**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined the facility failed to ensure a bed hold notice was provided to residents or their representatives at the time of the resident's transfer to the hospital. This was true for 1 of 12 residents (Resident #22) reviewed for transfers. This deficient practice created the potential for harm if residents were not informed of their right to return to their former bed or room at the facility within a specified time. Findings include: Resident #22 was admitted to the facility on [DATE], with multiple diagnoses including schizophrenia (a chronic mental disorder that affects a person's ability to think, perceive reality, and interact with others) and traumatic brain injury (a brain injury caused by an external force, such as a blow or jolt to the head). Resident #22's medical record documented she had been transferred to the hospital on [DATE], and returned to the facility on [DATE]. The facility bed hold document had not been completed until 10/15/24, 3 days after Resident #22 returned to the facility. On 12/4/24 at 2:40 PM, the DON stated the bed hold should have been completed at time of transfer to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined the facility failed to ensure the MDS assessment accurately reflected a resident's status. This was true for 3 of 12 residents (# 2, #14, and #33) whose MDS assessments were reviewed. This deficient practice had the potential for negative outcomes if the resident was not assessed and/or monitored due to inaccurate assessments. Findings include: 1. Resident #2 was admitted to the facility on the 1/18/18, with multiple diagnoses including bipolar and hypertension. Resident #2's Quarterly MDS, dated [DATE], did not document she had a feeding tube (a small, flexible tube that provides a way to deliver nutrition through the stomach). Resident #2's Quarterly MDS, dated [DATE], documented she had a feeding tube. On 12/2/24 at 11:58 AM, RN #1 stated Resident #2 did not have a feeding tube. On 12/3/24 at 10:48 AM, the DON stated the feeding tube documented on Resident # 2's MDS was an error in reporting and should not have been on her MDS. 2. Resident #14 was admitted to the facility on [DATE], with multiple diagnoses including psychotic disorder (a severe mental illness that causes a person to lose touch with reality and have abnormal perceptions and thoughts) and bipolar disease (a mental illness that causes extreme shifts in mood, energy, and activity levels). The Quarterly MDS dated [DATE], documented Resident #14 had an enteral feeding tube. On 12/2/24 at 9:00 AM, Resident #14 stated she did not have a feeding tube in place. On 12/4/24 at 2:59 PM, the DON stated Resident #14 has not had a feeding tube in place while at the facility. 3. Resident #33 was admitted to the facility on [DATE], with multiple diagnoses including dementia and major depressive disorder. Resident #33's pharmacy Drug Regimen Review report documented she was on Risperidone (an antipsychotic) for psychosis. Resident #33's care plan, dated 1/30/24, documented she used psychotropic medications related to her disease process of dementia with behavioral disturbance and psychosis. Resident #33's Quarterly MDS, dated [DATE], Section I - Active Diagnoses, documented she had major depressive disorder and depression. Psychiatric disorder (including dementia with behavior disturbances) was not documented on Resident #33's Quarterly MDS. Resident #33 did not have a psychosis diagnosis documented on her Quarterly MDS. On 12/5/24 at 11:39 AM, the DON stated the doctor had not updated Resident #33's medication list and therefore the Quarterly MDS was wrong. She further stated Resident #33's Quarterly Assessment should have included her diagnosis of psychosis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, it was determined the facility failed to ensure resident's care plans were revised to reflect current physician orders. This was true for 1 of 12 residents (Resident #10) whose care plans were reviewed. This placed residents at risk of adverse outcomes if care and services had been provided that were not ordered by the physician. Findings include: Resident #10 was admitted to the facility on [DATE], with multiple diagnoses including schizoaffective disorder depressive type (a mental illness that involves a combination of schizophrenia symptoms and depressive episodes) and rotator cuff tear (a tear in the muscles and tendons that surround the shoulder joint). On 12/3/24, Resident #10's care plan, initiated on 9/10/24, documented Resident #10 was to be given spironolactone (an anti-hypertensive medication) however, this medication was not listed in Resident #10's active or discontinued medication orders. On 12/4/24 at 1:50 PM, the DON stated Resident #10 was not receiving spironolactone and her care plan should have been updated to remove that medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, it was determined the facility failed to ensure care plans were followed. This was true for 1 of 12 residents (Resident #9) whose care plans were reviewed. This had the potential for adverse effects and possible harm to resident's medical and physical status. Findings include: Resident #9 was admitted to the facility on [DATE], with multiple diagnoses including schizoaffective disorder bipolar type (a rare mental illness that occurs when someone experiences both schizophrenia and bipolar disorder symptoms at the same time) and chronic obstructive pulmonary disease (a common lung disease causing restricted airflow and breathing problems). Resident #9's care plan, initiated on 10/17/24, directed CNAs and licensed nursing staff to keep oxygen saturations at 90% and licensed nursing staff are to contact the physician with decreased pulse oximetry. The following oxygen saturation checks below 90% were documented: 10/21/24 at 8:47 AM, SpO2 89%, obtained by CNA #1 10/26/24 at 10:03 AM, SpO2 89%, obtained by CNA #2 10/27/24 at 10:10 AM, SpO2 89%, obtained by CNA #3 10/31/24 at 9:34 AM, SpO2 84%, obtained by CNA #4 11/10/24 at 9:49 AM, SpO2 86%, obtained by CNA #2 11/15/24 at 2:46 PM, SpO2 84%, obtained by CNA #5 11/17/24 at 10:03 AM, SpO2 81%, obtained by CNA #6 11/18/24 at 12:20 AM, SpO2 86%, obtained by CNA #7 11/22/24 at 9:49 AM, SpO2 80%, obtained by CNA #8 Resident #9's medical record did not include documentation licensed nursing staff notified his physician. On 12/4/24 at 2:58 PM, the DON stated the CNAs documented the oxygen saturation information and had not notified the licensed nursing staff of the low oxygen level and should have.

Based on observation, interview, policy review, and U.S. Food and Drug Administration 2022 Food Code, the kitchen staff failed to appropriately store and label foods and wash hands prior to donning gloves. This deficient practice had the potential to affect all residents who received meals prepared in the facility's kitchen. Findings include: 1. U.S. Food and Drug Administration 2022 Food Code documented: Annex 3-304.15 documented hands must be washed before donning gloves. On 12/2/24 at 7:40 AM, observed a senior cook leave the serving line area to thin out puree with her gloves on and returned to the serving line area with gloves on. She then removed gloves but she did not wash hands before redonning gloves. On 12/2/24 at 8:00 AM, the Dietary Manager stated the senior cook should have washed her hands after doffing gloves and donning new gloves. 2. U.S. Food and Drug Administration 2022 Food Code documented: 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under § 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. On 12/2/24 at 7:05 AM, observed the following expired foods in the walk-in refrigerator: - cut up lettuce in a plastic bag with use by date of 11/30, - a container with ranch dressing with expired date of 11/30, - a container of pineapple juice with use by date of 12/1. On 12/2/24 at 7:08 AM, the Dietary Manager stated these expired food items should have been removed from the walk-in refrigerator. 3. The facility policy Refrigerated Food Storage, dated 6/5/24, documented under III. Procedure, A,2,b. Nursing staff will discard any food items that are marked with a date five (5) days prior to the current date or longer. On 12/4/24 at 2:24 PM, observed the following expired food items in the resident refrigerator: - Opened salsa with resident name and opened date of 8/1/24. - Opened mayonnaise with resident name and opened date of 4/14/24, expired date 10/26/24. - Opened French Onion Dip with resident name and opened date of 5/1/24. - Opened Watermelon Minute Maid with resident name and opened date of 8/6/24 and expired date of 10/18/24. On 12/4/24 at 3:10 PM, the DON stated those expired food items in the resident refrigerator should have been thrown away.

Based on observation, interview, Department of Health and Welfare - Idaho Administrative rules, and U.S. Food and Drug Administration 2022 Food Code review, the facility failed to ensure garbage cans were properly closed with lids to minimize attracting pests and rodents into the kitchen. This deficient practice had the potential to affect all residents and staff in the facility. Findings include: Department of Health and Welfare - Idaho Administrative Rules 16.03.02. Environmental Sanitation 108. Garbage and Refuse 03a. All containers used for storage of garbage and refuse shall be constructed of durable, nonabsorbent material and shall not leak or absorb liquids. Containers shall be provided with tight-fitting lids unless stored in vermin-proof rooms or enclosures, or in a waste refrigerator. U.S. Food and Drug Administration 2022 Food Code, 5-501.113 Covering Receptacles. Receptacles and waste handling units for REFUSE, recyclables, and returnables shall be kept covered: (A) Inside the FOOD ESTABLISHMENT if the receptacles and units: (1) Contain FOOD residue and are not in continuous use; or (2) After they are filled. On 12/2/24 at 8:04 AM, observed five uncovered garbage cans in the kitchen and food serving area without closing lids. On 12/4/24 at 9:25 AM, the Dietary Manager stated she was not aware the garbage cans had to have closing lids on them.

Based on observation, policy review, resident, and staff interview, it was determined the facility failed to ensure residents were treated with dignity and respect. This was true for 4 of 36 residents (#1, #18, #21, and #23) reviewed for respect and dignity. This deficient practice placed residents at risk of embarrassment and diminished sense of worth. Finding include: The facility's Dignity policy, dated 5/9/24, documented the facility would promote care for residents in a manner and in an environment, that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. The following residents were observed in an open area of the facility and had received medication or had their blood sugar checked: 1. On 12/2/24 at 7:44 AM, Resident #1 was observed sitting outside the dining room, waiting for her breakfast. Two other residents were sitting in the hallway and were able to observe RN #1 checking Resident #1's blood sugar. Resident #1's medical record did not document her wish to have her blood sugar checked in common areas. 2. On 12/3/24 at 7:48 AM, Resident #21 was observed sitting in the dining room, drinking a beverage. Another resident was sitting across the table from Resident #21 and observed RN #1 spoon feeding Resident #21 her medications. Resident #21's medical record did not document her wish to receive her medication in the dining room. 3. On 12/3/24 at 8:19 AM, Resident #23 was observed sitting in the common area, waiting for her breakfast. Two other residents were sitting in the common area and observed RN #1 checking Resident #23's blood sugar. Resident 23's medical record did not document her wish to have her blood sugar checked in common areas. 4. On 12/3/24 at 11:51 AM, Resident #18 was observed sitting in the activity room. There were 4 other residents in the activity room who observed RN #2 pulling Resident #18's sleeve up on her right arm and administering her insulin injection. Resident #18's medical record did not document her wish to receive her insulin in common areas. On 12/3/24 at 7:47 AM, RN #1 stated the facility conducts audits asking residents if they wanted their medications and blood sugar testing administered outside their rooms, and the residents had physician orders documenting the residents preferred their medications be given outside their rooms. On 12/4/24 at 11:49 AM, the DON stated there were no audits conducted to ensure residents had agreed to have their medications or blood sugars checked in common areas. She stated the residents should have orders that documented nurses may administer medications in a common area, and it should be on the resident's care plan. On 12/5/24 at 10:59 AM, the DON stated she did not have orders for Residents #1, #18, #21, or #23 to receive medications in common areas.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, and resident and staff interview, it was determined the facility failed to ensure residents' urinary drainage bags were kept in a privacy bag. This was true for 1 of 2 residents (Resident #25) reviewed for urinary catheters, and created the potential for harm should residents experience embarrassment related to their exposed urinary drainage bag. Findings include: The facility's policy for urinary catheters, dated 7/1/12, directed staff to maintain resident's privacy and dignity. Resident #25 was admitted to the facility on [DATE], with multiple diagnoses including schizoaffective disorder and benign prostatic hyperplasia (enlargement of the prostate). Resident #25's quarterly MDS assessment, dated 7/9/19, documented he was cognitively intact and required an indwelling catheter. On 8/19/19 at 3:36 PM, Resident #25 was sitting in a recliner in his room. A urinary drainage bag was observed in a pink basin on the floor. The urinary drainage bag was not in a privacy bag, and the contents of the urinary drainage bag were readily visible to anyone who passed by the doorway or entered the room. A privacy bag was hanging from the seated walker adjacent to Resident #25's recliner. Resident #25 said he had a catheter in place because he could not urinate, and staff placed the urinary drainage bag in the privacy bag only when he walked down to the dining room. On 8/20/19 at 8:51 AM, Resident #25 was sitting in his recliner in his room. A trash can was next to the recliner and the urinary drainage bag was hanging off the trash can. The urinary drainage bag was not in a privacy bag. On 8/21/19 at 10:13 AM, Resident #25 was sitting in his recliner in his room. The urinary drainage bag was in a pink basin on the floor. The urinary drainage bag was not in privacy bag and was visible from the doorway. CNA #1 said that was the way the drainage bag was typically stored. CNA #1 said there was a privacy bag on Resident #25's walker, and staff placed the urinary drainage bag in the privacy bag just when he was up and walking around. On 8/21/19 at 10:20 AM, RN #1 said Resident #25's urinary drainage bag was to be in a privacy bag.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined the facility failed to obtain informed consent for 1 of 5 residents (Resident #8) reviewed for psychotropic medication. This deficient practice placed residents at risk of receiving psychotropic medications without knowledge of the risks and benefits associated with each medication, alternative treatment options, and the right to refuse the medication. Findings include: Resident #8 was admitted to the facility on [DATE], with multiple diagnoses including schizoaffective disorder (a chronic mental health condition characterized by hallucinations, delusions, mania, and depression), dementia, and medication induced dyskinesia (involuntary muscle movements). Resident #8's August 2019 Physician's Orders documented he was receiving Trileptal tablets 150 milligrams orally twice a day for treatment of schizoaffective disorder and mood instability. Resident #8's physician's progress notes documented he received Trileptal from 9/17/12 to 11/17/16. A physician's order, dated 2/12/18, documented the Trileptal was restarted. Resident #8's record did not include a consent for the Trileptal when it was reordered. On 8/20/19 at 2:03 PM, the Administrator said Resident #8 had a daughter who made decisions for him. On 8/23/19 at 12:30 PM, the DNS said the facility did not need a consent for the Trileptal because it was classified as an antiseizure medication, not a psychotropic medication. On 8/23/19 at 2:07 PM, the Physician said the facility did not need a consent for the Trileptal because it was not classified as a psychotropic medication. Resident #8 and/or his representative was not provided the opportunity to consider all options before making the decision to add Trileptal to Resident #8's medication regimen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined the facility failed to ensure residents and residents' representatives had the right to formulate an Advance Directive. This was true for 1 of 7 residents (Resident #8) reviewed for Advance Directives. The deficient practice created the potential for harm should residents' wishes regarding end of life or emergent care not be honored when they were incapacitated. Findings include: The State Operations Manual (SOM) defined an Advance Directive as a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated. The SOM defined a Physician Orders for Life-Sustaining Treatment (or POLST) as a form designed to improve patient care by creating a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency, taking the patient's current medical condition into consideration. A POLST paradigm form is not an advance directive.If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether he or she has executed an advance directive or not, the facility may give advance directive information to the individual's resident representative in accordance with State Law. 1. Resident #8 was admitted to the facility on [DATE], with multiple diagnoses including schizoaffective disorder, dementia, chronic obstructive pulmonary disease (COPD - a lung disease resulting in shortness of breath), atrial fibrillation (irregular heart rhythm), heart failure, and orthostatic hypotension (low blood pressure with change in position). On 8/20/19 at 2:03 PM, the Administrator said Resident #8 had a daughter who made decisions for him. No documentation regarding Advance Directives being discussed with Resident #8 and/or his daughter were found in Resident #8's record. On 8/23/19 at 12:30 PM, the Administrator said they did not have periodic conversations with residents' representatives regarding Advanced Directives. The Administrator provided an Administrative Progress Note, dated 8/22/19 (the day before), which documented her conversation with Resident #8's daughter. The note documented Resident #8's daughter said an Advance Directive was not completed for him. The facility failed to provide Resident #8 and/or his representative with information regarding Advance Directives and offer assistance to formulate Advanced Directives.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, and staff interview, it was determined the facility failed to ensure neurological assessments were completed following unwitnessed falls as directed in the facility's neurological checks policy. This was true for 1 of 2 residents (Resident #3) reviewed for falls. This deficient practice created the potential for harm if changes in residents' neurological status went undetected and untreated after falls. Findings include: The facility's Neurological Check Protocol policy and procedure, last reviewed [DATE], documented: * Neurological checks are to be used for residents whose physical condition is such that they require increased staff assessment of monitoring to ensure their wellbeing. * Neurological checks may be initiated by the Unit Provider, Clinical Supervisor, Director of Nursing, Charge Nurse and/or House Supervisor by writing an order in CPRS (the facility's computerized record keeping system). * The order for neurological checks may contain the time frame for the checks otherwise staff are to follow the Neurological Observation Flow Sheet for the documentation and the duration of the checks. * A nursing progress note shall be made at least each shift by a nurse to document the resident's current neurological status. * Neurological checks shall be discontinued after 24 hours unless specified in the orders. The facility's Neurological Observation Flow Sheet documented neurological assessments were completed every 15 minutes for 1 hour, every 30 minutes for 1 hour, every 60 minutes for 4 hours, and every 4 hours for 24 hours, for a total of 17 assessments, with direction to progress along this time schedule only if signs were stable, and to contact the physician if signs were unstable. The Neurological Observation Flow Sheet also provided space for documented date, time, Glasgow Scale (a tool used to measure neurological status including eye, motor, and verbal responses), hand grasps, pupil size, pupil reaction, and vital signs (blood pressure, pulse, respiration rates), initials and name of staff, and to see nurse's notes if applicable. Resident #3 was admitted to the facility on [DATE], with multiple diagnoses including bipolar disorder (mood swings ranging from depressive lows to manic highs), severe depression with psychotic features (a disconnection from reality), anxiety, dementia, and diabetes mellitus type 2. Neurological checks were not completed after Resident #3's unwitnessed falls, as follows: a. A Progress Note, dated [DATE] at 11:10 PM, documented Resident #3 had an unwitnessed fall, was found sitting on the fall mat on the floor in his room with no apparent injury, and neurological assessments were started. A Fall Scene Investigation Report, dated [DATE] at 11:36 PM, documented Resident #3 was found at 11:10 PM sitting on the fall mat on the floor in his room and neurological assessments were initiated. The Neurological Observation Flow Sheet for Resident #3 started on [DATE] at 11:15 PM and was scheduled to end on [DATE] at 5:15 AM. The Neurological Observation Flow Sheet documented 12 of 17 assessments were not completed, as follows: - The Glasgow Scale, hand grasps, pupil size and reactions were not documented from [DATE] at 12:00 AM to [DATE] at 1:15 PM with sleeping documented for those times. - Vital signs were not documented from [DATE] at 12:45 AM to [DATE] to 1:15 PM with sleeping documented for those times. - The Glasgow Scale, hand grasps, pupil size and reactions were not documented from [DATE] at 9:15 PM to [DATE] at 5:15 AM with sleeping documented for this time. - Resident #3's vital signs were not documented from [DATE] at 1:15 AM through [DATE] at 5:15 PM. b. A Progress Note, dated [DATE] at 3:40 AM, documented Resident #3 had an unwitnessed fall and was found sitting on the fall mat in his room with no apparent injury. A Fall Scene Investigation Report, dated [DATE] at 4:00 AM, documented Resident #3 was found at 3:40 AM on his fall mat next to his bed and neurological assessments were initiated. The Neurological Observation Flow Sheet for Resident #3 started on [DATE] at 3:40 AM, and was scheduled for completion on [DATE] at 9:40 AM. The Neurological Observation Flow Sheet documented 9 of 17 assessments were not completed, as follows: - Hand grasps, pupil size and reactions were not documented on [DATE] at 4:25 AM to [DATE] at 9:40 AM with sleep documented for those times. - The Glasgow Scale was not documented from [DATE] to 4:40 AM to [DATE] at 9:40 AM and from [DATE] at 1:40 AM to [DATE] at 9:40 AM with sleep documented for those times. c. A Progress Note, dated [DATE] at 1:00 PM, documented Resident #3 had an unwitnessed fall and was found on the fall mat on the floor of his bedroom, with no apparent injury, and neurological checks were started. A Fall Scene Investigation Report, dated [DATE] at 2:29 AM, documented Resident #3 was found on [DATE] at 11:00 PM in a seated position on the fall mat next to his bed and neurological assessments were ongoing. The Neurological Observation Flow Sheet for Resident #3 started on [DATE] at 11:00 PM and was scheduled for completion on [DATE] at 5:00 AM. The Neurological Observation Flow Sheet documented 7 of 17 assessments were not completed, as follows: - No neurological assessments were documented from [DATE] at 12:30 AM to [DATE] at 9:00 AM and sleeping was documented for those times. - The Glasgow Scale, hand grasps, pupil size and reactions were not documented on [DATE] at 1:00 AM with sleeping documented for this time. d. A Progress Note, dated [DATE] at 12:00 AM, documented Resident #3 was found sitting on the fall mat on the floor in his room. A Fall Scene Investigation Report, dated [DATE] at 1:55 PM, documented Resident #3 was found on his buttocks on the fall mat at 11:00 AM with his back against the bed, his legs out in front, and neurological assessments were initiated due to his unwitnessed fall. The Neurological Observation Flow Sheet for Resident #3 started on [DATE] at 11:00 AM, and was scheduled for completion on [DATE] at 1:30 PM. The Neurological Observation Flow Sheet documented 2 of 17 assessments were not completed, as follows: - No neurological checks were documented on [DATE] at 9:30 PM and on [DATE] at 1:30 AM with sleeping documented for these times. e. A Progress Note, dated [DATE] at 12:00 PM, documented Resident #3 was found lying on his back on the fall mat in his room, no issues noted, and neurological checks were started due to the unwitnessed fall. A Fall Scene Investigation Report, dated [DATE] at 5:17 PM, documented Resident #3 fell on [DATE] at 12:00 PM, was found on his back on the mat in his room and neurological assessments were started. The Neurological Observation Flow Sheet for Resident #3 started on [DATE] at 12:05 PM and was scheduled for completion on [DATE] at 1:00 PM. The Neurological Observation Flow Sheet documented 8 of 17 assessments were not completed, as follows: - Resident #3's blood pressure was not documented on [DATE] at 1:00 PM. - No neurological assessments were documented on [DATE] from 2:00 PM to 4:00 PM and on [DATE] from 1:00 AM to 9:00 AM with sleeping documented for those times. - Resident #3's respiration rate was not documented on [DATE] at 4:00 PM. - Resident #3's Glasgow Scale, hand grasps, and pupil size and reactions were not documented on [DATE] at 1:00 PM. f. A Progress Note, dated [DATE] at 10:20 PM, documented Resident #3 was found lying on the fall mat in his room perpendicular to his bed, with no apparent injury. A Fall Scene Investigation Report, dated [DATE] at 10:20 AM, documented Resident #3 was found on the fall mat in his room on [DATE] at 10:20 AM and neurological assessments were initiated. The Neurological Observation Flow Sheet for Resident #3 started on [DATE] at 10:20 AM, and was scheduled for completion at [DATE] at 6:05 AM. The Neurological Observation Flow Sheet documented 2 of 17 neurological assessments were not completed, as follows: - No neurological assessments were documented from [DATE] at 11:05 PM to [DATE] at 6:05 AM with sleeping documented for those times. g. A Fall Scene Investigation Report, dated [DATE] at 10:20 AM, documented Resident #3 was found sitting on his fall mat next to his bed on [DATE] at 3:20 AM. The Neurological Observation Flow Sheet for Resident #3 started on [DATE] at 3:20 AM and was scheduled for completion at [DATE] at 5:50 AM. The Neurological Observation Flow Sheet documented 10 of 17 neurological checks were not completed, as follows: - No neurological assessments were documented on [DATE] from 4:05 AM to 6:50 AM, on [DATE] from 8:50 AM to 1:50 PM, and on [DATE] from 9:50 PM to [DATE] at 5:50 AM, and sleeping was documented for those times. On [DATE] at 10:30 AM, RN #1 said the facility performed neurological assessments if the resident had an unwitnessed fall, including vital signs and skin assessments. On [DATE] at 2:42 PM, the DNS said if a resident fall was unwitnessed, or the resident said he/she hit their head, the facility initiated neurological assessments. Upon review of the Neurological Check Protocol policy, the DNS said Resident #3's neurological assessments should have been completed and they were not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on contract review, policy review, observation, and staff interview, it was determined the facility failed to ensure infection control surveillance of the contracted laundry services which processed residents' personal laundry. This deficient practice hand the potential to impact 27 of 27 residents (#1 - #22, #24 - #27, and #79) residing in the facility, all of whom relied on the facility for laundering of personal clothing. The facility also failed to ensure appropriate hand hygiene was completed during dressing changes. This was true for 1 of 12 residents (Resident #19) reviewed for infection control. These deficient practices placed residents at risk of infection. Findings include: The contract between the facility, and the contracted company providing personal laundry and mending services documented the service requirement as: The Contractor shall comply with all applicable rules, regulations and policies as outlined by the Department of Health and Welfare (Department), the State of Idaho, and local, state and national standards, including The Joint Commission, relating to patient care and hospital operations. The facility and a hospital on the same property, were owned by the same organization. The contract did not include a description of the specific cleaning process or products being used. The facility did not provide documentation regarding how the facility monitored the contractor's process to ensure it met the required standards. On 8/22/19 at 9:42 AM, the Administrator said all laundry was contracted to outside contractors. On 8/22/19 at 9:47 AM, the Infection Preventionist (IP) said the laundry services were contracted offsite, one contractor for linens and another for personal clothing. The IP said she visited and reviewed the contractor's facility and protocols. The IP provided processing and wash formula information from the contractor for linens. The IP did not provide processing and wash formulas from the contractor providing personal clothing laundry services. The facility did not provide documentation that it monitored the contractor's laundry processing of residents' clothing, or the specific guidelines used by the contractor for residents' clothing. On 8/23/19 at 1:16 PM, the DNS and the Environmental Services Director (ESD), provided the facility's contract with the personal laundry service contractor. The DNS and ESD said when they asked the contractor for the processing and wash formula information used by the personal laundry service contractor, the contractor replied it was not in their contract to provide it. 2. The facility's policy for Hand Hygiene, dated 11/4/09, documented hand hygiene was required before applying and after removing gloves, after handling an invasive device, and after contact with body fluids, mucous membranes, non-intact skin, or wound dressings. Resident #19 was admitted to the facility on [DATE], with multiple diagnoses including BPH (enlargement of the prostate) with lower urinary tract symptoms and kidney failure. Resident #19's care plan directed nurses to provide care to his suprapubic catheter (a urinary catheter that drains the bladder through an incision in the abdomen) twice daily and as needed with water and 4 by 4's (gauze squares), pat dry, change the drain sponge and secure with tape. The intervention was initiated on 10/25/18 and revised on 11/14/18. Resident #19's quarterly MDS assessment, dated 4/30/19, documented he was cognitively intact and required an indwelling catheter. Resident #19's physician orders documented an order, dated 8/22/19, for the nurse to provide suprapubic catheter care daily, and as needed, as follows: Cleanse the area with water and 4 by 4's, pat dry, place dry drain sponge, and secure it with tape if needed. On 8/21/19 at 4:44 PM, LPN #1 said Resident #19's suprapubic catheter dressing change was just changed from twice a day to once a day. On 8/22/19 at 9:43 AM, LPN #2 was observed performing the dressing change to Resident #19's suprapubic catheter as follows: After washing her hands and applying gloves, LPN #2 removed the existing dressing. She then cleansed around the catheter insertion site and cleansed several inches of the catheter tubing from the abdomen outwards, then removed her gloves and did not perform hand hygiene. LPN #2 applied new gloves, retrieved a pen from a pocket in her top, opened a new dressing and wrote the date on it, and applied the new dressing around Resident #19's suprapubic catheter. LPN #2 then removed the used trash bag from the trash can and placed a new trash bag into the trash can. LPN #2 removed the glove from her left hand, did not perform hand hygiene, and exited the room carrying a used trash bag in her gloved right hand and a gray basin containing tape and dressing supplies in her ungloved left hand. LPN #2 walked down the hall carrying the items as previously described and entered the dirty utility room. LPN #2 said she washed her hands before removing Resident #19's old dressing, and then changed her gloves. LPN #2 said she did not wash her hands after removing her gloves and she probably should have. On 8/22/19 at 10:25 AM, the DNS said hand hygiene should be performed between residents, between glove changes, and if you felt your hands were dirty. The DNS said LPN #2 should have performed hand hygiene after removing her gloves during Resident #19's dressing change. On 8/22/19 at 10:51 AM, the Infection Preventionist said hand hygiene should be performed before and after contact with a resident, when going in and coming out of a resident's room, and if touching soiled items. The Infection Preventionist said hand hygiene should also be performed when going from something dirty to clean, and between glove changes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure residents received neurological assessments following unwitnessed falls. This was true for 1 of 5 residents (#15) reviewed for falls. This deficient practice placed Resident #15 at risk of harm if neurological changes resulting from a fall went undetected. Findings include: 1. Resident #15 was readmitted to the facility on [DATE], with multiple diagnoses, including chronic kidney disease with anemia, Type II Diabetes with retinopathy, thrombocytopenia, hypertension, insomnia, vascular dementia, schizoaffective disorder, and mild mental retardation. The facility's fall and accident prevention dated 8/10/17, did not direct staff to complete neurological assessments of residents following a fall or accident. Resident #15's annual MDS assessment, dated 9/12/17, documented she was severely cognitively impaired, required the assistance of two people for transfers, and was at risk for falls. Resident #15's physician order, dated 4/16/18, documented she required a low bed with a mattress on floor next to bed related to falls, and a pressure alarm while in bed for safety. Resident #15's care plan, dated 4/10/18, directed staff to complete ongoing 15 minute checks as she experienced delusional thinking and sometimes thought she could ambulate without assistance. On 3/5/18, the care plan directed staff to provide a low bed with a mattress on the floor next to the bed related to falls, and pressure alarm while in bed for safety. The care plan did not include the need to complete neurological assessments if Resident #15 experienced an unwitnessed fall. Resident #15's progress note, dated 2/12/18, documented she experienced an unwitnessed fall and was found face down on a mat on the floor by her bed. Resident #15's progress note, dated 3/7/18, documented she experienced an unwitnessed fall and was found sitting upright on the the fall mat next to her bed. During both incidents, Resident #15 was asked by staff if she had hit her head, and she stated no. As noted above, Resident #15 experienced delusions, was severely cognitively impaired, and had a diagnoses of vascular dementia. Resident #15's account of the fall could not be relied upon as accurate. Documentation of neurological assessments following the two falls were not found in Resident #15's record. On 5/2/18 at 1:59 PM, the DNS stated she would expect neurological assessments to be completed after Resident #15's 2/12/18 and 3/7/18 falls. The facility's Neurological Check Protocol, dated 8/10/17, documented neurological checks were for monitoring residents whose physical condition was such that they require increased staff assessment or monitoring to insure their wellbeing. The protocol documented that unless stated in an order, staff completing neurological checks were to follow the time frames noted on the Neurological Observation Flow Sheet. The Neurological Observation Flow Sheet documented neurological checks were to be completed every 15 minutes for one hour, every 30 minutes for one hour, every 1 hour for 4 hours, and then every 4 hours for 24 hours. Neurological checks were not completed for Resident #15 consistent with facility policy, following two unwitnessed falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, it was determined the facility failed to ensure physician orders were followed for residents who received nutritional interventions. This was true for 1 of 5 residents (#10) whose nutritional needs were reviewed. Resident #10 had the potential for harm when she was not provided with physician ordered nutritional supplements. Findings include: Resident #10 was admitted to the facility on [DATE] with diagnoses which included dementia and an eating disorder. A quarterly MDS assessment, dated 2/20/18, documented Resident #10 was severely cognitively impaired and required the assistance of one person for eating and drinking. The May 2018 Physician Orders documented Resident #10 was to receive Ensure (nutritional supplement) or Mighty Shake (nutritional supplement) three times a day between meals or as a meal replacement when meals were refused, ordered 7/6/15. The care plan addressing Resident #10's swallowing concerns, dated 6/4/15, documented Resident #10 had difficulty with thin liquids and solid foods. The care plan documented Resident #10 required pureed texture and pudding thick liquids. The care plan documented staff were to offer Ensure three times a day between meals and document when she accepted the Ensure. The 4/2/18 through 5/2/18 CNA documentation showed Resident #10 was provided Ensure on 4/30/18 only. Resident #10's clinical record did not include documentation that she was provided Ensure or a Mighty Shake 89 of 90 opportunities. On 5/3/18 at 3:27 PM, the DNS stated she could not find documentation Resident #10 was provided the Ensure or Mighty Shake three times a day between meals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #2 was readmitted to the facility on [DATE], with multiple diagnoses, including dysphagia (difficulty speaking), Type II diabetes, schizoaffective disorder, major neurocognitive disorder due to traumatic brain injury, chronic kidney disease, edentulous (without teeth), and debility due to muscle weakness. Resident #2's physician order, dated 2/22/18, documented she was to receive a mechanical soft diet, no lettuce or rice. Resident #2's SLP consult, dated 11/13/17 and 11/22/17, documented recommendations for: * Thin liquids via straw * Single sips and supervision * A mechanical soft diet with single textures and ground meats * Speech therapy The treatment included training Resident #2 in safe swallow techniques, and strengthening of pharyngeal musculature to improve the safety of her swallow. Resident #2's Speech Therapy plan of care documented she would be seen at an off-site location 2 times a week for 5 weeks for swallow therapy. The Consultation Sheet in Resident #2's medical record documented on 11/27/17, 11/30/17 and 12/5/17, Resident #2 refused to go to the swallow therapy appointments. The 12/5/17 documentation also noted .continues to refuse. Will DC (discontinue) consult. Resident #2's physician progress note, dated 12/4/17, documented the resident was being seen by speech therapy because she coughed after she ate and that she had refused treatment. The physician progress note stated nursing staff and Resident #2 reported that she continued to cough when she ate. The physician documented speech therapy treatment was discontinued but the other recommendations of the SLP would continue to be implemented. The physician progress note documented the physician discussed with Resident #2 that she was at risk of choking and aspirating that may lead to death. Resident #2's care plan, dated 3/8/18, directed staff to ensure she did not have a choking episode that required life saving measures, when receiving food/fluids that included a mechanical soft diet and supplements or other snack alternatives, and no lettuce or rice. Resident #2's MDS assessment, dated 3/1/18, documented the swallowing and nutritional status of the resident as coughing or choking during meals or when swallowing medications. Also, that she required a mechanically altered diet. Resident #2's dietitian progress note, dated 5/2/18 at 4:08 PM, documented the resident with a diagnosis of swallowing difficulty related to possible worsening of moderate oropharyngeal dysphagia as increased coughing during meal times, specifically with liquids. Resident #2's dietitian progress note, dated 4/12/18, documented her estimated nutritional needs were likely not being met due to poor appetite, more prompting required for foods, and the resident being a picky eater. Resident #2's nurse progress notes, dated 4/30/18 through 5/2/18, documented no issues with coughing or choking during meals. Progress notes, dated 4/29/18, documented Resident #2 with a productive cough. Resident #2's CNA notes, dated 4/30/18 through 5/2/18, documented no issues with coughing or choking during meals. On 4/30/18 at 5:20 PM, Resident #2 was coughing after eating green beans, mashed potatoes and macaroni and cheese, and drinking thin milk. LPN #1 intervened and continued to give the resident milk three times. Each time the resident continued to cough. Resident #2 was then moved to the nurses' station and given a sip of water. At 5:30 PM, LPN #1 assessed Resident #2's oxygen level and wet vocal cough. At 5:33 PM, Resident #2 stated she was not hungry and wanted a milkshake. LPN #1 auscultated the resident's chest, and she continued to cough. At 5:37 PM, Resident #2 was given a chocolate Ensure supplement and continued to cough as she was drinking. On 5/1/18 at 9:13 AM, Resident #2 was lying in a low bed on an air mattress. The ADON assessed the resident, checked vital signs, checked her throat, and asked if she was hurting while swallowing. Resident #2 stated that it hurt to swallow. At 9:22 AM, after the ADON noted Resident #2's vital signs were stable, the resident, while sitting upright, was asked to take deep breaths and take her medicine, one pill at a time. After taking some of the medicine, Resident #2 stated that she was feeling dizzy and getting weaker. The resident completed taking her medicine and stated that her throat was not hurting while swallowing pills. At 9:28 AM, CNA #1 assisted Resident #2 into a wheelchair and helped her perform ADLs. The resident was asked about what she wanted for breakfast. Resident #2 stated she did not want any breakfast, except maybe oatmeal. On 5/1/18 at 9:52 AM, Resident #2 was in the dining room eating a hard crusty cinnamon roll, and was coughing. CNA #1 stated the cinnamon roll was dry and the resident had a banana, a cheese stick, and milk. The resident had a wet cough. Resident #2 was not having difficulty swallowing and was able to eat two cheese sticks and ½ of a banana, 25% percent of her meal. She was offered other food, but declined. After eating, Resident #2 began coughing three different times. CNA #1 stated she was going to lay the resident down in her bed. At 10:09 AM, Resident #2 was placed flat in her low bed. The bed was not elevated after eating. The resident continued to cough. The CNA #1 acknowledged the resident's coughing, then raised the bed approximately 15 degrees and offered her a drink of water. After sipping the water, Resident #2 again began to have a wet cough and continued to intermittently cough for 45 minutes. At 10:47 at AM, Resident #2 was sitting upright in bed and was given a glucerna supplement with a straw by LPN #2. After eating, Resident #2 was laid back down and continued to cough. On 5/1/18 at 11:02 AM, the ADON was asked about the positioning of the Resident #2 in bed and stated it was not appropriate for her to be in a flat position. She stated Resident #2 should not be laid down directly after meals or after consuming supplements. The ADON raised the head of the bed to 45 degrees. The ADON stated the hard crusty cinnamon roll was not appropriate and Resident #2 should have been provided with oatmeal. The ADON stated the physician was notified of Resident #2 coughing. On 5/1/18 at 2:28 PM, Resident #2 was lying in a low bed upright at 45 degrees and continued to cough three different times. On 5/2/18 at 8:46 AM, the RD stated Resident #2 had a history of coughing and had been seen by an SLP for speech therapy. The SLP recommended the resident be placed on pureed texture and nectar thick liquids, which the resident refused, and should not have lettuce or rice. The RD was unable to provide a physician's evaluation consenting for the non-use of thickened liquids. The RD stated that when residents have demonstrated swallowing difficulties, they are encouraged to sit upright and tuck their chins during intake, and remain upright for at least 30 minutes following the intake. Based on observation, staff interview, record review, and review of in-service records, it was determined the facility failed to: a) Ensure physician ordered thickened liquids were the appropriate consistency when served to residents. This was true for 1 of 1 resident (#10) reviewed with orders for thickened liquids. Resident #10 was placed at risk of aspiration when she was provided nectar thick liquids rather than physician ordered pudding thick liquids. b) Ensure residents were provided proper positioning following food/fluid intake. This was true for 1 of 5 residents (#2) sampled for nutrition. The facility's failure placed Resident #2 at increased risk of aspirating or choking on food/fluids. Findings include: 1. Resident #10 was admitted to the facility on [DATE] with diagnoses which included dementia and an eating disorder. A quarterly MDS assessment, dated 2/20/18, documented Resident #10 was severely cognitively impaired and was dependent on one staff member with eating. The May 2018 Physician Orders documented Resident #10's dietary orders were as follows: * Pureed diet texture with pudding thick liquids, ordered 7/3/14. * Resident #10 was to be upright 90 degrees with eating and drinking and staff were to encourage Resident #10 to hold her head in the central position, ordered 7/3/14. The care plan addressing Resident #10's swallowing difficulties, dated 6/4/15, documented Resident #10 had trouble with thin liquids and solid foods. The care plan documented Resident #10 required pureed texture food and pudding thick liquids. The care plan documented staff were to alternate between small bites of food and sips of fluids. The care plan documented staff were to utilize a teaspoon for eating. a. On 5/1/18 at 12:15 PM, CNA #2 was assisting Resident #10 with her lunch meal and was not alternating between liquids and bites of foods. CNA #2 was providing Resident #10 her pureed food. CNA #2 was stirring Resident #10's cup of brown liquid which readily dripped off the spoon. CNA #2 stated the liquid was chocolate milk and stated CNAs prepared the liquids prior to the start of the meal. On 5/1/18 at 12:21 PM, CNA #2 was observed continuing to stir the chocolate milk, and the chocolate milk readily dripped off the spoon. CNA #2 provided Resident #10 a spoon full of the thin chocolate milk. The chocolate milk was removed and brought to the ADON. On 5/1/18 at 12:23 PM, the ADON stated the chocolate milk was not pudding thick and she would correct the issue. The ADON stated the food thickener was a new product and the facility had just completed a staff in-service on the new food thickener product on 4/24/18. A 4/24/18 In-service on Thickened Liquids new product, documented the following: * The staff introduced the new product. * Staff discussed how to thicken the powder and to stir the new product. * Staff were to allow extra set time of 10 minutes for milk and supplements. * Staff were demonstrated how to thicken juice to pudding thick consistency. * Staff were shown where the directions were found in the food room for the new food thickener on the two floors. A 4/24/18 sign-in sheet documented 21 of 35 staff members who worked during the week of 4/29/18, attended the in-service. CNA #2's name was not included as one of the employees who attended the in-service on 4/24/18. b. The facility's Instructions for Thickening Liquids included: * Pudding-thick not pourable but holds its shape like a pudding and is usually ingested with a spoon. * Water, apple/orange/cranberry juice, and coffee/tea required 10 teaspoons of powdered thickener for 8 ounces of fluids and staff was to stir with a spoon until it was dissolved and let the product stand for 2 minutes. * Milk required 10 teaspoons of powdered thickener for 8 ounces of fluids and staff was to stir with a spoon until it was dissolved and let the product stand for 10 minutes. * [NAME] light required 10-11 teaspoons of powdered thickener for 8 ounces of fluids and staff was to stir with a spoon until it was dissolved and let the product stand for 2 minutes. * Nutritional supplements required 11 teaspoons of powdered thickener for 8 ounces of fluids and staff was to stir with a spoon until it was dissolved and let the product stand for 10 minutes. On 5/1/18 at 4:42 PM, CNA #1 stated the CNAs were responsible for thickening the liquids. CNA #1 was in the process of preparing Resident #10's dinner which included 8 ounces of crystal light pudding thickened liquid. CNA #1 had placed the thickener into the crystal light and set the cup down for the fluid to thicken. On 5/1/18 at 4:50 PM, the thickened liquid was observed to readily drip off the spoon as the ADON stirred the crystal light. The ADON asked CNA #1 how many teaspoons of thickener she placed in the crystal light. CNA #1 stated 9 teaspoons. On 5/1/18 at 4:51 PM, the ADON stated the directions for crystal light required 11 teaspoons of thickener. The ADON added an additional 2 teaspoons of powdered thickener to the drink. On 5/2/18 at 8:46 AM, the RD stated the food thickener the facility utilized was a new product and the facility completed an in-service on the new product on 4/24/18. The RD stated the food thickener was to be stirred and allowed to set for 2-10 minutes depending on the type of fluids used. The RD stated the kitchen staff did not prepare Resident #10's fluids ahead of time because the RD wanted Resident #2 to have the option of what beverage to consume with her meals. The RD stated she observed meals 1 time a week minimally to ensure the meal trays were correct. The RD stated the ADON and DNS were available and assisted during meal times as well. The RD stated there was not a formal checks and balance system in place for checking the consistency of thicken liquids.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Resident #15 was readmitted to the facility on [DATE], with multiple diagnoses, including chronic kidney disease, Type II Diabetes with retinopathy, vascular dementia, schizoaffective disorder, and mild mental retardation. Resident #15's annual MDS assessment, dated 9/12/17, documented the resident was severely cognitively impaired, required the assistance of two people for transfers, and was at risk for falls. Resident #15's physician's order, dated 4/16/18, documented the need for a low bed with a mattress on floor next to bed related to falls, and pressure alarm while in bed for safety. The order did not include a requirement for her bed to be against the wall. Resident #15's care plan, dated 3/5/18, directed staff to provide a low bed with mattress on floor next to bed related to falls, and a pressure alarm while in bed for safety. The care plan did not reference a need for her bed to be against the wall. Resident #15's clinical record did not include an assessment, consent, or physician's order for the bed against the wall. On 5/2/18 at 3:47 PM, Resident #15's bed was observed next to the wall. The ADON and DNS stated there was not an order, care plan, or assessment for Resident #15's to be against the wall. The ADON and DNS indicated the beds were next to the walls because of the physical setup of the bedrooms. They said if the beds were moved, it would cause a problem for other residents in the room, and interfere with access to the bathroom and the door. They said the beds against the walls were not used to create a restraint for the residents. Based on observation, staff interview, and record review, it was determined the facility failed to ensure residents were free from restraints, including bed and chair alarms, beds against the wall, and bed U-rails (rail in the shape of an upside down U). The facility failed to identify the medical need for the restraint, ensure the least restrictive restraint was used, and re-evaluate the ongoing need for the restraint. This was true for 5 of 8 (#5, #6, #14, #15, and #20) residents sampled for restraints. This had the potential for physical harm if restraints were improperly used, and psychosocial harm if the resident experienced a psychological decline due to feelings of being restricted in movement. Findings include: 1. Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses, including dementia and encephalopathy. The readmission MDS assessment, dated 2/20/18, documented Resident #5 was severely cognitively impaired, required the assistance of 2 people for transfers, and was at risk for falls. On 4/30/18 at 4:47 PM, Resident #5's bed was positioned with the right-side of the bed against the wall. On 5/1/18 at 10:30 AM, Resident #5 was observed in bed with a U-rail on the left-side of the bed and right-side of the bed was against the wall. On 5/2/18 at 12:15 PM, the DNS stated Resident #5's bed was against the wall due to the size of the room and to ensure there was sufficient space for the Hoyer lift needed to assist Resident #5 with transfers. The DNS stated Resident #5 used the U-rail for bed mobility. Resident #5's clinical record did not include assessments, care plans, consents, or physician orders for the bed against the wall and the U-rail. 2. Resident #6 was admitted to the facility on [DATE] with multiple diagnoses, including schizoaffective disorder. The admission MDS assessment, dated 1/25/18, documented Resident #6 was severely cognitively impaired and was independent with transfers. On 5/2/18 at 2:00 PM, Resident #6's left-side of the bed was against the wall. The DNS stated Resident #6 wanted her bed against the wall to have more space in her room. Resident #6's clinical record did not include assessments, care plans, consents, or a physician order for the bed against the wall. 3. Resident #14 was readmitted to the facility on [DATE] with multiple diagnoses, including dementia. The annual MDS assessment, dated 3/6/18, documented Resident #14 was severely cognitively impaired, required the assistance of 2 people for transfers, and was at risk for falls. On 4/30/18 at 4:33 PM, Resident #14 was observed sitting in his wheelchair with an alarm attached to the back of the wheelchair. The left-side of Resident #14's bed was against the wall with a floor mat on the right-side of the bed. On 5/1/18 at 9:45 AM, Resident #14 was observed in bed, alarm sounding, and staff were answering the alarm promptly. Resident #14's clinical record did not include assessments, consents, or physician orders for the alarms and the bed against the wall. On 5/3/18 at 10:36 AM, the DNS was unable to provide assessments, consents, or physician orders for Resident #14's bed to be against the wall and alarms to his wheelchair and bed. 4. Resident #20 was admitted to the facility on [DATE] with multiple diagnoses, including schizoaffective disorder. A quarterly MDS assessment, dated 2/6/18, documented Resident #20 was cognitively intact and required one person assistance with transfers. On 5/2/18 at 12:00 PM, the DNS, ADON, and the Administrator observed Resident #20's bed was against the right-side of the wall and a U-rail on the left-side of her bed. The DNS stated Resident #20 wanted her bed positioned against the wall and used the U-rail for bed mobility. On 5/2/18 at 4:34 PM, the MDS Nurse stated Resident #20's bed against the wall was not a restraint, as Resident #20 was able to get out of bed on the left-side. The MDS Nurse stated Resident #20 used the U-rail for bed mobility. The MDS Nurse was unable to provide assessments for Resident #20's bed to be against the wall and the U-rail. Resident #20's clinical record did not include assessments, care plans, consents, or physician orders for the bed against the wall and the U-rail attached to the bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Resident #15 was readmitted to the facility on [DATE], with multiple diagnoses, including chronic kidney disease, Type II Diabetes with retinopathy, vascular dementia, schizoaffective disorder, and mild mental retardation. Resident #15's annual MDS assessment, dated 9/12/17, documented she was severely cognitively impaired, required the assistance of two people for transfers, and was at risk for falls. Resident #15's physician order, dated 4/16/18, documented she was to have a low bed with a mattress on floor next to bed related to falls, and a pressure alarm while in bed for safety. The order did not include a requirement for Resident #15's bed to be positioned against the wall. Resident #15's care plan, dated 3/5/18, did not include information about her bed being against the wall. On 5/2/18 at 3:47 PM, Resident #15's bed was observed next to the wall. At that time, the ADON and DNS stated there was not a care plan addressing Resident #15's bed being against the wall. They said the bed against the wall was not intended to serve as a restraint, but rather to make more space in the room. Based on observation, staff interview, and record review, it was determined the facility failed to develop and implement comprehensive resident-centered care plans. This was true for 5 of 8 (#5, #6, #14, #15, and #20) residents sampled for restraints. The residents' care plans did not address the beds against the walls, alarms, and bed U-rails (rail in the shape of an upside down U). This failure created the potential for residents to experience adverse events related to the use of potentially restrictive interventions that were not included in their care plans. Findings include: 1. Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses, including dementia and encephalopathy. The readmission MDS assessment, dated 2/20/18, documented Resident #5 was severely cognitively impaired, required the assistance of two people for transfers, and was at risk for falls. On 4/30/18 at 4:47 PM, Resident #5's bed was positioned with the right-side of the bed against the wall. On 5/1/18 at 10:30 AM, Resident #5 was observed in bed with a U-rail on the left-side of the bed and the right-side of the bed was against the wall. Resident #6's care plan, target date 5/22/18, did not include the bed against the wall and the U-rail. On 5/2/18 at 12:15 PM, the DNS stated Resident #5's bed was against the wall due to the size of the room and to ensure there was sufficient space for the Hoyer lift needed to assist Resident #5 with transfers. The DNS stated Resident #5 used the U-rail for bed mobility. The DNS was unable to provide a care plan for Resident #5's bed against the wall and the U-rail. 2. Resident #6 was admitted to the facility on [DATE] with multiple diagnoses, including schizoaffective disorder. The admission MDS assessment, dated 1/25/18, documented Resident #6 was severely cognitively impaired and was independent with transfers. On 5/2/18 at 2:00 PM, the left-side of Resident #6's bed was against the wall. The DNS stated Resident #6 wanted her bed against the wall for more space in her room. Resident #6's care plan, target date 5/3/18, did not include the bed against the wall. 3. Resident #14 was admitted to the facility on [DATE] with multiple diagnoses, including dementia. The annual MDS assessment, dated 3/6/18, documented Resident #14 was severely cognitively impaired, required the assistance of two people for transfers, and was at risk for falls. On 4/30/18 at 4:33 PM, Resident #14 was observed sitting in his wheelchair. The left-side of Resident #14's bed was against the wall. Resident #14's care plan, target date 6/7/18, did not include the bed against the wall. On 5/3/18 at 10:36 AM, the DNS was unable to provide a care plan for the bed against the wall. 4. Resident #20 was admitted to the facility on [DATE] with multiple diagnoses, including schizoaffective disorder. A quarterly MDS assessment, dated 2/6/18, documented Resident #20 was cognitively intact and required one person assistance with transfers. On 5/2/18 at 12:00 PM, the DNS, ADON, and the Administrator observed Resident #20's bed was against the right-side of the wall and a U-rail was on the left-side of the bed. The DNS stated Resident #20 wanted her bed positioned against the wall and used the U-rail for bed mobility. On 5/2/18 at 4:34 PM, the MDS Nurse stated Resident #20's bed against the wall was not a restraint, as Resident #20 was able to get out of bed on the left-side. The MDS Nurse stated Resident #20 used the U-rail for bed mobility not as a restraint. Resident #20's care plan, target date 5/15/18, did not include the bed against the wall and the U-rail.

Based on observation and staff interview, it was determined the facility failed to ensure cold food was stored at appropriate temperatures to prevent the growth of potential disease causing pathogen growth. This affected 20 of 20 sample residents (#1, #2, #5, #6, #8, #9, #10, #11, #12, #14, #15, #16, #17, #20, #22, #23, #24, #25, #26, and #27) and had the potential to affect the 9 additional residents who dined in the facility. Findings include: The 2017 FDA Food Code, Chapter 3, Part 3-5, Limitation of Growth of Organisms of Public Health Concern, subpart 3-501.12 Time/Temperature Control for Safety Food, Slacking, documented, (A) Under refrigeration that maintains the food temperature at 5 C (41 F [Fahrenheit]) or less . On 5/2/18 at 11:30 AM, [NAME] #1 was observed assessing the temperatures of the hot holding foods. On 5/2/18 at 11:43 AM, [NAME] #1 was observed removing the cold food items from a refrigerator and placed multiple small milk cartons, pears, cheese, pureed pear, Parmesan cheese, shredded lettuce, and sliced tomatoes into a transportation cart. [NAME] #1 was asked to assess the cold food temperatures. The temperatures of the cold foods were as follows: * Shredded Lettuce - 44 degrees F * Sliced Tomatoes - 44 degrees F * Pears - 52 degrees F * Parmesan cheese - 45 degrees F * Cheddar cheese - 45 degrees F * Pureed pear - 46 degrees F Cook #1 utilized 3 different thermometers to verify the temperature of the food items. On 5/2/18 at 11:45 AM, [NAME] #1 stated she normally did not assess the temperature of the cold food items in the main kitchen. [NAME] #1 said she normally assessed the temperature of the food in the satellite kitchens. [NAME] #1 was unsure what to do with the food items that were out of temperature range and the surveyor suggested placing the food items in the freezer to assist with the cooling process and suggested asking for the assistance of a manager. On 5/02/18 at 11:50 AM, the Certified Dietary Manager (CDM) instructed [NAME] #1 to take the food items with her to the other building and placed the food items in the freezer. The CDM stated the staff would send over replacement items as needed. The CDM asked [NAME] #1 where the food was placed in the refrigerator and [NAME] #1 stated the items were flush against the inside of the door. The CDM said the refrigerator was due to be replaced and the facility was waiting for funding. The CDM began assessing the temperatures of the other food items remaining in the refrigerator. The CDM was unsure why these select few items were out of the acceptable temperature range. Sample residents #1, #2, #5, #6, #8, #9, #10, #11, #12, #14, #15, #16, #17, #20, #22, #23, #24, #25, #26, and #27, ate food prepared in the facility's kitchen, and were at risk of consuming foods that may result in a food borne illness.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, policy review, and record review, it was determined the facility failed to update and implement policies and processes to minimize the risk of residents acquiring, transmitting, or experiencing complications from pneumococcal pneumonia. Specifically, a) The facility failed to ensure residents who were offered the pneumococcal vaccine received the vaccine and information and education consistent with current CDC [Centers for Disease Control and Prevention] recommendations for pneumococcal immunization for 2 of 5 residents (Residents #16 and #22) reviewed for the pneumococcal vaccination. b) The facility did not implement an immunization program to ensure residents' pneumococcal vaccines were being tracked with receiving or declining the pneumococcal vaccines PCV13 the first year, followed by the PPSV23 one year later. Findings include: The CDC website, updated 11/22/16, documented recommendations for pneumococcal vaccination (PCV13 or Prevnar13®, and PPSV23 or Pneumovax23®) for all adults 65 years or older: * Adults 65 years or older who have not previously received PCV13, should receive a dose of PCV13 first, followed 1 year later by a dose of PPSV23. * If the patient already received one or more doses of PPSV23, the dose of PCV13 should be given at least 1 year after they received the most recent dose of PPSV23. The facility's policy for Pneumococcal Vaccinations, revised 9/15/17, documented, Per CDC guidelines (published 10/6/09): Give 1 dose if unvaccinated or if previous vaccination history is unknown. 1. Give a 1-time revaccination 5 years or more after 1st dose to people: a. age [AGE] years and older if the 1st dose was given prior to age [AGE] years. The facility's policy stated administration of the pneumococcal vaccine would be made in accordance with current CDC recommendations, however the information and education provided to residents, as documented by the facility's pneumococcal vaccine policy, was not consistent with CDC recommendations. For adults older than [AGE] years old, CDC recommended vaccination of both PCV13 and PPSV23, at least a year apart. The facility's pneumococcal policy only referenced one (1) vaccine; Pneumovax. 1. Resident #16 was readmitted to the facility on [DATE] with multiple diagnoses which included Alzheimer's. A quarterly MDS assessment, dated 1/30/18, documented Resident #16 was severely cognitively impaired and was not up to date and was not offered the Pneumococcal Vaccination. On 5/3/18 at 2:30 PM, the MDS Nurse provided Resident #16's Pneumococcal Vaccine Consent Form, dated 9/24/17, which documented Resident #16 gave the facility permission for the vaccine to be administered. The MDS Nurse was unable to provide documentation Resident #16 received the pneumococcal vaccine. The consent form did not document if the vaccine was the PCV13 vaccine, the PPSV23, or tracking documentation when Resident #16 was to receive the next vaccine. 2. Resident #22 was admitted to the facility on [DATE] with multiple diagnoses which included dementia. A quarterly MDS assessment, dated 3/6/18, documented Resident #22 was not up to date and was offered and declined the Pneumococcal Vaccination. On 5/3/18 at 2:30 PM, MDS Nurse provided Resident #22's Pneumococcal Vaccine Consent Form, dated 9/19/17, which documented Resident #22 gave the facility permission for the vaccine to be administered. The MDS Nurse was unable to provide documentation Resident #22 received the pneumococcal vaccine or evidence of the refusal. The consent form did not document if the vaccine was the PCV13 vaccine, the PPSV23, or tracking documentation when Resident #22 was to receive the next vaccine. On 5/3/18 at 8:43 AM, the Infection Control Nurse was unable to provide current completed tracking of the Pneumococcal Vaccination PCV13 and PPSV23, which included tracking all residents receiving the pneumococcal vaccination PCV13 dose first, followed by the PPSV23 one year later. The Infection Control Nurse stated policies and procedures were reviewed annually with the CDC guidelines and then reviewed during the infection control committee meeting.