**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure two residents of 42 sampled residents' (R) Resident Assessment Instruments ([NAME]) accurately reflected the resident's hospice designation for R88 and ability to communicate for R58. This failure could result in the residents' needs, strengths, and areas of decline not being addressed appropriately for R 88 and R58. The findings include: During an interview with the Director of Nursing (DON) on 06/27/2024 at 10:32 AM, she stated she would check for a specific policy related to accurate Minimum Data Set (MDS) Assessments; however, further stated the facility followed the Centers for Medicare and Medicaid Services (CMS) RAI Manual for MDS instructions. No additional policy was provided. 1. Review of R88's undated admission Record located in the electronic medical record (EMR) under the Census tab revealed the facility admitted the resident on 04/16/2021, with diagnoses including advanced dementia, depressive disorder, and anxiety disorder. Review of R88's IDG Hospice Report dated 08/02/2023, located in the resident's EMR under the Resident Documents: Hospice/Palliative tab revealed R88 was admitted to [Hosparus] Care for hospice/comfort care on 05/20/2023. Review of R88's Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 02/20/2024, located in the resident's EMR under the MDS tab, revealed the MDS did not accurately reflect R88's hospice designation. Continued review revealed the facility also failed to identify R88's hospice status on the Annual MDS Assessment with the ARD of 05/22/2024. During an interview on 06/27/2024 at 9:08 AM, MDS 1 and MDS 2 stated, When a resident is on hospice, Section O should be coded for hospice services. It looks like we missed that for her (R88) . 2. Review of R58's undated admission Record located in the resident's EMR revealed he was admitted to the facility on [DATE], with diagnoses including cerebral palsy and communication deficits (deaf and nonverbal). Review of R58's Annual MDS Assessment with an ARD of 08/22/2023, located in the resident's EMR under the MDS tab revealed the MDS Section B indicated R58 had no speech. Review of the Quarterly MDS Assessment with an ARD of 05/14/2024, revealed Section B indicated R58 had no speech. In interview on 06/27/2024 at 9:08 AM, MDS 1 and MDS 2 stated R58 communicated with others through use of his iPad; however, they failed to capture that information in the communication section (Section B) of the MDS Assessments. They stated that tool was how R58 made his needs known to staff. MDS 1 and MDS 2 concurred that R58's two MDS Assessments had been coded as the resident had no speech, however, the resident was able to make himself understood with the tools provided by the facility.

Based on interview, and record review, the facility failed to ensure three of three residents (R) reviewed out of a sample size of 42 for Skilled Nursing Facility (SNF) Beneficiary Protection Notification, (R381, R71, and R95) whose Medicare therapy services were terminated, received an estimated cost for services if they chose to pay for the services themselves. This had the potential for residents not to be able to make an informed decision as to whether to continue therapy services. The findings include: The State Survey Agency (SSA) Contractor Surveyor asked the Administrator for the facility's Beneficiary Notice of Medicare Non-Coverage policy; however, such policy was not provided prior to exiting the survey. 1. Review of the undated Resident Face Sheet located in the electronic medical record (EMR) under the Face Sheet tab for R381, revealed the facility admitted the resident on 01/11/2024. Review of the information provided by the facility for R381 revealed the resident was discontinued from skilled therapy services on 01/30/2024, due to having exhausted the Medicare benefit days. Review of R381'sSkilled Nursing Facility Advance Beneficiary Notification of Non-coverage (SNF ABN) Form CMS-10055 revealed under the heading (Estimated Cost), no cost was listed. Therefore, R381 was not allowed the right to make an informed decision about continuing skilled services. 2. Review of the undated Resident Face Sheet located in the EMR under the Face Sheet tab for R71 revealed the facility admitted the resident on 06/26/2023. Review of the EMR revealed R71 had Medicare benefits and had been discontinued from skilled therapy services on 01/19/2024, due to exhausting the Medicare benefit days. Further review of R71's SNF ABN Form CMS-10055 revealed under the heading (Estimated Cost), no cost was listed. Therefore, R71 was not allowed to make an informed decision about continuing skilled services. 3. Review of the undated Resident Face Sheet located in the EMR under the Face Sheet tab for R95 revealed the facility admitted the resident on 02/28/2024. Continued review of the EMR revealed R95 had Medicare benefits and had been discontinued from skilled therapy services on 04/26/2024, related to exhausting the Medicare benefit days. Further review of R95's SNF ABN Form CMS-10055 revealed under the heading (Estimated Cost), no cost was listed. Therefore, R95 was not allowed to make an informed decision about continuing skilled services. During an interview on 06/25/2024 at 11:20 AM, the Business Office Manager (BOM), asked if she knew the estimated cost had to be filled in on the SNF ABN Form CMS-10055 document so residents would know the cost if they wanted to continue services. The BOM stated, I did not know that it had to be filled in with the cost. They all chose Option 3 where they are not responsible for paying and I can't appeal to see if Medicare would pay. I do not think that I have ever filled in the cost.

Based on interview, record review, and review of the facility policy, it was determined the facility failed to ensure each resident was treated with respect and dignity and ensure care was provided in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality, for two (2) of thirty-three (33) sampled residents (Residents #38 and #67). The findings include: Review of the facility's policy, Resident Rights, revised 08/16/18, revealed all residents have the right to be treated with respect and dignity. These rights will be promoted and protected by the facility. All residents will be treated in a manner and in an environment that promotes maintenance or enhancement of quality of life. Further review of the policy revealed when providing care and services, the stakeholders will respect the resident's individuality and value their input by providing them a dignified existence, through self-determination and communication with and access to persons and services inside and outside the facility. 1. Record review revealed the facility admitted Resident #38 on 07/04/18 with diagnoses which included Atherosclerotic Heart Disease, Muscle Weakness, Major Depressive Disorder, and Essential Hypertension. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 12/26/18, revealed the facility assessed Resident #38's cogntion as intact with a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resdient was interviewable. Interview with Resident #38, on 02/19/19 at approximately 10:20 AM, revealed there was not a lot of help during the night shift and he/she had issues receiving assistance from Certified Nurse Aide (CNA) #5. He/she stated every night when CNA #5 worked, it was always a bad night for me. Resident #38 stated CNA #5 does not want to provide assistance to him/her and made the resident feel guilty for asking for assistance or needing help. Resident #38 stated the other night when CNA #5 provided incontinent care for him/her, the CNA left him/her on the bedpan for over an hour. Resident #38 stated he/she got himself/herself off the bedpan without assistance and accidentally spilled urine on the bed. He/she stated when CNA #5 came into the room and observed the bedpan spilled, the CNA told Resident #38 he/she spilled it on purpose so the CNA would have to clean it up. Resident #38 stated when CNA #5 told her/him that, it made him/her feel belittled. Resident #38 stated CNA #5 never asked him/her if he/she needed assistance and never offered to help either. 2. Record review revealed the facility admitted Resident #67 on 09/07/16 with diagnoses which included Parkinson's Disease, Muscle Weakness, Major Depressive Disorder, and Hypertensive Heart Disease. Review of the Quarterly MDS assessment, dated 12/27/18, revealed the facility assessed Resident #67's cognition as intact with a BIMS score of fifteen (15), which indicated the resdient was interviewable. Interview with Resident #67, on 02/19/19 at approximately 10:40 AM, revealed staff do not provide her/him any incontinent care during the night shift. Resident #67 stated last night, on 02/18/19 during the night shift, CNA #5 and CNA #6 came into the resident's room and brought Registered Nurse (RN) #3 as a witness. Resident #67 stated CNA #5 and CNA #6 removed his/her incontinent brief and laid it on the bed. Resident #67 stated CNA #5 then took the brief and rubbed her finger around the edges of the brief, and stated to RN #3 the brief was not wet. CNA #5 told RN #3 the resident did not need any care provided. Resident #67 stated RN #3 left the room and CNA #5 told him/her that she would not come back into the resident's room for the remainder of the evening shift or answer his/her call light. Resident #67 stated RN #3 never said anything to CNA #5 during this incident, and the RN was no longer present when the CNA said she would not answer the call light. Resident #67 stated he/she had an ongoing issue with CNA #5 and had reported her/his concerns to RN #2; however, there continued to be issues. Resident #67 stated he/she felt humiliated when CNA #5 removed his/her incontinent brief in front of CNA #6 and RN #3, in an attempt to show the resident did not need any care to be provided. Attempted interviews on 02/21/19 with CNA #6, at 1:15 PM; RN #3 at 1:16 PM, RN #2 at 1:18 PM, and CNA #5 at 3:00 PM with messages left; however, CNA #6, RN #3, RN #2, and CNA #5 did not return the Surveyor's call. Interview with the Director of Nursing (DON), on 02/21/19 at approximately 2:32 PM, revealed she was unaware of the allegations by both residents. The DON stated her expectation was for all staff to provide care to all residents in a respectful and dignified manner. The DON also expressed her apologies due to her staff not returning the Surveyor's calls to discuss the allegations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure that each resident who experiences a significant change in status is comprehensively assessed using the CMS-specified Resident Assessment Instrument (RAI) process, for two (2) of thirty-three (33) sampled residents (Residents #86 and #87). The findings include: Review of the facility's policy, MDS Assessment Completion, revised 02/16, revealed the facility will conduct and submit resident assessments in accordance with the RAI Manual including deferral and state submission timeframes. Further review revealed a Significant Change in Status assessment will be completed on the fourteenth (14th) calendar day after determination of a Significant Change in status. 1. Record review revealed the facility admitted Resident #86 on 10/06/17 with diagnoses which included Dementia with Behavioral Disturbances, Hypothyroidism, Osteoarthritis and Gastroesophageal Reflux disease (GERD). Review of the Quarterly Minimum Data Set (MDS) assessment, dated 01/29/19, revealed the facility assessed Resident #86's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of (6), which indicated the resident was not interviewable. Review of a Quarterly MDS, dated [DATE], Section G, revealed his/her Activities of Daily Living (ADL's) were coded as follows: Bed: 2/2, Transfer: 1/1, Eating: 1/1, and Toileting: 1/1. Additionally, review of the Quarterly MDS, dated [DATE], Section G, revealed his/her ADL's were coded as Bed: 2/2, Transfer: 2/2, Eating: 1/2, and Toileting: 2/2. Record review revealed Resident #86 went from requiring set-up assistance by staff to requiring limited assistance in two (2) of the care areas (Transferring and Toileting); however, there was no evidence a Significant Change MDS was completed. 2. Record review revealed the facility admitted Resident #87 on 02/18/13 with diagnoses which included Advanced Dementia, Hypothyroidism, Anemia, and Depression. Review of the Quarterly MDS assessment, dated 01/30/19, revealed the facility assessed Resident #87's cognition as severely impaired as the BIMS was coded as ninety-nine (99), which indicated the resident was not interviewable. Review of an Annual MDS, dated [DATE], Section G, revealed his/her ADL's were coded as follows: Bed: 3/3, Transfer: 8/8, Eating: 2/2, and Toileting: 3/3. Further review of the Quarterly MDS, dated [DATE], Section G, revealed his/her ADL's were coded as Bed: 4/3, Transfer: 4/3, Eating: 1/1, and Toileting: 4/3. Record review revealed Resident #87 went from requiring extensive assistance by staff to not participating anymore in two (2) of the care areas (Bed and Toileting); however, there was no evidence a Significant Change MDS was completed. Interview with the MDS Coordinator, on 02/21/19 at approximately 1:30 PM, revealed Resident #86 wanted to be left alone and she felt edema in the lower extremity was the cause of Resident #86's ADL decline. She stated staff discussed doing a physical therapy referral for Resident #86; however, a referral was not completed. She stated Resident #86 was referred to Restorative on 01/16/19 prior to the MDS being completed on 01/29/19; however, there had been no additional follow-up, or additional referrals completed since the MDS was completed on 01/29/19. She confirmed a Significant Change MDS was not completed showing an ADL decline in two (2) of the care areas. Interview with the Assistant Director of Nursing (ADON), on 02/21/19 at approximately 1:45 PM, revealed the facility should have monitored Resident #87 for two (2) weeks after the MDS showed a decline in ADL's; however, that did not occur. The ADON stated the Interdisciplinary Team (IDT) should have been made aware in order for them to try to address the cause of the decline, so interventions could be put in to place to prevent further decline. She stated the IDT team was never made aware of the decline. The ADON stated a Significant Change MDS should have been completed; however, the MDS never triggered for a Significant Change MDS to be completed. Interview with the Director of Nursing (DON), on 02/21/19 at approximately 2:00 PM, revealed her expectations were that a Significant Change MDS should have been completed for Resident #86 and Resident #87 when the most recent MDS showed two (2) ADL declines in two (2) care areas. She stated the IDT team should have been made aware of the change/decline to put interventions in place to prevent any further decline, and attempt to restore residents back to their baseline.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review revealed the facility admitted Resident #110 on 05/12/17 with diagnoses which included Unspecified Dementia, Parkinson's Disease, Muscle Weakness, Cognitive Communication Deficit, and Unspecified Lack of Coordination. Review of the Quarterly MDS assessment, dated 2/11/19 , revealed the facility assessed the resident's BIMS score as three (3), which indicated the resident was cognitively impaired and not interviewable. Review of the Comprehensive Care Plan, dated 05/22/17, revealed Resident #110 was at risk for injury related to falls due to cognitive and physical deficits and a history of recurrent falls. Additional review of the care plan revealed there had been no updates or revisions to the care plan after falls that occurred in the facility on 12/31/18, 01/03/2019, 01/07/19 until after the last fall on 02/08/2019. Interview with LPN #2, Unit Manager, on 02/20/19 at 5:34 PM and on 02/21/19 at 8:11 AM revealed the IDT discusses interventions that are working or not, and decides if there should be an intervention added. Interview with the Director of Nursing (DON) on 02/21/19 at 2:49 PM revealed it is the unit supervisor's responsibility to implement new interventions. Additionally, the DON expected the care plans to be updated with any new interventions after a fall per policy. Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure the Comprehensive Care Plans were reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments and changes in conditions for three (3) of thirty-three (33) sampled residents (Residents #37, #44, and #110). Resident #37 sustained a fall on 09/12/18 and Resident #44 sustained falls on 08/19/18 and 02/07/19, however, the comprehensive care plans were not updated to reflect new interventions after the therapy department determined physical therapy was not indicated. In addition, Resident #110 sustained falls on 12/31/18, 01/03/19, 01/07/19 and 02/08/19; however, the comprehensive care plans was not updated to reflect new interventions. The findings include: Review of facility policy titled Falls, last revised 08/16/18, revealed it is the intent of the facility to provide residents with assistance and supervision in an effort to minimize the risk of falls and fall related injuries. The care plan will be reviewed following each fall, quarterly, annually, and with each significant change. Interventions are to be revised as indicated by the assessment. The Interdisciplinary Team (IDT)/Minimum Data Set (MDS) / Assistant Director of Nursing (ADON) reviews and revises the care plan as appropriate quarterly and as needed. Review of the facility policy titled Comprehensive Care Plans, last revised 07/19/18, revealed a person-centered Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. The care plan will include how the facility will assist the resident to meet their needs, goals and preferences. Care plan interventions are implemented after consideration of the resident's problem areas and their causes. Interventions address the underlying sources of the problem areas, rather than addressing only symptoms or triggers. The interventions will reflect action, treatment, or procedure to meet the objectives toward achieving the resident goals. Care plans are ongoing and revised as information about the resident and the resident's condition change. The nurse/interdisciplinary team is responsible for the review and updating of care plans. The care plans should reflect the current status of the resident and be updated with changes in the resident's status includes when there has been a significant change in the resident's condition and when the desired outcome is not met. 1. Record review revealed the facility admitted Resident #37 on 04/09/15 with diagnoses which included Cerebral Amyloid Angiopathy, Major Depressive Disorder, and Cognitive Communication Deficit. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #37's cognition as severely impaired as the resident was unable to complete the Brief Interview of Mental Status (BIMS) exam due to long-term and short-term memory impairment indicating the resident was not interviewable. Further review revealed the resident required extensive assistance of two (2) staff for transfers. Review of the facility provided fall investigation dated 09/12/18 revealed Resident #37 fell at 3:15 PM with no injury noted. The resident was found sitting on the floor at bedside as a result of an attempt to transfer unassisted. Implemented interventions were Physical Therapy (PT) / Occupational Therapy (OT) to evaluate and treat; neuro checks per policy; X-ray of right shoulder; and monitor for latent bruising and pain. Review of the Request for Therapy Evaluation, dated 09/12/18, revealed Resident #37 was evaluated due to a recent fall. It was noted the resident had not had a change in physical ability and the fall was not related to a decline; PT not indicated at this time. Review of Resident #37's Comprehensive Care Plan initiated 04/17/15 for At risk for fall related injury revealed an intervention dated 09/12/18 for OT and PT to evaluate as needed. However, further review revealed there was no intervention to address tthe root cause of the fall put in place after therapy evaluated the resident and determined therapy was not indicated. 2. Record review revealed the facility admitted Resident #44 on 04/06/17 with diagnoses which included Cerebral Palsy; Flaccid hemiplegia affecting right dominant side; Muscle Weakness; Abnormal Posture; Lack of Coordination; and Difficulty in Walking. Review of the Quarterly MDS, dated [DATE] revealed Resident #44's cognition as intact with a BIMS score of fifteen (15) which indicated the resident was interviewable. However, after interviewing the resident, it was determined the at resident provided information that was not reliable. Further review of the Quarterly MDS revealed Resident #44 required extensive assistance of one (1) for transfers. Review of the facility provided fall investigation dated 08/19/18 revealed Resdient #44 sustained a fall while picking out clothes to wear in his/her closet. Intervention for staff to assist resident to pick out clothes the night before and place on bed was developed. Review of the facility provided fall investigation dated 02/07/19 at 10:15 PM revealed Resident #44 sustained a fall with no injury noted. The resident was found lying beside bed on his/her right side. Behaviors contributing to falls were listed as impulsivity, poor safety awareness, and non-compliance. Further review revealed interventions put in place were for a therapy referral, and to monitor for signs and symptoms of latent bruising and pain related to fall. Review of the Request for Therapy Evaluation, dated 02/08/19, revealed Resident #44 was evaluated due to a recent fall. It was noted the resident did not have a change in physical ability and the fall was not related to a decline but the resident attempting to transfer without assistance in which he/she is not suppose to do. Review of Resident #44's Comprehensive Care Plan, initiated 04/14/17, revealed the resident was at risk for fall related injury related to right spastic Hemiplegia, Cerebral Palsy, and history of falls. Interventions listed under Approaches included OT, PT, Speech Therapy (ST) evaluate and Medications as ordered, dated 02/07/18. However, further review revealed there was no intervention put in place to address the root cause of the fall after therapy evaluated the resident and determined therapy was not indicated. Further review revealed the intervention for assistance with picking out clothes listed on the 08/19/18. Interview with LPN #2, Unit Manager, on 02/20/19 at 5:34 PM and on 02/21/19 at 8:11 AM revealed the IDT discusses interventions that are working or not, and decides if there should be an intervention added. LPN #2 stated she did not implement a new intervention once therapy evaluated the residents, nor was the care plan updated for the 08/19/18 fall. Interview with the Director of Nursing (DON) on 02/21/19 at 2:49 PM revealed once therapy communicated they were not picking up the residents for therapy, the fall is brought back to IDT for a new intervention to be implemented. She stated it was the unit supervisor's responsibility to implement the new intervention. She revealed she expected the care plans to be updated with any new interventions after a fall and per policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of facility policy, it was determined the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for two (2) of thirty-three sampled residents (Residents #37 and #44). Residents #37 and #44 had falls for which interventions were implemented to consult Physical Therapy (PT)/Occupational Therapy (OT). When therapy evaluated the residents, it was determined the falls were not related to the residents' decline and therapy was not indicated. However, another intervention was not implemented to prevent future falls. The findings include: Review of facility policy titled Falls, last revised 08/16/18, revealed it is the intent of the facility to provide residents with assistance and supervision in an effort to minimize the risk of falls and fall related injuries. Interdisciplinary Team (IDT)/Director of Nursing (DON)/or designee reviews during At Risk Meeting to identify additional referrals, consults, and interventions. 1. Record review revealed the facility admitted Resident #37 on 04/09/15 with diagnoses which included Cerebral Amyloid Angiopathy, Major Depressive Disorder, and Cognitive Communication Deficit. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #37's cognition as severely impaired as the resident was unable to complete the Brief Interview of Mental Status (BIMS) exam due to long-term and short-term memory impairment indicating the resident was not interviewable. Further review revealed the resident required extensive assistance of two (2) staff for transfers. Review of the facility provided fall investigation dated 09/12/18 and completed by Licensed Practical Nurse (LPN) #3 revealed Resident #37 fell at 3:15 PM with no injury noted. The resident was found sitting on the floor at bedside as a result of an attempt to transfer unassisted. Implemented interventions were Physical Therapy (PT)/Occupational Therapy (OT) to evaluate and treat; neuro checks per policy; X-ray of right shoulder; and monitor for latent bruising and pain. Review of the Request for Therapy Evaluation, dated 09/12/18, revealed Resident #37 was evaluated due to a recent fall. It was noted the resident had not had a change in physical ability and the fall was not related to a decline; PT not indicated at this time. Review of Resident #37's Comprehensive Care Plan initiated 04/17/15 for At risk for fall related injury revealed an intervention dated 09/12/18 for OT and PT to evaluate as needed. However, there was no intervention put in place to address the root cause of the fall after therapy evaluated the resident and determined therapy was not indicated. Review of the Progress Note, dated 09/13/18 at 4:53 PM, revealed an At-Risk meeting was held with IDT members related to Resident #37's fall of 09/12/18. The progress note revealed attributing factors to the fall included decreased safety awareness with impaired vision and an intervention of PT/OT evaluation reviewed and agreed to continue with plan of care. However, there was no documented evidence that the IDT revisited the fall information to determine the root cause of the fall and put an intervention in place to address the root cause. Interview with LPN #3 on 02/20/19 at 4:53 PM revealed the root cause of Resident #37's fall was poor safety awareness. She stated the initial intervention for PT / OT evaluation was implemented because she thought therapy would make the resident stronger to help prevent falls. Additionally, LPN #3 stated the nurse completing the fall investigation is responsible for updating the care plans with the interventions implemented at that time. She stated the fall information is forwarded to the IDT for post fall investigation and additional interventions may be added or the initial intervention may be changed. 2. Record review revealed the facility admitted Resident #44 on 04/06/17 with diagnoses which included Cerebral Palsy; Flaccid hemiplegia affecting right dominant side; Muscle Weakness; Abnormal Posture; Lack of Coordination; and Difficulty in Walking. Review of the Quarterly MDS assessment, dated 01/05/19 revealed Resident #44's cognition as intact with a BIMS score of fifteen (15) indicating the resident was interviewable. However, after interviewing the resident, it was determined the resident provided information that was not reliable. Further review of the Quarterly MDS revealed Resident #44 required extensive assistance of one (1) for transfers. Review of the facility provided fall investigation dated 02/07/19 and completed by LPN #4 revealed Resident #44 fell at 10:15 PM with no injury noted. The resident was found lying beside bed on his/her right side. Behaviors contributing to falls were listed as impulsivity, poor safety awareness, non-compliance. Implemented interventions were therapy referral, monitor for signs and symptoms of latent bruising and pain related to this fall. Review of the Request for Therapy Evaluation, dated 02/08/19, revealed Resident #44 was evaluated due to a recent fall. It was noted the resident did not have a change in physical ability and the fall was not related to a decline but the resident attempting to transfer without assistance in which he/she is not suppose to do. Review of Resident #44's Comprehensive Care Plan, initiated 04/14/17, revealed the resident was at risk for fall related injury related to right spastic hemiplegia, cerebral palsy, and history of falls. Interventions listed under Approaches included OT, PT, Speech Therapy (ST) evaluate and Medications as ordered, dated 02/07/18. However, there was no intervention to address the root cause of the fall after therapy evaluated the resident and determined therapy was not indicated. Interview with LPN #4 on 02/20/19 at 5:19 PM revealed Resident #44 had attempted to transfer independently from the wheel chair to the bed and was found lying beside the bed on his/her right side. She stated the immediate intervention was to refer the resident for therapy evaluation for stengthening to help prevent future falls. LPN #4 stated it is the responsibility of the nurse completing the investigation report to update the care plans with the immediate interventions put in place. Interview with LPN #2, Unit Manager, on 02/20/19 at 5:34 PM and on 02/21/19 at 8:11 AM revealed PT/OT was consulted for strengthening to prevent falls. LPN #2 stated the IDT discusses interventions that are working or not, and decides if there should be an intervention added. LPN #2 stated she did not implement a new intervention once therapy evaluated the residents, nor was the care plan updated. Interview with the Director of Nursing (DON) on 02/21/19 at 2:49 PM revealed once therapy communicated they were not picking up the residents for therapy, the fall is brought back to IDT for a new intervention to be implemented. She stated the Unit Supervisor was responsible for implementing new interventions

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and review of facility policy, it was determined the facility failed to ensure that a resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain for two (2) of thirty-three (33) sampled residents (Residents #86 and #110). The facility failed to assess Resident #110 and Resident #86 for possible interventions to improve the resident's noted decline in bowel and bladder continence. The Findings Include: Review of the Facility Policy titled Bowel and Bladder Management, dated 04/27/16, revised 7/19/18 revealed the Facility will evaluate, monitor and track resident's bowel and bladder patterns and will identify the need for early intervention. Further review revealed facility will evaluate Bowel and Bladder status upon admission, readmission, quarterly and annual and with significant change. The IDT team will review bowel and bladder data to determine if retraining is an option or a pattern has been identified. If retraining is indicated the resident's care plan will be updated to reflect results and the interventions. If pattern is identified, the IDT team will implement a voiding plan based on times indicated, cognition, functional ability and habits. 1. Record review revealed the facility admitted Resident #110 on 05/12/17 with diagnoses which included Unspecified Dementia, Parkinson's disease, Muscle Weakness, Cognitive Communication Deficit, and Unspecified lack of Coordination. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 2/11/2019 , revealed the facility assessed the resident's Brief Interview for Mental Status (BIMS) score as three (03), which indicated the resident was cognitively impaired and not interviewable. Review of Resident #110 Quarterly MDS dated [DATE], revealed the facility coded the resident as occasionally incontinent of bowel and bladder. Review of the 90 Day Quarterly MDS Assessment, dated 01/17/19, revealed the facility coded the resident as frequently incontinent of bowel and bladder. The IDT team did not review bowel & bladder data to determine if retraining was an option or try to identify a pattern per facility policy. 2. Record review, revealed the facility admitted Resident #86 on 10/06/17 with diagnoses which included Dementia with Behavioral Disturbances, Hypothyroidism, Osteoarthritis and GERD. Review of Quarterly Minimum Data Set (MDS) assessment, dated 1/29/19, revealed the facility assessed this resident's Brief Interview for Mental Status (BIMS) score as a six (06), which indicated this resident was not cognitively intact and not interviewable. Review of Resident #110 Annual MDS dated [DATE], revealed the facility coded the resident as always continent of bowel and bladder. Review of the 90 Day Quarterly MDS Assessment, dated 11/02/18, revealed the facility coded the resident as occasionally incontinent of bowel and bladder. The IDT team did not review bowel & bladder data to determine if retraining was an option or try to identify a pattern per facility policy. Interview with MDS Coordinator on 2/21/19 at approximately 1:30 PM revealed MDS coordinator stated Resident #86's bladder decline may have been a result if the medication Kayexalate that was prescribed on 10/17/18 but that she could not be certain that was the reason since there was no tracking method put in place to identify the decline and potentially restore back to Resident #86's baseline. MDS Coordinator stated the decline should have been addressed and interventions should have been put in place. Interview with ADON on 2/21/19 at approximately 3:15 PM revealed that once Resident #110's decline was observed it should have been brought to the attention of the IDT team to address the decline and identify interventions to prevent further decline and try to restore back to baseline. ADON stated there was no tracking of any kind put in place to identify bowel & bladder decline and possibly restore.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and review of facility policy, it was determined the facility failed to maintain medical records on each resident that are accurately documented for one (1) of thirty-three (33) sampled residents (Resident #65). The findings include: Review of the facility policy titled, Charting and Documentation, dated 07/02/18, revealed the following: Services provided to the resident, or any changes in the resident's medical condition or mental condition, shall be documented in the resident's medical record. Guidelines: For all skilled residents, documentation will occur at least daily. Documentation of procedures and treatments shall include care-specific details and shall include at a minimum the date and time treatment was provided, name and title of individual who provided care, assessment data and/or any unusual findings obtained during the procedure/treatment, signature and title of the individual documenting. Record Review revealed the facility admitted Resident #65 on 12/21/18 with diagnoses which included End Stage Renal Disease (ESRD), and Anemia in Chronic Kidney Disease. Review of an admission Minimum Data Set (MDS) dated [DATE] revealed the facility assessed Resident #65's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of eight (8) which indicated the resident was interviewable. Review of Physician's Orders dated 12/21/18 revealed an order to monitor the Permacath right upper chest site every shift and monitor Fistula site to right forearm for thrill, bruit and any sign of infection every shift. Review of the January and February 01-20, 2019 Medication Administration Record(MAR)/Treatment Administration Record (TAR) revealed on the 11:00 PM-7:00 AM shift checking of the right upper chest Dialysis site and Right forearm fistula site was charted as eleven on 01/01/19, 01/03/19, 01/06/19-01/08/19, 01/10/19, 01/12/19-01/15/19, 01/17/19, 01/20/19, 01/22/19, 01/24/19, 01/26/19-01/27/19, 02/05/19, 02/07/19, 02/09/19-02/11/19, 02/14/19, and 02/16/19-02/17/19. The coding interpretation indicated the number eleven meant No behavior. Interview with Director of Nursing (DON) on 02/21/19 at 8:27 AM in relation to staff charting for inspection of the Dialysis site No behaviors revealed nurses have been clicking the wrong button. When asked how one is to determine if the site was monitored, the DON replied Well, they (staff) acknowledge they have been putting incorrect information, hitting the wrong button in the computer system. Further interview with the DON on 02/21/19 at 3:15 PM revealed she would expect the nursing staff to do accurate documentation on Dialysis residents when checking the Dialysis port site and would expect staff to put the correct coding. .

3. Record review revealed the facility admitted Resident #83 on 03/02/18 with diagnoses which included Cerebral Infraction, Chronic Obstructive Pulmonary Disease (COPD), Muscle Weakness, Cognitive Communication Deficit, and Anxiety Disorder. Review of the Annual MDS assessment, dated 01/28/19, revealed the facility assessed the resident's BIMS score as fifteen (15), which indicated the resident was cognitively intact and interviewable. Review of a Comprehensive Care Plan for Activities of Daily Living (ADL's), self-care deficit, initiated 03/14/18, revealed the resident had a stroke with paralysis on one (1) side. Further review of the Care Plan revealed an intervention to include physical assist of one (1) person with all areas of care, grooming, and bathing. Review of the ADL Certified Nurse Aide (CNA) Care Plan, no date, revealed the resident was to be a total assist of one (1) person for bathing. However, review of a bathing sheet revealed the resident was charted as independent on 01/23/19, 01/26/19, 02/06/19, 02/09/19, 02/10/19, 02/11/19, 02/14/19, 02/15/19, and 02/18/19. 4. Record review revealed the facility admitted Resident #374 on 12/28/18 with diagnoses which included Difficulty in Walking, Muscle Weakness, Acute Kidney Failure, Hypothyroidism and Type 2 Diabetes. Review of the five (5) day PPS MDS assessment, dated 12/28/18, revealed the facility assessed the resident's BIMS score as a fifteen (15), which indicated the resident was cognitively intact and interviewable. Review of a Comprehensive Care Plan for ADL's, self-care deficit, initiated 01/07/19, revealed the resident required extensive assistance of two (2) persons for transfer and mobility. Further review of the care plan did not specify the amount of assistance required for areas such as care, grooming, and bathing. Review of the ADL CNA Care Plan, no date, revealed the resident was extensive assist of two (2) persons for bathing. However, review of a bathing sheet revealed the resident was charted as one (1) person physical assist on 01/21/19, 01/23/19, 01/24/19, 01/25/19, 01/28/19, 01/29/19, 01/30/19, 02/01/19, 02/02/19, 02/04/19, 02/05/19, 02/06/19, 02/07/19, 02/08/19, 02/09/19, and 02/18/19. 5. Record review revealed the facility admitted Resident #79 on 07/26/14 with diagnoses which included Alzheimer's, Muscle Weakness, Transient paralysis, and Major Depressive Disorder. Review of the admission MDS assessment, dated 01/05/19, revealed the facility assessed the resident's BIMS score as three (3), which indicated the resident was cognitively intact and interviewable. Review of a Comprehensive Care Plan for Activities of Daily Living (ADL's), self-care deficit, initiated 08/4/14, revealed the resident Resident #79 requires assist in Transfer, mobility and total care. had a stroke with paralysis on one (1) side. Further review of the Care Plan revealed an intervention to include physical assist of two (2) person with bathing. Review of the ADL Certified Nurse Aide (CNA) Care Plan, no date, revealed the resident was to be a total assist of two (2) person for bathing. However, review of a bathing sheet revealed the resident was charted as One person physical assist on 01/22/19, 01/24/19, 01/26/19, 01/29/19, 01/31/19, 02/02/19, 02/05/19, 02/07/19, 02/09/19, 02/12/19, 02/14/2019, 2/16/19 and 02/19/19. Interview with CNA #7, on 02/20/19 at 2:14 PM, revealed CNA staff all receive assignment sheets daily indicating which residents needed to receive a shower or bath that day. CNA #7 stated staff filled out the sheet daily, signed their name on the sheet, and then turned it in at the end of the shift to the nurse in charge on that hall. CNA #7 revealed the CNA care plans revealed the required assistance each resident required with ADL's. CNA #7 stated she assisted Resident #83 with a shower on 02/19/19. Interview with the Director of Nursing (DON), on 02/21/19 at 1:40 PM, revealed she expected staff to follow the Comprehensive Care Plan and CNA Care Plan, and offer the required assistance for the residents, and document accurately. The DON stated the Unit Managers were responsible for reviewing the documentation turned in by CNA staff, with periodic checks done weekly to ensure the documentation turned in by CNA staff accurately reflected the care and assistance provided for the residents. 3. Record review revealed the facility admitted Resident #110 on 05/12/17 with diagnoses which included Unspecified Dementia, Parkinson's Disease, Muscle Weakness, Cognitive Communication Deficit, and Unspecified Lack of Coordination. Review of the Quarterly MDS assessment, dated 02/11/19 , revealed the facility assessed the resident's BIMS score as three (3), which indicated the resident was cognitively impaired and not interviewable. Review of a Comprehensive Care Plan for Risk for fall related injury and history of falls due to cognitive and physical deficits, initiated 05/22/17, revealed falls interventions included to remind the resident when rising from a lying position to sitting up on the side of the bed a few minutes before transferring or standing, and to educate/remind him/her to request assistance prior to ambulation, and/or transfers. Further review of the Care Plan revealed updated interventions on 02/08/19 to educate the resident to call for assistance, remind him/her to call for assistance prior to attempting ambulation, educate him/her to stand before starting to walk to ensure steadiness before ambulation, and remind him/her to use an assistive device for ambulation. However, these interventions are not person centered for this resident per facility policy due to the facility assessing Resident #110's cognition as severely impaired. Interview (Post Survey) with DON on 03/08/19 at approximately 11:50 AM revealed she did not feel the interventions put in place were appropiate for Resident #110 due to his/her cognitive deficits. The DON stated she expected the interventions to be specific to Resident #110's needs and limitations in order to prevent future falls and keep him/her safe. Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure they developed and/or implemented a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment, for six (6) of thirty-three (33) sampled residents (Residents #30, #76, #79, #83, #110 and #374). The facility failed to implement care plans for Residents #30, #76, #79, #83, and #374 related to ADL assistance and failed to develop person centered interventions for falls related to Resident #110's severely impaired cognition. The findings include: Review of the facility Policy titled Comprehensive Care Plans , dated 07/19/18, revealed the following: A person-centered care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. The care plan will include how the facility will assist the resident to meet their needs, goals and preferences. The Minimum Data Set (MDS) will be used to assess the resident's clinical condition, cognitive and functional status and use of services. 1. Record review revealed the facility admitted Resident #30 on 09/23/16 with diagnoses which included Dementia, and Stroke. Review of a Quarterly MDS assessment, dated 12/18/18, revealed facility coded the Brief Interview for Mental Status (BIMS) score as ninety-nine (99), indicating the resident was severely cognitively impaired. Further review of the MDS revealed the facility assessed Resident #30 as totally dependent with assist of two for bathing. Review of a Comprehensive Care Plan for Activities of Daily Living (ADL's), self care deficit, initiated 10/03/16, revealed the resident had a stroke with paralysis of one (1) side. Further review revealed an intervention for two (2) person lift for transfers, and extensive assist with all areas of care, grooming, and bathing with no indication of how many staff to assist. Review of an ADL Certified Nurse Aide (CNA) Care Plan, dated 02/06/19, revealed the resident was to be a total assist of two (2) persons for bathing. However, review of a bathing sheet revealed the resident was charted as a one (1) person physical assist on 01/22/19, 01/23/19, 01/24/19, 01/27/19, 01/28/19, 02/01/19, 02/02/19, 02/04/19, 02/11/19, 02/12/19, 02/13/19, 02/15/19, 02/17/19, and 02/19/19 (total of fourteen (14) days). Observation of Resident #30, on 02/19/19 at 9:11 AM, revealed the resident was lying in bed on his/her back on an air mattress with Oxygen at two (2) liters per minute (LPM). 2. Record review revealed the facility admitted Resident #76 on 11/06/18 with diagnoses which included Paralysis from stroke affecting the right side, Rheumatoid Arthritis, and Healing of Fracture of Right femur. Review of an admission MDS assessment, dated 11/13/18, revealed the facility assessed Resident #76's cognition as severely impaired with a BIMS score of three (3) which indicated the resident was not interviewable. In addition, further review of the MDS assessment revealed the facility assessed the resident required extensive assistance of two (2) for bathing. Review of a Comprehensive Care Plan for self care deficit, initiated on 01/28/19, revealed an intervention for staff to provide the amount of assistance/supervision that is needed: Extensive assist; however, the intervention did not indicate the amount of staff needed. Review of the CNA Care Plan dated February 2019 revealed the resident was listed as Dependent with no type (one or two person) of assistance indicated for bathing or dressing. However, review of a Bathing sheet revealed the resident was charted as one person physical assist and total dependence on 01/22/19, 01/23/19, 01/24/19, 01/28/19, 01/29/19, 01/30/19, 02/01/19, 02/02/19, 02/03/19, 02/04/19, 02/13/19, 02/15/19, 02/17/19, 02/18/19 and 02/19/19. Observation of Resident #76 on 02/19/19 at 10:51 AM revealed the resident was in wheel chair in his/her room. Interview with CNA #4 on 02/21/19 at 2:30 PM revealed if her care plan did not address the amount of staff needed for bathing or stated one to two, she would ask her nurse. CNA #4 stated if the care plan indicated extensive assist/dependent, then the resident needs two (2) assist. Interview with CNA #1 on 02/21/19 at 2:32 PM revealed if the CNA Care Plan did not address the amount of staff needed she would ask the nurse. She stated if it indicated one-two assist, she would take another person with her, just to be on safe side.

3. Record review, revealed the facility admitted Resident #38 on 07/04/18 with diagnoses which included Heart Disease, Muscle Weakness, Major Depressive Disorder, and Essential hypertension. Review of Quarterly MDS assessment, dated 12/26/18, revealed the facility assessed Resident #38's cognition as intact with a BIMS score of fifteen (15), which indicated the resident was interviewable. Review of Resident #38's CNA Care Plan under the section ADL's revealed Resident #38 was scheduled to receive a bath/shower on Wednesday, Friday and Sundays during the 7:00 AM to 3:00 PM shift. Review of Resident #38's Bathing Report for the last thirty (30) days revealed Resident #38 did not receive a bath for six (6) days as the report revealed the resident was not bathed from 01/20/19 until 01/26/19. Further review revealed Resident #38 did not receive a bath for a seven (7) day period from 01/29/19 until 02/07/19, and did not receive another one until 02/12/19 four (4) days later. Further review of the report also showed the last time Resident #38 received a bath was on 02/16/19 and had not received another one as of the day the report was printed on 02/20/19. Interview with Resident #38 on 02/19/19 at approximately 10:20 AM revealed there was never a lot of help during the night shift and he/she had issues getting assistance from certain aides. Resident #38 stated he/she had issues getting baths regularly, and he/she did not get his/her bath three (3) times a week like he/she was scheduled. The resident revealed he/she informed staff but the problem has not been corrected. 4. Record review revealed the facility admitted Resident #83 on 03/02/18 with diagnoses which included Cerebral Infraction, Chronic Obstructive Pulmonary Disease, Muscle Weakness, Cognitive Communication Deficit, and Anxiety Disorder. Review of the Annual MDS assessment, dated 01/28/19, revealed the facility assessed the resident's BIMS score as fifteen (15), which indicated the resident was cognitively intact and interviewable. Review of Resident #83's CNA Care Plan under the section ADL's revealed Resident #83 was scheduled to receive a bath/shower on Tuesday, Friday, and Sundays during the 7:00 AM to 3:00 PM shift. Review of Resident #83's Bathing Report for the last thirty (30) days revealed Resident #83 did not receive a bath for seven (7) days, and the report revealed the resident was not bathed from 01/19/19 until 01/26/19 (seven {7} days). Further review revealed Resident #83 did not receive a bath for another seven (7) day period from 01/29/19 until 02/06/19. Interview with Resident #83 on 02/19/19 at approximately 9:58 AM revealed he/she was disappointed in the staff at the facility because he/she feels there was no consistency in the care provided. Resident #83 stated he/she cannot get a bath/shower on a regular basis and it has been two (2) weeks since the last time he/she received one. Resident #83 stated he/she has told staff but things do not ever change and get better. Interview with Resident #83's Family Member #1 on 02/20/19 at approximately 4:30 PM revealed that Family Member #1 was upset that Resident #83 had not received a bath/shower for almost two (2) weeks. Family Member #1 stated she went to the nurse's station yesterday and reported it to staff and Resident #83 finally received a bath/shower. Family Member #1 did not remember the name of the staff member she spoke with as she was just happy that it got Resident #83 a bath/shower. Interview with CNA #7 on 02/20/19 at approximately 2:14 PM revealed she worked both North and South Wings in the facility and each resident received a bath or shower three (3) times a week. CNA #7 stated all CNA staff receive assignment sheets daily which indicate which residents need to receive a shower or bath for that day. CNA #7 revealed the sheets were filled out daily and signed by the CNA staff member and it was turned in at the end of shift to the nurse in charge on the hall. CNA #7 stated she did assist Resident #83 with a shower on 02/19/19 and that Resident #83 reported to her that it had been a few days since he/she had received a shower. She stated Resident #83 was very glad that he/she was finally receiving one. CNA #7 revealed she did not report that information to anyone. 5. Record review revealed the facility admitted Resident #86 on 10/06/17 with diagnoses which included Dementia with Behavioral Disturbances, Hypothyroidism, Osteoarthritis and GERD. Review of the Quarterly MDS assessment, dated 01/29/19, revealed the facility assessed Resident #86's cognition as severely impaired with a BIMS score of six (6), which indicated the resident was not interviewable. Review of Resident #86's CNA Care Plan under the section ADL's revealed Resident #86 was scheduled to receive a bath/shower three (3) times weekly but no specific days were listed. Review of Resident #86's Bathing Report for the last thirty (30) days revealed Resident #86 did not receive a bath for seven (7) days, and the report revealed the resident was not bathed from 01/19/19 until 01/26/19 (seven {7}days). Further review of the report revealed Resident #86 did not receive a bath for another seven {7} day period from 01/29/19 until 02/06/19. Interview with Unit Manager Registered Nurse (RN) #4 on 02/20/19 at approximately 2:20 PM revealed Resident #86 refused to allow staff to provide him/her a bath/shower and that is why there was a long lapse in time between his/her bath/showers. RN #4 stated there was documentation to support this but RN #4 was unable to provide anything documented to show that Resident #86 ever refused a bath/shower when staff tried to provide this care. Interview with the Director of Nursing (DON) on 02/20/19 at approximately 5:27 PM revealed she expected staff to immediately and properly document refusals of any ADL assistance by residents and report the refusal to the charge nurse/unit manager. The DON stated she expected CNA's to follow the Comprehensive and CNA Care Plans for each resident and provide the required amount of assistance the resident was care planned for. The DON revealed she expected the Unit Manager to investigate refusals by residents and bring the information to IDT for administrative staff to explore possible interventions. The DON stated the Unit Manager was responsible for conducting reviews and periodic checks weekly and to monitor CNA documentation. The DON stated it was the Unit Manager's failure not to follow up during the month timeframe to catch these failures by staff not providing ADL's to residents. Based on interview, record review and review of facility policy, it was determined the facility failed to ensure five (5) of thirty-three sampled residents who were unable to carry out activities of daily living received the necessary services to maintain personal and oral hygiene (Residents #38, #76, #83, #86, and #427). The facility failed to provide oral hygiene to Resident #427, failed to ensure two (2) staff provided bathing for Resident #76, and failed to provide bathing every three (3) times a week for Residents #38, #83 and #86. The findings include: Review of Facility Policy titled Certified Nursing Assistant Job Description, dated 12/2011, revealed the following: Perform direct care duties under the supervision of licensed nursing personnel, provide personal care such as grooming, bathing, dressing, and oral care of residents daily and as needed. Review of the facility policy titled, Certified Nursing Assistant Job Description, dated December 2011, revealed the following: Perform direct care duties under the supervision of licensed nursing personnel, provide personal care such as grooming, bathing, dressing, and oral care of residents daily and as needed. 1. Record review revealed the facility admitted Resident #427 on 02/16/19 with diagnoses which included Respiratory Failure, Chronic Obstructive Pulmonary Disease (COPD), and Dysphagia. Review of an admission Baseline Care Plan initiated on 02/16/19 revealed the resident was Care Planned for being NPO (nothing to eat by mouth), tube feeding, weakness, decreased mobility with intervention to provide Activities of Daily Living (ADL) care to ensure daily needs are met. In addition, the resident was a Hydration risk with goal that resident will remain adequately hydrated as evidenced by good skin turgor; and, pink and moist mucous membranes. Review of the CNA Care Plan dated 02/16/19 revealed Resident #427 was listed as Independent for oral care. Observation of Resident #427 on 02/19/19 at 10:34 AM revealed the resident had Oxygen on at two (2) liters per minute (LPM) with no no humidification. The resident's lips were observed to be very dry, and teeth and lips had a red material that resembled dried blood. Further observation at this time revealed seven (7) oral swabs lying on the over the bed table in unopened packages. The resident was also observed to have an abdominal feeding tube. Resident #427 stated, They (staff) brought the things in to clean my mouth and never did it . Observation on 02/19/19 at 1:40 PM revealed Resident #427 kept licking his/her lips, and his/her lips were very dry with peeling skin and a red looking material on teeth and lips. There were still seven (7) oral swabs on the over bed table in unopened packages. Observation of Resident #427 on 02/20/19 at 4:40 PM and 5:55 PM, the resident's lips were still very dry with peeling skin and there were two (2) oral swabs on over bed table in unopened packages. At 5:55 PM, the resident stated his/her lips were sore. Interview with Resident #427 on 02/20/19 at 4:45 PM revealed he/she would be able to use swabs per self but Someone would have to moisten the swabs for me. When asked if staff ever put anything like chap stick or other lubricant on lips resident stated, They said they couldn't because of the oxygen. The resident further stated no one had used any swabs on his/her mouth recently. Observation on 02/21/19 at 8:57 AM revealed Resident #427 was licking his/her lips, lips were dry with peeling skin, and there were no oral swabs in sight. The resident stated at this time he/she could use swabs per self but someone would have to wet them for me. Asked if anyone had been in room to use swabs and resident stated well, they just used a wet wash cloth on my lips. Interview with Resident #427's cousin, on 02/20/19 at 4:40 PM revealed he came by last week and the resident's lips were very dry, bad looking, skin peeling off lips. Interview with CNA #2 on 02/21/19 at 9:15 AM revealed the first day she took care of Resident #427 (Tuesday {02/19/19} she wet the oral swabs for the resident and the resident did oral care his/herself. CNA #2 stated she did this care twice that Tuesday and she worked from 7:00 AM-3:00 PM. She further revealed she usually does oral care every two (2) hours on tube feeding residents but, this resident was listed as independent on her care plan sheet. Interview with CNA #3 on 02/21/19 at 9:30 AM revealed she provides oral care for residents with tube feeding every two (2) hours and she looks at mouth and lips when she does rounds, and will put something like chap stick to moisten lips if it is available. Interview with Licensed Practical Nurse (LPN) #1 on 02/21/19 at 9:03 AM revealed she did the admission assessment on Resident #427 and put resident as Independent for oral care as the resident had used oral swab one time. She stated she had not observed the resident using oral swab since admission and she had not done any oral care as the CNA's did that. LPN #1 revealed nothing was being put on the resident's lips such as chap stick as That was an over sight on my part. She stated the swabs would have to be moistened by staff for resident to use and if the CNA's were not doing oral care every two (2) hours it would be because the resident was listed as independent for oral care on the CNA care sheets. Interview with the Director of Nursing (DON) on 02/21/19 at 3:12 PM revealed she expected oral care to be completed on residents with tube feedings at a minimum every shift and as needed. She stated the CNA's do the oral care and nurses are responsible for making sure it is done. She stated she expected oral care to be included on the baseline care plans and the admission nurse was responsible for putting it on the Care Plan to ensure the CNA's do the oral care. 2. Record review revealed the facility admitted Resident #76 on 11/06/18 with diagnoses which included Paralysis from stroke affecting right side, Rheumatoid Arthritis, and healing of fracture of right femur. Review of an admission Minimum Data Set (MDS) assessment, dated 11/13/18, revealed the facility assessed Resident #76's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of three (3) which indicated the resident was not interviewable. Further review of the MDS assessment revealed the facility assessed the resident needed extensive assistance of two (2) staff for bathing. Review of a Comprehensive Care Plan for self care deficit initiated on 01/28/19 revealed an interventions of staff to provide the amount of assistance/supervision that was needed: Extensive assist. The care plan did not indicate there amount of staff that was needed to provide bathing. Review of the a CNA Care Plan dated February 2019 revealed the resident was listed as Dependent with no amount (one or two person) assistance listed. Review of a Bathing sheet revealed the resident was charted as one (1) person physical assist and total dependence on 01/22/19, 01/23/19, 01/24/19, 01/28/19, 01/29/19, 01/30/19, 02/01/19, 02/02/19, 02/03/19, 02/04/19, 02/13/19, 02/15/19,02/17/19,02/18/19 and 02/19/19. Observation of Resident #76 on 02/19/19 at 10:51 AM revealed the resident to be up in a wheel chair in his/her room with a urinary catheter in a dignity bag. Interview with CNA #4 on 02/21/19 at 2:30 PM revealed if there was nothing on her care plan about the amount of assistance required for a resident or listed as one (1) to two (2) assist, she would ask her nurse. She stated if a resident was care planned for extensive assist/dependent then the resident needs two (2) assist. Interview with CNA #1 on 02/21/19 at 2:32 PM revealed if the CNA Care Plan sheet did not list the amount of assistance needed for bathing, she would ask the nurse. She stated if the care plan stated one (1) to two (2) assist, she would take another person with her, just to be on the safe side.

Based on observation, interview and review of facility policy it was determined the facility failed to Store, prepare, distribute and serve food in accordance with professional standards for food service safety. Observations of the kitchen on 02/19/19 and 02/20/19, revealed during lunch tray-line, [NAME] #1 inserted the thermometer into the foods past the stem to the handle, which was not sanitized, was the handle was coming in contact with the foods. In addition, dishes were stored improperly. Review of the Census and Condition, dated 02/19/19, revealed one-hundred twenty-five (125) of one-hundred twenty-nine residents received their meals from the kitchen. The findings include: 1. Review of facility policy titled, Food Temperatures, last revised 01/04/19, revealed staff are to wash, rinse, sanitize a dial face, metal probe-type thermometer with an alcohol wipe and re-sanitize after each use and staff are to insert thermometer into center of product. Observation of [NAME] #1 on 02/19/19 at 11:28 AM, revealed [NAME] #1 checked the temperature of foods on tray-line and inserted the thermometer into the foods in a manner in which the thermometer stem was inserted all the way until the handle was making contact with the foods, even though the handle had not been sanitized. Interview with Dietary Manager on 02/19/19 at 11:52 AM, revealed she expected the cooks to not insert the thermometer deep enough into the foods that the handle was down in the foods. She further stated she expected the thermometer handle to not be down in the food when staff are checking temperature of foods. Interview with facility's Registered Dietician on 02/19/19 at 11:53 AM, revealed she expected the staff to keep the handle of the thermometer out of the foods that are being checked for temperature. 2. Review of facility policy titled, Dry Storage-Dishes and Utensils, last revised 02/01/12, revealed enclosed storage should be provided for clean and sanitized dishes and utensils. It further stated dish storage areas should be kept closed or covered when not in use. Observation of the kitchen on 02/20/19 at 9:40 AM, revealed a open wired rack storing pots and pans, with pans stored uncovered and not inverted with dust and white material collecting in the pans. Interview with Dietary Manager on 02/20/19 at 9:46 AM, revealed she expected all dishes, pots and pans to be stored either covered or inverted so they do not collect dust or other material.

Based on observation, interview and facility policy review, it was determined the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (1) of twenty-five (25) residents (Resident #71). Observation revealed CNA #1 failed to remove soiled gloves and wash hands after providing incontinent care , prior to touching personal belongings for Resident #71. The findings include: Review of the facility's procedure titled, Perineal Care Male/Female Competency, last reviewed 11/21/17, revealed to maintain standard precautions for prevention of cross-contamination and spread of infection during the procedure, remove and discard gloves, wash and dry hands thoroughly, and reposition patient comfortably. Record review revealed the facility admitted Resident #71 on 11/16/17 with diagnoses which included Neurogenic Bladder, Altered Mental Status, unspecified Dementia without behavioral disturbances, and Cognitive Communication Deficit. Observation of Certified Nurse Aide (CNA) #1 providing peri-care/incontinent care for Resident #71, on 02/14/18 at 2:23 PM, revealed CNA #1 failed to remove her gloves and wash her hands after providing catheter/peri-care/incontinent care, then proceeded to reposition the resident, and placed a pillow behind the residents back, without washing hands and putting on clean gloves. Interview with CNA #1 on 02/14/18 at 2:30 PM, revealed she should have removed the soiled gloves and washed her hands, and put on a clean pair of gloves before repositioning and touching Resident #71's personal belongings, in order to prevent the spread of infection. Interview with the Director of Nursing (DON) on 02/15/18 at 8:26 AM, revealed she would have expected the staff to have changed their gloves and washed their hands after providing catheter/peri-care/incontinent care, before proceeding to provide care for Resident #71, in order to prevent the spread of infection.