to not receiving proper assessments and care and services required to prevent delay in treatment, complications, hospitalization , or possible harm. Findings were: The facility's undated "Protection of Residents: Reducing the Threat of Abuse & Neglect" revealed: "...Charges of abuse and/or neglect are among the most serious allegations that can occur in a nursing home...It is the policy and practice of (this fill-in-the-blank section was left blank) that all residents will be protected from abuse and/or neglect...The facility must develop and operationalize policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect...The purpose is to assure that the facility is doing all that is within its control to prevent occurrences...Every resident in a long term care facility may be at risk for abuse and/or neglect due to the potential for diminished capacity ... Residents have the right to be treated by caring and [MEDICATION NAME] staff who have adequate knowledge to appropriately respond to residents with diverse behaviors and dependencies, facilitating a protective environment for both residents and staff...This facility does not condone resident abuse and/or neglect by anyone...Our residents and families depend on us to provide a safe and caring environment. This responsibility carries with it a number of factors. Residents and families look to us not only for physical care but also for emotional support...Our role is to reassure them that we have created a 'safe' and [MEDICATION NAME] place for care...Neglect is the failure to provide goods and services to avoid physical harm, mental anguish, or mental illness..." Lippincott's Nursing Procedures, Sixth Edition, pages 380 and 381, entitled Indwelling Urinary Catheter Insertion indicates: "...(For a female) Tape the catheter to the patient's thigh to prevent possible tension on the urogenital trigone...(For a male) Tape the catheter to the patient's abdomen or thigh to prevent pressure on the urethra at the penoscrotal junction, which can lead to formation of urethrocutaneous fistulas. Taping this way also prevents traction on the bladder and alteration in the normal direction of urine flow in males. As an alternative, secure the catheter to the patient's thigh using a leg band with a Velcro closure..." According to Lippincott's Nursing Procedures, Sixth Edition, pages 374-375, entitled Indwelling Urinary Catheter Care and Removal: "...the equipment and the patient's genitalia require inspection twice daily...Inspect the outside of the catheter where it enters the urinary meatus for encrusted material and suppurative drainage. Also inspect the tissue around the meatus for irritation or swelling...NURSING ALERT Provide enough slack before securing the catheter to prevent tension on the tubing, which could injure the urethral lumen or bladder wall..." The facility's undated "Daily Catheter Care" Policy revealed: "...In order to prevent infection, the daily catheter care procedure was developed...15. The catheter should be loosely taped to the resident's inner thigh to keep it from being pulled from the bladder or a catheter strap may be used with frail skin...Reporting procedures: Upon completion of giving catheter care, the nurse assistant should report the following to the staff/charge nurse: 1. That the catheter care had been given. 2. The time the care was given. 3. How the resident tolerated the procedure. 4. Any complaints the resident may have of burning, tenderness, pain in the urethral area, or changes in the appearance of the urine. 5. If the resident refused the treatment, the reason(s) why. 6. Your observations of anything unusual...Infection Control: To assure that infection control practices are being maintained:...9. Wash the perineal area daily with soap and water...Assessment: The assessment should include the following:...2. The resultant problems or limitations..." R #1 R #1's undated Face Sheet revealed a [AGE] year old male admitted to the facility on [DATE]. R #1's Admission Minimum Data Set ((MDS) dated [DATE] revealed R #1 had the [DIAGNOSES REDACTED]. R #1's Admission MDS dated [DATE] revealed R #1 had clear speech; made self understood and understood others; had intact cognition; did not have behavioral symptoms; required extensive assistance with bed mobility, dressing, eating, toilet use and personal hygiene; was totally dependent with bathing; and had an indwelling urinary catheter (a tube inserted into the bladder to enable urination.) R #1's Care Plans dated 08/05/14 revealed R #1 had an indwelling urinary catheter and interventions included "(indwelling urinary) catheter care protocol (policy)." The facility's undated "Daily Catheter Care" Policy included: "...In order to prevent infection, the daily catheter care procedure was developed...15. The catheter should be loosely taped to the resident's inner thigh to keep it from being pulled from the bladder or a catheter strap may be used with frail skin..." R #1's Physician order [REDACTED]. R #1's "Catheter Justification" Form dated 08/05/14 revealed R #1 had an indwelling urinary catheter due to non-healing pressure ulcers. R #1's Telephone Order dated 09/03/14 at 4:00 p.m. revealed an order to send R #1 to the hospital for evaluation and treatment. R #1's Emergency Provider Report from Hospital "AA" dated 09/03/14 revealed: "...Patient is a distressed, toxic looking 76 (year old) male...has a (indwelling urinary catheter) with severe catheter induced urethral (tube that drains urine from the bladder) erosion...appears septic (infection)..." According to www.ncbi.nlm.nih.gov on 09/18/14, entitled "Urethral erosion: a case for prevention, ... Existing research suggests that negative outcomes associated with urethral and meatal erosions can be prevented by properly securing the indwelling catheter..." R #1's History and Physical from Hospital "AA" dated 09/04/14 revealed: "...Assessment/Plan: Urosepsis-likely from UTI (urinary tract infection), with (indwelling urinary catheter) that was not properly cared for...penile meatus erosion and scrotal swelling..." According to www.sepsisalliance.org on 09/18/14, [MEDICAL CONDITION] and Urinary Tract Infections, "...An untreated (urinary tract infection) may spread to the kidney, causing more pain and illness. It can also [MEDICAL CONDITIONS] is the body's often deadly response to infection or injury. [MEDICAL CONDITION] kills and disables millions and requires early suspicion and rapid treatment for [REDACTED]. R #1's documented photographs from Hospital "AA" dated 09/03/14 of R #1's perineal area revealed: -White to yellow drainage from his penis, -The scrotum was swollen and red in color, -On the meatus of R #1's penis and on the underside of the urethra, an approximate one centimeter diameter area of skin was missing from the urethra, -The urethra was swollen and the approximate size of one centimeter, with an approximate 0.5 centimeter indentation at the bottom of the urethra where the indwelling urinary catheter rested against it, -Approximately four black colored areas with erosion approximately 0.125 centimeters in diameter on the tip of the penis, and along the right side of the urethra. Observation of R #1 in the Intensive Care Unit at Hospital "AA" on 09/04/14 at 3:15 p.m. revealed R #1 was unresponsive to investigator's questions. R #1 moaned when repositioned by hospital staff. On 09/04/15 at 3:10 p.m., Family Member (FM) "BB" stated R #1 had an indwelling urinary catheter inserted on or around 08/01/14 due to surgery and R #1's perineal area was "normal" when the urinary catheter was inserted. R #1's "Medication Record" dated 08/05/14 revealed facility nurses documented by initialing R #1 received indwelling urinary catheter care every day from 08/06/14 through 08/31/14 on the 7:00 a.m. to 3:00 p.m. shift, the 3:00 p.m. to 11:00 p.m. shift and the 11:00 p.m. to 7:00 a.m. shift. R #1's Treatment Record dated September 2014 revealed facility nurses documented by initialing R #1 received indwelling urinary catheter care on 09/01/14, 09/02/14 and 09/04/14 on the 11:00 p.m. to 7:00 a.m. shift. The sections for the 7:00 a.m. to 3:00 p.m. and the 3:00 p.m. to 11:00 p.m. shifts were left blank. R #1's Telephone Order dated 08/21/14 at 3:30 p.m. revealed an order to obtain a wound culture to "penial area" and an order for [REDACTED]. R #1's physician progress notes [REDACTED]. -08/22/14: "...(R #1) has no complaints...Nurses called (and) reported drainage out of penis around catheter...Penile discharge culture pending..." There was no evidence R #1's catheter or penis was assessed. R #1's Medication Administration Record [REDACTED]. Review of R #1's entire clinical record, including R #1's Nurses Notes, revealed there was no evidence R #1's penis was assessed from 08/21/14 through 09/02/14. R #1's physician progress notes [REDACTED]. -08/26/14: "...(R #1) has no complaints..." There was no evidence R #1's catheter or penis was assessed, -08/29/14: "(R #1) up in wheelchair. He has no complaints..." There was no evidence R #1's catheter or penis was assessed. R #1's Nurses Notes revealed: -08/30/14 at 7:41 a.m.: "...Resident difficult to arouse or unresponsive during the night. Blood pressure 69/45. Blood sugar 120. Respiratory very shallow...Call (sic) 911. Resident awakened on paramedic arrival and refused to be transferred to hospital for evaluation. Stated, 'I'm okay, nothing is wrong with me, I heard when you were calling me. I feel like not answering you.' Encouraged fluid intake and continue to monitor vital signs through the night. Blood pressure around 7:25am (sic) is 125/63...Notify the oncoming nurse to monitor resident vital signs and notify MD..." There was no evidence the other shifts on 08/30/14 monitored R #1's vital signs or notified R #1's physician. -08/31/14 at 6:45 a.m.: "...Alert and oriented x3...Continue to run low blood pressure during the night shift. Blood pressure around the 2am (sic) was 65/45...Noted in 24 hours (sic) report for morning nurse to notify MD..." There was no evidence the other shifts on 08/31/14 monitored R #1's blood pressure or notified R #1's physician. -09/01/14 at 8:20 a.m.: "...Alert and oriented x3 (A&Ox3)...Continue to rung (sic) low blood pressure. Notified morning nurse to monitor blood pressure. Poor pulses at extremities..." There was no evidence the other shifts on 09/01/14 monitored R #1's blood pressure. -09/02/14 at 10:10 a.m.: "...Pt is A&Ox3..." There was no evidence R #1's vital signs were monitored or R #1's physician was notified, and no other entries on 09/02/14. -09/03/14 at 2:21 p.m.: "...(indwelling urinary catheter) in place, dark yellow urine, with no odor...(complaining of) pain, medicated for pain as ordered as needed. Will continue to monitor. Assessed patient had red colored loose stools with foul odor, and head of penis has a hole on the left side. Called (MD "A's") office immediately to notify Dr..." R #1's physician progress notes [REDACTED]. -09/03/14: "(R #1) makes no complaints. He insists on going home in 2 days. He has developed erosion of urethra due to (indwelling urinary catheter)...His urine output is decreased...VSS (vital signs stable)...Penis with erosion of urethra (approximately) 1/2 penis...Consider suprapubic cath...He is high risk for hospitalization ." R #1's Nurses Notes dated 09/03/14: -11:03 p.m.: "(R #1) found unresponsive at 4:45 (p.m.), able to get patient to respond after 1-2 minutes. B/P (blood pressure) 74/58...(on-call for MD "A") notified of pt. status, orders given to transfer to the ER...Rechecked on patient (every) 30 minutes, pt. (patient) has a glassy look to his face, response is sluggish, B/P remained low..." On 09/05/14 at 8:55 a.m., MD "A" stated he assessed R #1's catheter on 08/12/14 and found no abnormalities. MD "A" stated "within a couple of days after he got (to the facility), we cultured (the penis) and started antibiotics." MD "A" stated he assessed R #1's catheter on 08/26/14 and "the discharge was gone. At that point, there was no change (to R #1's penis)." MD "A" stated he assessed R #1's penis on 09/03/14 and saw the "erosion" after the facility nurses reported the erosion to MD "A" and before R #1 was sent to the hospital. MD "A" stated R #1's erosion was caused from having a "chronic catheter." When investigator showed MD "A" Hospital "AA's" documented photographs dated 09/03/14 of R #1's perineal area, MD "A" said nothing. On 09/05/14 at 11:30 a.m., Licensed Vocational Nurse (LVN) "B" stated she routinely provided care to R #1. LVN "B" stated it was the facility's policy to provide residents with indwelling urinary catheter care every shift and as needed; to use an indwelling urinary catheter strap for stabilization; and to assess the catheter and surrounding tissue during care. LVN "B" stated she assessed R #1 on or around 08/23/14 and R #1 had "pus/yellowish clearish" coming from the tip of R #1's penis. LVN "B" stated R #1 received an antibiotic daily for the drainage, R #1's penis was "normal" in appearance every day she worked until 09/03/14 and she documented the condition of R #1's penis in the Nurses Notes. LVN "B" stated on 09/03/14, she assessed R #1 and "It was the first time he had a change." LVN "B" stated the "left side" on the "tip" of R #1's penis "was open. There was no skin there...It looked red. I didn't see any black areas." LVN "B" stated she notified MD "A." LVN "B" stated the Certified Nurse Aides (CNAs) provided R #1 with catheter care and LVN "B" ensured the catheter care was done daily on her shift as ordered by making rounds. LVN "B" stated she documented by initialing R #1's Treatment Administration Record R #1 received catheter care and if there were no initials, "you didn't do it." LVN "B" stated an indwelling urinary catheter strap's purpose was for "safety...Penis could break down." LVN "B" stated she did not "recall" R #1 having an indwelling urinary catheter strap and the "nurses" were "responsible" to ensure residents' indwelling urinary catheters were anchored. On 09/05/14 at 12:00 p.m., CNA "C" stated it was the facility's policy to provide indwelling urinary catheter care every shift and to report to the nurses "anything that doesn't look normal." CNA "C" stated the purpose of an indwelling urinary catheter strap was "so it doesn't pull on the urethra. Pressure could cause infection and pain and could cause skin to tear." CNA "C" stated R #1 "refused to let us do his catheter (care) most of the time. I would report it to (LVN "B")." CNA "C" stated R #1 had refused catheter care for approximately two weeks. On 09/05/14 at 12:20 p.m., LVN "B" stated she did not "remember being told about (R #1) refusing catheter care." On 09/05/14 at 12:25 p.m., the Director of Nurses (DON) stated it was the facility's policy to provide indwelling urinary catheter care "every shift and as needed." The DON stated, "The nurses should be making sure the catheters are cleaned during rounds and document on the Treatment Administration Record it was done." The DON stated if there was no documentation on the Treatment Administration Record, "It may not have been done." The DON stated she expected the nurses to assess a resident who had a change in condition and notify the physician. The DON stated if a resident refused care, the nurse should "talk" to the resident and "try again." The DON stated she was not aware R #1 refused catheter care and on 09/03/14, staff reported to her R #1's penis "didn't look right." The DON stated she assessed R #1 before he went to the hospital and saw that "part of the head of the penis was gone....(the) scrotum was swollen and raw. I didn't see any black areas." The DON stated she instructed staff to notify MD "A" and MD "A" assessed R #1 at approximately 3:30 p.m. on 09/03/14 but did not order R #1 to be sent to the hospital. The DON stated R #1 was sent to the hospital after R #1 became unresponsive on 09/03/14. The DON stated "My nurses dropped the ball" when asked if staff monitored R #1's indwelling urinary catheter. The Administrator was on leave during the investigation. On 09/05/14 at 1:50 p.m., CNA "D" stated R #1 would "put his hands in front of his penis" when CNA "D" attempted to provide indwelling urinary catheter care. CNA "D" stated she reported this to LVN "B." On 09/05/14 at 3:00 p.m., Registered Nurse (RN) "E" stated it was the facility's policy to provide indwelling urinary catheter care "daily." RN "E" stated nurses were responsible to provide indwelling urinary catheter care and to document the care was provided on the residents' Treatment Administration Record. RN "E" stated if there were no initials on the Treatment Administration Record, "It wasn't done." RN "E" stated she provided indwelling urinary catheter care for R #1 every day she worked. RN "E" stated R #1's penis was "normal" until 09/03/14, when she assessed R #1 and found it "looked like one half of his (penile) head was missing..." after getting report from LVN "B." RN "E" stated she sent R #1 to the hospital on [DATE] because R #1 became unresponsive. RN "E" stated R #1 never refused catheter care. On 09/05/14 at 4:50 p.m., CNA "F" stated he routinely provided care for R #1. CNA "F" stated providing indwelling urinary catheter care for R #1 was "hard because he was in pain...I didn't want to hurt him, so I stopped because he moaned." CNA "F" stated this occurred for approximately "one to two weeks" before R #1 was sent to the hospital on [DATE]. CNA "F" stated he reported R #1 was in pain to LVN "B" and RN "E." CNA "F" stated R #1 had "gunk" on the tip of his penis and it had been "getting worse" and "getting harder to remove and it was turning black." CNA "F" stated, "I don't remember telling the nurse it was black." On 09/05/14 at 5:20 p.m., CNA "G" stated she routinely provided care for R #1. CNA "G" stated approximately "one to two weeks" before R #1 was sent to the hospital on [DATE], CNA "G" noticed the "top of (R #1's) penis was red with pus...There was a piece of skin hanging and it started to bleed. I saw black areas." CNA "G" stated R #1 "started refusing catheter care" and she reported this to LVN "B" and RN "E." CNA "G" stated R #1 did not have an indwelling urinary catheter tubing strap "the whole time he was here." CNA "G" stated if a residents' indwelling urinary catheter tubing was not anchored, a residents' urethra "can get infected, start eating from the inside the urethra, could cause damage." R #1's Nurses Notes dated 08/05/14 through 09/03/14 revealed no evidence R #1 refused catheter care. R #2 R #2's undated Face Sheet revealed an [AGE] year old female admitted on [DATE] with the [DIAGNOSES REDACTED]. R #2's Quarterly MDS dated [DATE] revealed R #2 usually made self understood; usually understood others; was totally dependent on staff for toilet use and personal hygiene; and had an indwelling urinary catheter. R #2's Physician order [REDACTED]. R #2's "Catheter Justification" Form dated 06/11/14 revealed R #2 had an indwelling urinary catheter due to non-healing pressure ulcers. R #2's Treatment Administration Record dated August, 2014 revealed no evidence R #2 received indwelling urinary catheter care on the 7:00 a.m. to 3:00 p.m. shift on 08/08/14, 08/09/14, 08/14/14, 08/15/14, 08/20/14, 08/21/14, 08/26/14 and 08/27/14. R #2's Treatment Administration Record dated September, 2014 revealed no evidence R #2 received indwelling urinary catheter care on 09/03/14, 09/04/14 and 09/05/14 on the 3:00 p.m. to 11:00 p.m. shift; and on 09/01/14, 09/02/14, 09/03/14 and 09/04/14 on the 11:00 p.m. to 7:00 p.m. shift. Observation of R #2 on 09/05/14 at 8:52 a.m. revealed R #2's urinary catheter was not anchored. R #3 R #3's undated Face Sheet revealed a [AGE] year old female admitted on [DATE] with the [DIAGNOSES REDACTED]. R #3's Admission MDS dated [DATE] revealed R #3 understood others and made self understood; required extensive assistance with toilet use and personal hygiene; and did not have an indwelling urinary catheter. R #3's Telephone Order dated 09/04/14 revealed an order for [REDACTED]. Observation of R #3 on 09/05/14 at 9:20 a.m. revealed R #3's indwelling urinary catheter was not anchored. R #4 R #4's undated Face Sheet revealed a [AGE] year old female admitted on [DATE] with the [DIAGNOSES REDACTED]. R #4's Quarterly MDS dated [DATE] revealed R #4 usually understood others; usually made self understood; required extensive assistance with toileting and personal hygiene; and had an indwelling urinary catheter. R #4's Physician order [REDACTED]. R #4's "Catheter Justification" Form dated 02/11/14 revealed R #4 had an indwelling urinary catheter for comfort at end of life. R #4's Treatment Administration Record dated August, 2014 revealed no evidence R #4 received indwelling urinary catheter care on the 7:00 a.m. to 3:00 p.m. shift on 08/01/14; on the 3:00 p.m. to 11:00 p.m. on 08/08/14 and 08/09/14; and on the 11:00 p.m. to 7:00 p.m. shift on 08/07/14. R #4's Treatment Administration Record dated September, 2014 revealed no evidence R #4 received indwelling urinary catheter care on the 7:00 a.m. to 3:00 p.m. shift on 09/03/14, 09/04/14 and 09/05/14. Observation of R #4 on 09/05/14 at 9:22 a.m. revealed R #4's indwelling urinary catheter was not anchored. R #5 R #5's undated Face Sheet revealed a [AGE] year old male admitted on [DATE] with the [DIAGNOSES REDACTED]. R #5's Quarterly MDS dated [DATE] revealed R #5 understood others and made self understood; required extensive assistance with toileting and personal hygiene; had an indwelling urinary catheter. R #5's Physician order [REDACTED]. R #5's "Catheter Justification" Form dated 06/10/14 revealed R #5 had an indwelling urinary catheter due to urine retention. Observation of R #5 on 09/05/14 at 9:30 a.m. revealed R #5's indwelling urinary catheter was not anchored. R #7 R #7's undated Face Sheet revealed a [AGE] year old female admitted on [DATE] with the [DIAGNOSES REDACTED]. R #7's Admission MDS dated [DATE] revealed R #7 understood others and made self understood; required extensive assistance with toileting and personal hygiene; and had an indwelling urinary catheter. R #7's Physician order [REDACTED]. R #7's "Medication Record" dated August, 2014 revealed no evidence R #7 received indwelling urinary catheter care on the 7:00 a.m. to 3:00 p.m. shift on 08/31/14; and the 3:00 p.m. to 11:00 p.m. shift on 08/26/14 and 08/28/14. Observation of R #7 on 09/05/14 at 9:15 a.m. revealed R #7's indwelling urinary catheter was not anchored. R #8 R #8's undated Face Sheet revealed an [AGE] year old female admitted on [DATE] with the [DIAGNOSES REDACTED]. R #8's Annual MDS dated [DATE] revealed R #8 usually made self understood; usually understood others; required extensive assistance with toileting and personal hygiene; and had an indwelling urinary catheter. R #8's Physician order [REDACTED]. R #8's Treatment Administration Record dated August, 2014 revealed no evidence R #8 received indwelling urinary catheter care on the 7:00 a.m. to 3:00 p.m. shift on 08/08/14, 08/09/14, 08/14/14, 08/15/14, 08/20/14, 08/21/14, 08/26/14 and 08/27/14; and the 11:00 p.m. to 7:00 a.m. shift on 08/03/14 and 08/16/14. R #8's Treatment Administration Record dated September, 2014 revealed no evidence R #8 received indwelling urinary catheter care on the 3:00 p.m. to 11:00 p.m. shift on 09/01/14, 09/02/14, 09/03/14 and 09/05/14; and the 11:00 p.m. to 7:00 a.m. shift on 09/03/14. Observation of R #8 on 09/05/14 at 9:10 a.m. revealed R #8's indwelling urinary catheter was not anchored. R #9 R #9's undated Face Sheet revealed a [AGE] year old man admitted on [DATE] with the [DIAGNOSES REDACTED]. R #9's MDS dated [DATE] revealed R #9 understood others and made self understood; required extensive assistance with toileting and personal hygiene; and did not have an indwelling urinary catheter. R #9's Physician order [REDACTED]. Observation of R #9 on 09/05/14 at 9:40 a.m. revealed R #9's indwelling urinary catheter was not anchored. On 09/05/14 at 4:15 p.m., an IJ was identified and the DON was informed at 4:15 p.m. of the IJ due to the above failures. On 09/05/14 at 7:07 p.m., the facility's third Plan of Removal was accepted and contained the following: "This will serve as our allegation of compliance 1. What are we going to do for the resident affected a. The individual affected was sent out to hospital and remains hospitalized 2. What are we going to do for all others who have the potential to be affected a. All other residents who have the ability to be impacted by this allegation would be those residents who have a catheter i. All residents with catheters will immediately be assessed for proper placement, security, signs and symptoms of infection and drainage ii. Catheter justification worksheets will be completed on all residents with catheters immediately iii. All assessments will be documented in the clinical record 3. How are we going to address these systematic issues a. Immediately for those on shift and prior to providing care for those who are not on shift. All clinical staff will be trained on the following. i. Male and Female catheter care ii. S/S (signs and symptoms) of infection iii. Notification regarding change of condition, resident refusal of care. Nurse will be notified and will document in clinical record the refusal and notify the MD and family. The staff will attempt to render care at a later time. We will educate the resident on the risk of refusing care. We will constantly assess and document the residents condition. iv. Interact 3 to include 'stop and watch' and SBAR v. Shift to shift communication vi. Skills and competency check lists will be conducted on all clinical staff regarding pericare and catheter care as well as S/S of infection 4. How will we monitor ongoing compliance a. The charge nurse will document on the TAR every shift regarding i. Foley catheter placement ii. Security iii. Drainage iv. Signs and symptoms of infection b. The Director of Nursing/designee will review the TAR daily to ensure that documentation is present c. The Director of Nursing/designee will monitor residents with foley catheters daily to ensure that all care has been rendered and documentation is accurate. This will occur daily for seven days, after which time this will occur five times a week for seven days, after which time this will occur three times a week for seven days after which this will occur weekly ongoing. d. A log of monitoring will be maintained and shared with the Performance Improvement Committee for review and recommendations as applicable." End of Plan of Removal. Through observations, interviews and record reviews, surveyors determined that inservicing was initiated, residents with catheters were assessed and staff followed the residents at risk for catheter complications monitoring that was documented in the facility's Plan of Removal were implemented. On 09/05/14 at 8:00 p.m., the DON was informed the IJ was removed. However, the facility remained out of compliance at a level of severity for actual harm with a scope identified as pattern. The facility was still monitoring the Plan of Removal. The facility's Centers for Medicare and Medicaid Services Form CMS-802 dated 09/05/14 revealed eight residents with indwelling urinary catheters. Throughout the survey and during the exit conference, the facility was given the opportunity to provide additional information related to providing care and services to prevent urinary catheter complications. As of exit on 09/06/14 at 4:10 p.m., the facility provided no further information.

Based on observation, interview and record review, the facility failed to ensure services provided met professional standards of quality for eight Residents (R #1, R #2, R #3, R #4, R #5, R #7, R #8 and R #9) of nine Residents reviewed for quality of care. Facility staff failed to assess and provide care to R #1's indwelling urinary catheter. As a result, R #1 was sent to the hospital on [DATE] with penile erosion, blackened areas on his penis, drainage from his penis, swollen testicles and was missing part of his penile head. R #1 was diagnosed with [REDACTED]. The facility failed to anchor R #1, R #2, R #3, R #4, R #5, R #7, R #8 or R #9's indwelling urinary catheters, placing them at risk for urethral damage. These failures resulted in identification of an Immediate Jeopardy (IJ) on 09/05/14. While the IJ was removed on 09/05/14, the facility remained out of compliance for actual harm at a scope of pattern due to the facility was continuing to in-service staff and monitoring the Plan of Removal. These deficient practices placed eight residents with indwelling urinary catheters at risk of neglect due to not receiving proper assessments and care and services required to prevent delay in treatment, complications, hospitalization , or possible harm. Findings were: The Texas Administrative Code, Title 22, Part 11, Chapter 217, Rule 217.11, Standards of Nursing Practice states: "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 resulted. (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice; (B) Implement measures to promote a safe environment for clients and others; (C) Know the rationale for and the effects of medications and treatments and shall correctly administer the same; (D) Accurately and completely report and document: (i) the client's status including signs and symptoms;...(iv) administration of medications and treatments; (v) client response(s); and (vi) contacts with other health care team members concerning significant events regarding client's status..." R #1 R #1's undated Face Sheet revealed a [AGE] year old male admitted to the facility on [DATE]. R #1's Admission Minimum Data Set ((MDS) dated [DATE] revealed R #1 had the [DIAGNOSES REDACTED]. R #1's Admission MDS dated [DATE] revealed R #1 had clear speech; made self understood and understood others; had intact cognition; did not have behavioral symptoms; required extensive assistance with bed mobility, dressing, eating, toilet use and personal hygiene; was totally dependent with bathing; and had an indwelling urinary catheter (a tube inserted into the bladder to enable urination.) R #1's Care Plans dated 08/05/14 revealed R #1 had an indwelling urinary catheter and interventions included "(indwelling urinary) catheter care protocol (policy)." The facility's undated "Daily Catheter Care" Policy included: "...In order to prevent infection, the daily catheter care procedure was developed...15. The catheter should be loosely taped to the resident's inner thigh to keep it from being pulled from the bladder or a catheter strap may be used with frail skin..." R #1's Physician order [REDACTED]. R #1's "Catheter Justification" Form dated 08/05/14 revealed R #1 had an indwelling urinary catheter due to non-healing pressure ulcers. R #1's Telephone Order dated 09/03/14 at 4:00 p.m. revealed an order to send R #1 to the hospital for evaluation and treatment. R #1's Emergency Provider Report from Hospital "AA" dated 09/03/14 revealed: "...Patient is a distressed, toxic looking 76 (year old) male...has a (indwelling urinary catheter) with severe catheter induced urethral (tube that drains urine from the bladder) erosion...appears septic (infection)..." According to www.ncbi.nlm.nih.gov on 09/18/14, entitled "Urethral erosion: a case for prevention, ... Existing research suggests that negative outcomes associated with urethral and meatal erosions can be prevented by properly securing the indwelling catheter..." R #1's History and Physical from Hospital "AA" dated 09/04/14 revealed: "...Assessment/Plan: Urosepsis-likely from UTI (urinary tract infection), with (indwelling urinary catheter) that was not properly cared for...penile meatus erosion and scrotal swelling..." According to www.sepsisalliance.org on 09/18/14, [MEDICAL CONDITION] and Urinary Tract Infections, "...An untreated (urinary tract infection) may spread to the kidney, causing more pain and illness. It can also [MEDICAL CONDITIONS] is the body's often deadly response to infection or injury. [MEDICAL CONDITION] kills and disables millions and requires early suspicion and rapid treatment for [REDACTED]. R #1's documented photographs from Hospital "AA" dated 09/03/14 of R #1's perineal area revealed: -White to yellow drainage from his penis, -The scrotum was swollen and red in color, -On the meatus of R #1's penis and on the underside of the urethra, an approximate one centimeter diameter area of skin was missing from the urethra, -The urethra was swollen and the approximate size of one centimeter, with an approximate 0.5 centimeter indentation at the bottom of the urethra where the indwelling urinary catheter rested against it, -Approximately four black colored areas with erosion approximately 0.125 centimeters in diameter on the tip of the penis, and along the right side of the urethra. Observation of R #1 in the Intensive Care Unit at Hospital "AA" on 09/04/14 at 3:15 p.m. revealed R #1 was unresponsive to investigator's questions. R #1 moaned when repositioned by hospital staff. On 09/04/15 at 3:10 p.m., Family Member (FM) "BB" stated R #1 had an indwelling urinary catheter inserted on or around 08/01/14 due to surgery and R #1's perineal area was "normal" when the urinary catheter was inserted. R #1's "Medication Record" dated 08/05/14 revealed facility nurses documented by initialing R #1 received indwelling urinary catheter care every day from 08/06/14 through 08/31/14 on the 7:00 a.m. to 3:00 p.m. shift, the 3:00 p.m. to 11:00 p.m. shift and the 11:00 p.m. to 7:00 a.m. shift. R #1's Treatment Record dated September 2014 revealed facility nurses documented by initialing R #1 received indwelling urinary catheter care on 09/01/14, 09/02/14 and 09/04/14 on the 11:00 p.m. to 7:00 a.m. shift. The sections for the 7:00 a.m. to 3:00 p.m. and the 3:00 p.m. to 11:00 p.m. shifts were left blank. R #1's Telephone Order dated 08/21/14 at 3:30 p.m. revealed an order to obtain a wound culture to "penial area" and an order for [REDACTED]. R #1's physician progress notes [REDACTED]. -08/22/14: "...(R #1) has no complaints...Nurses called (and) reported drainage out of penis around catheter...Penile discharge culture pending..." There was no evidence R #1's catheter or penis was assessed. R #1's Medication Administration Record [REDACTED]. Review of R #1's entire clinical record, including R #1's Nurses Notes, revealed there was no evidence R #1's penis was assessed from 08/21/14 through 09/02/14. R #1's physician progress notes [REDACTED]. -08/26/14: "...(R #1) has no complaints..." There was no evidence R #1's catheter or penis was assessed, -08/29/14: "(R #1) up in wheelchair. He has no complaints..." There was no evidence R #1's catheter or penis was assessed. R #1's Nurses Notes revealed: -08/30/14 at 7:41 a.m.: "...Resident difficult to arouse or unresponsive during the night. Blood pressure 69/45. Blood sugar 120. Respiratory very shallow...Call (sic) 911. Resident awakened on paramedic arrival and refused to be transferred to hospital for evaluation. Stated, 'I'm okay, nothing is wrong with me, I heard when you were calling me. I feel like not answering you.' Encouraged fluid intake and continue to monitor vital signs through the night. Blood pressure around 7:25am (sic) is 125/63...Notify the oncoming nurse to monitor resident vital signs and notify MD..." There was no evidence the other shifts on 08/30/14 monitored R #1's vital signs or notified R #1's physician. -08/31/14 at 6:45 a.m.: "...Alert and oriented x3...Continue to run low blood pressure during the night shift. Blood pressure around the 2am (sic) was 65/45...Noted in 24 hours (sic) report for morning nurse to notify MD..." There was no evidence the other shifts on 08/31/14 monitored R #1's blood pressure or notified R #1's physician. -09/01/14 at 8:20 a.m.: "...Alert and oriented x3 (A&Ox3)...Continue to rung (sic) low blood pressure. Notified morning nurse to monitor blood pressure. Poor pulses at extremities..." There was no evidence the other shifts on 09/01/14 monitored R #1's blood pressure. -09/02/14 at 10:10 a.m.: "...Pt is A&Ox3..." There was no evidence R #1's vital signs were monitored or R #1's physician was notified, and no other entries on 09/02/14. -09/03/14 at 2:21 p.m.: "...(indwelling urinary catheter) in place, dark yellow urine, with no odor...(complaining of) pain, medicated for pain as ordered as needed. Will continue to monitor. Assessed patient had red colored loose stools with foul odor, and head of penis has a hole on the left side. Called (MD "A's") office immediately to notify Dr..." R #1's physician progress notes [REDACTED]. -09/03/14: "(R #1) makes no complaints. He insists on going home in 2 days. He has developed erosion of urethra due to (indwelling urinary catheter)...His urine output is decreased...VSS (vital signs stable)...Penis with erosion of urethra (approximately) 1/2 penis...Consider suprapubic cath...He is high risk for hospitalization ." R #1's Nurses Notes dated 09/03/14: -11:03 p.m.: "(R #1) found unresponsive at 4:45 (p.m.), able to get patient to respond after 1-2 minutes. B/P (blood pressure) 74/58...(on-call for MD "A") notified of pt. status, orders given to transfer to the ER...Rechecked on patient (every) 30 minutes, pt. (patient) has a glassy look to his face, response is sluggish, B/P remained low..." On 09/05/14 at 8:55 a.m., MD "A" stated he assessed R #1's catheter on 08/12/14 and found no abnormalities. MD "A" stated "within a couple of days after he got (to the facility), we cultured (the penis) and started antibiotics." MD "A" stated he assessed R #1's catheter on 08/26/14 and "the discharge was gone. At that point, there was no change (to R #1's penis)." MD "A" stated he assessed R #1's penis on 09/03/14 and saw the "erosion" after the facility nurses reported the erosion to MD "A" and before R #1 was sent to the hospital. MD "A" stated R #1's erosion was caused from having a "chronic catheter." When investigator showed MD "A" Hospital "AA's" documented photographs dated 09/03/14 of R #1's perineal area, MD "A" said nothing. On 09/05/14 at 11:30 a.m., Licensed Vocational Nurse (LVN) "B" stated she routinely provided care to R #1. LVN "B" stated it was the facility's policy to provide residents with indwelling urinary catheter care every shift and as needed; to use an indwelling urinary catheter strap for stabilization; and to assess the catheter and surrounding tissue during care. LVN "B" stated she assessed R #1 on or around 08/23/14 and R #1 had "pus/yellowish clearish" coming from the tip of R #1's penis. LVN "B" stated R #1 received an antibiotic daily for the drainage, R #1's penis was "normal" in appearance every day she worked until 09/03/14 and she documented the condition of R #1's penis in the Nurses Notes. LVN "B" stated on 09/03/14, she assessed R #1 and "It was the first time he had a change." LVN "B" stated the "left side" on the "tip" of R #1's penis "was open. There was no skin there...It looked red. I didn't see any black areas." LVN "B" stated she notified MD "A." LVN "B" stated the Certified Nurse Aides (CNAs) provided R #1 with catheter care and LVN "B" ensured the catheter care was done daily on her shift as ordered by making rounds. LVN "B" stated she documented by initialing R #1's Treatment Administration Record R #1 received catheter care and if there were no initials, "you didn't do it." LVN "B" stated an indwelling urinary catheter strap's purpose was for "safety...Penis could break down." LVN "B" stated she did not "recall" R #1 having an indwelling urinary catheter strap and the "nurses" were "responsible" to ensure residents' indwelling urinary catheters were anchored. On 09/05/14 at 12:00 p.m., CNA "C" stated it was the facility's policy to provide indwelling urinary catheter care every shift and to report to the nurses "anything that doesn't look normal." CNA "C" stated the purpose of an indwelling urinary catheter strap was "so it doesn't pull on the urethra. Pressure could cause infection and pain and could cause skin to tear." CNA "C" stated R #1 "refused to let us do his catheter (care) most of the time. I would report it to (LVN "B")." CNA "C" stated R #1 had refused catheter care for approximately two weeks. On 09/05/14 at 12:20 p.m., LVN "B" stated she did not "remember being told about (R #1) refusing catheter care." On 09/05/14 at 12:25 p.m., the Director of Nurses (DON) stated it was the facility's policy to provide indwelling urinary catheter care "every shift and as needed." The DON stated, "The nurses should be making sure the catheters are cleaned during rounds and document on the Treatment Administration Record it was done." The DON stated if there was no documentation on the Treatment Administration Record, "It may not have been done." The DON stated she expected the nurses to assess a resident who had a change in condition and notify the physician. The DON stated if a resident refused care, the nurse should "talk" to the resident and "try again." The DON stated she was not aware R #1 refused catheter care and on 09/03/14, staff reported to her R #1's penis "didn't look right." The DON stated she assessed R #1 before he went to the hospital and saw that "part of the head of the penis was gone....(the) scrotum was swollen and raw. I didn't see any black areas." The DON stated she instructed staff to notify MD "A" and MD "A" assessed R #1 at approximately 3:30 p.m. on 09/03/14 but did not order R #1 to be sent to the hospital. The DON stated R #1 was sent to the hospital after R #1 became unresponsive on 09/03/14. The DON stated "My nurses dropped the ball" when asked if staff monitored R #1's indwelling urinary catheter. The Administrator was on leave during the investigation. On 09/05/14 at 1:50 p.m., CNA "D" stated R #1 would "put his hands in front of his penis" when CNA "D" attempted to provide indwelling urinary catheter care. CNA "D" stated she reported this to LVN "B." On 09/05/14 at 3:00 p.m., Registered Nurse (RN) "E" stated it was the facility's policy to provide indwelling urinary catheter care "daily." RN "E" stated nurses were responsible to provide indwelling urinary catheter care and to document the care was provided on the residents' Treatment Administration Record. RN "E" stated if there were no initials on the Treatment Administration Record, "It wasn't done." RN "E" stated she provided indwelling urinary catheter care for R #1 every day she worked. RN "E" stated R #1's penis was "normal" until 09/03/14, when she assessed R #1 and found it "looked like one half of his (penile) head was missing..." after getting report from LVN "B." RN "E" stated she sent R #1 to the hospital on [DATE] because R #1 became unresponsive. RN "E" stated R #1 never refused catheter care. On 09/05/14 at 4:50 p.m., CNA "F" stated he routinely provided care for R #1. CNA "F" stated providing indwelling urinary catheter care for R #1 was "hard because he was in pain...I didn't want to hurt him, so I stopped because he moaned." CNA "F" stated this occurred for approximately "one to two weeks" before R #1 was sent to the hospital on [DATE]. CNA "F" stated he reported R #1 was in pain to LVN "B" and RN "E." CNA "F" stated R #1 had "gunk" on the tip of his penis and it had been "getting worse" and "getting harder to remove and it was turning black." CNA "F" stated, "I don't remember telling the nurse it was black." On 09/05/14 at 5:20 p.m., CNA "G" stated she routinely provided care for R #1. CNA "G" stated approximately "one to two weeks" before R #1 was sent to the hospital on [DATE], CNA "G" noticed the "top of (R #1's) penis was red with pus...There was a piece of skin hanging and it started to bleed. I saw black areas." CNA "G" stated R #1 "started refusing catheter care" and she reported this to LVN "B" and RN "E." CNA "G" stated R #1 did not have an indwelling urinary catheter tubing strap "the whole time he was here." CNA "G" stated if a residents' indwelling urinary catheter tubing was not anchored, a residents' urethra "can get infected, start eating from the inside the urethra, could cause damage." R #1's Nurses Notes dated 08/05/14 through 09/03/14 revealed no evidence R #1 refused catheter care. R #2 R #2's undated Face Sheet revealed an [AGE] year old female admitted on [DATE] with the [DIAGNOSES REDACTED]. R #2's Quarterly MDS dated [DATE] revealed R #2 usually made self understood; usually understood others; was totally dependent on staff for toilet use and personal hygiene; and had an indwelling urinary catheter. R #2's Physician order [REDACTED]. R #2's "Catheter Justification" Form dated 06/11/14 revealed R #2 had an indwelling urinary catheter due to non-healing pressure ulcers. R #2's Treatment Administration Record dated August, 2014 revealed no evidence R #2 received indwelling urinary catheter care on the 7:00 a.m. to 3:00 p.m. shift on 08/08/14, 08/09/14, 08/14/14, 08/15/14, 08/20/14, 08/21/14, 08/26/14 and 08/27/14. R #2's Treatment Administration Record dated September, 2014 revealed no evidence R #2 received indwelling urinary catheter care on 09/03/14, 09/04/14 and 09/05/14 on the 3:00 p.m. to 11:00 p.m. shift; and on 09/01/14, 09/02/14, 09/03/14 and 09/04/14 on the 11:00 p.m. to 7:00 p.m. shift. Observation of R #2 on 09/05/14 at 8:52 a.m. revealed R #2's urinary catheter was not anchored. R #3 R #3's undated Face Sheet revealed a [AGE] year old female admitted on [DATE] with the [DIAGNOSES REDACTED]. R #3's Admission MDS dated [DATE] revealed R #3 understood others and made self understood; required extensive assistance with toilet use and personal hygiene; and did not have an indwelling urinary catheter. R #3's Telephone Order dated 09/04/14 revealed an order for [REDACTED]. Observation of R #3 on 09/05/14 at 9:20 a.m. revealed R #3's indwelling urinary catheter was not anchored. R #4 R #4's undated Face Sheet revealed a [AGE] year old female admitted on [DATE] with the [DIAGNOSES REDACTED]. R #4's Quarterly MDS dated [DATE] revealed R #4 usually understood others; usually made self understood; required extensive assistance with toileting and personal hygiene; and had an indwelling urinary catheter. R #4's Physician order [REDACTED]. R #4's "Catheter Justification" Form dated 02/11/14 revealed R #4 had an indwelling urinary catheter for comfort at end of life. R #4's Treatment Administration Record dated August, 2014 revealed no evidence R #4 received indwelling urinary catheter care on the 7:00 a.m. to 3:00 p.m. shift on 08/01/14; on the 3:00 p.m. to 11:00 p.m. on 08/08/14 and 08/09/14; and on the 11:00 p.m. to 7:00 p.m. shift on 08/07/14. R #4's Treatment Administration Record dated September, 2014 revealed no evidence R #4 received indwelling urinary catheter care on the 7:00 a.m. to 3:00 p.m. shift on 09/03/14, 09/04/14 and 09/05/14. Observation of R #4 on 09/05/14 at 9:22 a.m. revealed R #4's indwelling urinary catheter was not anchored. R #5 R #5's undated Face Sheet revealed a [AGE] year old male admitted on [DATE] with the [DIAGNOSES REDACTED]. R #5's Quarterly MDS dated [DATE] revealed R #5 understood others and made self understood; required extensive assistance with toileting and personal hygiene; had an indwelling urinary catheter. R #5's Physician order [REDACTED]. R #5's "Catheter Justification" Form dated 06/10/14 revealed R #5 had an indwelling urinary catheter due to urine retention. Observation of R #5 on 09/05/14 at 9:30 a.m. revealed R #5's indwelling urinary catheter was not anchored. R #7 R #7's undated Face Sheet revealed a [AGE] year old female admitted on [DATE] with the [DIAGNOSES REDACTED]. R #7's Admission MDS dated [DATE] revealed R #7 understood others and made self understood; required extensive assistance with toileting and personal hygiene; and had an indwelling urinary catheter. R #7's Physician order [REDACTED]. R #7's "Medication Record" dated August, 2014 revealed no evidence R #7 received indwelling urinary catheter care on the 7:00 a.m. to 3:00 p.m. shift on 08/31/14; and the 3:00 p.m. to 11:00 p.m. shift on 08/26/14 and 08/28/14. Observation of R #7 on 09/05/14 at 9:15 a.m. revealed R #7's indwelling urinary catheter was not anchored. R #8 R #8's undated Face Sheet revealed an [AGE] year old female admitted on [DATE] with the [DIAGNOSES REDACTED]. R #8's Annual MDS dated [DATE] revealed R #8 usually made self understood; usually understood others; required extensive assistance with toileting and personal hygiene; and had an indwelling urinary catheter. R #8's Physician order [REDACTED]. R #8's Treatment Administration Record dated August, 2014 revealed no evidence R #8 received indwelling urinary catheter care on the 7:00 a.m. to 3:00 p.m. shift on 08/08/14, 08/09/14, 08/14/14, 08/15/14, 08/20/14, 08/21/14, 08/26/14 and 08/27/14; and the 11:00 p.m. to 7:00 a.m. shift on 08/03/14 and 08/16/14. R #8's Treatment Administration Record dated September, 2014 revealed no evidence R #8 received indwelling urinary catheter care on the 3:00 p.m. to 11:00 p.m. shift on 09/01/14, 09/02/14, 09/03/14 and 09/05/14; and the 11:00 p.m. to 7:00 a.m. shift on 09/03/14. Observation of R #8 on 09/05/14 at 9:10 a.m. revealed R #8's indwelling urinary catheter was not anchored. R #9 R #9's undated Face Sheet revealed a [AGE] year old man admitted on [DATE] with the [DIAGNOSES REDACTED]. R #9's MDS dated [DATE] revealed R #9 understood others and made self understood; required extensive assistance with toileting and personal hygiene; and did not have an indwelling urinary catheter. R #9's Physician order [REDACTED]. Observation of R #9 on 09/05/14 at 9:40 a.m. revealed R #9's indwelling urinary catheter was not anchored. The facility's undated "Protection of Residents: Reducing the Threat of Abuse & Neglect" revealed: "...Charges of abuse and/or neglect are among the most serious allegations that can occur in a nursing home...It is the policy and practice of (this fill-in-the-blank section was left blank) that all residents will be protected from abuse and/or neglect...The facility must develop and operationalize policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect...The purpose is to assure that the facility is doing all that is within its control to prevent occurrences...Every resident in a long term care facility may be at risk for abuse and/or neglect due to the potential for diminished capacity ... Residents have the right to be treated by caring and [MEDICATION NAME] staff who have adequate knowledge to appropriately respond to residents with diverse behaviors and dependencies, facilitating a protective environment for both residents and staff...This facility does not condone resident abuse and/or neglect by anyone...Our residents and families depend on us to provide a safe and caring environment. This responsibility carries with it a number of factors. Residents and families look to us not only for physical care but also for emotional support...Our role is to reassure them that we have created a 'safe' and [MEDICATION NAME] place for care...Neglect is the failure to provide goods and services to avoid physical harm, mental anguish, or mental illness..." Lippincott's Nursing Procedures, Sixth Edition, pages 380 and 381, entitled Indwelling Urinary Catheter Insertion indicates: "...(For a female) Tape the catheter to the patient's thigh to prevent possible tension on the urogenital trigone...(For a male) Tape the catheter to the patient's abdomen or thigh to prevent pressure on the urethra at the penoscrotal junction, which can lead to formation of urethrocutaneous fistulas. Taping this way also prevents traction on the bladder and alteration in the normal direction of urine flow in males. As an alternative, secure the catheter to the patient's thigh using a leg band with a Velcro closure..." According to Lippincott's Nursing Procedures, Sixth Edition, pages 374-375, entitled Indwelling Urinary Catheter Care and Removal: "...the equipment and the patient's genitalia require inspection twice daily...Inspect the outside of the catheter where it enters the urinary meatus for encrusted material and suppurative drainage. Also inspect the tissue around the meatus for irritation or swelling...NURSING ALERT Provide enough slack before securing the catheter to prevent tension on the tubing, which could injure the urethral lumen or bladder wall..." The facility's undated "Daily Catheter Care" Policy revealed: "...In order to prevent infection, the daily catheter care procedure was developed...15. The catheter should be loosely taped to the resident's inner thigh to keep it from being pulled from the bladder or a catheter strap may be used with frail skin...Reporting procedures: Upon completion of giving catheter care, the nurse assistant should report the following to the staff/charge nurse: 1. That the catheter care had been given. 2. The time the care was given. 3. How the resident tolerated the procedure. 4. Any complaints the resident may have of burning, tenderness, pain in the urethral area, or changes in the appearance of the urine. 5. If the resident refused the treatment, the reason(s) why. 6. Your observations of anything unusual...Infection Control: To assure that infection control practices are being maintained:...9. Wash the perineal area daily with soap and water...Assessment: The assessment should include the following:...2. The resultant problems or limitations..." On 09/05/14 at 4:15 p.m., an IJ was identified and the DON was informed at 4:15 p.m. of the IJ due to the above failures. On 09/05/14 at 7:07 p.m., the facility's third Plan of Removal was accepted and contained the following: "This will serve as our allegation of compliance 1. What are we going to do for the resident affected a. The individual affected was sent out to hospital and remains hospitalized 2. What are we going to do for all others who have the potential to be affected a. All other residents who have the ability to be impacted by this allegation would be those residents who have a catheter i. All residents with catheters will immediately be assessed for proper placement, security, signs and symptoms of infection and drainage ii. Catheter justification worksheets will be completed on all residents with catheters immediately iii. All assessments will be documented in the clinical record 3. How are we going to address these systematic issues a. Immediately for those on shift and prior to providing care for those who are not on shift. All clinical staff will be trained on the following. i. Male and Female catheter care ii. S/S (signs and symptoms) of infection iii. Notification regarding change of condition, resident refusal of care. Nurse will be notified and will document in clinical record the refusal and notify the MD and family. The staff will attempt to render care at a later time. We will educate the resident on the risk of refusing care. We will constantly assess and document the residents condition. iv. Interact 3 to include 'stop and watch' and SBAR v. Shift to shift communication vi. Skills and competency check lists will be conducted on all clinical staff regarding pericare and catheter care as well as S/S of infection 4. How will we monitor ongoing compliance a. The charge nurse will document on the TAR every shift regarding i. Foley catheter placement ii. Security iii. Drainage iv. Signs and symptoms of infection b. The Director of Nursing/designee will review the TAR daily to ensure that documentation is present c. The Director of Nursing/designee will monitor residents with foley catheters daily to ensure that all care has been rendered and documentation is accurate. This will occur daily for seven days, after which time this will occur five times a week for seven days, after which time this will occur three times a week for seven days after which this will occur weekly ongoing. d. A log of monitoring will be maintained and shared with the Performance Improvement Committee for review and recommendations as applicable." End of Plan of Removal. Through observations, interviews and record reviews, surveyors determined that inservicing was initiated, residents with catheters were assessed and staff followed the residents at risk for catheter complications monitoring that was documented in the facility's Plan of Removal were implemented. On 09/05/14 at 8:00 p.m., the DON was informed the IJ was removed. However, the facility remained out of compliance at a level of severity for actual harm with a scope identified as pattern. The facility was still monitoring the Plan of R

Based on observation, interview, and record review, the facility failed to ensure each resident received and provided the necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the plan of care for eight Residents (R #1, R #2, R #3, R #4, R #5, R #7, R #8 and R #9) of nine Residents reviewed for indwelling urinary catheter care. The facility failed to assess and provide care to R #1's indwelling urinary catheter. As a result, R #1 was sent to the hospital on [DATE] with penile erosion, blackened areas on his penis, drainage from his penis, swollen testicles and was missing part of his penile head. R #1 was diagnosed with [REDACTED]. The facility failed to anchor R #1, R #2, R #3, R #4, R #5, R #7, R #8 or R #9's indwelling urinary catheters, placing them at risk for urethral damage. These failures resulted in identification of an Immediate Jeopardy (IJ) on 09/05/14. While the IJ was removed on 09/05/14, the facility remained out of compliance for actual harm at a scope of pattern due to the facility was continuing to in-service staff and monitoring the Plan of Removal. These deficient practices placed eight residents with indwelling urinary catheters at risk of neglect due to not receiving proper assessments and care and services required to prevent delay in treatment, complications, hospitalization , or possible harm. Findings were: R #1 R #1's undated Face Sheet revealed a [AGE] year old male admitted to the facility on [DATE]. R #1's Admission Minimum Data Set ((MDS) dated [DATE] revealed R #1 had the [DIAGNOSES REDACTED]. R #1's Admission MDS dated [DATE] revealed R #1 had clear speech; made self understood and understood others; had intact cognition; did not have behavioral symptoms; required extensive assistance with bed mobility, dressing, eating, toilet use and personal hygiene; was totally dependent with bathing; and had an indwelling urinary catheter (a tube inserted into the bladder to enable urination.) R #1's Care Plans dated 08/05/14 revealed R #1 had an indwelling urinary catheter and interventions included "(indwelling urinary) catheter care protocol (policy)." The facility's undated "Daily Catheter Care" Policy included: "...In order to prevent infection, the daily catheter care procedure was developed...15. The catheter should be loosely taped to the resident's inner thigh to keep it from being pulled from the bladder or a catheter strap may be used with frail skin..." R #1's Physician order [REDACTED]. R #1's "Catheter Justification" Form dated 08/05/14 revealed R #1 had an indwelling urinary catheter due to non-healing pressure ulcers. R #1's Telephone Order dated 09/03/14 at 4:00 p.m. revealed an order to send R #1 to the hospital for evaluation and treatment. R #1's Emergency Provider Report from Hospital "AA" dated 09/03/14 revealed: "...Patient is a distressed, toxic looking 76 (year old) male...has a (indwelling urinary catheter) with severe catheter induced urethral (tube that drains urine from the bladder) erosion...appears septic (infection)..." According to www.ncbi.nlm.nih.gov on 09/18/14, entitled "Urethral erosion: a case for prevention, ... Existing research suggests that negative outcomes associated with urethral and meatal erosions can be prevented by properly securing the indwelling catheter..." R #1's History and Physical from Hospital "AA" dated 09/04/14 revealed: "...Assessment/Plan: Urosepsis-likely from UTI (urinary tract infection), with (indwelling urinary catheter) that was not properly cared for...penile meatus erosion and scrotal swelling..." According to www.sepsisalliance.org on 09/18/14, [MEDICAL CONDITION] and Urinary Tract Infections, "... An untreated (urinary tract infection) may spread to the kidney, causing more pain and illness. It can also [MEDICAL CONDITIONS] is the body's often deadly response to infection or injury. [MEDICAL CONDITION] kills and disables millions and requires early suspicion and rapid treatment for [REDACTED]. R #1's documented photographs from Hospital "AA" dated 09/03/14 of R #1's perineal area revealed: -White to yellow drainage from his penis, -The scrotum was swollen and red in color, -On the meatus of R #1's penis and on the underside of the urethra, an approximate one centimeter diameter area of skin was missing from the urethra, -The urethra was swollen and the approximate size of one centimeter, with an approximate 0.5 centimeter indentation at the bottom of the urethra where the indwelling urinary catheter rested against it, -Approximately four black colored areas with erosion approximately 0.125 centimeters in diameter on the tip of the penis, and along the right side of the urethra. Observation of R #1 in the Intensive Care Unit at Hospital "AA" on 09/04/14 at 3:15 p.m. revealed R #1 was unresponsive to investigator's questions. R #1 moaned when repositioned by hospital staff. On 09/04/15 at 3:10 p.m., Family Member (FM) "BB" stated R #1 had an indwelling urinary catheter inserted on or around 08/01/14 due to surgery and R #1's perineal area was "normal" when the urinary catheter was inserted. R #1's "Medication Record" dated 08/05/14 revealed facility nurses documented by initialing R #1 received indwelling urinary catheter care every day from 08/06/14 through 08/31/14 on the 7:00 a.m. to 3:00 p.m. shift, the 3:00 p.m. to 11:00 p.m. shift and the 11:00 p.m. to 7:00 a.m. shift. R #1's Treatment Record dated September 2014 revealed facility nurses documented by initialing R #1 received indwelling urinary catheter care on 09/01/14, 09/02/14 and 09/04/14 on the 11:00 p.m. to 7:00 a.m. shift. The sections for the 7:00 a.m. to 3:00 p.m. and the 3:00 p.m. to 11:00 p.m. shifts were left blank. R #1's Telephone Order dated 08/21/14 at 3:30 p.m. revealed an order to obtain a wound culture to "penial area" and an order for [REDACTED]. R #1's physician progress notes [REDACTED]. -08/22/14: "...(R #1) has no complaints...Nurses called (and) reported drainage out of penis around catheter...Penile discharge culture pending..." There was no evidence R #1's catheter or penis was assessed. R #1's Medication Administration Record [REDACTED]. Review of R #1's entire clinical record, including R #1's Nurses Notes, revealed there was no evidence R #1's penis was assessed from 08/21/14 through 09/02/14. R #1's physician progress notes [REDACTED]. -08/26/14: "...(R #1) has no complaints..." There was no evidence R #1's catheter or penis was assessed, -08/29/14: "(R #1) up in wheelchair. He has no complaints..." There was no evidence R #1's catheter or penis was assessed. R #1's Nurses Notes revealed: -08/30/14 at 7:41 a.m.: "...Resident difficult to arouse or unresponsive during the night. Blood pressure 69/45. Blood sugar 120. Respiratory very shallow...Call (sic) 911. Resident awakened on paramedic arrival and refused to be transferred to hospital for evaluation. Stated, 'I'm okay, nothing is wrong with me, I heard when you were calling me. I feel like not answering you.' Encouraged fluid intake and continue to monitor vital signs through the night. Blood pressure around 7:25am (sic) is 125/63...Notify the oncoming nurse to monitor resident vital signs and notify MD..." There was no evidence the other shifts on 08/30/14 monitored R #1's vital signs or notified R #1's physician. -08/31/14 at 6:45 a.m.: "...Alert and oriented x3...Continue to run low blood pressure during the night shift. Blood pressure around the 2am (sic) was 65/45...Noted in 24 hours (sic) report for morning nurse to notify MD..." There was no evidence the other shifts on 08/31/14 monitored R #1's blood pressure or notified R #1's physician. -09/01/14 at 8:20 a.m.: "...Alert and oriented x3 (A&Ox3)...Continue to rung (sic) low blood pressure. Notified morning nurse to monitor blood pressure. Poor pulses at extremities..." There was no evidence the other shifts on 09/01/14 monitored R #1's blood pressure. -09/02/14 at 10:10 a.m.: "...Pt is A&Ox3..." There was no evidence R #1's vital signs were monitored or R #1's physician was notified, and no other entries on 09/02/14. -09/03/14 at 2:21 p.m.: "...(indwelling urinary catheter) in place, dark yellow urine, with no odor...(complaining of) pain, medicated for pain as ordered as needed. Will continue to monitor. Assessed patient had red colored loose stools with foul odor, and head of penis has a hole on the left side. Called (MD "A's") office immediately to notify Dr..." R #1's physician progress notes [REDACTED]. -09/03/14: "(R #1) makes no complaints. He insists on going home in 2 days. He has developed erosion of urethra due to (indwelling urinary catheter)...His urine output is decreased...VSS (vital signs stable)...Penis with erosion of urethra (approximately) 1/2 penis...Consider suprapubic cath...He is high risk for hospitalization ." R #1's Nurses Notes dated 09/03/14: -11:03 p.m.: "(R #1) found unresponsive at 4:45 (p.m.), able to get patient to respond after 1-2 minutes. B/P (blood pressure) 74/58...(on-call for MD "A") notified of pt. status, orders given to transfer to the ER...Rechecked on patient (every) 30 minutes, pt. (patient) has a glassy look to his face, response is sluggish, B/P remained low..." On 09/05/14 at 8:55 a.m., MD "A" stated he assessed R #1's catheter on 08/12/14 and found no abnormalities. MD "A" stated "within a couple of days after he got (to the facility), we cultured (the penis) and started antibiotics." MD "A" stated he assessed R #1's catheter on 08/26/14 and "the discharge was gone. At that point, there was no change (to R #1's penis)." MD "A" stated he assessed R #1's penis on 09/03/14 and saw the "erosion" after the facility nurses reported the erosion to MD "A" and before R #1 was sent to the hospital. MD "A" stated R #1's erosion was caused from having a "chronic catheter." When investigator showed MD "A" Hospital "AA's" documented photographs dated 09/03/14 of R #1's perineal area, MD "A" said nothing. On 09/05/14 at 11:30 a.m., Licensed Vocational Nurse (LVN) "B" stated she routinely provided care to R #1. LVN "B" stated it was the facility's policy to provide residents with indwelling urinary catheter care every shift and as needed; to use an indwelling urinary catheter strap for stabilization; and to assess the catheter and surrounding tissue during care. LVN "B" stated she assessed R #1 on or around 08/23/14 and R #1 had "pus/yellowish clearish" coming from the tip of R #1's penis. LVN "B" stated R #1 received an antibiotic daily for the drainage, R #1's penis was "normal" in appearance every day she worked until 09/03/14 and she documented the condition of R #1's penis in the Nurses Notes. LVN "B" stated on 09/03/14, she assessed R #1 and "It was the first time he had a change." LVN "B" stated the "left side" on the "tip" of R #1's penis "was open. There was no skin there...It looked red. I didn't see any black areas." LVN "B" stated she notified MD "A." LVN "B" stated the Certified Nurse Aides (CNAs) provided R #1 with catheter care and LVN "B" ensured the catheter care was done daily on her shift as ordered by making rounds. LVN "B" stated she documented by initialing R #1's Treatment Administration Record R #1 received catheter care and if there were no initials, "you didn't do it." LVN "B" stated an indwelling urinary catheter strap's purpose was for "safety...Penis could break down." LVN "B" stated she did not "recall" R #1 having an indwelling urinary catheter strap and the "nurses" were "responsible" to ensure residents' indwelling urinary catheters were anchored. On 09/05/14 at 12:00 p.m., CNA "C" stated it was the facility's policy to provide indwelling urinary catheter care every shift and to report to the nurses "anything that doesn't look normal." CNA "C" stated the purpose of an indwelling urinary catheter strap was "so it doesn't pull on the urethra. Pressure could cause infection and pain and could cause skin to tear." CNA "C" stated R #1 "refused to let us do his catheter (care) most of the time. I would report it to (LVN "B")." CNA "C" stated R #1 had refused catheter care for approximately two weeks. On 09/05/14 at 12:20 p.m., LVN "B" stated she did not "remember being told about (R #1) refusing catheter care." On 09/05/14 at 12:25 p.m., the Director of Nurses (DON) stated it was the facility's policy to provide indwelling urinary catheter care "every shift and as needed." The DON stated, "The nurses should be making sure the catheters are cleaned during rounds and document on the Treatment Administration Record it was done." The DON stated if there was no documentation on the Treatment Administration Record, "It may not have been done." The DON stated she expected the nurses to assess a resident who had a change in condition and notify the physician. The DON stated if a resident refused care, the nurse should "talk" to the resident and "try again." The DON stated she was not aware R #1 refused catheter care and on 09/03/14, staff reported to her R #1's penis "didn't look right." The DON stated she assessed R #1 before he went to the hospital and saw that "part of the head of the penis was gone....(the) scrotum was swollen and raw. I didn't see any black areas." The DON stated she instructed staff to notify MD "A" and MD "A" assessed R #1 at approximately 3:30 p.m. on 09/03/14 but did not order R #1 to be sent to the hospital. The DON stated R #1 was sent to the hospital after R #1 became unresponsive on 09/03/14. The DON stated "My nurses dropped the ball" when asked if staff monitored R #1's indwelling urinary catheter. The Administrator was on leave during the investigation. On 09/05/14 at 1:50 p.m., CNA "D" stated R #1 would "put his hands in front of his penis" when CNA "D" attempted to provide indwelling urinary catheter care. CNA "D" stated she reported this to LVN "B." On 09/05/14 at 3:00 p.m., Registered Nurse (RN) "E" stated it was the facility's policy to provide indwelling urinary catheter care "daily." RN "E" stated nurses were responsible to provide indwelling urinary catheter care and to document the care was provided on the residents' Treatment Administration Record. RN "E" stated if there were no initials on the Treatment Administration Record, "It wasn't done." RN "E" stated she provided indwelling urinary catheter care for R #1 every day she worked. RN "E" stated R #1's penis was "normal" until 09/03/14, when she assessed R #1 and found it "looked like one half of his (penile) head was missing..." after getting report from LVN "B." RN "E" stated she sent R #1 to the hospital on [DATE] because R #1 became unresponsive. RN "E" stated R #1 never refused catheter care. On 09/05/14 at 4:50 p.m., CNA "F" stated he routinely provided care for R #1. CNA "F" stated providing indwelling urinary catheter care for R #1 was "hard because he was in pain...I didn't want to hurt him, so I stopped because he moaned." CNA "F" stated this occurred for approximately "one to two weeks" before R #1 was sent to the hospital on [DATE]. CNA "F" stated he reported R #1 was in pain to LVN "B" and RN "E." CNA "F" stated R #1 had "gunk" on the tip of his penis and it had been "getting worse" and "getting harder to remove and it was turning black." CNA "F" stated, "I don't remember telling the nurse it was black." On 09/05/14 at 5:20 p.m., CNA "G" stated she routinely provided care for R #1. CNA "G" stated approximately "one to two weeks" before R #1 was sent to the hospital on [DATE], CNA "G" noticed the "top of (R #1's) penis was red with pus...There was a piece of skin hanging and it started to bleed. I saw black areas." CNA "G" stated R #1 "started refusing catheter care" and she reported this to LVN "B" and RN "E." CNA "G" stated R #1 did not have an indwelling urinary catheter tubing strap "the whole time he was here." CNA "G" stated if a residents' indwelling urinary catheter tubing was not anchored, a residents' urethra "can get infected, start eating from the inside the urethra, could cause damage." R #1's Nurses Notes dated 08/05/14 through 09/03/14 revealed no evidence R #1 refused catheter care. R #2 R #2's undated Face Sheet revealed an [AGE] year old female admitted on [DATE] with the [DIAGNOSES REDACTED]. R #2's Quarterly MDS dated [DATE] revealed R #2 usually made self understood; usually understood others; was totally dependent on staff for toilet use and personal hygiene; and had an indwelling urinary catheter. R #2's Physician order [REDACTED]. R #2's "Catheter Justification" Form dated 06/11/14 revealed R #2 had an indwelling urinary catheter due to non-healing pressure ulcers. R #2's Treatment Administration Record dated August, 2014 revealed no evidence R #2 received indwelling urinary catheter care on the 7:00 a.m. to 3:00 p.m. shift on 08/08/14, 08/09/14, 08/14/14, 08/15/14, 08/20/14, 08/21/14, 08/26/14 and 08/27/14. R #2's Treatment Administration Record dated September, 2014 revealed no evidence R #2 received indwelling urinary catheter care on 09/03/14, 09/04/14 and 09/05/14 on the 3:00 p.m. to 11:00 p.m. shift; and on 09/01/14, 09/02/14, 09/03/14 and 09/04/14 on the 11:00 p.m. to 7:00 p.m. shift. Observation of R #2 on 09/05/14 at 8:52 a.m. revealed R #2's urinary catheter was not anchored. R #3 R #3's undated Face Sheet revealed a [AGE] year old female admitted on [DATE] with the [DIAGNOSES REDACTED]. R #3's Admission MDS dated [DATE] revealed R #3 understood others and made self understood; required extensive assistance with toilet use and personal hygiene; and did not have an indwelling urinary catheter. R #3's Telephone Order dated 09/04/14 revealed an order for [REDACTED]. Observation of R #3 on 09/05/14 at 9:20 a.m. revealed R #3's indwelling urinary catheter was not anchored. R #4 R #4's undated Face Sheet revealed a [AGE] year old female admitted on [DATE] with the [DIAGNOSES REDACTED]. R #4's Quarterly MDS dated [DATE] revealed R #4 usually understood others; usually made self understood; required extensive assistance with toileting and personal hygiene; and had an indwelling urinary catheter. R #4's Physician order [REDACTED]. R #4's "Catheter Justification" Form dated 02/11/14 revealed R #4 had an indwelling urinary catheter for comfort at end of life. R #4's Treatment Administration Record dated August, 2014 revealed no evidence R #4 received indwelling urinary catheter care on the 7:00 a.m. to 3:00 p.m. shift on 08/01/14; on the 3:00 p.m. to 11:00 p.m. on 08/08/14 and 08/09/14; and on the 11:00 p.m. to 7:00 p.m. shift on 08/07/14. R #4's Treatment Administration Record dated September, 2014 revealed no evidence R #4 received indwelling urinary catheter care on the 7:00 a.m. to 3:00 p.m. shift on 09/03/14, 09/04/14 and 09/05/14. Observation of R #4 on 09/05/14 at 9:22 a.m. revealed R #4's indwelling urinary catheter was not anchored. R #5 R #5's undated Face Sheet revealed a [AGE] year old male admitted on [DATE] with the [DIAGNOSES REDACTED]. R #5's Quarterly MDS dated [DATE] revealed R #5 understood others and made self understood; required extensive assistance with toileting and personal hygiene; had an indwelling urinary catheter. R #5's Physician order [REDACTED]. R #5's "Catheter Justification" Form dated 06/10/14 revealed R #5 had an indwelling urinary catheter due to urine retention. Observation of R #5 on 09/05/14 at 9:30 a.m. revealed R #5's indwelling urinary catheter was not anchored. R #7 R #7's undated Face Sheet revealed a [AGE] year old female admitted on [DATE] with the [DIAGNOSES REDACTED]. R #7's Admission MDS dated [DATE] revealed R #7 understood others and made self understood; required extensive assistance with toileting and personal hygiene; and had an indwelling urinary catheter. R #7's Physician order [REDACTED]. R #7's "Medication Record" dated August, 2014 revealed no evidence R #7 received indwelling urinary catheter care on the 7:00 a.m. to 3:00 p.m. shift on 08/31/14; and the 3:00 p.m. to 11:00 p.m. shift on 08/26/14 and 08/28/14. Observation of R #7 on 09/05/14 at 9:15 a.m. revealed R #7's indwelling urinary catheter was not anchored. R #8 R #8's undated Face Sheet revealed an [AGE] year old female admitted on [DATE] with the [DIAGNOSES REDACTED]. R #8's Annual MDS dated [DATE] revealed R #8 usually made self understood; usually understood others; required extensive assistance with toileting and personal hygiene; and had an indwelling urinary catheter. R #8's Physician order [REDACTED]. R #8's Treatment Administration Record dated August, 2014 revealed no evidence R #8 received indwelling urinary catheter care on the 7:00 a.m. to 3:00 p.m. shift on 08/08/14, 08/09/14, 08/14/14, 08/15/14, 08/20/14, 08/21/14, 08/26/14 and 08/27/14; and the 11:00 p.m. to 7:00 a.m. shift on 08/03/14 and 08/16/14. R #8's Treatment Administration Record dated September, 2014 revealed no evidence R #8 received indwelling urinary catheter care on the 3:00 p.m. to 11:00 p.m. shift on 09/01/14, 09/02/14, 09/03/14 and 09/05/14; and the 11:00 p.m. to 7:00 a.m. shift on 09/03/14. Observation of R #8 on 09/05/14 at 9:10 a.m. revealed R #8's indwelling urinary catheter was not anchored. R #9 R #9's undated Face Sheet revealed a [AGE] year old man admitted on [DATE] with the [DIAGNOSES REDACTED]. R #9's MDS dated [DATE] revealed R #9 understood others and made self understood; required extensive assistance with toileting and personal hygiene; and did not have an indwelling urinary catheter. R #9's Physician order [REDACTED]. Observation of R #9 on 09/05/14 at 9:40 a.m. revealed R #9's indwelling urinary catheter was not anchored. Lippincott's Nursing Procedures, Sixth Edition, pages 380 and 381, entitled Indwelling Urinary Catheter Insertion indicates: "...(For a female) Tape the catheter to the patient's thigh to prevent possible tension on the urogenital trigone...(For a male) Tape the catheter to the patient's abdomen or thigh to prevent pressure on the urethra at the penoscrotal junction, which can lead to formation of urethrocutaneous fistulas. Taping this way also prevents traction on the bladder and alteration in the normal direction of urine flow in males. As an alternative, secure the catheter to the patient's thigh using a leg band with a Velcro closure..." According to Lippincott's Nursing Procedures, Sixth Edition, pages 374-375, entitled Indwelling Urinary Catheter Care and Removal: "...the equipment and the patient's genitalia require inspection twice daily...Inspect the outside of the catheter where it enters the urinary meatus for encrusted material and suppurative drainage. Also inspect the tissue around the meatus for irritation or swelling...NURSING ALERT Provide enough slack before securing the catheter to prevent tension on the tubing, which could injure the urethral lumen or bladder wall..." The facility's undated "Daily Catheter Care" Policy revealed: "...In order to prevent infection, the daily catheter care procedure was developed...15. The catheter should be loosely taped to the resident's inner thigh to keep it from being pulled from the bladder or a catheter strap may be used with frail skin...Reporting procedures: Upon completion of giving catheter care, the nurse assistant should report the following to the staff/charge nurse: 1. That the catheter care had been given. 2. The time the care was given. 3. How the resident tolerated the procedure. 4. Any complaints the resident may have of burning, tenderness, pain in the urethral area, or changes in the appearance of the urine. 5. If the resident refused the treatment, the reason(s) why. 6. Your observations of anything unusual...Infection Control: To assure that infection control practices are being maintained:...9. Wash the perineal area daily with soap and water...Assessment: The assessment should include the following:...2. The resultant problems or limitations..." On 09/05/14 at 4:15 p.m., an IJ was identified and the DON was informed at 4:15 p.m. of the IJ due to the above failures. On 09/05/14 at 7:07 p.m., the facility's third Plan of Removal was accepted and contained the following: "This will serve as our allegation of compliance 1. What are we going to do for the resident affected a. The individual affected was sent out to hospital and remains hospitalized 2. What are we going to do for all others who have the potential to be affected a. All other residents who have the ability to be impacted by this allegation would be those residents who have a catheter i. All residents with catheters will immediately be assessed for proper placement, security, signs and symptoms of infection and drainage ii. Catheter justification worksheets will be completed on all residents with catheters immediately iii. All assessments will be documented in the clinical record 3. How are we going to address these systematic issues a. Immediately for those on shift and prior to providing care for those who are not on shift. All clinical staff will be trained on the following. i. Male and Female catheter care ii. S/S (signs and symptoms) of infection iii. Notification regarding change of condition, resident refusal of care. Nurse will be notified and will document in clinical record the refusal and notify the MD and family. The staff will attempt to render care at a later time. We will educate the resident on the risk of refusing care. We will constantly assess and document the residents condition. iv. Interact 3 to include 'stop and watch' and SBAR v. Shift to shift communication vi. Skills and competency check lists will be conducted on all clinical staff regarding pericare and catheter care as well as S/S of infection 4. How will we monitor ongoing compliance a. The charge nurse will document on the TAR every shift regarding i. Foley catheter placement ii. Security iii. Drainage iv. Signs and symptoms of infection b. The Director of Nursing/designee will review the TAR daily to ensure that documentation is present c. The Director of Nursing/designee will monitor residents with foley catheters daily to ensure that all care has been rendered and documentation is accurate. This will occur daily for seven days, after which time this will occur five times a week for seven days, after which time this will occur three times a week for seven days after which this will occur weekly ongoing. d. A log of monitoring will be maintained and shared with the Performance Improvement Committee for review and recommendations as applicable." End of Plan of Removal. Through observations, interviews and record reviews, surveyors determined that inservicing was initiated, residents with catheters were assessed and staff followed the residents at risk for catheter complications monitoring that was documented in the facility's Plan of Removal were implemented. On 09/05/14 at 8:00 p.m., the DON was informed the IJ was removed. However, the facility remained out of compliance at a level of severity for actual harm with a scope identified as pattern. The facility was still monitoring the Plan of Removal. The facility's Centers for Medicare and Medicaid Services Form CMS-802 dated 09/05/14 revealed eight residents with indwelling urinary catheters. Throughout the survey and during the exit conference, the facility was given the opportunity to provide additional information related to providing care and services to prevent urinary catheter complications. As of exit on 09/06/14 at 4:10 p.m., the facility provided no further information.

Based on observation, interview, and record review, the facility failed to ensure a resident received appropriate treatment and services to prevent urinary tract infections for eight Residents (R #1, R #2, R #3, R #4, R #5, R #7, R #8 and R #9) of nine Residents reviewed for indwelling urinary catheters. The facility failed to assess and provide care to R #1's indwelling urinary catheter. As a result, R #1 was sent to the hospital on [DATE] with penile erosion, blackened areas on his penis, drainage from his penis, swollen testicles and was missing part of his penile head. R #1 was diagnosed with [REDACTED]. The facility failed to anchor R #1, R #2, R #3, R #4, R #5, R #7, R #8 or R #9's indwelling urinary catheters, placing them at risk for urethral damage. These failures resulted in identification of an Immediate Jeopardy (IJ) on 09/05/14. While the IJ was removed on 09/05/14, the facility remained out of compliance for actual harm at a scope of pattern due to the facility was continuing to in-service staff and monitoring the Plan of Removal. These deficient practices placed eight residents with indwelling urinary catheters at risk of neglect due to not receiving proper assessments and care and services required to prevent delay in treatment, complications, hospitalization , or possible harm. Findings were: R #1 R #1's undated Face Sheet revealed a [AGE] year old male admitted to the facility on [DATE]. R #1's Admission Minimum Data Set ((MDS) dated [DATE] revealed R #1 had the [DIAGNOSES REDACTED]. R #1's Admission MDS dated [DATE] revealed R #1 had clear speech; made self understood and understood others; had intact cognition; did not have behavioral symptoms; required extensive assistance with bed mobility, dressing, eating, toilet use and personal hygiene; was totally dependent with bathing; and had an indwelling urinary catheter (a tube inserted into the bladder to enable urination.) R #1's Care Plans dated 08/05/14 revealed R #1 had an indwelling urinary catheter and interventions included "(indwelling urinary) catheter care protocol (policy)." The facility's undated "Daily Catheter Care" Policy included: "...In order to prevent infection, the daily catheter care procedure was developed...15. The catheter should be loosely taped to the resident's inner thigh to keep it from being pulled from the bladder or a catheter strap may be used with frail skin..." R #1's Physician order [REDACTED]. R #1's "Catheter Justification" Form dated 08/05/14 revealed R #1 had an indwelling urinary catheter due to non-healing pressure ulcers. R #1's Telephone Order dated 09/03/14 at 4:00 p.m. revealed an order to send R #1 to the hospital for evaluation and treatment. R #1's Emergency Provider Report from Hospital "AA" dated 09/03/14 revealed: "...Patient is a distressed, toxic looking 76 (year old) male...has a (indwelling urinary catheter) with severe catheter induced urethral (tube that drains urine from the bladder) erosion...appears septic (infection)..." According to www.ncbi.nlm.nih.gov on 09/18/14, entitled "Urethral erosion: a case for prevention, ... Existing research suggests that negative outcomes associated with urethral and meatal erosions can be prevented by properly securing the indwelling catheter..." R #1's History and Physical from Hospital "AA" dated 09/04/14 revealed: "...Assessment/Plan: Urosepsis-likely from UTI (urinary tract infection), with (indwelling urinary catheter) that was not properly cared for...penile meatus erosion and scrotal swelling..." According to www.sepsisalliance.org on 09/18/14, [MEDICAL CONDITION] and Urinary Tract Infections, "... An untreated (urinary tract infection) may spread to the kidney, causing more pain and illness. It can also [MEDICAL CONDITIONS] is the body's often deadly response to infection or injury. [MEDICAL CONDITION] kills and disables millions and requires early suspicion and rapid treatment for [REDACTED]. R #1's documented photographs from Hospital "AA" dated 09/03/14 of R #1's perineal area revealed: -White to yellow drainage from his penis, -The scrotum was swollen and red in color, -On the meatus of R #1's penis and on the underside of the urethra, an approximate one centimeter diameter area of skin was missing from the urethra, -The urethra was swollen and the approximate size of one centimeter, with an approximate 0.5 centimeter indentation at the bottom of the urethra where the indwelling urinary catheter rested against it, -Approximately four black colored areas with erosion approximately 0.125 centimeters in diameter on the tip of the penis, and along the right side of the urethra. Observation of R #1 in the Intensive Care Unit at Hospital "AA" on 09/04/14 at 3:15 p.m. revealed R #1 was unresponsive to investigator's questions. R #1 moaned when repositioned by hospital staff. On 09/04/15 at 3:10 p.m., Family Member (FM) "BB" stated R #1 had an indwelling urinary catheter inserted on or around 08/01/14 due to surgery and R #1's perineal area was "normal" when the urinary catheter was inserted. R #1's "Medication Record" dated 08/05/14 revealed facility nurses documented by initialing R #1 received indwelling urinary catheter care every day from 08/06/14 through 08/31/14 on the 7:00 a.m. to 3:00 p.m. shift, the 3:00 p.m. to 11:00 p.m. shift and the 11:00 p.m. to 7:00 a.m. shift. R #1's Treatment Record dated September 2014 revealed facility nurses documented by initialing R #1 received indwelling urinary catheter care on 09/01/14, 09/02/14 and 09/04/14 on the 11:00 p.m. to 7:00 a.m. shift. The sections for the 7:00 a.m. to 3:00 p.m. and the 3:00 p.m. to 11:00 p.m. shifts were left blank. R #1's Telephone Order dated 08/21/14 at 3:30 p.m. revealed an order to obtain a wound culture to "penial area" and an order for [REDACTED]. R #1's physician progress notes [REDACTED]. -08/22/14: "...(R #1) has no complaints...Nurses called (and) reported drainage out of penis around catheter...Penile discharge culture pending..." There was no evidence R #1's catheter or penis was assessed. R #1's Medication Administration Record [REDACTED]. Review of R #1's entire clinical record, including R #1's Nurses Notes, revealed there was no evidence R #1's penis was assessed from 08/21/14 through 09/02/14. R #1's physician progress notes [REDACTED]. -08/26/14: "...(R #1) has no complaints..." There was no evidence R #1's catheter or penis was assessed, -08/29/14: "(R #1) up in wheelchair. He has no complaints..." There was no evidence R #1's catheter or penis was assessed. R #1's Nurses Notes revealed: -08/30/14 at 7:41 a.m.: "...Resident difficult to arouse or unresponsive during the night. Blood pressure 69/45. Blood sugar 120. Respiratory very shallow...Call (sic) 911. Resident awakened on paramedic arrival and refused to be transferred to hospital for evaluation. Stated, 'I'm okay, nothing is wrong with me, I heard when you were calling me. I feel like not answering you.' Encouraged fluid intake and continue to monitor vital signs through the night. Blood pressure around 7:25am (sic) is 125/63...Notify the oncoming nurse to monitor resident vital signs and notify MD..." There was no evidence the other shifts on 08/30/14 monitored R #1's vital signs or notified R #1's physician. -08/31/14 at 6:45 a.m.: "...Alert and oriented x3...Continue to run low blood pressure during the night shift. Blood pressure around the 2am (sic) was 65/45...Noted in 24 hours (sic) report for morning nurse to notify MD..." There was no evidence the other shifts on 08/31/14 monitored R #1's blood pressure or notified R #1's physician. -09/01/14 at 8:20 a.m.: "...Alert and oriented x3 (A&Ox3)...Continue to rung (sic) low blood pressure. Notified morning nurse to monitor blood pressure. Poor pulses at extremities..." There was no evidence the other shifts on 09/01/14 monitored R #1's blood pressure. -09/02/14 at 10:10 a.m.: "...Pt is A&Ox3..." There was no evidence R #1's vital signs were monitored or R #1's physician was notified, and no other entries on 09/02/14. -09/03/14 at 2:21 p.m.: "...(indwelling urinary catheter) in place, dark yellow urine, with no odor...(complaining of) pain, medicated for pain as ordered as needed. Will continue to monitor. Assessed patient had red colored loose stools with foul odor, and head of penis has a hole on the left side. Called (MD "A's") office immediately to notify Dr..." R #1's physician progress notes [REDACTED]. -09/03/14: "(R #1) makes no complaints. He insists on going home in 2 days. He has developed erosion of urethra due to (indwelling urinary catheter)...His urine output is decreased...VSS (vital signs stable)...Penis with erosion of urethra (approximately) 1/2 penis...Consider suprapubic cath...He is high risk for hospitalization ." R #1's Nurses Notes dated 09/03/14: -11:03 p.m.: "(R #1) found unresponsive at 4:45 (p.m.), able to get patient to respond after 1-2 minutes. B/P (blood pressure) 74/58...(on-call for MD "A") notified of pt. status, orders given to transfer to the ER...Rechecked on patient (every) 30 minutes, pt. (patient) has a glassy look to his face, response is sluggish, B/P remained low..." On 09/05/14 at 8:55 a.m., MD "A" stated he assessed R #1's catheter on 08/12/14 and found no abnormalities. MD "A" stated "within a couple of days after he got (to the facility), we cultured (the penis) and started antibiotics." MD "A" stated he assessed R #1's catheter on 08/26/14 and "the discharge was gone. At that point, there was no change (to R #1's penis)." MD "A" stated he assessed R #1's penis on 09/03/14 and saw the "erosion" after the facility nurses reported the erosion to MD "A" and before R #1 was sent to the hospital. MD "A" stated R #1's erosion was caused from having a "chronic catheter." When investigator showed MD "A" Hospital "AA's" documented photographs dated 09/03/14 of R #1's perineal area, MD "A" said nothing. On 09/05/14 at 11:30 a.m., Licensed Vocational Nurse (LVN) "B" stated she routinely provided care to R #1. LVN "B" stated it was the facility's policy to provide residents with indwelling urinary catheter care every shift and as needed; to use an indwelling urinary catheter strap for stabilization; and to assess the catheter and surrounding tissue during care. LVN "B" stated she assessed R #1 on or around 08/23/14 and R #1 had "pus/yellowish clearish" coming from the tip of R #1's penis. LVN "B" stated R #1 received an antibiotic daily for the drainage, R #1's penis was "normal" in appearance every day she worked until 09/03/14 and she documented the condition of R #1's penis in the Nurses Notes. LVN "B" stated on 09/03/14, she assessed R #1 and "It was the first time he had a change." LVN "B" stated the "left side" on the "tip" of R #1's penis "was open. There was no skin there...It looked red. I didn't see any black areas." LVN "B" stated she notified MD "A." LVN "B" stated the Certified Nurse Aides (CNAs) provided R #1 with catheter care and LVN "B" ensured the catheter care was done daily on her shift as ordered by making rounds. LVN "B" stated she documented by initialing R #1's Treatment Administration Record R #1 received catheter care and if there were no initials, "you didn't do it." LVN "B" stated an indwelling urinary catheter strap's purpose was for "safety...Penis could break down." LVN "B" stated she did not "recall" R #1 having an indwelling urinary catheter strap and the "nurses" were "responsible" to ensure residents' indwelling urinary catheters were anchored. On 09/05/14 at 12:00 p.m., CNA "C" stated it was the facility's policy to provide indwelling urinary catheter care every shift and to report to the nurses "anything that doesn't look normal." CNA "C" stated the purpose of an indwelling urinary catheter strap was "so it doesn't pull on the urethra. Pressure could cause infection and pain and could cause skin to tear." CNA "C" stated R #1 "refused to let us do his catheter (care) most of the time. I would report it to (LVN "B")." CNA "C" stated R #1 had refused catheter care for approximately two weeks. On 09/05/14 at 12:20 p.m., LVN "B" stated she did not "remember being told about (R #1) refusing catheter care." On 09/05/14 at 12:25 p.m., the Director of Nurses (DON) stated it was the facility's policy to provide indwelling urinary catheter care "every shift and as needed." The DON stated, "The nurses should be making sure the catheters are cleaned during rounds and document on the Treatment Administration Record it was done." The DON stated if there was no documentation on the Treatment Administration Record, "It may not have been done." The DON stated she expected the nurses to assess a resident who had a change in condition and notify the physician. The DON stated if a resident refused care, the nurse should "talk" to the resident and "try again." The DON stated she was not aware R #1 refused catheter care and on 09/03/14, staff reported to her R #1's penis "didn't look right." The DON stated she assessed R #1 before he went to the hospital and saw that "part of the head of the penis was gone....(the) scrotum was swollen and raw. I didn't see any black areas." The DON stated she instructed staff to notify MD "A" and MD "A" assessed R #1 at approximately 3:30 p.m. on 09/03/14 but did not order R #1 to be sent to the hospital. The DON stated R #1 was sent to the hospital after R #1 became unresponsive on 09/03/14. The DON stated "My nurses dropped the ball" when asked if staff monitored R #1's indwelling urinary catheter. The Administrator was on leave during the investigation. On 09/05/14 at 1:50 p.m., CNA "D" stated R #1 would "put his hands in front of his penis" when CNA "D" attempted to provide indwelling urinary catheter care. CNA "D" stated she reported this to LVN "B." On 09/05/14 at 3:00 p.m., Registered Nurse (RN) "E" stated it was the facility's policy to provide indwelling urinary catheter care "daily." RN "E" stated nurses were responsible to provide indwelling urinary catheter care and to document the care was provided on the residents' Treatment Administration Record. RN "E" stated if there were no initials on the Treatment Administration Record, "It wasn't done." RN "E" stated she provided indwelling urinary catheter care for R #1 every day she worked. RN "E" stated R #1's penis was "normal" until 09/03/14, when she assessed R #1 and found it "looked like one half of his (penile) head was missing..." after getting report from LVN "B." RN "E" stated she sent R #1 to the hospital on [DATE] because R #1 became unresponsive. RN "E" stated R #1 never refused catheter care. On 09/05/14 at 4:50 p.m., CNA "F" stated he routinely provided care for R #1. CNA "F" stated providing indwelling urinary catheter care for R #1 was "hard because he was in pain...I didn't want to hurt him, so I stopped because he moaned." CNA "F" stated this occurred for approximately "one to two weeks" before R #1 was sent to the hospital on [DATE]. CNA "F" stated he reported R #1 was in pain to LVN "B" and RN "E." CNA "F" stated R #1 had "gunk" on the tip of his penis and it had been "getting worse" and "getting harder to remove and it was turning black." CNA "F" stated, "I don't remember telling the nurse it was black." On 09/05/14 at 5:20 p.m., CNA "G" stated she routinely provided care for R #1. CNA "G" stated approximately "one to two weeks" before R #1 was sent to the hospital on [DATE], CNA "G" noticed the "top of (R #1's) penis was red with pus...There was a piece of skin hanging and it started to bleed. I saw black areas." CNA "G" stated R #1 "started refusing catheter care" and she reported this to LVN "B" and RN "E." CNA "G" stated R #1 did not have an indwelling urinary catheter tubing strap "the whole time he was here." CNA "G" stated if a residents' indwelling urinary catheter tubing was not anchored, a residents' urethra "can get infected, start eating from the inside the urethra, could cause damage." R #1's Nurses Notes dated 08/05/14 through 09/03/14 revealed no evidence R #1 refused catheter care. R #2 R #2's undated Face Sheet revealed an [AGE] year old female admitted on [DATE] with the [DIAGNOSES REDACTED]. R #2's Quarterly MDS dated [DATE] revealed R #2 usually made self understood; usually understood others; was totally dependent on staff for toilet use and personal hygiene; and had an indwelling urinary catheter. R #2's Physician order [REDACTED]. R #2's "Catheter Justification" Form dated 06/11/14 revealed R #2 had an indwelling urinary catheter due to non-healing pressure ulcers. R #2's Treatment Administration Record dated August, 2014 revealed no evidence R #2 received indwelling urinary catheter care on the 7:00 a.m. to 3:00 p.m. shift on 08/08/14, 08/09/14, 08/14/14, 08/15/14, 08/20/14, 08/21/14, 08/26/14 and 08/27/14. R #2's Treatment Administration Record dated September, 2014 revealed no evidence R #2 received indwelling urinary catheter care on 09/03/14, 09/04/14 and 09/05/14 on the 3:00 p.m. to 11:00 p.m. shift; and on 09/01/14, 09/02/14, 09/03/14 and 09/04/14 on the 11:00 p.m. to 7:00 p.m. shift. Observation of R #2 on 09/05/14 at 8:52 a.m. revealed R #2's urinary catheter was not anchored. R #3 R #3's undated Face Sheet revealed a [AGE] year old female admitted on [DATE] with the [DIAGNOSES REDACTED]. R #3's Admission MDS dated [DATE] revealed R #3 understood others and made self understood; required extensive assistance with toilet use and personal hygiene; and did not have an indwelling urinary catheter. R #3's Telephone Order dated 09/04/14 revealed an order for [REDACTED]. Observation of R #3 on 09/05/14 at 9:20 a.m. revealed R #3's indwelling urinary catheter was not anchored. R #4 R #4's undated Face Sheet revealed a [AGE] year old female admitted on [DATE] with the [DIAGNOSES REDACTED]. R #4's Quarterly MDS dated [DATE] revealed R #4 usually understood others; usually made self understood; required extensive assistance with toileting and personal hygiene; and had an indwelling urinary catheter. R #4's Physician order [REDACTED]. R #4's "Catheter Justification" Form dated 02/11/14 revealed R #4 had an indwelling urinary catheter for comfort at end of life. R #4's Treatment Administration Record dated August, 2014 revealed no evidence R #4 received indwelling urinary catheter care on the 7:00 a.m. to 3:00 p.m. shift on 08/01/14; on the 3:00 p.m. to 11:00 p.m. on 08/08/14 and 08/09/14; and on the 11:00 p.m. to 7:00 p.m. shift on 08/07/14. R #4's Treatment Administration Record dated September, 2014 revealed no evidence R #4 received indwelling urinary catheter care on the 7:00 a.m. to 3:00 p.m. shift on 09/03/14, 09/04/14 and 09/05/14. Observation of R #4 on 09/05/14 at 9:22 a.m. revealed R #4's indwelling urinary catheter was not anchored. R #5 R #5's undated Face Sheet revealed a [AGE] year old male admitted on [DATE] with the [DIAGNOSES REDACTED]. R #5's Quarterly MDS dated [DATE] revealed R #5 understood others and made self understood; required extensive assistance with toileting and personal hygiene; had an indwelling urinary catheter. R #5's Physician order [REDACTED]. R #5's "Catheter Justification" Form dated 06/10/14 revealed R #5 had an indwelling urinary catheter due to urine retention. Observation of R #5 on 09/05/14 at 9:30 a.m. revealed R #5's indwelling urinary catheter was not anchored. R #7 R #7's undated Face Sheet revealed a [AGE] year old female admitted on [DATE] with the [DIAGNOSES REDACTED]. R #7's Admission MDS dated [DATE] revealed R #7 understood others and made self understood; required extensive assistance with toileting and personal hygiene; and had an indwelling urinary catheter. R #7's Physician order [REDACTED]. R #7's "Medication Record" dated August, 2014 revealed no evidence R #7 received indwelling urinary catheter care on the 7:00 a.m. to 3:00 p.m. shift on 08/31/14; and the 3:00 p.m. to 11:00 p.m. shift on 08/26/14 and 08/28/14. Observation of R #7 on 09/05/14 at 9:15 a.m. revealed R #7's indwelling urinary catheter was not anchored. R #8 R #8's undated Face Sheet revealed an [AGE] year old female admitted on [DATE] with the [DIAGNOSES REDACTED]. R #8's Annual MDS dated [DATE] revealed R #8 usually made self understood; usually understood others; required extensive assistance with toileting and personal hygiene; and had an indwelling urinary catheter. R #8's Physician order [REDACTED]. R #8's Treatment Administration Record dated August, 2014 revealed no evidence R #8 received indwelling urinary catheter care on the 7:00 a.m. to 3:00 p.m. shift on 08/08/14, 08/09/14, 08/14/14, 08/15/14, 08/20/14, 08/21/14, 08/26/14 and 08/27/14; and the 11:00 p.m. to 7:00 a.m. shift on 08/03/14 and 08/16/14. R #8's Treatment Administration Record dated September, 2014 revealed no evidence R #8 received indwelling urinary catheter care on the 3:00 p.m. to 11:00 p.m. shift on 09/01/14, 09/02/14, 09/03/14 and 09/05/14; and the 11:00 p.m. to 7:00 a.m. shift on 09/03/14. Observation of R #8 on 09/05/14 at 9:10 a.m. revealed R #8's indwelling urinary catheter was not anchored. R #9 R #9's undated Face Sheet revealed a [AGE] year old man admitted on [DATE] with the [DIAGNOSES REDACTED]. R #9's MDS dated [DATE] revealed R #9 understood others and made self understood; required extensive assistance with toileting and personal hygiene; and did not have an indwelling urinary catheter. R #9's Physician order [REDACTED]. Observation of R #9 on 09/05/14 at 9:40 a.m. revealed R #9's indwelling urinary catheter was not anchored. Lippincott's Nursing Procedures, Sixth Edition, pages 380 and 381, entitled Indwelling Urinary Catheter Insertion indicates: "...(For a female) Tape the catheter to the patient's thigh to prevent possible tension on the urogenital trigone...(For a male) Tape the catheter to the patient's abdomen or thigh to prevent pressure on the urethra at the penoscrotal junction, which can lead to formation of urethrocutaneous fistulas. Taping this way also prevents traction on the bladder and alteration in the normal direction of urine flow in males. As an alternative, secure the catheter to the patient's thigh using a leg band with a Velcro closure..." According to Lippincott's Nursing Procedures, Sixth Edition, pages 374-375, entitled Indwelling Urinary Catheter Care and Removal: "...the equipment and the patient's genitalia require inspection twice daily...Inspect the outside of the catheter where it enters the urinary meatus for encrusted material and suppurative drainage. Also inspect the tissue around the meatus for irritation or swelling...NURSING ALERT Provide enough slack before securing the catheter to prevent tension on the tubing, which could injure the urethral lumen or bladder wall..." The facility's undated "Daily Catheter Care" Policy revealed: "...In order to prevent infection, the daily catheter care procedure was developed...15. The catheter should be loosely taped to the resident's inner thigh to keep it from being pulled from the bladder or a catheter strap may be used with frail skin...Reporting procedures: Upon completion of giving catheter care, the nurse assistant should report the following to the staff/charge nurse: 1. That the catheter care had been given. 2. The time the care was given. 3. How the resident tolerated the procedure. 4. Any complaints the resident may have of burning, tenderness, pain in the urethral area, or changes in the appearance of the urine. 5. If the resident refused the treatment, the reason(s) why. 6. Your observations of anything unusual...Infection Control: To assure that infection control practices are being maintained:...9. Wash the perineal area daily with soap and water...Assessment: The assessment should include the following:...2. The resultant problems or limitations..." On 09/05/14 at 4:15 p.m., an IJ was identified and the DON was informed at 4:15 p.m. of the IJ due to the above failures. On 09/05/14 at 7:07 p.m., the facility's third Plan of Removal was accepted and contained the following: "This will serve as our allegation of compliance 1. What are we going to do for the resident affected a. The individual affected was sent out to hospital and remains hospitalized 2. What are we going to do for all others who have the potential to be affected a. All other residents who have the ability to be impacted by this allegation would be those residents who have a catheter i. All residents with catheters will immediately be assessed for proper placement, security, signs and symptoms of infection and drainage ii. Catheter justification worksheets will be completed on all residents with catheters immediately iii. All assessments will be documented in the clinical record 3. How are we going to address these systematic issues a. Immediately for those on shift and prior to providing care for those who are not on shift. All clinical staff will be trained on the following. i. Male and Female catheter care ii. S/S (signs and symptoms) of infection iii. Notification regarding change of condition, resident refusal of care. Nurse will be notified and will document in clinical record the refusal and notify the MD and family. The staff will attempt to render care at a later time. We will educate the resident on the risk of refusing care. We will constantly assess and document the residents condition. iv. Interact 3 to include 'stop and watch' and SBAR v. Shift to shift communication vi. Skills and competency check lists will be conducted on all clinical staff regarding pericare and catheter care as well as S/S of infection 4. How will we monitor ongoing compliance a. The charge nurse will document on the TAR every shift regarding i. Foley catheter placement ii. Security iii. Drainage iv. Signs and symptoms of infection b. The Director of Nursing/designee will review the TAR daily to ensure that documentation is present c. The Director of Nursing/designee will monitor residents with foley catheters daily to ensure that all care has been rendered and documentation is accurate. This will occur daily for seven days, after which time this will occur five times a week for seven days, after which time this will occur three times a week for seven days after which this will occur weekly ongoing. d. A log of monitoring will be maintained and shared with the Performance Improvement Committee for review and recommendations as applicable." End of Plan of Removal. Through observations, interviews and record reviews, surveyors determined that inservicing was initiated, residents with catheters were assessed and staff followed the residents at risk for catheter complications monitoring that was documented in the facility's Plan of Removal were implemented. On 09/05/14 at 8:00 p.m., the DON was informed the IJ was removed. However, the facility remained out of compliance at a level of severity for actual harm with a scope identified as pattern. The facility was still monitoring the Plan of Removal. The facility's Centers for Medicare and Medicaid Services Form CMS-802 dated 09/05/14 revealed eight residents with indwelling urinary catheters. Throughout the survey and during the exit conference, the facility was given the opportunity to provide additional information related to providing care and services to prevent urinary catheter complications. As of exit on 09/06/14 at 4:10 p.m., the facility provided no further information.

Based on observation, interview and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest, practicable physical, mental, and psychosocial well-being of each resident for eight Residents (R #1, R #2, R #3, R #4, R #5, R #7, R #8 and R #9) of nine Residents reviewed for indwelling urinary catheter care. The DON failed to: 1) Implement policies and procedures for indwelling urinary catheter care. 2) Put effective measures into place to ensure staff followed physician orders. 3) Supervise the nursing staff to ensure that the nursing staff were consistently assessing R #1 and consistently documenting those assessments. The facility failed to assess and provide care to R #1's indwelling urinary catheter. As a result, R #1 was sent to the hospital on [DATE] with penile erosion, blackened areas on his penis, drainage from his penis, swollen testicles and was missing part of his penile head. R #1 was diagnosed with [REDACTED]. The facility failed to anchor R #1, R #2, R #3, R #4, R #5, R #7, R #8 or R #9's indwelling urinary catheters, placing them at risk for urethral damage. These failures resulted in identification of an Immediate Jeopardy (IJ) on 09/05/14. While the IJ was removed on 09/05/14, the facility remained out of compliance for actual harm at a scope of pattern due to the facility was continuing to in-service staff and monitoring the Plan of Removal. These deficient practices placed eight residents with indwelling urinary catheters at risk of neglect due to not receiving proper assessments and care and services required to prevent delay in treatment, complications, hospitalization , or possible harm. Findings were: Findings were: On 09/05/14 at 12:25 p.m., the Director of Nurses (DON) stated it was the facility's policy to provide indwelling urinary catheter care "every shift and as needed." The DON stated, "The nurses should be making sure the catheters are cleaned during rounds and document on the Treatment Administration Record it was done." The DON stated if there was no documentation on the Treatment Administration Record, "It may not have been done." The DON stated she expected the nurses to assess a resident who had a change in condition and notify the physician. The DON stated if a resident refused care, the nurse should "talk" to the resident and "try again." The DON stated she was not aware R #1 refused catheter care and on 09/03/14, staff reported to her R #1's penis "didn't look right." The DON stated she assessed R #1 before he went to the hospital and saw that "part of the head of the penis was gone....(the) scrotum was swollen and raw. I didn't see any black areas." The DON stated she instructed staff to notify MD "A" and MD "A" assessed R #1 at approximately 3:30 p.m. on 09/03/14 but did not order R #1 to be sent to the hospital. The DON stated R #1 was sent to the hospital after R #1 became unresponsive on 09/03/14. The DON stated "My nurses dropped the ball" when asked if staff monitored R #1's indwelling urinary catheter. The Administrator was on leave during the investigation. On 09/06/14 at 4:00 p.m., the DON stated the IJ was the result of "poor monitoring" by the DON. R #1 R #1's undated Face Sheet revealed a [AGE] year old male admitted to the facility on [DATE]. R #1's Admission Minimum Data Set ((MDS) dated [DATE] revealed R #1 had the [DIAGNOSES REDACTED]. R #1's Admission MDS dated [DATE] revealed R #1 had clear speech; made self understood and understood others; had intact cognition; did not have behavioral symptoms; required extensive assistance with bed mobility, dressing, eating, toilet use and personal hygiene; was totally dependent with bathing; and had an indwelling urinary catheter (a tube inserted into the bladder to enable urination.) R #1's Care Plans dated 08/05/14 revealed R #1 had an indwelling urinary catheter and interventions included "(indwelling urinary) catheter care protocol (policy)." The facility's undated "Daily Catheter Care" Policy included: "...In order to prevent infection, the daily catheter care procedure was developed...15. The catheter should be loosely taped to the resident's inner thigh to keep it from being pulled from the bladder or a catheter strap may be used with frail skin..." R #1's Physician order [REDACTED]. R #1's "Catheter Justification" Form dated 08/05/14 revealed R #1 had an indwelling urinary catheter due to non-healing pressure ulcers. R #1's Telephone Order dated 09/03/14 at 4:00 p.m. revealed an order to send R #1 to the hospital for evaluation and treatment. R #1's Emergency Provider Report from Hospital "AA" dated 09/03/14 revealed: "...Patient is a distressed, toxic looking 76 (year old) male...has a (indwelling urinary catheter) with severe catheter induced urethral (tube that drains urine from the bladder) erosion...appears septic (infection)..." According to www.ncbi.nlm.nih.gov on 09/18/14, entitled "Urethral erosion: a case for prevention, ... Existing research suggests that negative outcomes associated with urethral and meatal erosions can be prevented by properly securing the indwelling catheter..." R #1's History and Physical from Hospital "AA" dated 09/04/14 revealed: "...Assessment/Plan: Urosepsis-likely from UTI (urinary tract infection), with (indwelling urinary catheter) that was not properly cared for...penile meatus erosion and scrotal swelling..." According to www.sepsisalliance.org on 09/18/14, [MEDICAL CONDITION] and Urinary Tract Infections, "...An untreated (urinary tract infection) may spread to the kidney, causing more pain and illness. It can also [MEDICAL CONDITIONS] is the body's often deadly response to infection or injury. [MEDICAL CONDITION] kills and disables millions and requires early suspicion and rapid treatment for [REDACTED]. R #1's documented photographs from Hospital "AA" dated 09/03/14 of R #1's perineal area revealed: -White to yellow drainage from his penis, -The scrotum was swollen and red in color, -On the meatus of R #1's penis and on the underside of the urethra, an approximate one centimeter diameter area of skin was missing from the urethra, -The urethra was swollen and the approximate size of one centimeter, with an approximate 0.5 centimeter indentation at the bottom of the urethra where the indwelling urinary catheter rested against it, -Approximately four black colored areas with erosion approximately 0.125 centimeters in diameter on the tip of the penis, and along the right side of the urethra. Observation of R #1 in the Intensive Care Unit at Hospital "AA" on 09/04/14 at 3:15 p.m. revealed R #1 was unresponsive to investigator's questions. R #1 moaned when repositioned by hospital staff. On 09/04/15 at 3:10 p.m., Family Member (FM) "BB" stated R #1 had an indwelling urinary catheter inserted on or around 08/01/14 due to surgery and R #1's perineal area was "normal" when the urinary catheter was inserted. R #1's "Medication Record" dated 08/05/14 revealed facility nurses documented by initialing R #1 received indwelling urinary catheter care every day from 08/06/14 through 08/31/14 on the 7:00 a.m. to 3:00 p.m. shift, the 3:00 p.m. to 11:00 p.m. shift and the 11:00 p.m. to 7:00 a.m. shift. R #1's Treatment Record dated September 2014 revealed facility nurses documented by initialing R #1 received indwelling urinary catheter care on 09/01/14, 09/02/14 and 09/04/14 on the 11:00 p.m. to 7:00 a.m. shift. The sections for the 7:00 a.m. to 3:00 p.m. and the 3:00 p.m. to 11:00 p.m. shifts were left blank. R #1's Telephone Order dated 08/21/14 at 3:30 p.m. revealed an order to obtain a wound culture to "penial area" and an order for [REDACTED]. R #1's physician progress notes [REDACTED]. -08/22/14: "...(R #1) has no complaints...Nurses called (and) reported drainage out of penis around catheter...Penile discharge culture pending..." There was no evidence R #1's catheter or penis was assessed. R #1's Medication Administration Record [REDACTED]. Review of R #1's entire clinical record, including R #1's Nurses Notes, revealed there was no evidence R #1's penis was assessed from 08/21/14 through 09/02/14. R #1's physician progress notes [REDACTED]. -08/26/14: "...(R #1) has no complaints..." There was no evidence R #1's catheter or penis was assessed, -08/29/14: "(R #1) up in wheelchair. He has no complaints..." There was no evidence R #1's catheter or penis was assessed. R #1's Nurses Notes revealed: -08/30/14 at 7:41 a.m.: "...Resident difficult to arouse or unresponsive during the night. Blood pressure 69/45. Blood sugar 120. Respiratory very shallow...Call (sic) 911. Resident awakened on paramedic arrival and refused to be transferred to hospital for evaluation. Stated, 'I'm okay, nothing is wrong with me, I heard when you were calling me. I feel like not answering you.' Encouraged fluid intake and continue to monitor vital signs through the night. Blood pressure around 7:25am (sic) is 125/63...Notify the oncoming nurse to monitor resident vital signs and notify MD..." There was no evidence the other shifts on 08/30/14 monitored R #1's vital signs or notified R #1's physician. -08/31/14 at 6:45 a.m.: "...Alert and oriented x3...Continue to run low blood pressure during the night shift. Blood pressure around the 2am (sic) was 65/45...Noted in 24 hours (sic) report for morning nurse to notify MD..." There was no evidence the other shifts on 08/31/14 monitored R #1's blood pressure or notified R #1's physician. -09/01/14 at 8:20 a.m.: "...Alert and oriented x3 (A&Ox3)...Continue to rung (sic) low blood pressure. Notified morning nurse to monitor blood pressure. Poor pulses at extremities..." There was no evidence the other shifts on 09/01/14 monitored R #1's blood pressure. -09/02/14 at 10:10 a.m.: "...Pt is A&Ox3..." There was no evidence R #1's vital signs were monitored or R #1's physician was notified, and no other entries on 09/02/14. -09/03/14 at 2:21 p.m.: "...(indwelling urinary catheter) in place, dark yellow urine, with no odor...(complaining of) pain, medicated for pain as ordered as needed. Will continue to monitor. Assessed patient had red colored loose stools with foul odor, and head of penis has a hole on the left side. Called (MD "A's") office immediately to notify Dr..." R #1's physician progress notes [REDACTED]. -09/03/14: "(R #1) makes no complaints. He insists on going home in 2 days. He has developed erosion of urethra due to (indwelling urinary catheter)...His urine output is decreased...VSS (vital signs stable)...Penis with erosion of urethra (approximately) 1/2 penis...Consider suprapubic cath...He is high risk for hospitalization ." R #1's Nurses Notes dated 09/03/14: -11:03 p.m.: "(R #1) found unresponsive at 4:45 (p.m.), able to get patient to respond after 1-2 minutes. B/P (blood pressure) 74/58...(on-call for MD "A") notified of pt. status, orders given to transfer to the ER...Rechecked on patient (every) 30 minutes, pt. (patient) has a glassy look to his face, response is sluggish, B/P remained low..." On 09/05/14 at 8:55 a.m., MD "A" stated he assessed R #1's catheter on 08/12/14 and found no abnormalities. MD "A" stated "within a couple of days after he got (to the facility), we cultured (the penis) and started antibiotics." MD "A" stated he assessed R #1's catheter on 08/26/14 and "the discharge was gone. At that point, there was no change (to R #1's penis)." MD "A" stated he assessed R #1's penis on 09/03/14 and saw the "erosion" after the facility nurses reported the erosion to MD "A" and before R #1 was sent to the hospital. MD "A" stated R #1's erosion was caused from having a "chronic catheter." When investigator showed MD "A" Hospital "AA's" documented photographs dated 09/03/14 of R #1's perineal area, MD "A" said nothing. On 09/05/14 at 11:30 a.m., Licensed Vocational Nurse (LVN) "B" stated she routinely provided care to R #1. LVN "B" stated it was the facility's policy to provide residents with indwelling urinary catheter care every shift and as needed; to use an indwelling urinary catheter strap for stabilization; and to assess the catheter and surrounding tissue during care. LVN "B" stated she assessed R #1 on or around 08/23/14 and R #1 had "pus/yellowish clearish" coming from the tip of R #1's penis. LVN "B" stated R #1 received an antibiotic daily for the drainage, R #1's penis was "normal" in appearance every day she worked until 09/03/14 and she documented the condition of R #1's penis in the Nurses Notes. LVN "B" stated on 09/03/14, she assessed R #1 and "It was the first time he had a change." LVN "B" stated the "left side" on the "tip" of R #1's penis "was open. There was no skin there...It looked red. I didn't see any black areas." LVN "B" stated she notified MD "A." LVN "B" stated the Certified Nurse Aides (CNAs) provided R #1 with catheter care and LVN "B" ensured the catheter care was done daily on her shift as ordered by making rounds. LVN "B" stated she documented by initialing R #1's Treatment Administration Record R #1 received catheter care and if there were no initials, "you didn't do it." LVN "B" stated an indwelling urinary catheter strap's purpose was for "safety...Penis could break down." LVN "B" stated she did not "recall" R #1 having an indwelling urinary catheter strap and the "nurses" were "responsible" to ensure residents' indwelling urinary catheters were anchored. On 09/05/14 at 12:00 p.m., CNA "C" stated it was the facility's policy to provide indwelling urinary catheter care every shift and to report to the nurses "anything that doesn't look normal." CNA "C" stated the purpose of an indwelling urinary catheter strap was "so it doesn't pull on the urethra. Pressure could cause infection and pain and could cause skin to tear." CNA "C" stated R #1 "refused to let us do his catheter (care) most of the time. I would report it to (LVN "B")." CNA "C" stated R #1 had refused catheter care for approximately two weeks. On 09/05/14 at 12:20 p.m., LVN "B" stated she did not "remember being told about (R #1) refusing catheter care." On 09/05/14 at 1:50 p.m., CNA "D" stated R #1 would "put his hands in front of his penis" when CNA "D" attempted to provide indwelling urinary catheter care. CNA "D" stated she reported this to LVN "B." On 09/05/14 at 3:00 p.m., Registered Nurse (RN) "E" stated it was the facility's policy to provide indwelling urinary catheter care "daily." RN "E" stated nurses were responsible to provide indwelling urinary catheter care and to document the care was provided on the residents' Treatment Administration Record. RN "E" stated if there were no initials on the Treatment Administration Record, "It wasn't done." RN "E" stated she provided indwelling urinary catheter care for R #1 every day she worked. RN "E" stated R #1's penis was "normal" until 09/03/14, when she assessed R #1 and found it "looked like one half of his (penile) head was missing..." after getting report from LVN "B." RN "E" stated she sent R #1 to the hospital on [DATE] because R #1 became unresponsive. RN "E" stated R #1 never refused catheter care. On 09/05/14 at 4:50 p.m., CNA "F" stated he routinely provided care for R #1. CNA "F" stated providing indwelling urinary catheter care for R #1 was "hard because he was in pain...I didn't want to hurt him, so I stopped because he moaned." CNA "F" stated this occurred for approximately "one to two weeks" before R #1 was sent to the hospital on [DATE]. CNA "F" stated he reported R #1 was in pain to LVN "B" and RN "E." CNA "F" stated R #1 had "gunk" on the tip of his penis and it had been "getting worse" and "getting harder to remove and it was turning black." CNA "F" stated, "I don't remember telling the nurse it was black." On 09/05/14 at 5:20 p.m., CNA "G" stated she routinely provided care for R #1. CNA "G" stated approximately "one to two weeks" before R #1 was sent to the hospital on [DATE], CNA "G" noticed the "top of (R #1's) penis was red with pus...There was a piece of skin hanging and it started to bleed. I saw black areas." CNA "G" stated R #1 "started refusing catheter care" and she reported this to LVN "B" and RN "E." CNA "G" stated R #1 did not have an indwelling urinary catheter tubing strap "the whole time he was here." CNA "G" stated if a residents' indwelling urinary catheter tubing was not anchored, a residents' urethra "can get infected, start eating from the inside the urethra, could cause damage." R #1's Nurses Notes dated 08/05/14 through 09/03/14 revealed no evidence R #1 refused catheter care. R #2 R #2's undated Face Sheet revealed an [AGE] year old female admitted on [DATE] with the [DIAGNOSES REDACTED]. R #2's Quarterly MDS dated [DATE] revealed R #2 usually made self understood; usually understood others; was totally dependent on staff for toilet use and personal hygiene; and had an indwelling urinary catheter. R #2's Physician order [REDACTED]. R #2's "Catheter Justification" Form dated 06/11/14 revealed R #2 had an indwelling urinary catheter due to non-healing pressure ulcers. R #2's Treatment Administration Record dated August, 2014 revealed no evidence R #2 received indwelling urinary catheter care on the 7:00 a.m. to 3:00 p.m. shift on 08/08/14, 08/09/14, 08/14/14, 08/15/14, 08/20/14, 08/21/14, 08/26/14 and 08/27/14. R #2's Treatment Administration Record dated September, 2014 revealed no evidence R #2 received indwelling urinary catheter care on 09/03/14, 09/04/14 and 09/05/14 on the 3:00 p.m. to 11:00 p.m. shift; and on 09/01/14, 09/02/14, 09/03/14 and 09/04/14 on the 11:00 p.m. to 7:00 p.m. shift. Observation of R #2 on 09/05/14 at 8:52 a.m. revealed R #2's urinary catheter was not anchored. R #3 R #3's undated Face Sheet revealed a [AGE] year old female admitted on [DATE] with the [DIAGNOSES REDACTED]. R #3's Admission MDS dated [DATE] revealed R #3 understood others and made self understood; required extensive assistance with toilet use and personal hygiene; and did not have an indwelling urinary catheter. R #3's Telephone Order dated 09/04/14 revealed an order for [REDACTED]. Observation of R #3 on 09/05/14 at 9:20 a.m. revealed R #3's indwelling urinary catheter was not anchored. R #4 R #4's undated Face Sheet revealed a [AGE] year old female admitted on [DATE] with the [DIAGNOSES REDACTED]. R #4's Quarterly MDS dated [DATE] revealed R #4 usually understood others; usually made self understood; required extensive assistance with toileting and personal hygiene; and had an indwelling urinary catheter. R #4's Physician order [REDACTED]. R #4's "Catheter Justification" Form dated 02/11/14 revealed R #4 had an indwelling urinary catheter for comfort at end of life. R #4's Treatment Administration Record dated August, 2014 revealed no evidence R #4 received indwelling urinary catheter care on the 7:00 a.m. to 3:00 p.m. shift on 08/01/14; on the 3:00 p.m. to 11:00 p.m. on 08/08/14 and 08/09/14; and on the 11:00 p.m. to 7:00 p.m. shift on 08/07/14. R #4's Treatment Administration Record dated September, 2014 revealed no evidence R #4 received indwelling urinary catheter care on the 7:00 a.m. to 3:00 p.m. shift on 09/03/14, 09/04/14 and 09/05/14. Observation of R #4 on 09/05/14 at 9:22 a.m. revealed R #4's indwelling urinary catheter was not anchored. R #5 R #5's undated Face Sheet revealed a [AGE] year old male admitted on [DATE] with the [DIAGNOSES REDACTED]. R #5's Quarterly MDS dated [DATE] revealed R #5 understood others and made self understood; required extensive assistance with toileting and personal hygiene; had an indwelling urinary catheter. R #5's Physician order [REDACTED]. R #5's "Catheter Justification" Form dated 06/10/14 revealed R #5 had an indwelling urinary catheter due to urine retention. Observation of R #5 on 09/05/14 at 9:30 a.m. revealed R #5's indwelling urinary catheter was not anchored. R #7 R #7's undated Face Sheet revealed a [AGE] year old female admitted on [DATE] with the [DIAGNOSES REDACTED]. R #7's Admission MDS dated [DATE] revealed R #7 understood others and made self understood; required extensive assistance with toileting and personal hygiene; and had an indwelling urinary catheter. R #7's Physician order [REDACTED]. R #7's "Medication Record" dated August, 2014 revealed no evidence R #7 received indwelling urinary catheter care on the 7:00 a.m. to 3:00 p.m. shift on 08/31/14; and the 3:00 p.m. to 11:00 p.m. shift on 08/26/14 and 08/28/14. Observation of R #7 on 09/05/14 at 9:15 a.m. revealed R #7's indwelling urinary catheter was not anchored. R #8 R #8's undated Face Sheet revealed an [AGE] year old female admitted on [DATE] with the [DIAGNOSES REDACTED]. R #8's Annual MDS dated [DATE] revealed R #8 usually made self understood; usually understood others; required extensive assistance with toileting and personal hygiene; and had an indwelling urinary catheter. R #8's Physician order [REDACTED]. R #8's Treatment Administration Record dated August, 2014 revealed no evidence R #8 received indwelling urinary catheter care on the 7:00 a.m. to 3:00 p.m. shift on 08/08/14, 08/09/14, 08/14/14, 08/15/14, 08/20/14, 08/21/14, 08/26/14 and 08/27/14; and the 11:00 p.m. to 7:00 a.m. shift on 08/03/14 and 08/16/14. R #8's Treatment Administration Record dated September, 2014 revealed no evidence R #8 received indwelling urinary catheter care on the 3:00 p.m. to 11:00 p.m. shift on 09/01/14, 09/02/14, 09/03/14 and 09/05/14; and the 11:00 p.m. to 7:00 a.m. shift on 09/03/14. Observation of R #8 on 09/05/14 at 9:10 a.m. revealed R #8's indwelling urinary catheter was not anchored. R #9 R #9's undated Face Sheet revealed a [AGE] year old man admitted on [DATE] with the [DIAGNOSES REDACTED]. R #9's MDS dated [DATE] revealed R #9 understood others and made self understood; required extensive assistance with toileting and personal hygiene; and did not have an indwelling urinary catheter. R #9's Physician order [REDACTED]. Observation of R #9 on 09/05/14 at 9:40 a.m. revealed R #9's indwelling urinary catheter was not anchored. The facility's Director of Nursing Job Description dated 08/05/11 indicated: "... The DIRECTOR of NURSING (DON) plans, organizes, develops, and directs the overall operation of the Nursing Services department to ensure the highest degree of quality resident care in accordance with all laws, regulations, and Life Care standards..." The facility's undated "Protection of Residents: Reducing the Threat of Abuse & Neglect" revealed: "...Charges of abuse and/or neglect are among the most serious allegations that can occur in a nursing home...It is the policy and practice of (this fill-in-the-blank section was left blank) that all residents will be protected from abuse and/or neglect...The facility must develop and operationalize policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect...The purpose is to assure that the facility is doing all that is within its control to prevent occurrences...Every resident in a long term care facility may be at risk for abuse and/or neglect due to the potential for diminished capacity ... Residents have the right to be treated by caring and [MEDICATION NAME] staff who have adequate knowledge to appropriately respond to residents with diverse behaviors and dependencies, facilitating a protective environment for both residents and staff...This facility does not condone resident abuse and/or neglect by anyone...Our residents and families depend on us to provide a safe and caring environment. This responsibility carries with it a number of factors. Residents and families look to us not only for physical care but also for emotional support...Our role is to reassure them that we have created a 'safe' and [MEDICATION NAME] place for care...Neglect is the failure to provide goods and services to avoid physical harm, mental anguish, or mental illness..." Lippincott's Nursing Procedures, Sixth Edition, pages 380 and 381, entitled Indwelling Urinary Catheter Insertion indicates: "...(For a female) Tape the catheter to the patient's thigh to prevent possible tension on the urogenital trigone...(For a male) Tape the catheter to the patient's abdomen or thigh to prevent pressure on the urethra at the penoscrotal junction, which can lead to formation of urethrocutaneous fistulas. Taping this way also prevents traction on the bladder and alteration in the normal direction of urine flow in males. As an alternative, secure the catheter to the patient's thigh using a leg band with a Velcro closure..." According to Lippincott's Nursing Procedures, Sixth Edition, pages 374-375, entitled Indwelling Urinary Catheter Care and Removal: "...the equipment and the patient's genitalia require inspection twice daily...Inspect the outside of the catheter where it enters the urinary meatus for encrusted material and suppurative drainage. Also inspect the tissue around the meatus for irritation or swelling...NURSING ALERT Provide enough slack before securing the catheter to prevent tension on the tubing, which could injure the urethral lumen or bladder wall..." The facility's undated "Daily Catheter Care" Policy revealed: "...In order to prevent infection, the daily catheter care procedure was developed...15. The catheter should be loosely taped to the resident's inner thigh to keep it from being pulled from the bladder or a catheter strap may be used with frail skin...Reporting procedures: Upon completion of giving catheter care, the nurse assistant should report the following to the staff/charge nurse: 1. That the catheter care had been given. 2. The time the care was given. 3. How the resident tolerated the procedure. 4. Any complaints the resident may have of burning, tenderness, pain in the urethral area, or changes in the appearance of the urine. 5. If the resident refused the treatment, the reason(s) why. 6. Your observations of anything unusual...Infection Control: To assure that infection control practices are being maintained:...9. Wash the perineal area daily with soap and water...Assessment: The assessment should include the following:...2. The resultant problems or limitations..." On 09/05/14 at 4:15 p.m., an IJ was identified and the DON was informed at 4:15 p.m. of the IJ due to the above failures. On 09/05/14 at 7:07 p.m., the facility's third Plan of Removal was accepted and contained the following: "This will serve as our allegation of compliance 1. What are we going to do for the resident affected a. The individual affected was sent out to hospital and remains hospitalized 2. What are we going to do for all others who have the potential to be affected a. All other residents who have the ability to be impacted by this allegation would be those residents who have a catheter i. All residents with catheters will immediately be assessed for proper placement, security, signs and symptoms of infection and drainage ii. Catheter justification worksheets will be completed on all residents with catheters immediately iii. All assessments will be documented in the clinical record 3. How are we going to address these systematic issues a. Immediately for those on shift and prior to providing care for those who are not on shift. All clinical staff will be trained on the following. i. Male and Female catheter care ii. S/S (signs and symptoms) of infection iii. Notification regarding change of condition, resident refusal of care. Nurse will be notified and will document in clinical record the refusal and notify the MD and family. The staff will attempt to render care at a later time. We will educate the resident on the risk of refusing care. We will constantly assess and document the residents condition. iv. Interact 3 to include 'stop and watch' and SBAR v. Shift to shift communication vi. Skills and competency check lists will be conducted on all clinical staff regarding pericare and catheter care as well as S/S of infection 4. How will we monitor ongoing compliance a. The charge nurse will document on the TAR every shift regarding i. Foley catheter placement ii. Security iii. Drainage iv. Signs and symptoms of infection b. The Director of Nursing/designee will review the TAR daily to ensure that documentation is present c. The Director of Nursing/designee will monitor residents with foley catheters daily to ensure that all care has been rendered and documentation is accurate. This will occur daily for seven days, after which time this will occur five times a week for seven days, after which time this will occur three times a week for seven days after which this will occur weekly ongoing. d. A log of monitoring will be maintained and shared with the Performance Improvement Committee for review and recommendations as applicable." End of Plan of Removal. Through observations, interviews and record reviews, surveyors determined that inservicing was initiated, residents with catheters were assessed and staff followed the residents at risk for catheter complications monitoring that was documented in the facility's Plan of Removal were implemented. On 09/05/14 at 8:00 p.m., the DON was informed the IJ was removed. However, the facility remained out of compliance at a level of severity for actual harm with a scope identified as pattern. The facility was still monitoring the Plan of Removal. The facility's Centers for Medicare and Medicaid Services Form CMS-802 dated 09/05/14 revealed eight residents with indwelling urinary catheters. Throughout the survey and during the exit conference, the facility was given the opportunity to provide additional information related to providing care and services to prevent urinary catheter complications. As of exit on 09/06/14 at 4:10 p.m., the facility provided no further information.