Based on interview, record review, and facility policy review, it was determined the facility failed to ensure Minimum Data Set (MDS) assessments were transmitted within fourteen (14) days after completion for two (2) unsampled residents (Resident #1 and Resident #191). Review of Resident #1's MDS assessments revealed the facility had completed an annual MDS assessment with a completion date of 07/08/19 for Resident #1. Review of a validation report revealed the assessment was not transmitted until 07/30/19, which was eight (8) days late. Review of Resident #191's MDS assessments revealed a re-entry MDS assessment with a completion date of 07/12/19. Review of a validation report revealed the assessment was not transmitted until 07/30/19, which was four (4) days late. The findings include: Review of the facility's policy, Electronic Transmission of the MDS, dated August 2017, revealed all MDS assessments would be completed and electronically transmitted in accordance with the current OBRA regulations governing the transmission of MDS data. Review of the RAI 3.0 User's Manual, Version 1.16, dated October 2018, Chapter 5 Submission and Correction of MDS Assessments, revealed comprehensive assessments must be transmitted electronically within fourteen (14) days of the Care Plan Completion Date (V0200C2 + 14 days). All other MDS assessments must be submitted within fourteen (14) days of the MDS Completion Date (Z0500B + 14 days). Entry and Death in Facility tracking records information must be transmitted within fourteen (14) days of the Event Date (A1600 + 14 days for Entry records and A2000 + 14 days for Death in Facility records). Review of the CMS Submission Report, MDS 3.0 NH Final Validation Report, dated 07/30/19, revealed the facility received a warning error message -3810c, record submitted late, submission date was more than 14 days after V0200C2 on this new (A0050 equals 1) comprehensive assessment (A0310A equals 01, 03, 04, or 05) for Resident #1. The facility received a warning error message -3810a, record submitted late, submission date was more than 14 days after A1600 on this new (A0050 equals 1) entry tracking record for Resident #191. 1. Review of Resident #1's medical record revealed the facility admitted the resident on 05/20/15, with diagnoses including Dementia. Review of Resident #1's annual MDS completed by the facility on 07/08/19 revealed the assessment had not been transmitted until 07/30/19 (eight days late). 2. Review of Resident #191's medical record revealed the facility admitted the resident on 12/06/16, with diagnoses that included Diabetes Mellitus and Dementia. Review of a re-entry MDS assessment completed by the facility on 07/12/19 revealed the assessment had not been transmitted until 07/30/19 (four days late). Interview conducted with the MDS Coordinator on 08/01/19 at 4:21 PM, revealed the MDS had not been transmitted. The MDS Coordinator stated the assessment was required to be transmitted within fourteen (14) days, but it had been missed. Interview with the Director of Nursing (DON) on 08/01/19 at 4:51 PM, revealed the MDS Coordinator was responsible for ensuring MDS assessments were transmitted timely. The DON stated Resident #1's and Resident #191's assessments had been missed. The DON stated she randomly reviewed MDS assessments to ensure accuracy and timely transmission and had not identified any previous concerns with MDS assessments not being transmitted timely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review it was determined that the facility failed to ensure an ongoing program of activities was developed to meet the needs of one (1) of twenty-two (22) sampled residents (Resident #59). Observations on 07/30/19, 07/31/19, and 08/01/19 revealed Resident #59 was either in his/her room or in the hallway and not involved in any activities. Review of the medical record revealed no care plan for the resident to receive any type of activities and interview with the Activities Director revealed there was no written plan for activities for Resident #59. The findings include: Review of the facility policy titled Protocol for Activity Program, revised March 2019, revealed the purpose of the policy was to ensure that there will be an ongoing program of activities to meet the interests and the physicial, mental, and psychosocial well-being of each resident. Review of the record for Resident #59 revealed the resident was admitted on [DATE] with diagnoses that include Seizure Disorder, Depression, Schizophrenia, and Alzheimer's Disease. Review of the most recent annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) score was 99, indicating the resident was not able to complete the interview. Further review of the assessment revealed the resident was rarely/never understood and therefore could not be interviewed related to daily and activity preferences. Reveiw of the staff assessment of daily and activity preferences revealed that none of the above was marked for the resident's preferences. Review of the Care Area Assessment (CAA) summary dated 03/14/19 revealed that the resident likes to stay to him/herself and does not like crowds. The summary stated that the resident is encouraged to participate in facility activities and staff talks with the resident and he/she will allow. Review of the comprehensive care plan dated 03/15/19 revealed no evidence of a care plan for activities for Resident #59. Review of the [NAME] for Resident #59 revealed the resident enjoys country music, Bingo, sitting on the front porch, outings, and watching TV. Observation of Resident #59 on 07/30/19 at 4:00 PM revealed the resident ambulated independently in the hallway from his/her room. Staff approached the resident, took the resident by the hand, and walked with the resident back to his/her room. On 07/31/19 at 10:01 AM, Resident #59 ambulated from his/her room to the nurses' station and then back to the resident's room. The resident sat down on the bed. The resident was unable to answer when asked what is your name? At 10:46 AM on 07/31/19, the resident was noted to be sitting on the side of the bed, looking out the window. There was no television or radio in the resident's room. On 08/01/19 at 11:36 AM the resident was observed sitting on the bed, looking out the window. There was no television or radio noted in the room. Review of the July Activity Participation Record for July 2019 for Resident #59 revealed the only activity documented for Resident #59 for the month of July was talking or conversing. The documentation did not include how long the activity lasted. The record did have a place to document the resident response to the acitivity, and an e was noted by each entry. Interview with State Registered Nursing Assistant (SRNA) #4 on 08/01/19 at 11:42 AM revealed that she was assigned to care for Resident #59 on 08/01/19. The SRNA stated that the resident had crayons in his/her drawer and he/she would color sometimes for an activity. She further stated if talking or conversing was marked as an activity, then they would have had a conversation with the resident. SRNA #4 further stated that the e documented on the participation record indicated that the resident enjoyed the activity, but was unable to explain how they determined if the resident enjoyed the activity. Review of the Activity Log for 1:1 Activities for July 2019 revealed that 1:1 activities had been provided for Resident #59 thirteen (13) times during the month of July, on 07/01/19, 07/03/19, 07/05/19, 07/08/19, 07/10/19, 07/12/19, 07/15/19, 07/17/19, 07/22/19, 07/24/19, 07/29/19, 07/29/19, and 07/31/19. The activities provided were documented as lotion therapy, walked around the nurses station, music therapy, relaxing music, magazine, looked at pictures, tactile, walked and looked out window, water beads/warm, colored/conversed about weather, and folded towels. The activity log did not include how long the activity took place, but did include the resident's response to the activity which ranged from resident relaxed to resident was hard to focus. Interview with the Activities Director on 08/01/19 at 1:24 PM revealed that she does 1:1 activities with Resident #59 a few times per week because the resident does not do well with crowds or group activities. She stated that she tries different things with the resident to ensure the resident is relaxed and enjoying the activity. She stated that the resident used to have a television in his/her room, but a few months ago (she could not remember the exact date) the resident seemed to become agitated with the television and it was removed from his/her room. The Activities Director further stated that the facility's Interdisciplinary Team (IDT) meets quarterly and she tells the team the activities that she is providing for the resident and the resident's response. She stated the resident did not have a written plan of activities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review it was determined that the facility failed to ensure that the environment remained as free as possible from accident hazards related to a diagnosis of seizure disorder for two (2) of twenty-two (22) sampled residents (Resident #13 and Resident #52). There was no evidence the facility had developed a care plan with specific interventions to ensure resident safety related to the residents' seizure disorder. Observations during the survey revealed the residents' beds were left at above waist height position. The findings include: Interview with the Director of Nursing (DON) on 08/01/19 at 5:08 PM revealed the facility had a policy titled Giving Female Perineal Care and a policy titled Turning and positioning the person (no development or revised date on either). The DON stated both policies stated that after care was rendered to Lower the bed to its lowest position. 1. Review of Resident #13's medical record revealed the facility admitted the resident on 07/17/15 with diagnoses including Seizures, Tracheostomy, Cerebrovascular Accident, and History of Neurocytoma Resection with shunt placement with neurological deficit. Review of Resident #13's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired, with no speech, rarely/never understood, and rarely/never understands. Section G of the MDS revealed the resident was totally dependent on staff for all Activities of Daily Living (ADLs) and required two (2) staff persons to assist with bed mobility. Section I (Active Diagnoses) of the MDS revealed the resident was marked for Seizure Disorder or Epilepsy. Further review of the resident's record [NAME] (care plan used by nursing assistants to care for residents) revealed the resident had been assessed to require total assistance with all ADLs and the [NAME] was flagged with stickers indicating the resident was HIGH FALL RISK and SEIZURE DISORDER. Review of Resident #13's Fall Risk Evaluation, (a tool to score how much the resident is at risk of falling) dated 04/22/19, revealed the resident scored 12. The instructions for the Fall Risk Evaluation revealed a total score of 10 or greater indicated that the resident should be considered at HIGH RISK for potential falls and a prevention protocol should be initiated immediately and documented on the care plan. Review of Resident #13's care plan dated 05/13/19 revealed he/she was care planned for potential for falls related to diagnoses with interventions to administer medications as ordered, concave mattress, ensure call light is within reach, notify MD with any changes, observe for decreased endurance, PT and OT as ordered, staff will provide ADL care, use mechanical lift as needed, and vital signs per protocol. There were no interventions on the care plan related to bed position. Further review of the resident's care plan revealed he/she was care planned for seizure disorder with interventions to administer medications as ordered, note the length of the seizure, notify the MD with any changes, observe for signs and symptoms of impending seizures, obtain labs, obtain vital signs, and prevent injury during seizure activity. There were no interventions regarding safety precautions to prevent injury in case of a seizure. Observation of Resident #13 on 07/30/19 at 11:37 AM revealed the resident in bed with eyes closed. Further observation revealed the bed was in a high position and there were no side rails on the bed. Observation of Resident #13 on 07/31/19 at 12:51 during tracheostomy care revealed the resident's bed was in a high position. After staff completed the tracheostomy care, the bed was left in the same position. Observation of Resident #13 on 07/31/19 at 3:16 PM revealed the bed was in a high position. Observation of Resident #13 on 08/01/19 at 10:37 AM revealed the bed was in a high position. 2. Review of Resident #52's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including Hemiplegia following Cerebrovascular Accident, Dysphagia, and Seizure Disorder. Review of Resident #52's MDS assessment dated [DATE] revealed the resident was severely cognitively impaired, with no speech, rarely/never understood, and rarely/never understands. Section G of the MDS revealed the resident was totally dependent on staff for all Activities of Daily Living and required assistance of two persons with bed mobility. Section I (Active Diagnoses) of the MDS revealed the resident was marked for Seizure Disorder or Epilepsy. Further review of the resident's record [NAME] revealed the resident had been assessed to require total assistance with all ADLs and the [NAME] was flagged with stickers indicating the resident was HIGH FALL RISK and SEIZURE DISORDER. Review of Resident #52's Fall Risk Evaluation, dated 06/03/19, revealed the resident scored 12. The instructions for the Fall Risk Evaluation revealed a total score of 10 or greater indicated that the resident should be considered at HIGH RISK for potential falls and a prevention protocol should be initiated immediately and documented on the care plan. Review of Resident #52's care plan, review date of 06/14/19, revealed they he/she was care planned for potential for falls related to diagnoses with interventions to administer medications as ordered, ensure call light is within reach, notify MD with any changes, provide a clutter-free environment with adequate lighting, PT and OT as ordered, staff to perform ADL care, use mechanical lift as needed, and vital signs per protocol. Further review of the resident's care plan revealed interventions related to the resident's seizure disorder that included administer medications as ordered, hold tube feeding for one hour before and after administration of Dilantin (a medication to treat seizures), note the length of the seizure, notify the MD with any changes, observe for signs and symptoms of impending seizures, obtain labs, obtain vital signs, and prevent injury during seizure activity. The care plan did not include specific safety interventions to ensure the resident's safety or prevent injuries during the seizures. Observation of Resident #52 on 07/30/19 at 11:37 AM revealed the resident was in bed with eyes closed. The bed was noted in a high position with no side rails. Observation of Resident #52 on 07/31/19 at 1:31 PM revealed the resident was in bed with his/her eyes closed and the bed was in a high position. Observation of Resident #52 on 08/01/19 at 10:15 AM revealed the resident was in bed with his/her eyes closed and the bed was in a high position. Interview on 08/01/19 at 10:30 AM with Stated Registered Nursing Assistants (SRNAs) #5 and #6 revealed that Residents #13 and #52 require the total assistance of two (2) staff members. Both SRNAs agreed that they were not aware of either resident having a fall and both agreed that the usual position for both residents' beds was at a higher position. Interview on 08/01/19 at 2:56 PM with the Clinical Coordinator revealed she updated the care plan and [NAME] as needed. She stated that any resident with seizures would be considered at higher risk for falls. The Coordinator agreed that any resident at risk for falls should have the bed lowered after care. The Coordinator stated she does rounds daily and had not noticed a problem with beds being in a high position. Interview on 08/01/19 at 3:26 PM with the MDS Care Coordinator revealed the resident should be care planned for safety concerns if they have a diagnosis of seizures. Interview on 08/01/19 at 5:08 PM with the DON revealed the residents should not have been in beds raised at that height and stated, I can see that would be a problem. The DON agreed there should have been a care plan regarding safety with residents with seizure activity being in a high bed. She stated that she does daily rounds and never had a concern with beds being in a high position.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility policy, it was determined that the facility failed to maintain an effective infection control and prevention program for one (1) of twenty-two (22) sampled residents (Resident #77). Observation of Resident #77 on 07/31/19 during care revealed that State Registered Nurse Aide (SRNA) #1 failed to wash/sanitize her hands after removing the resident's soiled breif and before applying a clean brief. The findings include: Review of the facility's Guidelines For Hand Hygiene policy, undated, revealed that hands should be decontaminated before having direct contact with residents, after contact with body fluids or excretions, and if moving from a contaminated body site to a clean body site during care. Review of Resident #77's medical record revealed the facility admitted the resident on 12/22/18, with diagnoses of Unspecified Dementia without Behaviors, Anxiety Disorder, Essential Primary Hypertension, Heart Failure, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes, and Alzheimer's Disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #77 was incontinent of bowel and bladder and required the assistance of one (1) person for care. Observation of Resident #77 on 07/31/19 at 9:24 AM, revealed SRNA #1 was providing care and perineal incontinence care to the resident. Upon entering the room, SRNA #1 did not wash or decontaminate her hands before starting care (vital signs). SRNA #1 then proceeded to remove a soiled brief, perform perineal care, and apply a clean brief without changing the contaminated gloves and/or washing her hands. An interview with SRNA #1 on 07/23/19 at 9:24 AM revealed that SRNA #1 did know that she should have changed gloves after removing the soiled bried and cleaning the resident but said she forgot. SRNA #1 revealed that they have in-services on Mondays and Fridays and that the last hand washing in-service was on Monday. An interview with the Clinical Coordinator on 08/01/19 at 11:00 AM revealed that education concerning perineal incontinence care and hand washing is provided upon hire, quarterly, annually, as needed, and during monthly in-services. She had no concerns prior to this incident. An interview with the Director of Nursing (DON) on 08/01/19 at 2:30 PM revealed that education concerning perineal incontinence care and hand washing is provided upon hire, annually, during regular in-services, and during random spot checks. The DON also revealed that SRNA #1 did not follow the policy and procedures concerning perineal incontinence care and hand washing. An interview with the Infection Control Nurse on 08/01/19 at 3:00 PM revealed that SRNA #1 did not follow policy and procedures for perineal incontinence care and hand washing. She revealed that staff are trained upon hire, quarterly, annually, during monthly in-services, and as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #13's medical record revealed the facility admitted the resident on 07/17/15 with diagnoses including Seizures, Tracheostomy, Cerebrovascular Accident, History of Neurocytoma Resection with shunt placement with neurological deficit. Review of Resident #13's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired, with no speech, rarely/never understood, and rarely/never understands. Section G of the MDS revealed the resident was totally dependent on staff for all Activities of Daily living (ADLs) and required assistance of two (2) persons with bed mobility. Section I (Active Diagnoses) of the MDS revealed the resident was marked for Seizure Disorder or Epilepsy. Further review of the resident's record [NAME] (care plan used by nursing assistants to care for residents) revealed the resident had been assessed to require total assistance with all ADLs and the [NAME] was flagged with stickers indicating the resident was HIGH FALL RISK and SEIZURE DISORDER. Review of Resident #13's Fall Risk Evaluation, (a tool to score how much the resident is at risk of falling) dated 04/22/19, revealed the resident scored 12. The instructions for the Fall Risk Evaluation revealed a total score of 10 or greater indicated that the resident should be considered at HIGH RISK for potential falls and a prevention protocol should be initiated immediately and documented on the care plan. Review of Resident #13's care plan dated 05/13/19 revealed he/she was care planned for potential for falls related to diagnoses with interventions to administer medications as ordered, concave mattress, ensure call light is within reach, notify MD with any changes, observe for decreased endurance, PT and OT as ordered, staff will provide ADL care, use mechanical lift as needed, and vital signs per protocol; however, there were no interventions related to bed positioning for safety. Further review of the resident's care plan revealed he/she was care planned for seizure disorder with interventions to administer medications as ordered, note the length of the seizure, notify the MD with any changes, observe for signs and symptoms of impending seizures, obtain labs, obtain vital signs, and prevent injury during seizure activity. There were no interventions regarding safety precautions prior to seizures. 3. Review of Resident #52's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including Hemiplegia, Cerebrovascular Accident, Dysphagia, and Seizure Disorder. Review of Resident #52's MDS assessment dated [DATE] revealed the resident was severely cognitively impaired, non-verbal, totally dependent on staff for all Activities of Daily living, and required assistance of two persons with bed mobility. In addition the MDS revealed the resident had an active diagnosis of Epilepsy (seizure disorder). Interviews on 08/01/19 at 2:56 PM with the Clinical Coordinator and at 3:26 PM with the MDS Care Coordinator revealed any resident at risk for falls should have interventions in place to ensure the resident's bed was kept in the low position. However, the intervention had not been placed on Resident #52's care plan. In addition the staff stated any resident who had a diagnosis of an active seizure disorder should have a care plan developed to ensure safety risks are in place related to the seizure disorder. However, safety interventions had not been added to Resident #52's care plan. Interview on 08/01/19 at 5:08 PM with the Director of Nursing (DON) revealed Resident #52 should have interventions listed on the care plan related to bed positioning and a diagnosis of seizure disorders. Based on observation, interview, record review, and facility policy review it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for three (3) of twenty-two (22) sampled residents (Resident #13, Resident #52, and Resident #59). Resident #13 and Resident #52 had diagnoses of seizure disorder and the facility failed to develop a plan of care that addressed safety interventions for the residents related to seizures. In addition, the facility failed to develop an individualized care plan for Resident #59 related to activity interventions. The findings include: Review of the facility policy titled Care Plan Policy and Protocol, with a revision date of September 2017, revealed the facility shall develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental/psychosocial needs that were identified in the resident's comprehensive assessment. 1. Review of the record for Resident #59 revealed the resident was admitted on [DATE] with diagnoses that included Seizure Disorder, Depression, Schizophrenia, and Alzheimer's Disease. Review of the most recent annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) score was 99, indicating the resident was not able to complete the interview. Further review of the assessment revealed the resident was rarely/never understood and therefore could not be interviewed related to daily and activity preferences. Reveiw of the staff assessment of daily and activity preferences revealed that none of the above was marked for the resident's preferences. Review of the Care Area Assessment (CAA) summary dated 03/14/19 revealed the resident triggered due to not participating in activities. The CAA summary further stated that the resident likes to stay to him/herself and does not like crowds. The summary stated that the resident is encouraged to participate in facility activities and staff talks with the resident and he/she will allow. The CAA summary stated proceed to care plan for this area. Review of the comprehensive care plan dated 03/15/19 revealed no evidence of a care plan for activities for Resident #59. Observation of Resident #59 on 07/30/19 at 4:00 PM revealed the resident ambulated independently in the hallway from his/her room. Staff approached the resident, took the resident by the hand, and walked with the resident back to his/her room. On 07/31/19 at 10:01 AM, Resident #59 ambulated from his/her room to the nurses' station and then back to the resident's room. The resident sat down on the bed. The resident was unable to answer when asked what is your name? At 10:46 AM on 07/31/19, the resident was noted to be sitting on the side of the bed, looking out the window. There was no television or radio in the resident's room. On 08/01/19 at 11:36 AM the resident was observed sitting on the bed, looking out the window. There was no television or radio noted in the room. Observation on 08/01/19 at 2:53 PM revealed Resident #59 was sitting in his/her room on the side of the bed, looking out the window. Interview with the Activities Director on 08/01/19 at 1:24 PM revealed that she does 1:1 activities with Resident #59 a few times per week because the resident does not do well with crowds or group activities. The Activities Director further stated that the facility's Interdisciplinary Team (IDT) meets quarterly and she tells the team the activities that she is providing for the resident and the resident's response. She stated the IDT discusses the resident's care and care plan; however, the resident did not have a written plan of activities and she does not develop the care plan for activities. Interview on 08/01/19 at 3:26 PM with the MDS Coordinator revealed that she was told that the Activities Department developed the activity plan and that a care plan for activities was not mandatory so therefore they did not develop a care plan for Resident #59. Interview with the Director of Nursing (DON) on 08/01/19 at 5:07 PM revealed there had been a misunderstanding regarding activities care plans. The DON stated that if a resident triggers for a care plan from the MDS assessment, then a care plan should be developed. She stated she was unsure why the care plan had not been developed, but it should have been.

Based on observation, interview, and facility policy review, it was determined the facility failed to store food under sanitary conditions for an undetermined number of residents who receive snacks. Observation during initial tour of the kitchen on 05/07/18 at 5:50 PM, revealed uncovered foods stored on a shelf in the kitchen, and bowls of food in the refrigerator unlabeled and undated. The findings include: Review of the facility's policy titled Purchasing, Receiving and Storage, undated, revealed food would be stored and protected from contamination. Review of the facility's policy titled Leftover Food Usage, last reviewed April 2012, revealed foods would be clearly labeled with the date and time that the food was first prepared. Observation during the initial tour of the kitchen on 05/07/18 at 5:50 PM, revealed a box of Quik Oats opened and not covered on a shelf in the kitchen. Further observation of the kitchen revealed a bowl of watermelon, a bowl of mixed fruit, and a bowl of deviled eggs in the refrigerator, that was not labeled with the date and time the food was prepared as required by the facility's policy. Interview with the Dietary Manager on 05/10/18 at 4:10 PM, revealed any opened food item on the shelf should be covered or stored in an airtight container. The Dietary Manager further revealed any item in the refrigerator should be labeled with a date. The Dietary Manager stated the bowl of watermelon, bowl of mixed fruit, and bowl of deviled eggs were going to be used for the evening snack cart.

**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 establish and maintain an effective infection control program to prevent urinary tract infection for two (2) of twenty-five (25) residents (Residents #62 and #8). Observation on 04/30/18 and 05/01/18 revealed Resident #62 and Resident #8's indwelling urinary catheter collection bags were observed to be on the floor. The findings include: Review of the facility policies titled Protocol for Use of Indwelling Catheters, and Giving Catheter Care, not dated, revealed the policies did not address how staff should secure a urinary catheter collection bag to prevent possible contamination and infection. Interview with the DON on 05/10/18 at 7:10 PM, revealed staff were expected to follow the facility's policies and procedures, and acknowledged that to prevent the spread of infection an indwelling urinary catheter collection bag should not touch the floor. 1. Observation of Resident #8 on 04/30/18 at 10:30 AM and 05/01/18 at 10:05 AM and 10:45 AM revealed the resident's urinary catheter collection bag was touching the floor. Review of Resident #8's medical record revealed the facility admitted the resident on 12/06/16 with diagnoses that included Dementia, Atrial Fibrillation, Vertigo, Cardiomegaly, and Essential Hypertension. Review of a Quarterly Minimum Data Set(MDS) dated [DATE] revealed the facility assessed Resident #8 to have a Brief Interview for Mental Status (BIMS) score of three (3), which indicated the resident had severely impaired cognition and was not interviewable. Further review of the MDS revealed that the resident had not been diagnosed with a urinary tract infection within the thirty (30) days prior to completion of the MDS. Review of Resident #8's comprehensive care plan dated 11/07/18 and revised 02/05/18, and the resident [NAME] (document that lists the care the resident required), revealed the facility identified that the resident utilized an indwelling urinary catheter, but the documents did not direct staff how to ensure the urinary catheter drainage was free from possible contamination. 2. Observation of Resident #62 on 04/30/18 at 4:20 PM and 05/01/18 at 10:05 AM and 10:45 AM revealed Resident #62's indwelling urinary catheter drainage bag was lying on the floor. Review of the medical record for Resident #62 revealed the facility readmitted the resident on 02/08/18 with diagnoses that included Cerebral Infarction (stroke), Fluid Excess, Congestive Heart Failure, and Aneurysm. Review of the Significant Change Minimum Data Set (MDS) dated [DATE] revealed the facility had assessed the resident to have a Brief Interview for Mental Status(BIMS) score of three (3), which indicated the resident had severely impaired cognition and was not interview able. The MDS also revealed that Resident #62 had not been diagnosed with a urinary tract infection thirty (30) days prior to completion of the MDS. Review of Resident #62's comprehensive care plan dated 03/09/18 with a revision date of 04/16/18, and the resident's [NAME] (document that lists the care the resident required), revealed the facility identified that the resident utilized an indwelling urinary catheter, but the documents did not direct staff how to ensure the urinary catheter drainage was free from possible contamination. Interview with State Registered Nursing Assistant (SRNA) #9 on 05/01/18 at 1:50 PM revealed he/she was not aware that Resident #8 and Resident #62's urinary catheter drainage bags had been touching the floor. SRNA #9 reported that he/she reviewed each resident [NAME] to determine the residents' care needs. The SRNA stated residents' urinary catheter bags should not have been touching the floor. Interview with SRNA #8 on 05/01/18 at 2:00 PM revealed the SRNA knew that a urinary catheter bag was not supposed to touch the floor. The SRNA acknowledged that when a catheter bag was on the floor the resident was at risk for infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the medical record for Resident #56 revealed the facility admitted the resident on 12/17/17 with diagnoses including Chronic Obstructive Pulmonary Disease, Muscle Weakness, Difficulty Walking, Thoracic Aortic Aneurysm, Coal Worker's Pneumoconiosis, Malaise, Lack of Coordination, Muscle Wasting and Atrophy, Dysphagia, Abnormalities of Gait, Hyperlipidemia, and Benign Prostatic Hypertrophy. Observation of Resident #56 on 05/07/18 at 6:25 PM revealed the resident was in bed positioned on his/her right side, with a half bed rail on each side of the bed. Review of the significant change MDS dated [DATE] for Resident #56 revealed the facility assessed the resident to have a BIMS score of four (4), which indicated the resident had impaired cognition and was not interviewable. The assessment also revealed the resident did not require the use of any restraints. Review of the Quarterly Physical Restraint Elimination Device Use Assessment form dated 03/23/18 for Resident #56 revealed the facility assessed the resident to require bilateral half bed rails to assist with turning and repositioning. Review of Resident #56's comprehensive care plan dated 04/03/18 revealed the facility also developed an intervention for the resident to have half bed rails to aid with bed mobility. However, there was no evidence the facility developed interventions to monitor and supervise the resident's bed rail usage and no evidence monitoring/supervision was being provided. Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure each resident had a person-centered comprehensive care plan developed and implemented to address monitoring and supervising bed rail usage for six (6) of twenty-five (25) residents (Resident #189, #82, #56, #33, #16, and #18). The findings include: Review of the facility's policy titled, Care Plan Policy & Protocol, revised September 2017, revealed the facility would develop a comprehensive care plan for each resident within seven (7) days after the completion of the comprehensive assessment which would include measurable objectives and timetables to meet a resident's medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment. The policy further stated the [NAME] would also be utilized as a guide for Nurse Aides in providing care on a daily basis. As part of the care plan, the [NAME] would reflect person-centered care preferences. 1. Review of a closed record for Resident #189 revealed the facility admitted the resident on 10/24/14. The resident's diagnoses included Dementia, Contractures of Multiple Joints, Cardiomyopathy, Congestive Heart Failure, and Depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 99, which indicated the resident was unable to complete the interview. Further review of the MDS revealed the resident required extensive assistance of two (2) staff members for bed mobility. The resident was also assessed to have limitation in range of motion to both lower extremities. The MDS indicated the resident did not use any type of restraint. Review of a RESTRAINT/BED RAIL USE ASSESSMENT FORM signed as completed on 10/24/14 revealed the resident utilized bed rails that enabled the resident to participate in activities of daily living. Review of Resident #189's plan of care revealed the facility identified that the resident had the potential for falls/injury and developed an intervention of Bilateral ½ side rails in use to aid with bed mobility. However, the plan of care did not direct staff how often to monitor the resident's bed rail use or direct the frequency of supervision of the resident using bed rails. 2. Review of the medical record for Resident #82 revealed the facility admitted the resident on 11/20/13, with diagnoses including Alzheimer's disease, Spinal Stenosis, Osteoarthritis, and Falls. Review of a Restraint/Bed Rail Consent Form, dated 11/20/13, revealed the facility assessed Resident #82 to require bilateral half bed rails to assist with the resident's turning and repositioning. Review of a significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the facility had assessed Resident #82 to have a BIMS score of three (3), which indicated the resident had severely impaired cognition and was therefore not interviewable. The MDS also revealed the resident did not require the use of any restraints. Review of Resident #82's comprehensive care plan dated 03/05/18 and a review of the resident's [NAME] (document that lists the care the resident requires) revealed the facility developed an intervention for the resident to continue to have half bed rails to aid with bed mobility. However, there was no evidence the facility developed interventions to monitor/supervise the resident's bed rail usage. 4. Review of the medical record for Resident #33 revealed the resident was admitted to the facility on [DATE] with diagnoses that included Hypertension, Seizure Disorder, Hepatitis B, Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Debility, and Anxiety. Observation of Resident #33 on 05/09/18 at 9:12 AM and on 05/10/18 at 9:27 AM revealed the resident's bed had half bed rails. Further review of Resident #33's medical record revealed the facility completed a Quarterly Physical Restraint Elimination/Device Use Assessment on 03/08/18, which stated the resident continued to require bed rails to assist in bed mobility. Review of the Annual MDS assessment dated [DATE] revealed Resident #33 was assessed to have a BIMS score of fifteen (15), indicating the resident was cognitively intact and interviewable. The MDS further revealed the resident did not utilize a physical restraint. Review of Resident #33's Comprehensive Care Plan dated 03/13/18 revealed the facility developed an intervention for the resident to utilize half bed rails to aid with bed mobility. However, there was no evidence the facility developed a care plan with interventions to monitor and supervise the resident's bed rail usage. 5. Review of the medical record for Resident #16 revealed the resident was readmitted to the facility on [DATE], with diagnoses including Dementia, Diabetes Mellitus Type II, Varicose Veins, Muscle Wasting and Atrophy, Bipolar Disorder, and Atherosclerotic Heart Disease. Observation of Resident #16 on 05/08/18 at 10:17 AM and on 05/10/18 at 10:09 AM revealed half bed rails were raised and in use by the resident. Review of a Quarterly Physical Restraint Elimination/Device Use Assessment completed for Resident #16 on 02/09/18 revealed the resident utilized bed rails to aid with bed mobility. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #16 was assessed to have a BIMS score of fifteen (15), indicating the resident was mentally cognitive and therefore interviewable. The MDS assessment further revealed the resident did not utilize a physical restraint. Review of Resident #16's Comprehensive Care Plan revealed the facility developed a care plan dated 08/14/17 with an intervention to utilize for the use of bed rails for turning and repositioning. However, there was no evidence the facility developed interventions for monitoring and supervision of the bed rails. 6. Review of the medical record for Resident #18 revealed the resident was readmitted to the facility on [DATE] with diagnoses including Alzheimer's disease, Contracture, Cognitive Communication Deficit, Anxiety Disorder, Major Depressive Disorder, and Hypertension. Observation of Resident #18 on 05/07/18 at 6:45 PM and on 05/10/18 at 9:24 AM revealed the resident's bed rails were down bilaterally and not in use. However, further review of the medical record revealed the facility completed a Restraint/Bed Rail Use Assessment Form on 11/05/17, which stated Resident #18 required bed rails as an enabler to aid in weakness and bed mobility. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #18 was unable to complete a BIMS score, and was not interviewable. Review of Resident #18's Comprehensive Care Plan revealed the facility developed a care plan on 11/15/17, with an intervention for the resident to utilize bilateral half bed rails to aid with bed mobility as an intervention. Further review of the Comprehensive Care Plan revealed no evidence the facility developed interventions for monitoring and supervision of the bed rails. Interview with Registered Nurse #1 on 05/10/18 at 6:45 PM revealed the admission Assessment Packet for residents includes a Bed Rail Assessment Form. RN #1 revealed she was responsible upon admission of a resident to assess the resident to determine if the resident is a candidate for bed rails. RN #1 further stated she did not develop a Comprehensive Care Plan Focus and/or Intervention specifically for monitoring/supervising residents' bed rail usage. However, RN #1 stated she should have developed interventions regarding the monitoring and supervision of bed rails. Interview with Licensed Practical Nurse (LPN) #1 on 05/02/18 at 4:10 PM revealed staff did not document any specific monitoring on bed rail use. Interview with the Registered Nurse (RN) #2, the Clinical Coordinator/MDS Coordinator, on 05/02/18 at 2:45 PM, revealed staff did not document monitoring or supervision of the bed rail use. Interview with the Director of Nursing (DON) on 05/10/18 at 7:10 PM revealed she randomly monitored Comprehensive Care Plans and stated staff should monitor and supervise residents with bed rails daily and record in the resident's medical record. However, the DON stated the facility did not develop residents' Comprehensive Care Plans with interventions regarding monitoring and supervising bed rail usage.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the medical record for Resident #56 revealed the facility admitted the resident on 12/17/17, with diagnoses including Chronic Obstructive Pulmonary Disease, Muscle Weakness, Difficulty Walking, Thoracic Aortic Aneurysm, Coal Worker's Pneumoconiosis, Malaise, Lack of Coordination, Muscle Wasting and Atrophy, Dysphagia, Abnormalities of Gait, Hyperlipidemia, and Benign Prostatic Hypertrophy, Observation of Resident #56 on 05/07/18 at 6:25 PM revealed the resident was in bed, positioned on his/her right side, and half bed rails (rails on the upper portion of the bed) were on both sides of the bed. Review of Resident #56's significant change Minimum Data Set (MDS) dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of four (4), which indicated the resident had impaired cognition and was not interviewable. The facility also assessed the resident to require the extensive assistance of two (2) persons for bed mobility and for turning and repositioning. According to the MDS, the resident had not sustained any falls since the previous assessment and did not require the use of any restraints. Review of the Quarterly Physical Restraint Elimination/Device Use Assessment form dated 03/23/18 revealed the facility assessed Resident #56 to require bilateral half bed rails to assist the resident with turning and repositioning. The form revealed the benefits of the bed rails were to provide safe bed parameters and to assist with turning and repositioning. Review of Resident #56's comprehensive care plan dated 04/03/18 also revealed an intervention for the resident to have half bed rails to aid with bed mobility. However, further review of Resident #56's medical record revealed no documentation that indicated the facility was monitoring and supervising the resident's use of bed rails. Based on observation, interview, record review, and review of the facility's bed rail policy, it was determined the facility failed to ensure alternatives to bed rails were attempted, risks and benefits of bed rails were reviewed with the resident/responsible party, and consent was obtained prior to installation of bed rails, and/or failed to provide specific direct monitoring and supervision for six (6) of twenty-five (25) residents who utilized bed rails (Residents #189, #82, #56, #33, #16, and #18). The findings include: Review of the facility's policy titled Proper Use Of Bed Rails, revised October 2010, revealed bed rails could be used to restrain residents or to assist in mobility and transfer of residents. The policy stated the resident/Responsible Party would be consulted on the appropriateness of the bedrail use, the risks and benefits of the use of bed rails would be discussed, and a consent form would be signed. In addition, the use of bed rails must be addressed in the resident's care plan. The policy also revealed the resident would be observed frequently for safety. 1. Review of a closed record for Resident #189 revealed the facility admitted the resident on 10/24/14. The resident's diagnoses included Dementia, Contractures of Multiple Joints, Cardiomyopathy, Congestive Heart Failure, and Depression. The resident was listed as having a history of falls and a Myocardial Infarction. A letter in the resident's record dated 12/09/14 revealed a state guardian had been appointed for Resident #189. The resident was discharged from the facility in April 2018 and was no longer a resident of the facility. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status score of 99, which indicated the resident was unable to complete the interview. Further review of the MDS revealed the resident required extensive assistance of two (2) staff members for bed mobility. The resident was also assessed to have limitations in range of motion to both lower extremities. The MDS indicated the resident did not use any type of restraint. Review of a RESTRAINT/BED RAIL USE ASSESSMENT FORM signed as completed on 10/24/14 revealed increased weakness and vertigo were listed as the specific medical symptoms that required the use of the restraint/bed rail. The form indicated the use of the bed rail promoted self-mobility while in bed and provided safe bed parameters. The facility indicated on the form that the bed rails enabled the resident to participate in activities of daily living. The assessment did not include an evaluation of the alternatives to the use of bed rails that were attempted or how those alternatives failed to meet the resident's needs. Review of the additional information received on 05/03/18 revealed a Statement of Acknowledgement form with no date. The form had the resident's initials by the area of the form for the resident signature and was signed by the former admission Clerk. The form listed that the resident had been given an admission packet which included: 1. Description of all available services . 12. General information . The form did not specifically list bed rails. A form titled CONSENT AND AUTHORIZATION was also provided on 05/03/18 which was signed by the resident and dated 11/21/14. This form listed that Side [bed] rails may be placed on my bed and raised for my protection. There was also a Guide to Safety form provided which was not signed or dated and this form included the risks and benefits of bed rail use. There was no evidence that the Consent and Authorization form signed by the resident contained the risks and benefits of bed rail use or a statement that this information was reviewed with the resident. Further review of the additional information provided revealed no consent form for bed rail use signed by the resident's guardian. An interview with the former admission Clerk was conducted on 05/03/18 at 4:37 PM. The clerk stated she no longer worked at the facility. Per the clerk, residents/families/responsible parties were provided with an admission packet upon admission to the facility. The admission Clerk stated she did not remember the specific information she gave the resident or families, but thought the packet contained information on bed rails. The Clerk stated she did not remember the risks, but thought the benefit was keeping the resident from getting hurt. Interview with the resident's guardian on 05/07/18 at 2:30 PM revealed she did not recall the facility going over the risks of bed rail use for Resident #189 or signing consent for the use of bed rails. The guardian stated the resident was appointed an emergency guardian on 12/09/14. According to the letter in the resident's record, the state guardian interviewed was the same guardian appointed on 12/09/14. Further review of Resident #189's medical record revealed no documented evidence that facility staff monitored and supervised the use of bed rails for this resident. The resident's plan of care for potential for falls/injury had an intervention of Bilateral ½ side rails in use to aid with bed mobility. The plan of care did not direct staff on how often to monitor the resident's bed rail use or direct the frequency of supervision of the resident using bed rails. Interview with Licensed Practical Nurse (LPN) #1 on 05/02/18 at 4:10 PM revealed staff did not document any specific monitoring regarding bed rail use. Interview with Registered Nurse (RN) #2, the Clinical Coordinator/MDS Coordinator, on 05/02/18 at 2:45 PM revealed staff did not document monitoring or supervision of bed rail usage. Interview with RN #1, the Medicare Coordinator/Infection Control Nurse, on 05/02/18 at 12:20 PM and 2:30 PM revealed she had recently changed positions and was the nurse who completed MDS assessments and tracked incidents until her recent change in position. RN #1 stated she had completed bed rail assessments during the MDS process and the assessments were completed with an admission, annual, significant change, or quarterly MDS. When asked if bed rails were sometimes discontinued after an assessment of the bed rails, RN #1 stated that if a resident experienced a fall while utilizing bed rails, then staff might consider discontinuing the use of the bed rails. The RN stated if staff thought the bed rails were a problem, then they would be removed/not used. Interviews were conducted with the Director of Nursing (DON) on 05/01/18 at 2:50 PM, and 05/02/18 at 12:10 PM and 4:50 PM. Initially the DON stated that if bed rails were not considered a restraint, risks and benefits were not reviewed and a consent for use was not obtained from the resident or responsible party. The DON stated Resident #189 liked to have bed rails and would get upset if staff did not raise them after providing care. In a later interview, the DON stated that staff do review risks and benefits of bed rail use with residents/responsible parties upon admission and quarterly. The DON stated that the facility started using a new bed rail assessment form in October 2017 which listed the assessment of risks verses benefits. The DON further stated that Resident #189 had a behavior of leaning over the bed rails to spit. According to the DON, staff did not document that resident bed rail usage was monitored or supervised; however, staff made rounds several times per day and observed residents for any problems. Interview with Resident #189's attending physician on 05/01/18 at 3:55 PM revealed the physician had cared for Resident #189 for several years. The physician stated that the resident routinely utilized the bed rails to move about in bed. Per the physician, the benefits of bed rail usage for this resident outweighed the risks, as it permitted the resident to be mobile while in bed. Interview with the Administrator on 05/01/18 at 2:50 PM and 05/02/18 at 4:50 PM revealed the facility assessed every bed with bed rails prior to use and Maintenance completed a risk of entrapment evaluation of every bed when the bed was received, with any mattress change, and bi-annually. The Administrator asked the Maintenance Director to demonstrate the evaluation of the bed for entrapment risks. The Administrator stated Resident #189 had a mattress change in March (she believed on 03/13/18). Per the Administrator, the facility did not keep track of the bed each resident was using. She stated the beds were numbered, but the facility did not monitor which bed a resident utilized. Review of the Bed System/Maintenance Log revealed documentation of a bed assessment after the change in mattress for two (2) beds on 03/13/18. However, further review of Resident #189's medical record revealed no assessment of Resident #189 related to bed rail use after the mattress change.4. Observation of Resident #33 on 05/09/18 at 9:12 AM and 05/10/18 at 9:27 AM revealed the resident's bed had a half bed rail on both sides of the resident's bed. Review of the medical record for Resident #33 revealed the resident was admitted to the facility on [DATE] with diagnoses including Hypertension, Seizure Disorder, Hepatitis B, Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Debility, and Anxiety. Review of the medical record revealed the facility completed a Restraint/Bed Rail Use Assessment Form upon admission on [DATE]. The form indicated the resident used bed rails as an enabler to aid in bed mobility. The facility completed a Quarterly Physical Restraint Elimination/Device Use Assessment on 03/08/18, which stated the resident continued to require bed rails to assist with bed mobility. Review of Resident #33's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #33 to have a Brief Interview for Mental Status (BIMS) score of fifteen (15), indicating the resident was cognitively intact and interviewable. The MDS further revealed the resident was assessed to not use bed rails while in bed as a physical restraint. Review of Resident #33's Comprehensive Care Plan dated 03/13/18 revealed the facility developed an intervention for the resident to utilize bilateral half bed rails to aid with bed mobility. However, there was no evidence staff monitored/supervised the resident's use of the bed rails. 5. Review of the medical record for Resident #16 revealed the resident was readmitted to the facility on [DATE] with diagnoses including Dementia, Diabetes Mellitus Type II, Varicose Veins, Muscle Wasting and Atrophy, Bipolar Disorder, and Atherosclerotic Heart Disease. Observation of Resident #16 on 05/08/18 at 10:17 AM and 05/10/18 at 10:09 AM revealed the resident's upper half bed rails were raised and in use by the resident. Review of a Restraint/Bed Rail Use Assessment Form completed for Resident #16 on 08/10/17, revealed the resident utilized bed rails as an enabler to aid in bed mobility. Review of a Quarterly Physical Restraint Elimination/Device Use Assessment completed on 02/09/18, revealed the resident continued to utilize bed rails to aid with bed mobility. Review of Resident #16's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 was assessed to have a BIMS score of fifteen (15), indicating the resident was not cognitively impaired and was interviewable. The MDS assessment further revealed the resident was assessed to not use bed rails as a physical restraint. Review of Resident #16's Comprehensive Care Plan revealed the facility developed a care plan for the resident dated 08/14/17, which stated the resident required the use of bed rails for turning and repositioning. However, a review of the medical record for Resident #16 revealed no documented evidence the facility was monitoring and supervising the resident's use of bed rails. 6. Review of the medical record for Resident #18 revealed the resident was readmitted to the facility on [DATE] with diagnoses including Alzheimer's disease, Contractures, Cognitive Communication Deficit, Anxiety Disorder, Major Depressive Disorder, and Hypertension. Observation of Resident #18 on 05/07/18 at 6:45 PM and 05/10/18 at 9:24 AM revealed the resident's bed rails were not in use. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #18 was unable to complete the Brief Interview for Mental Status (BIMS). Further review of the MDS Assessment revealed the resident was assessed to not utilize a physical restraint. Review of a Restraint/Bed Rail Use Assessment Form for Resident #18 dated 11/05/17 revealed the resident utilized bed rails as an enabler to aid in bed mobility due to weakness. Review of Resident #18's Comprehensive Care Plan dated 11/15/17 revealed the resident continued to utilize half bed rails to aid in bed mobility. However, there was no documented evidence the facility monitored Resident #18's bed rail usage. Interview with State Registered Nursing Assistant (SRNA) #1 on 05/10/18 at 3:55 PM revealed that prior to the survey she had never been instructed to monitor residents' bedrail usage. Interview conducted with SRNA #3 on 05/07/18 at 4:00 PM, revealed she monitored residents to ensure the resident was not too close to the bedrail and monitored to ensure the bedrail was up. The SRNA stated she did not document the observations anywhere. Interview conducted with SRNA #8 on 05/10/18 at 5:39 PM revealed she reviewed the resident's [NAME] (document that lists the care the resident required) at the beginning of the shift to determine the care needs for the resident. She stated she looked to see if the resident was utilizing the bed rails if they were required, but did not monitor/supervise the resident until after the survey was initiated. Interview conducted with Licensed Practical Nurse (LPN) #3 on 05/10/18 at 4:05 PM revealed she did not routinely monitor bed rail usage and would not document anything regarding bed rails unless she observed something wrong. Interview conducted with LPN #1 on 05/10/18 at 4:10 PM revealed she did not routinely monitor bed rail usage. The LPN stated the nurse aides would let her know if anything was wrong. 2. Review of the medical record for Resident #82 revealed the facility admitted the resident on 11/20/13, with diagnoses that included Alzheimer's disease, Spinal Stenosis, Osteoarthritis, and Falls. Observation of Resident #82 on 05/07/18 at 6:55 PM, revealed the resident was in bed on his/her back with bilateral half bed rails on both sides of the bed. Review of a Restraint/Bed Rail Consent Form signed by Resident #82 on 11/20/13, revealed the resident had been assessed to require bilateral half bed rails to assist with the resident's turning and repositioning. The benefits of the bed rails were to enable bed mobility, better positioning, assist with transfer in and out of bed, and to enable the resident to feel secure by setting bed parameters. The facility listed the risks as being skin tears or abrasions. Review of a significant change Minimum Data Set (MDS) assessment dated [DATE], revealed the facility had assessed the resident to have a Brief Interview for Mental Status (BIMS) score of three (3), which indicated the resident had severely impaired cognition and was not interviewable. The MDS also revealed the resident required total assistance of two (2) persons for bed mobility and for turning and repositioning. Further review of the MDS revealed the resident had not sustained any falls since the previous assessment and did not require the use of any restraints. Review of Resident #82's comprehensive care plan dated 03/05/18, revealed the resident continued to require half bed rails in use to aid with bed mobility. However, there was no documented evidence facility staff were monitoring and supervising the resident's use of bed rails.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure medications were safely stored. Observation of medication pass on 04/30/18 and 05/01/18 revealed medication carts were observed to be unlocked and unattended with a bottle of insulin left on top of the cart. In addition, Resident #38 was observed to have a medication cup with two (2) pills at bedside. The findings include: Review of the facility policy titled Medication Storage in the Facility, dated May 2007, revealed medications and biologicals were required to be stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The policy stated medications were accessible only to licensed nursing personnel or staff members lawfully authorized to administer medications. According to the policy, medication rooms, carts, and supplies were locked or attended by persons with authorized access. 1. Observation of medication administration on 04/30/18 at 4:55 PM revealed the medication cart was left unlocked and unattended for approximately five (5) minutes while Licensed Practical Nurse (LPN) #4 entered a resident room to administer medication. A bottle of NovoLog insulin was observed on top of the cart while the medication cart was unattended. Observation of the medication cart on 05/01/18 at 9:30 AM revealed the cart was outside a resident room and was unlocked and unattended for approximately three (3) minutes while Kentucky Medication Aide (KMA) #1 was in a resident room administering medication. Interview with LPN #4 on 05/01/18 at 4:55 PM revealed she was trained on how to correctly store and administer medication. She stated she should have returned the insulin to the medication cart and secured the cart prior to walking away. Interview with KMA #1 on 05/01/18 at 3:25 PM revealed she had also been trained on how to properly store medications. KMA #1 acknowledged that she should not have left the medication cart unlocked and unattended. Interview with the Director of Nursing (DON) on 05/03/18 at 12:35 PM revealed she monitored staff while administering medications and had not identified any concerns with medication storage or administration. The DON stated it was her expectation for staff to follow the facility's policy on medication storage and administration, and secure the medication cart prior to walking away. 2. Observation and interview with Resident #38 on 04/30/18 at 2:30 PM revealed the resident was alert and resting in bed. The resident stated he/she had received too much medication this morning and pointed to a medication cup sitting on his/her bedside table. Resident #38 said that there were four (4) capsules in his/her morning medication, instead of the two (2) capsules that he/she normally received. The resident stated he/she did not take all of the medication, as he/she was only supposed to take two (2) capsules. Licensed Practical Nurse (LPN) #1 was notified of the unsecured medication on Resident #38's bedside. Interview with LPN #1 on 04/30/18 at 2:45 PM revealed the medication in the cup at Resident #38's bedside was Dilantin. The LPN stated she had given the resident two (2) 100 milligram (mg) capsules that morning. The LPN and surveyor reviewed the resident's available medications and confirmed the medication was Dilantin. The LPN and surveyor also reviewed the resident's Medication Administration Record (MAR) and confirmed that the resident was supposed to have received the medication that morning. LPN #1 stated that nursing staff was required to observe residents take their medication and she had observed Resident #38 take his/her medication that morning and could not explain why the resident had medication at the bedside. Review of Resident #38's medical record with LPN #1 revealed the resident had a Dilantin level obtained on 04/27/18, and the resident's Dilantin level was 12 (therapeutic range 10-20).