Based on observation, interviews, and the 2017 Food and Drug Administration Food Code, the facility failed to ensure a dietary staff member did not remove hot dogs from a fork with her bare hands and give them to a resident to eat during the lunch meal on 9/26/19. This affected one resident assisted in one of three dining rooms during the lunch meal on 9/26/19. Findings include: The 2017 Food Code mandates under section 3-301.11 Preventing Contamination from Hands. . (B) .FOOD EMPLOYEES may not contact exposed, READY-TO-EAT FOOD with their bare hands and shall use suitable UTENSILS such as deli tissue, spatulas, tongs, single-use gloves, or dispensing EQUIPMENT. On 09/26/19 at 12:15 PM, the surveyor observed a Dietary Staff member, Employee Identifier (EI) #2, assisting a resident in the 300 Hall Dining Room with the removal of two hot dogs from the bun, at the resident's request. EI #2 used her bare fingers to remove the hot dogs from the fork used in the transfer of the hot dogs. At this time, the surveyor asked EI #2 if she typically helped to feed the residents. EI #2 affirmed she did, if requested. When asked if she realized she had used her bare hands to pull the resident's hot dogs off the fork, EI #2 responded, no. The surveyor asked why was she not supposed to handle food with bare hands. EI #2 replied it was not sanitary. On 09/26/19 at 1:00 PM, the surveyor interviewed the Unit Manager, EI #3, who was responsible for the 300 Hall dining room. The above incident was described and the surveyor asked what concern would the handling of food with bare hands pose to residents. EI #3 immediately responded, infection control.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure: 1. Employee Identifier (EI) #7, Licensed Practical Nurse (LPN), did not hold a medicine cup with her ungloved hand covering the rim of the cup before giving the medication to Resident Identifier (RI) #14, and 2. EI #8, LPN, did not put her ungloved fingers inside of a plastic bag of crushed medication to be given to RI #7. These deficient practices affected RI #7 and RI #14, two of eight residents observed during medication administration. Findings include: 1. RI #14 was admitted to the facility on [DATE], with a diagnosis of Alzheimer's Disease. On 09/25/19 at approximately 5:24 p.m., the surveyor observed EI #7 prepare medication to administer to RI #14. EI #7 placed her (bare) hand on the rim of the medication cup prior to administering the medication to the resident. At this time, the surveyor asked EI #7 how had she held the medication cup while carrying it to the resident. EI #7 demonstrated her hands touching the rim of the medication cup. The surveyor asked EI #7 how should she have carried the medication cup. EI #7 said so that her hands were not touching the rim of the medication cup. The surveyor asked EI #7 what were the issues with that. EI #7 said contamination. On 9/26/19 at 11:18 a.m., the surveyor conducted an interview with EI #5, Registered Nurse (RN)/Infection Control Nurse. The surveyor asked EI #5 how should a medication cup be carried. EI #5 said holding it in a way that staff do not touch the rim. The surveyor asked when can a nurse put ungloved hands on the rim of the medication cup. EI #5 said never. EI #5 was asked what were the issues with that. EI #5 said they (staff) would transfer their germs to the cup. 2. RI #7 was admitted to the facility on [DATE], with a diagnosis of Depression. On 9/25/19 at 5:38 p.m., the surveyor observed EI #8 crush medication and place her fingers inside the plastic bag to open it and pour medication into a medication cup. The crushed medication was mixed with pudding and administered to RI #7. On 9/25/19 at 6:11 p.m., the surveyor conducted an interview with EI #8. EI #8 agreed she opened the plastic bag with her fingers. The surveyor asked EI #8 how should she have opened the plastic bag. EI #8 said by rubbing the bag together then opening the bag with a wooden tongue (depressor) if needed. The surveyor asked EI #8 what were the issues with this. EI #8 said that was an infection control concern and was just nasty. On 9/26/19 at 10:35 a.m., the surveyor conducted an interview with EI #5. The surveyor asked EI #5 how should a nurse open the plastic bag to pour out crushed medication. EI #5 said they should slide it open and pinch the side, then thump the bag to make sure all the powdered medication came out. The surveyor asked EI #5 when would staff put their fingers inside of the plastic bag before the medication had been removed. EI #5 said staff would not because they could absorb the medication. The surveyor asked EI #5 what were the issues with this. EI #5 said infection control. EI #5 further stated staff do not know what germs they could have on their hands and those germs could cross over to the resident and into their digestive system.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of a facility policy titled, Care Plan - Comprehensive, the facility failed to ensure a care plan was developed for the use of a psychotropic medication. This affected Resident Identifier (RI) #81, one of nineteen residents whose care plans were reviewed. Findings Include: A review of the facility policy titled, Care Plan - Comprehensive, with a revision date of 11/28/17, revealed: . Procedure . 5. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment . RI #81 was admitted to the facility on [DATE] with a diagnosis of Adjustment Disorder with Depressed Mood. Review of RI #81's written PHYSICIAN'S ORDER SHEET revealed an order dated 8/6/18 for the psychotropic medication Prozac, prescribed for a diagnosis of Adjustment Disorder with Mixed Anxiety/Depression. The order indicated RI #81 received 20 milligrams of Prozac every day. However, on 08/21/18 at 5:32 p.m., RI #81's comprehensive care plans were reviewed. There was no care plan addressing the use of a psychotropic medication. On 8/22/18 at 11:54 a.m., an interview was conducted with Employee Identifier (EI) #10, Registered Nurse, Minimum Data Set Coordinator. EI #10 was asked if there was a current care plan that addressed a psychotropic medication for RI #81. EI #10 replied no. EI #10 was asked why there should be care plan addressing the use of psychotropic medications. EI #10 replied that the care plan should address a psychotropic medication to ensure the Interdisciplinary Team can figure out if the medication is working for the resident. EI #10 was asked, what was the purpose of the care plan. EI #10 replied it should address or guide the care of the residents. EI #10 was asked when was the order for the psychotropic drug written. EI #10 replied that it was written on 08/06/18. EI #10 was asked after receiving the psychotropic medication order, when should the care plan be developed. EI #10 replied that the care plan should be developed within fourteen days of knowing there is a new change for the plan of care for the resident. EI #10 was asked why was the care plan not developed. EI #10 replied that she did not realize that RI #81 was put on an antidepressant medication. EI #10 was asked what date should the care plan, for the psychotropic drug, have been developed. EI #10 replied it should have been developed by August 20, 2018.

Based on observation, interviews, review of a facility document titled Refrigerator/Freezer Temperature Log, and review of a facility policy titled Medication - Room Refrigerator, the facility failed to ensure the temperatures, on the two-hundred hall Medication Refrigerator Daily Log, were routinely checked and recorded. This affected one of three medication room refrigerators in the facility. Findings Include: A review of a facility policy titled Medication - Room Refrigerator, with a revised date of 02/01/2015, documented: .Procedure . 2. The charge nurse or designee shall monitor and record the temperature for the refrigerator . each shift . On 08/22/2018 at 7:47 a.m., the surveyor observed with Employee Identifier (EI) #1, a Registered Nurse/Charge Nurse, that the temperatures on the Medication Refrigerator Daily Temperature Log, located in the two-hundred hall medication room, were not routinely documented. The following dates were observed not checked and recorded on the daily 5 a.m.-5 p.m. shift Medication Refrigerator Daily Temperature Log: August 14, 15, 16, 19, and 20, 2018. The following dates were observed not checked and recorded on the daily 5 p.m.-5 a.m. shift Medication Refrigerator Daily Temperature Log: August 1 and 19, 2018. On 8/22/2018 at 11:00 a.m., an interview was conducted with EI #1. EI #1 was asked when should the Medication Refrigerator Daily Temperature Logs on the two-hundred hall be checked and recorded. EI #1 replied the temperatures should be recorded on each shift by the charge nurse on the hall. EI #1 was asked what dates and shifts were not recorded in August, 2018 on the Medication Refrigerator Daily Temperature Log for the two-hundred hall medication room. EI #1 replied that the following dates and shifts were not recorded: 5 a.m. - 5 p.m. shift- 8/14, 8/15, 8/16, 8/19, and 8/20/2018 5 p.m. - 5 a.m. shift- 8/1 and 8/19/2018 EI #1 was asked why these dates and shifts were not checked and recorded on the Medication Refrigerator Daily Temperature Logs. EI #1 replied that she did not know what happened on those days. EI #1 was asked what would be the harm in the temperatures not being checked and recorded daily on each shift of the log. EI #1 stated that if the medications were not kept in the temperature range, the medication could be ineffective to treat the resident or make them sick. EI #1 was asked if there was a facility policy on checking and recording the medication refrigerator temperatures. EI #1 replied yes, and said the policy stated that the charge nurse or designee shall monitor and record the temperature of the refrigerator for each shift. EI #1 was asked if the policy was followed on August 1, 14, 15, 16, 19 and 20, 2018. EI #1 replied no. On 8/22/2018 at 11:30 a.m., an interview was conducted with EI #2, Registered Nurse and two-hundred hall Supervisor. EI #2 was asked when the temperatures for the medication refrigerator on the two-hundred hall should be checked and recorded. EI #2 stated that it should be checked on each of the twelve hour shifts daily by the charge nurse. EI #2 was asked why the temperature should be recorded on the Refrigerator Medication Daily Temperature Log. EI #2 stated that it should be done to make sure the temperatures were in the correct range to ensure the medications do not become ineffective to treat an illness. EI #2 also stated residents could get sick. EI #2 was asked if there was a policy on recording the temperatures of the medication room refrigerator. EI #2 stated yes and explained the policy stated the charge nurse or designee shall monitor and record the temperature for the refrigerator for each shift.

Based on observation, interviews and record review, this facility failed to ensure a licensed nurse accurately documented the nebulizer mask and tubing were changed as was documented on the Medication Administration Record (MAR) of Resident Identifier (RI) #58. This deficient practice was identified for one of 3 sampled residents with nebulizer masks/tubing. Findings Include: Resident Identifier #58 was admitted to facility on 06/20/18 with a readmit date of 07/2/18. The August, 2018, MAR revealed the facility is to change the nebulizer tubing and mask every seven days on 11-7 shift and as needed and the oxygen tubing is to be changed every week on Sunday on the 11-7 shift and as needed. This MAR incidates that EI #7, LPN initialed on 08/12/18 and 08/19/18 that the nebulizer mask and tubing had been replaced. On 08/21/18 at 1:28 PM, the surveyor observed a nebulizer mask and tubing on the bedside table next to RI #58's bed. The nebulizer chamber was dated 08/05/18. The surveyor asked the nurse on duty, EI #1 to verify date on nebulizer mask chamber. EI #1 said the date was 08/05/18. EI #1 removed the nebulizer mask and tubing and discarded the equipment and stated, night shift should have replaced this. The surveyor asked nurse EI #1 how often nebulizer masks and tubing were replaced, EI #1 stated they are replaced every Sunday night on night shift. On 08/22/18 at 11:15am an interview with EI #7 was conducted. The surveyor asked EI #7 what shift she work. EI #7 by saying the night shift. The surveyor asked how often the nebulizer tubing/masks are supposed to be changed. EI #7 responded by saying once a week. When asked when you the MAR is initialed, what does that mean, EI #7 responded, it means that it's done. When the surveyor asked,when RI # 58's nebulizer mask and tubing should have been replaced, EI #7 responded, on 8/12/19 but the last time it should have been changed was on 08/19/18. Surveyor asked EI #7, why didn't you replace the mask and tubing as you signed in the MAR on 08/12/18 and 08/19/18, EI #7 responded, I should have but I didn't.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and review of medical records as well as review of the facility's policy titled, Isolation - Categories of Transmission-Based Precautions, this facility failed to ensure that Resident Identifier (RI) #58's nebulizer mask and tubing was changed in accordance with the order listed on the Medication Admnistration Record and that contact precautions were followed when care was being provided for RI #338, a resident on contact precautions. This affected two of 3 residents reviewed for infection control practices and precautions. Findings Include: 1. Resident Identifier #58 was admitted to facility on 06/20/18 with a readmit date of 07/2/18. The August, 2018, MAR revealed the facility is to change the nebulizer tubing and mask every seven days on 11-7 shift and as needed and the oxygen tubing is to be changed every week on Sunday on the 11-7 shift and as needed. This MAR incidates that EI #7, LPN initialed on 08/12/18 and 08/19/18 that the nebulizer mask and tubing had been replaced. On 08/21/18 at 1:28 PM, the surveyor observed a nebulizer mask and tubing on the bedside table next to RI #58's bed. The nebulizer chamber was dated 08/05/18. The surveyor asked the RN, EI #1 to verify the date on the nebulizer mask. EI #1 said the date was 08/05/18. EI #1 removed the nebulizer mask and tubing and discarded the equipment and stated, night shift should have replaced this. The surveyor asked nurse EI #1 how often nebulizer masks and tubing were replaced, EI #1 stated they are replaced every Sunday night on night shift. On 08/22/18 at 11:10 AM, an interview was conducted with EI #4, the infection control nurse. The surveyor asked, according to facility policy, how often are nebulizer masks and tubing replaced. EI #4 responded by saying, every week on Sunday night. The surveyor asked what is the potential risk of failing to replace nebulizer masks and tubing per policy. EI #4 responded, the spread of infection. When the surveyor asked when should this nebulizer have been replaced, EI #4 responded, every 7 days. On 08/22/18 at 11:15 AM an interview with EI #7, LPN, was conducted. The surveyor asked EI #7 what shift she works. EI #7 responded by saying, the night shift. The surveyor asked EI #7 how often the nebulizer tubing/masks are supposed to be changed. EI #7 responded by saying once a week. EI #7 was asked when she initials the MAR, what does that means, EI #7 responded, it means that it's done. When the surveyor asked when RI # 58's nebulizer mask and tubing should have been replaced, EI #7 responded, on 08/12/19 but the last time it should have been changed was on 08/19/18. The surveyor asked EI #7, why didn't you replace the mask and tubing as you signed in the MAR on 08/12/18 and 08/19/18, EI #7 responded, I should have but I didn't. On 08/22/18 at 11:20 AM, an interview with EI #3, RN, DON was conducted. The surveyor asked, what is the policy for replacing nebulizer masks and tubing. EI #3 responded, every 7 days on Sunday night shift. The surveyor asked, has (EI #7) ever reported a shortage of supplies to you, EI #3 responded, not to me. The surveyor asked, were you aware of the documentation on the back of RI #58's MAR for the month of July stating Nebulizer masks/tubing could not be replaced due to a lack of supplies. EI #3 responded, no, that was prior to me coming to this facility. The surveyor asked, what does the nurse's initials on an MAR indicate. EI #3 stated that that particular thing has been done or given by that nurse. When the surveyor asked EI #3 who is responsible for assuring staff and residents have supplies needed, EI #3 stated, All management. When asked, when should the nebulizer tubing I observed in RI #58's room with date 8/5/18 been replaced, EI #3 stated, twice, on the 12th and 19th. 2. RI #338 was admitted to the facility on [DATE] with diagnoses including Enterocolitis d/t (due to) Clostridium difficile (C-diff.). Review of the medical record revealed physician's orders dated 08/20/18 which states, RESIDENT IS ON CONTACT ISOLATION. A review of facility policy dated 11/09/09 and titled Isolation - Categories of Transmission-Based Precautions under the section titled Contact Precautions states . c. Gloves and Handwashing, 1 wear gloves (clean, non-sterile) when entering the room, d. Gown, 1. wear a gown (clean, non-sterile) for all interactions that may involve contact with the resident or potentially contaminated items in the residnet's environment. On 08/22/18 09:05 AM, a cart was observed outide the room of RI #338 containing Personal Protection Equipment (PPE) supplies, to include gowns, gloves and red bags. There was signage on door notifying staff and visitors of contact transmission-based precautions and what PPE is required. The surveyor observed EI #6, CNA enter RI #338's room to assist EI #5, CNA with am care without donning (putting on) a gown, or gloves. 08/22/18 09:08 AM the surveyor observed CNA EI #5 exit RI#338's room with a bedpan covered with a plastic bag and gloves on her hands. CNA #5 walked down the hallway, returned with empty bedpan and a glove to right hand. CNA #5 asked for assistance from CNA #6 to don a glove to left hand before entering room. 08/22/18 09:11 AM, an interview was conducted with EI #5, CNA the surveyor asked what care was being provided at this time and she responded, AM (morning) care. EI #5 stated the resident is sick at his/her stomach and had a bowel movement. The surveyor asked what precautions was the reisdnet on. EI #5 stated, contact precautions. When the surveyor asked why she failed to don a gown before entering the resident's room, CNA #5 stated she usually does, stating she did before and just forgot that time. 08/22/18 09:15 AM , during an interview with EI #6, CNA,the surveyor asked what precautions was (RI #338) currently on. EI #6, said the resident is on contact precautions. When the surveyor asked what precautions staff take with this resident, EI #6 stated, before entering the room, staff have to have on gloves and gowns. When the surveyor asked why she failed to don a gown and gloves before entering the resident's room, she stated she was just assisting with care, not providing care and from what she understand she didn't have to have to gown and glove as long she don't touch the resident. Upon interview with EI #4, the Infection Control Nurse on 08/22/18 11:26 AM, the surveyor asked if RI #338 is currently on any transmission-based precautions. EI #4 responded by saying the resident is contact precautions. When asked, what PPE should staff don before entering this room, EI #4 said gloves and a gown. The surveyor asked EI #4 why should this PPE be donned before entering a room under this precaution. EI# 4 responded by saying, to protect the staff. When asked what PPE should EI #6 don to enter RI #338's room to assist EI #5 with AM care, EI # 4 responded, gown and gloves. The surveyor asked what is the risk of staff failing to don proper PPE when entering the room of a resident under contact precautions, EI #4 responded by saying the spread the infection. On 08/22/18 at 11:37 am, an interview was conducted with EI#3, the Director of Nursing. The surveyor asked, what is the policy for PPE with a resident with c-diff. EI #3 responded gloves and a gown. When asked if all staff entering room to provide care to this resident should don gloves and a gown, EI #3 stated, yes.

Based on observations and interviews, the facility failed to ensure walls in RL (Room Locator) #s 1-9 were free of holes, scuffed paint, and missing baseboards and bathroom ceiling tiles were free of brown stains. This affected nine of 62 rooms, located on two of four floors in the facility. Findings include: During the initial tour of the facility on 09/05/2017 beginning at 3:14 p.m. the following observations were made: 1. RL #1 (Fourth Floor): An observation was made of side A's baseboard missing as well as the sheetrock next to the closet, and scuffed paint under the papertowel dispenser. 2. RL #2 (Fourth Floor): An observation was made of scuffed paint underneath the papertowel dispenser on Side A. 3. RL #3 (Fourth Floor): An observation was made of chipped paint on the wall on the left of Side A's sink. 4. RL #4 (Fourth Floor): An observation was made of chipped/scuffed paint on the wall next to the sink on side A. 5. RL #5 (Fourth Floor): An observation was made of missing baseboard on side A near the closet and chipped/scuffed paint on the wall and chipped/scuffed paint on the wall above the mirror on side A. 6. RL #6 (Fourth Floor): An observation was made of the blinds on Side B with bent blinds. 7. RL #7 (Fourth Floor): An observation was made of chipped/scuffed paint on the wall next to the sink on Side A and a hole the size of a quarter in the wall. 8. RL #8 (Fourth Floor): An observation was made of scrapped sheetrock on the wall on Side B, Side A was observed with scrapped paint on the wall above the baseboard. 9. RL #9 (Third Floor): An observation was made on the bathroom ceiling tile with brown stains. On 09/07/2017 beginning at 7:31 p.m., the surveyor and Employee Identifier (EI) #1, the Maintenance Director, observed RL #s 1-9. EI #1 acknowledged the areas of concern in each room. On 09/07/2017 at 7:52 p.m., an interview was conducted with EI #1. EI #1 was asked how often were residents' rooms inspected for needed repairs. EI #1 said monthly. EI #1 was aked why should walls be free of holes, scuffed paint, scuffed drywall and bent blinds. EI #1 replied, It's a home environment. EI #1 was asked why should ceiling tiles be free of brown stains. EI #1 explained so it would not become mildewed. EI #1 was asked was he aware of the issues he observed such as scuffed paint on walls and holes in walls. EI #1 said, Yes ma'am. EI #1 was asked why should baseboards be in good repair. EI #1 explained it could be a trip hazard, and it should look like a homelike environment. EI #1 was asked who was responsible for ensuring walls were free of scuffed paint and holes in walls. EI #1 replied, My responsibility. EI #1 was aked what was the potential harm for residents' rooms to have holes in walls, scuffed paint, scuffed sheetrock, bent blinds and stained ceiling tiles. EI #1 said it was not homelike and should be in good repair.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of the facility's policy titled Assessment for Bowel and Bladder, the facility failed to develop individualized care plan approaches addressing Resident Identifier (RI) #s 7 and 8's incontinence needs. This affected two of eight residents sampled for bowel and bladder and two of 16 residents for whom care plans were reviewed. Findings include: Review of the facility's policy titled Assessment for Bowel and Bladder, revised 09/01/2005, revealed the following: .Procedure . 3. Plan for treatment should be established on an individual basis . 1. RI #7 was admitted to the facility on [DATE] with diagnoses of Acute Cholecystitis, Diabetes Mellitus Type Two, and Constipation. RI #7's care plan, with an onset date of 08/18/2017, addressing frequent incontinence of both bowel and bladder, included an approach to assist with the bed pan and urinal. There were no individualized approaches instructing staff when or how frequently to assist RI #7. RI #7's admission Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 08/25/2017, indicated RI #7 had moderate cognitive impairment, was frequently incontinent of both urine and bowel, and required extensive assistance of one person for toileting needs. The facility was unable to provide evidence RI #7 had been tracked to determine individual bowel and bladder elimination patterns. ADL (Activities of Daily Living) documentation only reflected if RI #7 was wet and/or soiled each shift, not the times in which the episodes occurred. During the initial tour of the facility, beginning at 3:55 p.m., RI #7 stated when he/she notified staff, he/she would use a bed pan. RI #7 further stated staff assisted with the bed pan but did not come at any set times. 2. RI #8 was admitted to the facility on [DATE] with diagnoses of Constipation, Diabetes Mellitus Type Two, Urinary Tract Infection, and Dementia. RI #8's admission MDS Assessment, with an ARD of 05/09/2017, indicated RI #7 had severe cognitive impairment, was always incontinent of bowel, had a urinary catheter, and required extensive assistance of two people for toileting needs. RI #8's Physician's Orders included an order dated 05/25/2017, to discontinue the urinary catheter. RI #8's careplan addressing urinary and bowel incontinence, onset date 05/25/2017, indicated RI #8 wore disposable briefs and was assisted with perineal cleansing as needed. There were no individualized approaches instructing staff when or how frequently to assist RI #8. RI #8 was reassessed for a quarterly RESTORATIVE EVALUATION OF BOWEL AND BLADDER on 07/31/2017. However, this assessment indicated RI #8 still had a urinary catheter. The facility was unable to provide evidence RI #8 had been tracked to determine individual bowel and bladder elimination patterns. During the initial tour of the facility on 09/05/2017, beginning at 3:55 p.m., RI #8's spouse said RI #8 could use a urinal if she caught it in time. She also stated RI #8 knew when he/she had to go. RI #8's spouse said staff did not keep a urinal beside the resident's bed. Employee Identifier (EI) #4, Restorative Nurse, was interviewed on 09/07/2017 at 9:00 a.m EI #4 said residents were assessed for bowel and bladder upon admission, quarterly and with a significant change. EI #4 said she utilized ADL records to determine residents' voiding patterns. When asked how the information obtained would be incorporated into a care plan, EI #4 said residents had to have a care plan addressing bowel and bladder. EI #4 said she was responsible for bowel and bladder care plans, and they should address how often, when, and how the resident was using the restroom. EI #4 reviewed RI #7's incontinence care plan and said it indicated the resident should receive assistance with the bed pan and urinal, pericare as needed, and should use disposable briefs. EI #4 agreed the care plan did not specify times RI #7 required assistance from staff. After reviewing RI #8's incontinence care plan, EI #4 said it did not address when or how often RI #8's toileting needs should be met. EI #4 said it would be possible for RI #8 to avoid some incontinent episodes if a urinal was used. During an interview with EI #2, the MDS/Care Plan Coordinator, on 09/07/2017 at 10:10 a.m., EI #2 confirmed the Restorative Nurse (EI #4) was responsible for developing bowel and bladder care plans. EI #2 explained the interventions should be specific to each resident. EI #5, the Director of Nursing, was interviewed on 09/07/2017 at 4:50 p.m EI #5 said residents should be assessed for bowel and bladder and monitored to determine their individual voiding patterns. EI #5 explained using that information, you should be able to identify patterns and implement resident specific interventions. After reviewing RI #7 and #8's approaches to assist with the bedpan and urinal and pericare as needed, EI #5 agreed the interventions were not resident specific. EI #5 said the care plan should address if the resident uses the toilet, urinal, or bedpan, and when or how often it is used. EI #5 said if that is not done residents are at risk for being incontinent, since bowel and bladder training was designed to provide residents with a possibility for improved continence status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of the facility's policy titled Assessment for Bowel and Bladder, the facility failed to ensure Resident Identifier (RI) #7 was monitored to determine normal bowel and bladder patterns so that care approaches could be developed and implemented to maintain or improve RI #7's continence status. Further, the facility failed to ensure RI #8 was reevaluated for bowel and bladder and monitored to determine individual voiding patterns following the discontinuation of a urinary catheter on 05/25/2017. This affected two of eight residents reviewed for bowel and bladder. Findings include: Review of the facility's policy titled Assessment for Bowel and Bladder, revised 09/01/2005, revealed the following: Purpose To ensure each resident who is incontinent of bladder receives appropriate treatment and services to . restore as much normal bladder function as possible . Procedure 1. Evaluate the resident upon admission and whenever there is a change in cognition, physical ability or urinary tract function. Identify residents with reversible and irreversible causes of incontinence. 2. When completing the comprehensive assessment, consider the following: * Prior history of urinary incontinence . * Voiding Patterns- such as frequency, volume, nighttime or daytime, quality of stream and, for those already experiencing urinary incontinence, voiding pattern over several days . 3. Plan for treatment should be established on an individual basis . 4. Programs that require the resident's cooperation and motivation in order for learning and protocol include the following: * Bladder Rehabilitation/Bladder Retraining . 5. Programs that are dependent on staff involvement and assistance, as opposed to resident function, include the following: * Promoted Voiding is a behavioral technique appropriate for use with dependent or more cognitively impaired residents . Residents who are assessed with urge or mixed incontinence and are cognitively impaired may be candidates for prompted voiding . * Habit Training/Scheduled Voiding is a behavioral technique that calls for scheduled toileting at regular intervals on a planned basis to match the resident's voiding habits . Residents who cannot self toilet may be candidates for habit training or scheduled voiding programs . 1. RI #7 was admitted to the facility on [DATE] with diagnoses of Acute Cholecystitis, Diabetes Mellitus Type Two, and Constipation. RI #7's care plan, with an onset date of 08/18/2017, addressing frequent incontinence of both bowel and bladder, included an approach to assist wit the bed pan and urinal. The approaches did not indicate when or how frequently staff were to assist RI #7. RI #7's admission Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 08/25/2017, indicated RI #7 had moderate cognitive impairment, was frequently incontinent of both urine and bowel, and required extensive assistance of one person for toileting needs. RI #7's admission RESTORATIVE EVALUATION FOR BOWEL AND BLADDER, dated 08/25/2017, indicated RI #7 exhibited symptoms of both urge and functional incontinence. The evaluation did not consider the residents history prior to admission. The section of the evaluation related to MEDICAL HISTORY included a question for the date urinary incontinence was first identified. However, this section was not completed. The evaluation also indicated RI #7 was alert and oriented, required assistance with toileting, and utilized a bedpan/urinal. The Goal was marked as Contain, instead of Restore or Decrease or Manage. The areas for Bowel and Bladder Training and Prompted Voiding/Habit Training were not marked. The facility was unable to provide evidence RI #7 had been tracked to determine individual bowel and bladder elimination patterns. ADL (Activities of Daily Living) documentation from 08/18-08/31/2017 only reflected if RI #7 was wet and/or soiled each shift, not the times in which the episodes occurred. During the initial tour of the facility, beginning at 3:55 p.m., RI #7 stated when he/she notified staff , he/she would use a bed pan. RI #7 further stated staff assisted with the bed pan but did not come at any set times. 2. RI #8 was admitted to the facility on [DATE] with diagnoses of Constipation, Diabetes Mellitus Type Two, Urinary Tract Infection, and Dementia. RI #8's admission MDS Assessment, with an ARD of 05/09/2017, indicated RI #7 had severe cognitive impairment, was always incontinent of bowel, had a urinary catheter, and required extensive assistance of two people for toileting needs. RI #8's Physician's Orders included an order dated 05/25/2017, to discontinue the urinary catheter. RI #8's careplan addressing urinary and bowel incontinence, onset date 05/25/2017, indicated RI #8 wore disposable briefs and was assisted with perineal cleansing as needed. The approaches did not indicate when or how frequently staff were to assist RI #8. RI #8 was reassessed for a quarterly RESTORATIVE EVALUATION OF BOWEL AND BLADDER on 07/31/2017. However, this assessment indicated RI #8 still had a urinary catheter. The facility was unable to provide evidence RI #8 had been tracked to determine individual bowel and bladder elimination patterns following the discontinuation of his/her catheter. During the initial tour of the facility on 09/05/2017, beginning at 3:55 p.m., RI #8's spouse said RI #8 could use a urinal if she caught it in time. She also stated RI #8 knew when he/she had to go. RI #8's spouse said staff did not keep a urinal beside the resident's bed. RI #8's spouse said she had to request the urinal, but it often disappeared. She was able to locate a urinal inside of a drawer in RI #8's room. Employee Identifier (EI) #4, Restorative Nurse, was interviewed on 09/07/2017 at 9:00 a.m EI #4 said residents were assessed for bowel and bladder upon admission, quarterly and with a significant change. EI #4 said she utilized ADL records to determine residents' voiding patterns. When asked how the information obtained would be incorporated into a care plan, EI #4 said residents had to have a care plan addressing bowel and bladder. EI #4 said she was responsible for bowel and bladder care plans, and they should address how often, when, and how residents were using the restroom. EI #4 said RI #7's 08/25/2017 bowel and bladder evaluation indicated he/she was frequently incontinent. She said RI #7's elimination pattern was determined by reviewing ADL records. EI #4 explained staff documented incontinence episodes by shift, so she would not be able to pinpoint any specific times the resident tended to urinate or have a bowel movement. When asked if RI #7 qualified for a bowel and bladder program, EI #4 said not for bowel, due to diarrhea. She then said the main focus of urinary incontinence would be to get RI #7 to call for assistance, but staff should be offering as well. She said RI #7 was not on a program because she considered it as they were training the resident to let them know. EI #4 then reviewed the information for RI #8. EI #4 said RI #8 had a catheter on admission that was discontinued on 05/25/2017. EI #4 said RI #8's quarterly RESTORATIVE EVALUATION OF BOWEL AND BLADDER, dated 07/31/2017, indicated RI #8 still had the catheter. She said the assessment was wrong, and said RI #8 should have been reevaluated at the time the catheter was discontinued and assessed to determine if he/she had a pattern of elimination. She said it was important to determine if RI #8 had a pattern to ensure he/she was as continent as possible, and so they could do scheduled or prompted voiding. A follow-up interview was conducted with EI #4 on 09/07/2017 at 4:20 p.m EI #4 said she also utilized a tool with hourly documentation of bowel and bladder, but said she was unable to provide these for RI #s 7 and 8. When asked how their evaluations took into account a resident's past bowel and bladder history, EI #4 said they asked if a resident was continent at the time of admission but did not go into their history prior to admission to the facility. EI #4 agreed that, per policy, their evaluation should take into account residents' past history. EI #4 said when RI #8's catheter was discontinued, he/she should have been reassessed and monitored to determine voiding patterns. EI #4 said the importance of bowel and bladder retraining was to determine residents' patterns. EI #5, the Director of Nursing, was interviewed on 09/07/2017 at 4:50 p.m EI #5 said residents should be assessed for bowel and bladder and monitored to determine their individual voiding patterns. EI #5 said the purpose of this evaluation was to determine if the resident is able to be trained. EI #5 explained using the information obtained in the evaluation and monitoring, you should be able to identify patterns and implement resident specific interventions. When asked if this procedure was followed for RI #s 7 and 8, EI #5 said she was not always involved in the day to day activities, but indicated it should be documented in the residents' medical records. EI #5 reviewed documentation for RI #7 and said he/she was capable of being on a program. EI #5 also said RI #8 should have been reassessed after the catheter was removed to determine if he/she would qualify for a program. When asked what the risk to the resident was, if the facility did not follow their procedure for bowel and bladder, EI #5 said it placed the residents at risk for being incontinent.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to ensure alternatives were attempted prior to implementing side rails for Resident Identifier (RI) #s 3, 7, 8, and 9, four of nine residents reviewed for side rail use. Findings include: 1. RI #3 was admitted to the facility on [DATE] with diagnoses of History of Falling, Muscle Spasm, Difficulty Walking, and Hemiplegia following Cerebral Infarction Affecting Right Nondominant Side. A Side Rail Evaluation was completed upon RI #3's admission to the facility on [DATE]. This assessment indicated RI #3 required 1/2 (half) siderails at the head of the bed at the time of admission. RI #3's admission Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 07/24/2017, indicated RI #3 had severe cognitive impairment, required extensive assistance of one person for bed mobility and extensive assistance of two people for transfers. This assessment also indicated RI #3 had range of motion impairments on one side for upper and lower extremities, and was only able to stabilize with staff assistance when doing surface to surface transfers and from sitting to standing. RI #3's care plan for ADL (Activities of Daily Living) assistance, with an onset date of 07/17/2017, included an active approach for siderails to be up times two. 2. RI #7 was admitted to the facility on [DATE] with a diagnosis of History of Falling. A Side Rail Evaluation was completed upon RI #7's admission to the facility on [DATE]. This assessment indicated RI #7 required 1/2 siderails at the head of the bed at the time of admission. RI #7's admission MDS, with an ARD of 08/25/2017, indicated RI #7 had moderate cognitive impairment, required extensive assistance of two people for bed mobility and transfers, and was only able to stabilize with staff assistance when moving from the seated to standing position and for surface to surface transfers. RI #7's ADL care plan, onset date 08/18/2017, included an approach for 1/2 siderails up times two at the head of the bed. During the initial tour of the facility on 09/05/2017 beginning at 3:55 p.m. RI #7 was observed in bed with 1/2 side rails up times two at the head of the bed. 3. RI #8 was admitted to the facility on [DATE] with diagnoses of History of Falling and Difficulty in Walking. A Side Rail Evaluation was completed upon RI #8's admission to the facility on [DATE]. This assessment indicated RI #8 required 1/2 siderails at the head of the bed at the time of admission. RI #8's admission MDS assessment, with an ARD of 05/09/2017, indicated RI #8 had severe cognitive impairment, required extensive assistance of two people for bed mobility, total assistance of two people for transfers, and was only able to stabilize with staff assistance when moving from the seated to standing position and for surface to surface transfers. RI #8's quarterly Side Rail Evaluation, dated 07/31/2017, also indicated RI #8 required 1/2 siderails at the head of the bed. RI #8's ADL care plan, onset date 05/02/2017, included an active approach for the use of side rails. 4. RI #9 was admitted to the facility on [DATE] with a diagnosis of Dementia. RI #9's Side Rail Evaluation was completed upon admission to the facility on [DATE] and indicated RI #9 required 1/2 side rails up at the head of the bed. Employee Identifier (EI) #4, Restorative Nurse, was interviewed on 09/07/2017 at 9:00 a.m When asked if alternatives were attempted prior to installing siderails, EI #4 said when residents come in, most come in on the second floor, where most of their beds are equipped with 1/2 side rails. EI #4 said they generally go ahead with the use of the side rail if it is not restrictive, such as preventing the resident from getting out of the bed. When asked if she was familiar with the regulatory changes effective 11/28/2016 (related to side rails), EI #4 said no, but she knew some changes were coming up in 11/2017. When asked if she was aware it was a requirement to attempt alternatives prior to installing side rails, EI #4 said she knew there were alternatives to use before using full side rails, but 1/2 rails did not restrict residents. After reviewing the information for RI #s 3, 7, 8, and 9, EI #4 said all of their side rails were implemented the day of admission, and no alternatives were attempted prior. During an interview on 09/07/2017 at 4:50 p.m., EI #5, the Director of Nursing, said residents were assessed for siderails upon admission. When asked what alternatives should be attempted prior to utilizing siderails, EI #5 said they encourage residents and families not to use them but a lot of them request the side rails. When asked why no alternatives had been attempted prior to using side rails for RI #s 3, 7, 8, and 9, EI #5 said that was often due to requests and preferences; however, she said that was not documented for these residents. When asked if she was aware of regulatory changes that went into effect 11/28/2016, EI #5 said she recently learned the new changes did address side rails, but they just missed that.

Based on interviews, review of the facility's policies titled Quality Assessment and Assurance Plan and Bed Rails, and review of the QAPI (Quality Assurance and Performance Improvement) Meeting Agenda Form, the facility failed to ensure the Quality Assessment and Assurance (QAA) committee identified changes needed to their side rail policies and/or procedures after reviewing changes to regulatory requirements, effective 11/28/2016. This affected four of nine residents sampled for side rail use. Findings include: Cross reference F323. During the survey concerns were identified related to the facility's failure to attempt alternatives prior to using side rails for Resident Identifier #s 3, 7, 8, and 9. Review of the facility's policy titled Quality Assessment and Assurance Plan, revised 06/03/2016, revealed the following: . Policy To develop, implement, and maintain an ongoing program designed to monitor and evaluate the quality of resident care, pursue methods to improve quality care and to resolve identified problems . The facility's QAPI Agenda form, undated, indicated policies and procedures were to be reviewed at each meeting. Review of the facility's policy titled Bed Rails, revised 06/01/2008, revealed the policy did not reflect new regulation changes related to the requirement for alternatives prior to installing side rails. During an interview with Employee Identifier (EI) #5, the Director of Nursing, on 09/07/2017 at 6:38 p.m., EI #5 stated she acted as the QA director until 05/2017. EI #5 was asked how the QAA committee addressed regulatory changes that went into effect 11/28/2016. She explained the committee met to discuss the changes, and had a copy of the different phases of changes for review. EI #5 said the committee did not discuss the changes related to side rails, because they did not recognize it as a change. EI #5 said the committee should have recognized there were changes related to the use of side rails because they had looked at the regulations. EI #5 said the purpose of the QAA committee was to identify concerns or issues and put plans in place to correct them.

Based on record review and interviews, the facility failed to ensure Certified Nursing Assistants (CNAs) routinely caring for Resident Identifier (RI) #s 1-8 and 11 participated in the care planning process. This affected 9 of 9 residents reviewed for care plan meeting participation, as well as all 84 residents in the facility at the time of the survey who had already had care plan meetings conducted. Findings include: The facility's Resident Census and Condition of Residents form, dated 09/05/2017, indicated the facility had a census of 92 residents. An undated handwritten list provided by the facility indicated all but 8 current residents of the facility had already had a care plan meeting. Care Plan Meeting Sheets for RI #s 1-8 and RI #11 were reviewed and revealed meetings were conducted on the following dates, without a CNA in attendance: RI #1 had care plan meetings on 03/28/2017, 06/13/2017, and 07/12/2017. RI #2 had care plan meetings on 04/25/2017, 05/03/17, 06/20/2017, and 08/03/2017. RI #3 had a care plan meeting on 08/01/2017. RI #4 had care plan meetings on 05/18/2017 and 08/10/2017. RI #5 had care plan meetings on 02/16/2017, 05/11/17, and 07/20/2017. RI #6 had care plan meetings on 02/07/2017, 04/25/2017, and 07/18/2017. RI #7 had a care plan meeting on 09/05/2017. RI #8 had care plan meetings on 05/16/2017 and 08/08/2017. RI #11 had care plan meetings on 01/19/2017, 04/18/2017, 06/06/2017, and 07/27/2017. Employee Identifier (EI) #2, the MDS (Minimum Data Set) Coordinator/Care Plan Coordinator, was interviewed on 09/07/2017 at 10:10 a.m When asked who participated in care plan meetings, EI #2 said usually all department heads (including the Dietary Manager, Wound Nurse, herself and the other MDS staff, the Restorative Nurse, Activities Director, and Social Services) and any residents or family members that chose to attend. EI #2 said they had discussed CNAs participating in the care planning process because they are on the front line day to day caring for the patients, but said at this point CNAs were not participating. When asked why not, EI #2 said she thought it came down to the amount of time they spent doing meetings. When asked who had discussed CNAs participating in the care plan meetings, EI #2 said the corporate nurse had told her the CNAs would be required to participate but had not said it was already in effect. EI #2 stated at the current time no one in the facility had had a CNA participate in the care plan meetings/process. When asked why a CNA's participation would be beneficial, EI #2 said because CNAs work with the residents day in and day out and can give valuable feedback. EI #3, the corporate Case Mix Consultant (over the facility's MDS staff), was interviewed on 09/07/2017 at 3:30 p.m EI #3 agreed no CNAs had been participating in the care planning process, but said their participation was a requirement. When asked why CNAs had not been participating, EI #3 said it just never clicked with her they were not attending. EI #3 said she had informed EI #2, the MDS/ Care Plan Coordinator, CNA participation was required. EI #3 said CNA participation was beneficial because they know the residents better than anyone and can give more information.