Based on observation, interview, record review, review of facility policy, and review of the Centers for Disease Control and Prevention (CDC) guidelines the facility failed to establish and 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 three (3) residents. Observation of wound care for Resident (R)54 revealed a failure to remove contaminated gloves prior to touching Resident's clothing, bedding, walker, table, and chair. The findings include: Review of policy Infection Control, reviewed 01/17/2025, revealed Facility infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections . All personnel will be trained on infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. The depth of employee training shall be appropriate to the degree of direct resident contact and job responsibilities. Review of policy Hand Hygiene, reviewed 09/13/2024, revealed All personnel shall be trained on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . hand hygiene is the final step after removing and disposing of personal protective equipment. The use of gloves does not replace hand washing/hand hygiene. Review of the (CDC) guidelines, dated 02/27/2024. revealed Gloves should be used whenever healthcare workers anticipate contact with blood, bodily fluids, mucous membranes, nonintact skin, or potentially contaminated surfaces and equipment. The CDC stresses that gloves must be changed between, patient contacts and when moving from contaminated to clean tasks for the same patient. This practice helps ensure that microorganisms are not inadvertently spread . Review of R54's Face Sheet, located in the resident's Electronic Health Record (EHR), revealed the facility admitted the resident on 10/20/2023 with diagnoses to include chronic obstructive pulmonary disease, unspecified dementia, and type two diabetes mellitus with hyperglycemia. Review of R54's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 01/30/2025, completed related to a significant change, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] of 3 out of 15, which indicated severe cognitive impairment. Review of R54's Comprehensive Care Plan, revealed R54 was care planned for Enhanced Barrier Precautions related to chronic wounds, with a start date of 02/13/2025. The short-term goal, with a target date of 05/13/2025, was that Resident would not experience any adverse outcomes related to enhanced barrier precautions. The goal would be achieved by the following approaches: disinfect high touch surfaces as able/as needed (PRN), attempt to maintain environmental cleanliness, personal protective equipment as indicated, and report to physician signs and symptoms of infection as needed. Observation of the dressing change of R54's coccyx wound on 03/12/25 at 10:25 AM revealed the Assistant Director of Nursing (ADON) did not remove her gloves and sanitize her hands after changing the dressing and before assisting the resident to a chair at the bedside. Failure to remove her gloves and sanitize her hands resulted in contaminating resident's clothing, walker, table and any other item that were touched. In an interview with ADON on 03/12/2025 at 10:35 AM, she stated she should have removed her gloves after completing R54's dressing change and donned clean gloves before placing the resident's clothing back on and assisting her to the bedside chair. In an interview on 03/13/25 9:43 AM with Licensed Practical Nurse/Infection Preventionist/Staff Development Coordinator (LPN IP/SDC), she stated skills checks were done with a skills checkoff for hand hygiene and other skills. She further stated surveillance was done daily to ensure staff were using proper infection control techniques regarding hand hygiene and wound care as well as enhanced barrier precautions. She further stated she expected all staff to follow the facility policies and procedures as written related to infection control practices.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of facility policy, the facility failed to treat each resident with respect, dignity and care in a manner and an environment that enhances his or her quality of life by not announcing themselves before entering the room of (5) residents. (Resident (R) R9, R16, R17, R27, and R28). The findings include: Review of the facility's policy titled, Resident Rights, reviewed 09/13/2024, revealed all residents had the right to be treated with respect and dignity. These rights would be promoted and protected by the facility. All residents would be treated in a manner and in an environment that promoted maintenance or enhancement of quality of life. When providing care and services, the stakeholders would 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. Further review of the policy revealed the facility would make every effort to support each resident in exercising his/her right to assure that the resident is always treated with respect, kindness, and dignity. 1. Review of R9's medical record revealed the facility admitted the resident on 03/20/2023 with diagnoses which included: chronic obstructive pulmonary disease, type 2 diabetes mellitus, and gastro-esophageal reflux disease. Review of R9's Annual Minimum Data Set (MDS) Assessmennt with an Assessment Reference Date (ARD) date of 02/11/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. [NAME] an interview with R9 on 03/12/2025 at 1:28 PM, she stated, sometimes staff knock but not always. R9 stated she would like for staff to knock on the door before entering. 2. Review of R16's medical record revealed the facility admitted the resident on 01/24/2024 with diagnoses which included: type 2 diabetes mellitus, cognitive communication deficit and gastro-esophageal reflux disease. Revoew of R16's Quarterly MDS Assessment with an ARD date of 02/19/202, revealed the facility assessed the resident to have a BIMS score of 8 out of 15, indicating intact cognition. During an interview with R16 on 03/12/2025 at 1:05 PM, she stated staff were always coming in and out of her room without knocking. She further stated it would be nice if someone knocked on the door. 3. Review of R17's medical record revealed the facility admitted the resident on 02/07/2025 with diagnoses which included: chronic obstructive pulmonary disease and gastro-esophageal reflux disease. Review of R17's Quarterly MDS Assessment with an ARD date of 02/07/2025, revealed the facility assessed the resident to have a BIMS score of 15 out of 15, indicating intact cognition. 4. Review of R28's medical record revealed the facility admitted the resident on 04/05/2019 with diagnoeses which included: unspecified dementia and a history of abnormal weight loss. Review of R28's Quarterly MDS Assessment with an ARD date of 02/06/2025, revealed the facility assessed the resident to have a BIMS score of three (3) out of 15, which indicated severe cognition. 5. Review of R27's medical record noted she was admitted to the facility on [DATE] with diagnoses which include generalized anxiety disorder and moderate intellectual disabilities. Review of R27's Quarterly MDS Assessment with an ARD date of 01/31/2025, revealed the facility assessed the resident to have a BIMS score of 3 out of 15 which indicated severe cognition During a lunch observation meal pass on 03/12/2025 at 11:45 AM, Registered Nurse (RN) 1 was passing trays to rooms [ROOM NUMBERS] and failed to announce herself or knock on the resident's door prior to enterting the room. Further observation of the meal pass 03/12/2025 at 11:45 AM, revealed Certified Nurse Aide, (CNA) 4 failed to announce herself or knock on the resident's door prior to enterting the rooms [ROOM NUMBER]. During an interview with RN1 on 03/12/2025 at 2:18 PM, she stated she should have knocked on the resident's door before entering the resident rooms. She stated she knew it was a dignity issue since this is the residents' home. During an interview with CNA4 on 03/12/2025 at 2:10 PM, she stated she was aware she was supposed to knock on resident's doors before entering the room; however, she stated she had her hands full with a tray and didn't want to drop the tray. She further stated she could have voiced her arrival at doorway and alerted residents she was entering their room. CNA 4 stated she was trained to knock on resident rooms prior to entering because it was the residents home and staff should respect that. During an interview with the Administrator on 03/13/25 at 3:48 PM, he stated he expected staff to knock on residents' doors or verbally announce themselves prior to entering the rooms per the facility policy and practices. During an interview with the Director of Nursing (DON) on 03/13/25 at 3:50 PM, she stated she expected staff to introduce themselves before entering residents rooms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record revealed that Resident #314 was admitted to the facility on [DATE] with a diagnosis of dementia. Resident #314 had a Kentucky Emergency Medical Services Do Not Resuscitate (DNR) form located in the medical record, which was signed by the resident's representative and dated [DATE]. Review of current physician orders revealed the resident had an order for DNR. Further review of the medical record revealed DNR printed on a red paper in the front of the chart. Review of Resident #314's care plan dated [DATE] revealed a Full Code status care plan with interventions that cardio-pulmonary resuscitation (CPR) would be initiated in the event of a code (cardiopulmonary arrest). Interview with the Social Services Director (SSD) on [DATE] at 1:52 PM, revealed she was responsible for updating the code status care plans. She stated that sometimes she did not update the care plan if Nursing told her they updated it with the new order. She stated she was unaware that the care plan for Resident #314 had not been updated with the new code status of DNR and stated she must not have been aware of the new order. Interview with the Director of Nursing (DON) on [DATE] at 2:08 PM, revealed that in the event that the SSD was unavailable to update the care plan with new orders then Nursing was responsible to update the care plan. Based on observation, interview, record review, and review of the facility policy it was determined the facility failed to ensure revision of a comprehensive care plan for one (1) of nineteen (19) sampled residents and failed to ensure the notification/invitation of a care plan meeting for one (1) of nineteen (19) sampled residents. The facility failed to notify/invite Resident #38 to the care plan meeting for [DATE] following the quarterly comprehensive assessment dated [DATE]. The comprehensive care plan for Resident #314 did not reveal a revision to the code status change from full code to the status of do not resuscitate (DNR), which occurred on [DATE]. The findings include: Review of the facility policy, Comprehensive Care Plans, dated [DATE], revealed each resident had the right to participate in the choosing of treatment options and will be given the opportunity to participate in the development, review, and revision of their care plan. Further review of the facility policy revealed that care plans are ongoing and revised as information about the resident and the resident's condition changes. 1. Observation of Resident #38 during initial tour on [DATE] at 2:00 PM, revealed the resident in bed, lying on his/her back with the head of bed up about forty-five (45) degrees watching TV. The resident stated he/she had not been informed of care plan meetings and did not remember attending one. Review of the medical record revealed Resident #38 was admitted to the facility on [DATE] with diagnoses of Multiple Sclerosis, Depression, Mononeuropathy, Trigeminal Neuralgia, and Overflow Incontinence. The Minimum Data Set (MDS) quarterly assessment, dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of fourteen (14) which indicated the resident was cognitively intact. Further review of the medical record revealed a quarterly MDS assessment was completed on [DATE]. Review of the Care Plan Conference Summary forms for Resident #39 revealed a summary form not done for the October quarterly assessment. Further review revealed the most recent form completed prior to the October assessment was dated for [DATE]. This Care Plan Conference Summary was noted to have the attendees as the Director of Nursing, the Social Services Director, and a family member. Review of the progress notes dated [DATE] revealed a note that stated an Interdisciplinary Team meeting was held discussing the quarterly assessment dated [DATE]. The documentation did not reveal attendance by the resident and did not reveal why the resident was not in attendance. Interview with Resident #38 on [DATE] at 4:16 PM, revealed he/she had not received any notifications regarding care plan meetings. Interview with the Social Services Director (SSD) on [DATE] at 1:15 PM, revealed she was responsible for notifying and inviting residents and family to the care plan meetings. She stated the resident was always invited verbally, but this was not documented. Interview with the Administrator on [DATE] at 3:05 PM, revealed residents were invited verbally to the care plan meetings; however, this had not been documented. He stated he could not provide any evidence that the resident had been invited or notified regarding the care plan meeting in [DATE]. The Administrator also stated the facility policy stated the resident was to be included in the care plan meeting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, record review, and facility policy review, the facility failed to ensure the environment for one (1) of nineteen (19) sampled residents (Resident #314) remained free of accident hazards. Resident #314 was assessed upon admission to be at risk for elopement. The facility failed to reassess the resident's risk for elopement quarterly according to facility policy. The findings include: Review of the facility policy titled Elopement/Wandering, dated 05/30/2018, revealed an elopement/wandering assessment would be completed upon admission and quarterly thereafter. Observation of Resident #314 on 01/21/2020 at 2:26 PM, 3:45 PM, and 4:01 PM and on 01/23/2020 at 10:09 AM revealed the resident was wandering throughout the facility. The resident was observed to have a wander guard bracelet (device that alarms if a resident is attempting to exit the facility) on his/her left ankle. Review of the record for Resident #314 revealed the resident was admitted to the facility on [DATE] with diagnoses that include dementia and confusion. Further review of the record revealed the most recent Minimum Data Set (MDS) on 01/14/2020 revealed the resident had impaired cognition with the resident being rarely/never understood. The MDS further revealed that the resident displayed wandering behavior 1 to 3 days during the assessment period. The record revealed a physician order for Wander Guard. An elopement risk evaluation was completed on 11/15/2018 upon admission, which assessed the resident to be at risk for elopement due to being cognitively impaired, independently mobile, had poor decision-making, demonstrated exit-seeking behavior, wandered oblivious to safety needs, and had a history of elopement and ability to exit the facility. Review of the Wander Club binder revealed Resident #314's information was in the book and the resident was identified as an elopement risk. Further review of the record revealed no evidence that an assessment had been completed since admission to reassess the resident's risk for elopement. Interview with the MDS Coordinator on 01/22/2020 at 2:37 PM revealed that the Social Services Director (SSD) was responsible for completing the elopement assessments. Interview with the SSD on 01/22/2020 at 2:40 PM revealed that the charge nurses on each hallway were responsible for completing the elopement assessments and that she was responsible to update the binder that included information about wandering residents. Interview with Licensed Practical Nurse (LPN) #1 on 01/22/2020 at 3:00 PM revealed she was responsible for the care of Resident #314. LPN #1 further stated that the nurses were not responsible for the elopement assessments and stated that the SSD was responsible for completing the elopement assessments. Interviews with the Director of Nursing (DON) on 01/22/2020 at 2:50 PM and on 01/23/2020 at 1:34 PM revealed elopement assessment should be completed for residents on a quarterly basis and should be completed by nursing staff. The DON further stated he was unaware that Resident #314's assessment had not been completed quarterly according to policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure two (2) residents not in the selected sample of twenty-one (21) residents received restorative services to maintain or improve his/her ability to carry out eating or grooming/hygiene (Residents #4 and #46). Review of the Restorative Service Delivery Records for Resident #4 and #46, two (2) of two (2) residents who were assessed and care planned for restorative services for eating or hygiene/grooming, revealed the residents had received restorative nursing services for only five (5) days during October 2018. The findings include: Review of the facility policy titled, Restorative Nursing Policy and Procedure Manual, dated July 2010, revealed restorative nursing is a collection of interventions designed to promote resident independence and safety. It is part of a three-level process. Level III is Rehabilitation Therapy, Level II is Restorative Nursing, and Level I is Basic Nursing Care. The goal, at all levels, is to restore the resident's functionality whenever possible, improve the ability for self-care, and maintain independence as long as possible. Further review of the policy revealed the Restorative Nursing Staff will provide the care in accordance with the Restorative Plan of Care to help enhance resident's normal range of motion, and activities of daily living. 1. Record review revealed the facility admitted Resident #4 on 10/31/15, with diagnoses which included Dementia, Muscle Weakness, Other lack of coordination. Review of Resident #4's Comprehensive Care Plan, dated 08/15/18, revealed the resident was at risk for decline in ability to perform ADLs and was care planned for restorative therapy for grooming and hygiene. Review of Physician's orders, dated October 2018, revealed an order for Restorative Therapy for grooming/hygiene, ADLs, dated 08/15/18. Review of the Restorative Service Delivery Record, dated October, 2018, revealed Resident #4 had received only five (5) days of restorative therapy for the entire month of October. Observation of Resident #4, on 11/02/18 at 9:03 AM, with restorative nursing staff and the OT revealed the resident demonstrated no decline in ADLs. 2. Record review revealed the facility admitted Resident #46 on 03/01/13, with diagnoses which included Alzheimer's Disease, Muscle Weakness, Unspecified Lack of Coordination and History of Falls. Review of the Comprehensive Care Plan, dated 08/10/18, revealed Resident #46 had an actual decline in ability to feed self secondary to positioning and was care planned for restorative therapy for dining. Review of Physician's orders revealed an order, dated 08/15/18, for Restorative Therapy, restorative dining for swallowing. Review of the Restorative Delivery Record, dated October 2018, revealed Resident #46 had received only five (5) days of restorative therapy for the entire month of October. Surveyor was unable to observe Resident #46 for decline as he/she was sent to the emergency room on [DATE] for an acute episode. Interview with Restorative Aide (RA) #1, on 11/01/18 at 11:10 AM, revealed she was pulled to the floor several times a week and while she worked the floor she did not have enough time to complete restorative duties. She further stated she had voiced her concerns to the restorative nurse coordinator and nothing had changed. She revealed if she had provided restorative care she would have documented it. Interview with RA #2, on 11/02/18 at 11:15 AM, revealed she was pulled to the floor frequently to work as an aide. She stated it was impossible to do the fifteen (15) minute restorative programs for all residents while on the floor because some residents have more than one (1) care area. She stated she had not made anyone aware of restorative tasks not being done because they must know since she was being pulled to the floor so much. Interview with RA #3, on 11/02/18 at 11:24 AM, revealed she was pulled to the floor about fifty (50) percent of the time to work as an aide because the resident census was low. She stated she had been told by the restorative nurse to get restorative programs done if we could. She stated she had not made anyone aware that restorative was not being done because they know it was impossible to do all of it while working the floor. Interview with the Restorative Nurse Coordinator, on 11/01/18 at 12:02 PM, revealed she was not aware the Restorative Service Delivery Records for residents were incomplete for the month of October 2018. She stated she had noticed some holes for October in the restorative records, but failed to follow-up as to why. She stated she knew the restorative aides were being pulled to the floor, but assumed they were doing their restorative duties with the help of other aides. She further stated she had told the restorative aides to make her or the Director of Nursing (DON) aware if restorative care was not being provided so they could help and ensure restorative programs were being done. She stated none of the restorative aides had made her aware the restorative programs were not being provided to the residents, and she thought it was being done while residents were receiving daily care needs. She stated if she knew the tasks were not being done, she would have made the DON aware. She stated the restorative aides were being pulled to the floor because resident census was down and the restorative case load could be completed while they worked the floor. Interview with the Directive of Nursing (DON), on 11/01/18 at 12:54 PM, revealed if the restorative aides were on the floor, they should still be doing the restorative. She further stated she would expect the restorative programs to be done and if not, they should be reporting it to her, or another manager. She stated she had been off sick recently and was not made aware the restorative was not being done. Telephone interview with the DON, on 11/16/18 at 2:28 PM, revealed restorative was available seven (7) days a week and must be provided at least six (6) days a week to be counted on the MDS assessment. She further stated restorative was a nursing measure and the orders do not specify as to how many days the resident will receive restorative therapy. Interview with the Administrator, on 11/02/18 at 11:59 AM, revealed the restorative aides were directed to complete both the floor duties and restorative duties when pulled to the floor. He stated based on resident census, acuity, and restorative case load, they should have completed the restorative and documented it.

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure the one (1) of twenty-one (21) residents environment was free of accident hazards (Resident #20). The facility identified Resident #20's shoes could be an accident hazard for the resident due to the resident not having shoes on properly and care planned for staff to ensure the resident's shoes were on properly and shoe laces were tied. However, on 10/24/18, Resident #20 was being assisted by staff and the resident stumbled and fell sustaining a hematoma to the right leg. It was determined the resident's shoes were not on properly and the heels were flopping. The findings include: Review of the facility policy titled, Falls, not dated, revealed falls resulting from environmental factors will be reviewed at monthly Safety Committee. Further review of the policy revealed a Comprehensive Care Plan will be implemented and interventions are to be revised as indicated. Record review revealed the facility readmitted Resident #20 on 07/05/17, with diagnoses which included Vascular Dementia With Behavioral Disturbance, Difficulty Walking, and Muscle Weakness. Review of the quarterly Minimum Data Set (MDS) assessment, dated 09/14/18, revealed the facility assessed Resident #20's cognition as intact with a Brief Interview for Mental Status (BIMS) score of eight (8). Review of the Comprehensive Care Plan, dated 10/04/12, revealed an intervention for staff to ensure shoes were completely on and tied (secured). Review of a facility fall investigation revealed, on 10/24/18 at 12:00 PM, Resident #20 stumbled into the door facing and sustained a hematoma to the right leg. Further review revealed the resident did not have his/her shoes on properly and the heels were flopping. Attempted interviews with Resident #20 on 10/30/18 at 4:20 PM and 10/31/18 at 8:29 AM revealed the resident was unable to provide information about the fall on 10/24/18. Interview with Certified Nurse Aide (CNA) #1, on 11/01/18 at 12:45 PM, revealed she was assisting Resident #20 when he/she fell and stated the resident's shoes appeared to be on correctly. She stated the resident was walking really fast during this time. Interview with Licensed Practical Nurse (LPN) #3 who completed the fall investigation, on 11/01/18 at 12:26 PM, revealed an aide was present when Resident #20 fell but she could not catch the resident. She stated she would have expected the aide to ensure the resident's shoes were on properly. Interview with the Director of Nursing (DON), on 11/01/18 at 12:49 PM, revealed the resident had a tendency to put his/her shoes on the wrong foot and staff were constantly attempting to redirect the resident. She stated she would have expected the staff to ensure the residents shoes were on properly prior to ambulation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of twenty-one (21) sampled residents received the appropriate catheter care to prevent urinary tract infections (Resident #40). Observation of Resident #40, on 10/20/18, 10/31/18, and 11/02/18, revealed the catheter tubing was placed at a level higher than the bladder, not allowing the bladder to drain properly. The findings include: Review of the facility policy titled, Catheterization Care, not dated, revealed to routinely check to ensure catheter tubing is not looped or positioned above the level of the bladder. Record review revealed the facility admitted Resident #40 on 01/14/14 with diagnoses which included Type 2 Diabetes Mellitus with other diabetic kidney complication, History of Urinary Tract Infections, Chronic Kidney Disease, Neuromuscular Dysfunction of Bladder, and Parkinson's. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 09/07/18, revealed the facility assessed Resident #40's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of nine (9), which indicated the resident was interviewable. However, the resident had impaired communication due to mumbled and slurred speech making it difficult to interview him/her. Further review of the MDS revealed the resident had limited functional range of motion (ROM) to bilateral upper and lower extremities, required extensive to total assist with all activities of daily living (ADLs), and had an indwelling urinary catheter. Review of Resident #40's Comprehensive Care Plan for I have a [diagnosis] of neurogenic bladder retention and atony of bladder with supra-pubic catheter for urinary elimination; at risk for complications/Urinary Tract Infection, last reviewed 09/11/18, with an approach to Keep drainage bag positioned to promote urinary drainage. However, further review revealed there was no specific approach to address proper placement of the tubing to allow for urine drainage. Further review of the medical record revealed Resident #40 had been hospitalized [DATE] through 07/04/18 and again on 09/26/18 through 09/29/18 for urinary tract infections. Observation, on 10/30/18 at 11:17 AM, and on 10/31/18 at 8:25 AM and 11:15 AM, revealed the supra-pubic catheter tubing was positioned so that it was draped up and over the bed bolster causing the tubing to be at a higher level than Resident #40's bladder; therefore, not allowing the bladder to drain properly. Interview with Certified Nurse Aide (CNA) #3, on 10/31/18 at 11:15 AM, revealed the tubing should not be draped in this fashion (over the bed bolster), because it doesn't allow the urine to drain properly. Observation, on 11/02/18 at 9:18 AM, revealed the catheter tubing had been extended to the foot of the bed with the drainage bag hanging from the bed frame. However, the foot of the bed was elevated which allowed urine to back flow into the bladder and did not allow the bladder to empty properly. Interview with CNA #4, on 11/02/18 at 12:16 PM, revealed she just received an in-service regarding the placement of urinary catheter tubing on the morning of 11/02/18. She stated the drainage tubing should be placed under the bed bolster, not over it so the catheter can drain correctly and not back flow into the bladder. CNA #4 further stated she was not aware of proper placement of drainage tubing until this morning's in-service and often placed the catheter over the bed bolster when providing care, I just didn't think about it. Interview with CNA #5, on 11/02/18 at 12:24 PM, revealed the tubing and the bag were suppose to be placed lower than the bladder. She stated she received an in-service on this information on the morning of 11/02/18, but was aware that the tubing and drainage bag needed to be placed lower than the bladder prior to the in-service. CNA #5 revealed she was aware if the tubing and the drainage bag were not placed appropriately, the urine could drain back into the bladder and cause infections. CNA #5 further stated the resident's bladder leaked often, but was not aware about the urine black flow, and extension of the bladder could cause the leakage. Interview with Licensed Practical Nurse (LPN) #4, on 10/31/18 at 11:25 AM, revealed the catheter tubing over the bed bolster was too high and it allowed urine to back flow into the bladder. She stated she would position the catheter so it was below the bladder level, at least. Interview with the Assistant Director of Nursing (ADON), on 11/01/18 at 10:15 AM, revealed she would expect the catheter tubing to be placed under the bolster, at the resident's side or at least lower than bladder level. Interview with the Director of Nursing (DON), on 11/01/18 at 10:37 AM, revealed the catheter tubing should be placed under the bed bolster and expected staff to follow the policy regarding tubing and drainage bag placement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, it was determined the facility failed to implement or develop a comprehensive person-centered care plan for six (6) of twenty-one (21) sampled residents (Residents #3, #11, #20, #40, #50, and #51), and seven (7) unsampled residents (Residents #2, #4, #6, #31, #45, #46, and #55). Resident #20 was care planned for staff to ensure his/her shoes were on properly; however, on 10/24/18, the resident stumbled and sustained a bruise to his/her right leg due to his/her shoes not being on properly. Review of Restorative Services Delivery Records for Residents #3, #11, #40, and #51; and Unsampled Residents #2, #4, #6, #31, #45, #46, and #55 revealed the residents were not provided restorative nursing services per care plan. In addition, Resident #50 was referred to the Restorative Program on 10/18/18; however, the facility failed to develop a care plan for restorative services for Resident #50. The findings include: Review of the facility policy titled, Comprehensive Care Plans, not dated, 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. Further review of the policy revealed the care plan will include how the facility will assist the resident to meet their needs, goals, and preferences. Continued review of the policy revealed each resident's comprehensive care plan is designed to incorporate identified problem areas; Incorporate risk factors associated with identified problems; Build on residents' strengths; Identify the professional services that are responsible for each element of care; Aid in preventing or reducing declines in the resident's functional status and/or functional levels; Enhance the optimal functioning of the resident by focusing on a rehabilitative program. 1. Record review revealed the facility readmitted Resident #20 on 07/05/17, with diagnoses which included Vascular Dementia with Behavioral Disturbance, Difficulty Walking, and Muscle Weakness. Review of the quarterly Minimum Data Set (MDS) assessment, dated 09/14/18, revealed the facility assessed Resident #20's cognition as intact with a Brief Interview for Mental Status (BIMS) score of eight (8). Review of the Comprehensive Care Plan, dated 10/04/12, revealed an intervention for staff to ensure shoes were completely on and tied (secured). However, review of the facility provided fall investigation revealed, on 10/24/18 at 12:00 PM, revealed the resident did not have his/her shoes on properly and the heels were flopping which resulted in the resident stumbling into the door facing and sustaining a hematoma to the right leg. Several attempted interviews with the resident revealed he/she was unable to provide information about his/her fall on 10/24/18. Interview with Certified Nurse Aide (CNA) #1, on 11/01/18 at 12:45 PM, revealed she was assisting Resident #20 when he/she fell and stated the resident's shoes appeared to be on correctly. She stated the resident was walking really fast during this time. Interview with Licensed Practical Nurse (LPN) #3 who completed the fall investigation, on 11/01/18 at 12:26 PM, revealed an aide was present when Resident #20 fell but she couldn't catch the resident. She stated she would have expected the aide to ensure the resident's shoes were on properly per care plan. Interview with the Director of Nursing (DON), on 11/01/18 at 12:49 PM, revealed the resident had a tendency to put his/her shoes on the wrong feet and staff were constantly attempting to redirect the resident. She stated she would have expected the staff to ensure the resident's shoes were on properly prior to ambulation per care plan. 2. Record review revealed the facility readmitted Resident #11 on 09/02/18, with diagnoses which included Heart Failure, Hypertension, and Type 2 Diabetes. Review of Resident #11's Comprehensive Care Plan, revealed on 08/02/18, the resident was care planned for restorative nursing therapy for Active Range of Motion (AROM) to the bilateral upper extremities. However, review of the Restorative Service Delivery Record, dated October 2018, revealed Resident #11 had received only three (3) days of restorative therapy. 3. Record review revealed the facility readmitted Resident #3 on 06/15/18, with diagnoses which included Muscle Weakness, Unspecified Lack of Coordination, and Hypertension. Review of Resident #3's Comprehensive Care Plan, dated 08/14/18, revealed the resident to be at risk for decline in the ability to transfer with limited level of assistance. Further review of the care plan revealed approaches to include a restorative transfer program to assist the resident in transfers from bed to chair, and transfers from chair to bed with the use of a gait belt. However, review of the Restorative Service Delivery Record, dated October 2018, revealed Resident #3 had received only three (3) days of restorative therapy. 4. Record review revealed the facility admitted Resident #6 on 03/26/18, with diagnoses which included Multiple Sclerosis, Muscle Weakness, and Other Chronic Pain. Review of Resident #6's Comprehensive Care Plan, dated 08/14/18, revealed the resident to have impaired functional mobility related to weakness and neurological deficit. Further review of the care plan revealed approaches to include Passive Range of Motion (PROM), assist in movement through tolerated range, supporting joints above and below the lower extremities (hip/thigh). However, review of the Restorative Service Delivery Record, dated October 2018, revealed Resident #6 had received only three (3) days of restorative therapy. 5. Record review revealed the facility admitted Resident #45 on 06/26/18, with diagnoses which included Unspecified Intellectual Disabilities, Need for Assistance with personal care, and Muscle Weakness. Review of Resident #45's Comprehensive Care Plan, dated 06/13/18, revealed the resident to have actual declines in the ability to self-transfer secondary to weakness. Further review of the care plan revealed approaches to include a restorative transfer program to assist the resident in transfers from bed to chair, transfer from chair to bed, transfer from wheelchair to commode and transfer from commode to wheelchair. However, review of the Restorative Service Delivery Record, dated October 2018, revealed Resident #45 had received only three (3) days of restorative therapy. 6. Record review revealed the facility readmitted Resident #55 on 11/10/17, with diagnoses which included Muscle Weakness, Difficulty in Walking, and Hypertension. Review of Resident #55's Comprehensive Care Plan, dated 07/12/18, revealed the resident required a restorative therapy program for AROM to the upper extremities; however, review of the Restorative Service Delivery Record, dated October 2018, revealed Resident #55 had received only three (3) days of restorative therapy. 7. Record review revealed the facility admitted Resident #2 to the facility on [DATE] with diagnoses which included Difficulty in Walking, Anxiety Disorder, and Cognitive Communication Disorder. Review of Resident #2's Quarterly MDS assessment, dated 10/31/18, revealed the facility assessed the resident's BIMS score to be three (3), which indicated he/she had severely impaired cognition and was not interviewable. Review of the Restorative Nursing Care Plan, dated 07/11/18, revealed Resident #2 was to be assisted to ambulate three-hundred (300) feet, one (1) time per day, six (6) to seven (7) days per week; however, review of the Restorative Delivery Record, dated October 2018, revealed Resident #2 had received only four (4) days of restorative therapy for the entire month of October 2018. 8. Record review revealed the facility admitted Resident #4 on 10/31/15, with diagnoses which included Dementia, Muscle Weakness, Other lack of coordination. Review of Resident #4's Comprehensive Care Plan, dated 08/15/18, revealed the resident was at risk for decline in ability to perform ADLs and was care planned for restorative therapy for grooming and hygiene. However, review of the Restorative Service Delivery Record, dated October 2018, revealed Resident #4 had received only five (5) days of restorative therapy for the entire month of October 2018. 9. Record review revealed the facility admitted Resident #31 on 10/04/17, with diagnoses which included Dementia, Muscle weakness, Unspecified lack of coordination, and History of falls. Review of Resident #31's Comprehensive Care Plan, dated 07/11/18, revealed the resident was at risk for developing an impairment in functional joint mobility related to weakness and was care planned to receive restorative therapy for AROM to the bilateral upper extremities. However, review of the Restorative Delivery Record, dated October 2018, revealed Resident #31 had received only four (4) days of restorative therapy for the entire month of October 2018. 10. Record review revealed the facility admitted Resident #40 on 01/14/14, with diagnoses which included Muscle Weakness, Muscle Wasting and Atrophy, and Repeated falls. Review of the Comprehensive Care Plan, dated 06/13/18, revealed Resident #40 had impaired functional mobility related to weakness and was care planned for restorative therapy for AROM to the bilateral upper extremities. However, review of the Restorative Delivery Record, dated October 2018, revealed Resident #40 had received only four (4) days of restorative therapy for the entire month of October 2018. 11. Record review revealed the facility admitted Resident #46 on 03/01/13, with diagnoses which included Alzheimer's Disease, Muscle Weakness, Unspecified Lack of Coordination and History of Falls. Review of the Comprehensive Care Plan, dated 08/10/18, revealed Resident #46 had an actual decline in the ability to feed self secondary to positioning and was care planned for restorative therapy for dining. However, review of the Restorative Delivery Record, dated October 2018, revealed Resident #46 had received only five (5) days of restorative therapy for the entire month of October 2018. 12. Record review revealed the facility admitted Resident #51 on 02/26/16 with diagnoses which included Unspecified Dementia, Repeated Falls, and Muscle Weakness. Review of the Comprehensive Care Plan, dated 08/10/18, revealed Resident #51 had impaired functional mobility related to weakness and was care planned for restorative therapy for AROM to the bilateral upper extremities and grooming and hygiene. However, review of the Restorative Delivery Record, dated October 2018, revealed Resident #51 had received only four (4) days of restorative therapy for the entire month of October 2018. 13. Record review revealed the facility admitted Resident #50 on 03/08/18 with diagnoses which included Hemiplegia, Muscle Weakness, and Need for Assistance with Personal Care. Review of Resident #50's Quarterly MDS assessment, dated 10/18/18, revealed the facility assessed the resident's BIMS score to be a fifteen (15), which indicated his/her cognition was intact and interviewable. Review of a Physician's order, dated 10/18/18, revealed an order to discontinue Physical Therapy to Restorative Nursing Program. Review of Therapy's Communication to Nursing form, dated 10/18/18, revealed Resident #50 should be on a restorative nursing program for transfers, to be done six (6) to seven (7) days per week, and a restorative nursing program for range of motion to be done six (6) days per week. However, review of the Comprehensive Care Plan, last revised 10/19/18, revealed there was no evidence a restorative nursing program care plan was developed for him/her regarding the restorative nursing programs which was to be implemented. Review of Resident #50's clinical record, revealed there was no Restorative Delivery Record for Resident #50's restorative for transfers and range of motion and no documentation the restorative was provded. Interview with the Restorative Nurse Coordinator, on 11/01/18 at 10:16 AM, revealed therapy communication to nursing was on 10/18/18, for Resident #50, to be on restorative nursing for strengthening and ROM. She stated they did not start Resident #50's restorative programs or develop a restorative care plan until 11/01/18. She stated the program was not started immediately due to trying to get the new restorative pilot program up and running. Interview with Restorative Aide (RA) #1, on 11/01/18 at 11:10 AM, revealed she was pulled to the floor several times a week, and while she worked the floor she did not have enough time to complete restorative duties. She further stated she had voiced her concerns to the Restorative Nurse Coordinator and nothing had changed. She further stated if she had provided restorative care, she would have documented it. Interview with RA #2, on 11/02/18 at 11:15 AM, revealed she was pulled to the floor frequently to work as an aide. She stated it was impossible to do the fifteen (15) minute restorative programs for all residents while on the floor, because some residents have more than one (1) care area. She stated she had not made anyone aware of restorative tasks not being done, and stated they must know since she was being pulled to the floor so much. Interview with RA #3, on 11/02/18 at 11:24 AM, revealed she was pulled to the floor about fifty (50) percent of the time to work as an aide because the resident census was low. She stated she had been told by the restorative nurse to get restorative programs done if possible. She stated she had not made anyone aware that restorative was not being done because they knew it was impossible to do all of it while working the floor. Interview with the Restorative Nurse Coordinator, on 11/01/18 at 12:02 PM, revealed she was not aware the Restorative Service Delivery Records for residents were incomplete for the month of October 2018. She stated she had noticed some holes for October in the restorative records, but failed to follow-up as to why. She stated she knew the restorative aides were being pulled to the floor, but assumed they were doing their restorative duties with the help of other aides. She further stated she had told the restorative aides to make her or the DON aware if restorative care was not being provided so they could help and ensure restorative programs were being done. She stated none of the restorative aides had made her aware the restorative programs were not being provided to the residents, and she thought it was being done while residents were receiving daily care needs. She stated if she knew the tasks were not being done, she would have made the DON aware. She stated the restorative aides were being pulled to the floor because resident census was down and the restorative case load could be completed while they worked the floor. Interview with the DON, on 11/01/18 at 12:54 PM, revealed if the restorative aides were on the floor, they should still be doing the restorative. She further stated she would expect the restorative programs to be done and if not, they should be reporting it to her, or another manager. She stated she had been off sick recently and was not made aware the restorative was not being done. Interview with the Administrator, on 11/02/18 at 11:59 AM, revealed the restorative aides were directed to complete both the floor duties and restorative duties when pulled to the floor. He stated based on resident census, acuity, and restorative case load, they should have completed the restorative and documented it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, it was determined the facility failed to ensure there was sufficient nursing staff to provide restorative nursing services for five (5) of twenty-one (21) sampled residents (Residents #3, #11, #40, #50, and #51), and seven (7) unsampled residents (Residents #2, #4, #6, #31, #45, #46, and #55). Review of the Restorative Service Delivery Records for all twelve (12) residents in the facility's Restorative Program had received restorative nursing services for only three (3) to five (5) days during the month of October 2018. In addition, Resident #50 was discharged from Rehabiltaion Services to Restorative Nursing on 10/18/18; however, restorative nursing was not started until 11/01/18, fourteen (14) days after therapy's communication to nursing. The findings include: Review of the facility policy titled, Scheduling and Staffing, last revised 05/24/18, revealed the facility is to establish consistent work shift scheduling practices to allow for efficient business operations and continuity of resident care. Further review of the policy revealed the facility will establish an electronic master schedule and the facility will staff the building using the following considerations, when applicable as it pertains to each individual facility resident needs and population: acuity based staffing (ABS) modeling as a guideline, not a minimum, which considers the resident population's Minimum Data Set (MDS) input; each facility's volume of assessments and admissions. Further review of the policy revealed, based on the resident census and acuity, a facility may need to add or cancel Stakeholders work shifts in order to maintain appropriate levels of resident care. 1. Record review revealed the facility readmitted Resident #11 on 09/02/18, with diagnoses which included Heart Failure, Hypertension, and Type 2 Diabetes. Review of the care plan, dated 08/02/18, revealed restorative nursing therapy program for Active Range of Motion (AROM) to bilateral upper extremities. Review of the Restorative Service Delivery Record, dated October 2018, revealed Resident #11 had received only three (3) days of restorative therapy. 2. Record review revealed the facility readmitted Resident #3 on 06/15/18, with diagnoses which included Muscle Weakness, Unspecified Lack of Coordination, and Hypertension. Review of the care plan, dated 08/14/18, revealed a restorative transfer program to assist the resident in transfers from bed to chair, transfers from chair to bed with the use of a gait belt. Review of the Restorative Service Delivery Record, dated October, 2018, revealed Resident #3 had received only three (3) days of restorative therapy. 3. Record review revealed the facility admitted Resident #6 on 03/26/18, with diagnoses which included Multiple Sclerosis, Muscle Weakness, and Other Chronic Pain. Review of the care plan, dated 08/14/18, revealed Passive Range of Motion (PROM), assist in moving through tolerated range, supporting joints above and below lower extremities (hip/thigh). Review of the Restorative Service Delivery Record, dated October, 2018, revealed Resident #6 had received only three (3) days of restorative therapy. 4. Record review revealed the facility admitted Resident #45 on 06/26/18, with diagnoses which included Unspecified Intellectual Disabilities, Need for Assistance with personal care, and Muscle Weakness. Review of the care plan, dated 06/13/18, revealed transfer from bed to chair, transfer from chair to bed, transfer from wheelchair to commode and transfer from commode to wheelchair. Review of the Restorative Service Delivery Record, dated October, 2018, revealed Resident #45 had received only three (3) days of restorative therapy. 5. Record review revealed the facility readmitted Resident #55 on 11/10/17, with diagnoses which included Muscle Weakness, Difficulty in Walking, and Hypertension. Review of the care plan, dated 07/12/18, revealed the resident required a restorative therapy program for AROM to the upper extremities. Review of the Restorative Service Delivery Record, dated October, 2018, revealed Resident #55 had received only three (3) days of restorative therapy. 6. Record review revealed the facility admitted Resident #4 on 10/31/15, with diagnoses which included Dementia, Muscle Weakness, Other lack of coordination. Review of the care plan, dated 08/15/18, revealed the resident was at risk for decline in ability to perform ADLs and was care planned for restorative therapy for grooming and hygiene. Review of the Restorative Service Delivery Record, dated October, 2018, revealed Resident #4 had received only five (5) days of restorative therapy for the entire month of October. 7. Record review revealed the facility admitted Resident #31 on 10/04/17, with diagnoses which included Dementia, Muscle weakness, Unspecified lack of coordination, and history of falls. Review of the care plan, dated 07/11/18, revealed the resident was at risk for developing an impairment in functional joint mobility related to weakness and was care planned to receive restorative therapy for AROM to bilateral upper extremities. Review of the Restorative Delivery Record, dated October 2018, revealed Resident #31 had received only four (4) days of restorative therapy for the entire month of October. 8. Record review revealed the facility admitted Resident #40 on 01/14/14, with diagnoses which included Muscle Weakness, Muscle Wasting and Atrophy, and Repeated falls. Review of the care plan, dated 06/13/18, revealed the resident had impaired functional mobility related to weakness and was care planned for restorative therapy for AROM to the bilateral upper extremities. Review of the Restorative Delivery Record, dated October 2018, revealed Resident #40 had received only four (4) days of restorative therapy for the entire month of October. 9. Record review revealed the facility admitted Resident #46 on 03/01/13, with diagnoses which included Alzheimer's Disease, Muscle Weakness, Unspecified Lack of Coordination and History of Falls. Review of the care plan, dated 08/10/18, revealed the resident had an actual decline in ability to feed self secondary to positioning and was care planned for restorative therapy for dining. Review of the Restorative Delivery Record, dated October 2018, revealed Resident #46 had received only five (5) days of restorative therapy for the entire month of October. 10. Record review revealed the facility admitted Resident #51 on 02/26/16 with diagnoses which included Unspecified Dementia, Repeated Falls, and Muscle Weakness. Review of the care plan, dated 08/10/18, revealed the resident had impaired functional mobility related to weakness and was care planned for restorative therapy for AROM to the bilateral upper extremities and grooming and hygiene. Review of the Restorative Delivery Record, dated October, 2018, revealed the resident had received only four (4) days of restorative therapy for the entire month of October. 11. Record review revealed the facility admitted Resident #2 to the facility on [DATE] with diagnoses which included Difficulty in Walking, Anxiety Disorder, and Cognitive Communication Disorder. Review of the restorative nursing walking program, dated 07/11/18, revealed the resident was to be assisted to ambulate three-hundred (300) feet one (1) time per day six (6) to seven (7) days per week. Review of the Restorative Delivery Record, dated October, 2018, revealed Resident #2 had received only four (4) days of restorative therapy for the entire month of October. 12. Record review revealed the facility admitted Resident #50 to the facility on [DATE] with diagnoses which included Hemiplegia, Muscle Weakness and Need for Assistance with Personal Care. Review of therapy's communication to nursing, dated 10/18/18, revealed the resident was to be on a restorative nursing program for transfers to be done six (6) to seven (7) days a week and a restorative nursing program for range of motion (ROM) to be done six (6) days a week. Review of Resident #50's clinical record revealed restorative nursing was not started until 11/01/18 for Resident #50, which was fourteen (14) days later. Interview with the Restorative Nurse Coordinator, on 11/01/18 at 10:16 AM, revealed therapy communication to nursing was on 10/18/18, for Resident #50, to be on restorative nursing for strengthening and ROM. She stated they did not start Resident #50's restorative programs until 11/01/18. She stated the program was not started immediately due to trying to get the new restorative pilot program up and running. Interview with Restorative Aide (RA) #1, on 11/01/18 at 11:10 AM, revealed she was pulled to the floor several times a week and while she worked the floor she does not have enough time to complete restorative duties. She further stated she had voiced her concerns to the restorative nurse coordinator and nothing had changed. She further stated if she had provided restorative care she would have documented it. Interview with RA #2, on 11/02/18 at 11:15 AM, revealed she was pulled to the floor frequently to work as an aide. She stated it was impossible to do the fifteen (15) minute restorative programs for all residents while on the floor because some residents have more than one (1) care area. She stated she had not made anyone aware of restorative tasks not being done because they must know since she was being pulled to the floor so much. Interview with RA #3, on 11/02/18 at 11:24 AM, revealed she was pulled to the floor about fifty (50) percent of the time to work as an aide because the resident census was low. She stated she had been told by the restorative nurse to get restorative programs done if we could. She stated she had not made anyone aware that restorative was not being done because they know it was impossible to do all of it while working the floor. Further interview with the Restorative Nurse Coordinator, on 11/01/18 at 12:02 PM, revealed she was not aware the Restorative Service Delivery Records for residents were incomplete for the month of October 2018. She stated she had noticed some holes for October in the restorative records, but failed to follow-up as to why. She stated she knew the restorative aides were being pulled to the floor, but assumed they were doing their restorative duties with the help of other aides. She further stated she had told the restorative aides to make her or the Director of Nursing (DON) aware if restorative care was not being provided so they could help and ensure restorative programs were being done. She stated none of the restorative aides had made her aware the restorative programs were not being provided to the residents, and she thought it was being done while residents were receiving daily care needs. She stated if she knew the tasks were not being done, she would have made the DON aware. She stated the restorative aides were being pulled to the floor because resident census was down and the restorative case load could be completed while they worked the floor. Interview with the DON, on 11/01/18 at 12:54 PM, revealed If the restorative aides were on the floor, they should still be doing the restorative. She further stated she would expect the restorative programs to be done and if not they should be reporting it to her, or another manager. She stated she had been off sick recently and was not made aware the restorative was not being done. She stated the facility was staffed based on resident census and needs. She further stated if the restorative aides had communicated to management that restorative had not been done, appropriate steps would have been taken my herself or the unit manager to ensure residents received restorative. Interview with the Administrator, on 11/02/18 at 11:59 AM, revealed the restorative aides were directed to complete both the floor duties and restorative duties when pulled to the floor. He stated based on resident census, acuity, and restorative case load they should have completed the restorative and documented it. He further stated he did not feel there was an issue with staffing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure residents received retorative services to maintain, or increase range of motion amd/or mobility for five (5) of twenty-one (21) sampled residents (Residents #3, #11, #40, #50, and #51), and five (5) unsampled residents (Residents #2, #6, #31, #45, and #55). Review of the Restorative Service Delivery Records for ten (10) of ten (10) residents in the Restorative Program related to range of motion and mobility (Residents #2, #3, #4, #6, #11, #31, #40, #45, #46, #51, and #55) revealed the residents received restorative nursing services for only three (3) to four (4) days during October 2018. In addition, Resident #50 was discharged from Rehabilitation Services on 10/18/18 to Restorative Services for transfers; however, the restorative services for mobility were not started until 11/01/18, (fourteen days later). The findings include: Review of the facility policy titled, Restorative Nursing Policy and Procedure Manual, dated July 2010, revealed restorative nursing is a collection of interventions designed to promote resident independence and safety. It is part of a three-level process. Level III is Rehabilitation Therapy, Level II is Restorative Nursing, and Level I is Basic Nursing Care. The goal, at all levels, is to restore the resident's functionality whenever possible, improve the ability for self-care, and maintain independence as long as possible. Further review of the policy revealed the Restorative Nursing Staff will provide the care in accordance with the Restorative Plan of Care to help enhance resident's normal range of motion, and activities of daily living. 1. Record review revealed the facility readmitted Resident #11 on 09/02/18, with diagnoses which included Heart Failure, Hypertension, and Type 2 Diabetes. Review of Resident #11's Comprehensive Care Plan, dated 01/15/15, revealed the resident required assist of staff with Activities of Daily Living (ADLs) due to decreased mobility. Further review of the care plan revealed, on 08/02/18, the resident was care planned for restorative nursing therapy program for Active Range of Motion (AROM) to bilateral upper extremities. Review of the Physician's Order, dated October 2018, revealed an order for restorative therapy with AROM to the upper extremities. Review of the Restorative Service Delivery Record, dated October 2018, revealed Resident #11 had received only three (3) days of restorative therapy. Observation of Resident #11, on 11/02/18 at 8:37 AM, with Restorative Nursing staff and Occupational Therapist (OT) #1, revealed the resident demonstrated no decline in his/her AROM. 2. Record review revealed the facility readmitted Resident #3 on 06/15/18, with diagnoses which included Muscle Weakness, Unspecified Lack of Coordination, and Hypertension. Review of Resident #3's Comprehensive Care Plan, dated 08/14/18, revealed the resident to be at risk for decline in his/her ability to transfer with limited level of assistance. Further review of the care plan revealed approaches to include a restorative transfer program to assist the resident in transfers from bed to chair, transfers from chair to bed with the use of a gait belt. Review of the Restorative Service Delivery Record, dated October, 2018, revealed Resident #3 had received only three (3) days of restorative therapy. Observation of Resident #3, on 11/02/18 at 11:10 AM, with restorative nursing staff and Physical Therapist (PT) #1, revealed the resident demonstrated no decline in his/her ability to transfer. 3. Record review revealed the facility admitted Resident #6 on 03/26/18, with diagnoses which included Multiple Sclerosis, Muscle Weakness, and Other Chronic Pain. Review of Resident #6's Comprehensive Care Plan, dated 08/14/18, revealed the resident to have impaired functional mobility related to weakness and neurological deficit. Further review of the care plan revealed approaches to include Passive Range of Motion (PROM), assist in moving through tolerated range, supporting joints above and below lower extremities (hip/thigh). Review of the Restorative Service Delivery Record, dated October, 2018, revealed Resident #6 had received only three (3) days of restorative therapy. Observation of Resident #6, on 11/02/18 at 8:44 AM, with restorative nursing staff and PT #1, revealed the resident demonstrated no decline in his/her PROM. 4. Record review revealed the facility admitted Resident #45 on 06/26/18, with diagnoses which included Unspecified Intellectual Disabilities, Need for Assistance with personal care, and Muscle Weakness. Review of Resident #45's Comprehensive Care Plan, dated 06/13/18, revealed the resident to have actual declines in ability to self-transfer secondary to weakness. Further review of the care plan revealed approaches to include transfer from bed to chair, transfer from chair to bed, transfer from wheelchair to commode and transfer from commode to wheelchair. Review of the Restorative Service Delivery Record, dated October, 2018, revealed Resident #45 had received only three (3) days of restorative therapy. Interview with Resident #45 revealed he/she refused to allow the surveyor to observe care on 11/02/18 at 10:40 AM. 5. Record review revealed the facility readmitted Resident #55 on 11/10/17, with diagnoses which included Muscle Weakness, Difficulty in Walking, and Hypertension. Review of Resident #55's Comprehensive Care Plan, dated 07/12/18, revealed the resident required a restorative therapy program for AROM to the upper extremities. Review of the Restorative Service Delivery Record, dated October, 2018, revealed Resident #55 had received only three (3) days of restorative therapy. Observation of Resident #55, on 11/02/18 at 8:30 AM, with restorative nursing staff and OT #1, revealed the resident demonstrated no decline in his/her AROM. 6. Record review revealed the facility admitted Resident #31 on 10/04/17, with diagnoses which included Dementia, Muscle weakness, Unspecified lack of coordination, and history of falls. Review of Resident #31's Comprehensive Care Plan, dated 07/11/18, revealed the resident was at risk for developing an impairment in functional joint mobility related to weakness and was care planned to receive restorative therapy for AROM to bilateral upper extremities. Review of Physician's orders revealed an order, dated 07/11/18, for Restorative Therapy, AROM for upper extremities. Review of the Restorative Delivery Record, dated October 2018, revealed Resident #31 had received only four (4) days of restorative therapy for the entire month of October. An attempt was made to observe Restorative Therapy with Resident #31, on 11/02/18 at 9:32 AM; however, the resident refused, stating he/she did not feel well, was cold and had a headache. 7. Record review revealed the facility admitted Resident #40 on 01/14/14, with diagnoses which included Muscle Weakness, Muscle Wasting and Atrophy, and Repeated falls. Review of the Comprehensive Care Plan, dated 06/13/18, revealed Resident #40 had impaired functional mobility related to weakness and was care planned for restorative therapy for AROM to the bilateral upper extremities. Review of Physician's orders revealed an order, dated 06/13/18, for Restorative Therapy, AROM for upper bilateral extremities. Review of the Restorative Delivery Record, dated October 2018, revealed Resident #40 had received only four (4) days of restorative therapy for the entire month of October. Observation of Resident #40, on 11/02/18 at 9:14 AM, with restorative nursing staff and Occupational Therapist revealed the resident demonstrated no decline in ADLs. 8. Record review revealed the facility admitted Resident #51 on 02/26/16 with diagnoses which included Unspecified Dementia, Repeated Falls, and Muscle Weakness. Review of the Comprehensive Care Plan, dated 08/10/18, revealed Resident #51 had impaired functional mobility related to weakness and was care planned for restorative therapy for AROM to the bilateral upper extremities and grooming and hygiene. Review of Physician's orders revealed an order, dated 08/10/18, for AROM for bilateral upper extremities and grooming and hygiene. Review of the Restorative Delivery Record, dated October, 2018, revealed Resident #51 had received only four (4) days of restorative therapy for the entire month of October. Observation of Resident #51, on 11/02/18 at 9:36 AM, with restorative nursing staff and OT revealed the resident demonstrated no decline in ADLs. 9. Record review revealed the facility admitted Resident #2 to the facility on [DATE] with diagnoses which included Difficulty in Walking, Anxiety Disorder, and Cognitive Communication Disorder. Review of Resident #2's Quarterly MDS assessment, dated 10/31/18, revealed the facility assessed the resident's Brief Interview for Mental Status (BIMS) score to be a three (3), which indicated he/she had severely impaired cognition and was not interviewable. Review of Resident #2's restorative nursing walking program, dated 07/11/18, revealed Resident #2 was to be assisted to ambulate three-hundred (300) feet one (1) time per day six (6) to seven (7) days per week. Review of the Restorative Delivery Record, dated October, 2018, revealed Resident #2 had received only four (4) days of restorative therapy for the entire month of October. Observation of Resident #2, on 11/02/18 at 8:43 AM, with restorative nursing staff and PT revealed the resident demonstrated no decline in ambulation. 10. Record review revealed the facility admitted Resident #50 to the facility on [DATE] with diagnoses which included Hemiplegia, Muscle Weakness and Need for Assistance with Personal Care. Review of Resident #50's Quarterly MDS assessment, dated 10/18/18, revealed the facility assessed his/her BIMS score to be a fifteen (15), which indicated his/her cognition was intact and interviewable. Review of a Physician's order, dated 10/18/18, revealed an order to discontinue Physical Therapy to Restorative Nursing Program. Review of therapy's communication to nursing, dated 10/18/18, revealed Resident #50 was to be on a restorative nursing program for transfers to be done six (6) to seven (7) days a week and a restorative nursing program for range of motion (ROM) to be done six (6) days a week. Review of Resident #50's clinical record revealed restorative nursing was not started until 11/01/18 for Resident #50, which was fourteen (14) days after the initial order to start restorative nursing programs. Interview with Resident #50, on 10/31/18 at 8:59 AM, revealed he/she stated the facility had not implemented his/her restorative nursing program for him/her due to the census had been low and the restorative nursing CNAs had to work the floor. Interview with the Restorative Nurse Coordinator, on 11/01/18 at 10:16 AM, revealed therapy communication to nursing was on 10/18/18, for Resident #50, to be on restorative nursing for strengthening and ROM. She stated they did not start Resident #50's restorative programs until 11/01/18. She stated the program was not started immediately due to trying to get the new restorative pilot program up and running. Interview with Restorative Aide (RA) #1, on 11/01/18 at 11:10 AM, revealed she was pulled to the floor several times a week and while she worked the floor she did not have enough time to complete restorative duties. She further stated she had voiced her concerns to the restorative nurse coordinator and nothing had changed. She further stated if she had provided restorative care she would have documented it. Interview with RA #2, on 11/02/18 at 11:15 AM, revealed she was pulled to the floor frequently to work as an aide. She stated it was impossible to do the fifteen (15) minute restorative programs for all residents while on the floor because some residents have more than one (1) care area. She stated she had not made anyone aware of restorative tasks not being done because they must know since she was being pulled to the floor so much. Interview with RA #3, on 11/02/18 at 11:24 AM, revealed she was pulled to the floor about fifty (50) percent of the time to work as an aide because the resident census was low. She stated she had been told by the restorative nurse to get restorative programs done if we could. She stated she had not made anyone aware that restorative was not being done because they know it was impossible to do all of it while working the floor. Further interview with the Restorative Nurse Coordinator, on 11/01/18 at 12:02 PM, revealed she was not aware the Restorative Service Delivery Records for residents were incomplete for the month of October 2018. She stated she had noticed some holes for October in the restorative records, but failed to follow-up as to why. She stated she knew the restorative aides were being pulled to the floor, but assumed they were doing their restorative duties with the help of other aides. She further stated she had told the restorative aides to make her or the Director of Nursing (DON) aware if restorative care was not being provided so they could help and ensure restorative programs were being done. She stated none of the restorative aides had made her aware the restorative programs were not being provided to the residents, and she thought it was being done while residents were receiving daily care needs. She stated if she knew the tasks were not being done, she would have made the DON aware. She stated the restorative aides were being pulled to the floor because resident census was down and the restorative case load could be completed while they worked the floor. Interview with the DON, on 11/01/18 at 12:54 PM, revealed if the restorative aides were on the floor, they should still be doing the restorative. She further stated she would expect the restorative programs to be done and if not, they should be reporting it to her, or another manager. She stated she had been off sick recently and was not made aware the restorative was not being done. Telephone interview with the DON, on 11/16/18 at 2:28 PM, revealed restorative was available seven (7) days a week and must be provided at least six (6) days a week to be counted on the MDS assessment. She further stated restorative was a nursing measure and the orders do not specify as to how many days the resident will receive restorative therapy. Interview with the Administrator, on 11/02/18 at 11:59 AM, revealed the restorative aides were directed to complete both the floor duties and restorative duties when pulled to the floor. He stated based on resident census, acuity, and restorative case load, they should have completed the restorative and documented it.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety. Observation of the kitchen, on 10/30/18, revealed open and unsealed foods being stored in the freezer, sanitation bucket not measuring any sanitation present and staff failed to wash hands prior to starting trayline. Review of the facility Census and Condition, dated 10/30/18, revealed fifty-eight (58) of fifty-eight (58) residents received their meals from the kitchen. The findings include: Review of facility policy Food Storage, revised 09/14/18, revealed frozen foods should be stored in their original containers if designed for freezing and foods to be frozen should be stored in airtight containers or wrapped in heavy-duty aluminum foil or special laminated papers. Review of facility policy Proper Handwashing, dated 01/14, revealed hands must be washed prior to beginning work in the kitchen and after contact with unsanitary surfaces. Review of facility policy Sanitizer Use Concentrations For Food Service and Food Production Communities, dated 09/01/2014, revealed sanitation buckets must be established with appropriate sanitizing solution. Observation of the kitchen's walk-in freezer #1, on 10/30/18 10:34 AM, revealed walk-in freezer #1 had an open to air/unsealed bag of country beef breaded patties being stored on the shelf. Observation of the kitchen's walk-in freezer #2, on 10/30/18 10:35 AM, revealed walk-in freezer #2 had an open to air/unsealed bag of cookie dough being stored on the shelf. Observation of the lunch trayline in the kitchen, on 10/30/18 at 11:50 AM, revealed Dietary Aide #1 had been throughout the kitchen touching various items, then started to assist in setting up resident trays and never washed her hands prior to handling clean dishes and setting up trays for the residents' lunch meals. Observation of the kitchen, on 10/30/18 at 11:59 AM, revealed one (1) sanitation bucket inside the kitchen which measured no sanitation present when the Dietary Manager was asked to measure the sanitation level. Interview with the Dietary Manager, on 10/30/18 at 10:37 AM, revealed all food items in the freezers were to be covered and sealed completely. Further interview at 11:55 AM, revealed she expected all staff that work on the trayline to wash their hands prior to starting trayline. Additional interview at 12:01 PM, revealed the sanitation bucket should measure an appropriate sanitizing solution level and the sanitation bucket should have had new sanitizing solution put in it. Interview with the Registered Dietician, on 10/31/18 at 03:48 PM, revealed she expected all foods to be sealed in the freezer completely, the sanitation water in the sanitation bucket to be changed routinely, and staff to start trayline with clean hands.