**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility document review, record review, observation, and resident and staff interview, it was determined the facility failed to ensure residents' rights for self-determination was honored. This was true for 3 of 3 residents (#5, #35, and #49) reviewed for choices. This deficient practice had the potential for Resident #5, #35, and #49 to experience a decreased sense of well-being, lack of self-worth, and frustration when their preference for having the television (TV) on in the dining room during meals was not accommodated. Findings include: Review of the facility document, Resident Rights 2017, documented .The Resident has the right to make choices about the aspects of his/her life in the facility that are significant to the resident . - Resident #5 was admitted to the facility on [DATE] with multiple diagnoses including spina bifida (a condition that occurs when the spine and spinal cord do not form properly which can range from being mild to causing serious disabilities) and muscle weakness. An annual MDS assessment, dated 3/22/24, documented Resident #5 was moderately cognitively impaired. Resident #5's care plan for activities, revised 12/27/23, documented Resident #5 has engaged in bingo, coloring, watching TV . - Resident #35 was initially admitted to the facility on [DATE], with multiple diagnoses including diabetes and depression. A quarterly MDS assessment, dated 5/3/24, documented Resident #35 was moderately cognitively impaired. Resident #35's care plan for activities, revised 2/5/24, documented Resident #35 .Will watch TV in dining room at mealtimes only . - Resident #49 was initially admitted to the facility on [DATE] with multiple diagnoses including diabetes and muscle weakness. A quarterly MDS assessment, dated 3/25/24, documented Resident #49 was cognitively intact. Resident #35's care plan for activities, revised 2/5/24, documented staff were to .Provide a program of activities that is of interest and empowers the resident by encouraging/allowing choice, self-expression, and responsibility . 1. On 6/19/24 at 12:15 PM, Resident #5, Resident #35, and Resident #49 were observed in the B-Hall independent dining room watching TV while waiting for lunch to be served. When the lunch trays arrived at 12:30 PM, CNA #3 was observed turning the TV off, in the middle of a program that Resident #5, Resident #35, and Resident #49 were watching. Resident #5, Resident #35, and Resident #49 stated to CNA #3 their dislike of the TV being turned off and CNA #3 stated .I know, but I have to . and walked away. During an interview on 6/19/24 at 12:45 PM, Resident #35 and Resident #49 stated they liked the TV on during their meal and did not like it being turned off. Resident #49 stated he was told the TV was to be turned off during meals to .avoid distractions . during the meal. Resident #49 also stated some staff turned the TV off and some did not, and he ate all his meals in the dining room. Resident #35 agreed with Resident #49 that some staff would turn it off and others did not, but he also preferred to watch TV while eating. Resident #5 agreed with Resident #35 and Resident #49 that she preferred to have the TV on while eating. The TV was turned back on at 1:00 PM by CNA #4. Resident #35 and Resident #49 had finished eating and left the dining room, however Resident #5 was still eating and was observed actively watching the TV. 2. On 6/20/24 at 11:30 AM, in the B-Hall independent dining room, Resident #5, Resident #35, and Resident #49 were observed watching TV while waiting for the lunch meal to be served. Lunch was served at 12:15 PM and the TV was not turned off, or the volume turned down, while the residents ate. During an interview on 6/20/24 at 12:45 PM, Resident #35, Resident #5, and Resident #49 stated they were happy the TV was not turned off while they ate their meal. During an interview on 6/22/24 at 9:15 AM, Resident #6, who was the current Resident Council President, stated some staff would turn off the TV during meals in the dining room and others did not. She stated she was unsure why some turned it off and stated .I think they want us to talk to each other . She also stated this concern had not been brought up at resident council meetings. 3. On 6/22/24 at 11:15 AM, the TV was observed on and Resident #49 and Resident #35 were in the dining room actively watching TV while waiting for lunch. Lunch was served at 12:05 PM and the TV was not turned off, or the volume turned down, during the meal. Resident #5, Resident #35, and Resident #49 were actively watching TV while eating. During an interview on 6/22/24 at 12:20 PM, LPN #1 for B-Hall stated the TV could be left on during mealtimes, especially if the residents requested it. LPN #1 stated the volume could be lowered if needed, but if the residents requested the TV to be left on it should be on as it was their choice as this was their home. LPN #1 also stated that CNA #3 would turn the TV off and was educated by LPN #1 if the residents want the TV left on, it could be, but there was no policy that stated that the TV had to be turned off. During an interview on 6/22/24 at 12:30 PM, the Administrator and DON stated the TV could be left on during meals, as this was the residents' home and their choice. The Administrator stated the volume could be adjusted so the staff could be aware of any potential choking concerns, but if they wanted the TV on, it should be left on. The Administrator also stated the facility did not have a specific policy regarding this but referred to the facility Resident Rights 2017 document provided to all residents.

**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 a fall prevention intervention was implemented following a fall. This was true for 1 of 3 residents (Resident #10) whose records were reviewed. This had the potential for harm if the resident sustained an injury from a fall. Findings include: The facility's Accidents and Supervision to Prevent Accidents policy, dated 10/15/22, documented .The facility provides an environment that is free from accident hazards over which the facility has control and provides supervision and assistance devices to each resident to prevent avoidable accidents . Resident #10 was admitted to the facility on [DATE], with multiple diagnoses including abnormalities of gait and mobility. A fall risk evaluation, dated 8/8/23, documented Resident #10 was a fall risk. A quarterly MDS assessment, dated 8/10/23, documented Resident #10 was moderately cognitively impaired. The assessment further documented she required extensive assistance of one staff for bed mobility and extensive assistance of two staff for transfers and was dependent on staff for bathing. An incident progress note, dated 10/22/23, documented a post fall investigation was completed for Resident #10. The note documented Resident #10 sustained a fall from her bed and was found on the floor near the bed. The progress note further documented Resident #10 was assessed for injuries she hit her head and had possible bruising to the posterior scalp. An interdisciplinary team (IDT) progress note, dated 10/23/23, documented Resident #10's fall was reviewed and Resident #10 said she was going to prepare lunch for her mother. The IDT note documented Resident #10 was on comfort measures and refused to get out of bed. The IDT recommended a low bed and to have a fall mat placed next to her bed. Resident #10's care plan, dated 10/23/23, documented the facility implemented an impact floor mat to increase the Resident #10's safety. A fall risk evaluation, dated 2/5/24, documented Resident #10 continued to be a fall risk. A health status progress note, dated 2/5/24, documented a NA found Resident #10 on the floor face down adjacent to her bed with her feet at the head of the bed. The note documented Resident #10 stated she had a dream she could walk. Another progress note, dated 2/5/24, documented Resident #10 sustained a bruise on her right cheek and was sent to the local emergency room for evaluation and treatment. An emergency room progress note, dated 2/5/24, documented Resident #10 presented to the hospital due to a recent fall and the resident struck the right side of her face. Tests were run and there were no injuries. The resident was later returned to the facility on the same day. On 6/18/24 at 10:16 AM, two NAs were observed conducting a mechanical lift transfer of Resident #10. There was no impact floor mat next to Resident #10's bed during this observation. On 6/19/24 at 1:26 PM, Resident #10 was in bed and stated she felt safe. There was no impact floor mat next to her bed. During an interview on 6/19/24 in Resident #10's room at 4:25 PM, NA #2 confirmed she worked with Resident #10 a great deal and she confirmed Resident #10 did not have a fall mat on the floor, next to her bed. NA #1 was also present and confirmed there was no floor mat on the floor next to Resident #10's bed and there was none located in her room. During an interview on 6/20/24 at 2:20 PM, the DON stated the floor mat was to be placed on the floor next to Resident 10's bed since this would reduce the likelihood of injury if the resident fell on the floor.

**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 residents were offered a pneumococcal vaccine they were eligible to receive. This was true for 2 of 5 residents (#31 and #52) whose records were reviewed for pneumococcal vaccinations. This failure created the potential for residents to have an increased risk of pneumococcal (bacterial) pneumonia and the potential for severe illness or death. Findings include: The Centers for Disease Control and Prevention (CDC) Pneumococcal Vaccine Timing for Adults, dated 3/15/23, located at https://www.cdc.gov/vaccines/vpd/pneumo/downloads/pneumo-vaccine-timing.pdf, included recommendations for pneumococcal vaccinations for all adults 65 years or older as follows: - For those who have never received any pneumococcal vaccine, the CDC recommends receiving one dose of PCV20 or PCV15. - For those who have previously received PCV13 at any age and PPSV23 at less than [AGE] years of age, the CDC recommends receiving PCV20 at least five years after administration of PCV13 or PPSV23. The CDC also stated these adults can talk with their doctor and decide, together, whether to get the PCV20 vaccine. The facility's Pneumococcal Program policy, dated 5/31/23, documented for routine vaccination for those who are age [AGE] or older who have not previously received a dose of PCV13, PCV15, or PCV20, or whose previous vaccination history is unknown, 1 dose of PCV15 or 1 dose of PCV20 should be offered. For those who have previously received only the PCV13, 1 dose of PCV20 at least 1 year after the PCV13 was administered or to complete the recommended PPSV23 series should be offered. The following residents who were eligible for the PCV20 vaccine did not have documentation in their record they were offered or received the PCV20 vaccination: a. Resident #31 was admitted to the facility on [DATE], with multiple diagnoses including stroke and muscle weakness. Resident #31's immunization record documented he received the PPSV23 on 10/14/13 and the PCV13 on 4/6/15. Resident #31's record did not include documentation of shared decision-making between Resident #32 and/or his representative and his primary care physician on the possible administration of the PCV20 vaccination. b. Resident #52 was admitted to the facility on [DATE], with multiple diagnoses including end stage renal disease and muscle weakness. Resident #52's immunization record documented he received PCV13 on 11/1/11 and the PPSV23 on 11/1/12. The PCV13 and PPSV23 were administered to the resident before he turned [AGE] years old. Resident #52's record did not include documentation of shared decision-making between Resident #52 and/or his representative and his primary care physician on the possible administration of the PCV20 vaccination. During an interview on 6/20/24 at 10:02 AM, the Infection Preventionist stated the facility did not have a process between the resident and the physician which would reflect a shared decision making on PVC20 vaccination.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure waste was properly contained with lids or otherwise covered. This created the potential for insect and pest infestation of the facility's premises and had the potential to adversely affect all 90 residents residing in the facility. Findings include: The facility's Pest Control policy, dated 10/18/23, documented routine inspections were conducted at the facility for evidence of pests. The policy documented staff were to keep the facility grounds free of trash and brush and to keep the dumpster area clean and the lid closed. On 6/18/24 at 10:20 AM, with the Dietary Manager the area in the parking lot behind the kitchen where the trash dumpster was located was observed. One dumpster used to contain the facility trash and recycling material was open and the lid was flipped back exposing boxes and bags of trash. During an interview on 6/18/24 at 10:20 AM, the Dietary Manager stated, The dumpster should be closed and not left open.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #168 was admitted to the facility on [DATE] with a diagnosis of kidney failure. Resident #168's current physician orders documented an order for Sevelamer HCl Tablet 800 MG [milligrams] - Give 1 tablet by mouth with meals for kidney failure - May leave medication with patient in room so that it can be taken just prior to first bite of food. On 1/31/19 at 12:03 PM, RN #4 said Resident #168 had an order for Sevelamer HCL tablet 800 mg and to give 1 tablet by mouth with meals for kidney failure. RN #4 said Resident #168's order included, May leave medication with patient in room so that it can be taken just prior to first bite of food. RN #4 delivered the medication to Resident #168 and left the room before she took the medication. RN #4 said she would check with her RCM to find out if an assessment was completed. On 1/31/19 at 7:05 PM, RCM #1 said she could not find evidence of an assessment for self-administration of medications for Resident #168, and she completed one on that day. Based on observation, resident and staff interview, and record review, it was determined the facility failed to ensure 2 of 2 residents (#15 and #168) reviewed for self-administration of medications were clinically appropriate to do so prior to allowing them to self-administer medications. This had the potential for harm should the residents administer medications contrary to physician orders. Findings include: 1. Resident #15 was admitted to the facility on [DATE] with multiple diagnoses, including major depressive disorder, insomnia, anxiety disorder, and bipolar disorder. Resident #15's quarterly MDS assessment, dated 12/4/18, documented he was cognitively intact, did not exhibit behaviors, and required supervision for bed mobility, transfers, walking in his room and the corridor, locomotion, dressing, and eating, and required limited assistance with toilet use. On 1/30/19 at 2:25 PM, Resident #15 had a baggie with a prescription cream inside the bag on his overbed table. The pharmacy label on the cream documented it was ordered on 9/22/18 and read, Mupirocin 2% and Bactroban 2% ointment [an antibiotic ointment combination] apply to the affected area two times a day as needed. Resident #15 stated the nurse let him keep the ointment and put it on his toe as needed. He stated currently he was not using it because he wanted his toenail to harden up and he believed it was keeping his toenail soft. On 1/30/19 at 2:35 PM, RN #3 said Resident #15 had the prescription ointment in his room and could self-administer it. Resident #15's medical record did not include a self-administration of medication order and self-administration assessment. On 1/31/19 at 5:44 PM, RCM #2 stated Resident #15 should have had an assessment for self-administration and an order to self-administer the ointment prior to being allowed to keep it in his room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and resident and staff interviews, it was determined the facility failed to ensure a resident's physician and representative were notified of significant changes in the resident's clinical condition in a timely manner. This was true for 1 of 3 residents (Resident #319) reviewed for notification of changes. This failure created the potential for harm when the facility failed to immediately notify Resident #319's physician and family member of his decreased level of consciousness. Findings include: The facility's policy for Resident Change of Condition, dated 11/28/17, documented the following: * When a potentially life-threatening condition is recognized, the nurse should relay the information to the health care provider. * Changes of condition may include a change in functional status, new or increased confusion, deteriorating mobility, falls, changes in behavior, and potentially life threatening conditions related to a change in the resident's chronic disease state and medical condition. * The physician should be notified as close to the time of the event as possible, and should be notified immediately if any sign or symptom is sudden in onset, a marked change compared to the resident's usual signs and symptoms, or not improved with previously prescribed measures. * Significant change is a decline or improvement in a resident's condition that would not normally improve without staff intervention, affects more than one area of the resident's health status, and requires review or revision of the care plan by the interdisciplinary team. * The facility is to immediately inform the resident, seek advice from the physician, and notify the resident's representative when there is a significant change in the resident's physical, mental, or psychosocial status, or a need to significantly change treatment. 1. Resident #319 was admitted to the facility on [DATE] with multiple diagnoses, including Amyotrophic Lateral Sclerosis (a degenerative neurological disease), altered mental status, Type 2 diabetes mellitus, schizophrenia, major depressive disorder, chronic kidney disease, after effects of cerebral infarction (stroke), history of pulmonary embolism (blood clot), and hepatic (liver) failure. Resident #319's Progress Notes documented the following: * On 8/23/18 at 9:25 PM, he was admitted to the facility and was able to communicate his needs. * On 8/26/18 at 3:14 AM, he was alert and oriented with slight confusion at times, he was able to verbalize his needs, and was pleasantly happy. * On 8/26/18 at 8:00 AM, he had two witnessed falls within 30 minutes. * On 8/26/18 at 1:25 PM, there was increased confusion, he was impulsive and having a difficult time complaining. He was having difficulty with mobility due to increased confusion. * On 8/27/18 at 12:31 AM, Resident #319 had been unresponsive that morning. The physician was making rounds in the facility, evaluated Resident #319, and was unable to waken him. Resident #319's wife was visiting, and the physician ordered immediate transport to the emergency room. An IDT Review of Falls that occurred on 8/26/18 documented Resident #319 was admitted to the facility after being hospitalized for liver failure and cirrhosis (degenerative disease of the liver). He was alert and oriented with some confusion at 3:14 AM, and had a fall at 6:00 AM. Resident #319 fell again at 8:00 AM and 8:30 AM. When the physician was making rounds on Monday morning (8/27/18), Resident #319 was difficult to arouse and was sent to the emergency room. There was no documentation in Resident #319's clinical record regarding when he became unresponsive and when his physician and wife were notified of his change in condition. On 1/31/19 at 5:27 PM, LPN #5 said she did not recall when Resident #319's level of consciousness changed or when his physician and wife were made aware of his change in condition. On 2/1/19 at 10:27 AM, the Clinical Resource Nurse said she could not tell from the documentation when Resident #319's condition changed or when his physician and wife were notified of his change in condition. The Clinical Resource Nurse said she would expect Resident #319's physician and wife to be notified when his condition changed.

Based on observation, policy review, and resident and staff interview, it was determined the facility failed to ensure the residents' living environment was homelike. This was true for 4 of 22 residents (#16, #24, #29, and #41) reviewed for homelike environment. This failure created the potential for diminished quality of life and psychosocial harm for those residents with room wall damage. Findings include: The facility's General Environmental Condition policy and procedure, dated 11/28/17, documented a comfortable environment was provided for residents, staff and the public. Plant operation and maintenance services were provided to maintain the inside and outside of the building, as necessary (e.g., painting, building repair such as handrails, flooring, plumbing, electrical, yard work, etc.). On 1/28/19 at 10:55 AM, Resident #16's room was observed with 4 inch by 4 inch wall damage above the baseboard on the west wall, and 12 inch by 12 inch wall damage on the south wall. Resident #16 stated he could not avoid hitting the wall with his wheelchair and the other wall damage was done by the back of a stationary chair. Resident #16 stated the holes on the west wall were fixed months ago, and the painting needed to be done. Resident #16 stated he knew the staff were busy and doing other things that were more important, and he would really like the wall to be fixed. On 1/28/19 at 11:19 AM, Resident #29's room had a 2 inch circle of missing paint, and 2 inch by 2 inch area of paint bubbling up on the east wall. Resident #29 stated he could avoid hitting the wall with his wheelchair and he would like the damage to the wall fixed. On 1/28/19 at 3:24 PM, Resident #24's and #41's room was observed with 6 inch by 12 inch significant wall damage on the left side of Resident #41's bed, and two 3 inch by 2 inch places of wall damage on the north side of the room. Resident #24 and Resident #41 stated the wall damage had been there since the side rails were put in place. On 1/29/19 at 3:00 PM, the Maintenance Director stated he was aware of the wall damage in the rooms of Residents #16, #24, #29 and #41. The Maintenance Director stated the wall damage was on his list to be repaired and he tried to touch up walls after residents were discharged .

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure the required documentation was completed when a resident was transferred to the hospital. This was true for 1 of 3 residents (#318) reviewed for transfer or discharge, and had the potential for harm if the required documentation was not obtained from the physician and the pertinent information made available to the receiving facility. Findings include: The facility's policy for Transfer and Discharge, dated 11/28/17, documented the following: Information provided to the receiving facility should include, at a minimum, contact information of the responsible medical practitioner and the resident's representative, Advance Directive information, special instructions and/or precautions for ongoing care, the resident's care plan goals, and all information necessary to meet the resident's needs . A Progress Note, dated 1/27/19 at 3:11 AM, documented Resident #318 was transferred to the emergency room per MD verbal order at 1:30 AM due to increased blood in her Foley catheter, worsening flank pain, and headache. There was no documentation in Resident #318's clinical record of the physician's name or a physician's order to transfer her to the emergency room. An emergency room physician note, dated 1/27/19 at 3:21 AM, documented Resident #318 was evaluated in the emergency room and was diagnosed with a urinary tract infection. A Progress note, dated 1/27/19 at 8:12 AM, documented Resident #318 returned to the facility from the hospital at 5:00 AM. Resident #318's clinical record did not contain documentation regarding her transfer summary or what information was provided to the receiving facility at the time of her transfer. On 1/30/19 at 11:49 AM, RCM #1 said she did not see a physician's order in Resident #318's clinical record for her to be transferred to the emergency room. RCM #1 said a transfer evaluation was usually completed when a resident was transferred, but she did not see it documented for Resident #318. On 1/31/19 at 9:46 AM, the DNS said an evaluation for transfers and a physician's order should have been completed for Resident #318 when she was transferred to the hospital.

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure a notice of transfer was provided in writing to a resident and/or her representative when she was transferred to the hospital. This was true for 1 of 3 residents (#318) reviewed for transfer or discharge, and had the potential for harm if residents were not made aware of or able to exercise their rights related to transfers. Findings include: The facility's policy for Transfer and Discharge, dated 11/28/17, documented the following: Contents of the written notice would include the reason for transfer/discharge, the effective date, the location of where the resident is being transferred/discharged , the contact information for the state ombudsman, and the contact information for the agency responsible for protection and advocacy of those who are developmentally disabled or mentally ill. A Progress Note, dated 1/27/19 at 3:11 AM, documented Resident #318 was transferred to the emergency room at 1:30 AM due to increased blood in her Foley catheter, worsening flank pain, and headache. An emergency room physician note, dated 1/27/19 at 3:21 AM, documented Resident #318 was seen in the emergency room, was diagnosed with a urinary tract infection. A Progress note, dated 1/27/19 at 8:12 AM, documented Resident #318 returned to the facility from the hospital at 5:00 AM. On 1/30/19 at 11:49 AM, RCM #1 said Resident #318's family was not notified in writing of her transfer to the emergency room. On 1/30/19 at 4:31 PM, RCM #1 said she did not follow up on notifying Resident #318 and her family regarding her transfer to the hospital. On 1/30/19 at 5:02 PM, the Medical Records Coordinator said Resident #318 did not receive a notice of transfer when she was transferred to the emergency room because she had arrived at the facility so recently.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, it was determined the facility failed to complete a comprehensive assessment when a resident experienced a significant change in health and functional status. This was true for 1 of 1 resident (#65) reviewed for hospice. This had the potential for harm if facility staff did not recognize changes in the resident's health status and needs. Findings include: The facility's Resident Assessment policy, dated 11/28/17, documented a significant change assessment should be completed within 14 days after the facility determines or should have determined there has been a significant change in the resident's physical or mental condition. Resident #65 was admitted to the facility on [DATE] with multiple diagnoses, including dementia. Resident #65's admission MDS assessment, dated 11/2/18, documented he did not have hospice services. There were no other comprehensive MDS assessments found in Resident #65's clinical record. Resident #65's progress note, dated 11/21/18, documented a discussion regarding hospice services. Resident #65's hospice election form, dated 11/23/18, documented he was to receive hospice services. Resident #65's physician orders, dated 11/26/18, documented an order for hospice. Resident #65's physician hospice justification and hospice plan of care, dated 11/28/18, documented he was to receive hospice services. On 1/31/19 at 11:33 AM, the MDS Nurse said there should have been a significant change MDS assessment completed when Resident #65 was placed on hospice, and it was missed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #43 was admitted to the facility on [DATE] with multiple diagnosis, including Type 2 diabetes mellitus and cerebrovascular (related to blood vessels of the brain) disease. Resident #43's POST, dated 12/18/18, documented a code status of Full Code (initiate life-saving measures). Resident #43's current comprehensive care plan did not include documentation of his code status. On 1/30/19 at 12:04 PM, the DNS stated Resident #43's code status was not included on the comprehensive care plan. Based on observation, record review, policy review, and staff interview, it was determined the facility failed to develop and implement comprehensive resident-centered care plans to include code status and assistance with eating. This was true for 2 of 21 residents (#40 and #43) who were reviewed for care plans. This failure created the potential for harm if residents received inappropriate or inadequate care, and if their resuscitation code status wishes were not honored. Findings include: The facility's care plan policy, dated 11/28/17, documented comprehensive person-centered care plans would be developed for each resident to attain or maintain residents highest practicable physical, mental, and psychosocial well-being. 1. Resident #40 was admitted to the facility on [DATE] with multiple diagnoses, including aphasia (loss of ability to understand or express speech, caused by brain damage), muscle weakness, dysphagia (difficulty swallowing), and dementia. Resident #40's admission MDS assessment, dated 12/29/18, documented he required the assistance of one staff for eating. Resident #40's care plan did not document the need for staff to assist him with eating. Resident #40's History and Physical, dated 12/28/18, documented, I met with [Resident #40] today to admit him to our facility. Due to his dementia and schizophrenia he is non-verbal and requires assistance with all ADLs . He is sitting up in his chair and appears to be comfortable. On 1/30/19 at 12:50 PM, CNA #1 fed Resident #40 and she confirmed Resident #40 could not feed himself. During an interview with RCM #2 on 1/30/19 at 6:32 PM, RCM #2 confirmed Resident #40 needed feeding assistance. RCM #2 looked through the care plan and confirmed Resident #40's need for assistance with eating was not on the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and resident and staff interview, it was determined the facility failed to ensure residents received treatment and services to prevent further decrease in ROM (range of motion). This was true for 1 of 5 residents (#38) reviewed for treatment and services related to ROM. This deficient practice placed residents at risk of experiencing a decrease in mobility and function due to lack of active ROM (AROM) or passive ROM (PROM) services. Findings include: The facility's Range of Motion policy and procedure, dated 11/28/17, documented staff were to provide care and treatment to help residents reach and maintain his/her highest level of range of motion as a maintenance program or as a preventative measure to reduce the risk of or prevent avoidable decline. Resident #38 was admitted to the facility on [DATE] and was readmitted on [DATE], with multiple diagnoses which included diabetes mellitus, muscle weakness, and difficulty walking. A quarterly MDS assessment, dated 10/25/18, documented Resident #38 was cognitively intact and she had functional limitation of her lower extremity on one side. A Restorative Services Referral form, signed on 12/13/18, documented Resident #38's restorative program was AROM, transfer training with her front wheeled walker, and for her to use a recumbent stepper for 10 minutes. The referral form did not include the frequency of her restorative nursing program. On 1/28/19 at 9:58 AM, Resident #38 said she used to have physical therapy almost daily but recently she had been to the gym only 3 times. An ADL ROM report, dated 12/25/18 through 12/31/18 (7 days), documented Resident #38 refused treatment on 12/26/18. The report did not include documentation Resident #38 received restorative nursing services the other 6 days. An ADL ROM report, dated 1/1/19 through 1/26/19 (26 days), documented Resident #38 completed transfer training with her front wheel walker on 5 days, on 1/15/19, 1/22/19, 1/23/19, 1/25/19 and on 1/26/19. The report did not include documentation Resident #38 received restorative nursing services the other 21 days. On 1/30/19 at 11:41 AM, the PT (Physical Therapy) Director said Resident #38 was discharged from the PT program on 12/24/18 and referred to the restorative program. The PT Director reviewed the referral form and said it was an incomplete request/order. The PT Director said Resident #38 should have 15 minutes for each of her restorative programs 6 days a week. On 1/30/19 at 2:54 PM, RCM #1, who was the RNA program supervisor, said Resident #38's restorative nursing program was for AROM, recumbent stepper, and transfer training with her front wheel walker 6 days a week, and 15 minutes for each exercise. RCM #1 reviewed at the ADL ROM documentation and said Resident #38 might have completed the restorative program and the RNA (Restorative Nursing Aide) forgot to document it. RCM #1 said there were times when the RNA was asked to work on the floor when the facility had unexpected sick calls. RCM #1 said the facility first called other staff members to work and if unable to fill the shift, the facility called the staffing agency to assist in filling the vacant shift. RMC #1 said if the agency could not provide staff, they asked the RNA to work on the floor. On 1/31/19 at 5:31 PM, CNA #10, who was the Transportation Coordinator, said she was asked to provide restorative nursing services on 1/30/19 and 1/31/19. On 2/1/19 at 9:10 AM, CNA #6, who was the RNA, said she used to be the only RNA in the facility and she was unable to meet the residents' needs. CNA #6 said she had 34 residents who needed restorative nursing services, and she worked with 15 residents per day. CNA #6 said she was also asked to work on the floor last month when they had unexpected sick calls, but this had not happened lately since the facility hired another RNA.

**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 ensure the bowel protocol was followed and implemented for 1 of 2 residents (#267) reviewed for bowel and bladder care. This had the potential to place residents at risk for fecal impaction. Findings include: The facility's Bowel Care Protocol, updated on June 2018, stated CNAs were to document each shift residents' number of bowel movement or lack of bowel movement, bowel consistency, and size of bowel movement. When a resident did not have documented bowel movement in the last 48 hours, the night nurse was responsible to ensure the physician's orders included approval to follow the Bowel Care Protocol or other bowel regime orders. Resident #267 was admitted to the facility on [DATE], with multiple diagnoses which included depression and hypertension. Resident #267's January 2019 Physician Order summary included the following: * Milk of Magnesia (MOM) suspension 1200 mg/15 ml if no bowel movement for 2 days. * Dulcolax suppository 10 mg, insert 1 suppository rectally, as needed, if no result from MOM concentrate within 8 hours, for constipation. * Fleet enema 7-19 gm/18 ml, give if no results from Dulcolax suppository in 8 hours Resident #267's bowel movement records and MAR, dated 12/31/18 through 1/29/18, documented the following: * Resident #267 did not have a bowel movement between 12/31/18 and 1/6/18 (7 days). Resident #267's MAR documented she was administered MOM with no results on 1/2/19, and on 1/7/19, 5 days later, she was administered MOM at 9:51 AM and a Fleet Enema with positive results. Resident #267 did not receive a Dulcolax suppository at any time during the 7 day period, after there were no results from the MOM. Resident was administered MOM and a Fleets enema on 1/7/19. There was not a physician's order for MOM to be given at that time, and the Fleets enema was administered on day 7 without a bowel movement. Resident #267's physician's orders, if followed, required the Fleets enema to be given on day 4 of no bowel movement. * Resident #267 did not have a bowel movement between 1/9/19 and 1/16/19 (8 days). Resident #267's MAR documented she received MOM with no results on 1/13/19, instead of 1/11/19, day 3 without a bowel movement. On 1/14/19 Resident #265 was administered a Dulcolax suppository with no result. Three days later, on 1/17/19, Resident #267 was administered a Fleets enema with positive results. The Fleets enema was not administered 8 hours after she was administered a Dulcolax suppository with no result. On 1/30/19 at 3:38 PM, the DNS reviewed Resident #267's bowel movement record and said the resident's bowel care protocol was not consistently followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, it was determined the facility failed to ensure residents' weights were monitored in accordance with their nutritional assessment and plan of care. This was true for 1 of of 8 residents (#44) reviewed for weight loss. This failure created the potential for harm if Resident #44 experience further weight loss and interventions were not in place in timely manner. Findings include: The facility's Weight Measurement policy and procedure, dated 11/28/17, directed staff to weigh residents at least monthly and as needed. Resident #44 was admitted to the facility on [DATE], with multiple diagnoses which included diabetes mellitus, dysphagia (difficulty swallowing), gastroparesis (stomach cannot empty itself of food in a normal fashion). A quarterly MDS assessment, dated 11/3/18, documented Resident #44 was cognitively impaired and she required extensive assistance of 2 staff members for activities of daily living. A Nutritional care plan, revised on 11/6/18, documented Resident #44 had a potential for altered nutritional status related to dementia, diabetes mellitus, dysphagia, and gatroparesis, shortness of breath, and hernia repair. The care plan documented Resident #44 was on a therapeutic diet and wandered out of the dining room in her wheelchair during meals. Interventions included in her care plan revised on 12/12/18, directed staff to obtain her weights daily. Resident #44's November 2018 Weight Flow Sheet, documented her weights as follows: *11/11/18: 175 pounds *11/15/18: 176 pounds *11/20/18: 172.2 pounds *11/25/18: 171.6 pounds Resident #44's clinical record did not include documentation her weight was obtained in December 2018. On 1/30/19 at 3:45 PM, the RD said Resident #44's weights were obtained 4 times in November and her weight was not checked or obtained in December 2018. The RD said Resident #44's weight was not obtained daily in accordance with her care plan. On 1/30/19, Resident #44's weight was obtained and she weighed 163.4 pounds. On 1/31/19 at 6:21 PM, RCM #2 said Resident #44's weights were not obtained in December 2018. RCM #2 said Resident #44 had experienced weight loss and he did not know the reason Resident #44 was not weighed daily according to her care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy review, observation, and interviews with staff and a resident, it was determined the facility failed to ensure a physician's order was in place prior to a resident receiving oxygen therapy. This was true for 1 of 1 resident (#318) reviewed for oxygen. This failure created the potential for harm if residents received oxygen inconsistent with physician orders. Findings include: The facility's policy and procedure for Oxygen Therapy, dated 11/14/17, documented staff were to verify the physician's order prior to initiating oxygen. Resident #318 was admitted to the facility on [DATE] with multiple diagnoses, including chronic heart disease, pulmonary hypertension, and acute respiratory failure with hypoxia (low oxygen level). On 1/28/19 at 11:20 AM, Resident #318 was in her room and had oxygen in place by nasal cannula at 2.5 liters per minute. On 1/29/19 at 3:32 PM, Resident #318 was in her room and had oxygen in place by nasal cannula at 1.5 liters per minute. A physician order for Resident #318's oxygen was not found in her record at that time. On 1/28/19 at 2:54 PM, Resident #318 was in her room and did not have oxygen in place. Resident #318 said she should be receiving oxygen. On 1/29/19 at 3:38 PM, RN #5 said she expected there to be an order for Resident #318's oxygen, and she did not see an order in her clinical record. On 1/30/19 at 12:09 PM, RCM #1 said she expected to have a physician's order prior to oxygen being administered to a resident. RCM #1 said Resident #318's hospital discharge orders did not indicate oxygen, but her history and physical from the hospital documented she was dependent on oxygen at 1 liter per minute.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review, record review, and interviews with staff and a resident's family member, it was determined the facility failed to ensure that prior to the placement of bed rails, residents were thoroughly assessed for the risk of entrapment and a consent was in place. This was true for 1 of 4 residents (#54) reviewed for bed rail use, and created the potential for harm from entrapment or injury related to the use of bed rails. Findings include: The facility's policy for Restraints, dated 11/28/17, documented prior to use of bed rails, the facility would assess the resident for risk of entrapment, review the risks and benefits of bed rails with the resident or their representative, and obtain informed consent prior to installing the bed rails. Resident #54 was admitted to the facility on [DATE], with multiple diagnoses including hemiplegia and hemiparesis (weakness and paralysis on one side) following cerebral infarction (stroke) affecting the right side, and difficulty walking. On 1/28/19 at 3:47 PM and 1/30/19 at 2:36 PM, bilateral bed canes (small bed rails) were present on Resident #54's bed. Resident #54's representative was present at the time and said she did not recall signing a consent form for the use of the bed canes. Resident #54's clinical record did not document an assessment for the safety of the bed canes or consent from Resident #54 or his representative for use of the bed canes. On 1/30/19 at 4:40 PM, RCM #1 said she did not find documentation of when Resident #54 received the bed canes on his bed. RCM #1 said she did not see a safety assessment for Resident #54's use of the bed canes in his clinical record. RCM #1 said there would be a separate consent form for the bed canes, and she did not see documentation of consent from Resident #54 or his representative for the use of the bed canes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interview, policy review, review of meeting minutes, and record review, it was determined the facility failed to provide guidance to assist the Resident Council group with agenda items to address and discuss facility policies/rules, concerns and grievances, and requests that resulted from the group meetings, and failed to act promptly to resolve and respond to requests from the group meetings. This was true for 13 of 13 (#3, #4, #7, #15, #16, #19, #28, #32, #36, #38, #41, #50, and #53) residents who attended the Resident Group Meeting. These negative practices placed residents at risk of ongoing frustration and decreased sense of self-worth, as well as, unmet care needs, when issues of concern to them were not promptly addressed by the facility. Findings include: Review of the facility's 11/28/17 policy, Resident & Family Group Meetings, indicated the facility was to, Respect their residents' right to organize and participate in resident/family groups in the facility. Definition . Resident's Group . A group that meets regularly to: Discuss and offer suggestions about the facility policies and procedures affecting residents' care, treatment, and quality of life; Support each other; Plan resident activities; Participate in educational activities; or for any other purpose. [The] Facility procedure provides a resident group, if one exists, and takes reasonable steps, with the approval of the group, to make resident members aware of upcoming meetings in a timely manner . Educate the Resident Group President on protocols for presiding over the meetings . Assist residents with the structure of the group (i.e., election of officers, etc.) . Establish an agenda the residents and [the] Facility administration mutually agreed upon . A Resident Group appointee presides (usually the Resident Group President) over the meeting. [The] Facility representative does not conduct the meeting . [The] Facility provides a designated staff person who is approved by the resident group and the facility and who is responsible for providing assistance and responding to written requests that result from group meetings . [and to] Communicate results of the meeting to facility administration . The facility considers the views of a resident or family group and acts promptly upon grievances and recommendations of such groups concerning issues of resident care and life in the facility . The facility documents their response and rationale for the response to the residents or family recommendations and/or concerns . This should not be construed to mean that the facility must implement as recommended every request of the resident or family group. Documentation Guidelines . Document communication of the meeting results to the facility's administration in the Performance Improvement minutes . Document actions taken to address needs or concerns expressed by the Resident Group/Family Group members. The Resident Council Meeting minutes for the past six months were requested in the afternoon on 1/28/19. The facility provided the Resident Community Meeting minutes for five of the past six months in the morning on 1/29/19. Review of the Resident Community Meeting minutes for 8/7/18, 9/4/18, 10/3/18, 11/6/18, and 1/8/19 (the December 2018 minutes were not provided) documented the group reviewed activities topics only; it did not address or discuss facility policies/rules, rights, concerns and grievances, or other topics. These meetings were attended by 19 different residents. A Resident Group Interview was held on 1/29/19 at 10:30 AM, with Residents #3, #4, #7, #15, #16, #19, #28, #32, #36, #38, #41, #50, and #53, in attendance. Eleven of the 13 residents in attendance stated their cares were not being met and voiced concerns of possible retaliation, such as cares not being provided, if they voiced or filed grievances. The group said they met monthly, did not have a president, and no one was in charge. They said the meeting was on the activities calendar. They said there was a box outside the social services office with grievance forms to fill out, or staff could fill out the grievance forms as needed. Residents said the facility did not consistently respond to concerns/grievances, especially verbal concerns. Residents said call light response times were a problem last month, with 30 to 90 minutes elapsing before the lights were answered - with the worst response times being before breakfast, bed time, shift change, and weekends. The residents said the nurses did not answer lights and would not help residents near change of shift, so the next shift would have to take care of the residents' needs. They said the nurses worked 12 hours shifts from 6:00 AM to 6:00 PM and some of the CNAs (Certified Nurse Aides) worked eight hours shifts, when other CNAs worked 12 hours shifts. The residents said the night shift had the best call light response times with about a five-minute response time. During an interview on 1/30/19 at 5:17 PM, the Activities Director and the Administrator stated the Resident Community Meetings were about activities, and confirmed they did not address resident rights, concerns/grievances, or follow-up from previous meetings. They confirmed this meeting was the Resident Council Meeting. They said none of the residents wanted to be the President, [NAME] President, or Secretary. Instead of officers, they had a Board of Directors, which was whomever attended each meeting. They said the attendees were cognitively intact and were usually the residents who were the most active in activities. The Activities Director said the calendar showed monthly menu reviews with the chef every second Tuesday, followed by a group discussion with the Administrator to go over concerns or recommendations. They said they would provide the meeting minutes and follow-up for the additional group meetings. During an interview on 1/31/19 at 9:30 AM, the Administrator provided minutes for the monthly group meetings with the chef, and for the monthly group meetings with the Administrator. None of the minutes provided included evidence of meeting the requirements for Resident Council. The grievances were not all resolved. The Administrator provided the Performance Improvement Plan (PIP) for call light response times. When asked about a lack of grievances, which reported concerns about call light responses, he agreed there was only one grievance form filled out for call lights, and said the Ombudsman told him there were call light response concerns. The Administrator then said he had not interviewed the residents to find out when the problems with call lights were happening. The Administrator confirmed the minutes should reflect a logical flow to the Resident Council concerns that detailed the process of forwarding concerns to the department heads, the actions taken by the department heads to resolve the concerns or provide resolutions to the residents, and whether or not the residents confirmed resolution of the concerns. The Administrator confirmed he did not interview residents about call light response times and did not have documented evidence of resident interviews. Review of the 1/17/19 PIP call light audits showed several random call light audits were performed. The Administrator acknowledged the call light audits may not necessarily be for the times the residents complained about because the residents were not interviewed about call lights. The Administrator confirmed he worked on resolving concerns/grievances. He said he was doing work right away to resolve concerns; however, he was not taking credit for his actions by documenting those actions. He said only one of the three group meetings reviewed had evidence of reviewing the grievances. Review of the first Group Discussion with the Administrator minutes for 10/3/18, showed seven residents attended. Documented concerns included: My room is hot and the hallway is cool. O2 [oxygen] cannula tubing not changed regularly. CNAs [Certified Nurse Aides] not returning to give showers. Review of the 11/6/18 Group Discussion with the Administrator minutes showed seven residents attended. There was no documented evidence the concerns/grievances voiced at the October 2018 group meeting were addressed or resolved for the residents. New documented concerns included: Can we have nursing taught how to program with the remotes so when we have an issue we don't have to track down maintenance. Why do I have to constantly ask for towels, they take my towels instead of getting more towels. Couple of times my room mates [sic] bed pan has been left in the bathroom sink. Review of the 12/11/18 Group Discussion with the Administrator minutes showed 10 residents attended. There was no documented evidence the concerns/grievances voiced at the November 2018 group meeting were addressed or resolved for the residents. New documented concerns included: Shower towels are not always collected and or new ones provided. Our towel racks should be closer to the sink not across the bathroom. Shower aide pulled to floor. New staff need to be better informed on how to do their job. I feel I need to be checked on more often, I feel like they forget about me because my room is in the corner. Review of the 1/8/19 Group Discussion with the Administrator minutes showed 10 residents and one family member attended. There was no documented evidence the concerns/grievances voiced at the December 2018 group meeting were addressed or resolved for the residents. New documented concerns included: She continually get [sic] carrots, broccoli and chicken breast when she doesn't like them and it is on her ticket. Assured daughter that this will be communicated to the dietary staff. All staff members are to work together to read the meal ticket to assure that what is placed on the plate is correct. Chef [name] will also be informed. Executive Director reminded all residents/family present to not hesitate to use the green grievance cards to voice any [of] their concerns. We try very hard to resolve any issues/problems. Address it to the appropriate [department] manager if its [sic] regarding meds, appts [sic] direct to nursing. If you find that your concerns are not being addressed, then bring it to the attention of the executive director. Review of the 10/3/18 Menu Review with the Chef minutes showed seven residents and one family member attended. Documented concerns included: Can we have more grain wheat bread and english [sic] muffins. Also croissants would be nice. Sliders on a roll for a snack would be nice. Salad bowls are to [sic] small, difficult to stir up the dressing. There's no staff to help on the opposite side of the dining room sometimes. Review of the 11/3/18 Menu Review with the Chef minutes showed seven residents attended. There was no documented evidence the concerns/grievances voiced at the October 2018 group meeting were addressed or resolved for the residents. New documented concerns included: Can't we have a different type of lettuce for our salads. Chef suggested Spring Mix, group agreed. I don't like to [sic] much pepper or spicy foods, please put that on my ticket. Yeah, no spicy for me or no tomatoes, no acidic type foods for me. Can I get my food chopped up for me. I don't care for ground beef or bread. Review of the 12/11/18 Menu Review with the Chef minutes showed 10 residents attended. There was no documented evidence the concerns/grievances voiced at the November 2018 group meeting were addressed or resolved for the residents. New documented concerns included: Food isn't hot. They don't serve fast enough. Salt & pepper shakers missing from the tables. Can the gravy be put on the side as not everyone likes lots of gravy on their food. Can we have beans and cornbread sometimes . fresh fruit, apples, oranges sometimes too. Review of the 1/8/19 Menu Review with the Chef minutes showed 10 residents and one family member attended. There was no documented evidence the concerns/grievances voiced at the December 2018 group meeting were addressed or resolved for the residents. New documented concerns included: My mom continues to receive carrots and broccoli, [and] chicken breast and she dislikes these items. The Chef responded, I will remind my staff to look more closely at the tickets. I would like to see more meat at breakfast. The Chef responded, I can look at that, we don't have a second option for breakfast, but I will look at that. It seems like breakfast is always late getting to the dining room. A functional, organized Resident Council had not been developed at the facility to promote resident rights and address residents' concerns and preferences.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Resident #43 was admitted to the facility on [DATE], with multiple diagnosis including type II diabetes and cerebrovascular (related to blood vessels of the brain) disease. Resident #43's POST, dated 12/18/18, documented a code status of Full Code. The POST section for Advance Directives to identify a Living Will was blank. Resident #43's care conference note, dated 12/27/18, documented the Advance Directive was reviewed and continued. On 1/30/19 at 10:41 AM, Resident #43 said he had a living will. On 1/30/19 at 4:12 PM, Resident #43's spouse said she was unsure if a copy of the living had been provided to the facility, and said she had a copy of the living will in the car, if the facility needed it. On 1/31/19 at 10:04 AM, the Social Worker said she knew Resident #43 had a living will, and did not see a copy of it in his chart. 4. Resident #54 was admitted to the facility on [DATE] with multiple diagnoses, including hemiplegia and hemiparesis (weakness and paralysis on one side) following cerebral infarction (stroke) affecting the right side, and aphasia (loss of ability to understand or express speech). A Multidisciplinary Care Conference note, dated 12/4/18 at 12:20 PM, documented Resident #54's Advance Directive was reviewed and to continue the Advance Directive. Resident #54's admission MDS assessment, dated 12/6/18, documented he had severely impaired cognitive skills for daily decision making. Resident #54's physician orders, dated 1/30/19, documented his code status was Full Code (initiate all life-saving measures). Resident #54's care plan documented he had a POST in place, initiated on 11/30/18 and revised on 12/14/18. The care plan documented his code status was Full Code. Resident #54's POST documented his code status as Full Code, and was signed by his representative on 11/29/18. Resident #54's clinical record did not include an Advance Directive or documentation he had been provided information regarding formulating an Advanced Directive and offered assistance to do so, and declined the offer. On 1/31/19 at 10:04 AM, the Social Worker said when a resident came in for admission to the facility, the admission Coordinator asked for a copy of the Advanced Directive. If the resident did not have an Advanced Directive, it would be discussed in the initial care conference and documented in the admission care conference note. The Social Worker said the Advance Directive might not be in the chart of some residents who had been in the facility for awhile and before she became aware an Advance Directive was to be discussed. On 1/31/19 at 10:26 AM, the Social Worker and Clinical Resource Nurse said they did not find anything other than a POST form in Resident #54's clinical record. Based on record review, policy review, and resident, family, and staff interview, it was determined the facility failed to ensure a) residents were provided information regarding Advance Directives upon admission, b) assisted to formulate Advance Directives if necessary, c) residents' records included documentation of this process, and d) a copy of the residents' Advance Directives or documentation of their decision not to formulate Advance Directives were included in residents' records. This was true for 6 of 13 residents (#32, #37, #38, #43, #54 and #267) whose records were reviewed for Advance Directives. These failures increased the risk of residents not having their decisions documented, honored, and respected when they were unable to make or communicate health care preferences. Findings include: The facility's Advance Directives policy and procedure, dated 10/2017, documented residents had the right to accept or refuse medical or surgical treatment and to formulate Advance Directives. During the admission process the facility determined whether the resident had an Advance Directive. If the resident or the resident's legal representative had executed an Advance Directive, a copy was requested and maintained in the resident's record. If the resident did not have an Advance Directive, the facility provided assistance to the resident and their family to establish an Advance Directive. The facility documented in the resident's record the discussions regarding Advance Directives and any healthcare decisions the resident made. If the resident decided to change their Advance Directive, it was documented in their record. 1. Resident #37 was admitted to the on 8/4/18, with multiple diagnoses which included muscle weakness and diabetes mellitus. A Multidisciplinary Care Conference report, dated 11/5/18, documented Resident #37's Advance Directive was reviewed and to continue her Advance Directive. Resident #37's care plan, revised on 12/14/18, documented she had a POST and her Advance Directives was reviewed on admission, quarterly and with a change of condition. Resident #37's POST signed by her representative on 8/4/18, documented her code status was DNR. Resident #37's clinical record did not include an Advance Directive or documentation she had been provided information regarding formulating an Advanced Directive and offered assistance to do so, and declined the offer. On 1/31/19 at 1:35 PM, the Social Worker said the facility did not have a copy of Resident #37's Advance Directive. The Social Worker said when Resident #37 Multidisciplinary Care Conference report documented the Advance Directive was reviewed, it was referring to the POST that was reviewed with the residents and/or their families during the care conferences. 2. Resident #38 was admitted to the facility on [DATE] and was readmitted on [DATE], with multiple diagnoses which included diabetes mellitus, muscle weakness, and difficulty walking. A Multidisciplinary Care Conference report, dated 10/25/18, documented Resident #38's Advance Directive was reviewed and to continue her Advance Directive. Resident #38's care plan, revised on 12/14/18, documented she had a POST and her Advance Directive was reviewed on admission, quarterly and with a change of condition. A POST signed by Resident #38 documented her code status was DNR. Resident #38's clinical record did not include an Advance Directive or documentation she had been provided information regarding formulating an Advanced Directive and offered assistance to do so, and declined the offer. On 1/31/19 at 1:35 PM, the Social Worker said the facility did not have a copy of Resident #38's Advance Directive. The Social Worker said when Resident #38 Multidisciplinary Care Conference report documented the Advance Directive was reviewed, it was referring to the POST that was reviewed with the residents and/or their families during the care conference. 3. Resident #267 was admitted to the facility on [DATE], with multiple diagnoses which included depression and hypertension. Resident #267's care plan, revised on 12/28/18, documented she had a POST and her code status was DNR. A POST signed by Resident #267's representative on 12/26/18, documented her code status was DNR. Resident #267's clinical record did not include an Advance Directive or documentation she had been provided information regarding formulating an Advanced Directive and offered assistance to do so, and declined the offer. On 1/31/19 at 1:35 PM, the Social Worker said Resident #267's POST was reviewed to establish the care plan, not information regarding an Advance Directive. 6. Resident #32 was admitted to the facility on [DATE] with multiple diagnoses, including multiple sclerosis (degenerative neurological disorder). Resident #32's Physician's Orders documented her Advance Directive was listed as, Do Not Resuscitate, Physician Order for Scope of Treatment (DNR, POST). Resident #32's current care plan documented her code status as DNR. Resident #32's POST, dated 7/23/18, signed by her, documented her code status was DNR. Resident #38's clinical record did not include an Advance Directive or documentation she had been provided information regarding formulating an Advanced Directive and offered assistance to do so, and declined the offer. On 1/31/19 at 10:33 AM, the Social Worker and the Clinical Resource Nurse said they did not have a copy of a Living Will, an Advance Directive, or a Durable Power of Attorney, or information related to Advanced Directives documented for Resident #32.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, review of meeting minutes, and resident, family member, and staff interview, it was determined the facility failed to ensure grievances were responded to, investigated, and prompt corrective action taken to resolve the grievances. This was true for 4 of 21 residents (#1, #24, #41, and #64) reviewed for grievances and 13 of 13 residents (#3, #4, #7, #15, #16, #19, #28, #32, #36, #38, #41, #50, and #53) who participated in the Resident Group Interview. This failure created the potential for harm if residents' grievances, both verbal and written, were not acted upon and residents did not receive appropriate care or were at risk for abuse or neglect. Findings include: The facility's Complaints and Grievances policy and procedure, dated 11/28/17, documented an individual had the right to voice grievances to the facility or other agency or entity that hears grievances without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which had been furnished as well as that which had not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay. The facility should make prompt efforts to resolve grievances the resident may have. Complaint/grievances may be verbal or written including social media. Complaints/grievances were acknowledged, investigated, and the complainant apprised of progress toward a resolution and takes appropriate corrective action if the alleged violation was confirmed by the facility. 1. The Resident Council Meeting minutes for the past six months were requested in the afternoon on 1/28/19. The facility provided the Resident Community Meeting minutes for five of the past six months in the morning on 1/29/19. Review of the Resident Community Meeting minutes for 8/7/18, 9/4/18, 10/3/18, 11/6/18, and 1/8/19 (the December 2018 minutes were not provided) documented the group reviewed activities topics only; it did not address or discuss resident concerns and grievances. A Resident Group Interview was held on 1/29/19 at 10:30 AM, with Residents #3, #4, #7, #15, #16, #19, #28, #32, #36, #38, #41, #50, and #53, in attendance. The group said they met monthly, did not have a president, and no one was in charge. They said the meeting was on the activities calendar. They said there was a box outside the social services office with grievance forms to fill out, or staff could fill out the grievance forms as needed. Residents said the facility did not consistently respond concerns/grievances, especially verbal concerns. Resident #38 said there were not enough staff in the facility. She said her call light sometimes took an hour or more to be answered, and another 10 out of 13 residents in the Resident Group Interview said their call lights were not answered in timely manner. Residents said call light response times were a problem last month, with 30 to 90 minutes elapsing before the lights were answered - with the worst response times being before breakfast, bed time, shift change, and weekends. The residents said the nurses did not answer lights and would not help residents near change of shift, so the next shift would have to take care of the residents' needs. They said the nurses worked 12 hours shifts from 6:00 AM to 6:00 PM and some of the CNAs (Certified Nurse Aides) worked eight hours shifts, when other CNAs worked 12 hours shifts. The residents said the night shift had the best call light response times with about a five-minute response time. During an interview on 1/30/19 at 5:17 PM, the Activities Director and the Administrator stated the Resident Community Meetings were about activities, and confirmed they did not address residents' concerns/grievances, or follow-up from previous meetings. They confirmed this meeting was the Resident Council Meeting. They said the attendees were cognitively intact and were usually the residents who were the most active in activities. The Activities Director said the calendar showed monthly menu reviews with the chef every second Tuesday, followed by a group discussion with the Administrator to go over concerns or recommendations. They said they would provide the meeting minutes and follow-up for the additional group meetings. During an interview on 1/31/19 at 9:30 AM, the Administrator provided minutes for the monthly group meetings with the chef, and for the monthly group meetings with the Administrator. The minutes provided did not consistently included evidence of the facility's response to the concerns/grievances shared at the Resident Council meetings. The grievances were not all resolved. The Administrator provided the Performance Improvement Plan (PIP) for call light response times. When asked about a lack of grievances, which reported concerns about call light responses, he agreed there was only one grievance form filled out for call lights, and said the Ombudsman told him there were call light response concerns. The Administrator then said he had not interviewed the residents to find out when the problems with call lights were happening. The Administrator confirmed the minutes should reflect a logical flow to the Resident Council concerns that detailed the process of forwarding concerns to the department heads, the actions taken by the department heads to resolve the concerns or provide resolutions to the residents, and whether or not the residents confirmed resolution of the concerns. The Administrator confirmed he did not interview residents about call light response times and did not have documented evidence of resident interviews. Review of the 1/17/19 PIP call light audits showed several random call light audits were performed. The Administrator acknowledged the call light audits may not necessarily be for the times the residents complained about because the residents were not interviewed about call lights. The Administrator confirmed he worked on resolving concerns/grievances. He said he was doing work right away to resolve concerns; however, he was not taking credit for his actions by documenting those actions. He said only one of the three group meetings reviewed had evidence of reviewing the grievances. Review of the first Group Discussion with the Administrator minutes for 10/3/18, showed seven residents attended. Documented concerns included: My room is hot and the hallway is cool. O2 [oxygen] cannula tubing not changed regularly. CNAs [Certified Nurse Aides] not returning to give showers. Review of the 11/6/18 Group Discussion with the Administrator minutes showed seven residents attended. There was no documented evidence that the concerns/grievances voiced at the October 2018 group meeting were addressed or resolved for the residents. New documented concerns included: Can we have nursing taught how to program with the remotes so when we have an issue we don't have to track down maintenance. Why do I have to constantly ask for towels, they take my towels instead of getting more towels. Couple of times my room mates [sic] bed pan has been left in the bathroom sink. Review of the 12/11/18 Group Discussion with the Administrator minutes showed 10 residents attended. There was no documented evidence the concerns/grievances voiced at the November 2018 group meeting were addressed or resolved for the residents. New documented concerns included: Shower towels are not always collected and or new ones provided. Our towel racks should be closer to the sink not across the bathroom. Shower aide pulled to floor. New staff need to be better informed on how to do their job. I feel I need to be checked on more often, I feel like they forget about me because my room is in the corner. Review of the 1/8/19 Group Discussion with the Administrator minutes showed 10 residents and one family member attended. There was no documented evidence the concerns/grievances voiced at the December 2018 group meeting were addressed or resolved for the residents. New documented concerns included: She continually get [sic] carrots, broccoli and chicken breast when she doesn't like them and it is on her ticket. Assured daughter that this will be communicated to the dietary staff. All staff members are to work together to read the meal ticket to assure that what is placed on the plate is correct. Chef [name] will also be informed. Executive Director reminded all residents/family present to not hesitate to use the green grievance cards to voice any [of] their concerns. We try very hard to resolve any issues/problems. Address it to the appropriate [department] manager if its [sic] regarding meds, appts [sic] direct to nursing. If you find that your concerns are not being addressed, then bring it to the attention of the executive director. Review of the 10/3/18 Menu Review with the Chef minutes showed seven residents and one family member attended. Documented concerns included: Can we have more grain wheat bread and english [sic] muffins. Also croissants would be nice. Sliders on a roll for a snack would be nice. Salad bowls are to [sic] small, difficult to stir up the dressing. There's no staff to help on the opposite side of the dining room sometimes. Review of the 11/3/18 Menu Review with the Chef minutes showed seven residents attended. There was no documented evidence the concerns/grievances voiced at the October 2018 group meeting were addressed or resolved for the residents. New documented concerns included: Can't we have a different type of lettuce for our salads. Chef suggested Spring Mix, group agreed. I don't like to [sic] much pepper or spicy foods, please put that on my ticket. Yeah, no spicy for me or no tomatoes, no acidic type foods for me. Can I get my food chopped up for me. I don't care for ground beef or bread. Review of the 12/11/18 Menu Review with the Chef minutes showed 10 residents attended. There was no documented evidence the concerns/grievances voiced at the November 2018 group meeting were addressed or resolved for the residents. New documented concerns included: Food isn't hot. They don't serve fast enough. Salt & pepper shakers missing from the tables. Can the gravy be put on the side as not everyone likes lots of gravy on their food. Can we have beans and cornbread sometimes . fresh fruit, apples, oranges sometimes too. Review of the 1/8/19 Menu Review with the Chef minutes showed 10 residents and one family member attended. There was no documented evidence the concerns/grievances voiced at the December 2018 group meeting were addressed or resolved for the residents. New documented concerns included: My mom continues to receive carrots and broccoli, [and] chicken breast and she dislikes these items. The Chef responded, I will remind my staff to look more closely at the tickets. I would like to see more meat at breakfast. The Chef responded, I can look at that, we don't have a second option for breakfast, but I will look at that. It seems like breakfast is always late getting to the dining room. The facility failed to address residents' concerns/grievances. 2. On 1/28/19 at 3:27 PM, Resident #1's responsible party stated Resident #1 was missing clothes, especially pajama pants. She stated at times she would see other residents wearing clothes that looked like his missing pajama pants. She also stated she brought in eight cloth pads, that cost $30.00 each, to cover and protect the seat of his recliner. She stated now all eight pads were missing and she did his laundry; the pads did not show up in the laundry. Signs were posted on his closet and wall, informing staff that the family did Resident #1's laundry. Resident #1's responsible party stated she told RCM #2 many times about the missing items; however, they did not find them, did not replace them, and she had not heard anything back. On 1/31/19 at 5:44 PM, RCM #2 said, with the Clinical Resource Nurse present, Resident #1's responsible party did report the missing clothes and pads to him. He could not remember the date, but he stated it was sometime in the past month. He stated he took her to the laundry and they located a couple pairs of pajama pants, but did not locate any of the cloth pads and did not locate all the clothes she reported as missing. He stated he did not follow up or complete an investigation. The Clinical Resource Nurse said RCM #2 should have filled out a grievance form and a further investigation should have been completed. 3. Resident #64 was admitted to the facility on [DATE] with multiple diagnoses, including muscle weakness. On 2/1/19 at 9:30 AM, Resident #64 said he told housekeeping and laundry staff at the end of December that he was missing a pair of blue Nike shorts, a pair of Nike sweats, and a blue Boise State shirt. He said laundry staff kept losing his clothes despite having his name put on them. Resident #64 said no one had filled out a grievance or offered to fill out a grievance for him. On 2/1/19 at 9:36 AM, the Director of Hospitality Services said Resident #64 told her about some missing clothes about a week ago, and she did not fill out a grievance for him. She said she should have filled out a grievance and given it to the Social Worker. The Director of Hospitality Services said she posted the missing clothes on an undated list and hung it on the wall in the laundry room and had been looking for the clothes. The undated list documented missing clothes, including a pair of blue shorts, a pair of black sweats, and a blue Boise State shirt. On 2/1/19 at 9:44 AM, the Social Worker said she did not have a grievance for Resident #64's missing clothes. She said staff were to fill out a grievance and/or let residents know they can complete one when issues came up. The Social Worker said if the clothes were not found, then the facility would replace them. 4. Resident #24 was admitted to the facility on [DATE] with multiple diagnoses, including history of falls, cognitive communication deficit, and depression. Resident #41 was admitted to the facility on [DATE] with multiple diagnoses, including history of falls, cognitive communication deficit, difficulty walking, and generalized muscle weakness. Resident #24 and Resident #41 were roommates. On 1/28/19 at 3:24 PM, Resident #24 and Resident #41, stated they made several complaints to staff since admission regarding cares and treatment, and the facility ignored their concerns. Resident #24 stated he did not know what a grievance was, how to complete a grievance or to whom to submit the grievance, and staff did not provide information regarding grievances at any time when he voiced a concern. Resident #24 and Resident #41 stated the complaints included concerns such as missing clothing and call lights taking 30 minutes up to 2 hours to be answered. Resident Grievances, dated 4/11/18 through 1/22/19, were reviewed and did not document grievances for Resident #24 and Resident #41. On 1/31/19 at 4:52 PM, the Social Worker stated residents or staff would complete a grievance form and place it in the box outside her office, which was checked once or twice a day. The Social Worker stated she resolved any issues that she was able to, signed and dated the form after completion and placed it in the grievance binder. The Social Worker stated any unresolved issues or problems that had many of the same items were directed to the specific departments. The Social Worker stated call lights were a concern for every facility and she was unsure why there were not more call light grievances in the binder. The Social Worker stated she was unsure of who educated the residents or staff on grievances and did not know about the resident council meetings. On 2/1/19 at 9:22 AM, the Director of Community Relations stated he reviewed the facility tour and admission packet information with each resident and their representative on admission. The Director of Community Relations stated he provided an admission Packet, which included a summary of the facility's grievance policy and a copy of a grievance form. The Director of Community Relations stated he explained the grievance information and resident rights, and he provided a description of grievance examples and to whom to submit the grievance after the grievance was completed. The Director of Community Relations stated the Administrator was the first person to submit grievances to and the Social Worker was the second person to submit the grievance to once the grievance form was completed, and it could be completed by a charge nurse or department head. The Director of Community Relations stated he was unsure if there was a process for educating staff, a follow up process for educating residents, whether grievances were discussed in resident group meetings, or if verbal grievances were completed and submitted by staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 9. Resident #7 was admitted to the facility on [DATE], with multiple diagnoses including history of falls, cognitive communication deficit, difficulty walking, and generalized muscle weakness. Resident #7's admission MDS assessment, dated 6/28/18, documented she was cognitively intact, having her family involved in discussions about her care was very important, and she required the assistance of one person for bathing. Resident #7's care plan, dated 1/6/19, directed staff to provide Resident #7 with one shower a week. Resident #7's bathing/shower flowsheets, dated 10/1/18 through 1/26/19, documented if the resident refused to please call her daughter and notify social services. On 1/29/19 at 8:50 AM, Resident #7's daughter stated she was adamant that Resident #7 be provided with two showers a week and had requested the facility to contact her if she was not provided the showers. On 1/31/19 at 12:13 PM, Resident #7 stated she should have been provided with two showers a week. On 1/31/19 at 4:08 PM, the DNS, with the Clinical Resource Nurse present, reviewed Resident #7's care plan which directed staff to provide Resident #7 with one shower a week, and stated she would update Resident #7's care plan to provide Resident #7 with two showers a week and would call Resident #7's daughter when she refused. 7. Resident #54 was admitted to the facility on [DATE] with multiple diagnoses, including hemiplegia and hemiparesis (weakness and paralysis on one side) following cerebral infarction (stroke) affecting the right side, and aphasia (loss of ability to understand or express speech). On 1/28/19 at 3:47 PM and 1/30/19 at 2:36 PM, Resident #54 had bilateral bed canes (handle or grab bar type device attached to a bed) present on his bed. Resident #54's care plan did not document the use of bed canes. On 1/30/19 at 4:40 PM, RCM #1 said she did not see bed canes documented on Resident #54's care plan. 8. Resident #318 was admitted to the facility on [DATE] with multiple diagnoses, including polyneuropathy (degeneration of nerves), chronic heart disease, and severe chronic kidney disease. Resident #318's physician orders, dated 1/30/19, documented Trazadone (antidepressant medication) 50 mg tablet at bedtime for insomnia was ordered on 1/25/19. Resident #318's MAR documented the Trazadone was administered each day on 1/26/19 to 1/29/19 and the hours of sleep were documented each day and night shift. Resident #318's care plan did not document insomnia or medication for insomnia. On 2/1/19 at 9:41 AM, RCM #1 said she would expect to see Trazadone for insomnia on the care plan and she did not see it documented on Resident #318's care plan. RCM #1 said any nurse could add Trazadone for insomnia to the care plan. 6. Resident #267 was admitted to the facility on [DATE], with multiple diagnoses which included major depressive disorder. An admission MDS assessment, dated 1/2/19, documented Resident #267 was severely cognitively impaired. Resident #267's Care Conference form, dated 12/28/18, was blank. Resident #267's clinical record did not include documentation a care conference was held with her or with her family. On 2/1/19 at 11:04 AM, the Social Worker said a care conference was held with Resident #267's representative over the phone, but she failed to complete the care conference form. 5. Resident #64 was admitted to the facility on [DATE], with multiple diagnoses including muscle weakness. A Care Conference note, dated 9/24/18, documented a care conference was conducted with Resident #64, social services, nursing, the Administrator, and therapy. The note documented he was on a regular diet with regular texture and consistency. There was no documentation that a member of food and nutrition services attended the care conference. A Care Conference note, dated 12/28/18, documented a care conference was conducted with Resident #64, social services, and nursing. The note documented his diet was reviewed with no changes. There was no documentation that a member of food and nutrition services attended the care conference. Resident #64's current care plan documented he was on a regular diet. On 1/28/19 at 10:15 AM, Resident #64 said he knew what care conferences were and said he had not been to one since he was admitted to the facility. He said food was important to him, he did not like the food, and he generally ate from the alternate menu. On 1/31/19 at 10:33 AM, the Social Worker said there were no staff from the dietary department at Resident #64's care conferences, and she was unaware that dietary staff needed to be at the care conferences. On 2/1/19 at 10:04 AM, the Dietary Manager said he had not attended a care conference for Resident #64. The Dietary Manager said that he was aware of Resident #64's dietary needs. 4. Resident #14 was admitted to the facility on [DATE] with multiple diagnoses, including dementia, abnormalities of gait and mobility, Parkinson's disease (degenerative neurological disorder), and repeated falls. Resident #14's quarterly MDS assessment, dated 12/9/18, documented he required extensive assistance of two staff persons for bed mobility and transfers, and was frequently incontinent. Resident #14's physician orders, dated 11/20/18, documented he was to be toileted every two hours while awake, every shift. Resident #14's care plan, dated 7/1/18, documented he had occasional episodes of bladder incontinence. The interventions included: * Check for incontinence before and after meals, at bedtime, and as required during the night. * Offer toileting to Resident #14 before and after meals, at bedtime, and as needed. Resident #14's care plan did not document toileting every 2 hours as ordered by the physician. On 2/1/19 at 10:54 AM, the Clinical Resource Nurse stated Resident #14 had an order for toileting every two hours while awake, and the intervention was not on the current care plan. Based on resident, family, and staff interview and record review, it was determined the facility failed to ensure care plans were reviewed and/or revised, and failed to ensure residents and/or resident representatives were involved in the development of the care plan for 9 of 22 residents (Residents #1, #7, #14, #15, #32, #54, #64, #267, and #318) whose care plans were reviewed. This failure created the potential for harm should residents receive inappropriate care due to inaccurate information on their care plan and should residents' input not be considered on the care plan. Findings include: 1. Resident #32 was admitted to the facility on [DATE], with multiple diagnoses including muscle weakness, abnormal posture, multiple sclerosis (degenerative neurological disorder), and hereditary spastic paraplegia (progressive weakness and stiffness of the legs). Resident #32's quarterly MDS assessment, dated 10/29/18, documented she was cognitively intact. She required extensive assistance from staff for bed mobility, dressing, toilet use, and personal hygiene. Resident #32's Care Conference Notes documented she was admitted on [DATE]. The one Care Conference documented in her record was dated 11/28/18 at 2:00 PM. The attendance list on the 11/28/18 care conference documented Resident #32 and the social worker were present and no other members of the interdisciplinary team were present for the conference. On 1/28/19 at 9:25 AM, Resident #32 stated she was not invited to participate in planning her care related to medicine, therapy, and other treatments. Resident #32 stated she had not been to a care conference since she was admitted to the facility in July 2018. On 1/31/19 at 10:30 AM, the Care Conference information was reviewed with the Social Worker and the Clinical Resource Nurse. They both stated the meeting on 11/28/18 was the only care plan meeting documented for Resident #32. They stated a meeting was not completed upon admission, the first meeting was completed four months after admission, and only involved the resident and the Social Worker, and the meeting did not include applicable members of the interdisciplinary team. 2. Resident #1 was admitted to the facility on [DATE], with multiple diagnoses including difficulty walking, generalized muscle weakness, history of falls, and dementia without behavioral disturbances. Resident #1's admission MDS, dated [DATE], and quarterly MDS, dated [DATE], documented he had severe cognitive impairment. He required extensive assistance from staff for bed mobility, transfers, dressing, personal hygiene, and toileting, was totally dependent on staff for bathing, and required limited assistance to walk in his room and to eat. He was not steady or able to balance with transfers. Resident #1's Care Conference notes documented the last conference was held on 10/2/18 at 1:00 PM, and his responsible party attended the conference. No additional care conferences were held after 10/2/18. On 1/28/19 at 3:32 PM, Resident #1's representative stated she had not been invited to care conferences and asked whether the facility had them. On 1/31/19 at 10:30 AM, the Care Conference information was reviewed with the Social Worker and the Clinical Resource Nurse, and they stated a care plan meeting was not held for Resident #1 since 10/2/18. 3. Resident #15 was admitted to the facility on [DATE] with multiple diagnoses, including major depressive disorder, insomnia, gastrointestinal hemorrhage (bleeding), acute and chronic respiratory failure, diverticulosis (when pockets develop in the intestines and become inflamed or infected) of the large intestine with bleeding, acute respiratory failure with hypoxia (low oxygen level), dependence on supplemental oxygen, bipolar disorder, ileostomy (surgically created opening in the abdominal wall through which digested food passes), and colostomy. Resident #15's quarterly MDS assessment, dated 12/4/18, documented he was cognitively intact and did not exhibit behaviors. He required supervision for bed mobility, transfers, walking in his room and in a corridor, locomotion, dressing, and eating, and required limited assistance with toilet use. Resident #15's Care Conference notes documented he attended a care conference on 5/9/18, 5/24/28, and 8/28/18. Resident #15's record did not include documentation of a Care Conference being completed since 8/28/18. On 1/28/19 at 11:21 AM, Resident #15 stated he did not feel like he was given the opportunity to participate in making decisions related to his care, medications, and treatment, and he was not informed of his plan of care or invited to care conferences. On 1/31/19 at 10:30 AM, the Care Conference information was reviewed with the Social Worker and the Clinical Research Nurse, and they stated a care conference meeting was not held for Resident #15 since 8/28/18.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident #7 was admitted to the facility on [DATE], with multiple diagnoses including history of falls, cognitive communication deficit, difficulty walking, and generalized muscle weakness. Resident #7's admission MDS assessment, dated 6/28/18, documented she was cognitively intact, family involvement in discussions about her care was very important, and she required the assistance of one person for bathing. Resident #7's care plan, dated 1/6/19, directed staff to provide Resident #7 with one shower a week. Resident #7's bathing/shower flowsheets and nurses' progress notes, dated 10/1/18 through 1/26/19, documented missing shower entries. The flowsheets documented if Resident #7 refused, to please call her daughter and notify social services. Showers should have been provided for Resident #7 on Sundays and Thursdays. Resident #7 did not receive baths/showers as follows: * Documentation from 10/6/18 - 10/14/18 included: - On 10/6/18 shower - On 10/10/18 not applicable - On 10/14/18 shower Resident #7 did not receive a shower for 7 days (10/7/18 - 10/13/18) * Documentation from 10/28/18 - 11/8/18 included: - On 10/28/18 shower - On 10/31/18 not applicable - On 11/3/18 resident not available - On 11/8/18 shower Resident #7 did not receive a shower for 10 days (10/29/18 - 11/7/18) Documentation from 11/22/18 - 11/29/18 included: - On 11/22/18 shower - On 11/24/18 not applicable - On 11/28/18 not applicable - On 11/29/18 shower Resident #7 did not receive a shower for 6 days (11/23/18 - 11/28/18) * Documentation from 12/3/18 - 12/9/18 included: - On 12/3/18 shower - On 12/5/18 not applicable - On 12/6/18 resident refused - On 12/8/18 not applicable - On 12/9/18 shower Resident #7 did not receive a shower for 5 days (12/4/18 - 12/8/18) Documentation from 1/3/19 - 1/9/19 included: - On 1/3/19 shower - On 1/5/19 not applicable - On 1/6/19 resident refused - On 1/9/19 shower Resident #7 did not receive a shower for 5 days (1/4/19 - 1/8/19) * Documentation from 1/20/19 - 1/27/19 included: - On 1/20/19 shower - On 1/23/19 not applicable - On 1/26/19 not applicable - On 1/27/19 shower Resident #7 did not receive a shower for 6 days (1/21/19 - 1/26/19) On 1/29/19 at 8:50 AM, Resident #7's daughter stated she was adamant that Resident #7 be provided with two showers a week and requested the facility to contact her if she were not provided showers. On 1/31/19 at 12:13 PM, Resident #7 stated she should have been provided with two showers a week. On 1/30/19 at 3:15 PM, the RCM #2 stated there was not a follow up or documentation system in place to make sure the residents were getting their showers. RCM #2 stated there were missing showers for Resident #7. On 1/31/19 at 4:08 PM, the DNS, with the Clinical Resource Nurse present, reviewed Resident #7's care plan which directed staff to provide Resident #7 with one shower a week, and stated she would update Resident #7's care plan to provide Resident #7 with two showers a week and would call Resident #7's daughter when she refused. 5. Resident #41 was admitted to the facility on [DATE], with multiple diagnoses including history of falls, cognitive communication deficit, difficulty walking, and generalized muscle weakness. Resident #41's care plan, dated 11/20/18, directed staff to provide 2-person assist with hoyer (mechanical) lifts for toileting and transfers. Resident #41's admission MDS assessment, dated 12/15/18, documented her cognition was moderately impaired, and she required 2-person assistance with ADLs. Resident #41's bathing/shower flowsheets and nurses' progress notes, dated 11/18/18 through 1/29/19, documented missing shower entries and progress notes did not document the reason for the missing showers. Showers were to be provided for Resident #41 on Tuesdays and Saturdays. Resident #7 did not receive baths/showers as follows: * Documentation from 12/11/18 - 12/18/18 included: - On 12/11/18 shower - On 12/15/18 resident refused - On 12/18/18 shower Resident #41 did not receive a shower for 6 days (12/12/18 - 12/17/18). * Documentation from 12/25/18 - 1/3/19 included: - On 12/25/18 shower - On 1/1/19 not applicable - On 1/3/19 shower Resident #41 did not receive a shower for 7 days (12/26/18 - 1/2/19). * Documentation from 1/3/19 - 1/15/19 included: - On 1/3/19 shower - On 1/5/19 not applicable - On 1/12/19 resident refused - On 1/15/19 shower Resident #41 did not receive a shower for 11 days (1/4/19 - 1/14/19). * Documentation from 1/22/19 - 1/29/19 included: - On 1/22/19 shower - On 1/23/19 not applicable - On 1/24/19 not applicable - On 1/26/19 not applicable - On 1/29/19 not applicable Resident #41 did not receive a shower for 7 days (1/23/19 - 1/29/19). On 1/28/19 at 3:24 PM, Resident #41 stated she should have been provided with two showers a week. On 1/30/19 at 11:00 AM, CNA #2 stated the facility had a shower aide, but the CNAs helped with showers when the aide was not there or if the shower aide needed help. CNA #2 said if a resident got a shower, it would be documented 'shower', if the resident refused, it would be documented 'resident refused', and if the resident did not receive a shower, it would be documented 'not applicable'. On 1/30/19 at 3:15 PM, RCM #2 stated there were missing showers for Resident #41. On 1/31/19 at 12:54 PM, CNA #4 stated she provided resident showers on the B side for the long term care residents and worked Sunday through Thursday. CNA #4 stated she tried hard to get the showers done, but it was impossible to complete all the showers in one day and it helped when some of the residents refused to take their showers. CNA #4 said there was a time when she was pulled to the floor once or twice last month because somebody called in sick and she was unable to complete baths/showers. CNA #4 said the facility needed more aides to help with the showers, especially on Mondays and Wednesdays. CNA #4 stated she documented when the resident was given a shower or if the resident refused. If the resident refused a shower, she came back later and offered the resident a shower on at least three separate occasions, and notified the nurse if the resident was not provided a shower. CNA #4 stated there was no documentation of when the nurses were notified of missed showers. On 1/31/19 at 4:08 PM, the DNS, with the Clinical Resource Nurse present, reviewed Resident #7's and #41's ADL bathing/shower flowsheets and nurses' progress notes from October 1, 2018 through January 26, 2019. The DNS stated Resident #7 and #41 had missing shower days, progress notes did not document Resident #7's daughter was called when she refused, and a process was not in place for follow up and documentation for aides providing showers and nurses being notified when residents were not provided showers. 3. Resident #37 was admitted on [DATE], with multiple diagnoses which included muscle weakness and diabetes mellitus. a. A quarterly MDS assessment, dated 8/10/18, documented Resident #37 was moderately cognitively impaired and required the assistance of two staff for bathing. The Activities of Daily Living care plan, dated 8/5/18, documented Resident #37 was totally dependent on staff for bathing. Resident #37's January 2019 bathing/shower flowsheet documented her bathing schedule was every Tuesday and Friday. Resident #37 did not receive a bath/shower as follows: * Documentation from 1/1/19 - 1/29/19 included: - On 1/1/19 not applicable - On 1/4/19 not applicable - On 1/8/19 resident refused - On 1/11/19 not applicable - On 1/15/19 resident refused - On 1/18/19 not applicable - On 1/21/19 shower - On 1/22/19 resident refused - On 1/25/19 not applicable - On 1/29/19 not applicable Resident #37 did not receive a shower for 20 days (from 1/1/19 - 1/20/19) and did not receive a shower for 8 days (from 1/22/19 - 1/29/19). On 1/29/19 at 2:27 PM, RCM #2 reviewed Resident #37's bathing/shower flowsheet and said Resident #37 had one shower from 1/1/19 through 1/29/19. RCM #2 said when a resident refused the bath/shower the Shower Aide should reapproach the resident at least 3 times and if the resident continued to refuse it was to be reported to the nurse. RCM #2 said the nurse should document the resident's refusals. RCM #2 said he did not find documentation as to why Resident #37 refused her bath/shower or if the nurse reapproached her. On 1/31/19 at 1:02 PM, CNA #4, who was the Shower Aide, said it was difficult for her to complete the bath/shower of the residents. She said her busiest day was Monday with 17 residents scheduled to receive their baths/showers. CNA #4 said the only time she could complete all of baths/showers was when some of the resident refused their showers. CNA #4 said there was a time when she was pulled to the floor because somebody called in sick and she was unable to complete any of the baths/showers. CNA #4 said she always documented refused when the resident refused a bath/shower. b. A quarterly MDS assessment, dated 11/10/18, documented Resident #37 was moderately cognitively impaired and she required the assistance of one staff member with eating. The assessment also documented Resident #37 required the assistance of two or more staff for bed mobility. Resident #37's care plan area addressing her food and fluid intake, documented she had inadequate oral food and beverage intake related to a variety of diagnoses including protein calorie malnutrition, anemia related to chronic kidney disease, and a left hip fracture. The care plan documented staff were to assist Resident #37 with eating and drinking. On 1/28/19 the following were observed for Resident #37: * 10:28 AM: Resident #37 was observed lying flat in bed watching television on her roommate's television. An over-the-bed table was approximately two feet away from her bed. On top of the over-the-bed table was a tray of food, which consisted of one-half banana, a full glass of apple juice, a small bowl of oatmeal with plastic cover, a plate with a cover, a bowl of fruit with plastic cover, and utensils that were wrapped together with a brown cloth. *10:51 AM: Same as above. *11:02 AM: CNA #11 and CNA #8 entered Resident #37's room. CNA# 8 left Resident #37's room. CNA #11 assisted Resident #37's to the bathroom. *11:11 AM: RCM #2 asked Resident #37 what she would like to eat for lunch and if she wanted a menu. RCM #2 left the room without asking Resident #37 if she wanted to eat her breakfast. *11:13 AM: CNA #11 left Resident #37's room. *11:30 AM: Same as at 10:28 AM above. *12:07 PM: Same as at 10:28 AM above. *12:13 PM: CNA #11 brought Resident #37's breakfast food tray out of her room. CNA #11 said Resident #37 was a picky eater, and staff usually left Resident #37's tray on the over-the-bed table and she would just pick whatever she wanted to eat. On 1/30/19 at 12:15, the DNS said Resident #37 was able to feed herself. The DNS said the CNAs should have repositioned Resident #37 to eat, set-up her meal, removed the plate cover, and ensured the food was within her reach. Resident #37 was not provided with staff assistance for the breakfast meal. Based on observation, resident, resident representative, and staff interviews and record review, the facility failed to ensure residents were provided assistance with bathing and eating consistent with their needs. This was true for 5 of 6 residents (#1, #7, #15, #37, and #41) reviewed for activities of daily living. This failure created the potential for residents to experience embarrassment, isolation, decreased sense of self-worth, skin impairment, and compromised physical and psychosocial well-being. Findings include: 1. Resident #1 was admitted to the facility on [DATE] with multiple diagnoses, which included difficulty in walking and generalized muscle weakness. A quarterly MDS assessment, dated 9/20/18, documented he had severe cognitive impairment and he required extensive assistance of 1 to 2 staff member for activities of daily living. On 1/28/19 at 3:38 PM, Resident #1's representative stated she did not know how often Resident #1 got bathed. She stated she had asked the staff about how often they bathed or showered him and no one had provided her with an answer. Resident #1's care plan for ADLs, revised 12/17/18, documented he was totally dependent on staff and the staff were to provide him a bath or shower two times a week. Resident #1's bathing/shower flowsheet, dated 12/26/18 through 1/30/19, documented he did not receive a bath/shower as follows: * Documentation from 12/26/18 - 1/30/19 included: - On 12/26/18 shower - On 1/7/19 shower - On 1/9/19 shower - On 1/14/19 resident refused - On 1/16/19 resident refused - On 1/21/19 shower - On 1/23/19 shower - On 1/30/19 shower Resident #1 did not receive a shower for 11 days (12/27/18 - 1/6/19), did not receive a shower for 11 days (1/10/19 - 1/20/19), and did not receive a shower for 6 days (1/24/19 to 1/29/19). On 1/31/19 at 12:55 PM, CNA #4 stated she was the shower aide and responsible for providing showers to the residents on the B unit. She stated she was scheduled to work Sunday through Thursday and the aides who worked on the floor were to complete the Friday and Saturday showers. CNA #4 stated Resident #1 did not receive showers during the timeframes noted above. CNA #4 stated she could not see Resident #1 refusing two showers in a row, unless he was the last person on her list and she did not have time to go back and encourage him to take a shower a second time. 2. Resident #15 was admitted to the facility on [DATE], with multiple diagnoses which included major depressive disorder, and chronic obstructive pulmonary disease (lung disease that makes it hard to breathe). Resident #15's quarterly MDS assessment, dated 12/4/18, documented he was cognitively intact and required assistance of 1 staff member for activities of daily living. The MDS assessment documented Resident #15 had not bathed during the 7 days prior to the assessment. Resident #15 ADL care plan, revised on 1/2/19, documented he required assistance of 1 staff member with bathing and personal hygiene related to his weakness and shortness of breath. On 1/28/19 at 10:57 AM, Resident #15 stated he was to have a shower twice a week and said he received a shower about every 11 days. He stated he wanted to have his showers twice weekly. Resident #15's bathing/shower flowsheet, dated 1/1/19 through 1/31/19, documented he did not receive baths/showers as follows: * Documentation from 1/1/19 - 1/28/19 included: - On 1/1/19 shower - On 1/5/19 not applicable - On 1/12/19 supervision (with shower) - On 1/15/19 resident refused - On 1/16/19 resident refused - On 1/19/19 not applicable - On 1/21/19 shower - On 1/26/19 not applicable - On 1/28/19 physical help (with shower) Resident #15 did not receive a bath/shower for 10 days (1/2/19 - 1/11/19), for 8 days (1/13/19 - 1/20/19), and for 6 days (1/22/19 - 1/27/19). Resident #15's Nurse's Progress Notes did not include documentation to explain why he did not receive his showers as care planned. On 1/31/19 at 1:10 PM, CNA #4 stated she was the shower aide on the unit where Resident #15 resided and she worked Sunday through Thursday. Resident #15's bathing/shower flowsheet documented his shower schedule was Tuesdays and Saturdays. CNA #4 said the CNAs working on the floor were responsible to provide Resident #15 his shower on Saturdays. CNA #4 stated when the shower was marked not applicable it indicated the shower was not given. CNA #4 stated she was scheduled to shower up to 20 residents a day, and if she was unable to complete them, or if the resident refused or asked for a shower at a different time, she told the next shift. She said the next shift did not complete the showers she was unable to give. CNA #4 stated the showers scheduled for Saturdays were not being completed by the CNAs. She stated Resident #15's shower was not completed on 1/16/19 and he had refused that day because he had a therapy appointment. She said the only showers Resident #15 received in January were on 1/12/19, 1/21/19, and 1/28/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Resident #43 was admitted to the facility on [DATE] with multiple diagnosis, including unspecified fall, hip fracture, and general muscle weakness. Resident #43's Incident Report, dated 1/20/19 at 11:45 PM, documented Resident #43 found on the floor in his room while attempting to get up to go to the bathroom, and sustained a bump on the head. A Neurological Assessment Flow Sheet was initiated on 1/20/19 at 11:45 PM and were stopped on 1/21/19 at 8:45 PM. There were no more neurological checks documented to complete the 72 hour policy requirement. On 1/30/19 at 12:20 PM, RCM #1 stated neurological checks were part of the facility's protocol if a resident fell with a bump to the head. On 1/30/19 at 3:55 PM, RN #4 said neurological assessments were to be completed consistent with the facility's Neurological Evaluation Policy. 6. Resident #32 was admitted to the facility on [DATE] with multiple diagnoses, including muscle weakness, abnormal posture, multiple sclerosis (degenerative neurological disorder), and hereditary spastic paraplegia (an inherited disorder that results in progressive weakness and stiffness of the legs). Resident #32's quarterly MDS assessment, dated 10/29/18, documented she was cognitively intact. She required extensive assistance from staff for bed mobility, dressing, toilet use, and personal hygiene. Resident #32's physician orders documented a handwritten order, dated 12/27/18, for terbinafine (antifungal medication) 1% to be applied to the sole/sides of her feet twice daily for two weeks for probable tinea pedis (athlete's foot). Resident #32's MAR documented the first time the terbinafine 1% was applied to her feet was on 1/6/19, ten days after the order was documented. On 1/28/19 at 9:25 AM, Resident #32 stated the facility was two weeks late obtaining a foot medication because they lost the prescription. On 1/31/19 at 6:26 PM, the DNS stated the terbinafine prescription was ordered from the pharmacy on 1/3/19. She stated on 1/3/19 Resident #32 gave her the prescription. She stated Resident #32 went out of the facility to her private physician and did not give the prescription to the facility until that date. The DNS stated the prescription was entered into the computer and transmitted to the pharmacy on 1/3/19, and it took the pharmacy three days to get the medication to the facility. On 2/10/19 at 9:56 AM, the Clinical Resource Nurse stated the pharmacy was late delivering the terbinafine due to insurance issues, and she verified the terbinafine 1% foot cream was started on 1/6/19. The Clinical Resource Nurse confirmed Resident #32's physician was not notified that the medication was not ordered until 1/3/19 or that the medication was not started until 1/6/19. 7. Resident #15 was readmitted to the facility on [DATE] with multiple diagnoses including gastrointestinal hemorrhage (bleeding), diverticulosis (when pockets develop in the intestines and become inflamed or infected) of large intestine without perforation or abscess with bleeding, ileostomy (surgically created opening in the abdominal wall through which digested food passes), and colostomy. Resident #15's quarterly MDS assessment, dated 12/4/18, documented he was cognitively intact and he did not exhibit behaviors. He required supervision for bed mobility, transfers, walking in room/corridor, locomotion, dressing, and eating, and required limited assistance with toilet use. Resident #15's clinical record documented he had an appointment with a gastroenterologist on 12/28/18, and the gastroenterologist ordered Anusol HC 25 mg rectal suppositories twice a day for 10 days. Resident #15's MAR documented the Anusol suppositories were started on 1/7/19, 10 days after the gastroenterologist's order. On 1/28/19 at 11:08 AM, Resident #15 stated he had to wait for a suppository ordered by the physician. He stated it took 11 days for the facility to receive the suppository from the pharmacy. On 1/30/19 at 3:16 PM, RN #3 verified the Anusol suppositories were not initiated because there was an issue with the pharmacy obtaining insurance approval. RN #3 said she called the pharmacy and was told it took awhile to fill the order because Resident #15's health insurance refused to pay for the suppositories. According to RN #3, the prescription was filled on 1/7/19 after the facility agreed to pay for the medication. RN #3 said there was no documented evidence of notifying the physician of the suppositories being late until 1/7/19, the day the Anusol suppositories were started. On 2/1/19 at 2:53 PM, the Nursing Notes were reviewed with the Clinical Resource Nurse, and she verified the medication was ordered on 12/28/18, and was started 1/7/19. 3. Resident #54 was admitted to the facility on [DATE] with multiple diagnoses, including hemiplegia and hemiparesis (weakness and paralysis on one side) following cerebral infarction (stroke) affecting the right side, difficulty walking, facial weakness following cerebral infarction, and aphasia (loss of ability to understand or express speech). Resident #54's admission MDS assessment, dated 12/6/18, documented he had severe cognitive impairment for daily decision making and one fall with injury since admission. Resident #54's current care plan documented he was at high risk for falls related to confusion, deconditioning, and lack of awareness of safety needs, initiated on 12/3/18. The care plan directed staff to follow the facility's fall protocol. Resident #54's Fall Risk Assessment Tool, dated 11/29/18 at 3:56 PM, documented he was at risk for falls. An Incident Follow-Up and Recommendation Form, dated 12/1/18 documented Resident #54 was found on the floor face down at 4:15 AM with injury/swelling to the right side of his forehead and neurological checks were started. Resident #54's Neurological Assessment Flow Sheet documented neurological checks on 12/1/18 at 3:15 AM through 12/2/18 at 2:00 PM. The level of consciousness was not documented on 16 out of 21 opportunities. The pupil response was not documented on 19 out of 21 opportunities. Hand grasps were not documented on 20 out of 21 opportunities. Motor function of extremities was not documented on 16 out of 21 opportunities. Pain response was not documented on 17 out of 21 opportunities. Vital signs were not documented on 2 out of 21 opportunities. The staff signature was not documented on 9 out of 21 opportunities. Additionally, the neurological checks were not completed for 72 hours following the fall, as required by the facility's Neurological Evaluation Policy. Resident #54's Post Fall Investigation Assessment Tool, dated 1/13/19 at 10:43 PM, documented he was found lying on his back with his legs straight and arms by his side. Immediate interventions included nursing assessment, neurological checks, vital signs, and pain assessment. Further neurological checks were not found documented in Resident #54's clinical record following this fall. Resident #54's Post Fall Investigation Assessment Tool, dated 1/26/19 at 8:09 PM, documented he was found sitting on his buttocks with his legs straight out in front of him and his head against the bed mattress. The immediate interventions included initiation of neurological checks and a pain assessment. Further neurological checks were not found documented in Resident #54's clinical record. On 1/31/19 at 7:06 PM, the DON said she would check to see if neurological checks were documented somewhere for Resident #54. On 2/1/19 at 9:39 AM, RCM #1 said if a resident had an unwitnessed fall, she would expect neurological checks to be completed. RCM #1 said she did not see any neurological checks documented for Resident #54 after the falls on 1/13/19 and 1/26/19. On 2/1/19 at 10:18 AM, the Clinical Resource Nurse said neurological checks were not completed for Resident #54 and they should be completed for 72 hours unless the physician said to stop neurological checks sooner. 4. Resident #319 was admitted to the facility on [DATE] with multiple diagnoses, including Amyotrophic Lateral Sclerosis (a degenerative neurological disease), altered mental status, Type 2 diabetes mellitus, schizophrenia, major depressive disorder, chronic kidney disease, and unspecified sequelae (after effects) of cerebral infarction (stroke). A Post Fall Investigation, dated 8/26/18 at 1:00 AM, documented Resident #319 was found sitting on his buttocks with both legs straight out in front of him. Resident #319's Neurological Assessment Flow Sheet documented neurological checks were performed on 8/26/18 though 8/27/19 at 4:00 AM. The level of consciousness was not documented on 3 of 14 opportunities. Pupil response was not documented on 3 of 14 opportunities. Hand grasps and motor function of extremities was not documented on 3 of 14 opportunities. Pain response was not documented on was not documented on 3 of 14 opportunities. The staff signature was not documented on 10 of 14 opportunities. Additionally, the neurological checks were not completed for 72 hours following the fall, as required by the facility's Neurological Evaluation Policy. On 1/31/19 at 7:03 PM, the DNS said it looked like there were a few areas of missing information on Resident #319's Neurological Assessment Flow Sheet. The DNS said she was not aware of any reason for the missing information, and she would expect all of the areas to be completed on the Neurological Assessment Flow Sheet. Based on record review, resident and staff interview, and policy review, it was determined the facility failed to ensure professional standards of practice were maintained related to neurological checks being completed following unwitnessed falls, pressure reduction interventions initiated as stated on the care plan, and medication availability. This was true for 7 of 9 residents (#1, #43, #54, #65, & #319) reviewed for falls and 2 of 22 residents (#15 and #32) whose medication regimes were reviewed. These failures created the potential for harm if changes in residents' neurological status went undetected and untreated after falls, if medications were not given in a timely manner, and/or residents developed skin impairments. Findings include: The facility's Fall Response and Management Policy, dated 11/28/17, documented that after a fall the resident's condition was to be evaluated for injuries, soreness, weakness, pain, and psychosocial adverse affects, for at least 72 hours following the fall. The facility's Neurological Evaluation policy and procedure, dated 11/28/17, documented: * Neurological vital signs supplement the routine measurement of temperature, pulse rate, and respirations when a resident is suspected to have hit their head (e.g , a fall) or had hit his/her head. * The physician's order dictates the frequency of neurological evaluations. * The neurological evaluation consists of assessing the resident's level of consciousness, pupils and eye movement, and motor function response. * In the absence of physician orders, neurological evaluations should be assessed every 15 minutes for an hour, then; every 30 minutes for an hour, then; every hour for 2 hours, then every 4 hours until the physician stated it was no longer necessary or in the 72 hours if the resident's condition is stable and showing no signs and symptoms of neurological injury. The facility's Fall Response and Management Policy, dated 11/28/17, documented that after a fall the resident's condition was to be evaluated for injuries, soreness, weakness, pain, and psychosocial adverse affects, for at least 72 hours following the fall. 1. Resident #65 was admitted to the facility on [DATE] with multiple diagnoses, including repeated falls, dementia, and disorientation. a. Resident #65's Incident Report, dated 10/27/18, documented he had an unwitnessed fall in his room at 3:45 AM that day, and was found on the floor in a fetal position. Resident #65's Neurological Assessment Flow Sheet documented neurological assessments were started on 10/27/18 at 4:30 AM and were stopped on 10/28/18 at 6:30 AM. There were no more neurological checks completed to meet the policy requirement of 72 hours. b. Resident #65's Incident Report, dated 10/28/18, documented he had an unwitnessed fall that day and was found on the floor of the bathroom at 10:00 AM. There were no neurological assessments found in Resident #65's clinical record after the fall. c. Resident #65's Incident Report, dated 11/3/18, documented he had an unwitnessed fall in his room at 10:45 AM, and was found on the floor in a fetal position. Resident #65's Neurological Assessment Flow Sheet documented neurological assessments were started on 11/3/18 at 10:45 AM and were stopped on 11/3/18 at 12:45 PM. There were no more neurological checks completed to meet the policy requirement of 72 hours. d. Resident #65's Incident Report, dated 11/15/18, documented he had an unwitnessed fall in his room at 5:42 PM and sustained a skin tear to his right elbow. The report documented Resident #65 appeared very tired at the time of the fall, did not open his eyes, and had slow movements. There were no neurological assessments found in Resident #65's clinical record after the fall. e. Resident #65's Incident Report, dated 11/18/18 at 3:00 PM, documented Resident #65 was found on the floor in another resident's room. There were no neurological assessments found in Resident #65's clinical record after the fall. f. Resident #65's Incident Report, dated 11/19/18 at 5:00 AM and 11:00 AM, documented he was found on the floor in his room. Resident #65's Neurological Assessment Flow Sheet documented neurological assessments were started on 11/19/18 at 5:00 AM and were stopped on 11/19/18 at 6:00 PM. There were no more neurological checks completed to meet the policy requirement of 72 hours. g. Resident #65's Incident Report, dated 11/21/18 at 11:00 AM, documented he had unwitnessed falls and was found on the floor in his bathroom. The report documented he sustained a small bump to his forehead. A neurological check was documented in nursing progress notes on 11/21/18 at 1:00 PM. Further neurological checks were not found in Resident #65's clinical record until 11/21/18 at 7:30 PM. The neurological assessments were stopped on 11/22/18 at 4:00 PM. There were no more neurological checks completed to meet the policy requirement of 72 hours. h. Resident #65's Incident Report, dated 1/23/19, documented he had an unwitnessed fall in his bathroom at 10:00 AM on that day. There were no neurological assessments found in Resident #65's clinical record after the fall. On 1/30/19 at 3:55 PM, RN #4 said neurological assessments were to be completed for 72 hours at the time points identified in the facility's Neurological Evaluation policy. On 1/31/19 at 12:06 PM, the DNS said she expected staff to follow the facility's policy and complete neurological checks for 72 hours after a fall or an unwitnessed fall. The DNS said Resident #65's neurological checks were either not done or they were not completed correctly. 2. Resident #1 was admitted to the facility on [DATE] with multiple diagnoses, including difficulty in walking, generalized muscle weakness, history of falls, and unspecified dementia without behavioral disturbances. Resident #1's admission MDS, dated [DATE], and quarterly MDS, dated [DATE], documented he had severe cognitive impairment. He required extensive assistance of staff for bed mobility, transfers, dressing, personal hygiene, and toileting, was totally dependent on staff for bathing, and required limited assistance to walk in room and eat. He was not steady or able to balance with transfers. Resident #1's care plan for falls, revised on 12/24/18, documented he was at risk for falls due to having actual falls with no injuries and due to having dementia with poor safety awareness, poor balance, confusion, vision/hearing problems, and having an unsteady gait. The interventions on the plan of care included neurological assessment checks per policy and procedure. Resident #1's Post Fall Investigation report, Incident Follow-Up Documentation Form, nursing notes, and Neurological Assessment Flow sheets were reviewed for each of the falls since his admission in September 2018. The falls and fall documentation were reviewed with the Clinical Resource Nurse on 2/1/19 at 9:30 AM. Review of the documentation with the Clinical Resource Nurse was as follows: * On 9/16/18 at 6:30 AM, Resident #1 had an unwitnessed fall when he was found on the floor in his room with his back against the bed and his legs straight out in front of him. Documentation of his neurological checks was requested. The Clinical Resource Nurse stated they were not able to locate documentation to show neurological checks were completed after this fall. * On 9/29/18 at 12:40 PM, Resident #1 was found in his room lying on the floor next to the bed on his left side. The Post Fall Investigation document it was an unwitnessed fall. There was no documented evidence of neurological checks related to this fall. The Clinical Resource Nurse verified neurological checks were not completed after this fall. * On 11/26/18 at 11:25 PM, Resident #1 was found with his knees on the floor and his torso on the bed. The Post Fall Investigation report and the Incident Follow-Up and Recommendation form documented the fall was not witnessed. Resident #1's Neurological Assessment Flow Sheet documented neurological checks were completed on 11/26/18 from 11:45 PM through 11/27/18 at 2:00 AM. The Clinical Resource Nurse verified the neurological checks were not completed as expected because they were not completed for 72 hours after the unwitnessed fall occurred. * On 12/8/18 at 3:00 AM, Resident #1 was found on the floor in his room. The incident follow up report documented he crawled out of bed and was noted to have increased restlessness. Resident #1's Neurological Assessment Flow Sheet documented neurological checks were completed on 12/8/18; however, only one neurological check was documented on 12/9/18 at 2:00 PM. The Clinical Resource Nurse verified the neurological checks were not completed as expected for 72 hours after the fall. * On 12/21/18 at 11:40 PM, Resident #1 was found on the floor with a skin tear to his left arm. The Post Fall Investigation, dated 12/22/18, documented the fall was unwitnessed. Review of neurological checks documented they were completed on 12/21/18 from 11:45 PM through 4:45 PM. The Clinical Resource Nurse verified the neurological checks were not completed as expected for 72 hours after the fall. On 2/1/19 at 9:30 AM, the Clinical Resource Nurse stated the facility did not follow the facility policy regarding neurological assessments. b. Resident #1's admission MDS assessment, dated 9/20/18, and quarterly MDS assessment, dated 12/20/18, documented he was severely cognitively impaired. The assessment documented he required extensive assistance of staff for bed mobility, transfers, dressing, and toileting, and required limited assistance to walk in his room and to eat. The assessment stated Resident #1 was not steady or able to balance with transfers. Resident #1's care plan, revised on 12/17/18, documented he had moderate skin/tissue integrity risk due to diagnoses of immobility, deconditioning, sepsis, dementia, and incontinence. The goal was for the resident to have intact skin. The interventions included using a pressure relieving device while in a chair. Resident #1 was observed sitting in his wheelchair on 1/28/19 at 2:14 PM, 1/29/19 at 8:18 AM, 1/30/19 at 12:00 PM, 12:27 PM, 5:31 PM, and 6:16 PM, 1/31/19 at 12:00 PM, 2:07 PM, 3:26 PM, 3:34 PM, and 4:30 PM. He sat in his wheelchair directly on the seat portion of the wheelchair and had no pressure relieving device in place. On 1/31/19 at 3:26 PM, Resident #1 sat in his wheelchair in the activity room next to the activity director. He did not have a pressure relieving device in place. The Activity Director verified Resident #1 did not have a cushion or pressure relieving device in the seat of his wheelchair. On 1/31/19 at 3:34 PM, CNA #1 verified Resident #1 did not have a pressure relieving device in the seat of his wheelchair. She stated she routinely cared for him on the 2:00 PM to 10:00 PM shift and he generally did not have a cushion or pressure relieving device in the seat of his wheelchair. She stated Resident #1 sat directly on the seat of the wheelchair when he was in the wheelchair.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. The facility's Resident Mobility - Safety policy and procedure, dated 11/28/17, documented bed mobility, repositioning and transfer assistance needs were communicated to the staff. Staff were trained by persons demonstrating knowledge and competency in the Safe Resident Handling and Movement. The policy and procedure did not direct staff in the use and care of resident beds. The facility's Operation and Maintenance Manual for Alterra [NAME] Long Term Care Bed, dated 1/1/17, documented the bed was equipped with two brakes locks; one on the head end of the bed and one on the foot end. To operate the brake locks, press down on the red pedal from either side of the bed. To unlock, press the green foot pedal from either side of the bed. Always use the brake locks except when moving the bed. Pads can be adjusted by rotating them clockwise or counter-clockwise to ensure proper contact with floor. Secure the individual locking casters. If all four casters are not locked, swivel and wheel rotation will allow bed motion with little or no resistance. This can result in loss of balance, fall and personal injury. Ensure that all four casters are locked to avoid any bed movement during resident transfer and/or use. Staff did not follow instructions in the facility's Operation and Maintenance Manual for Alterra [NAME] Long Term Care Bed, to promote residents' safey. Examples include a. Resident #7 was admitted to the facility on [DATE], with multiple diagnoses including history of falls, cognitive communication deficit, difficulty walking, and generalized muscle weakness. Resident #7's care plan, dated 7/3/18, documented she was at risk for falls and directed staff to lock the bed brakes. Resident #7's admission MDS assessment, dated 7/5/18, documented she was cognitively intact, at risk for falls, and she required the assistance of one person with some ADLs. On 1/28/19 at 10:40 AM, Resident #7 was lying in bed watching television, and the bed was observed in an unlocked position. On the same date at 12:00 PM, Resident #7 was observed sitting in the dining room, and her bed was observed in an unlocked position. On 1/29/19 at 12:13 PM, Resident #7 was observed sitting in the dining room, and her bed was observed in an unlocked position. On the same date at 2:44 PM, Resident #7 was observed going to the bathroom, and her bed was observed in an unlocked position. b. Resident #24 and Resident #41 shared a room. Resident #24 was admitted to the facility on [DATE], with multiple diagnoses including history of falls, cognitive communication deficit, and depression. Resident #41 was admitted to the facility on [DATE], with multiple diagnoses including history of falls, cognitive communication deficit, difficulty walking, and generalized muscle weakness. Resident #41's care plan, dated 11/20/18, directed two staff were required to assist her with ADLs and transfers using with Hoyer (mechanical) lift. Resident #41's admission MDS assessment, dated 12/15/18, documented her cognition was moderately impaired, at risk for falls, and she required 2-person assist with ADLs. On 1/28/19 at 3:24 PM, and on 1/29/19 at 2:39 PM, Resident #24 was observed sitting on the edge of the bed and #41 was observed sitting in her wheelchair and their beds were observed in an unlocked position. On 1/29/19 at 9:40 AM, CNA #3 and CNA #5 were observed unlocking Resident #41's bed from a locked position with the red foot lock in place, to an unlocked position with the green foot lock in place, while transferring Resident #41 to the bathroom. Resident #41 was transferred with a Hoyer lift from her wheelchair to her bed, from her bed to the commode, from the commode to the bed, and from the bed to the wheelchair. After cares, Resident #41's bed was observed in an unlocked position. On 1/29/19 at 3:00 PM, the Maintenance Director stated the beds in the rooms of Residents' #7, #24 and #41 were not locked in place. The Maintenance Director stated the beds should be locked. The Maintenance Director stated staff training on how to use the beds should be coordinated by the Staff Development Coordinator. On 1/29/19 at 3:15 PM, the Staff Development Coordinator, with CNA #1 present, stated she had been employed since November 2018 and was not aware of all the things staff were to be trained on. The Staff Development Coordinator stated she was not trained on the use of the beds and had not trained other staff. CNA #1 stated she was trained on the use of beds and had been working to train others. On 1/30/19 at 2:32 PM, CNA #5 stated she had been working at the facility since December 2018, and was trained on locking the beds in place with the green/red locks. CNA #5 stated she had known the bed were not locked in place during and after transport while providing cares for Resident #41 on 1/29/19 at 9:40 AM, as noted above. Based on observation, family member and staff interview, policy review, and record review, it was determined the facility failed to provide adequate supervision to meet residents' needs and implement fall interventions. This was true for 3 of 9 residents (#1, #40, & #65) reviewed for supervision and falls. The facility also failed to ensure bed wheel locks were applied to prevent accidents and falls. This was true for 3 of 21 residents (#7, #24, & #41) reviewed for accidents. This created the potential for harm if residents experienced falls and injuries. Findings include: The facility's policy for Fall Response and Management, dated 11/28/17, directed staff to implement immediate interventions to prevent a repeat fall, review the post-fall evaluation and investigation, determine the cause, and revise the care plan interventions. The facility's Falling Star Program policy, dated July 2018, directed staff to place a star on a resident's door to identify the resident at high risk for falls. The purpose of the program was to alert staff that a resident was at a higher risk of falling. The facility's 1:1 staff procedure, dated September 2018, directed staff to be within view of the resident at-all-times and to have another staff member take over supervision if the assigned 1:1 staff needed to be relieved. These policies and procedures were not followed. Examples include: 1. Resident #65 was admitted to the facility on [DATE], with multiple diagnoses including repeated falls, dementia, and disorientation. Resident #65's Fall Risk Assessments, dated 10/26/18 and 1/26/19, documented he was at risk for falling. Resident #65's admission MDS assessment, dated 11/2/18, documented he was severely cognitively impaired, exhibited physical and verbal aggression and wandering behaviors, and required the assistance of one-person while walking in his room and in a corridor. Resident #65's Frequent Checks Report, dated 10/27/18 at 5:00 PM through 11/4/18, documented he was checked by staff every 30 minutes. Resident #65 was not provided the supervision necessary to protect him from falls, as follows: * Resident #65's Incident Report, dated 10/28/18, documented he fell in his bathroom at 10:00 AM and had no injury. New interventions were to continue frequent checks and to add him on the Falling Star Program. Resident #65's care plan was revised on 10/28/18 and directed staff to check on him frequently to meet his needs and to add him on the Falling Star Program for increased supervision. * Resident #65's Incident Report, dated 11/3/18, documented he fell in his room at 10:45 AM and had no injury. A new intervention was to add 1:1 staff supervision due to the frequency of Resident #65's falls and poor safety awareness. Resident #65's care plan was revised on 11/3/18 and directed staff to add a 1:1 sitter due to poor safety awareness. The intervention was discontinued on 11/4/18. * Resident #65's Incident Report, dated 11/18/15, documented he fell on the bathroom floor of the room adjacent to his room at 3:00 PM and had no injury. A new intervention was to move him to a room on a different side of the facility for increased supervision. Resident #65's care plan was revised on 11/19/18 and directed a room change to a different side of the building. Resident #65's progress note, dated 11/19/18 at 4:00 AM, documented he appeared confused and agitated with his new surroundings and became aggressive with staff. * Resident #65's Incident Report, dated 11/19/18, documented he was found on his bathroom floor in the fetal position at 5:00 AM and had no injury. New interventions included to move him to another room which was more visible to the nurses' station. Resident #65's care plan was revised on 11/19/18 and directed a room change to the opposite side of the building and to move him to a room in a more visible area (near the nurses' station). Resident #65's census list, dated 11/19/18, documented he changed rooms twice within a 24 hour period. Resident #65's progress note, dated 11/19/18 at 5:39 PM, documented he was moved to a room across from the nurses' station at 4:30 PM. A progress note, dated 11/20/18 at 1:22 AM, documented he appeared confused with the room change. * Resident #65's Incident Report, dated 11/20/18 at 10:30 AM, documented he fell or kneeled down on his hands and knees on his room floor and had no injury. Resident #65 said he was cleaning the floor. The intervention identified on the report was to continue with the new room directly across from the nurses' station. * Resident #65's Incident Report, dated 11/20/18 at 1:30 PM, documented he was found on his bathroom floor attempting to fix his sink and had no injury. A new intervention was to add 1:1 staff supervision for the night of 11/20/18, to determine Resident #65's intent. The follow-up section documented he purposely laid on the floor the night of 11/20/18. Resident #65's progress note, dated 11/21/18 at 4:56 AM, documented the 1:1 sitter observed Resident #65 lay down on the floor of his room because he was more comfortable on the floor and was offered a blanket and a pillow where he slept for hours. Resident #65's care plan was revised on 11/21/18 and directed staff for a 1:1 sitter through the night of 11/20/18 to establish patterns and intent. Resident #65 was noted to purposely lay on the floor during this time. * Resident #65's Incident Report, dated 11/21/18, documented he was found on his bathroom floor with a small bump to his forehead. A new intervention was to add 1:1 staff supervision for safety. Resident #65's care plan was revised on 11/21/18 and directed staff for a 1:1 sitter continuously to be within arms length as Resident #65 would allow. Resident #65 did not fall again until 1/23/19. * Resident #65's Incident Report, dated 1/23/19, documented he was found on his bathroom floor with a skin tear to his right forearm. The report documented CNA #1, who worked for a contracted staffing agency, said Resident #65 was agitated and needed to use the toilet. The reported stated CNA #1 allowed Resident #65 to go to the bathroom by himself. The report documented CNA #1 then closed the bathroom door and sat down in the chair in Resident #65's room. The report documented CNA #1 heard a noise in the bathroom a few minutes later, opened the bathroom door, and found Resident #65 on the floor. The report stated CNA #1 was educated to be within arms length of Resident #65 for safety. The new intervention was to continue 1:1 staff supervision and staff to be nearby Resident #65 at all times. On 1/28/19 at 11:58 AM, Resident #65 was sitting at a dining room table with three other residents eating his lunch meal without staff within arms reach. At 12:06 PM, CNA #2, who worked for the contracted staffing agency and was Resident #65's 1:1 staff for that shift, was in the dining room passing out lunch plates to other residents and not within arms reach of Resident #65. At 12:14 PM, four staff members were standing near the meal service area, more than 3 feet away with their backs turned to Resident #65, who was seated at a nearby table. During this time, CNA #2 had delivered several meals to other residents' rooms. At 12:23 PM, CNA #2 squatted next to Resident #65, asked him about his meal, said she was going to help other residents, and walked away to deliver more meals to other residents. At 12:33 PM, CNA #2 placed a chair next to Resident #65 and walked away. At 12:35 PM, CNA #2 sat down next to Resident #65 and asked if he was done with his meal. He said he wanted to go back to his room. On 1/28/19 at 12:45 PM, CNA #2 said that day was her first time as a 1:1 staff and said the training she received was from the 1:1 staff previously assigned to Resident #65. She said she was not given instructions from the nurse or provided with the facility's 1:1 staff procedures. She said she was to be with him at all times due to his behaviors, falls, and wandering. On 1/29/19 at 9:54 AM, CNA #12 said she had been one of Resident #65's 1:1 staff for two months and said he could get agitated with large groups. On 1/30/19 at 12:06 PM, Resident #65 was seated at the dining room next to CNA #12 when he abruptly stood up and walked away from the table as CNA #12 walked along side of him. On 1/31/18 at 9:55 AM, Resident #65's room door was open and at the closest edge of the A wing nurses' station a one-foot corner section of Resident #65's room could be seen. Due to the diagonal angle of the room from the nurses' station, the remainder of the room was not visible. On 1/31/19 at 12:06 PM, the DNS said after the 10/28/18 fall, Resident #65 was placed on the Falling Star Program and he was to be checked on every hour. She said the Falling Star Program alerted staff that he was a high fall risk. The DNS said the Falling Star Program did not direct staff on how the intervention would keep Resident #65 from falling. The DNS said after the 11/3/18 fall, a 1:1 staff was initiated and she was not sure why the intervention was discontinued the next day. The DNS said after the 11/18/18 fall, Resident #65 was moved to a room on the opposite side of the building to increase supervision due to a higher staff to resident ratio, which helped increase visualization. The DNS said after the 11/19/18 fall, Resident #65 was moved to a room close to the nurses' station where there was more traffic in and around the nurses' station and he could be seen more frequently. The DNS said after the 11/20/18 fall, a temporary 1:1 staff was placed for the night to see if Resident #65 was placing himself on the floor or falling and found that he had intentionally laid on the floor during the night. The DNS said this intervention was more of an investigation to determine Resident #65's patterns. The DNS said after the 1:1 staff was taken away, Resident #65 fell again on 11/21/18, and then a 1:1 staff was placed permanently with him. The DNS said CNA #1 should not have left Resident #65 alone in the bathroom on 1/23/19, as the staff was to be within arms reach of him. The DNS said CNA #2 should have been within arms reach instead of delivering meals during the 1/28/19 meal observation. The DNS said 1:1 staff were to report to each other when taking over for each other, were to talk to the nurse, and review the resident's care plan. The facility failed to provide adequate supervision to protect Resident #65 from repeated falls, when interventions failed to: * direct staff what to do to keep him from falling, * ensure adequate supervision while relying on higher traffic areas to provide that supervision, * continue a 1:1 staff intervention twice without adequate time to test its effectiveness, and * train 1:1 staff adequately to keep him safe by following the 1:1 staff procedures and Resident #65's care plan. 2. Resident #40 was admitted to the facility on [DATE], with diagnoses including schizophrenia, aphasia (loss of ability to understand or express speech due to brain damage), dementia, abnormal involuntary movements, restlessness, agitation, and convulsions. Resident #40's History and Physical, dated 12/28/18, documented, I met with [Resident #40] today to admit him to our facility. Due to his dementia and schizophrenia he is non-verbal and requires assistance with all ADLs . He is sitting up in his chair and appears to be comfortable. Resident #40's progress note, dated 1/21/19 at 5:16 AM, documented, Resident was found on the floor this morning. He was lying on his left side, in a fetal position, head at the end of the bed. Redness noted to his right forehead . No bleeding noted. Slight abrasion to the forehead . resident indicating no pain. Resident assisted back to bed without signs of discomfort. Resident #40's Incident Report, dated 1/21/19, documented he was found on floor in his room at 5:00 AM. He had a minor abrasion to his forehead. The intervention was to place his bed in the low position when he was in bed with bilateral mats at the bedside. Resident #40's physician orders, dated 1/21/19, documented an order for, Bed in low position with bilateral mats on floor. Resident #40's care plan was revised on 1/21/19 to include fall mats at his bedside with his bed in the low position. On 1/28/19 at 2:12 PM, Resident #40's family member said she was notified when the resident was found on the floor with his head at the foot of the bed in the fetal position. The family member said Resident #40 was able to move his legs. On 1/28/19 at 2:20 PM, 1/29/19 at 9:25 AM, and on 1/30/19 at 11:08 AM, Resident #40 was in his bed. His bed was not in the lowest position and there were no fall mats on the floor to either side of his bed or elsewhere in the room. On 1/31/19 at 2:22 PM, Resident #40 was in bed and his bed was not in the lowest position. RN #3 said Resident #40's bed was not in the low position. CNA #2, also present, said she did not know Resident #40's care plan had changed to include the fall mats and the low bed. Fall prevention interventions included in Resident #40's care plan were not followed. 3. Resident #1 was admitted to the facility on [DATE], with multiple diagnoses including a history of falls, difficulty walking, muscle weakness, and dementia without behavioral disturbances. Resident #1's admission MDS assessment and the quarterly MDS assessment, dated 09/20/18 and 12/20/18, respectively, documented he was severely cognitively impaired, required extensive assistance of staff for bed mobility, transfers, dressing, and toileting; and required limited assistance to walk in his room and eat; and he was not steady or able to balance with transfers. Resident #1's care plan, revised on 12/24/18, directed staff that he was at risk for falls due to actual falls with no injuries and due to dementia with poor safety awareness, poor balance, poor communication/comprehension, confusion, incontinence, vision/hearing problems, and unsteady gait. Resident #1's Incident Reports, dated 9/16/18 at 6:30 AM, 9/29/18 at 12:40 PM, 11/26/18 at 11:25 PM, 12/8/18 at 3:00 AM, and on 12/21/18 at 11:40 PM, documented he experienced unwitnessed falls from his bed. Resident #1's Incident Report, dated 11/26/18 at 11:25 PM, documented he experienced an unwitnessed fall from his bed and was found with his knees on the floor and his torso on the bed. The recommendation was for the Physical Therapist to evaluate mobility to see if current interventions are appropriate. According to the investigation, the bed was in the low position and a fall mat was in place at the time of this fall. Resident #1's Physical Therapy Evaluation & Plan of Treatment, dated 11/28/18, documented, Patient has shown increased potential for transfers, gait, and bed mobility. He still has notable confusion but can follow simple single step instruction . D/C [discontinue] use of bed-side mat and low-bed. Patient is at risk for falling with mat in place. The low bed and the use of the bed side mat was not listed on the care plan. On 1/29/19 at 2:20 PM and 3:38 PM, Resident #1 rested in bed with the bed in the low position and a mat on the floor beside the bed. The mat was on the floor beside the bed during intermittent observations conducted on all days of the survey and was also next to the bed when Resident #1 was not in bed during the day and evening shifts from 1/28/19 through 2/1/19. On 1/30/19 at 2:54 PM, RN #3 said Resident #1 had experienced falls and his bed was placed in the low position, with one side of the bed against the wall, and a mat on the floor to prevent him from falling. On 1/31/19 at 3:34 PM, CNA #1 said she routinely cared for Resident #1 during the 2:00 PM to 10:00 PM shift. CNA #1 said Resident #1's bed was always in the low position with the mat on the floor beside the bed when he was in bed. On 2/1/19 at 9:30 AM, the Clinical Resource Nurse said the Physical Therapist recommended discontinuing the low bed and fall mat, but the facility did not review and implement the recommendation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility failed to ensure the dishwasher was maintained at an appropriate rinse temperature to ensure the dishes and utensils were sanitized, and failed to ensure food was placed on and held at a safe temperature on the steam table. These deficient practices placed the 79 of 79 residents who resided in the facility (each consumed food prepared by the facility) at risk of contracting foodborne illnesses. Findings include: 1. On 1/30/19 at 11:13 AM, FSE (Food Service Employee) #1 ran pots, pans, and utensils through the dishwasher. The rinse temperature of the dishwasher reached 173 degrees Fahrenheit (F) when she ran the pots/pans through the dishwasher, and 169 degrees (F) when she ran the rack of silverware through the dishwasher. She continued using the dishwasher even though the rinse temperature did not reach 180 degrees (F). On 1/30/19 at 11:15 AM, FSE #1 said she had not checked the water temperature and did not know what temperature the rinse was required to reach. On 1/30/19 at 11:15 AM, the Dietary Manager said the rinse temperature should have reached 180 degrees (F) in accordance with the manufacturer's instructions. On 1/30/19 at 11:17 AM, FSE #2 removed the silverware from the clean end of the dishwasher and began preparing them for transport to the units for the noon meal. The Dietary Manager redirected FSE #2 to stop and place the silverware back through the dishwasher after he got the rinse temperature back to 180 degrees (F). The Dietary Manager stated the rinse temperature dropped because of build up in the machine that was causing the water temperature to drop. After he cleaned the dishwasher, the rinse temperature reached 180 degrees (F). On 1/30/19 at 3:39 PM, the Registered Dietician provided the manufacturer's instruction and facility policy for the dishwasher. Review of the manufacturer's instructions for the [NAME] Dishwasher documented the minimum rinse temperature for the dishwasher was 180 degrees (F). Review of the facility's undated policy for Dish Machine Temperature Log documented The food service manager will train dishwashing staff to monitor dish machine temperatures revealed throughout the dishwashing process. The Registered Dietitian stated it did not reach 180 degrees (F) and stated if the surveyor had not noticed the temperature was low, the utensils would have been used at the noon meal without being properly sanitized. 2. Review of the facility's policy for Food Safety, dated 11/28/17, documented food was to be stored and distributed in a manner to minimize the risk of foodborne illness. Review of the facility's policy for Food Preparation, dated 11/28/17, documented hot foods must be held and distributed at 135 degrees (F) or hotter to minimize the risk of foodborne illness. On 1/30/19 at 11:53 AM, pans of food for the steam table were removed from the heated cart on the B unit and placed in the steam table for the noon meal. After placing the food on the steam table, FSE #3 obtained the temperature of the food items. At that time, the mechanical soft roast beef was 131 degrees (F) and the pureed carrots were 134 degrees (F). FSE #3 began serving at 12:00 PM without ensuring the mechanical soft meat and puree carrots were at least 135 degrees (F) or higher. At 12:18 PM, FSE #3 obtained the temperature of the mechanical soft roast beef a second time and it registered 124 degrees (F). FSE #3 verified the temperature to the surveyor and continued serving the mechanical soft roast beef.