Based on record review, staff interview, and facility policy review, the facility failed to transmit MDS assessments within 14 days of completion for (10) of (52) sampled residents. (Resident #3, Resident #48, Resident #52, Resident #54, Resident #81, Resident #96, Resident #98, Resident #102, Resident #116, and Resident # 134). Findings include: Review of the facility's policy, Minimum Data Set (MDS) Assessment, revised 9/2019, revealed, .The facility follows Resident Assessment Instrument (RAI) manual from Centers of Medicare and Medicaid services (CMS) for all Residents .Assessment Timing (will follow the RAI manual guidelines) . Record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated October 2019 revealed . Transmitting Data: . Assessment Transmission: Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date (V0200C2 + 14 days) .All other MDS assessments must be submitted within 14 days of the MDS Completion Date (Z0500B + 14 days). Resident # 3: A record review of the admission Record revealed the facility admitted Resident #3 on 4/19/24 with diagnoses that included Type 2 Diabetes and Bradycardia. A record review of Resident #3'sDischarge MDS with an Assessment Reference Date (ARD) of 4/24/24 revealed Section Z0500B was dated 05/08/24. A record review of the facility's Final Validation Report revealed the assessment had been submitted on 9/25/24. Resident #3 had a target date of 04/24/24, which was more than 14 days after the date indicated on Section Z0500B of the MDS. Resident #48: A record review of the admission Record revealed the facility admitted Resident #48 on 5/15/14 with diagnoses including Anoxic Brain Damage. A record review of Resident #48's Quarterly MDS revealed an ARD of 8/13/2024 and Section Z0500B revealed a date of 8/20/24. Record review of the facility's Final Validation Report revealed the assessment target date of 08/13/24 had been submitted on 9/24/24, which was more than 14 days after the date indicated on Section Z0500B of the MDS. Resident #52: A record review of the admission Record revealed the facility admitted Resident #52 on 10/16/2020 with diagnoses including Heart Disease. A record review of the Quarterly MDS with an ARD of 8/15/2024 revealed Section Z0500B was dated 8/21/24. A record review of the Final Validation Report revealed the assessment target date of 08/15/24 had been submitted on 9/24/24, which was more than 14 days after the date indicated on Section Z0500B of the MDS Resident #54: A record review of the admission Record revealed the facility admitted Resident #54 3/18/24 with the diagnoses including Type 2 Diabetes Mellitus. A record review of the Discharge MDS with an ARD of 06/19/24 revealed Section Z0500B was dated 07/03/24. A record review of the facility's Final Validation Report revealed Resident #54 Discharge Assessment with target date of 06/19/24 was transmitted on 09/25/24, which was more than 14 days after the date indicated on Section Z0500B of the MDS. Resident #81 A record review of the facility's admission Record revealed the facility admitted Resident #81 on 6/5/18 with diagnoses including Acute and Chronic Respiratory Failure. A record review of Resident #81's Quarterly MDS with an ARD of 8/6/2024 revealed Section Z0500B was dated 8/20/24. Record review of the facility's Final Validation Report revealed a target date of 08/6/24 was transmitted on 09/24/24, which was more than 14 days after the date indicated on Section Z0500B of the MDS. Resident #96 A record review of the admission Record revealed the facility admitted Resident #96 on 1/23/2020 with diagnoses including Unspecified Dementia and Type 2 Diabetes. A record review of the Quarterly MDS with an ARD of 8/15/24 revealed Section Z0500B was dated 8/22/24. A record review of the facility's Final Validation Report revealed a target date of 08/15/24 and was transmitted on 09/24/24, which was more than 14 days after the date indicated on Section Z0500B of the MDS. Resident #98 A record review of the admission Record revealed the facility admitted Resident #98 on 5/18/23 with a diagnosis of Cerebral Palsy. A record review of the Quarterly MDS with an ARD of 8/12/2024 revealed Section Z0500B was dated 08/20/24. A record review of the facility's Final Validation Report revealed a target date of 08/12/24 and was transmitted on 09/24/24, which was more than 14 days after the date indicated on Section Z0500B of the MDS. Resident # 102 Record review of admission Record revealed the facility admitted Resident #102 on 08/24/23 with diagnoses including Unspecified Convulsions. A record review of the Discharge MDS with an ARD of 05/31/24 revealed Section Z0500B was dated 06/14/24. A record review of the facility's Final Validation Report revealed target date of 05/31/24 and was transmitted on 9/25/24, which was more than 14 days after the date indicated on Section Z0500B of the MDS. Resident #116 A record review of the admission Record revealed the facility admitted Resident #116 on 3/22/22 with diagnoses including Hemiplegia. A record review of Quarterly MDS with an ARD of 8/12/2024 revealed Section Z0500B was dated 08/20/2024. A record review of the Final Validation Report for Resident #116 revealed the MDS transmission had a Target Date of 8/12/2024 and was transmitted on 9/24/24, which was more than 14 days after the date indicated on Section Z0500B of the MDS. Resident # 134 A record review of the admission Record revealed the facility admitted Resident #134 on 05/02/24 with diagnoses including Hemiplegia and Hemiparesis Disease. A record review of the Discharge MDS with an ARD of 05/19/24 revealed Section Z0500B was dated 05/31/24. A record review of the facility's Final Validation Report revealed a target date of 5/19/24 was submitted on 9/25/24, which was more than 14 days after the date indicated on Section Z0500B of the MDS. On 09/25/24 at 1:56 PM, during an interview with the Licensed Practical Nurse (LPN) # 1, she revealed she and the team were responsible for completing and transmitting MDS assessments. She explained the facility recently had an update in their Electric Medical Record (EMR) system which had caused delays in the submission of the MDS. On 09/26/24 at 8:12 AM, in an interview with the Director of Nursing (DON) she explained she was not aware that MDS Assessments were not transmitted timely, and confirmed it was the responsibility of the LPN/ MDS Coordinator to transmit the assessments. The DON stated she expected the MDS to be transmitted timely. On 09/26/24 at 10:32 AM, during an interview with the Administrator, he explained the MDS staff are responsible for completing and transmitting MDS assessments timely. He was unaware there were late MDS transmissions. He stated that timely submission was important for federal reporting and reimbursement processes.

Based on record review, staff interview, and facility policy review, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the resident's status regarding hospice services for one (1) of 52 sampled residents. Resident #99 Findings include: A review of the facility's policy Minimum Data Set (MDS) Assessments, revised 09/2019, revealed . Resident assessments will be conducted to assist in developing person-centered care plans. This facility follows Resident Assessment Instrument (RAI) manual from the Centers for Medicare and Medicaid Services (CMS) for all Residents regardless of payer source . The RAI process requires: a. The assessment accurately reflects the Resident's status . A record review of the Order Summary Report with active orders as of 09/24/24 revealed a Physician's Order, dated 11/28/23, to admit Resident #99 to hospice services. A record review of the admission Record revealed the facility admitted Resident #99 on 04/18/22 with diagnoses including Acute and Chronic Respiratory Failure with Hypoxia and Polyneuropathy. A record review of the Quarterly MDS with an Assessment Reference Date (ARD) of 09/02/24 revealed in Section O Special Treatments, Procedures, and Programs under K1 Hospice Care was not selected for Resident #99. On 09/26/24 at 8:35 AM, during an interview with the Licensed Practical Nurse (LPN) #, 1 she revealed herself and the MDS team are responsible for completing different sections of the MDS and each individual is responsible for their own accuracy. She confirmed Resident #99 is currently on Hospice care and has been for almost one (1) year. the LPN who completed Section O of Resident #99's MDS assessment was not working today. She confirmed section O Hospice on the recent Quarterly MDS was not marked and was not accurate. At 9:10 AM on 09/26/24, during an interview with Registered Nurse (RN)#1/MDS nurse, she explained each person on the MDS team was responsible for ensuring MDS assessments are accurate and reflect the resident's condition. She confirmed that Resident #99 was currently on hospice services, however, the Quarterly MDS inaccurately indicated he was not on hospice services. At 10:10 AM on 09/26/24, during an interview with the Administrator, he explained he expected the MDS team to code each residents assessments accurately and to the follow the RAI manual and the facility's policy for any assistance needed.

Based on observation, interview and facility policy review, the facility failed to store food in accordance with professional standards for food safety related to a food item not labeled, a scoop stored in a dry bin container, a food item not refrigerated, and an opened food item not discarded after the Best Before date for one (1) of two (2) kitchen observations. Findings include: A review of the facility's policy, Food Receiving and Storage, Revised October 2017, revealed, Foods shall be .stored in a manner that complies with safe food handling practices .6. All foods will be labeled with open date at the time of unsealing .9. All foods stored in the refrigerator or freezer will be .labeled and dated . On 09/23/24 at 10:12 AM, an observation and interview with the Dietary Manager (DM) revealed Freezer #1 had one (1) Styrofoam cup of a frozen substance with no date or label, that the DM was unable to identify the contents. An observation of the pantry revealed one (1) opened bag of dried cranberries with a Best Before date of 7/17/24. There was one (1) opened bottle of lime juice with a facility date of 6/17/24 and the manufactures label instructed to refrigerate after opening. There was a large bin of cornmeal in which the scoop was stored in the corn meal and not in a designated area. The DM stated the dried cranberries should have been discarded and the lime juice should have been stored in the refrigerator. The DM also confirmed the scoop should not have been stored in the corn meal bin. The DM stated the staff are in-serviced every 2 weeks on food safety. On 09/25/24 at 1:21 PM, an interview with the Administrator revealed he was made aware by staff that the lime juice was not stored properly, and a scoop was stored in the corn meal bin.

Based on interviews, record review and facility policy review the facility failed to provide written documentation when residents were transferred to the hospital for two (2) of four (4) residents reviewed for hospitalizations. Resident #72 and Resident #117. Findings Included: Record review of the facility's policy, titled Bed- Holds and Returns, dated March 2017 revealed .Policy Interpretation and Implementation .3. Prior to a transfer, if possible, written information will be given to the residents and the resident representatives that explains in detail .d. The details of the transfer (per the Notice of Transfer) . Resident #72 Record review of the Face Sheet revealed the facility admitted Resident #72 on 5/6/22 and she had diagnoses of Chronic Diastolic Congestive Heart Failure and Chronic Kidney Disease, Stage IV. Record review of the Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/23/22 revealed Resident #72 was discharged to an acute hospital. Record review of the Departmental Notes revealed a Nurses Note dated 8/23/22 at 5:20 PM, which noted Resident #72 was transferred to the local hospital and the family was notified by phone. Record review of the Discharge MDS with an ARD of 9/23/22 revealed Resident #72 was discharged to an acute hospital. Record review of the Departmental Notes revealed a Nurses Note dated 9/23/22 at 3:44 PM, which noted Resident #72 was transferred to a behavioral unit and the family was notified by phone. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/8/22 revealed Resident #72 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact. During an interview with Resident #72 on 10/12/22 at 4:47 PM, she stated that she has not received a anything from the Social Worker in writing about her hospitalizations. Resident #72 said if it was left in her room her daughter must have taken it home. Resident #72 said she has been having periods of confusion and her daughter has been handling her business. During an interview with Resident #72's daughter on 10/13/22 at 12:53 PM, she said she has not received a letter from the facility in writing about her mother going to the hospital. The daughter said the facility does notify her by phone when the resident is transferred to the hospital. Resident #117 Record review of the Face Sheet revealed the facility admitted Resident #117 on 6/6/22 and she had diagnoses including Peripheral Vascular Disease, Type 2 Diabetes Mellitus, and Unspecified Atrial Fibrillation (abnormal heart rhythm). Record review of the Discharge MDS with an ARD or 6/7/22 revealed Resident #117 was discharged to an acute hospital. Record review of the Departmental Notes revealed a Nurses Note dated 6/7/22 at 10:27 AM that noted Resident #117 was transferred to the local hospital via stretcher for respiratory distress and decreased level of consciousness. The family was notified by phone Record review of the Discharge MDS with an ARD of 6/27/22 revealed Resident #117 was discharged to an acute hospital. During an interview with the Director of Nursing (DON) on 10/12/22 at 1:30 PM, she stated that Resident #117 was transferred to the hospital directly from dialysis related to Atrial Flutter (abnormal heart rhythm) on 6/27/22. Record review of the Discharge Summary dated 6/27/22 from the local hospital revealed Resident #117 was transferred to the local hospital. Record review of the Discharge MDS with an ARD of 7/1/22 revealed Resident #117 was discharged to an acute hospital. Review of the Departmental Notes revealed a Nurses Note dated 7/1/22 at 12:33 PM, noted Resident #117 was transferred to a local hospital from the dialysis unit due to severe tachycardia (increased heart rate) and chest pain. Record review of the Quarterly MDS with ARD of 9/12/22 revealed Resident #117 had a Brief Interview for Mental Status (BIMS) of 14, which indicated she was cognitively intact. During an interview on 10/11/22 at 02:15 PM, with the Resident #117's daughter, she said she has not received a letter from the facility letting her know her mother was sent to the hospital. During an interview with the Social Worker on 10/12/22 at 1:04 PM, she said she either mailed the written notification of transfer to the family or placed them at the bedside when the resident was transferred to the hospital. She stated that she did not keep a copy of the document to be placed in the residents' medical records because she did not know that she needed to keep a copy. During an interview with the Administrator on 10/13/22 at 1:00 PM, he said the Social Worker told him that she mailed the transfer letters to the families. The Social Worker also said she left the residents that are their own responsible party letters at their bedside.

Based on interviews, record review, and facility policy review the facility failed to provide written documentation records related to bed hold upon resident transfer to the hospital for two (2) of four (4) residents reviewed for hospitalizations. Resident #72 and Resident #117. Findings Included: Review of the facility's policy, titled Bed-Holds and Returns, dated March 2017 revealed prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of bed-hold and return policy. Resident #72 Record review of the Face Sheet revealed the facility admitted Resident #72 on 5/6/22 and she had diagnoses of Chronic Diastolic Congestive Heart Failure and Chronic Kidney Disease, Stage IV. Record review of the Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/23/22 revealed Resident #72 was discharged to an acute hospital. Record review of the Departmental Notes revealed a Nurses Note dated 8/23/22 at 5:20 PM, which noted Resident #72 was transferred to the local hospital and the family was notified by phone. Record review of the Discharge MDS with an ARD of 9/23/22 revealed Resident #72 was discharged to an acute hospital. Record review of the Departmental Notes revealed a Nurses Note dated 9/23/22 at 3:44 PM, which noted Resident #72 was transferred to a behavioral unit and the family was notified by phone. Record review of the Quarterly MDS with ARD of 8/8/22 revealed Resident #72 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated she was cognitively intact. On 10/12/22 at 4:47 PM, in an interview with Resident #72, she stated she has not received any letters from the Social Worker when she was transferred to the hospital. Resident #72 commented that if any paperwork was left in her room, then her daughter must have taken it home. She admitted that she has had periods of confusion and now her daughter handles her business for her. On 10/13/22 at 12:53 PM, in an interview with Resident #72's daughter, she stated that she has not received anything from the facility related to her mother going to the hospital. Resident #117 Record review of the Face Sheet revealed the facility admitted Resident #117 on 6/6/22 and she had diagnoses including Peripheral Vascular Disease, Type 2 Diabetes Mellitus, and Unspecified Atrial Fibrillation (abnormal heart rhythm). Record review of the Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) or 6/7/22 revealed Resident #117 was discharged to an acute hospital. Record review of the Departmental Notes revealed a Nurses Note dated 6/7/22 at 10:27 AM that noted Resident #117 was transferred to the local hospital via stretcher for respiratory distress and decreased level of consciousness. The family was notified by phone Record review of the Discharge MDS with an ARD of 6/27/22 revealed Resident #117 was discharged to an acute hospital. On 10/22/22 at 1:20 PM, in an interview with the Director of Nursing (DON), she verified that on 6/27/22, Resident #117 was transferred to the hospital directly from the dialysis unit and not from the facility. She was sent to the hospital due to Atrial Flutter (abnormal heart rhythm). Record review of the Discharge Summary dated 6/27/22 from the local hospital revealed Resident #117 was transferred to the local hospital. Record review of the Discharge MDS with an ARD of 7/1/22 revealed Resident #117 was discharged to an acute hospital. Review of the Departmental Notes revealed a Nurses Note dated 7/1/22 at 12:33 PM, noted Resident #117 was transferred to a local hospital from the dialysis unit due to severe tachycardia (increased heart rate) and chest pain. Record review of the Quarterly MDS with ARD of 9/12/22 revealed Resident #117 had a Brief Interview for Mental Status (BIMS) of 14, which indicated she was cognitively intact. During an interview on 10/11/22 at 02:15 PM with the Resident #112's daughter, she said she has not received a letter from the facility letting her know her mother was sent to the hospital. On 10/12/22 at 1:04 PM, in an interview with the Social Worker, she either mailed the bed hold notifications or placed them at the bedside when the resident was transferred to the hospital. She confirmed that she does not keep a copy of the bed hold letter that she sends to the resident or resident representative. She was unaware that she should retain a copy of the notification that was mailed. On 10/13/22 at 1:00 PM, in an interview with the Administrator, he stated that the Social Worker told him that she mailed the bed hold letters to the families or gives them to the resident when a resident transfers out of the facility.

Based on facility policy review, staff interview, and record review, the facility failed to code a Significant Change in Status Assessment (SCSA) on the Minimum Data Set (MDS) for one (1) of eight (8) residents reviewed for Preadmission Screening and Resident Review (PASARR), Resident #157. Findings include: Review of facility's policy, titled Resident Assessment Instrument, dated September 2010, revealed: The Assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment Team conduct timely resident assessments and reviews according to the following schedule: Within fourteen days of the residents admission to the facility; When there has been a significant change in the residents condition; at least quarterly; and once every 12 months. All persons who have completed any portion of the Minimum Data Set (MDS) Resident Assessment Form must sign such document attesting to the accuracy of such information. Record review of the Face Sheet revealed Resident #157 was admitted by the facility on 04/28/17. Record review of the Pre-admission Screening (PAS) Level I, dated 05/10/17,revealed no Level II criteria was required at this time. Record review of the Diagnosis/History Report for Resident #157, revealed a Change in condition with a new diagnosis of Schizophrenia noted, on 11/07/18, with no PASARR Level II change in status found in the chart. Record review of the (Name of Healthcare Management Services Company)'s Level II Change in Status Request (case number-499344), dated 02/27/19, revealed the need for a Level II assessment for the diagnosis of Major Depressive Disorder. The Schizophrenia diagnosis obtained on 11/07/18 was not identified on the Level II request at this time. Record review of the Physician's Orders, dated 11/07/18, revealed Resident #157 was ordered Risperidone 0.5 milligram (mg) one (1) tablet twice a day by mouth for Mood Disorder/Aggressive behavior. Record review of a document provided and signed by Registered Nurse #2/Quality Assurance (QA) Nurse, as well as signed by the facility's Administrator, revealed: Regarding case number-499344, personnel at (Name of Healthcare Services Company) stated that a case number was located in the system, but it had not been processed, though it had been several months since it was submitted. Personnel stated that she was unsure why Level I outcomes and /or Level II outcomes were not completed and could not further assist. I was transferred to Level II division or (Name of Healthcare Management Company), however personnel stated that there was no profile in the level II division of the company. I spoke with the Department of Mental Health (DMH) Summary Reviewer regarding case number and she stated that the (Name of Healthcare Management Company) would have to send her department and as of date case number is not there. Record review of the current Physician's Order for July 2019, for Resident #157, revealed Risperdal 0.5 mg tablet give one-half (1/2) tablet by mouth every morning (Schizophrenia); Risperdal 0.5 mg tablet (1) one by mouth at bed time (Schizophrenia). An interview, on 07/11/19 at 9:12 AM, with Registered Nurse (RN) #2/Quality Assurance (QA) Nurse, revealed that when she took the position in February, she did a wide spread audit of all charts and sent to (Name of Healthcare Management Company) those residents that were needing Level II assessments. RN #2 revealed Resident #157 was one of the residents that she found needing the Level II assessment. RN #2 revealed she felt the resident's change in status for the Schizophrenia Diagnosis just fell through the crack. RN #2 revealed she sent Resident #157's need for a Level II to (Name of Healthcare Management Company) when she discovered that he had a change in status in November and the Level II request had not been done. The Level II request was sent to (Name of Healthcare Management Company) on 02/27/19. It was an abnormal length of time before his was sent to (Name of Healthcare Management Company). An interview, on 07/11/19 at 9:15 AM, with Licensed Practical Nurse (LPN)#3/Minimum Data Set (MDS) Coordinator, revealed she had just started in the MDS position not too long ago, but she remembered that they went way back and did a clean sweep to see who didn't have a Level II or a change of status. LPN #3 revealed she felt like the resident's change of status just fell through the crack because that is an abnormal length of time before it was discovered and reported. An interview, on 07/11/19 at 5:54 PM, with RN #2/QA Nurse, revealed she called (Name of Healthcare Management Company) for the resident's status on the Level II request sent 02/27/19, and was told by an (Name of Healthcare Management Company) employee that the resident had not had a Level II performed as of yet. She stated the lady at the company told her they were behind, and his paperwork was still in a pile to be processed. An interview, on 07/12/19 at 9:25 AM, with the facility's Administrator, revealed the facility realized in February they had several people who had not received a Level II assessment and several that requests had been sent to the (Name of Healthcare Management Company) with no visit from management company for some of these. He stated there were numerous requests sent at the same time and day by RN #2/QA Nurse, requesting these assessments. The Administrator revealed there should have been a process to follow up on the requests, but there wasn't a process really in place since the healthcare management company usually comes quickly for the assessments. He stated he knew (Name of the Healthcare Management Company) was behind because they had even come on weekends before to do assessments. After they realized there was a problem, in February, the facility then took the problem to the Quality Assurance team to be placed on their QA list. The Administrator stated the facility now has a process in place to follow up with the healthcare management company's requests. The process is the Transitional Care Nurse will do the Level I requests on Admission, and then the MDS Nurse will pick up if there is a change of status and file a request with the healthcare management company. The Administrator stated he was going to add a log for the healthcare management company requests so they could better follow along with the process of who has received the Level II assessments, and who had not yet received the assessment. An interview, on 07/12/19 at 11:39 AM, with the Director of Nursing (DON) revealed at the time that Resident #157 had a change in status, with a new diagnosis of Schizophrenia and a new medication given, the MDS nurse was responsible to put the information into the computer for a Level II assessment as well as putting it into the MDS and she just dropped the ball.

Based on record review, staff interview, and facility policy review, the facility failed to provide an accurate Preadmission Screening and Resident Review (PASARR) for one (1) of eight (8) residents reviewed for PASARR. Resident #76. Findings Include: Review of the facility's admission Policy titled, admission Criteria, revised December 2016, revealed our facility will admit only those residents whose medical and nursing care needs can be met. Nursing and medical needs of individual with mental disorders or intellectual disabilities will be determined by coordination with the Medicaid Pre-admission Screening and Resident Review Program (PASSAR) to the extent practicable. Review of the PASSAR, dated 02/25/2019, revealed Resident #76 did not have a mental illness. The PASSAR also stated the resident did not have a recent history of mental Illness. This PASSAR was done prior to admission. Review of the admission History and Physical upon admission, dated 02/21/2019, revealed the Resident #76 was admitted with a diagnosis of Psychosis. The History and Physical also stated Resident #76 had some severe behavioral disturbances where he became very angry and agitated requiring an injection of Haldol. It took several hours for the resident to become manageable. During an interview with the doctor, Resident#76 became agitated, yelling and then immediately apologized. the doctor said Resident #76 exhibited very spontaneous anger and agitation. Resident #76 had rapid speech, and was easily agitated. Resident #76 was ordered Haldol twice a day. On 07/12/19 1:55 PM, an interview with Registered Nurse (RN) #2/Quality Assurance (QA) Nurse confirmed the PASSAR wasn't accurate upon admission. The facility did not send the resident's PASSAR to (Name of Healthcare Management Company) to be evaluated because the Level 1 was not done accurately.

Based on facility policy review, staff interview, and record review, the facility failed to identify the need for a Level II referral in a timely manner for one (1) of eight (8) residents reviewed for Level II review. Resident #157. Findings include: Review of facility's policy titled, admission Criteria, dated December 2016, revealed: The objective of our admissions criteria policy is to admit residents who can be cared for adequately by the facility; Nursing and medical needs of individuals with mental disorders or intellectual disabilities will be determined by coordination with the Medicaid Pre-admission Screening and Resident Review Program (PASARR) to the extent practicable. Potential residents with mental disorders or intellectual disabilities will only be admitted if the State Mental Health Agency has determined (through the preadmission screening program) that the individual has a physical or mental condition that requires a level of services provided by the facility. Review of the Minimum Data Set (MDS) Summary Report, dated 07/11/19 for Resident #157, revealed no significant change for the diagnosis of Schizophrenia, which identified on 11/07/18, was entered into the MDS between the dates of 09/24/18 and 06/17/19. An interview, on 07/12/19 at 11:39 AM, with the Director of Nursing (DON) revealed, at the time that Resident #157 had a change in status with a new diagnosis of Schizophrenia and a new medication given, the MDS nurse was responsible to put the information into the computer for a Level II assessment as well as putting it into the MDS, and she just dropped the ball. An interview, on 07/12/19 2:20 PM, with Licensed Practical Nurse (LPN) #3/MDS Coordinator, revealed, The resident should have had a significant change after he received the diagnosis of Schizophrenia, and there was not one done. Him having a new diagnosis and having a new medication, it should have been a significant change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and facility policy review, the facility failed to revise Resident #89's Comprehensive Care Plan for the use of a Foley Catheter for one (1) of 37 resident care plans reviewed. Findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated December 2016, revealed that it is the policy of this facility that a comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The facility policy stated that assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. During the initial tour of the facility, on 07/09/2019 at 10:30 AM, it was observed, from the hallway Resident #89's catheter tubing was laying over the top of her bed's side rail, thus it was above the level of her bladder. It was observed that Resident #89's side rail on her bed was in an upright position. During a follow-up observation, on 07/09/2019 at 12:15 PM, it was observed that Resident #89's catheter tubing was still laying across the top of the bed's side rail, which was still in an upright position. Review of Resident #89's medical record document titled, Care Plan, revealed the Care Plan had not been revised to include upon the resident's return from the hospital, on 06/13/2019, she now had an indwelling Foley catheter. During an interview, on 07/09/2019 at 12:18 PM, Licensed Practical Nurse (LPN) #1, revealed the catheter tubing should not be hanging over the bed's side rail, because it was above the level of Resident #89's bladder. LPN #1 stated that if the catheter tubing was higher than the bladder, it would cause the urine to back up into the resident's bladder causing a Urinary Tract Infection (UTI). During an interview, on 07/09/2019 at 3:11 PM, Registered Nurse (RN) #1/ Infection Control Officer, confirmed the catheter tubing should not be over the bed's side rail, above the level of Resident #89's bladder. RN #1 stated the Certified Nursing Assistants (CNA) know better. RN #1 stated they must have forgotten to re-position the catheter after giving her a bath. RN#1 also stated it could have been the hospice CNA. During an interview, on 07/12/2019 at 10:07 AM, Licensed Practical Nurse (LPN) #3/ Care Plan Coordinator, revealed the Care Plan, in regards to Resident #89's indwelling catheter, had not been revised when Resident #89 returned from the hospital on [DATE]. During an interview, on 07/12/2019 at 10:19 AM, the Director of Nursing (DON), confirmed Resident #89's Care Plan had not been updated and revised. The DON stated it should have been revised to reflect the resident's status change, regarding the use of a Foley catheter. Review of the Face Sheet revealed Resident #89 was admitted by the facility, on 08/15/2014, with diagnoses to include Cardiac Arrhythmia and Alzheimer's Disease (AD).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff interview, and facility policy review, the facility failed to provide catheter/perineal care in a manner to prevent the possible spread of infection for four of six (4 of 6) catheter care observations, for Resident #7, Resident #88, Resident #89 and Resident #139. Findings include: Review of the facility's policy titled, Catheter Care, Urinary, dated September 2014, revealed it is the policy of this facility that the purpose of this procedure is to prevent catheter-associated Urinary Tract Infections (UTI). The policy also stated under the general guidelines, that when maintaining unobstructed urine flow, the urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. Further review of the policy revealed to prevent catheter-associated Urinary Tract Infections the Steps included in the procedure for a male resident: Use a washcloth with warm water and soap/or cleansing wipe to cleanse around the meatus. Cleanse the glans using circular strokes from the meatus outward. Change the position of the washcloth/wipe with each stroke. With a clean wash cloth, if used, rinse with warm water using the above technique. Return foreskin to normal position. Use clean washcloth with warm water and soap/or cleansing wipe to cleanse and rinse the catheter from insertion site to approximately four inches outward. Resident #89 During the initial tour of the facility, on 07/09/2019 at 10:30 AM, it was observed, from the hallway Resident #89's catheter tubing was laying over the top of her bed's side rail, thus it was above the level of her bladder. It was observed that Resident #89's side rail on her bed was in an upright position. During a follow-up observation, on 07/09/2019 at 12:15 PM, it was observed that Resident #89's catheter tubing was still laying across the top of the bed's side rail, which was still in an upright position. Review of Resident #89's medical records document titled New Physician's Orders (Physician Visits and Telephone Orders, dated 06/13/2019, revealed an order for a Foley Catheter for Resident #89. The telephone orders also revealed that catheter care is to be done every shift (Q-shift) and as needed (PRN) per facility policy and procedure. During an interview, on 07/09/2019 at 12:18 PM, Licensed Practical Nurse (LPN) #1, revealed the catheter tubing should not be hanging over the bed's side rail, because it was above the level of Resident #89's bladder. LPN #1 stated that if the catheter tubing was higher than the bladder, it would cause the urine to back up into the resident's bladder causing a Urinary Tract Infection (UTI). During an interview, on 07/09/2019 at 3:11 PM, Registered Nurse (RN) #1/ Infection Control Officer, confirmed the catheter tubing should not be over the bed's side rail, above the level of Resident #89's bladder. RN #1 stated the Certified Nursing Assistants (CNA) know better. RN #1 stated they must have forgotten to re-position the catheter after giving her a bath. RN#1 also stated it could have been the hospice CNA. Review of the Face Sheet revealed Resident #89 was admitted by the facility, on 08/15/2014, with diagnoses to include Cardiac Arrhythmia and Alzheimer's Disease (AD). Resident #7 Record review of the facility's training titled, CNA (Certified Nursing Assistant) Performance And Skills Evaluation revealed the Certified Nursing Assistants (CNAs) were in-serviced 12/06/2018, 02/14/2019 and 04/15/2019 on providing appropriate catheter care. An observation, on 07/10/19 at 2:24 PM, revealed CAN #2 provided Resident #7's catheter care. CNA #2 washed her hands and applied gloves. CNA #2 applied soap to the wet wipe, and cleansed the right side of the catheter tubing, and then cleansed the left side of the catheter tubing with the same wipe. CNA #2 did not rotate the wipe. CNA #2 rinsed the catheter tubing with a wet wipe without rotating the wipes. During an interview, on 07/10/19 at 3:46 PM, Registered Nurse (RN) #3/Staff Development Nurse revealed the CNAs are trained upon hire and annually on the appropriate way to provide catheter care in a manner to prevent infection. During an interview, on 07/10/19 at 3:49 PM, the Director of Nursing (DON) revealed CNA #2 should have rotated the wipe during the catheter care. The DON said the staff was trained annually how to provide catheter care. An interview, on 07/11/19 at 9:42 AM, CNA #2 confirmed the she failed to rotate the wipes during the catheter care. CNA #2 said she was nervous and did not realize she didn't rotate or change the wipes. Review of the Face Sheet revealed the facility admitted Resident #7, on 01/29/2018, with diagnoses, which included Neurogenic Bladder, Urinary Retention and Stage 4 Pressure Ulcers. A review of Resident #7's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/2/2019, revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident was cognitively impaired. Resident #139 An observation, on 07/10/19 at 2:30 PM, revealed Resident #139's catheter/peri care was provided by CNA #1. CNA #1 washed her hands, applied gloves, and then began to clean the catheter tubing with wet wipes. No concerns were noted. CNA #1 left the room to get more wipes. CNA #1 returned to the room and placed the wipes on the table without a barrier. CNA #1 did not wash her hands, placed gloves on her hand and wiped the shaft of the resident's penis three times and dried the shaft of the penis. CNA #1 did not clean the head of the penis. During an interview, on 07/10/19 at 2:31 PM, RN #3 Staff Development Nurse said the staff was trained upon hire and annually to clean the head of the penis while performing catheter and peri care. RN #3 said CNA #1 should have cleaned the head of the penis by pulling the skin back, and wipe the right and left side in a circular motion with the wipe. During an interview, on 07/10/19 at 2:35 PM, with the DON revealed CNA #1 should have cleaned the head of the penis to prevent infection. During an interview, on 07/11/19 at 9:26 AM, CNA #1 confirmed she forgot to wash the head of Resident #139's penis because she was in a hurry. CNA #1 also said she forgot to put down her barrier. A review of the Face Sheet revealed the facility admitted Resident #139, on 06/03/2019, with diagnoses which included Neuromuscular Dysfunction of the Bladder, Diabetes Mellitus and Major Depressive Disorder. A review of Resident #139 Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/20/2019, revealed Resident #139 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Resident #88 On 07/09/19 at 2:45 PM, an observation revealed Certified Nursing Assistants (CNAs) #3 and #4 provided Resident #88's catheter care. CNA #3 and #4 washed their hands. CNA #3 set a clean barrier and placed a package of wipes, clean brief, and a box of clean gloves on the barrier. CNA #1 retrieved a clean wipe from the the package and cleaned around the resident's penis head x four (4) using the same wipe, did not rotate the wipe. CNA #3 discarded that wipe, retrieved another wipe from the package of wipes and cleaned around the resident's penis head x four (4) using the same wipe without rotating the wipe again. CNA #3 discarded that wipe, and CNA #3 retrieved another wipe from the package of wipes and cleaned around the resident's penis head x four (4) times using the same wipe and without rotating the wipe. Both CNAs positioned the resident onto his left side to remove the soiled brief and pad. They then positioned the resident onto his right side to finish removing soiled brief and pad. The CNAs applied a clean brief and pad to the resident. The CNAs discarded all of the soiled items into the biohazard trash and placed the linens in a biohazard linen hamper in the resident's room. Neither CNA cleaned the catheter tubing. The CNAs repositioned the resident on his left side, placed the catheter drainage bag on the left side of the bed, ensured the catheter securing device was in place, covered the resident up, and washed their hands. On 07/10/19 at 9:15 AM, an observation revealed CNA #5 and #6 provided Resident #88's catheter care. CNA #5 set up her supplies; water basin, placed two clear trash bags on the foot of the resident's bed, a box of gloves, and a package of wipes. Both CNAs applied clean gloves, and CNA #5 removed several clean wipes from the package of wipes, and CNA #5 placed the wipes on the resident's bed. CNA #5 wet the washcloth with soap and water and wiped the resident's right groin area in a back and forth motion without rotating the washcloth. She then wiped the resident's left groin area in a back and forth motion multiple times. CNA #5 retrieved a wipe and anchored the resident's catheter tubing nearest the meatus and wiped in an outward motion x four (4) in a back and forth motion and without rotating the wipe. She retrieved another wipe and wiped the resident's catheter tubing in a back and forth motion x four (4), and without rotating the wipe. While using a dry towel, CNA #5 dried the area also using a back and forth motion four (4), and dried the catheter tubing again by patting around the catheter tubing and penis area x six (6) without rotating the dry towel. On 07/11/19 at 10:05 AM, an interview with CNA #5, revealed she should have wiped in a downward motion and should have rotated her washcloth. She also stated wiping in a back and forth motion is cross contamination and could cause an infection. On 07/11/19 at 10:15 AM, an interview with CNA #6, revealed she placed the wipes on the resident's bed, and could have used a barrier before sitting them on the resident's bed covers or placed them in the clean plastic bag. She also stated the wipes became contaminated by sitting them on the resident's bed covers. On 07/11/19 at 10:20 AM, an interview with Registered Nurse (RN) #4/Unit Manager, revealed the CNA should not have wiped in a back and forth motion. RN #4 stated the CNA should have wiped in a downward motion one time and discarded the wipe. [NAME] stated, if the CNA was using a towel, she should have rotated the towel. She also stated, it is not okay to wipe in a back and forth motion, because it introduces germs back up the catheter and into the bladder and could cause a Urinary Tract Infection. On 07/11/19 at 11:25 AM, an interview with CNA #3, revealed she should have rotated her wipe as she was cleaning the resident's penal area. She stated she should have made the wipe to fit around her hand like a glove so she could have rotated it. She also stated, she should have held the catheter tubing at the end near the penis and wiped away from the penis. On 07/11/19 at 11:35 AM, an interview with CNA #4, revealed when cleaning the catheter tubing the CNA should hold it at the end close to the penis and wipe away from the penis and throw the wipe away. On 07/11/19 at 2:05 PM, an interview with RN #1/Infection Control Nurse, revealed CNA #3 should have rotated or thrown that wipe away and obtained another one, and not use the same wipe. She also stated the CNA should have cleaned from the meatus area outward on the catheter tubing. On 07/11/19 at 2:10 PM, an interview with RN #1/Infection Control Nurse, revealed when CNA #6 placed the wipes that was pulled from the package on the resident's covers with no barrier present, that contaminated the wipes. She stated CNA #6 should have used a barrier. She also stated CNA #5 should have wiped once or only used one wipe and rotated that wipe and never clean in a back and forth motion. She also stated she should have wiped the catheter tubing once in an outward motion from the meatus area and thrown the wipe away and never wipe in a back and forth motion. On 07/12/19 at 10:45 AM, an interview with the DON, revealed the CNAs should not have gone from dirty to clean because they can introduce bacteria which could cause an infection.

Based on observation, record review, facility policy review, resident interview, and staff interview, the facility failed to provide tracheostomy care in a manner to prevent cross contamination for two (2) of three (3) residents observed for tracheostomy care, (Resident #22 and Resident #88) and failed to provide nebulizer treatment under staff supervision for one (1) of two (2) resident nebulizer treatment observations. (Resident #86) Findings include Review of the facility's policy titled, Administering Medications Though a Small Volume (Handheld) Nebulizer, dated October 2010, revealed it is the policy of this facility that the purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into resident's airway. The facility policy stated that one of the steps in the procedure was to remain with the resident for the treatment. Resident #86 During an observation, on 07/10/2019 at 9:30 AM, revealed Resident #86 was in her room, lying in bed, with a nebulizer treatment in progress. Further observation revealed there was no staff or nurse present in the room, or nearby in the hallway. Review of Resident #86's medical record documentation titled, Physician's Orders dated July 2019, revealed an order, dated 11/27/2018, for one (1) vial containing 0.25 milligrams (mg) of the medication budesonide (a steroid) to be suspended in a Two (2) milliliters (ml) of saline solution, given via a Nebulizer, two (2) times (x) a day (BID). Review of Resident #86's medical record documentation titled, E-Mar (Electronic Medication Administration Record), revealed that one (1) vial containing 0.25 milligrams (mg) of the medication budesonide (a steroid) to be suspended in a Two (2) milliliters (ml) of saline solution, given via a Nebulizer was administered on 7/10/2019 at 9:30 AM, by Licensed Practical Nurse (LPN) #1. During an interview, on 7/10/2019 at 9:30 AM, with Resident #86, she stated the nurse never stays in the room for the entire treatment time. Resident #86 stated, sometimes when it is finished, I just take the mask off myself. An interview, on 07/11/2019 at 3:44 PM, revealed License Practical Nurse (LPN) #2/ Transitional Care Nurse, stated he was supervising the morning of 07/10/2019. LPN #2 said he was aware Resident # 86 was receiving a nebulizer treatment, but he had left the room to go check on something and left the resident alone with a nebulizer treatment in progress. LPN #2 stated he was aware that a nurse should remain with the resident for the duration of the treatment to monitor response and effectiveness of the treatment. A telephone interview, on 07/11/2019 at 4:26 PM, with Licensed Practical Nurse (LPN) #1, revealed she was the nurse who started the nebulizer treatment for Resident #86 on 7/10/2019. LPN #1 stated she got very busy preparing the rest of Resident #86's medications and did not stay with the resident for the duration of her nebulizer treatment. LPN #1 said she knew it was the facility's policy for the nurse to stay with a resident during a nebulizer treatment until it was finished. An interview, on 07/12/2019 at 10:19 AM, with the Director of Nursing (DON), confirmed that the nurse should have stayed with the resident for the duration of the nebulizer treatment. The DON stated that the correct way for administering nebulizer treatments is in the facility's policy for nebulizer treatments administration. The DON said the nurse should have stayed with the resident Review of the Face Sheet revealed Resident #86 was admitted by the facility on 06/3/2015 and re-admitted the resident on 12/15/2015, with diagnoses to include Pressure Ulcer of the Sacral Region and Chronic Obstructive Pulmonary Disease (COPD). Resident #22 On 07/10/19 11:42 AM, an observation revealed Licensed Practical Nurse (LPN) #4 provided Resident #22's tracheostomy care. LPN #4 washed her hands and applied the sterile gloves just like they were regular gloves. She removed the tracheostomy dressing and inner cannula. LPN #4 washed her hands and applied clean gloves. She then cleaned around the tracheostomy plate area and around the inner cannula with a sterile water moistened 4x4 using a back and forth motion x six (6). She moistened a Q-tip with the sterile water and cleaned the inner cannula area in a back and forth motion multiple times and discarded the Q-tip. LPN #4 retrieved another Q-tip, moistened it with sterile water and cleaned the inner cannula area in a back and forth motion and discarded it. She then moistened a 4x4 gauze with sterile water and cleaned the neck plate wiping it in a back and forth motion multiple times and discarded it. She washed her hands, applied clean gloves, and placed a new inner cannula. She discarded all the soiled supplies. On 07/12/19 10:15 AM, an interview with LPN #4, revealed she should have wiped in one direction and thrown the 4x4 gauze and Q-tip away while providing tracheotomy care to Resident #22. She also stated wiping in a back and forth motion would cause cross contamination. On 7/12/19 at 10:35 AM, during an interview with the Director of Nursing (DON), the DON revealed LPN #4 should not have gone from dirty to clean, because that is cross contamination and could cause an infection. She also stated the nurse should have maintained a sterile technique with handling the inner cannula Resident #88 On 7/9/19 at 10:50 AM, an observation revealed the Respiratory Therapist (RT) entered the resident's room to provide Resident #88's tracheostomy care. The RT set up his supplies. He attempted to put on the sterile gloves that were in the packet but changed his mind and wrote the current date on the sterile water bottle. He organized his supplies, poured the sterile water into a clear plastic basin that he removed the sterile gloves and other tracheostomy supplies from the Tracheostomy Care Tray kit and placed the items on the barrier. He applied the sterile gloves that he had bought into the room with him, moistened a 4x4 gauze with the sterile water, and cleaned around the tracheostomy neck plate x eight (8) in a back and forth motion using the same 4x4 gauze without rotating the gauze. He then retrieved another gauze, moistened it with the sterile water and cleaned around the tracheostomy neck plate again using a back and forth motion x 10, and did not rotate the 4x4 gauze. He removed the inner disposable cannula and changed his gloves. The RT cleaned around the tracheostomy inner cannula area using a 4x4 moistened gauze with sterile water wiping in a back and forth motion x six (6) and again did not rotate the gauze. He then used a Q-tip moistened with sterile water and cleaned around the tracheostomy inner cannula area in a back and forth motion x 10. The RT retrieved another Q-tip, moistened it with sterile water, and cleaned again around the tracheostomy inner cannula area using a back and forth motion x eight (8). He obtained a 4x4 gauze, moistened it with sterile water and wiped around the tracheostomy inner cannula area in a back and forth motion x four (4). He retrieved another 4x4 gauze, moistened it with sterile water and wiped around the tracheostomy inner cannula area in a back and forth motion x eight (8) without rotating the gauze. He placed a new inner cannula in the tracheostomy and disposed of the soiled supplies in the biohazard trash can in the resident's room. On 7/11/19 at 1:45 PM an interview with the RT, revealed, he probably should have washed his hands during glove changes. He also stated he did not have his bag and likes to have his soiled utility bag. The RT stated, he has an injury to his left smallest finger, so he could not wear the sterile gloves that were in the Tracheostomy kit. He stated because he knew Resident #88, he felt like he could provide tracheostomy care to the resident on room air and did not need to pre-oxygenate the resident prior to providing tracheostomy care. He also stated he had checked the O2 sat but forgot to tell the surveyor. The RT stated he could contaminate the area by not rotating the gauze or throwing away the gauze after wiping one time. He stated he would have most definitely done things differently, such as letting the surveyor know that he had checked the 2 sat, he would pre-oxygenate before providing O tracheostomy care, and he would wipe once and discard the 4x4s and/or Q-tips. On 7/11/19 at 2:05 PM an interview with Registered Nurse (RN) #1/Infection Control Nurse revealed, the RT should have wiped the area once and thrown the 4x4 gauze away and wiped with a circular motion with the Q-tip once, thrown it away, and gotten another one to wipe again. An interview, on 07/10/19 8:36 AM with the Doctor revealed, the resident coded as a result of respiratory failure and had to receive the tracheostomy. Review of the Physician's Orders, dated July 2019, revealed the following orders: Suction tracheostomy site per policy and procedure prn (as needed) and as ordered by a physician. Change tracheostomy tubing, oxygen delivery, mask, T-tube (tracheostomy tube) and oxygen humidifier bottles and tubing prn. Change tracheostomy tubing, oxygen delivery, mask, T-tube and oxygen humidifier bottles and tubing prn. Oxygen sign on front and back of door. Check O2 sats (oxygen saturations) prn notify MD if sats < (less than) 88% (percent). Check O2 sats Q (every) shift, notify MD (Medical Doctor) if O2 sat is < 88%. Humidified O2 @ (at) 2 liters per trach mask T-tube. Chest physiotherapy (CPT) or positive expiratory pressure (PEP) therapy prn airway clearance, prevent or treat atelectasis. Pulmonary lavage with sterile normal saline per tracheostomy per licensed nurse or Registered Respiratory Therapist. May use 2-4 ML (milliliters) 20% mucomyst nebulized or via instillation with pulmonary lavage Q 4 hrs prn. Tracheostomy HME (heat and moisture exchanger) applied to tracheostomy as needed for humidification when out of bed (use only if resident's secretions are thick). EzPAP (positive airway pressure therapy) via (by) tracheostomy x15 minutes prn lung expansion, airway clearance per licensed nurse or respiratory therapist. May use 3 ML 7% NaCL/duoneb (sodium chloride/dual nebulizer) 2 ML mucomyst. Mouth care every shift. Suction secretions from oral cavity prn. Notify MD if tracheostomy is dislodged. Type and size of tracheostomy, #8 Shiley DCT (disposable cuff tube). Document characteristics and amount of sputum secretions. A review of the admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 05/28/19, revealed the MDS was coded to include tracheostomy care.

Based on observation, staff interview, record review, and facility policy review, the facility failed to clean the drip pan under the stove burners in a timely manner to prevent the potential for fire, for one (1) of three (3) days Kitchen observations. Findings Include: Review of the facility's policy titled, Cleaning Instructions Range and Griddle Ovens, with an originated date of 09/04, revealed it is the facility's policy that the equipment shall be maintained in a clean and sanitary condition. Empty the broiler grease pan daily, or whenever it is 1/2 full. The drip shield, grids and grease pan/trough should be washed with a mild grease dissolving solution. Scrub the broiler chamber and body front frequently to reduce smoking. Review of the Cleaning Schedule revealed the back stove was scheduled to be cleaned on 07/02/2019. The schedule was not signed by the Cook. An observation of the Kitchen, on 07/10/19 at 10:42 AM, revealed the back stove drip pan had a large amt of thick black carbon build up. The [NAME] immediately removed the pan and cleaned it. During an interview, on 07/10/19 at 12:46 PM, the Dietary Manager revealed the [NAME] did not clean the stove the day it was due because they were short of staff. The [NAME] said she did not get a chance to clean the stove. The Dietary Manager said the stove could catch on fire if it's not cleaned in a timely manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy review, resident interview, and staff interview, the facility failed to follow the Comprehensive Care Plan related to tracheostomy care for two (2) of three (3) residents observed for tracheostomy care, Resident #22 and Resident #88, for nebulizer treatments for one (1) of two (2) resident nebulizer treatment observations, Resident #86, and for catheter care for one three (3) of five (5) residents observed for catheter care, Resident #7, Resident #88, and Resident #139. Finding include: Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated December 2016, revealed it is the policy of this facility that a comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The facility policy also stated the Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. Resident #86 Review of Resident #86's Care Plan revealed a Focus problem, with an Onset Date of 05/20/2019, for the risk of respiratory distress and discomfort related to a diagnosis of Chronic Obstructive Pulmonary Disease (COPD. The Care Plan revealed an Approach to this focused problem included the nebulizer treatment to be given as ordered; monitor for effectiveness; adverse side effects and document; report as needed. An observation, on 07/10/2019 at 9:30 AM, revealed Resident #86 was her room, lying in bed, with a nebulizer treatment in progress. Further observation revealed there was no staff present in the room, or nearby in the hallway. During an interview, on 07/10/2019 at 9:30 AM, with Resident #86, revealed she stated the nurse never stays in the room for the entire treatment time. Resident #86 stated, Sometimes when it is finished, I just take the mask off myself. During an interview, on 07/11/2019 at 3:44 PM, Licensed Practical Nurse (LPN) #2/ Transitional Care Nurse, stated he was supervising the morning of 07/10/2019. LPN #2 stated he was aware that Resident # 86 was receiving a nebulizer treatment, but he had left the room to go check on something and left the resident alone with a nebulizer treatment in progress. LPN #2 stated he was aware that a nurse should remain with the resident for the duration of the treatment to monitor response and effectiveness of the treatment. During a telephone interview, on 07/11/2019 at 4:26 PM, Licensed Practical Nurse (LPN) #1 revealed she was the nurse who started the nebulizer treatment for Resident #86 on 07/10/2019. LPN #1 stated she got very busy preparing the rest of Resident #86's medications and did not stay with the resident for the duration of her nebulizer treatment. LPN #1 stated she knew it was the facility's policy for the nurse to stay with a resident during a nebulizer treatment until it's finished. During the interview, on 07/12/2019 at 10:07 AM, with Licensed Practical Nurse (LPN) #3/Care Plan Coordinator, it was confirmed there was a Focused problem on Resident #86's Care Plan regarding the resident being at risk for respiratory distress and discomfort, related to the diagnosis of Chronic Obstructive Pulmonary Disease (COPD). LPN #3 also confirmed that an approach to this Focus problem was to provide nebulizer treatments as ordered, and monitor for effectiveness. LPN #3 stated the Care Plan had not been followed by the nurse administering the treatment, because she left the resident's room before the breathing treatment was done. During an interview, on 07/12/2019 at 10:19 AM, with the Director of Nursing (DON), it was confirmed the nurse should have stayed with the resident for the duration of the respiratory treatment. The DON stated that the correct way for administering nebulizer treatments is in the facility's policy for nebulizer treatments administration. The DON stated the nurse should have stayed with the resident. The DON stated Resident #86's Care Plan was not followed as what was intended for the administration of the nebulizer treatment. Review of the Face Sheet revealed Resident #86 was admitted by the facility, on 06/3/2015 and re-admitted on [DATE], with diagnoses to include Pressure Ulcer of the Sacral Region and Chronic Obstructive Pulmonary Disease (COPD). Resident #7 Review of the Comprehensive Care Plan revealed Resident #7 had a potential for complications related to the presence of a Suprapubic Catheter, related to a Stage 4 Pressure Ulcer to the sacrum, and a diagnosis of Neurogenic Bladder. Interventions included: Place drainage bag in a privacy bag, catheter care every shift and as needed, observe for signs and symptoms of a Urinary Tract Infection, secure catheter to thigh with catheter strap to prevent pulling on tubing, keep collection bag below bladder level, and check tubing for kinks. An observation, on 07/10/19 at 2:24 PM , revealed Resident #7 was provided catheter care by Certified Nursing Assistant (CNA) #2. CNA #2 washed her hands, applied gloves and applied soap to a wet wipe CNA #2 cleansed the right side of the catheter tubing, and cleaned the left side of catheter tubing with the same wipe. CNA #2 did not rotate the wipe. CNA #2 rinsed the catheter tubing with a wet wipe without rotating the wipes. During an interview, on 07/10/19 at 3:46 PM, Registered Nurse (RN) #3/Staff Development Nurse revealed the CNAs are trained upon hire and annually on the appropriate way to provide catheter care in a manner to prevent infection. During an interview, on 07/10/19 at 3:49 PM, the Director of Nursing (DON) revealed CNA #2 should have rotated the wipe during catheter care. The DON said the staff was trained annually how to provide catheter care. During an interview, on 07/11/19 at 9:42 AM, CNA #2 confirmed the she failed to rotate the wipes during Resident #7's catheter care. CNA #2 said she was nervous and did not realize she didn't rotate or change the wipes. During an interview, on 07/12/19 at 3:19 PM, LPN #3 revealed she expected the staff to provide catheter care according to the standards of practice and to follow the care plan. Review of the Face Sheet revealed the facility admitted Resident #7, on 01/29/201), with diagnoses which included Neurogenic Bladder, Urinary Retention and Stage 4 Pressure Ulcers. Review of Resident #7 Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/2/2019, revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident was cognitively impaired. Resident #139 Record Review of the Care Plan revealed Resident #139 was at risk for a Urinary Tract Infection related to the presence of an indwelling catheter for the diagnosis of Neuromuscular Dysfunction. Interventions included: Place the catheter drainage bag in a privacy bag, catheter care every shift and as needed per policy, obtain labs as ordered, observe for signs and symptoms for a Urinary Tract Infection, keep the drainage bag below the bladder level, and check for kinks in the tubing. An observation, on 07/10/19 at 2:30 PM, revealed CNA #1 provided Resident #139's catheter/peri care. CNA #1 washed her hands, applied gloves and cleaned the catheter tubing with wet wipes. No concerns were noted. CNA #1 left the room to get more wipes. On her return to the room, CNA #1 placed the wipes on the table without a surface barrier. CNA #1 did not wash her hands, and then placed gloves on her hands. CNA #1 wiped the shaft of the penis three times and dried the shaft of the penis. CNA #1 did not clean the head of the penis. During an interview, on 07/10/19 at 2:31 PM, RN #3/Staff Development Nurse said the staff was trained upon hire and annually to clean the head of the penis while performing catheter and peri care. RN #3 said CNA #1 should have cleaned the head of the penis by pulling the skin back, and then wipe the right and left side in a circular motion with the wipe. During an interview, on 07/10/19 at 2:35 PM, the DON revealed CNA #1 should have cleaned the head of the penis to prevent infection. During an interview, on 07/11/19 at 9:26 AM, CNA #1 confirmed she forgot to wash the head of Resident #139's penis because she was in a hurry. CNA #1 also said she forgot to put down her barrier. During an interview, on 07/12/19 at 3:16 PM, LPN #3 revealed she expected the CNAs to follow the care plan to provide catheter care in a manner to prevent infection, A review of the facility's Face Sheet revealed the facility admitted Resident #139, on 06/03/2019, with diagnoses which included Neuromuscular Dysfunction of the Bladder, Diabetes Mellitus and Major Depressive Disorder. A review of Resident #139's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/20/2019, revealed Resident #139 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Resident #22 Review of the Comprehensive Care Plan revealed a Problem/Need, dated 01/11/2019, for a tracheostomy related to Traumatic Brain Injury with Encephalopathey. At risk for respiratory distress, decreased oxygen saturation (O2 sat). Goals included the resident would not experience acute respiratory failure/distress with appropriate interventions next 90 days, 07/20/19. Interventions included: Provide tracheostomy care as ordered (per protocol). Monitor oxygen sats every shift and as needed. On 07/10/19 at 11:42 AM, an observation revealed LPN #4 provided Resident #22's tracheostomy care. LPN #4 washed her hands and applied the sterile gloves just like they were regular gloves. She removed the tracheostomy dressing and inner cannula, washed her hands and applied clean gloves. She then cleaned around the tracheostomy plate area and around the inner cannula with a sterile water moistened 4x4 using a back and forth motion x 6. She moistened a Q-tip with the sterile water and cleaned the inner cannula area in a back and forth motion multiple times and discarded the Q-tip. She retrieved another Q-tip, moistened it with sterile water and cleaned the inner cannula area in a back and forth motion and discarded it. She then moistened a 4x4 gauze with sterile water and cleaned the neck plate in a back and forth motion multiple times and discarded it. She washed her hands, applied clean gloves, and placed a new inner cannula. She discarded all of the used/soiled supplies. On 07/12/19 at 10:15 AM, an interview with LPN #4 revealed she should have wiped in one direction and thrown the 4x4 gauze and Q-tip away when providing the tracheotomy care to Resident #22. She also stated wiping in a back and forth motion would cause cross contamination. On 7/12/19 at 10:35 AM, an interview with the DON, revealed the nurse should not have gone from dirty to clean, because that is cross contamination and could cause an infection. She also stated the nurse should have maintained a sterile technique while handling the inner cannula. The DON also stated the oxygen sat should have been checked prior to the nurse providing tracheostomy care. She stated she has never known of hyper-oxygenating the resident before providing tracheostomy care. On 7/12/19 at 3:10 PM, an interview with LPN #3/MDS-Care Plan Nurse, revealed, she would expect the staff to do what the care plan states to do to take care of the resident. She also stated when the care plan indicates tracheostomy care as ordered, she would expect the staff to provide care according to the facility protocol. Resident #88 Tracheostomy Care Review of Resident #88's Comprehensive Care Plan revealed a Problem/Need, dated 05/22/2019, for a tracheostomy related to Anoxic Brain Injury with Hypoxia and Hypercapnia. At risk for respiratory distress, decreased oxygen saturation. Interventions included: Provide tracheostomy care as ordered (per protocol). On 07/09/19 at 10:50 AM, an observation revealed the Respiratory Therapist (RT) provided Resident #88's tracheostomy care. The RT entered resident's room, set up his tracheostomy care supplies on the bedside table without wiping the table off, or placing a surface barrier. The RT attempted to put on the sterile gloves that were in the Tracheostomy Care Tray Kit, but changed his mind and wrote the current date on the sterile water bottle. The RT organized his supplies, poured the sterile water into a clear plastic basin that he removed with the sterile gloves and other tracheostomy supplies from the Tracheostomy Care Tray kit and placed the items on the barrier. He applied the sterile gloves that he had bought into the room with him, moistened a 4x4 gauze with the sterile water, and cleaned around the tracheostomy neck plate x eight (8) in a back and forth motion using the same 4x4 gauze without rotating the gauze. He then retrieved another gauze, moistened it with the sterile water and cleaned around the tracheostomy neck plate again using a back and forth motion x 10 and not rotating the 4x4 gauze. He removed the inner disposable cannula and changed his gloves. The RT cleaned around the tracheostomy inner cannula area using a 4x4 moistened with sterile water wiping in a back and forth motion x six (6) and not rotating the gauze. He then used a Q-tip moistened with sterile water and cleaned around the tracheostomy inner cannula area in a back and forth motion x 10. The RT retrieved another Q-tip, moistened it with sterile water, and cleaned again around the tracheostomy inner cannula area using a back and forth motion x eight (8). He obtained a 4x4 gauze, moistened it with sterile water and wiped around the tracheostomy inner cannula area in a back and forth motion x 4. He retrieved another 4x4 gauze, moistened it with sterile water and wiped around the tracheostomy inner cannula area in a back and forth motion x eight (8) without rotating the gauze. He placed a new inner cannula in the tracheostomy and disposed of the soiled supplies in the biohazard trash can in the resident's room. On 07/11/19 at 1:45 PM, an interview with the RT, revealed he probably should have washed his hands during glove changes. He also stated he did not have his bag and likes to have his soiled utility bag. The RT stated, he has an injury to his left smallest finger, so he could not wear the sterile gloves that were in the Tracheostomy kit. He stated because he knew this resident, he felt like he could provide tracheostomy care to the resident on room air and did not need to pre-oxygenate the resident prior to providing tracheostomy care. He also stated he had checked the O2 sat, but forgot to tell the surveyor. The RT stated you could contaminate the area by not rotating your gauze or throwing away your gauze after wiping one time. He stated he would have most definitely did things differently, such as letting the surveyor know that he had checked the O2 sat, he would pre-oxygenate before providing tracheostomy care, and he would wipe once and discard the 4x4s and/or Q-tips. On 07/11/19 at 2:05 PM, an interview with Registered Nurse (RN) #1/Infection Control Nurse, revealed the RT should have wiped the area once and thrown the 4x4 gauze away and wiped with a circular motion with the Q-tip once, thrown it away, and got another one to wipe again. On 07/12/19 at 3:10 PM, an interview with Licensed Practical Nurse (LPN) #3/MDS-Care Plan Nurse, revealed she would expect the staff to do what the care plan states to do to take care of the resident. She also stated when the care plan indicates tracheostomy care as ordered, she would expect the staff to provide care according to the facility protocol. On 07/10/19 at 8:36 AM, an interview with the Physician revealed, the resident coded as a result of respiratory failure, and had to receive the tracheostomy. Review revealed, the admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 05/28/19, revealed the MDS was coded to include tracheostomy care. The physician orders dated July 2019 revealed the following orders: Orders to suction tracheostomy site per policy and procedure prn and as ordered by a physician. Change tracheostomy tubing, oxygen delivery, mask, T-tube and oxygen humidifier bottles and tubing prn (as needed). Change tracheostomy tubing, oxygen delivery, mask, T-tube and oxygen humidifier bottles and tubing prn. Oxygen sign on front and back or door. Check O2 sats prn notify MD if sats < (less than) 88%. Check O2 sats Q (every) shift, notify MD (Medical Doctor) if O2 sat is < 88%. Humidified O2 (oxygen) @ 2 liters per trach mask T-tube. Chest physiotherapy (CPT) or positive expiratory pressure (PEP) therapy prn airway clearance, prevent or treat atelectasis. Pulmonary lavage with sterile normal saline per tracheostomy per licensed nurse or Registered Respiratory Therapist. May use 2-4 ML (two to four milliliters) 20% mucomyst nebulized or via instillation with pulmonary lavage Q 4 hrs prn. Trach HME (heat and moisture exchanger) applied to trach as needed for humidification when out of bed (use only if resident's secretions are thick). EzPAP (positive airway pressure therapy) via trach x 15 minutes prn lung expansion, airway clearance per licensed nurse or respiratory therapist. May use 3 ML 7% NaCL(Sodium Chloride)/duoneb 2 ML mucomyst. Mouth care every shift. Suction secretions from oral cavity prn. Notify MD if trach is dislodged. Type and size of tracheostomy, #8 Shiley DCT. Document characteristics and amount of sputum secretions. Catheter Care Review of the Comprehensive Care Plan revealed a Problem/Need for potential complications related to the presence of an indwelling catheter due to a Unstagable Pressure Ulcer with eschar and slough to the coccyx. The Goals included there would be no signs and symptoms of a Urinary Tract Infection by the next review, 0820/19. The Interventions included: Catheter care [NAME] shift and as needed per the facility's protocol. On 07/09/19 at 2:45 PM, an observation revealed Certified Nursing Assistants (CNAs) #3 and #4 provided Resident #88's catheter care. CNA #3 and #4 washed their hands. CNA #3 set a clean barrier and placed a package of wipes, clean brief, and a box of clean gloves on the barrier. CNA #1 retrieved a clean wipe from the the package and cleaned around the resident's penis head x four (4) using the same wipe, did not rotate the wipe. CNA #3 discarded that wipe, retrieved another wipe from the package of wipes and cleaned around the resident's penis head x four (4) using the same wipe without rotating the wipe again. CNA #3 discarded that wipe, and CNA #3 retrieved another wipe from the package of wipes and cleaned around the resident's penis head x four (4) times using the same wipe and without rotating the wipe. Both CNAs positioned the resident onto his left side to remove the soiled brief and pad. They then positioned the resident onto his right side to finish removing soiled brief and pad. The CNAs applied a clean brief and pad to the resident. The CNAs discarded all of the soiled items into the biohazard trash and placed the linens in a biohazard linen hamper in the resident's room. Neither CNA cleaned the catheter tubing. The CNAs repositioned the resident on his left side, placed the catheter drainage bag on the left side of the bed, ensured the catheter securing device was in place, covered the resident up, and washed their hands. On 07/10/19 at 9:15 AM, an observation revealed CNA #5 and #6 provided Resident #88's catheter care. CNA #5 set up her supplies; water basin, placed two clear trash bags on the foot of the resident's bed, a box of gloves, and a package of wipes. Both CNAs applied clean gloves, and CNA #5 removed several clean wipes from the package of wipes, and CNA #5 placed the wipes on the resident's bed. CNA #5 wet the washcloth with soap and water and wiped the resident's right groin area in a back and forth motion without rotating the washcloth. She then wiped the resident's left groin area in a back and forth motion multiple times. CNA #5 retrieved a wipe and anchored the resident's catheter tubing nearest the meatus, and wiped in an outward motion x four (4) in a back and forth motion and without rotating the wipe. She retrieved another wipe, and wiped the resident's catheter tubing in a back and forth motion x four (4), and without rotating the wipe. While using a dry towel, CNA #5 dried the area also using a back and forth motion four (4), and dried the catheter tubing again by patting around the catheter tubing and penis area x six (6) without rotating the dry towel. On 07/11/19 at 10:05 AM, an interview with CNA #5, revealed she should have wiped in a downward motion and should have rotated her washcloth. She also stated wiping in a back and forth motion is cross contamination and could cause an infection. On 07/11/19 at 10:15 AM, an interview with CNA #6, revealed she placed the wipes on the resident's bed, and could have used a barrier before sitting them on the resident's bed covers or placed them in the clean plastic bag. She also stated the wipes became contaminated by sitting them on the resident's bed covers. On 07/11/19 at 10:20 AM, an interview with Registered Nurse (RN) #4/Unit Manager, revealed the CNA should not have wiped in a back and forth motion. RN #4 stated the CNA should have wiped in a downward motion one time and discarded the wipe. [NAME] stated, if the CNA was using a towel, she should have rotated the towel. She also stated, it is not okay to wipe in a back and forth motion, because it introduces germs back up the catheter and into the bladder and could cause a Urinary Tract Infection. On 07/11/19 at 11:25 AM, an interview with CNA #3, revealed she should have rotated her wipe as she was cleaning the resident's penal area. She stated she should have made the wipe to fit around her hand like a glove so she could have rotated it. She also stated, she should have held the catheter tubing at the end near the penis and wiped away from the penis. On 07/11/19 at 11:35 AM, an interview with CNA #4, revealed when cleaning the catheter tubing the CNA should hold it at the end close to the penis and wipe away from the penis and throw the wipe away. On 07/11/19 at 2:05 PM, an interview with RN #1/Infection Control Nurse, revealed CNA #3 should have rotated or thrown that wipe away and obtained another one, and not use the same wipe. She also stated the CNA should have cleaned from the meatus area outward on the catheter tubing. On 07/11/19 at 2:10 PM, an interview with RN #1/Infection Control Nurse, revealed when CNA #6 placed the wipes that was pulled from the package on the resident's covers with no barrier present, that contaminated the wipes. She stated CNA #6 should have used a barrier. She also stated CNA #5 should have wiped once or only used one wipe and rotated that wipe and never clean in a back an forth motion. She also stated she should have wiped the catheter tubing once in an outward motion from the meatus area and thrown the wipe away and never wipe in a back and forth motion. On 07/12/19 at 10:45 AM, an interview with the DON, revealed the CNAs should not have gone from dirty to clean because they can introduce bacteria which could cause an infection. On 07/12/19 at 3:10 PM, an interview with LPN #3/MDS-Care Plan Nurse, revealed she would expect the staff to do what the care plan states to do to take care of the resident. She also stated when the care plan indicates catheter care as ordered, she would expect the staff to provide care according to the facility's protocol.