**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, it was determined the facility failed to develop and implement a Comprehensive Care Plan (CCP) for one (1) of six (6) sampled residents (Resident #25). Observations and record review revealed Resident #25 had an indwelling urinary catheter, however, there was no documented evidence a care plan had been implemented to include catheter care. The findings include: Review of the facility's policy, Care Plans, dated 09/23/2022, revealed, Plans of Care were developed by the interdisciplinary team to coordinate and communicate care approaches and goals for the resident. The facility developed a comprehensive plan of care for each resident that included measurable objectives and timetables to meet a residents medical, nursing, and mental/psychosocial needs that were identified on the comprehensive assessment. Care plans were individualized and specific to the resident's care needs. When a new approach/intervention or goal was identified the care plan would be updated accordingly. Review of the facility's policy, Appropriate Use of Catheters and Feeding Tubes, dated 08/02/2015 and reviewed on 12/01/2022, revealed documentation in the medical record should reveal continual assessment for use of the catheter and the plan of care should address catheter use and strategies to prevent urinary tract infections. Record review revealed the facility admitted Resident #25 on 05/26/2023 with diagnosis which included Cerebral Infarction due to Unspecified occlusion or stenosis of unspecified cerebral artery, and Retention of urine. Review of Resident #25's Quarterly Minimum Data Set (MDS) Assessment, dated 06/30/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of thirteen (13) of fifteen (15), which indicated the resident was interviewable. Observation of Resident #25 on 09/06/2023 at 9:17 AM revealed he/she was lying in bed asleep and his/her catheter bag was lying on the floor beside his/her bed. Review of Resident #25's records revealed a care plan had not been implemented for catheter care. In an interview with Certified Nursing Assistant (CNA) #9 on 09/06/2023 at 3:30 PM she stated she would look at the [NAME] to know how to care for residents. In an interview with the Minimum Data Set (MDS) Coordinator on 09/08/2023 at 12:05 PM, she stated the purpose of a Care plan was to guide staff on the care a resident would need. She stated a baseline Care Plan should be implemented upon admission by the nurse performing the admission assessment. The MDS Coordinator stated she would then complete a Comprehensive Care Plan by day twenty-one (21) and was responsible for updating the care plan with any revisions or new interventions. She further stated changes with residents were discussed daily during the morning meetings and a Care Plan should be initiated or revised immediately when changes in the resident's care occurred. The MDS Coordinator stated if the resident had a catheter the resident's care plan should continued to state that staff should reflect that. In an interview with the Director of Nursing (DON) on 09/08/23 at 9:46 AM, she stated it was the responsibility of the MDS Coordinator to ensure care plans were updated to reflect the resident's status. The DON further stated all residents should have a care plan in place if they had a catheter. She further stated she expected the resident's care plans to be up to date and revised with any change in condition. In an interview with the Administrator on 09/08/2023 at 3:14 PM, she stated the MDS coordinator was responsible for ensuring care plans were updated and this was discussed daily during morning meetings. The Administrator stated she expected staff to follow the care plans and make revisions when changes occurred with the resident.

Based on observation, interview, record review, facility policy review and review of the facility's investigation, it was determined the facility failed to ensure one (1) of six (6) sampled residents received adequate supervision to prevent elopement from the facility. Record review revealed Resident #18 exited the facility through the front door as an employee was leaving for lunch on 07/07/2023. Resident #18 exited the facility on 07/07/2023 at approximately 1:30 PM. After the incident, the Wander Risk Assessment was completed again at which time the resident scored six to eleven (6-11) points, which indicated the resident had a moderate risk and the need for an Elopement Care Plan which was initiated with interventions put into place. The findings include: Review of the facility's policy, Missing Resident/Elopement, revised 10/12/2020, revealed residents making an adjustment to the facility, or who did not understand where they were, may be subject to leaving the facility without supervision. Unsupervised activity outside the facility could lead to serious injury of a resident due to the many hazards such as traffic, water, storms and hot/cold temperatures. Further review of the policy revealed elopements occurred when a resident leaves the premises or a safe area without authorization and/or necessary supervision to do so. Record review revealed the facility admitted Resident #18 on 06/26/2023 with diagnoses which included Dementia with Mood Disturbance and Hallucinations. Review of Resident #18's admission Minimum Data Set (MDS) Assessment, dated 07/03/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of ten (10) out of fifteen (15), which indicated the resident was interviewable. Review of the admission assessment, dated 06/26/2023, revealed Resident #18 was assessed to be alow risk, zero through five (0-5) for wandering on admission. Review of the facility's investigation, dated 07/11/2023, revealed that on 07/07/2023 at 1:30 PM, Resident #18 followed the maintenance man out of the front door and sat on the front porch. The resident reported to the receptionist he/she was going to wait on the daughter's arrival. At that time, the receptionist did not realize the individual was a new resident. The Certified Nurse Aide (CNA) #4 was returning from break through the front door of the facility and asked the receptionist why Resident #18 was out on the porch. At that time the receptionist realized the individual was actually a new resident. The Restorative Aide reported to the charge nurse to call a CODE PINK and the Aide and the receptionist headed back out the front door. When they reached the porch, Resident #18 had started walking around the side of the building and was located near another facility entrance. The resident was escorted back inside the facility and was assessed by the nurse and found to have no injuries. The resident was placed on increased supervision with checks every fifteen (15) minutes for forty-eight (48) hours. The resident's daughter was notified of the incident. Staff were re-educated on Elopements and Elopement drills were initiated at random times. In an interview with Resident #18, on 08/29/2023 at 10:20 AM, he/she stated she had went outside to wait for his/her daughter and had sat on the front porch. In an interview with the Receptionist, on 08/29/2023 at 3:00 PM, she stated Resident #18 was walking up the hall to the front lobby. She had opened the front door with the button for the maintenance man when Resident #18 had told the receptionist he/she was going to wait on the porch for his/her daughter. At that time, the receptionist stated she did not realize the individual was a resident of the facility. When the Certified Nurse Aide (CNA) #4 came in the front door, she asked the receptionist why the resident was outside without supervision. The Receptionist stated it was at that time she realized the individual was a current resident. She stated staff escorted the resident back into the facility. The Receptionist stated a log book of current residents was now located at the reception area for staff. In an interview with Maintenance, on 08/29/2023 at 3:51 PM, he stated he was not aware the resident was not supposed to be outside unattended until after the incident. He stated the doors were equipped with a Wanderguard system but the facility had not used it for several years. In an interview with Certified Nurse Aide (CNA) #3, on 08/30/2023 at 10:55 AM, she stated the day of the elopement of Resident #18, she remembered seeing the resident after lunch but she was unsure what time it was. She stated later that day the resident was put on every fifteen (15) minute checks after the resident was found sitting outside unattended. In an interview with CNA #4 on 08/31/2023 at 8:45 AM, she stated when returning from break on 07/07/2023 she noticed Resident #18 sitting on the front porch of the facility in a rocking chair, unattended. She asked the resident who was with him/her and the resident told her no one. CNA #4 asked the receptionist why the resident was outside and she stated the person had told her they were waiting on their daughter. She stated she told the charge nurse and the two of them walked outside where they found the resident sitting outside of a second facility entrance. CNA #4 stated the resident was escorted back into the facility. In a interview with the Director of Nursing (DON), on 08/31/2023 at 12:32 PM, she stated she had no reason to suspect Resident #18 was at risk of leaving the facility as he/she had never attempted to leave unattended. She stated she expected residents would sign out in the log book if they were leaving the facility. In an interview with the Administrator, on 09/01/2023 at 1:54 PM, she stated Resident #18 had never expressed the desire to leave the facility. She stated staff had been inserviced on the elopement policy.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two of six (6) sampled residents (Resident #7 and Resident #25). Observations of Resident #7 and #25, on 09/06/2023 and 09/07/2023, revealed the resident's catheter bags were not properly secured and were touching the floor. The findings include: Review of the facility's policy, Infection Prevention, dated 12/01/2022, revealed the facility's Infection Prevention and Control Program would follow national standards and guidelines to prevent, recognize and control the onset and spread of infection whenever possible. The Infection Prevention and Control Program included 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 regulatory requirements and following accepted national standards. Review of the facility's policy, Appropriate Use of Catheters and Feeding Tubes, dated 12/01/2022, revealed that documentation in the medical record should reveal continual assessment for use of the catheter and the plan of care should address catheter use and strategies to prevent urinary tract infections. 1. Record review revealed the facility admitted Resident #25 on 05/26/2023 with diagnosis which included Cerebral Infarction due to Unspecified occlusion or stenosis of unspecified cerebral artery, Retention of urine, unspecified, and Hemiplegia and Hemiparesis following cerebral infarction affecting right dominant side. Review of Resident #25's Quarterly Minimum Data Set (MDS) Assessment, dated 06/30/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of thirteen (13) of fifteen (15), which indicated the resident was interviewable. Observation of Resident #25, on 09/06/2023 at 9:17 AM, revealed he/she had an indwelling catheter and the catheter bag were lying on the floor beside his/her bed. 2. Record review revealed the facility admitted Resident #7 on 10/30/2008 with diagnoses which included Neuromuscular Dysfunction of the Bladder and the presence of a Pressure Ulcer of the Sacral Region. Observation of Resident #7, on 09/06/2023 at 9:27 AM, revealed his/her indwelling catheter drainage bag was hanging from the bedrail and touching the floor. Additional observation of Resident #7, on 09/07/2023 at 2:27 PM, revealed his/her catheter drainage bag was touching the floor. In an interview with Certified Nurse Aide (CNA) #4, on 09/08/2023 at 10:19 AM, she stated the indwelling drainage bag should be hooked on the bedframe, the tubing looped and secured to the bed linen with the blue clip. She stated the bag should not touch the floor as it was an infection control issue. In an interview with Certified Nursing Assistant (CNA) #9 on 09/06/2023 at 3:30 PM, she stated catheters should be anchored to bed/chair and off the floor to ensure proper flow of urine. In an interview with Licensed Practical Nurse (LPN) #4 on 09/08/2023 at 2:06 PM, she stated all nursing staff to include CNA's were responsible for ensuring urinary catheters were properly anchored and kept off the floor. In an interview with the Director of Nursing (DON) on 09/08/23 at 9:46 AM, she stated proper catheter care should include the catheter cord being looped and hooked onto the side of the bed, not touching the floor and with a privacy bag in place. The DON further stated the catheter bag could bust and potentially cause an infection. She stated if a resident's bed was in the low position, the catheter bag should still be off the floor and in a privacy bag. In an interview with the Administrator, on 09/08/2023 at 3:15 PM, she stated she expected staff to follow facility policies related to catheter care.

Based on observation, interview, record review, facility policy review and review of the Centers for Disease Control (CDC) documentation, it was determined the facility failed to maintain its infection control and prevention program in accordance with CDC guidelines for COVID-19. CDC guidelines stated for counties with substantial or high transmission rates of COVID-19, staff were to wear eye protection when caring for patients (residents). The facility failed to ensure its staff wore the appropriate eye protection during all patient encounters as indicated in the CDC guidance. The deficient practice had the potential to affect all residents residing in the facility. The findings include: Review of the CDC publication (guidelines) titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, last updated 09/10/2021, revealed If SARS-CoV-2 infection was not suspected in a patient (resident) presenting for care (based on their symptom and exposure history), healthcare personnel (HCP) who were working in facilities located in counties which had substantial or high transmission should use Personal Protective Equipment (PPE) such as eye protection (goggles or a face shield which covered the front and sides of the face) during all patient (resident) care encounters. Review of the CDC' COVID Data Tracker, on the website, revealed the facility's county had a high community transmission rate of COVID-19 as of 12/08/2021. Review of the facility's policies and procedures regarding the COVID-19 pandemic revealed no documented evidence of the CDC's guidance related to use of face shields and/or goggles as indicated in the CDC's Interim Infection Prevention and Control Recommendations for Health. Observation on 12/06/2021 at 12:27 PM, revealed six (6) unidentified staff members assisting six (6) residents with their noon meal in the common area. Per observation, the six (6) staff members were sitting approximately one (1) to two (2) feet from the resident they were assisting, with face masks in place. However, further observation revealed none of the six (6) staff members were wearing goggles and/or a face shield during their interaction with the residents. Observation on 12/07/2021 at 8:00 AM, revealed Licensed Practical Nurse (LPN) #1 administering medications to Resident #30 and Resident #31. Continued observation revealed LPN #1 wore only a face mask, with no goggles and/or face shield in place during the medication administration. Observation on 12/07/2021 at 12:01 PM, revealed a Physical Therapy Assistant (PTA providing therapy services for Resident #134 in his/her room. Per observation, the PTA was sitting approximately four (4) feet from Resident #134 wearing a mask. Further observation revealed however, the PTA did not have goggles and or a face shield on during the interaction with the resident. Observation on 12/07/2021 at 12:29 PM, revealed five (5) staff members, Certified Nursing Assistant (CNA) #1, CNA #2, CNA #3, CNA #4, and LPN #1, assisting residents with their noon meal in the common area. Per observation, the staff members were sitting approximately one (1) to two (2) feet from the resident they were assisting. Continued observation revealed all the staff members were wearing a face mask; however, did not have goggles and/or a face shield on during their interactions with the residents. Interview, with the staff members at the time of observation, revealed they only wore regular masks, unless a COVID-19 positive resident was present in the building. Further interview revealed if a COVID-19 resident was present in the building, then they had to wear a gown, face shield or goggles, gloves, an N 95 mask (a particulate-filtering facepiece respirator), and foot covers. Observation on 12/07/2021 at 12:30 PM, revealed CNA #5 sitting in the dining room area, approximately one (1) to two (2) feet from a resident who needed cueing for eating. Per observation, CNA #5 was not wearing goggles and/or face shield during the interaction with the resident. Observation on 12/07/2021 at 12:33 PM, revealed CNA #5 pushing a resident in a wheelchair from the dining room to the resident's room. Per observation, the CNA was approximately one (1) to two (2) feet from the resident during the interaction. Continued observation revealed Registered Nurse (RN) #1 was also observed sitting approximately one (1) to two (2) feet from another resident in the dining room. Observation further revealed CNA #5 and RN #1 had no goggles and/or face shield in place while assisting the residents. Interview on 12/07/2021 at 12:34 PM, with RN #1 revealed the facility only required staff to wear a face shield or goggles if a resident had been diagnosed with COVID-19. Continued observations during the survey, from 8:00 AM through 4:00 PM, on 12/06/2021 through 12/08/2021, revealed all staff observed providing resident care were not wearing goggles and/or a face shield while in resident care areas. Interview on 12/08/2021 at 9:58 AM, with the Director of Nursing (DON) revealed all staff were to wear a face mask. The DON stated even though the facility was in a high-transmission county, staff were not required to wear goggles or a face shield at that time. Per the DON, wearing eye protection when the facility did not have a COVID-19 positive resident was not a part of the facility's policy. Further interview revealed the facility based their policies and procedures on the CDC recommendations and State Guidelines.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure to develop and implement a baseline care plan for one (1) of thirteen (13) sampled residents (Resident #135). Resident #135 was care planned to keep bed in low position; however, staff failed to return the resident's bed to the low position prior to leaving the resident to wash their hands. The findings include: Review of the facility policy titled, Baseline Care Plans, dated September 2017 revealed the purpose was to develop and implement a baseline care plan for each resident that includes the instructions needed to provide an effective and person-centered care of the resident that meet professional standards of quality care needs within forty-eight hours of admission. Record review revealed the facility admitted Resident #135 on 08/23/19 with diagnoses which included Status Post Spiral Fracture Shaft of Left Femur and Seizures. No Minimum Data Set was available due to the admission date. Review of Resident #135's Baseline Plan of Care for Falls Risk/Safety not dated revealed an intervention to keep bed in low position. However, observation on 08/27/19 at 9:33 PM, revealed Certified Nurse Aide (CNA) #1 and CNA #2 failed to lower Resident #135's bed after providing incontinent care while they went to wash their hands. Interviews on 08/27/19 at 9:50 PM with CNA #1 and CNA #2 revealed they should have followed the care plan and not have left the resident alone with the bed in high position. Interview with the Clinical Nurse Leader on 08/29/19 at 10:55 AM revealed she expected the CNA's to follow the care plan and not leave the resident with the resident's bed not in the low position, Interview with the Director of Nursing on 08/29/19 at 1:17 PM revealed she expected all staff to follow the Baseline care plans as written.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of seven (7) sampled residents' environment remained as free of accident hazards as is possible (Resident #135). Observation revealed two staff left Resident #135 in bed with bed in high position. The staff failed to ensure the bed was lowered prior to leaving the resident to wash their hands. The findings include: Review of the facility policy titled, Incidents and Accidents dated August 2015 and revised 02/21/18 revealed the purpose of the policy was to ensure the resident environment remains as free of accident hazards as is possible. Interventions will be implemented immediately to reduce potential for incident/accidents. Keep bed in low position. Record review revealed the facility admitted Resident #135 on 08/23/19 with diagnoses which included Status Post Spiral Fracture Shaft of Left Femur. No Minimum Data Set was available due to the admission date. Review of Resident #135's Baseline Plan of Care, not dated, revealed a plan for Falls Risk/Safety with a goal for the resident to remain free of injuries and falls. Further review revealed an Intervention to keep the bed in low position. Review of the Certified Nurse Aide (CNA) Care Plan dated 08/23/19 revealed the resident was to have two assist with incontinent care and was on Seizure precautions. Observation of incontinent care on 08/27/19 at 9:33 PM, revealed CNA #1 and CNA #2 raised the residents' bed to high position. The CNA's then proceeded to go to the residents' bathroom and wash their hands together, leaving the resident alone; and with bed in high position which placed the resident in danger of falling off the bed. After incontinent care was completed, the CNA's placed the bed back in low position. Interview on 08/27/19 at 9:50 PM with CNA#1 and CNA #2 revealed they should have never left the resident alone with the bed in high position to wash their hands. They stated one should have stayed with resident and they should have taken turns to wash hands. Interview with the Clinical Nurse Leader on 08/29/19 at 10:55 AM revealed she expected one CNA to stay at resident's bedside at all times when residents' bed was in high position. Interview with the Director of Nursing (DON) on 08/29/19 at 1:17 PM revealed she expected at least one staff to stay at the bedside if resident is in the bed and the bed is raised in high position; or if they both have to leave the bedside, to place the bed back in low position. She stated she also expected staff to follow facility policy and care plans as written.