**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review, the facility failed protect the resident's right to be free from physical abuse by staff for one of five residents (Resident (R) 13) reviewed for abuse out of a total sample of 21 residents. Findings include: Review of R13's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/12/24, located in the electronic medical record (EMR) under the MDS tab, revealed R13 admitted to the facility on [DATE]. R13 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. Per the MDS, the resident did not exhibit any behaviors during the assessment period. Review of the Resident Allegation of Abuse Investigation, dated 07/26/24, indicated, [R13] . with a primary diagnosis of aftercare following ulna fracture . Resident reported to social services on this date at approximately 9:45 AM to file a grievance against one of the facility's CNAs [Certified Nurse Aides] [CNA4] . [R13] said smoke break was in the process of ending and the aide announced smoke break was over and she needed to get back in the building. [R13] states [sic] she was in the process of taking a drag off her cigarette when [CNA 4] reached over and grabbed her arm and wrist in what she felt was an aggressive manner to put her cigarette out and ended up burning the resident and herself . On 07/26/24 at 10:45 AM, this administrator met with [another resident] . he stated [R13] was taking a smoke off her cigarette and the assistant reached over and grabbed her arm to put her cigarette out . He confirmed he felt it was done in an aggressive manner and was done intentionally. Director of Nursing [DON] will meet with staff member on 07/29/24 (remained on leave until this date) at which time she will be terminated. During an interview on 08/06/24 at 2:41 PM, R13 stated CNA4 grabbed her hand and put the cigarette in the ashtray. R13 stated she was startled she [CNA4] would do something like that. R13 said CNA4 grabbed her wrist, burned her finger and put her cigarette out. R13 stated it was not a bad burn just some redness, but it was enough to scare her. R13 completed a grievance form and then heard from the DON that CNA4 was fired. During an interview on 08/07/24 at 10:30 AM, R30 stated she was in the smoking area when CNA4 grabbed R13's arm. R30 stated she thought both R13 and CNA4 were burned when CNA4 grabbed R13 to put her cigarette out. During an interview on 08/07/24 at 5:00 PM, the Administrator stated she immediately investigated the grievance after hearing about it and terminated CNA4. Review of the facility's policy titled, Abuse: Prevention of and Prohibition Against, dated 12/2023, revealed All identified events are reported to the Administrator immediately . After receiving the allegation, and after the investigation, the Administrator will ensure that all residents are protected from physical and psychosocial harm.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to investigate an injury of unknown origin and an allegation of sexual abuse for two residents out of five residents (Resident (R) 73 and R63) reviewed for abuse out of a sample of 21. Failure to thoroughly investigate and take appropriate action for allegations had the potential to place other residents at risk of abuse/neglect. Findings include: 1. Review of R73's Face Sheet located in the Profile tab of the electronic medical record (EMR), revealed re-admission to the facility on [DATE] with diagnosis of mild cognitive communication deficit. Review of R73's annual Minimum Data Set (MDS), located in the electronic medical record (EMR) under the MDS tab, with an Assessment Reference Date (ARD) of 02/02/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated no cognitive impairment. Review of a Nurse's Note, located in the EMR under the Notes tab, written by Licensed Practical Nurse (LPN) 1, dated 07/03/23 at 12:16 AM, revealed, results from x-ray to residents fifth toe came back, results are acute oblique fractures (break on an angle) are seen in the distal fourth and fifth metatarsals. Review of facility provided Incident report, dated 07/03/24 at 8:42 AM, revealed R73 was seen by the in-house podiatrist with an order to obtain an x-ray of the right 5th toe to rule out bone lesions. X-ray performed and results were an acute oblique fracture are seen in the distal fourth and fifth metatarsals. During an interview on 08/08/24 at 11:21 AM, LPN1 stated staff should notify the Administrator or main supervisor within 2 hours of any abuse concern or an injury of unknown origin. She said she was the nurse on shift when the results for R73's x-ray came back. But she was not sure if she reported the fractures to anyone, but she should have reported it to a supervisor and if she did, she should have documented that. During an interview on 08/07/24 at 6:22 PM the Director of Nursing (DON) stated they investigated R73's broken toes and provided a paper with five questions dated 07/09/24 but did not have any additional documentation. The questions were conducted six days after x-ray results were received by the facility. The DON did not know how R73's toes were broken. No additional documentation related to an investigation was provided. 2. Review of the ''Bureau of Facility Standards Long Term Care Reporting system, dated 08/08/24 and completed by the Administrator, revealed a report of sexual abuse for R63 as reported by Licensed Practical Nurse (LPN) 7. The document was provided by the administrator as the incident report that was submitted to the State Survey Agency. The form did not indicate the date or time the report was online submitted. The ''incident type'' as documented on the form indicated ''resident to resident incident (verbal, physical, mental, or sexual) was not marked to specify sexual abuse. The incident description documented ''during routine rounds licensed nurse observed resident [R49] in the room of [R63] being affectionate, [R49] cooperated with being immediately redirected out of room to his room next door to [R63], family members of both residents were notified and aware of the situation. The ''immediate protective action plan'' documented on the form stated R63 and R49 were immediately separated, R49 was placed on 15-minute monitoring checks for intrusive wandering and referred to Nurse Practitioner on 07/15/24 to assess for any medical status changes. The document indicated R63 frequently invited passersby into her room and was being monitored for any psychosocial changes related to the incident. Review of R63's ''Face Sheet,'' located in the ''Profile'' tab of the EMR, revealed an admission date of 03/03/20 with diagnoses to include but not limited to unspecified dementia with other behavioral disturbance, anxiety disorder, cognitive communication deficit, need for assistance with personal care, unspecified psychosis, and depression. Review of R63's ''MDS, located in the MDS tab of the EMR, with an ARD of 06/06/24, revealed a BIMS score of 4 out of 15 which indicated R63 was severely cognitively impaired. Review of R63's care plan, located in the Care Plan tab of the EMR and revised 07/15/24, revealed she was at risk for impaired cognitive function, Activities of Daily Living (ADL) self-care performance deficit, altered mood/behaviors, evidenced by yelling out to people passing her door to come into her room, and physically aggressive, with a history of wandering. The ''Nursing Progress Notes,'' located in the Progress Notes tab in the EMR, documented R63's family member was not concerned with leaving R49 next door to his mother. Also documented in the progress note was his comment that R63 frequently tried to kiss him inappropriately and was easily redirected. During an interview on 08/08/24 02:21 PM with R63 in her room with Caregiver (CGR) 1 present, R63 stated she did not remember any ''boys'' or men coming into her room or kissing her. R63 responded that no boys entered her room. R63 appeared happy and smiling with no fear of any ''boys'' coming into her room. Review of R49's ''Face Sheet,'' located in the ''Profile'' tab of the EMR, revealed an admission date of 07/01/18 with diagnosis to include but not limited to mild dementia without behavioral disturbance. mild cognitive deficit, ambulatory and independent for ADL. Review of R49's ''MDS, located in the MDS tab of the EMR, with an ARD of 07/04/24, revealed a BIMS score of 15 out of 15 which indicated R63 was cognitively intact. Review of R49's care plan, located in the Care Plan tab of the EMR, dated and revised 07/04/24, revealed R49 had a language barrier and was Spanish speaking only. R49's care plan revealed he had a history of engaging in unwelcome sexual behaviors and non-reciprocated sexual advances toward others as evidenced by grabbing others, kissing others, and intrusive wandering, initially dated 07/01/20 and revised 07/15/24. Interventions included redirecting resident and assisting him to develop more appropriate methods of coping and interacting with others, and to protect other residents by closely monitoring his possible behaviors, counseling with him as needed to stay out of other resident rooms. Review of Practitioner Progress Note, located in the EMR Progress Notes tab and dated 07/17/24, documented the following, ''During a recent visit on 07/16/2024, [R49] was found in [R63's] room being affectionate, likely due to cognitive deficits from a previous subdural hemorrhage. He was placed on 15-minute checks and alert charting. During an interview on 08/07/24 at 5:36 PM, the Director of Nursing (DON) stated he had written a summary of the incident, but did not have documented evidence of date, time, or name of residents or staff that he had interviewed after the alleged abuse incident. On 08/08/24 at 8:39 AM, the DON provided a sheet of paper that contained the three questions below, along with the signatures of three residents, R17, R23, and R50. Has any person come into your room that has been uninvited? Has any male, resident or staff come into your room that has been uninvited. Has anyone resident or staff been wandering into your room that has been uninvited? No documentation of the interview conversation or the answers provided by the residents in response to the questions was provided. During an interview on 08/08/24 at 10:22 AM, the Administrator stated she was not aware of the care plan entry for R63 that documented his previous history of inappropriate behaviors and sexual advances and wandering into other resident's rooms. When asked about measures implemented to prevent further possible abuse of other residents, the Administrator stated she had discussed with other staff and family members about moving R49 and his spouse to another room/hall, but there were no other rooms available in the facility for a couple. The Administrator stated that additional craft and activity items were ordered for R63 on 07/15/24 to give R63 more things to do. The Administrator stated a ''owl'' door motion detector alarm was ordered and placed on the door of R63's room that would alert (by sounding loudly at her door) staff of anyone entering R63's room. Documentation of a ''15 Minute Check List'' of R63 was provided by DON. The documents indicated inconsistent random checks performed daily from 07/14/24 through 08/07/24. The DON stated R63 was only monitored during the same shift the initial allegation occurred on. During a phone interview on 08/08/24 at 4:34 PM, LPN7 recalled R49 standing in R63's room beside the recliner of R63 with his hands touching her face and her arms around his neck with their lips touching. LPN7 stated she calmly directed R49 out of R63's room and back to his room next door and then reported the incident to the administrator. Review of the facility policy titled ''Abuse Reporting and Investigation,'' revised February 2024, revealed ''all reports of resident abuse, neglect, and injuries of unknown source shall be thoroughly and promptly investigated by the facility.''

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to implement a care plan for a resident with a known history of wandering and exit seeking behaviors for a resident who gained access to the facility parking lot without staff supervision or knowledge for one of three residents (Resident (R) 95) reviewed for elopement. This has the potential to affect all residents who were at risk of wandering and elopement. Findings include: Review of R95's Face Sheet located in the Profile tab of the electronic medical record (EMR), revealed re-admission to the facility on [DATE] and with diagnoses including attention and concentration deficit, aphasia, and memory deficit. Review of R95's annual Minimum Data Set (MDS), located under the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 05/24/24, revealed the Brief Interview for Mental Status (BIMS) could not be completed due to resident rarely being understood. Review of R95's care plan, located under the ''Care Plan'' tab of the EMR and dated 03/18/24, revealed the resident was an elopement risk/wanderer due to a history of attempts to leave the facility unattended. Review of a Nurse's Note, located in the EMR under the Notes tab, written by Former Social Worker (FSW) on 08/15/23 at 1:51 PM, revealed, it was brought to the attention of the social worker that R95 has been gathering his stuff and trying to get to the front door of the facility to leave. Staff spoke with R95 who continued to wheel himself down the hall. After the Director of Nursing (DON) spoke with R95 he agreed to stay. Review of a Nurse's Note, located in the EMR under the Notes tab, written by Licensed Practical Nurse (LPN) 8 on 12/13/23 at 6:04 PM, revealed R95 continued on alert charting for increase in wandering. Review of a Nurse's Note, located in the EMR, under the Notes tab, written by Licensed Practical Nurse (LPN) 2 on 03/16/24 at 5:39 PM indicated, R95 was outside in front parking lot, staff assisted R95 back inside the facility, unable to determine why R95 went outside into parking lot. During an interview on 08/07/24 at 6:22 PM, the Director of Nursing said the interdisciplinary team (IDT) was aware R95 had known wandering behaviors and a documented desire to leave the facility, and he was not sure why nothing was put into place prior to 03/16/24 but stated they should have definitely put interventions in place. During an interview on 08/08/24 at 3:31 PM, the Former Social Worker (FSW) stated after staff became aware R95 verbalized a desire to leave the facility and exhibited an increase in wandering which made him an elopement risk it should have been care planned. A review of the facility's policy title Comprehensive Person-Centered Care Planning, reviewed 12/2023, revealed it is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychological needs that are identified in the comprehensive assessment. A review of the facility's course transcript titled Wandering and Elopement, dated 2023 revealed once a resident has been identified as being high risk for elopement, develop an interdisciplinary plan of care that includes prevention strategies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interview, the facility failed to provide services based on acceptable standards of practice by specifically failing to accurately check a finger stick glucose level and failing to administer nebulized medication correctly for two of two residents (Resident (R) 48 and R103) reviewed for professional standards of 21 sample residents. Findings include: 1. Review of R48's Face Sheet, located under the Resident tab of the electronic medical record (EMR), documented R48 was admitted to the facility on [DATE] with a diagnosis of type two diabetes mellitus with chronic kidney disease. Review of R48's annual Minimum Data Sheet (MDS) with an Assessment Reference Date (ARD) of 06/28/24, located under the MDS tab of the EMR, documented R48 had a Brief Interview for Mental Status (BIMS) of 13 out of 15 indicating, R48 was cognitively intact. Review of R48's care plan, dated 08/06/24 and located under the Care Plan tab of the EMR, documented R48 had diabetes mellitus and would remain free of signs and symptoms of hypoglycemia through the next review date. Review of R48's active orders for August 2024, located under the Orders tab of the EMR, indicated to check blood sugar before bedtime to make sure the resident was not hypoglycemic. During an observation on 08/08/24 at 11:07 AM, Licensed Practical Nurse (LPN) 3 checked R48's blood sugar. LPN3 cleaned R48's finger with an alcohol wipe prior to sticking R48's finger with the lancet. LPN3 then used the dirty alcohol pad to wipe away the first drop of blood prior to obtaining the blood sample. During an interview on 08/08/24 at 11:20 AM, LPN3 stated she should have used a clean alcohol pad or a dry cotton ball/gauze to wipe away the first drop of blood. LPN3 stated she accidentally picked up the dirty alcohol swab. During an interview on 08/08/24 at 3:20 PM, the Director of Nursing (DON) stated you should introduce yourself, explain what you are going to do, and gather your supplies. The DON stated you then cleanse the finger with alcohol, let it air dry, stick the finger with the lancet, discard the first drop of blood with gauze and not the alcohol pad, and then use the next drop for the test sample. During an interview on 08/08/24 at 5:36 PM, the DON stated he did not have a policy regarding how to properly check a blood sugar. He stated they just follow physician orders. 2. Review of R103's Face Sheet, located under the Resident tab of the EMR, documented R103 was admitted to the facility on [DATE] with diagnoses which included obstructive sleep apnea and morbid obesity. Review of R103's admission MDS with an ARD of 07/01/24, located under the MDS tab of the EMR, documented R103 had a BIMS of 15 out of 15, indicating she was cognitively intact. Review of R103's care plan, dated 07/01/24 and located under the Care Plan tab of the EMR, indicated R103 had chronic obstructive pulmonary disease (COPD, a lung disease causing restricted air flow), shortness of breath (SOB) and wheezing. The care plan indicated R103 would be free of signs or symptoms of infection through review date and aerosol bronchodilators would be given as ordered. Review of R103's current physician orders, located under the EMR Orders tab, dated August 2024, documented the following order, started 07/02/24, Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML inhale one vile three times a day for COPD. During an observation on 08/08/24 at 1:06 PM, LPN6 administered a nebulizer breathing treatment to R103. Ipratropium bromide (a medication used to treat COPD) one ampule was administered. A clear liquid was observed in the medication chamber when LPN6 and the surveyor entered the room. LPN6 added the ampule of ipratropium to the medication chamber and began the treatment. R103 was observed coughing. R103 stated she took the breathing treatments for her COPD diagnosis. During an interview on 08/08/24 at 1:13 PM, LPN6 stated he did not notice the liquid in the medication chamber prior to adding the current dose of medication. LPN6 stated the equipment should be rinsed, dried and stored in a plastic bag between each use. LPN6 stated he should have checked the chamber to ensure it was clean and ready for use. During an interview on 08/08/24 at 3:20 PM, the DON stated the nursing staff should check the respiratory equipment prior to use and ensure they are clean, free of debris, residue, or liquids. The DON stated staff should rinse the equipment after it is used, let it dry, and then place it in a plastic bag. Review of the undated document provided by the Administrator and obtained at lung.org titled ABCs of Using a Nebulizer indicated the following: 1. After each treatment, disassemble and wash the nebulizer part in warm soapy water or in the dishwasher 2. Rinse and let the pieces air dry and store in [a] clean dry place.

Based on record review and staff interview, it was determined the facility failed to ensure residents received information and assistance to exercise their rights to formulate an Advance Directive. This was true for 2 of 6 residents (#7 and #8) reviewed for Advance Directives. The deficient practice created the potential for harm should residents' wishes regarding end of life or emergent care not be honored if they were incapacitated. Findings include: Resident #7 and Resident #8 did not have a copy of an Advance Directive in their record and their records did not include documentation an Advance Directive was discussed with them. The records for Resident #7 and Resident #8 also did not include documentation they were provided assistance to formulate an Advance Directive. On 7/10/19 at 3:53 PM, the RSD said she discussed creating Advance Directives with residents upon admission and reviewed Advance Directives annually with the residents. On 7/11/19 at 11:26 AM, the RSD said she did not find documentation an Advance Directive was discussed with Resident #7 or Resident #8.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interview, policy review, record review, and review of grievances, it was determined the facility failed to ensure grievances were responded to and investigated, and prompt corrective action was taken to resolve grievances. This was true for 1 of 18 residents (Resident #79) reviewed for grievances. This failure created the potential for psychosocial harm if resident grievances were not acted upon. Findings include: The facility's Grievance policy, revised 11/2017, documented the Grievance Official responded to an individual who expressed a concern within 3 working days, and contacted all parties with the outcome of the investigation. Resident #79 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including diabetes mellitus. Resident #79's quarterly MDS assessment, dated 6/21/19, documented she was cognitively intact. On 7/8/19 at 1:57 PM, Resident #79 said she was missing two rings, a necklace, and one set of earrings since 12/2018. She said the missing jewelry was a gift from her son last Christmas. Resident #79 said she filed a grievance about the missing jewelry and had not heard about it. The facility's grievance file from 12/2018 through 7/2019 was reviewed. There was no grievance for Resident #79 regarding her missing jewelry. On 7/10/19 at 1:40 PM, the RSD said she was the Grievance Official and she remembered the grievance about Resident #79's missing jewelry. The RSD said Resident #79 told her the missing jewelry was irreplaceable because it was a gift from her son last Christmas. The RSD said they searched Resident #79's room but did not find the jewelry. The RSD stated she contacted Resident #79's son and asked him to provide the receipt for the jewelry. The RSD said Resident #79's son told her not to worry about repaying him for the missing jewelry. The RSD said she remembered talking to Resident #79 about her conversation with her son. The RSD was unable to provide documentation of her investigation, resolution, or outcome regarding Resident #79's missing jewelry.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review, record review, and staff interview, it was determined the facility failed to ensure fall prevention was implemented as care planned. This was true for 1 of 5 residents (Resident #44) reviewed for falls. This failure had the potential for harm if residents sustained bone fractures or other serious injuries from falls. Findings include: The facility's policy for Fall Prevention, revised 5/2018, documented the facility investigated the circumstances surrounding each resident fall and implemented actions to reduce the incidence of additional falls and minimized the potential for injury. Resident #44 was admitted to the facility on [DATE], and was readmitted on [DATE], with multiple diagnoses including muscle weakness, dementia and diabetes mellitus. A quarterly MDS assessment, dated 5/17/19, documented Resident #44 had moderate cognitive impairment, required extensive assistance of one staff member for bed mobility, transfers, locomotion, dressing, toilet use and personal hygiene. The assessment also documented Resident #44 was not steady and required staff assistance to stabilize her when moving from a seated to a standing position and on and off the toilet. Resident #44 used a walker or a wheelchair for mobility. A nursing progress note, dated 2/27/19 at 11:20 PM, documented Resident #44 was found on the floor next to her bed. The note documented Resident #44 stated she was trying to catch bugs and fell. A Fall care plan, revised 3/11/19, documented Resident #44 was at risk for falls. The care plan goal was for Resident #44 not to sustain a serious injury through the next care plan review. Interventions included in Resident #44's care plan, dated 9/25/18, documented staff were to place a floor mat beside her bed. A nursing progress note, dated 5/15/19 at 2:30 AM, documented Resident #44 slid down to the floor and landed on her buttocks when she self-transferred from her bed to her wheelchair. The note documented Resident #44 stated she was getting up to go to the restroom. Resident #44 was noted to have an approximately 3 centimeter (cm) x 3 cm skin tear on her right great toe. A nursing progress note, dated 5/25/19 at 5:14 AM, documented Resident #44 had a fall when she attempted to self-transfer from her bed to her wheelchair. A nursing progress note, dated 7/5/19 at 11:43 PM, documented Resident #44 was observed on the floor in her room in front of her roommate's bed. Resident #44 was noted to have a hematoma above her right eyebrow. A Fall Risk Assessment, dated 7/6/19, documented Resident #44 had 1-2 falls in the past 3 months and was at high risk for falls. The Fall Assessment also documented Resident #44 required assistance with elimination and required an assistive device for ambulation. On 7/8/19 at 3:27 PM, 7/9/19 at 9:30 AM, 11:26 AM, 2:50 PM, 7/10/19 at 9:16 AM, 10:02 AM and 1:42 PM and on 7/11/19 at 9:44 AM, Resident #44 was observed in bed without the floor mat in place. On 7/11/19, at 9:28 AM, Resident #44's medical record was reviewed with the DON. The DON said Resident #44 had a history of falls and had a care plan intervention to have a floor mat in place next to her bed. On 7/11/19 at 9:49 AM, the surveyor and DON, observed Resident #44 in bed without a floor mat next to her bed. The DON verified Resident #44 did not have a floor mat beside her bed in accordance with her plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #186 was admitted to the facility on [DATE] with diagnoses which included colon cancer, breast cancer, and colostomy. An admission MDS assessment, dated [DATE], documented Resident #186 was cognitively intact and was independent with most cares. The [DATE] Physician Orders documented Resident #186 was a full code, ordered [DATE]. Resident #186's care plan did not include the resident's code status. On [DATE] at 2:50 PM, the DON stated he could not locate a code status in Resident #186's care plan. 3. Resident #187 was readmitted to the facility [DATE] with diagnoses which included respiratory failure, acute kidney failure, and heart disease. A quarterly MDS assessment, dated [DATE], documented Resident #187 was cognitively intact and was dependent on staff with most cares. The [DATE] Physician Orders documented Resident #187's was DNR, ordered [DATE]. An [DATE] Physician Progress note documented Resident #187 requested a change to a full code status. Resident #187's current care plan did not include her code status wishes. On [DATE] at 2:50 PM, the DON stated he could not locate a code status in Resident #187's care plan. Based on record review and staff interview, it was determined the facility failed to ensure the comprehensive care planning process included advance care directives, such as full code or Do Not Resuscitate (DNR), with re-evaluation on a routine basis and when there was a significant change in condition. This was true for 3 of 6 residents (#31, #186 and #187) whose advance directives were reviewed. The failure created the potential for harm if a resident's wishes were not followed due to lack of direction in their care plan. Findings include: 1. Resident #31 was admitted to the facility on [DATE] with diagnoses which included right side hemiplegia related to cerebral infarction (stroke), dysphagia (difficulty swallowing), muscle weakness, and abnormal gait and mobility. A Resident/Family Consent for Cardiopulmonary Resuscitation documented Resident #31 chose the following option, I understand that CPR [cardiopulmonary resuscitation] constitutes an extraordinary measure and should not be done on [resident's name]. The resident signed the form on [DATE]. Resident #31's active physician orders documented a [DATE] order of DNR. Resident #31's comprehensive care plan did not document her advance care directive code status. On [DATE] at 10:50 AM, LPN #2 reviewed Resident #31's care plan and said Resident #31's code status was not in the care plan. On [DATE] at 10:55 AM, LPN #1 said Resident #31's code status was added to the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interview, policy review, review of I&A reports, and record review, it was determined the facility failed to ensure residents were free from potential abuse. This was true for 1 of 1 resident (#82) reviewed for potential abuse. There was no investigation or assessment regarding two large bruises on Resident #82's left forearm, sustained during cares by staff. The deficient practice created the potential for Resident #82 to experience ongoing abuse/neglect without detection. Findings include: Resident #82 was admitted to the facility on [DATE] with multiple diagnoses including morbid obesity and that she was unable to voluntarily move her left side of her body following a stroke. The quarterly MDS assessment, dated 4/27/18, documented Resident #82 was cognitively intact. The MDS assessment documented Resident #82 required extensive assistance of 2 staff members with bed mobility. The MDS assessment documented Resident #82 had impaired mobility on one side. The facility's policy and procedure on abuse investigation, dated 11/28/17, documented: * All identified events are reported to the administrator immediately. * A licensed nurse will immediately examine the resident upon receiving reports of alleged physical or sexual abuse. The findings of the examination shall be recorded in the resident's medical record. On 5/14/18 at 3:58 PM, Resident #82 was observed with two dark purple bruises on her left upper forearm. On 5/14/18 at 3:59 PM, Resident #82 said she was pushed up against the bed rail during incontinence cares while in bed. She said she did not remember which CNAs provided the incontinence care or specifically when it occurred. Resident #82 stated she remembered she cried out in pain when it happened. She stated cares were rushed in the morning. The facility could not provide an incident report, investigation, care plan, or nursing notes for the bruises observed on Resident #82's left forearm on 5/14/18 at 3:58. On 5/22/18, the facility provided multiple skin observation sheets, dated 5/15/18 at 9:30 AM and 5/16/18 at 9:00 AM, that documented there were no bruises. On 5/16/18 at 3:33 PM, with LPN #5 present, Resident #82 again stated the bruises on her left forearm were caused by staff when she was turned in bed. Resident #82 stated she was pushed against the left rail of her bed during cares and called out in pain when it happened. She did not remember who was there when it occurred or when it happened. LPN #5 stated she had not seen the bruises previously. On 5/16/18 at 3:40 PM, CNA #5 stated he was not aware of when Resident #82 was injured. He stated he saw the bruises and did not report them because they were there when he came to work on the hall Resident #82 resided on. On 5/16/18 at 3:44 PM, the DON stated he was not aware that an injury had occurred with Resident #82. The DON stated there was no documentation regarding bruising in Resident #82's record and he was not aware of the incident. On 5/16/18 at 3:52 PM, LPN #5 said Resident #82's family stated they saw the bruises over the weekend and did not mention the bruises to facility staff. LPN #5 stated she provided teaching regarding the need to alert staff of changes they observe during visits.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #186 was admitted to the facility on [DATE] with diagnoses which included colon cancer, breast cancer, and colostomy. The resident was transferred to a hospital on 8/22/17. An admission MDS assessment, dated 8/9/17, documented Resident #186 was cognitively intact and was independent with most cares. A Progress Note, dated 8/22/17, documented Resident #186 complained of nausea in her sternal area (bone in the center of the chest). The note documented Resident #186 had bowel tones in all four quadrants and her ostomy (opening in her colon) had green brown liquid stool. The note documented Resident #186 was not experiencing emesis (vomiting) and she declined pain medicine, anti-emetic medicine, and food and fluids. The note documented a nurse practitioner assessed Resident #186 and offered to send her to the hospital. The note documented Resident #186 agreed to the hospital transfer. The note documented Resident #186 was transferred to the hospital. Resident #186's record did not include documentation of transfer information sent to the hospital. On 5/16/18 at 2:50 PM, the DON stated when a resident was sent emergently to the hospital the facility sent a packet of information to the receiving facility. The DON stated they provided the resident's face sheet, vital signs, advanced directive information, physician orders, and a nursing progress note, if it was documented before the resident left the facility. Documentation of transfer information for Resident #186 being sent to the hospital was not provided by the facility. Based on staff interview and record review, it was determined the facility failed to ensure transfer information was provided to the receiving hospital for emergent situation for 2 of 5 residents (#18 and #186) reviewed for transfer. This deficient practice had the potential to cause harm if the resident was not treated in a timely manner due to a lack of information. Findings include: 1. Resident #18 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Parkinson's disease and heart failure. A quarterly MDS assessment, dated 5/9/18, documented Resident #18's cognition was intact and she needed extensive assistance with most ADLs. Nursing Progress Notes, dated 4/28/18, documented the following: * 10:33 AM - Resident began vomiting at approximately 7:00 AM, went back to bed to rest, and drank fluids but did not eat anything solid. * 3:16 PM - Resident continued to vomit, was diaphoretic (sweating heavily), febrile (feverish), hypertensive (high blood pressure), tachycardic (rapid heart rate), oxygen saturation was 99%, the physician was notified and recommended the resident be sent to the hospital emergency room. * 4:21 PM - Resident was sent to an emergency room with paramedics. * 10:50 PM - Resident was admitted to a hospital for acute encephalopathy (disorder or disease of the brain). There was no documentation that information about Resident #18, or the events that lead up to her transfer to the emergency room on 4/28/18, were conveyed to the paramedics who transported the resident or to the emergency department. On 5/17/18 at 3:00 PM, the DON said there was no specific policy for urgent/emergent transfers. The DON said the nurse would send the resident's face sheet, diagnoses, medication list, advance directive, and vital signs, and give a verbal report to EMTs but there was no record of what was actually sent.

Based on record review and staff interview it was determined the facility failed to ensure residents received assessments and care in accordance with professional standards of practice. This was true for 1 of 4 (#33) residents reviewed who were prescribed blood pressure medications. Resident #33 had the potential for harm from low blood pressure or high heart rate when blood pressure medications were administered without consistently monitoring blood pressures and heart rates as ordered. Findings include: 1. Resident #33 was admitted to facility 2/14/2017 with diagnoses which included dementia, chronic atrial fibrillation, coronary artery disease (CAD) and essential (primary) hypertension. A significant change MDS assessment, dated 3/23/18, documented Resident #33 was severely cognitively impaired. Resident #33's May 2018 active physician orders included the following: *Resident #33's blood pressure and heart rate were to be checked every day shift, ordered 3/19/18. *Amlodipine Besylate tablet 10 mg one time a day for hypertension *Metoprolol tablet 25 mg two times a day for hypertension Resident #33's care plan, dated 3/30/18, for hypertension documented she was to be given anti-hypertensive medications as ordered and be monitored for orthostatic hypotension (low blood pressure), increased heart rate (tachycardia), and the effectiveness of the medication. Resident #33's record did not include documentation her heart rate and blood pressure were assessed between 3/22/18 and 4/4/18, 4/6/18 and 4/10/18, 4/11/18 and 4/20/18, and 4/21/18 and 5/1/18. On 5/17/18 at 12:00 PM, the DON said if an order to check blood pressure and heart rate was active, the checks would have been done.

Based on observation, staff interview, and review of I&A reports and resident records, it was determined the facility failed to ensure residents received the level of supervision necessary to prevent falls and elopement from the facility. This was true for 1 of 1 (#33) resident reviewed for supervision. Resident #33 had the potential for harm when the facility failed to provide her with the necessary supervision and assistive devices while walking through the facility and outside. Findings include: Resident #33 was admitted to facility on 2/14/17 with diagnoses which included traumatic brain hemorrhage, dementia, muscle weakness, history of falls, Alzheimer's Disease, and cognitive communication deficit. A significant change MDS assessment, dated 3/23/18, documented Resident #33 was severely cognitively impaired. The MDS assessment documented Resident #33 required extensive assistance of 1 to 2 staff members with bed mobility, transfers, and locomotion on and off the unit. An Initial Nursing Assessment, dated 4/14/18, documented Resident #33 was not ambulatory or self-mobile in her wheelchair. The assessment documented (If yes, an Elopement/Wandering Evaluation will be triggered). Resident #33's current care plan documented she had a wander guard to prevent elopement. Resident #33's care plan documented she required 1-2 staff members assistance with cares including bed mobility, transfers, and locomotion. Resident #33's I&A Reports documented she experienced three falls and eloped from the facility one time, as follows: * On 9/9/17 Resident #33 eloped from the facility and was returned within 15 minutes of front door alarm reset, by the local police department, without injury. * On 2/28/18 Resident #33 experienced a fall and stated she might have hit her head. * On 4/3/18 and 4/9/18 Resident #33 experienced a fall in the dining room. Resident #33 was observed without supervision, assistive devices, and wander guard, as follows: * On 5/14/18 at 4:40 PM, Resident #33 was sitting on the edge of her bed reaching for her shoes on the floor. Her forehead was close to touching the floor. No staff members were present and she was calling out for help. * On 5/14/18 at 4:51 PM, a surveyor asked CNA #3 to assist Resident #33. CNA #3 assisted Resident #33 to bed and removed her shoes from her hands. CNA #3 stated Resident #33 should not be up without staff assistance. CNA #3 left Resident #33's room. * On 5/14/18 at 5:05 PM, Resident #33 was raising herself to a sitting position on the edge of her bed and began rocking back and forth. * On 5/14/18 at 5:19 PM, Resident #33 stood from her bed and walked toward her bedroom door while in her stocking feet. Resident #33 was not using a cane or a wheelchair to assist her while walking. No staff were present. * On 5/14/18 at 5:20 PM, CNA #4 was called to assist Resident #33. CNA #4 asked Resident #33 where her cane was located, and stated she should be using it. CNA #4 stated she thought Resident #33 was cleared to walk without staff assistance by therapy as of 5/14/18. * On 5/14/18 at 6:39 PM, Resident #33 was observed walking into the dining room without staff assistance and without a cane. * On 5/16/18 11:49 AM, Resident #33 was in her wheelchair in the fenced court yard without supervision. She was seen leaning down to pick up a piece of paper from the ground while seated in her wheelchair. No staff were present for 20 minutes. * On 5/16/18 at 5:00-5:30 PM, Resident # 33 was in the lobby on the couch sitting with a cane at her side. No staff were present in the lobby area during this time. Her wheelchair was not present. Resident #33 did not have a wander guard on her person. * On 5/17/18 at 4:00 PM- 4:36 PM, Resident #33 was laying on the couch without a cane or wander guard. The MDS Nurse was asked to see Resident #33 in the lobby. On 5/17/18 at 4:36 PM, the MDS Nurse acknowledged there were no staff and no assistive devices or wander guard present. He stated Resident #33 had not been cleared by the Physical Therapy Department. A 4/6/18 Physical Therapy Note documented Resident #33 was evaluated and treatment was ordered. The note documented Resident #33 required gait training, therapeutic activities, therapeutic exercise, neuro re-education, and manual interventions to address abnormal gait and mobility, 3 days per week. A 5/14/18 Physical Therapy Note documented Resident #33 was a fall risk with limited cognition. The note documented that Resident #33 had need of a single point cane with mobility, that she had intermittent confusion that improved as they worked together. On 5/18/18 at 1:08 PM, the Physical Therapist stated Resident #33 was still on services and required stand by assistance with transfers, bed mobility, and ambulation. The PT stated she should not be walking by herself and she required supervision and a cane. On 5/18/18 at 11:50 AM, the DON and LPN #1 stated they thought she was released from physical therapy. The DON said he was unaware of Resident #33's care plan for a wander guard.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and resident interview, review of the facility's bowel care protocol, and record review, it was determined the facility failed to consistently monitor bowel function for residents in accordance with standard nursing practice. This was true for 3 of 5 residents (#33, #68, and #82) assessed for ordered bowel regimen. The facility failed to implement a bowel protocol order for Residents #33 and #68 and failed to hold a bowel medication for Resident #82. Residents #33 and #68 had the potential for harm from constipation or impaction. Resident #82 had the potential for harm from electrolyte imbalance related to increased fluid loss and/or infection from excess fecal contamination of open excoriated skin. Findings include: On 5/17/18 at 1:40 PM, the DON provided typed nursing orders for bowel protocol as follows: * Prune juice 4-8 ounce every 24 hours as needed for bowel care if no bowel movement (BM) for 48 hours. * Milk of magnesia (MOM) Give 30 cc by mouth every 24 hours as needed for bowel care if no BM for 3 days. * Dulcolax Suppository insert 10 mg rectally every 24 hours as needed for bowel care if no results from MOM. * Fleet enema insert 1 unit rectally every 24 hours as needed for bowel care if no results from Dulcolax. 1. Resident #33 was admitted to facility on 2/14/17 with diagnoses which included traumatic brain hemorrhage, dementia, constipation, and cognitive communication deficit. A significant changed MDS assessment, dated 3/23/18, documented Resident #33 was severely cognitively impaired. The 4/1/18 through 4/30/18 Bowel Movement Record documented Resident #33 did not experience a bowel movement between 4/25/18 to 4/29/18 (4 days). The facility tracked all residents without a bowel movement in two days on a document called the Bowel Care List. The following was documented regarding Resident #33: * 4/27/18 - Resident #33 went two days without a bowel movement. There was no documentation prune juice was administered. * 4/28/18 Resident #33 went three days without a bowel movement and prune juice was administered and MOM was refused. * 4/29/18 Resident #33 went four days without a bowel movement and refused medication and suppository. Resident #33's 4/1/18 through 4/30/18 MAR did not document bowel protocol measures of prune juice, MOM, or a suppository were implemented or refused between those days. Resident #33's progress notes did not contain documentation she refused the bowel medications. Resident #33's Bowel Movement Record, Bowel Care List, Progress Notes, and MAR contained inconsistent data and conflicting interventions. On 5/17/18 at 12:00 PM, the DON stated staff was expected to treat residents with standard nursing practice and follow the bowel protocol. 2. Resident #82 was admitted to the facility on [DATE] with diagnoses which included morbid obesity, irritable bowel syndrome without diarrhea, and constipation The quarterly MDS assessment, dated 4/27/18, documented Resident #82 was cognitively intact and was always incontinent of bowel. On 5/14/18 at 3:58 PM, Resident #82 stated she was having too many loose water bowel movements. She said her bottom was raw and really hurt. Resident #82's physician's order dated 2/7/18, documented Resident #82 was to receive one Senna Plus tab by mouth two times a day. The order also documented to hold the medication for loose stools. An active order for Miralax was not found in Resident #82's medical record. The DON provided an order dated 1/29/18. Resident #82's Order Summary Report documented that on 2/7/18, the order for Miralax was discontinued. Resident #82's 3/1/18 through 5/14/18 MAR documented Resident #82 received 59 doses of Miralax out of 75 opportunities. The 5/1/18 through 5/14/18 Bowel Movement Record documented she was consistently experiencing 1 bowel movement per day except for the following: *On 5/6/18 Resident #82 had three documented bowel incontinent episodes. *On 5/9/18 Resident #82 had two bowel incontinent episodes. *On 5/12/18 Resident #82 had two bowel incontinent episodes. A Nursing Progress Note, dated 5/10/18, documented Resident #82 had redness to her groin and buttocks. The note documented Resident #82 frequently received incontinence care. On 5/15/18 at 9:20 AM, RN #1 stated she was aware Resident #82 was getting Miralax and Senna Plus daily and was aware Resident #82 was having frequent loose stools. RN #1 stated that Resident #82's skin excoriation was improving with new order for nystatin powder and ordered creams. The facility continued a discontinued order for Miralax for approximately 90 days and nursing staff failed to follow orders to hold the Senna Plus tab when Resident #82 experienced loose stools. 3. Resident #68 was admitted to the facility on [DATE] with multiple diagnoses, including dementia with behavioral disturbances and generalized muscle weakness. Resident #68's annual MDS assessment, dated 4/19/18, documented she was severely cognitively impaired, totally dependent on staff for ADL assistance, and received hospice care. Resident #68's care plan documented she was at risk for bowel and bladder incontinence related to dementia and staff were directed to monitor Resident #68 for constipation and treat per bowel protocol, check for incontinence with morning and afternoon cares, before meals and as needed, monitor and document the number of episodes of elimination, incontinence per shift. Resident #68's May 2018 physician's orders included: * Colace capsule 100 mg - give 2 capsules by mouth two times a day for constipation, * Miralax Powder 17 grams - mix 1 capful with glass of water or juice once a day for constipation * Milk of Magnesia (MOM) 30 cc - if no bowel movement for three days * Dulcolax suppository 10 mg - insert 1 suppository rectally every 24 hours for constipation if no results from Milk of Magnesia, * Fleet enema 7-19 grams - insert 1 unit rectally every 24 hours as needed for constipation if Dulcolax suppository is ineffective. Resident #68's Bowel Movement Records, dated 4/17/18 through 5/17/18, documented she did not have a bowel movement between: * 4/17/18 and 4/21/18 (5 days) * 5/8/18 and 5/11/18 (4 days) Resident #68's MAR, dated 4/17/18 through 5/17/18, did not document that she received MOM during the days she was constipated. On 5/17/18 at 1:48 PM, the DON reviewed the MAR and said MOM was not given to Resident #68 during the days she was constipated. The facility failed to follow the physician orders for bowel care during the periods when Resident #68 had no bowel movements for more than three days, which placed Resident #68 at risk for complication related to constipation.

Based on observation, staff interview, and review of facility policies and resident records, it was determined the facility failed to ensure the facililty consistently monitored a central venous catheter (CVC) used for dialysis. This was true for 1 of 1 (#3) resident reviewed for dialysis. This deficient practice placed Resident #3 at risk of infection, bleeding, or displacement of central venous catheter when the facility failed to assess the catheter daily and update the resident's care plan to include the central venous catheter and related interventions. Findings include: Resident #3 was admitted to facility on 2/21/17, with diagnoses which included end stage renal disease and a dependence on dialysis. An annual MDS assessment, dated 5/3/18, documented Resident #3 was cognitively intact. The facility's policy and procedure for dialysis documented: * Assess resident daily for function related to dialysis. * Any problems with the resident's access should be addressed IMMEDIATELY. * Excessive bleeding from graft site, redness, swelling, pain, or non-functioning graft requires medical attention and notification to the medical provider. * Documentation: Assess care given and condition of renal access. A Nursing Progress Note, dated 4/28/18, documented Resident #3 had a newly placed central venous catheter to the right chest for hemodialysis. Nursing Progress Note documented Resident #3's right chest CVC was assessed on 4/29/18, 4/30/18, 5/5/18, 5/6/18, and 5/10/18. On 5/14/18 a verbal order issued by a healthcare practitioner documented staff were to monitor Resident #3's dialysis catheter, to his right chest, one time a day until it was discontinued. The facility documented in Resident #3's care plan on 5/14/18, a new order to monitor CVC. The facility updated the treatment administration record (TAR) 5/14/18. The catheter was placed in right upper chest on 4/28/18. On 5/16/18 at 2:11 PM, the DON stated Resident #3's catheter was placed in April and the facility staff would monitor the site daily for a newly placed CVC and then periodically after that. The DON stated the staff did not assess the location daily as specified in the facility's policy, prior to 5/14/18. The DON stated there was no update to the care plan for the dialysis CVC prior to 5/14/18. The facility failed to ensure orders, monitoring, and a care plan were in place for a new dialysis CVC access site in a timely manner.

Based on observation, staff interview, and record review, it was determined the facility failed to ensure the medication error rate was less than 5%. This was true for 2 of 26 medications (7.69%) which affected 2 of 5 residents (#45 and #67) whose medication administration was observed. The failure created the potential for sub-therapeutic effect when Resident #45's powder laxative was mixed in less fluid than recommended and when Resident #67 was administered the wrong dose of an inhaled corticosteroid medication. Findings include: 1. On 5/17/18 at 8:00 AM, LPN #3 was observed as she poured 14 medications for Resident #45, including 17 grams (one capful) of polyethylene glycol powder. The dry powder was in a small plastic cup and the LPN poured 3 ounces of water in another small plastic cup. LPN #3 said she would mix the powder in the water in the resident's room if the resident agreed to take it. When LPN #3 said she was ready to take the medications to Resident #45, she was asked how much water was in the cup to mix with the polyethylene glycol powder. LPN #3 measured 3 ounces of water in the cup. LPN #3 then read the label on the bottle of polyethylene glycol which instructed 4 to 8 ounces of fluid and said that 3 ounces was not enough water. Immediately after that, LPN #3 obtained a larger glass with approximately 6 ounces of water, which she took to the resident's room with the medications. When the resident agreed to take the polyethylene glycol, the LPN mixed the powder in the 6 ounces of water and administered it to the resident. 2. On 5/17/18 at 5:45 PM, LPN #2, was observed as she poured 2 medications for Resident #67, including Flonase nasal spray. The pharmacy label on the Flonase instructed 2 sprays in each nostril daily as needed. The LPN administered 1 spray in each of the resident's nostrils. At 5:50 PM, LPN #2 was asked to reread the pharmacy label on the resident's Flonase, which she did. LPN #2 then read the physician's order and the MAR instructions for the Flonase, both of which documented 2 sprays daily as needed. LPN #2 said she misread the label instructions on the resident's Flonase. LPN #2 then returned to Resident #67's room and administered another spray of Flonase in each of the resident's nostrils.

Based on observation, staff interview, and record review, it was determined the facility failed to ensure pharmacy labels matched physician orders and the MAR for 1 of 23 prescription medications. This was true for 1 of 5 residents (#45) during medication pass observations. The failure created the potential for Resident #45's anticonvulsant medication, lamotrigine (anticonvulsant), to be administered at the wrong time. Findings include: On 5/17/18 at 8:00 AM, LPN #3 was observed as she poured 14 medications for Resident #45, including the lamotrigine. The lamotrigine pharmacy label documented the medication was to be administered at bedtime. When LPN #3 said she was ready to administer the medications, she was asked to reread the lamotrigine pharmacy label, which she did. LPN #3 said the resident's lamotrigine was always administered in the morning and that the pharmacy label was wrong. The LPN said she would contact the pharmacy about the error. Resident #45's active physician orders for May 2018, documented the lamotrigine was ordered one time since 3/2/18 and the May 2018 MAR documented it was scheduled for 7:00 AM daily. On 5/17/18 at 10:00 AM, LPN #1, said the pharmacy had been contacted about the label error for Resident #45's lamotrigine.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of a contract between a hospice provider and the facility, and staff interview, it was determined the facility failed to ensure care was coordinated with a hospice provider and duties of the hospice provider and the facility were delineated. This was true for 1 of 2 residents (#68) sampled for hospice care. The lack of communication and coordination created the potential for Resident #68 to receive inadequate care. Findings include: Resident #68 was admitted to the facility on [DATE] with multiple diagnoses, including dementia with behavioral disturbances and generalized muscle weakness. Resident #68's annual MDS assessment, dated 4/19/18, documented she was severely cognitively impaired, totally dependent on staff for ADLs assistance, and received hospice care. Resident #68's care plan documented she had a terminal prognosis related to Alzheimer's (problems with memory, thinking and behavior) disease and had elected to be DNR. Interventions included hospice to provide nursing, social services, clergy and ADL support, provide additional bathing and supply incontinent products, and directed staff were to call the hospice provider with questions or significant changes, keep the environment quiet, calm, dry, and wrinkle free, and keep lighting low and familiar objects near. On 5/16/18 at 4:10 PM, CNA #4 said the hospice representative came to the facility and provided nursing care to Resident #68 according to their schedule and checked in with the nurse. CNA #4 also stated the facility provided nursing care to Resident #68 24 hours a day. On 5/17/18 at 1:48 PM, the DON said the facility provided 24 hour services to Resident #68 and called the hospice provider when they had a concern with the resident. The DON provided a copy of the hospice care plan and facility contract with the hospice provider the following day. Included in the contract was Exhibit D Designation of Hospice & [and] Facility Roles and Responsibilities. The DON was unable to provide designation of duties between the facility and the hospice provider specific for Resident #68. This lack of communication or coordination of care between the facility and hospice provider placed Resident #68 at risk of lack of care by both providers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to ensure pneumococcal immunizations were administered consistent the current CDC recommendations and that pneumococcal immunization consent forms reflected the current CDC recommendations . This was true for 1 of 5 sampled residents (#33) reviewed for pneumococcal immunizations. Findings include: The CDC website, updated on 11/30/15, recommended pneumococcal vaccination (PCV13 or Prevnar13®, and PPSV23 or Pneumovax23®) for all adults 65 years or older as follows: *Give a dose of PCV 13 to adults 65 years or older who have not previously received a dose. Then administer a dose of PPSV23 at least 1 year later. *If the patient already received one or more doses of PPSV23, give the dose of PCV13 at least 1 year after they received the most recent dose of PPSV23. The CDC recommendation above was earlier issued 11/30/15. Resident #33 was readmitted to the facility on [DATE] with multiple diagnoses including traumatic subdural hemorrhage (brain injury) without loss of consciousness. Her age was greater than 65 years. Resident #33's immunization Electronic Medical Record (EMR) documented she required Prevnar13. On 5/17/18 at 11:00 AM, RN #3 said Resident #33 did not received Prevnar 13 according to the entry on her EMR. RN#3 said she would ask for Resident #33's paper chart from the medical records and look for more information regarding her vaccination. On 5/21/18 at 4:47 PM, the facility faxed Resident #33's consent for immunization dated 2/14/17 and February 2017's MAR to Bureau of Facility Standards (BFS). Resident #33's February 2017's MAR, documented she received Pneumococcal 23 vaccine on 2/20/17. No documentation was provided to describe the reason Resident #33 received the Pneumococcal 23 vaccine prior to the PCV 13 vaccine Documentation that Resident #33 received the PCV 13 vaccine a year after receiving the Pneumococcal 23 vaccine was not provided by the facility. Resident #33's consent form, dated 2/14/17, documented her Power of Attorney (POA) gave verbal consent for her to receive Pnu23. The facility's Pneumococcal Informed Consent form included the following information: *Clinical symptoms of pneumonia, *Population that should receive Pneumococcal Vaccine which include all adults [AGE] years of age and older, resident in care centers .Second dose is recommended for residents 65 years or older, that received first dose prior to age [AGE]. If second dose is given, it should be given 5 years after initial dose. *Clinical side effects of Pneumococcal Vaccine, and *Vaccine information statement provided to resident which included the resident had been educated on the benefits and risks associated with the Pneumococcal Polysaccharide Vaccine (PPSV). The facility's Pneumococcal Immunization Informed Consent form did not include information regarding the Prevnar13 vaccine or what type of Pneumococcal vaccine will be given after the first dose was administered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interview, and record review, it was determined the facility failed to ensure residents' beds positioned against a wall were assessed as potential restraints. This was true for 6 of 6 (#41, #45, #54, #68, #77, & #82) residents sampled for potential restraints. This deficient practice placed the residents at risk of having their beds placed against a wall as a method of restraint without assessment of the need and safety of the restraint. Findings include: 1. Resident #82 was admitted to the facility on [DATE] with diagnoses which included morbid obesity, she was unable to voluntarily move her left side of her body following a stroke. The quarterly MDS assessment, dated 4/27/18, documented Resident #82 was cognitively intact. The MDS assessment documented Resident #82 required extensive assistance of two staff members with bed mobility. The MDS assessment documented Resident #82 had impaired mobility on one side. On 5/14/18 at 3:58 PM, Resident #82's bed was observed against the wall. At that time, Resident #82 stated she had no idea why her bed was against the wall. On 5/16/18 at 4:44 PM, the DON stated he knew Resident #82's bed was against the wall. The DON stated there was no documentation of assessment of the bed against the wall as a potential restraint. 2. Resident #41 was admitted to the facility on [DATE] with diagnoses which included cerebral palsy, contractures of multiple joints, and pressure ulcers. A quarterly MDS assessment, dated 3/29/18, documented Resident #41 was cognitively intact and required extensive assistance of 2 staff members with bed mobility. On 5/14/18 at 10:10 AM, Resident #41's bed was observed positioned against the wall. Resident #41's clinical record did not include an assessment of her bed against the wall as a possible restraint. On 5/17/18 at 6:18 PM, LPN #3 stated Resident #41wanted the bed against the wall due to a fear of falling. LPN #3 stated the facility had not assessed residents' beds against the walls as potential restraints because they did not consider them restraints. 3. Resident #77 was readmitted to the facility on [DATE] with diagnoses which included muscle weakness, limitation of activity, and abnormalities of gait and mobility. An admission MDS assessment, dated 4/30/18, documented Resident #77 was cognitively intact and required extensive assistance of 2 staff members with bed mobility. On 5/14/18 at 11:40 AM, Resident #77's bed was observed positioned against the wall. Resident #77's clinical record did not include an assessment of his bed against the wall as a possible restraint. On 5/16/18 at 4:30 PM, the DON stated he was aware residents' beds were positioned against the wall. The DON stated he was not aware beds positioned against the wall was a potential restraint and stated the facility had not completed assessments. 4. Resident #68 was admitted to the facility on [DATE] with multiple diagnoses, including dementia with behavioral disturbances and generalized muscle weakness. Resident #68's annual MDS assessment, dated 4/19/18, documented she was severely cognitively impaired, required assistance of two staff members for bed mobility, transfer and toilet use. On 5/16/18 at 10:38 AM and 3:19 PM, and on 5/17/18 at 11:55 AM and 12:40 PM, Resident #68 was observed in her bed with her bed positioned against the wall. Resident #68's clinical record did not include an assessment of her bed against the wall as a possible restraint. On 5/16/18 at 4:30 PM, the DON stated he was not aware beds positioned against the wall was a potential restraint and the facility had not completed assessments. 5. Resident #45 was admitted to the facility on [DATE] with multiple diagnoses, including cellulitis (bacterial skin infection) of right lower leg. Resident #45's quarterly MDS assessment, dated 3/30/18, documented she was cognitively intact and required the assistance of one staff for bed mobility and transfer. On 5/14/17 at 12:49 PM and on 5/18/18 at 9:14 AM, Resident #45's bed was observed positioned against the wall. Resident #45's clinical record did not include an assessment of her bed against the wall as a possible restraint. On 5/16/18 at 4:30 PM, the DON stated the facility had not completed assessments of beds against the wall as potential restraints. 6. Resident #54 was admitted to the facility on [DATE] with multiple diagnoses, including stress fracture of the right humerus (bone of the upper arm) and generalized muscle weakness. Resident #54's quarterly MDS assessment, dated 4/10/18, documented she was moderately cognitively impaired, and required the assistance of two staff members for bed mobility, transfer and dressing. On 5/14/18 at 3:30 PM and 4:24 PM, Resident #54 was in bed sleeping, with her bed against the wall. Resident #54's clinical record did not include an assessment of her bed against the wall as a possible restraint. On 5/17/17 at 6:06 PM, LPN #1 said the residents' beds were positioned against the wall to give them more space in their rooms. LPN #1 said the facility did not assess the residents' beds against the wall as possible restraints because they did not consider a bed against the wall as a potential restraint.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and resident and staff interview, it was determined the facility failed to ensure residents and their representatives, if applicable, received a written summary of the baseline care plan. This was true for 4 of 8 residents (#16, #29, #31, and #49) whose baseline care plans were reviewed. The failure created the potential for harm when residents and their representatives were not included in planning the resident's care. Findings include: 1. Resident #29 was originally admitted to the facility on [DATE] with diagnoses which included general muscle weakness, abnormal gait/mobility, and dementia. The resident was discharged to a community setting on 11/17/17. Seventeen days later, on 12/4/17, the resident was readmitted to the facility from a hospital with new diagnoses, including right hip fracture & fractures of two fingers on the right hand. A admission MDS assessment, dated 12/11/17, documented Resident #29's cognition was moderately impaired, she was usually understood by others and usually able to understand others, and she and her legal representative participated in the assessment and goal setting. Resident #29's current care plan included problem areas and interventions created during her first stay in the facility (11/4/17 to 11/17/17) which were revised and initiated on 12/4/17 when she returned to the facility. The care plan areas revised and initiated on 12/4/17 included the potential for skin impairment, self care deficit, activities, risk for falls, potential for nutritional problems, and pain related to a history of hip and lumbar fractures. There was no documented evidence in Resident #29's clinical record that a written summary of the baseline care plan was given to the resident or her representative. On 5/18/18 at 11:40 AM, the DON, said he did not find documentation that a summary of the baseline care plan was given to Resident #29 or her representative. 2. Resident #31 was admitted to the facility on [DATE] with diagnoses which included right side hemiplegia related to cerebral infarction (stroke), dysphagia (difficulty swallowing), muscle weakness, and abnormal gait and mobility. The admission MDS assessment, dated 3/22/18, documented Resident #31's cognition was intact, she was understood by others and able to understand others, and she participated in the assessment and goal setting. On 5/18/18 at 10:15 AM, LPN #1 provided an Initial Care Plan, which she said was Resident #31's baseline care plan. The baseline care plan was signed by a nurse on 3/15/18. LPN #1 said there was no documentation that a baseline care plan summary was given to the resident. On 5/18/18 at 10:26 AM, Resident #31 said the facility did not review the plan for her care or give her papers within the first few days after she was admitted to the facility. 3. Resident #49 was originally admitted to the facility on [DATE] with multiple diagnoses which included left hip traumatic arthropathy (condition or disease of a joint), muscle weakness, abnormal gait, chronic pain syndrome, and Alzheimer's disease. The resident was discharged to an assisted living facility on 1/24/18. Sixteen days later, on 2/9/18, she was readmitted to the facility with the same diagnoses. An admission MDS assessment, dated 12/30/17, documented Resident #49's cognition was moderately impaired, she was usually understood by others and was usually able to understand others, and she and her family or significant other participated in the assessment and goal planning. An admission MDS assessment, dated 2/16/18, documented Resident #49's cognition was moderately impaired, she was usually understood by others and was usually able to understand others, and she and her legal guardian or legal representative participated in the assessment and goal planning. On 5/17/18 at 6:15 PM, LPN #1 provided an Initial Care Plan, dated 12/24/17, which she said was Resident #49's baseline care plan for the 12/24/17 admission and the baseline care plan for the 2/9/18 admission was integrated into the comprehensive care plan. LPN #1 said the baseline care plans were not given to Resident #49 or her representative. 4. Resident #16 was admitted to the facility on [DATE], with diagnoses which included cancer of the small intestine, intestinal obstruction, anxiety, and pain. A admission MDS assessment, dated 2/20/18, documented Resident #16's cognition was severely impaired, she was understood by others, she was able to understand others, and she participated in the assessment and goal setting. On 5/17/18 at 6:15 PM, LPN #1 provided an Initial Care Plan, dated 2/14/18, which she said was Resident #16's baseline care plan. LPN #1 said Resident #16's baseline care plan was not given to the resident or her representative.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident #41 was admitted to the facility on [DATE] with diagnoses which included cerebral palsy, contractures of multiple joints, and pressure ulcers. A quarterly MDS assessment, dated 3/29/18, documented Resident #41 was cognitively intact and required extensive assistance of 2 staff members with bed mobility. On 5/14/18 at 10:10 AM, Resident #41's bed was observed positioned against the wall. Resident #41's care plan did not document her bed was positioned against the wall. On 5/17/18 at 6:18 PM, LPN #3 stated the resident wanted the bed against the wall due to a fear of falling. LPN #3 stated the facility had not documented Resident #41's bed position in the care plan. 5. Resident #77 was readmitted to the facility on [DATE] with diagnoses which included muscle weakness, limitation of activity, and abnormalities of gait and mobility. An admission MDS assessment, dated 4/30/18, documented Resident #77 was cognitively intact and required extensive assistance of 2 staff members with bed mobility. On 5/14/18 at 11:40 AM, Resident #77's bed was observed positioned against the wall. Resident #77's care plan did not document his bed was positioned against the wall. On 5/16/18 at 4:30 PM, DON stated he was aware residents' beds were positioned against the wall. The DON stated beds positioned against the wall were not included in residents' care plans. 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. This was true for 6 of 18 sampled residents (#18, #41, #45, #54, #68, and #77) whose care plans were reviewed. The residents' care plans did not address the bed positioned against the wall as a possible restraint, and the setting for the use of a CPAP (Continuous Positive Airway Pressure) machine, which created the potential for residents to receive inappropriate or inadequate care with subsequent decline in health. Findings include: 1. Resident #68 was admitted to the facility on [DATE] with multiple diagnoses, including dementia with behavioral disturbances and generalized muscle weakness. Resident #68's annual MDS assessment, dated 4/19/18, documented she was severely cognitively impaired, and required assistance of two staff members for bed mobility, transfer and toilet use. On 5/16/18 at 10:38 AM and 3:19 PM, and on 5/17/18 at 11:55 AM and 12:40 PM, Resident #68 was observed in her bed with her bed positioned against the wall. Resident #68's care plan did not address the positioning of her bed against the wall. On 5/16/18 at 4:30 PM, the DON stated he was not aware a bed positioned against the wall was a potential restraint and the facility did not include them in resident care plans. 2. Resident #45 was admitted to the facility on [DATE] with multiple diagnoses, including cellulitis (bacterial skin infection) of right lower leg. Resident #45's quarterly MDS assessment, dated 3/30/18, documented she was cognitively intact and required the assistance of one staff member for bed mobility and transfer. On 5/14/17 at 12:49 PM and on 5/18/18 at 9:14 AM, Resident #45's bed was observed positioned against the wall. Resident #45's care plan did not document her bed was positioned against the wall. On 5/16/18 at 4:30 PM, the DON stated he was not aware a bed positioned against the wall was a potential restraint and the facility did not include them in resident care plans. 3. Resident #54 was admitted to the facility on [DATE] with multiple diagnoses, including stress fracture of the right humerus (bone of the upper arm) and generalized muscle weakness. Resident #54's quarterly MDS assessment, dated 4/10/18, documented she was moderately cognitively impaired, and required an assistance two staff members for bed mobility, transfer and dressing. On 5/14/18 at 3:30 PM and 4:24 PM, Resident #54 was in bed sleeping, with her bed against the wall. Resident #54's care plan did not document her bed was positioned against the wall. On 5/17/17 at 6:06 PM, LPN #1 said the residents' bed were positioned against the wall to give them more space in their room. The LPN said the facility did not included bed against the wall in the residents' care plan because they did not consider bed against the wall as a potential restraint. 6. Resident #18 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Parkinson's disease and heart failure. A quarterly MDS assessment, dated 5/9/18, documented Resident #18's cognition was intact; she needed extensive assistance with most ADLs; and section O, regarding respiratory treatments, was blank. Resident #18's current care plan included altered respiratory status/difficulty breathing related to Sleep Apnea on 3/12/18. One interventions was, Provide CPAP [continuous positive airway pressure] as ordered. It was initiated on 3/12/18. Resident #18's active orders for 3/1/18 to 5/31/18 included a 5/2/18 order for CPAP per settings every night shift. On 5/14/18 at 11:33 AM and through out the survey, a CPAP machine and mask were observed on Resident #18's bedside table. On 5/17/18 at 6:20 PM, when asked what the care plan was for Resident #18's CPAP, LPN #2 reviewed the resident's care plan, then the CPAP order, then said the setting for CPAP was not documented. On 5/17/18 at 7:30 PM, RN #6 said she applied Resident #18's CPAP at night. When asked what the care plan was for the CPAP settings, RN #6 reviewed the resident's care plan, then the CPAP order, then said the setting for the CPAP was not documented. On 5/21/18 at 4:35 PM, the facility faxed Resident #18's order, dated 11/21/17, for CPAP PS [pressure setting] 12 for obstructive sleep apnea.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident #3 was admitted to facility on 2/21/17, with diagnoses which included end stage renal disease and a dependence on dialysis. An annual MDS assessment, dated 5/3/18, documented Resident #3 was cognitively intact. A Nursing Progress Note, dated 4/28/18, documented Resident #3 had a newly placed central venous catheter (CVC) to right chest for hemodialysis. Resident #3's care plan, initiated on 5/9/18, documented staff were to assess his fistula daily. The care plan was not updated when the dialysis access site was changed from a fistula to a CVC on 4/28/18. The facility obtained an order to assess Resident #3's CVC to right upper chest daily until discontinued, on 5/14/18. On 5/16/18 at 2:11 PM, the DON stated Resident #3's care plan was not updated to reflect the CVC prior to 5/14/18. The DON stated the facility did not have a strict policy when to revise a care plan. Based on record review and staff interview, it was determined the facility failed to ensure care plans were revised as residents' needs changed. This was true for 4 of 18 residents (#3, #41, #77, and #187) whose care plans were reviewed. The failure created the potential for harm when: * Resident #3's care plan was not revised when his dialysis access device was changed. * Resident #41's care plan was not revised to include all of her specific signs and symptoms of depression. * Resident #77's care plan was not revised after he was removed from isolation precautions after active C-diff (a serious infection of the colon that causes severe diarrhea). * Resident 187's family was not a part of the comprehensive care planning process. Findings include: 1. Resident #187 was readmitted to the facility 8/15/17 with diagnoses which included respiratory failure, acute kidney failure, and heart disease. A quarterly MDS assessment, dated 7/7/17, documented Resident #187 was cognitively intact and was dependent on staff with most cares. a. An IDT approach was not utilized during Resident #187's comprehensive care planning process as follows: A Progress Note, dated 7/18/17, documented a care conference was held for Resident #187 and social services and a CNA were present at the meeting. The note documented the resident was invited to attend and no other parties were invited. On 5/17/18 at 1:50 PM, the Social Services Director and Licensed Social Worker (LSW) stated letters were sent out to residents' family members a week in advance of a care conferences inviting them to attend. The Social Services Director and LSW were unable to provide documentation of when or who a letter was sent to regarding Resident #187's 7/18/17 care conference meeting. b. A care plan conference was not held after Resident #187 was readmitted from the hospital as follows: Resident #187's clinical record did not contain a care plan conference dated after her readmission of 8/15/17. On 5/17/18 at 1:50 PM, the Social Services Director stated a care conference would occur 24 - 48 hours after readmission from a hospital stay. The Social Services Director stated she did not know why this did not occur after Resident #187 was readmitted on [DATE]. 2. Resident #41 was admitted to the facility on [DATE] with diagnoses which included depression. A quarterly MDS assessment, dated 3/29/18, documented Resident #41 was cognitively intact and had minimal signs and symptoms of depression. Resident #41's care plan, dated 3/29/18, documented she was at risk for depression and anxiety and refused cares at times. The care plan documented Resident #41 would remain free of signs and symptoms of distress, symptoms of depression, anxiety, or sad mood through the review date. Resident #41's MAR, dated 5/1/18 through 5/17/18, documented depression presented as crying, sad worried facial expressions, and voicing depression. On 5/18/18 at 10:00 AM, the LSW stated Resident #41's symptom of depression was occasionally refusal of cares. The LSW stated Resident #41 previously refused care often and now she did not refuse care as often. The LSW stated the facility monitored the refusals in nursing progress notes. The LSW stated Resident #41's main sign and symptom of depression listed on the care plan was sad mood. On 5/18/18 at 10:15 AM, the Social Services Director stated Resident #41's depression signs and symptoms on the MAR did not match the care plan. 3. Resident #77 was readmitted to the facility on [DATE] with diagnoses which included colitis and C-diff. An admission MDS assessment, dated 4/30/18, documented Resident #77 was cognitively intact. Resident #77's care plan, dated 4/23/18, documented he had active C-diff on admission from the hospital. C-diff is contagious and can be spread from person-to-person by touch or by direct contact with contaminated objects and surfaces. Isolation and contact precautions are necessary to avoid the spread of the infection to others. Resident #77's discharge instructions from the hospital, dated 4/23/18, documented he did not require isolation. On 5/14/18 at 11:40 AM, Resident #77 was observed in a recliner chair with staff entering the room and there were no isolation precautions present at the entrance of the door or notifications. On 5/18/18 at 1:20 PM, the DON stated the care plan should not have documented Resident #77 had active C-diff. On 5/18/18 at 1:20 PM, LPN #1 stated Resident #77 was having formed stools while in the hospital and the hospital did not have him on contact precautions. The Nurse Manager said Resident #77 was not placed on precautions at the facility upon admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of I&A reports, and resident and staff interview, it was determined the facility failed to ensure appropriate alternatives were identified and attempted, consents obtained, and safety assessments were completed prior to the installation of bed rails. This was true for 5 of 7 sample residents (#16, #31, #41, #49, and #54) reviewed for bed rail use. The failure created the potential for harm if residents were to become entrapped in bed rails, experience falls, or were otherwise injured due to the use of bed rails. Findings include: 1. Resident #41 was admitted to the facility on [DATE] with diagnoses which included cerebral palsy, abnormal posture, and contractures of bilateral upper extremities including shoulders, elbows, wrists, and hands. A quarterly MDS assessment, dated 3/29/18, documented Resident #41 was cognitively intact and required extensive assistance of 2 staff members with bed mobility. The MDS assessment documented bed rails were not used as a restraint. The assessment documented Resident #41 had range of motion and functional limitation impairment in both upper and lower extremities. Resident #41's care plan, dated 12/19/17, documented she required 2 staff member assistance with bed mobility to reposition. The care plan also documented Resident #41 had bilateral 1/4 bed rails to promote independence with bed mobility. The care plan contradicted itself. An Initial Nursing Assessment, dated 12/18/17, documented Resident #41 had contractures to her hands, fingers, hips, knees, and foot. The assessment documented she had weakness to her right and left arms and legs. The assessment documented she had range of motion impairments to her neck, shoulders, elbows, wrists, fingers, hips, knees, ankles, toes, and other joints. The assessment documented she had Full Loss of voluntary movement to the same areas. An I&A Report, dated 12/23/17, documented Resident #41 was found on the floor on her right side. Resident #41's bilateral 1/4 bed rails were observed in the raised position on 5/14/18 at 10:10 AM, 5:33 PM, and 5:49 PM; and on 5/15/18 at 11:00 AM. On 5/14/18 at 5:33 PM, Resident #41 was receiving pericare from CNA #3 and CNA #2. CNA #3 and CNA #2 were observed turning and repositioning Resident #41 throughout the observation. Resident #41 did not utilize the bed rails to assist the CNAs with positioning during the observation. Resident #41 was observed while CNA #2 and CNA #3 utilized a mechanical lift to place her into her wheelchair. On 5/14/18 at 5:49 PM, Resident #41 was observed with contractures to her extremities. Resident #41's Restraint Enabling Device Safety Evaluation, dated 4/20/18, was completed after the bilateral bed rails were in place. The evaluation did not include Resident #41's diagnoses of cerebral palsy and did not include an evaluation of the risk for entrapment. The evaluation documented Resident #41 was able to utilize the bed rails to promote independence with bed mobility and the bed rails were not considered a restraint. Resident #41's bed rail consent form, dated 5/14/18, was completed after the bilateral bed rails were in place. On 5/17/18 at 6:18 PM, LPN #3 stated the resident wanted the bed rails due to a fear of falling. LPN #3 stated the manufacturer of Resident #41's bed frame required bed rails for safety purposes, due to the air mattress. 5. Resident #54 was admitted to the facility on [DATE] with multiple diagnoses, including stress fracture of the right humerus (bone of the upper arm) and generalized muscle weakness. On 5/14/18 at 3:30 PM and 4:24 PM, Resident #54 was observed in bed sleeping, with her bed against the wall, and the left bed rail was observed in the raised position. Resident #54 care plan did not document the use of a bed rail. There was no documentation found in Resident #54's clinical record that the bed rail was assessed for safety, consent signed for bed rails, or an order was obtained for use of bed rails. On 5/15/18 at 10:44 AM, RN #3 said Resident #54 should not have a bed rail and she did not know why her bed rail was in place. RN #3 also said residents who have bed rails should have a physician's order, be assessed for safety, and have the bed rails included on their care plans. On 5/15/18 at 11:10 AM, Resident #54 said her bed rail was always in the raised position. 2. Resident #16 was admitted to the facility on [DATE] with multiple diagnoses which included general muscle weakness and abnormal mobility. An admission MDS assessment, dated 2/20/18, documented Resident #16's cognition was severely impaired, extensive assistance with bed mobility and transfers was required, and bed rails were not used as a restraint. Resident #16's comprehensive care plan for ADL self care deficit included an intervention for bilateral 1/4 bed rails to promote independence with bed mobility. The intervention was initiated 3/18/18. The resident's active physician orders documented the bed rails were ordered on 3/18/18. Resident #16 was observed in bed with the bilateral bed rails in the raised position on 5/14/18 at 10:45 AM and 3:50 PM; on 5/15/18 at 10:12 AM, 11:30 AM, 12:44 PM, and 2:41 PM; on 5/16/18 at 12:15 PM and 2:15 PM, and 5/17/18 at 10:03 AM. A Restraint/Enabling Device/Safety Device Evaluation, dated 3/18/18, documented Resident #16 was a New Admit. The evaluation documented the bed rails were not a restraint and that the resident was able to utilize the bed rails safely to promote independence with bed mobility. The evaluation did not include an assessment of the resident for risk of entrapment. On 5/17/18 at 6:18 PM, LPN #3 said Resident #16 wanted the bed rails. 3. Resident #31 was admitted to the facility on [DATE] with multiple diagnoses which included right side hemiplegia (one side paralysis) and general muscle weakness. Resident #31's admission MDS assessment, dated 3/22/18, documented intact cognition, extensive assistance by 2 people was needed for bed mobility and transfers, functional limitation in ROM in 1 upper extremity and 1 lower extremity, and bed rails were not used as a restraint. Resident #31's baseline care plan and comprehensive care plan for falls, both dated 3/15/18, documented one intervention was, Side rails as ordered. The comprehensive care plan for ADL self care deficit, dated 3/15/18, documented bilateral 1/4 bed rails were initiated on 4/16/18. Resident #31's left bed rail was observed in the raised position on 5/14/18 at 4:15 PM; on 5/15/18 at 10:00 AM, 11:00 AM, 12:22 PM and 2:22 PM; and on 5/16/17 at 11:13 AM. On 5/18/18 at 10:26 AM, bilateral bed rails were observed in the raised position and Resident #31 said she used the bed rails to help her move in bed and to get in and out of bed. A bed rail consent, dated 3/15/18, documented Resident #31 consented to the use of one upper bed rail on the right side. Another bed rail consent, dated 4/28/18, documented the resident consented to the use of bilateral upper bed rails. A Restraint/Enabling Device/Safety Device Evaluation, dated 4/16/18, documented Resident #31 was a New Admit. The evaluation documented, Resident desires use of side rail .and .is able to use device safely. No other Restraint/Enabling Device/Safety Device Evaluations were found in Resident #31's clinical record and the facility did not provide any other bed rail evaluations. An assessment of Resident #31's risk of entrapment was not completed prior to the implementation of any bed rail. In addition, the consent for the bilateral bed rails was obtained 12 days after the bed rails were placed on the resident's bed. On 5/17/18 at 6:18 PM, LPN #3 said the 4/28/18 consent was late and the resident wanted the bed rails. 4. Resident #49 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses which included left hip traumatic arthropathy (condition or disease of a joint), muscle weakness, abnormal gait, chronic pain syndrome, and Alzheimer's disease. Resident #49's admission MDS assessments, dated 12/30/17 and 2/16/18, both documented moderately impaired cognition, usually understood by others and usually able to understand others, extensive assistance with bed mobility and transfers required, and bed rails were not used as a restraint. Resident #49's ADL self care deficit care plan, initiated 12/24/17 and revised 2/22/18, documented bilateral bed rails were initiated on 3/18/18. The resident's active physician orders documented bilateral bed rails were ordered on 3/18/18 to promote independence with bed mobility. Bilateral bed rails were observed in the raised position on Resident #49's bed on 5/14/18 at 10:30 AM, 11:20 AM and 4:18 PM; on 5/15/18 at 10:03 AM, 11:00 AM, and 12:30 PM; and on 5/16/18 at 2:31 PM. A Restraint/Enabling Device/Safety Device Evaluation, dated 3/18/18, documented Resident #49 was a New Admit. There was no documented evidence in Resident #31's clinical record that an assessment of the resident for risk of entrapment was completed prior to the implementation of the bed rails. Resident #31 signed a consent for bilateral bed rails on 5/1/18, 49 days after the bed rails were implemented. On 5/17/18 at 6:18 PM, LPN #3 said the bed rails were initiated because the resident wanted them and that consent for the bed rails was obtained after the bed rails were implemented.

Based on observation and staff interview, it was determined the facility failed to ensure hand hygiene was performed and completed correctly, tube feeding product was refrigerated after opened and unused, and catheter bags did not touch the floor. This was true for 4 of 18 residents (#18, #41, #56, and #135) reviewed for infection control. These failures created the potential for the spread of infection among residents. Findings include: The Centers for Disease Control and Prevention (CDC) recommend the following procedure for hand hygiene with soap and water: * Wet hands first with water, * Apply the recommended amount of anti-bacterial soap, * Rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers, * Rinse hands with water and use disposable towels to dry, and * Use towel to turn off the faucet. The CDC guidelines also documented other entities had recommended cleaning hands with soap and water for approximately 20 seconds and documented either amount of time was acceptable. Best Practice for Managing Tube Feeding A Nurse's Pocket Manual, dated 2015, documented Preventing Contamination of Formula and Delivery System Used for Adults . 3. Maintain proper storage and handling of formula: A. Thoroughly clean the top of formula containers before opening B. Record date/time formula is opened C. Cover opened, unused formula in refrigerator . The above standards of practice were not followed. Examples include: 1. On 5/14/18 from 11:52 AM and 12:21 PM, CNA #1 was observed during the lunch meal service in the Big Band Dining Room feeding Resident #56 and Resident #135 their beverages and their lunch meals. CNA #1 was observed through the observation with her chin rested on the palm of her left hand and her fingernails curled into her mouth, scratching her face, brushing her hair out of her face, and wiping her own mouth off while continuing to feed Resident #56 and Resident #135. CNA #1 was observed using her left hand to adjust the edge of Resident #56's straw after she had wiped the corner of her mouth with her left hand. Throughout the observation CNA #1 did not perform hand hygiene practices. On 5/14/18 at 12:54 PM, CNA #1 stated she did not realize she had touched her face. 2. On 5/14/18 from 10:11 AM to 5:19 PM an opened and used container of Jevity 1.2 (tube feeding formula) was observed placed on a bedside table with a control method to cool it down. This was also observed on 5/15/18 at 11:00 AM. On 5/15/18 at 11:13 AM, the DON was shown the standards of practice for tube feeding safety and stated, the tube feeding formula should be refrigerated if not used. 3. On 5/14/18 at 5:33 PM, Resident #41 was receiving pericare from CNA #3 and CNA #2. CNA #3 removed the soiled attends and proceeded to wipe the resident with wet wipes. CNA #3 took her gloves off and asked CNA #2 to finish while she washed her hands. CNA #3 disposed of the soiled attends and gloves and approached the sink to wash her hands. CNA #3 turned the water on, applied soap, rinsed her hands, and turned the water off within 7 seconds. While CNA #3 was washing her hands, CNA #2 continued to clean Resident #41. CNA #2 and CNA #3 applied Resident #41's clean attends and handled the sling for a mechanical lift with her used gloves. CNA #2 did not change her gloves or wash her hands after transition between dirty to clean. CNA #2 assisted Resident #41 into her wheelchair with the used gloves and touched Resident #41's blanket that went between her contracted legs. Once Resident #41 was situated in the chair CNA #2 removed her gloves and washed her hands, turned the water on, applied soap, rinsed her hands, and turned the water off within 5 seconds. 4. On 5/14/18 at 5:56 PM, Resident #18's catheter drainage bag was observed on the floor in a dining room. On 5/14/18 at 6:01 PM, RN #5 stated the catheter bag was not attached properly to Resident #18's wheelchair. RN #5 stated the catheter bag should not have touched the floor. On 5/17/18 at 11:07 AM, RN #3 who identified herself as the Infection Control Nurse said the facility performed hand washing surveillance every 3 months randomly. RN #3 stated staff should wash their hands before and after resident contacts and when their hands were visibly soiled staff should wash their hands. RN #3 stated the facility staff could utilize hand sanitizer or soap and water throughout the facility.

Based on observation and staff interview, it was determined the facility failed to ensure measures were in place to prevent possible cross-contamination of dirty to clean areas in the kitchen. This affected 16 of 16 (#3, #16, #18, #29, #31, #33, #41, #45, #49, #54, #56, #67, #68, #77, #82, and #135) sample residents who resided in the facility and the 65 other residents who dined in the facility. This failure created the potential for harm if residents contracted foodborne illnesses. Findings include: On 5/17/18 at 2:27 PM, a Dishwasher and Dietary Aide (DA) #1were observed during the dish washing process. DA #1 was observed during the dishwashing process placing cleaned dried dishes into their storage areas. DA #1 was not wearing an apron. DA #1 removed the cleaned dishes from the trays and rested the clean dishes against her chest to carry them towards their storage area. The Certified Dietary Manager (CDM), present during the observation, stated this was not the correct procedure for handling clean dishware. She stated DA #1 should not allow dishes to touch her body while carrying dishes. The CDM stated the dishes should be carried away from the body or placed on a cart to transport them to the appropriate area. The CDM had the Dishwasher re-sanitize the dishes.