**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, review of the facility's grievance log, and review of facility policy, the facility failed to ensure the grievance process was followed consistently for two (Resident Identifier (RI) # 37 and RI # 59) of two residents reviewed for grievances. The facility failed to keep a record of grievances, take prompt action, and investigate, and inform the complainant of the results of the investigation regarding grievances in such area as staff language and/or missing clothes. Findings included: A review of a facility policy titled, Resident Grievances, with an effective date of 03/2018, revealed, The resident has a right to voice grievances without discrimination or reprisal. The facility will make prompt efforts to resolve grievances and will keep the resident appropriately apprised of its progress towards resolution .The facility Grievance Official is the Director of Social Services or designee. That person shall be responsible for .1. Overseeing the grievance process, receiving, tracking and working with individual departments .issuing written grievance decisions to the resident .4. Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concern(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as result of the grievance, and the date the written decision was issued. 1. Review of an admission Minimum Data Set (MDS), dated [DATE], revealed RI #37 was admitted to the facility on [DATE]. Per this MDS, RI #37 was cognitively intact. During an initial interview on 03/23/21 at 1:45 PM, RI #37 stated that last week sometime, while providing care, staff were insulting to her. She was asked if she had told someone about this. She stated she had spoken to the Administrator about it but had not heard anything back in response to her complaint. She further stated that whatever he said must have worked, as for one day they were nice, but then they went back to being insulting again. A review of the grievance log book for 2021 revealed that for the month of January, there were three grievances. For the months of February and March 2021, there was zero evidence of any grievances. In an interview on 03/24/21 at 3:50 PM, Employee Identifier (EI) #1, the Administrator, stated that RI #37 had spoken to him about her concern, and he felt her concerns did not rise to the level of abuse, so it was not investigated. EI #1was asked if he had logged the incident in the grievance book. He stated no, he just handled the concern verbally. 2. Review of a quarterly MDS with an Assessment Reference Date (ARD) of 02/21/21 revealed staff assessed RI #59 as moderately impaired in cognition. In a family interview on 03/23/21 at 11:41 AM, when asked if RI#59 had any missing personal items, the family member stated there had been missing clothes. He was asked if he had reported the missing clothing and if the facility investigated the concern. He stated the facility did look for them; however, nothing had been found or reported back to him. He further stated the facility did not have a good system in place and therefore, he had stopped buying clothes for RI #59. In an interview on 03/25/21 at 8:41 AM, EI #3, the Social Services staff, was asked if grievances were documented when there were missing items. She stated that she would let the resident decide if their concern was a grievance or not. EI #3 was asked if there was any documentation of investigation or follow through. EI #3 did not answer the question. When asked how grievances were tracked if there was no documentation, EI #3 acknowledged that it would be difficult to track then if there was no documentation. In a follow-up interview on 03/26/21 at 11:53 AM, EI #1 was asked about the facility's grievance process. He stated that grievances were mostly verbal and that they would be looked into by the staff person who had received the complaint. EI #1 was shown the grievance log for 2021, which listed a total of three grievances for the year. He stated that there was an obvious process, as in 2020 there were numerous documented entries; however, he agreed that the whole grievance process needed to be reviewed and updated to include documentation, tracking/trending, and documentation that the resident and/or family members had been informed and the issue resolved.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one (Resident Identifier (RI) #12) of one sampled residents reviewed for range of motion received care and services to prevent potential further decline in his range of motion. RI #12's right-hand splint was not applied routinely per his plan of care. Findings include: Review of RI #12's undated Face Sheet, found in the Electronic Medical Record (EMR) under the Demographics Tab, revealed RI #12 was a long-term resident with diagnoses including a history of traumatic brain injury (TBI) and contracture of unspecified joints. RI #12's Functional Management Program, dated 01/14/19, read, Splint: Right hand/wrist. Wear 6 hours per day. RI #12's current Contracture Care Plan, found in the resident's EMR under the Care Plan Tab and dated 06/08/19, read, Problem: [Resident] has the use of a splint to his right hand; and Approaches: Apply splint to right hand mon - fri (Monday through Friday) in the AM (morning) and remove in the evening or as tolerated. RI #12's current Physician Orders, found in the resident's EMR under the Orders Tab and dated March 2021, indicated no order for splints. RI #12 was observed on 03/23/21 at 10:30 AM, 12:00 PM, and 2:50 PM. The resident was lying in bed on his back with the head of his bed elevated approximately 30 degrees. The resident's right hand was observed to be severely contracted, with his fingers tightly curled into the palm of his hand. No splinting device was observed on RI #12's right hand during any of the indicated observations. RI #12 was observed in bed on 03/24/21 at 10:15 AM and 3:15 PM. The resident was not wearing his right-hand splint during either observation. During an interview with Employee Identifier (EI) #11, a Licensed Practical Nurse, on 03/25/21 at 11:01 AM, she indicated RI #12 was to wear a brace on his right hand during the day and either nursing or the restorative aide was to apply it. She further stated, I was here yesterday, and I know I didn't put it on then. During an interview with EI #7, a Restorative Certified Nursing Assistant, on 03/25/21 at 11:21 AM, she confirmed RI #12 was to wear a brace on his right hand during the day. She stated, I have a Functional Maintenance Plan for it [the brace]. Usually I put it [the brace] on. I didn't put it on yesterday or the day before because I was on the halls doing weights and didn't have time. The brace should be on [RI #12's hand] for four to six hours per day, five days per week. I normally put it on in the morning and take it off before I leave work for the day. During an interview with EI #4, the Assistant Director of Nursing, on 03/25/21 at 3:53 PM, she indicated RI #12 had been sent out to the hospital from [DATE] through 06/08/19 and that when he returned to the facility, the order for his splint had dropped out of the EMR system. She confirmed RI #12 needed the splint and stated she put a new order in for it on that date, after surveyor intervention. Review of a Telephone Order, provided to the survey team on 03/25/21 at approximately 4:30 PM and dated 03/25/21, read Nursing/Restorative Aide to apply right hand splint Monday through Friday. Apply in AM and remove at 2:00 PM. May remove sooner if not tolerated. During an additional interview with EI #4 on 03/26/21 at 9:43 AM, she stated there was no facility policy related to splinting/contracture management.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of facility policy, the facility failed to ensure each resident's right to determine their advance directives for four (Resident Identifier (RI) #11, RI #26, RI #50, and RI #116) of seven residents reviewed for advance directives. Expressed wishes for No Code or Do Not Resuscitate (DNR) status were not followed up on to assure that the facility had all documentation and that required forms were complete and notarized, if required, to validate that this was the resident's current request per their code status. The failure to assure that all needed documentation regarding advance directives was obtained creates the potential for the resident to receive services which are not requested or per their informed preference. Findings include: The facility's Do Not Resuscitate Orders Policy dated 03/2019 indicated, When the resident is competent, the Do-Not-Resuscitate order must be reached by the resident and his physician. When the resident is incompetent, the decision must be reached by appropriate surrogate (spouse, children, parents, etc.), or legal representative, and the physician . If the resident has a declaration pursuant to the Alabama Natural Death Act, a copy of this declaration shall, if available, be made part of the resident's medical record . In the event that the resident is discharged from, and subsequently readmitted to, the facility, and the resident desires to have a Do-not-Resuscitate order, a new order should be obtained from the resident's physician. 1. RI #11 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hypertensive heart disease with heart failure and type 2 diabetes, according to the undated Face Sheet found in the Electronic Medical Record (EMR) under the Demographics Tab. RI #11's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/24/20, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 11/15, indicating mild to moderate cognitive impairment. Review of RI #11's Power of Attorney document, dated 01/15/21 and found in the resident's paper clinical record under the Advance Directive Tab, indicated, that to the statement, I want to have life sustaining treatment if I am terminally ill or injured, the answer initialed by the resident was No. To the statement, I want to have life-sustaining treatment if I am permanently unconscious, the answer initialed by the resident was No. Hospital discharge documentation, dated 02/17/21 which was provided to the survey team on 03/25/21 at approximately 4:00 PM, indicated RI #11 had a Full Code order in place in the hospital. Physician's Orders, dated 02/17/21 and found in the resident's paper medical record under the Orders Tab, indicated an order for Full Code Status. The resident's Physicians Orders, dated March 2021 and found in the EMR under the Orders Tab, also indicated an order for Full Code Status. Further review of Physician's Orders revealed a new order, dated 03/24/21 (after the initiation of the survey) indicated an order for DNR (Do Not Resuscitate). Review of Departmental Notes, dated 03/24/21 and found in the EMR under the Notes Tab, indicated, Spoke with son, Healthcare Proxy, in regard to resident's code status. With recent diagnosis of Dementia and review of advance directive, code status updated to DNR. The facility was unable to provide the resident's Advance Directive Acknowledgement Form, routinely completed upon admission and kept in the Admissions Office, prior to the survey exit date of 03/26/21. The surveyor was unable to interview RI #11 regarding their wishes related to their Advance Directives due to their decline in mental status. During an interview with RI #11's family member/responsible party on 03/24/21 at 3:50 PM, she stated she was the resident's co-responsible party per the resident's Medical Proxy. She indicated she lived locally and visited the resident frequently, and stated, She [RI #11] has never wished to be full code, and it would surprise me if she wanted that now. She further stated the facility had reached out to her that morning to request that she bring in another copy of the resident's Advance Directive, as the copy they had was not signed by a Notary, and that this was the requirement for the facility to implement a DNR order for the resident. The resident's family member indicated the copy of the Advance Directive originally provided to the facility had not been notarized, but the facility had not reached out to the family prior to 03/24/21 to indicate they would need the form notarized in order to implement a DNR order. During an interview with Employee Identifier (EI) #4, the Assistant Director of Nursing (ADON), on 03/25/21 at 9:01 AM, she indicated she had just spoken with RI #11's son/co-proxy, and that he indicated he wanted RI #11 to remain DNR until he could have a conversation with the resident to see if her wishes regarding her Code Status had recently changed. EI #4 stated that the resident's son had confirmed that RI #11 had always wished to be a DNR status. 2. RI #26 was admitted to the facility on [DATE] with diagnoses, according to the undated Face Sheet found in the EMR under the Demographics Tab, including dissection of unspecified site of aorta and vascular dementia. RI #26's most recent MDS, a comprehensive Annual Assessment with an ARD of 12/16/20, indicated the resident had a BIMS of 3/15, indicating severe cognitive impairment. Physician's Orders, dated 12/02/17 and found in the resident's paper medical record under the Orders Tab, indicated an order for Do Not Resuscitate. The resident's Physicians Orders, dated March 2021 located in the EMR under the Orders Tab, also indicated an order for Do Not Resuscitate. RI #26's Advanced Directive Care Plan dated 12/05/17 also indicated, Problem: [Resident] and/or family request DNR order to be in effect; and Respect end of life decisions and provide emotional support. The resident's Advance Directive Acknowledgement Form, dated 08/23/16 and kept in the Admissions Office, was reviewed, and indicated none of the following boxes were checked regarding the resident's Advance Directive Status: Advance Directive in existence was blank, Advance Directive not in existence was blank, and Copy of Advance Directive Provided to the facility was blank. The facility was unable to provide an Advance Directive or any other documentation to the survey team, prior to facility exit on 03/26/21, to indicate the resident or her responsible party had been informed about the process related to her DNR status, or that she or her responsible party had chosen the DNR status vs Full Code Status. The surveyor was unable to interview RI #26 regarding their wishes related to their Advance Directives due to their decline in mental status. 3. RI #50 was re-admitted to the facility on [DATE] with diagnoses, according to the undated Face Sheet found in the EMR under the Demographics Tab, including COVID-19 and unspecified Dementia. RI #50's most recent MDS, a comprehensive admission Assessment with an ARD of 01/21/21, indicated the resident had a BIMS of 13/15, indicating the resident was cognitively intact. Physician's Orders, dated 01/15/21 and found in the resident's paper medical record under the Orders Tab, indicated an order for Full Code. The resident's Physicians Orders, dated March 2021 and found in the EMR under the Orders Tab, also indicated an order for Full Code. However, RI #50's Advanced Directive Care Plan dated 10/27/20 with a resolution date of 01/15/21 indicated, Problem: [Resident] and/or family request DNR order to be in effect; and Respect end of life decisions and provide emotional support. The resident's Advance Directive Acknowledgement Form, dated 01/15/21 and kept in the Admissions Office, indicated none of the following boxes were checked regarding the resident's Advance Directive Status: Advance Directive in existence was blank, Advance Directive not in existence was blank, Portable Do Not Resuscitate (DNR) Order in existence was blank, and Copy of Advance Directive Provided to the facility was blank. The surveyor was unable to interview the resident related to Code Status due to confusion the resident was experiencing throughout the survey period. 4. RI #116 was admitted to the facility on [DATE] with diagnoses, according to the undated Face Sheet, found in the EMR under the Demographics Tab, including myocardial infarction (heart attack). RI #116's MDS was not complete as of the date of the survey due to her recent admission to the facility and was not available for review. The resident's Comprehensive admission Assessment, dated 03/10/21 and found in the EMR under the Assessment Tab, indicated the resident was cognitively intact. Physician's Orders, dated 03/10/21 and found in the resident's paper medical record under the Orders Tab, indicated an order for Full Code. The resident's Physicians Orders, dated March 2021 and found in the EMR under the Orders Tab, also indicated an order for Full Code. However, the resident's Advance Directive Acknowledgement Form, dated 01/15/21 and kept in the Admissions Office, indicated Portable Do Not Resuscitate (DNR) Order Provided to Facility. RI #116's Portable DNR Order could not be located in the resident's record, nor was the facility able to provide the order to the survey team prior to the survey exit date of 03/26/21. During an interview conducted with RI #116 on 03/25/21 at 4:27 PM, she stated, We have a living will. I'm not going to do anything to myself, but when God thinks it's time, I believe it's time. During an interview with EI #5, a Licensed Practical Nurse (LPN)/Treatment Nurse, on 03/24/21 at 12:11 PM, she indicated she was typically responsible for resident admission/re-admission paperwork, and that any time a resident was sent out to the hospital and then readmitted to the facility, a new code order was obtained to match the hospital order. She indicated both RI #11 and RI #50 had both recently been re-admitted to the facility from the hospital, and that their hospital orders must have indicated their current code status. During an interview with EI #4 on 03/25/21 at 10:30 AM, she stated the facility process was that code status was to be reviewed with residents and their responsible parties upon admission and the Advance Directive Acknowledgement Form was to be filled out. The form was to be discussed and then the resident/responsible party was to fill it out to indicate whether or not an Advance Directive/Portable DNR was in existence. She indicated if an Advance Directive or Portable DNR was in existence, staff should follow up to ensure the forms were provided to the facility in a timely manner. She further stated orders for residents returning from the hospital were based on hospital code status. She stated that if the Advance Directive Acknowledgement Form indicated a resident had an Advance Directive or Portable DNR Form, and the resident's ordered code status was Full Code, this meant the facility had not obtained a copy of those documents. She stated it was Admissions and Social Services (SS) responsibility to follow up on any missing documentation related to code status in a timely manner. During an interview with EI #6, a Corporate Admissions Coordinator, on 03/25/21 at 3:26 PM, she stated she was currently helping the facility while they were trying to fill their facility admission position. She stated she would go over the admission Packet, including the Advance Directive Acknowledgement Form with residents and their responsible parties at the time of admission to the facility. She stated that sometimes residents/responsible parties would check the box indicating an Advance Directive was in place but would not have the actual document in hand at the time of admission. She stated, We let them know that we have to have the documentation in hand, and until we do they [the resident] will be a Full Code. If a resident says they don't have anything [an Advance Directive] in place, we offer assistance to fill out/give information on portable DNR. The social worker would need to then follow up regarding the DNR paperwork. Information [related to Code Status] is also passed off to the nurses. If I expect additional paperwork to be delivered [by the family], I pass that to the staff. The facility staff should absolutely follow up [related to Code Status paperwork/forms]. During a follow up interview with EI #4 on 03/26/21 at 9:49 AM, she indicated SS should be discussing Code Status with residents and families upon admission/ re-admission. She stated, If someone indicates there is a DNR order, she [SS] should get a copy. If she can't get a copy at admission, then she needs to follow up. During an interview with EI # 8, a Registered Nurse, on 03/26/21 at 10:06 AM, she stated each nurses' station had a book with copies of each resident's Code Order. She stated if a resident were to code, she would go to the book to find the copy of the resident's code order. She indicated she could, additionally, log into the computer to look at a code order if needed, but that it was quicker to look in the book. The surveyor verified the code books were at each nurses' station, and included the current code orders for RI #11, RI #26, RI #50, and RI #116. During an interview with EI #10, an LPN, on 03/26/21 at 10:15 AM, she indicated if a resident were to code, she would go to the Code Status Book or the EMR to find the resident's current Code Orders. During an interview with EI #12, Social Services staff, on 03/26/21 at 1:50 PM, she stated, Code status is a clinical thing for us. Full Code or DNR that is between patient and physician and family. We would go to the nurse manager [for decisions related to Code Status] here. It is not social services. It [Code Status] is something nursing follows up on. If an issue related to Code Status was brought to my attention, I would get that issue to the clinical team. Nothing has been brought to my attention [related to any concerns about Code Status]. If someone comes into the facility and they don't have an advanced directive, we have advanced directive forms in the office, and we can get those and go over them with a resident. We do have that information on advanced directives available.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews and a review of a facility policy titled Resident Assessment Instrument the facility failed to ensure RI # 4, 5 and 6's Minimum Data Set (MDS) assessments were transmitted within the 14 days required time frame. This affected 3 of 3 residents whose assessments were not transmitted timely. Findings Include: A review if a facility policy titled, Resident Assessment Instrument (RAI) with an effective date of 3/2018, revealed: PURPOSE: Residents are assessed, based on a comprehensive assessment process, in order to ensure they receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the resident's choices. Tracking Records and Discharge Assessments . b) Death in the facility tracking record c) Discharge Assessment. A review of the Resident Assessment task of the survey process system revealed RI #4, #5 and #6's MDS were over 120 days old. On [DATE] at 9:00 a.m., Employee Identifier (EI) #5, Registered Nurse was interviewed. EI #5 stated that RI #4 was admitted to the facility on [DATE] and expired on [DATE]. EI #5 said RI #4's assessment was closed but not submitted. EI #5 said RI #5 came to the facility [DATE] and was discharged on [DATE]. She reported RI #5's assessment should have been closed and submitted. EI #5 reported RI #6 was admitted to the facility [DATE] and was discharged on [DATE]. EI #5 said RI #6's assessment was completed but not submitted. On [DATE] at 9:43 am, an interview was conducted with EI #6, the MDS Supervisor. EI #6 was asked who was responsible for transmitting resident data to the CMS (Centers for Medicare & Medicaid Service) system. EI #6 replied, she was or EI #5. EI #6 was asked who was responsible for transmitting RI #4, #5, and #6's data to CMS. EI #6 replied, she was. EI #6 was asked why was RI #4, #5, and #6's data not transmitted to CMS. EI #6 replied, because it did not show up on the transmit list due to be completed, but not closed. EI #6 was asked why was it important to transmitted data to CMS. EI #6 replied, CMS kept a record of the assessment data that they send to them and it was for reimbursement purpose. EI #6 was asked when should they transmit resident data to CMS. EI #6 replied, transmit weekly, but should be transmitted 14 days of the completion date. EI #6 was aked what did the facility policy say regarding transmitting resident data to CMS. EI #6 replied, to transmit accurate assessment in timely. EI #6 was asked where was it documented that RI #4, #5 and #6's data was transmitted to CMS. EI #6 replied, it was not documented that it was transmitted. EI #6 was asked why she was not alerted to transmit RI #4, #5 and #6's data to CMS. EI #6 replyed, they were not closed to pull over to her transmit list.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and a facility policy titled, Resident Assessment Instrument, the facility failed to ensure Resident Identifier ( RI ) #18's most current Minimum Data Set (MDS) assessment was coded for Hospice. This affected 1 of 19 sampled residents whose MDS' were reviewed. Finding include: A review of a facility policy titled, Resident Assessment with an effective date of 3/2018 revealed . Process: b) The individual interdisciplinary team . members responsible for the following sections of the Minimum Data Set . Nursing . O . RI #18 was readmitted to the facility on [DATE]. Diagnoses included Alzheimer's Disease. On 03/07/17 Encounter for palliative care was added to the diagnoses list. A review of the physician's orders revealed RI #18 was admitted to hospice on 05/23/18. A review of RI #18's November 9, 2018 MDS was not coded for Hospice in section O k. Hospice care. On 1/30/19 at 2:20, an interview was conducted with Employee Identifier (EI) Registered Nurse, #5. EI #5 was asked when did she check the Hospice box on RI # 18's November 9, 2018 MDS . EI #5 replied, that day, January 30. EI #5 was asked why was she late checking the box. EI #5 replied, it was an error in reporting it on the MDS. EI #5 was asked who was responsible for coding section O of the MDS'. EI #5 replied, she was. EI #5 was asked when should the O section be complete on the MDS. EI #5 replied, no later than 14 days of the ARD (Assessment Reference Date). EI #5 was asked why should the MDS be accurate. EI #5 replied, to get an accurate picture of the patient. EI #5 was asked what was the process for coding the MDS when a resident has a change. EI #5 replied, if a resident came on or off hospice that was a significant change, or if they had a change in two areas such as ADL (Activity of Daily Living), weight loss or pressure ulcer. EI #5 was asked how was she made aware when a resident was placed on hospice. EI #5 replied, normally the unit manage would let her know there was a hospice consult, when someone had move to hospice. EI #5 was asked what was the potential harm to the resident when the MDS was not coded accurately. EI #5 replied, it reflects on their care and they may not get the care if not coded correctly. EI #5 was asked when was the resident discharged from hospice. EI #5 replied, she continues to be on hospice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, review of the Potter / [NAME] Ninth Edition Fundamental of Nursing text and the facility policy titled, Dressings, Clean (Wound Care), the facility failed to ensure: 1. a Certified Nursing Assistant (CNA) did not place a clean brief and cloth pad under Resident Identifier (RI) #7 with the same soiled gloves worn during the provision of RI #7's care. The CNA further failed to wash his hands between glove changes while performing the incontinent care for RI #7; and 2. a licensed staff did not clean RI #7's wound on the right heel, and with the same soiled gloves placed the clean treatment on the heel. Also, during the care of the sacral wound, the nurse cleaned the wound and with the same soiled gloves on, applied the clean treatment to the wound. This affected one of one resident observed for incontinent care and affected one of 2 residents observed for wound care. Findings Include: 1. A review of Potter / [NAME] Ninth Edition Fundamental of Nursing was conducted. The text, Chapter 29 Infection Prevention and Control, page 458, addressed hand hygiene. The text revealed, . the most effective basic technique in preventing and controlling the transmission of infection is hand hygiene. The recommended hand hygiene guidelines included, . 3. * When moving from a contaminated to a clean body site during care . * After removing gloves. RI #7 was admitted to the facility on [DATE] with diagnoses to include Pressure Ulcer of right heel, Pressure Ulcer of left heel and Obstructive and reflux uropathy. On 1/29/19 at 9:50 AM, two CNAs were observed performing incontinent care for RI #7. Employee Identifier (EI) #3, CNA was observed to loosen the brief of RI #7, while EI #4, CNA removed the gown from the resident and placed the soiled gown in RI #7's bedside chair. After EI #3 cleaned bowel movement (BM) from RI #7's buttocks she placed a clean brief and another clean pad under RI #7, wearing the same soiled gloves. EI #3 handed the soiled pad to EI #4 and she placed it in the bedside chair with the gown. EI #3 then placed and secured a clean brief wearing the same soiled gloves. EI #3 then changed his gloves without washing his hands. EI #3 cleaned RI #7's face and hands with a clean wipe then put on a clean gown. On 1/29/19 at 10:10 AM an interview was conducted with EI #3. EI #3 was asked what were they to do regarding when to wash hands during incontinent care. EI #3 replied, he should wash his hands before and after care and in between glove changes. EI #3 was asked if he washed his hands when he changed gloves. EI #3 replied, no. EI #3 was asked what was the harm in not washing hands with a glove change. EI #3 replied, he could spread germs. EI #3 was asked what were they to do regarding changing gloves while performing incontinent care. EI #3 replied, he should change gloves after cleaning a resident. EI #3 was asked if the resident had a bowel movement. EI #3 replied, yes. EI #3 was asked if he placed a clean brief and a clean pad under RI #7 with the same gloves he cleaned the bowel movement. EI #3 replied, yes ma'am I did. EI #7 was asked when should he have washed his hands. EI #3 replied, after he cleaned RI #7 and before he placed the clean things. EI #3 was asked what was the risk of cleaning the resident with BM then placing the clean brief and cloth pad with same gloves. EI #3 replied, passing germs. On 1/29/19 at 10:20 AM, an interview was conducted with EI #4, CNA. EI #4 was observed placing the soiled gown and soiled cloth pad, removed from RI #7, in the bedside chair. EI #4 was asked where were they to place soiled gowns and pads when removed from a resident. EI #4 replied, in a plastic bag. EI #4 was asked where did she put the gown and pad. EI #4 replied, in the chair next to the bed. EI #4 was asked what was the harm in putting the gown and soiled pad in the chair. EI #4 replied, spreading germs, then someone may sit in the chair. 2. A review of a facility policy titled Dressings, Clean (Wound Care) with an effective date of 3/2018 revealed: PURPOSE: To provide guidelines for the care of wounds and soiled dressings, to decrease the potential for nosocomial infection. PROCESS: .4. Wash hands and put on clean gloves 5. Remove the existing dressing 6. Pull your glove off the hand and over the dressing; discard . 7. Wash hands and put on clean gloves 8. Cleanse the wound as ordered . 10. Wash hands and put on clean gloves 11. Apply treatment as ordered . A review of RI #7's January 2019 Physician Orders revealed . 1/21/19 CLEAN LEFT HEEL WOUND WITH NORMAL SALINE .EVERY OTHER DAY .CLEAN RIGHT HEEL WITH NORMAL SALINE .EVERY OTHER DAY . CLEAN SACRUM .DAILY . On 1/30/19 at 10:10 AM, the surveyor observed wound care for RI #7, performed by EI #2, Treatment/Registered Nurse (RN). After set up the supplies EI #2 provided cleaning and treatment to RI #7's left heel. EI #2 cleaned the wound then patted the wound dry, wearing the same soiled gloves. EI #2 then applied the treatment and outer covering to the heel wound, wearing the same soiled gloves. EI #2 then provided cleaning and treatment to the resident's sacral area. After cleaning the area, she patted the area dry, wearing the same soiled gloves. She then applied the treatment and outer covering, wearing the same soiled gloves. EI #2 then removed her gloves and washed her hands. On 1/30/19 at 11:07 AM, an interview was conducted with EI #2. EI #2 was asked what was the policy on washing hands during wound care. EI #2 replied, it does not say, but you wash hands before starting, after removing soiled dressing and after completing the care. EI #2 was asked when should she wash her hands during wound care. EI #2 replied, you wash your hands if gloves were visibly soiled. EI #2 was asked when a wound was cleaned was it a clean area or a dirt area. EI #2 replied, if your hands were not visibly soiled, it would be clean. EI #2 was asked if she washed her hands when she cleaned the wounds before placing the treatment. EI #2 replied, no. EI #2 was asked what would the potential for harm be in not washing her hands after cleaning the wounds before applying the ordered treatment. EI #2 replied, you could re-contaminate the wounds. On 1/30/19 at 3:08 PM, an interview was conducted with EI #1, Director of Nursing. EI #1 was asked what was the policy on providing incontinent care. EI #1 replied, wash hands, put on gloves, clean the resident, after cleaning remove gloves and wash hands and put on clean gloves and place clean brief and pads. EI #1 was asked when should a CNA clean BM from a resident, then with the same gloves place a clean brief and clean cloth pad. EI #1 replied, they should not. EI #1 was asked what was the policy on washing hands with glove changing. EI #1 replied, they were supposed to wash their hands everytime they remove their gloves. EI #1 was asked what was the potential for harm if a CNA performed incontinent care on a resident, then with the same gloves place a clean brief and pad. EI #1 replied, there was the potential for cross contamination. EI #1 was asked what was the policy on washing hands and changing gloves during wound care. EI #1 replied, the staff was to change gloves and wash hands after removing the soiled dressing and after cleaning the wound. EI #1 was asked when should a nurse clean a resident's wounds, then with the same gloves place the clean treatment. EI #1 replied, they should not. EI #1 was asked what was the harm in a nurse having on the same gloves she cleaned a wound with to place the clean treatment. EI #1 replied, cross contamination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of a facility policy titled, Care Plans - Person Centered, and interviews, the facility failed to ensure a plan of care was developed for a resident with a diagnosis of Depression. This affected RI (Resident Identifier) #5, one of twenty-five resident whose care plans were reviewed. Findings Include: A review of the facility policy titled, Policy: Care Plans - Person Centered, with an effective date of 10/17, revealed: . PURPOSE: Person centered care plans are developed by the interdisciplinary team, to coordinate and communicate care approaches and goals for the resident that include measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in comprehensive assessment. A review of the medical record revealed RI #5 was admitted to the facility on [DATE] with diagnoses to include Depression, Dementia, and Generalized Anxiety Disorder. A review of the physician's orders for RI #5 revealed: . TRAZODONE 100 MG (Milligrams) GIVE ONE (1) TABLET BY MOUTH ONCE DAILY AT BEDTIME DX (DIAGNOSIS): DEPRESSION . A review of the admission MDS (Minimum Data Set) assessment for RI #5 dated 11/14/17, revealed a diagnosis of Depression. A review of the care plans for RI #5 revealed no problem, goal, or interventions for the diagnosis of Depression. During an interview on 02/15/18 at 2:45 PM, EI (Employee Identifier) #3, a Certified Nursing Assistant (CNA), was asked what she used to guide the care and monitoring of residents. EI #3 answered the print-outs from the care plan. EI #3 was asked what did the care plan indicate to monitor for, related to the diagnosis of Depression for RI #5. EI #3 answered that she did not remember it saying anything about Depression. EI #3 was asked if the care plan did not address Depression, how would staff know to monitor for signs and symptoms of Depression. EI #3 answered she usually monitored for anything that might be a concern, but if it was not in the care plan, she would ask the nurse. During an interview on 02/15/18 at 2:54 PM, EI #2, a Licensed Practical Nurse (LPN), was asked if the admission MDS assessment had a diagnosis of Depression and she answered yes. EI #2 was asked what did the care plan include for the diagnosis of Depression and EI #2 replied nothing. EI #2 was asked what was the purpose of the plan of care and she answered it gave staff an idea of what was going on and how to treat it. EI #2 said it was a plan for their care, goals to work toward and it kept everybody on the same page. EI #2 was asked if it should address the diagnosis of Depression for RI #5 and she answered yes. EI #2 was asked why. EI #2 answered because Depression can cause so many other things, a goal of what to watch for to prevent things from happening or worsening was needed. During an interview on 02/15/18 at 3:15 PM, EI #1, the Care Plan Coordinator, was asked what was the purpose of the plan of care. EI #1 answered it guided staff in the care of the residents. EI #1 was asked what was the facility policy regarding developing a plan of care that correlated with a resident's needs and diagnoses. EI #1 answered staff added care plans to go along with their diagnoses for the well-being of the residents. EI #1 was asked what did the plan of care indicate for RI #5's diagnosis of Depression. EI #1 answered that it just told staff to assist RI #5 to talk about his/her feelings and talk to RI #5 about his/her work history and if weather permitted, see if RI #5 wanted to go outside. EI #1 was asked if the initial/admission MDS included a diagnosis of Depression and she answered yes. EI #1 was asked if the plan of care should include interventions and/or guidance for monitoring related to a diagnosis of Depression and she answered yes.