**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to ensure one resident's (Resident #36) code status (if the resident wished to received cardiopulmonary resuscitation (CPR - a lifesaving technique that is used when someone's breathing or heartbeat has stopped) was consistent and accurate throughout the resident's medical record. The facility census was 60. Review showed the facility did not provide a policy regarding code status. 1. Review of Resident #36's face sheet showed the following information: -admission date of [DATE]; -Diagnoses included dementia (progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking), cerebral infarction (stroke), unstageable pressure ulcer (full-thickness pressure injuries in which the base is obscured by eschar (dry, dark scab) of left heel, and left knee osteoarthritis (degeneration of joint cartilage and the underlying bone); -Do not resuscitate (DNR - person has decided not to have CPR attempted on them if their heart or breathing stops); -On hospice services (program designed to make the process of dying as comfortable as possible for patients and their families). Review of the resident's physician order sheet, current as of [DATE], showed the following: -An order, dated [DATE], for full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive). Review of the resident's care plan, last reviewed [DATE], showed the following: -Resident on hospice services; -Resident chooses to be full code and plan long term care; -Staff should start CPR and call 911, in case of no pulse or no respirations. Review of the resident's nursing progress note, dated [DATE] showed the following: -Staff documented there was a care plan meeting on [DATE], at 11:25 A.M. The resident's family members were in attendance, along with facility staff and hospice provider. The family chose hospice on [DATE]. Observation of the resident's room door showed a name tag, along with a red dot on the tag. (The red tag indicated the resident wished to be a DNR.) During an interview on [DATE], at 8:30 A.M., Certified Nurse Aide (CNA) D said resident code status can be located on the resident's name tag at room door. A red dot indicated DNR code status and a green dot indicated full code status. The aide said that he/she believed it was also in electronic medical chart and the information should match. During an interview on [DATE], at 8:45 A.M., CNA I said that resident's code status was located on the resident room door name tags by a red or green sticker. The information was also located in the electronic medical record by their name and the information should match. During an interview on [DATE], at 10:35 A.M., Certified Medication Tech (CMT) J said that resident code status was located on the medication administration record and the face sheet. He/she said the information should match. During an interview on [DATE], at 11:05 A.M., Registered Nurse (RN) H said the following: -Resident code status was located on the resident door and in computer; -Code status was also in a code book at the nurses' station with a purple sheet if resident was a DNR; -Review of the book with the nurse showed that Resident #36 did not have a purple sheet in the book; -The nurse said that the resident had recently changed to hospice status; -The nurse said that the code status should match throughout chart. During an interview on [DATE], at 12:25 P.M., the Assistant Director of Nursing (ADON) said that code status was located on resident doors with a red or green dot. The red dot was for DNR and green dot was for full code. The information would also be on the resident's face sheet and on the physician order sheet. This information is printed when sending a resident out of the facility. The care plan will also indicate if the resident wishes for full code or DNR. The information should match throughout the records. During an interview on [DATE], at 2:05 P.M., the Administrator said resident code status was on resident doors by red or green dot, and on the staff computer kiosk with the resident names. There was also a book up front with all the face sheet with code sheet on the front of it. Code status would be noted on the physician orders. The Social Service Designee (SSD) checks all code status at least once week to make sure they are accurate. The information should match throughout chart.

Based on observation, record review, and interview, the facility failed to ensure residents were free of significant medication errors when staff attempted to provide one resident (Resident #27) with a double dose of medication during a random medication pass observation. The facility had a census of 60. Review of the facility policy titled Medication Administration, undated, showed the following: -Staff should read the label three times before administering medication: -First when comparing the label top the medication sheet; -Second when setting up the medication; -Third when preparing to administer the medication to the resident. 1. Review of Resident #27's face sheet showed the following: -admission date of 10/18/22; -Diagnoses included Parkinson's disease (disorder of the central nervous system that affects movement, often including tremors) with dyskinesia (abnormality or impairment of voluntary movement), dementia without behavioral disturbance, and drug induced akathisia (state of agitation, distress, and restlessness that is an occasional side-effect of antipsychotic and antidepressant drugs). Review of the resident's physician order sheet, current as of 02/01/24, showed the following: -An order, dated 07/10/20, to rush or alter mediations unless otherwise indicated; -An order, dated 11/22/23, for carbidopa/levodopa (used to treat Parkinson's) 25-100 milligram (mg), two tablets orally three times per day; Review of the resident's care plan, dated 11/17/23, showed the following: -Resident at risk for behaviors related to diagnosis of Parkinson's, dementia, depression, and anxiety; -Staff should administer medications as directed; -Staff should monitor for signs and symptoms of adverse effects. Observation on 01/31/24, at 11:20 A.M., of the medication pass showed the following: -Certified Medication Technician (CMT) J and Registered Nurse (RN) N were at the medication cart near the nursing station preparing medication administration; -The CMT had multiple empty medication cups that were labeled with resident names; -The CMT removed a medication card from the cart for Resident #27 and found the medication card to be empty; -The CMT and RN went to the medication room to the stat safe; -The CMT held the empty medication card with the pharmacy label; -The RN entered his/her access information into the stat safe; -The RN then entered the resident and the medication needed - carbidopa/levodopa (brand name Sinemet CR) 25-100 mg (milligram, dosage of medication); -The CMT and RN reviewed the medication card and noted it to say carbidopa/levodopa 25-100 mg, administer carbidopa/levodopa two tablets (50-100 mg) three times per day; -The stat safe drawer opened, the RN removed the appropriate medication box; -The RN removed four tablets of carbidopa/levodopa 25-100 mg and put into the medication cup; -The RN and CMT returned to the medication cart; -The CMT took a small plastic bag out of medication cart and stated that the resident's medications were to be crushed; -As the CMT began to pour the four tablets into the plastic bag, the state surveyor requested the CMT stop and review the orders again in the computer; -The CMT reviewed the orders again and said that his/her calculation was off and he/she should have only provide two tablets. During an interview on 02/01/24, at 10:35 A.M., CMT J said the following: -Staff should review the physician orders and the medication card when providing medications to residents; -Staff should double and triple check the orders and the medication administration record; -Medication errors should be reported the nurse and the Director of Nursing (DON); -Providing a double dose of carbidopa/levodopa would not be good for the resident. If a resident received too much medication, he/she would require increased monitoring and observation and staff would notify the physician. During an interview on 02/01/24, at 10:55 A.M., CMT K said the following: -Staff should review medication cards and medication orders multiple time when administering medications; -Medication should not be given as a double dose during medication administration; -A medication error should be reported immediately when staff become aware and staff would have to explain what occurred; -He/she do not know what the outcome would be if a resident received an overdose of any medication. During an interview on 02/01/24, at 11:05 A.M., Registered Nurse (RN) H said the following: -Staff should triple check the directions and dose on the medication cards and the electronic medication administration record before completing medication administration; -A a resident should not receive four tablets of a medication if the order was for two tablets. That would be a medication error; -Staff would report to the DON and the physician for any medication error. The resident would likely require increased monitoring. During an interview on 02/01/24, at 12:25 P.M., the Assistant Director of Nursing (ADON) said that staff should not provide residents with a double dosage of medication. Staff should be checking the orders to verify medication provided each time. Medication errors should be reported, doctors should be notified, and residents should be monitored or follow doctor new orders. During an interview on 02/01/24, at 2:05 P.M., the Administrator said that staff should follow physician orders for medication administration and should not give four tablets if the order was for two tablets. If a medication error occurs the staff should notify the DON or ADON and fill out the medication error form. Staff should contact the physician, chart the error, and provide extra monitoring of resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #15's face sheet (gives basic profile information) showed the following information: -admission date of 08/06/20; -Diagnoses included Alzheimer's disease (progressive disease that destroys memory and other important mental functions) and personal history of traumatic brain injury (TBI - Brain dysfunction caused by an outside force, usually a violent blow to the head). Review of the resident's annual MDS, dated [DATE], showed the following: -Severe cognitive deficit; -Required supervision or touching assistance with eating; -Resident received a mechanically altered diet. Review of the resident's care plan, last updated 09/18/23, showed the following: -The resident was unable to perform activities of daily living (ADLs - fundamental skills required to independently care for oneself); -The resident was not able to feed him/herself; -Staff should place a clothing protector on the resident and over the resident's lap to protect the clothing. Observation on 01/28/24, at 5:50 P.M., showed CNA L stood over the resident and gave him/her bites of pureed food. The resident sat in a Broda chair (a specialized type of wheelchair that assists in positioning and helps resolve seating issues such as slumping, sliding, poor lateral support and patient falls) with a clothing protector on. 3. Review of Resident #8's face sheet showed the following information: -admission date of 07/04/21; -Diagnoses included Parkinson's disease with dyskinesia (abnormality or impairment of voluntary movement), psychotic disorder (group of serious illnesses that affect the mind) with hallucinations, chronic obstructive pulmonary disease (COPD - group of lung diseases that block airflow and make it difficult to breathe), and Type 2 diabetes mellitus (a problem in the way the body regulates and uses sugar as a fuel). Review of the resident's annual MDS, dated [DATE], showed the following: -Severe cognitive deficit; -Resident received a mechanically altered diet; -Resident received a therapeutic diet. Review of the resident's care plan, last updated 11/28/23, showed the following: -The resident would continue to assist with care task completion to the extent possible, related to the disease process; -The resident was able to feed self with set up assist at meals; -The resident preferred someone to feed him/her most of the time; -Staff should allow plenty of time to eat the meal; -Staff should not allow the resident to feel rushed; -Staff should encourage meals in the dining room unless contraindicated. Observation on 01/29/24, at 12:20 P.M., showed Licensed Practical Nurse (LPN) M stood over the resident and gave him/her bites of pureed food. The resident sat in a Broda chair with a clothing protector on. Observation on 01/30/24, at 12:32 P.M., showed CNA I was stood over the resident and gave him/her bites of pureed food. The resident sat in a Broda chair with a clothing protector on. 4. During an interview on 02/01/24, at 8:30 A.M., CNA D said that staff should assist the resident with items at meals, including opening items. The CNA said that staff should be seated next to the resident and said that it was okay to stand over the resident during meals. During an interview on 02/01/24, at 8:45 A.M., CNA I said that generally staff should sit next to a resident to assist with meals. The CNA said if the resident was in a Broda chair he/she could not reach the resident, so he/she had to stand up to help. The CNA said that staff should try to remain at the resident's level when talking to or assisting a resident. During an interview on 02/01/24, at 10:35 A.M., CMT J said that he/she was usually seated when providing feeding assistance to residents at mealtime. He/she said that he/she was so short that sometimes he/she would have to stand to feed residents in Broda chairs. During an interview on 02/01/24, at 11:05 A.M., Registered Nurse (RN) H said that he/she was unsure if it mattered if staff were standing above a resident when feeding. He/she said that he/she liked to sit with the resident to keep eye contact. During an interview on 02/01/24, at 12:25 P.M., the Assistant Director of Nursing (ADON) said staff are not supposed to stand over resident when assisting with feeding. The ADON said that staff should sit and chat to make the resident have a more homelike environment. During an interview on 02/01/24, at 2:05 P.M., the Administrator said staff should not be standing over the residents when assisting with meals and should only be feeding or assisting one resident at time. 5. Review of Resident #43's face sheet showed the following information: -admission date of 08/17/23; -Diagnoses included cerebral infarction (stroke), hemiplegia and hemiparesis (paralysis on one side of the body) affecting left non-dominant side following cerebral infarction, congestive heart failure (CHF - a condition in which the heart can't pump enough blood to the body's other organs), and generalized anxiety disorder. Review of the resident's care plan, last updated 11/28/23, showed the following: -Resident had an ADL self-deficit; -Staff will assist the resident with ADLs as needed; -Resident at risk for behavioral episodes; -Staff should report any behavior changes and/or verbal behaviors to the charge nurse for assistance. Review of the resident's significant change in status MDS, dated [DATE], showed the following: -Cognitively intact; -Resident has almost constant pain; -Resident has physical and verbal behavioral symptoms directed to others daily. Review of the facility Grievance/Complaint Report, dated 12/21/23, showed the following: -Resident and resident representative initiated the complaint; -Housekeeper E came into Resident #43's room and he/she was taking a piss. The housekeeper told the resident to cover it up. The resident told him/her to pull the curtain which the staff did and called the resident little fucking asshole. The resident told the staff to look in the mirror. The staff was always hateful when coming into the resident's room. Then the staff threatened the resident saying, I'll go get the Administrator on your ass; -The Administrator took a statement from Housekeeper E via telephone with Social Service Director (SSD) and the Housekeeping Supervisor present as witnesses; -Education to staff and discipline write-up completed; -Housekeeper E was given a write-up and educated on abuse of residents, including verbal, physical, and emotional abuse. Staff notified the resident of the results in one-to-one conversation and notified resident's representative phone. During an interview on 01/30/23, at 11:15 A.M., the resident said that only one staff member had talked to him/her without respect by yelling and cursing at him/her. He/she said that the Administrator took care of it and there were no other problems. During an interview on 02/01/24, at 11:20 A.M., Housekeeper E said that he/she received abuse and neglect training at least once per year, and this included resident right to be treated with respect and dignity. The staff said that he/she knocked on the resident's door one day in December and after entering the room he/she started coughing. The housekeeper had recently recovered from being ill, but had a continued lingering cough. The resident said, Don't bring that shit in to me. The staff said he/she told the resident that he/she was not ill and only had a cough. The resident then said, pull that curtain closed bitch. The staff then said he/she called the resident an asshole. Housekeeper E said that he/she should not have cursed at the resident. During an interview on 02/01/24, at 8:30 A.M., CNA D said that he/she received training on hire that included the resident rights to be treated with dignity and respect. He/she said it was not okay for staff to curse or yell at residents. During an interview on 02/01/24, at 8:55 A.M., CNA I said he/she received abuse and neglect training, which included resident rights to be treated with dignity and respect. He/she said it was not okay to talk mean or yell at residents, and it was not okay to curse at residents. He/she would notify the charge nurse and DON of any concerns. During an interview on 02/01/24, at 10:35 A.M., CMT J said residents have the right to be treated with dignity and respect, and staff should not curse or yell at residents. During an interview on 02/01/24, at 10:45 A.M., Housekeeper G said that staff should not cuss at a resident and staff should notify the supervisor if witness any incident. During an interview on 02/01/24, at 11:05 A.M., RN H said that he/she had received resident right training and in-services, that included the right to be treated with respect. Staff should not cuss or speak inappropriately to residents. During an interview on 02/01/24, at 11:10 A.M., Housekeeper F said he/she received training on hire that included treating resident with respect and dignity. He/she said that if he/she heard anyone yell or curse at a resident, he/she would go to the supervisor. During an interview on 02/01/24, at 12:25 P.M., the ADON said that the facility reviews abuse and neglect in-service every February and more often any time there is an incident. The training includes resident rights to be treated with dignity and respect. He/she said that staff should report any allegation of staff not treating residents with respect to the supervisors. During an interview on 02/01/24, at 2:05 P.M., the Administrator said that on 12/21/23 there was an incident with a housekeeper cussing at a resident. This occurred during the holiday weekend. She said that she was notified on Monday 12/25/23 by finding a note on her desk that evening when she came into the facility. She had to wait until the following day to talk to the supervisors to see if anyone had done anything about the incident. At that time a full investigation was started, and the resident's representative was notified. During the interview with Housekeeper E, he/she said that Resident #43 was rude and yelling at him/her. Housekeeper E said that the resident called him/her a grumpy old bitch and he/she called the resident an asshole. The employee was given a first and final warning, and educated on resident rights, as well as education on de-escalating situation with a resident in the nursing home. Based on observation, interview, and record review, the facility failed to ensure staff treated each resident with respect and dignity when staff left two residents (Residents #42 and #27) exposed during transfer and/or incontinent care, stood over two residents (Residents #15 and #8) while assisting the residents to eat, and cursed at one resident (Resident #43). The facility census was 60. Review of a facility policy entitled Resident Rights, undated, showed the following: -It is the purpose of this facility to meet the Federal and State mandate in respect to resident rights. The resident has a right to a dignified existence. A facility must protect the rights of each resident; -Rights include privacy and respect. Review of a facility policy entitled Perineal Care, undated, showed to provide privacy for the resident. Review of the facility policy, Feeding the Resident (Dependent Eating), undated, showed the following: -Purpose to assist the resident with feeding and provide adequate nutrition; -Do not discuss unpleasant subjects while resident is eating; -Never make the resident feel that the meal must be hurried, but that the experience is pleasant; -Sit so you (staff) are at the same level as the resident when possible. 1. Review of Resident #42's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 12/02/23, showed the following information: -admission date of 10/30/19; -Diagnoses included dementia, anxiety, and high blood pressure; -Severely impaired cognition; -Incontinent of bowel and bladder. Review of Resident #27's annual MDS, dated [DATE], showed the following information: -admission date of 10/18/22; -Diagnoses included dementia, Parkinson's disease (disorder of the central nervous system that affects movement), anxiety, depression, high blood pressure, and gastroesophageal reflux disease (GERD - stomach acid backs up into the esophagus); -Moderately impaired cognition; -Incontinent of bowel and bladder. Observation on 01/29/24, at 1:14 P.M., showed Nurse Aide (NA) A and Certified Nurse Aide (CNA) B entered the room of Residents #42 and #27 and closed the residents' door. The NA and CNA used a Hoyer (mechanical) lift to transfer Resident #42 from a Broda chair (specialty reclining wheelchair) to his/her bed. The privacy curtain between the roommates remained open. Resident #27 sat in his/her wheelchair facing Resident #42. NA A and CNA B lowered Resident #42's pants and rolled him/her to his/her right side facing the wall. Without closing the privacy curtain, CNA B removed the resident's wet brief and cleaned the buttocks and coccyx (tailbone) area of feces smear. NA A applied barrier cream to the buttocks and coccyx before covering the resident. Observation on 01/30/24, at 1:26 P.M., showed the room door remained closed, but the privacy curtain between the roommates remained open. NA A and CNA B used a sit-to-stand mechanical lift to raise Resident #27 from his/her wheelchair. With the resident suspended in the lift and facing the door and roommate, NA A lowered the resident's pants and removed his/her wet brief. The resident was left exposed from waist to knees for two to three minutes while the NA retrieved supplies. NA A then used wipes to clean the resident's perineal area and buttocks. NA A and CNA B then turned the lift around and lowered the resident onto his/her bed before covering him/her. During an interview on 02/01/24, at 8:30 A.M., CNA D said staff should always close the room door and pull the privacy curtain closed when provided personal cares for a resident to provide privacy. He/she said it was not okay to not close curtain if resident has roommate during cares. During an interview on 02/01/24, at 8:55 A.M., CNA I said that staff should shut the room door and pull curtain for privacy when completed personal hygiene cares for a resident. He/she said it was not okay to keep curtain open if resident has roommate. During an interview on 02/01/24, at 10:35 A.M., Certified Medication Tech (CMT) J said that staff should always ensure that the room door and privacy curtain was closed for privacy during resident personal cares. He/she said it would not be okay to leave the curtain open, especially if there was a roommate in room. During an interview on 02/01/24, at 10:55 A.M., CMT K said staff should close the door and pull the privacy curtain when providing care for a resident. The privacy curtain should not remain open when there is a roommate. During an interview on 02/01/24, at 11:05 A.M., Registered Nurse (RN) H staff should close the room door and pull the privacy curtain when assisting the resident with personal cares. Staff should not leave the curtain open if the resident has a roommate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Review of Resident #'2's face sheet showed the following: -admission date of 10/24/23; -Diagnoses included Parkinsonism (umbrella term that refers to brain conditions that cause slowed movements, rigidity (stiffness) and tremors), bipolar disorder (mental health condition that causes extreme mood swings), and dementia (progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking). Review of the resident's Physician Order Sheet (POS), current as of 02/01/24, showed the following: -An order, dated 10/23/23, for carbidopa/levodopa (used to treat Parkinson symptoms) 25-100 milligram (mg), administer one tablet three times per day; -An order, dated 10/23/23, for gabapentin (used to treat nerve pain) 100 mg, administer one capsule three times per day; -An order, dated 10/24/23, for ropinirole (used treat the symptoms of Parkinson's disease and restless legs syndrome) one mg, administer one tablet three times per day; -An order, dated 02/01/24, for acetaminophen (used to relieve mild or chronic pain and to reduce fever) 325 mg, administer two tabs three times per day; -An order, dated 02/01/24, for lorazepam (used to treat anxiety) 0.5 mg, administer one tablet three times per day. Observation on 01/31/24, at 10:45 A.M., showed Certified Medication Tech (CMT) J and Registered Nurse (RN) N preparing medications at the medication cart near the nurses' station: -CMT J removed the medication cards for the resident from the medication cart; -CMT reviewed the orders and began popping medications out of the card and into the cup; -The CMT popped the gabapentin 100 mg pill into his/her hand and then put the pill into the medication cup; -The CMT completed putting the medications into the cup, including lorazepam, ropinirole, carbidopa/levodopa, and acetaminophen; -The CMT handed the cup to RN N; -RN N attempted to deliver the medications to the resident near the nurses' desk; -The resident refused the medications and said that he/she would only take the medication for Parkinson's; -The RN returned the medication cup to the CMT and the CMT poured the pills out into his/her bare hand without completing hand hygiene; -The CMT then removed the carbidopa/levodopa pill with his/her fingers from his/her hand and put into a new medication cup. -He/she then put the remaining tablets into the medication cup and put into the medication cart drawer to be disposed of later; -The resident took the medication. During an interview on 02/01/24, at 10:35 A.M., CMT J said the following: -Staff should not touch pills when preparing medications, the medication should be popped into a medication cup; -If a resident refused a medication, the staff should put away the medications to be disposed of properly and notify the charge nurse;. -He/she said that he/she should probably have put on a glove to touch the pills when the resident only wanted one of the prepared pills; -He/she said that he/she sanitizes the medication cart before every shift, so if a pill fell on the cart, he/she would pick it up and put into the medication cup. During an interview on 02/01/24, at 10:55 A.M., CMT K said that staff should complete hand hygiene between every resident when administering medications. He/she said that medications should be popped into medication cup and staff should not touch the pills with their bare hands. During an interview on 02/01/24, at 11:05 A.M., RN H said that staff should not pop medications into hands. Staff should put on a glove if need to touch any pills. Hand hygiene should be completed between each resident. During an interview on 02/01/24, at 12:25 P.M., Assistant Director of Nursing (ADON) said that staff should complete hand hygiene between each resident when administering medications. Staff should not touch any pills with their bare hands. Staff should not pour medications into their bare hand and pick out the one pill the resident wanted. During an interview on 02/01/24, at 2:05 P.M., Administrator said that staff should complete hand hygiene in between resident with medication pass. Staff should not touch the pills with their hands. 2. Review of Resident #8's face sheet showed the following: -Most recent re-admission on [DATE]; -Diagnoses included open wound on right foot and open wound on left lower leg. Review of the resident's POS, current as of 02/01/24, showed the following: -An order, dated 01/25/24, for staff to clean the left ankle with wound cleanser, apply skin prep (barrier wipe to create an invisible layer on your skin to protect it from adhesive), apply gentamicin (used to treat skin infections), and optifoam (adhesive foam dressing that is waterproof and has a high fluid-handling capacity). Staff to wrap with kerlix (bandage roll) and secure with tape. Staff to change daily and as needed. Observation on 01/30/24, at 1:10 P.M., showed the following: -RN C prepared supplies for wound care; -The RN entered the resident's room with the wound cleanser bottle and resident's antibiotic gentamicin tube, dry gauze and two skin prep pads; -The resident was seated in the Broda chair (a specialized type of wheelchair that assists in positioning and helps resolve seating issues such as slumping, sliding, poor lateral support and patient falls) in room; -The nurse placed the supplies on the top of the resident's dresser with no clean barrier; -The nurse removed protective the boot and put it on the resident's bed. The nurse then took off the sock on the left foot to show a dressing dated 01/29/24; -The nurse applied gloves without performing no hand hygiene; -The nurse wiped the scissors with an alcohol wipe and removed the dressing using the scissors. The nurse then removed the optifoam cover from wound; -Without changing gloves or completing hand hygiene, the nurse picked up the wound cleanser bottle and sprayed onto dry gauze pads. The nurse then wiped the wound and entire foot with the wound cleanser gauze; -The nurse removed his/her gloves and disposed of the gloves. The nurse donned new gloves without completing hand hygiene; -The nurse opened the gentamicin ointment tube and squeezed it onto the optifoam dressing. The nurse then applied the dressing to the open wound; -He/she opened the skin prep wipe and wiped entire left ankle, heel, foot, and toes with same skin prep; -He/she used a second skin prep wipe and wiped entire foot with wipe a second time; -The nurse removed his/her left glove to return to nurse cart at room door and obtain an ABD (highly absorbent gauze) pad; -He/she entered room and removed his/her right glove; -Without completing hand hygiene, the nurse opened the ABD pad package, applied it to leg and covered with kerlix. The nurse applied tape and dated the dressing; -The nurse re-applied the resident's sock; -Without completing hand hygiene the nurse removed the resident's right sock and inspected resident's foot, reapplied sock; -The nurse removed the supplies and washed hands at sink; -The nurse left the resident's room and put the wound cleanser on the top of the cart and the ointment into the cart without cleaning the containers. 3. Review of Resident #37's face sheet showed the following: -admission date of 04/25/23; -Diagnoses included superficial (shallow) injury of left lower leg and laceration (cut or skin wound) of right lower leg. Review of the care plan, last reviewed on 11/28/23, showed the following: -Resident had a wound on the left lower leg; -The goal was for the wound was to heal without signs and symptoms of infection; -Staff should complete treatments as ordered; -Wound care clinic to be involved as ordered. Review of the resident's physician orders, current as of 02/01/24, showed the following: -An order, dated 01/03/24, for skin prep on right lower extremity once per day. -An order, dated 01/29/24, for wound care on left lower extremity. Staff to cleanse with Pure & Clean (brand name of a wound cleanser), blot dry, apply collagen wound dressing (protein dressing used to encourage wound healing), cover with ABD, wrap with kerlix, secure with tape, and change every other day and as needed for soiling; Observation on 01/31/24, at 8:55 A.M., showed the following: -RN H applied hand sanitizer, applied gloves, put wound cleanser on dry gauze, and entered the resident's room with supplies; -The nurse put the supplies on the residents bedside table on a clean paper towel. -The nurse cut the gauze wrap off the resident's left lower leg. The dressing was dated 01/29/24; -The nurse removed soiled dressing and placed it in trash bag; -The nurse applied wound cleanser gauze to remove the stuck on optifoam on the wound bed; -The nurse removed his/her gloves and without completing hand hygiene and applied new gloves; -The nurse cut the collagen to the wound size and placed it on the wound bed. He/she then applied an ABD pad, wrapped with Kerlix, secured the wrap with tape, and dated the dressing 01/31/24; -Without removing his/her gloves or completing hand hygiene, the nurse moved to right leg and applied skin prep to two areas of dried unopened wounds; -The nurse disposed of supplies into trash bag and removed gloves; -The nurse washed his/her hands at the sink and left the room. 4. Review of Resident #11's face sheet showed the following: -re-admission to the facility on [DATE]; -Diagnoses included superficial injury of right thigh. Review of the resident's POS, current as of 02/01/24, showed the following: -An order, dated 01/11/24, for nystatin ointment (antibiotic used to treat fungal infections) 100,000 unit/gram. Mix with A&D (used as a moisturizer to treat or prevent dry, rough, scaly, itchy skin and minor skin irritations) and Zinc cream (used to treat and prevent diaper rash and other minor skin irritation). Staff to apply to left and right inner thigh wounds with incontinence (lack of voluntary control over urination and defecation) cares. -An order, dated 01/28/24, to cleanse posterior (back) left thigh with wound cleanser, apply optifoam to open area, and cover with border gauze; -An order, dated 01/28/24, to cleanse right posterior thigh with wound cleanser, apply optifoam to open area and cover with border gauze; Review of the resident's care plan, dated 01/28/24, showed the following: -Resident currently had a pressure ulcer/wound; -The goal was for the wound to heal without signs and symptoms of infection; -Staff should complete treatments as ordered; -Wound clinic to be involved in treatment as ordered. Observation on 01/31/24, at 9:30 A.M., showed the following: -RN H applied hand sanitizer and prepared wound care supplies at the nurse cart. The nurse sprayed wound cleanser on dry gauze; -RN H and CNA D entered the resident's room; -The nurse brought the wound cleanser dry gauze to the resident room; -The nystatin powder and zinc oxide tube were on the resident's shelf in the room; -The nurse put on gloves and mixed the nystatin powder with zinc oxide in a mediation cup to make a paste; -The staff assisted the resident to roll to his/her right side; -The nurse placed the wound care supplies on the resident's bed; -The nurse wiped the back side of the upper left thigh with the gauze with wound cleanser, the wound area was bleeding; -The nurse wiped the right upper thigh area with wound cleanser on a gauze pad. The area was open with no drainage; -The nurse wiped fecal matter off the resident's buttock with the gauze and put the gauze on the bed pad. The nurse continued wiping the wounds with wound cleanser on a gauze pad. The nurse did not complete a glove change or hand hygiene; -The nurse applied the zinc nystatin paste with a wooden applicator with the same gloved hands; -The nurse touched the resident's left hip area with his/her right gloved hand while applying paste to the wounds with left gloved hand; -The nurse wiped his/her soiled gloved left hand on the bed pad; -The nurse rolled the soiled pad under the resident and removed his/her gloves; -The nurse applied new gloves with no hand hygiene; -The nurse put clean bed pad under resident; -Staff then assisted the resident to roll to his/her left side; -The CNA pulled the soiled bed pad out from under the resident and pulled through the clean pad; -Staff then assisted the resident to roll to his/her right side; -The CNA went to the bathroom, removed his/her glove from the right hand and obtained a trash bag then put on a new glove on the right hand without completing hand hygiene; -The aide picked up the soiled laundry and put into the trash bag; -The nurse pulled the lift sheet through and assisted the resident to roll to his/her back; -The nurse and the aide pulled the resident up in the bed, to the head of bed with the same gloved hands; -The staff covered resident, ensured had call light and bed control in reach; -The nurse put a pillow under residents left buttock area for pressure relief; -The nurse removed his/her gloves and washed hands at sink; -The CNA cleaned up the room and removed gloves and washed hands at the sink. 5. During an interview on 02/01/24, at 8:30 A.M., CNA D said staff should complete hand hygiene before care and after resident cares. Depending on what the staff was doing, staff would only change gloves if soiled during cares. During an interview on 02/01/24, 8:45 A.M., CNA I said staff should complete hand hygiene before entering any resident room, in between glove changes, when visibly soiled, and after completed with resident cares. During an interview on 02/01/24, at 10:35 A.M., CMT J said that staff should be completing hand hygiene between every dirty and clean process, when assisting with resident meals, after every glove change, and before starting the shift. During an interview on 01/31/24, at 10:00 A.M., RN H said the following: -He/she washed hands before and after wound care; -He/she liked to change gloves between clean and dirty; -It was really not convenient to use hand sanitizer between glove changes, but it probably would be best practice. During an interview on 02/01/24, at 11:05 A.M., RN H said that staff should complete hand hygiene before and after every resident care, including wound care, and between glove changes, and if visibly soiled. During an interview on 02/01/24, at 12:25 P.M., Assistant Director of Nursing (ADON) said staff should complete hand hygiene before, during, and after wound care. Staff should always wash hands or use hand sanitizer between glove changes, and gloves should be change between any dirty to clean process. Staff should use hand sanitizer between each resident. During an interview on 02/01/24, at 2:05 P.M., the Administrator said staff should use hand sanitizer or wash hands before starting a resident care and after finished. Depending on the type of care, the staff should use hand sanitizer in between glove changes, and they should change gloves between the dirty to clean process. Staff should complete hand hygiene before wound care, and between dirty and clean process of glove changes. Based on observation, interview, and record review, the facility failed to maintain an effective infection prevention and control program when staff administered medication to one resident (Resident #2) after touching the medication with bare hands and placing the medication directly on top of the medication cart, and when staff failed to complete routine hand hygiene during and after wound care for three residents (Resident #8, Resident #37, and Resident #11). The facility census was 60. Review of the Centers for Disease Control and Prevention's (CDC) Hand Hygiene Guidance, dated 01/30/20, showed the following in reference to healthcare settings: -Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: immediately before touching a patient; before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices; before moving from work on a soiled body site to a clean body site on the same patient; after touching a patient or the patient ' s immediate environment; after contact with blood, body fluids, or contaminated surfaces; and immediately after glove removal; -Ensure that healthcare personnel perform hand hygiene with soap and water when hands are visibly soiled. Review of the facility policy entitled Wound Care and Treatment, undated, showed the following: -Care must be taken to prevent contamination of the supplies and surfaces used in wound care; -The treatment cart should be left in the hall and locked. Move the cart to the resident's room and park it outside the room. Remove the supplies needed and re-lock the cart; -Medications should be for one designated resident only except large volume liquids (i.e., saline). These may be poured into a cup to take to the bedside; -Set up the supplies on a clean surface. Cover the surface with a clean, impervious barrier before putting the supplies down; -Hand washing must be done as outlined in the guidelines; -Cut the tape with clean scissors; -Put gloves on; -Remove the soiled dressing and place in the trash bag. Place the soiled scissors on one corner of setup, not touching any other supplies; -Remove the gloves and discard in the bag; -Clean scissors with 60 seconds of contact with alcohol and place on a clean corner of setup; -Wash hands and put on clean gloves; -Clean the wound according to the order; -Place soiled gauze in the trash bag; -Remove gloves, place in trash bag, and put on clean pair of gloves; -Apply clean dressing as ordered; -Wash hands.

Based on observation, interview and record review, the facility failed to keep food safe from potential contamination or bacterial growth when staff stacked wet dishware inside one another, trapping moisture, which could potentially contaminate food served from those items. The facility census was 60. Review of the facility's policy titled General Dish Room Sanitation, by Nutrition and Dining Services Manual, dated April 2011, showed the following information: -All items are to be air dried; -No moisture can be found on any stacked item. Review of the 1999 Food Code, issued by the Food and Drug Administration, showed the following information: -After cleaning and sanitizing, equipment and utensils shall be air-dried or used after adequate draining before contact with food; -Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. 1. Observations on 01/28/24, beginning at 9:57 A.M., of the kitchen showed 48 juice cups with water droplets trapped inside, upside down, stacked on top of one another on trays. Observations on 01/30/24, beginning at 12:20 P.M., of the kitchen showed the following: -There were 41 juice cups with water droplets trapped inside, upside down on top of each other, stacked on trays; -Three clear, square measuring bowls with water droplets trapped inside, upside down, stacked trapping the moisture. Observation on 01/31/24, beginning at 12:30 P.M., showed the following items stacked, and/or placed upside down on one another, not allowing for air flow and keeping and trapping moisture: -102 clear juice cups; -Two small round clear measuring bowls; -Five plastic bowls; -Nine plastic plates; -Three large metal baking bins from the steam table -One metal cup with lid During an interview on 02/01/24, at 11:58 A.M., Dietary Aide P said he/she knows not to put dishes away wet, but thinks the kitchen staff still needs to be educated about this. During an interview on 02/01/24, at 12:18 A.M., Dietary Aide Q said he/she has not been trained on how to stack the dishes once clean. During an interview on 02/01/24, at 11:58 A.M., the Dietary Manager said the following: -He/she knows that dishes cannot be stacked or placed upside down if they still have moisture in them; -He/she is aware of the fact that bacteria can possibly grow if the dishes are not air dried. During an interview on 02/01/24, at 2:08 P.M., the Administrator said all items should be left out until done being air dried.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standard and the resident's choice when the facility failed to obtain complete orders for restorative therapy, failed update care plans regarding specific restorative therapy plans, and failed to consistently provide restorative therapy for six residents (Residents #3, #4, #6, #7, #8, and #10). The facility census was 71. Review of the facility's policy titled The Restorative Nursing (RNA) Program, undated, showed the following: -The restorative nursing program is an integral part of maximizing the daily restorative care process for the residents; -It is the purpose of this facility see that each resident receives and the facility provides the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care; -The RNA program is a means of providing restorative treatment to those residents identified as having a change in function that has stabilized and is no longer in need of skilled intervention or residents who exhibit a potential for decline; -It is the entire staff's responsibility to prevent deterioration and further functional loss of each resident tin the facility; -Clear lines of authority, expectations, and responsibilities are necessary for implementation of the RNA program; -Referrals to the RNA program may be made by nursing, physical therapy (PT), occupational therapy (OT), speech therapy (ST), and physicians, as well as through the Minimum Data Set (MDS - a federally mandated assessment tool to be completed by facility staff) process, certified nursing assistant (CNA), and family/resident input; -Upon assessment by nursing, PT, OT, ST, the referral to RNA is made; -The nurse or therapist initiating the referral transfers the assessment information to the Restorative Nursing Treatment Plan; -Distribute the form to the licensed supervising nurse and RNA with a copy to be kept by referring therapist; -The Care Plan Coordinator will make the entry into the Care Plan with input from the RNA. The Care Plan must include the problem, need and/or concern of the resident, measurable and time limited goal(s) to be reached, and the approach to be taken; -RNA initiates treatment and documentation per facility protocol; -Criteria for resident entry to, movement within, and discharge from the RNA program must be clearly established; -Residents are discharged from the restorative program when certain criteria/guidelines are demonstrated; -A mechanism for monitoring and on-going evaluation of the RNA programs must be established; -Repeated assessment through MDS, nursing assessments, therapist screens, etc., will assist in determining if and when certain criteria are met. Nursing will be responsible for final determination. 1. Review of Resident #3's face sheet showed the following: -admission date of 03/31/22; -Diagnoses included dementia, anxiety, and depression. Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 12/29/22, showed the following: -Independent with bed mobility, toileting, transfers, and walking; -No indication regarding functional rehab potential. Review of the facility's restorative therapy participants, not dated, showed the resident received restorative therapy assistance with ambulation twice a week (no start date indicated). Review of the resident's nurses' notes, dated 02/24/23, showed the resident on restorative therapy for ambulation. Review of the resident's restorative therapy log, dated 02/01/23 to 02/28/23, showed on 02/14/23, 02/21/23, and 02/22/23, staff documented the resident walked 15 minutes. Review of restorative therapy log, dated 03/01/23 to 03/10/23, showed on 03/03/23, 03/08/23, 03/09/23, and 03/10/23, staff documented the resident walked 15 minutes. Review of the resident's care plan, dated 03/10/23, showed the following: -PT/OT/ST as ordered; -Implement exercise program that targets strength, gait, and balance. (Staff did not care plan regarding a specific restorative plan.) Review of restorative therapy log, dated 03/11/23 to 03/21/23, showed staff did not document regarding restorative therapy data recorded from 03/11/23 to 03/31/23. Review of the therapy referral log showed the following: -On 03/22/23, therapy staff requested an evaluation due to decline in mobility; -On 03/23/23, the facility Interdisciplinary Team (IDT) denied the therapy request as the resident's fall risk status had not changed and the resident participates in restorative therapy. Review of the resident's annual MDS, dated [DATE], showed the following: -Supervision with bed mobility, toileting, transfers, and walking; -No indication regarding functional rehab potential. Review of the resident's Physicians' Orders Sheet (POS), current as off 05/23/24, showed a physician's order, dated 03/31/22, for PT and OT to evaluate and treat as needed. The order did not have an end date. There were no orders related to restorative program. Record review of restorative therapy log dated 04/01/23 to 04/30/23 showed no restorative therapy data recorded. Record review of restorative therapy log dated 05/01/23 to 05/24/23, showed no restorative therapy data recorded. During an interview on 05/23/23, at 2:30 P.M., the DOR said the following: -The resident received therapy from 03/31/22 to 05/4/22; -Therapy staff observed the resident declining; -On 03/22/23, therapy fill out a therapy evaluation request; -On 05/23/23, the IDT denied the request as the resident has always been a fall risk and nothing has changed. During an interview on 05/24/23, at 10:30 A.M., the resident said he/she does not receive any type of therapy. During an interview on 05/24/23, at 11:11 A.M., the physician said the following: -He/she has not received a request for a therapy evaluation for the resident; -The resident should not be denied a therapy evaluation, because he/she has always been a fall risk. During an interview on 05/24/23, at 11:20 A.M., CNA A said the resident walks bent over with his/her walker. CNA is fearful the resident could fall. During an interview on 05/24/23, at 11:34 A.M., CNA B said he/she is unsure if the resident receives therapy or restorative therapy. CNA B said the resident leans when walking and is a fall risk. During an interview on 05/24/23, at 11:45 A.M., CMT C said the resident scares him/her when walking. He/she is a fall risk. The resident does not receive any therapy. During an interview on 05/24/23, at 3:28 P.M., the Director of Nursing (DON) said the following: -The resident has Parkinson's Disease (a disorder of the central nervous system that affects movement, often including tremors); -No falls documented in the last 6 months; -Therapy recommended the resident have an evaluation; -The resident only needs to be reminded by staff to stand up straight when using his/her walker; -Therapy is not necessary as the resident just needs to be prompted; -The resident receives restorative therapy. During an interview on 05/24/23, at 4:30 P.M., the Administrator said that therapy observed the resident using his walker inappropriately. The resident constantly needs re-education/reminders on proper walker usage. The resident would not benefit from treatment and currently receives restorative therapy. 2. Review of Resident #4's face sheet showed the following: -admission date of 05/05/19; -Diagnoses included dementia, unsteadiness on feet, repeated falls, difficulty in walking, and muscle weakness. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Extensive assistance from staff with bed mobility, toileting, transfers, walking in room, and in corridor; -No indication regarding functional rehab potential. Review of the resident's therapy referral log showed the following: -On 04/05/23, the special care unit (SCU) staff referred the resident for an evaluation due to a decline when performing transfers; -On 04/06/23, the facility Interdisciplinary Team (IDT) denied the therapy request stating the resident could participate in restorative therapy. Record review of the resident's annual MDS, dated [DATE], showed the following: -Extensive assistance from staff with bed mobility, toileting, and transfers; -No walking occurred in room or corridor during prior 7 days; -No indication regarding functional rehab potential. Record review of the resident's care plan, dated 04/28/23, showed the following: -Consider PT consult for conditioning and wheelchair assessment; -Resident is able to transfer self and ambulate short distances. Resident unsteady, but able to stabilize. Notify charge nurse of changes in level of assistance needed; -Therapy as per physician orders with quarterly and PRN (as needed) screenings by therapist; -Restorative plan as ordered. (Staff did not care plan specifics regarding the restorative program.) Review of the facility's restorative therapy participants, not dated, did not show resident receiving restorative therapy. Review of the resident's POS, current as of 05/24/23, did not reflect any orders for PT/OT. During an interview on 05/23/23, at 2:30 P.M., the DOR said the following: -Staff from the SCU referred the resident to therapy due to a decline in the ability to stand for transfers; -On 04/05/23, therapy filled out a therapy evaluation request; -On 04/06/23, the IDT denied the request as they felt restorative therapy could address the issue; -The DOR is unsure if the resident received restorative therapy. During an interview on 05/24/23, at 10:34 A.M., the NP said he/she did not receive a request for a therapy order for the resident. If staff or therapy believes a resident would benefit from treatment, he/she will write an order for a therapy evaluation. The NP or the physician should have been notified if the the resident requested therapy. During an interview on 05/24/23, at 12:00 P.M., RNA D said the resident no longer receives restorative therapy. During an interview on 05/24/23, at 3:28 P.M., the DON said the following: -The resident was referred to therapy because the DOR said the resident was not transferring; -Nursing staff did not report any concerns regarding transfers to the DON; -The DON did not observe a decline and observed the resident transfer themselves; -The resident did not receive restorative therapy because the DOR would not write out a restorative program for the resident; -The DON believes he/she contacted the physician about the request for a therapy evaluation, and the physician said to do what the DON deemed appropriate. During an interview on 05/24/23, at 4:30 P.M., the Administrator said the resident wanted to walk again, but hadn't walked in a year. Restorative was working with the resident with strength and standing. The Administrator is unsure if staff contacted the physician in regard to the request for a therapy evaluation. 3. Review of Resident #6's face sheet showed the following: -admission date of 06/15/20; -Diagnoses included Alzheimer's disease, major depressive disorder, anxiety disorder, and muscle weakness. Review of the facility's restorative therapy participants, not dated, showed resident to received restorative therapy assistance with ambulation twice a week (no start date indicated). Review of the resident's nurse's notes, dated 02/09/23, showed resident on restorative nursing for ambulation. Review of resident's restorative therapy log, dated 02/01/23 to 02/28/23, showed resident received therapy 15 minutes of ambulation therapy on 02/21/23 and 02/22/23. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Extensive assistance from staff with bed mobility, toileting, and transfers; -Extensive assistance from staff with walking in room or corridor during prior seven days; -No indication regarding functional rehab potential. Review of the resident's restorative therapy log, dated 03/01/23 to 03/08/23, showed resident received 15 minutes of ambulation therapy on 03/03/23. Review of the resident's care plan, dated 03/08/23, showed the following: -Resident at risk for falls; -Therapy as per physician orders with quarterly and as needed screenings by therapist. (Staff did not care plan regarding the restorative program.) Review of the resident's restorative therapy log, dated 03/09/23 to 03/31/23, showed resident received 15 minutes of ambulation therapy on 03/09/23 and 03/10/23. Review of the resident's nurse's notes, dated 03/10/23, showed resident on restorative therapy for ambulation. Resident doing well, will continue to monitor. Review of the resident's restorative therapy log, dated 03/01/23 to 03/31/23, showed resident received 15 minutes of ambulation therapy on the following dates: -On 03/13/23; -On 03/14/23; -On 03/17/23; -On 03/22/23; -On 03/23/23; -On 03/24/23. Review of the resident's restorative therapy log, dated 04/01/23 to 04/30/23, showed resident received 15 minutes of ambulation therapy on the following dates: -On 04/11/23; -On 04/13/23; -On 04/14/23; -On 04/18/23; -On 04/19/23; -On 04/21/23. Review of the resident's nurse's note, dated 04/28/23, showed the resident on restorative therapy for ambulation. Review of the resident's restorative therapy log, dated 05/01/23 to 05/24/23, showed no restorative therapy data recorded. Review of the resident's POS, current as of 05/34/23, showed it did not reflect any orders for therapy. During an interview on 5/24/23, at 1:00 P.M., CNA F said he/she has not observed a restorative aide work with the resident on ambulation. 4. Review of Resident #7's face sheet showed the following: -admission date of 04/21/20; -Diagnoses included dementia, unsteadiness on feet, Alzheimer's disease, and major depressive disorder. Review of the resident's POS, current as of 05/24/23, showed a physician's order, dated 07/21/22, for PT and OT to evaluate and treat the resident as needed. The order did not have an end date. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Extensive assistance from staff with bed mobility, toileting, transfers, walking in room and in corridor; -No indication regarding functional rehab potential. Review of the facility's restorative therapy participants, not dated, showed resident to receive restorative therapy assistance with ambulation twice a week (no start date indicated). Review of the resident's restorative therapy log, dated 02/01/23 to 02/28/23, showed staff did not document regarding restorative therapy. Review of the resident's nurse's note, dated 02/09/23, showed resident on restorative nursing for transfer training. Review of resident's nurse's note, dated 02/24/23, showed resident on restorative nursing for transfer training. Review of the resident's restorative therapy log, dated 03/01/23 to 03/10/23, showed resident received 15 minutes of ambulation therapy on the following dates: -On 03/03/23; -On 03/08/23; -On 03/09/23; -On 03/10/23. Review of the resident's nurse's note, dated 3/10/23, showed the resident rolled out of bed and onto the floor. No injuries noted. Review of the resident's nurse's notes, dated 03/10/23, showed the resident on restorative therapy for ambulation. Resident doing well, will continue to monitor. Review of the resident's restorative therapy log, dated 03/11/23 to 03/31/23, showed resident received 15 minutes of ambulation therapy on the following dates: -On 03/13/23; -On 03/14/23; -On 03/21/23; -On 03/22/23; -On 03/23/23; -On 03/24/23. Review of the resident's restorative therapy log, dated 04/01/23 to 04/30/23, showed resident received 15 minutes of ambulation therapy on the following dates: -On 04/11/23; -On 04/12/23; -On 04/13/23; -On 04/14/23. Record review of the resident's annual MDS, dated [DATE], showed the following: -Extensive assistance from staff with bed mobility, toileting, and transfers; -No walking occurred in room or corridor during prior seven days; -No indication regarding functional rehab potential. Review of the resident's restorative therapy log, dated 04/01/23 to 04/30/23, showed resident received 15 minutes of ambulation therapy on the following dates: -On 04/18/23; -On 04/19/23; -On 04/21/23. Record review of the resident's care plan, dated 04/28/23, showed the following: -Resident at risk for falls; -Therapy as per physician orders with quarterly and as needed screenings by therapist. (Staff did not care plan regarding restorative therapy.) Record review of resident's nurse's note, dated 04/28/23, showed resident on restorative nursing for transfer training. Record review of the resident's restorative therapy log, dated 05/01/23 to 05/24/23, showed staff did not document regarding restorative therapy. During an interview on 5/24/23, at 1:00 P.M., CNA F said the following: -He/she transfers resident, but no one specifically works with the resident on transfers; -The resident has requested therapy to assist him/her with transfers; -CNA F spoke to therapy about the resident's request; -CNA F believes the resident would benefit from therapy. 5. Review of Resident #8's face sheet showed the following: -admission date of 12/21/20; -Diagnoses included multiple sclerosis (a disease in which the immune system eats away at the protective covering of nerves), repeated falls, restless leg syndrome, major depressive disorder, and anxiety. Record review of the facility's restorative therapy participants, not dated, showed resident to received restorative therapy assistance with ambulation twice a week (no start date indicated). Review of the resident's POS, current as of 05/24/23, did not reflect any orders for therapy. Review of the resident's nurse's notes, dated 02/09/23, showed the resident on restorative nursing for range of motion. Review of restorative therapy log, dated 02/01/23 to 02/28/23, showed the following: -On 02/09/23, resident received 15 minutes of active range of motion therapy; -On 02/14/23, resident received 15 minutes of passive range of motion therapy; -On 02/21/23. received received 15 minutes of passive range of motion therapy. Review of restorative therapy log, dated 03/01/23 to 03/03/23, showed on 03/05/23, resident received 15 minutes of active range of motion therapy. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Extensive assistance from staff with bed mobility, toileting, and transfers; -No walking occurred in room or corridor during prior seven days; -No indication regarding functional rehab potential. Review of restorative therapy log, dated 03/06/23 to 03/10/23, showed the following: -On 03/09/23, the resident received 15 minutes of passive range of motion therapy and 15 minutes of active range of motion therapy; -On 03/10/23, the resident received 15 minutes of passive range of motion therapy and 15 minutes of active range of motion therapy. Review of the resident's nurse's notes, dated 03/10/23, showed the following: -Resident on restorative therapy for range of motion; -Resident doing well, will continue to monitor. Review of restorative therapy log, dated 03/06/23 to 03/13/23, showed on 03/13/23, the resident received 15 minutes of passive range of motion therapy and 15 minutes of active range of motion therapy. Record review of the resident's care plan, dated 03/14/23, showed the following: -Resident at risk for pressure ulcer; -Consider PT consult for conditioning and wheelchair assessment; -Resident at risk for falls; -Implement exercise program that targets strength, gait, and balance. (Staff did not care plan regarding restorative plan.) Review of restorative therapy log, dated 03/14/23 to 03/10/23, showed the following: -On 03/17/23, the resident received 15 minutes of passive range of motion therapy and 15 minutes of active range of motion therapy; -On 03/22/23, the resident received 15 minutes of passive range of motion therapy and 15 minutes of active range of motion therapy; -On 03/23/23, the resident received 15 minutes of passive range of motion therapy and 15 minutes of active range of motion therapy; -On 03/24/23, the resident received 15 minutes of passive range of motion therapy and resident received 15 minutes of active range of motion therapy. Review of the resident's restorative therapy log, dated 04/01/23 to 04/30/23, showed resident received the following therapy: -On 04/11/23, 15 minutes of passive range of motion therapy and 15 minutes of active range of motion therapy; -On 04/12/23, 15 minutes of passive range of motion therapy and 15 minutes of active range of motion therapy; -On 04/13/23, 15 minutes of passive range of motion therapy and 15 minutes of active range of motion therapy; -On 04/14/23, 15 minutes of passive range of motion therapy and 15 minutes of active range of motion therapy. Record review of the resident's restorative therapy log, dated 05/01/23 to 05/24/23, showed staff did not document regarding restorative therapy. During an interview on 5/24/23, at 1:28 P.M., the resident said staff do not come in and work with him/her. The resident was not aware staff were supposed to be working with him/her. During an interview on 05/24/23, at 1:30 P.M., Resident #9 said the following: -He/she and Resident #8 have been roommates for approximately a year; -Resident #9 does not leave the room often and has not observed staff come in and work with Resident #8. 6. Review of Resident #10's face sheet showed the following: -admission date of 01/30/15; -Diagnoses included cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain), anxiety disorder, major depressive disorder, Type 2 diabetes, heart failure, weakness, abnormalities of gait and mobility, and muscle wasting and atrophy (wasting or thinning of muscle mass). Review of the facility's restorative therapy participants, not dated, showed resident to received restorative therapy assistance with ambulation twice a week (no start date indicated). Review of the resident's POS, current as of 05/24/23, did not reflect any orders for therapy. Review of the resident's nurse's notes, dated 02/09/23, showed resident on restorative nursing for range of motion for contractures. Review of the residents' restorative therapy log, dated 02/01/23 to 02/28/23, showed the resident received therapy on the following dates: -On 02/09/23, resident received 15 minutes of passive range of motion therapy; -On 02/14/23, resident received 15 minutes of passive range of motion therapy; -On 02/21/23, resident received 15 minutes of active range of motion therapy. Review of the resident's nurse's notes, dated 02/24/23, showed resident on restorative nursing for range of motion. Review of the residents' restorative therapy log, dated 03/01/23 to 03/09/23, showed the resident received therapy on the following dates: -On 03/03/23, the resident received 15 minutes of passive range of motion therapy and 15 minutes of active range of motion therapy; -On 03/09/23, the resident received 15 minutes of passive range of motion therapy and 15 minutes of active range of motion therapy. Review of the resident's nurse's note, dated 03/10/23, showed the following: -Resident on restorative therapy for range of motion; -Resident doing well, will continue to monitor. Review of the residents' restorative therapy log, dated 03/10/23 to 03/12/23, showed on 03/10/23, the resident received 15 minutes of passive range of motion therapy and 15 minutes of active range of motion therapy; Review of the resident's quarterly MDS, dated [DATE], showed the following: -Extensive assistance from staff with bed mobility, toileting, and transfers; -No walking occurred in room or corridor during prior seven days; -No indication regarding functional rehab potential. Review of the residents' restorative therapy log, dated 03/13/23 to 03/19/23, showed the resident received therapy on the following dates: -On 03/13/23, the resident received 15 minutes of passive range of motion therapy and 15 minutes of active range of motion therapy; -On 03/14/23, the resident received 15 minutes of passive range of motion therapy and 15 minutes of active range of motion therapy; -On 03/17/23, the resident received 15 minutes of passive range of motion therapy and 15 minutes of active range of motion therapy; Review of the resident's care plan, dated 03/20/23, showed the following: -Assist resident in designing a progressive activity/exercise program to my maximal potential -Resident is a fall risk due to generalized weakness and paralysis from a stroke; -Observe, document, and report any functional decline and provide increased assistance as needed; -Therapy as per physician order with quarterly and PRN screenings by therapist. (Staff did not care plan regarding the resident's restorative plan.) Review of the resident's restorative therapy log, dated 03/20/23 to 03/09/23, showed the resident received therapy on the following dates: -On 03/21/23, the resident received 15 minutes of passive range of motion therapy and 15 minutes of active range of motion therapy; -On 03/22/23, the resident received 15 minutes of passive range of motion therapy and 15 minutes of active range of motion therapy; -On 03/23/23, the resident received 15 minutes of passive range of motion therapy and 15 minutes of active range of motion therapy; -On 03/24/23, the resident received 15 minutes of passive range of motion therapy and 15 minutes of active range of motion therapy. Review of the resident's restorative therapy log, dated 04/01/23 to 04/30/23, showed the resident received therapy on the following dates: -On 04/11/23, resident received 15 minutes of passive range of motion therapy and 15 minutes of active range of motion therapy; -On 04/12/23, resident received 15 minutes of passive range of motion therapy and 15 minutes of active range of motion therapy; -On 04/13/23, resident received 15 minutes of passive range of motion therapy and 15 minutes of active range of motion therapy -On 04/14/23, resident received 15 minutes of passive range of motion therapy and 15 minutes of active range of motion therapy; -On 04/17/23, resident received 15 minutes of passive range of motion therapy and 15 minutes of active range of motion therapy; -On 04/18/23, resident received 15 minutes of passive range of motion therapy and 15 minutes of active range of motion therapy; -On 04/21/23, resident received 15 minutes of passive range of motion therapy and 15 minutes of active range of motion therapy. Review of the resident's nurse's notes, dated 04/28/23, showed resident on restorative nursing for range of motion. Record review of resident's restorative therapy log, dated 05/01/23 to 05/24/23, showed staff did not document regarding restorative therapy. 7. During an interview on 05/23/23, at 2:30 P.M., the DOR said the following: -A physician's order is needed to screen a resident for therapy; -Staff will alert therapy to residents that are declining and feel can benefit from therapy; -Therapy will make a referral and a meeting is held approximately once a week with the Administrator and DON to discuss the referral; -The Administrator and DON will determine if a resident is appropriate for a therapy evaluation; -The DOR does not contact the physician directly about obtaining a therapy evaluation as there is a process he/she is to follow, which is to have the Administrator and DON review all therapy requests. 8. During an interview on 05/24/23, at 10:34 A.M., the NP said the following: -The NP or physician should be notified regarding all therapy referrals; -Nursing will notify the NP if a resident needs an order for therapy. If the NP has concerns/questions, they will talk with therapy; -The NP can assess residents and give an order for a therapy evaluation; -Therapy can reach out the NP or the facility physicians and request an order for a therapy evaluation; -Verbal orders are given for restorative therapy and nursing enters the order. 9. During an interview on 05/24/23, at 11:11 A.M., the physician said the following: -He/she should be contacted if therapy is recommending a resident receive a therapy evaluation; -Residents do not always have an order for restorative therapy. Residents sometimes receive an order when progressing off of therapy. 10. During an interview on 05/24/23, at 11:20 A.M., CNA A said the following: -He/she discusses concerns regarding a resident's physical decline with a nurse and therapy; -The transport driver is also the restorative therapy aide; -CNA A does not know when restorative therapy is complete since the aide is often out on transport; -CNA A believes therapy and restorative is documented in the care plan, which are located at the nurse's station; -Nurses update care plans. 11. During an interview on 05/24/23, at 11:34 A.M., CNA B said the following: -He/she talks to therapy about any concerns regarding resident's physical decline; -He/she does not know if residents receive restorative therapy; -The restorative aide also is in charge of transportation; -Therapy and restorative should be documented in the care plans, which are located at the nurse's station; -Medical records updates the care plan to document the resident's needs. 12. During an interview on 05/24/23, at 11:45 A.M., CMT C said the following: -The restorative aide quit; -Residents are not receiving restorative therapy; -Care plans document therapy and restorative; -Medical Records updates the care plans based on a resident's needs. 13. During an interview on 05/24/23, at 12:00 P.M., Restorative Nursing Assistant (RNA) D said the following: -RNA D was the restorative aide and the transport driver for approximately six months; -The facility hired a new RNA, however he/she quit two weeks ago; -The previous RNA was unable to complete his/her RNA duties as he/she was often pulled to work the floor as a CNA; -RNA D has been on leave for the last few weeks, but returned last week; -RNA D has resumed transport duties, but not restorative therapy; -Residents have not received restorative therapy in the month of May 2023; -RNA D documents restorative therapy in the electronic chart; -Any concerns regarding a resident's physical decline is reported to the DON or Administrator during their morning meeting; -Care plans are located in the resident's electronic chart; -Therapy and restorative should be documented in the care plan; -The MDS coordinator updates the care plans. 14. During an interview on 05/24/23, at 1:00 P.M., CNA F said the following: -CNA F does not know if the facility currently has a restorative aide; -When the facility had a restorative aide, they did not provide therapy to the SCU; -CNA F believes the restorative aide was often pulled to the floor to work. 15. During an interview on 05/24/23, at 1:50 P.M., Registered Nurse (RN) E said the following: -If a resident's physical ability is declining, he/she will discuss concerns with the DON and will proceed based on the DON's recommendation;<[TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure recommended interventions for weight loss, including weekly weights and supplemental nutritional shakes, were implemented and care planned and failed to ensure meal intake was properly documented for one resident (Resident #29). The census was 70. Record review of the facility's policy titled Nutrition, dated March 2012, showed the following information: -Residents will be provided meals three times a day at facility-determined times; -Diet ordered by physician will be followed; -Residents will be offered bed time snacks unless contraindicated; -At no time will this facility withhold nutrition to promote or hasten death; -Examples of Nutritional Interventions without a physician's order: whole milk, juice, supercereal, extra butter, extra desserts, snacks; -Examples of interventions that require a physician's order: Carnation VHC 2.25 (calorie dense oral supplement), NuBasics Juice/Boost Breeze (juice supplement used when milk based formula not accepted), Protein powder/liquid (this is given when protein is needed and calories are not). 1. Record review of Resident #29's face sheet (a one page summary of important information about a resident) showed the following: -admission date of 10/12/16; -Diagnoses included dementia without behavioral disturbances (loss of cognitive functioning, remembering, and reasoning), chronic obstructive pulmonary disease with acute exacerbations (airflow blockage and breathing-related problems) , gastro-esophageal reflux disease without esophagitis (when stomach acid frequently flows back into the tube connecting your mouth and stomach), and depressive episodes (feelings of sadness and loss of interest). Record review of the resident's Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 08/05/21, showed the following: -Severe cognitive impairment; -Needs supervision, oversight, encouragement or cueing for eating, and requires set up for eating; -Weight loss of 5% or more last month or 10% or more in the last six months showed no or unknown. Record review of the resident's care plan, last revised on 11/03/21, showed the following: -Problem start date of 11/07/26, and an approach date of 11/19/20; -Resident has potential for nutritional decline related to disease process. There are times when the resident may choose not to eat; -Interventions will be in place to prevent nutritional decline and/or maintain current status to the extent possible through the next review; -Allow resident ample time to ingest meal, do not rush, and encourage all meals in the dining room. Determine food preferences. -Document food consumption at every meal. Encourage 75% meal intake; offer substitutions for food not eaten, notify charge nurse if less than 25% of meal is eaten; -Monitor weight monthly (and as ordered), notify physician/responsible party of significant weight changes; -Offer between meal and bedtime snacks. Document intake; -Praise when eating well and making attempts to follow diet. Record review of the resident's nurse's notes showed the following: -On 9/03/21, at 10:32 A.M., the Director of Nursing (DON) noted resident had lost 6.8% in 90 days. Resident has refused meals periodically. Obtaining UA (urinary analysis) this morning due to increased lethargy. staff will start weekly weights to establish trend. Record review of the resident's care plan, dated 11/03/21, showed staff did not update the care plan regarding the weight loss or new interventions. Record review of the resident's vital signs, dated September 2021, showed the following: -Sixteen meals with consumption of 25-50%; -Eleven meals with consumption of 1-25% ; -Twelve meals with none consumed; -Eight meals refused. Record review of the resident's medical record showed the following weights: -On 9/07/21, 137 pounds (lbs) -On 09/15/21, 136 lbs -On 09/20/21, 137 lbs -On 09/27/21, 136 lbs Record review of the resident's vital signs, dated October 2021, showed the following -Eighteen meals with consumption of 25-50% ; -Ten meals with consumption of 1-25%; -Fourteen meals with none consumed; -Twelve meals refused. Record review of the resident's medical record showed the following weights: -On 10/06/21, 131 lbs (a five pound weight in nine days). Record review of the resident's nurses' notes showed the following: -On 10/07/21, at 1:46 P.M., the DON noted the resident lost 5 pounds in last week. and had a recent UTI (urinary tract infection). Staff will provide Two Cal (nutritionally complete, high calorie formula), 60 ml (milliliters) PO (by mouth) BID (twice a day) with medication. Staff will continue weekly weights. (Staff did not document notifying the physician of the weight loss.) Record review of the resident's care plan, dated 11/03/21, showed staff did not update the care plan regarding the weight loss or new interventions. Record review of the resident's medical record showed the following weights: -On 10/11/21, 130 lbs. Record review of the resident's dietary notes dated 10/13/21, at 12:43 P.M., the Registered Dietitian (RD) noted the following; -Reviewed due to weight loss of 5.1% in 1 month (137>130); -Diet: Regular, fortified foods at meals; -Intake varies but is often 26-50%; -Dietary Service Manager (DSM) the resident is less interested in things lately; -Noted resident recently had a UTI and was on antibiotic therapy; -Per RAR (Resident at Risk) notes staff plan to add Two Cal HN 60 ml BID with meds.RD agreed with this plan; -Resident is on weekly weights. RD will review facility weights and make recommendations as needed. Record review of the resident's dietary notes dated 10/15/21, at 10:44 A.M., DON noted the following; -RAR - Order to start Two Cal 60 ml PO BID due to recent weight loss per dietitian. Staff will monitor weekly weights. Record review of the resident's medical record showed the following weights: -On 10/18/21, 130 lbs. -On 10/27/21, 131 lbs. Record review of the resident's Treatment Administration Record (TAR), dated October 2021, showed no order for Two Cal and no Two Call provided to the resident. Record review of the resident's vital signs, dated November 2021, showed the following -Thirteen meals with consumption of 25-50%; -Nine meals with consumption of 1-25%; -Twelve meals with none consumed; -Twelve meals refused. Record review of the Observation Detail List, by the DSM, dated 11/02/21, at 11:26 A.M., showed the following; -Regular diet; -Current weight 131 lbs; -10% weight loss in the last 6 months; -Average intake percentage is 51% to 75%; -Set up only assistance with eating; -Comments, Resident has been slowing losing weight, he/she is down -11.5% X 6 months and -7.7% X 3 months. He/she has just been added on weekly weights and Two Cal 60 ml BID. He/she is already on fortified foods. Record review of the resident's medical record showed the following weights: -On 11/05/21, 129 lbs (Staff did not document any addition weights for November 2021.) Record review of the resident's current physician order sheet (POS), dated 11/01/21- 1/13/22, showed the following -Diet: Regular/Fortified food; -Weight monthly unless otherwise indicated. (No new orders were entered based on the RD and DON's recommendations.) Record review of the resident's TAR, dated November 2021, showed no order for Two Cal and no Two Call provided to the resident. Record review of the resident's vital signs, dated December 2021, showed the following: -Seventeen meals with consumption of 25-50% ; -Eight meals with consumption of 1-25%; -Nine meals with none consumed; -Eleven meals refused;. Record review of the resident's medical record showed the following weights: -On 12/03/21, 127 lbs. (Staff did not document any addition weights for November 2021.) Record review of the resident's TAR, dated December 2021, showed no order for Two Cal and no Two Call provided to the resident. Record review of the resident's TAR, dated January 2022, showed no order for Two Cal and no Two Call provided to the resident. Observation on 1/10/22, beginning at 12:10 P.M., showed the following: -The resident received the lunch meal and ate independently and slowly; -On occasion Certified Nurse Aide (CNA) J said to all residents eat; -At 12:34 P.M., the resident had consumed half of the meatloaf, 10% of the potatoes, two bites of the roll, 75% of the corn and half the brownie; -Staff did not encouraged the resident eat more and staff did not offer other foods. Record review of the resident's vital sheet for lunch on 1/10/22 showed staff documented the resident consumed 51 to 75% of meal. Record review of the resident's vital signs for consumption of food showed the following: -On 1/11/22, resident consumed 51 to 75% of breakfast meal. Observation and interview on 1/11/22, beginning at 11:58 A.M., showed the following: -The resident was lying in his/her bed with eyes closed while lunch was being served in the dining hall; -Staff did not place a meal tray in the resident's room; -CNA J, said the resident doesn't always eat lunch if he/she eats a good breakfast. Record review of the resident's vital sheet for lunch on 1/11/22 showed staff documented the resident consumed none of the meal. Observation on 1/12/22, at 12:14 P.M., showed the following: -The resident received the lunch meal and slowly; -At 12:39 P.M., resident had consumed approximately 75% of the beans (took out most of the ham), a few bites of cornbread, one bite of the potatoes and ate none of the cabbage; -CNA J asked resident if he/she was done and the resident pushed the plate away; -Staff did not encourage the resident to eat, nor offer other food options to the resident; - At 12:4 P.M., CNA J dumped the resident's food into the trash container. Staff did not document food consumption at that time. Record review of the resident's vital sheet for lunch on 1/12/22 showed staff documented the resident consumed 26- 50% of meal. Observation on 1/13/22, at 7:20 A.M., showed the following: -The resident received a morning meal and ate slowly; -At 7:45 A.M., the resident had ate about half the oatmeal, 25% of eggs, and 75% of sausage and toast. Record review of the resident's vital sheet for breakfast on 1/12/22 showed staff documented the resident consumed 76 to 100% of meal. During an interview on 1/12/22, at 1:55 P.M., Nurse Aide (NA) M said if a resident is struggling, staff assist the resident with eating. He/she also encourages residents to eat. Residents are given nutritional shakes if they're losing weight. Residents are given a tray at every meal. The resident is always offered a tray, if he/she is in their room, staff try to get the resident to eat in the dining area. During an interview on 1/12/22, at 2:20 P.M., CNA L said staff know which residents require assistance with eating by watching the residents. He/she assist residents with eating if needed, and encourage residents to eat. Resident's food consumption is monitored and charted. If the resident is losing weight, the nurse is told and speech therapy gets involved. All residents are provided a meal at mealtime and encouraged to eat. During an interview on 1/12/22, at 3:21 P.M., Certified Medication Technician (CMT) O said if resident's are not feeding themselves, assistance would be needed. He/she encourages the residents to eat. If residents are losing weight, he/she would notify the nurse. Resident's food consumption is monitored and documented in the notes. During an interview on 1/12/22, at 3:40 P.M., Registered Nurse (RN) D said if residents have weight loss, Two Cal is ordered by doctor and the dietitian. Two Cal is administered to residents when medications are given. During an interview on 1/13/22, at 6:55 A.M., CNA K said the following: -If residents are not eating, he/she would assist them with eating. Residents are also offered other choices if they don't want the meals served; -He/she tries to monitor how much food residents are eating when the plates are being dumped. He/she documents the amount of food eaten in the computer; -If residents are losing weight, he/she doesn't know what interventions would be used; -He/she always encourages liquids more than food; -Some residents do receive shakes. He/she always offers residents a tray at mealtime. He/she prefers residents eat in the dining area for supervision; -The resident always has a tray. The resident does go lay in his/her bed and doesn't always like to get up when meals are served. The resident does eat better when in the dining area. During an interview on 1/13/22, at 8:07 A.M., Social Services Staff said the following: -If residents are losing weight he/she would discuss at risk meetings and care planning; -Some interventions would be the addition of two cal; -Dietary does the ordering of two cal once a physician's order is received; -Residents are also offered snacks; -Resident's food consumption is monitored and if this is low, the aides are responsible for notifying the kitchen. During an interview on 1/13/22, at 8:55 A.M., the DSM said the following: -Any weight loss issues are discussed every Thursday at the Risk meeting; -The RD is notified when a resident has been noted for weight loss. If this is urgent, the dietician is notified immediately; -Two Cal is requested by the dietitian and the doctor completes and order; -The DON may be the one to order the two cal. Med techs give the two cal with the medications. During an interview on 1/13/22, at 11:05 A.M., the RD said the following: -He/she would expect all residents to receive a plate of food at each meal whether in the dining or their room. -He/she said risk meetings are held to address resident concerns and sometimes Two Cal is ordered; - He/she sometimes requests Two Cal to be ordered, these requests are given to the DON and the DON would notify the doctor; -The med techs administer Two Cal with resident medications. He/she has reviewed the resident's records and sees there is an 11.35% weight loss in the last six months; -He/she did not see where Two Cal was ordered. He/she looked in the medical record system and was not able to locate an order. During an interview on 1/13/22, at 11:14 A.M., DON said the following: -The dietary manager observes one to two meals per day; -Aides are expected to tell management if a resident needs assistance with eating, less food being consumed or weight decline. This issue is addressed in the risk management meeting.; -He/she expects all residents to receive a tray at each meal; -Care plans reveal any eating needs or interventions. Some interventions put in place would include weekly weights, fortified foods and two cal. Some residents do not like Two Cal. Med techs provide two cal when passing medications to residents and document the amount of Two Cal consumed by the resident.; -Some residents receive ice-cream shakes or house shakes with their meals; -DON would notify the doctor if resident has weight loss, and the physician would order Two Cal. The DON would follow up to make sure the Two Cal has been ordered; -He/she looked in the computer and did not locate an order of Two Cal for the resident. During an interview on 1/13/22, at 12:25 P.M., Administrator said the following: -All residents should be provided a tray at each meal; -If the resident ate well during the prior meal, the resident should still be offered a tray or some type of food. If the resident is in their room sleeping, the resident should still be offered a meal; -If a resident is losing weight, the staff look at possible medical as well as food interventions; medication changes, offer snacks, fortified foods, supplements and Two Cal shakes; -Some residents eat better if their families are present; -Dietary needs are documented on care plans; -The RD usually recommends Two Cal, this is discussed with the doctor and the doctor approves the order. During an interview on 1/13/22, at 2:15 P.M., the resident's physician said the following: -He/she was not aware of weight loss, outside of the naturally progressive weight loss; -He/she was not aware the resident has lost 11.35% over the last six months; -He/she did not know if two cal had been ordered, but would address this issue during the next visit; -He/she expects staff to provide food trays to residents at all meals whether they're in the dining area or their rooms.

Based on observation, record review, and interview, the facility failed to ensure staff administered medications with an error rate of less than 5% when a nurse failed to prime the insulin pen needle per the manufacturer's guidelines before administering rapid acting insulin to two residents (Resident #32 and Resident #307). The medication error rate was 8% based on two medication errors out of 25 opportunities. The facility census was 70. Record review of the Novolog (a type of fast-acting insulin) website guidance, dated May 2018, showed the following information: -The Novolog FlexPen (a prefilled insulin pen): the method of administration may affect glycemic control (a medical term referring to the typical levels of blood sugar in person with diabetes mellitus (a chronic condition that affects the way the body processes blood sugar (glucose)) and predispose the person to hypoglycemia (abnormally low blood sugar) or hyperglycemia (abnormally high blood sugar). To avoid injecting air and ensure proper dosing, prime the pen (referred to as air shot, before each injection small amounts of air may collect in the cartridge during normal use) before each injection. Record review of the facility's Subcutaneous (a medical term referring to applying a medication under the skin) Injection Policy guidelines, dated March 2015, showed the following information: -Inform the resident you are ready to give the injection and cleanse the site using friction. Allow to dry; -Expel air from syringe. Accumulate a well-defined roll of skin with thumb and index finger and insert needle to its full length at a 45 to 90-degree angle, depending on the amount of tissue available. Record review of the facility's Mediation Administration policy, dated March, 2015, did not address insulin pen preparation procedures. 1. Record review of Resident #32's face sheet (general resident information) showed the following information: -A admission date of 11/22/19; -Diagnoses included type 2 diabetes mellitus (a chronic condition in which the body does not produce enough insulin). Record review of the resident's Physician Order Sheet (POS), dated 12/13/21 to 1/13/22, showed the following information: -An order, dated 12/24/22, to inject 10 units of Novolog FlexPen insulin with meals. Observation on 1/13/22, at 7:36 A.M., showed Registered Nurse (RN) D applied a pen needle to the resident's Novolog FlexPen and dialed it to 10 units of insulin. RN D injected 10 units of insulin into the resident's abdomen after cleaning his/her skin with an alcohol wipe. RN D did not prime the insulin pen before dialing to 10 units of insulin and administering the insulin. 2. Record review of Resident #307's face sheet showed the following information: -admission date of 11/421; -Diagnoses included type 2 diabetes mellitus. Record review of the resident's POS, dated 12/13/21 to 1/13/22, showed the following information: -An order, dated 12/17/22, to inject 12 units of Novolog Flexpen insulin before meal. Observation on 1/13/22, at 7:41 A.M., showed RN D applied a pen needle to the resident's Novolog Flexpen and dialed it to 12 units of insulin. RN D injected 12 units of insulin into the resident's right arm after cleaning his/her skin with an alcohol wipe. RN D did not prime the insulin pen before dialing to 10 units of insulin and administering the insulin. 3. During an interview on 1/13/22, at 7:59 A.M., RN D said he/she got training on how to administer insulin both at the facility and in nursing school. RN D said he/she was trained to prime the pen needle with two units of insulin in nursing school, but that he/she forgot to do that today. 4. During an interview on 1/13/22, at 9:37 A.M., the Director of Nursing (DON) said when a nurse is first hired the nurse who is training the new hire trains the new nurse on insulin administration. He/she doesn't know if trainers train on priming of the insulin pen needle. His/her expectation is that nurses have been taught to prime the pen needle in nursing school. The DON said nurses should be priming the pen needle before each insulin pen injection.

Based on observation, record review, and interview, the facility failed to prevent a significant medication errors when a nurse failed to prime the insulin pen needle per the manufacturer's guidelines before administering rapid acting insulin to two residents (Resident #32 and Resident #307). The facility census was 70. Record review of the Novolog (a type of fast-acting insulin) website guidance, dated May, 2018, showed the following information: -The Novolog FlexPen (a prefilled insulin pen): the method of administration may affect glycemic control (a medical term referring to the typical levels of blood sugar in person with diabetes mellitus (a chronic condition that affects the way the body processes blood sugar (glucose)) and predispose the person to hypoglycemia (abnormally low blood sugar) or hyperglycemia (abnormally high blood sugar). To avoid injecting air and ensure proper dosing, prime the pen (referred to as air shot, before each injection small amounts of air may collect in the cartridge during normal use) before each injection. Record review of the facility's Subcutaneous (a medical term referring to applying a medication under the skin) Injection Policy guidelines, dated March 2015, showed the following information: -Inform the resident you are ready to give the injection and cleanse the site using friction. Allow to dry; -Expel air from syringe. Accumulate a well-defined roll of skin with thumb and index finger and insert needle to its full length at a 45 to 90-degree angle, depending on the amount of tissue available. Record review of the facility's Mediation Administration policy, dated March 2015, showed it did not address insulin pen preparation procedures. 1. Record review of Resident #32's face sheet (general resident information) showed the following information: -admission date of 11/22/19; -Diagnoses included of type 2 diabetes mellitus (a chronic condition in which the body does not produce enough insulin). Record review of the resident's Physician Order Sheet (POS), dated 12/13/21 to 1/13/22, showed the following information: -An order, dated 12/24/21, to inject 10 units of Novolog FlexPen insulin with meals. Observation on 1/13/22, at 7:36 A.M., showed Registered Nurse (RN) D applied a pen needle to the resident's Novolog FlexPen and dialed it to 10 units of insulin. RN D injected 10 units of insulin into the resident's abdomen after cleaning his/her skin with an alcohol wipe. RN D did not prime the insulin pen before dialing to 10 units of insulin and administering the insulin. 2. Record review of Resident #307's face sheet showed the following information: -admission date of 11/421; -Diagnoses included type 2 diabetes mellitus. Record review of the resident's POS, dated 12/13/21 to 1/13/22, showed the following information: -An order, dated 12/17/21, to inject 12 units of Novolog Flexpen insulin before meals Observation on 1/13/22, at 7:41 A.M., showed RN D applied a pen needle to the resident's Novolog Flexpen and dialed it to 12 units of insulin. RN D injected 12 units of insulin into the resident's right arm after cleaning his/her skin with an alcohol wipe. RN D did not prime the insulin pen before dialing to 10 units of insulin and administering the insulin. 3. During an interview on 1/13/22, at 7:59 A.M., RN D said he/she got training on how to administer insulin both at the facility and in nursing school. He/she was trained to prime the pen needle with 2 units of insulin in nursing school, but that he/she forgot to do that today. 4. During an interview on 1/13/22, at 9:37 A.M., the Director of Nursing (DON) said when a nurse is first hired the nurse who is training the new hire trains the new nurse on insulin administration. He/she doesn't know if trainers train on priming of the insulin pen needle. His/her expectation is that nurses have been taught to prime the pen needle in nursing school. Nurses should be priming the pen needle before each insulin pen injection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 10. Record Review of Resident #65's face sheet showed the following information: -admission date of 12/28/20; -Diagnosis included seizures (disorder in which nerve cell activity to the brain is disturbed), unspecified sequelae of cerebral infarction (damage to tissues in the brain due to a loss of oxygen), hypoxic ischemic encephalopathy (type of brain dysfunction that occurs when the brain doesn't receive enough oxygen or blood flow for a period of time). Record review of resident's care plan, revised 10/26/21, showed the following information: -Nonverbal and makes occasional sounds so please anticipate needs/wants; -Unsteady at times when walking, walk with resident or supervise unsteadiness. (Staff did not care plan the use of side rails.) Record review of the resident's admission MDS, dated [DATE], showed the following information: -Memory problems; -Severely impaired, never/rarely made decisions; -Fall risk; -Extensive assistance, one person assist with bed mobility; -Supervision with transfer, walking in room and mobility; -No assistance needed when rolling from left to right, sit to lying, lying to sitting; -Did not use side rails. Record review of the resident's current showed no order for side rail usage. Observation on 1/10/22, at 10:30 A.M., showed the the resident's bed had half side rails, in the raised position. Observation on 1/12/22, at 8:46 A.M., showed bed rails in the raised position, and the resident resting in bed. Observation on 1/13/22, at 7:49 A.M., showed bed rails in the raised position, and the resident resting in bed. Record review of the resident's medical record showed staff did not document a complete side rail evaluation (to include a risk/benefit review and alternatives attempted prior to use of side rails), ongoing evaluation of side rails, obtaining informed consent for side rails, and a side rail safety check and regular inspections of the bed frame and side rails for risk of entrapment. During an interview on 1/12/22, at 1:55 P.M., NA M said the following: -Resident # 65 has bed rails so that he doesn't fall off the lowered bed; -Doesn't know the process for resident's to be assessed for bed rails. During an interview on 1/12/22, at 2:20 P.M.,Certified Nurse Aide (CNA) L said the resident is a fall risk and he/she climbs over the bed rails. 11 During an interview on 1/12/2022, at 2:14 P.M., CMT O said residents have side rails to keep them from rolling out of bed. He/she thinks someone does an assessment to make sure the resident needs the rails before they are installed and someone makes sure the beds are measured before the rails are put on. CMT O thinks the resident's responsible party signs a consent for the rails. 12. During an interview on 1/12/22, at 2:20 P.M., with CNA L said the following: -Residents have bed rails for transferring or fall risk and to assist with turning in bed; -Maintenance puts the bed rails on; -Nurses do the assessments to determine the resident's needs for bed rails. 13. During an interview on 1/12/22, at 2:36 P.M., NA G said that side rails are used for residents that try to roll or climb out of bed. He/she knows that a doctor's order is needed. He/she did not know how the decision was made of which resident had side rails and did not know who did a measurement assessment. 14. During an interview on 1/12/22, at 2:44 PM, LPN H said residents feel more secure with side rails since they keep residents from rolling out of bed. Residents use side rails for positioning and residents who are more alert feel more secure having side rails. There is an assessment on the computer for bed rails that is pretty involved. The assessment includes measurements. The assessment is available for nurses, but the nurses don't use it as much as just verbally asking residents and the family if they want bed rails. LPN H said technically, the Maintenance Supervisor installs the bed rails and measures them. Usually the facility has one or two beds where the bed rails are already installed. Consent for side rails may be part of the admission packet. Nurses don't always fill out the side rail assessment and it is not necessary to get a doctor's order for side rails, because it is a safety issue. 15. During an interview on 1/13/22, at 8:02 A.M., RN D said side rails are for helping resident with mobility. The admitting nurse does the assessment form for side rails upon admission, and then the Director of Nursing (DON) looks over that form. He/she is not sure about measurements or who does those. He/she is sure someone would have to sign a consent for them. 16. During interviews on 1/13/2022, at 9:00 A.M. and 11:05 A.M., the DON said care plans should include anything to assist staff with caring for the resident. After the MDS and CAAS (care areas triggered by MDS), it may not trigger all the care areas, so there are some other things that need like pain medications, anticoagulants (blood thinners), behaviors, side rails, continence, and wounds. Everyone who does MDS is able to make changes on the care plan. The nursing staff initially assess residents for need of side rails. Some residents come from the hospital and are used to side rails, so the resident and the family do not want them removed. Some residents are afraid of falling out of bed, and some residents use for bed mobility and for assistance with transfers. Most of the time nursing will request the therapy department work with the residents regarding side rails for mobility. She did not know if that was documented anywhere. Side rail use should be in the resident care plans. 17. During an interview on 1/13/22, at 9:13 A.M., the Maintenance Supervisor said side rails are for repositioning. He/she doesn't do an assessment for the bed rails. He/she measures them to make sure the bed rails are the right size. The DON has it documented if a resident needs the bed rails. He/she writes the measurements down on a form, and that the DON and Medical Records keep that form. 18. During an interview on 1/12/2022, at 10:00 A.M., the administrator said she expects staff to have assessments, consents, and measurements for all residents who have positioning bars. Side rails are not to be used for residents to prevent falls. 6. Record review of Resident #5's face sheet showed the following: -admission date of 10/9/19. -Diagnoses included morbid obesity due to excess calories (an abnormally high body mass), adult failure to thrive (poor nutritional intake or weight loss), and cellulitis (a bacterial infection involving the inner layers of skin) of the right lower limb Record review of the resident's care plan, dated 4/13/21, showed the following information: -The resident is at risk for falls; -The resident's activities of daily living/ rehabilitation potential includes that he/she requires a max assist with transfers and the resident does not ambulate; -The resident requires assist of one to two staff with all activities of daily living. (Staff did not address side rail usage on the care plan.) Record review of the resident's annual MDS, dated [DATE], showed the following information: -cognitively intact; -Extensive assistance with two person physical assist for bed mobility, toilet use, dressing, and personal hygiene; -Did not use side rails. Record review of the resident's POS, dated 12/13/21 to 1/13/22, showed no order for side rails. Observation on 1/11/22, at 11:05 A.M., showed the resident's bed with two upper half side rails in the up position. During an interview on 1/11/22, at 11:05 A.M., the resident said that his/her side rails came with the bed. During an interview on 1/13/22, at 9:00 A.M., the resident said the side rails were on the bed when he/she got it. The resident said he/she couldn't remember if anyone assessed him/her for the side rails. The resident said he/she wants the side rails, because he/she uses them for positioning with rolling and sitting up. The resident did not remember if he/she signed a consent form for the side rails. Record review of the resident's medical record showed staff did not document a complete side rail evaluation (to include a risk/benefit review and alternatives attempted prior to use of side rails), ongoing evaluation of side rails, obtaining informed consent for side rails, and a side rail safety check and regular inspections of the bed frame and side rails for risk of entrapment. During an interview on 1/12/22, at 2:36 PM, Nurse Aide (NA) G said he/she is not sure why the resident has side rails. During an interview on 1/12/22, at 2:44 PM, Licensed Practical Nurse (LPN) H said the resident has side rails to help him/her roll over and for positioning. During an interview on 1/13/22, at 8:02 A.M., Registered Nurse (RN) D said he/she is not sure why the resident has bed rails. 7. Record review of Resident #11's face sheet showed the following: -admission date of 9/28/16; -Diagnoses included schizophrenia (a mental disorder characterized by episodes of psychosis) and mild intellectual disabilities. Record review of the resident's care plan, dated 5/27/21, showed the following information: -The resident has a history of pseudoseizures (a seizure that is a physical reaction to mental or psychological stress) and hallucinations which cause him/her to be a fall risk; -The resident's activities of daily living/ rehabilitation potential includes that he/she ambulates independently with supervision, uses a walker, and needs limited assistance with dressing. (Staff did not address side rails usage on the care plan.) Record review of the resident's quarterly MDS, dated [DATE], showed the following information: -Cognitively intact; -Supervision with one person physical assist for bed mobility; -Limited assistance with one person physical assist for personal hygiene; -Independent with no setup or help from staff with walking, transfers, locomotion on and off the unit, dressing, and toilet use; -Did not use side rails. Record review of the resident's POS, dated 12/13/21 to 1/13/22, showed no order for side rails. Observation on 1/11/22, at 11:46 A.M. showed the resident's bed with two upper half bed rails in the up position. During an interview on 1/13/22, at 8:55 A.M., the resident said he/she wanted side rails so he/she does not fall out of bed. The resident said he/she thinks he/she asked for the bed rails when he/she moved to this room and then staff installed them. Record review of the resident's medical record showed staff did not document a complete side rail evaluation (to include a risk/benefit review and alternatives attempted prior to use of side rails), ongoing evaluation of side rails, obtaining informed consent for side rails, and a side rail safety check and regular inspections of the bed frame and side rails for risk of entrapment. During an interview on 1/12/22, at 2:36 PM, NA G said he/she is not sure the resident has side rails. During an interview on 1/12/22, at 2:44 PM, LPN H said the resident has side rails to help him/her roll over and for positioning. The LPN could not locate a side rail assessment for the resident. During an interview on 1/13/22, at 8:02 A.M., RN D said he/she is not sure why the resident has bed rails. 8. Record review of Resident #31's face sheet showed the following: -admission date of 11/27/18; -Diagnoses included hemochromatosis (a disorder where extra iron builds up in the body to harmful levels), dementia (a long term brain disorder causing personality changes and impaired memory, reasoning, and social function), and delusional disorders (a mental disorder in which a person has delusions, or strong false beliefs). Record review of the resident's care plan, dated 6/10/21, showed the following information: -The resident has a diagnosis of dementia and sometimes gets confused or has delusions; -The resident is at risk for falls; -The resident is wheelchair bound due to knee pain -The resident needs assistance with transferring, toileting, and set up assistance with oral hygiene. (Staff did not address side rail usage on the care plan.) Record review of the resident's annual MDS, dated [DATE], showed the following information: -Cognitively intact; -Extensive assistance with two person physical assist for bed mobility, transfers, dressing, toilet use, and personal hygiene. -Did not use side rails. Record review of the resident's POS, dated 12/13/21 to 1/13/22, showed an order, dated 11/29/28, for one quarter side rail times one to bed for positioning, started 11/29/18 Record review of the resident's nursing progress notes, dated 11/29/18, showed a quarter side rail documented per resident and family request for positioning. Observation on 1/11/22, at 9:39 A.M., showed the resident's bed with two upper half side rails in the up position. During an interview on 1/11/22, at 9:39 A.M., the resident said he/she wanted side rails so he/she does not fall out of bed. Record review of the resident's medical record showed staff did not document a complete side rail evaluation (to include a risk/benefit review and alternatives attempted prior to use of side rails), ongoing evaluation of side rails, obtaining informed consent for side rails, and a side rail safety check and regular inspections of the bed frame and side rails for risk of entrapment. During an interview on 1/12/22, at 2:36 PM, NA G said the resident is physically dependent, cannot stand up, and is not good with his/her bed mobility alone. That is why the resident has bed rails. During an interview on 1/12/22, at 2:44 PM, LPN H said the resident has side rails to help him/her roll over and for positioning. During an interview on 1/13/22, at 8:02 A.M., RN D said he/she is not sure why the resident has bed rails. 9. Record review of Resident #221's face sheet showed the following: -admission date of 17/17/21; -Diagnoses included fracture of right lower leg, difficulty in walking, and pain. Record review of the resident's care plan, dated 1/12/22, showed the following: -The resident's activities of daily living/rehabilitation potential includes decreased mobility related to right ankle fracture and non-weight baring to right lower extremity; -The resident is at risk for falls;. (Staff did not address side rail usage on the care plan.) Record review of the resident's admission MDS, dated [DATE], showed the following information: -Cognitively intact; -Extensive assistance with two person physical assist for bed mobility, dressing, and toilet use; -Extensive assistance with one person physical assist for personal hygiene; -Did not use side rails. Record review of the resident's POS, dated 12/13/21 to 1/13/22 showed the following information: -Non-weight baring to right ankle; -No order for side rails. Observation on 1/10/22, at 2:07 P.M., showed the resident's bed with two upper half bed rails in the up position. During an interview on 1/13/22, at 9:05 A.M., the resident said he/she doesn't know if the bed rails were on the bed when he/she was admitted to the facility. The resident said staff had to hunt for a bed for the resident. The resident said he/she wanted the bed rails for positioning and turning while in bed. The resident said there was no assessment done for his/her bed rails and he/she did not sign a consent form for the bed rails that he/she is aware of. Record review of the resident's medical record showed staff did not document a complete side rail evaluation (to include a risk/benefit review and alternatives attempted prior to use of side rails), ongoing evaluation of side rails, obtaining informed consent for side rails, and a side rail safety check and regular inspections of the bed frame and side rails for risk of entrapment. During an interview on 1/12/22, at 2:36 PM, NA G said he/she is not sure why the resident has side rails. During an interview on 1/12/22, at 2:44 PM, LPN H said the resident has side rails to help him/her roll over and for positioning. During an interview on 1/13/22, at 8:02 A.M., RN D said he/she is not sure why the resident has bed rails. 3. Record review of Resident #17's face sheet showed the following: -admission date of 4/17/18; -Diagnosis included mild intellectual disabilities (slower in all areas of conceptual development and social and daily living skills), obsessive-compulsive disorder (personality disorder characterized by excessive orderliness, perfectionism, attention to details, and a need for control in relating to others), cognitive communication deficit, Parkinson's disease (progressive nervous system disorder that affects movement), schizoaffective disorder-bipolar type ( mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms). Record review of the residents quarterly MDS, dated [DATE], showed the following: -The resident had mild cognitive impairment; -He/she had no side rails or alarms. Record review of the resident's physician's order sheet (POS), dated 1/13/22, showed no order for any side rail use. Record review of the the resident's current care plan showed staff did no care plan side rail usage. Observations of the resident's bed showed the following: -On 1/11/22, at 10:45 A.M., left half side rail was on the resident's bed in the up position; -On 1/12/2022, at 9:20 A.M., left half side rail in the up position;. -On 1/13/2022, at 8:45 A.M., left half side rail in the up position. During an interview on 1/13/22, at 8:45 A.M., the resident said he/she used the side rail for the call light and to sit up in the bed. Record review of the resident's medical record showed staff did not document a complete side rail evaluation (to include a risk/benefit review and alternatives attempted prior to use of side rails), ongoing evaluation of side rails, obtaining informed consent for side rails, and a side rail safety check and regular inspections of the bed frame and side rails for risk of entrapment. 4. Record review of Resident #41's face sheet showed the following: -admission date of 11/6/21; -Diagnosis included central cord syndrome (incomplete spinal cord injury characterized by impairment in the arms and hands and to a lesser extent in the legs),neuromuscular dysfunction of bladder (lack of bladder control due to brain, spinal cord or nerve problems), abnormalities of gait and mobility (unable to walk in the usual way), and anxiety disorder. Record review of the resident admission MDS, dated [DATE], showed the following: -The resident had moderate cognitive impairment; -He/she had no side rails or alarms. Record review of the resident's current care plan showed staff did not care plan side rail usage. Record review of the resident's POS, dated 1/13/22, showed no order for side rail use. Observation on 1/10/22, 12:20 P.M., showed the resident in bed resting and bilateral half side rails in the up position. Observation on 01/11/22, at 10:28 A.M., showed the bilateral half side rails in the up position. Observation and interview on 01/12/22, at 9:01 A.M., showed the bilateral half side rails, in the up position. The resident rested in the bed. The resident said he/she is not able to use his/her arms. He/she said that he/she was not able to use the side rails for positioning. Record review of the resident's medical record showed staff did not document a complete side rail evaluation (to include a risk/benefit review and alternatives attempted prior to use of side rails), ongoing evaluation of side rails, obtaining informed consent for side rails, and a side rail safety check and regular inspections of the bed frame and side rails for risk of entrapment. During interviews on 1/13/2022, at 9:00 A.M. and 11:05 A.M., the Director or Nursing (DON) said the resident and his/her family wanted the resident to have side rails. 5. Record review of Resident #64's face sheet showed the following: -admission date of 12/21/20; -Diagnoses included multiple sclerosis (chronic disease affecting the central nervous system (the brain and spinal cord), repeated falls, abnormalities of gait and mobility (unable to walk in the usual way), and Unspecified disorder of adult personality and behavior (mental disorder in which you have a rigid and unhealthy pattern of thinking, functioning and behaving). Record review of the resident's annual MDS, dated [DATE], showed the following: -The resident had moderate cognitive impairment; -He/she had no side rails or alarms. Record review of the resident's POS, dated 1/13/22, showed no order for side rail use. Record review of the the resident's current care plan showed staff did not care plan side rail usage. Observation and interview on 01/10/22, at 12:10 P.M., showed the bilateral side rails in the middle of the bed. The resident was in bed with the television on. Resident said he/she was not able to use his/her arms and required assistance of staff to transfer to the wheelchair. Observation on 01/11/22, at 2:22 P.M., showed the left half side rail had been raised to the top of the bed and the right side rail was in the up position in the middle of the bed frame. Observation on 01/12/22, at 1:26 P.M., showed two staff assisted the resident to standing position and transfer from the wheelchair to the bed. The staff completed personal hygiene cares and covered the resident. The staff put bilateral side rails in the up position. The resident did not use the side rails for mobility during personal cares. Record review of the resident's medical record showed staff did not document a complete side rail evaluation (to include a risk/benefit review and alternatives attempted prior to use of side rails), ongoing evaluation of side rails, obtaining informed consent for side rails, and a side rail safety check and regular inspections of the bed frame and side rails for risk of entrapment. During interviews on 1/13/2022, at 9:00 A.M. and 11:05 A.M., the DON the resident an hold onto the side rail when staff is repositioning him/her. Based on observation, interview, and record review, the facility failed to complete a side rail evaluation form, to include a risk/benefit review and alternatives attempted prior to use of side rails, failed to document an ongoing evaluation of side rails, failed to obtain a physician order for side rails, failed to obtain informed consent for side rails, failed to complete a side rail safety check and regular inspections of the bed frame and side rails for risk of entrapment, and failed to develop care plan interventions and approaches for side rails for ten residents, (Resident #5, Resident #11, Resident #17, Resident #31, Resident #41, Resident #47, Resident #54, Resident #64, Resident #65, and Resident #221) The facility census was 70. Record review of the facility's policy, titled Restraints, Use of, dated March 2015, showed the following: -Restraints shall only be used for the safety and well-being of the residents and only after other alternatives had been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptoms and never for discipline or staff convenience, or for the prevention of falls; -Equipment defined as a restraint included: Seat belt, soft cloth mittens, tray with spring-release device, side rails (bed rails), and appropriate restraint device as indicated; -Staff should obtain an order for the restraint; -Develop or review the resident's care plan for the type of restraint, reason for use, alternate methods to be used or method of application; -Determine the type of side rails to be used; -Determine the medical symptoms to be treated with side rails; -Involve the resident and resident ' s representative in planning for side rail use. Many residents request to have side rails up when in bed to improve bed mobility and provide a feeling of safety. Record review showed the facility did not provide a side rail policy separate from a restraint policy. 1. Record review of Resident #54's face sheet (a brief resident profile sheet) showed the following: -admission date of 8/18/20; -Diagnoses included congestive heart failure (CHF-a condition in which the heart doesn't pump blood as well as it should), dementia, and hemiplegia/hemiparesis (weakness and paralysis) following a stroke. Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 12/7/21, showed the following: -The resident was cognitively intact; -He/she had no side rails or alarms. Record review of the resident's physician orders (POS), dated 10/7/20, showed an order for a grab bar to assist with the resident positioning. Record review of the resident's care plan, last reviewed 12/7/21, showed the following: -An approach, dated 10/22/20, which showed the resident had a grab bar on his/her bed to help with positioning to transfer him/herself. Observations of the resident's bed in his/her room showed the following: -On 1/11/22, at 9:15 A.M., bilateral (both sides) half side rails (larger than grab bars) were on the resident's bed in the up position; -On 1/12/22, at 9:00 A.M., bilateral half side rails were in the up position; -On 1/13/22, at 8:15 A.M., bilateral half side rails were in the up position. The resident was resting in the bed. During an interview on 1/11/22, at 9:15 A.M., the resident said after he/she admitted to the facility, he/she had a fall out of the bed and the rails were installed. Record review of the resident's medical record showed staff did not document a complete side rail evaluation (to include a risk/benefit review and alternatives attempted prior to use of side rails), ongoing evaluation of side rails, obtaining informed consent for side rails, and a side rail safety check and regular inspections of the bed frame and side rails for risk of entrapment. During an interview on 1/12/2022, at 2:14 P.M., Certified Medication Technician (CMT) O said the resident has rails to keep him/her from rolling out of bed. 2. Record review of Resident #47's face sheet showed the following: -admission date of 11/22/21; -Diagnoses included adult failure to thrive (a decline seen in older adults-typically those with multiple chronic medical conditions-resulting in a downward spiral of poor nutrition, weight loss, inactivity, depression, and decreasing functional ability), syncope and collapse (a temporary loss of consciousness caused by a fall in blood pressure), and cognitive communication deficit (difficulty with thinking and how someone uses language). Record review of the resident's admission MDS, dated [DATE], showed the following: -The resident was moderately cognitively impaired; -He/she had no side rails or alarms. Record review of the resident's current POS showed no order for side rail usage. Record review of the resident's current care plan showed staff did not care plan side rail use. Observations of the resident's bed showed the following: -On 1/11/22, at 1:34 P.M., the resident had bilateral half rails, positioned in the up position, in the center of the mattress; -On 1/12/22, at 2:05 P.M., the left half rail was in the down position, the right half rail was in the up position. The rails were positioned in the center of the mattress; -On 1/13/22, at 8:48 A.M., the left half rail was in the up position, the right half rail was in the down position. Both rails were positioned in the center of the mattress. Record review of the resident's medical record showed staff did not document a complete side rail evaluation (to include a risk/benefit review and alternatives attempted prior to use of side rails), ongoing evaluation of side rails, obtaining informed consent for side rails, and a side rail safety check and regular inspections of the bed frame and side rails for risk of entrapment. During an interview on 1/12/2022, at 2:14 P.M., Certified Medication Technician (CMT) O said the resident has rails to keep him/her from rolling out of bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Record review of Resident #221's admission MDS, dated [DATE], showed the following information: - Cognitively intact; - Required extensive assistance with two person physical assist from staff for bed mobility, dressing, and toileting; - Always continent of bowel and bladder. Record review of the resident's care plan, dated 12/23/21, showed the following information: -The resident was incontinent of bowel and bladder and was at risk for skin impairment, urinary tract infection (an infection of the bladder and/or other parts of the urinary system), and odor; -Staff will give the resident verbal prompts, cuing, and/or assistance, as needed to find and use the bathroom, and staff will assist the resident as needed with perineal care and clothing changes for incontinent episodes; - Staff would provide perineal care when the resident was incontinent, check the resident's skin for redness and/or skin breakdown and apply topical barrier cream with each incontinent episode; - Staff would toilet the resident every two hours and as needed while the resident is awake. Observation on 1/12/22 at 11:32 A.M., showed the following: -CNA A and CNA B washed their hands and applied gloves before providing incontinent care on the resident; -Without removing his/her gloves or washing his/her hands, CNA B applied antifungal cream to the resident's bottom with his/her left gloved hand; -CNA B then removed his/her left-hand glove that had the antifungal cream on it, and CNA B applied a new glove to that hand without washing his/her hands; -The two CNAs then rolled the resident, applied a new brief to the resident, and applied pants to the resident; -CNA B removed his/her gloves and applied new gloves without washing his/her hands; -CNA A applied a mechanical lift pad under the resident and lifted the resident with the mechanical lift to the wheelchair while CNA B guided the resident to the wheelchair; -CNA B removed the trash bag from the trash bin, removed his/her gloves, and washed his/her hands; -CNA A made the bed and then removed his/her gloves and washed his/her hands. 6. Record review of Resident #7's care plan, last reviewed 9/30/20, showed the following information: -The resident was frequently incontinent of bowel and bladder and was at risk for skin impairment, urinary tract infection, and odor; -Staff would check and change briefs every two hours and as needed; -Staff would give verbal prompts, cueing, and/or assistance as needed to find and use the bathroom, and staff would assist as needed with perineal care and clothing changes for incontinent episodes; -Staff would toilet every two hours and as needed while awake. -Staff would monitor for signs and symptoms of urinary tract infection and notify the physician. Record review of the resident's quarterly MDS, dated [DATE], showed the following information: - Severe cognitive impairment; - Required extensive assistance with two person physical assist from staff for bed mobility, transfers, dressing, toilet use, and personal hygiene; - Always incontinent of bowel and bladder. Observation on 1/13/22 at 7:01 A.M., showed the following: -CNA A and CNA C, both washed their hands and applied gloves; -CNA A raised the bed and opened the new brief; -CNA A and CNA C provided incontinent care; -CNA A removed his/her gloves and applied new gloves without washing his/her hands; -CNA A applied zinc paste to the resident's bottom; -CNA A removed his/her gloves and washed his/her hands and applied new gloves; -CNA A applied a new brief, pants, and house shoes to the resident; -Both aides assisted the resident up to the sit to stand (a type of mechanical lift used to help transfer residents from a seated position to a standing position to help the resident transfer between bed and chair) and moved the resident to the wheelchair; -Both aides applied a clean shirt to the resident; -CNA A removed his/her gloves; -CNA C brushed the resident's dentures wearing the same gloves he/she wore from the beginning of the resident care; -CNA A washed his/her hands while CNA C applied dentures into the resident's mouth wearing the same gloves he/she used from the beginning of the resident care; -CNA C then removed his/her gloves and washed his/her hands. 7. During an interview on 1/12/22, at 1:52 P.M., CNA B said staff should wear gloves when completing resident care and should wash their hands between residents. During an interview on 1/13/2022 at 7:20 A.M., CNA B said staff should perform hand hygiene before beginning incontinent care and when finishing incontinent care. During an interview on 1/13/2022 at 7:25 A.M., CNA E said staff should perform hand hygiene before beginning incontinent care, should change gloves when going from a soiled body surface to a clean body surface, and after completing incontinent care. During an interview on 01/13/22 at 8:34 A.M., CNA A said he/she received training for incontinent care in his/her CNA training classes and during facility in-services. CNA A said he/she was told to do hand washing before and after resident care, including with incontinent care. During an interview on 01/13/22 at 8:35 A.M., CNA C, said he/she got training on hand washing with his/her CNA training classes with the facility's CNA educator. CNA C said staff are to wash hands before and after resident care. It is the same with incontinent care. Staff are wash their hands before and after incontinent care, and also in between incontinent care staff are to take dirty gloves off and wash their hands, put clean gloves on before touching the resident again. During an interview on 1/13/2022 at 8:55 A.M., Certified Medication Technician (CMT) F said staff should perform hand hygiene before beginning incontinent care, between soiled and clean body surfaces, and when finished performing incontinent care. During an interview on 01/13/22 at 9:26 A.M., Registered Nurse (RN) D said staff get training on hand washing at the facility's monthly in-services. Aides should wash their hands between every resident, and aides should wash their hands during incontinent care, both before and after resident care and in between touching clean and dirty items or residents. Handwashing should be done after they've touched a soiled brief or resident, before a clean brief is applied to a resident. During an interview on 01/13/22 at 9:30 A.M., the Director of Nursing (DON) said aides should wash hands any time they come in contact with a residents. With incontinent care aides should wash their hands after they're done changing a resident. Aides should change their gloves and wash hands or sanitize hands after touching a soiled brief or soiled resident. During an interview on 1/13/22 at 12:25 P.M., the Administrator said staff should wash their hands in between any clean and dirty stuff, including with incontinent care. Staff should wash their hands or sanitize hands between dirty and clean steps of incontinent care. Staff should wash their hands between different residents and that if staff change their gloves they should also wash or sanitize their hands. 4. Record review of Resident #64's face sheet showed the following: -Diagnosis included multiple sclerosis (chronic disease affecting the central nervous system (the brain and spinal cord)), local infection of the skin of left hand on the second and third digits (fingers), and anxiety disorder. Record review of resident's annual MDS, dated [DATE], showed the following: -Resident required extensive assistance of two staff for bed mobility, transfers, dressing, toileting, and personal hygiene; -Resident was always incontinent of bowel and bladder; -Resident required wheelchair for locomotion. Record review of the residents care plan, updated 12/16/21, showed the following: -The resident needed assist with activities of daily living (tasks such as bathing, grooming, and dressing); -He/she was incontinent of bowel and bladder and was at risk for skin impairment, urinary tract infection (an infection of the bladder and/or other parts of the urinary system), and odor; - Staff would provide perineal care when the resident was incontinent, check the resident's skin for redness and/or skin breakdown and apply topical barrier cream with each incontinent episode; - Staff would toilet the resident every two hours and as needed while the resident is awake. Observation on 01/12/22 at 1:26 P.M., showed the following: -CNA E and CNA C entered the resident's room and applied gloves; -Staff removed dirty linens from the bed and removed foot pedals from wheelchair; -The CNA's applied a gait belt and assisted the resident to stand and transfer to bed; -Staff removed the resident's pants and socks and removed an incontinent brief; -CNA E and CNA C provided peri-care; -Wearing the same gloves, CNA E pulled resident's covers up, adjusted pillow, and ensured resident had call light.Based on observation, interview, and record review, the facility failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious carrying contaminants when staff failed to use appropriate hand hygiene after performing incontinent care for four residents (Resident #7, Resident #64, Resident #69, and Resident #221), and failed to maintain an infection control program that provided a safe and sanitary environment for all residents during a Coronavirus Disease 2019 (COVID-19, an infectious disease caused by severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2)) pandemic when staff failed to follow their policy and standards of practice when staff failed to wear personal protective equipment (PPE) facemasks appropriately in a home with a COVID outbreak. The facility census was 70. 1. Record review of the updated guidance for healthcare workers from the Centers for Disease Control and Prevention (CDC) titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel during the Coronavirus Disease 2019 (COVID-19) Pandemic, updated on 09/10/2021, showed the following: -Implement Source Control Measures -- Source control refers to use of respirators or well-fitting facemasks or cloth masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing; -Source control options for health care personnel (HCP) include: a NIOSH-approved N95 or equivalent or higher-level respirator; or a respirator approved under standards used in other countries that are similar to NIOSH-approved N95 filtering face piece respirators (note: these should not be used instead of a NIOSH-approved respirator when respiratory protection is indicated); or a well-fitting facemask; -Source control and physical distancing (when physical distancing is feasible and will not interfere with provision of care) are recommended for everyone in a healthcare setting. This is particularly important for individuals, regardless of their vaccination status, who live or work in counties with substantial to high community transmission. Record review of the COVID Data Tracker, on the CDC website, showed the facility's county had a high transmission rate for 01/10/22 to 01/14/22. Record review of the updated guidance for healthcare workers from the CDC titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel during the Coronavirus Disease 2019 (COVID-19) Pandemic, updated on 02/23/21, showed the following: -Source control refers to use of well-fitting cloth masks, facemasks, or respirators to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing; -Health Care Providers (HCP) should wear well-fitting source control at all times while they are in the healthcare facility, including in break rooms or other spaces where they might encounter co-workers. Record review of the CDC guidance for Healthcare Workers, titled Facemask Do's and Don'ts, dated 06/02/20, showed the following: -Do secure the bands around the ears; -Do secure the straps at the middle of the head and the base of the head; -Don't wear the facemask under the nose or mouth; -Don't wear the facemask around the neck. Observation on 1/12/22 showed the following: -At 2:11 P.M., Certified Nurse Aide (CNA) J had his/her face mask below his/her nose and just below his/her upper lip, staff entered a resident room in the 400 hall and asked how he/she was feeling. He/she then left the room. His/her face mask remained below his/her nose; -At 2:13 P.M., CNA J entered another resident room with his/her face mask below his/her nose and upper lip. The CNA checked on the resident; -At 2:15 P.M., CNA J cleaned a resident's face with a wet wipe in the 400 hall with his/her face mask remaining below the nose and upper lip. Observations on 1/13/22 showed the following: -At 6:28 A.M., Nursing Assistant (NA) I exited the dining room and came into the center of the facility with his/her N95 down under his/her mouth and nose. Multiple unmasked residents were in the dining room; -At 6:30 A.M., Certified Medication Technician (CMT) F walked in the center area of the facility with his/her N95 mask down under his/her mouth. One unmasked, unnamed resident was sitting nearby in a wheelchair, resting with his/her eyes closed, and with his/her mouth open. During an interview on 1/13/2022 at 6:40 A.M., Certified Medication Technician (CMT) F said he/she has had in-services on how to wear his/ her mask properly. Masks should be worn covering the mouth and nose and any time he/she is in the building. It is never appropriate to be in the building with his/her mask down. He/she had been educated on how Covid spreads. During an interview on 1/13/2022 at 6:50 A.M., NA I said masks should be worn covering the mouth and nose, and any time staff is in the building. If the mask had to be down at any time, staff should go in the bathroom. It was never acceptable to be near residents with masks down. During an interview on 1/13/2022 at 9:00 A.M., the Director of Nursing (DON) said staff are in-serviced regarding PPE. She expected staff to wear PPE at all times when they are in the building. She expected staff to wear masks covering their mouth and nose. If staff need to pull their masks down for a few moments, they are to go in the bathroom or in an empty office. It is never acceptable to be in a resident area. 2. Record review of the Centers for Disease Control and Prevention (CDC) website, updated 1/30/2020, showed the following: -Hand hygiene (washing hands or using alcohol based hand rub) should be performed before putting on gloves; -Hand hygiene should be performed before moving from work on a soiled body site to a clean body site on the same resident; -Hand hygiene should be performed after body fluid exposure or assisting with toileting, or performing wound care; -Hand hygiene should be performed after direct contact with a resident; -Hand hygiene should be performed after removing gloves. Record review of the CDC guidance for Healthcare Providers, titled Clean Hands Count for Healthcare Providers, reviewed 1/8/2021, showed the following: -Hand hygiene means cleaning hands by using either handwashing, antiseptic hand wash, antiseptic hand rub (alcohol based hand sanitizer), or surgical hand antisepsis (the practice of using antiseptics to eliminate the microorganisms that cause disease); -Hand hygiene should be performed immediately before touching a patient; -Hand hygiene should be performed before moving from work on a soiled body site to a clean body site on the same patient; -Hand hygiene should be performed before applying gloves; -Hand hygiene should be performed after touching a patient or the patient's immediate environment; -Hand hygiene should be performed immediately after glove removal. Record review of the facility policy, titled Perineal Care (cleaning the private areas of a patient), dated March 2015, showed the following: -The purpose of perineal care is to prevent infection and odor; -Put on gloves; -Clean resident's genital area; -Clean resident's buttocks; -Remove gloves and perform hand hygiene; -Reposition resident, replace blanket. 3. Record review of Resident #69's face sheet (a brief summary sheet) showed the following: -Diagnoses included hypo-osmolality (a condition where the levels of electrolytes, proteins, and nutrients in the blood are lower than normal), hyponatremia (a condition where the level of sodium in the blood is too low), urinary tract infection (UTI), anxiety, and depression. Record review of the resident's care plan, updated 10/27/21, showed the following: -The resident needed assist with activities of daily living (tasks such as bathing, grooming, and dressing); -He/she was continent of bowel and bladder, but should have incontinent care provided if he/she has incontinent episodes. Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 12/23/21, showed the following: -The resident was cognitively intact; -He/she was continent of bowel and bladder. Observation on 1/13/2022 at 7:00 A.M., showed the following: -CNA B and CNA E performed hand hygiene and entered the resident's room; -CNA B and CNA E performed incontinent care; -The CNAs did not remove their gloves or perform hand hygiene during or after pericare; -The CNAs put a new brief on the resident and put clean pants on the resident; -The CNAs rolled the resident back over in bed, and removed the resident's shirt; -The CNAs placed the resident's boots on his/her feet; -CNA B removed the dirty trash bag from the waste can; -The CNAs assisted the resident to his/her recliner; -The CNAs removed the old linens from the bed and placed them into a bag; -The CNAs then removed their gloves and performed hand hygiene.

Based on interview and record review, the facility failed to provide the services of a registered nurse (RN), other than the Director of Nursing, for at least eight consecutive hours per day seven days per week with the facility average daily occupancy over 60 residents. The facility census was 70. Record review showed the facility did not provide a policy regarding RN coverage. 1. Record review of the facility Daily Nurse Staffing Form (posted staffing sheets), dated December 2021 and January 2022, showed no RN was scheduled from 6:00 A.M.-2:00 P.M., 2:00 P.M.-10:00 P.M., and 10:00 P.M.-6:00 A.M. shifts on the following days: -On 12/6/21, with a census of 72. -On 12/10/21, with a census of 73; -On 12/11/21, with a census of 72; -On 1/10/22, with a census of 70. During interview on 1/13/22, at 11:05 A.M., the Director of Nursing (DON) said the following: -The facility currently only had one full-time RN, two part-time RN's, and two as needed (PRN) RN's; -There had been no Assistant Director of Nursing (ADON) since 12/20/21 and no Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff) staff since 12/23/21; -She thought that she was able to count herself as the RN in the building. During an interview on 1/12/22, at 9:50 A.M., the Administrator said the facility had multiple days over the past three months where there was no RN coverage, and the DON covered those days. The DON covered multiple weekends as well, and was under the assumption that if the weekends were not her usual scheduled days, those days would be covered as an RN, and not as DON.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide restorative nursing services to maintain or improve residents' functional status as directed by therapy for one resident (Resident #79) out of 18 sampled residents. The facility census was 82. Record review of the facility's policy titled, the restorative nursing (RNA) program, updated 5/1/06, showed the following information: -The restorative nursing program is an integral part of maximizing the daily restorative care process for the resident; -The RNA program is a part of the logical step-down process in resident care; -A proactive approach is necessary to prevent future negative outcomes. -It is the purpose of this facility to see that each resident receives and the facility provides the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. -It is the entire staff's responsibility to prevent deterioration and further functional loss of each resident in the facility. The objective of the RNA program is to provide restorative care necessary to meet the needs of all residents to enable them to achieve the standard of care as described by OBRA, 1987. -Clean lines of authority, expectations, and responsibilities are necessary for implementation of the RNA program; -Restorative services are to be made available seven days a week, per resident's assessed needs; -Criteria for resident entry to, movement within, and discharge from the RNA program must be clearly established; -A mechanism for monitoring and on-going evaluation of the RNA programs must be established; -Restorative Nursing Aids (RNA's) must be adequately trained and provided with on-going training and consultation. 1. Record review of Resident #79's admission record showed the resident admitted to the facility on [DATE]. Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 2/26/19, showed the following information: -Cognitively intact; -Required extensive assistance for bed mobility, transfer, dressing, toilet use, and personal hygiene; -Activity did not occur for walk in room and walk in corridor; -Not steady in moving from seated to standing position, moving on and off toilet, and surface to surface transfer; -Activity did not occur for walking and turning around; -Impairment on one side for upper and lower extremities; -Mobility devices included a wheelchair. Record review of the resident's care plan, revised on 2/28/19, showed the following information: -Resident moved about in electric wheelchair, having the chair was very important to resident because the resident had left sided hemiparesis from a stroke; -Resident needed help with almost all of activity of daily living (ADLs), such as dressing, bathing, toileting, and transfers; -Staff to assist resident with ADLs as needed. Encourage to do what he/she could safely to promote independence to the extent possible with disease process; -Required extensive assistance to dependence with transfers/mobility; -Observe, document, and report any decline in function and provide increased assistance as needed; -RNA as ordered; -Staff did not address any specific restorative nursing plan for the resident. Record review of the nurses' notes, dated 4/15/19, showed staff sent the resident to the emergency room. Record review of the resident's face sheet, showed the following information: -Returned to the facility on 4/22/19; -Diagnoses included heart failure, contracture of muscle (permanent shortening of the muscle), unspecified site; hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side (left sided weakness after a stroke); generalized muscle weakness; unspecified abnormalities of gait and mobility. Record review of the nurses' notes, dated 4/22/19, showed the resident readmitted to the facility from the psychiatric unit. Resident in electric wheelchair. Record review of the physician order sheet (POS), dated 4/25/19, showed an order for occupational therapy (OT) to begin treatment five times a week for four weeks for ADLs, functional activity, and therapy exercise. Record review of the resident's physical therapy (PT) Discharge summary, dated [DATE], showed the following information: -Received PT services from 4/23/19 until 5/8/19; -Skilled services provided since start of care included therapy exercises/activities, improved patient's abilities in ADLs; -Post discharge recommendations for staff follow through included sit to stand lift; -Precautions included low endurance, need frequent rests, balance precaution include fall risk, impulsive at times, needs assistance device of electric wheelchair, and left-sided hemiplegia; -Discharge plans and instructions included: discharge planned for this patient, recommendations discussed with patient and/or caregivers included Restorative Nursing Program (RNP). Record review of the current POS did not show any order for restorative services. During an interview on 5/20/19, at 10:00 A.M., Resident #79 said he/she had suffered a stroke that resulted in his/her left side being paralyzed. He/she had finished therapy about three weeks ago and would like to have restorative services. Observations on 5/21/19, showed the following: -At 8:39 A.M., the resident sat in the hallway in his/her wheelchair. The resident wore a splint on his/her left hand. -At 10:49 A.M., showed the resident wheeled self down the hall; -At 2:20 P.M., the resident sat in his/her wheelchair in the resident room, with splint on his/her left hand. During an interview on 5/22/19, at 9:41 A.M., the physical therapist said she had Resident #79 several times in therapy. They keep a splint on Resident #79's left hand to keep his/her fingers and hand straight so they will not contract. Resident #79 has had physical therapy and occupational therapy but he/she doesn't make big progress so Medicaid won't pay for it. Restorative will pick him/her up. There are physician orders for restorative. Resident #79 keeps moving and it helps to do sit to stand on the parallel bars. It also helps to keep the splint on. Resident #79 completed therapy about three weeks ago. She recommended Resident #79 should continue with restorative services. During an interview on 5/23/19, at 8:38 A.M., Certified Nursing Assistant (CNA) A said he/she is responsible for restorative services. He/she has not completed any restorative in the last month. He/she started providing restorative services in February for maybe a week. He/she completed one or two days of restorative services since February. Therapy will have a list of residents who would benefit from restorative, but he/she does not know if restorative is getting completed. He/she is working right now as a CNA and doing weights. During an interview on 5/23/19, at 10:15 A.M., CNA B said CNA A is supposed to be doing restorative but most of the time he/she works as a CNA providing personal care. CNA B is a bath aide but works on the hall providing CNA care three days a week. Last couple weeks have been ok. The facility will pull a shower aide or restorative aide because they are short on the floor with CNAs. During an interview on 5/23/19, at 10:29 A.M., CNA E said CNA A is the restorative aide. CNA A gets pulled five out of five days to work the floor as a CNA and is not providing restorative services. During an interview on 5/23/19, at 10:39 AM, Registered Nurse (RN) C said restorative services are not happening because the aide is having to work the floor as a CNA. Sometimes physical therapy will seek residents out who are needing help and help them. During an interview on 5/23/19, at 10:49 A.M., RN D said CNA A provides restorative services with physical therapy's help. CNA A is not providing restorative services right now. During an interview on 5/23/19, at 11:26 A.M., the administrator said it is hit or miss on restorative. They have had some shortages and they pull from there. A bath aide had some medical issues and they pulled the restorative aide to help provide direct personal care. CNA A was going to provide restorative services, but the facility cannot do without him/her working as a CNA right now. It has been two or three months since the facility has provided restorative services. It would be easier if they used a Certified Medication Technician (CMT). The facility felt that getting showers completed was more important than restorative at that point. During an interview on 5/23/19, at 12:39 P.M., the Director of Nursing (DON) said the restorative aide walked out on 11/15/18. The facility hired some staff and interviewed for restorative in February and hired CNA A. CNA A probably worked a month doing both CNA work and restorative work two or three times a week. Last month, April 2019, a bath aide hurt his/her back and they felt showers were more important so they had CNA A work the floor, as a CNA. They lost more staff and that is why CNA A hasn't done restorative.