**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the facility face sheet for R2 revealed the facility admitted him on 05/08/2015, with diagnoses of traumatic brain injury, paraplegia, and aphasia. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed R2 to have a BIMS score of 14 out of 15, indicating intact cognitive function. Further MDS review revealed the facility had not assessed R2 to exhibit any behavioral symptoms of physical, verbal or rejection of care and as dependent on staff for care needs. Review of the facility initial incident report dated 12/27/2023, for an incident that occurred on 12/26/2023 at 4:40 PM, revealed CNA 3 and CNA 4 witnessed CNA 2 using foul language and being verbally rude to R2 while providing his care. Per review, R2 had held onto his shirt and would not let go of it while CNA 2 was providing his care. Continued review revealed however, the allegation of abuse was not reported to the Administrator until 12/27/2023 at 10:30 AM. Further review revealed the Administrator had not submitted the initial report of the incident to the SSA until 12/27/2023 at 4:41 PM. Review of the facility's final report/5 day follow up investigation information revealed CNA 3's and CNA 4's witness statements dated 12/27/2023, which noted they overhead CNA 2 say to R2 you're not going to fucking hit me with that. Let go or I will break your fucking hand. Interview on 08/09/2024 at 2:57 PM with the Director of Nursing (DON) revealed she began employment with the facility on 12/04/2023. The DON stated suspected abuse was immediately reported to the Abuse Coordinator who was also the Administrator. She stated the Administrator was responsible to send information of abuse allegations to the State Agency. In interview on 08/09/2024 at 4:00 PM, the Administrator stated the incident involving R2 occurred during an evening shift, and she was not notified until the following morning of the incident by the SSD. The Administrator stated after the SSD informed her an investigation was immediately initiated. She further stated she reported the incident to the required agencies within 2 hours of finding out about the incident. The Administrator additionally stated at the time she believed the facility was following the CMS guidelines for reporting due to there not being any physical injury or harm to R2. The facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made for 3 of 23 sampled residents (R)2, R48, R86. The findings include: Review of the facility policy titled, Resident Rights dated 01/02/2020, and revised 02/16/2024, revealed the facility ensured all staff were educated on the rights of residents and the responsibility of the facility to properly care for its residents. Further review of the policy revealed the resident had the right to be treated with respect and dignity. Review of the facility policy titled, Abuse, Neglect, and Exploitation reviewed/revised 08/2023, revealed the facility was to protect the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prevented abuse. Continued review revealed the abuse prohibition plan included reporting of all alleged violations to the State Agency immediately, but not later than two hours after the allegation was made, if the event involved abuse. Further review revealed reports would not be made later than 24 hours if the allegation had not involved abuse and did not result in serious bodily injury. 1. Review of the medical record for R48 revealed the facility admitted the resident on 01/13/2022, with diagnoses including dementia, depression, anxiety, and psychotic disorder with delusions. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed R48 with a Brief Interview for Mental Status (BIMS) score of zero out of 15, indicating the resident was severely cognitively impaired. Review of the facility's investigation for an incident on 11/18/2023 at 7:50 PM, revealed staff witnessed R85 strike R48 on top of the head, with no assessed physical injury. Further review revealed the facility had not emailed the initial report to the State Survey Agency (SSA) until 11/20/2023 at 9:43 AM. In interview on 08/09/2024 at 3:39 PM, the Administrator stated she was the only employee responsible to report abuse to the State Agency. She stated she had access from home to report on those occasions when she was not in the facility at the time of the allegation. The Administrator stated she had two hours to make the initial report of an allegation to the SSA. She stated she tried multiple times to email the SSA the initial report of the incident that occurred on 11/18/2023 at 7:50 PM; however it failed to send a couple of times. In continued interview she stated she did not have records of the failed email attempts. The Administrator additionally stated she was not aware she could fax the initial reports (to the SSA) as well. 2. Review of the facility investigation for an incident that occurred on 10/25/2023 at around 11:45 AM, revealed R86 made an allegation of physical abuse against Certified Nursing Assistant (CNA) 8. Continued review revealed R86 reported the CNA hitting his/her leg. Further review revealed the facility had not emailed the initial report of the incident to the SSA until 10/25/2023 at 5:16 PM. In interview with the Administrator on 08/09/2024 at 3:39 PM, she stated R86 had not experienced any serious bodily injury and therefore, she had 24 hours to report to the SSA. She further stated she could not recall who told her she did not have to report incidents of abuse within two hours.

Based on interview, record review and review of facility policy, the facility failed to prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation was in progress for 1 of 23 sampled residents (R), R86. The findings include: Review of the facility policy titled, Abuse, Neglect, and Exploitation reviewed/revised 08/2023, revealed the facility was to protect the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prevent abuse. Continued review revealed instances of abuse of residents could cause harm, pain, or mental anguish, and the facility was to make efforts to ensure all residents were protected during an investigation. Review of the facility investigation for an incident involving R86 on 10/25/2023 at around 11:30 AM, revealed the resident alleged Certified Nursing Assistant (CNA) 8 hit his/her leg. Continued review revealed the facility sent the CNA home for the day. Further review revealed education for CNA 8 on resident rights, signed by the aide on 10/27/2023. Additional review revealed the facility's final report/5-day follow-up was signed on 10/28/2023 and emailed to the State Survey Agency (SSA) on 10/29/2023. Review of the facility's, Assignment Sheet dated 10/26/2023 and 10/27/2023 revealed CNA 8 was scheduled to work on the other unit in the facility, even though review of the facility's investigation revealed it was not completed until 10/28/2023. Review of the Timecard for CNA 8 revealed the aide clocked out of work at 12:06 PM on 10/25/2023 (The date of the incident). Continued review of the timecard revealed CNA 8 worked 12 hour shifts on 10/26/2023 and on 10/27/2023. In interview on 08/08/2024 at 4:19 PM and on 08/09/2024 at 10:43 AM, the Administrator stated CNA 8 was suspended the rest of her shift on the day the allegation was made. The Administrator also stated CNA 8 was then moved to the other unit in the facility to work. (However, review of the facility investigation revealed it was not completed until 10/28/2023.) In interview on 08/09/2024 at 11:11 AM, CNA 8 stated she went on break after changing R86 and was informed of the allegation when she returned from break. She further stated she was taken off R86's hall and came back to work the next day on the other unit. On 08/09/2024 at 2:57 PM interview with the Director of Nursing (DON) revealed if the facility received an allegation of abuse and the staff member was working, the employee was removed from the floor immediately and suspended during the investigation, usually for three days. She stated the purpose of the investigation was to find more evidence and determine if the abuse occurred. The DON further stated the staff member was suspended during the investigation to prevent the individual from continuing to abuse residents or retaliate against someone who reported. She also stated the Administrator was the facility's Abuse Coordinator. In additional interview with the Administrator on 08/09/2024 at 3:39 PM, she stated when she received the abuse allegation she sent CNA 8 home for the day and initiated the investigation. She stated the investigation lasted three days from start to finish. The Administrator stated once the interviews for the investigation were completed the aide was allowed to return to work on the facility's other unit. She stated she did not feel CNA 8 abused the resident or anyone else. The Administrator further stated the facility investigation had not been completed when CNA 8 returned to work on 10/26/2024.

Based on observation, interview, and review of the facility's policies, the facility failed to ensure its staff performed hand sanitation measures and maintained appropriate infection control measures during medication administration for 3 out of 39 sampled residents (R47, R52, R16, R57), which placed residents at increased risk for healthcare-associated infections (HAI). The findings include: Review of the facility's policy titled, Infection Prevention and Control, dated 09/03/2021 and revised 02/21/2024, revealed all hand hygiene was to be performed in accordance with the facility-established hand hygiene procedures. Review of the facility policy titled, Medication Administration Guidelines dated May 2022 for medication administration the general guidelines noted the person administering medication was to adhere to good hand hygiene, to include washing hands thoroughly. Observation on 08/08/2024 at 9:30 AM, revealed two hand sanitizer dispensers located at each end of the resident hallways available for staffs' use. Observation on 08/08/2024 at 10:12 AM, of medication administration by Registered Nurse (RN) 1 revealed the RN failed to wash or sanitize her hands between administering medications to R16 and R57. Observation also revealed RN 1 placed all medications in her bare hands before putting them into the medication cup for administration. Further observation revealed RN 1 did not disinfect the top of the cart's surface or place a barrier on top of the cart while preparing the residents' medications. Even though hand sanitizer dispensers were available at the end of the hallway, observation revealed RN 1 failed to utilize sanitizer prior to preparing the residents' medications. Observation on 08/07/2024 at 10:25 AM, during medication administration for R47, revealed Licensed Practical Nurse (LPN) 2 failed to sanitize her hands before she opened medication Lasix 40 milligram (mg) blister pack over a medication cup; however, the medication dropped onto the medication cart where no barrier was located or disinfection of the cart occurred. LPN 2 was observed to pick the Lasix tablet up and place it into the medication cup for administration. Even though hand sanitizer dispensers were available at the end of the hallway, observation revealed LPN 2 failed to utilize the sanitizer after R47's medication administration and before she prepared the next resident's medication. Observation on 08/07/2024 at 10:28 AM, of medication administration for R52, revealed LPN 2 failed to sanitize her hands before she opened the resident's Vitamin D3 over the medication cup; however, dropped one of the two tablets onto the top of the cart with no barrier in place. Continued observation revealed LPN 2 picked the tablet up off the cart and placed it in the cup with R52's other medications for administration. Further observation revealed LPN 2 had not disinfected the top of the cart. During an interview with LPN 2 on 08/07/2024 at 10: 30 AM, she stated it was important for her to disinfect her hands with alcohol gel or soap and water to keep infection risks down. She further stated she had been nervous and overlooked that step, but was aware of that expectation. During an interview after her medication administration, RN 1 on 08/08/2024 at 11:10 AM, she stated she should have washed her hands or used sanitizer before medication administration. She further stated she had sanitizer in her pocket; however, just forgot to use it. During an interview on 08/09/2024 at 2:57 PM, with the Director of Nursing (DON), she stated she expected nurses to wash their hands or use hand sanitizer before each medication administration. She stated hand sanitizer was located on the walls of each resident care area. The DON further stated there were also smaller bottles of sanitizer available.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of facility policy, it was determined the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights that included measurable objectives and timeframes for 7 of 28 sampled residents (R). R1, R5, R22, R36, R61, R64 and R76 were observed in the dining room consuming meals without the assistive devices or nutritional supplements they had been care planned to receive. The findings include: Review of the facility policy titled, Comprehensive Care Plans, revised on 02/28/2024, revealed it was the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident to meet the resident's medical, physical, mental and psychosocial needs. 1. Review of the Face Sheet for R1 revealed the facility admitted the resident on 07/01/2005, with diagnoses to include; chronic obstructive pulmonary disease (COPD), type 2 diabetes, and dysphagia. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of thirteen out of fifteen indicating R1 was cognitively intact. Review of the 03/20/2024, physician's order revealed an order for R1 to have a regular mechanical soft diet with special instructions that read divided plate and sip cup lid. Review of R1's Comprehensive Care Plan dated 06/23/2022, revealed a focus problem for nutritional risk related to a diagnosis of dysphagia and receiving a mechanically altered diet. Review further revealed interventions dated 06/23/2022, which included providing R1's diet as ordered, and providing a divided plate and spouted lid with meals. Observation on 08/07/2024 at 12:30 PM, revealed R1's meal tray contained a tray card noting the resident was supposed to have a sip lid cup and a divided plate. However, further observation revealed the divided plate and the sip lid cup were not on R1's meal tray. 2. Review of the Face Sheet for R5 revealed the facility admitted the resident on 02/27/2024, with diagnoses to include: dysphagia, cerebral palsy, and unspecified intellectual disabilities. Review of the Quarterly MDS assessment dated [DATE] revealed the facility completed an assessment and assessed R5 to have severe cognitive impairment and as rarely or never understood. Further MDS review revealed R5 was assessed as a dependent diner and was to be fed by staff. Review of the physician's order for R5 dated 03/14/2024, revealed the resident was to receive a regular pureed diet with honey thick liquids. Additionally, review of the order further revealed special instructions that stated R5 was to have a small coated spoon, and double meat portions were to be sent with every meal. Review of R5's Comprehensive Care Plan dated 08/09/2022, revealed a focus problem indicating the resident was at risk for nutritional status related to a history of dysphagia, being underweight, and receiving a pureed diet and honey-thick liquids. Further review revealed interventions which included: providing a pureed diet with double meat portions; and for staff to provide adaptive equipment that included a small spoon. Observation on 08/06/2024 at 12:17 PM, revealed R5 was in the dining room being fed by staff during the noon meal and the resident's meal tray contained a tray card. Review of R5's meal tray card revealed a small coated spoon was to be used. However, further observation revealed staff were using a regular spoon to feed R5, not the small coated spoon as per the care plan. 3. Review of the Face Sheet for R22 revealed the facility admitted the resident on 01/27/2018, with diagnoses that included, dementia, schizophrenia, and Parkinson's Disease. Review of a Significant Change in Status MDS assessment dated [DATE], revealed the facility assessed R22 to have a BIMS score of seven out of 15, indicating severe cognitive impairment. Continued review of the MDS revealed R22 was dependent on staff for eating. Review of the physician's order dated 6/20/2022, revealed R22's diet was regular, pureed. Continued review revealed special instructions for a plate guard and built-up utensils, double meat portions, and magic cups with lunch and dinner. Review of R22's Comprehensive Care Plan dated 06/20/2022, revealed the resident was at risk for malnutrition related to dysphasia, abnormal labs, and dementia. Continued review revealed interventions for staff to provide R22's diet as ordered with double meat portions, a plate guard and built up utensils. Observation of R22 on 08/06/2024 at 12:17 PM, in the dining room, revealed the resident was being fed by staff. Observation of R22's meal tray revealed a meal tray card noting the resident was to have a plate guard and built-up utensils. However, further observation revealed those devices were not in use for R22. 4. Review of the Face Sheet for R76 revealed the facility admitted the resident on 06/07/2024, with diagnoses to include: protein calorie malnutrition, fracture of the left femur, and schizophrenia unspecified. Review of the Quarterly MDS assessment dated [DATE], revealed the facility completed an assessment of R76 and assessed the resident as having severe cognitive impairment and as rarely or never understood. Review of the physician's order dated 08/01/2024, for R76 to receive a mechanical soft diet with magic cups at lunch and dinner, a divided plate, and double portions. Review of R76's Comprehensive Care Plan dated 06/07/2024, revealed a focus problem for nutritional status related to a diagnosis of severe protein-calorie malnutrition. Further review revealed the interventions included: providing R76's diet as ordered, and the magic cup with lunch and dinner. However, further review of the care plan revealed it had not been updated to include the divided plate or double portions. Observation in the assisted dining room, on 08/06/2024 at 12:17 PM, revealed R76's meal tray contained a tray card which read divided plate and double portions. However, further observation revealed the divided plate was not in use for R76, and the double portions, magic cup or other supplement were not present on the resident's meal tray. 5. Review of R36's Face Sheet revealed the facility admitted the resident on 03/02/2021, with diagnoses of dysphagia, gastroesophageal reflux disease (GERD) and COPD. Review of the Quarterly MDS assessment dated [DATE], revealed R36 had been assessed as being rarely or never understood. Continued review of the MDS revealed R36 was dependent on staff for eating. Review of the physician's order for R36 dated 05/30/2024, revealed an order for a pureed diet with honey thick liquids and a magic cup at lunch and dinner. Review of the Comprehensive Care Plan dated 06/11/2022, revealed R36 was at risk for nutritional status related to dysphagia, dementia, and significant weight gain. Review further revealed interventions which included providing R36's diet as ordered with magic cups at lunch and dinner. Observation on 08/06/2024 at 12:17 PM, revealed R36 was not served the magic cup as care planned. 6. Review of R61's Face Sheet revealed the facility admitted the resident on 07/03/2024, with diagnoses to include: dementia, chronic stage 3 kidney disease, and Alzheimer's Disease. Review of the admission MDS assessment dated [DATE], for R61 revealed the facility assessed the resident to have a BIMS score of three, indicating the resident had severe cognitive impairment. Further review of the MDS revealed R61 was assessed as dependent on staff for eating. Review of the physician's order for R61 dated 07/15/2024, revealed a diet order for a mechanical soft diet. Additional review revealed the order included special instructions for finger foods, fruit and cottage cheese with lunch and dinner, and a magic cup with lunch and dinner as per the family's request. Review of the Comprehensive Care Plan dated 07/03/2024, revealed a problem for R61's nutritional status as at risk for alteration in nutritional status related to dementia, poor appetite and poor intakes. Continued review revealed the interventions included providing R61's diet as ordered. However, further review revealed there was no documentation of an intervention noting R61 was to have fruit and cottage cheese, finger foods or nutritional supplements, such as a magic cup. Observation on 08/06/2024 at 12:17 PM, of R61 in the dining room, revealed the facility failed to provide the resident's fruit and cottage cheese, magic cup or an alternative supplement on the meal tray. 7. Review of R64's Resident Face Sheet revealed the facility admitted the resident on 02/21/2024, with diagnoses of dysphagia, hemiplegia and heriparesis following cerebral vascular disease, and cerebral infarction due to embolism. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed R64 to have a BIMS score of five indicating severe cognitive impairment. Continued MDS review revealed R63 was dependent on staff for eating. Review of R64's physician's order dated 08/05/2024, revealed the resident was to receive a mechanical soft diet, a scoop plate, and house shakes at lunch and dinner. Review of the Comprehensive Care Plan dated 02/22/2024, revealed a focus problem for R64's nutritional status as at risk for alteration of nutritional status related to difficulty with diet, and obesity. Continued review revealed the interventions included providing R64's diet as ordered. However, further review revealed no documentation of the scoop plate or house shakes noted on the care plan. Observation in the dining room on 08/06/2024 at 12:17 PM, revealed neither R64's scoop plate or house shake were provided for the resident. Additionally, observation of R64's meal tray revealed a tray card which did not indicate R64's need for a scoop plate. In interview with Certified Nursing Assistant (CNA) 1 on 08/06/2024 at 12:24 PM, she stated assistive devices were on the residents' care profile. She stated CNA's had access to residents' care plans in Matrix (facility's charting system) and reviewed it when charting in Matrix. In interview with CNA 5 on 08/09/2024 at 9:15 AM, she stated she checked residents' tray cards before taking their tray into their room. She stated she thought supplements and assistive devices were on the residents' care profiles. CNA 5 further stated the care profile was reviewed where she charted. During interview with CNA 6 on 08/09/2024 at 9:20 AM, she stated she reviewed residents' care profiles/plans daily. She stated if a resident was to have an assistive device it should be on their care plan. In interview with the former Registered Dietitian (RD) on 08/09/2024 at 4:00 PM, she stated she had been the person responsible for updating residents' care plans. She stated she had not worked at the facility for over a month. She stated assistive devices were to be on the residents' care plans, as well as any supplements ordered. During an interview with the Director of Nursing on 08/09/2024 at 4:17 PM, she stated she or the Assistant Director of Nursing (ADON) usually initiated a new resident's baseline care plan. She stated the MDS Nurse was then responsible for completion of the resident's comprehensive care plan. The DON stated each department updated and revised their own section of residents' care plans. She stated the RD, up until her last day, had updated residents' dietary or nutrition care plans. Per the DON's interview, it was her expectation for staff to follow residents' care plans. She stated CNAs could review residents' care plans in the facility's Electronic Medical Record (EMR). The DON further stated if items were not available on residents' tray cards, such as supplements or devices, she expected nursing staff to go to the kitchen and request those items. In an interview with the Administrator on 08/9/2024 at 4:32 PM, she stated she expected residents' care plans to be implemented and followed. She further stated the care plan guided residents' care and staff had to be aware of it to follow the care a resident needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility failed to accommodate food preferences for 5 of 7 sampled residents (R) 61, R36, R22, R76 and R64. Observation during the noon meal service on 08/06/2024 at 12:17 PM, revealed the facility failed to provide residents with their nutritional supplements and double portions as ordered by the physician. The findings include: 1. Review of the Face Sheet located in R61's medical record revealed the facility admitted the resident on 07/03/2024, with diagnoses that included; dementia, Alzheimer's Disease with late onset, and chronic kidney disease stage 3. Review of the admission Minimum Data Set (MDS) Assessment for R61 dated 07/07/2024, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of three out of 15, indicating severe cognitive impairment. Review of the MDS further revealed the facility assessed the resident as dependent on staff for eating. Review of a physician's order for R61 dated 07/15/2024. revealed a diet order for a mechanical soft diet. Review further revealed special instructions included: finger foods; fruit and cottage cheese with lunch and dinner; and a magic cup (frozen dessert for increased protein and calories) with lunch and dinner per family's request. Review of the Comprehensive Care Plan for R61 dated 07/03/2024, revealed a nutritional status problem noting the resident was at risk for alteration in nutritional status related to poor appetite and intakes, and a history of dementia. Continued review revealed the interventions included, providing R61's diet as ordered. However, review further revealed no documentation of the fruit and cottage cheese, finger foods or nutritional supplements R61 was ordered to receive. Observation on 08/06/2024 in the dining room at 12:17 PM, revealed R61's meal tray contained a tray card. Review of the tray card revealed no documentation noting R61 was to have finger foods or fruit and cottage cheese at lunch and dinner, but did include the magic cup. Further observation revealed however, the magic cup was not provided on R61's meal tray. 2. Review of the Face Sheet located in R36's medical record revealed the facility admitted the resident on 03/02/2021, with diagnoses which included dysphagia, chronic obstructive pulmonary disease (COPD) and gastroesophageal reflux disease. Review of the Quarterly MDS Assessment for R36 dated 05/20/2024, revealed the facility assessed the resident as being rarely or never understood, and dependent on staff for eating. Review of a physician order for R36 dated 05/30/2024, revealed a diet order for a pureed diet with honey thick liquids and a magic cup at lunch and dinner. Review of the Comprehensive Care Plan for R36 dated 06/11/2022, revealed a risk for nutritional status problem related to diagnosis of dysphagia, significant weight gain, and dementia. Review further revealed interventions that included providing R36's diet as ordered and magic cups at lunch and dinner. Observation on 08/06/2024 at 12:17 PM, revealed however, R36 was not served a magic cup or other supplement as ordered and care planned. 3. Review of the Face Sheet located in R22's medical record revealed the facility admitted the resident on 01/27/2018, with diagnoses that included schizophrenia, dementia, and Parkinson's disease. Review of a Significant Change in Status Minimum Data Set (MDS) assessment dated [DATE], revealed R 22 had a Brief Interview for Mental Status (BIMS) score of seven of fifteen indicating severe cognitive impairment. Continued review of the MDS revealed R 22 dependent on staff for eating. Review of a physician's order for R22 dated 06/20/2022, revealed a diet order for a regular, pureed diet. Further review revealed R22 was to have a plate guard and built-up utensils, double meat portions, and a magic cup with lunch and dinner. Review of the Comprehensive Care Plan for R22 dated 06/20/2022, revealed the resident was at risk for malnutrition related to dysphasia, dementia, and abnormal labs. Further review revealed interventions that included staff were to provide diet as ordered with double meat portions, a plate guard and built up utensils and supplements as ordered. Observation on 08/06/2024 at 12:17 PM, of R22 in the dining room, revealed staff were feeding the resident. Continued observation revealed R22's meal tray contained a tray card. Review of the tray card revealed R22's order for double meat portions and the magic cup were not documented on the card. Observation further revealed R22 had no magic cup or other nutritional supplement on the meal tray, and no double portion of meat. 4. Review of the Face Sheet located in R76's medical record revealed the facility admitted the resident on 06/07/2024, with diagnoses that included schizophrenia, protein calorie malnutrition, and fracture of the left femur. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed R76 as having severe cognitive impairment and was rarely or never understood. Review of the physician's order for R76 dated 08/01/2024, revealed an order for a mechanical soft diet with magic cups at lunch and dinner, a divided plate and double portions (of food). Review of the Comprehensive Care Plan for R76 dated 06/07/2024, revealed a problem for nutritional status related to a diagnosis of severe protein-calorie malnutrition. Continued review revealed the interventions included; providing the diet as ordered and magic cup with lunch and dinner. However, further review of the care plan revealed it had no been updated to include the ordered divided plate or double portions. Observation in the assisted dining room of R76 on 08/06/2027 at 12:17 PM, revealed the resident's meal tray contained a tray card. Review of the tray card revealed no indication that double portion were to be served. Further observation revealed R76 was not served double portions and did not have a magic cup as ordered. 5. Review of the Face Sheet located in R64's medical record revealed the facility admitted the resident on 02/21/2024, with diagnoses that included dysphagia, hemiplegia and hemiparesis following cerebral vascular disease, and cerebral infarction due to embolism. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed R64 to have a BIMS score of five out of 15, indicating severe cognitive impairment. Review further revealed the facility assessed R64 as dependent on staff for eating. Review of physicians order for R64 dated 08/05/2024, revealed an order for a mechanical soft diet, house shakes at lunch and dinner and use of a scoop plate. Review of the Comprehensive Care Plan for R64 dated 02/22/2024, revealed a problem for nutritional status for the resident as at risk for alteration of nutritional status related to obesity, and difficulty with diet. Further review revealed the interventions included providing R64's diet as ordered. Additional review revealed however, the ordered scoop plate or house shakes were noted on the care plan. Observation in the dining room of R64 on 08/06/2024 at 12:17 PM, revealed the resident's meal tray contained a tray card. Review of the tray card revealed R64 was to have a house shake, 4 ounces. Further observation revealed however, the house shake was not provided. In interview with Certified Nursing Assistant (CNA) 1 on 08/06/2024 at 12:24 PM, she stated if residents' necessary items were not present on their meal tray, but were noted on the card, she typically let the kitchen staff know. She further stated she should have informed dietary staff that residents were missing items. In interview with CNA 5 on 08/09/2024 at 9:15 AM, she stated she checked residents' tray cards before taking their tray into their room. CNA 5 stated if a magic cup or special utensils were not on the tray, she notified the kitchen or went to the kitchen to request the missing item(s). She further stated sometimes the kitchen ran out of items; however, provided something else for the resident. During interview with CNA 6 on 08/09/2024 at 9:20 AM, she stated she looked at a resident's tray card when taking the tray to the resident. CNA 6 stated if the meal tray was missing a food or drink she usually notified the kitchen. She stated sometimes a regular plate would be on the resident's meal. CNA 6 further stated however, she did not take the plate back to the kitchen and went ahead and served it to the resident. In interview with Dietary Aide (DA) 1 on 08/09/2024 at 10:15 AM, she stated she worked on the tray line preparing residents' trays during meals. The DA stated she reviewed the meal tray cards and read aloud what the resident was supposed to have. She stated she would say whatever the supplement was to include house shakes, or magic cups. The DA stated the facility sometimes ran out of magic cups because they were hard to get, but there was a list of alternatives that could be sent for a resident. In interview with DA 2 on 08/09/2024 at 10:18 AM, she stated on the tray line tray cards were read out loud. DA 2 stated the cook or whoever was serving knew what to give the residents. She stated the assistive devices or supplements were usually located at the bottom of the tray card. In interview with the Dietary Manager (DM) on 08/09/2024 at 10:24 AM, she stated she had been the facility's DM for approximately 3 weeks. The DM stated changes occurring with resident diets were communicated to the kitchen from nursing staff using a communication slip. She stated she was responsible for updating residents' tray cards, but she was still learning that process and was still in training. Per the DM's interview, the facility was out of the magic cups nutritional supplements that week; however, she had gone to a sister facility to obtain some. She further stated it was important for residents to receive their nutritional supplements, as not providing the supplements could contribute to weight loss in the residents. In interview with the former Registered Dietitian (RD) on 08/09/2024 at 11:48 AM, she stated nutritional supplements should always be provided as ordered to the residents. She stated she had emailed the DM, as well as the DON, a list of supplements that could be used for substitutions if magic cups and house supplements were not available. The RD stated residents could be offered puddings, ice creams, yogurts, anything that would allow for extra calories. She further stated the facility sometimes did not have magic cups due to shortages, but other supplements were provided in its place. In interview with the Director of Nursing (DON) on 08/09/2024 at 4:18 PM, she stated nursing staff were responsible for communicating changes with residents' diets to the dietary staff. She stated the RD typically recommended residents' supplements and she thought the DM was responsible for updating residents' tray cards to include any nutritional supplements. The DON stated if items were not on the tray at meal time she expected the CNA to retrieve the necessary items from the kitchen. She stated if supplements were not available, there was a list of items that could be offered for substitutes such as pudding, yogurt and ice cream. The DON further stated she did not know if the current DM was aware of the substitute list. During an interview with the Administrator on 08/09/2024 at 4:32 PM, she stated she was aware of issues with the dietary department. She stated the current DM was the third DM the facility had employed in a year. The Administrator stated she expected kitchen staff, as well as nursing staff to be aware of what was on the meal tray cards. She stated kitchen staff were to ensure all assistive devices and nutritional supplements were in place on residents' meal trays. The Administrator further stated she expected nursing staff to go to the kitchen and ask for anything that was missing on the tray card.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation interview and review of facility policy, it was determined the facility failed to provide special adaptive equipment and utensils for residents who needed them when consuming meals and snacks for 5 of 15, out of 28 sampled residents, (R)1, R5, R22, R76, and R64. The findings include: Review of the facility policy titled, Adaptive Self Feeding Devices, undated, revealed the use of adaptive, self-help feeding devices was encouraged when determined to be helpful to the resident. Continued review revealed the dietary department was responsible for all sanitizing of adaptive utensils after each use and for placing the devices on the meal trays as needed. 1. Review of the Resident Face Sheet for R1 revealed the facility admitted the resident to the facility on [DATE], with diagnoses to include: chronic obstructive pulmonary disease (COPD), type 2 diabetes, and dysphagia. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed R1 to have a Brief Interview for Mental Status (BIMS) score of thirteen out of fifteen, indicating the resident was cognitively intact. Review of the physician order for R1 dated 03/20/2024, revealed an order for the resident to have a regular mechanical soft diet. Continued review of the order revealed R1 was to have a divided plate and sip cup lid. Review of R1's Comprehensive Care Plan dated 06/23/2022, revealed a focus for nutritional risk related to receiving a mechanically altered diet and a diagnosis of dysphagia. Continued review revealed interventions dated 06/23/2022, included providing diet as ordered; and providing a divided plate and spouted lid with meals. Observation on 08/07/2024 at 12:30 PM, of the meal tray card for R1 revealed the resident was to have a sip lid cup. However, further observation revealed no sip lid cup on the resident's meal tray. 2. Review of the Resident Face Sheet for R5 revealed the facility admitted the resident on 02/27/2024, with diagnoses to include: cerebral palsy, unspecified intellectual disabilities and dysphagia. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed R5 as having severe cognitive impairment and as rarely or never understood. Continued review of the MDS revealed R5 the facility also assessed the resident as a dependent diner and to be fed by staff. Review of the physician order dated 03/14/2024, revealed orders for R5 to receive a regular pureed diet with honey thick liquids. Additionally, review of the order revealed R5 was to have a small coated spoon, and double meat portions with every meal. Review of R5's Comprehensive Care Plan dated 08/09/2022, revealed a focus problem for the resident as at risk for nutritional status related to a history of being underweight, pureed diet and honey-thick liquids for diagnosis of dysphagia. Further review revealed interventions which included: providing a pureed diet with double meat portions; and for staff to provide adaptive equipment that included a small spoon. Observation on 08/06/2024 at 12:17 PM, revealed R5 was being fed by staff in the dining room during the noon meal. Review of R5 meal tray card revealed a small coated spoon was to be used. However, further observation revealed staff using a regular spoon to feed R5, and not the small, coated spoon. 3. Review of R22's Resident Face Sheet, revealed the facility admitted the resident on 01/27/2018, with diagnoses that included: Parkinson's Disease, dementia, and schizophrenia. Review of the Significant Change in Status MDS assessment dated [DATE], revealed the facility assessed R22 as having a BIMS score of seven out of 15, indicating severe cognitive impairment. Continued MDS review revealed the facility additionally assessed R22 as dependent on staff for eating. Review of the physician's order dated 6/20/2022, revealed R22's diet was regular, puree with a plate guard and built-up utensils; double meat portions; and magic cups (frozen dessert that adds protein and calories) with lunch and dinner. Review of R22's Comprehensive Care Plan dated 06/20/2022, revealed the resident was at risk for malnutrition related to dementia, dysphasia and abnormal labs. Continued review revealed the interventions included staff providing R22's diet as ordered with double meat portions, a plate guard and built up utensils. Observation of R22 on 08/06/2024 at 12:17 PM, in the dining room, revealed the resident was being fed by staff. Review of the meal tray card revealed R22 was to have a plate guard and built up utensils. However, further observation revealed those devices were not in place and being used. 4. Review of F76's Resident Face Sheet, revealed the facility admitted the resident on 06/07/2024, with diagnoses to include; schizophrenia, fracture of the left femur, and protein calorie malnutrition. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed R76 as being severely cognitively impaired and as rarely or never understood. Review of R76's physician's order dated 08/01/2024, revealed the resident was to receive a mechanical soft diet with magic cups at lunch and dinner. Additionally, review of the order revealed R76 was to have a divided plate and double portions. Review of R76's Comprehensive Care Plan dated 06/07/2024, revealed a focus for nutritional status related to a diagnosis of severe protein-calorie malnutrition. Continued review revealed the interventions included: providing diet as ordered; magic cup with lunch and dinner. However, further review revealed R76's care plan had not been updated to include the interventions for a divided plate or double portions. 5. Review of R64's Resident Face Sheet, revealed the facility admitted the resident on 02/21/2024, with diagnoses of cerebral infarction due to embolism, dysphagia, and hemiplegia and hemiparesis following cerebral vascular disease. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed R64 to have a BIMS score of five out of 15, indicating severe cognitive impairment. Continued MDS review revealed the facility assessed R64 as dependent on staff for eating. Review of R64's physician's order dated 08/05/2024, revealed the resident was to have a mechanical soft diet, house shakes at lunch and dinner, and a scoop plate. Review of R64's Comprehensive Care Plan dated 02/22/2024, revealed a focus for nutritional status as at risk for alteration of nutritional status related to obesity, and difficulty with diet. Further review revealed interventions that included providing diet as ordered. However, further review revealed R64's ordered scoop plate, nor the house shakes were documented on the care plan. Observation of R64 in the dining room on 08/06/2024 at 12:17 PM, revealed the resident did not have the ordered scoop plate. Additionally, review of R64's meal tray card revealed no documentation noting the scoop plate as ordered. In an interview with Certified Nursing Assistant (CNA) 5 on 08/09/2024 at 9:15 AM, she stated she checked the residents' tray cards before taking the tray into a resident's room. CNA 5 stated if she noted the card said the resident needed a magic cup or special utensils and it was not on the tray, she notified or went to the kitchen and requested the item. She stated sometimes the kitchen was out of the requested item, or the utensils had been thrown away. CNA 5 further stated she did not know the reason utensils would thrown away. During interview with CNA 6 on 08/09/2024 at 9:20 AM, she stated she looked at the tray card when taking the meal tray to the resident, and if it was missing an item, she notified the kitchen. She stated sometimes a resident card said they needed a divide plate; however, their food would be served on a regular plate. CNA 6 further stated she would not take that plate back to the kitchen and went ahead and served it to the resident. In an interview with Dietary Aide (DA) 1 on 08/09/2024 at 10:15 AM, she stated she worked on the tray line during meals preparing residents' trays. She stated she reviewed the meal tray card and read aloud what the resident was supposed to have. The DA stated she said, Regular, divided plate if a resident was supposed to have a divided plate. She further stated she had been employed for eight months and had never seen a small spoon used for any resident. In an interview with DA 2 on 08/09/2024 at 10:18 AM, she stated when on the tray line the tray cards were all read out loud. She stated the cook or whoever was serving food knew what to give the resident. DA 2 stated the assistive devices or supplements were usually located at the bottom of the tray line. In an interview with the Dietary Manager (DM) on 08/09/2024 at 10:24 AM, she stated she had been the dietary manager for approximately three weeks. She stated changes with residents' diets were communicated to the kitchen from nursing staff using a communication slip. The DM stated she was responsible for updating the tray meal cards; however, she was still in training and learning the facility's process. She stated the meal tray card was to be read out loud so the server knew what type of diet to served and what (if any) assistive devices to place on the tray. The DM stated there were newer staff in the kitchen and she had reeducated those staff on making sure they read the tray cards. She further stated on occasion, nursing staff did come to the kitchen and request items if they were not on the resident's tray. In an interview with the Regional Training Manager on 08/09/2024 at 10:29 AM, he stated it was the Dietary Manager's responsibility to update meal tray cards when changes came in from nursing or therapy services. He stated the Dietary Aides or whoever was working the tray line were to read the cards out loud so the server knew what diet to serve and what devices to utilize. The Regional Training Manager further stated he realized there were errors on Tuesday (08/06/2024) and having new staff contributed to errors as the new staff were nervous. In an interview with the Director of Nursing (DON) on 08/09/2024 at 4:18 PM, she stated nursing staff was responsible for communicating changes with diets and assistive devices to the kitchen staff. She stated she thought the Dietary Manager was responsible for updating the meal tray cards to include assistive devices and any nutritional supplements. The DON further stated if items were not on a resident's tray at meal time she expected the CNA to retrieve the items from the kitchen. During an interview with the Administrator on 08/09/2024 at 4:32 PM, she stated she was aware issues with the dietary department. She stated the current Dietary Manager was the third one in the facility in a year. The Administrator stated she expected the kitchen staff as well as the nursing staff to be aware of what was on residents' meal tray cards. She stated the kitchen staff were to ensure residents' assistive devices and nutritional supplements were in place on the meal trays. The Administrator further stated she expected nursing staff to go to the kitchen and ask for anything that was missing from the tray cards or trays.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined the facility failed to provide maintenance services necessary to maintain a safe clean and comfortable environment for the 100 unit residents. Observation of the 100 unit hall ceiling vents from rooms 101 through 115, on 10/29/19, 10/30/19, and 10/31/19, revealed dust accumulation. The findings include: Review of the facility Resident Rights under Federal Law Policy, undated, revealed residents had the right to a safe, clean, comfortable and homelike environment including, but not limited to receiving treatment and supports for daily living safety. The Center must provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Observation on 10/29/19 at 12:30 PM; 10/30/19 at 10:00 AM; and 10/31/19 at 2:00 PM, revealed dust accumulation in the ceiling vents of the 100 unit hall from rooms 101 through room [ROOM NUMBER]. Interview on 10/31/19 at 2:45 PM, with the Maintenance Director, revealed the vents were cleaned on a monthly basis, and the air filters were changed monthly as well. Per interview, if the vents were dusty, this could affect the air quality for residents who could not breathe well. Further interview revealed there should not have been an accumulation of dust on the vents. Interview on 10/31/19 at 4:00 PM, with the Director of Nursing (DON), revealed the vents were scheduled to be cleaned regularly to promote cleaner air quality for residents with respiratory and/or chronic pulmonary disease. Interview on 10/31/19 at 4:39 PM, with the Administrator, revealed the dust accumulation in vents in the hallway could be an allergen or air quality issue for residents.

Based on observation, interview, record review, and review of facility Policy, it was determined the facility failed to ensure each resident was free from any physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, for one (01) of one (1) sampled resident reviewed for restraints out of twenty-two (22) sampled residents (Resident # 33). The facility initiated a self-releasing alarming seatbelt to Resident #33's wheelchair as a fall intervention, on 02/11/19. However, there was no documented evidence they Physician's Order identified the medical symptom being treated when using the restraint. In addition, observation on 10/29/19, revealed Resident #33 was sitting in the joy room (dining room) in his/her wheelchair at a table, with no staff in the room. The residents self-releasing seatbelt wiring was underneath the wheelchair arm. At the State Surveyor's request, Licensed Practical Nurse (LPN) #1 released the seatbelt; however, it did not sound. The facility failed to identify the alarming seatbelt restraint was not working properly. (Refer to F-656) The findings include: Review of the facility Use of Restraints Policy, revised 07/01/18, revealed patients have the right to be free from physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms. Additionally, when a restraint was indicated, the least restrictive device would be used for the least amount of time and the ongoing evaluation to determine the need for the restraint would be documented per state regulations. Further, there would be documentation identifying the medical symptom being treated and an order for the use of the specific type of restraint. Per policy, a consent would be obtained prior to the application of the restraint. Review of Resident #33's Medical Record, revealed the facility admitted the resident on 12/28/18 with diagnoses including, but not limited to Alzheimer's Dementia, Type II Diabetes, Abnormal Posture, and Intervertebral Disc Degeneration/Lumbar Region. Review of Resident #33's Physician's Orders, dated 10/31/19, revealed an order for a self-releasing seat belt to the wheelchair when up, release every two (02) hours and for meals, dated 02/11/19. However, there was no documented evidence the order included the presence of a medical symptom and how the alarming seat belt would treat the medical symptom and protect the safety of the resident. Review of Resident #33's Restrictive Device Consent, dated 02/11/19, revealed a self-releasing alarming seatbelt had been ordered by the Physician as part of the resident's overall plan of care. Additionally, the medical reason for use was poor safety awareness and impulse control. Further, the restraint was to be used when up in the wheelchair. Continued review revealed the Consent included risk versus benefits and was signed by the resident's representative. Review of Resident #33's Restraint Release Reduction Assessment, dated 08/23/19, revealed over eight (08) shifts the resident's response to release/reduction was unsuccessful. The resident attempted to self-transfer frequently, and staff were unable to redirect. Per the Assessment, the resident required increased supervision; attempted unsafe transfer; leaned forward when the seatbelt was released; and attempted to stand on his/her own. Further, the Assessment concluded the resident had inconsistent response to the trial and recommendations were to continue the seatbelt alarm while the resident was up in the wheelchair related to impaired cognition, inability to follow safety measures, and unstable independent ambulation. Review of Resident #33's Quarterly Minimum Data Set (MDS) Assessment, dated 08/26/19, revealed the facility assessed the resident as having both short and long term memory problems. Additionally, the facility assessed the resident as requiring total assistance of two (02) staff for bed mobility, transfers, and toileting. Continued review revealed the resident did not ambulate and required total assistance of one (01) staff for locomotion in the wheelchair. Per the Assessment, the resident had unsteady balance, only able to stabilize with staff assistance during transition from surface to surface. Continued review revealed a chair and bed alarm was used daily and the resident used no physical restraints. Review of Resident #33's Comprehensive Care Plan (CCP), revised on 09/05/19, revealed the resident was at risk for falls related to cognitive loss, lack of safety awareness, impaired mobility, and falls. The goal stated the resident would have no falls with injury for ninety (90) days. Interventions included, but were not limited to: nonskid socks, 12/31/18; pressure alarm to wheelchair and bed to alert staff of unsafe attempts to self-transfers, 01/11/19; resident not to be left alone in [NAME] room (dining room) without staff supervision, 02/05/19; self releasing seatbelt with alarm, check and release every two (02) hours and as needed, 02/14/19; and resident to sit in high traffic areas after lunch, 05/19/19. (Refer to F-656) Review of the Treatment Administration Record (TAR), dated October 2019, revealed each shift, nurses checked the function of the alarming seatbelt every two (02) hours. Observation on 10/29/19, at 1:30 PM, revealed Resident #33 was sitting in the joy room (dining room) in his/her wheelchair at a table. Continued observation revealed there were no staff in the joy room. The resident's self-releasing seatbelt wiring was underneath the wheelchair arm. At the State Surveyor's request, LPN #1 released the seatbelt; however, it did not sound. Further, LPN #1 acknowledged staff had failed to identify the alarm on the seatbelt restraint was not working properly until this time. Interview with LPN #2, on 10/30/19 at 1:35 PM, revealed she had worked at the facility for ten (10) years. Per interview, the alarming seat belt was used for Resident #33 because he/she attempted to self-transfer and had a history of falls. Additional interview revealed there were Physician's Orders for restraints and interventions on the Treatment Administration Record (TAR) for nurses to check restraints every two (02) hours to ensure the device was functioning properly. Continued interview revealed Resident #33's Physician's Orders should have included the reason for the restraint and frequency in which it was to be used. Further, it was a big safety concern that Resident #33's alarming seatbelt did not alarm on 10/30/19 because if the seatbelt was not working properly and the facility did not identify the malfunction, the resident's safety could not be ensured. Interview with State Registered Nursing Assistant (SRNA) #2, on 10/30/19 at 2:00 PM, revealed Resident #33's seatbelt was used to reduce falls and was to be worn when the resident was up in the wheelchair. Per interview, the resident would attempt to self-transfer and lose his/her balance and fall. Additionally, the seatbelt was released at meals and every two (02) hours. Further, it was important for the seatbelt to be functioning properly to alert staff if the resident tried to get out of the wheelchair, as the resident could potentially sustain a fall. Interview with the Director of Nursing (DON), on 10/31/19 at 3:05 PM, revealed she expected the facility policy related to restraints to be followed. Per interview, Resident #33's alarming seatbelt was a long term intervention the Interdisciplinary Team determined would reduce the resident's risk for falls. Additionally, she expected the Physician's Order to identify the medical symptom being treated with use of the restraint and to identify the least time possible to use the device. Further, she expected the alarming seatbelt to function properly and staff to identify any issues with the function of the restraint timely. Interview with the Administrator, on 10/31/19 at 4:06 PM, revealed he expected the facility policy and regulation related to restraints to be followed. Additionally he expected restraints to FUNCTION PROPERLY. Per interview, the Physician's Order for a restraint should identify the medical symptom being treated, and the time element in which the restraint should be used.

Based on interview, record review, review of facility Policy, and review of the Centers for Medicare and Medicaid Services (CMS), Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to ensure the Comprehensive Care Plan (CCP) was reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs for two (02) of twenty-two (22) sampled residents (Resident #33 and Resident #56). Resident #33 sustained a fall on 10/18/19 and the Fall Investigation revealed a fall floor mat was placed on the favored side of the bed; however, there was no documented evidence which side of the bed was the favored side (left/right) or that the Care Plan was revised to include this intervention. Further, there was no documented evidence of a Root Cause Analysis of the fall in the investigation or in the medical record in order to revise the Care Plan with appropriate interventions to prevent falls of the same nature. (Refer to F-689) Further, Resident #56 sustained a fall on 10/12/19, and the Fall Investigation revealed roll bolsters would be placed on the bed. However, there was no documented evidence the Care Plan was revised to include this intervention. In addition, there was no documented evidence of a Root Cause Analysis of the fall in the investigation or in the medical record in order to revise the Care Plan with appropriate interventions to prevent falls of the same nature. (Refer to F-689) The findings include: Review of the facility's Person Centered Care Plan Policy, revised 07/01/19, revealed a person center care plan will include measurable objective and timetables to meet the resident's physical, psychosocial and functional needs. Additionally, the care plan process will include a resident's personal preferences. Further, the Care Plan will describe the services to be provided to maintain or attain the residents' highest practicable physical, mental, and psychosocial wellbeing; include identified problem areas; and aid in preventing or reducing decline in functional status/level. Review of the facility's Falls Management Policy, revised on 11/01/19, revealed residents experiencing a fall will receive appropriate care and investigation of the cause. Further, the practice standards included reviewing and revising the Care Plan. Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated October 2016, revealed the care plan must be reviewed and revised periodically, and the services provided or arranged should be consistent with each resident's written plan of care. Continued review of the Manual, revealed the care plan was driven not only by identified resident issues and/or conditions, but also by a resident's unique characteristics, strengths, and needs. Furthermore, a care plan based on a thorough assessment and effective clinical decision making, was compatible with current standards of clinical practice that provide a strong basis for optimal approaches to quality of care and quality of life needs of individual residents. A well developed and executed assessment and care plan: re-evaluates the resident's status at prescribed intervals (quarterly, annually, or if a significant change in status occurs) using the RAI and then modifies the individualized care plan as appropriate and necessary. 1. Review of Resident #33's clinical record revealed the facility admitted the resident on 12/28/18 with diagnosis including, but no limited to Alzheimer's Dementia, Type II Diabetes, Abnormal Posture, and Intervertebral Disc Degeneration/Lumbar Region. Review of Resident #33's Quarterly Minimum Data Set (MDS) Assessment, dated 08/26/19, revealed the facility assessed the resident to have both short and long-term memory problems. Further, the facility assessed the resident as requiring extensive assistance or total assist of two (02) staff for bed mobility, transfers, and toileting. Additional review revealed the resident did not ambulate and required total assistance of one (01) staff for locomotion in the wheelchair. Per the MDS Assessment, the resident had unsteady balance, and was only able to stabilize with staff assistance during transition from surface to surface. Continued review revealed the resident had sustained falls since the prior assessment; one (01) non-injury and two (02) injury falls. Review of the Comprehensive Care Plan (CCP), revised 09/05/19, revealed Resident #33 was at risk for falls related to cognitive loss, lack of safety awareness, impaired mobility, and falls. The goal revealed the resident would have no falls with injury for ninety (90) days. The interventions included, but were not limited to: nonskid socks, 12/31/18; pressure alarm to wheelchair and bed to alert staff of unsafe attempts to self-transfers, 01/11/19; resident not to be left alone in [NAME] room (dining room) without staff supervision, 02/05/19; self releasing seatbelt with alarm, check and release every two (02) hours and as needed, 02/14/19; and resident to sit in high traffic areas after lunch, 05/19/19. Review of Resident #33's Fall Investigation, dated 10/18/19, revealed the bed alarm was sounding and the resident was noted on the floor next to the bed. Further review revealed the resident sustained a skin tear to his/her right arm and treatment was applied. Additional review revealed the resident was transferred back to bed after an assessment. Per the Investigation, a fall floor mat was placed on the favored side of the bed; however, the investigation did not specify which side of the bed the mat was to be placed. In addition, there was no documented evidence of contributing factors of the fall, specifics of the fall or the Root Cause Analysis of the fall in the investigation or in the medical record in order to revise the care plan with relevant, consistent, and individualized interventions to prevent falls of the same nature. There was no documented evidence the CCP was revised to include the intervention for a floor fall mat to the favored side of the bed, status post fall on 10/18/19, nor was there documented evidence of any revision of the CCP after this fall. 2. Review of Resident #56's clinical record revealed the facility admitted the resident on 03/19/19 with diagnoses including, but not limited to Hemiplegia affecting left non-dominant side, Acquired absence left leg below knee, Vascular Dementia, Abnormal Posture, Reduced Mobility, Need for Assistance with personal care, Heart Failure, Muscle Weakness, Lack of Coordination, Restlessness and Agitation, and Major Depressive Disorder. Review of Resident #56's Significant Change Minimum Data Set (MDS) Assessment, dated 09/25/19, revealed the facility assessed the resident as having a BIMS score of three (03) which indicated severe cognitive impairment. Further, the facility assessed the resident as requiring extensive assistance of two (02) staff for bed mobility and requiring total assistance for all other ADLS. Per the MDS Assessment, the facility assessed the resident as not being able to stabilize without staff assistance during surface to surface transfers, and as sustaining no falls. Additional review of the MDS Assessment, revealed the facility assessed the resident as having no falls since the previous assessment. Review of the Comprehensive Care Plan (CCP), revised 07/18/19, revealed Resident #56 was at risk for falls related to cognitive loss, lack of safety awareness, impaired mobility, high-risk medication and falls. The goal revealed the resident would have no falls with injury through the next review. The interventions included, but were not limited to: offer/assist with urinal/commode as requested, 12/06/18; place on get up list to help prevent resident from attempting to get out of bed, 04/04/19; approach resident in a calm manner, 04/19/19; place floor mat next to right side of bed when resident is in bed to help prevent injury, 04/19/19; wheelchair cushion replaced that attaches to wheelchair with clip, 09/06/19; and offer food and snack 08/28/19. Review of the Fall Investigation, dated 10/12/19, revealed Resident #56 sustained an unwitnessed fall. Additional review revealed the resident was found on the floor, on the fall mat, and bolsters were placed on the bed. However, the investigation did not address factors of the fall, specifics of the fall or the Root Cause Analysis of the fall in the investigation or in the medical record in order to revise the care plan with relevant, consistent, and individualized interventions to prevent falls of the same nature. There was no documented evidence the CCP was revised to include the intervention for roll bolsters to the bed, status post fall 10/12/19, nor was there documented evidence of any revision of the CCP after this fall. Interview with Licensed Practical Nurse (LPN) #2, on 10/30/19 at 1:35 PM, revealed the residents' Care Plan was to be revised with an immediate intervention to ensure resident safety and provide necessary care after a fall. Interview with the Director of Nursing (DON), on 10/25/19 at 10:45 AM, revealed she expected the RAI Manual Guidelines to be followed to ensure the CCP was revised as necessary. Additionally, she expected the CCP to be revised after each fall event for all residents to ensure the facility was providing safe, necessary care. Per interview, the facility changed their Electronic Medical Record systems and the process in which the facility investigated and reviewed fall events changed. She further stated she was new to this role and until this week, she had been unsure of the process to follow up on an investigation. Per interview, the facility failed to revise the CCP after the Fall Investigations. Interview with the Administrator, on 10/25/19 at 12:18 PM, revealed he expected the CCP to be revised with interventions after fall events per RAI guidelines. Further interview revealed it was important to ensure the CCP was revised to include fall interventions status post fall events to prevent an additional fall of the same nature and to provide safe care to meet resident needs.

Based on observation, interview, record review, and review of facility Policy, it was determined the facility failed to ensure adequate supervision and assistive devices to prevent accidents for two (02) of four (4) sampled residents reviewed for falls out of twenty-two (22) sampled Residents (Resident #33 and Resident #56). Resident #33 sustained a fall on 10/18/19 from his/her bed, and received a skin tear injury. The Fall Investigation revealed a fall floor mat was placed on the favored side of the bed; however, there was no documented evidence which side of the bed was the favored side (left/right) or that the Care Plan was revised to include the intervention to place a fall mat on the favored side of the bed. In addition, there was no documented evidence of contributing factors of the fall, specifics of the fall or the Root Cause Analysis of the fall in the investigation or in the medical record in order to implement interventions to prevent falls of the same nature. (Refer to F-657) Further, Resident #56 sustained a non-injury fall on 10/12/19, from his/her bed. The Fall Investigation revealed roll bolsters would be placed on the bed. However, there was no documented evidence the Care Plan was revised to include the intervention to place the roll bolsters on the bed, status post fall on 10/12/19. In addition, there was no documented evidence of contributing factors of the fall, specifics of the fall or the Root Cause Analysis of the fall in the investigation or in the medical record in order to implement interventions to prevent falls of the same nature. (Refer to F-657) The findings include: Review of the facility's Falls Management Policy, revised on 11/01/19, revealed residents determined to be at risk for falls will receive appropriate interventions to reduce risk and minimize injury. Additionally, residents experiencing a fall will receive appropriate care and investigation of the Cause of the fall. Per Policy, the purpose was to reduce the risk for falls and minimize the actually occurrence of the falls and to address injury and provide care for a fall. Further, the practice standards included assessing for fall risk; developing, reviewing and revising the Care Plan; documenting the accident/incident; and conducting a post fall review. 1. Review of Resident #33's medical record revealed the facility admitted the resident on 12/28/18 with diagnoses including, but no limited to Alzheimer's Dementia, Type II Diabetes, Abnormal Posture, and Intervertebral Disc Degeneration/Lumbar Region. Interview with the Director of Nursing on 10/31/19 at 3:05 PM, revealed the Nursing Quarterly Notes were what the facility utilized as a Fall Risk Assessment. Review of the Nursing Documentation Note, dated 08/25/19, revealed the resident had a history of falls, and was at risk for falls. Review of Resident #33's Quarterly Minimum Data Set (MDS) Assessment, dated 08/26/19, revealed the facility assessed the resident as having both short and long-term memory problems. Additionally, the facility assessed the resident as requiring extensive assistance of two (02) staff or total assistance of two (02) staff for bed mobility, transfers, and toileting. Continued review revealed the resident did not ambulate and required total assistance of one (01) staff for locomotion in the wheelchair. Per the Assessment, the resident had unsteady balance, and was only able to stabilize with staff assistance during transition from surface to surface. Continued review revealed the resident had falls since the prior assessment; one (01) non-injury and two (02) injury falls. Further review revealed the resident utilized daily use of a chair and bed alarm and the resident used no physical restraints. Review of Resident #33's Comprehensive Care Plan (CCP), revised 09/05/19, revealed the resident was at risk for falls related to cognitive loss, lack of safety awareness, impaired mobility, and falls. The goal stated the resident would have no falls with injury for ninety (90) days. Interventions included, but were not limited to: nonskid socks, 12/31/18; pressure alarm to wheelchair and bed to alert staff of unsafe attempts to self-transfers, 01/11/19; resident not to be left alone in [NAME] room (dining room) without staff supervision, 02/05/19; self releasing seatbelt with alarm, check and release every two (02) hours and as needed, 02/14/19; and resident to sit in high traffic areas after lunch, 05/19/19. Interview with the Director of Nursing, on 10/31/19 at 3:05 PM, revealed the Fall Risk Management Assessment (FRMA) was the facility Post Fall Assessment. However, the FRMA could not be printed out of the Electronic Medical Record. Further, she copied and pasted the information into a Word Document. Review of the Word Document, dated 10/18/19, untimed, revealed Resident #33 was in his/her room in bed, the bed alarm sounded and the nurse went into the resident's room to find the resident on the floor sitting beside his/her bed. Additionally, blood was noted to the resident's right arm from a skin tear; the skin tear was cleansed and a dressing was applied. Continued review revealed the nurse and the aide transferred the resident back to the bed. Further, a floor mat was placed on the favored side of the bed. However, the favored side of the bed was not identified. Review of Resident #33's Fall Investigation, dated 10/18/19, untimed, revealed the bed alarm was sounding and the resident was noted to be on the floor next to the bed. Additional review revealed the resident had a skin tear to his/her right arm and treatment was applied. Continued review revealed the resident was transferred back to bed after an assessment. Further, a fall floor mat was placed on the favored side of the bed; however, there was no specification related to which side of the bed. In addition, there was no documented evidence of contributing factors of the fall, specifics of the fall or the Root Cause Analysis of the fall in the investigation or in the medical record in order to implement relevant, consistent, and individualized interventions to prevent falls of the same nature. Additionally, further review of the (CCP), revised 09/05/19, revealed there was no documented evidence the Care Plan was revised to include the fall intervention for the floor fall mat to the favored side of the bed, status post fall on 10/18/19. 2. Review of Resident #56's medical record revealed the facility admitted the resident on 03/19/19 with diagnoses including, but not limited to Hemiplegia affecting left non-dominant side, Acquired absence left leg below knee, Vascular Dementia, Abnormal Posture, Reduced Mobility, Need for Assistance with personal care, Heart Failure, Muscle Weakness, Lack of Coordination, Restlessness and Agitation, and Major Depressive Disorder. Review of the Nursing Documentation Note, dated 09/06/19, revealed the resident had a history of falls, and was at risk for falls. Review of Resident #56's Significant Change Minimum Data Set (MDS) Assessment, dated 09/25/19, revealed the facility assessed the resident as having a BIMS score of three (03) indicating severe cognitive impairment. Additionally, the facility assessed the resident as requiring extensive assistance of two (02) staff for bed mobility and requiring total assistance for all other Activities of Daily Living (ADLS). Per the MDS Assessment, the facility assessed the resident as not being able to stabilize without staff assistance during surface to surface transfers, and as having no falls. Further, per the MDS Assessment, the resident had no falls since the previous assessment. Continued review revealed the resident used no physical restraints. Review of Resident #56's Comprehensive Care Plan (CCP), revised on 07/18/19, revealed the resident was at risk for falls related to cognitive loss, lack of safety awareness, impaired mobility, high-risk medication and falls. The goal stated the resident would have no falls with injury through the next review. Interventions included, but were not limited to: offer/assist with urinal/commode as requested/needed, 12/06/18; place on get up list to help prevent resident from attempting to get out of bed, 04/04/19; approach resident in a calm manner, 04/19/19; place floor mat next to right side of bed when resident is in bed to help prevent injury, 04/19/19; wheelchair cushion replaced that attaches to wheelchair with clip, 09/06/19; and offer food and snack 08/28/19. Review of the Word Document, dated 10/12/19, untimed, revealed Resident #56 was in his/her room in bed, and the aide notified the nurse who then went into the room. Additionally, the nurse observed the resident's head and upper extremities were off the mat, and lower extremities were on the mat. Continued review revealed there was no apparent injury. Further, roll bolsters were put in place. Review of Resident #56's Fall Investigation, dated 10/12/19, untimed, revealed the resident had an unwitnessed fall. Additional review revealed the resident was found on the floor, on the fall mat. Further, bolsters were placed on the bed. However, there was no documented evidence of contributing factors of the fall, specifics of fall or the Root Cause Analysis of the fall in the investigation or in the medical record in order to implement relevant, consistent, and individualized interventions to prevent falls of the same nature. Additionally, review of the CCP, revealed no documented evidence it was revised to include the intervention to roll bolsters to the bed status post fall on 10/12/19. Interview with Licensed Practical Nurse (LPN) #2, on 10/30/19 at 1:35 PM, revealed she had worked at the facility for ten (10) years. Additionally, direct care nurses completed the FRMA with each fall. Per interview, the purpose of completing FRMA was to track falls and keep an ongoing timeline of falls (circumstances and interventions that have been effective in the past) for the residents to ensure safety and provide necessary care. Continued interview revealed it was important to complete a thorough assessment of a fall event to include contributing factors of the fall events, and specifics of falls because the assessments were used to determine the Root Cause Analysis (RCA) and necessary in order to implement an intervention to prevent falls of the same nature. Further, the care plan was revised with an immediate intervention by the direct care nurse and the Unit Manager followed up to ensure the most appropriate intervention was revised to the care plan. Continued interview revealed Resident #33 and Resident #56 had a history of falls related to poor safety awareness secondary to impaired cognition. Interview with the Director of Nursing (DON), on 10/31/19 at 3:05 PM, revealed she expected the facility policy on Falls Management to be followed. Per interview, she expected staff to complete a thorough investigation of the cause of the fall, to include contributing factors, and specifics of a fall event to ensure the interdisciplinary team could review that data and determine the Root Cause Analysis of the fall event. Continued interview revealed completing a thorough assessment of each fall event ensured a safe environment to all residents. Further, since August 2019, the facility was using a new fall assessment, the FRMA. Continued interview revealed the FRMA needed to be edited to include areas for contributing factors, specifics of the falls and a Root Cause to be documented. Per interview, the facility nurses also needed training on documenting resident fall events to include specific data and contributing factors of fall events because there was not consistent documentation. Additional interview revealed there was a morning meeting Monday through Friday and falls were discussed for the previous twenty-four (24) hours or after a weekend which included the Administrator, DON, Unit Managers, and Therapy. However, she stated Resident #33 and Resident #56's falls were evidently not discussed in these morning meetings as there was no root cause identified and no new interventions care planned. Interview with the Administrator, on 10/31/19 at 4:06 PM, revealed he expected regulations and facility policies to be followed in order to prevent accidents and injuries. Additionally, he expected the staff to complete a thorough assessment post fall to determine the cause of the fall. Further, he expected the revision of the care plan to include an appropriate intervention to prevent accidents/injuries or falls of the same nature.

Based on observation, interview, record review, and review of facility Policy, it was determined the facility failed to ensure residents are free of any significant medication errors for one (1) of twenty-two (22) sampled residents. Resident #55 did not receive injections of Lantus insulin 10 units daily as ordered by the Physician from 10/01/19 through 10/30/19. The findings include: Review of the facility's Medication Administration NSG305, revised 07/01/19, revealed medication doses will be administered within one (1) hour of the prescribed times unless otherwise indicated by the prescriber. Review of Resident #55's medical record revealed the facility admitted the resident on 09/17/19 with diagnoses including Diabetes Mellitus. Review of Resident #55's Physician's Orders dated 09/21/19, revealed orders for Lantus insulin 10 units to be injected subcutaneous one (1) time a day for treatment of Diabetes Mellitus. Along with the Lantus insulin, the Physician also ordered Metformin 500 milligrams to be given twice a day, and Victoza Solution 1.2 milligrams to be injected subcutaneous once a day to treat Diabetes Mellitus. Review of Resident #55's September 2019 Medication Administration Record (MAR), revealed Lantus insulin 10 milligrams was documented as have been administered by facility nursing staff as prescribed starting 09/22/19. However, record review of the resident's October 2019 MAR revealed Lantus insulin 10 units was not listed as part of the resident's medication regimen, and there was no documented evidence the resident received the prescribed Lantus insulin 10 units daily as ordered by the Physician from 10/01/19 through 10/30/19. Further review of the September 2019 and October 2019 MARs, revealed the resident's Metformin and Victoza medications were listed and documented as administered as ordered. Record review of Resident #55's twice a day blood sugar checks for October 2019, revealed the resident's blood glucose levels remained stable for the month. The recorded glucose levels ranged from a low of 121 on 10/17/19 to a high of 246 on 10/03/19. The average blood glucose level for Resident #55 was 168 for October 2019. Interview was conducted on 10/31/19 at 10:49 AM, with Licensed Practical Nurse (LPN) #1. During the interview, LPN #1 acknowledged the discrepancy of the missing Lantus insulin 10 unit for Resident # 55 on the October 2019 MAR. The LPN stated the Lantus insulin should have been administered by nurses who worked on the 11:00 PM to 7:00 AM shift. However, LPN #1 stated the nurses would not have known to administer the Lantus insulin since it was not listed on the resident's MAR. Interview was conducted on 10/31/19 at 10:51 AM, with the Unit Manager for the 200 Unit in which the resident resided. During the interview, she stated she was responsible for change over of monthly MARs on her unit. She described the process as printing paper copies of the upcoming months MARS, verifying the medications listed on the MAR with the corresponding Physician's Orders for the medication and then placing the MAR in a binder. The 200 Unit Manager acknowledged the discrepancy of the missing Lantus insulin on the October 2019 MAR. She stated she must have failed to place the paper print out of the October 2019 MAR in the binder. Per interview, this would cause the 11:00 PM to 7:00 AM shift nurses not to be aware they were to administer Lantus 10 units every day. The 200 Unit Manager stated she would notify Resident #55's Physician of the missed medication error for the month of October. Interview was conducted on 10/31/19 at 11:40 AM, with LPN #5. During the interview she stated she had worked on 10/29/19 from 7:00 PM to 10/30/19 7:00 AM and would have been responsible for administering the Lantus Insulin to Resident #55 the morning of 10/30/19. LPN #5 stated she would only know to give a resident Insulin if it was listed on the MAR. She stated, Since Lantus was not listed on the MAR I did not give it. Interview on 10/31/19 on 2:56 PM, with the Director of Nursing (DON), revealed it was her expectation facility nurses administer residents' medication as prescribed. The DON further stated it was her expectation the Unit Managers verify Physician's Orders, and place printed MARs in binders during the monthly MAR change over process. Interview on 10/31/19 at 4:16 PM, with the Administrator, revealed it was his expectation that nursing staff follow Physician's Orders when administering medications. The Administrator further stated he expected the Unit Managers to verify Physician's Orders during the monthly MAR changeover processes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility failed to develop and implement a Comprehensive Care Plan (CCP) for each resident, that includes measurable objectives and timeframes to meet a resident's needs for four (4) of twenty-two (22) sampled residents (Residents #9, #33, #42, #56). Resident #9's Monthly October 2019 Physician's Orders, revealed current orders for left hand splint as needed dated 11/28/16; and gentle stretch and wear left resting hand splint at night, dated 02/10/17. However, there was no documented evidence the facility developed the CCP to include interventions related to the left resting hand splint. Additionally, the resident was discharged from Physical Therapy (PT) on 10/17/19, with recommendations to transition to the Restorative Nursing Program (RNP) in order to maintain current level of function with bed mobility, and bilateral lower extremity (BLE) Active Range of Motion (AROM). However, there was no documented evidence the facility developed or implemented the CCP related to transfers, bed mobility, or BLE AROM. (Refer to F-688) Resident #33's CCP, revised 09/05/19, revealed interventions for Restorative transfers, Restorative bed mobility and Restorative Range of Motion (ROM) related to cognitive loss/dementia and functional deterioration. However, there was no documented evidence the facility implemented the Plan of Care during September and October 2019. (Refer to F-688) In addition, Resident #33's CCP, revised 09/05/19, was not developed to include the medical symptom to justify the use of restraint, interventions related to the frequency or circumstance in which the restraint was to be used, interventions for ongoing evaluations for the restraint to ensure it was the least restrictive device or effective for this resident to prevent accidents/incidents; or interventions to address potential complications. (Refer to F 604). Additionally, per Resident #33's CCP, the resident was not to be left unsupervised in the [NAME] Room (dining room). However, observation on 10/29/19, at 1:30 PM, revealed Resident #33 was sitting in the joy room (dining room) in his/her wheelchair at a table, and there was no staff in the joy room. Resident #42 was discharged from Occupational Therapy (OT) on 09/15/19, with recommendations to transition to a RNP for bilateral upper extremity (BUE) AROM and BLE transfer training. However, there was no documented evidence the facility developed or implemented the CCP related to AROM to BUE and BLE transfer training. (Refer to F-688). Resident #56's CCP revised 01/29/19, revealed interventions for Restorative bed mobility and Restorative ROM related to cognitive loss/dementia and functional deterioration; however, there was no documented evidence the facility implemented the Plan of Care during September and October 2019. (Refer to F-688) The findings include: Review of the facility's Person Centered Care Plan Policy, revised 07/01/19, revealed a person center care plan will include measurable objective and timetables to meet the resident's physical, psychosocial and functional needs. Additionally, the care plan process will include a resident's personal preferences. Further, the Care Plan will describe the services to be provided to maintain or attain the residents' highest practicable physical, mental, and psychosocial wellbeing; include identified problem areas; and aid in preventing or reducing decline in functional status/level. 1. Review of Resident #9's clinical record revealed the facility admitted the resident on 11/28/16 with diagnoses including Hemiplegia left non-dominant side, Osteoarthritis, Abnormal Posture, Reduced Mobility, Abnormality of Gait, Lack of Coordination, History of Falls, Polyneuropathy, Pain, Furuncle of Limb, Type II Diabetes, Major Depressive Disorder, and Anxiety Disorder. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 10/17/19, revealed the facility assessed Resident #9 as having a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) indicating intact cognition. Further, the facility assessed the resident as requiring extensive assistance of one (01) staff for bed mobility and extensive assistance of two (02) staff for transfers. Per the MDS Assessment, the resident was assessed as having Functional Limitation in Range of Motion (ROM) to (01) upper and one (1) lower extremity. Review of the Monthly October 2019 Physician's Orders, revealed current orders for left hand splint as needed and Therapy evaluation/ treatment as recommended, dated 11/28/16; and gentle stretch and wear left resting hand splint at night, dated 02/10/17. Review of the Physical Therapy (PT) Discharge summary, dated [DATE], revealed recommendations for Resident #9 to transition to a Restorative Nursing Program (RNP) to maintain current level of function with bed mobility, and bilateral lower extremity (BLE) Active Range of Motion (AROM). However, record review revealed there was no documented evidence the Resident #9's CCP was developed to include interventions for the left resting hand splint as per the Physician's Order, dated 02/10/17. In addition, record review revealed there was no documented evidence the facility developed and implemented a RNP Plan of Care with interventions to maintain current functional status with bed mobility, or BLE AROM, as per the Therapy Discharge summary, dated [DATE]. 2. Review of Resident #33's clinical record revealed the facility admitted the resident on 12/28/18 with diagnoses including, but not limited to Alzheimer's Dementia, Type II Diabetes, Abnormal Posture, and Intervertebral Disc Degeneration/Lumbar Region. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 08/26/19, revealed the facility assessed Resident #33 as having a BIMS score of ninety-nine (99) and having both short and long term memory problems. Further, the facility assessed the resident as requiring total assistance of two (02) staff for all Activities of Daily Living (ADLS). Per the Assessment, this resident had Functional Limitation in Range of Motion (ROM) bilaterally to upper and lower extremities. Per the MDS Assessment, the resident last received therapy on 05/30/19. Review of the Comprehensive Care Plan (CCP), revised 09/05/19, revealed Resident #33 required Restorative Transfer: The resident demonstrated deficit in transferring related to Cognitive loss/Dementia and Functional Deterioration. The goal revealed the resident would safety transfer from bed to chair for ninety-two (92) days. Interventions initiated on 02/22/19 included: providing verbal cues for sequencing and to lock the wheelchair; placing transfer surface as close as possible and free from obstacles; ensuring surfaces are stable; and cueing patient for transfer techniques. Additional review of the CCP, revised 09/05/19, revealed Resident #33 required Restorative Bed mobility: The resident demonstrated deficit in positioning self in bed related to Cognitive loss/Dementia and Functional Deterioration. The goal revealed the resident would achieve maximum level of independence related to moving in bed for ninety-two (92) days. The interventions initiated on 02/22/19 included; standby assist with rolling side-to-side, supine to so sit and sit to supine. Further review of the CCP, revised 09/05/19, revealed Resident #33 required Restorative Range of Motion: The resident demonstrated loss in ROM in bilateral upper extremities related to Cognitive loss/Dementia and Functional Deterioration. The goal revealed contractures would be prevented and skin integrity would be maintained for ninety-two (92) days. The interventions initiated on 02/22/19 included: AROM to upper extremities; teach resident and family to perform the ROM exercises; and provide reminders, supervision or actual physical assist to move extremity. However, record review revealed there was no documented evidence the facility implemented the CCP related to interventions to maintain current functional status: transfers, bed mobility, and ROM, for September or October 2019. 3. Review of Resident 42's clinical record revealed the facility admitted the resident on 10/22/07 with diagnoses including Cerebrovascular Disease with Right Hemiplegia, Muscle Weakness, Peripheral Vascular Disease and Diabetes Mellitus Type 2. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 09/06/19, revealed the facility assessed the resident as having a BIMS score of twelve (12) out of fifteen (15) which indicated moderate cognitive impairment. Additionally, the facility assessed the resident as requiring extensive assist of two (2) persons for transfers and as having Functional Limitation in Range of Motion to one (01) lower extremity. Review of the Occupational Therapy Discharge summary, dated [DATE], revealed the resident was discharged with recommendations to transition to the Restorative Nursing Program (RNP) in order to maintain current level of function with Active Range of Motion (AROM) to bilateral upper extremities (BUE) and BLE transfer training. However, there was no documented evidence the facility developed or implemented the CCP related to AROM to BUE and BLE transfer training. 4. Review of Resident #56's clinical record revealed the facility admitted the resident on 03/19/19 with diagnoses including, but not limited to Hemiplegia affecting left non-dominant side, Acquired absence of left leg below knee, Vascular Dementia, Abnormal Posture, Reduced Mobility, Need for Assistance with personal care, Heart Failure, Muscle Weakness, Lack of Coordination, Restlessness and Agitation, and Major Depressive Disorder. Review of the CCP, revised 01/29/19, revealed Resident #56 required Restorative Bed mobility: The resident demonstrated deficit in positioning self in bed related to Cognitive loss/Dementia and Functional Deterioration. The goal revealed the resident would achieve maximum level of independence related to moving in bed for ninety-two (92) days. The interventions initiated on 01/29/19 included; moderate assist rolling side to side and raise head of bed to approximately forty-five (45) degrees so resident can pull self up into long sitting position with minimal assist. Further review of the CCP, revised 01/29/19, revealed Resident #56 required Restorative Range of Motion: The resident demonstrated loss in ROM in bilateral upper extremities related to Cognitive loss/Dementia and Functional Deterioration. The goal revealed the resident would be able to move bilateral lower extremities through normal ROM without discomfort for ninety-two (92) days. The interventions initiated on 01/29/19 included: support above and below the joint; provide pain medications as needed; explain each step prior to doing it; teach patient to perform the ROM exercises; and for Passive ROM provide move joint slowly and gently, never force past resistance, avoid fast movements or stretching. Review of the Significant Change Minimum Data Set (MDS) Assessment, dated 10/25/19, revealed the facility assessed Resident #56 as having a BIMS score of three (03) indicating severe cognitive impairment. Also, the facility assessed the resident as requiring extensive assistance of two (02) staff for bed mobility and requiring total assistance for all other ADLS. Per the MDS Assessment, the facility assessed the resident to have Functional Limitation in Range of Motion (ROM) of one (1) lower extremity and as not receiving therapy or RNP. However, record review revealed there was no documented evidence the facility implemented the CCP related to Restorative Nursing for bed mobility and ROM in September or October 2019. Interview with Licensed Practical Nurse (LPN) #2, on 10/30/19 at 1:35 PM, revealed the CCP should be a current, accurate reflection of the residents because it was used by the interdisciplinary team (IDT) and direct care givers to ensure residents received safe quality care to meet their needs. She stated if residents had Physician's Orders related to a splint or had recommendations from therapy upon discharge for the RNP, the CCP should be developed and implemented with interventions specific to the orders and recommendations. Additionally, she stated it was important the CCP was implemented related to RNP and residents were provided necessary care and devices to ensure residents maintained their highest level of function, and wellbeing and to prevent and/or decrease risk for complications such as contracture, skin breakdown, and pain. Further interview with LPN #2, revealed the facility was in between RNP staff at this time as the Restorative Nurse had accepted the Interim Unit Manager position for the 100 hallway and it had been several weeks since the RNP program had been placed on hold. Interview with State Registered Nursing Assistant (SRNA) #2, on 10/30/19 at 2:00 PM (restorative aide for the 200 hallway) revealed she used the CCP as a reference in providing care to the residents. Additionally, the CCP should be developed to include all treatment and services the residents required and the CCP should be followed to ensure each resident's needs were met. Further interview revealed she was the Restorative Aide for the 200 hallway Unit, but during the last two (02) months she had not been assigned to complete RNP duties, but was assigned to work as a direct care SRNA. Further, the RNP services and treatments were not being administered to the residents as per the Care Plans. Interview with the Therapy Director, on 10/31/19 at 11:15 AM, revealed the RNP Plan of Care was based on a nursing referral with noted decline in function or a referral from the therapy department after skilled therapy to maintain gains made in therapy. Per interview, the Therapist would complete a form on discharge and choose a program based on individual resident needs. That form was given to Restorative Nurse and who would develop the RNP and train the Restorative Aides to implement the RNP plan based on the referral. Further, she expected a RNP Plan to be implemented by nursing to maintain the highest level of independence for residents. Additional interview revealed she had identified a cycle over the last several months where residents were not getting RNP and she had discussed her concerns with Administration related to residents declining without the RNP. Interview with the Interim Unit Manager, 100 hallways, on 10/31/19 at 2:25 PM (previous Restorative Nurse) revealed the CCP should be developed and implemented by nursing staff to meet the needs of the individual residents. Per interview, following the care plan ensured optimal care, and progress towards meeting the residents' care needs. Additionally, the Restorative Nurse was responsible to develop the RNP Plan of Care based on therapy recommendations. Further, the Restorative Aides were responsible to implement the RNP Plan of care. Interview with the Director of Nursing (DON), on 10/31/19 at 3:05 PM, revealed if there were recommendations in place from therapy, the facility was responsible and accountable to develop and implement the RNP Plan of Care. Additionally, if there was a RNP Plan of care developed the facility was responsible and accountable to implement the RNP Plan of Care. Per interview, it was very important to ensure residents received effective, safe care, and to reduce complications. Further, if there was a Physician's Order for a splint, the CCP should be developed with this intervention. Additional interview revealed LPN #2 was responsible for the facility's RNP since the previous Restorative Nurse took the position of Unit Manager for the 100 hallway, in August 2019. However, the DON stated she had identified that LPN #2 was not effective and was not able to maintain the RNP while working as a direct care nurse. She stated she hired a new Restorative Nurse last week. Further interview revealed she was aware the RNP in the facility had not been maintained for residents over the last few months, and the CCPs were not being developed or implemented related to RNP. 5. Review of Resident #33's clinical record revealed the facility admitted the resident on 12/28/18 with diagnoses including, but not limited to Alzheimer's Dementia, Type II Diabetes, Abnormal Posture, and Intervertebral Disc Degeneration/Lumbar Region. Review of Resident #33's Physician's Orders, dated 10/31/19, revealed orders for a self-releasing seat belt to the wheelchair when up, release every two (02) hours and for meals, dated 02/11/19. Review of Resident #33's Restrictive Device Consent, dated 02/11/19, revealed a self-releasing alarming seatbelt had been ordered by as part of the resident's overall plan of care. Additionally, the medical reason for use was poor safety awareness and impulse control. Per the Consent, the restraint was to be used when up in the wheelchair. Additional review revealed the Consent included risk versus benefits and was signed by the resident's representative. Review of Resident #33's Restraint Release Reduction Assessment, dated 08/23/19, revealed the resident had inconsistent response to the trial and recommendations were to continue the seatbelt alarm while the resident was up in the wheelchair related to impaired cognition, inability to follow safety measures, and unstable independent ambulation. Review of Resident #33's Quarterly Minimum Data Set (MDS) Assessment, dated 08/26/19, revealed the facility assessed the resident as having both short and long term memory loss. Further, the facility assessed the resident as requiring total assistance of two (02) staff for bed mobility, transfers, and toileting. Additional review revealed the resident did not ambulate and required total assistance of one (01) staff for locomotion in the wheelchair. Per the MDS Assessment, the resident had unsteady balance, only able to stabilize with staff assistance during transition from surface to surface. Further review revealed a chair and bed alarm was used daily and the resident used no physical restraints. Review of Resident #33's Comprehensive Care Plan (CCP), revised 09/05/19, revealed the resident was at risk for falls related to cognitive loss, lack of safety awareness, impaired mobility, and falls. The goal revealed the resident would have no falls with injury for ninety (90) days. The interventions included, but were not limited to: nonskid socks, 12/31/18; pressure alarm to wheelchair and bed to alert staff of unsafe attempts to self-transfers, 01/11/19; resident not to be left alone in [NAME] room (dining room) without staff supervision, 02/05/19; self releasing seatbelt with alarm, check and release every two (02) hours and as needed, 02/14/19; and resident to sit in high traffic areas after lunch, 05/19/19. However, the CCP was not developed to include the need to complete ongoing evaluations related to the self-releasing alarming seat belt to ensure this was an effective intervention for this resident, or to ensure the device was not a restraint. Additionally, the CCP was not developed to address the medical symptom to justify the use of restraint, the frequency or circumstance when to use the restraint; or interventions to address potential complications. Interview with Licensed Practical Nurse (LPN) #2, on 10/30/19 at 1:35 PM, revealed Resident #33's CCP should have been developed to include ongoing evaluations of the alarming seat belt, the medical symptom to justify the use of restraint, the frequency or circumstance when to use the restraint and interventions to address potential complications. Per interview, these criteria would ensure the restraint was an effective intervention for this resident, and the least restrictive device. Observation on 10/29/19, at 1:30 PM, revealed Resident #33 was sitting in the joy room (dining room) in his/her wheelchair at a table. Continued observation revealed there were no staff in the joy room (dining room). However, per the CCP, the resident was not to be left unsupervised in the [NAME] Room (dining room). Additional interview with the Director of Nursing (DON), on 10/31/19 at 3:05 PM, revealed Resident #33's CCP should have been developed to include the medical symptom to justify the use of restraint, the frequency or circumstance in which the restraint was to be used, ongoing evaluations of the alarms to ensure the alarms were the least restrictive devices or were appropriate or effective for this resident to prevent accidents/incidents, and interventions to address potential complications of the restraint. Furthermore, she stated she expected the CCP to be implemented related to not leaving the resident unsupervised in the [NAME] Room (dining room). Interview with the Administrator on 10/31/19 at 4:06 PM, revealed he expected the facility policy and regulations to be followed related to developing and implementing the CCP. Further, he expected nursing staff to develop care plans and provide services and treatment as per the individualized written plans related to restorative nursing. Additional interview with Administrator, revealed Resident #33's CCP should have been developed with further interventions related to restraint use as per regulation, and the resident's CCP should have been implemented related to not leaving the resident in the joy room unattended.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of Resident 42's Medical Record revealed the facility admitted the resident on 10/22/07 with diagnoses including Cerebrovascular Disease with Right Hemiplegia, Muscle Weakness, Peripheral Vascular Disease and Diabetes Mellitus Type 2. Review of the Quarterly MDS Assessment, dated 09/06/19, revealed the facility assessed the resident as having a BIMS score of twelve (12) out of fifteen (15) indicating moderate cognitive impairment. Additionally, the facility assessed the resident as requiring extensive assist of two (2) persons for transfers and as having Functional Limitation in Range of Motion (ROM) to one (01) lower extremity. Review of Resident #42's Occupational Therapy Discharge summary, dated [DATE], revealed discharge recommendations for caregiver assist with Activities of Daily Living (ADL) and follow up with RNP addressing BUE AROM and BLE transfer training. However, there was no documented evidence the facility implemented a RNP Plan of Care with interventions to maintain current functional status related to AROM and transfers. Review of the Restorative Binder, for the 100 hall where Resident #42 resided, revealed the RNP for this resident dated 09/2019 included Active Range of Motion (AROM) to Bilateral Upper Extremities (BUE) and Bilateral Lower Extremities (BLE) ten to fifteen (10-15) repetitions each for six (6) to seven (7) days per week; transfer training five to ten (5-10) repetitions daily for six (6) to seven (7) days per week; and minimum assist with transfers chair to toilet, toilet to chair, chair to bed and bed to chair. Additional review revealed there was no documented evidence the facility implemented the RNP related to AROM and transfers to maintain the resident's functional status as there was no staff initials or signatures. In addition, there was no documented evidence the resident participated in a RNP as per the 09/15/19 OT recommendations, in September or October 2019. 5. Furthermore, review of the RNP Binders, for the 100 and 200 hallways, revealed forty-one (41) residents with RNP Plans dated September 2019. However, there was no documented evidence the services were provided as per the RNP Plans. Additionally, there was no documented evidence of October 2019 RNP Plans. Interview with Licensed Practical Nurse (LPN) #2, on 10/30/19 at 1:35 PM, revealed she had worked at the facility for ten (10) years. Per interview, the facility was in between RNP staff at this time as the Restorative Nurse had accepted the Interim Unit Manager position for the 100 hallway and the Restorative Aides were working as direct care aides. Additionally, it had been several weeks since the RNP program had been placed on hold. Further, Restorative aides received specific training on RNP services as opposed to direct care aides and Restorative Aides were usually assigned to implement the RNP set by the Restorative Nurse based on therapy referral. LPN #2 stated, only the Restorative Aides were knowledgeable of the RNP Plans and where and how to document on the Restorative Nursing Record. Additional interview with LPN #2, revealed there was no current RNP Plans in the Restorative binder because there had been no Restorative Nurse to complete them. However, LPN #2 stated it was important to implement and maintain a RNP program to ensure residents kept their highest level of function, and wellbeing. Further, the RNP program was important to ensure quality of care and quality of life and prevent and/or decrease risk for complications such as contractures, skin breakdown, and pain. Interview with State Registered Nursing Assistant (SRNA) #2, on 10/30/19 at 2:00 PM, revealed she was the Restorative Aide for the 200 hallway Unit. She stated during the last two (02) months she had not been assigned to complete RNP duties, but was assigned to work as a direct care SRNA. Per interview, there was no longer a Restorative Nurse to implement or make changes to the RNP plans. Continued interview revealed there had been no updates to the RNP plans and the October RNP Plans were not developed and placed in the RNP Binders on the units. Per interview, the RNP services and treatments were not being administered to the residents. Further, it was important to provide RNP services and treatments to residents to maintain their functional level and prevent declines such as contractures, pain, or skin breakdown. Interview with the Therapy Director, on 10/31/19 at 11:15 AM, and at 2:15 PM, revealed at times the therapy department discharged residents with recommendations to transition to the RNP after skilled therapy to maintain gains made in therapy. Per interview, a Therapist would complete a form on discharge and choose a program based on individual resident needs. That form was given to the Restorative Nurse who would train the Restorative Aides to implement the RNP plan based on the referral. Additionally, she expected a RNP plan to be implemented by nursing in order to ensure residents maintained their highest level of independence. Continued interview with the Therapy Director, revealed she had identified a cycle over the last several months where residents were not getting RNP and she had discussed her concerns related to residents declining without the RNP to Administration. Per interview, a nurse was recently hired for the RNP, as of last week. Further, it was her expectation that Resident #9 have a RNP in place, per therapy discharge recommendations on 10/17/19. In addition, she stated Resident #56 should have a functional maintenance plan to maintain mobility and ROM since he/she was comfort care now. Additionally, she stated Resident #33's RNP Plan should have been implemented per the CCP. Further interview revealed Resident #42 was discharged from the therapy program and was to transition to the RNP to assist with transition and continuity of resident care and the restorative nurse was notified of the change in programs for this resident. Interview with the Interim Unit Manager, for the 100 hallway, on 10/31/19 at 2:25 PM, revealed she had been in this role since 08/02/19 and had previously been responsible for the RNP two (02) days a week. Per interview, she was not aware of who was responsible for the RNP after she took her new role in August; however, the RNP services and treatment had been integrated into direct care over the last few months and the regular SRNAs were providing RNP services. Continued interview revealed she could not ensure the RNP services and treatments were being administered per the RNP Plans because there was no documented evidence of the services being provided. Additional interview with the Interim Unit Manager, for the 100 hallway, revealed she expected Restorative Nursing to be provided to all residents with identified needs to prevent and decrease risk for decline in function and maintain ROM. Continued interview revealed a resident with recommendations for RNP should have a RNP Plan in place and services and treatment should be provided by Restorative Aides, and documented in the Restorative Nursing Record, kept in the Restorative Binders on each unit. Further, RNP Plans were important in order to ensure residents maintained their capabilities of self-care, and current function and enabled staff to determine when a decline in self care had occurred. Interview with the Director of Nursing (DON), on 10/31/19 at 3:05 PM, revealed she expected RNP services and treatment to be provided to residents per the facility policy to prevent and decrease risk for decline in functional status. Additionally, she expected residents with recommendations for RNP to have a RNP Plan in place and services and treatments to be administered and documented by nursing staff per the Plan. Further interview revealed LPN #2 was responsible for the facility's RNP since the previous Restorative Nurse took the position of Unit Manager for the 100 hallway, in August 2019. However, she had identified that LPN #2 was not effective and was not able to maintain the RNP while working as a direct care nurse. Therefore, she stated she had hired a new Restorative Nurse last week. Further, she was aware the RNP in the facility had not been maintained for residents over the last few months. Interview with the Administrator, on 10/31/19 at 4:06 PM, revealed he expected the facility policy and procedures to be maintained related to the RNP. Further, he expected nursing staff to provide services and treatment as per the individualized written plans and as per therapy recommendations related to restorative nursing. Additional interview revealed the RNP was important to ensure residents receive necessary care to meet their needs and maintain the highest quality of life. Based on observation, interview, record review, and review of facility Policy, it was determined the facility failed to ensure a resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable for four (04) of five (05) residents reviewed related to Limited Range of Motion (ROM) out of twenty-two (22) sampled residents (Resident # 9, Resident #33, Resident #42, and Resident #56). Resident #9's Monthly October 2019 Physician's Orders, revealed current orders for left hand splint as needed and Therapy evaluation and treatment as recommended, dated 11/28/16; and gentle stretch and wear left resting hand splint at night, dated 02/10/17. In addition, the resident was discharged from Physical Therapy (PT) on 10/17/19, with recommendations to transition to a Restorative Nursing Program (RNP) to maintain current level of function with bed mobility, and bilateral lower extremity (BLE) Active Range of Motion (AROM). However, there was no documented evidence the facility implemented the RNP related to interventions to maintain current functional status: bed mobility, BLE AROM or splints, in September or October 2019. (Refer to F-656) Resident #33's Comprehensive Care Plan (CCP), revised 09/05/19, revealed the resident required RNP for transfers, bed mobility and Range of Motion (ROM) related to cognitive loss/dementia and functional deterioration. However, there was no documented evidence the facility implemented the RNP related to transfers, bed mobility and ROM to maintain the resident's functional status in September or October 2019. (Refer to F-656) Resident #42 was discharged from Occupational Therapy on 09/15/19, with recommendations to transition to a RNP for bilateral upper extremity (BUE) AROM and BLE transfer training. However, there was no documented evidence the facility implemented the RNP related to AROM and transfers to maintain the resident's functional status in September or October 2019. (Refer to F-656) Resident #56's Comprehensive Care Plan (CCP), revised 01/29/19, revealed the resident required RNP for bed mobility and Range of Motion (ROM) related to cognitive loss/dementia and functional deterioration. However, there was no documented evidence the facility implemented the RNP related to bed mobility and ROM in order to maintain the resident's functional status in September or October 2019. (Refer to F-656) Furthermore, review of the RNP Binders, for the 100 and 200 hallways, revealed forty-one (41) residents with RNP Plans dated September 2019. However, there was no documented evidence the services were provided as per the RNP Plans. Additionally, there was no documented evidence of October 2019 RNP Plans. The findings include: Review of the facility Restorative Nursing Policy, revised 03/15/16, revealed residents would receive Restorative Nursing care as needed to promote and maintain optimal physical, mental, and psychosocial functioning. Additionally, Restorative Nursing consisted of nursing interventions that may not be accompanied by formalized rehabilitation services. Continued review revealed the goals and objectives of restorative were individualized and resident centered, and would be outlined in the resident's Care Plan. Further, the RNP would be implemented per the specifics on the Care Plan. Per the Policy, the RNP would be documented daily on the Restorative Nursing Record. 1. Review of Resident #9's Medical Record, revealed the facility admitted the resident on 11/28/16 with diagnoses including Hemiplegia left non-dominant side, Osteoarthritis, Abnormal Posture, Reduced Mobility, Abnormality of Gait, Lack of Coordination, History of Falls, Polyneuropathy, Pain, Furuncle of Limb, Type II Diabetes, Major Depressive Disorder, and Anxiety Disorder. Interview with Resident #9, on 10/29/19 at 9:30 AM, revealed he/she had not received RNP after being recently discharged from therapy. Further, the resident was concerned that he/she would decline in functional status and his/her goal to maintain gains made in therapy would not be met without RNP services Review of Resident #9's Quarterly Minimum Data Set (MDS) Assessment, dated 10/17/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) indicating intact cognition. Additionally, the facility assessed the resident as requiring extensive assistance of one (01) staff for bed mobility and extensive assistance of two (02) staff for transfers. Per the Assessment, the resident had Functional Limitation in Range of Motion (ROM) to (01) upper and one (1) lower extremity. Per the MDS Assessment, the resident last received therapy on 10/17/19. Review of Resident #9's Monthly October 2019 Physician's Orders, revealed current orders for left hand splint as needed and Therapy evaluation and treatment as recommended, dated 11/28/16; and gentle stretch and wear left resting hand splint at night, dated 02/10/17. Review of Resident #9's Physical Therapy (PT) Discharge summary, dated [DATE], revealed recommendations for the Resident to transition to a RNP to maintain current level of function with bed mobility, and bilateral lower extremity (BLE) Active Range of Motion (AROM). However, there was no documented evidence the facility implemented a RNP Plan of Care with interventions to maintain current functional status: bed mobility, BLE AROM or splints, in September or October 2019. Review of the Restorative Binder, dated September 2019, for the 200 hall where Resident #9 resided, revealed a RNP for this resident related to Passive ROM to left upper and lower extremities and AROM to right upper and lower extremities six (06) to seven (07) days a week; and splint to left hand up to four (04) to six (06) hours a day six (06) to seven (07) days a week. However, there was no documented evidence these interventions were implemented for Resident #9 as there were no staff initials or signatures. Review of Resident #9's Progress Notes, dated 10/01/19 through 10/30/19 revealed no documented evidence of a RNP Plan. 2. Review of Resident #33's Medical Record, revealed the facility admitted the resident on 12/28/18 with diagnoses including, but not limited to Alzheimer's Dementia, Type II Diabetes, Abnormal Posture, and Intervertebral Disc Degeneration/Lumbar Region. Observation of Resident #33, on 10/29/19 at 9:22 AM, 1:00 PM and 4:00 PM; and on 10/30/19 at 9:00 AM; revealed the resident was in bed lying on his/her back, in high fowlers position. Further observation on 10/31/19 at 1:30 PM, revealed the resident was in the dining room seated in a high back wheelchair with an alarming seat belt across his/her lap. Review of Resident #33's Quarterly Minimum Data Set (MDS) Assessment, dated 08/26/19, revealed the facility assessed the resident as having both short and long term memory problems. Additionally, the facility assessed the resident as requiring total assistance of two (02) staff for all Activities of Daily Living (ADLS). Per the Assessment, the resident had Functional Limitation in Range of Motion (ROM) bilaterally to upper and lower extremities. Further, per the MDS Assessment, the resident last received therapy on 05/30/19. Review of Resident #33's Monthly October 2019 Physician's Orders, revealed current orders for Therapy evaluation and treatment as recommended, dated 11/28/19. Further review revealed current orders for self-releasing seat belt to wheelchair when up, release every two (02) hours and for meals, dated 02/11/19. Review of Resident #33's Comprehensive Care Plan (CCP), revised 09/05/19, revealed the resident required Restorative Transfer: The resident demonstrated deficit in transferring related to Cognitive loss/Dementia and Functional Deterioration. The goal stated the resident would safety transfer from bed to chair for ninety-two (92) days. Interventions initiated on 02/22/19 included: provide verbal cues for sequencing and to lock the wheelchair; place transfer surface as close as possible and free from obstacles; ensure surfaces are stable; and cue patient for transfer techniques. Additional review of Resident #33's CCP, revised 09/05/19, revealed the resident required Restorative Bed mobility: The resident demonstrated deficit in positioning self in bed related to Cognitive loss/Dementia and Functional Deterioration. The goal stated the resident would achieve maximum level of independence related to moving in bed for ninety-two (92) days. Interventions initiated on 02/22/19 included; standby assist with rolling side-to-side, supine to so sit and sit to supine. Further review of Resident #33's CCP, revised 09/05/19, revealed the resident required Restorative Range of Motion: The resident demonstrated loss in ROM in bilateral upper extremities related to Cognitive loss/Dementia and Functional Deterioration. The goal was to prevent contractures and maintain skin integrity for ninety-two (92) days. Interventions initiated on 02/22/19 included: AROM to upper extremities; teach resident and family to perform the ROM exercises; and provide reminders, supervision or actual physical assist to move extremity. Review of the Restorative Binder, for the 200 hall where Resident #33 resided, revealed a RNP dated September 2019, for this resident to receive Active ROM to bilateral upper and lower extremities ten (10) repetitions each, six (06) to seven (07) days a week; and self feeding-setup assist/verbal cues and divided plate two (02) to three (03) times a day, six (06) to seven (07) days a week. However, there was no documented evidence the services were provided as per the RNP as there were no staff initials or signatures. Further, there was no documented evidence of a RNP completed for Resident #33 for October 2019. In addition, there was no documented evidence the facility implemented a RNP Plan of Care related to transfers, and bed mobility to maintain his/her functional status in September or October 2019. Review of Resident #33's Progress Notes, dated 10/01/19 through 10/30/19 revealed no documented evidence of a RNP Plan. 3. Review of Resident #56's Medical Record, revealed the facility admitted the resident on 03/19/19 with diagnoses including, but not limited to Hemiplegia affecting left non-dominant side, Acquired absence of left leg below knee, Vascular Dementia, Abnormal Posture, Reduced Mobility, Need for Assistance with personal care, Heart Failure, Muscle Weakness, Lack of Coordination, Restlessness and Agitation, and Major Depressive Disorder. Observation of Resident #56, on 10/29/19 at 9:32 AM, revealed the resident was lying flat in bed on his/her back, in a low bed with a wedge under the left flank and right knee. Additional observation, on 10/29/19 at 12:30 PM, revealed the resident was in the dining room sitting in a geri chair. The resident slid down in the chair multiple times and two (02) staff repositioned him/her. Review of Resident #56's CCP, revised 01/29/19, revealed the resident required Restorative Bed mobility: The resident demonstrated deficit in positioning self in bed related to Cognitive loss/Dementia and Functional Deterioration. The goal stated the resident would achieve maximum level of independence related to moving in bed for ninety-two (92) days. Interventions initiated on 01/29/19 included; moderate assist rolling side to side and raise head of bed to approximately forty-five (45) degrees so resident can pull self up into long sitting position with minimal assist. Further review of Resident #56's CCP, revised 01/29/19, revealed the resident required Restorative Range of Motion: The resident demonstrated loss in ROM in bilateral upper extremities related to Cognitive loss/Dementia and Functional Deterioration. The goal stated the resident would be able to move bilateral lower extremities through normal ROM without discomfort for ninety-two (92) days. Interventions initiated on 01/29/19 included: support above and below the joint; provide pain medications as needed; explain each step prior to doing it; teach patient to perform the ROM exercises; and for Passive ROM provide move joint slowly and gently, never force past resistance, avoid fast movements or stretching. Review of Resident #56's Significant Change Minimum Data Set (MDS) Assessment, dated 10/25/19, revealed the facility assessed the resident as having a BIMS score of three (03) indicating severe cognitive impairment. Additionally, the facility assessed the resident as requiring extensive assistance of two (02) staff for bed mobility and requiring total assistance for all other ADLS. Per the MDS Assessment, the facility assessed the resident as having Functional Limitation in Range of Motion (ROM) of one (1) lower extremity. Further, per the MDS Assessment, the resident had not received therapy or RNP. Review of Resident #56's Monthly October 2019 Physician's Orders, revealed a current order for Therapy evaluation and treatment as recommended, dated 09/18/19. Review of the Restorative Binder, for the 200 hall where Resident #56 resided, revealed no documented evidence of a RNP Plan including ROM or bed mobility, for September or October 2019 for this resident. Review of Resident #56's Progress Notes, dated 10/01/19 through 10/30/19 revealed no documented evidence of a RNP Plan. Further, there was no documented evidence the facility implemented a RNP Plan of Care related to bed mobility and ROM to maintain his/her functional status in September or October 2019.

Based on observation, interview, and review of facility Policy, it was determined the facility failed to ensure each resident receives food and drink that is palatable, attractive, and at a safe and appetizing temperature. Observation of the test tray conducted on the 200 unit at the lunch meal service on 10/31/19, revealed the hot foods were not hot, the cold foods were at room temperature, and some food items were not palatable. In addition, interviews with Resident #29 and #49, revealed foods were not served at appropriate temperatures and was not palatable. The findings include: Review of the facility Food Handling Policy, dated 10/01/15, revealed temperature control for food safety must maintain an internal temperature of forty one ( 41) degrees Fahrenheit or lower, and one hundred forty five (145 ) degrees Fahrenheit or higher while being held for service. Further review revealed during transportation of food from the kitchen to the dining room/resident room, care is to be taken to keep hot food hot, and cold food cold, and food protected from contamination. Interview with Resident #29, on 10/29/19 at 9:45 AM, revealed quality of food in the facility was poor. Further, menu items he/she ordered arrived either late, or at the wrong temperature and was not palatable. Continued interview revealed the majority of residents he/she conversed with had the same opinions concerning the food. The resident stated he/she resided on the 200 unit and ate meals in his/room. Resident #29 was assessed by the facility in a Quarterly Minimum Data Set (MDS) Assessment, dated 08/04/19, as having a Brief Interview for Mental Status of a fifteen (15) out of fifteen (15) indicating the resident was cognitively intact. Interview with Resident #49 on 10/29/19 at 10:15 AM, revealed food service in the facility continued to decline. Per interview, food arrived to his/her room late, incorrectly prepared, and hot foods were no longer hot, while foods needing to be cold were served warm. Further interview revealed the resident had voiced concerns to Administration. The resident verified he/she resided on the 200 unit and ate meals in his/room. Resident #49 was assessed by the facility in a Quarterly Minimum Data Set (MDS) Assessment, dated 08/02/19, as having a Brief Interview for Mental Status of a fifteen (15) out of fifteen (15) indicating the resident was cognitively intact. Observation of lunch meal service on 10/29/19 at 12:00 PM, revealed meals were delivered to the dining rooms first, then followed by separate meal carts going to both the 100 unit and 200 unit. Further observation revealed meals were not contained in a hot box, but did have a protective covering enclosing the trays. The meal trays were organized by room number, and were labeled with resident information and diet specifics. Observation and Food Test Tray testing conducted 10/31/19 at 12:15 PM, on the 200 unit, revealed servings of mixed fruit, Vegetable soup, Lemonade, Potato Salad, and a Roast Beef Sandwich. A temperature was obtained for each separate item and taste tested. The findings included mixed fruit registering at seventy (70) degrees Fahrenheit; Vegetable soup registering at one hundred fifty-two (152) degrees Fahrenheit with a bland taste; Lemonade registered at fifty four (54) degrees Fahrenheit with a cool taste; Potato Salad registered at sixty nine (69) degrees Fahrenheit with good taste, but was too warm to hold integrity; and Roast Beef Sandwich registered at one hundred thirty four (134) degrees Fahrenheit and was not hot to taste. Interview with State Registered Nurse Aide (SRNA) #1, on 10/31/19 at 1:30 PM, revealed SRNAs were responsible for delivering trays to resident rooms. Once trays arrived to the units, they were dispersed to residents in order by room number. Per interview, residents had complained that hot foods were delivered cold and the food did not taste good. Further interview revealed if residents complained about the food, they would get a replacement food item or meal tray. Interview with the Director of Nursing (DON), on 10/31/19 at 2:00 PM, revealed there could be concerns for food borne pathogens if food items were served at improper temperatures. Further, there was the potential of nutritional decline for residents as an unintended consequence of serving food items at improper temperature, or serving food items that were not palatable to residents. Interview with the Assistant Dietary Manager, on 10/31/19 at 3:00 PM, revealed foods served hot should remain hot, and foods meant to be served cold should remain cold. Further interview revealed food temperatures were obtained on the steam table, the food was plated and prepared on the meal tray, and then served to residents in the dining room and on the units. Per interview, food was covered at all times while being transported and the facility did not utilize hot boxes. Additional interview revealed residents had the right to be served foods at proper temperatures and periodic training was conducted with dietary staff to address dietary failures. Per interview, the Assistant Dietary Manager would be implementing new policies and methods to improve food quality. Interview with the District Dietary Manager, on 10/31/19 at 3:30 PM, revealed there was no particular Point of Service policy related to food temperatures; however, food temperatures should be maintained from preparation to delivery. Per interview, food served that was not palatable or served at incorrect temperatures could lead to possible foodborne illness or nutritional decline in residents. Continued interview revealed temperatures should be continually monitored and maintained, and Corporate would need to look into the concern of foods not holding temperatures. Interview with the Administrator, on 10/31/19 at 4:00 PM, revealed it was his expectation that all foods served be palatable and at correct temperatures for both hot and cold foods. Per interview, this was a resident's right and the facility must honor resident rights. Additional interview revealed incorrect food temperatures and poor food quality posed the potential for food borne illness and nutritional decline in residents who were vulnerable.

Based on observation, interview and review of facility Policy, it was determined the facility failed to prepare and store food under sanitary conditions. Observation on 10/29/19, during initial kitchen tour, revealed two (2) beverage pitchers were not labeled or dated, the ingredient bins had dry dusty food particles on the outside and the kitchen had a general dusty appearance. In addition, observation revealed the Manager in Training was not using correct procedure to to measure the sanitizer in the pot and pan sink. Continued observation of the kitchen on 10/29/19, revealed two (2) holes in the back wall over the back prep table. In addition, the floors to the base boards appeared soiled; window sills were dusty; walls throughout the kitchen needed paint, and paint was peeling off the wall near the hand sink. Further, the exhaust hood fire extinguisher pipes were dusty; the pot and pan rack over the prep table was dusty; the ceiling vents were dusty; and the top shelf of the prep table was dusty and had a greasy feel. Additionally, interviews with Dietary Staff on 10/31/19, revealed they were not knowledgeable of how to properly use the Quat Sanitizer, and were mixing Bleach with the Sanitizer. Furthermore, observation on 10/29/19 of the nourishment refrigerator on the 100 unit, revealed one (1) chocolate and four (4) strawberry 4 ounce (oz.) Sysco supplements were not dated. Moreover, observation on 10/29/19 of the nourishment refrigerator on the 200 unit, revealed eight (8) 4 oz. Sysco Vanilla shakes were not dated. Also, there was medical gauze dressing on the floor in a container; a bowl of bagged potato chips in the sink; and a wet washcloth on the sink. The findings include: Review of facility Policy, titled Food Handling, dated 12/01/15, revealed foods are stored, prepared and served in a safe and sanitary manner in order to prevent bacterial contamination and the possible spread of infection. Cold food that remains under refrigeration during service should be covered, labeled, dated with use by dates, and served by use by date. Review of the Dietary Detail Cleaning Schedule dated 10/13/19 to 10/21/19, revealed the Dietary Aides were responsible to clean the prep table top, bottom and shelves under the table; the Morning Aides were responsible to clean walls on Mondays; the Morning [NAME] was responsible to clean the wall behind the three (3) compartment sink on Wednesday and on Saturday; the Morning Dietary Aides were to clean all tables and floors; and the afternoon Dietary Aides were to clean all shelves on Saturday. However, there was no directive related to cleaning the cooks pot and pan rack, the window sills, the ingredient bins and areas behind the equipment. Review of the Quat Sanitizer instructions, revealed ECO-Lab Three Compartment Sink Sanitizer is an Environmental Protection Agency (EPA)registered, concentrated, no rinse Quat sanitizer that is effective across a dilution range of 0.25 - 0.67 ounce (oz.) per gallon of water. It provides a wider sanitization range with maximum convenience. It is an easy spray and wipe, mop bucket or third sink sanitizer application with no rinsing required. Continued review revealed dilute with water to obtain proper Parts per Million (PPM) to sanitize against different pathogens includes Escherichia coli, Staphylococcus aureas, Campylobactor jejuni, Escherichia coli 0157:H7, Klebsiella pneumonia, Listeria monocytogenes, Salmonella choleraesuis, Shigella sonnei, Yersinia enterocolitica and Enterobacter sakazakii on food contact surfaces. Review of the Clorox Bleach Safety Data Sheet (SDS), dated 06/12/15 revealed: reacts with other household chemicals, or products containing ammonia to produce hazardous irritating gases, such as chlorine and other chlorinated compound. 1. Observation on 10/29/19 at 9:30 AM, during initial tour of the kitchen, revealed two (2) beverage pitchers were not labeled or dated. One (1) pitcher was ¼ full of a white liquid substance and one (1) pitcher was ¼ full of a dark liquid substance. In addition, the ingredient bins had dry dusty food particles on the outside and the kitchen had a general dusty appearance. Additionally, the Dietary Manager in Training was observed trying to measure the sanitizer in the pot and pan sink by dragging the test strip quickly through the sanitizer. However, he did not hold the test strip in the sanitizer long enough to register the strength of the sanitizer until Surveyor intervention. Interview with the Manager in Training during the observation, revealed he was unaware he needed to dip the test strip in the sanitizer and hold it there long enough for it to register. Observation of the kitchen on 10/29/19 at 12:00 PM, during lunch tray line revealed two (2) holes in the back wall over the back prep table. In addition, the floors to the base boards appeared soiled; window sills were dusty; walls throughout the kitchen needed paint, and paint was peeling off the wall near the hand sink. Further, the exhaust hood fire extinguisher pipes were dusty; the pot and pan rack over the prep table was dusty; and the ceiling vents were dusty. In addition the top shelf of the prep table was dusty and had a greasy feel. Interview on 10/31/19 10:40 AM, with Dietary Aide #1, revealed staff was to label and date the beverage pitchers daily. She further revealed she was only responsible for cleaning the microwave, toaster and counters and explained further the method of sanitizing the kitchen. She stated she used sanitizer water from the dish room combined with bleach to pour into the red sanitizing buckets in order to clean kitchen surfaces and equipment. She stated it was important to properly sanitize the equipment and counter surfaces to prevent cross contamination. Interview on 10/31/19 at 10:48 AM, with Dietary Aide #2, revealed the beverage pitchers were to be labeled and dated daily. Per interview, if beverage pitchers were not labeled or dated, the contents of the pitchers should be thrown out because staff would not know how long the beverage had been in the pitcher. Further interview revealed she was responsible for cleaning the dish room, floor, and the counters in the kitchen. She stated she used the sanitizer from the dish room and added a little bleach to the sanitizer buckets in order to clean these areas. Interview on 10/31/19 at 10:54 AM, with [NAME] #1, revealed the beverage pitchers were to be labeled and dated daily and changed daily. Continued interview revealed she was responsible to clean the grill, steam table, and the cooks areas and signed off on the matrix for cleaning when completed. [NAME] #1 stated she sometimes cleaned the ingredient bins. Per interview, she also cleaned the windowsills, pot and pan rack and top shelf above the cooks table. Per interview, it was important to clean and sanitize the kitchen in order to prevent cross contamination of the food. Additional interview revealed she used the pot and pan sink sanitizer mixed with bleach for real greasy messes. Further interview revealed if the kitchen was not properly sanitized this could cause cross contamination of the surfaces. Further interview on 10/31/19 at 11:01 AM, with the Dietary Manager in Training, revealed the beverage pitchers were to be changed daily, cleaned and sanitized for the next day. Per interview, the beverage pitchers should be labeled and dated daily in order for staff to be knowledgeable of the expiration date. Further interview revealed there was an assigned cleaning list for the AM (morning) and PM (evening) staff, and staff was to sign when the work was completed. Per interview, Maintenance staff assisted with cleaning of the ceiling during non-production hours. Further, Dietary Staff was responsible to clean all reachable areas in the kitchen, as dust could fall into the food and cause cross contamination. Continued interview revealed the holes in the wall could allow pests to enter the kitchen and peeling paint could be a concern as debris could get into the food. Additional interview with the Dietary Manager in Training, revealed staff was to use the three (3) compartment sink Quat Sanitizer or the dish room Quat Sanitizer to sanitize the pots, pans and kitchen surfaces. Per interview, the Quat test strips were available to test the sanitizer in the pot and pan sink and in the red sanitizer buckets to ensure it was at appropriate PPM and effective. Further, this Quat Sanitizer was not to be mixed with bleach as this could cause the mixture to be toxic and not effective for sanitizing food contact surfaces. Interview on 10/31/19 at 11:17 AM, with the District Manager, revealed staff was to label and date the pitchers of fluids daily. Per interview, the leftover beverages in the pitchers was to be thrown out, washed and new beverages added to the pitchers daily. Further, if the pitchers were not dated, staff would not know when the beverages were prepared and needed to be discarded. Continued interview revealed Dietary Staff had a cleaning list with specific areas assigned to be cleaned in the kitchen. Upon completion of the cleaning task, staff was to sign the cleaning list to indicate the cleaning had been completed. The District Manager stated the dust in the kitchen over the production areas could fall into the food and cause cross contamination, and the holes in the kitchen wall could allow rodents and bugs to enter. Further interview revealed the kitchen did need repainting. Additional interview with the District Manager, revealed the sanitizer from the pot and pan sink was used for sanitizing the kitchen, and the sanitizer from the dish machine was used to clean stainless steel. Per interview, some staff preferred bleach and water to clean and sanitize the kitchen. The District Manager stated sanitizer and bleach were not to be mixed together because this would change the effects of the sanitizer on the food contact surfaces and allow for cross contamination of bacteria. Interview on 10/31/19 at 2:45 PM, with the Maintenance Director, revealed he cleaned the kitchen vents and changed air filters once monthly as scheduled during non-production times and another cleaning was not due until next month. Further, Dietary Staff was responsible for cleaning all the other areas of the kitchen. He stated the holes in the wall could allow pests to enter and the walls needed to be repaired. Interview on 10/31/19 at 4:00 PM, with the Director of Nursing (DON), revealed dietary staff should label and date all foods with the date of expiration. Per interview, the kitchen should be properly cleaned and sanitized to protect against the potential for food borne pathogens. Further, the kitchen should be free of dust or debris in the air which could contaminate food. Additional interview revealed the holes in the kitchen wall could allow pests to enter and contaminate food products. 2. Interview on 10/30/19 at 1:21 PM with the Administrator, revealed there was no facility policy related to labeling and dating food in the nourishment refrigerator. Observation on 10/29/19 at 12:35 PM, of the nourishment refrigerator on the 100 unit, revealed one (1) chocolate and four (4) strawberry 4 ounce (oz.) Sysco supplements were not dated. Observation on 10/29/19 at 12:40 PM, of the nourishment refrigerator on the 200 unit, revealed eight (8) 4 oz. Sysco Vanilla shakes were not dated. In addition, there was medical gauze dressing on the floor in a container; a bowl of bagged potato chips in the sink; and a wet washcloth on the sink. Interview on 10/31/19 at 2:00 PM, with State Registered Nurse Assistant (SRNA) #11, who was working the 100 unit, revealed the supplements were placed into the nourishment refrigerator when the residents refused them. Per interview, staff should date all supplements prior to putting them into the refrigerator in order for staff to know the date of expiration. Interview on 10/31/19 at 2:05 PM, with SRNA #4, who worked the 100 unit, revealed if supplements were not dated, they should be discarded immediately. Interview on 10/31/19 at 2:30 PM, with SRNA #5, who was working the 200 unit, revealed if supplements were not dated, they should be discarded. Interview on 10/31/19 at 2:35 PM, with Licensed Practical Nurse (LPN) #5, who worked the 200 unit, revealed supplements should be labeled and dated to ensure they were not expired. LPN #5 stated staff should throw out any expired, unlabeled or undated foods and contact Dietary. Per interview, staff should not remove the label or date on the supplements before placing them in the nourishment refrigerator. Interview on 10/31/19 at 2:40 PM, with the Unit Manager #2 for the 200 unit, revealed if a resident refuses a supplement, the SRNA should notify the nurse. Per interview, the label and date information should remain on the supplement if it was placed in the nourishment refrigerator and if the supplement was not labeled or dated, it should be thrown out. Further, there should be no medical equipment items kept in the nourishment room. Continued interview revealed the washcloth should not have been left on the back of the sink in the nourishment room, but should have been placed into the soiled linen room. Interview on 10/31/19 at 4:00 PM, with the Director of Nursing (DON), revealed nursing staff should label and date all supplements stored in the nourishment refrigerator to ensure it was discarded upon expiration. Further, there should not have been a wet washcloth left on the sink in the nourishment room and medical supplies should not have been left on the floor in the nourishment room as the nourishment room needed to be clean and sanitary. Interview on 10/31/19 at 4:23 PM, with the Administrator, revealed the beverage pitchers in the reach-in refrigerator of the kitchen should have been labeled and dated. Further interview revealed it was his expectation for staff to follow the cleaning schedule in the kitchen in order for the kitchen to be clean and sanitary at all times. Per interview, the dust build up in the kitchen allowed for the possibility of dust to get into the food causing cross contamination. In addition, the holes in the kitchen allowed for the potential for pests to enter the kitchen and contaminate food products. Further interview revealed it was his expectation for the kitchen staff to be knowledgeable of how to properly use the sanitizer. Additional interview with the Administrator, revealed it was his expectation for the 100 and 200 units to properly label and date all supplements stored in the nourishment refrigerators to ensure they were discarded upon expiration. Further, the wet washcloth should not have been left on the back of the sink in the nourishment room and medical supplies should not have been stored in the nourishment room on the floor, as this was not sanitary.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure all medications and biologicals available for use were not expired on one (1) of two (2) halls, the 100 Hall. Observation of the emergency intravenous (IV) fluid cart on the 100 Hall revealed it contained expired IV fluids and IV administration sets. The findings include: Review of the facility's policy, Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles, revised 10/31/16, revealed the facility should ensure medications and biologicals 1) with an expired date on the label; 2) retained longer than recommended by the manufacturer or supplier; or 3) that had been contaminated or deteriorated; were stored separate from other medications until destroyed or returned to the pharmacy or supplier. Observation of the 100 Hall, on 08/23/18 at 10:30 AM, revealed a large metal cart in the locked utility closet had multiple bags of IV fluids and IV needle/tubing administration sets. There were fourteen (14) items expired on the cart. The items included: three (3) 500 milliliter (ml) bags of 0.9% Sodium Chloride, one with an expiration date of 05/2018 and two with expiration dates of 06/2018; one (1) 250 ml bag of 5% Dextrose with an expiration date of 04/2018; one (1) 1000 ml bag of 0.9 % Sodium Chloride with an expiration date of 07/2018; two (2) 100 ml bags of 5% Dextrose with expiration dates of 09/2017; one (1) 500 ml bag of 5% Dextrose with an expiration date of 04/2018; and one (1) 1000 ml bag of 10% Dextrose with an expiration date of 11/2017. In addition, the cart contained one (1) Medimark Inc., Hypodermoclysis Kit with an expiration date of 05/2018, and two (2) Mini Loc Port/Access Kits, one with an expiration date of 09/28/17, and the other with an expiration date of 12/28/17. There was also one (1) BD Nexiva IV needle set/single port with an expiration date of 04/2016, and one (1) StatLock Catheter Stabilization Device with an expiration date of 02/2018. Interview, on 08/23/18 at 10:35 AM, with Unit Manager (UM) #1 revealed the facility's contracted pharmacy provided the emergency IV fluid cart and its contents. The UM stated the nurses were responsible for auditing the IV fluid cart for expired items and sufficient stock. She stated the audit of the IV fluid cart should occur the same time the medication and treatment carts were audited, and the night shift nurses should complete the audits. The UM stated if an expired IV fluid was used for resident care, it could be harmful to the resident because an expired product might not be as effective, and could prevent the best outcome for the resident needing the fluids. Review the facility's Medication and Treatment Cart Assignment Sheet, dated 02/21/14, revealed each nurse was responsible for stocking medication carts for the on-coming shift nurse and to check daily for expired contents. The document was stored in a binder at the 100 Hall nurses' station. The binder contained a log for signing off on completion of deep cleaning of the medication carts and treatment carts; however, nothing addressed the auditing of the emergency IV cart stored in the utility room. Interview, on 08/23/18 at 10:50 AM, with Licensed Practical Nurse (LPN) #1 revealed she personally did not think of the emergency IV cart in the same way she thought of the medication and treatment carts. She stated the facility needed to make staff aware of where the IV cart was stored, and include the audit of the IV cart with the routine audits of the medication and treatment carts. Interview, on 08/23/18 at 2:15 PM, with the Center Nurse Executive (CNE) revealed there should not be expired IV supplies in the facility. She stated the contracted pharmacy delivered the emergency IV fluids and supplies and if staff took a bag of IV fluids or other supplies from the cart, they would communicate with the pharmacy via a facsimile (fax), which should prompt the pharmacy to replace the item. She stated reordering was completed on an item-by-item basis. The CNE further stated it was the nursing department's responsibility to audit the IV fluid cart and remove expired items. The CNE stated staff seldom used the IV fluids stored in the cart, as most physician ordered IV fluids were delivered directly by the pharmacy, labeled specifically for the resident. She stated in the event of an emergency, it might be necessary to use the IV fluids and supplies stored in the cart, so the facility should not keep supplies that were expired, as they might not be as effective in the delivery of best resident care and outcome. Interview, on 08/23/18 at 2:36 PM, with the Center Executive Director (CED) revealed the CNE and Unit Managers were responsible for ensuring all medications, IV fluids, and biologicals stored in the facility were not expired. The CED stated there had been no pattern of discovering expired medications or supplies, but if so, the matter would be addressed in the Quality Assurance meetings.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure staff documented medication administration per policy for one (1) of nineteen (19) sampled residents, Resident #83. Observation of medication administration revealed the nurse documented medications as administered prior to administering the medications to the resident. The findings include: Review of the facility's policy, Medication Administration: General, revised 07/24/18, revealed the purpose of the policy was to provide a safe, effective medication administration process. The policy stated licensed staff assisted the resident as needed and remained with the resident until the medication administration was complete, monitored the resident, and then documented in the Medication Administration Record. Review of the facility's policy, Clinical Record: Charting and Documentation, revised 01/01/13, revealed the purpose of the policy was to provide a complete account of the resident's total stay from admission through discharge. Licensed nurses and other licensed staff were to be concise, accurate, complete, factual, and objective when charting treatments, medications, vital signs, and weights. Observation, on 08/23/18 at 8:50 AM, revealed LPN #3 prepared Resident #83's medication and initialed the Medication Administration Record (MAR), which documented the medications as administered, for the medications as soon as she verified them and put them into a cup. The medications included Aspirin 81 milligrams (mg), Buspar 15 mg, ½ Tab, Calcium/Vitamin D 600/400 mg, Dexlansoprazole 60 mg, Flexeril 10 mg, Isosorbide 30 mg, 1/2 Tab, Lactobacillus, Metanx 3-35-2 mg, Gabapentin 300 mg, Gabapentin 800 mg, Percocet 5-325 mg, Miralax 17 gram (gm), Potassium ER 30 milliequivalent (mEq), and Senna 8.6 mg. Interview with LPN #3, on 08/23/18 at 9:07 AM, revealed she was supposed to sign/initial the medications on the MAR after she administered them because a resident might refuse the medications. She stated if she signed the medications as administered prior to giving the medications, as in Resident #83's instance, it appeared as if the resident took them, but in actuality, the resident had not received them. LPN #3 stated she did not follow facility policy when she documented the medications as administered prior to the resident taking them. Interview with Unit Manager (UM) #2, on 08/23/18 at 10:30 AM, revealed the nurse should sign/initial the MAR after medications were administered. She stated if the nurse signed/initialed the medications prior to giving them to the resident, they would show as administered; however, that was not correct. The UM stated she expected nurses to follow the policy and sign/initial all medications after they were administered to the resident. Interview with the Center Nurse Executive (CNE), on 08/23/18 at 11:08 AM, revealed nurses should sign/initial medications after the resident took them, and circle medications if the resident refused or spit them out. She stated the same was true for narcotics. However, she stated the facility had a blue book for narcotics and the nurse was required to sign/initial the narcotic book as soon as they were removed from the blister pack, administer the medication, and then sign/initial the MAR. She further stated if the MAR was signed/initialed prior to medication administration; it was not the correct procedure because a resident might refuse the medications. The CNE expected nurses to follow facility policy; however, the CNE stated in Resident #83's instance, the policy was not followed. Interview with the Center Executive Director (CED), on 08/23/18 at 11:23 AM, revealed the CNE and Assistant CNE educated staff on medication administration annually. He received reports from them and followed up with the Quality Assurance Performance Improvement if the need arose. He stated nursing staff should follow facility policy and the policy was not followed if a nurse signed/initialed medications prior to giving them and it was a documentation error.

**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 infection control program to prevent possible infection in one (1) of two (2) halls, the 200 Hall. Observation revealed two (2) rooms on the 200 Hall with resident nebulizer mask/mouthpieces left uncovered. The findings include: Review of the facility's policy, Infection Prevention and Control Program Description, dated 03/01/18, revealed the program addressed preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for residents, staff, volunteers, visitors, and other individuals providing services under contractual agreement. The policy further stated the facility monitored for proper infection prevention and control technique, as indicated and appropriate, and reviewed infection prevention control practices directly related to resident care. Observation of Resident room [ROOM NUMBER], on 08/21/18 at 9:42 AM, 08/22/18 at 12:51 PM and 5:13 PM, and 08/23/18 at 10:05 AM, revealed an uncovered oxygen mask laying on top of Bed B's (Resident #35) night stand next to a nebulizer. Record review for Resident #35 revealed the resident had a nebulizer treatment scheduled every four (4) hours, for shortness of air/wheezing, while awake. Observation of Resident room [ROOM NUMBER], on 08/22/18 at 5:13 PM and 08/23/18 at 10:13 AM, revealed an uncovered nebulization mouthpiece laying near the pillow on top of the resident's bed (Resident #192-A). Record review for Resident #192-A revealed the resident had nebulizer treatments scheduled every eight (8) hours as needed for shortness of breath. Interview with Registered Nurse (RN) #1, on 08/23/18 at 10:01 AM, revealed if a nebulizer mask was not in a bag, the mask could get contaminated which could cause a respiratory infection issue. She stated a resident could get Pneumonia, so nursing staff should put the nebulizer mask in a bag and date it. Interview with Licensed Practical Nurse (LPN) #2, on 08/23/18 at 10:20 AM, revealed a nebulizer mouthpiece should not be on the bed and was supposed to be in a bag to prevent infections. He stated all nursing staff, from the Certified Nursing Assistants (CNA) to the managers, were responsible to keep the equipment bagged. Interview with Unit Manager #2, on 08/23/18 at 10:30 AM, revealed oxygen tubing mouthpieces and masks should be placed in a bag and dated. She stated if nebulizer equipment was not put in a bag, it could cause the residents to get an infection. Interview with the Center Nurse Executive (CNE), on 08/23/18 at 10:56 AM, revealed nebulizer masks and mouthpieces should be placed in a bag with the date, and resident's name and room number. She stated if the nebulizer equipment was not bagged, there was a risk for the items to get contaminated because the items laid on surfaces containing germs, which could lead to an infection, possibly Pneumonia. Interview with the Center Executive Director, on 08/23/18 at 11:34 AM, revealed nebulizer mouth pieces and masks, as well oxygen tubing, should be bagged and labeled. He stated all staff should follow the infection control policy to prevent the spread of infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility policy review, it was determined the facility failed to maintain a homelike environment in eight (8) of fifty-one (51) resident rooms. Rooms 105, 107, 204, 207, 217, and 218 had damaged wood wall protectors beside the resident beds. In addition, rooms [ROOM NUMBERS] had cabinet drawers that were off the tracks and did not close properly. The findings include: Review of the facility's policy, Preventive Maintenance, revised 06/01/07, revealed the entire company would request routine maintenance on physical plant fixtures and equipment via work order. Maintenance responded to work orders timely. All work orders were logged into the computer tracking software (TELS) system by the Director of Maintenance, to show when received and when completed. Review of the facility's Work Order, undated, revealed the form requested who to route to, Maintenance or Housekeeping, the date, and a description of the issue. The form also had fields, which required the date of completion, triaged by importance, and remarks. There was a signature field for the requestor and the Administrator. The form included a carbon duplicate distributed to the Administrator and the second copy to the department of concern. 1. Observation of Rooms 105, 107, 204, 207, 217, and 218, on 08/22/18 at 2:42 PM, revealed wood wall protectors behind the resident beds were gouged, scraped, and splintered. Interview with the Housekeeper, on 08/23/18 at 9:39 AM, revealed he noticed the gouged wood in the resident rooms because his dust cloth caught on them. He stated he did not know how to put in a work order to communicate the issue to the Director of Maintenance; however, he verbally reported the damaged wood to his supervisor, the Director of Environmental Services, a couple of weeks ago. Interview with the Director of Environmental Services (DES), on 08/23/18 11:11 AM, revealed he had not noticed the damaged wood but recalled the Housekeeper reported it to him and he passed it on to the Maintenance Director verbally a couple of weeks ago. The DES did not know about the written work order process, as he was an employee of an outside management company and was not trained on all the facility systems. Interview with Certified Nursing Assistant #2, on 08/23/18 at 1:46 PM, revealed she had not noticed the damaged wood but would have filled out a work order if she needed any repairs. She explained there was a box to put the work orders in near the dining room and the Maintenance Director would pick them up. Interview with Unit Manager #2, on 08/23/18 1:24 PM, revealed when she identified a maintenance problem, she filled out a work order and dropped it in the maintenance box. She stated she had not noticed the damaged wood and had no concerns. Interview with the Maintenance Director, on 08/23/18 at 1:29 PM, revealed he could not recall receiving information from Housekeeping about the damaged wood boards. He explained he might not remember if it was not written on a work order, which was his maintenance system. He stated he had not received any work orders regarding the wall protectors; however, he and the Center Executive Director (CED) had discussed the broken wood many times. He further stated he and the CED had decided to replace the wood protectors in every room with a high impact plastic half-round protector, like used in hospitals. He stated he was not sure when they would be replaced, but they would do the work in phases. Interview with the CED, on 08/23/18 at 1:42 PM and 2:23 PM, revealed he and the Maintenance Director had met on 08/01/18 and conducted a facility wide tour, which led them to discuss wall protectors. He stated the resident rooms did not look as homelike as they should. He stated every wall protector in the building would be replaced; however, he did not have firm dates, as it was a work in progress. 2. Observation of room [ROOM NUMBER], on 08/22/18 at 4:00 PM, revealed the sink in the room was held up by a cabinet containing four (4) drawers. The third drawer from the top was loose from the drawer track and partially opened, hanging down. Observation of room [ROOM NUMBER], on 08/22/18 at 4:06 PM, revealed the sink in the room was held up by a cabinet containing four (4) drawers. The top two (2) drawers were labeled 'Bed A' and the bottom two (2) drawers were labeled 'Bed B'. The second drawer from the top was not on its track and was broken. Resident #194 attempted to open the drawer and found it very difficult to open and close. Interview with Resident #194, on 08/22/18 at 4:06 PM, revealed he/she had told staff previously about the broken drawer in his/her room. Resident #194 stated he/she wished it was fixed because he/she was using the bottom drawer since he/she did not have a roommate, but when he/she got a roommate, he/she would not have a place for all of his/her things. Interview with the Maintenance Director, on 08/23/18 at 1:55 PM, revealed he had been replacing several broken drawers throughout the facility. He stated the plastic pieces located in the back of the cabinets broke frequently and had to be replaced. He stated he did not know room [ROOM NUMBER] and room [ROOM NUMBER] had broken cabinet drawers. He stated the cabinet drawers needed to be fixed because residents needed a place to put their items that they could access easily.