**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility's Baseline Care Plan policy, it was determined the facility failed to ensure the Baseline Care Plan was developed and implemented to provide effective person-centered care for one (1) of seventy-one (71) sampled residents (Resident #299). Resident #299's Baseline Care Plan, initiated on 03/17/2022, revealed the resident required isolation as warranted per the resident's condition. However, the facility failed to further implement the Baseline Care Plan to include interventions related to Resident #299's Droplet Precaution isolation. Observations on 03/20/2022, revealed staff entered the resident's room to provide care without appropriate Personal Protective Equipment (PPE). Further observations on 03/20/2022 revealed staff exited the resident's room without following proper infection control guidelines. The findings include: Review of the facility's policy, Baseline Care Plan Process, dated 07/18/2018, revealed the charge nurse who admitted residents to the facility initiated the Baseline Care Plan to ensure care needs were met, utilizing a person-centered focus. Additionally, the Baseline Care Plan would be the working tool (Care Plan) for the first forty-eight hours. During the first forty-eight hours, all disciplinary team members, along with the resident and/or resident's Power of Attorney (POA)/family, reviewed the Baseline Care Plan and used it to build a Comprehensive Care Plan. Further, the Baseline Care Plan was presented to the resident and/or representative prior to completion of the Comprehensive Care Plan. Review of Resident #229's, Resident Face Sheet, revealed the facility admitted the resident from an acute care hospital, on 03/17/2022, with diagnoses which included History of COVID-19, Urinary Tract Infection (UTI), and Metabolic Encephalopathy. Review of Resident #299's Physician's Orders, revealed an order, dated 03/17/2022, for isolation, droplet precautions related to the resident not being fully vaccinated against COVID-19. The order had an end date of 03/31/2022. Review of Resident #299's Baseline Care Plan, dated 03/17/2022, revealed a care plan component, Problem of Infection Control. The resident was at risk for active infection related to potential exposure to COVID-19. The goal was the resident would not demonstrate signs or symptoms of an active COVID-19 infectious process. Interventions included but were not limited to: Isolation as warranted per resident's condition; and, maintain appropriate Personal Protective Equipment (PPE) use according to State requirements and availability, dated 03/17/2022. Observation of Resident #299's room, on 03/20/2022 at 4:05 PM, revealed an open door with Droplet Precautions and Contact Precautions Isolation signs. Per the signage, droplet isolation required an N-95 face mask, a closed door, and use of dedicated equipment, which would stay in the resident's room. Continued observation revealed a don and doff (put on/ take off) PPE instructional sheet on the open door. Additional observations revealed a plastic three (3) drawer PPE cart at the door, in the hallway with gowns, gloves, and surgical masks. However, outside the room, there was no evidence of sanitizing wipes, N-95 masks, or brown bags for storage of dedicated masks. Further observation, on 03/20/2022 at 4:10 PM, revealed State Registered Nursing Assistant (SRNA) #1, SRNA #2, and Hospitality Aide (HA) #3 donned PPE in the hallway outside Resident #299's room. The staff members put on gowns and gloves, but the aides failed to change their dedicated mask to an N-95 mask. Instead, they all wore their dedicated surgical masks and eye protection into the room. Further observation revealed the staff assisted Resident #299 and his/her roommate Resident #12, who was in Contact isolation, without changing their PPE. Additional observations revealed the staff doffed the PPE, (gowns and gloves) in the isolation room and disposed of it in dedicated bins, washed their hands, and exited the room. However, staff brought a mechanical lift out of the room without sanitizing it, and they did not clean their eye protection or change their surgical masks after exiting the room. The lift was not disinfected, before it left the isolation room, and SRNA #1 parked the lift on the opposite hallway. The aides then went to the nurses' station. Interview with SRNA #1, SRNA #2 and HA #3 on 03/20/2022 at 4:15 PM, revealed she was aware Resident #299 was in Droplet Isolation related to not receiving all COVID-19 vaccines yet. She stated she read about Resident #299's care on the [NAME]. Further interviews with SRNA #1, SRNA #2 and HA #3, revealed they received training on care plans, and they were aware the care plans were on the [NAME], in a notebook at the nurse's station. Continued interview revealed they followed the Care Plan when caring for Resident #299 to ensure his/her safety and the safety of the staff. They stated that it was important to follow the care plan to maintain infection control practices per policy, in order to prevent the spread infection to other residents. Interview with the Unit Manager (UM)/Registered Nurse (RN) #3, on 03/26/2022 at 12:10 PM, revealed she had been in the UM role for three (3) weeks. Per her interview, she expected staff to follow the resident's care plan to ensure proper and safe care was provided per the resident's needs, as assessed. Continued interview revealed staff was expected to refer to the Care Plan each time they provided care to any resident because care interventions could have changed. Additionally, all staff was responsible for ensuring residents' care plans were implemented and followed. She further stated, aides, nurses, and supervisors were responsible for immediately intervening, addressing, and correcting care, if the resident's care plan was not being followed. The UM said she monitored care plan implementation by assisting with resident care, making observations of staff while providing care, and speaking with residents, family, and staff. She said if staff had questions about how to provide resident care, they could ask her or other staff nurses for help. The UM stated she had not identified concerns with implementation of resident care plans. Interview with SRNA #6, on 03/26/2022 at 1:00 PM, revealed she looked at resident Care Plans daily to verify the care needs of the residents. The SRNA stated it was important to follow the resident's Care Plan in order to provide resident care in a safe manner. Interview with RN/Minimum Data Set (MDS) Nurse #1, on 03/26/2022 at 3:41 PM, revealed she used the facility's policies and the Resident Assessment Instrument (RAI) manual for guidance when she completed the Minimum Data Set (MDS). Assessments. She stated, in addition, she used a worksheet with information gathered from the resident's chart, family, staff, and face- to-face, and hands on assessments. She stated the floor nurse initiated the Baseline Care Plan, and it would be reviewed at the next clinical meeting. Continued interview revealed the MDS nurse would continue to develop the care plan. RN/MDS Nurse #1 stated the care plan should be the guide for provision of resident care. Interview with the Director of Nursing (DON)/Infection Control Nurse on 03/26/2022 at 4:00 PM, revealed floor nurses, MDS nurses, and members of the Interdisciplinary Team (IDT) developed and revised the Baseline Care Plan. Continued interview revealed all staff was responsible for ensuring the Baseline Care Plan was followed. Additionally, she expected staff to refer to and follow the Baseline Care Plan, because it was developed according to the resident's needs. She stated she had not identified issues with staff not following Baseline Care Plans. After the SSA (State Survey Agency) Surveyor discussed the observations she made on 03/20/2022, the DON/Infection Control Nurse said staff should have followed the Baseline Care Plan. Interview with the Administrator, on 03/26/2022 at 4:30 PM, revealed all staff members were responsible for following the Baseline Care Plans for each resident, and for ensuring safe care was provided. The Administrator stated staff leaders made rounds and observed resident care to ensure Baseline Care Plans were followed. Further, he stated staff talked with residents, families, and staff; and that Baseline Care Plans were discussed in clinical morning meetings. The Administrator stated he had not identified concerns with Baseline Care Plans. Continued interview revealed after the SSA Surveyor discussed observations made on 03/20/2022, the Administrator stated ongoing education was necessary related to following the Baseline Care Plans, and maintaining proper infection control practices.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, review of the facility's policies, review of the Centers' for Disease Control and Prevention (CDC), the Centers for Medicare and Medicaid Services (CMS) guidelines; and the CDC's website, HTTPS://www/Coronavirus, it was determined the facility failed to implement the CDC's and CMS's interventions to establish and maintain an infection prevention and control program designed to provide a safe, and sanitary environment to help prevent and control the development and transmission of communicable diseases including COVID-19. Total census was 97. Observations on 03/20/2022, revealed staff did not use Personal Protective Equipment (PPE) in residents' rooms, who were under Droplet Precautions and Contact Precautions. Resident #299 and Resident #12 had Physician's Orders to be in isolation. However, observations revealed the facility's staff entered Resident #299's and Resident #12's room without donning (putting on) PPE required in order to enter the room. An additional observation revealed staff exited Resident #299's and Resident #12's isolation room, into a common hallway with a mechanical lift brought from the isolation room. Observations revealed staff left the lift in the hallway without disinfecting it after it was used in the room. In addition, staff continued with resident care without cleaning their eye protection worn in the room, and did not change the surgical masks worn in the room. Observation of the facility's mechanical lifts (ML)s revealed the calf rests had dried brown and black matter on the surface, and the lift handles had dried white matter. Interviews revealed staff was unsure when the mechanical lifts were routinely disinfected. In addition, the facility could not provide documentation to show staff cleaned the mechanical lifts/equipment on a scheduled time frame. The findings include: Review of the facility's policy, Infection Control (IC), revised 10/2018 revealed the facility intended to maintain a safe, sanitary and comfortable environment to help prevent and manage transmission of disease and infection. The objectives with the IC policies and practice included to prevent, detect, investigate and control infections in the facility and provide guidelines for the safe cleaning and reprocessing of reusable resident-care equipment. Review of the facility's policy, Resident Lift, dated 05/30/2018, revealed the policy did not address infection control guidance after or with use of the equipment. Review of the facility's policy titled, Personal Protective Equipment (PPE), revised 10/2018, revealed the facility provided PPE for specific requirements for staff. Review of the facility's policy titled, Novel Coronavirus (COVID-19), revised 03/18/2022, revealed general prevention measures included PPE. Review of the facility's policy titled, Isolation-Categories of Transmission-Based Precautions (TBP), revised 10/2018, revealed TBP included additional measures which protected staff from becoming infected. The three (3) types included contact, droplet, and airborne. Review of CDC's website (https://www.cdc.gov/infectioncontrol/basics/transmission-based-precautions.html#anchor 1564058155), Transmission-Based Precautions, Droplet Precautions, review date of 03/21/2022, revealed before entering a resident's room who was on the precautions, the person(s) entering the room ensured their eyes, nose and mouth were fully covered and were to remove the face protection prior to leaving the room. Review of the CDC guide titled, How to safely remove PPE., undated, revealed upon exit of the area, masks were to be discarded in the waste container. Review of the facility's policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revised 10/2018, revealed all Durable Medical Equipment (DME) must be cleaned and disinfected before reuse by another resident. Review on 03/24/2022 at 3:45 PM, of a sign posted in the nurses' station, revealed the Hoyer (brand name of a mechanical lift) was to be cleaned weekly and when visibly soiled. Review of the sign titled, Special Droplet/Contact Precautions, dated 03/09/2020, revealed Personal Protective Equipment should be worn and included: gown, gloves, eye protection, and a N-95 mask. Additionally, before leaving an isolation room, the gown, and gloves should be disposed of, and all shared equipment should be cleaned and disinfected. Furthermore, the room door was to be closed at all times. Review of the facility's Education In-Service Attendance Record, dated 10/20/2021, revealed eighty (80) staff, including nurses, aides, housekeeping, dietary, maintenance, laundry, therapy, administrative, social services, and human resource staff received training that included review of the CDC Module, Responding to Coronavirus and Keeping COVID-19 Out. Further review revealed the facility's training included hand hygiene; donning and doffing Personal Protective Equipment (PPE); COVID-19; and following Transmission Based Precautions (TBP). Review of Resident #229's Electronic Medical Record (EMR), revealed the facility admitted the resident from an acute hospital, on 03/17/2022, with diagnoses that included History of COVID-19, Urinary Tract Infection (UTI), and Metabolic Encephalopathy. Review of Resident #299's Physician's Orders, revealed an order, dated 03/17/2022, for Isolation, Droplet Precautions related to not being fully COVID-19 vaccinated. The order had an end date of 03/31/2022. Review of Resident #299's Immunization record revealed he/she had received one (1) Moderna COVID-19 vaccine on 09/07/2021. Review of Resident #299's Baseline Care Plan, dated 03/17/2022, revealed a Problem for Infection Control, because the resident was at risk for active infection related to potential exposure to COVID-19. The goal was the resident would not demonstrate signs or symptoms of active COVID-19 infectious process. Interventions included but were not limited to: Isolation as warranted per resident's condition and Maintain appropriate Personal Protective Equipment (PPE) use according to state requirements and availability. Observation of Resident #299's room, on 03/20/2022 at 4:05 PM, revealed an open door with Droplet Precautions and Contact Precautions Isolation signs. Per the signage, droplet isolation required an N-95 face mask, gown, a closed door, and dedicated equipment. Continued review revealed a don and doff (put on/take off) PPE instructional sheet was on the open door. Additional observations revealed a plastic three (3) drawer PPE cart at the door in the hallway with gowns, gloves and surgical masks; however, there was no evidence of availability of sanitizing wipes, N-95 masks, or brown bags for storing dedicated masks. Further observation, 03/20/2022 at 4:10 PM revealed State Registered Nursing Assistant (SRNA) #1, SRNA #2, and Hospitality Aide (HA) #3 put on PPE in the hallway outside Resident #299's room. Gowns and gloves were donned, but the aides failed to change their dedicated mask to a N-95 mask, and they all wore their dedicated surgical mask and eye protection into the room. Further, staff left the isolation door open, and the State Survey Agency observed from the hallway, while the staff assisted Resident #299 and his/her roommate, who was in Contact isolation, without changing PPE. Additional observations revealed the staff doffed and disposed of their PPE (gown, gloves) in the isolation room, washed their hands, and exited room. SRNA #1 brought the mechanical lift out of the room without sanitizing it, and they did not clean their eye protection or change their surgical mask after exiting the room. The lift, that was used in the room, was not disinfected, but SRNA parked it on the opposite hallway (Civil War). Then the aides went to the nurses' station. Interview with SRNA #1, SRNA #2 and HA #3, on 03/20/2022 at 4:15 PM revealed they had received training on infection control, including COVID-19, types of Transmission-based Precautions (TBP), what PPE to wear in each type of isolation, using dedicated equipment recently (2-3 months ago). Per interview, they should have changed their surgical masks and cleaned their eye protection with Clorox (brand of bleach) wipes; however, they forgot to do it because the SSA was watching and they didn't check the PPE container to see if they were available. Further review revealed they should not have pushed the mechanical lift out of the isolation room into the clean hallway and placed at the other hallway without wiping it down/cleaning it with Clorox wipes. She stated they did not check to see if there were wipes available to clean the lift and they forgot they should clean the lift. They stated that it was important to maintain infection control practices per policy to not contaminate other residents and spread infection. Interview with Licensed Practical Nurse (LPN) Staff Development Coordinator, on 03/21/2022 at 11:30 AM, revealed that she had been in the role since 03/01/2022. Per interview, since she had been in the role, she had provided In-Service education on use of PPE, handwashing and general infection control refreshers. She said she had not identified concerns related to infection control. Interview with the Unit Manager (UM)/Registered Nurse (RN) #3, on 03/26/2022 at 12:10 PM, revealed she had been in the role for three (3) weeks. Per interview, she expected staff to follow Infection Control Guidelines, policies, and practices related to isolation on a daily basis. She stated residents in contact isolation required staff to wear PPE per the instructions posted on the door. Additionally, staff members were expected to don and doff and use the appropriate PPE when providing care when droplet isolation precautions were in effect. The UM stated nursing staff should obtain the isolation order, ensure PPE, signage, and other necessary supplies were in place per the guidelines and policy. The UM stated there was adequate PPE available in the facility, and she had not identified concerns with Infection Control practices on Two (2) North or with the isolation rooms. However, she stated she had not conducted walking floor rounds to observe for potential infection control issues on equipment and that proper isolation supplies/equipment were available. She stated she did participate in Ambassador rounds, and resident rooms were checked for cleanliness, availability of Personal Protective Equipment, and that door signs for isolation were in place. She stated the rounds were completed daily and all management staff participated and were responsible for assigned rooms, but she was unaware if the rounds were documented as completed. Observations, that were made on 03/20/2022, at Resident #299's room, were discussed with the UM, and she stated the information provided would not be acceptable practice. She stated droplet isolation required staff to wear an N-95 mask, and residents not fully vaccinated were treated as potentially positive for COVID-19. She said if staff did not wear the proper mask while caring for that resident, there was a potential for spreading infection to other residents. The UM stated the lift used in Resident #299's should have been disinfected before it was parked in the hallway, because it could have been soiled by respiratory droplets while in use in the resident's room. She stated the direct care staff should have cleaned their eye protection and changed their masks after caring for Resident #299, and before they exited the room. The UM said the direct care staff should have located and donned the appropriate PPE before entering the room, because it was important to maintain IFC practices, and prevent the potential for the spread of infection to other residents at the facility. The UM said she had received annual and as need IFC training. Interview with the Infection Control Nurse/Director of Nursing (DON), on 03/26/2022 at 4:00 PM, revealed she had been in that role for one (1) year, and had previously served as the Unit Manager for one (1) year. She stated Infection Control policies were based on information from the Centers for Disease Control and Prevention (CDC) and reviewed by the corporation. When the Corporation sent the policies to the facility, she ensured staff was educated on the policy. Continued interview revealed it was the facility's practice to screen new admissions related to their COVID-19 vaccination status and their diagnoses. If residents were not completely vaccinated for COVID-19, the resident would be placed under Droplet Precautions for ten (10) days. She stated direct care nurses were responsible for ensuring all necessary orders, equipment, and signs were in place for residents who required isolation. She stated nurse managers completed rounds to ensure PPE was available on the floors and in central supply. Further interview revealed the facility completed education on infection control and would continue to provide training to ensure, as much as possible, that the facility maintained practices that prevented the spread of germs/bacteria. After discussion of the infection control concerns identified on Sunday 03/20/2022, the DON stated the observations were not acceptable. She stated the staff had been provided ongoing education and should have been able to provide Resident #299's care in a safe/acceptable manner. Interview with the Administrator, on 03/26/2022 at 4:30 PM, revealed he had served as administrator since 06/01/2021. He stated all staff were responsible for following infection control guidelines and policies. He stated infection control practices were essential for halting the spread of infections. Per interview, education for infection control was ongoing, and any issues identified were discussed in the facility's Quality Assurance Performance Improvement (QAPI) meetings. The Administrator stated no issues had been identified related to infection control. After the SSA Surveyor discussed the infection control concerns identified on Sunday 03/20/2022, he stated the observed practices were not acceptable, and the policy guidelines should always be followed to stop the spread of infection. 2. Review of the facility's mechanical lifts manifest revealed the facility had full body lifts #1, #4, #7 and #9, and stand assist lifts #3, #6, #8, and #10. Observation on 03/20/2022 at 2:50 PM, revealed lifts #3 and #6 were in the hallway by room [ROOM NUMBER] and 2304. Both lifts had white and brown matter crusted on the bilateral calf rests and a white and brown matter on the footrests. Interview with Registered Nurse (RN) #1, on 03/20/2022 at 3:30 PM, revealed she could not identify the white or brown encrusted matter on lifts #3 and #6 without a microscope. The RN stated she did not have knowledge of a cleaning schedule, or a form which identified when the lifts were to be cleaned, and who was responsible to clean the lifts. She stated she would have to ask the supervisor about a log for cleaning the lifts. The RN did not provide the requested information during the survey. Observations on 03/24/2022 at 12:51 PM, revealed lifts #3 and #6 were in the hallway next to resident rooms [ROOM NUMBERS]. Observation of lift #3 revealed brown and white matter on the footrests and on the back of the calf rests. The left and right handles had white encrusted matter on the surfaces. Observation of lift #6 revealed splattered brown matter on both lower calf rests; the footrest had white, brown, and black debris; and, the left handle had a white encrusted matter on the surface. Observation on 03/24/2022 at 2:00 PM, revealed SA lift #8 and FB lift #1 were observed on the resident hallways with a sling. Lift #8 had white crusted matter on the left handle the size of one-half (1/2) of a dime and white and brown matter on the entire surface of the footrest/surface. Observations of lift #1 revealed the footrests had a white powdery substance with brown crumb-like matter over the entire footrest. Interview and observation with LPN #4, on 03/24/2022 at 2:52 PM, revealed she observed lifts #1 and #8. The lifts had brown and white matter on both lifts and white dried matter on lift #8's handle. She stated she did not know what the matter was and when asked to provide a cleaning log for the lifts or an equipment cleaning log for the unit, the LPN stated she would have to ask the supervisor about the logs. Interview with Registered Nurse (RN) #13, on 03/24/2022 at 2:52 PM, revealed with the State Survey Agency Surveyor present, she observed lifts #1 and #8 with brown and white matter on the lift foot rests and white dried matter on the handle of lift #8. She said she could not identify the matter. Observation on 03/24/2022 at 2:55 PM, revealed RN #13 obtained a wipe from the medication cart. The container was labeled as Sani-wipe (a no-rinse disposable wipe which kills common viruses and bacteria). The RN returned to lifts #1 and #8 and wiped the handles, calf rests, and footrest. The use of the wipe by the RN removed the brown matter and the matter on the handles of the lifts. The white matter was identified by the RN as possible break down of the pad. Continued interview with RN #13, on 03/24/2022 at 3:00 PM, revealed the Sani- wipe removed the brown, black substance on the calf rests and footrest and the white substance on the handles. She stated the lifts were dirty and obviously not cleaned by staff. She said the lifts were to be cleaned after use with a resident and weekly. However, she was unsure when the weekly cleaning occur. Observation, on 03/24/2022 at 2:16 PM, revealed a lift identified as #10. Observations revealed the calf rest and footrest had white and brown crusted matter on the surface and a quarter size brown sticky matter on the left leg rest. Continued observations revealed the right black handle had white raised matter. Further observation of lift #7 revealed the base of the lift had white and brown matter scattered over the surface on the base of the lift. Interview with SRNA #7, on 03/24/2022 at 2:24 PM, revealed with the State Survey Agency Surveyor present, the SRNA identified matter on lifts #7 and #10 as dried brown and white dirt. The aide stated after resident use, staff cleaned the lifts when they removed the lift from the room. The aide stated the facility cleaned the lifts to prevent cross contamination and possible spread of infection. The aide stated when staff did not clean multi-resident use equipment (lifts) bacteria could be transferred to another resident which could cause the resident to get sick. The aide stated staff should clean the lifts with a bleach wipe or Sani-wipe. The aide stated the units had a checklist to document when staff routinely cleaned the lifts. However, the aide stated she was not sure what day or shift the lifts were to be cleaned. She said the facility provided education for prevention of the spread of infection, and anyone in m,the facility could clean a lift. Interview with the ADON, on 03/24/2022 at 3:45 PM, revealed staff cleaned the lifts after each use, weekly, and when dirty. She stated the staff did not document on a form when they completed weekly cleaning of the lifts and to her knowledge the facility did not have a log. She stated the nurses' stations had a sign with instructions about when to clean the lifts. Continued interview with the Assistant Director of Nursing (ADON), on 03/24/2022 at 3:45 PM, revealed the units completed the lift cleaning task on different days. However, she did not know what days the different units completed the task. She stated the facility wanted to make sure the lifts were cleaned to prevent the risk of the transmission of infection. The ADON stated if cross contamination occurred, residents could get sick or decline. She stated staff was to follow the policy for infection control in order to prevent cross contamination. Further interview revealed staff members were to clean the lifts after use with a resident who was under isolation precautions. She said anyone in the facility could clean a lift. Interview with the DON (Director of Nursing), on 03/26/2022 at 3:10 PM, revealed direct care staff cleaned all lifts on Friday nights, after use with a resident, and after a lift was used for a resident under isolation precautions. However, observation, during the interview revealed a posted sign for weekly cleaning of lifts did not specify a day, a shift, or which staff members were responsible for the weekly disinfection of the lifts. She stated clinical staff observed lifts for cleanliness during walking rounds. She further stated staff was educated on infection control prevention measures. The DON stated the staff cleaned the lifts to prevent the spread of infections. The DON said the clinical IDT had not identified issues with dirty lifts. Interview with the Administrator, on 03/26/2022 at 4:30 PM, revealed all staff members were responsible for following Infection Control guidelines and policies. Additionally, he stated Infection Control measures were the most important steps to stop the spread of infections. He stated the facility provided ongoing Infection Control education, and any issues identified were discussed in Quality Assurance Performance Improvement (QAPI) meetings. However, he stated dirty mechanical lifts had not been an identified issue. 2. Review of the facility's Electronic Medical Record (EMR) for Resident #12 revealed the facility admitted the resident, on 06/17/2019, with diagnoses that included Chronic Respiratory Failure, unspecified whether with hypoxia or hypercapnia, Dementia with behavioral disturbance, Diabetes Mellitus with Diabetic Neuropathy, Recurrent Urinary Tract Infection, unspecified and Extended Spectrum Beta Lactamase (ESBL) resistance. Review of Resident #12's most recent Quarterly Minimum Data Set (MDS) Assessment, dated 12/20/2021, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of nine (09) which indicated he/she had moderate cognitive impairment. Review of Resident #12 record revealed on 02/03/2022 and 03/16/2022, the resident was placed on Contact Isolation due to Vancomycin Resistant Enterococcus (VRE) in his/her urine; a bacterial infection that is resistant to the antibiotic Vancomycin, which is commonly used to treat this type of bacteria and required transmission- based precautions (TBP) to prevent the spread of infection. Review of Resident #12's Comprehensive Care Plan (CCP) revealed, on 02/03/2022, the resident was care planned for Infection Control due to a diagnosis of VRE. The goal was the resident's signs and symptoms would resolve as evidenced by a normal temperature, decreased urgency, decreased frequency, decreased complaints of abdominal pain, decreased complaints of burning on urination, decreased confusion, decreased weakness within forty-eight hours of start of antibiotic treatment. Interventions included Contact Isolation per order; vital signs every shift until completion of antibiotic; administer antibiotic, as ordered; observe for side effects related to antibiotic therapy; and report to physician (rash, itching, nausea/vomiting, diarrhea, difficulty breathing. Review of Resident #12's CCP revealed no documentation the facility revised the most recent Infection Control order of Contact Isolation, with VRE in urine, dated 03/16/2022. Review of Resident #12's Physician Orders, dated February 2022, revealed an order dated 02/03/2022, for Contact Isolation, due to Vancomycin Resistant Enterococcus (VRE) in urine. Further review revealed an order to start Linezolid (antibiotic) 600 milligram (mg) per oral every twelve (12) hours times seven (7) days. Review of Resident #12's Interdisciplinary Team (IDT), Progress Note, dated 02/04/2022 at 9:27 AM, revealed the resident remained in isolation precautions; IDT discussed antibiotic use with no adverse drug reaction (ADR) noted. Review of Resident #12's Physician Orders, dated March 2022, revealed an order for Contact Isolation, dated 03/16/2022, for urinary tract infection (UTI) due to VRE in urine culture results. Further review revealed an order to start Macrobid (antibiotic) 50 mg, oral every six (6) hours, times five (5) days. Continued review of Resident #12's Progress Note dated 03/16/2022 at 3:50 PM, revealed urinalysis results of VRE greater than one-hundred (100) colony forming unit (cfu) per milliliter (ml). Observation on 03/20/2022 at 4:05 PM, revealed Resident #12 was in Contact Precautions. The door was open and there were two (2) isolation signs on the door. One (1) noted Contact Isolation and the other one (1) noted Droplet Precaution. Additional observations revealed the Droplet and Contact sign on door listed precautions: N95 mask, close door and use dedicated equipment. Continued observations revealed an instructional sheet on the door which noted how to don (put on) and doff (take off) PPE. Further observations revealed a plastic three (3) drawer cart in the hallway at the doorway for PPE with gowns, gloves, and surgical mask; however, there was no evidence of sanitizing wipes or brown bags for dedicated mask outside the room. Continued observations on 03/20/2022 at 4:05 PM, revealed Certified Nursing Assistant (SRNA) #1, SRNA #2, and Hospitality Aide (HA) #3, don Personal Protective Equipment (PPE) in hallway outside Resident #12's room. All three aides donned gown, then gloves, but failed to change their dedicated mask to a N95 mask; they all wore their dedicated surgical mask and eye protection into the room. Further observation revealed the staff assisted both Resident #12 who was in Contact isolation, and his/her roommate, who was in Droplet Precautions, without changing PPE. Additional observations revealed the staff doffed the PPE (gown, gloves) in the isolation room and disposes it in dedicated bins, washed their hands, and exited the room. However, staff brought a mechanical lift out of the room without sanitizing it and staff did not clean their eye protection or change their surgical mask after exiting the room. The lift was not cleaned before leaving the isolation room and was parked on the opposite hallway. The aides went to the nursing station. Observation and interview of Resident #12, on 03/21/2022 at 8:40 AM, revealed he/she was lying in bed, watching ('television) without any signs/symptoms of distress noted. There were no odors in the room and the resident was clean and dry; he/she voiced no complaints. Interview with Resident #12, at the time of the observation, revealed the resident did know why he/she had been placed in isolation; I often get this type of infection in my urine, and it is unfortunate and irritating at times. Interview with SRNA #1, on 03/20/2022 at 4:15 PM, revealed Resident #12 was in contact isolation related to a type of contagious bacteria in his/her urine. Additionally, SRNA #1 stated it was required to wear gown, gloves, mask, and eye protection in the isolation room. SRNA #1 added, ongoing Infection Control trainings and education occurred to stop the spread of bacteria and germs. Interview with SRNA #1, SRNA # 2 and HA #3, on 03/20/2022 at 4:15 PM revealed they received training on infection control, including COVID-19, types of Transmission-based Precautions (TBP), what PPE to wear in each type of isolation, using dedicated equipment two (2) to three (3) months ago. Additionally, they stated they should have worn PPE per the signs on the door and changed their PPE in between residents. Per interview, they also should have changed their surgical masks and cleaned their eye protection with Clorox wipes when they exited the isolation room; however, they forgot. Further, they should not have pushed the mechanical lift out of the isolation room into the clean hallway and placed at the other hallway without wiping it down/cleaning it with Clorox wipes; they did not check to see if there were wipes available to clean the lift and they forgot they should clean the lift. However, it was important to maintain infection control practices per policy to not contaminate other residents and spread infection. Interview on 03/22/2022 at 2:30 PM, with SRNA #2 revealed she received training on types of isolation, and how and what type of PPE to wear for each type of isolation. SRNA #2 added Resident #12 was in isolation due to infection of VRE in his/her urine. She revealed staff should always follow the isolation precautions posted on doors and encourage residents in isolation to stay in their rooms. Further, staff should also encourage residents to practice infection control measures to decrease the spread of infection to other people in the facility. Interview with SRNA #12 and SRNA #13, on 03/26/2022 at 2:54 PM, revealed all nursing staff worked together as a team, and an individualized resident Kardex (Care Plan) was located on all units, at each nursing station for all staff to reference for resident care needs. Continued interview revealed the Kardex was updated daily per the Unit Manager. Additionally, the aides used the Kardex routinely throughout shift; at the beginning of every shift the nurses perform rounds to discuss, review and check all residents for any changes in conditions and what type of specific care to provide, including TBP. Continued interview revealed the admissions office notified the nurse management team and the Unit Manager of the type of TBP's a newly admitted residents required. Additionally, the Unit Manager ordered the needed supplies for the new resident. Per interview, the direct care nursing staff would prepare all supplies for the infection control cart to be placed in front of the room and place proper signage/type of TBP's on the door. Further, the nurse management in the facility routinely audited and made observations of resident rooms and staff's performance to ensure proper type of isolation was ordered and provided. Continued interview revealed Administration took infection control practices very serious, all staff were monitored routinely and if they were not performing properly and/or safely staff would be written up; would require re-training's and a performance improvement was placed in the staff records. Interview with SRNA #10, on 03/26/2022 at 9:20 AM, revealed she was provided education on ways to help residents minimize the spread of COVID-19 and transmission-based infections such as in hand washing, wearing masks, following isolation precautions, and social distancing. Continued interview with the aide revealed the staff encouraged all residents and other staff to practice and promote the correct type of isolation practices when in isolation rooms and providing nursing care to residents. SRNA #10 stated, it was necessary for all staff to practice correct and proper infection control practices in order, to prevent the spread of germs and to keep the residents well. Interview with Licensed Practical Nurse (LPN)/ Staff Development Coordinator #23, on 03/21/2022 at 11:30 AM, revealed she provided In-services, re-education on PPE, handwashing, and infection control, as refreshers. The SDC stated she had not identified any concerns in those areas. Additionally, LPN/SDC #23 added, if any identified concern would arise, she would provide education to all staff in all departments as applicable. Interview with RN #3 (Unit Manager on Two (2) North and Two (2) South), on 03/24/2022 at 10:03 AM, revealed she received infection control training which included the types of transmission-based precautions (TBP) to use; what PPE to wear in each type of isolation, and the proper use of and how to properly don/doff (put on/take off) PPE. Per interview, RN #3 stated the facility placed the resident in contact isolation for VRE in his/her urine. She stated antibiotics were started on 03/16/2022 and completed on 03/21/2022. Continued interview with RN #3, revealed all staff should don PPE each time they entered an isolation room regardless of whether the resident was in their room or not. RN #3 additionally stated, it was important for residents[TRUNCATED]

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to store, handle, prepare, distribute, serve food, maintain safe temperatures of food in storage, in order to ensure food safety. Observation, on 03/20/2022 during the initial kitchen tour at 2:00 PM, revealed dirty floors, staff members with their masks positioned below the nose, open food not labeled or dated, a dirty stove, pitchers of tea and coffee uncovered and not labeled, a trash can with its lid open, the dishwasher was broken, the sanitizing solution in the three (3) compartment sink and the sanitizing bucket were not maintained at the correct concentration. Additionally, observation, on 03/20/2022, revealed inconsistencies with documentation logs for the standing refrigerator and dry storage, and the dishwasher was not in use/broken. Further observation, on 03/21/2022 at 11:35 AM, during lunch meal service, revealed two (2) male staff with hair on their face and neck with no beard restraint, and another staff person was observed with the mask below the nose. The findings include: Review of the facility's policy titled, Manual Warewashing, dated 09/2017, revealed all cookware, dishware, and service ware that was not processed through the dish machine would be manually washed and sanitized. Additionally, the staff would be knowledgeable of proper techniques including wash temperature at no less than 110 F (Fahrenheit); chemical sanitizer testing and proper concentration of the sanitizing solutions. Further, appropriate test strips would be utilized to measure the concentration of the sanitizing solution. Results would be recorded on the three (3) compartment sink log. Review of the facility's policy titled, Warewashing, dated 05/2014, revealed all dishware, serviceware, and utensils will be cleansed and sanitized after each use. Additionally, the dining staff will be knowledgeable in the proper technique for processing dirty dishware through the dish machine and proper handling of sanitized dishware. Further, temperature and/or sanitizer concentration logs would be completed as appropriate. Review of the facility's policy titled, Equipment, dated 09/2017, revealed all food service equipment would be clean, sanitary and in proper working order. Additionally, all equipment would be routinely cleaned and maintained in accordance with the manufacturer's direction and training materials. All staff would be properly trained in the cleaning and maintenance of all equipment. All food contact equipment would be cleaned and sanitized after every use. All non-food contact equipment would be clean and free of debris. The Dining Service Director would submit requests for maintenance or repair to the Administrator and/or Maintenance Director, as needed. Copies of a service repair and preventative maintenance report would be submitted monthly. Review of the facility's policy titled, Disposal of Garbage and Refuse, dated 08/2017, revealed all garbage and refuse would be collected and disposed of in a safe and efficient manner. Additionally, the Dining Service Director would ensure appropriately lined containers were available within the food service area for disposal of garbage. Appropriate lids were provided for containers. Garbage was removed from the kitchen area routinely during the day and at the end of the workday. Staff were to observe proper hand washing and glove practices after handling garbage. Further, the Dining Services Director would ensure appropriate recycling practices were in place as required by state and local authorities. Review of the ECOLAB Scout Pot and Pan Wash Procedure, dated 2011, revealed the Environmental Protection Agency (EPA) registered no rinse quat sanitizer that was effective across a dilution range of 0.25-0.67 per gallon of water. Further there were illustrations noted on the Paper Hydrion testing strips (withdrawal 2 inches); temperature 65-75 F, 10 second, compare to strip for acceptable range diagram on testing paper label. Review of the Sani Safe Quaternary Ammonia QUAT test paper label, revealed an expiration date of 11/01/2023. In addition, there were instructions to compare the paper strip when wet to the color-coded diagram listing with parts per million concentration (0-100-200-300-400). Review of Dining Services Department In-Service, dated 12-20-2021, revealed kitchen staff attended an in-service on Hair nets and beard guards, name tags, uniforms not worn during DM unit inspection. Review of Dining Services Department In-Service, dated 01/31/2022, revealed kitchen staff attended an in-service on New COVID/CDC regulations with quarantine, vaccines, wearing Personal Protective Equipment while in the facility. Observation during the initial kitchen tour, on 03/20/2022 at 2:00 PM, revealed the stove had a blackened substance on the backsplash of the stovetop, dried up substance with crumbs was noted beside the stovetop and the griddle. Additionally, there was a pitcher of tea and coffee in front of the coffee machines not covered, labeled, or dated. Continued observations revealed the lid of the trash can was raised up and leaning against the wall. The trash can was overflowing with a box containing coffee grounds and condiment cups. Review of the Refrigerator Temperature Log, dated March 2022, revealed staff did not consistently document AM and PM temperatures. Further review revealed the following: nineteen (19) blanks on 03/05/2022 AM; 03/15/2022 AM; 03/16/2022 AM and PM; 03/17/2022 AM and PM; 03/18/2022 AM and PM; and 03/19/2022 PM. Continued observations on 03/20/2022 at 2:00 PM, revealed the Dry Storage Temperature log, dated March 2022, revealed missing documentation of the AM and PM temperatures. There was a total of eight (8) blank spaces which included 03/15/2022 AM; 03/16/2022 AM; 03/17/2022 AM; 03/18/2022 AM; 03/16/2022 PM; 03/17/2022 PM; 03/18/2022 PM; and on 03/19/2022 PM. Observation on 03/20/2022 at 2:00 PM, revealed Dietary Aide #1 washing dishes at the three (3) compartment sink. Dietary Aide #2 was rinsing washed items at the solution sink; her face mask was below her nose. Per interview, at the time of the observation Dietary Aide #1 stated that she had just made the water and solution in the sink. Additionally, she did not know what the temperature of the water was, or the location of the thermometer. She stated she checked the water by touching it with her hand to ensure it was hot. Dietary Aide #2 stated she usually worked with the dish machine and was not familiar with the temperature, solution, and documentation for the three (3) compartment sink. Further, she stated she wore her mask below her nose because she was hot. However, she had received training on how to properly wear a face mask and on infection control. Continued observations revealed the sanitizing solution concentration in the three compartment sink and the solution in the red bucket were below 150 parts per million (PPM). The thermometer could not be found to take the temperature of the water. Review of the Three (3) Compartment Sink Log, undated, revealed eight (8) blanks on the 15th, 16th, 17th, 18th, 19th lunch, and dinner meals and, on the 20th lunch meal were blank. Observation revealed there was no documentation of the time, temperature of the water, concentration, or staff initials. Further, the bottom of the log, to document to the Manufacturer Recommendation Sanitizer PPM was blank. Observations on 03/21/2022 at 11:35 AM, of the lunch tray line, revealed Dietary Aide #4, was plating food, but was not wearing a beard guard. Additional observations revealed Dietary Aide #2 plating food with a face mask below her nose. Further, the Dietary Manager was noted at the three (3) compartment sink, and was not wearing a beard guard. Observations on 03/23/2022 at 10:30 AM, revealed blackened food crumbs/substance on the stove burners. Interview with the District Manager, at the time of the observation, revealed the cook was responsible to clean the stove one (1) time a week to ensure food crumbs were cleaned off, so food served was not contaminated. Additional observations on 03/23/2022 at 10:30 AM, revealed a trash can by the coffee pot. The trash can lid was open with a brown dried food substance and dried liquid. The trash can was full to the top and contained old grapes in a bag, and open condiment containers. Interview with the District Manager, at the time of the observation, revealed the trash can lid should be clean and closed to maintain infection control and prevent contamination of food. Continued interview revealed the observations of the uncovered pitchers of coffee and tea, that were not tabled, should have been covered to prevent contamination. Interview on 03/20/2022 at 3:09 PM, with the Assistant Dietary Manager, revealed she had worked at the facility since June 2021, and her direct supervisor was the Dietary Manager. Per interview, the kitchen staff had been hand washing dishes for three (3) weeks since the dish machine had been down. Additionally, the three compartment sink log was completed by staff, each time the water was made (three {3} times a day), including the red bucket of sanitizing solution. Continued interview revealed the temperature of the water, the solution concentration and staff's initials should be documented on the log. The staff assigned to the dishes was responsible to complete the documentation after making the water/solution. It was important to have a record to prove the temperature and concentration could sanitize properly to prevent the spread of food borne illness and communicable illness. Per interview, she had not identified any issues with the temperature or concentration of water at the three compartment sink or the log. She also was unaware of any training provided to kitchen staff three (3) weeks ago (after the dish machine broke), related to the three compartment sink, temperatures of water, or concentration of the solution. Further, she normally looked at the refrigerator and dry storage temperature logs a couple times a week, to ensure temperatures were not too hot or cold; however, she had not identified any blanks in the logs. She was unsure why there were blanks on the logs, but they should have been filled in completely. Continued interview revealed the stove should be cleaned if it was visibly dirty with food crumbs or blackened food particles to ensure food being cooked was not contaminated. She stated it was everyone's responsibility that used the stove to ensure it was clean and the stove should be cleaned at least weekly. Per interview, the garbage can lid should be clean and placed on the can for infection control purposes, to ensure food and equipment were not contaminated. Lastly, she stated the pitchers of beverages, coffee and tea, should be covered to ensure they were not contaminated, and staff who filled the pitchers should have covered them. Interview with the Dietary Manager, on 03/21/2022 at 10:08 AM, revealed that one (1) year ago he was a dish washer and cook at the facility. Since 02/28/2022, he had been the Dietary Manager in Training. Per interview, the Training Manager was in the building two (2) days a week and available via telephone, as needed, and the Registered Dietician (RD) was in the building twice a week. Continued interview revealed the RD completed meal tracker audits. The Training Manager completed audits for temperature logs, preparation of food, attended the morning meetings, and provided staff in-services. Additionally, the District Manager was in the building one (1) time a week, and he completed audits with the Dietary Manager on temperature logs, the three (3) compartment sinks, signs, the cooler and dry stock, and in-services with staff. The Dietary Manager stated there was no tracking process or policy for when test solution strips were changed, where they were stored, label requirements, etc. All staff members were responsible to change the strips, which were kept in the manager's office and also taped to wall by the three (3) compartment sink. After review of observations made on 03/20/2022 with the Manager, he stated there should be a label in the test strip box to note the expiration date to ensure the strips were viable. However, the strips taped to the wall by the sink, were observed to not have a label. He stated that he expected the staff to use the strips in the manager's office, and to know the expiration date, and the solution level using the ECO lab posters on the wall behind the sinks. Observation at the time of the interview revealed the manager searched his office drawers and found two (2) loose boxes of strips and said the one (1) taped on the wall was in the same lot as the strips in the office. The expiration date was 11/01/2023. Further interview with the Dietary Manager revealed that each log should be fully completed at the designated time and that he expected his staff to complete all of them. He stated he expected staff to wear masks appropriately, to decrease the risk for the spread of infection, and that staff had been educated in infection control and on wearing Personal Protective Equipment (PPE) appropriately. Staff was provided in-service education related to necessary changes in the process because the dish machine was broken, but staff was already aware of the expectation because it was the same process (3 compartment sink) before the dish machine broke. However, there was no documentation provided related to an in-service training for the kitchen staff approximately three (3) weeks ago related to the three compartment sink, sanitizing solution concentration, and test results of the sanitizing solution. Review of Dining Services Department In-Service, dated 02/11/2022, revealed kitchen staff attended an in-service on Fridge/freezer/dish machine logs filled out correctly, and tray-line accuracy. Review of Dining Services Department In-Service, dated 02/15/2022, revealed kitchen staff attended an in-service on Label and dating, temperature log usage, daily/weekly cleaning matrix, and menu compliance. Interview with the Training Manager, on 03/22/2022 at 8:30 AM, revealed he had been with the facility for one (1) year. Per interview, the repair company was at the facility on 03/22/2022, and was supposed to return in (2) days to repair the main board, which was the identified broken area. Continued interview with the Training Manager revealed they were made aware that the three (3) compartment sink on 03/20/2022, was not in appropriate range. She stated the facility had staff turnover and struggled to keep and train staff. She stated the new staff members were not familiar with policies and practices. Additionally, it was important that the water temperature and the sanitizer were at the right temperature and concentration to protect residents from contamination, and to decrease the risk for food borne illness. Continued interview with the Training Manager revealed documentation should be consistently completed each time the sink concentrations were made. Further, she was not aware of staff members in the kitchen who wore a face masks improperly, below the nose. She stated staff had been provided education on properly wearing face masks. The Dietary Manager provided education on beard guards, and if a staff member had facial hair, the employee should have a beard guard on while in the kitchen. The Dietary Manager stated, We do not want hair to fall in the food. Per interview, monthly in-service education covered infection control, use of masks, documentation of temperatures and concentrations. Interview with the Staff Development Coordinator, on 03/21/2022 at 11:30 AM, revealed she had been in that role since 03/01/2022. Additionally, she had provided in-services on Personal Protective Equipment, handwashing and infection control. However, she had not provided in-servicing to kitchen staff. Further, she stated she was responsible to provide training and education related to all identified concerns in the building, for all staff, and all departments as applicable. Interview with Dietary Aide #1, on 03/24/2022 at 11:40 AM, revealed he had worked in the kitchen for two (2) and a half years, and had been trained on temperature logs, refrigerator logs, the three (3) compartment sink log, and the dry storage log. Per interview, it was important to have record of temperatures, in order to know they were in the right range to ensure food was not spoiled. He stated dishwater was made and tested every two (2) hours and he would know the right concentration was prepared by testing the sink water with the strip paper for 10 seconds. He said the strip's color would be compared to the color key on the side of the box of strips. He stated the strip dipped in the sanitizer treated water should read 200 PPM, because that would be the acceptable range. Continued interview with Dietary Aide #1 revealed the proper chemical concentration was important for proper sanitation of the cookware/dishware. In addition, he said the number was important, because if the dishes used for serving food were contaminated, that could lead to food borne illnesses. Per interview, he stated the water temperature should be 120 degrees Fahrenheit for soap water, rinse water should be 110 degrees Fahrenheit; and sanitizer water should measure 65-75 degrees Fahrenheit. The Dietary Aide stated the stove should be cleaned at least once a week, and the cook cleaned it. Further, the trash can lids were cleaned weekly, and the trash can tops should always be in the down position, to prevent food and refuse from falling on the floor. He said pitchers of beverages should be covered and labeled to prevent contamination. He stated it had been awhile since he received training on those issues, but he had received training on wearing beard guards in the kitchen, in order to keep hair out of the food. Interview with the Director of Nursing, on 03/26/2022 at 4:00 PM, revealed that she expected the kitchen to be clean and sanitary at all times to ensure Infection Control. Interview with the Administrator, on 03/26/2022 at 4:30 PM, revealed he expected the kitchen to be clean and sanitized at all times so food would be served in a safe manner.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to provide a safe, clean, and comfortable homelike environment for two (2) of thirty-one (31) sampled residents, Resident #55 and #102. Observation and interview revealed Resident #55's mattress was deteriorated, and the soap holder in Resident #102's shower was broken with sharp, protruding edges. The findings include: The facility did not provide a policy pertaining to resident mattresses. Review of the facility's policy, Maintenance Service, dated January 2005, revealed the maintenance department was responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. The maintenance department would maintain the building in good repair and free from hazards. 1. Interview with Resident #55, on 01/21/19 at 3:00 PM, revealed his/her mattress was broken down and hurt his/her back. Observation, on 01/21/19 at 3:12 PM, with Registered Nurse (RN) #4 revealed Resident #55's mattress's outer waterproof cover was worn off, exposing the fabric layer of the mattress and the mattress was sagging in the area the resident positioned his/her hips when in bed. Interview with RN #4, on 01/21/19 at 3:13 PM, revealed Resident #55's mattress was deteriorated, as it was compressed throughout the area the resident laid and the waterproofing layer was worn off. She stated she requested a new mattress for the resident about one (1) week previous, but the resident had not yet received it. The RN stated there was not a reply to the request in the maintenance book. Review of the Maintenance Book, dated 01/12/19, revealed a request for Resident #55 to have a new mattress. Interview with Certified Nursing Assistant (CNA) #14, on 01/24/19 at 3:04 PM, revealed if she saw a needed repair in a resident's room, she wrote it in the maintenance book for the Plant Operations staff. She stated she would make a written request, and tell a nurse, if the waterproof cover was worn off a mattress so another mattress could be ordered. The CNA stated the waterproof covering was important to avoid the mattress staying wet and soaking the sheets, which could lead to resident skin breakdown and infection. Interview, on 01/21/19 at 3:27 PM, with Plant Operations Staff revealed requests for replacement mattresses were reported to Central Supply. Interview, on 01/23/19 at 11:02 AM, with the Central Supply Director revealed she was responsible for ordering mattresses for resident rooms and had ordered three (3) mattresses, which were on back order. She further stated when nurses complained about a resident mattress, she asked the Administrator to approve an order for a new mattress because the facility did not keep new mattresses on hand. She stated nursing staff would verbally tell her or note the request in a book when a resident needed a new mattress. In addition, she stated staff replaced mattresses with other mattresses from empty beds. The Supply Director stated mattresses should be immediately replaced if urine soaked, saggy, or if the waterproofing layer was worn and not intact. She further stated she did not inspect mattresses; it was nursing staff's responsibility to inform her if a resident needed a replacement. She stated she observed Resident #55's mattress and it was deteriorated, as the mattress sagged in the middle and the waterproofing layer was worn. Interview, on 01/23/19 at 2:40 PM and 01/24/19 at 2:17 PM, with Resident #55 revealed staff replaced the mattress on his/her bed from another bed; however, the mattress was not comfortable, was saggy, and lacked support. He/she stated he/she preferred to spend time in his/her room, in bed, watching television. However, his/her mattress was uncomfortable and he/she was dissatisfied with the mattress. Interview and observation, on 01/23/19 at 2:41 PM, with RN #6 revealed Resident #55's replacement mattress was deteriorated, as the middle of the mattress was compressed and felt like it would not bounce back. The RN stated the mattress on the bed would not give support to the resident and would be uncomfortable. The RN stated a resident sleeping on a deteriorated mattress would cause discomfort to the resident. RN #6 stated if the waterproofing of a mattress was not intact; it posed a risk of infection for the resident due to potential moisture such as urine seeping into the mattress causing contamination and bacteria growth. Interview, on 01/24/19 at 4:03 PM, with the Plant Operations Director revealed nursing staff should write a request for a new mattress in the supply request book, not the maintenance request book. However, when the Plant Operations Director and Plant Operations staff saw a request for a mattress in the maintenance book, they reminded nursing staff which book to use for the request and then would pass on the request to Central Supply. She stated she did not audit the condition of resident mattresses and did not know if the Central Supply Director audited the condition of the mattresses. Interview, on 01/24/19 at 3:27 PM, with the Director of Nursing (DON) revealed stated nursing staff should observe resident mattresses for tears, cuts, rough edges, odors, worn off waterproof covering, or any breakdown of the mattress including mattress compression resulting in lack of support. She stated if the waterproof cover was worn off, the mattress should be replaced immediately, and if necessary, a mattress could be obtained from an empty bed until a new mattress could be ordered. According to the DON, the waterproofing layer of the mattress had antimicrobial properties, and if worn off, it was ineffective and an infection control issue. In addition, she stated it was important to have resident mattresses in good condition, not broken down, to give proper support and pressure relief. The DON stated risks for deteriorated mattresses included lack of comfort for the resident, bacterial growth, infection, and cross contamination. Interview, on 01/24/19 at 4:56 PM, with the Administrator revealed he expected staff to look at mattresses when they changed bed linens and to report a need for mattress replacement. He further stated a deteriorated mattress with the waterproofing worn off should be replaced. However, he stated he did not know if staff was trained on what to look for related to mattress conditions. He stated he was not aware of any facility audits for mattress conditions. He stated Central Supply made rounds related to passing supplies but did not look at mattresses. 2. Observation of Resident #102's bathroom, on 01/24/19 at 9:24 AM, revealed the soap dish formed into the wall of the shower stall was cracked, with sharp edges protruding out. Interview with CNA #14, on 01/24/19 at 3:04 PM, revealed if she saw something needing repair in a resident's room, she wrote it in the maintenance book for Plant Operations to repair, which would include broken areas in a shower stall. She stated it was important to have shower stall walls intact to ensure staff and residents were not injured during showers. Interview with CNA #2, on 01/24/19 at 4:34 PM, revealed she assisted Resident #102 to the bathroom and had not noticed any issues with the shower stall. The CNA looked in the resident's shower stall and stated there was a busted soap dish in the wall of the shower. She stated when she observed things needing repaired; she reported them by writing a request in the maintenance book at the nurses' station. The CNA stated the broken edge posed a risk for a skin tear to the resident or staff. Interview with Licensed Practical Nurse (LPN) #18, on 01/24/19 at 3:23 PM, revealed for problems in a resident's shower stall such as sharp edges, CNAs should report the problem to a nurse and the nurse should write the issue in the maintenance book. The LPN reviewed the maintenance request book for the unit and stated there was no request for repair related to sharp edges of the soap holder in Resident #102's shower. Interview, on 01/24/19 at 3:27 PM, with the DON revealed the soap holder in Resident #102's shower was broken and had sharp edges. She stated the sharp edge was not part of a home like environment and it looked like there had been a repair that was not holding. The DON further stated as soon as staff discovered the broken area, they should tell the nurse, unit manager, or her. She stated she expected the nurse to write a repair request in the maintenance book, or if needed, call for immediate repair. She further stated the broken soap holder should have been reported immediately to maintenance, who should have completed the repair immediately to avoid a skin tear to the resident or staff. The DON reviewed the maintenance request book for the unit and stated there was no request for repair of the soap holder. The DON stated it was the responsibility of nursing staff to observe and ensure the environment was safe, comfortable, and homelike. Interview, on 01/24/19 at 4:03 PM, with the Plant Operations Director revealed any staff member who saw a broken edge, such as a soap holder in a shower stall, was responsible to inform her or Plant Operations Staff of the needed repair. She stated facility staff informed Plant Operations by entering the information in the maintenance book, but often staff called her with the information. The Director stated she made rounds on the units and looked at several things, including the shower stalls and other areas for needed repair. She stated if nursing staff did not report issues, she would not know until she made rounds. She stated a broken edge in a shower stall was not home like and should be reported and repaired. Interview, on 01/24/19 at 4:56 PM, with the Administrator revealed Plant Operations made rounds to identify repairs needed and staff should report a broken soap holder by filling out a work request in the maintenance book. In addition, he stated he expected staff to take measures to cover the sharp edges of a soap dish in some way until repaired to protect residents and staff from injury.

**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 follow the care plan for four (4) of thirty-one (31) sampled residents, Resident #19, #88, #91, and #168. The facility care planned for staff to assist with Activities of Daily Living needs; however, interviews revealed staff failed to meet the needs of the residents timely. The findings include: Review of the facility's policy, Comprehensive Care Plans, dated 07/19/18, revealed the care plan included objectives and timetables to meet residents' medical, nursing, mental, and psychological needs. In addition, the care plan included how the facility would assist the resident to meet their needs, goals, and preferences and aided the resident in reducing declines in functional status and/or functional levels. 1. Review of Resident #168's clinical record revealed the facility admitted the resident on 01/10/19, with diagnoses of Chronic Obstructive Pulmonary Disease, Muscle Weakness, and Difficulty Walking. Review of the resident's admission Minimum Data Set (MDS), dated [DATE], revealed the resident required the assistance of one (1) staff for transfers, toileting, personal hygiene, and bathing, and the resident was occasionally incontinent of urine. The facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of seven (7) of fifteen (15) and determined the resident was not interviewable. Review of Resident #168's Care Plan, dated 01/21/19, revealed the resident had Activities of Daily Living (ADL) Self-Care deficit with interventions for one (1) staff to assist with toileting or incontinence care. The facility care planned the resident for Actual or Potential Complications associated with urinary incontinence with interventions for staff to provide incontinence care as needed and one (1) staff to assist with toileting. Review of the facility's Certified Nursing Assistant (CNA) Care Record, dated January 2019, revealed one (1) staff was to assist Resident #168 with toileting. Observation of and interview with Resident #168, on 01/23/19, at 3:03 PM, revealed the resident in bed and stated he/she was too weak to get out of bed without assistance. The resident stated earlier in the morning he/she needed assistance to toilet and put on the call light. A female staff came in the and the resident told staff he/she needed help to toilet, but staff turned off the call light and told the resident she would be right back; however, she never came back to help. According to the resident, he/she waited a long time and then urinated in his/her brief because he/she could not wait any longer. The resident stated no one came to assist with incontinent care or toileting throughout the morning and when his/her daughter came at noon, he/she was still in a wet brief and the daughter gave him/her a shower. Per interview, he/she was occasionally incontinent but if staff took him/her to the toilet more often, he/she could stay dry better. Interview, on 01/23/19 at 3:22 PM, with CNA #9 revealed she was Resident #168's CNA for the day and after lunch, the resident's daughter told her no one had checked on the resident all morning. CNA #9 stated she started work at 6:00 AM and was in the resident's room around 8:00 AM to 9:00 AM to take the resident's roommate to the toilet. However, the CNA did not check on Resident #168 from 6:00 AM until the time she was there to assist the roommate. According to CNA #9, she rounded on residents every two (2) hours, which included checking for incontinence and changing briefs, but she did not check on Resident #168 during rounds because the resident would let staff know when he/she needed assistance. The CNA stated on a previous occasion, Resident #168 was incontinent due to not getting to the toilet in time. The CNA stated the CNA Care Record directed CNAs to check on the resident every two (2) hours and the resident was occasionally incontinent. Interview, on 01/24/19 at 2:43 PM, with Registered Nurse (RN) #4 revealed Resident #168 needed assist of one (1) staff for toileting and was care planned for assistance with toileting and incontinent care. The RN stated a staff member should check the resident every two (2) hours and ask the resident if he/she needed to toilet or needed anything else including any other Activity of Daily Living care need. The RN stated if the resident did not receive assistance with toileting or incontinent care, then staff did not follow the care plan. Interview, on 01/24/19 at 3:38 PM, with the Director of Nursing (DON) revealed CNAs should provide incontinent care and hygiene care to residents as needed before breakfast. She stated if Resident #168's care plan noted to assist the resident with toileting, and staff did not offer to assist the resident with toileting, then the care plan was not followed. She stated it was the responsibility of all licensed nursing staff to monitor and ensure the care plan was followed. 2. Review of Resident #19's clinical record revealed the facility admitted the resident on 08/17/18, with diagnoses of Muscle Weakness, Difficulty in Walking, Age Related Osteoporosis, and Presence of Cardiac Pacemaker. Review of the Quarterly MDS, dated [DATE], revealed the facility assessed Resident #19 with a BIMS score of ten (10) of fifteen (15) and determined the resident was interviewable. The facility assessed the resident required extensive assistance of two (2) staff for surface-to-surface transfer and toileting. The resident was always incontinent of bowel and bladder. Review of Resident #19's Care Plan, dated 10/03/14, revealed the resident was at risk for ADL Self-Care Deficit, and had a bowel elimination problem and required assistance for toileting. Interventions included staff was to provide assistance to meet his/her ADL needs and with incontinence care after incontinence episodes. Interview, on 01/21/19 at 11:05 AM, with Resident #19 revealed he/she required assistance to the bathroom because he/she was unable to get up by himself/herself, but did not always receive the help he/she required. The resident stated he/she waited half an hour or more, and sometimes waited for hours and this happened daily, which caused him/her to soil himself/herself. 3. Record review revealed the facility admitted Resident #88 on 11/26/18, with diagnoses of Alzheimer's Disease, Muscle Weakness, Difficulty in Walking, and Primary Osteoarthritis. Review of the admission MDS, dated [DATE], revealed the facility assessed the resident with a BIMS score of eight (8) of fifteen (15) and determined the resident was interviewable. The facility assessed the resident required extensive assistance of two (2) staff for a surface-to-surface transfer, and was occasionally incontinent of bladder and required extensive assistance of one (1) staff for toileting. Review of Resident #88's Care Plan, dated 12/05/18, revealed the resident was at risk for ADL Self-Care Deficit related to generalized muscle weakness, had complications with urinary incontinence, and a bowel elimination problem. Interventions included for nursing staff to provide assistance with toileting as needed. Interview, on 01/22/19 at 8:42 AM, with Resident #88 revealed he/she soiled himself/herself because of waiting for staff assistance. The resident stated he/she needed help to go to the bathroom and at times, he/she wet his/her pants because the facility did not provide the help. The resident further stated he/she had soiled himself/herself at least once a day for the past month. 4. Record review revealed the facility admitted Resident #91 on 02/02/18, with diagnoses of Muscle Weakness, History of Falling, Lack of Coordination, Primary Osteoarthritis, and Abnormalities of Gait and Mobility. Review of the Annual MDS, dated [DATE], revealed the facility assessed Resident #91 with a BIMS score of fifteen (15) of fifteen (15) and determined the resident was interviewable. The facility assessed the resident required limited assistance of one (1) staff for surface-to-surface transfer and toileting. Review of Resident #91's Care Plan, dated 06/01/16, revealed the resident was at risk for ADL Self-Care Deficit related to morbid obesity and general muscle weakness in all extremities. Interventions included staff was to provide assistance with daily needs, including all ADLs. Interview, on 01/21/19 at 2:47 PM, with Resident #91 revealed , it took staff longer than one (1) hour to assist him/her with toileting. The resident stated he/she was not able to wipe himself/herself after toileting and needed help to use the bathroom. Interview, on 01/23/19 at 3:32 PM, with CNA #1 revealed some residents needed direct care assistance with toileting and some incontinent residents soiled themselves because there was not always enough CNA available. CNA #1 stated when residents soiled themselves, their skin could break down and they could get pressure ulcers. Interview, on 01/24/19 at 9:21 AM, with CNA #2 revealed when the facility did not have enough CNAs, the residents did not receive timely brief changes and were not toileted frequently enough. She stated this could result in skin breakdown and attempts to self-transfer to the toilet and fall. She stated she was not able to make rounds as frequently as she should and when residents had to wait a long time to get assistance, it was not good quality of care. Interview, on 01/24/19 at 9:04 AM, with CNA #3 revealed she was aware residents depended on her assistance and had soiled themselves because she could not always provide assistance in a timely manner, because there was not enough staff. CNA #3 stated the CNAs, including herself, could not provide the care that was care planned. Interview, on 01/24/19 at 8:45 AM, with Licensed Practical Nurse (LPN) #3 revealed most of the time there was only two (2) CNAs available to provide direct care to residents, which resulted in residents long wait times. The LPN further stated the longer wait time affected resident's skin integrity and could lead to falls. She stated residents waiting long periods of time to receive assistance meant the care plan was not followed. Interview, on 01/23/19 at 3:43 PM, with RN #1 revealed the residents did not always get the care and services they needed in a timely manner because there was not enough staff. The RN further stated this could lead to skin breakdown and falls as residents tried to go to the restroom by themselves. She stated if assistance was not given to the residents as care planned, than the care plan was not followed. Interview, on 01/23/19 at 11:27 AM, with UM #2 revealed the facility was short staffed on CNAs almost daily, which affected residents care needs and how long residents had to wait to get assistance. She stated residents who waited too long affected their bowel and bladder continence. Interview, on 01/23/19 at 1:26 PM, with UM #1 revealed there was not enough CNAs to assist residents, and she was aware some residents urinated on themselves and other personal care needs were not met. She further stated residents could experience skin break down and were at increased risk for falls. Interview, on 01/24/19 at 4:32 PM, with UM #3 revealed if nursing staff did not provide the care needed to residents, it was not quality of care. She stated following the care plan was important because all nursing staff was required to meet resident needs. Interview, on 01/24/19 at 10:33 AM, with the DON revealed nurses were to accommodate resident care needs, which included toileting and brief changes. She stated the care plan addressed the residents' risk and care services, and if care was not provided to residents as planned, it was a performance issue. Interview, on 01/24/19 at 4:56 PM, with the Administrator revealed nursing staff should provide all ADL care, including incontinent care, to meet residents' needs. He stated staff should provide care according to the residents' care plans and Charge Nurses should monitor and ensure staff provided appropriate care.

Based on interview, record review, and facility policy review, it was determined the facility failed to revise the care plan for one (1) of thirty-one (31) sampled residents, Resident #316. Resident #316 sustained a non-injury fall on 01/20/19, and the facility failed to revise the care plan after the fall with interventions to prevent further falls. The findings include: Review of the facility's policy, Comprehensive Care Plans dated 09/21/16, revealed a person-centered comprehensive care plan that included measureable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs was developed for each resident. The care plan included how the facility would assist the resident to meet their needs, goals, and preference. The care plans were ongoing and revised as information about the resident and the resident's condition changed. The nurse/Interdisciplinary Team was responsible for the review and updating of care plans. The care plan should reflect the status of the resident and updated with changes in the resident status and when residents were readmitted to the facility from a hospital stay. Review of the facility's policy, Falls, dated 06/01/15, revealed the intent of the policy was to provide residents with assistance and supervision in an effort to minimize the risk of falls and fall related injuries. A Comprehensive Care Plan would be implemented based on the fall risk evaluation score, with an individual goal and interventions specific to each resident. The care plan would be reviewed following each fall, quarterly, annually, and with each significant change. Interventions were revise as indicated by the assessment. Record review revealed the facility admitted Resident #316 on 01/16/19, with diagnoses of Chronic Respiratory Failure, Muscle Weakness, and Difficulty Walking. Review of the Nursing admission Information, dated 01/16/19, revealed Resident #316 needed assistance for transfers, walking, and toileting. Review of the resident's Baseline admission Care Plan, dated 01/17/19, revealed Resident #316 had a self-care deficit related to weakness and staff would provide Activities of Daily Living care to ensure needs were met. Review of a Health Status Note, dated 01/20/19, revealed staff found Resident #316 on the floor on his/her left side at 12:20 PM. The resident stated he/she was ambulating with the walker to the bedside commode and lost his/her balance and fell on his/her tailbone. Further review of the resident's care plan revealed the facility did not revise the plan with interventions to prevent further falls. Interview, on 01/24/19 at 3:24 PM, with Resident #316's daughter revealed the resident told her he/she decided to go to the bathroom on his/her own after waiting for over an hour for someone to assist him/her. Interview with Licensed Practical Nurse (LPN) #15, on 01/24/19 at 11:04 AM, revealed nurses were responsible for following the direction of a resident's care plan and updating the care plan ensured the residents received appropriate care. Interview with LPN #7, on 01/24/19 at 4:40 PM, revealed nurses were responsible for updating care plans. The LPN stated nurses and CNAs utilized the care plan to provide the best care possible for resident safety and quality of life they deserved. Interview with LPN #3, on 01/24/19 at 4:43 PM, revealed nurses and Unit Mangers were responsible for updating care plans. The stated staff should update care plans when there was a change in resident status or anything new with a resident. According to the LPN, care plan updates were important so all staff was aware of resident needs, so the needs could be met. She stated if the care plan was not updated, it could result in harm to a resident. Interview with the Director of Nursing (DON), on 01/24/19 at 1:59 PM and 4:15 PM, revealed Resident #316 fell trying to go to the bathroom because he/she said he/she waited over an hour for assistance. She stated it was the responsibility of all nurses to monitor and ensure the care plan was followed and the Charge Nurse, unit nurse, and she was responsible for updating care plans Interview with the Administrator, on 01/24/19 at 4:45 PM, revealed nursing staff was to update the care plan after a fall with interventions to prevent a fall from happening again.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility failed to assist residents to toilet for one (1) of four (4) sampled residents, Resident #168, who was unable to toilet himself/herself. The findings include: The facility did not provide a policy for provision of Activities of Daily Living. Record review for Resident #168 revealed the facility admitted the resident on 01/10/19, with diagnoses of Chronic Obstructive Pulmonary Disease, Muscle Weakness, and Difficulty Walking. Review of the admission Minimum Data Set (MDS), dated [DATE], revealed the resident required the assistance of one (1) staff for transfers, toileting, personal hygiene, and bathing, and the resident was occasionally incontinent of urine. The facility assessed the resident with Brief Interview for Mental Status (BIMS) score of seven (7) out of fifteen (15) and determined the resident was not interviewable. Review of the facility's Certified Nursing Assistant (CNA) Care Record, dated January 2019, revealed staff was to provide assist of one (1) for toileting Resident #168. Review of the Care Plan, dated 01/21/19, revealed Resident #168 had potential complications associated with urinary incontinence and one (1) staff was to assist with toileting and provide incontinence care as needed. Observation of and interview with Resident #168, on 01/23/19, at 3:03 PM, revealed the resident in bed and he/she stated he/she was too weak to get out of bed to toilet without assistance. The resident stated earlier this morning (01/23/19), he/she put on the call light and a female staff member came in the room and he/she told staff he/she needed help to toilet. However, the staff member turned off the call light and told the resident she would be right back but never came back. Resident #168 stated he/she waited a long time and then was unable to wait any longer and urinated in his/her brief. The resident stated no one came to check on him/her to assist with incontinent care or toileting throughout the morning. The resident stated when his/her daughter came in at noon, he/she was still in a wet brief and his/her daughter gave him/her a shower. The resident stated the daughter made staff change the bed and the daughter was mad. Per interview, he/she was occasionally incontinent but if staff took him/her to the toilet more often, he/she could stay dry better. The resident stated he/she drank fewer fluids now to avoid needing to toilet. Interview with CNA #9, on 01/23/19 at 3:22 PM, revealed she was assigned to care for Resident #168 and after lunch she assisted the resident when the resident's daughter told her no one had checked on the resident all morning. CNA #9 stated she was in the resident's room around 8:00 AM to 9:00 AM to take the resident's roommate to the toilet; however, stated she did not check on the resident from 6:00 AM until the time she was there to assist the roommate. The CNA stated she made rounds on residents at least every two (2) hours, which included checking residents for incontinence and changing briefs as needed, but she did not check on Resident #168 during rounds because the resident would let staff know when he/she needed assistance. CNA #9 stated the facility permitted staff to turn off call lights, leave the room, and come right back to assist the resident. The CNA stated she did not know who turned off the call light and left and did not go back to assist Resident #168 to toilet. Interview with Registered Nurse (RN) #4, on 01/24/19 at 2:43 PM, revealed she assisted Resident #168 with toileting many times. The RN stated staff should not turn off a call light until addressing the resident's needs. In addition, she stated staff should ask the resident if he/she needed to toilet during the morning and check on him/her every two (2) hours to see if he/she needed to toilet. The RN stated a resident that sat too long waiting for incontinence care could have skin breakdown or could have tried to toilet themselves and fallen. Interview with the Director of Nursing (DON), on 01/24/19 at 3:38 PM, revealed CNAs should make rounds initially after arriving to work in the morning and provide incontinent care to residents as needed before breakfast. She stated when answering call lights, staff should turn off the light only after meeting the resident's needs. She stated it was not acceptable for staff to turn off a resident's call light and tell the resident they would be right back. In addition, the DON stated if a resident was dependent on staff for toileting, staff should offer assistance during rounds, as incontinence could cause skin break down, pain, odor, and was a dignity issue. Interview with the Administrator, on 01/24/19 at 4:56 PM, revealed nursing staff should provide all Activities of Daily Living care, including incontinent care, to meet residents' needs. He stated staff should make rounds, check on residents, and ask residents if they needed anything. The Administrator revealed the Charge Nurses should monitor to ensure staff provided appropriate care to residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents received appropriate treatment and services related to enteral feeding (directly into the stomach) for one (1) of four (4) sampled residents, Resident #110. Observation of the resident's tube feeding bags revealed there was no label to include the resident's name, date, time, or initials of staff that hung the tube-feeding. The findings include: Review of the facility's policy, Gastrostomy Feeding, reviewed 06/05/18, revealed feeding administration systems were to be changed every twenty-four (24) hours. The piston syringe was to be replaced every twenty-four (24) hours. Review of the facility's policy, Infection Prevention and Control Program, revised October 2018, revealed an element of the infection control program was the prevention of infections, which included instituting measures to prevent complications, education, and ensuring staff adhered to proper techniques and procedures. Review of Resident #110's clinical record revealed the facility admitted the resident on 05/01/09, with the diagnoses of Paraplegia, Aphasia, and Gastrostomy Status. Review of Resident 110's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident had a feeding tube for nutritional intake. Observation, on 01/21/19 at 10:21 AM, revealed Resident #110 was receiving enteral feeding through a tube in the stomach area. At the bedside, a feeding system, which included a bottle of formula and a bag of water, interconnected to one tube system connected to the feeding tube. The water bag was not labeled with the date, time, name, or nurse's initials. Observation of Resident #110, on 01/21/19 at 12:22 PM, revealed a gastric syringe at the bedside in a clear container, not covered. The syringe was not labeled with the date, time, name of Resident #110, or initials of the nurse. Observation, on 01/22/19 at 8:39 AM, revealed Resident #110's nutritional bottle and water bag were dated 01/22/19. However the bags were not timed, initialed, and the resident's name was not on the bags. Observation, on 01/23/19 at 11:51 AM, revealed the feeding container and water bag were infusing to the resident. The feeding container and water bag were not labeled with the date, time, initials, or resident's name. Interview with Licensed Practical Nurse (LPN) #6, on 01/24/18 at 2:10 PM, revealed water bags and nutrition bottles were to have the resident's name, date, and time on the label. She stated the bag and tubes for the feeding system were only good for three (3) days because old nutrition could cause an infection. Interview with LPN #7, on 01/24/19 at 2:16 PM, revealed the feeding system was to be changed every twenty-four (24) hours and labeled with the date, time, and initials to prevent infection. She stated the nurse who changed the system was responsible to ensure it was labeled so staff would know when the system needed to be changed to prevent the resident from becoming ill. Interview with LPN #8, on 01/24/19 at 2:34 PM, revealed feeding systems were to be changed every twenty-four (24) hours and properly labeled with the resident's name, date, time, and the initials of the nurse who hung the system. She stated a feeding system, which hung greater than twenty-four (24) hours, could cause bacteria to go directly into the resident's stomach and make the resident sick. She stated it was the nurse's responsibility to ensure the system was labeled properly when they changed the system. She stated she completed annual education for enteral feeding and skills check-off on how to handle a feeding system. She further stated the Staff Educator and management did not monitor the feeding systems. Interview with Registered Nurse (RN) #4, on 01/24/19 at 2:29 PM, revealed the feeding system was to be changed every twenty-four (24) hours and all tubing and nutrition was to be labeled with the date, time, nurse's initials, and resident's name, in order for staff to know when it was hung. She stated bacteria could grow if the system was up to long and could cause the resident to get sick. Interview with Unit Manager (UM) #3, on 01/24/19 at 2:52 PM, revealed she monitored compliance with labels on feeding systems when she passed medications; however, did not have an audit tool to use. She stated staff was to place the resident's name, date, the time started, and the nurse's initials on the feeding system, and the system was to be changed every twenty-four (24) hours. The UM stated the facility did not have a policy on when to change the system but she taught staff to change the system every twenty-four (24) hours. She stated labeling was important to ensure the residents did not get sick to their stomach. Interview with the Assistant Director of Nursing (ADON), on 01/24/19 at 2:53 PM, revealed staff was educated to label the feeding system with the resident's name, date, time the system was hung, and initials of the nurse. She stated staff who changed the system was responsible to label the system properly to prevent residents from becoming ill because of bacteria growth, which occurred when systems hung over twenty-four (24) hours. The ADON stated she did not audit staff compliance with proper labeling of feeding systems. She stated staff had annual training for gastric feeding as well as they completed online modules annually. Interview with the Staff Educator, on 01/24/19 at 4:31 PM, revealed all nursing staff was to complete and pass gastric tube feeding competency skills testing, which proper labeling was part of the skill, as well as complete the online module on a yearly basis. She stated she did not do random audits to ensure the nurses were completing the skill correctly. She stated as the educator of the facility, she was responsible to orient new staff, provide education to staff, and was to track and monitor infections in the facility. Interview with the Director of Nursing (DON), on 01/24/19 at 3:53 PM, revealed nurses were to label all feeding system components, as well as the syringe, with the date, time, nurse's initials, and resident's name to eliminate confusion regarding when the system was started. She stated the systems were to be changed every twenty-four (24) hours to help prevent residents from becoming ill with a bacterial infection. She stated the UM and ADON were responsible to ensure nursing staff labeled items properly, as she did not complete audits, and she was not aware of issues with improper labeling. Interview with the Administrator, on 01/24/19 at 6:53 PM, revealed he was not aware of issues with labeling the feeding systems. He stated the DON made rounds to audit nursing care; however, he was unsure if feeding systems were reviewed. He further stated the DON and nursing administration was to ensure staff provided appropriate care to ensure resident safety.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure each resident was treated with respect and dignity for four (4) of eighteen (18) sampled residents, Residents #19, #74, #88, and #91. Interviews revealed the facility failed to meet the personal care needs of the residents in a timely manner. The findings include: Review of the facility's policy, Resident Rights, revised 08/16/18, revealed all residents had the right to be treated with respect and dignity. The residents' rights were protected and promoted by the facility in a manner that maintained or enhanced the residents' quality of life. When staff provided care and services, they respected the residents' individuality and valued their input by providing a dignified existence, through self-determination and communication, and with access to persons and services inside and outside the facility. Observation of the first floor north hall, on 01/23/19 at 9:39 AM, revealed the call light for Resident room [ROOM NUMBER] was on and remained unanswered until 9:59 AM, when answered by a Certified Nursing Assistant (CNA). At 9:46 AM, the call light for Resident room [ROOM NUMBER] went on and was not answered until 9:59 AM, by the Administrator. Registered Nurse (RN) #1 was documenting on the computer at the medication cart while the call lights were sounding; however, did not attempt to answer either call light. Interview with RN #1, on 01/23/19 at 9:57 AM, revealed when asked why she did not answer the call lights, she responded she did not usually work on the north hall and had not worked on the hall for over a month. 1. Record review revealed the facility readmitted Resident #19 on 08/17/18, with diagnoses of Muscle Weakness, Difficulty in Walking, Age Related Osteoporosis, and Presence of Cardiac Pacemaker. Review of the Quarterly MDS, dated [DATE], revealed the facility assessed Resident #19 with a BIMS score of ten (10) of fifteen (15) and determined the resident was interviewable. The facility assessed the resident required extensive assistance of two (2) staff for surface-to-surface transfer and toileting. The resident was always incontinent of bowel and bladder. Interview with Resident #19, on 01/21/19 at 11:05 AM and 01/23/19 at 9:25 AM, revealed he/she required assistance to go to the bathroom and did not always get the help he/she needed. The resident stated he/she waited half an hour or more, and at times, waited for hours. He/she knew how long it took staff to answer the call light because there was a clock on the wall and he/she had a cellphone that showed the time. The resident further stated he/she soiled himself/herself at least once a day, which made him/her feel awful. Resident #19 stated it was very cold when he/she had to sit in wet undergarments when staff did not come to assist him/her. He/she had complained about this to staff but could not recall whom he/she complained too. 2. Record review revealed the facility readmitted Resident #74 on 12/17/18, with diagnoses of Lack of Coordination, History of Falling, Muscle Weakness, Rheumatoid Arthritis, and Abnormalities of Gait and Mobility. Review of the admission MDS, dated [DATE], revealed the facility assessed Resident #74 with a BIMS score of twelve (12) of fifteen (15) and determined the resident was interviewable. The facility assessed the resident required extensive assistance of two (2) staff for surface-to-surface transfer and toileting. The resident was occasionally incontinent of bowel and bladder. Interview with Resident #74, on 01/21/19 at 10:26 AM, revealed when he/she turned his/her call light on, it took a good while for staff to assist him/her, sometimes about two (2) hours, which occurred about twice a week. The resident stated he/she used the clock and a cellphone to monitor how long it took staff to answer the call light. According to the resident, staff came to his/her room and did not seem to know he/she needed help with toileting. 3. Record review revealed the facility admitted Resident #88 on 11/26/18, with diagnoses of Alzheimer's Disease, Muscle Weakness, Difficulty in Walking, and Primary Osteoarthritis. Review of the admission MDS, dated [DATE], revealed the facility assessed the resident with a BIMS score of eight (8) of fifteen (15) and determined the resident was interviewable. The facility assessed the resident required extensive assistance of two (2) staff for a surface-to-surface transfer, and was occasionally incontinent of bladder required extensive assistance of one (1) staff for toileting. Interview with Resident #88, on 01/22/19 at 8:42 AM, revealed the resident soiled himself/herself waiting for staff assistance. The resident stated he/she needed help to go to the bathroom and sometimes wet his/her pants because staff did not assist him/her. The resident stated he/she had waited between a half hour and one (1) hour to get help. The resident further stated he/she requested to speak to the Director of Nursing (DON); however, the DON was not available. Resident #88 stated he/she felt undignified when he/she soiled himself/herself. Interview with the family of Resident #88, on 01/23/19 at 9:30 AM, revealed the resident told her about the long wait times and he/she had wet his/her pants. Resident #88 told her he/she had to wait so long to get assistance it had made him/her feel down. 4. Record review revealed the facility admitted Resident #91 on 02/02/18, with diagnoses of Muscle Weakness, History of Falling, Lack of Coordination, Primary Osteoarthritis, and Abnormalities of Gait and Mobility. Review of the Annual MDS, dated [DATE], revealed the facility assessed Resident #91 with a BIMS score of fifteen (15) of fifteen (15) and determined the resident was interviewable. The facility assessed the resident required limited assistance of one (1) staff for surface-to-surface transfer and toileting. Interview with Resident #91, on 01/21/19 at 2:47 PM, revealed when he/she put his/her call light on, it took staff longer than one (1) hour to respond. The resident stated he/she kept track of the time with his/her watch. The resident stated he/she needed help to use the bathroom and would lay waiting, and one time soiled himself/herself and felt embarrassed. Interview with Certified Nursing Assistant (CNA) #1, on 01/23/19 at 3:32 PM, revealed the facility did not have enough CNAs at least twice a week, four (4) to five (5) times a month. She stated some residents got upset and some understood there was not enough help. The CNA revealed some residents required assistance with toileting and she knew some had soiled themselves and got upset and irritated. She further stated there should be enough nursing staff to accommodate residents' need for toileting otherwise the residents felt nasty, awful, and undignified. Interview with CNA #3, on 01/24/19 at 9:04 AM, revealed at times, residents soiled themselves depending on their urgency. She stated the facility was short-staffed two (2) to three (3) times a week, which caused residents to have to wait longer periods for staff to answer call lights and get them to the bathroom. Residents were dependent on staff assistance and if staff could not provide it timely, it affected the quality of care. CNA #3 stated soiling themselves affected residents' dignity, their mood, and at times their behavior. Interview with CNA #2, on 01/24/19 at 9:21 AM, revealed the facility was short staffed at least once a week, mainly on the weekends and during those times, residents would not be changed or toileted frequently enough and residents had accidents and felt down about it. The CNA stated this was not good quality of care and residents should be treated with respect and their call lights should be answered timely. Interview with Licensed Practical Nurse (LPN) #3, on 01/24/19 at 8:45 AM, revealed the facility was short staffed for CNAs three (3) to four (4) times a week and each unit was supposed to have three (3) CNAs. However, most of the time only two CNAs were available to assist residents, which meant residents had to wait at least ten (10) minutes longer to receive assistance with their care needs. LPN #3 stated it was a dignity issue if residents soiled themselves and residents felt disappointed and embarrassed when this occurred. Interview with RN #1, on 01/23/19 at 3:43 PM, revealed there were not enough CNAs scheduled at least three (3) times a week and the residents did not get the care and services they needed in a timely manner. The RN further stated call lights were answered late even when she assisted the CNAs, and some residents got angry and hollered out. She further stated the facility needed more CNAs in order to assist those residents who required the assist of two (2) staff. Interview with Unit Manager (UM) #2, on 01/23/19 at 11:27 AM, revealed the facility was short staffed for CNAs almost daily, as each unit was supposed to have (3) CNAs but often only two (2) CNAs worked even when the facility was almost filled to capacity. The UM stated unfortunately the short staffing affected resident care needs and long wait times for the residents. She stated it took nursing staff longer to answer call lights and residents had to wait to go to the bathroom, which made residents feel bad. She further stated family members had expressed unhappiness about the long wait for nursing staff to answer the call light. Not having enough CNAs affected the residents' bowel and bladder continence and their faith in the care staff provided, which held true for residents' family members. Interview with UM #1, on 01/23/19 at 1:26 PM, revealed the units were supposed to have three (3) CNAs but often only two (2) were available, which affected resident call light wait times. The UM stated she knew some residents urinated on themselves and other personal care needs were not met and made the residents feel awful and humiliated. She further stated nursing staff should answer call lights timely and residents should not have to wait more than ten (10) to twenty (20) minutes. The UM stated she observed CNAs completely ignore call lights and she spoke to Administration about the issue and the call light response time had gotten better for a brief time; however, the response time had gotten worse again. Interview with UM #3, on 01/24/19 at 4:32 PM, revealed if nursing staff did not address care concerns of residents, and if the residents soiled themselves, it could make them feel humiliated. Interview with the DON, on 01/24/19 at 10:33 AM, revealed nursing staff was to accommodate resident care needs, which included toileting and brief changes and she expected nursing staff to answer the call light within three (3) to five (5) minutes. If a CNA could not assist a resident due to completing another resident's care needs, she expected the CNA to let the resident know how long it would take to help him/her. The DON further stated the CNA was to leave the call light on to assure the resident would receive assistance and it was unacceptable for residents to wait an hour because the facility had enough staff to accommodate resident care needs. Interview with the Administrator, on 01/24/19 at 1:47 PM, revealed nursing staff and Unit Managers were to answer call lights timely and if a resident was soiled, nursing staff was to address the situation immediately. He stated the facility was the residents' home and he wanted the residents to have a better experience and feel the facility was an extension of their home. He expected nursing staff to work together and provide the highest quality of care. He stated there had been an issue with nursing staff answering call lights and nursing staff was required to attend an in-service related to the issue in September 2018; however, not all staff had attended.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's policy and resident rights, it was determined the facility failed to invite one (1) of two (2) sampled residents, Resident #91, to participate in his/her care plan conference. The findings include: Review of the facility's policy, Comprehensive Care Plans, revised 07/19/18, revealed the resident and the representative participated in the interdisciplinary team meeting as much as practicable for the resident and the representative. Each resident had the right to participate in choosing his/her treatment options, and was able to participate in the development, review, and revision of their care plan and was considered part of the interdisciplinary team. When a resident refused to participate in the development of the care plan, the facility staff entered the appropriate documentation into the resident's medical record. Review of the facility's Resident Rights, revised on 08/16/18, revealed the resident had a right to participate in decisions and care planning, which included seeing his/her care plan and the right to sign after significant changes to the care plan. Review of Resident #91's clinical record revealed the facility admitted the resident on 02/02/18, with diagnoses of History of Falling, Lack of Coordination, Primary Osteoarthritis, Muscle Weakness, and Other Abnormalities of Gait and Mobility. Review of the Annual Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #91 with a Brief Interview for Mental Status (BIMS) score of fifteen (15) of fifteen (15) and determined the resident was interviewable. Interview with Resident #91, on 01/21/19 at 2:47 PM, revealed he/she received a written invitation to attend the care plan meeting; however, nursing staff did not remind him/her to attend the scheduled care plan meeting. The resident further stated nursing staff did not assist him/her with transporting in the wheelchair so he/she could participate in the care plan meeting. Review of Resident #91's Care Plan Conference Summary Forms, dated 03/07/18, 04/04/18, 07/05/18, 10/03/18, and 12/05/18, revealed no signature of the resident or family member indicating they attended the conference and understood changes/updates to his/her care needs. Interview with the Social Worker (SW), on 01/23/19 at 10:27 AM, revealed she was new to the facility and had not met Resident #91. She stated typically, the MDS Coordinator scheduled care plan meetings and invited residents and family. However, she was unsure how the resident received the invitation. Further interview with the SW revealed she contacted the resident and/or the family if the care plan meeting was rescheduled. Interview with the MDS Coordinator, on 01/23/19 at 10:32 AM, revealed she made the schedule for each resident's care plan meeting, sent the schedule to the SW, and then the receptionist sent out a letter. She further stated residents with a high BIMS score were to receive a copy of the invitation. However, she was not sure if the residents actually received the invitation. The MDS Coordinator stated when the care plan meeting was held; staff attending signed a summary sheet of the meeting. Interview with Unit Manager (UM) #1, on 01/23/19 at 1:46 PM, revealed she got a list of residents scheduled for the quarterly care plan meeting and relied on the residents to let her know if they wanted to attend the meeting. She had not realized Resident #91 had not attended the care plan meetings and she had not offered the resident to attend the care plan meeting, which was a concern. The UM stated she should at least have attempted to invite the resident so he/she had an opportunity to decline attendance. Interview with the Director of Nursing (DON), on 01/24/19 at 10:24 AM, revealed she expected staff to ask residents if they wished to attend the care plan meeting or if they wanted to opt out. From what she understood, either the UM or the SW should go into a resident's room and remind him/her about the meeting so they could attend. The DON further stated it was a resident's right to attend or refuse the scheduled care plan meeting and if a resident's physical condition did not permit attending outside of his/her room, the meeting was held at the bed side. Interview with the Administrator, on 01/24/19 at 2:13 PM, revealed it was the resident's right to attend the care plan meeting. He expected the care plan team to invite residents to the meeting in the conference room, or in his/her room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility's Census and Conditions, it was determined the facility failed to ensure there was a sufficient amount of nursing staff to meet resident needs for eight (8) of eighteen (18) sampled residents, Resident #16, #19, #28, #64 #74, #88, #91, and #102. Nursing staff failed to answer resident call lights in a timely manner to address the residents' needs. The findings include: Review of the facility's Census and Conditions of Residents, dated 01/21/19, revealed the facility had one hundred and twenty-three (123) residents. One hundred and eight (108) residents required the assist of one (1) or two (2) staff for transferring and toilet use. Review of the facility's Weekly Schedule, dated 01/11/19 to 01/17/19, revealed on 01/11/19, the facility scheduled sixteen (16) Certified Nursing Assistants (CNA); however, review of the facility's Punch Variances Report (time staff clocked in/out) revealed only nine (9) CNAs worked. Continued review of the Schedule and Variance Report revealed on 01/12/19, twenty (20) CNAs were scheduled but only eleven (11) worked. On 01/13/19, nineteen (19) CNAs were scheduled but only thirteen (13) worked. On 01/14/19, eighteen (18) CNAs were scheduled but only thirteen (13) worked. On 01/15/19, twenty (20) CNAs were scheduled but only thirteen (13) worked. On 01/16/19, twenty-three (23) CNAs were scheduled but only seventeen (17) worked. On 01/17/19, twenty-two (22) CNAs were scheduled but only twelve (12) worked. 1. Interviews during Resident Council Group, on 01/22/19 at 10:05 AM, revealed Resident #28, #74, and #102 complained staff did not answer their call lights in a timely manner. Review of Resident Council Meeting Minutes, dated 08/03/18, revealed the main issues discussed by residents were care, call lights, and staffing. Review of the Complaint/Grievance Report, dated 01/23/19, revealed Resident #28, the counsel president, stated his/her call light went unanswered for over one (1) hour, at 2:00 AM when the resident needed medication. Record review revealed the facility re-admitted Resident #28 on 06/01/18, with diagnoses including Heart Failure, Dementia, and Anxiety Disorder. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of fifteen (15) of fifteen (15) and determined the resident was interviewable. The facility assessed the resident required extensive assistance for transfers with one (1) staff, and was frequently incontinent of bladder and required extensive assistance of one (1) staff for toileting. Interview, on 01/22/19 at 10:17 AM, with Resident #28 revealed an issue with call lights. The resident stated he/she could not walk and when he/she needed his/her pain medication it took one (1) hour and forty (40) minutes to get it. The resident stated he/she initiated a complaint with the previous Administrator and reported the call light was turned off at the nurses' station. The resident further stated he/she had to put the call light on again, which made him/her mad, and he/she had to ambulate via wheelchair to the nurses' station to get nursing staff's attention and assistance. 2. Record review revealed the facility admitted Resident #74 on 12/17/18, with diagnoses including Lack of Coordination, History of Falling, Muscle Weakness, Rheumatoid Arthritis, and Other Abnormalities of Gait and Mobility. Review of the admission MDS, dated [DATE], revealed the facility assessed Resident #74 with a BIMS score of twelve (12) of fifteen (15) and determined the resident was interviewable. The facility assessed the resident required extensive assistance with transfers and two (2) staff, and determined the resident was occasionally incontinent of bowel and bladder and required extensive assistance of two (2) staff for toileting. Interview, on 01/21/19 at 10:26 AM, with Resident #74 revealed the facility did not have enough help. The resident stated when he/she turned his/her call light on, it took a good while for staff to assist him/her and he/she knew it took a long time because he/she had a clock on the wall and a cellphone. Resident #74 stated he/she did not get the help he/she needed about twice a week. 3. Record review revealed the facility re-admitted Resident #102 on 09/26/18, with diagnoses including Diabetes Mellitus, Manic Depression, and Respiratory Failure. Review of the Annual MDS, dated [DATE], revealed the facility assessed the resident with a BIMS score of fifteen (15) of fifteen (15) and determined the resident interviewable. Interview, on 01/22/19 at 10:07 AM, with Resident #102 revealed when he/she used the call light to get ice water, it took nursing staff one (1) hour to get it because the facility did not have enough help. 4. Record review revealed the facility admitted Resident #16 on 10/26/18, with diagnoses including Cognitive Communication Deficit, Repeated Falls, Weakness, Difficulty Walking, and Neurogenic Bladder. Review of the admission MDS, dated [DATE], revealed the facility assessed the resident with a BIMS score of nine (9) of fifteen (15) and determined the resident was interviewable. The facility assessed the resident required extensive assistance for transfers with two (2) staff. Resident #16 had an indwelling catheter and was always incontinent of bowel and required extensive assistance of two (2) staff for toileting. Interview with Resident #16, on 01/21/19 at 11:41 AM, revealed he/she did not respond appropriately to questions and was visiting with his/her family. Interview with the Family revealed call lights went unanswered for thirty (30) minutes and the facility seemed short staff. The family stated the resident was no longer able to independently transfer and reposition in bed and they were concerned about the resident receiving appropriate assistance. 5. Record review revealed the facility admitted Resident #19 on 08/17/18, with diagnoses including Muscle Weakness, Difficulty in Walking, Age Related Osteoporosis, and Presence of Cardiac Pacemaker. Review of the Quarterly MDS, dated [DATE], revealed the facility assessed the resident with a BIMS score of ten (10) of fifteen (15) and determined the resident was interviewable. The facility assessed the resident required extensive assistance for transfers with two (2) staff, and was always incontinent of bowel and bladder and required extensive assistance of two (2) staff for toileting. Interview, on 01/21/19 at 11:05 AM, with Resident #19 revealed he/she required assistance to go to the bathroom because he/she could not get up by himself/herself. The resident stated he/she waited half an hour or more, and at times, waited hours to get help, which occurred daily. The resident stated he/she kept track of how long it took by the clock on the wall. The resident further stated he/she soiled himself/herself at least once a day waiting for assistance. 6. Record review revealed the facility re-admitted Resident #64 on 10/30/17, with diagnoses including Quadriplegia and Multiple Sclerosis. Review of the Annual MDS, dated [DATE], revealed the facility assessed the resident with a BIMS score of fifteen (15) of fifteen (15) and determined the resident was interviewable. The facility assessed the resident required extensive assistance for transfers with two (2) staff, and assessed the resident as occasionally incontinent of bladder and required extensive assistance of two (2) staff for toileting. Interview, on 01/22/19 at 10:05 AM, with Resident #64 revealed his/her call light got ignored by nursing staff and he/she waited between one (1) to three (3) hours to use the bathroom and get his/her needs met. He/she further stated he/she had soiled himself/herself while waiting for assistance, which happened several times a week. When nursing staff saw his/her call light, he/she stated they simply ignored it. 7. Record review revealed the facility admitted Resident #88 on 11/26/18, with diagnoses including Alzheimer's Disease, Muscle Weakness, Difficulty in Walking, and Primary Osteoarthritis. Review of the admission MDS, dated [DATE], revealed the facility assessed the resident with a BIMS score of eight (8) of fifteen (15) and determined the resident was interviewable. The facility assessed the resident required extensive assistance for transfers with two (2) staff, and the resident was occasionally incontinent and bladder and required extensive assistance of one (1) staff for toileting. Interview, on 01/22/19 at 8:42 AM, with Resident #88 revealed he/she soiled himself/herself at least once a day because of waiting a long time for staff assistance. The resident stated he/she needed help to go to the bathroom but the facility did not have enough staff to help him/her. According to the resident, he/she waited a half hour to an hour to receive assistance from staff. 8. Record review revealed the facility admitted Resident #91 on 02/02/18, with diagnoses including Muscle Weakness, History of Falling, Lack of Coordination, Primary Osteoarthritis, and Other Abnormalities of Gait and Mobility. Review of the Annual MDS, dated [DATE], revealed the facility assessed the resident with a BIMS score of fifteen (15) of fifteen (15) and determined the resident was interviewable. The facility assessed the resident required limited assistance for transfers with one (1) staff, and the resident was incontinent of bowel and bladder and required limited assistance of one (1) staff for toileting. Interview, on 01/21/19 at 2:47 PM, with Resident #91 revealed when he/she put his/her call light on, it took nursing staff longer than an hour to respond. The resident knew how long it took because he/she stated he/she kept track by the clock on the wall. The resident stated he/she could not walk on his/her own, could not wipe himself/herself after toileting, and needed help for different things like ice water, which he/she did not always get it. The resident stated he/she had soiled himself/herself while waiting for help. Interview, on 01/23/19 at 3:32 PM, with CNA #1 revealed the facility did not have enough nursing assistants at least twice a week. She further stated some residents required assistance with toileting and knew some residents had soiled themselves waiting for assistance. Interview, on 01/24/19 at 9:04 AM, with CNA #3 revealed the facility was short-staffed two (2) to three (3) times a week, which affected residents by them having to wait longer for their call lights to be answered. The CNA further stated the longer waiting periods caused some residents to soil themselves because they were dependent on staff assistance. She stated she had spoke about her staffing concerns to the Unit Manager. Interview, on 01/24/19 at 9:21 AM, with CNA #2 revealed the facility was short staffed at least once a week, but mainly on weekends, and during those times residents would not be changed or toileted frequently enough because she could not make rounds as frequently. Interview, on 01/24/19 at 8:45 AM, with Licensed Practical Nurse (LPN) #3 revealed the facility was short-staffed CNAs three (3) to four (4) times a week. She stated each unit was supposed to have three (3) CNAs; however, on most days only two (2) CNAs were available to assist residents, which meant residents had to wait longer to receive assistance with their care needs. Interview, on 01/23/19 at 3:43 PM, with Registered Nurse (RN) #1 revealed there were not enough CNAs scheduled at least three (3) times a week, which caused the residents not to get the care and services they needed in a timely manner. The RN further stated call lights were not answered timely, even when she assisted the CNAs. She further stated some residents got angry and hollered out in frustration. Interview, on 01/23/19 at 11:27 AM, with Unit Manager (UM) #2 revealed the facility was short staffed with CNAs almost daily, and although each unit was supposed to have (3) CNAs, there were often only two (2) available. The UM stated the short staffing affected residents care needs and how long residents had to wait to go to the bathroom. Interview, on 01/23/19 at 1:26 PM, with UM #1 revealed the unit was supposed to have three (3) CNAs but often there were only two (2) available and this happened about 50% percent of the time. She stated residents were affected by having longer call light answer times, and she was aware some residents urinated on themselves and other personal care needs were not met. The UM further stated she had spoke about the issue to the Administrator and the issue had gotten better for a brief time; however, staffing issues continued. Interview, on 01/24/19 at 10:33 AM, with the Director of Nursing (DON) revealed nursing staff was to accommodate resident care needs, which included toileting and brief changes. She stated nursing staff should answer call lights in a timely manner, within three (3) to five (5) minutes. The DON stated it was unacceptable for residents to wait one (1) hour for staff to accommodate their needs. If residents waited that long to receive assistance for brief changes and toileting, a resident's skin could break down, which could further lead to an infection and cause pain. Interview, on 01/24/19 at 1:47 PM, with the Administrator revealed nursing staff and Unit Managers should answer call lights timely. If residents were soiled, nursing staff was to address the situation immediately. He further stated nursing staff should work together and provide the highest quality of care.

Based on observation, interview, and record review, it was determined the facility failed to ensure records were maintained to account for controlled drugs for five (5) of eight (8) medication carts. Record review revealed missing staff signatures on the controlled drug accountability forms, which were used to count and reconcile controlled drugs at shift change. The findings include: The facility did not provide a policy for controlled medication accountability. Review of the facility's Controlled Substance Accountability Count form, dated January 2013, revealed the form was used to verify controlled drugs on hand had been counted, and each medication count was in agreement with the quantity stated on Controlled Drug Record(s). The form was to be dated, the shift identified, and signed by the on-coming nurse and the off-going nurse. Review of the Controlled Substance Accountability Count form, dated January 2019, for the Rehab Unit, revealed missing staff signatures on 01/02/19 at 7:00 AM, 01/03/19 at 7:00 PM, 01/04/19 at 7:00 PM, 01/05/19 at 7:00 PM, 01/07/19 at 7:00 PM, 01/08/19 at 7:00 AM, 01/08/19 at 9:00 PM, 01/09/19 at 7:00 AM, 01/09/19 at 9:00 AM, 01/10/19 at 7:00 AM, 01/10/19 at 9:00 PM, 01/11/19 at 7:00 AM, 01/11/19 at 9:00 AM, 01/14/19 at 7:00 AM, and 01/16/19 at 7:00 AM. Review of the Controlled Substance Accountability Count form, dated January 2019, for Cart 1 on the First Floor North Hall, revealed missing staff signatures on 01/02/19 at 7:00 AM, 01/02/19 at 7:00 PM, 01/08/19 at 7:00 PM, and 01/09/19 at 7:00 AM. The facility did not provide documentation after 01/09/19. Review of the Controlled Substance Accountability Count form, dated January 2019, for Cart 2 on the Second Floor North Hall, revealed missing staff signatures on 01/03/19 at 3:00 PM, 01/08/19 at 9:00 PM, 01/10/19 at 7:00 AM, 01/10/19 at 7:00 PM, and 01/13/19 at 7:00 PM. In addition, there was no shift documented on 01/15/19 and 01/16/19. The facility did not provide documentation for 01/17/19 and after. Review of the Controlled Substance Accountability Count form, dated January 2019, for Cart 1 on the Second Floor South Hall, revealed missing staff signatures on 01/06/19 at 7:00 PM, 01/07/19 at 7:00 AM, 01/19/19 at 7:00 PM, 01/20/19 at 7:00 AM, 01/21/19 at 7:00 AM, 01/22/19 at 7:00 AM, 01/23/19 at 7:00 AM, and 01/23/19 at 7:00 PM. Review of the Controlled Substance Accountability Count form, dated January 2019, for Cart 2 on the Second Floor South Hall, revealed missing staff signatures on 01/03/19 at 7:00 PM, 01/04/19 at 7:00 AM, 01/05/19 at 7:00 PM, 01/23/19 at 7:00 AM, and 01/23/19 at 7:00 PM. The facility did not provide documentation for 01/06/19 through 01/22/19. Interview with Licensed Practical Nurse (LPN) #8, on 01/24/19 at 10:50 AM, revealed nursing staff was to sign the narcotic control accountability form in the on-coming and off-going areas at shift change to account for scheduled medication. She stated the nurses were responsible to sign the sheet after the count was completed and accepting the keys to the medication cart. She stated the narcotic control accountability form was to be accurate. Interview with Registered Nurse (RN) #6, on 01/24/19 at 11:24 AM, revealed scheduled medications were counted when the cart responsibility was given to another nurse. She stated staff was to sign the narcotic control accountability form when the count was complete and accurate, as the form was part of the scheduled drug count process. If a discrepancy was found, she stated the Unit Manager would look into it and try to resolve the situation. Interview with RN #4, on 01/24/19 at 11:34 AM, revealed two (2) nurses were responsible to count scheduled medication and both signed the narcotic control accountability form. She stated the facility was to ensure the signatures were on the form as it signified the count was correct. She further stated missing signatures could be a sign of diversion. Interview with Unit Manager #2, dated 01/24/19 at 11:48 PM, revealed new staff was oriented to the scheduled narcotic count process with the Staff Development Manager and then were assigned a nurse to follow on the floor. She stated missing staff signatures could be a problem if the medication count was inaccurate, as there was a potential for diversion. She stated she was not responsible to ensure staff completed documentation on the narcotic control accountability forms. Interview with the Staff Education Director, on 01/24/19 at 4:31 PM, revealed staff was to complete the scheduled narcotic form after count was completed, which indicated the count was correct and the accepting nurse agreed the count was accurate at the time of shift change. Interview with the Director of Nursing (DON), on 01/24/19 at 3:53 PM, revealed nurses were to sign the narcotic control accountability form during shift change. She stated the on-coming and off-going nurses were to verify the schedule medications count was correct and sign the accountability form. The DON stated she did not audit the forms but expected all nurses to complete the count process. She stated the Unit Managers did not report any issues and she expected the Unit Managers to audit the forms weekly. Interview with the Administrator, on 01/24/19 at 6:53 PM, revealed the DON and the Unit Managers did not report issues with the narcotic control accountability form. He stated the DON was unable to review the forms because she was dealing with other issues in the facility. He stated all nursing staff should complete all required documentation.

Based on observation and interview, it was determined the facility failed to ensure refrigerated narcotics were stored in a permanent affixed compartment in the medication refrigerators in two (2) of four (4) medication rooms. In addition, the medication refrigerators were small and not secured and could be removed from the medication rooms. The findings include: The facility did not provide a policy for the security of refrigerated scheduled medications or medication refrigerators. Observation of the second floor south hall medication room, on 01/24/19 at 10:50 AM, revealed a small locked medication refrigerator not affixed to the wall or to a counter. The refrigerator contained Dronabinol (scheduled III medication) 2.5 milligrams (mg) tablets, not secured in a separate affixed box in the refrigerator. Further observation revealed Licensed Practical Nurse (LPN) #8 picked up the small refrigerator and moved off the cart toward the door. Observation of the second floor north hall medication room, on 01/24/19 at 11:34 AM, revealed a small locked medication refrigerator not affixed to the wall or to a counter. The refrigerator contained twenty-one (21) tablets of Dronabinol 5 mg, not secured in a separate affixed box in the refrigerator. Observation of the first floor north and south hall medication rooms, on 01/24/19 at 11:45 AM, revealed each room contained a small locked refrigerator on top of a stand. The medication refrigerators were not secured and could be removed from the room. There were no scheduled medications in either medication refrigerator. Interview with LPN #8, on 01/24/19 at 10:50 AM, revealed Dronabinol should be in a secured box inside the refrigerator in order to ensure the medication was double-locked. She stated all nurses with cart keys had access to all medication rooms; however, the padlocks on the refrigerators could only be opened by the two (2) nurses assigned to the hall. Further interview revealed the small refrigerator was not secured to the wall or a counter and she was able to move the refrigerator off the cart and move it away from the wall towards the door. She stated the refrigerator did not contain a locked box secured inside the refrigerator for scheduled medications. According to LPN #8, all four (4) medication rooms in the building did not have secured refrigerators to the wall as well as secured medication boxes inside them. Interview with Registered Nurse (RN) #6, on 01/24/19 at 11:16 AM, revealed the scheduled medication in the refrigerators were not in separate and secured affixed boxes in the refrigerators. She stated she never worried about the refrigerator being secured to the wall and was unaware the medication was to be stored in a separate affixed box inside the refrigerator. Interview with Unit Manager (UM) #3, on 01/24/19 at 11:48 AM, revealed she was not aware refrigerated scheduled medications were to be secured inside the refrigerator in a separate box. She stated the facility always put the medications inside the refrigerator, not in a box. Interview with the Staff Education Director, on 01/24/19 at 4:31 PM, revealed refrigerated scheduled medication were to be secured in the medication rooms in the locked refrigerators. She stated nurses assigned to a medication cart with keys were able to access all medication rooms. She stated she was not aware of any medication refrigerator that was bolted to a wall. Interview with the Director of Nursing (DON), on 01/24/19 at 3:53 PM, revealed she was unaware the medication room refrigerators did not contain a separate locked narcotic box or were small enough to be picked up and removed from the medication room. She stated the medication refrigerators were not reviewed for safety and the Unit Manager had not reported any issues to her. Interview with the Administrator, on 01/24/19 at 6:53 PM, revealed he was unaware scheduled medications in refrigerators were to be in a secured affixed compartment to prevent removal from the refrigerator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility failed to assess one (1) of twenty-four (24) sampled residents, Resident #1, for the use of a possible restraint. Resident #1 used a Broda chair (reclining chair with wheels) for positioning and locomotion. The findings include: Review of the facility's Use of Restraints Policy, last reviewed 11/22/16, revealed restraints may only be used for the safety and well-being of the resident (s), and only after consideration, evaluation, and the use of all other viable alternatives. All residents had the right to be free from restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation. The guidelines of the policy revealed physical restraints were defined as any manual method, or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that an individual could not remove easily and which restricted the resident's freedom of movement or normal access to his/her body. The device itself did not determine whether it was a restraint. If a resident could not remove a device in the same manner staff applied it, and restricted a resident's ability to change his/her physical position or place, the device might be considered a restraint. The policy further revealed a restraint should be used only if alternative, less restrictive methods did not sufficiently protect a resident or others from injury. Before using a restraint, and except in cases of an emergency, the facility would conduct a pre-restraint evaluation and review. The facility would assess the possible underlying causes of the resident's medical symptom at issue and determine if less restrictive interventions (programs, devices, referrals, etc.) were viable options. The policy further revealed the facility should regularly review residents using restraints (at least quarterly) to determine whether reduction of restraint use, less restrictive methods, or total restraint elimination could be achieved. Observation of Resident #1, on 11/19/17 at 11:30 AM, revealed the resident sitting in a Broda chair with an alarm attached. Observation at 1:30 PM, revealed Resident #1 sitting in the Broda chair by the nurses' station and was leaning forward in the chair. Observation of Resident #1, on 11/20/17 at 8:02 AM, revealed Resident #1 sitting in the Broda chair by the nurses' station and resting with a pillow behind his/her head. Observation at 10:00 AM, revealed Resident #1 sitting in the Broda chair at the nurses' station and the chair was reclined back and the resident had his/her eyes closed. Observation at 11:10 AM, revealed the resident in the Broda chair and taken into the room to eat lunch. Staff fed Resident #1 while he/she sat in the Broda chair. Observation at 12:10 PM and 03:30 PM, revealed Resident #1 in the Broda chair in the hall by the nurses' station. Review of Resident #1's clinical record revealed the facility readmitted the resident on 02/02/16, with diagnoses of History of Falls, Hypertension, Muscle Weakness, Dementia with Aggressive Behaviors, Altered Mental Status, and Pseudo Bulbar Affect. Review of Resident #1's quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) with no score and determined the resident not interviewable. The facility assessed the resident required two (2) person assist for walking in the room and required extensive assistance of one (1) person for locomotion on unit. The MDS revealed Resident #1 received physical and occupation therapy. There was not a MDS restraint assessment completed. Further review of the clinical record revealed the facility had not completed a restraint assessment or pre-screening restraint assessment. Interview with Resident #1's family, Family Member #3, on 11/19/17 at 1:00 PM, revealed Resident #1 had been able to ambulate independently previously, but had fallen and was put into a wheelchair. Family Member #3 stated Resident #1 was running into things with the wheelchair and was leaning forward so the facility put Resident #1 in a Broda chair. Family Member #3 stated Resident #1 could not maneuver the Broda chair. Interview with Licensed Practical Nurse (LPN) #1, on 11/21/17 at 11:15 AM, revealed Resident #1 used to be in a wheelchair but leaned forward and was running into things with the wheelchair. She stated the facility had to get a chair that Resident #1 would not be able to run into things and into other residents. She stated the Broda chair was not considered a restraint and Resident #1 was safer and more comfortable if he/she used it. Interview with Unit Manager #1, on 11/21/17 at 1:00 PM, revealed Resident #1 used a Broda chair for locomotion with staff assist. She stated Resident #1 could not propel himself/herself in the Broda chair. The Unit Manager stated she did not do any physical restraint assessments on Resident #1. She revealed the facility used to do the restraint assessments, but they did not do it any longer. Unit Manager #1 stated if something was a restraint, it would be in the therapy notes and they would alert nursing and nursing would call the physician to get an order. Interview with the Occupational Therapist (OT), on 11/21/17 at 2:50 PM, revealed therapy had worked with Resident #1 on several occasions due to poor posture and poor positioning. She stated Resident #1 was unsafe in a regular wheelchair due to poor positioning by leaning forward. The OT deemed the Broda chair as not being a restraint; however, they did not do restraint assessments. She stated the MDS Coordinator did the restraint assessments. There was no clinical documentation to determine the Broda chair was not deemed a restraint. Interview with MDS Coordinator #2, on 11/21/17 at 1:30 PM, revealed she had seen Resident #1 attempt to get up from the Broda chair, but not actually stand all the way. She stated Resident #1's posture was poor in the wheelchair and unsafe. She revealed therapy had seen Resident #1 and recommended a Broda chair instead of the wheelchair; however, she had not done a pre-restraint or restraint assessment on Resident #1. Interview with MDS Coordinator #1, on 11/21/17 at 2:00 PM, revealed the facility did not have any restraints in the building. She stated she had not done Resident #1's assessment in a while, but knew Resident #1 had been bending over in the wheelchair and looking at the floor. She stated the Broda chair was used for positioning and was not considered a restraint and she had not done a restraint assessment on Resident #1. She stated if the Broda chair were reclined back, Resident #1 would not be able to stand up independently. Interview with the Director of Nursing (DON), on 11/21/17 at 11:30 AM, revealed a restraint was something that kept a resident from getting up and moving their body freely. She stated if staff put a resident in something and the resident could not get up, and it kept them from moving or limiting their abilities, then it was a restraint. She stated if staff put a resident in a chair that they could not move freely from, that was a restraint. The DON further revealed restraints should not be used just because a resident might fall. Interview with the Administrator, on 11/21/17 at 3:42 PM, revealed he was unaware of any issues regarding restraints. He stated it was important to use the least restrictive intervention as it affected quality of care and quality of life.

**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-four (24) sampled residents, Resident #17, was free from chemical restraints. Record review revealed Resident #17 received multiple administrations of psychotropic/hypnotic medications without appropriate behavior monitoring. The findings include: Review of the facility's policy, Behavior Management, reviewed September 2016, revealed the Social Worker would initiate a target behavior analysis and develop a Behavior Management Care Plan when staff or the MDS (Minimum Data Set) process identified behaviors. The Care Plan would identify appropriate interventions to manage the identified behavior(s) and the discipline responsible for implementing interventions. In addition, a Behavior/Intervention Monthly Flow record would be implemented on the resident's Medication Administration Record (MAR). The Social Worker would begin an initial education of the Behavior Management Care Plan with all disciplines noted and it was the responsibility of each discipline noted to read the care plan located at each nurses' station. The policy stated it was the responsibility of the Clinical Nurse Manager to ensure the Licensed Nurses completed the Behavior/Intervention Monthly Flow record correctly in the MAR and the responsibility of the Social Worker to monitor the record in the MAR on a periodic basis. Nursing would document each episode of the resident's behavior, precipitating factors, interventions, and outcomes of the interventions with the noted side effects of psychoactive medications using the Behavior/Intervention Monthly Flow record in the MAR. Review of the facility's policy, Use of Restraints, reviewed 11/22/16, revealed restraints might only be used for the safety and well-being of the resident(s), and only after consideration, evaluation, and the use of all other viable alternatives. All residents had the right to be free from restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation. Chemical restraints were defined as any drug used for discipline or convenience and not required to treat a resident's medical symptoms. The policy stated restraints should be used only if alternative, less restrictive methods do not sufficiently protect a resident or others from injury. Restraint alternatives might include restorative programs, management of each resident's personal environment, recognition of each resident's past, current interests, preferences, and routines, and the use of supportive devices and special equipment. Review of Resident #17's clinical record revealed the facility admitted the resident on 09/08/17, with diagnoses to include Alzheimer's Disease, Repeated Falls, Muscle Weakness, and Difficulty in Walking. Review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident was not able to complete the Brief Interview for Mental Status and determined the resident not interviewable. Review of Physician Orders revealed Resident #17 had an order, dated 09/08/17, for Roxanol (Morphine Sulfate) solution 5 milligram (mg) sublingual every four (4) hours as needed (PRN) for pain and an order dated 09/14/17, for Ativan (Lorazepam) 1 mg tablet by mouth three (3) times a day as needed for anxiety/agitation. In addition, the resident had an order for a fall mat every shift for fall risk and a bed/chair alarm every shift for safety. Review of the Physician's Progress Note, dated 09/11/17, revealed nursing reported Resident #17 was agitated and trying to get out of bed. The note further revealed the resident's status required staff to stay by the bedside constantly. Review of the Interim admission Care Plan, dated 09/08/17, revealed Resident #17 was at risk for behavior problems including persistently attempting to get up without assistance. Review of Resident #17's Comprehensive Care Plan, dated 06/02/11, revealed the resident was at risk for behavior problems including continuously trying to get up. The interventions included monitoring behavior episodes and attempting to determine the underlying cause. Additional interventions included the medications Klonopin, Namenda, Geodon, and Depakote. Review of the Certified Nursing Assistant (CNA) Care Record for Resident #17, dated November 2017, revealed there were no behavior care interventions listed. Review of Resident #17's MAR, for September 2017, revealed Ativan 1 mg was administered on 09/12/17 at 6:34 AM and 2:35 PM. Roxanol 5 mg was administered on 09/12/17 at 7:57 AM and 4:02 PM. Review of the TAR (Treatment Administration Record), for September 2017, revealed there were no entries regarding the resident's behaviors, interventions, or the effectiveness of the interventions. Review of the CNA Behavior Report, dated 09/12/17 at 9:22 AM, revealed the resident exhibited wandering behaviors that were easily altered. Review of Resident #17's Behavior Note, dated 09/12/17 at 10:02 AM, revealed the resident was restless, continuously attempted to stand without assistance, and 1 mg of PRN Ativan was administered. The note further revealed the resident had refused his/her breakfast and staff was unable to leave the resident alone due to high risk for falls. The documentation revealed the resident exhibited facial grimacing but was unable to describe, rate, or report location of his/her pain. The noted stated PRN Roxanol was administered at 8:00 AM and the resident was currently in bed with his/her eyes closed. Further review of Resident #17's Progress Notes for 09/12/17, revealed there were no further Behavior Notes indicating the rationale for the PRN Ativan that was administered at 2:33 PM. In addition, there was no pain assessment or interventions noted for the PRN Roxanol administered at 4:02 PM. Review of Resident #17's MAR, for October 2017, revealed PRN Ativan was administered seven (7) times between 10/01/17 and 10/04/17. Review of Resident #17's Progress Notes revealed there were no behavior notes, rationales, or less restrictive interventions attempted prior to the seven (7) times Ativan was administered. Observation, on 11/20/17 at 5:10 PM, revealed Resident #17 seated at the 2 South nurses' station and a CNA was seated next to the resident, feeding him/her supper. Observation, on 11/21/17 at 10:24 AM, revealed Resident #17 lying in bed with his/her eyes closed. Observation, on 11/21/17 at 1:23 PM, revealed Resident #17 walking in the 2 South corridor with the assistance of a family member. Interview with Resident #17's Family Member, on 09/21/17 at 1:30 PM, revealed the resident often appeared sedated when he visited. He further stated the resident enjoyed reading books and walking prior to his/her admission to the facility. Interview with Certified Nursing Assistant (CNA) #2, on 11/21/17 at 11:00 AM, revealed CNAs were responsible for reporting resident behaviors to the nurse. The CNA stated hitting and screaming were considered behaviors that could be a result of an unmet need the resident was unable to express to the caregiver. The CNA revealed interventions for behaviors included walking, toileting, or offering a snack/drink to the resident. Interview with Licensed Practical Nurse (LPN) #1, on 11/21/17 at 10:30 AM, revealed nurses were responsible for the assessment and documentation of resident pain, including severity, location, and effectiveness. The nurse revealed assessment of pain included the use of a pain scale (0-10) as reported by the resident and observation for non-verbal signs, including facial grimacing or moaning. She revealed nurses were responsible for documenting pain management and interventions on the MAR and in the nurses' notes. The LPN revealed Resident #17 would sometimes complain of pain or exhibit non-verbal signs such as moaning, but was not able to utilize the pain scale related to his/her Dementia. LPN #1 stated she had not notified the resident's physician regarding potential alternatives to the PRN Roxanol. The LPN revealed Roxanol was a strong pain medication for such a little resident and she probably needed to ask the doctor for something different. Review of a Nutritional Note, dated 10/05/17, revealed Resident #17 weighed 89.8 pounds. Further interview with LPN #1, on 11/21/17 at 10:30 AM, revealed nurses were responsible for assessing, monitoring, and documenting resident behaviors in the nurses' notes. She revealed hitting, kicking, or spitting was considered behaviors. The LPN revealed Resident #17's attempts to stand without assistance could be an indication of an unmet need such as toileting. She stated primary interventions included playing music or walking with the resident. The nurse stated Resident #17's PRN Roxanol was not indicated for behaviors and would be considered a chemical restraint. Interview with Unit Manager (UM) #1, on 11/21/17 at 2:00 PM, revealed Resident #17 frequently stood from his/her chair without assistance. The UM stated appropriate interventions would include toileting and assessing the resident for pain. The UM revealed CNA's were responsible for documenting the behaviors and notifying the resident's nurse. In addition, the resident's nurse was responsible for documenting the behavior, as well as, the effectiveness of interventions. The UM stated she reviewed resident medication orders monthly to ensure accuracy and had not identified any concerns with Resident #17's medications. The UM stated she had not notified Resident #17's physician regarding less sedating alternatives to PRN Roxanol. She revealed Roxanol was indicated for pain and would be considered a chemical restraint if administered for something other than what it was prescribed for. Interview with the Social Services Assistant (SSA) and the Social Services Director (SSD), on 11/21/17 at 3:25 PM, revealed Resident #17 did not have aggressive behaviors, but liked to stand up from his/her chair without assistance. The SSD stated nurses were responsible for notifying her of resident behaviors either verbally or by electronic notification triggered in the nurses' note. The SSD stated Resident #17 did not have a Behavior Management Care Log and the current monitoring process did not appear to be effective because nurses did not always trigger the resident's Behavior Care Plan. In addition, the SSD stated there had been high SSD turnover, which had affected the facility's ability to manage the Behavior Care Log. The SSD revealed medication was not an appropriate intervention for a resident that was repeatedly standing up and down from a chair unassisted. She further revealed it was important to document and monitor resident behaviors in order to determine if interventions were effective. Interview with the Director of Nursing (DON), on 11/21/17 at 4:20 PM, revealed the CNAs were responsible for documenting resident behaviors in the electronic kiosk (computer) and reporting the behaviors to the nurse. She stated the nurse was responsible for documenting all resident behaviors in the clinical record and notifying the physician as needed. The DON stated the SSD was responsible for reviewing the nursing documentation, monitoring the resident for three (3) days following the event, and updating the Behavior Management Care Log located at each nurses' station. The DON revealed the interdisciplinary team (IDT) reviewed resident behaviors during daily meetings to determine the root cause. She stated she was not aware there were no Behavior Care Logs at the nurses' stations and revealed there seemed to be a lack of communication among the IDT. The DON revealed Resident #17's attempts to rise from the chair without assistance would not be considered a behavior and Ativan would not be considered an appropriate intervention. The Director revealed alternate interventions, such as providing magazines, activities, or walking with the resident, should be implemented prior to the use of medications. The Director stated the UM was responsible for monitoring MARs and should have notified the physician regarding a possible decrease or change of the PRN Roxanol. The DON revealed the administration of Ativan to Resident #17 would be considered a chemical restraint based upon the lack of documented behaviors. Interview with the Administrator, on 11/21/17 at 3:42 PM, revealed he was unaware of any issues regarding chemical restraints. He stated in was important to use the least restrictive intervention as it affected quality of care, quality of life, and could make behaviors worse.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to follow physician orders regarding medication administration for one (1) of the twenty-five (25) sampled and unsampled residents, Unsampled Resident A. The findings include: Review of the facility's Non-Controlled Medication Order Policy, dated December 2012, revealed medications were to be administered upon the receipt of a clear, complete, and signed order by a person lawfully authorized to prescribe. Review of the facility's General Guidelines Policy, dated May 2016, revealed if a dose of regularly scheduled medication was withheld, refused, or given at a time other than the scheduled time, the space provided on the front of the Medication Administration Record (MAR) for that dosage administration was to be initialed and circled and an explanatory note was to be entered on the reverse side of the record. It further revealed if two (2) consecutive doses of a vital medication was withheld or refused, the physician was to be notified. Review of Unsampled Resident A's Physician Order, dated 10/30/17, revealed an order for Eliquis 5 milligram (mg), give twice a day at 8:00 AM and 8:00 PM for Atrial Fibrillation Observation during medication administration, on 11/20/17 at 8:15 AM, revealed Unsampled Resident A had Eliquis 5 mg ordered; however, Licensed Practical Nurse (LPN) #4 did not administer the medication. Interview with the LPN #4, on 11/20/17 at 8:16 AM, revealed Eliquis was not available and according to the MAR, it had not been administered to the resident 11/17/17 through 11/19/17. Review of Unsampled Resident A's MAR, for November 2017, revealed staff documented 99 for Eliquis administration on 11/17/17 at 8:00 PM, 11/18/17 at 8:00 AM and 8:00 PM, and on 11/19/17 at 8:00 AM and 8:00 PM. Further review of the MAR revealed 99 meant the medication was held because it was not available. Review of Unsampled Resident A's clinical record revealed the facility admitted Unsampled Resident A on 10/30/17, with diagnoses of Chronic Atrial Fibrillation, Cerebral Infarction, and Heart Failure. Review of Resident #17's Progress Notes, dated 11/17/17 through 11/19/17, revealed no documentation staff notified the physician or family that the Eliquis was not available for Unsampled Resident A. Continued interview with LPN #4, on 11/20/17 at 8:16 AM, revealed the Eliquis was not available because the insurance would not pay for it without prior authorization, which had not been obtained. She stated the physician had been notified of the need for a prior authorization. LPN #4 stated Unsampled Resident A was on Eliquis because of a stroke and Eliquis was a blood thinner to help prevent another stroke. Further observation during the medication pass on 11/20/17, revealed LPN #4 checked the Emergency Box and Eliquis was not available. Interview, on 11/21/17 at 9:40 AM, with Unit Manager #3, revealed if a medication was not available, the nurse was to check the overflow drawer, the Emergency Box, and if still not available, should call the pharmacy and have the medication sent over stat (immediately). She further revealed if a dose was missed, the physician, family, and the Director of Nursing (DON) should be notified. She stated if a prior authorization was needed and not yet obtained, the facility would pay for the medication until the authorization was obtained or the medication changed. The UM stated if the Eliquis was not available on 11/17/17, the pharmacy should have been notified, and a stat dose brought over after the DON was called to get approval for payment. Interview with the DON, on 11/21/17 at 11:00 AM, revealed if a medication was unavailable, the nurse was supposed to check the other nurses' station to see if it had been delivered to the wrong area. The nurses should then check the Emergency Box to see if the needed medication was in there. If the medication was unavailable, like the Eliquis, then staff should call her to get approval for the facility to pay for the medication until it was approved or the physician changed the medication to something else that was covered. The DON stated staff did not call her to approve the Eliquis for 11/17/17 through 11/19/17. The DON revealed Eliquis was a blood thinner and Unsampled Resident A was at risk of a blood clot due to Atrial Fibrillation. She stated it was important for Unsampled Resident A to get the Eliquis routinely as ordered by the physician. The DON further revealed staff should notify the physician and family when medication was not being administered. The DON revealed the Unit Manager for each unit monitored omission reports and brought them to the clinical meetings daily. Interview with the Administrator, on 11/21/17 at 3:42 AM, revealed he was unaware of issues related to medications not available for administration. He stated it was important for residents to receive their medications to maintain their health.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #17's clinical record revealed the facility admitted the resident on 09/08/17, with diagnoses to include Alzheimer's, Type 2 Diabetes Mellitus, and Hypertension. Review of the MDS, dated [DATE], revealed the facility assessed the resident was not able to complete the BIMS and determined the resident not interviewable. Review of Resident #17's Nutrition Risk Review, dated 09/14/17, revealed the resident was below ideal weight range (IWR), had a low body mass index (BMI), and was on a mechanically altered diet, which placed him/her at nutritional risk. Recommendations included high calorie, high protein foods (fortified), and Special Nutrition Program (SNP) with all meals. Review of Resident #17's weight report, dated 11/06/17, revealed he/she weighed 87.0 pounds. Review of Resident #17's Physician Orders, valid 10/30/17 through 11/30/17, revealed an order for a pureed diet, thin liquids, and SNP with meals. Observation of Resident #17, on 11/20/17 at 11:10 AM, revealed the resident sitting in his/her room with staff assisting with the meal. The tray card revealed regular SNP diet three (3) times a day with 8 ounces (oz) of milk and fortified mashed potatoes. Further observation revealed there was no milk on the resident's meal tray. Observation, on 11/20/17 at 5:10 PM, of Resident #17 revealed Certified Nursing Assistant (CNA) #3 was feeding the resident at the 2 South nurses' station. There was no milk on the meal tray. Interview with CNA #3, on 11/20/17 at 5:10 PM, revealed she was responsible for ensuring the food on the resident's tray was correct and matched the order on the tray card. The CNA stated had not noticed the milk was missing from the tray. Interview with CNA #2, on 11/21/17 at 11:00 AM, revealed staff was responsible for verifying the food on the meal tray matched the tray card. The CNA stated it was important residents were served the prescribed diet in order to support weight and maintain skin integrity. Interview with Licensed Practical Nurse (LPN) #1, on 11/21/17 at 10:30 AM, revealed the SNP diet was a therapeutic diet. The LPN further revealed it was important Resident #17 received the prescribed SNP diet because he/she needed the extra calories and vitamins. The nurse stated she conducted random audits of meal trays but had not identified any concerns. Interview with UM #1, on 11/21/17 at 8:03 AM, revealed the SNP diet was fortified with extra calories. The UM stated dietary recommended the SNP diet for residents with or at risk of weight loss. Further interview at 2:00 PM, revealed when staff passed trays, they were responsible for checking the tray card and the food on the tray, to ensure the correct resident was served the correct diet and food consistency. The UM stated it was important to ensure Resident #17 received the fortified SNP diet to support his/her body weight. Interview with Registered Nurse (RN) #1, on 11/21/17 at 9:55 AM, revealed staff was generally very busy during meal pass times. She stated, during the week, administration staff assisted with passing the meal trays; however, on weekends administration staff was not available and there was less staff to assist with the task of passing trays. She stated incorrect plating of food for multiple residents increased the likelihood that the wrong diet could be served. She further revealed that providing the incorrect diet to a resident could cause the resident to fail to receive their nutritional needs, weight loss, or the resident could develop problems. Interview with the Dietary Manager, on 11/21/17 at 10:35 AM, revealed the facility utilized menu cards to inform staff of the ordered diet, consistency, and resident preferences. She also revealed dietary staff was to check the tray for accuracy prior to placing the tray on the rack delivered to the dining rooms and care areas; however, that was only done with staff permitting. She stated on occasions when the dietary department did not have sufficient staff, she would place drinks on the trays as well as complete the final check. She further stated a resident who received the wrong consistency of diet was at risk of choking. Interview with the Registered Dietitian, on 11/21/17 at 11:15 AM, revealed she reviewed and assessed resident nutritional needs at weekly visits to the facility and further expected all ordered diets to be provided to the residents. She stated a resident who received an improper consistency diet was at risk for aspiration, and a resident who received the wrong diet could cause an increase in blood sugar, or an insufficient protein or calorie intake, thereby causing weight loss or potential for complications. Interview with the DON, on 11/21/17 at 4:20 PM, revealed staff was responsible for ensuring meal trays were correct prior to serving the resident. The DON further revealed serving residents the wrong diet could affect blood sugars, pose a choking hazard, or result in weight loss. The DON stated the UMs were responsible for monitoring the meal tray pass. The Director stated she had not identified any concerns with therapeutic diets. Interview with the Administrator, on 11/21/17 at 3:42 PM, revealed it was important for the facility to ensure residents received therapeutic diets because of swallowing issues and needed nutrition. He stated he was unaware residents were not receiving therapeutic diets. Based on observation, interview, record review, and facility policy review, it was determined the facility failed to provide a therapeutic diet as ordered by the physician for two (2) of twenty-four (24) sampled residents, Residents #15 and #17. The findings include: Review of the facility's Therapeutic Diets Policy, revised 07/20/17, revealed therapeutic diets were prepared and served as prescribed by the attending physician or delegated to a registered or licensed dietitian when allowed by state law when those diets were desired by the residents. Therapeutic diets were reflected on the menu extension and individual tray card. The Nursing Department was responsible for having diet orders submitted to the Dietary Department in writing. The policy revealed the orders must correspond to the physician's diet orders in the resident's medical record. 1. Observation of Resident #15, on 11/20/17 at 12:05 PM, in the dining room, revealed his/her lunch tray contained pureed pinto beans, pureed tomatoes, mashed potatoes, and regular consistency pinto beans. The diet card had regular puree level one as the diet order. Interview with the Assistant Director of Nursing (ADON), on 11/20/17 at 12:10 AM, revealed Resident #15 was on a pureed diet and the regular consistency pinto beans should not have been served. The ADON stated having the wrong consistency of food was a choking risk for Resident #15. The ADON revealed she did not know why Resident #15 received both pureed pinto beans and regular consistency pinto beans. Observation of Resident #15, on 11/20/17 at 5:30 PM, revealed the resident's supper tray had pureed peaches, pureed meatloaf, pureed potatoes, and ice cream on the tray. Review of the diet card revealed a puree diet level one. Review of the clinical record for Resident #15 revealed the facility readmitted the resident on 11/17/16, with diagnoses of Alzheimer's, Dysphagia, and Diverticulitis. Review of Resident #15's Physician Orders, signed on 11/06/17, revealed a diet order for mechanical soft with chopped meats and gravy, not pureed. Review of the Dietary Interview/Prescreen Summary, dated 11/21/17, revealed the diet texture listed was regular puree level one. Further review of the clinical record revealed no dietary or nursing staff documentation that the diet was changed to pureed. Interview with the ADON, on 11/21/17 at 8:20 AM, revealed the current physician diet order for Resident #15 included mechanical soft and chopped meats. She stated Resident #15 received a pureed diet. Interview with Unit Manager (UM) #2, on 11/21/17 at 8:30 AM, revealed Resident #15 should have received a mechanical soft diet according the physician order. She further revealed when the physician made a diet order change, the nurse made a dietary communication note and sent it to the dietary department and a copy remained in the record. However, review of the record reviewed she could not find where the diet had been changed to pureed. Interview with the Assistant Dietary Manager, on 11/21/17 at 8:40 AM, revealed the dietary department received dietary order changes in different ways. She stated sometimes staff would just knock on the door and tell them, put the order on the dietary cart, or put the change in the dietary box. A dietary change slip for Resident #15 could not be found and she did not know why the resident was on a pureed diet and not the mechanical soft with chopped meat, as ordered by the physician. Interview with the Dietary Manager, on 11/21/17 at 9:00 AM, revealed she did not know how long Resident #15 had been receiving a pureed diet because they could not find the diet change paper. Interview with the Director of Nursing (DON), on 11/21/17 at 1:30 PM, revealed if the physician ordered a mechanical soft diet, Resident #15 should have received the mechanical soft diet and not a pureed diet. She revealed a diet change slip or physician order could not be found changing the diet to pureed.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to provide pharmaceutical services that ensured medications were available to meet the needs of one (1) of twenty-five (25) sampled and unsampled residents, Unsampled Resident A. Unsampled Resident A did not have medication available for administration. The findings include: Review of the facility's Non-Controlled Medication Order Policy, dated December 2012, revealed medications were to be administered upon the receipt of a clear, complete and signed order by a person lawfully authorized to prescribe. Review of the facility's General Guidelines Policy, dated May 2016, revealed if a dose of regularly scheduled medication was withheld, refused, or given at other than the scheduled time, the space provided on the front of the Medication Administration Record (MAR) for that dosage administration was to be initialed and circled. An explanatory note was to be entered on the reverse side of the record. If two (2) consecutive doses of a vital medication was withheld or refused the physician was to be notified. Review of the facility's Medication Ordering and Receiving from Pharmacy Provider Policy, dated September 2010, revealed medications and related products were to be received from the provider pharmacy on a timely basis. Review of Unsampled Resident A's clinical record revealed the facility admitted Unsampled Resident A on 10/30/17, with diagnoses of Chronic Atrial Fibrillation, Cerebral Infarction, and Heart Failure. Review of Unsampled Resident A's Physician Order, dated 10/30/17, revealed an order for Eliquis 5 milligram (mg), give twice a day at 8:00 AM and 8:00 PM for Atrial Fibrillation Observation during medication administration, on 11/20/17 at 8:15 AM, revealed Unsampled Resident A had Eliquis 5 mg ordered; however, Licensed Practical Nurse (LPN) #4 did not administer the medication. Interview with the LPN #4, on 11/20/17 at 08:16 AM, revealed Eliquis was not available and according to the MAR, it had not been administered to the resident 11/17/17 through 11/19/17. Further observation during the medication administration on 11/20/17, revealed LPN #4 checked the Emergency Box and Eliquis was not available. Review of Unsampled Resident A's MAR, for November 2017, revealed staff documented 99 for Eliquis administration on 11/17/17 at 8:00 PM, 11/18/17 at 8:00 AM and 8:00 PM, and on 11/19/17 at 8:00 AM and 8:00 PM. Further review of the MAR revealed 99 meant the medication was held because it was not available. Continued interview with LPN #4, on 11/20/17 at 8:16 AM, revealed the Eliquis was not available because the insurance would not pay for it without prior authorization, which had not been obtained. She stated the physician had been notified of the need for a prior authorization. LPN #4 stated Unsampled Resident A was on Eliquis because of a stroke and Eliquis was a blood thinner to help prevent another stroke. Interview, on 11/21/17 at 9:40 AM, with Unit Manager #3, revealed if a medication was not available, the nurse was to check the overflow drawer, the Emergency Box, and if still not available, should call the pharmacy and have the medication sent over stat (immediately). She stated if a prior authorization was needed and not yet obtained, the facility would pay for the medication until the authorization was obtained or the medication changed. The UM stated if the Eliquis was not available on 11/17/17, the pharmacy should have been notified, and a stat dose brought over after the DON was called to get approval for payment. Interview with the DON, on 11/21/17 at 11:00 AM, revealed if a medication was unavailable, the nurse was supposed to check the other nurses' station to see if it had been delivered to the wrong area. The nurse should then check the Emergency Box to see if the needed medication was in there. If the medication was unavailable, like the Eliquis, then staff should call her to get approval for the facility to pay for the medication until it was approved or the physician changed the medication to something else that was covered. The DON stated staff did not call her to approve the Eliquis for 11/17/17 through 11/19/17. In addition, the pharmacy was responsible for getting prior authorization; however sometimes they requested the facility to get the prior authorization. The DON revealed Eliquis was a blood thinner and helped prevent Unsampled Resident A from developing a blood clot due to Atrial Fibrillation. She stated it was important for Unsampled Resident A to get the Eliquis routinely as ordered by the physician. Interview with the Pharmacy Support Staff, via telephone, on 11/21/17 at 2:10 PM, revealed if a medication needed prior authorization and it had not yet been obtained, then they would send a limited supply and bill the facility, usually a three (3) or four (4) day supply. The pharmacy would request the physician to change the medication to something that was on the formulary and if the physician refused, then an authorization had to be obtained. The Pharmacy Support Staff stated they sent the facility a seven (7) day supply of Eliquis on 10/30/17, and billed the facility. Another three (3) day supply of Eliquis was sent on 11/07/17 and 11/13/17. She revealed the facility requested a fourteen (14) day supply on 11/20/17. She stated the pharmacy did not do the prior authorization for the type of insurance Unsampled Resident A had. She stated if the physician did not respond to a prior authorization, then the authorization could be initiated by the facility. Interview with the Administrator, on 11/21/17 at 3:42 PM, revealed the pharmacy was responsible for obtaining authorization for medication and not the facility.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to maintain effective infection control practices for one (1) of the twenty-four (24) sampled residents, Resident #7. Staff failed to perform hand hygiene and change gloves during Resident #7's perineal care. The findings include: Review of the facility's policy, Hand Washing and Use of Gloves, effective December 2010, revealed hand washing would be performed before and after resident care rendered and after handling contaminated articles. When providing care to different residents, hand washing would be done between residents. If gloves were worn, the gloves should be removed and the hands washed. Hand washing would be done before caring for a resident who was susceptible to infection or immunocompromised, before and after touching wounds, after contact with surfaces or items that were contaminated with blood, body fluids, secretions, mucous membranes, and non-intact skin, before performing invasive procedures such as categorization or inserting a feeding tube, and after using the toilet. Review of the facility's policy, Perineal Care, revealed the proper procedure involved thorough cleansing of the patient's external genitalia and surrounding skin. In addition, gloves were to be worn during perineal care because of the risk of contracting infectious organisms present in fecal, urinary, or vaginal secretions. Review of the facility's clinical record for Resident #7 revealed the facility readmitted the resident on 01/16/15 with diagnoses that included Obesity, Epilepsy, and Urinary Retention. Review of Resident #7's quarterly Minimum Data Set revealed the facility assessed the resident required two (2) person assistance with personal hygiene and bathing. Review of Resident #7's Care Plan, dated 06/30/15, revealed staff would assist Resident #7 with hygiene and bathing. Observation of Resident #7, on 11/19/17 at 3:45 PM, revealed Certified Nursing Assistant (CNA) #7 performed the resident's peri-care. CNA #7 donned gloves and began to clean the folds of the resident's abdomen using wipes. CNA #7 then repositioned the resident using both of her gloved hands. Resident #7 had a bowel movement and CNA #7 cleaned the feces off the resident and placed the soiled brief on the bed. Without removing gloves and performing hand hygiene, CNA #7 applied powder on the buttocks and placed a new brief on the resident. CNA #7 placed the old brief in the garbage can, removed her gloves, and without performing hand hygiene, donned new gloves. Interview with CNA #7, on 11/19/17 at 3:45 PM, revealed she should have changed gloves immediately after cleaning the feces off Resident #7 to prevent the spread of infection. However, she stated she forgot to change gloves and wash her hands. Interview with the Director of Nursing (DON), on 11/21/17 at 11:00 AM, revealed staff should remove gloves and wash hands after cleaning feces off a resident. She stated staff should roll up dirty briefs and place them at the foot of the bed or in a trash bag, which was then tied up and placed outside the resident's room. According to the DON, staff should place a clean brief on the resident after washing their hands and donning new gloves. Interview with the Administrator, on 11/21/17 at 3:42 PM, revealed the facility recently educated staff on hand washing. He stated hand washing was important to prevent the spread of infection.