Based on interview, personnel record review, and facility policy review, the facility failed to ensure it had a process in place to ensure contracted employees had the Kentucky Adult Caregiver Misconduct Registry checked as required by KRS 209.032 for 2 of 5 employee files sampled. The findings include: Review of the facility policy Abuse, Neglect, and Misappropriation of Property revised 09/15/2023 revealed the facility included screening to provide protection for the health, welfare, and rights of each resident residing in the facility. Continued review revealed the screening included conducting criminal background checks and a search of the State Nurse Aide Abuse Registry. Review further revealed however, the Kentucky Adult Caregiver Misconduct Registry (KACMR) checks were not included as part of the screening. Review of the Kentucky Revised Statutes (KRS) 209.032 revealed a vulnerable adult services provider, such as a long term care facility was to, Query as to whether prospective or current employee has validated substantiated finding of adult abuse, neglect, or exploitation -- Administrative regulations -- Central registry of substantiated findings made on or after July 15, 2014. Continued review of the Statute revealed an employee included a person hired directly or through contract by a vulnerable adult services provider with duties that involved or might involve one-on-one contact with a resident. Further review revealed a vulnerable adult services provider was to query the cabinet as to if a validated substantiated finding of adult abuse, neglect, or exploitation was entered against an individual who was a prospective employee of the provider. 1. Review of the personnel file for Dietary Aide (DA) 2 revealed she was employed by the facility through a contracted company on 05/03/2024. Further revealed no documentation noting the facility conducted the check of the Kentucky Adult Caregiver Misconduct Registry (KACMR) for DA 2 as required. 2. Review of the laundry employee's personnel file revealed she was employed at the facility through a contracted company on 08/05/2024. Further review revealed no documentation indicating the facility provided the check of the KACMR for Laundry employee as required. In interview with the Director of Nursing (DON) on 08/23/2024 at 5:34 PM, she stated she reviewed contracted employees' personnel information related to education and tuberculosis (TB) checks. She stated she was unaware if anyone verified the KACMR checks were completed as required as those checks were not clinical. The DON stated the purpose of completing the KACMR checks was to see if potential new employees had a report of abuse in a prior setting against them. She stated this was to ensure safety of residents with the new employee coming into the facility. Additionally, she stated the facility would not have employees in their building with a finding of abuse against them. The DON further stated if the KACMR checks were not completed there was a risk to residents' safety. In interview on 08/23/2024 at 6:27 PM, the Administrator stated the facility did not have a Human Resources employee. She stated her expectation for contracted employees potentially working at the facility, was for the contract agency to check them to ensure the contracted employee was ready for employment. The Administrator stated the KACMR was to be completed before a potential employee was hired. She stated the KACMR check was a regulated, mandated law in Kentucky and the facility would not allow their own employee to work if the check was not completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** [NAME] 2. Additional review of the facility policy titled, Storage of Medication dated 01/2023, revealed refrigerated medications should be kept in closed and labeled containers, with internal medications separated from external medications. Continued review revealed all medications should be segregated from fruit juices, applesauce, and other foods used in administrating medications. Review further revealed any other foods, such as employee lunches and activity department refreshments, should not be stored in the medication refrigerator. Observation on 08/22/2024 at 4:00 PM, during performance of the medication storage and labeling task, revealed a personal lunch bag stored in the locked medication refrigerator in the medication room on the 100 unit. Continued observation revealed when opened the lunch bag contained a bag of potato chips, a can of Dr. Pepper, and a water bottle. When asked in interview, at the time of observation, RN 2 stated it was a staff person's lunch bag and should not have been in the medication refrigerator. RN 2 stated that refrigerator was only to be used for medication (storage). The SSA Surveyor asked RN 2 what the concern of having food stored in the medication refrigerator was, and she stated it could contaminate the medication in the fridge or the medication could contaminate the food which could be consumed. RN 2 stated that the facility policy for the medication refrigerator was for it to only be used for residents' medication and biologicals storage. Further observation revealed RN 2 removed the lunch bag from the refrigerator, locked it and removed the lunch bag from the medication room. In interview with LPN 1 on 08/22/2024 at 11:30 AM, she stated no food was permitted to be stored inside the medication refrigerators due to risk of contamination of the medications as well as potential contamination to the food products. LPN 1 stated food items used for administering medications was not allowed to be stored in the medication refrigerator and the facility policy was to store those foods in a separate refrigerator only intended for resident food items. In interview with RN 3 on 08/22/2024 at 4:26 PM, she stated the facility policy prohibited any food from being stored in the medication refrigerators throughout the facility. RN 3 stated food could contaminate the medications and/or the biologicals, and the food could also become contaminated from the medications or biologicals. In interview with the DON on 08/23/2024 at 2:37 PM, she stated the facility had three (3) medication storage refrigerators. She stated only the nurse assigned to the medication cart on a unit and the unit managers had keys to the locked medication room and locked medication storage refrigerators in the rooms. The DON stated the policy of the facility was no food storage in medication refrigerators was allowed at any time for any reason. She stated the expectation was for all staff to follow all (facility) policies at all times. The DON further stated education would be provided to staff on the (facility's) medication storage policy. In additional interview, she stated if the owner of the lunch bag was identified that person would receive one on one coaching on the policy, along with the risks of storing food in a medication refrigerator. In interview with the facility Administrator on 08/23/2024 at 6:30 PM, she stated all medication storage rooms and refrigerators should be locked at all times, with only licensed personnel who administered medication on that unit having the keys to access the rooms and refrigerators. In further interview, the Administrator stated no food items should be stored in the medication refrigerators. She additionally stated the facility had designated refrigerators for food storage for residents and staff, and it was the expectation for all employees to follow the facility's policies. Based on observation, interview, and facility policy review, the facility failed to ensure drugs and biologicals were stored in accordance with State and Federal laws for one (1) of three (3) facility medication storage refrigerators. In addition, the facility also failed to ensure medications were secured during medication administration for 1 medication cart. Observation of the medication room on the facility's 100 unit revealed a personal lunch bag with food and drinks stored inside the locked medication refrigerator located in the room. Additionally, observation revealed Registered Nurse (RN) 7 prepared a resident's medications, then stepped away from the medication cart leaving the pills in a medication cup unattended, and out of view of staff. The findings include: Review of the facility policy, Medication Administration, last revised 6/24/2024, revealed medications were administered as prescribed in accordance with manufacturers' specifications. Continued review revealed medications were also administered in accordance with good nursing principles and practices, and only by persons legally authorized to do so. Further review revealed medications were to be administered at the time they were prepared. Review of the facility policy, Medication Storage, dated 01/2023, revealed medications and biologicals were to be stored properly, following the manufacturer's, provider's, or pharmacy recommendations. Per review, proper storage of medications and biologicals was to maintain their integrity and to support safe effective drug administration. Continued review revealed the medication supply should only be accessible to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Further review of the policy revealed the provider pharmacy was to dispense medications in containers that met state and federal labeling requirements, including requirements of good manufacturing practices established by the United States Pharmacopeia (USP). In addition, policy review revealed medications were to remain in the pharmacy containers and were to be stored in a controlled environment. 1. Observation on 08/22/2024 at 8:35 AM, of Registered Nurse (RN) 7 during medication administration for Resident (R)65, revealed he prepared the residents' morning medications. Per observation, R65's medications included: Aspiring 81 milligrams (mg) oral (po), Isosorbide (used to treat angina) 30 mg po, Jardiance (used to treat high blood sugar in Type 2 diabetics) 25 mg po and Protonix 40 mg po. Continued observation revealed RN 7 opened and placed the medications in a medication cup on top of the medication cart. Further observation revealed RN 7 then stepped away from the medication cart, going to the medication room, and leaving R65's pills unattended on top of the cart. During interview with RN 7 on 08/22/2024 at 8:35 AM, he stated he had left R65's medication unsecured; however, the State Survey Agency (SSA) Surveyors were standing by the cart. He further stated the reason medications should not be left unattended was that a resident could access and take pills that were not intended for them. During interview with Licensed Practical Nurse (LPN) 11 on 8/23/2024 at 9:45 AM, she stated she must never leave medications unattended. She stated if she had to step away from her medication cart, then she took any prepped medications with her. In further interview, she stated it was not safe to leave medications unsecured (at any time) because a resident might take them. During interview with LPN 7 on 8/23/2024 at 9:52 AM, she stated medications should never be left unattended. During interview with LPN 12 on 8/23/2024 at 10:15 AM, she stated nurses should never leave medications unattended because it could be unsafe for other residents. During interview with the Assistant Director of Nursing (ADON) on 08/23/2024 at 2:15 PM, she stated medications should never be left unattended. She stated this was because anyone, including residents, could take those medications not intended for them. The ADON stated if a resident took medication not intended for them they could possibly take something they were allergic to or have an adverse reaction from that medication. She stated her expectation was that nurses and Certified Medication Technicians (CMTs) not leave any medications unattended and they should follow the facility's medication administration policy. During interview with the Director of Nursing (DON) on 08/23/2024 at 05:35 PM, she stated medications should never be left unattended. She said the nurse should either take prepared medications with them if they must step away from the medication cart or lock them in an area of the cart until they returned. In further interview she stated you never know who could come by and pick the medications up. The DON stated it was necessary to ensure medications were secure and not put anyone at risk. She further stated the risks (of medication being left unattended) would depend on the person and the medications, but there was the potential the person could have an allergic reaction or other adverse reaction. During interview with the Administrator on 08/23/2024 at 6:36 PM, she stated it was never acceptable to leave medications unattended. She stated she did not want to speculate on associated risks (of medications left unattended), but the protocol was to never leave medications unattended and she expected the staff to follow that.

Based on observation, interview, review of the U.S. Food and Drug Administration (FDA) Food Code, 2022, and review of the facility's policies, it was determined the facility failed to store food in accordance with professional standards for food service safety. During observation on 08/20/2024 of the kitchen walk in refrigerator, multiple produce items were rotting. Additionally, multiple sleeves of bread were found with no label or expiration date. Also, leftover tomatoes were observed in container with no use by date. The findings include: Review of the facility's policy, Food Storage: Cold Foods, revised 02/2023, revealed all Time/Temperature Control for Safety (TCS) foods, frozen and refrigerated, were to be appropriately stored in accordance with guidelines of the Food and Drug Administration (FDA) Food Code. Further review revealed all foods were to be stored, wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Review of the facility's policy, Food Storage: Dry Goods, revised 02/2023, revealed all dry goods were to be appropriately stored in accordance with the FDA Food Code. Further review revealed storage areas were to be neat, arranged for easy identification, and dates marked as appropriate. Review of the FDA Food Code 2022, revealed containers holding food or food ingredients removed from the original packages for use in the food establishment, were to be identified with the common name of the food, except containers holding food readily and unmistakably recognized. Per policy review, packaged foods were required to conform to specific labeling laws. Continued review revealed foods packaged within the food establishment must also conform to the appropriate labeling laws, be accurate, and not misleading. Policy review revealed refrigerated, ready-to-eat, time/temperature control for safety, food prepared and held in a food establishment for more than 24 hours was to be clearly marked to indicate the date or day by which the food was to be consumed. Further review revealed refrigerated, ready-to-eat, time/temperature control for safety food prepared and held was also to be discarded when held at a temperature of 41 degrees Fahrenheit (F) or less for a maximum of seven days, with the day of preparation counted, or the day of opening the original container, noted as Day 1. (1) Observation on 08/20/2024 at 9:38 AM, during kitchen tour, revealed four small bowls of applesauce, undated, in the stand-up refrigerator. Continued observation also revealed slices of tomatoes in a pan, covered with no label or date. (2) Observation of the walk-in refrigerator, revealed a ham, noted as packed on 07/19/2024, with no delivery date on the unopened box, and bacon noted as packed 07/02/2024, opened 08/18/2024, but with no expiration date documented. Review of the labeling information noted to keep the meat frozen until used. Continued observation in the walk-in refrigerator revealed celery, delivered 07/26/2024, that was brown and softening on the ends, and a box of tomatoes, with one tomato rotted on one side. Observation also revealed one watermelon that was cracked open, in a box that was wet with (juice) saturation. Further observation in the walk-in refrigerator revealed 33 packages of prepared red apple slices in individual packs with expiration date of 08/16/2024, and a box of eight cucumbers, delivered on 08/13/2024 with five of the eight cucumbers being soggy and spongy. (3) Observation in the dry storage area of the kitchen revealed a package of cornstarch, delivered 10/14/2023, with packaging description that indicated best if used by 07/18/2024. Continued observation of the dry storage revealed three sleeves of thick bread loaves, and four sleeves of hot dog buns, stored with no further packaging, nor labeled or dated. During interview with the District Certified Dietary Manager (CDM) on 08/20/2024 at 10:35 AM, she stated she was covering for the facility's CDM, also known as the account manager, who was not working that week. She stated the facility went by the policy for how long to store food items. She further stated the account manager was responsible to do a walk through daily to check for decaying produce. Additionally, the CDM stated expired or spoiled food items served to residents may increase their risk of illness. During interview with the Healthcare Services Registered Dietician (RD) on 08/20/2024 at 11:30 AM, he stated daily tasks were posted by the tray line for dietary staff. He further stated it was a CDM task to conduct a check of produce quality and for expiration dates for any food item. During interview with the Senior Director of Operations (SDO) on 08/23/2024 at 11:15 AM, he stated his expectation was expiration dates on food packaging were followed. He stated the facility followed labeling and dating sheets, and produce was a different matter, but the CDM should be checking food items and discarding food if it appeared degraded. During interview with the Administrator on 08/23/2024 at 6:36 PM, she stated there were guidelines and protocols that needed to be adhered to for proper food storage. She stated she did not want to speculate on the protocols; however, they were in place for a reason and staff should follow them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of standard of practice reference, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of six sampled residents, Resident (R) 65. Observation of medication administration revealed Registered Nurse (RN) 7 failed to perform hand hygiene after administering medications for the resident, and prior to preparing medications for another. The findings include: Review of the facility's reference book, Fundamentals of Nursing, 10th Edition, by [NAME] and [NAME], pages 439 and 618, revealed the most effective basic technique for preventing and controlling the transmission of infection was hand hygiene. Per review, hand hygiene was defined as a general term that applied to four techniques: handwashing, antiseptic hand wash, antiseptic hand rub, or surgical hand anti-sepsis. Continued review revealed handwashing was defined as the vigorous, brief rubbing together of all surfaces of lathered hands, followed by rinsing and stream of warm water for 15 seconds. Review revealed the fundamental principle behind handwashing was removing microorganisms mechanically from one's hands. Further review revealed if hands were not visibly soiled, using an alcohol based, waterless, antiseptic agent for routinely decontaminating hands in clinical situations. Review further revealed clinical situations in which antiseptic hand rubs were before, after, and between direct patient contact such as taking a pulse. Additionally review of the reference revealed hand hygiene should be performed both before and after medication administration. Observation of medication administration for R65 on 08/22/2024 at 8:35 AM, revealed RN 7 failed to wash or sanitize his hands before preparing the resident's medications. Per observation, RN 7 also failed to don gloves to administer insulin. During interview at the time of observation, RN 7 stated the reason hand hygiene was necessary was to prevent spread of infection. During interview with Licensed Practical Nurse (LPN) 11 on 08/23/2024 at 9:45 AM, she stated it was expected for staff to wash their hands or use hand sanitizer between residents. She further stated hand hygiene was important to prevent cross contamination. During interview with LPN 7 on 08/23/2024 at 9:52 AM, she stated hand washing or using hand sanitizer was necessary when providing care between residents, including giving medications. She further stated hand washing was important to help prevent infection. During interview with LPN 12 on 08/23/2024 at 10:15 AM, she stated staff giving medications should wash or sanitize their hands between residents. In addition, she stated staff should also wash or sanitize their hands before medication preparation and then again when exiting the resident's room to prevent spread of infection. During interview with the Assistant Director of Nursing (ADON) on 08/23/2024 at 2:15 PM, she stated her expectation was for staff to follow the facility's medication administration policy. The ADON further stated handwashing helped prevent spreading infections. During interview with the DON on 08/23/2024 at 5:35 PM, she stated she expected nurses to follow the facility's medication administration policy and standard of practice. She additionally stated that included handwashing between residents. During interview with the Administrator on 08/23/2024 at 6:36 PM, she stated she did not want to speculate on the risks associated with not using sanitizer or washing hands. She further stated however, she did expect staff to follow the protocol and accepted practice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview it was determined the facility failed to provide treatment and care for one (1) of the thirty (30) sampled residents, Resident #51. Resident #51 had a physician order to be sent to the emergency room because the resident had complained of chest pain and was not sent until the following day. The physician was not notified until the next day that Resident #51 did not go out to the emergency room as the physician had ordered. The findings include: Review of Resident #51's clinical record revealed the facility admitted the resident 06/16/17 and readmitted the resident on 10/21/19, with diagnosis of sepsis, pulmonary embolism, chronic respiratory failure, and chronic obstructive pulmonary disease. In addition, resident has intellectual diagnosis of borderline intellectual functioning, Alzheimer's disease, dementia and cognitive impairment. Review of Resident #51's annual Minimum Data Set, dated [DATE], revealed the facility assessed the resident with a Brief interview for Mental Status score of ten (10) out of fifteen (15) and determined the resident was interviewable. Review of telephone order for Resident #51, date 08/31/19, revealed physician order to send resident to the emergency room, signed by Licensed Practicing Nurse (LPN) #5. Review of Resident #51's progress note, on 08/31/19 at 7:12 PM, revealed LPN #5 failed to notify physician, Advanced Practice Registered, ADON, and/or DON for direction after emergency services classified the resident's status as a non-emergency for directions on next steps. Continued review of the resident's progress notes, revealed Resident #51 was admitted to hospital the following day, 09/01/19 at 7:45 AM after complaints chest pain. Observation of Resident #51, on 11/12/19 at 11:39 AM, resident was in bed with eyes closes with oxygen in place and set on two (2) ml, fully dressed, and room was free from cutter. Observation of Resident #51, on 11/13/19 at 1:10 PM, resident was observed eating lunch with another resident. Brief interview with Resident #51, revealed he enjoyed living at the facility, however,did not remember going to the hospital. Resident #51 continued to wear cannula for oxygen. Interview with Resident #51, on 11/13/19 at 1:22 PM, revealed resident reported no concerns with the facility or the staff. Interview with LPN #5, on 11/16/19 at 3:37 PM, revealed he completed an assessment on Resident #51 after complaints of chest pain. He then obtained a physician order to send resident to the emergency room. LPN #5 reported emergency services (EMS) arrived, however, after their assessment deemed Resident #51 a non-emergency and refused to transport resident to the emergency room. Continued interview with LPN, revealed he failed to follow up with physician, APRN, and/or the DON to communicate EMS did not transport Resident #51 to the emergency room due to non-emergency call. LPN #5 reported he forgot the process and procedure when physician's orders were not followed. He also stated he failed to continue contacting other ambulance service for transportation to the emergency room for Resident #51. Interview with Direction of Nursing (DON), on 11/16/19 at 4:09 PM, revealed she was not the DON during Resident #51's change of condition. The DON states she was not aware of the incident regarding nursing staff lack of physician notification after denial of transportation to the emergency room. The DON stated it was important for the LPN to follow up with the physician due to the initial order was not followed. Phone interview with Medical Director (MD), on 11/16/19 at 6:26 PM, revealed if an order was to send a resident out to the hospital for chest pain, they expected nursing staff to follow the physician order. However, if the resident was viewed as a non-emergency by emergency services, she would expect another form of communication from the facility for review to determine if another order was warranted. Phone interview with former Unit Manager (UM) #3, on 11/16/19 at 7:46 PM, revealed she could not remember the details from the date of 09/01/19 however, her nursing documentation was accurate. She revealed the day after the first complaint of chest pain Resident #51 had complained again of chest pain, vitals were checked and deemed necessary to contact physician/APRN and request ambulance for transport. At that time, she called rural metro, who came right away to transport resident to the hospital. Unit Manager revealed she would expect nursing staff to contact the physician and/or the Director of Nursing for medical direction when physician orders could not be followed as ordered Interview with the Administrator, on 11/16/19 at 8:11 PM, revealed she was notified on Monday 09/01/19, by Unit Manager #3, Resident #51 was hospitalized . She stated in her experience when emergency medical services responded to a call and deemed the resident a non-emergency, the resident would have to wait up 24-hours for transportation. She further stated, emergency medical services was not refusing residents however, nursing staff failed to contact the on-call physician, the DON, or the Administrator to make them aware of the situation.

Based on observation, interview, and record review it was determined the facility failed to maintain a homelike environment for two (2) of three (3) units. Observations and interviews revealed the facility had an odor of urine and the resident shower rooms for two (2) of three (3) units, had toilets with identified fecal matter. In addition, metal poles used in resident rooms were rusted and caked with white sticky matter. The findings include: The facility did not provide a policy for homelike conditions upon request. 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. Observation, on 11/12/19 at 09:50 AM, revealed physical entry to the 100 hallway had an odor of ammonia. Observation, on 11/12/19 at 10:48 AM, upon physical passage through the facility door to the residential area by the dining hall entrance, revealed a strong musty ammonia odor. Continued observation of the two-hundred (200) hallway again revealed, an odor of pungent urine in the hallway of rooms, two-hundred (200) down to two hundred and sixteen (216) hall. Observations, on 11/12/19 at 11:08 AM, revealed Resident #17's room smelled of a heavy ammonia like odor. The aide placed clean linen to the residents bed. Inspection of the resident's bathroom revealed less odor in the area of the bathroom. Continued observations revealed the smell of an ammonia odor was heavily present in the general area of the hallway around Resident #17's room. Observation, on 11/12//9 at 11:43 AM, revealed upon physical entry into the residential area at the dining room entrance was an odor of ammonia. Observation, on 11/13/19 at 9:45 AM, upon entry onto two hundred (200) hallway, revealed an ammonia like odor. Entry into room Resident #17's room revealed an odor of ammonia. Review of Resident #17's clinical record revealed the resident was admitted to the facility 08/16/06 with the diagnoses of Dementia, Hypertension, and anemia Review of Resident #17's quarter Minimum Data Set (MDS), on 08/17/19, revealed the resident was an extensive assist with toileting, wore briefs, and was frequently incontinent. Observation, on 11/13/19 at 4:00 PM, revealed the facility toilet for the one hundred hall (100) shower room contained brown matter adhered to the toilet seat and yellow dried matter. Continued observation revealed brown matter at the bottom to the toilet. Interview with the 100 Unit Manager, on 11/13/19 at 4:00 PM, revealed facility aides responsibilities included to clean the shower chairs and toilets when residents completed showers. She stated she checked the shower rooms daily. However, she further stated she could not identify how long the fecal matter was on the toilet. She stated toilets in the showers were to be clean. Observation, on 11/14/19 at 10:40 AM, revealed entry into Resident #17's room smelled of an ammonia like odor. Interview with Resident #17, on 11/14/19 at 10:40 AM, revealed the resident was unsure of the smell of a urine type odor in his/her room. However, the resident further stated he/she lived in the facility for over ten (10) years and would not know if there was any odors. Observation on 11/14/19 at 4:51 PM, revealed a strong odor of ammonia in the residential area at the dining hall entrance. Observation on 11/13/19 at 9:54 AM, of a black box emergency outlet, mounted on the wall in Resident #11's, was held together with tape. Interview with the Maintenance Director (MD), on 11/15/19 at 9:59 AM, revealed he noted a black box secured into a red emergency plug taped with multiple layers of clear tape, which held the box together. He stated it was an unsafe situation and a fire hazard to the facility. He stated staff were to notify the department of repair needs. However, the staff notified central supply for equipment order needs. Observations, on 11/13/19 at 3:59 PM, revealed the two-hundred (200) shower with the over the toilet high-rise chair contained dark brown matter to the inner portion of the seat ring. Further observations revealed brown matter in the bottom portion of the toilet water accompanied with white paper material. Continued observations of the Two-Hundred (200) Shower room, on 11/14/19 at 9:03 AM, revealed facility staff accompanied surveyor into the room. Observation of the shower by staff an identified used toilet paper on the floor. The staff identified the toilet over the bed chair with brown matter to the left side inner ring and loose stool identified in the toilet with white paper in the same position. Staff stated a strong odor of stool in the bathroom was present. Observations, on 11/16/19 at 11:21 AM, revealed Resident #85's room received enteral feeding to which a metal pole held the bottle and was rust and a sticky with sticky matter to the base of pole. Continued observation revealed Resident #90's medical pole with a dried cream sticky matter, on the base of the device, and rust on the base of the pole. Continued interview with the MD, on 11/15/19 at 11:01 AM, revealed the department audits do not include metal poles. He stated the department does not inspect for safe function or condition of the resident poles. He further stated the condition of the poles could be an indication of the care and services provided in the facility. Interview with Certified Nursing Aide (CNA) #2, on 11/14/19 at 11:00 AM, revealed the aide identified the smell in the room and hallways as urine. The aide stated part of the odor was Resident #17's mattress, and it always smelled of old musty urine. The aide stated the resident was often incontinent, out of the brief, when found in his/her bed. The aide stated the resident's urine soaked into the mattress and occurred for the six (6) years the aide as an employee. The aide stated staff wiped down the residents mattress with an incontinent episode. However, the aide stated the mattress just held the odor after many years of use. The aide stated previous staff reports did not address the odor issues; so therefore staff just stopped trying to address the issue. The aide stated the facility was aware of the odors because Resident #17's room and the hallway always smelled of urine. The aide further stated the residents in the room was not recognize the odors having lived with the odors for so long it was not recognized anymore as a smell. The aide stated the facility mattress and room's odor was an issue for several residents, and the odors filtered out to the hallways. The aide further stated the facility's visitor chairs made of cloth routinely smelled of urine. The aide stated nobody wanted to live in a room or home with the constant smell of urine. Interview with Resident Family Member #3, on 11/15/19 at 4:00 PM, revealed the facility smelled like urine at all the times. The family member stated the facility did not address the dirt and smell of the resident rooms after numerous complaints to the Director of Nursing and Administrator. She stated the facility floors, beds, chairs; visitor chairs constantly looked dirty or smelled of urine. She stated the facility residents and visitors complained to the facility staff without improvements. She further stated requests for housekeeping services went on deaf ears. Interview with the Housekeeping Manager (HM) with Healthcare Services, on 11/15/19 at 9:49 AM, revealed the company provided deep cleaning services to mattresses on a rotation schedule, cleaned resident rooms, showers and all other cleaning needs. However, he stated there was a lack of adequate staff for the facility services. He stated the company made daily rounds for inspection of services. The HM stated the facility identified Resident #53's room on the 200 hallway to have strong urine odors, most of the time; and identified the mattress and un-bagged soiled clothing with urine, as the source of the odors. However, he did not complete a mattress evaluation to address odors reported from the room and the facility did not replace the mattress. The HM further stated Resident #53 soiled their clothing with urine and staff placed the soiled articles into the resident's laundry hamper without a bag. He stated the employee's hated to handle urine soaked clothing, and this was a huge reason the urine odor in the residents room was prevalent, as well as the hallway. He stated they attempted to deodorize mattress when notified. He further stated they notified maintenance if the odors persist. He stated and acknowledged the facility smelled of urine. He further stated the facility conducted a program of Ambassadors who were to advocate for the residents and this included dirty and odorous rooms. He stated the maintenance department was responsible for the order of new mattresses for residents. He stated the department audits schedule for mattress conditions were not included in the audit and not automatically changed out at a five (5) year use date. He stated housekeeping cleaned resident shower's daily. He stated the aide had to notified staff to clean toilets in the showers when soiled. He further stated facility aides placed laundry for families to complete, in bags while the facility waited for pickup. However, the facility aides placed cloths in the closet, without the placement of a bag and the lack of bagging contributed to the odors of urine throughout the facility. He further stated families complained daily of the odors of urine and the impression would be the facility lacked good care of residents. He further stated a person would not want to live in an environment at home, with odors of urine, because it smelled and could looked like an unsanitary environment. Interview with the Medical Director, on 11/15/19 at 10:30 AM, revealed staff notified the department for issues with resident mattresses. He stated if residents complain of the condition of the mattress they will change out to another mattress. He stated staff were to report mattress's with strong odors of urine. He further stated the department did not have requests for mattress changes for any resident. He stated the facility and department was aware of Resident # 53's mattress with odors of urine. However, the mattress change out did not occur as of this date but the department received the report the past couple weeks. He stated the facility was aware of the urine odors in the building. He stated the odors filter out from the resident rooms. He further stated because he worked for a long time in the facility that he did not notice the odors anymore. He stated the facility audit and tracking of mattresses did not occur and staff notified the department of issues. He further stated facility would be unappealing for residents, family, visitors, and staff with the odor of urine. He stated the facility expected the grounds to be neat and clean as well as repaired when needed. He further stated he would not like to live in a home, which smelled like urine. He stated the facility ambassador program provided feedback for residents whom were unable to vocalize issues or needs and completed two times a week. Review of daily ambassador round audit tool, undated, revealed the Quality Area has to observe and report included closets free of heavily soiled clothes, dirty poles, dirty shower rooms, and hallway with odors. Review of Housekeeping Daily Focus Calendar, undated, revealed the facility scheduled included resident equipment were cleaned on Thursdays. Interview with the Director of Nursing (DON), on 11/14/19 at 9:07 AM, revealed staff notified housekeeping if a resident mattress required cleaning when soaked with urine so the resident mattress received disinfection care. The DON stated clean linen were not to be placed on a bed mattress if the linen was soiled and mattress wet. The DON continued and stated dried urine caused odors in the resident's rooms and would come out into common resident areas. The DON stated soiled linen and clothing were to be placed in plastic bags to keep the soilage contained and decreased odors of urine. The DON further revealed she made walking rounds for audits of care and services for residents, conditions of rooms, and overall condition of the common areas of the facility. The DON further stated the condition of the facility including odors, frequently came to topic with Interdisciplinary team meetings for the facility. Interview with the Administrator, on 11/16/19 10:12 PM revealed the facility responsibility included a homelike environment. She stated the facility responsibility included compliance with all regulations for the care needs of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's Policy, it was determined the facility failed to provide written information to the resident or resident representative that specifies the duration of the state bed-hold policy for two (2) of thirty (30) sampled residents (Resident #16 and Resident #55). Record review revealed Resident #16 was transferred to the hospital for evaluation following a change of condition on 10/31/19; however, there was no documented evidence the facility provided the resident or the resident's representative written information related to the facility's Bed-hold Policy. Review of the medical record revealed Resident #55 was sent to the hospital for evaluation following a change of condition on 09/25/19; however, there was no documented evidence the facility provided the resident or the resident's representative written information related to the facility's Bed-hold Policy. The findings include: Review of the facility's Facility Bedhold Policy, dated revised 11/12/18, revealed the facility would notify the resident/responsible party of the facility's bed hold and readmission policies at admission and anytime a resident was transferred to the hospital or goes out on therapeutic leave. Continued review of the policy revealed the facility's bed hold and re-admission policies would be discussed with the resident/responsible party and the facility would provide written notice of the bed hold and re-admission policies before a resident's transfer to the hospital or for overnight therapeutic leave and included in the resident's transfer packet. The facility's clinical team would facilitate the resident's transfer packet. The facility's Social Worker or Licensed Nurse would document verbal and written notification in the medical record. Per policy, in an emergency, time of admission or time of transfer may mean up to twenty-four (24) hours. 1. Review of the clinical record revealed the facility admitted Resident #16 on 03/25/19. Resident #16 had diagnoses which included Pneumonia, unspecified organism; Other Specified Disorders of prostate; and Unspecified Intellectual Disabilities. Review of the progress notes dated 10/31/19 revealed the resident yelled and screamed he/she was in pain with complaint of abdominal pain, the ARNP/MD (Advanced Registered Nurse Practitioner/Medical Doctor) was notified and the resident was transported to the Emergency Department. Per the documentation, Resident #16 returned to the facility on [DATE]. There was no documented evidence the facility provided the resident or the resident's representative written information related to the facility's Bed-hold Policy. 2. Review of the clinical record for resident #55 revealed the facility admitted Resident #55 on 07/15/15. Diagnoses included Hemiplegia and Hemiparesis following unspecified Cerebrovascular disease affecting right dominant side; Aphasia following unspecified Cerebrovascular disease; Unspecified open wound of penis, sequela (history of). Review of the progress notes dated 09/25/19 revealed Resident #55 was sent to the hospital emergency department for a change in condition, and returned to the facility on [DATE]. There was no documented evidence the facility provided the resident or the resident's representative written information related to the facility's Bed-hold Policy. Interview with the 100 Hall Unit Manager, on 11/16/19 at 3:50 PM, revealed she had been employed as Unit Manager for three (3) weeks. Continued interview revealed the nurse sending the resident out should call and ask family and tell family the reason the resident was being sent out and there should be a form that was completed with information on the bed hold. Further interview revealed she was unsure of who sent written information regarding the bed hold to the resident's family. Interview with the facility Clinical Nurse Consultant, on 11/15/19 at 4:04 PM, revealed the facility could not find any documentation the facility provided the resident or the resident's representative written information related to the facility's Bed-hold Policy for Resident #16 or Resident #55 when each resident was sent to the hospital emergency department. Interview with the Director of Nursing (DON), on 11/16/19 at 9:43 AM, revealed the nurse's should have completed the document for bed holds, with the written information related to the facility's Bed-hold Policy. Continued interview revealed the written information related to the facility's Bed-hold Policy should have then been sent to medical records, and medical records should send the bed hold document to the resident's representative/family, and place a copy in each resident's chart. Continued interview with the DON, revealed if written information related to the facility's Bed-hold Policy was not completed, the resident/responsible party/family would not be made aware of potential bed hold. The DON further stated the resident/responsible party/family have to be made aware of the option to hold the bed, because they may choose not to hold the bed, but without the documented bed hold notification form, they would not know. Continued interview with the DON, revealed not informing residents/responsible parties of the written information related to the facility's Bed-hold Policy, could cause an issue when the resident returned to the facility, if a bed was not available, due to not given the option to hold the bed. Interview on 11/16/19 at 4:20 PM with the Administrator revealed she expected resident care to be provided. Continued interview revealed it was her expectation the staff follow the policies and procedures of the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. (Refer to F690) Review of the clinical record revealed the facility admitted Resident #55 on 07/15/15. Diagnoses included Hemiplegia and hemiparesis following unspecified Cerebrovascular disease affecting right dominant side; Aphasia following unspecified Cerebrovascular disease; Unspecified open wound of penis, sequela (history of). Further review revealed the resident received hospice services. Continued record review revealed Resident #55 was re-admitted to the facility on [DATE], with a Foley catheter, and there was no documented evidence of a Physician's Order for the Foley Catheter after the re-admission, and no evidence the Comprehensive Care Plan was revised to include interventions for car or monitoring the Foley catheter. Review of the Quarterly MDS (Minimum Data Set) Assessment, dated 09/22/19 revealed Resident #55 was assessed as rarely/never understands/understood, and no BIMS score was assessed. Resident #55 was assessed by the facility as severely impaired for cognitive skills of daily decision making. The facility assessed Resident #55 as requiring total dependence of one staff for bathing and was assessed always incontinent of urine and bowel. Per the MDS, the resident was not assessed as having an indwelling catheter. Review of the progress notes dated 09/25/19 revealed Resident #55 was transferred to the emergency department for a change in condition, and was re-admitted to the facility on [DATE]. Further review of the progress notes, dated 09/27/19, revealed Resident #55 returned to the facility with a Foley catheter. Review of the Comprehensive Care Plan revealed a problem dated 07/04/19, for elimination and noted the resident had a potential for complications related to bowel and bladder incontinence and the resident was at risk for falls, skin breakdown, and UTI (urinary tract infection). Further review revealed a goal that the resident would not experience complications related to bowel and bladder incontinence with a goal date of 10/02/19. Interventions included provide incontinence care after each incontinent episode, report signs of UTI, use briefs for incontinent care, and report any signs of skin breakdown. Continued review of the Comprehensive Care Plan revealed no documented evidence the plan of care was reviewed or revised to include care for the Foley catheter when Resident #55 returned to the facility on [DATE] through the survey. Review of the Physician's Order's and past orders for Resident #55 revealed no evidence of an order for the catheter or for catheter care after the resident returned to the facility with the catheter on 09/27/19. Review of the Electronic Medication Treatment Record revealed no documented evidence the resident's Foley catheter was monitored or care provided related to the Foley catheter when the resident returned from the hospital with the Foley catheter on 09/27/19. Observations of Resident #55, on 11/12/19 at 12:43 PM, revealed the resident was in bed on his/her back, with eyes closed. Catheter tubing was observed with pale yellow urine in tubing to covered bedside drainage bag. Observations on 11/12/19 at 2:20 PM, 4:16 PM, on 11/13/19 at 9:56 AM and 3:50 PM, on 11/14/19 at 8:54 AM, and 11/15/19 10:16 AM, revealed the resident continued to have the catheter to bedside drainage. Observation of Resident #55's catheter, on 11/16/19 at 2:03 PM, with RN #6, revealed no leg strap securing the catheter. Interview with RN #6 at that time revealed if the resident had a leg strap, it would anchor the catheter to his/her leg better. The catheter bag was observed with approximately 100 cc urine in bag and per RN #6 interview. Continued observation revealed the area around the glans with yellowish white crusty substance in an amount that the nurse manually moved with her finger, and odor was noted when she moved the substance. Continued observation revealed a reddened extended area, approximately one (1) cm on the distal penis shaft on right side. RN #6 stated the resident had a growth that was removed from this area, and it is growing back. RN #6 revealed nursing was responsible for catheter care and she had not done catheter care at this time. RN #6 stated she thought the resident might have something like yeast or fungal and also stated she was unsure if today was the resident's scheduled bath day. Further interview with RN #6 revealed the nurse aides would change the resident's brief if the resident had a bowel movement or if it was bath day, and the aides empty the catheter collection bag. Review of a subsequent progress note, dated 11/16/19 at 2:13 PM, documented by RN #6, revealed the nurse cleaned around penis and noted some white exudate around base of head of penis with slight odor noted. Continued review of the note revealed that after the area was cleaned, the area was slightly red and she notified the NP of this and received and noted order to use TAO (Triple Antibiotic Ointment) PRN as needed. Review of Resident #55 Prescription order revealed an order dated 11/16/19 for Triple Antibiotic Ointment topical as needed. Interview with SRNA #7, on 11/16/19 at 02:03 PM, revealed she was the aide assigned to Resident #55 on this date. Continued interview revealed she was to empty the catheter bag at the end of shift. SRNA #7 indicted she does not clean the catheter unless bowel movement was on it; however she stated with the resident's bath, she would clean around the area and clean the penis. SRNA #7 stated she checked the resident to make sure the resident had not had a BM (bowel movement) today, and he/she had not and stated she hasn't looked at that area (catheter or penis) today. Interview with RN #6, on 11/16/19 at 8:45 AM, revealed she had worked with Resident #55 in past and was assigned his care today. Continued interview revealed when Resident #55 returned from the hospital with a catheter, the nurse should clarify with the Physician to continue the catheter, and the care plan should be updated because the resident requires catheter care. Continued interview revealed she thought catheter care was done every shift and check to make sure nothing crimped. RN #6 stated the aides do catheter care/perineal care and empty every shift. Continued interview with RN #6 revealed she reviewed the EMR for Resident #55. Per interview, there was no physician's order for the catheter when the resident returned to the facility on [DATE], no treatment noted on the Treatment Record, and nothing documented in the progress notes regarding care or treatment of the catheter. RN #6 stated there was no documentation on the Care Plan to address Resident #55's catheter. Continued interview revealed Resident #55's catheter should have been monitored. RN #6 indicted potential problems with a catheter not being monitored could be UTI, if the catheter was not cared for properly; or the resident could become distended or the catheter may not be in place anymore, if the resident was not having urine output. Interview with LPN #5, on 11/16/19 at 1:35 PM, revealed he cared for Resident #55 on 09/27/19, when the resident returned to the facility with the catheter. LPN #5 indicated he was advised by the hospital that the resident had the catheter because of surgery and a growth they removed from the penis, and the resident had stitches that fall off. LPN #5 stated he called the on call physician who advised him the facility physician would evaluate and see if resident needs catheter and discontinue if not. Continued interview revealed the physician order was supposed to have diagnosis documented. LPN #5 did not provide reason why he did not obtain physician's order for the catheter. Additional interview with LPN #5 revealed Resident #55's care plan should have been revised to include care of the catheter, after returning the facility with the catheter. LPN #5 stated the nurse on duty enters orders and then IDT (Interdisciplinary Team) does care plan and goes over everything in their meeting. Interview with the MDS Coordinator, on 11/16/19 at 11:55 AM, revealed when a resident returned to the facility with a catheter, the nurse should update the care plan. Per interview, the reason for updating the Care Plan was to know how to take care of the catheter and monitor the resident with the catheter. The MDS Coordinator stated she did not review the Care Plans the nurses put in place and she reviews Care Plans after each resident's MDS Assessment. Further interview revealed she had also seen Physician Orders that addressed when the catheter should be changed or for catheter care for residents in past. Continued interview revealed it was important to monitor residents with catheters, and if the catheter was not monitored, the resident could pull the catheter out or get infections. Interview with the Unit Manager on Resident #55's Unit, on 11/16/19 at 3:58 PM revealed when Resident #55 returned from the hospital with the catheter, Physician orders should have been obtained to include the size of the catheter, balloon size and diagnosis for the catheter as well as treatment orders for the Foley catheter care, and the resident's Care Plan should have been updated to include catheter care. However, she stated she did not find any documented evidence these things were completed when she reviewed Resident #55's record. Per interview, this could cause problems such as infection, as there was no documentation Resident #55 received catheter care. Interview with the DON, on 11/16/19 at 9:43 AM and 2:09 PM, revealed when Resident #55 returned from the hospital on 9/27/19, a Physician's order should have been obtained with diagnosis, on admission and the Care Plan should have been revised to address the catheter care. She further explained the catheter should have been monitored by nursing staff every shift, and this should have been on the Treatment Record. Continued interview revealed the IDT reviews every resident returning from the hospital and newly admitted residents, and review orders and ensure the Care Pan is updated. The DON stated the nurse admitting the resident should have obtained Physician's order's and initiated the Care Plan and then the IDT should have ensured it was in place. Per interview, nurses should do catheter care each shift, and typically there was a Physician's Order for catheter care every shift and this should be on the Care Plan. Interview with the Administrator, on 11/16/19 at 11:27 AM and 4:20 PM, revealed new orders were sent when a resident returned from the hospital to the facility with a catheter. The Administrator further stated the assessment was completed and orders should be clarified with the physician for diagnosis and a plan of care and should be put in place and followed. Further interview revealed newly admitted residents were reviewed in IDT meeting and they ensured orders were in place. She stated she was not clinical but aware residents could get UTI's (Urinary Tract Infections) with catheters. Per interview, it was her expectation that staff follow policies and procedures of the facility, that residents have Care Plans to meet needs of the resident and that the Care Plans be followed. She stated it was her expectation that all resident care was provided and this be documented in the record. 3. (Refer to F791) Review of facility policy titled Dental Services, dated last reviewed 06/05/18, revealed the facility must assist residents in obtaining routine and twenty four (24) hour emergency dental care. Continued review revealed the facility will assist the resident in making appointments and arranging for transportation to and from dentist's office. Review of the clinical record revealed the facility admitted Resident #9 on 05/23/11. Resident #9 had diagnoses which include Dementia in other diseases classified elsewhere with behavioral disturbance; Displaced fracture of left radial styloid process, subsequent encounter for closed fracture with routine healing and Muscle weakness. Review of the MDS assessment dated [DATE], a Significant Change assessment, revealed Resident #9 was assessed as having a BIMS (Brief Interview Mental Status) score of eleven (11) out of fifteen (15). Continued review revealed no items were assessed within the oral/dental section of the MDS. Review of the Quarterly MDS assessment dated [DATE] revealed the resident was assessed with a BIMS score of nine (9) of fifteen (15). Review of the Comprehensive Care Plan for Resident #9 revealed no documented evidence of a plan of care to address the resident's dental status. Record review revealed Resident #9 was seen by the dentist on 07/18/19. Further review of the documentation revealed the resident needed additional dental work for tooth #21 and #28. Per the dental evaluation documentation, Resident #9 had teeth #18, 24, 26, 29, and 30, which were documented non restorable and needed to be extracted by an oral surgeon. Continued review of the record revealed an Oral Surgery Referral, dated 07/18/19, for Resident #9. Record review revealed no documented evidence Resident #9 was evaluated by the oral surgeon per the referral 07/18/19 to through the date of survey 11/16/19. In addition, there was no documented evidence Resident #9's plan of care was revised to include the resident's dental needs. Observation and interview with Resident #9, on 11/12/19 at 12:35 PM and 11/13/19 at 10:17 AM, revealed the resident was observed to have some natural teeth. Interview with Resident #9 revealed he/she had seen the dentist in past at the facility but needed to see the dentist again. Resident #9 did not report any teeth causing pain at this time. Interview with the MDS Coordinator, on 11/16/19 at 11:55 AM, revealed the facility does not usually do referrals, such as the oral surgeon referral, on the Care Plan. She stated after the extractions the resident's Care Plan would be updated to include pain or follow up and instructions. Interview with the Social Services Assistant, on 11/15/19 at 3:12 PM, revealed she when a resident returned with a written order for referral to oral surgeon, the nurse received the order and completed an appointment sheet, then provided it to the appointment/transportation scheduler to set up the appointment. She stated it was then put in an appointment book. Subsequent interview on 11/16/19 at 2:12 PM revealed she did not know why the process was not completed at the time of referral on 07/18/19 for Resident #9. Interview with the Appointment/Transportation Scheduler, on 11/16/19 at 1:07 PM, revealed he was responsible for scheduling resident appointments and transportation. The Scheduler stated he had never received a referral for Resident #9. Interview with the Unit Manager 100 Unit, on 11/16/19 at 4:02 PM, revealed she was unsure of the policy but if paperwork was received for an appointment, the appointment should be scheduled the next business day. The Unit Manager stated she found no documentation Resident #9 was seen by the oral surgeon after the referral 07/18/19. She stated the nurse should have given the referral to the Appointment/Transportation Scheduler. Continued interview with the Unit Manager revealed potential problems with delay in the appointment could be pain, or weight loss if the resident wasn't eating an adequate amount of food. Interview with the DON, on 11/16/19 at 9:59 AM, revealed when Resident #9 returned to the facility with the consult/referral to oral surgeon, the nurses should have made the Appointment/Transportation Scheduler/Coordinator aware to schedule the appointment. She further stated Resident #9 should have had a Care Plan developed at the time the dental issue was identified by the nurse receiving documentation of the dental issue. Interview with the Administrator, on 11/16/19 at 11:18 AM and 4:20 PM, revealed she was unaware of any dental issues with Resident #9. She stated the process was if the dentist made a referral, the facility should make sure the follow up appointment was scheduled. The Administrator further stated dental issues should be on the resident's Care Plan. Continued interview revealed it was her expectation that staff follow policies and procedures of the facility. Based on observation, record review, and interview it was determined the facility failed to revise a comprehensive care plan for three (3) of the thirty (30) sampled residents. Resident #55 had a care plan for elimination however it was not revised to include the Foley catheter. Resident #79 had a care plan for nutrition however it was not revised to include the gluten free and lactose free allergies. Resident #9 had a care plan that was not updated to include dental status. The findings include: Record review of the facility policy titled, Comprehensive Care plans last revised on 07/19/18, revealed a person-centered comprehensive care plan would be developed for each resident and that would assist the facility on how to meet the residents needs. Record review further revealed the care plans were ongoing and revised as the resident had changes. The policy further revealed the nurse/Interdisciplinary Team was responsible for updating the care plans. 1. Interview with Resident #79 during the initial tour, on 11/13/19 at 9:55 AM, revealed the kitchen could not get the meals straight. Resident #79 stated he/she had to have lactose free and gluten free food and he/she cannot drink regular milk or eat white bread and he/she did not think the dietary department understood that. Resident #79 revealed they brought him/her regular milk today and it had to be sent back. Resident #79 stated if he/she had drank the regular milk she/he would have had diarrhea and sometimes vomiting. Record review of the face sheet for Resident #79 revealed the facility admitted the resident on 11/06/19 with diagnoses of Acute Pulmonary Edema, Congestive Heart Failure, End Stage Renal Disease, Hypertension, Diabetes Mellitus, Renal Dialysis, and Chronic Obstructive Pulmonary Disease. The record revealed Resident #79 was allergic to gluten. Record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/14/19, revealed Resident #79 had a Brief Interview of Mental Status (BIMS) of twelve (12) which meant the resident was not cognitively impaired. Record review further revealed Resident #79 was visually impaired and needed supervision with set up help for eating. Record review of the comprehensive care plan revealed a problem for nutritional status was addressed related to fluid restrictions and Irritable Bowel Syndrome. Diet as ordered was one of the interventions. Review of the comprehensive care plan revealed there was no indication Resident #79 had any food allergies and no interventions incorporated with the care plan to address the gluten free diet and lactose free diet. Interview with the MDS Assistant Coordinator, on 11/16/19 at 3:48 PM, revealed there was a care plan for nutrition and the problem was because Resident #79 was at risk for decline in nutrition. Interview further revealed the care plan had interventions for monitoring intakes, weights, diet: however she did not see allergy issues addressed. Interview further revealed Resident #79's care plan should have addressed food allergies. The MDS Assistant Coordinator further revealed Resident #79 needed lactulose free and gluten free foods but it was not included on her/his care plan and it should have been. The MDS Assistant Coordinator revealed the care plan informed the staff of what special diet the residents were on. The MDS Assistant Coordinator revealed she did not know why the food allergies was not addressed on the nutrition care plan and it should be. The MDS Assistant Coordinator stated she had several people doing the care plans and whoever did Resident #79's did not address allergies. Interview with the Administrator, on 11/16/19 at 10:12 PM, revealed they recognized they had a problem with comprehensive care plans and Certified Nursing Assistant (CNA) care plans in October 2019.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interview it was determined the facility failed to provide an ongoing program of activities for two (2) of the thirty (30) sampled residents from the care areas. Resident #90 and Resident #35 were to have facility provided activities, however, were observed to stay in their rooms with no activities provided. The findings include: Record review of the facility policy titled, Activity Program which was last revised on 07/25/17, revealed the facility would provide an on-going activities program designed to support the interest and choice of the residents. It further revealed the activity program was to help the resident obtain the highest level of mental, physical, and cognitive needs. In addition individualized and group activities were meant to encourage meaningful interacts to enhance the resident's sense of well-being. The policy further revealed residents were invited and encouraged to participate in activities. Record review of the facility policy titled, One-to-One Activities Program with a last revised date of 07/25/17, revealed the intent of the policy was to give residents who did not leave their rooms an opportunity to participate in activities. The policy further revealed activities would be scheduled on a regular basis. The policy stated a record of the activities would be provided on the activity record sheet and would include: the date. the activity provided, the amount of time in the activity, and the resident's response to the activity. The policy further revealed one-to-one activities would directly reflect the resident's needs, interests, and hobbies. 1. Observation of Resident #90, on 11/12/19 at 10:43 AM and 4:06 PM revealed he/she was just lying in the bed in his/her room. There was a communication board in the room. Observation, on 11/13/19 at 10:47 AM, revealed Resident #90 was lying in the bed in his/her room and was asleep. Observation further revealed, on 11/13/19 at 4:05 PM, Resident #90 was in his/her room and was awake. Observation further revealed he/she did not have a television for his/her viewing, however there was a CD player on his/her side of the room and it was not turned on. Observation, on 11/14/19 at 8:40 AM, revealed Resident #90 was in the bed in his/her room, awake there and was television or cd player on. Observation, on 11/14/19 at 3:21 PM, revealed Resident #90 was lying in bed in his/her room and there was no television or cd player on. Observation, on 11/15/19 at 03:22 PM, of Resident #90 revealed he/she was lying in bed in his/her room and was looking out the door. Observation further revealed there was no television or cd player on. Observation on 11/15/19 at 3:23 PM revealed there were thirteen (13) residents sitting down in the the dining room listening to a musician sing and play the guitar. Record review revealed the facility admitted Resident #90 on 10/02/19 with the diagnoses of Dysphagia, Intracranial Hemorrhage, Speech and Language Deficits, Hemiplegia, Hemiparesis, Cerebral Infarction, Respiratory Failure, Chronic Obstructive Pulmonary Disease, Gastrostomy, Hypertension, Tracheostomy, Schizophrenia, and Wound Myiasis. Record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/09/19, revealed Resident #90 did not have any hearing or vision problems. Review revealed they were unable to complete the cognition portion so there was no Brief Interview for Mental Status (BIMS) score. Review of the customary portion of the MDS revealed it was somewhat important to him/her to look at books, listen to music, be around animals, keep up with the news, and he/she liked to do things with groups, and he/she liked religious services. Record review of the functions section of the MDS revealed Resident #90 needed extensive assistance from staff for bed mobility, dressing, toileting, and hygiene. Record review further revealed Resident #90 had impaired range of motion to both of the lower legs. Record review of the comprehensive care plan for Resident #90 revealed a problem was listed for activities. The problem noted Resident #90 was at risk for decline in activities from previous recreational interests. One goal was for Resident #90 to participate in preferred activities and he/she would participate in one to one (1:1) visits. The approaches included one on one visits as scheduled, activities was to invite and encourage the resident to go to activity programs and 1:1 visits was to be done. Record review of the progress notes for Resident #90 revealed, on 11/14/19, he/she had requested a visit from the chaplain because he/she was depressed, frustrated, and angry. Interview on 11/16/19 at 1:29 PM, with the Activity Assistant, revealed she had only been in the position for less than a month. She revealed the Activity Director left employment around November 2, 2019. Interview further revealed the old activity person was doing activities with Resident #90 and the last recorded activity was October 28, 2019 and that was a worship visit. The Activity Assistant revealed she had not provided any activities to Resident #90 and she did not have a log of activities for her/him, because she was busy with other residents activities. She stated Resident #90 liked to attend church, listen to music, and watch television. The Activity Assistant stated Resident #90 was care planned for an altered activity program. Interview further revealed the facility had a musician come in the day before to entertained the residents, however, she did not invite Resident #90 because he/she was in bed when she walked down the hall and did not ask staff to get him/her up. She revealed Resident #90 might have liked to attend the activity with the musician. Observation, on 11/16/19 at 1:49 PM, revealed the Activity Director and this surveyor went down to Resident #90's room. Observation with the Activity Director and Resident #90 revealed Resident #90 shook his/her head yes when asked if he/she would like to get up and go watch a movie that was going to be played. Observation further revealed when asked if he/she liked music she touched yes on the communication board and when asked if he/she liked to watch television he/she touched yes on the communication board. Observation further revealed when asked if she/he liked guitar playing and singing he/she touched yes on the communication board. Interview, on 11/16/19 at 1:49 PM, with the Activity Assistant, revealed the purpose of the activity program was to improve the residents daily life. The Activity Assistant further revealed activities kept the residents minds stimulated. Interview with the MDS Assistant Coordinator, on 11/16/19 at 3:12 PM, revealed Resident #90 had an activity care plan and the approaches included: one on one visits, pet visits, and the resident was to be invited and encouraged to attend activity programs. Interview further revealed Resident #90 could have general loneliness, feel isolated, and develop depression if not able to attend activities. Interview with Registered Nurse (RN) #3, on 11/16/19 at 2:30 PM, revealed Resident #90 could get up in a wheelchair and go to activities but right now therapy was working on a more comfortable wheelchair for him/her. RN #3 revealed Resident #90 could still participate in activities in her room. 2. Observation on 11/12/19 at 10:49 AM revealed Resident #35 was lying in bed on the left side and was asleep. Observation on, 11/13/19 at 9:45 AM, revealed Resident #35 was lying in bed and no activities had occurred. Observation on 11/13/19 at 3:49 PM, revealed Resident #35 did not have any activities going on in his/her room. Observations, on 11/14/19 at 8:47 AM, revealed Resident #35 was sitting up in bed eating his/her breakfast. Observation, on 11/14/19 at 9:43 AM, revealed Resident #35 was in his/her room with no in room activities. Observation, on 11/16/19 at 9:29 AM revealed Resident #35 was lying in bed on the back with no in activities. Record review revealed Resident #35 was admitted on [DATE] with diagnoses to include Heart Failure, Acute Respiratory Failure, Chronic Obstructive Pulmonary Disease, Hypertension, Dementia without Behavioral Disturbance, Pressure Ulcer of Sacral Region, Stage Four (4), Wound Myiasis, and Pressure Ulcer of the Left Heel, Stage 1. Record review of the current physician orders for October 16, 2019 to November 16, 2019, revealed Resident #35 was to limit the time out of bed to one and one half hours a day for fourteen (14) days. Record review of the quarterly Minimum Data Set (MDS) with an Assessment Review Date (ARD), of 09/06/19, revealed Resident #35 needed extensive assist of one person for dressing and bed mobility. Resident #35 had a BIMS score of seven (7) which indicated he/she had impaired cognition. Further review revealed it was somewhat important to the resident to have books, music, new, group, and religious activities. In addition, Resident #35 was incontinent of bowel and bladder. Record review of the annual MDS with an ARD of 06/06/19 revealed Resident #35 was totally dependent on one staff for bed mobility and needed extensive assist of one for dressing. Record review of the comprehensive care plan, revealed Resident #35 had a problem listed for activities and the goal was for the resident to be engaged in programs within his/her abilities. Record review of the approaches on the care plan revealed the facility was to provide specialized small group, sensory, and one-on-one activities. Record review of the Annual Quality of Life Lifestyle Review dated 05/30/19 revealed Resident #35 enjoyed pet visits, and listening to music, Interview, on 11/16/19 at 2:03 PM, with the Activity Assistant revealed Resident #35 would not come out of the room very much and had refused at times, but there was no documentation of the refusal of activities. Interview with the Activity Assistant revealed she had not done any activities with Resident #35 since October. The Activity Assistant revealed Resident #35 had pet therapy on October 15, 2019 and worship service on 10/28/19 and that was the last documented activity with the resident. The assistant stated Resident #35 was nominated for an award and he/she went to that on November 7, 2019 and that was the only activity done with the resident since October 2019. The Activity Assistant revealed the old Director had done most of the one-on-one activities with the resident and since the Director was gone, she had not been able to work with Resident #35. Interview, on 11/16/19 at 2:32 PM, with Registered Nurse (RN) #3, revealed Resident #35 was limited to the amount of time he/she was allowed up in the chair because of the pressure area on the coccyx. RN #3 revealed he/she should only be up two or three hours a day but if he/she wanted to stay up longer the physician said it would be okay. RN #3 stated Resident #35 could go to activities or could have activities in the room. Interview, on 11/16/19 at 3:04 PM, with the MDS Assistant Coordinator, revealed Resident #35 had a care plan for activities and the approaches should have been implemented. The MDS Assistant Coordinator revealed if the activity care plan had not been followed then Resident #35 could have loneliness and psychosocial problems. Resident #35 would be at risk for depression if the comprehensive care plan for activities was not followed. Interview, on 11/16/19 at 4:26 PM, with the DON revealed she did not know why Resident #35 and #90 were not provided activities. Interview, on 11/16/19 at 10:12 PM, with the Administrator revealed she was not aware of any issues with activities.

Based on observation, record review, and interview it was determined the facility failed to provide treatment and care for one (1) of the thirty (30) sampled residents, Resident #70. Resident #70 was to have his/her leg wrapped with an ace wrap and this was not done consistently. The findings include: Record review of the facility policy titled, Review of Physician Orders last revised on 11/06/19, revealed the Director of Nursing /designee would review the Electronic Medical Record (EMR) regarding documentation to support a change in condition and appropriate measures were provided, Record review of the clinical record revealed the facility admitted Resident #70 on 09/28/18 with diagnoses of Atherosclerotic Heart Disease, Cerebral Infarction, Hypertension, Diabetes Mellitus, Dysphagia, Psychotic Disorder with Delusions, Wound Myiasis, Excoriation disorder, and Non Specific Skin Eruptions. Record review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/29/19 revealed Resident #70 had a Brief Interview of Mental Status (BIMS) score of thirteen (13) which meant the resident did not have impaired cognition. Record review of the functions section on the MDS revealed Resident #70 needed extensive assist of one person for transfer, locomotion, dressing, eating, toileting, and hygiene. Record review further revealed Resident #70 had impaired range of motion on one side of the lower extremity and he/she had a prosthetic leg. Record review of the physician orders for 11/01/19 through 11/13/19, revealed the left lower extremity was to be cleansed with soap and water, moisturizer and kerlix applied and then the leg was to have a four (4) inch Ace wrap from the toes to the ankle and a six (6) inch Ace wrap from the ankle to the knee. This was to be done daily. Record review of the physician orders further revealed the Kerlix and Ace wraps were to be removed once a day at bedtime. Review of the order on the Medication Administration Record for the left lower leg, stated Kerlix and Ace wraps to be removed once a day at bedtime between 19:00 and 23:00 hours. Continued review revealed there was no application time for the morning Ace wrap application listed; everything was listed as nightly. Record review of the comprehensive care plan revealed a problem was listed for several non pressure open areas to the left lower extremity. Review of the goal was for the open areas to heal without complications. Record review of the approaches showed Ace wraps were to be applied as ordered. Observation of Resident #70, on 11/12/19 at 11:44 AM, revealed he/she was in physical therapy. Observation further revealed there were three small bandages on the left leg and the right leg was amputated and the resident had a prosthetic leg in place. Observation of Resident #70, on 11/13/19 at 12:12 PM, revealed the left leg was not wrapped with any type of bandage. Interview with Resident #70, on 11/12/19 at 11::44 AM, revealed the nurses were supposed to apply the Ace wraps in the morning and remove them at night, but they did not seem to know when to put the wraps on or when to take them off. Resident #70 stated the Ace wraps were to be applied to help keep the swelling down and when on his/her leg felt better. Interview with the MDS assistant coordinator, on 11/16/19 at 4:32 PM, revealed she was not the coordinator but the assistant and they had just hired a new MDS coordinator but she had not started yet. The MDS assistant coordinator stated the Ace wraps should have been applied because the wraps would provide pressure for better circulation. She revealed if the wraps were not applied it could cause the sores to worsen and more could development. Interview, on 11/15/19 at 10:30 AM, with the Director of Nursing (DON), revealed Resident #70 had a physician order for left lower extremity Ace wraps. She revealed Resident #70 had to have the ACE wraps for compression to keep the leg from having increased edema. The DON further revealed it was the nurses responsibility to apply the ACE wraps and she did not know why it was not done. However after reviewing the MAR she revealed the wraps may not have applied because of the way the order was written on the MAR. She revealed there was no area for the day shift nurse to initial that the wraps were applied. The DON revealed the physician orders should have been followed for the safety and wellness of Resident #70. Interview with the Administrator, on 11/16/19 at 10:12 PM, revealed her job as the administrator was to oversee the well being of the residents and make sure the facility met regulatory expectations.

Based on observation, interview, and record review it was determined the facility failed to provide care to prevent the development of pressure ulcers for one (1) resident of the thirty (30) sampled residents. Resident # 35 was to have heel lift boots on at all times, except when transferring or in a wheelchair. Observations revealed Resident #35 did not have heel lift boots on for two days. The findings include: Record review of the facility policy, Pressure Ulcer (Injury) Treatment revised on 07/24/18, revealed the purpose of the policy was to provide guidelines for the prevention of additional pressure injuries. The policy further revealed pressure-relieving devices were to be implemented in conjunction of the resident's assessed needs. Observation on 11/14/19 at 9:45 AM, revealed Resident #35 was lying in bed on a Recovery Pressure Mattress. Licensed Practical Nurse (LPN) #1 was going to do his/her pressure sore treatment to the coccyx. Nurse Consultant #9 assisted LPN #1. Observation revealed Resident #35 did not have any pressure relieving devices on the feet before the treatment began and LPN #1 did not apply any heel lift boots or prevalon boots to the feet when the treatment to the coccyx was completed. Skin assessments revealed no other skin issues for Resident #35. Observation on 11/16/19 at 9:29 AM, revealed Resident #35 was lying in bed and did not have any heel lift boots on the feet. Record review revealed the facility admitted Resident #35 on 6/26/18 with diagnoses to include Heart Failure, Acute Respiratory Failure, Chronic Obstructive Pulmonary Disease, Hypertension, Dementia without Behavioral Disturbance, Pressure Ulcer of Sacral Region, Stage Four (4), Wound Myiasis, and Pressure Ulcer of the Left Heel, Stage 1. Record review of the current physician orders for October 16, 2019 to November 16, 2019 revealed Resident #35 was to have a Prevalon boot to the left foot at all times except when transferred or ambulated. Another physician order revealed heel lift boots were to be worn to bilateral lower extremities and no shoes but non skid stockings only. Record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/06/19 revealed Resident #35 needed extensive assist of one person for dressing and bed mobility. Record review further revealed Resident #35 was incontinent of bowel and bladder. The quarterly MDS further revealed Resident #35 had a stage IV pressure ulcer to the coccyx. Record review of the annual MDS with an ARD of 06/06/19 revealed Resident #35 was totally dependent on one staff for bed mobility and needed extensive assist of one for dressing. Review of the annual MDS further revealed Resident #35 did not have any pressure sores. Record review of the comprehensive care plan for Resident #35 revealed the resident was at risk for alteration in skin integrity because the resident was incontinent and immobile. Review of the interventions revealed Resident #35 was to have his/her heels floated while in bed. Another problem on the comprehensive care plan was for an alteration in skin integrity because Resident #35 had a Stage 1 pressure injury to the right and left heels. Review of the interventions revealed the heels were to be floated while in bed. Record review of the Certified Nursing Assistant (CNA), Care Report, not dated, for Resident #35, revealed there was no indication that the resident needed heel lift boots or prevalon boots at all times. Interview with Registered Nurse (RN) #3, on 11/16/19 at 9:33 AM, revealed Resident #35 was to have heel lift boots on bilateral with a prevalon boot to the left foot except with transfers and ambulation. RN #3 went into Resident #35 room and noted he/she did not have any heel lifts boots or prevalent boots on either foot and after she looked around the room she determined there were none in the room for him/her to wear. RN #3 revealed Resident #35 had an old wound to the left heel that had healed. RN #3 revealed the resident was at risk for the pressure area to reoccur if the heels were not floated on the bed with the prevalon boots or heel lift boots. RN #3 revealed the nurses or the CNA could apply the heel boots. Interview with LPN/Certified Nursing Assistant (CNA) #2, on 11/16/10 at 9:40 AM, revealed she was an LPN but was working as a CNA that day. LPN #2 revealed Resident #35 was total care and that she was not aware that the resident needed heel lift boots in bed but she would go check the CNA care book. LPN #2 revealed she could not review the kiosk to see what the resident needed but would check the CNA care plan book on the unit. LPN #2 reviewed the CNA care plan and revealed there was nothing on it to indicate Resident #35 needed any heel protectors. Interview with RN #4, on 11/16/19 at 9:47 AM, revealed Resident #35 was at risk for pressure sore formation because he/she was in bed a lot. RN #4 revealed she did not know if the resident needed any kind of boots for the heels when in bed but she would review the physician orders. Interview with RN #4, after she reviewed the physician orders, revealed Resident #35 was supposed to have prevalon boots on the left because more than likely the heels were soft or had redness. RN #4 revealed she had been into see Resident #35, but had not checked to see if there were boots on. RN #4 revealed the heel lift boots and prevalon boots were probably a preventative measure to prevent skin breakdown. Interview with the Minimum Data Set (MDS) Coordinator, on 11/16/19 at 3:24 PM, revealed Resident #35 had a problem listed for pressure to the left and right heels and one of the interventions was to float the heels when in bed. The MDS Coordinator further revealed Resident #35 had an order for heel lift boots to the lower extremity for every shift and this should be done and the care plan should be implemented to relieve pressure to the heels and prevent further skin breakdown. Interview with the Director of Nursing (DON), on 11/16/19 at 4:22 PM, revealed the physician orders should have been followed and did not know why the heel lift boots and prevalon boots were not applied as ordered. The DON stated the boots were ordered to protect Resident #35's skin because he/she was at risk for skin breakdown. Interview with the Administrator, on 11/16/19 at 10:12 PM, revealed her role was to oversee the well being of each resident and make sure the facility had met the regulatory expectations. The Administrator revealed she had no quality issues about pressure sores.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview and policy review it was determined the facility failed to ensure two (2) residents out of the thirty (30) sampled residents was free from potential falls, Resident #9 and #61. Resident #61 had a history of falls and was supposed to have non skid socks on to help prevent falls. Resident #9 was supposed to have a physical therapy (PT) evaluation done after a fall with a fracture and the PT evaluation was not done. In addition, the investigation of the fall was not comprehensive. The findings include: Record review of the facility policy titled, Falls last revised on 11/06/19, revealed the intent was to provide residents care to minimize the risk of falls and injury. The policy further revealed the care plan interventions would be implemented and evaluated. Review further revealed the care plan would be reviewed after each fall and revised as needed in accordance with the assessment. The Falls policy stated if a fall occurred the Interdisciplinary Team (IDT) would determine the root cause and a referral to therapy would be done if indicated. Record review of the facility policy titled, Safety and Supervision of Resident last reviewed 05/31/18, revealed staff should make routine resident checks to help maintain resident safety to prevent accident. 1. Observation of Resident #61, on 11/12/19 at 11:37 AM, revealed the resident was laying in bed and then stood up from the side of the bed with nothing on his/her feet. Resident #61's pants and shirt were wet and he/she was shaking and unsteady as she/he bent forward to get his/her shoes that were on the floor. Observation further revealed the sheets were partly hanging from the side of the bed and onto the floor where he/she had tried to stand up. Registered Nurse (RN) #7, observed in the hallway, was summoned to the room and she was not sure if the resident could stand or walk alone. RN #7 kept watch on Resident #61 as she stood at the door to try and get help from someone. Finally Certified Nursing Aid (CNA) #6 came into the room and assisted the resident. Observation further revealed CNA #6, stated he/she smelled like the resident needed to be changed. Observations revealed CNA #6 changed Resident #61's brief and put his/her clothes back on and then applied non slip socks to the feet. Observation of Resident #61, on 11/12/19 at 12:45 PM, revealed his/her clothes had been changed. Observation of Resident #61, on 11/14/19 at 8:00 AM, revealed he/she was sitting on the side of the bed, trying to remove the hospital gown and did not have any shoes or socks on. Observation, on 11/14/19 at 9:28 AM, of Resident #61, revealed he/she was sitting in the wheelchair in the hallway and staples were noted to be on the side of his/her head in the scalp. Record review of the clinical record revealed the facility admitted Resident #61 on 08/15/16 with diagnoses of Moderate Intellectual Disabilities, Urinary Tract Infection, Hypertension, Mood Disorder, Reflux, Dysphagia, Seizures, Panic Disorder, Anxiety, and Depression. Record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/27/19, revealed Resident ##61 had a Brief Interview of Mental Status (BIMS) of seven (7) which meant the resident was cognitively impaired. Review of the functional ability revealed with bed mobility, transfer, dressing, eating, toileting, hygiene Resident #61 needed extensive assist of one person. Review further revealed Resident #61 needed supervision of one person with walking. Review of the balance section revealed Resident #61 was not steady but was able to stabilize himself/herself without human touch. Review showed Resident #61 did not have any impairment of the range of motion. Review further revealed Resident #61 was incontinent of bladder and had a colostomy. Record review of the falls section revealed Resident #61 had fallen and did not have any major injury. Record review of the fall risk evaluation done on 04/08/2019, revealed Resident #61 had a score of seventeen (17) which meant he/she was at risk for falls. Review of the evaluation revealed a score of higher than ten (10) they were at risk for falls. Record review of the comprehensive care plan for Resident #61 revealed the resident was at risk for falls related to urinary incontinence, poor safety awareness, potential adverse reaction to psychoactive medication, and a balance deficit. Review of the approaches revealed Resident #61 was to be assisted to sit when he/she was restless, referral to physical therapy or occupational therapy, and he/she was to have non-slip socks on at all times. Interview with Registered Nurse (RN) #4, on 11/16/19 at 10:06 AM, revealed Resident #61 needed to wear non slip socks at all times because he/she was sometimes unsteady and the non slip socks kept him/her from slipping and falling. Interview with the MDS assistant coordinator, on 11/16/19 at 3:18 PM, revealed Resident #61 was at risk for falls and he/she had fallen before. The MDS assistant coordinator further revealed it was important for staff to follow the care plan for Resident #61 because one of the interventions was for non slip socks to be worn at all times and that meant in bed too. She revealed Resident #61 had poor balance and he/she ambulated without assistance. She further revealed the non slip socks was a measure to help prevent falls and if the resident was barefooted there was more of a risk that he/she might fall and be injured. Interview with the Director of Nursing (DON), on 11/15/19 at 11:12 AM, revealed Resident #61 had a history of falls and had sustained a fall on 11/06/19 at 8:40 PM, when he/she lost their balance and fell in the hallway. The DON revealed she did not know if the resident had shoes and socks on that day and it was not noted in the fall investigation. Resident #61 had to go to the emergency room and received two staples for the laceration to the head. The fall was brought to the Interdisciplinary (IDT) team meeting and they tried to figure out the root cause. Interview with the DON further revealed the facility did not consider a physical therapy consult to increase endurance because Resident #61 had not had a decline in gait but was just walking more that day. The DON revealed Resident #61 had not had any recent therapy other than speech therapy. The DON revealed they do not like to use alarms on residents because of the chance of increased agitation as denoted in recent studies. Interview further revealed Resident #61 should have non slip socks on at all times and that was one of the interventions incorporated into the comprehensive care plan. Record review of the fall investigation for Resident #61 revealed on 11/6/19 the resident lost his/her balance while walking in the hallway and fell and hit his/her head. The investigation was completed and the root cause was identified as fatigue when standing for long periods. Interview with the Administrator, on 11/16/19 at 10:12 PM, revealed they had identified a problem with falls in Septembers 2019. The Administrator revealed it was her role as the administrator to oversee the well being of the residents and make sure the facility met regulatory expectations. 2. Review of the clinical record revealed the facility admitted Resident #9 on 05/23/11. Continued record review revealed Resident #9 had diagnoses which included Dementia in other diseases classified elsewhere with behavioral disturbance; Displaced fracture of left radial styloid process, subsequent encounter for closed fracture with routine healing; Muscle weakness; and Difficulty in walking, not otherwise classified. Review of the Significant Change MDS assessment dated [DATE], revealed Resident #9 was assessed as having a BIMS (Brief Interview Mental Status) score of eleven (11) out of fifteen (15). Continued review revealed the facility assessed Resident #9 as independent with no setup or physical help from staff for ambulating in room and corridor. Resident #9 was assessed as having one (1) fall with major injury since the prior assessment. Review of the Quarterly MDS assessment dated [DATE] revealed the resident was assessed with a BIMS score of nine (9) of fifteen (15). Continued review revealed the facility assessed Resident #9 as independent with no setup or physical help from staff for bed mobility, transfer, ambulating in room and corridor, and on and off the unit. Resident #9 was assessed as having no falls since the prior assessment. Review of the Fall Risk Evaluation dated 05/01/19, revealed Resident #9 scored ten (10) with a resident score of ten (10) or higher being at risk. Review of the Fall Risk Assessment Tool dated 07/26/19, after the resident sustained the fall, revealed the resident's fall risk score was fifteen (15) indicating high fall risk for score greater than thirteen (13). Review of the Comprehensive Care Plan for Resident #9 revealed a plan of care for falls, dated 07/24/19, which documented the resident was at risk for fall related injury related to: previous fall, balance deficit, poor posture, potential adverse effects related to psychoactive and pain medications. Continued review revealed a goal the resident's fracture would continue to heal without complications with a target date 02/14/20. Interventions included remind and encourage resident not to wait too long before heading to the toilet, dated 08/16/19, and referral for screen and treatment as needed with OT and PT checked, with approach start date 07/24/19. Interview with Resident #9, on 11/13/19 at 10:22 AM, revealed he/she tripped one time and fractured his/her left wrist, and had a cast. Per interview, the resident thought it happened about a year ago. Continued interview with the resident revealed he/she stumbled in the hall, and someone came to the facility and took x-rays. The resident stated he/she went to the doctor for the broken arm as well. Observation of Resident #9, on 11/12/19 at 12:35 PM, revealed the resident was wearing shoes, sitting at the dining room table. Interview with the resident revealed he/she likes bingo and attends activities. Observations on 11/13/19 at 9:55 AM and 3:46 PM, revealed Resident #9 was sitting in a chair in area near the Nurse's station, talking with another resident, and wearing shoes. Observation on 11/15/19 at 10:17 AM, revealed Resident #9 in bed on back, with eyes closed. Review of the Event Report created by Licensed Practical Nurse (LPN) #5, dated 07/24/19, revealed the fall was witnessed as the resident stood up and walked to the dining room for dinner. Record review of Progress notes revealed a note, dated 07/25/19 at 4:05 AM, revealed the Advanced Practical Registered Nurse (APRN) gave an order to send to the resident to the emergency room (ER) related to fracture needing to be set. Review of a progress note, dated 07/25/2019 at 4:03 AM, revealed the facility sent the resident to ER related to x-ray showing left acute distal radial fracture. Review of progress notes revealed no evidence of documentation at the time of the fall. Review of the facility Fall Investigation created by Licensed Practical Nurse (LPN) #5, revealed the resident sustained a fall on 07/24/19, and the physician was notified at 6:10 PM. New orders were received and directed staff to monitor the resident, do an X-ray of the left wrist, elbow, and fingers. Continued review of the Fall Investigation revealed the resident was walking in the hallway, lost his/her balance, and fell very close to the Nurse's Station, with his/her bottom on the floor and left hand and elbow on the floor. Further review revealed there was no documentation of whether the root cause analysis was conducted or not, and there was no documented evidence of what the root cause was determined to be. Further review of the Fall Investigation summary revealed the Interdisciplinary Team reviewed the fall, and noted the resident presented with Dementia, fell and attempted to break his/her fall and sustained a fracture to left forearm. Interventions put in place was to have Physical and Occupation Therapy to evaluate. Continued review of the record revealed Resident #9 was evaluated by OT on 08/13/19. However, there was no documented evidence Resident #9 was evaluated by PT, after the resident's fall per the facility Fall Investigation and the resident's Comprehensive Care Plan. Interview with LPN #5 on 11/16/19 at 1:43 PM, revealed he was working when Resident #9 sustained the fall on 07/24/19 and saw it happen. Continued interview revealed the resident told him he/she lost balance and fell. He stated the resident had shoes on and was able to ambulate on his/her own. LPN #5 stated he checked the resident and ROM (range of motion) to the extremities. An x-ray was completed and was positive for fracture and the facility sent the resident to the hospital. Further interview revealed after a resident fall, he was to complete incident report and fall investigation and document in the progress notes. However, when he reviewed the progress notes he stated he did not find the note regarding the fall but he should have completed the documentation. Continued interview revealed if they find the cause of the fall, they update the care plan and Falls were reviewed in the IDT meeting. LPN #5 stated the ITD may do more interventions or change them. LPN #5 stated generally a PT evaluation was completed after a resident fall, but he did not complete PT/OT referrals, for Resident #9, and further stated the IDT must have completed the referral. Interview with the MDS Coordinator, on 11/16/19 at 11:55 AM, revealed falls were discussed in the IDT meetings and the DON signed off on fall investigations. Continued interview revealed Resident #9 should have had a PT evaluation after the fall if the care plan was revised to do this. Further interview revealed the facility has a form that anyone can complete for therapy referral and residents were usually seen by PT after a fall. Interview by phone on 11/16/19 at 7:57 PM, with the Therapy Director, revealed she could not recall receiving a referral for Resident #9 for PT after the fall. Continued interview revealed PT had received a recent referral around the end of October related to the resident not walking as well. The Therapy Director further explained when a therapy referral was received, they sometimes do a full write up or just make a note on the referral, and then documentation was placed in a mailbox to send to medical records, as therapy did not have a way to make a narrative note in the EMR. Further interview revealed after Resident #9's fall on 07/24/19, she thought Therapy's only involvement was OT. Interview with the Licensed Practical Nurse (LPN) Unit Manager on Unit 100, on 11/16/19 at 4:07 PM, revealed the process after a fall was to assess the resident, check ROM, notify the Physician and family, and determine the root cause-what was resident trying to do and what do to prevent in future. The Unit Manager further stated there should be progress notes and follow up documentation, and stated she had looked and there was no documentation in the Progress Notes at the time of resident #9's fall, and only documentation the following day. Continued interview revealed the nurse should call the DON and advise her of prior interventions and over phone the nurse and DON should determine intervention and place on the care plan at the time. She further stated Falls were reviewed in the IDT meeting, which therapy attends, and if the Care Plan was updated for OT/PT, the resident should have been evaluated and the referral completed by the nurse on the unit. Interview on 11/16/19 at 11:45 AM and 12:25 PM, with the Clinical Nurse Consultant, revealed the fall was an isolated incident for the Resident #9, and stated the resident had no prior falls and no falls since. She further stated she does not know why the root cause was not on the Fall Investigation form nor why it was not signed. She stated the Director of Nursing (DON) normally was responsible but the DON at that time was no longer employed at the facility and stated it could have been when they had an interim DON. Continued interview with the Clinical Nurse Consultant, revealed she did not find any documentation the PT evaluation was completed per the Care Plan after Resident #9's fall on 07/24/19, and it should have been completed or there should have been documentation as to why it was not completed. Interview with the Director of Nursing (DON), on 11/16/19 at 2:18 PM, revealed the current process with a resident fall was for the nurse to assess the resident, identify what resident was doing, check the scene, and identify what intervention/s they could implement to prevent another fall. She stated currently nursing staff were to call her with all falls and nursing would be responsible for completing PT/OT referrals, but she was not sure how this was done at the time of Resident #9's fall as she was not employed at the facility at that time. She further stated typically the DON completed the fall investigation, but this investigation was prior to her working at the facility. Continued interview with the DON revealed she reviewed the fall investigation and Event Report/Incident Report for Resident #9 and said she does not see where root cause analysis was investigated, and the reason for the investigation was to try to prevent future occurrences and change in the resident. Continued interview revealed there should have been a PT evaluation or screening, per the care plan intervention. She stated a problem with the PT evaluation not being completed, was the resident could have a decrease in functional mobility or falls. Interview with the Administrator, on 11/16/19 at 11:24 AM and 4:20 PM, revealed she was not employed at the facility at the time of Resident #9's fall on 07/24/19. Continued interview revealed it was her expectation that the residents root cause be identified with each fall and it was not for Resident #9. She further stated it was her expectation that staff follow facility policies and procedures. Continued interview revealed it was her expectation that after a fall, interventions be put in place, and care plans be updated and followed to prevent future falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Interview on 11/16/19 at 3:00 PM with the facility Nurse Consultant revealed the facility does not have a specific policy on catheters or catheter monitoring, and only have a Catheterization policy and Catheter Care Procedures which were provided. Review of the Catheterization policy, dated last reviewed 05/23/18, revealed the policy documented Guideline Steps for the procedure of catheterizing a resident. Further review of the policy revealed tape the catheter or apply a Velcro leg strap. Never leave the room until the catheter is secured. The mechanical irritation caused by catheter movement can cause urethral and meatal tearing, accidental removal, and serious complications. For the female resident, secure the catheter to the upper thigh. The catheter in the male is secured to either the upper thigh (with a leg strap) or the abdomen (with tape). Review of the Catheter Care Procedures policy, dated last reviewed 05/23/18, revealed the policy documented Guideline Steps for providing catheter care. Review of the policy Review of Physician's Orders, dated last reviewed 11/06/19, revealed it was the standard of this facility that physician orders were reviewed daily to ensure delivery of applicable care, tracking of change of condition and updating care plans were consistently provided. Per policy guideline, Physician Orders were to be reviewed daily by nursing administration during the Clinical Meeting, residents would be added to the respective tracking logs, and DON/designee would review EMR (electronic medical record) as indicated regarding documentation supporting the change of condition and providing appropriate measures. Review of the facility policy titled Change of Condition, dated reviewed and revised 11/06/19, revealed the facility would evaluate and document changes in a resident's health status, relay evaluated information to the Physician, and document actions such as a significant change or need to alter treatment. Per policy, the licensed nurse or NP (Nurse Practitioner) would evaluate any change of condition through direct observation, physical examination, and vital signs at the onset of change and as ordered by the physician. Enter orders as needed in the EMR, follow up and documentation by the licensed nurse should continue for seventy-two (72) hours, address the change on the twenty-four (24) hour report, and update the care plan as needed. Review of the clinical record revealed the facility admitted Resident #55 on 07/15/15. Diagnoses included Hemiplegia and hemiparesis following unspecified Cerebrovascular disease affecting right dominant side; Aphasia following unspecified Cerebrovascular disease; Unspecified open wound of penis, sequela (history of). Further review revealed the resident received hospice services. Review of the Quarterly MDS (Minimum Data Set) Assessment, dated 09/22/19 revealed Resident #55 was assessed as rarely/never understands others and rarely/never understood and no BIMS score was assessed. Resident #55 was assessed as severely impaired for cognitive skills of daily decision making. Resident #55 was assessed as total dependence of one staff for bathing and always incontinent of urine and bowel. The resident was not assessed as having an indwelling catheter. Review of the progress notes, dated 09/25/19, revealed Resident #55 was sent to the hospital emergency department for a change in condition, and returned to the facility on [DATE]. Per progress notes, dated 09/27/19, a 16 French Indwelling Foley catheter was noted on return, related to Urinary retention, and also noted a spot on resident's Penis was removed and 3 stitches noted. Further review of the note revealed Discharge orders were verified by Hospice APRN, who also made changes to resident's orders, and orders transcribed and noted. Continued review of the progress notes revealed no further documentation regarding the resident's catheter after the resident returned from the hospital on [DATE] through the survey, until 11/16/19. Review of the Physician's Order's and past orders for Resident #55 revealed no evidence of an order for the catheter or for catheter care after the resident returned to the facility with the catheter on 09/27/19. Review of the Physician's Order Report, dated 11/14/19 revealed an order, dated 11/12/19, documented as follows, Foley Catheter to straight drainage, Special Instructions: Privacy bag at all times. However, no diagnosis or indication for catheter use was found. Review of the EMR Treatment Record revealed no documented evidence the resident's Foley catheter was monitored or care provided related to the Foley catheter when the resident returned from the hospital with the Foley catheter on 09/27/19. Review of the Treatment Administration History, dated 11/01/19 through 11/16/19 revealed no documented evidence of treatment order in place until 11/16/19. Continued review of the Treatment Administration History revealed new treatments, dated 11/16/19, which included Foley catheter care every shift, Foley output every shift, and change catheter prn leakage, blockage or dislodgement. Review of the Comprehensive Care Plan revealed a problem with a start date 07/04/19, for elimination. Continued review revealed the resident has a potential for complications related to bowel and bladder incontinence and the resident was at risk for falls, skin breakdown, and UTI (urinary tract infection). Documented goad was resident will not experience complications related to bowel and bladder incontinence with a goal date of 10/02/19. Interventions included provide incontinence care after each incontinent episode, report signs of UTI, use briefs for incontinent care, and report any signs of skin breakdown. Review of the Comprehensive Care Plan for resident #55, revealed no documented evidence the plan of care was updated to care for the Foley catheter, when the resident returned to the facility with the catheter on 09/27/19. Observations of Resident #55, on 11/12/19 at 12:43 PM, revealed the resident was in bed on his/her back, with eyes closed. Catheter tubing was observed with pale yellow urine in tubing to covered bedside drainage bag. Observation on 11/12/19 at 2:20 PM, revealed the resident was in bed with lunch tray on the bedside table, in reach of the resident. Attempt to interview resident revealed the surveyor was unable to determine resident speech. Staff entered asking resident if he/she was going to eat. Observation on 11/12/19 at 4:16 PM, revealed the resident was in bed laying toward right side, eyes closed, pale yellow urine in catheter tubing. Observations of Resident #55 on 11/13/19 at 9:56 AM and 3:50 PM, and 11/14/19 at 8:54 AM, and 11/15/19 10:16 AM revealed the resident continued to have catheter to bedside drainage. Observation of Resident #55's catheter, on 11/16/19 at 2:03 PM, with RN #6, revealed no leg strap securing the catheter. Interview with RN #6 at that time revealed if the resident had a leg strap, it would anchor the catheter to his/her leg better. The catheter bag was observed with approximately 100 cc urine in bag. Continued observation revealed the area around the glans with yellowish white crusty substance in an amount that the nurse could manually move with her finger, and when she moved the substance, foul odor was noted. Continued observation revealed a reddened extended area, approximately one (1) cm on the distal penis shaft on right side. RN #6 stated this is the growth that was removed and it is growing back. Continued interview with RN #6 revealed she had not done catheter care at this time. RN #6 stated it looked like the resident might have something like yeast or fungal, and the nurse was not sure if it is was the resident's bath day. Continued interview with RN #6 revealed the nurse aides would change the resident's brief if the resident had a bowel movement or if it was bath day, and that the nurses do the catheter care. RN #6 further stated the nurse aides check output and empty the collection bag. Review of a progress note dated 11/16/19 at 2:13 PM, documented by RN #6, revealed the nurse cleaned around penis. Noted some white exudate around base of head of penis. Slight odor noted. After area cleaned, area slightly red. Notified NP of this and order noted to use TAO (Triple Antibiotic Ointment) PRN as needed. Orders noted. Review of Resident #55 Prescription order, revealed an order dated 11/16/19, for Triple Antibiotic Ointment topical as needed. Interview with Certified Nursing Assistant (CNA) #6, on 11/15/19 at 11:26 AM, revealed he had worked with the resident a couple times a while back and the resident did not have a catheter. Continued interview revealed the kiosk directed the aides what to do for each resident and they have an aide Care Plan book. CNA #6 indicated if a resident had a catheter, the staff would empty the catheter drainage bag every shift and check and clean the resident every 2 hours and tell the nurse if any issues, or if catheter was old looking. However, there was no documented evidence this occurred. Interview with CNA #7, on 11/16/19 at 02:03 PM, revealed she was the aide assigned to Resident #55 on this date. Continued interview revealed she was to empty the catheter bag at the end of shift. Further interview revealed she did not clean the catheter unless bowel movement was on it. CNA #7 further stated with the resident's bath, she would clean around the area and clean the penis, but she thought the resident's baths were on evening shift. Per interview, if she saw crusty or white substance on the penis, she would clean it, and would report to the nurse if any drainage or anything. CNA #7 stated she checked the resident to make sure the resident had not had a BM (bowel movement) today, and he/she had not and she has not looked at that area (catheter or penis) today. Interview with Registered Nurse (RN) #6, on 11/16/19 at 8:45 AM, revealed she had worked with Resident #55 in past and was assigned his/her care today. Continued interview revealed Resident #55 returned from the hospital with a catheter. She said when a resident returned with a catheter, the nurse should clarify with family and Physician to continue the catheter, and call the physician and reconcile orders. Per interview, she believed the order or a catheter should contain the reason for the catheter, and stated Resident #55 had a growth removed from the penis and had stitches. Continued interview revealed the care plan should be updated because the resident required catheter care. Continued interview revealed she thought catheter care was done every shift and staff should check to make sure the tubing was not crimped. Continued interview with RN #6, revealed she reviewed the medical record for Resident #55 and stated there was nothing on the Care Plan to address the resident's catheter. RN #6 further stated there was no order for Foley catheter on return from the hospital and no order until 11/12/19, but stated the resident had the catheter as far as she knew since returning from the hospital 09/27/19. RN #6 reviewed the Treatment record and stated catheter care should be under treatments; however, she stated there was nothing documented on the Treatment Record regarding care for Resident #55's catheter. RN #6 further stated being a nurse I would know and do the care, and it could always be document in the progress notes. However, RN #6 reviewed the progress notes and stated did not see any progress notes where Resident #55's catheter was monitored. RN #6 further reviewed the paper chart for Resident #55 and stated there was no documentation on the chart related to the resident's catheter. Continued interview revealed Resident #55's catheter should have been monitored and problems with the catheter not being monitored could be UTI, if the catheter was not cared for properly, may not know if having urine output and the resident could get distended, or the catheter may not be in place anymore. Interview on 11/16/19 at 1:35 PM with LPN #5 revealed he cared for Resident #55 on 09/27/19, when the resident returned to the facility with the catheter. Continued interview revealed he asked the hospital why the resident had the catheter and they said because surgery and growth and they removed from penis and he had stitches that fall off. LPN #5 stated he called the on call physician and told her and she said the facility physician would evaluate and see if resident needs catheter and discontinue if not. Continued interview revealed the physician order was supposed to have diagnosis documented. LPN #5 did not provide reason why he did not obtain physician's order for the catheter and stated maybe hospice wrote the order. LPN #5 reviewed the record and stated there was no order for the catheter when Resident #55 returned from the hospital. Continued interview with LPN #5 revealed when Resident #55 returned with the catheter, the resident should have a care plan, and stated the nurse on duty enters orders and then IDT (Interdisciplinary Team) does care plan and goes over everything in the meeting. Interview with the MDS Coordinator on 11/16/19 at 11:55 AM revealed when a resident returned to the facility with a catheter, the nurse should update the care plan. Per interview, the reason for updating the Care Plan was to know how to take care of the catheter and monitor the resident with the catheter. Continued interview revealed she did not review the Care Plans the nurses put in place and she reviews Care Pans after each resident's MDS Assessment. Further interview revealed when the resident returned from the hospital, there should have been a Physician's Order for the catheter and the order should include the reason the resident had the catheter. The MDS Coordinator stated she had also seen Physician Orders that addressed when the catheter should be changed or for catheter care. Per interview it was important to monitor residents with catheters, and if the catheter was not monitored, the resident could pull the catheter out or get infections. Interview with the Unit Manager on Resident #55's Unit, on 11/16/19 at 3:58 PM revealed she had been employed at the facility for three (3) weeks. The Unit Manager stated when Resident #55 returned from the hospital with the catheter, Physician orders should have been obtained to include the size of the catheter, balloon size and diagnosis for the catheter as well as treatment orders for the Foley catheter care, and the resident's Care Plan should have been updated to include catheter care. She indicated she was unsure what happened but she did not find any documented evidence of this when she reviewed Resident #55's record. Continued interview revealed a problem could be infection, as there was no documentation Resident #55 received catheter care. Interview with the DON, on 11/16/19 at 9:43 AM and 2:09 PM, revealed Resident #55 returned from the hospital on [DATE] and a physician's order should have been obtained with diagnosis, on admission. The DON stated the Care Plan should have been revised to address the catheter care, and the catheter should have been monitored by nursing staff every shift, and this should be on the Treatment Record. Continued interview revealed the IDT reviews every resident returning from the hospital and newly admitted residents, and review orders and ensure the Care Pan is updated. The DON stated the nurse admitting the resident should have obtained Physician's order's and initiated the Care Plan and then the IDT should have ensured it was in place. Continued interview with the DON revealed nurses should do catheter care each shift, and typically there is a Physician's Order for catheter care every shift and should be on the Care Plan. Interview with the Administrator, on 11/16/19 at 11:27 AM and 4:20 PM, revealed when a resident returned from the hospital to the facility with a catheter, new orders are sent. She further stated the assessment should be completed and orders should be clarified with the physician for diagnosis. In addition, the plan of care should be put in place and followed. Further interview revealed newly admitted residents were reviewed during the Interdisciplinary team meeting and to ensure orders were put in place. She stated she was not clinical but aware residents could get UTI's (Urinary Tract Infections) with catheters. The Administrator further stated it was her expectation the resident receive catheter care and this be documented in the record. Per interview, it was her expectation that staff follow policies and procedures of the facility, that residents have Care Plans, and the plans be followed and all resident care provided. Based on observation, record review, interview and policy review it was determined the facility failed to provide services and assistance to prevent urinary tract infections and failed to have a diagnosis for Foley catheter use for two (2) residents out of the thirty (30) sampled residents, Resident #90 and #55. Resident #90 had complaints of urinary symptoms and the facility received an order to perform a urinalysis (UA), however, did not obtain the UA. Record review revealed Resident #55 was re-admitted to the facility on [DATE], with a Foley catheter and no documented evidence of a Physician's Order with a diagnosis for continuing the Foley Catheter after the re-admission. In addition, no documented evidence of monitoring or care for the catheter, and no interventions for the Foley catheter care on the resident's Comprehensive Care Plan. The findings include: Record review of the facility policy titled, Change of Condition last revised 11/06/19, revealed the facility would evaluate and document changes in a resident's health and inform the physician of the change. The policy further revealed the licensed nurse should continue to follow up for seventy-two (72) hours. Record review of the facility policy titled, Review of Physician Orders last revised on 11/06/19, revealed physician orders were reviewed daily to ensure delivery of care. Review further revealed new orders would be reviewed by the Interdisciplinary team to ensure changes had occurred. 1. Observation of Resident #90, on 11/12/19 at 10:43 AM and 4:06 PM, revealed he/she was lying in the bed in his/her room and there was a communication board in the room. Observation, on 11/13/19 at 10:47 AM, revealed Resident #90 was lying in the bed in his/her room with eyes closed. Observation further revealed, on 11/13/19 at 4:05 PM, Resident #90 was in his/her room and was awake. Observation, on 11/14/19 at 8:40 AM, revealed Resident #90 was in the bed in his/her room and was awake. Observation, on 11/14/19 at 3:21 PM, revealed Resident #90 was lying in bed in his/her room. Observation, on 11/15/19 at 3:22 PM, of Resident #90 revealed he/she was lying in bed in his/her room and was looking out the door. Record review of the clinical record revealed the facility admitted Resident #90 on 10/02/19 and the diagnoses included Dysphagia, Intracranial Hemorrhage, Speech and Language Deficits, Hemiplegia, Hemiparesis, Cerebral Infarction, Respiratory Failure, Chronic Obstructive Pulmonary Disease, Gastrostomy, Hypertension, Tracheostomy, Schizophrenia, and Wound Myiasis. Record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/09/19, revealed Resident #90 did not have any hearing and vision problems. Review revealed they were unable to complete the cognition portion so there was no Brief Interview for Mental Status (BIMS) score. Record review of the functions section of the MDS revealed Resident #90 needed extensive assistance from staff for bed mobility, dressing, toileting, hygiene and he/she was totally dependent for bathing. Record review further revealed Resident #90 was incontinent of bowel and bladder. Record review further revealed Resident #90 had impaired range of motion to both of the lower legs. Record review of the progress notes for Resident #90 revealed, on 10/31/19 at 6:46 AM, the resident used the letter board to inform nursing that his/her urine burns and my feces burns my skin. Record review of the telephone physician order obtained on 11/01/19 revealed a urinalysis with culture and sensitivity (C&S) was to be done for Resident #90. Record review of the progress notes for 11/01/19, 11/02/19, 11/03/19, and 11/04/19 revealed no documentation that a urine sample had been obtained. Record review of the progress notes for 11/05/19 revealed the urine sample was not obtained and there was no documentation as to why the urine specimen had not been obtained. Record review of the physician telephone orders for 11/15/19 revealed the U/A was discontinued due to incontinence and lower extremity contractures. Review further revealed a Complete Blood Count (CBC) was ordered for 11/16/19. Record review of the comprehensive care plan revealed a problem was listed for elimination and the resident was at risk for urinary tract infections (UTI). The goal for the problem was the resident would not exhibit signs or symptoms of a UTI. One of the approaches was for labs to be obtained as ordered by the physician. Interview with the Director of Nursing (DON), on 11/15/19 at 11:39 AM, revealed there was a telephone order for a U/A to be obtained for Resident #90 and after she reviewed the clinical record she could not find where the urine specimen had been obtained. Interview further revealed she did see a progress note that stated the specimen had not be obtained on 11/05/19, but the note did not indicate why the specimen was not obtained. The DON reviewed the clinical record for Resident #90 and stated the physician had not been notified that the specimen had not been obtained. The DON stated when the nurse could not get the specimen she should have notified the physician and see what the physician wanted done. The DON revealed not obtaining the U/A as ordered by the physician put Resident #90 at risk for septicemia and possible hospitalization. Interview with the DON further revealed the nurse had tried to obtain the specimen but Resident #90 held his/her legs too tight and the nurse passed the information along in report but no one followed up to make sure the specimen was obtained. Interview with the Minimum Data Set (MDS) Coordinator, who was a nurse, on 11/16/19 at 3:15 PM, revealed the U/A should have been obtained because Resident #90 was at risk for Urinary Tract Infection (UTI) due to incontinence of urine and was care planned for that risk. The MDS Coordinator stated if the order for a U/A was not followed then it put Resident #90 at risk for worsening of the UTI and could cause hospitalization. Interview with the Administrator, on 11/16/19 at 10:12 PM revealed her role as administrator was to oversee the well being of the residents and make sure the facility met regulatory expectations. The Administrator revealed the facility had not identified any UTI issues.

Based on interview, record review, and review of policy it was determined the facility failed to ensure an individual and Comprehensive Care Plan (CCP) was developed to ensure individual care was provided for one (1) of twenty-seven (27) residents with the diagnosis of Dementia. The finding: The facility did not provide a policy for Dementia. Review of Alzheimer's Association Facts and Figures, dated 2015, revealed the diagnosis of Alzheimer's was a common form of Dementia. Dementia was classified as the neurocognitive disorder which caused cognitive decline and debilitated the person to complete basic care needs. Review of Minimum Data Set (MDS) job description, dated 03/2013, revealed the MDS coordinator ensured all Care Area Assessments (CAA's) were care planned to meet the needs of the individual. Review of Comprehensive Care Plan (CCP) policy, revised 07/19/18, revealed the facility CCP included measurable objectives and interventions to meet the individual's mental and psychological care needs to maintain optimum function and status. Review of Resident #26's clinical record revealed the facility admitted the resident, on 05/13/19, with the diagnoses of Alzheimer's disease Late Onset, Manic-Depression, and Psychotic disorder. Review of Resident #26's MDS admission assessment, dated 05/20/19, revealed the Alzheimer's disease section unchecked under Section-I for diagnosis. The facility assessed the resident's cognition with the Brief Interview for Mental Status (BIMS) assessment tool with a determined score of eleven (11) out of the possible score of fifteen (15). Review of the admission Care Area Assessment (CCA) two (2), dated 05/20/19, revealed the facility assessment triggered the Cognitive Loss or Dementia worksheet and the facility started on 06/10/19. The facility assessment inclusion of the neurological factor of Alzheimer's disease, Manic-Depression, or the diagnosis Psychotic disorder were not checked. However, further review revealed the facility marked the care plan decision for cognition as 'yes' with the reason to allow facility staff to anticipate wants, needs, notifications, and consults as needed for the resident. Review of Resident #26's Care Plan, dated 09/25/19, revealed the facility's CCP for Resident #26 with the identified diagnosis of Alzheimer's disease and CAA's trigger for cognition care plan was not initiated after the resident's initial CCP. Review of Resident #26's MDS quarterly assessment, dated 08/29/19, revealed the facility assessed the resident and included the active diagnoses of Alzheimer's disease, Manic-Depression, Psychotic disorder and Anxiety. The facility assessed the resident's cognition with the BIMS assessment tool with a score of six (6) out of the possible score of fifteen (15). Review of Resident #26's Care Plan, reviewed 09/25/19, revealed the facility the identified a care plan for the problem of psychosocial well-being with behaviors of rummaging through his/her roommate's personal belongings. The facility goal included the resident would not rummage through the roommates belongings. The facility interventions included intervene to protect resident rights, exhibit a calm approach and provide re-education. The facility also initiated the intervention of printed signs as a reminder of which closet belonged to him/her. The facility revision of the CCP did not include the diagnosis of Alzheimer's disease, Manic-Depression, Psychotic disorder and Anxiety. Interview with MDS assistant, on 11/16/19, revealed the facility CCP for residents were reflective of admission diagnosis, behaviors, care needs, and the facility BIMS assessment. She stated Dementia or Alzheimer's diagnoses would trigger the facility to continue to assess the need for a care plan under the CAA's portion of the CCP. She stated she completed some cognitive or behavior problem areas. However, she stated social services responsibility included diagnoses of dementia's and behaviors with the initial CCP. She stated the facility's cognition care plans provided insight to ensure staff were knowledgeable of the residents care needs for physical and emotional/behavior. She further stated the facility assessed for further decline for residents with the quarterly assessment. She stated the facility prevention of complications included to ensure residents' needs were met. Interview with the Social Service Assistant (SSA), on 11/16/19 at 4:07 PM, revealed the facility completed CCP assessment for cognitive care plan needs at admission. She stated CCP meant an individualized care plan with interventions. She stated the staff needed to know specific care needs of residents. She stated social services completed all cognitive and behavioral care plans. She further stated the facility assessment which determined a BIMS score less than thirteen (13) would trigger a care plan for cognition as well. She stated the facility generated the Certified Nursing Assistants (CNA) and the CCP care guide from the residents CCP. She stated the CNA care guide provided care needs for a cognitively impaired resident. Further review with the SSA of Resident #26's care plan revealed the SSA stated the facility failed to develop a Dementia related care plan. She further stated the facility assessment included mental health diagnosis which were not developed. She stated as the SSA she could not explain why the CCP lacked the diagnoses. She stated the department received notification by the MDS department when cognition or behavior's CAA's triggered by an email. She further stated the facility care plan audits lacked follow through the past couple of months with new staff. She stated the facility turn over on the management level occurred around the same time. Interview with the Director of Nursing (DON), on 11/16/19 at 4:37 PM, revealed MDS coordinators, Social Services and facility nurses generated and reviewed resident care plans. She stated the previous management team reviewed care plan to ensure the CCP reflected the resident. She stated as DON the care plan review included to ensure the CCP reflected the resident so staff could take care of the residents. She stated if the facility CCP lacked information, inaccurate or not completed the resident progression effected them to reach their goals on the care plan. She stated the facility CCP responsibility included an accurate picture of the resident. Interview with the Executive Director, on 11/16/19 at 10:12 PM, revealed the facility identified issues did not include care plans for behaviors or Dementia and the lack of development. She stated as the responsibility as administrator included to ensure the resident needs were met and the facility followed regulations.

Based on observation, interview and record review it was determined the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys for one (1) of three (3) units. Observation of the 100 hall Nourishment Refrigerator on 11/16/19 revealed medications were stored in the nourishment refrigerator with foods. Continued observation revealed eleven (11) unopened insulin pens, five (5) individual dose influenza vaccines, multiple suppositories for nine (9) residents and one (1) box of Perforomist inhalation solution for one (1) resident. The Findings Include: Review of the facility policy titled Medication Storage Storage of Medication 4.1, dated 09/18 revealed medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration and the medication supply shall be accessible only to licensed personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Continued review of the policy revealed refrigerated medications should be kept in closed and labeled containers, with internal medications separated from external medications and all medications segregated from fruit juices, applesauce, and other foods used in administering medications. Any other foods such as employee lunches and activity department refreshments should not be stored in this refrigerator. Observation of the 100 Hall Nourishment refrigerator on 11/16/19 at 8:37 AM with Registered Nurse (RN) #6 revealed a tuna sandwich and a chicken sandwich wrapped with no date, in the refrigerator. Additional items observed included condiments, such as ketchup, mustard, and mayonnaise, and juice cups in the refrigerator. Continued observation revealed eleven (11) unopened insulin pens, five (5) individual dose influenza vaccines, multiple suppositories for nine (9) residents and one (1) box of Perforomist inhalation solution for one (1) resident. Interview with RN #6 at the time of the observation, on 11/16/19, revealed the sandwiches should have been dated because with no date, there was no way to know if they were expired and this could cause illness. Continued interview with RN #6 revealed medications were not supposed to be stored with food and she was unsure why the medication was in the nourishment refrigerator and stated maybe the medications were too large to fit in the medication refrigerator. Further interview revealed storing medications and foods in the same refrigerator could cause contamination. Interview with the Unit Manager on the 100 Hall, on 11/16/19 at 3:50 PM, revealed she had been the Unit Manager for three (3) weeks. Continued interview revealed she usually checked the Nourishment refrigerator each morning. She further stated she had not checked it on 11/16/19, prior to the surveyor checking the refrigerator. Continued interview revealed medications should not have been stored in the Nourishment refrigerator and should have been locked up in the locked medication refrigerator. Continued interview revealed food and resident medications should not be stored together because as it could be an infection control issue. Interview with the Dietitian, on 11/16/19 at 4:57 PM, revealed medications should not be stored in the nourishment refrigerator with food for safety reasons. The Dietitian stated medications should be locked in the medication refrigerator. Interview with the facility Clinical Nurse Consultant, on 11/16/19 at 9:06 AM, revealed medications were not typically stored with the food. Continued interview revealed sandwiches should be dated so it can be determined when they expire, and to ensure they did not expire and go bad. The Clinical Nurse Consultant further stated the facility did not want contamination between the food and medication. Interview with the Director of Nursing (DON), on 11/16/19 at 9:30 AM and 3:41 PM, revealed medications were not to be stored with foods in the nourishment refrigerator. Continued interview revealed the reason was risk for contamination. The DON indicated nursing staff on each unit was responsible for checking the nourishment refrigerator and the back-up person would be the Unit Coordinator. Interview with the Administrator, on 11/16/19 at 9:05 AM and 4:20 PM, revealed she did not think medications and foods should be stored together. Continued interview revealed it was her expectation that staff follow policies and procedures of the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of facility policy it was determined the facility failed to ensure residents were provided or obtained from an outside resource, dental services to meet the needs of each resident, to include routine dental services (to the extent covered under the State plan), and assist the resident in making appointments; and arranging for transportation to and from the dental services locations for one (1) of thirty (30) sampled residents (Resident #9). Resident #9 was evaluated by the dentist on 07/18/19, and received a referral to Oral Surgery for extractions. There was no evidence the resident was seen by Oral Surgery as of 11/16/19. The Findings Include: Review of facility policy titled Dental Services, dated last reviewed 06/05/18, revealed the facility must assist residents in obtaining routine and twenty four (24) hour emergency dental care. Per policy, routine and emergency dental services were provided to residents through a contract with a local dentist, referral to the resident's personal dentist, referral to community dentists, or referral to other health care organizations that provide dental services. Continued review revealed the facility would assist the resident in making appointments and arranging for transportation to and from dentist's office. Review of the clinical record revealed the facility admitted Resident #9 on 05/23/11. Resident #9 had diagnoses which included Dementia in other diseases classified elsewhere with behavioral disturbance; Displaced fracture of left radial styloid process, subsequent encounter for closed fracture with routine healing; Muscle weakness; Paranoid Schizophrenia; and Difficulty in walking, not otherwise classified. Review of the Significant Change MDS assessment dated [DATE], revealed Resident #9 was assessed as having a BIMS (Brief Interview Mental Status) score of eleven (11) out of fifteen (15). Continued review revealed no items were assessed within the oral/dental section of the MDS. Review of the Quarterly MDS assessment dated [DATE] revealed the resident was assessed with a BIMS score of nine (9) of fifteen (15). Review of the Comprehensive Care Plan for Resident #9, revealed no plan of care developed with regards to dental. Interview with the MDS Coordinator, on 11/16/19 at 11:55 AM, revealed the facility does not usually put referrals, such as the oral surgeon referral, on the Care Plan. She stated after the extractions the resident's Care Plan would be updated to include pain or follow up and instructions. Record review revealed Resident #9 was seen by the dentist on 07/18/19. Further review of the documentation revealed the resident needed additional dental work for tooth #21 and #28. Per the dental evaluation documentation, Resident #9 had teeth #18, 24, 26, 29, and 30, which were documented non restorable and needed to be extracted by an oral surgeon. Continued review of the record revealed an Oral Surgery Referral, dated 07/18/19, for Resident #9. Record review revealed no documented evidence Resident #9 had seen the oral surgeon per the referral. Observation of Resident #9, on 11/12/19 at 12:35 PM, revealed the resident was sitting at the dining room table awaiting lunch. Resident observed to have some natural teeth. Interview with Resident #9, on 11/13/19 at 10:17 AM, revealed he/she had seen the dentist in past at the facility but needed to see the dentist again. Resident #9 did not report any teeth causing pain at this time. Interview with the Social Services Assistant, on 11/15/19 at 3:12 PM, revealed she had been in the position for about a year and the facility was in the process of getting a new social services director. Continued interview revealed she was checking to see if Resident #9 saw the oral surgeon, and stated said the appointment scheduler/transportation scheduler does appointments. She further stated when a resident returned with a written order for referral to oral surgeon, the documentation goes to the nurse, who completes an appointment sheet, and the nurse gives the documentation to the appointment scheduler/transportation scheduler to set up the appointment. She stated it was then put in an appointment book. Further interview with the Social Services Assistant, revealed since Resident #9 saw the dentist 07/18/19, he/she should have had an appointment by now. Per interview, the documentation could have gone to any nurse on the unit, and she will look for anything regarding the appointment. Subsequent interview on 11/16/19 at 2:12 PM, with the Social Services Assistant, revealed the facility attempted to call to get an appointment yesterday, and they were already closed. The Social Services Assistant stated she honestly did not know why the process was not completed at the time of referral. Interview with the Appointment Scheduled/Transportation Scheduler, on 11/16/19 at 1:07 PM, revealed he was responsible for scheduling resident appointments and transportation. Continued interview revealed dental and oral surgery referrals usually came from the social worker. The Scheduler stated he had never received a referral for Resident #9. He stated the facility asked him about this yesterday and if he would schedule it, but it was late afternoon, near 5:00 PM, and they were closed. He further stated after resident appointments were scheduled, he documented this on a calendar he kept, and also the appointment was documented on a calendar on the unit. Interview with the Unit Manager 100 Unit, on 11/16/19 at 4:02 PM, revealed she was unsure of the policy, but if paperwork was received for an appointment, the appointment should be scheduled the next business day. Per interview, the documentation should go to the Appointment/Transportation Scheduler and the facility has an appointment book and a document, and a nurse completes top part. The Unit Manager stated she found no documentation Resident #9 was seen by the oral surgeon. She stated she was unsure where the break was, but the process was the nurse should have given the referral to the Appointment/Transportation Scheduler. Continued interview revealed the process to monitor appointments was to discuss in the IDT meeting. Continued interview with the Unit Manager revealed potential problems with delay in the appointment could be pain, or weight loss if the resident was not eating an adequate amount of food. The Unit Manager stated the time frame from July (07/18/19) to now for Resident #9's appointment to be scheduled with oral surgery was not acceptable. Interview with the Director of Nursing (DON), on 11/16/19 at 9:59 AM, revealed when Resident #9 returned with the consult with oral surgeon referral, the nurses should have made the Appointment/Transportation Scheduler/Coordinator aware to schedule the appointment. The DON stated she did not know why Resident #9's appointment was not scheduled and completed and it should have been done by now. She further stated Resident #9 should have had a Care Plan developed at the time the dental issue was identified by the nurse receiving documentation of the dental issue. She stated typically dental appointments weren't reviewed in IDT meetings. Interview with the Administrator, on 11/16/19 at 11:18 AM and 4:20 PM, revealed she was unaware of any dental issues with Resident #9. She stated the process was if the dentist made a referral, the facility should make sure the follow up appointment was scheduled. She stated this should be scheduled immediately, and for Resident #9's appointment 07/18/19 to now was too long. She further explained all appointments should all go through the Appointment/Transportation Scheduler/Coordinator for scheduling and transportation and this began in September, 2019. In addition, the Administrator stated if a resident had documentation provided to the nurse, follow up recommendations should be brought to Interdisciplinary team meeting. The Administrator further stated dental issues should be on the resident's Care Plan. Continued interview revealed it was her expectation that staff follow policies and procedures of the facility.

Based on observation, interview, record review and review of facility policy it was determined the facility failed to ensure each resident received and the facility provided food that accommodated resident allergies, intolerances, and preferences for one (1) of thirty (30) sampled residents (Resident #79). Observation during tray line on 11/13/19 revealed regular bread was placed on the tray for Resident #79, who was ordered a gluten free diet. The Findings Include: Review of the facility policy Food Allergy/Intolerance Awareness, dated revised 08/31/18, revealed food that accommodates resident allergies, intolerances, and preferences should be prepared and served. Continued review of the policy revealed a food substitute for the food allergy, intolerance, or preference should be consistent with the usual or ordinary food item provided to the community. Observation during the tray line beginning, on 11/13/19 at 11:30 AM, revealed Dietary Aide #2 was observed to place regular bread on the tray for Resident #79, and placed the tray on the cart for delivery. Interview with Dietary Aide #2 at the time revealed she stated the bread she placed on the resident's tray was regular bread. After the surveyor stopped the line and asked Dietary Aide #2 about the bread, the [NAME] told Dietary Aide #2 to remove the bread from Resident #79's tray. Continued observation revealed there was no additional bread placed on the resident's tray. Interview with Dietary Aide #2, on 11/15/19 at 10:24 AM, revealed she did not know anything about gluten free bread, just about cereal and lactose free milk. Continued interview revealed she hadn't received training to specifically know what a resident can and can't have on a gluten free diet. Further interview revealed she did not know if the facility had gluten free bread. She stated that in past, cooks marked bread gluten free. Interview with Resident #79 during the initial tour, on 11/13/19 at 9:55 AM, revealed the kitchen could not get the meals straight. Resident #79 stated he/she had to have lactose free and gluten free food and he/she cannot drink regular milk or eat white bread and he/she did not think the dietary department understood that. Resident #79 revealed they brought her regular milk today and it had to be sent back. Resident #79 stated if he/she had drank the regular milk she/he would have had diarrhea and sometimes vomiting. Observation on, 11/13/19 at 12:38 PM, revealed Resident #79 lunch tray was served and it had a corn, carrot, and peas mixture. Observation further revealed Resident #79 only ate a small portion of the meal because of the corn and he/she fixed herself/himself a bowl of cereal with lactose free milk. Observation further revealed there was not any bread on the tray. Interview with Resident #79, on 11/13/19 at 12:38 PM, revealed he/she could not eat the corn because he/she has diverticulosis and he/she would get sick. Interview with Resident #79, on 11/16/19 at 10:45 AM, revealed she/he has to have gluten free and lactose free food and she/he has to tell the staff what she/he can or cannot have. Resident #79 stated he/she was legally blind and had to ask the staff what was on her tray before she/he ate anything. Resident #79 revealed he/she did not pour the milk on the cereal until he/she knew for sure it was lactose free because he/she has had to return the milk multiple times because it was not lactose free. Resident #79 further revealed she/he had a diagnosis of celiac disease and diverticulosis and cannot have nuts or seeds. Resident #79 stated if they serve a salad he/she had to be careful and make sure the tomatoes were taken off before it was ate. Resident #79 revealed when she/he did got food that were not gluten free or lactose free she/he would know about it real quick because he/she would have diarrhea, cramping, nausea, and vomiting. Resident #79 revealed sometimes staff did not tell her/him what was on the tray and since he/she cannot see well enough to be able to distinguish what was gluten free or lactose free he/she sometimes ate the wrong food and it had made her/him sick. Record review of the face sheet for Resident #79, revealed the facility admitted the resident on 11/06/19 with diagnoses of Acute Pulmonary Edema, Congestive Heart Failure, End Stage Renal Disease, Hypertension, Diabetes Mellitus, Renal Dialysis, and Chronic Obstructive Pulmonary Disease. The face sheet further revealed Resident #79 was allergic to gluten. Record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/14/19 revealed Resident #79 had a Brief Interview of Mental Status (BIMS) of twelve (12) which meant the resident was not cognitively impaired. Record review further revealed Resident #79 was visually impaired. and needed supervision with set up help for eating. Record review of the comprehensive care plan revealed a problem for nutrition was addressed however gluten free and lactose free foods were not addressed in the care plan. Record review of the physician orders for 10/16/19 to 11/16/19 revealed Resident #79 was allergic to gluten. Review further revealed Resident #79 was to have Liberal House Renal diet with sugar substitutes and was allergic to gluten. On 11/15/19 at 10:37 AM, interview with the Dietary Manager (DM), revealed all resident diets should be followed. In addition, Resident #79 or any resident on gluten free diet should not receive regular bread. Per interview, if the resident had celiac disease or gluten allergy, regular bread could make the resident sick. On 11/16/19 at 4:57 PM, interview with the Dietitian, revealed menus and diets should be followed and Resident #79, who was ordered a gluten free diet, should not have received regular bread on his/her tray. The dietitian stated the resident should have received gluten free bread, because a resident on gluten free diet who received regular bread could have effects such as bloated belly, diarrhea, inflammation, or potential constipation. Interview on 11/16/19 at 9:30 AM, with the Director of Nursing (DON), revealed she had concerns with meal and dietary services since she started her employment with the facility. The DON confirmed Resident #79 had gluten intolerance, a gluten free diet order, and should not get regular bread. Continued interview revealed staff told her yesterday that dietary put regular bread on Resident #79's tray and due to allergy should have received gluten free bread. On 11/16/19 at 4:20 PM, interview with the Administrator, revealed she was aware of dietary issues in kitchen. She further stated the facility had a new Dietary Manager, who just started this week, and has not had time to provide education to the staff. Per interview, she was present when Resident #79, ordered a gluten free diet, had regular bread put on his/her tray. Continued interview revealed it was her expectation that staff follow policies and procedures of the facility.

**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 maintain an accurate and complete clinical record for one (1) of thirty (30) sampled residents, Resident #51. Record review revealed a physician order, dated 8/31/19, for the facility to transport Resident #51 to the emergency room. Further review revealed no documented evidence the facility staff communicated with the physician after emergency services would not transport the resident. The findings include: Review of the facility's policy, Charting and Documentation, revised 07/02/18, revealed any services provided to the resident, or any changes in the resident's medical condition, were document in the resident's medical record. Furthermore, the policy reveals documentation of procedures and treatments should include the minimum: the name and title of the procedure/treatment provided, the assessment data and/or any unusual findings obtained during the procedure/treatment, how the resident tolerated the procedure/treatment and notification of family, physician or other staff. Review of the facility's policy, Change of Condition, revised 11/06/19, revealed the facility would document changes in a resident's health in an efficient and effective manner; relay evaluation information to physician and to document actions. Complete the Situation, Background, Assessment, and Recommendations (SBAR) in the Electronic Medical Record (EMR) to provide the physician with necessary evaluation findings. Document physician, nurse practitioner and/or physician assistant notification in the EMR. Review of Resident #51's clinical record revealed the facility original admitted the resident 06/16/17 and readmitted the resident on 10/21/19, with diagnosis of sepsis, pulmonary embolism, chronic respiratory failure, and chronic obstructive pulmonary disease. In addition, resident has intellectual diagnosis of borderline intellectual functioning, Alzheimer's disease, dementia and cognitive impairment. Review of Resident #51's annual Minimum Data Set, dated [DATE], revealed the facility assessed the resident with a Brief interview for Mental Status score of ten (10) out of fifteen (15) and determined the resident was interviewable. Review of telephone order for Resident #51, date 08/31/19, revealed physician order to send resident to the emergency room, signed by Licensed Practicing Nurse (LPN) #5. Review of progress notes for Resident #51, on 08/31/19 at 7:12 PM, revealed the facility failed to continue to document signs and symptoms throughout LPN shift after the resident complained of chest pains. Continued to review of Resident #51's progress notes, the facility failed to clarify the resident's ongoing condition throughout shift and after emergency services refused to transport. Observation of Resident #51, on 11/12/19 at 11:39 AM, resident was sleep, wearing a cannula and oxygen set on two (2) ml. Observation of Resident #51, on 11/13/19 at 1:10 PM, resident observed during dining service wearing the cannula, with portable oxygen, and motorized wheelchair. Interview with Resident #51, on 11/13/19 at 1:22 PM, revealed resident does not remember going to the hospital for chest pain. Interview with Licensed Practical Nurse (LPN) #5, on 11/16/19 at 3:37 PM, revealed he failed to complete and update documentation for Resident #51 on 08/31/19. LPN #5 revealed he had forgotten to document Resident #51's medical status after resident express having chest pains during breakfast. Continued interview with LPN #5, on 11/16/19 at 7:01 PM, revealed Resident #51's oxygen tank had been exchanged, breathing treatment given and EKG had been given by emergency service, however, these treatments had not been documented in resident's record. Interview with Direction of Nursing (DON), on 11/16/19 at 4:09 PM, revealed she expected her staff to complete full/detailed documentation of residents to obtain a full representation of the resident's care. Interview with the Administrator, on 11/16/19 at 8:11 PM, revealed her job as the administrator was to oversee the well-being of the residents, the stakeholders, and make sure the facility met regulatory expectations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview it was determined the facility failed to maintain an infection prevention program that was to provide a sanitary environment and help prevent the transmission of disease and infections for one (1) resident out of the thirty (30) sampled residents. Staff was observed to provide care to Resident #61 and did not wash or sanitize their hands after care. In addition the same staff was observed to throw linens on the floor that had urine in them. The findings include: Record review of the facility policy titled, Handwashing/Hand Hygiene revised on August 2015, revealed all personnel should follow handwashing/hand hygiene procedures to help prevent the spread of disease. The policy further stated staff should use alcohol-based hand rub or alternatively soap and water before and after contact with residents, after contact with a resident's intact skin, after removing gloves, and after contact with objects in the immediate vicinity of the resident. Review further revealed using gloves does not replace hand washing/hand hygiene which was the best practice to prevent infections. The policy revealed when you remove gloves you should perform hand hygiene. Record review of the facility policy titled, Linen Handling, last reviewed 6/12/18, revealed soiled linen should be placed into the covered linen receptacle or plastic bag and staff should not place soiled linen on the floor. Record review of Resident #61's clinical record revealed the facility admitted the resident on 08/15/2016 with diagnoses Urinary Tract Infection, Hypertension, Intellectual disability, and Seizures. Record review of the comprehensive care plan revealed there was a problem for incontinence and one for colostomy care. Record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/27/19, revealed Resident #61 was incontinent of bladder. Observation, on 11/11/19 at 11:37 AM, of Resident #61 revealed the resident had on wet gray pants and a shirt with food on it that he/she was trying to remove. The resident's bed linens were partly on the floor. Observations revealed a nurse came into the room to assist the resident and she was trying to assist Resident #61 and get help from someone. Observation further revealed Certified Nursing Assistant (CNA) #6 came into the room and assisted Resident #61. When CNA #6 entered the room he stated it smelled like Resident #61 needed to be changed and he changed the resident. Observation revealed CNA #6 stated the bed was wet and he changed the sheets and threw the wet sheets on the floor. CNA #6 picked the wet sheets up off the floor and put them in a plastic bag and he had gloves on. Observation further revealed clean sheets was placed back on the bed. Observation revealed the mattress of the bed where the wet sheets had been lying was not cleaned before the clean sheets was applied. CNA #6 removed his gloves and went to the utility room and disposed of the dirty laundry. Observations revealed CNA #6 did not wash his hands or sanitize his hands before or after leaving the room. Observation further revealed CNA #6 went down the hall to the clean linen room, obtained clean linen and went back to Resident #61's room and finished making up the bed. CNA #6 took the rest of the clean linens from the room and went into room [ROOM NUMBER], then left that room and went into room [ROOM NUMBER] bed B, where he made the bed up. CNA #6 touched the bed rails and the clean linen. CNA#6 had not washed his hands or sanitized his hands since leaving Resident #61's room. CNA #6 went back down the hall, touched his notepad and went to the laundry room where he put his fingers on the keypad to open the door. CNA #6 walked back down the hall and touched a resident's shoulder, then walked back into room [ROOM NUMBER], where he put a blanket on the bed. Observation further revealed CNA #6 left room [ROOM NUMBER], and went into room [ROOM NUMBER], where he put gloves on and emptied a urinal and then threw the urinal away. CNA #6 removed his gloves and told the resident he would get him another one CNA #6 left that room and went into room [ROOM NUMBER], and came back out and down the hall to the utility room and opened the door. CNA #6 then touched the keypad on another door, but did not go in and went down the hall to room [ROOM NUMBER], where staff needed help. Observation revealed CNA #6 touched the wheelchair by bed B in 211, and then went to bed A and opened candy for that resident. CNA #6 applied gloves and touched the wheelchair and touched the resident as he assisted with the transfer of the Resident in bed B. Observation of CNA #6 revealed he removed his gloves, but did not wash his hands or sanitize them after leaving the room. Observation further revealed CNA #6 touched the keypad of the room where ice was and came back out with a cup of ice and said he was going to lunch. Interview with CNA #6, on 11/15/19 at 1:53 PM, revealed he stated I knew it, I knew it, you were supposed to wash your hands as soon as you entered the room. CNA #6 revealed staff were supposed to put the gloves on, do the care, remove the dirty gloves, and wash hands. CNA #6 stated everytime he removed his gloves he was supposed to wash his hands. CNA #6 revealed the reason he did not wash his hands the other day, when he was in Resident #61's room, was because there were no paper towels in the room. CNA #6 stated he had washed his hands when he went into the shower room. CNA #6 further revealed he was supposed to sanitize his hands when he went into the room because if he did not it could cause cross contamination and he did not want people to get sick. CNA #6 revealed the dirty linens were supposed to be put in a bag before they touched the floor. CNA #6 stated the reason he threw the soiled linens on the floor was because he was in a rush and that hall was the hardest hall in the facility. The CNA #6 revealed the linens were wet, but not soaking wet, and there was no residual left on the floor from them, but they still were dirty. CNA #6 stated if there was something left from the wet sheets on the floor it could be left on your shoes if you walked in it. CNA #6 revealed he always cleaned his shoes with bleach wipes before he got in his car. CNA #6 further revealed you had to bleach wipe the mattresses to clean them because it would be cross contamination if you put clean sheets on a dirty wet mattress. CNA #6 stated he did clean the mattress, but it was after he walked back into the room and he could still smell that smell so he removed the clean sheets he had put on the bed and wiped the mattress down and then reapplied clean sheets. CNA #6 further revealed the aides were supposed to wipe the mattress with bleach wipes and you did not have to notify housekeeping. CNA #6 revealed the surveyor was not in the room when he went back in there and cleaned the mattress. Interview with the Director of Nursing (DON), on 11/14/19 at 9:07 AM, revealed staff should wash their hands before and after any care provided. The DON revealed if staff were going from one room to another they should at least sanitize or wash their hands even if the residents were not touched. The DON further revealed if care was provided to Resident #61 the staff should have washed their hands because it was an infection control issue to prevent the spread of germs. The DON stated if the mattress was wet the housekeepers should be notified by the CNA, so they can disinfect and sanitize the mattress. The DON revealed it was not appropriate to put clean sheets onto a bed mattress that had wet sheets on it previously. The DON revealed if urine dried on the mattress you would get odors and bacteria and that would be an infection control issue. The DON stated if a resident had a urinary tract infection and the urine was on the mattress the infection could spread. The DON stated they do not use lift pads here only sheets. The DON further revealed it was not appropriate to throw wet sheets on the floor because of infection control and staff could track anything that might had been on the floor from the wet sheets. The DON revealed wet sheets should be put in a plastic bag and put in the soiled utility. The DON stated she made rounds and tried to see how the staff was doing. She stated when she saw something she educated the staff right then. Interview with the Administrator, on 11/16/19 at 10:12 PM, revealed she was not aware of any infection control issues. The Administrator revealed her role as administrator was to oversee the well being of the residents and make sure the facility met regulatory expectations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Review of Resident #51's clinical record revealed the facility original admitted the resident 06/16/17 and readmitted the resident on 10/21/19, with diagnosis of sepsis, pulmonary embolism, chronic respiratory failure, and chronic obstructive pulmonary disease. In addition, resident has intellectual diagnosis of borderline intellectual functioning, Alzheimer's disease, dementia and cognitive impairment. Review of Resident #51's annual Minimum Data Set, dated [DATE], revealed the facility assessed the resident with a Brief interview for Mental Status score of ten (10) out of fifteen (15) and determined the resident was interviewable. Review of Resident #51 Physician Order, date 05/14/19, revealed the physician reviewed and approved nursing home plan of care, orders and treatment plans. Review of Resident #51's Care Plan, dated 05/24/19, revealed nursing staff did not follow physician orders through notification to physician, Advanced Practice Registered for next direction for resident care. Continued review of Resident #51's care plan revealed no evidence nursing staff developed interventions directing staff to administer the physician order for transportation to ensure resident received emergency service for care needs were met. Review of Resident #51's progress note, on 8/31/19 at 7:12 PM, revealed Licensed Practical Nurse #5 failed to notify physician, Advanced Practice Registered, ADON, and/or DON for next direction for resident care since classified as a non-emergency by emergency services. Continued review of resident's progress notes, revealed Resident #51 was admit to hospital the following day, 09/01/19 at 7:45 AM for chest pain. Observation of Resident #51, on 11/12/19 at 11:39 AM, resident was sleep with oxygen set on two (2) liters, laying on air mattress, fully dressed, room was free from cutter. Observation of Resident #51, on 11/13/19 at 1:10 PM, resident was observed eating lunch with another resident. Brief interview with Resident #51, revealed he enjoyed living at the facility however did not remember going to the hospital. Resident #51 continued to wear his cannula for oxygen. Interview with Resident #51, on 11/13/19 at 1:22 PM, revealed resident reported no concerns with the facility or the staff. On 11/16/19 at 3:37 PM, interview with Licensed Practical Nurse (LPN) #5, revealed he completed an assessment on Resident #51 after he/she complained of chest pain, notified the physician, and obtained an order to transport to the emergency room. LPN #5 reported emergency services (EMS) arrived and refused to transport resident to the emergency room because the resident non-emergent status. Continued interview with LPN, revealed he failed to follow up with physician, APRN, and/or the DON to communicate EMS did not transport Resident #51 per the plan of care. LPN #5 report he forgot the process and procedure related to care plan implementation when physician's orders were received for a change in condition. Interview with Direction of Nursing (DON), on 11/16/19 at 4:09 PM, revealed she was not the DON during Resident #51's change of condition. The DON states she was not aware staff did not follow the plan of care after the physician ordered transportation to the emergency room. The DON stated it was important for the LPN to follow up with the physician due to the initial order was not followed. Phone interview with Medical Director (MD), on 11/16/19 at 6:26 PM, revealed, if an order was given to send a resident out to the hospital for chest pain, she expected the nursing staff to follow physician orders the first time. However, if emergency services deemed the resident a non-emergency, she would expect another form of communication from the facility for review to determine if another order was warranted. Phone interview with former Unit Manager (UM) #3, on 11/16/19 at 7:46 PM, revealed Resident #51 had complained of chest pain and it was deemed necessary to contact physician/APRN and request ambulance for transport. The Unit Manager revealed she would expect nursing staff to contact the physician and/or the Director of Nursing for medical direction when the care plan was not followed. Interview with the Administrator, on 11/16/19 at 8:11 PM, revealed she notified on Monday 09/01/19, by Unit Manager #3, of Resident #51 hospitalization. She stated in her experience when emergency medical services responded to a call and deemed the resident a non-emergency, the resident would have to wait up 24-hours for transportation. She further stated nursing staff failed to contact the on-call physician, the DON, or the Administrator to make them aware of the situation per the plan of care. Based on observation, record review, and interview it was determined the facility to develop and implement comprehensive care plans for six (6) of the thirty (30) sampled residents. Resident # 51 had a comprehensive care plan for following physician orders that was not implemented. Resident #51 had a physician order to send out to the emergency room and this was not done until the following day when he/she started experiencing chest pain again. Resident #9 had a comprehensive care plan for a physical therapy evaluation to be done and it was not implemented. Resident #70 was care planned for his/her leg to be wrapped with ACE wraps and this was not consistently done. Resident #90 was care planned to have labs done as ordered and this was not implemented. In addition Resident #90 was care planned to attend activities and this was not implemented. Resident #35's comprehensive care plan included heel lift boots as an intervention and observation revealed this was not implemented consistently. In addition Resident #35 care plan included a problem for activities and the interventions were not implemented. Resident #61 had a problem on the comprehensive care plan for falls and observation revealed the approach for non slip socks was not implemented consistently. In addition, Resident #51's care plan for physician notification was not followed after the resident was not transferred to the emergency room as ordered. The findings include: Record review of the facility policy titled, Comprehensive Care Plans last revised on 07/19/18, revealed each resident would have a person-centered comprehensive care plan that would include how the facility would assist the resident to meet their needs. Record review further revealed each comprehensive care plan was developed to identify problems, incorporate risk factors, reflect treatment goals, timetables, and aid in the prevention or decline in the residents functional status. Record review further revealed the Minimum Data Set (MDS) would be utilized to assess the clinical condition and the Care Area Assessments (CAA) were used to develop the comprehensive care plan. Record review further revealed the comprehensive care plan was ongoing and revised as needed. 1. Observation, on 11/12/19 at 11:44 AM and 11/13/19 at 12:12 PM, revealed Resident #70 did not have ACE wraps on his/her leg. Interview with Resident #70, on 11/12/19 at 11:44 AM, revealed he/she was to have ACE wraps to the left leg and staff had not applied them. Record review of the comprehensive care plan revealed a problem was listed for several non pressure open areas to the left lower extremity. Review of the goal was for the open areas to heal without complication. Record review of the approaches showed ACE wraps were to be applied as ordered. Interview with the Minimum Data Set (MDS) assistant coordinator, on 11/16/19 at 4:32 PM, revealed she was not the coordinator but the assistant and they had just hired a new MDS coordinator, but she had not stated yet. The MDS assistant coordinator revealed the purpose of the comprehensive care plan was to let staff know what problems the resident had and approaches implemented to provide the care that needed to be done and to help the situation. She revealed if an intervention was on the comprehensive care plan then it should be followed. The MDS assistant coordinator revealed the comprehensive care plan for Resident #70 included a problem for skin issues to the leg, knee, and toes and one of the approaches was ACE wraps were to be applied to the left leg. She revealed the comprehensive care plan should have been followed and the ACE wraps should have been applied as outlined in the care plan. The MDS assistant coordinator further revealed the ACE wraps would provide pressure for better circulation for the resident. She revealed if the ACE wraps were not applied it could cause the sores to worsen and could development more. Interview with the Director of Nursing (DON), on 11/15/19 at 10:30 AM, revealed Resident #70 had an order for ACE wraps to the left leg and it was on the care plan and the ACE wraps should have been applied. The DON further revealed the ACE wraps was utilized to control edema for compression. 2. Observation, on 11/14/19 at 9:45 AM and 11/16/19 at 9:29 AM, revealed Resident #35 was lying in bed on a Recovery Pressure Mattress and did not have any heel lift boots on the feet. Record review revealed the facility admitted Resident #35 on 06/26/18 with diagnoses to include Heart Failure, Acute Respiratory Failure, Chronic Obstructive Pulmonary Disease, Hypertension, Dementia without Behavioral Disturbance, Pressure Ulcer of Sacral Region, Stage Four (4), Wound Myiasis, and Pressure Ulcer of the Left Heel, Stage 1. Record review of the current physician orders for, October 16, 2019 to November 16, 2019, revealed Resident #35 was to have a Prevalon boot to the left foot at all times except when transferred or ambulated. Record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/06/19 revealed Resident #35 needed extensive assist of one person for dressing and bed mobility. Record review of the comprehensive care plan for Resident #35, revealed the resident was at risk for alteration in skin integrity because the resident was incontinent and immobile. Review of the interventions revealed Resident #35 was to have his/her heels floated while in bed. Another problem on the comprehensive care plan was for an alteration in skin integrity because Resident #35 had a Stage 1 pressure injury to the right and left heels. Review of the interventions revealed the heels were to be floated while in bed. Record review of the Certified Nursing Assistant (CNA), Care Report for Resident #35 revealed there was no indication that the resident needed heel lift boots or prevalon boots at all times. Interview with Registered Nurse (RN) #3, on 11/16/19 at 9:33 AM, revealed Resident #35 was to have heel lift boots on bilateral with a prevalon boot to the left foot except with transfers and ambulation. RN #3 went into Resident #35 room and noted he/she did not have any heel lifts boots or prevalent boots on either foot and after she looked around the room she revealed there were none in the room for him/her to wear. RN #3 revealed Resident #35 had an old wound to the left heel that had healed. RN #3 revealed the resident was at risk for the pressure area to reoccur if the heels were not floated on the bed with the prevalon boots or heel lift boots. Interview with Licensed Practical Nurse/Certified Nursing Assistant (CNA) #2, on 11/16/10 at 9:40 AM, revealed she was an LPN but was working as a CNA that day. LPN #2 revealed Resident #35 was total care and that she was not aware the resident needed heel lift boots in bed, but she would go check the CNA care book. LPN #2 revealed she could not review the kiosk to see what the resident needed but would check the CNA care plan book on the unit. LPN #2 reviewed the CNA care plan and revealed there was nothing on it to indicate Resident #35 needed any heel protectors. Interview with the Minimum Data Set (MDS) assistant coordinator, on 11/16/19 at 3:24 PM, revealed Resident #35 had a problem listed for pressure to the left and right heels and one of the interventions was to float the heels when in bed. The MDS Assistant Coordinator further revealed Resident #35 had an order for heel lift boots to the lower extremity for every shift and this should be done and the care plan should be implemented to relieve pressure to the heels and prevent further skin breakdown. Interview with the Director of Nursing (DON), on 11/16/19 at 4:22 PM, revealed the physician orders and the comprehensive care plan should have been followed and did not know why the heel lift boots and prevalon boots were not applied as ordered. The DON stated the boots were ordered to protect Resident #35's skin because he/she was at risk for skin breakdown. Observations, on 11/12/19 at 10:49 AM, 11/13/19 at 9:45 AM, 11/14/19 at 9:43 AM, and 11/16/19 revealed Resident #35 was lying in bed and no activities were provided for the resident. Record review revealed the facility admitted Resident #35 on 6/26/18 with diagnoses to include Heart Failure, Acute Respiratory Failure, Chronic Obstructive Pulmonary Disease, Hypertension, Dementia without Behavioral Disturbance, Pressure Ulcer of Sacral Region, Stage Four (4), Wound Myiasis, and Pressure Ulcer of the Left Heel, Stage 1. Record review of the quarterly MDS with an ARD of 9/06/19, revealed it was somewhat important to the Resident #35 to have books, music, new, group, and religious activities. Record review of the comprehensive care plan for Resident #35 revealed a problem was listed for activities and the goal was for the resident to be engaged in programs within his/her abilities. Record review of the approaches on the care plan revealed the facility was to provide specialized small group, sensory, and one-on-one activities. Record review of the Annual Quality of Life Lifestyle Review, dated 5/30/19, revealed Resident #35 enjoyed pet visits and listening to music, Interview, on 11/16/19 at 2:03 PM, with the Activity Assistant, revealed she had not done any activities with Resident #35 since October when the activity director left. Interview, on 11/16/19 at 3:04 PM, with the MDS Assistant Coordinator, revealed Resident #35 had a care plan for activities and the approaches should have been implemented. The MDS Coordinator revealed if the activity care plan had not been followed, then Resident #35 could have loneliness and psychosocial problems. Resident #35 would be at risk for depression if the comprehensive care plan for activities was not followed. Interview, on 11/16/19 at 4:26 PM, with the DON revealed she did not know why Resident #35 not provided activities and the care plan should have been followed. 3. Observation of Resident #90, on 11/12/19 at 10:43 AM and 4:06 PM revealed he/she was just lying in the bed in his/her room. Record review revealed the facility admitted Resident #90 on 10/02/19 and the diagnoses included Dysphagia, Intracranial Hemorrhage, Speech and Language Deficits, Hemiplegia, Hemiparesis, Cerebral Infarction, Respiratory Failure, Chronic Obstructive Pulmonary Disease, Gastrostomy, Hypertension, Tracheostomy, Schizophrenia, and Wound Myiasis. Record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/09/19, revealed Resident #90 did not have any hearing and vision problems. Review revealed they were unable to complete the cognition portion so there was no Brief Interview for Mental Status (BIMS) score. Record review of the functions section of the MDS revealed Resident #90 needed extensive assistance from staff for bed mobility, dressing, toileting, hygiene and he/she was totally dependent for bathing. Record review further revealed Resident #90 was incontinent of bowel and bladder. In addition, Resident #90 had impaired range of motion to both of the lower legs. Record review of the telephone physician order obtained on 11/01/19, revealed a urinalysis (U/A) with culture and sensitivity (C&S) was to be done for Resident #90. Record review of the progress notes for 11/01/19, 11/02/19, 11/03/19, and 11/04/19 revealed no documentation that a urine sample had been obtained. Record review of the comprehensive care plan revealed a problem was listed for elimination and the resident was at risk for urinary tract infections (UTI). The goal for the problem was the resident would not exhibit signs or symptoms of a UTI. One of the approaches was for labs to be obtained as ordered by the physician. Interview with the Director of Nursing (DON), on 11/15/19 at 11:39 AM, revealed there was a telephone order for a U/A to be obtained for Resident #90 and after she reviewed the clinical record she could not find where the urine specimen had been obtained Interview with the Minimum Data Set (MDS) Assistant Coordinator, on 11/16/19 at 3:15 PM, revealed Resident #90 was at risk for a urinary tract infection (UTI) related to incontinence. Interview further revealed interventions on the care plan included, medications as ordered, labs as ordered, report results to the physician, provide incontinent care, and monitor for signs and symptoms of a UTI. The comprehensive care plan should have been followed and the U/A should have been obtained. The MDS Assistant Coordinator further revealed if the U/A was not obtained it put the resident at risk for worsening of the UTI and hospitalization. Observation of Resident #90, on 11/12/19 at 10:43 AM and 4:06 PM, 11/13/19 at 10:47 AM and 4:05 PM revealed he/she was just lying in the bed in his/her room. Record review revealed the facility admitted Resident #90 on 10/02/19 and the diagnoses included Dysphagia, Intracranial Hemorrhage, Speech and Language Deficits, Hemiplegia, Hemiparesis, Cerebral Infarction, Respiratory Failure, Chronic Obstructive Pulmonary Disease, Gastrostomy, Hypertension, Tracheostomy, Schizophrenia, and Wound Myiasis. Record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/9/19 revealed Resident #90 was not to complete the cognition portion so there was no Brief Interview for Mental Status (BIMS) score. Review of the customary portion of the MDS revealed it was somewhat important to her to look at books, listen to music, be around animals, keep up with the news, and he /she liked to do things with groups, and he/she liked religious services. Record review of the comprehensive care plan for Resident #90 revealed a problem was listed for activities. The problem noted Resident #90 was at risk for decline in activities from previous recreational interests. One goal was for Resident #90 to participate in preferred activities and he/she would participate in 1:1 visits. The approaches included 1 on 1 visits as scheduled, activities was to invite and encourage the resident to go to activity programs and 1:1 visits was to be done. Interview, on 11/16/19 at 1:29 PM, with the Activity Assistant revealed revealed she had not done any activities with Resident #90 and she did not have any log for her/him because she was busy with other residents activities. The Activity Assistant stated Resident #90 was care planned for altered activity program. Interview with the MDS Assistant Coordinator, on 11/16/19 at 3:12 PM, revealed Resident #90 had an activity care plan and the approaches included: one on one visits, pet visits, and the resident was to be invited and encouraged to attend activity programs. Interview further revealed Resident #90 could have general loneliness, feel isolated, and develop depression if not able to attend activities. The MDS Assistant Coordinator further revealed the care plan interventions outlined in the comprehensive care plan should have been implemented. Interview with the DON, on 11/16/19 at 4:26 PM, revealed the comprehensive care plan should be followed. 4. Observation of Resident #61, on 11/12/19 at 11:37 AM, revealed the resident was laying in bed and then stood up from the side of the bed with nothing on his/her feet. Observation of Resident #61, on 11/14/19 at 8:00 AM, revealed he/she was sitting on the side of the bed, trying to remove the hospital gown and did not have any shoes or socks on. Record review of the clinical record revealed the facility admitted Resident #61 on 08/15/16 with diagnoses of Moderate Intellectual Disabilities, Urinary Tract Infection, Hypertension, Mood Disorder, Reflux, Dysphagia, Seizures, Panic Disorder, Anxiety, and Depression. Record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/27/19 revealed Resident ##61 had a Brief Interview of Mental Status (BIMS) of seven (7) which meant the resident was cognitively impaired. Review further revealed Resident #61 needed supervision of one person with walking. Review of the balance section revealed Resident #61 was not steady but was able to stabilize himself/herself without human touch. Record review of the comprehensive care plan for Resident #61 revealed the resident was at risk for falls related to urinary incontinence, poor safety awareness, potential adverse reaction to psychoactive medication, and a balance deficit. Review of the approaches revealed Resident #61 was to be assisted to sit when he/she was restless, referral to physical therapy or occupational therapy, and he/she was to have non-slip socks on at all times. Interview with the MDS Assistant Coordinator, on 11/16/19 at 3:18 PM, revealed Resident #61 was at risk for falls and he/she had fallen before. The MDS Assistant Coordinator further revealed it was important for staff to follow the care plan for Resident #61 because one of the interventions was for non slip socks to be worn at all times and that meant in bed too. She revealed Resident #61 had poor balance and he/she ambulated without assistance. She further revealed the non slip socks was a measure to help prevent falls and if the resident was barefooted there was more of a risk that he/she might fall and be injured. Interview with the Director of Nursing (DON), on 11/15/19 at 11:12 AM, revealed Resident #61 had a history of falls. Interview further revealed Resident #61 should have non slip socks on at all times and that was one of the interventions incorporated into the comprehensive care plan and the care plan should be followed. Interview with the Administrator, on 11/16/19 at 10:12 PM, revealed her role as the administrator included overseeing the well being of the residents and making sure the facility met regulatory expectations. The Administrator revealed the Quality Assurance (QA) team met monthly. The team included the Medical Director, the DON, herself, Social Services, Maintenance, MDS Coordinator, Activities Coordinator, Medical Records, and two (2) nurses from the units. The Administrator revealed comprehensive care plans and Certified Nursing Assistant (CNA) care plans had been identified as a concern in the month of October. 5. (Refer to F689) Review of the clinical record revealed the facility admitted Resident #9 on 05/23/11. Record review revealed Resident #9 had diagnoses which included Dementia in other diseases classified elsewhere with behavioral disturbance; Displaced fracture of left radial styloid process, subsequent encounter for closed fracture with routine healing; Muscle weakness; and Difficulty in walking, not otherwise classified. Review of the MDS (Minimum Data Set) assessment dated [DATE], a Significant Change assessment, revealed the facility assessed Resident #9 as having a BIMS (Brief Interview Mental Status) score of eleven (11) out of fifteen (15). Per the MDS Assessment, the facility assessed Resident #9 as independent with no setup or physical help from staff for ambulating in room and corridor. Continued review revealed Resident #9 was assessed as having one (1) fall with major injury since the prior assessment. Review of the Quarterly MDS Assessment, dated 11/04/19, revealed the facility assessed Resident #9 with a BIMS score of nine (9) of fifteen (15). Continued review revealed the facility assessed Resident #9 as independent with no setup or physical help from staff for bed mobility, transfer, ambulating in room and corridor, and on and off the unit. Resident #9 was assessed as having no falls since the prior assessment. Record review revealed a Fall Risk Evaluation, dated 05/01/19, and the facility assessed Resident #9's score as ten (10), with a resident score of ten (10) or higher being at risk. Review of the Fall Risk Assessment Tool dated 07/26/19, after the resident sustained a fall on 07/24/19, revealed the facility assessed the resident's fall risk score as fifteen (15), indicating high fall risk, when high fall risk noted on document for score greater than thirteen (13). Review of Resident #9's Comprehensive Care Plan, revealed a plan of care for falls, dated 07/24/19, which documented the resident was at risk for fall related injury related to: previous fall, balance deficit, poor posture, potential adverse effects related to psychoactive and pain medications. Continued review of the plan of care for falls revealed a goal that resident fracture will continue to heal without complications with a target date 02/14/20. Per review, interventions included remind and encourage resident not to wait too long before heading to the toilet, dated 08/16/19; and referral for screen and treatment as needed with OT and PT checked, with approach start date 07/24/19. Record review of Progress notes for Resident #9 revealed a note, dated 07/25/19 at 4:03 AM, which documented the facility transferred the resident to the emergency room, related to X-ray showing a left acute distal radial fracture. Review of the facility Fall Investigation, dated 07/24/19 and created by LPN #5, revealed Resident #9 was walking in the hallway, lost his/her balance, and fell very close to the Nurse's Station, with his/her bottom on the floor and left hand and elbow on the floor. Further review of the Fall Investigation summary revealed IDT reviewed, intervention in place, care plan updated and resident presents with Dementia, fell and attempted to break her fall and sustaining a fracture to left forearm. PT/OT evaluation was documented on the Fall Investigation. Continued review of the record revealed no documented evidence Resident #9 was evaluated by PT after the resident's fall per the facility Fall Investigation and the resident's Comprehensive Care Plan. Interview with Resident #9, on 11/13/19 at 10:22 AM, revealed he/she tripped and fell one time and fractured his/her left wrist, and had a cast. Per interview, the resident thought it happened about a year ago. Further interview with Resident #9 revealed he/she stumbled in the hall, and someone came to the facility and took x-rays. Resident #9 stated he/she went to the doctor for the broken arm as well. Interview with Licesned Practical Nurse (LPN) #5, on 11/16/19 at 1:43 PM, revealed he was working when Resident #9 fell on [DATE] and witnessed the fall. Continued interview revealed the resident told him he/she lost balance and fell. Further interview revealed the resident was wearing shoes and able to ambulate independently. LPN #5 stated he checked the resident's ROM (range of motion) to extremities, an x-ray was completed and positive, and the resident was transferred to the hospital. Further interview revealed after the fall, he was to complete the incident/event report and fall investigation and document in the progress notes and if they find the cause of the fall, they update the care plan. He stated falls were then reviewed in the IDT meeting. LPN #5 stated ITD may do more interventions or change them. LPN #5 stated generally a PT evaluation was completed after a resident fall but he did not complete PT/OT referrals for Resident #9, and further stated the IDT must have completed the referral. Interview with the MDS Coordinator, on 11/16/19 at 11:55 AM, revealed Resident #9 should have had a PT evaluation after the fall if the care plan was revised to do this. Further interview revealed the facility has a form that anyone can complete for therapy referral and residents were usually seen by PT after a fall. Interview by phone on 11/16/19 at 7:57 PM, with the Therapy Director, revealed she could not recall receiving a referral for resident #9 for PT after the fall. Further interview revealed after Resident #9's fall on 07/24/19, she thought Therapy's only involvement was OT. Interview with the LPN Unit Manager on Unit 100, on 11/16/19 at 4:07 PM, revealed the current process was for the nurse to call the DON after a resident fall, and advise the DON of prior care plan interventions. The nurse and DON should then determine an intervention and place on the care plan at that time. She further stated if the Care Plan was updated for OT/PT, the resident should have been evaluated and the referral completed by the nurse on the unit. Interview with the Clinical Nurse Consultant, on 11/16/19 at 11:45 AM and 12:25 PM, revealed the fall was an isolated incident for the Resident #9, and stated the resident had no prior falls and no falls since. Further interview revealed she was unable to find documented evidence a PT evaluation was completed per the Care Plan after Resident #9's fall on 07/24/19, and it should have been completed or there should have been documentation as to why it was not completed. Interview with the Director of Nursing (DON), on 11/16/19 at 2:18 PM, revealed she was not sure of the process for falls at the time of Resident #9's fall, as she was not employed at the facility at the time this investigation was completed. The DON reviewed the fall investigation and Event Report/Incident Report for Resident #9 and said the reason for the investigation was to try to prevent future occurrences and change in the resident. Continued interview revealed there should have been a PT evaluation or screening, per the care plan intervention. She stated a problem with the PT evaluation not being completed, was the resident could have a decrease in functional mobility or falls. Interview with the Administrator, on 11/16/19 at 11:24 AM and 4:20 PM, revealed at the time of Resident #9's fall on 07/24/19, she was not employed at the facility. Continued interview revealed it was her expectation that interventions be put in place, and care plans be updated and followed, after a resident fall.

Based on observation, interview, record review, and review of facility policy it was determined the facility failed to employ sufficient dietary staff with the appropriate competencies and skill sets to carry out the functions of food and nutrition service for 96 residents nine (nine residents received tube feeding) of 105 residents who received meals at the facility. Review of the Resident Census and Conditions of Residents, signed by the DON (Director of Nursing) on 11/12/19 revealed there were one hundred five (105) total residents and nine (9) residents received tube feeding. Observation and interview revealed there was not enough dietary staff to ensure meals were served to residents in a timely manner, per the facility posted meal times. (Refer to F809). In addition, resident food allergies and intolerances were not followed for Resident #79 with regards to gluten free diet and dietary staff interview revealed no training on gluten free diets. (Refer to F806). Frosted Spice Cake was not served per the menu on 11/12/19, per interview, due to lack of staff (Refer to F803). The Findings Include: Review of facility policy titled Staffing Schedules, dated revised 10/22/18, revealed schedules were created to provide the work force necessary for accomplishment of identified output. Review of the facility Meal Times, undated, revealed the lunch meal times for the Gold/Main Dining Room was at 12:30 PM. Further review revealed 200 Hall lunch was at 11:30 AM. Per the Meal Times document, Trays would be delivered by posted time. Review of the Menu dated Tuesday, November 12, 2019, revealed the lunch menu items were Chicken Burrito, Latin Flavored Corn, Southwest Salad, Tortilla Chips and Salsa, Frosted Spice Cake, and Choice of Beverage. Review of the facility policy Food Allergy/Intolerance Awareness, dated revised 08/31/18, revealed food that accommodates resident allergies, intolerances, and preferences should be prepared and served. Continued review of the policy revealed a food substitute for the food allergy, intolerance, or preference should be consistent with the usual or ordinary food item provided to the community. Observations on 11/12/19 at 1:08 PM, revealed residents were being served drinks in the Dining Room. Observations revealed residents in the Gold Dining area were being served on 11/12/19 at 1:50 PM, which was past the Meal Times schedule of 12:30 PM. Observations revealed the food cart arrived on the 200 unit at 1:50 PM on 11/12/19, which was past the Meal Times schedule of 11:30 AM. Observation of the lunch meal service on 11/12/19 revealed Frosted Spice Cake was not served to residents with the lunch meal, per the menu. Observation on 11/12/19 at 10:57 AM, revealed the Dietitian assisted kitchen staff with washing dishes. Observation during the tray line beginning on 11/13/19 at 11:30 AM, revealed Dietary Aide #2 was observed to place regular bread on the tray for Resident #79, and placed the tray on the cart for delivery. Interview with Dietary Aide #2 at the time revealed she stated the bread she placed on the resident's tray was regular bread. After the surveyor stopped the line and asked Dietary Aide #2 about the bread, the [NAME] told Dietary Aide #2 to remove the bread from Resident #79's tray. Continued observation revealed there was no additional/gluten free bread placed on the resident's tray. Interview with Dietary Aide #2, on 11/15/19 at 10:24 AM, revealed she had been employed at the facility for three (3) years. Continued interview revealed she did not know about gluten free bread, just about cereal and lactose free milk. Per interview she had not received training to specifically know what a resident could or could not have on a gluten free diet and she did not know if the facility had gluten free bread. She stated that in past, cooks marked bread gluten free. Further interview with Dietary Aide #2, revealed everyone was doing extra in the kitchen due to not having enough staff, and it took longer to complete tasks when short staffed. Continued interview revealed the Dietary Manager had to make sure menus were followed. Per interview, if there was not enough dessert, she would provide something else and on 11/12/19, the Frosted Spice Cake was supposed to be made the night before but it was not prepared due to short staffing. Interview with the Dietary Manager (DM), on 11/15/19 at 10:37 AM, revealed he began employment as the DM on Monday, 11/11/19. Continued interview revealed the kitchen had a staff shortage, and there was supposed to be three (3) full time staff and now were only two (2) full time staff. Per interview, he believed there had been a staffing shortage for several weeks. Continued interview revealed the Frosted Spice Cake on the lunch menu for 11/12/19, was supposed to have been made the night before; however, the kitchen was short staffed so it did not get made. Per interview, resident diets should be followed, and the facility had gluten free bread. Continued interview revealed Resident #79, who was ordered a gluten free diet, should have received gluten free bread and should not receive regular bread, because regular bread could make the resident sick. Continued interview with the DM revealed staffing shortage had caused issues, such as meals not served timely to residents. He indicated the budget calls for 3 staff for the AM shift and 3 for the PM shift, consisting of one (1) cook and two (2) dietary aide each shift. He further stated the facility had only two (2) people to pick from. He indicated he had been in contact with corporate recruiting staff, and there were four (4) to six (6) new staff in orientation starting the following week. Further interview revealed the Dietitian was assisting with washing dishes on 11/12/19, to be able to get dishes washed for the next meal. Per interview, if the kitchen was staffed, he would be an extra set of eyes and supervision, rather than serving the tray line and that he was unable to do that when he was cooking or cleaning. Interview by phone with the Dietitian, on 11/16/19 at 4:57 PM, revealed she had been employed at the facility for six (6) to seven (7) months, and there had been turnover and lack of dietary management in the kitchen. Per interview, the dietary department was short staffed on 11/12/19 and she helped wash dishes. Continued interview revealed the dietary aide told her she substituted fruit with cinnamon for the Frosted Spice Cake which was on the menu on 11/12/19, but did not elaborate as to the reason the Frosted Spice Cake was not served, per the menu. Per interview, dietary staff had been challenged as they didn't know how to do things or what to do, and meals had been late since the assistant DM left about a month ago, as the facility was trying to fill positions. Continued interview revealed late meals could cause blood sugar drops or could cause stomach issues for residents. Per interview, menus should have been followed and residents on gluten free diets should receive gluten free bread, as regular bread could cause bloated belly, diarrhea, inflammation, or potential constipation. Per interview, she indicated staff needed a review on diets and felt this would be accomplished since the facility has a new DM. Interview with the Director of Nursing (DON), on 11/16/19 at 9:30 AM, revealed she had been employed at the facility for six (6) weeks and stated the dietary department had been a concern. Per interview, she was not aware residents did not get Frosted Spice Cake, per the menu on 11/12/19, and menus should be followed. Further interview revealed she was aware meals arrived late and residents had complained. Per the DON, late meals could result with hypoglycemia for diabetic residents. Continued interview revealed she was informed dietary staff placed regular bread on Resident #79's tray and stated Resident #79 had gluten intolerance. Per the DON, Resident #79 should not have had regular bread placed on the tray, but should have received gluten free bread; however, she stated non medial staff would not know this without training. Continued interview revealed the facility was working on staffing for the kitchen and she thought there were kitchen staff in orientation this week. Interview with the Administrator, on 11/16/19 at 4:20 PM, revealed she was aware of dietary issues in kitchen. Further interview revealed the facility had a new DM, who started this week, and the DM had not had time to provide education. Per interview, on 11/12/19, there were two (2) Dietary Aides and the DM, who was also the cook for that date. Per interview, there typically should be the DM and 3 staff. Further interview revealed it was her expectation that staff follow policies and procedures of the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined the facility failed to provide at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care. Review of the facility posted Meal Times, which was not dated, revealed the lunch meal was to be served to the Gold/Main Dining Room at 12:30 PM. Observations during the meal service on 11/12/19 revealed the lunch meal was served late. Interviews with Resident's #18, #22, #28, and #155, revealed meals were often served late. Interview with Resident #155 revealed he/she would refuse prescribed short acting insulin until he/she knew for sure the trays were on the unit, due to the short acting insulin would make his/her sugar drop. The findings include: Review of the facility Meal Times, undated, revealed the lunch meal times for the Gold/Main Dining Room was at 12:30 PM. Further review revealed 200 Hall lunch was at 11:30 AM. Per the Meal Times document, Trays will be delivered by posted time. Review of the policy Staffing Schedules, dated revised 10/22/18, revealed schedules were created to provide a work force necessary for the accomplishment of the identified output. Observations on 11/12/19 at 1:08 PM, revealed residents were being served drinks in the Dining Room. Observations revealed facility staff were serving residents in the Gold Dining area, on 11/12/19 at 1:50 PM, which was past the Meal Times schedule of 12:30 PM. Observations revealed the food cart arrived on the 200 unit at 1:50 PM on 11/12/19, which was past the Meal Times schedule of 11:30 AM. Observation, on 11/15/19 at 8:15 AM, during the medication pass revealed Resident #155 would not let the nurse administer the short acting insulin until the breakfast trays were brought to the unit. Interview with Resident #155, on 11/15/19 at 8:15 AM, revealed she was alert and oriented. Interview further revealed the short acting insulin will make her sugar drop and she would get shaky. Resident #155 revealed that the trays on the unit sometimes did not get delivered until around 10:00 AM or 10:30 AM and by that time her sugar would drop too low so she refused to take the short acting insulin until she knew for sure the trays were on the unit. Record review of the face sheet for Resident #155 revealed the facility admitted he/her on 10/22/19 with diagnoses of Cellulitis of the right upper limb, Diabetes Mellitus, and Asthma. Record review of the physician orders for 10/16/19 - 11/16/2019 revealed an order for Novolog Flexpen, give twelve (12) units subcutaneous with meals and it was to be given three times a day. Interview with Resident #18, on 11/12/19 at 12:14 PM, revealed meals were often late. Review of the clinical record revealed the facility admitted Resident #18, per the face sheet, on 07/06/17. Diagnoses included Obstructive Hydrocephalus; Bipolar Disorder, Unspecified; and Type 2 Diabetes Mellitus without complications. Review of the MDS assessment dated [DATE] revealed the resident was assessed as having a BIMS score of twelve (12) of fifteen (15). Interview on with Resident #22, 11/13/19 at 9:18 AM, revealed they were supposed to get their lunch meal at noon, when things were going right. Resident #22 revealed the kitchen had been messed up for quite awhile because they do not have enough staff and there was no one to oversee it. Resident #22 revealed last evening they did not get their supper tray until 6:30 PM. Resident #22 revealed you never know what food you were going to get. Resident #22 stated he/she would fill out a menu and if they did not have the food they would just anything. Resident #22 revealed a third of the time they run out of what was on the menu and would just serve them anything. Resident #22 stated he/she felt they should at least get a heads up of what they were about to eat. Record review of the clinical record revealed the facility admitted Resident #22 on 10/10/16 with diagnoses of Diabetes Mellitus, Convulsions, Acquired Absence of the Right and Left Legs, and Stage Two (2) Chronic Kidney Disease. Record review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/21/19 revealed a Brief Interview of Mental Status (BIMS) of fifteen (15) which meant the resident was not cognitively impaired. Record review of the physician orders for 11/1/19 to 11/15/19 revealed Resident #22 had Novolog sliding scale ordered to be given before meals. Resident #22 also had other medications for Diabetes order which included, Metformin 500 milligrams (mg) to be given twice a day and Levemir Insulin twenty one (21) units to be given subcutaneous twice a day, Interview with Resident #28, on 11/12/19 at 12:00 PM and 11/14/19 at 12:28 PM, revealed meals were late and sometimes he/she did not receive lunch until 2:30 PM. Record review revealed the facility admitted Resident #28 on 05/23/19 with diagnoses which included End Stage Renal Disease and Type 2 Diabetes Mellitus without complications. Continued review revealed the facility assessed Resident #28 as having a BIMS (Brief Interview Mental Status) score of fourteen (14) out of fifteen (15) on the MDS assessment dated [DATE], indicating the resident was cognitively intact. Record review revealed the resident's ordered diet was regular liberalized renal double protein. Interview with Certified Nursing Assistant (CNA) #6, on 11/15/19 at 11:26 AM, revealed the past three (3) weeks or so, meals had been late due to a kitchen staffing shortage. Interview with Dietary Aide #2, on 11/15/19 at 10:24 AM, revealed dietary services had experienced short staffing for about 2 months and sometimes meals were delivered late. Continued interview revealed everyone was doing extra in the kitchen due to not enough staff. Per interview, depending on how many staff were working, or if there were staff who did not know how things were done, such as staff whom came from another facility/building, it took longer to complete tasks. Interview with the Dietary Manager (DM), on 11/15/19 10:37 AM, revealed the dietary department was short staffed and he believed staffing had been short for several weeks. Per interview, there were three (3) full time staff and now there were only two (2) full time staff. The DM stated staffing problems had caused issues, such as meals not served timely to residents. He indicated the budget calls for 3 staff for the AM shift and 3 for the PM shift, consisting of one (1) cook and two (2) dietary aide each shift. He further stated the facility had only two (2) people to pick from. He indicated he had been in contact with corporate recruiting staff, and there were four (4) to six (6) new staff in orientation starting the following week. Further interview revealed the Dietitian was assisting with washing dishes on 11/12/19, to be able to get dishes washed for the next meal. Interview with the Dietitian by phone, on 11/16/19 at 4:57 PM, revealed there had been staff turnover and the facility was trying to fill the voids. Continue interview revealed there had been a lack of dietary management in dietary services but stated the facility now had a new DM. Further interview revealed meals had been late since the prior assistant DM left, about a month or so ago. She indicated the kitchen was short staffed on 11/12/19 and she helped wash dishes. Continued interview revealed late meals could cause a problem with diabetic residents as their blood sugar could drop. Interview with the DON, who stated she had been employed at the facility for six (6) weeks, on 11/16/19 at 9:30 AM revealed dietary has been a concern, and she was aware that meals were arriving late and resident had complaints about the late meals. Continued interview revealed late meals could be a problem and could result with hypoglycemia for diabetic residents. Interview with the Administrator, on 11/16/19 at 4:20 PM, revealed she was aware of dietary issues in the kitchen. She indicated the facility had been working on the schedule and should have three 3 staff on the AM shift and three (3) staff on the PM shift. Per interview, the new DM has not had time to provide education to staff and just started this week. She indicated it was her expectation that facility policies and procedures be followed.

Based on observation, interview and review of the facility's Policies, it was determined the facility failed to prepare, store, distribute and serve food in accordance with professional standards for food service safety. Observation of the kitchen, on 11/12/19 revealed low fat cottage cheese with an open date 10/27/19, and turkey, which was labeled with two labels, one label documenting use by 10/7/19 and one label with the date 11/5/19, and a use by date of 11/20/19. Continued observation revealed chocolate pudding, dated to use by 11/10/19, an opened gallon of 2 percent milk with manufacturer use by date of 11/10/19, and potato salad opened 11/07/19. Furthermore, observation on 11/12/19 revealed ground pepper and ginger powder opened with no date, ground cumin dated opened 05/15/18, Mediterranean ground oregano labeled 09/22/17, and black pepper, which was not dated and the label was such that the date received could not be read. Observations revealed sugar, rice and flour bins were observed with brown substance on the containers. Moreover, observations of the walk in freezer on 11/12/19 revealed ice on floor and cord to the plug, with ice and frost on pre packaged pie crusts. Homestyle Chicken Breast tenders were observed in a box with the inner bag opened, unsealed, and undated, and turkey sausage patties were observed in a box inside an inner plastic bag, and the plastic bag was observed open, unsealed, and undated. In addition, observation of the 100 Unit Nourishment refrigerator on 11/16/19 revealed a tuna sandwich and a chicken sandwich wrapped, with no dates on either sandwich. The findings include: Review of the facility policy Refrigerated Storage Quick Reference Guide, dated revised 11/29/17, revealed cottage cheese was good for 7 to 10 days once opened. Continued review revealed potato salad was good Review of the policy Refrigerated Leftover Storage, dated revised 12/08/18, revealed a leftover foods should not be saved and used for human consumption if there is any doubt of the wholesome quality. Per policy a leftover was a product that has been on the meal service line one time. These timeframes were not only used to control sanitation but the quality of the food also. Further review revealed date container with use by date. Review of the policy Dry Storage Chart, dated revised 05/12/16, revealed the chart was a recommended outline of proper storage times for opened and unopened dry items and where different, follow manufacturer's directions and expiration dates. The policy noted expiration dates supercede these guidelines. Review of the facility policy Freezer Storage Chart, dated revised 10/15/18 revealed the document was a recommended outline of proper storage times for opened and unopened frozen items and where different, follow manufacturer's directions and expiration dates. Per policy, expiration dates supercede the guidelines. Further review of the policy revealed if frozen status is maintained and food is properly sealed, recommended storage times were the same as unopened. Review of the policy Nourishment Preparation, dated revised 09/16/18, revealed individual nourishments should be prepared, covered, labeled, dated and delivered to each nursing station. Per policy, nourishments stored in the nourishment refrigerator must be labeled and dated. Observations during the initial kitchen tour, on 11/12/19 at 9:53 AM, of refrigerated items, revealed low fat cottage cheese with an open date 10/27/19. Interview with the DM at this time, revealed he just began working at the facility one (1) day ago. Further interview revealed cottage cheese was good for 7 days after opened, per policy. Review of the facility Refrigerated Storage Quick Reference Guide, dated revised 11/29/17, revealed cottage cheese was good for 7 to 10 days once opened. Further observation revealed cooked turkey meat in a plastic container, observed with two (2) labels, one documented a use by date of 10/7/19, and the second label was dated 11/5/19 and a use by date of 11/20/19. Interview with the DM revealed the turkey was improperly labeled, so it could not be determined which dates determine when the food expired. Review of the facility policy Refrigerated Storage Quick Reference Guide revealed cooked meat was good for three (3) to four (4) days after opened. Chocolate pudding was observed with a use by date of 11/10/19, and an opened gallon of 2 percent milk was observed with the manufacturer use by date of 11/10/19. Interview with the DM revealed these items were expired, and should have already been discarded. Further observation revealed a container of potato salad opened 11/07/19. Per interview with the DM, the health department gives seven (7) days but he planned to have staff discard after three (3) days. Continued observation during the initial kitchen tour revealed ground pepper was observed opened with no date, ginger powder was observed opened with no date, ground cumin was dated opened 05/15/18, Mediterranean ground oregano was labeled 09/22/17 and black pepper was observed opened and not dated, and the date on the label was illegible. Interview with the DM revealed spices should be dated when opened and were only good for 6 months. He indicated these spices should have been discarded. Review of the policy Dry Storage Chart revealed ground spices and herbs were good for six (6) months after opening. Large sugar, rice and flour bins were observed with brown substance on the containers. Interview with the DM revealed it looked like coffee on the containers. Observation of the walk in freezer during the initial kitchen tour revealed ice was observed on the freezer floor and plug cord, and from a shelf which contained pre packaged pie crusts. The pie crusts were observed with with ice and frost on them. Interview with the DM revealed the pie crusts would have to go in trash due to having ice and frost on them. The DM stated he was unsure why the walk in freezer had ice build up. Continued observation revealed Homestyle Chicken Breast tenders were observed in a box inside an inner bag, which was observed opened, unsealed, and undated. In addition, a box of turkey sausage patties were observed opened, unsealed, and no date was observed. Interview with the DM revealed the Chicken Breast Tenders and Turkey sausage should have been submerged in plastic, labeled and dated. Observation on 11/13/19 at 12:42 PM, during tray line, revealed silver plate warmers fell out of warmer onto floor and staff placed them back inside oven/warmer. Continued observation revealed the Administrator was present and told the staff not to use the plate warmers, and dietary staff removed them and placed them in dish room to be washed. Observation of the 100 Unit Nourishment refrigerator, on 11/16/19 at 8:37 AM, with Registered Nurse (RN) #6, revealed a tuna sandwich and a chicken sandwich, observed wrapped, with no date. Further observation revealed medications were stored in the refrigerator with the food. Interview with RN #6 at this time, revealed medications should be stored in the medication refrigerator. Further interview revealed medications were not supposed to be stored with food, as this could cause contamination. Further interview revealed the sandwiches should have been dated, and if not dated, there was no way to know if they were expired, and this could cause illness. Interview with the Unit Manager on 100 Unit, on 11/16/19 at 3:50 PM, revealed dietary sends snacks, and the sandwiches in the nourishment refrigerator should have been be dated when received from dietary; because the food could be old or cause a resident to be sick. The Unit Manager stated she usually checked the nourishment refrigerator each morning but had not checked it yet on this date. Interview on 11/16/19 at 9:06 AM, with the Regional Nurse Consultant revealed normally medications were not stored with the food because it could cause contamination between the two. Continued interview revealed the sandwiches should have been dated, to determine when they expire and so staff would know when the food went bad. Interview with the DM, on 11/13/19 at 12:53 PM, revealed the DM reported he had contacted Maintenance to look at walk in freezer. Interview on 11/13/19 at 1:03 PM, with the Maintenance Director revealed he had not looked at it yet. Subsequent interview on 11/16/19 at 3:19 PM, revealed the facility recently had the walk in freezer resealed. He further stated the current problem was with the latch and he thought this was the cause for the frost in the freezer. He stated the latch was supposed to go in a grove and it was not automatically doing that. Interview with the DM on 11/14/19 at 3:25 PM revealed maintenance checked the walk in freezer and the latch at the top was causing it to not have a good seal, causing the freezer to work harder. Continued interview revealed temperatures were in range and maintenance obtaining a new part for the freezer. Continued interview with the DM, on 11/15/19 at 10:37 AM, revealed foods in the freezer should be sealed and wrapped to keep foreign particles out, prevent freezer burn and prevent cross contamination. Further interview revealed the foods such as the turkey in the refrigerator should have been discarded. Continued interview revealed the reason for dating food items was to assure food was safe. The DM stated if food was not dated properly, it could cause food borne illness, or could make residents sick. Interview by phone with the Dietitian, on 11/16/19 at 4:57 PM, revealed she had been employed at the facility for six (6) to seven (7) months, and the dietary department had experienced staff turnover and lack of dietary management. Per interview, dietary staff had been challenged as they did not know how to do things or what to do, since the assistant DM left about a month ago, and the facility was trying to fill positions. Continued interview revealed foods in the freezer should have been wrapped and dated. Further interview revealed foods should be dated when opened including dairy, and expired food and milk should have been thrown away. Further interview revealed the sandwiches in the 100 hall should have been dated. Per interview if food was not dated, this could cause food borne illness. Interview with the Director of Nursing (DON), on 11/16/19 at 9:30 AM and 3:41 PM, revealed kitchen sanitation should be followed and all foods should be dated and labeled. Per interview foods should be discarded when outdated. Further interview revealed nursing staff on units were responsible for checking the nourishment refrigerator, with the Unit Coordinator as back-up. Continued interview revealed the tuna and chicken sandwiches in the 100 Unit Nourishment refrigerator should have been dated. Per the DON, foods were dated to ensure they were not expired; because if expired, this could cause illness. Interview with the Administrator, on 11/16/19 at 4:20 PM, revealed she was aware of dietary issues in the kitchen. Kitchen sanitation and food storage issues were reported to the Administrator. Per interview, it was her expectation that staff to follow the policies and procedures of the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of the facility's policy, it was determined the facility failed to maintain a safe and homelike environment in two (2) of seventy-seven (77) resident rooms, rooms [ROOM NUMBERS]. Observation revealed room [ROOM NUMBER] had tile with multiple cracks that created an uneven surface at the entry to the restroom. room [ROOM NUMBER] had an area of chunked out tile at the base of the toilet along with a long crack in the tile. The findings include: 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. Observation of room [ROOM NUMBER], on 09/07/18 at 8:30 AM, revealed at the entrance of the restroom, the tile was broken in several places and created an uneven surface. Resident #93 occupied the room. Interview, 09/07/18 at 8:30 AM, with Resident #93 revealed the crack in the tile in his/her restroom had not caused any trouble for him/her so far. He/she stated it was okay as long as he/she could get safely in and out of the restroom. Observation of room [ROOM NUMBER], on 09/07/18 at 8:37 AM, revealed a cracked tile with a chunk of the tile missing at the base of the toilet in the restroom. Interview, on 09/07/18 at 2:38 PM, with Licensed Practical Nurse (LPN) #1 revealed he had not noticed the floor tiles in disrepair in rooms [ROOM NUMBERS], but would have reported them to the maintenance department by logging the needed repairs in the Maintenance Communication Log kept at the nurses' station. LPN #1 stated he was concerned about the cracked un-level tile in room [ROOM NUMBER] because it could potentially cause a resident injury. Interview, on 09/07/18 at 3:04 PM, with LPN #4 who was also the Charge Nurse, revealed she had not noticed the broken tiles in rooms [ROOM NUMBERS], but if she had she would have listed them in the maintenance repair book kept at the nurses' station. She stated Resident #93 lived in room [ROOM NUMBER] and ambulated independently to the bathroom and could accidentally step on the cracked tile and receive a skin tear or the tile could cause the resident to lose his/her balance. She stated Resident #23 lived in room [ROOM NUMBER] and used that restroom and could receive a skin tear from the broken tile at the base of the toilet, and she also thought it was an infection control issue. LPN #4 stated broken bathroom tiles did not provide the most clean or comfortable atmosphere in those residents' rooms. Interview, on 09/07/18 at 3:15 PM, with the Director of Plant Operations revealed he was aware of the broken tile in room [ROOM NUMBER] because he saw it one day while painting an area in the room. He stated he ordered a replacement tile, but had not yet completed the repair. He was not aware of the damaged bathroom floor tile in room [ROOM NUMBER] and stated the missing chunk of tile at the base of the toilet was an infection control issue because it would be difficult to get the floor completely clean by simply mopping the area. The Director of Plant Operations stated he or his assistant checked the maintenance logs at each nurses' station at least daily to learn of any reported issues or necessary repairs on the nursing units. He further stated the broken bathroom floor tiles did not give a clean, comfortable appearance to those resident restrooms. Interview, on 09/07/18 at 4:05 PM, with the Director of Nursing (DON) revealed department heads were to make rounds on their assigned areas of the nursing units every day they worked. While rounding, the department heads were to check on the well-being of the residents in their assigned areas, but they were to also observe the resident living environment and report anything that was in some state of disrepair. She stated the staff person could write the need into the maintenance log or call the maintenance director. The DON stated the broken tile in room [ROOM NUMBER] could present a fall hazard, and the tile in disrepair in room [ROOM NUMBER] would not be easy to clean. Interview, on 09/07/18 at 5:01 PM, with the Administrator revealed the facility had an Ambassador Program in place, which meant department heads were to routinely check on the well-being of their assigned residents and observe each resident's room and bathroom. If they identified any areas in need of repair, they should report the issue to the maintenance staff. The Administrator stated the staff assigned to monitor rooms [ROOM NUMBERS] should have reported the broken tiles if they saw those areas of disrepair.

Based on observation, interview, and record review, it was determined the facility failed to provide the necessary care and services to maintain appropriate grooming for one (1) of twenty-two (22) sampled residents, Resident #57. Observation revealed the resident with long, jagged fingernails with a brown substance under the nails. In addition, Resident #57 was not clean-shaven. The findings include: The facility did not provide a policy on grooming. Observation of Resident #57, on 09/06/18 at 12:45 PM, revealed the resident in the main dining area. His/her fingernails were long, jagged, and soiled with a brown substance underneath some of the nails. Observation of Resident #57, on 09/07/18 at 11:15 AM, revealed the resident's nails remained long, jagged, with a brown substance underneath. In addition, the resident was not shaved. Certified Nursing Assistant (CNA) #6 stated she had just gotten the resident up for the day and ready for lunch. Interview with Resident #57, on 09/07/18 at 11:30 AM, revealed no one would shave him/her or cut his/her nails and he/she wished someone would. Record review revealed the facility assessed the resident required extensive assistance of one (1) staff to complete personal hygiene. Interview with CNA #4, on 09/07/18 at 3:15 PM, revealed Activities of Daily Living (ADL) should include washing the face, getting residents dressed, and anything they needed assistance with on a daily basis, which included nail care. CNA #4 stated nail care included making sure nails were clean and clipped so they did not scratch themselves. She stated she thought the residents would like to keep their nails neat and trim the way she liked to keep her nails neat and trim. Interview with CNA #5, on 09/07/18 at 3:40 PM, revealed ADL care included bathing and CNAs should do a quick assessment of the resident's nails and trim if needed. Interview with CNA #6, on 09/07/18 at 4:35 PM, revealed CNAs should do nail care with the residents' bath. Interview with Certified Medication Technician (CMT) #2, on 09/07/18 at 3:20 PM, revealed ADL care included toileting, showering, shaving, and trimming nails. The CMT stated nail care was important because residents sometimes scratched themselves causing infections and sometimes scratched staff. Interview with Licensed Practical Nurse (LPN) #4, on 09/07/18 at 4:15 PM, revealed she knew Resident #57's nails were long and needed to be cut and she noticed they always had stuff underneath them. She stated the resident played in his/her feces. The LPN revealed she had been employed for a month and had never seen his/her nails trimmed and were always long and dirty. She stated all staff was responsible for nail care, which was important to prevent a resident from scratching themselves or staff and possibly cause an infection. Interview with the Director of Nursing (DON), on 09/07/18 at 5:34 PM, revealed the CNAs were responsible for resident nail care, which should be done on shower day and recorded on the skin sheets that were kept in a binder at the nurses' station. The DON stated shaving and nail care was very important to the residents because it made them feel clean and look nice. She stated a resident with long nails could possibly scratch themselves or staff causing an injury and possible infection. Review of the facility's CNA Skin Care Alert sheets, dated 08/06/18 to 09/07/18, revealed no documentation Resident #57 was shaved or provided nail care.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure medications remained in locked compartments for one (1) of three (3) medication carts, on the 100 Hall. Observation revealed staff left medication on top of the medication cart unattended. The findings include: Review of the facility's policy, Medication Storage, dated November 2017, revealed medications and biologicals were stored properly, following manufacturer's or provider pharmacy recommendations to maintain their integrity and to support safe effective drug administration. The medication supply should be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications Observation of the medication cart on 100 Hall, with Licensed Practical Nurse (LPN) #1, on 09/07/18 at 11:14 AM, revealed he set up medication for administration and left them on top of the medication cart while he entered the resident's room to get his/her blood pressure. A resident was seated in his/her wheelchair in the doorway next door. Another resident ambulated at the end of hallway and upon arrival to the medication cart area; he/she paused and then entered the room across the hall. Interview with LPN #1, on 09/09/18 at 9:20 AM, revealed medications should be locked in the medication cart when staff was not present at the medication cart. The LPN stated he should not have walked away from the medication cart, leaving medication on top of the cart available to residents or staff. He stated residents were present wandering in the corridor and another resident was seated in his/her doorway next to the room he entered. He stated a resident could have a bad outcome if they took their medication and another resident's medication, whether it was from a blood pressure drop or allergic reaction. Interview with Unit Manager #1, on 09/07/18 at 4:14 PM, revealed staff should review the medications due, obtain the vital signs necessary for the medication pass, and then return to the cart and prepare medications for administration. The process was to ensure medications remained locked in the drawers of the medication cart when staff was not in attendance of the medication cart. Interview with the Director of Nursing (DON), on 09/07/18 at 4:28 PM, revealed staff should obtain vital signs prior to setting up medications, especially for residents with parameters for blood pressure or heart rates. She stated if staff left medication unattended and accessible to residents, it could lead to a negative outcome for residents, even an allergy could be a major problem for someone.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and facility policy review, it was determined the facility failed to ensure discontinued controlled substances were disposed of in a timely manner in one (1) of one (1) discontinued medication storage areas. Observation revealed three thousand nine hundred and sixty-eight (3968) controlled medication pills stored in the Director of Nursing's office. In addition, there was liquid controlled medication, 282.25 milliliters (ml) of Ativan, 29.5 ml of Morphine, 51.25 ml of Oxyfast, 215 ml of Oxycodone, and 370 ml of Roxicodone, stored in the same location. The findings include: Reviewed of the facility's policy, Medication Storage Controlled Medication Storage, dated [DATE], revealed medications included in the Drug Enforcement Administration (DEA) classification as controlled substances were subject to special handling, storage, disposal, and record keeping in the nursing care center in accordance with federal, state, and other applicable laws and regulations. Review of the facility's policy, Disposal of Medications, dated [DATE], revealed medications included in the DEA classification as controlled substances (or those classified as such by state regulation) were subject to special handling, storage, disposal, and record keeping in the nursing care center in accordance with federal and state laws and regulations. Review of DEA 21 CFR 1317.80, dated [DATE], revealed a long-term care facility may dispose of controlled substances in Schedules II, III, IV, and V on behalf of an ultimate user who resided, or had resided, at such long-term care facility by transferring those controlled substances into an authorized collection receptacle located at the long-term care facility. When disposing of such controlled substances by transferring those substances into a collection receptacle, such disposal shall occur immediately, but no longer than three (3) business days after the discontinuation of use by the ultimate user. Discontinuation of use included a permanent discontinuation as directed by the physician as the result of the resident's transfer from the long-term care facility, or as a result of death. Interview with the Director of Nursing (DON), on [DATE] at 4:20 PM, revealed she stored discontinued, discharged , or expired resident controlled medications in her office until the controlled medications were disposed. She stated two (2) Unit Managers had access to the keys to her office and the controlled medication storage cabinet in her office when they were working on the weekends, or covering. She stated she periodically disposed controlled medication in the Destroyer Container. The DON obtained the controlled medication storage keys from the 300 Unit Manager and upon return to her office, she unlocked the controlled medication storage cabinet and the overflow cards of medication fell out of the cabinet and she attempted to catch them from falling and pushed them back into the cabinet. She had two (2) keys for the two (2) locks on the cabinet; however, each key opened both locks. The cabinet was completely full on all three (3) shelves and she requested an hour to dispose of the medications. Observation of the count of controlled medication in the DON's cabinet, on [DATE] from 6:55 PM to 10:00 PM, revealed the cabinet had three thousand nine hundred and sixty-eight (3968) pills and nine hundred forty-eight (948) ml of controlled medication. During the count, it was identified the medications were removed from the medication carts on [DATE], [DATE], [DATE], [DATE], and [DATE]. The DON, Minimum Data Set (MDS) Nurse, 300 Unit Manager, and the 200 Unit Manager completed the count. Interview with the MDS Nurse, on [DATE] at 6:55 PM, revealed she did not understand why there was a problem with controlled medication stored in the DON's office. She stated she had been the DON before and it was never an issue, as long as the medications were stored in the DON's office. Telephone interview with the Pharmacist, on [DATE] at 6:20 PM, revealed he was not aware of the quantity of scheduled medications stored at the facility, or the length of time they were stored. He stated the pharmacy typically sent a thirty (30) day supply of medication to the facility. Interview with the Administrator, on [DATE] at 6:10 PM, revealed she did not have a concern with the controlled medication stored in the DON's office. She stated they were periodically reconciled and disposed of.

Based on observation, interview, and review of the facility's policies, it was determined the facility failed to maintain a sanitary environment in the kitchen. Observation revealed kitchen equipment had dried white spots and grease stains on them; the floor was soiled with small white particles and grease spots between the kitchen equipment; there were missing wall tiles, and the ceiling had dried brown particles and peeling paint. In addition, a male kitchen staff did not have on a beard guard and did not perform hand hygiene prior to serving food. The findings include: Review of the facility's policy, Personal Hygiene, dated 07/05/18, revealed beards or any exposed body hair must be covered. Review of the facility's policy, Tray Line Setup and Service, dated 07/02/18, revealed food should not be handled with bare hands. Hands should be washed before working the tray line. Review of the facility's policy, Handwashing and Glove Use, dated 02/01/14, revealed gloves may be used when working with food to avoid contact with hands. Gloves must be worn when touching any ready-to-eat food. Review of the facility's policy, Walls and Ceilings, dated 03/14/18, revealed walls and ceilings must be washed thoroughly at least twice per a year. Heavy soiled surfaces must be cleaned more frequently and as required. It was important to repair peeling paint as soon as they appeared. Walls and ceilings must be free of chipped and/or peeling paint and there should be no holes in the walls or ceilings. Observation of the Kitchen, on 09/05/18 at 8:22 AM, revealed the floor had a pool of greasy substance between the steam cabinet, oven, warmer, and large kitchen cart. There were white spots and dark matter around the bottom legs of the steam cabinet, oven, warmer, steam table, drying racks, and large kitchen cart. The ice machine had a worn rubber seal and rust/brown substance around the outside seal. There was peeling paint on the ceiling, and broken tile behind the door of the manager's office. The pipes were covered with a thick dust like greasy substance. Continued observation revealed Dietary Aide #1 did not have on a beard guard and touched his bearded face and then served breakfast from the steam tale without washing his hands or donning gloves. Interview with Dietary Aide #2, on 09/07/18 at 1:52 PM, revealed the kitchen task sheet was located on the staff bulletin board and included utilizing the sign off sheet, which listed all duties for each shift. She stated if other cleaning or sanitation tasks needed to be completed in the kitchen, those directions came from the Manager or [NAME] on duty. Furthermore, deep cleaning was done monthly and the last time the kitchen was deep cleaned was last month and again this week by the Manager. She stated a clean kitchen reduced the contamination of food for the residents' wellbeing. According to Dietary Aide #2, staff was required to enter the kitchen in uniform, proper shoes, wash hands, and place hair in net/beard guard. Interview with Dietary Aide #3, on 09/07/18 at 2:05 PM, revealed all staff was required to enter the kitchen in uniform, proper shoes, wash hands, and place hair in net/beard guard. She stated the kitchen cleaning schedule was available for all dietary employees and staff had been trained to clean the kitchen. Review of the kitchen cleaning schedules, dated 08/26/18 to 09/01/18, revealed staff documented daily cleaning was performed on the steam table, plate warmer, the prep tables, the carts and speed racks, all sides of the dish machine, and the floor was swept. The deep cleaning schedule, dated 08/12/18 to 08/18/18, revealed staff documented deep cleaning was performed on the floors. Interview with the Assistant Dietary Manager, on 09/05/18 at 8:25 AM, revealed the grease on the floor had been there for about two (2) years. She stated staff had tried to clean the grease on the floor; however, the area would not stay clean. The Manager stated staff had a cleaning schedule for daily, weekly, and monthly cleaning, and deep cleaning was done monthly. Interview with the Dietary Manager, on 09/05/18 at 9:33 AM and 11:11 AM, revealed the importance of keeping the kitchen clean was to reduce foodborne illnesses, cross contamination, and food contamination. The Manager stated the floors had white spots due to paint drops from when the ceiling was painted. He stated the [NAME] was in charge when management staff was not present in the kitchen and the [NAME] should follow the cleaning schedule to insure tasks were completed. He did not know why dietary staff did not follow protocol for cleaning. Interview with the Administrator, on 09/07/18 at 5:30 PM, revealed tours of the kitchen were completed monthly and sanitation logs were reviewed during Quality Assurance and Performance Improvement Plan Review (QAPI). She stated the Dietary Manager was responsible for the overall operation of the kitchen, including daily cleaning, monthly deep cleaning, and prevention of infection process. She stated if policies were not followed consistently for cleaning procedures and beard guards, cross contamination could happen. She understood the facility served a vulnerable population, perhaps with a decreased immune system, and wanted to prevent infections and food borne illnesses.