Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #20) with limited mobility, received appropriate equipment and assistance to maintain mobility when staff failed to ensure the resident wore palm protectors properly and daily in accordance with physician orders and recommendations by therapy to address hand contractures (fixed tightening of muscle, tendons, ligaments, or skin, preventing normal movement). The sample was 12. The census was 43 with 29 residents in certified beds. Review of Resident #20's medical record, showed: -Diagnoses included contracture to unspecified joint, Alzheimer's disease, and dementia; -A physician order, dated 5/23/24, for restorative - splint/brace. Please place splints on resident's hands every day and remove every night. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/15/24, showed: -Severe cognitive impairment; -Rejection of care behavior not exhibited; -Dependent on assistance for upper body dressing. Review of the resident's care plan, in use at the time of survey, showed: -Problem: Resident has activity of daily living (ADL) self-care deficit related to decreased mobility and muscle weakness; -Goal: Resident's ADLs and self-care will be managed through the next review; -Interventions included use of braces and splints as ordered. Review of the resident's Occupational Therapy (OT) progress report, dated 9/11/24, showed: -Progress of short-term goals: -Continue: The patient will remain the same with bilateral upper extremity passive range of motion shoulder flexion; -Functional maintenance program established included splint and brace program in place. Observation on 10/7/24 at 12:20 P.M., showed the resident seated in the dining room with palm protectors on both hands with a strap with finger slots at the top of each palm protector to straighten the resident's fingers and secure the resident's hand to the base of the splint, and a strap at the bottom to secure the resident's forearm to the base of the splint. The top strap on the resident's right palm protector was not secure. Certified Nurse Aide (CNA) A sat next to the resident and provided feeding assistance. At 12:29 P.M., the top strap of the right palm protector was not secure and the resident's fingers curled into the palm of his/her hands. Throughout the meal, the right palm protector remained unsecured over the resident's hand while staff provided feeding assistance, and the resident's fingers curled into the palm of his/her hand. Observation on 10/7/24 at 5:26 P.M., showed the resident seated in the dining room next to CNA/Certified Medication Technician (CMT) G. The resident had no palm protectors on his/her hands, and the resident's fingers curled into the palm of his/her hand. Observation on 10/8/24 at 7:55 A.M., showed CNA/CMT B entered the resident's room to get the resident out of bed. The resident's palm protectors were located on the resident's bedside table. At 8:16 A.M., CNA/CMT B exited the resident's room with the resident and escorted the resident to the dining table. The resident had no palm protectors on his/her hands, and the resident's fingers curled into the palm of his/her hands. Review of the resident's administration history, showed Licensed Practical Nurse (LPN) F documented the resident's splint/brace administered on 10/8/24 at 8:00 A.M. Observations on 10/8/24, showed: -At 11:28 A.M., the resident seated in his/her room with no palm protectors on either hand. The resident's fingers curled into the palms of his/her hands. The resident was unable to be interviewed; -At 12:20 P.M., the resident seated in the dining room next to CNA/CMT B, who provided feeding assistance to the resident. The resident had no palm protectors on his/her hands, and the resident's fingers curled into the palm of his/her hands; -At 1:50 P.M., the resident seated in his/her room with no palm protectors on either hand and the resident's fingers curled into the palms of his/her hands. During an interview on 10/9/24 at 8:54 A.M., CNA/CMT C said the resident's hands were contracted and he/she had palm protectors for both hands to make sure the contractures don't get worse. The aide who is assigned to the resident is responsible for putting the resident's palm protectors on his/her hands. Staff should ensure the resident's fingers are properly inserted in the slots of the top strap, and that the straps of the palm protector are secure. The resident can pull his/her hands out of the palm protectors at times and when this occurs, staff should reapply the palm protector. Once the palm protector is applied, the nurse marks the treatment as administered in the resident's record. The nurse should not mark the treatment as completed if the palm protectors were not applied. During an interview on 10/9/24 at 9:03 A.M., LPN D said the resident wears palm protectors on his/her hands during the day to prevent his/her contractures from getting worse. The aides or nurses can put the palm protectors on the resident, and they should ensure the palm protectors are properly applied. If the resident pulls off the palm protector or it becomes loose, staff should put the palm protectors back on the resident. Nurses were responsible for ensuring the palm protectors are applied and once verified, they mark the treatment as completed in the resident's record. If the resident refuses to wear the palm protector, the nurse should document that on the administration record. Staff should not document a treatment as administered when it was not. During an interview on 10/9/24 at 9:40 A.M., LPN E said aides can put palm protectors on residents, but ultimately, it is up to the nurse to ensure the palm protectors are put on correctly and as ordered. Once the nurse verifies the palm protectors are on, they mark the treatment as completed in the administration record. If the palm protectors were not applied for whatever reason, the nurse should document this in resident's record. It was not appropriate to mark the treatment as completed if the palm protectors were not put on. During an interview on 10/9/24 at 9:27 A.M., the Assistant Director of Nurses (ADON) said the resident wears palm protectors every day to keep his/her fingers straight because they curl into his/her palms. He/She tolerates the palm protectors well. CNAs are responsible for putting the palm protectors on the resident and making sure they are on properly. If the straps become undone, it is expected that staff reposition the palm protectors to secure them. Nurses are responsible to ensure the palm protectors are applied and then marking the treatment as administered in the administration record. It was not appropriate to mark a treatment as administered if it was not completed. During an interview on 10/9/24 at 9:46 A.M. with the Director of Nurses (DON) and Administrator, they said palm protectors are used to keep the resident's hand open and fingers extended to address contractures. If the straps on the palm protectors become loose, it is expected that staff put the straps back on securely. Nurses are responsible for verifying the palm protectors are applied and marking the treatment as administered in the resident's record. It was not appropriate to mark a treatment as administered if it was not. If the palm protectors were not applied, it was expected that the nurse document why the treatment was not administered in the resident's record.

Based on observation, interview, and record review, the facility failed to answer call lights in a timely manner and to ensure all clinical nursing staff carried a call light pager per the facility's call light exception, approved by the Department of Health and Senior Services (DHSS). This affected three of three residents sampled for call light concerns (Residents #18, #8 and #1). The census was 68 with 24 residents in certified beds. Review of the facility's exception letter, approved by DHSS, dated 7/28/20, showed for each approval listed, the facility is required to comply with the stipulations that follow: -The operator will ensure that all direct care staff carry and utilize the wireless nurse call pagers at all times; -The operator will ensure that a wireless nurse call system report is available for review upon request. 1. During a group interview on 12/7/22 at 10:00 A.M., Residents #18 and #8 said they had to wait a long time for staff to answer the call light. Resident #8 said he/she needs his/her medication and sometimes staff take a long time to come. Having to wait for his/her medications for a long time makes him/her angry, anxious, and feel abandoned. Review of Resident #18's call light log for the past 30 days, showed: -On 11/9/22, elapsed time of 1 hour, 5 minutes; -On 11/9/22, elapsed time of 1 hour, 25 minutes; -On 11/12/22, elapsed time of 1 hour, 13 minutes; -On 11/13/22, elapsed time of 3 hours, 13 minutes; -On 11/13/22, elapsed time 1 hour; -On 11/13/22, elapsed time 1 hour, 18 minutes; -On 11/22/22, elapsed time 2 hours, 7 minutes; -On 11/24/22, elapsed time 1 hour, 41 minutes; -On 11/30/22, elapsed time of 4 hours, 4 minutes; -On 12/1/22, elapsed time of 3 hours, 7 minutes; -On 12/4/22, elapsed time of 1 hour, 29 minutes; -On 12/7/22, elapsed time of 1 hour, 30 minutes. Review of Resident #8's call light log, for the past 30 days, showed on 11/13/22, elapsed time of 59 minutes. 2. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/29/22, showed: -Cognitively intact; -Diagnoses included Crohn's disease (a type of inflammatory bowel disease), diabetes mellitus and respiratory failure. During an interview on 12/5/22 at 10:59 A.M., the resident said night staff do not answer his/her call light in a timely manner. Staff told him/her they do not always see his/her call light. Observation on 12/7/22 at 11:57 A.M., showed the resident pushed his/her room call light. The call light above the resident's door on the outside of the resident's room showed the call light illuminated. Review of the resident's call light log for the past 30 days, showed: -On 11/7/22, elapsed time of 55 minutes; -On 11/10/22, elapsed time of 55 minutes; -On 11/10/22, elapsed time of 50 minutes; -On 11/18/22, elapsed time of 51 minutes; -On 11/26/22, elapsed time of 1 hour, 10 minutes; -On 11/29/22, elapsed time of 1 hour; -On 12/4/22, elapsed time of 53 minutes. 3. During an interview on 12/7/22 at 11:56 A. M., Licensed Practical Nurse (LPN) G said the facility uses a call light pager system. When the resident pushes their call light, the staff gets a notification on their pager. Staff then go to the resident's room and push the black button on the wall to turn the call light off. LPN G said only the certified nurse assistants (CNAs) carry a pager. 4. During an interview on 12/7/22 at 1:23 P.M., Registered Nurse (RN) H said he/she did not have a pager on him/her. 5. During an interview on 12/7/22 at 1:28P.M., RN J said he/she does not have a call light pager and never has. 6. During an interview on 12/7/22 at 1:45 P.M., Certified Medication Technician (CMT) I said he/she has a pager but it is on the medication cart at the moment. 7. During an interview on 12/7/22 at 1:41 P.M., the Director of Nurses and administrator said CNAs are the staff who carry call light pagers. If the call light is not answered within a certain timeframe, an alert is sent to the next CNA on the assignment. When the CNAs are on break, the CNA is supposed to give their call light pager to the nurse. Since the nurses do not carry a pager, they are to look for the light above the resident's door to know if the resident needs help. It is expected that call lights are answered as soon as possible. Waiting an hour or longer for a call light to be answered is considered too long. The administrator said she was aware the facility's exemption requires all direct clinical staff to carry pagers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement their written policies and procedures to identify when, how, and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded by failing to assess residents ability to consent to sexual activity for two residents (Residents #10 and Resident #11). The facility census was 121 with 51 in certified beds. Review of the Centers for Medicare and Medicaid services (CMS) State Operations Provider Certification, showed §483.12 Freedom from Abuse, Neglect, and Exploitation: -Sexual abuse, is defined at §483.5 as non-consensual sexual contact of any type with a resident; -Generally, sexual contact is nonconsensual if the resident either: -Appears to want the contact to occur, but lacks the cognitive ability to consent; or -Does not want the contact to occur; -A resident may have a representative that has been appointed legally under State law through, for example, a power of attorney, guardian, limited guardian, or conservatorship. These legal appointments vary in the degree that they empower the appointed representative to make decisions on behalf of the resident. While a legal representative may have been empowered to make some decisions for a resident, it does not necessarily mean that the representative is empowered to make all decisions for the resident. The individual arrangements for legal representation will have to be reviewed to determine the scope of authority of the representative on behalf of the resident; -When a resident with capacity to consent to sexual activity and his/her representative disagree about the resident engaging in sexual activity, the facility must honor the resident's wishes irrespective of that disagreement if the representative's legal authority does not address that type of decision-making for sexual activity. If the resident representative's legal authority addresses decision-making for sexual activity, then the facility must honor the resident representative's decision consistent with 42 CFR 483.10(b); -The facility must have and implement written policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves (but is not limited to): -Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse, such as the identify when, how, and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded; and the resident's right to establish a relationship with another individual, which may include the development of or the presence of an ongoing sexually intimate relationship. 1. Review of the facility's policy for Supporting Resident Autonomy Related to Expressions of Intimacy, dated 1/17/15, showed: -Policy: It is the belief of this community that, based on the teachings of the Alzheimer's Association, the expression of intimacy is a human need. As long as the two people, neither of whom has been declared to be legally incompetent, as consensual, it is each person's right, including those living with dementia, to express intimacy; -It is also the belief of this community that knowing each resident, who they were, and who they are, is essential to providing quality of care and quality of life for the individual. This is best accomplished through the completion of a resident life story, in collaboration with the resident and their family. Understanding the individuals history related to desire for intimacy can assist in understanding their desires and actions as well as potential risk for themselves or others; -Procedure: When two residents express through word or action a desire to engage in intimacy, community interdisciplinary team (IDT), including the resident's physician, is to assess the appropriateness of (i.e. evidence of the level of comfort of those involved, understanding of the actions, location and impact on other residents) decision making capacity of the individuals involved as well as their response to the intimacy; -An individualized plan of care for the residents will be developed by the IDT and incorporated into the Individualized Service Plan: -The ABC approach may be utilized to support problem solving. This includes defining what triggered the behavior, including environmental factors, the details of the behaviors, and the consequence, actual or potential. When evaluating the scope or severity of a problem and defining interventions. Note: in the case of intimacy, the behavior may have potential and/or negative consequences; -If it is assessed that intimacy is not consensual on the part of both residents, the plan of care will define how the staff will monitor and intervene in providing over-sight to the non-consenting resident, as well as any other residents in the household, and to provide interventions for the resident who has initiated the intimacy. These interventions maybe include: -Fostering social and recreational activities; -Modify clothing of resident to promote modesty without restraining the resident; -Discouraging revealing clothing for staff members; -Avoiding explicit television shows; -Defining, encouraging, and reinforcing alternative behavior; -Documentation of resident encounters, including the response to the encounter and to related interventions, will be included in the clinical record. Documentation will also be included in Individualized Service Plan and the monthly review. 2. Review of Resident #11's medical record, showed no documentation of an assessment to determine if the resident has the capacity to consent to sexual contact, intimacy and/or sexual relationship. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/23/19, showed: -Brief Interview of Mental Status (BIMS) score of 3 out of 15; -A BIMS score of 0-7, shows the resident had severe cognitive impairment; -Diagnoses included heart failure, hypertension (high blood pressure), Alzheimer's disease, and dementia; -Physical behavior symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, and abusing others sexually): Behavior not exhibited; -Required extensive assistance with transfers; -Used a wheelchair. Review of the resident's care plan, dated 12/14/16 and in use at the time of the survey, showed: -Problem: Resident has altered thought process, he/she has long and short term memory deficits and moderate impaired decision making capabilities: -Goal: He/she will function at his/her highest level of cognition by next review date; -Interventions: Encourage involvement in activities. 1:1 for socialization; -Problem: He/she has a history of and currently trying to touch staff and other residents inappropriately: -Goal: He/she will decrease the amount of times he/she is inappropriate with staff and residents by next review date; -Interventions: Document all aggression or sexual behavior when it occurs. Provide him/her with other activities or distractions. Move him/her away from source when behavior is being noticed. Redirect behavior; -Problem: He/she demonstrated inappropriate behaviors as evidenced by him/her touching another resident in the area of his/her chest on 6/8/19: -Goal: He/she will not demonstrate inappropriate behaviors towards other residents; -Interventions: If he/she is demonstrating inappropriate behaviors, provide verbal cues to distract him/her and redirect him/her. Monitor him/her for signs/symptoms of a urinary tract infection which often accompanies increased behaviors. He/she is on routine Medroxyprogesterone (hormone management medication) to manage sexual urges/behaviors; -No documentation of the resident's capacity to consent to sexual contact, intimacy and/or sexual relationships. Review of the resident's progress notes, showed on 6/8/19 at 10:57 P.M., the resident was found sitting in his/her wheelchair next to another resident, who was seated in a recliner chair in the common area. Resident #11 was noted to be squeezing the other resident's chest area and was immediately removed, redirected, and placed at the dining room table until further investigation could occur. A call was placed to the resident's physician, who stated Resident #11 had a history of behaviors and in these events, the resident did not have a urinary tract infection. 3. Review of Resident #10's medical record, showed no documentation of an assessment that resident has the capacity to consent to sexual contact, intimacy and/or sexual relationship. Review of the resident's quarterly MDS, dated [DATE], showed: -BIMS score of 8 out of 15, shows the resident was moderately impaired; -A BIMS score of 8-12, indicates moderately impaired cognition; -Diagnoses included dementia and psychotic disorder; -No behaviors exhibited. Review of the resident's care plan, dated 10/14/16 and in use at the time of the survey, showed: -Problem: Resident has a long term memory problem: -Interventions: Encourage family/friends to bring pictures, special memories, and talk with him/her about past events. Engage him/her in talking about past events/roles. Use prompts or cues (pictures, mail, etc.) as needed. Engage in activities that remind him/her of past roles/times (music/stories); -Problem: Resident has a short term memory problem: -Interventions: Encourage/help him/her participate in recreational activities. Maintain consistent routine, introduce change slowly to reduce confusion; -No documentation of the resident's capacity to consent to sexual contact, intimacy and/or sexual relationships. 4. During an interview on 6/21/19 at 8:14 A.M., Activity Aide D said he/she had been working with Resident #11 for two years. He/she primarily sits with his/her spouse, Resident #10. The resident likes to move around in his/her wheelchair. He/she observed Resident #11 touching his/her spouse. It would be a pat on the arm or the buttocks, but that is it. Resident #10 would get embarrassed and tell Resident #11 to stop. It was kind of cute. 5. During an interview on 6/21/19 at 10:14 A.M., Social Services I said the facility has married couples. They determine the capacity to consent to sexual relationship by determining the cognition of the residents. They check the family dynamic and check the level of involvement of the family to ensure there was no harm and it was consensual. They check to see if the resident likes to be touched or if the resident is aware it is his/her spouse. The facility is expected to act responsibility if the resident does not have the capacity to consent. Social Services I did not know if there was an assessment to determine capacity to consent or if it was completed. If there was an assessment, it would be in the medical record. There was a discussion about Resident #11 and Resident #10's capacity to consent. She would expect it to be documented in the care plan. Resident #11's care plan did address his/her history with touching others. Other than eating meals together, Social Services I was not sure if there was any other interaction between Resident #10 and Resident #11. They sat together, but there was no public display of affection. One of the reasons why they were separated was because they bickered a lot with each other. There were issues with sexual behaviors between Resident #11 and other residents, but there was medication modification to treat this. Social Services I never heard anything about the spouse being embarrassed with being touched or telling him/her to stop. If they were aware that a married resident was uncomfortable, they would expect the nursing staff to contact social services. Social services would contact the family. They would put interventions in place, such as not allowing them to be alone together. 6. During an interview on 6/21/19 at 10:52 A.M., the Director of Nursing (DON) said she was unaware of how the IDT team assessed a resident's capacity to consent. She would assume that when the residents show interest, they would involve social services to determine if the resident had the capacity to consent. It is not something the facility would do on everyone when they are admitted , but only if they express interest. If a resident is touching another resident and the residents involved cannot consent, she would expect there to be a nurse's note. Resident #10 and #11's family member wanted them to meet in the common areas only. There has been no discussion about Resident #10 and Resident #11's capacity to consent to sexual contact; however, when Resident #11's inappropriate touching was discussed, it was decided to provide behavior monitoring and watch what he/she was doing. 7. During an interview on 6/21/19 at 12:15 P.M., the Administrator in Training said the facility did not have a formal capacity to consent to intimacy and sexual behavior assessment; however, if they were a married couple, they would see if they wanted to be intimate and call the power of attorney. They would look at their BIMS score, but it comes up in the care plan meeting. They would check if it was safe and if the family was ok with it. The POA would have a strong say in determining if they could be intimate. She did not know if there was any documentation on whether or not Resident #10 and Resident #11 had to capacity to consent. Resident #11 did not have a favorite or single out a particular resident. If there was intimacy with another person, then they would get the social worker involved. If there was a behavior, the resident indicated a dislike or non-permission, they would intervene. If the resident was not able to communicate or had a diagnosis of dementia, they would take a look at the resident's BIMS score, gesturing, body positioning, and non-verbal communication. She did not think they would need consent for Resident #11 to swat Resident #10 on the buttocks; but Resident #10 has the right to say stop or jerk away from the resident. If it happened, she would expect staff to intervene and re-direct them.

Based on observation, interview and record review, the facility failed to ensure the services provided or arranged by the facility meet professional standards of practice by failing to ensure all physician orders were followed when staff failed to administer a treatment for one sampled resident, who had a preventative treatment order (Resident #108). In addition, the facility failed to follow the fall management policy for one of one sampled resident that experienced unwitnessed falls. Staff failed to complete the neurological assessments for a fall and did not care plan updated interventions to prevent future falls for one of three falls the resident experienced since admission (Resident #38). The sample size was 13. The census was 121 with 51 residents in certified beds. 1. Review of Resident #108's electronic physician order sheet (ePOS), in use during the survey, showed: -Diagnoses included malignant neoplasm (cancer) of the kidneys, secondary malignant neoplasm of the lung, anemia, congestive heart disease (impaired heart function) and chronic kidney disease (CKD, impaired kidney function); -An order dated 6/9/19, to apply Allevyn (an absorbent foam dressing) every 3 days to the coccyx (tailbone) for redness. Review of the resident's admission skin assessment, dated 6/8/19, showed: -Reddened area to coccyx is blanchable (blood flow quickly returns after pressure applied) and pink with moisture dermatitis (skin irrigation due to moisture); -No open areas; -No size or further description of the area. Review of the resident's Braden Scale (used for predicting pressure ulcer risk), dated 6/8/19, showed a score of 17 (15 to 18 = at risk). Review of the resident's progress notes, showed on 6/9/19 at 1:37 P.M., Resident and family member asked questions about a pressure relief mattress for the resident's bed. Resident had reddened area to coccyx and complaints of soreness to the area. Review of the resident's electronic treatment administration record (eTAR), showed: -An order dated 6/9/19, to apply Allevyn every 3 days for redness to the coccyx; -Staff documented they applied the Allevyn on 6/9, 6/12, 6/15, and 6/18/19. On 6/18/19, Nurse A documented he/she administered the treatment at 9:00 A.M., but then documented on the eTAR at 2:35 P.M., that he/she was unable to put the Allevyn on the resident's coccyx due to the resident in pain and requested not to be moved; -No further documentation found that the Allevyn had been changed as ordered as late as 6/20/19 at 9:25 A.M. Observation on 6/20/19 at 7:30 A.M., showed the resident lay in bed, Certified Nurse Assistant (CNA) B provided the resident with care. CNA B removed the resident's slacks and adult incontinence brief and exposed the Allevyn dressing on the resident's coccyx dated 6/15/19, with staff initials. During an observation and interview on 6/20/19 at 7:53 A.M., the Assistant Director of Nursing (ADON) verified the Allevyn dressing was dated 6/15/19. She looked at the eTAR, said it was documented as last changed on 6/18/19, and she would expect staff to change the dressing as ordered to promote healing and prevent further skin breakdown. During an observation and interview on 6/20/19 at 9:25 A.M., showed the resident lay in bed. Nurse C said the resident does not normally refuse treatments and had not heard of him/her refusing care. Nurse C told the resident he/she was going to change the dressing, washed his/her hands, put on gloves, removed the old Allevyn dressing and revealed a reddish/purple colored area on the coccyx that measured approximately 5 centimeters (cm) long by 4 cm wide without any open areas. Nurse C verified the area was red without any open areas. Nurse C cleansed the area, applied, dated and initialed a new Allevyn dressing. During an interview on 6/20/19 at 9:45 A.M., the ADON said when she printed out the eTAR, she saw the note from the nurse dated 6/15/19, where the resident refused the Allevyn dressing change. She would expect staff to tell the oncoming shift if a treatment had not been done and the treatment should be done on the next shift or rescheduled. During an interview on 6/20/19 at 9:50 A.M., the resident denied ever refusing to have the Allevyn dressing changed, even when he/she was not feeling well, because the treatment provided cushioning and made his/her tailbone feel better. During an interview on 6/21/19 at 11:30 A.M., the Director of Nursing (DON) said she would expect staff to administer the Allevyn treatment as ordered to promote healing and prevent skin breakdown. If the resident refused the treatment due to being in pain, she would expect staff to administer pain medication and administer the treatment after the pain medication was effective. 2. Review of the Centers for Medicare and Medicaid services (CMS) State Operations Provider Certification, showed: -Definitions: Fall refers to unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force (e.g., resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. Review of the facility's assessing falls and their cause policy, revised 1/30/18, showed: -Purpose: To provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall; -Preparation: Review the resident's care plan to assess for any special needs of the resident and identify the resident's current medications and active medical conditions; -Steps: -If a resident has just fallen, or is found on the floor without a witness to the event, nursing staff will record vital signs and evaluate for possible injuries to the head, neck, spine and extremities; -Nursing staff will observe for delayed complications of a fall for approximately 48 hours after an observed or suspected fall, and document findings in the medical record; -Documentation will include any observed signs or symptoms of pain, swelling, bruising, deformity and/or decreased mobility, any changes in level of responsiveness/consciousness and overall function and it will note the presence or absence of significant findings. Review of the facility's neurological evaluation policy, dated 7/1/18, showed: -Purpose: To provide guidelines for neurological assessment upon physician order, when following an unwitnessed fall, subsequent to a fall with a suspected head injury or when indicated by the resident condition. Review of Resident #38's medical record, showed: -Severe cognitive impairment; -Total staff assistance required with transfers; -Diagnoses of irregular heartbeat, diabetes, anxiety, heart failure and dementia; -Experienced a fall one month and six months before admission. Review of the admission Morse fall scale assessment (rapid and simple method of assessing a resident's likelihood of falling), completed on 5/22/19, showed a total score of 25 (a low risk for falls). Review of the resident's progress notes, showed: -On 5/26/19 at 11:15 P.M., the resident found on the floor in his/her bedroom lying on his/her abdomen. Staff assessed the resident and assisted into the bed with a mechanical lift. Skin tear noted to the left elbow, the area cleaned and treatment applied. Nurse notified the resident's spouse and physician. The resident's bed placed in low position and wedge in place to prevent him/her from rolling out of the bed while sleeping. Review of the resident's Morse fall scale assessment, completed on 5/26/19, showed a total score of 75 (a high fall risk). Further review of the resident's progress notes, showed: -On 5/30/19 at 3:37 P.M., the resident found sitting next to the side of the bed. His/her bed noted to be in low position. Staff provided assessment and no injuries noted. Staff assisted him/her back into the bed; -On 6/9/19 at 5:48 P.M., the resident found on the floor by the aide. The aide reported the resident had been transferred to his/her wheelchair. Staff had left the resident's room and when staff returned to the room five minutes later, the resident had been found on the floor. The resident lay with his/her head toward the door and under the seat of his/her wheelchair. The resident unable to state or recall if he/she had hit his/her head. He/she received skin tears to the right finger and the back of the right forearm and the left thumb. Treatment applied to all areas. The resident's nurse practitioner notified. Review of the resident's neurological check flow sheet, dated 6/9/19, showed: -The checklist should be completed at baseline, every 15 minutes x 4 and every eight hours x 72 hours; -On 6/9/19 at 1:55 P.M., baseline assessment started and within normal limits; -15 minute scheduled assessments completed on 6/9/19 at 2:10 P.M., 2:25 P.M., 2:40 P.M., and 2:55 P.M., showed normal findings; -30 minute scheduled assessments completed on 6/9/19 at 3:25 P.M., within normal limits. Scheduled 30 minutes assessments at 3:55 P.M., and 4:55 P.M., noted as incomplete and blank; -At 7:55 P.M., showed assessment within normal limits; -An eight hour assessment, dated 6/10/19 at 6:00 A.M., as within normal limits; -No further neurological assessments found. Further review of the Morse fall scale assessment, dated 6/9/19 showed a total score of 35 (a low fall risk). Review of the resident's care plan, in use at the time of the survey and updated on 6/9/19, showed: -Problem: The resident is at risk for falls/injury related to cognitive impairment and behavior; -Goal: The resident will not sustain a fall related injury by utilizing fall precautions; -Interventions: Staff will remind and reinforce safety awareness, lock the brakes on the bed, the wheelchair and remind and educate the resident to request assistance for all ambulation and transfers, maintain the bed in the lowest position, use a wedge while in bed to prevent throwing his/her legs out of the bed related to a fall on 5/26/19 and place the resident in the common area when he/she is in the wheelchair related to a fall on 6/9/19; -No updated interventions or mention of the fall on 5/30/19. During an interview on 6/21/19 at 7:53 A.M., the DON said if a fall is unwitnessed, the staff should assume the resident could have hit their head and always complete neurological assessments for 72 hours post fall. The assessment is triggered in the resident's chart when the fall event is created and should be completed. Neurological assessments are very important to complete because the assessment is used to monitor for brain injury and missed assessments could cause the staff to miss small changes in the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review and based upon current professional standards of practice, the facility failed to follow facility policy and ensure catheter orders contained the diagnosis for catheter use, catheter size and the catheter balloon size, for one of three sampled residents who used indwelling urinary catheters (Resident #273). The census was 121 with 51 residents in certified beds. Review of the facility's physician orders policy, dated 4/26/18, showed: -Policy statement: Orders for medication and treatment will be consistent with principles of safe and effective order writing. All orders will be transcribed and followed as directed; -Recording Foley catheter (brand of indwelling urinary catheter, a flexible tube that is placed into the bladder to drain urine) orders: When recording orders for Foley catheters, specify the size of the catheter, size of the balloon (inflated to hold the catheter in the bladder) and diagnosis of catheter. Review of Resident #34's medical record, showed: -readmitted to the facility on [DATE]; -Cognitively intact; -Extensive staff assistance required with hygiene, transfers, toileting and mobility; -admitted with indwelling urinary catheter; -Diagnoses included stroke and neurogenic bladder (poor bladder control caused by a neurological condition). Review of the resident's care plan, dated 5/2/19, showed: -Problem: At risk for infection related to an indwelling urinary catheter; -Goal: The resident will remain free of urinary tract infection (UTI) during the period of catheterization; -Interventions: Change drainage bag per current policy, clean around catheter with soap and water, keep tubing below level of bladder and free of kinks or twists, record output per shift, report any sign of infection (temperature, pain, urine that looks cloudy, dark, or with blood), cover the Foley drainage bag with a dignity bag while in the bed and the wheelchair and encourage the resident to drink fluids on meal trays; -The care plan did not address the catheter use diagnoses. Review of the resident's readmission clinical note, dated 5/19/19 at 7:13 P.M., showed the resident readmitted to the facility from the hospital. Use 18 French (size) Foley catheter in place and draining clear, yellow urine. Review of the resident's electronic physician order sheet (ePOS), showed an order dated 5/27/19 to change the Foley catheter once monthly. The order did not specify the catheter size, no catheter use diagnosis or catheter balloon size. Review of the resident's June 2019, treatment administration record, showed an order dated 5/27/19 to change the Foley catheter once monthly. The order did not specify the catheter size, diagnosis or balloon size. Observation on 6/18/19 at 9:40 A.M., showed the resident with an indwelling urinary catheter draining to gravity. During an interview on 6/21/19 at 7:58 A.M., the Director of Nursing said all catheter orders should include the catheter size, diagnosis for use, balloon size and frequency of catheter changes. It is the nurse's responsibility to clarify orders upon admission. It is important to verify that catheter orders are complete to ensure that the catheter is changed correctly and for the correct diagnosis.

Based on observation and interview, the facility failed to store food in accordance with professional standards for food service safety, by failing to cover stored food and by failing to completely air-dry dishes before use. This had the potential to affect all residents who eat from the facility kitchen. The census was 121 with 51 in certified beds. 1. Observation on 6/18/19 at 3:21 P.M., showed a large wheeled metal storage rack with approximately six large trays filled with sliced fish, uncovered, located next to the walk in refrigerator. Two additional large metal storage racks filled with sliced zucchini and okra, uncovered, located next to the walk in refrigerator. Observation and interview on 6/19/19 at 2:13 P.M., showed a large wheeled metal storage rack with approximately six large trays filled with chopped potatoes, located in the rear of the kitchen, uncovered. Chef M said the potatoes were to be served around 4:30 P.M. Observation and interview on 6/19/19 at 2:20 P.M., showed inside the blast chiller/freezer (which allows food to cool quickly), a large pan of cooked lasagna, another pan of hash browns and a large pan of Salisbury steak, all uncovered. Chef M said staff do not cover the food in the blast chiller until it is removed, then the items are covered. These will go into the walk in refrigerator and be served tomorrow. Observation on 6/21/19 at 10:35 A.M., showed a large wheeled metal storage rack with two trays of fish, uncovered, located next to the hand washing station while staff washed their hands. During an interview on 6/21/19 at 10:46 A.M., the executive chef said food should to be covered, there is bacteria in the air and covering the food protects it from cross contamination. 2. Observation and interview on 6/19/19 at 2:16 P.M., showed stacked pans, with the inside of the pans dripping wet, next to the dish washing area. Chef M said the pans should be allowed to air dry, otherwise bacteria could grow. Observation and interview on 6/21/19 at 10:46 A.M., showed stacked pans, the inside of the pans and rims of the pans, visibly wet. The executive chef said pots and pans should be stacked dry because stacking them wet would allow for bacteria to grow. 3. On 6/21/19 at 10:46 A.M., a copy of the facility food storage and dishwashing/drying policy was requested. As of 6/26/19, none was provided.