Based on observation, interview, review of facility policy, and review of the Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure staff implemented proper infection control practices while providing care to residents on enhanced barrier precautions. This affected two of three residents (#13 and #45) reviewed for infections and had the potential to affect 25 additional residents (#29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #31, #42, #43, #44, #46, #47, #48, #49, #50, #52, #52, #53 and #54) who resided on the 200 hall where State Tested Nurse Aide (STNA) #340 contaminated high touch surfaces. The facility census was 54. Findings include: 1. Review of the medical record for Resident #13 revealed an admission date of 02/20/24 with diagnoses including pneumonia, type two diabetes mellitus, dependence on renal dialysis, dislocation of the tarsometatarsal joint of the right foot, and osteomyelitis (infection of the bone) of the right ankle and foot. Review of the admission Minimum Data Set (MDS) assessment completed on 02/24/24 revealed Resident #13 had intact cognition, was frequently incontinent of bowel and bladder, had a surgical wound, and an infection of the foot. Review of the physician orders revealed an order dated 02/22/24 indicating Resident #13 had an external fixator to her right lower extremity and an order dated 03/13/24 revealed Resident #13 had a dialysis catheter in her right subclavian. Review of the care plan revealed Resident #13 was placed in enhanced barrier precautions (EBP) on 02/21/24 secondary to a wound and medical device. Interventions included staff were to wear a gown and gloves for care per recommendations for EBP. Random observation on 03/25/24 at 10:40 A.M. revealed a sign posted to the left of Resident #13's door signaling visitors Resident #13 was on EBP. There was no personal protective equipment (PPE) outside her room at the time of this observation. Observation from outside Resident #13's room on 03/25/25 at 11:46 A.M. revealed the sign indicating Resident #13 was on enhanced barrier precautions, but no cart, stand, or drawers containing PPE was found outside the door to her room. Further observation revealed Physical Therapist (PT) #357 was sitting on Resident #13's bed moving her right leg with the external fixator, and she was not wearing a gown at the time of care. As the observation continued, PT #357 was noted completing additional exercises with Resident #13 then repositioning her in the bed. Interview on 03/25/24 at 11:55 A.M. with PT #357 confirmed she was sitting on Resident #13's bed with no gown while assisting with therapeutic exercises. Further interview revealed PT #357 did not realize Resident #13 was still on EBP, since there was no PPE outside the door. At this time, PT #357 confirmed the sign indicating Resident #13 was in EBP was still posted beside her door. Interview on 03/25/24 at 11:58 A.M. with Registered Nurse (RN) #350 confirmed Resident #13 was on EBP due to her wound status and further confirmed there was no PPE outside the door to Resident #13's room. During the interview, RN #350 confirmed PPE was supposed to be outside the resident rooms when they were on any type of precautions. Interview on 03/25/24 at 5:1 P.M. with RN #319 confirmed PPE should be available outside the resident's rooms when on enhanced barrier precautions and should be checked and restocked at the end of every shift and as needed. Review of the undated facility policy titled Enhanced Barrier Precautions revealed wounds and indwelling medical devices were indications for being placed on EBP and the facility was to ensure PPE was maintained outside the resident's room. Further review of the policy revealed staff were to wear gowns for high touch resident care activities. 2. Review of the medical record for Resident #45 revealed an admission date of 05/31/23 with diagnoses including infection and inflammatory reaction due to an indwelling urethral catheter, neuromuscular dysfunction of the bladder, atrial fibrillation, bipolar disorder, dysphagia, kidney failure, and dementia. Review of the Minimum Data Set (MDS) assessment completed on 03/04/24 revealed Resident #45 had severely impaired cognition, had an indwelling catheter, was always incontinent of bowel, and was dependent on staff for bathing, toileting, and personal hygiene. Review of the care plan revealed Resident #45 was placed in enhanced barrier precautions (EBP) on 06/01/23 secondary to a suprapubic catheter, wounds, and a percutaneous endoscopic gastrostomy (PEG) tube (a tube through the resident's stomach for nutrition and/or medications). Interventions included staff were to wear a gown and gloves during care per recommendations for EBP. Observation on 03/25/24 at 2:45 P.M. of catheter care revealed State Tested Nurse Aide (STNA) #340 did not bag the soiled linen, then used soiled gloved hands to open and close Resident #45's bedroom door and the soiled linen cart in the hallway. During the observation, STNA #340's soiled gloved hands touched both the inside and the outside doorknobs, as well as the soiled linen cart other staff were observed pushing through the hallway throughout the day of the survey. This process occurred twice during the observation of catheter care. Interview on 03/25/24 at 2:50 P.M. with STNA #340 confirmed she opened and closed Resident #45's door and handled the linen cart in the hallway with soiled gloves both times she removed soiled linen from Resident #45's room. During the interview, STNA also confirmed staff were supposed to place soiled linen into plastic bags as they were used during care and close the bags filled with soiled linen prior to removing them from residents' rooms. Interview on 03/2/24 at 3:10 P.M. with the Administrator confirmed Resident #45's doorknobs should not have been handled with soiled gloves. Interview on 03/25/24 at 5:20 P.M. with the Director of Nursing (DON) confirmed exposed linen was not supposed to leave the resident's room and that the linen should first be bagged. Interview with the DON further confirmed soiled gloves should not be used to manipulate high touch surfaces like doorknobs. Review of the policy titled Laundry and Bedding, Soiled, dated September 2022 revealed contaminated linen and laundry bags should not be held close to the body, should be handled with minimal agitation, and staff should use appropriate standard precautions. Review of CDC Updates as of July 12, 2022 revealed the following. 1. Multidrug-resistant organism (MDRO) transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. 2. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. 3. EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: o Wounds or indwelling medical devices, regardless of MDRO colonization status o Infection or colonization with an MDRO. 4. Effective implementation of EBP requires staff training on the proper use of personal protective equipment (PPE) and the availability of PPE and hand hygiene supplies at the point of care. 5. Standard Precautions, which are a group of infection prevention practices, continue to apply to the care of all residents, regardless of suspected or confirmed infection or colonization status. Review of the resident census provided by the facility dated 03/24/25 revealed Residents #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #31, #42, #43, #44, #46, #47, #48, #49, #50, #52, #52, #53 and #54 resided on the 200 hall. This deficiency represents non-compliance investigated under Complaint Number OH00151588.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of medical record for Resident #33 revealed an admission date of 09/24/21. Diagnoses included chronic obstructive pulmonary disease (COPD) with (acute) exacerbation and chronic respiratory failure. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #33 was cognitively intact and did not use oxygen. Review of Resident #33's physician orders revealed an order dated 11/18/22 for oxygen two liters via nasal cannula, may titrate as needed. Review of Resident #33's care plan dated 09/25/21 revealed the resident had an impaired respiratory status related to anxiety, being a current smoker, and having shortness of breath. Interventions included oxygen as ordered by the physician. Observation on 01/16/24 at 10:35 A.M. of Resident #33's room revealed the resident was not in the room, but there was an oxygen concentrator in room. Observation on 01/17/24 at 9:42 A.M. revealed Resident #33 was in room receiving oxygen via nasal cannula. Interview on 01/18/24 at 10:02 A.M. with RN #354 confirmed the Resident #3's quarterly 12/13/23 MDS was incorrectly marked, since Resident #33 should have been marked as receiving oxygen. Based on medical record review, observation, and interview, the facility failed to accurately reflect residents' status on Minimum Data Set (MDS) assessments related to mental health status and oxygen use. This affected three (Residents #11, #21, and #33) of 24 residents whose assessments were reviewed. The facility census was 53. Findings include: 1. Review of Resident #11's medical record review revealed diagnoses including schizoaffective disorder (bipolar type), psychosis, pseudobulbar affect, depression, bipolar disorder and anxiety disorder. A Preadmission Screen and Resident Review dated 07/05/22 indicated Resident #11 had no indications of serious mental illness. Resident #11 was hospitalized between 11/14/22 and 12/07/22. Review of a Preadmission Screen and Resident Review Determination (PASRR) determination revealed Resident #11 was approved for nursing facility services. The attached summary report dated 12/01/22 indicated Resident #11 was first medically hospitalized ( for increased ammonia level in the blood and diagnosed with pneumonia and metabolic encephalopathy) and when stable was transferred to the inpatient psychiatric unit. The summary indicated Resident #11 had mental health diagnoses of psychotic disorder, language disorder - cognitive communication deficit, major depressive disorder, bipolar disorder, and dependence on psychotropic medications with induced mood disorder and anxiety disorder. The summary indicated Resident #11 was hospitalized for having unreal thoughts and seeing and hearing things that were not there. Resident #11 also exhibited physical aggression. The summary indicated Resident #11 had one inpatient psychiatric hospitalization in the past two years and was receiving psychotropic medication. There were no recommendations for disability specific services. However, the summary indicated services and supports which would be needed to be provided included an Occupational Therapy evaluation, a safety plan, ongoing evaluation of the effectiveness of psychotropic medications on target symptoms, ongoing medication review by a psychiatrist or similarly-credentialed professionals, medication evaluation and monitoring by a designated physician, family involvement in care, and socialization and recreation activities to decrease isolation, improve mood and increase social interaction. Review of Resident #11's annual MDS dated [DATE] indicated Resident #11 was not currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or related conditions. During an interview on 01/18/24 at 9:48 A.M., Registered Nurse (RN) #355 verified the annual MDS dated [DATE] was marked incorrectly regarding serious mental illness. 2. Review of Resident #21's medical record revealed diagnoses including bipolar disorder, schizoaffective disorder, brief psychotic disorder, and anxiety disorder. Resident #21 was admitted to the facility 06/19/20. Review of a facsimile (fax) dated 06/17/20 revealed the facility in which Resident #21 previously resided provided PASRR information they had available. A PASRR identification screen dated 06/22/17 indicated Resident #21 had a diagnosis of bipolar disorder and had continuously received ongoing case management from a mental health agency over two years. Due to the mental health disorder, Resident #21 had experienced functional limitations on a continuing or intermittent basis over the prior six months. Resident #21 was determined to have indications of serious mental illness. A level II determination dated 04/02/18 indicated Resident #21 was located in a nursing facility and was requesting continued placement in a nursing facility. A resident review assessment was completed on 04/01/18. Resident #21 did not have the potential to live in the community and was receiving case management. The determination indicated Resident #21 had a history of serious mental illness with diagnoses including Bipolar 1 Disorder, mixed and severe major depressive disorder. The determination indicated Resident #21 had an unspecified personality disorder by history. No specialized services were recommended. The determination indicated services recommended included ongoing medication review by a physician to assure medical conditions were appropriately treated, medication education on the value of taking medication as prescribed, and a behavior management safety plan to decrease inappropriate behaviors and ensure safety. Review of Resident #21's annual MDS dated [DATE] indicated Resident #21 was not currently considered by state II PASRR process to have a serious mental illness. On 01/16/24 at 12:47 P.M., RN #355 verified the annual MDS section A1500 was marked incorrectly as the most recent PASRR determination indicated Resident #21 did have a serious mental illness.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to ensure preadmission screening and record review assessments were resubmitted after a new major mental illness diagnosis was added for Resident #43. This affected one (Resident #43) of four residents reviewed for preadmission screening and resident review. The facility census was 53. Findings include: Review of Resident #43's medical record revealed an admission date of 04/12/23 with diagnoses that included chronic obstructive pulmonary disease, hyperlipidemia, major depression and anxiety. A Preadmission Screening and Resident Review (PASARR) completed on 04/11/23 indicated Resident #43 had only anxiety. Upon admission to the facility, Resident #43 was prescribed Navane (antipsychotic medication) five milligrams (mg) twice daily which the resident was on long term prior to admission. Further review of the medical record, including psychiatrist evaluations, revealed the Navane was gradually reduced and discontinued on 06/06/23. Review of Resident #43's progress notes indicated the resident had a new onset of paranoid behaviors and was transferred and admitted directly to a geriatric in-patient psychiatric unit on 06/13/23. On 06/27/23 Resident #43 was readmitted to the facility with a new diagnosis of paranoid schizophrenia added. Review of hospital records revealed Resident #43 had a prior history of mental illness including schizophrenia with Navane use. On 06/22/24 the geriatric in-patient psychiatric hospital resubmitted a PASARR which indicated major depression with psychotic features. No evidence of schizophrenia was noted. No evidence of any new PASARR was submitted by the facility after readmission on [DATE] despite the new mental illness diagnosis of schizophrenia. On 01/17/24 at 10:48 A.M., interview with the Administrator verified no PASARR assessment was submitted following readmission with the identified new diagnosis of schizophrenia for Resident #43.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review and facility policy, the facility failed to ensure oxygen tubing was changed weekly for Residents #33 and #51. This affected two residents (#33 and #51) of four residents reviewed for respiratory care. The facility census was 53. Findings include: 1. Review of the medical record for Resident #33 revealed an admission date of 09/24/21. Diagnoses included chronic obstructive pulmonary disease (COPD) with (acute) exacerbation and chronic respiratory failure. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #33 was cognitively intact. Review of Resident #33's physician orders revealed an order dated 11/18/22 for oxygen two liters via nasal cannula, may titrate as needed. Review of Resident #33's care plan dated 09/25/21 revealed the resident had an impaired respiratory status related to anxiety, being a current smoker, and having shortness of breath. Interventions included oxygen as ordered by the physician. Observation and interview on 01/16/24 at 10:37 A.M. with Respiratory Therapist (RT) #354 revealed Resident #33 oxygen tubing was dated 12/20. RT #354 confirmed, at the time of observation, the tubing had a date of 12/20 and the tubing should be changed weekly. RT #354 stated it was his first day on the job, and he was getting ready to change it out. Interview on 01/16/24 at 10:38 A.M. with Resident #33 confirmed the oxygen tubing was not changed weekly, but it was usually changed every other week. 2. Review of the medical record for Resident #51 revealed an admission date of 11/27/23. Diagnoses included unspecified diastolic (congestive) heart failure and chronic obstructive pulmonary disease (COPD) with (acute) exacerbation. Review of the 11/30/23 admission Minimum Data Set (MDS) revealed Resident #51 was cognitively intact and used oxygen. Review of Resident #51's physician orders revealed an order dated 11/28/23 to change oxygen tubing and set up every night shift every Tuesday and an order dated 01/17/24 for three liters oxygen via nasal cannula as needed, may titrate as needed. Review of care plan dated 11/29/23 revealed Resident #51 had impaired respiratory status related to congestive heart failure (CHF) and COPD with emphysema. Interventions included provide oxygen as needed when the resident exhibits signs/symptoms of difficulty breathing (short of breath, cyanosis, and low oxygen saturation levels). Observation and interview on 1/16/24 at 10:27 A.M. with Respiratory Therapist (RT) #354 revealed Resident #51's oxygen tubing was dated 12/20. RT #354 confirmed, at the time of observation, the tubing had a date of 12/20 and the tubing should be changed weekly. RT #354 stated it was his first day on the job, and he was getting ready to change it out. Interview on 1/17/24 at 10:29 A.M. with Resident #51 confirmed his oxygen tubing was not changed out weekly. Review of facility policy Departmental (Respiratory Therapy), revised November 2011 revealed oxygen tubing should be changed every seven days and dated.

Based on interview, food committee meeting minutes and facility menu review, the facility failed to provide a menu which offered a variety of items served at the breakfast meal. This had the potential to affect 52 residents who received meals from the kitchen. The facility identified Resident #13 as receiving nothing by mouth. The facility census was 53. Findings include: Review of facility food committee meeting minutes dated 07/31/23 revealed concern related to repeating menu items was noted. Review of the facility's fall 2023-24 four-week (28 day) menu revealed scrambled eggs were served 14 out of 28 days. For week three, scrambled eggs were served five days (Sunday, Monday, Tuesday, Thursday, and Saturday) out of seven days and three days in a row between the end of week four and the beginning of week one (week four Saturday, week one Sunday, and week one Monday). Interview on 01/17/24 at 11:56 A.M. with the Dietary Supervisor revealed she did have residents complain to her there was too much repetition of some items on the menu. Interview on 01/17/24 at 1:14 P.M. with the Registered Dietitian confirmed, upon review of the menus, there was a lot of scrambled eggs, but scrambled eggs were a cheap option. She stated the menus came pre-made, but she had the option to adjust the menu. Interview on 01/17/24 at 3:24 P.M. with Resident #38 revealed there were too many scrambled eggs on the menu.

Based on observation, medical record review, and interview the facility failed to monitor circulatory status of a resident who had an edematous (swollen) left foot and studies indicating a thrombus (blood clot). This affected one (Resident #97) of 17 residents observed for evidence of edema. Findings include: Observations on 02/01/22 at 8:38 A.M. and 11:06 A.M. and on 02/02/22 at 7:50 A.M. and 12:20 P.M. revealed Resident #97 sitting on the side of his bed with his legs dangling off the side of the bed and his feet on the floor. Review of Resident #97's medical record revealed a diagnosis of a fracture of the left femur. On 12/30/21 an order was written for a venous ultrasound of the left lower extremity due to increased edema. Venous doppler results dated 12/31/21 indicated there appeared to be a thrombus (a blood clot formed in situ within the vascular system of the body and impeding blood flow) in the left gastrocnemius vein (The gastrocnemius vein is considered a deep muscular vein of the calf.) There was no evidence of circulatory assessments related to the thrombus. On 02/03/22 at 10:55 A.M., the Director of Nursing (DON) verified she was unable to locate any evidence of circulatory checks and stated she understood the concern of circulatory checks not being completed for a resident with a blood clot.

Based on observation, medical record review and staff interview the facility failed to ensure range of motion services were provided for residents identified with a limitation in joint mobility. This affected one (Resident #26) of two residents reviewed for range of motion services. The facility census was 46. Findings include: Review of Resident #26's medical record revealed an admission date of 10/18/15 and a readmission date of 09/18/19 with diagnoses that included Alzheimer's disease with dementia and congestive heart failure. Review of the Minimum Data Set (MDS) 3.0 assessment with a reference date of 12/31/21 indicated Resident #26 had limitation in range of motion to both upper and lower extremities. Further review of the medical record including a hospice recertification completed on 12/31/21 indicated Resident #26 had contractures to the bilateral legs and hands. Further review of the medical record found no evidence of any splint device use or any restorative services for joint mobility. No documentation was found to indicate a reason for joint mobility services not provided. Interview with the Director of Nursing on 02/03/22 at 8:55 A.M. verified Resident #26 had limitation in joint mobility to bilateral hands and legs, does not receive any joint mobility services and there was no documentation to indicate a reason for not providing joint mobility services.

Based on medical record review and staff interview the facility failed to ensure monthly pharmacy reviews identified physician orders were not being followed regarding acetaminophen administration. This affected one (Resident #12) of five residents reviewed for monthly pharmacy reviews. The facility census was 46. Findings include: Review of Resident #12's medical record revealed an admission date of 07/13/16 with diagnoses that included Alzheimer's disease with dementia, osteoarthritis and epilepsy. Review of the physician's orders revealed current orders for acetaminophen (analgesic) 650 milligram (mg) three times daily and Norco (hydrocodone and acetaminophen analgesic) 5 mg - 325 mg four times daily. A total of 3250 mg of acetaminophen was administered daily. Review of the Medication Administration Record (MAR) revealed acetaminophen and Norco administered daily as ordered for a total of 3.25 gm of acetaminophen administered each day. An additional physician's order indicated to not exceed 3 grams (gm) of acetaminophen daily. Review of monthly pharmacy recommendations revealed no indication the acetaminophen dosage exceeding physician orders was identified by the reviewing pharmacist. Interview with the Director of Nursing on 02/02/22 at 1140 A.M. verified Resident #12 received 3.25 gm of acetaminophen on a daily basis and monthly pharmacy recommendations did not address the acetaminophen dosage exceeding physician orders.

Based on medical record review and staff interview the facility failed to ensure physician orders were followed regarding acetaminophen dosage. This affected one (Resident #12) of five residents reviewed for medication use. The facility census was 46. Findings include: Review of Resident #12's medical record revealed an admission date of 07/13/16 with diagnoses that included Alzheimer's disease with dementia, osteoarthritis and epilepsy. Review of the physician's orders revealed current orders for acetaminophen (analgesic) 650 milligram (mg) three times daily and Norco (hydrocodone and acetaminophen analgesic) 5 mg - 325 mg four times daily. A total of 3250 mg of acetaminophen was administered daily. Review of the Medication Administration Record (MAR) revealed acetaminophen and Norco administered daily as ordered with 3.25 gm of acetaminophen administered each day. An additional physician's order indicated to not exceed 3 grams (gm) of acetaminophen daily. Interview with the Director of Nursing on 02/02/22 at 8:40 A.M. verified Resident #12 received 3.25 gm of acetaminophen on a daily basis despite the physician's order to not exceed 3 gm per day.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, review of the facility's admission packet and policy review, the facility failed to ensure dignity was maintained for three residents (Residents #32, #49, and #52) of five residents (Residents #13, #17, #32, #49, and #52) reviewed for dignity. The facility census was 69. Findings include: 1. Review of the medical record revealed Resident #32 was initially admitted to the facility on [DATE] with diagnoses including major depressive disorder, urinary tract infections, chronic vaginitis, overactive bladder, and bipolar disorder. Resident #32's medical record revealed a quarterly Minimum Data Set (MDS) 3.0 assessment with an Assessment Reference Data (ARD) of 04/05/19 which indicated Resident #32 had intact cognition, required total dependence of two people for transfers, extensive assistance of two people for hygiene, and was dependent for bathing. Resident #32's activities of daily living (ADL) plan of care dated 01/31/15 and preferences plan of care dated 01/22/16 stated Resident #32 required a mechanical lift with transfers and would prefer a sponge bath when a full bath or shower could not be tolerated, and her following morning routine preference upon rising was to shower, get dressed, and have breakfast. Resident #32 was observed on 05/19/19 at 10:54 A.M. in her room sitting in the shower chair, with her back to the door and the room door was open. Resident #32 was then observed to be lifted by mechanical lift into the air and transferred into her wheelchair by State Tested Nursing Assistant (STNA) #504 and STNA #505. Resident #32 was in a shower sling with a hole cut out around the rear end for toilet use and Resident #32's rear, backs of her thighs, and lower back were exposed to the hallway. Also observed standing in the hallway at the time of the transfer was the Maintenance Director and a housekeeper. Interview with STNA #504 verified on 05/19/19 at 10:58 A.M. the door to Resident #32's room was open and should have been shut during the mechanical lift transfer. STNA #504 also verified, Resident #32's rear end and back of body was able to be observed by individuals in the hallway. Interview with Resident #32 on 05/20/19 at 8:43 A.M. revealed staff often leave the door open during transfers with the mechanical lift, including after bathing and when she was not fully clothed. Resident #32 also stated she does have a privacy curtain which could be used to draw around the bed if the door cannot be closed. Review of the facility policy titled, Lifting Machine, revised July 2017, does not address how to maintain resident privacy such as closing the door. Review of the facility policy titled, Shower/ Tub Bath, revised October 2010, stated when transporting a resident to and from the bath area, ensure the resident is covered and his or her privacy is maintained. The policy also stated to never take the resident outside of his or her room without clothes or appropriate coverings, once the shower/ tub bath is completed, the resident is to be taken back to their room and the cubicle curtain pulled around the resident's bed for privacy. 2. Review of the medical record revealed Resident #49 was initially admitted to the facility on [DATE] with diagnoses including cellulitis, dissociative and conversion disorder, lymphedema, and hypertension. Medical record review for Resident #49 revealed physician orders for an indwelling Foley catheter for continuous urine drainage due to wounds with catheter care twice daily and as needed. Resident #49's medical record revealed a 30-day MDS 3.0 assessment with an ARD of 05/09/19 which revealed Resident #49 to have intact cognition. Resident #39's urinary catheter plan of care dated 04/12/19 listed an intervention to cover the urine collection bag with a dignity bag per protocol. Resident #49 was observed in her room on 05/19/19 at 8:49 A.M. with her Foley urine collection bag uncovered hanging on the bottom of the hospital bed. Interview with Licensed Practical Nurse (LPN) #506 verified on 05/19/19 at 8:55 A.M. Resident #49's Foley urine collection bag was not covered with a dignity bag and should have been. Interview with Resident #49 on 05/20/19 at 9:07 A.M. revealed Resident #49 knows her Foley urine collection bag was supposed to be in a dignity bag. Resident #49 stated her Foley urine collection bag was usually not in a dignity bag, however when staff were aware her family was going to visit they would bring a dignity bag in her room. Review of the facility policy titled, Catheter Care, Urinary, revised September 2014, did not address the need for urinary collection bags to be covered for resident dignity. 3. Review of Resident #52's medical record revealed diagnoses including a brief psychotic disorder and dementia. A significant change MDS 3.0 assessment dated [DATE] indicated Resident #52 was severely cognitively impaired and required extensive assistance for dressing. On 05/19/19 at 11:26 A.M., Resident #52 was observed sitting in the hall across from the 200 hall nursing station wearing a facility gown with her right upper thigh exposed. At 11:30 A.M., Resident #52 was propelled into the day room by staff and her tray was set up. At 11:36 A.M., Resident #52 was observed leaning forward in the wheelchair feeding herself. Resident #52's gown was tied at the neck but gaping open with Resident #52's entire back exposed except the shoulder area. Resident #52's incontinence brief was also exposed. At 11:42 A.M., Resident #52 remained exposed. Interview on 05/19/19 at 11:43 A.M., STNA #88 verified Resident #52's brief, thigh, and back were exposed while she sat in a common area. Review of the facility's admission packet revealed residents were provided with a copy of Resident Rights including the right to be treated with respect and dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #3's medical record revealed diagnoses including heart failure, sleep disorder, depression, chronic obstructive pulmonary disorder, and dementia. A quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #3 was able to make herself understood, had highly impaired vision, and had moderate cognitive impairment for daily decision making. Interview on 05/19/19 at 10:00 A.M., Resident #3 stated there were times when staff removed her call light from her reach. On 05/20/19 at 5:17 A.M., Resident #3 was observed lying in bed. The call light was curled up and laying on the foot of the mattress. On 05/20/19 at 5:58 A.M., STNA #84 was interviewed regarding the placement of Resident #3's call light at the foot of the bed and verified Resident #3 was unable to reach it, stating sometimes Resident #3 would kick the call light. Interview on 05/20/19 at 6:10 A.M., STNA #501 acknowledged the call light had been at the foot of the bed and stated there was no way to secure the call light in place. On 05/21/19 at 2:38 P.M., Resident #3 was observed lying in bed on her right side. The call light was not in reach with the call light cord appearing to disappear behind the foot of the bed. At 3:20 P.M., Resident #3 was yelling out she wanted to get out of bed. STNA #79 verified Resident #3's call light was not in reach and obtained it from under the bed. Based on observation, interview and record review, the facility failed to place call light cords within reach for Resident's #3, #6 and #70 to be able to call for assistance. This affected three of 69 residents in the facility. Findings include: 1. Observation on 05/19/19 at 11:00 A.M. revealed Resident #6 was lying at the edge of the bed on the left side. Interview with Resident #6 on 05/19/19 at 11:00 A.M. revealed she needed assistance to reposition herself and was not able to find her call light to request assistance. The surveyors requested assistance for Resident #6. State Tested Nurse Aides (STNA) #87 and #505 responded and repositioned Resident #6 to safely be in the middle of the bed. The STNA's found her call light cord tangled up in her blankets. Interview with the STNA's on 05/19/19 at 11:05 A.M. verified the call light cord was not in her reach. 2. Observation on 05/19/19 at 11:24 A.M. revealed Resident #70 was observed without her call light in reach. The call light was caught between the side rail and mattress, and she could not reach it. Interview with Resident #70 on 05/19/19 at 11:24 A.M. said she had been soaked all night. The resident complained she was wet all night and was not able to reach her call light. She said she needed attention and no on was helping her. The surveyors requested assistance for Resident #70. Registered Nurse (RN) #88 and STNA #85 responded. RN #88 found Resident #70's call light cord caught between the mattress and the quarter side rail. RN #88 and STNA #85 verified Resident #70's incontinence brief was heavily soiled with urine.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, policy review and interview, the facility failed to notify a physician of a resident's non-pressure related skin impairment. This affected one (Resident #3) of two residents reviewed for notification of change. The facility census was 69. Findings include: On 05/19/19 at 10:00 A.M., Resident #3 was observed sitting in a wheelchair in the hall. A dressing was observed on the dorsal aspect (back) of the right wrist. There was no date on the dressing. Review of Resident #3's medical record revealed diagnoses including dementia and macular degeneration. No documentation was located regarding skin impairment or treatment to the back of the right wrist. A care plan created on 10/28/15 indicated Resident #3 was at risk for skin tears related to propelling herself in the wheelchair, impaired vision, and fragile skin. One of the interventions was to treat the skin tear as ordered by the physician. On 05/19/19 at 10:42 A.M., Licensed Practical Nurse (LPN) #125 was interviewed regarding why Resident #3 had a dressing on her right wrist and stated Resident #3 got skin tears easily. LPN #125 verified although someone had treated the right wrist, there was no documentation of skin impairment or physician notification. On 05/22/19 at 12:45 P.M., Registered Nurse (RN) #135 verified prior to 05/21/19 when documentation regarding the skin impairment on the right wrist was requested, there was no documentation. RN #135 provided an assessment dated [DATE] for a skin tear and indicated the physician was notified at midnight on 05/21/19. Review of the facility's change in condition policy, issued 01/01/17, indicated the physician was to be notified when there was a change that was sudden in onset, a change that marked difference in usual sign/symptoms and/or the signs/symptoms were unrelieved by measures already prescribed. Specific information that required prompt notification included, but was not limited to, a discovery of injuries of an unknown source or a need to alter the resident's medical treatment significantly. Review of the facility's policy, Care of Skin Tears-Abrasions and Minor Breaks, revised September 2013, revealed nurses were to obtain a physician's order as needed. Document physician notification in the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review and record review, the facility failed to implement care plans for three (Residents #3, #17, and #60) of 41 residents whose care plans were reviewed. The facility census was 69. Findings include: 1. Review of Resident #3's medical record revealed diagnoses including dementia, macular degeneration and constipation. A plan of care initiated 09/15/14 indicated Resident #3 had a history of urinary tract infections with an intervention to encourage adequate fluid intake. Resident #3 had a diet order dated 02/19/15 for a regular diet, mechanically altered texture with thin liquids. A plan of care initiated 10/17/17 indicated Resident #3 was at an increased risk for dehydration or potential fluid deficit related to diuretic use, diabetes and cardiovascular disease. Interventions dated 10/17/17 indicated to encourage Resident #3 to drink fluids as necessary and ensure Resident #3 had access to cold water whenever possible or when she requested. On 01/15/18, a physician order was written for a two handled cup for independence. A care plan initiated 11/14/18 indicated Resident #3 was at nutritional risk and/or dehydration risk due to chewing problems, mechanically altered diet and use of diuretics. On 12/31/18, the care plan was revised to reveal the use of a two handled cup to decrease spillage. A quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #3 had highly impaired vision, used corrective lenses, was moderately cognitively impaired and required extensive assistance for bed mobility and eating. Interview on 05/19/19 at 10:00 A.M., Resident #3 stated she did not always get sufficient fluids because staff did not consistently pass ice water. On 05/19/19 at 10:00 A.M. a Styrofoam cup dated 05/19/19 (no time) was observed sitting on Resident #3's night stand. There was no ice in the cup, but it was full of water. On 05/19/19 at 12:26 P.M., Licensed Practical Nurse (LPN) #125 was informed water cups were monitored for several residents and it was noted none of the residents had ice in their water. LPN #125 stated ice melted fast in the Styrofoam cups and only lasted about two hours. On 05/20/19 at 5:17 A.M., Resident #3 was lying in bed on her right side. The call light was not in reach, and Resident #3 was calling for help. When Resident #3 was asked what she needed, she responded she wanted a drink. The Styrofoam cup with water was on the night stand on the left side of the bed and not able to be reached. On 05/21/19 at 11:04 A.M., Resident #3 was observed lying in her bed on her right side facing away from the night stand. A water cup dated 05/21/19 was approximately half full with a straw in the cup. The same was observed at 1:05 P.M. On 05/22/19 at 12:15 P.M., Resident #3 was observed sitting in the dining room with a cup of water in a spouted cup in front of her. On 05/23/19 at 8:33 A.M., Resident #3 was sitting in the dining room drinking fluid from a spouted cup with encouragement. At 2:05 P.M., Resident #3 was observed lying in bed on her right side facing away from the Styrofoam cup with a lid and straw on her night stand. At that time, Registered Nurse (RN) #135 and Corporate Nurse #600 were interviewed regarding Resident #3 being identified at risk for dehydration with care plan interventions to ensure she had cold water when possible and an order for a two handled cup and asked if a two handled cup had been considered to be used during water pass to promote fluid intake. RN #135 acknowledged the use of the styrofoam cup at the bedside and stated she thought the use of the two handled cup was an intervention for meals. Review of the facility's Serving Drinking Water policy (revised October 2010) revealed it did not mention use of adaptive equipment when serving drinking water. 2. Review of Resident #17's medical record revealed diagnoses including urinary retention, history of urinary tract infections, congestive heart failure, chronic kidney disease, and Alzheimer's disease. A 5-day MDS 3.0 assessment dated [DATE] indicated Resident #17 was able to make herself understood and had some cognitive deficits for daily decision making in new situations only. The MDS indicated Resident #17 required extensive assistance with eating and drinking. On 04/16/19, a physician order was written for a regular diet with mechanical soft texture and nectar thickened liquids. A nursing note dated 04/22/19 at 1:19 P.M. indicated Resident #17's daughter-in-law was informed of an order for intravenous fluids due to results of blood urea nitrogen and creatinine results (blood tests to monitor hydration). Care plan interventions included encouraging Resident #17 to drink and ensuring Resident #17 had access to cold water whenever possible or as requested. On 05/19/19 at 10:59 A.M., a cup with water was sitting on the night stand. The cup was dated 05/17/19. On 05/19/19 at 11:04 A.M., State Tested Nursing Assistant (STNA) #71 stated fresh water was supposed to be provided to resident twice a shift and cups were supposed to be dated. STNA #71 verified the cup for Resident #17 was dated 05/17/19 and was unable to explain why, stating she would have provided Resident #17 with fresh water if she would have known. On 05/21/19 between 12:26 P.M. and 1:00 P.M., Resident #17 was observed in the dining room drinking fluids independently. 3. Review of Resident #60's medical record revealed diagnoses including dementia, dysphagia (difficulty swallowing), generalized muscle weakness, and Parkinson's disease. A care plan initiated 08/22/14 indicated Resident #60 had altered nutritional status related to swallowing/chewing deficit and Parkinson's with hand tremors and food spillage. The care plan was updated 12/09/18 with an intervention for two handled cups with all drinks. A physician order dated 11/28/18 indicated fluids were to be encouraged related to frequent urinary tract infections. An annual MDS 3.0 assessment dated [DATE] indicated Resident #60 was able to make herself understood, was cognitively intact, required supervision for eating and extensive assistance for bed mobility. On 05/19/19 at 1:00 P.M., Resident #60's husband stated he was usually at the facility from 10:00 A.M. to 10:00 P.M. and fresh ice water was provided once during that time frame each day. Resident #60's daughter was visiting and stated to Resident #60 the physician had told her to drink more water because of her history of urinary tract infections. Resident #60's son picked up the styrofoam cup and verified the water was not cold and there was no ice in the cup. On 05/21/19 at 12:15 P.M., Resident #60 was observed in the dining room. Fluids were provided in two handled cups. At 2:42 P.M., Resident #60 was sitting in the wheelchair in her room and a Styrofoam cup of water was sitting on the night stand. The cup was dated 05/21/19 and was 3/4 full with no ice. Resident #60 stated she wanted a drink of water but she wanted ice water. Corporate Nurse #601 was informed of the request. On 05/23/19 at 7:54 A.M., Resident #60 was observed lying in bed with her over the bed table at the foot of the bed and approximately two feet away from the bed. A Styrofoam cup with a straw and lid dated 05/23/19 was placed on the over the bed table. At 2:05 P.M., Corporate Nurse #600 was interviewed regarding the use of Styrofoam cups for providing water at bedside when residents had orders and/or care plan interventions for two handled cups when residents were able to drink fluids independently. Corporate Nurse #600 stating she was checking on the use of adaptive equipment for fluids at bedside. Corporate Nurse #600 stated fluids should be kept where residents could reach them when in bed. On 05/28/19 at 7:14 A.M., Resident #60 was observed lying in bed and had a Styrofoam cup on the bed side table. Resident #60 had her eyes closed. On 05/29/19 at 7:43 A.M., Registered Nurse (RN) #135 stated on 05/28/19 she had the dietary department go around and provide residents who needed adaptive cups at meals with adaptive cups at bedside for fluid intake because it made sense if they needed a special cup to consume fluids at meals they would need one to consume fluids at bedside.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to accurately update the dental care plan for one (Resident #13) of one resident reviewed for dental services. The facility census was 69. Findings included: Observation conducted 05/19/19 at 8:50 A.M. on the initial facility tour revealed Resident #13 seated in a wheelchair in the resident's room. Resident #13 was eating breakfast of pancakes and bacon with no difficulty chewing or swallowing. Upon query at the time of the observation the cognitively impaired resident stated yes breakfast was good and yes when permission was requested to observe the conditions of the resident's room and bathroom but the resident was not interview-able. During a family interview conducted 05/19/19 at 11:40 A.M. to 12:15 P.M. the family revealed they visited daily. The family expressed concern staff did not clean the resident's upper denture regularly and the resident's bottom denture was missing, perhaps broken and out for repair but unknown to the family. The family stated when visiting they found the resident's upper denture discolored and with food debris build up and family frequently had to clean the upper denture. The family member stated the resident was unable to clean her own dentures and staff should be cleaning them daily and taking them out at night so the dentures did not get lost. This concern was shared with facility social services staff on 05/21/19 at 4:00 P.M. Record review revealed Resident #13 was admitted to the facility 08/08/17 with diagnoses including convulsions, transient ischemic attack, restlessness, agitation, fracture lower leg, major depressive disorder, anemia, hypertension, cardiomegaly, aphasia, anxiety disorder, dementia with behaviors. Review of the most recent quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severe cognitive impairment, required assistance with personal hygiene and had no dental problems. Review of an admission nursing assessment completed upon return from a hospital stay and dated 04/18/19 revealed Resident #13 had upper dentures only. Review of the resident's activities of daily living care plan revised 01/10/19 revealed the resident had her own teeth and was able to brush her own teeth with assist of set up of oral care supplies as necessary. An interview was conducted with facility MDS Registered Nurse (RN) #88 on 05/22/19 at 10:30 A.M. During the interview the dental plan of care for Resident #13 was reviewed. RN #88 stated facility staff conducted an interview with the family and confirmed the resident did have a missing lower denture not previously reported to the facility. RN #88 confirmed the resident's care plan inaccurately identified the resident had her own natural teeth and could brush her teeth and stated the care plan would be revised and staff re-educated on the resident's oral care needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide assessed restorative services to maintain or improve Resident's #10 and #33's abilities in activities of daily living. This affected two of three residents (#40) reviewed for restorative services of 41 records reviewed. The facility census was 69. Findings include: 1. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including muscle weakness, difficulty in walking, spastic hemiplegic cerebral palsy and hemiplegia affecting the left non-dominant side. Review of the annual comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated she was alert, oriented and independent in daily decision making ability. She did not have symptoms of psychosis or behaviors. She received five days of restorative transfer services during the assessment period. Review of the plan of care initiated on 04/27/18 related to having impairment with self-transfer due to limited mobility and weakness and indicated the interventions included a restorative active range of motion program to bilateral lower extremities six to seven days per week for 15 minutes and a restorative transfer program for six to seven days per week for 15 minutes. Review of the restorative quarterly review dated 04/29/19 indicated Resident #10 attended the therapy gym after breakfast. She was able to tolerate the current number of repetitions and the program would continue as outlined. Review of the restorative data records revealed Resident #10 was marked not applicable on 12 days in March 2019, 15 days in April 2019 plus one blank and 11 days in May 2019 plus one blank. Interview with the restorative State Tested Nurse Aide (STNA) #77 on 05/28/19 at 2:05 P.M. indicated when she was not able to get restorative services completed when working on the unit she would mark not applicable. She verified restorative services were not always provided as planned. On 05/29/19 at 8:49 A.M. Resident #10 was seated in her wheelchair in the doorway of her room. She was very difficult to understand and drooled when she tried to speak. She indicated she received restorative services and the rest was unintelligible. 2. Review of the medical record revealed Resident #33 was admitted to the facility on [DATE] with diagnoses including post polio syndrome, vertigo and osteoporosis. Review of the comprehensive MDS 3.0 assessment dated [DATE] indicated she was alert, oriented and independent in daily decision making ability. She had no symptoms of psychosis or behaviors. She received five days of restorative active range of motion. Review of the restorative assessment dated [DATE] indicated active range of motion to bilateral upper extremities six to seven days per week and ambulation six to seven days per week. Review of the restorative quarterly review dated 04/05/19 indicated she was compliant with bilateral upper extremity and bed exercises at all times. The restorative program remained appropriate. Review of the plan of care related to restorative services initiated on 07/28/17 indicated she was at risk for decline in functional range of motion related to limited mobility, pain in her left shoulder and latent complexities of polio syndrome. The interventions included to provide active range of motion for bilateral upper extremities 15 minutes per day six to seven days per week. Review of restorative data revealed Resident #33 was marked as not applicable or blanks for four days and marked as refusing service on four days in March 2019. She was marked as not applicable for four days and had five blanks for April 2019 and was marked as not applicable for five days, not available for one day and had 10 blanks for May 2019. Interview with Resident #33 on 05/19/19 at 10:40 A.M. said the facility did not have enough staff to provide her restorative services. She said the restorative aide was being pulled to the floor as an STNA and couldn't provide service. Interview with the restorative STNA #77 on 05/28/19 at 2:05 P.M. indicated when she was not able to get restorative services completed when working on the unit she would mark not applicable. She verified restorative services were not always provided as planned.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, policy review and interview, the facility failed to assess and monitor a non-pressure skin injury. This affected one (Resident #3) of 24 residents observed for skin impairment. The facility census was 69. Findings include: On 05/19/19 at 10:00 A.M., Resident #3 was observed sitting in a wheelchair in the hall with a bandage on the back of her right wrist. Resident #3 stated her wrist was bumped when staff were propelling her in the wheelchair. Review of Resident #3's medical record revealed diagnoses including dementia and macular degeneration. A care plan created on 10/28/15 indicated Resident #3 was at risk for skin tears related to propelling herself in the wheelchair, impaired vision, and fragile skin. One of the interventions was to treat skin tears as ordered by the physician. No documentation was located in the medical record regarding skin impairment or treatment to the back of the right wrist. On 05/19/19 at 10:42 A.M., Licensed Practical Nurse (LPN) #125 was interviewed regarding why Resident #3 had a dressing on her right wrist and stated Resident #3 got skin tears easily. LPN #125 verified although someone had treated the right wrist, there was no documentation of skin impairment or physician notification. On 05/22/19 at 12:45 P.M., Registered Nurse (RN) #135 verified prior to 05/21/19 when documentation regarding the skin impairment on the right wrist was requested, there was no evidence of an assessment. RN #135 provided an assessment dated [DATE] for a skin tear on the right wrist which measured 1.5 centimeters (cm) in length by 1.0 cm in width by less than 0.5 cm in depth. Review of the facility's policy, Care of Skin Tears-Abrasions and Minor Breaks, revised September 2013, revealed nurses were to obtain a physician's order as needed. Document physician notification in the medical record. Information that was to be recorded in the medical record included completing in-house investigation of causation, generate Non-Pressure form, document physician and family notification and resident education, how the resident tolerated the procedure, any problems or resident complaints related to the procedure, any complications related to the abrasion, and interventions implement or modified to prevent additional abrasions. When an abrasion/skin tear/bruise was discovered, complete a Report of Incident/Accident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, policy review and interview, the facility failed to implement orders for pressure ulcer prevention for one (Resident #17) of four residents reviewed for pressure ulcers. The facility identified ten residents with pressure ulcers. The facility census was 69. Findings include: Review of Resident #17's medical record revealed diagnoses including type II diabetes mellitus, generalized muscle weakness, localized edema, chronic kidney disease, severe protein-calorie malnutrition, malignant neoplasm of the skin and Alzheimer's disease. Review of the plan of care indicated Resident #17 was at risk for pressure ulcers related to diabetes, cardiac insufficiency, chronic leg edema, history of a stroke, and use of psychoactive medications. The care plan indicated Resident #17 would be assessed for pressure ulcer risk upon admission, readmission, with a significant change and quarterly. A physician order dated 03/18/19 indicated Prevalon boots (a boot that helps reduce pressure by keeping the heel floated) were to be worn when Resident #17 was in bed for promoting skin integrity. A five day Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #17 was usually able to make herself understood and only had impaired cognitive skills for decision making in new situations although she had short and long term memory problems. The MDS indicated Resident #17 required extensive assistance for bed mobility and was dependent on others for dressing. Resident #17 was assessed as being at risk of developing pressure ulcer but had no unhealed pressure ulcers. A Braden Scale for Predicting Pressure Ulcer Risk assessment dated [DATE] indicated risk factors for developing pressure ulcers included occasionally moist skin, chairfast status, very limited mobility, and a potential problem with friction and shear. On 05/20/19 at 1:36 P.M., Resident #17 was observed lying in bed on her back with her eyes closed. Resident #17 had a sheet over her legs but did not appear to have Prevalon boots on. On 05/20/19 at 2:40 P.M., State Tested Nursing Assistant (STNA) #85 verified Resident #17 was in bed with no Prevalon boots on. On 05/21/19 at 11:06 A.M., Resident #17 was observed lying in bed with no Prevalon boots applied. On 05/21/19 at 11:18 A.M., Registered Nurse (RN) #135 verified Resident #17 was in bed with no Prevalon boots on. On 05/21/19 at 3:30 P.M., urinary catheter care was provided. After urinary catheter care was completed and Resident #17 was repositioned, it was observed no Prevalon boots were applied. State Tested Nursing Assistant (STNA) #77 verified Prevalon boots had not been applied, stating she was unaware of Resident #17 ever had Prevalon boots.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Observation conducted 05/19/19 at 8:50 A.M. on the initial facility tour revealed Resident #13 seated in a wheelchair in the resident's room. Resident #13 was wearing pajamas and eating breakfast. An alarm box was present on the back of the resident's wheelchair. Resident #13 was unable to answer screening questions and was not interviewable. During a family interview conducted 05/19/19 at 11:40 A.M. to 12:15 P.M. the family revealed they visited daily. The family expressed concern the resident had several falls in the facility and the facility was not doing enough to prevent falls. Record review revealed Resident #13 was admitted to the facility 08/08/17 with diagnoses including convulsions, transient ischemic attack, restlessness, agitation, fracture lower leg, major depressive disorder, anemia, hypertension, cardiomegaly, aphasia, anxiety disorder, and dementia with behaviors. Review of the most recent quarterly MDS assessment dated [DATE] revealed Resident #13 required extensive staff assistance for bed mobility, transfers and locomotion on the unit. The MDS revealed the resident had sustained one fall in the facility since the last assessment with no injury. Review of current physician orders and care plan for fall prevention revealed orders to assist with all transfers, bed and chair alarms, resident was to have slipper socks on at all times, right side of bed against wall for increased space; one half side rail on the left side of the bed for bed mobility; pressure sensitive floor mat for fall prevention; check floor mat alarm for placement and function every shift , check bed and chair alarm every shift for placement and function; staff to apply slip-on gripper socks with evening care; and transfer with one person assist. Review of facility fall investigations provided by the facility revealed on 02/23/19 Resident #13 was assisted back to bed after being found leaning between her bed and wheelchair in the resident's room and on 04/11/19 the resident fell from her wheelchair while self-propelling in the hallway. The documentation did not reveal if the resident's bed or chair alarms sounded. An additional resident observation was conducted 05/19/19 at 2:31 P.M. Resident #13 was asleep in bed in the resident's room, positioned on the resident's right side. An alarming pressure pad (bed alarm pad) was visible under the resident's hips area on top of the mattress. The observation revealed the alarm pad had a connecting wire draped on the side rail that was not attached to any alarm box. A pressure alarm box was noted on the back of the resident's wheelchair in the room. The observation revealed a floor mat type pressure alarm was present positioned completely under the resident's bed and not attached to the alarm on the resident's side rail. An interview was conducted on 05/19/19 at 2:35 P.M. with facility STNA #71. During the interview STNA #71 stated Resident #13 was a fall risk and bed and floor pressure alarms were used to notify the staff if the resident tried to self-transfer or ambulate without assistance. An observation was conducted of Resident #13 asleep in bed at the time of the interview with STNA #71. During the observation STNA #71 confirmed the bed alarm was on the resident's bed but not attached to the alarm and the floor mat alarm was under the bed where the resident's feet would not touch it if the resident attempted to transfer out of the bed. STNA #71 confirmed the STNA assisted the resident into bed after lunch and did not attach the alarm to the bed alarm pad and did not position the floor alarm properly or attach the alarm to the floor pad. STNA #71 confirmed the alarms were non-functional at the time of the observation and could not help to prevent falls for Resident #13. This concern was shared with the facility Director of Nursing 05/20/19 at 8:30 AM. The DON stated facility staff would be re-educated on fall prevention measures. 3. Review of Resident #15's medical record revealed diagnoses including subdural hemorrhage (03/04/19), congestive heart failure, anemia, age-related cataract, cerebrovascular disease, and Alzheimer's disease. Documentation in nursing notes and fall incident reports revealed Resident #17 had a history of falls with falls on 12/04/18, 01/06/19, 03/09/19 and 03/10/19. Review of Resident #17's physician order sheet revealed an order written 03/14/19 for a bed alarm at all times while occupied. Check placement and function every shift. An order dated 03/16/19 indicated Resident #17's bed was to be in the lowest position at all times while occupied. On 05/20/19 at 1:36 P.M., Resident #17 was observed lying in bed with no bed alarm and the bed was not in the lowest position. No staff were present. On 05/20/19 at 2:40 P.M., STNA #85 verified Resident #17's bed was not in lowest position, lowering it approximately six inches. STNA #85 verified although there was a pressure pad under Resident #17, there was no alarming unit attached to it. On 05/21/19 at 11:06 A.M., Resident #17 was observed lying in bed with no bed alarm noted. On 05/21/19 at 11:18 A.M., Registered Nurse (RN) #135 verified Resident #17 did not have a bed alarm in place while lying in bed. On 05/28/19 at 7:14 A.M., Resident #17 was observed lying in bed on her right side. The bed was not in the lowest position. This was verified by STNA #70 on 05/28/19 at 7:15 A.M. Review of the facility's policy, Managing Falls and Fall Risk, revised March 2018, revealed environmental factors which could contribute to falls included incorrect bed height. Staff would implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls. In conjunction with the attending physician, staff would identify and implement relevant interventions to try to minimize serious consequences of falling. Position-change alarms could be used to assist staff in identifying patterns and routines of the resident. If interventions were successful in preventing falling, staff would continue the interventions or reconsider whether the measures were still needed if a problem required the intervention had resolved. Based on observation, interview, record and policy review, the facility failed to provide sufficient supervision to prevent Resident #13 from leaving the building unattended and sufficient supervision and assistive devices to prevent falls for Resident's #13 and #17. This affected two of three residents reviewed for accidents of 41 records reviewed. The facility census was 69. Findings include: 1. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbance, advanced bilateral non-exudative age-related macular degeneration, anxiety disorder, restlessness and agitation, blindness in one eye and low vision in the other eye, major depressive disorder and aphasia following cerebrovascular disease. Review of the elopement risk assessment dated [DATE] indicated Resident #13 was at moderate risk for elopement. The note within indicated Resident #13 was actively expressing a desire to leave the facility but was able to be re-directed at that time. She was place on 15 minute checks for safety. The elopement risk assessment dated [DATE] identified her at high risk and on 01/23/19 she was identified at moderate risk for elopement. Review of the quarterly Minimum Data Set (MDS) 3.0 dated 03/15/19 indicated she was moderately cognitively impaired and she displayed no psychosis or behavioral symptoms. Review of the plan of care related to Resident #13 at risk for elopement/wandering indicated she had a history of attempts to leave the facility unattended, had packed her belongings and indicated she was going home, had impaired safety awareness and was difficult to redirect/distract at times from intent to leave. The interventions included to attempt to distract her, offer pleasant diversions, structured activities, food, conversation, television and books as she accepts; identify a pattern of wandering; monitor her location as needed; 30 minute safety checks and document the wandering behavior and attempted diversional interventions in the behavior log. Review of the nurses' progress note dated 06/08/18 at 4:39 P.M. she attempted to leave the facility saying she had to catch a train to go to a wedding. The nurse noted she walked with the resident outside and down the sidewalk. The nurse attempted to redirect her without success. Once she was brought back into the facility an as needed medication was administered and noted to be effective. Review of the social service note dated 07/25/18 at 10:54 A.M. indicated a meeting was held with the family regarding Resident #13's risk for elopement and possible consideration to have her transferred to a locked unit. The family refused the idea of a transfer and asked if 15 minute checks could continue and they would work with the facility in any way so long as the resident was not moved to a locked unit. It was noted the Director of Nursing was in agreement with 15 minute checks to visualize her safety at that time. Review of the nurse's progress note dated 07/30/18 at 4:35 P.M. Resident #13 was found outside the facility by another resident. The resident was placed on one to one observation for the remainder of the night. Review of the social service note dated 09/14/18 at 12:14 P.M. indicated another meeting was held with the family regarding falls and continuous exit seeking behavior. The family was educated regarding the need for a secured dementia unit. The family refused the idea of a transfer. It was noted education was provided for immediate and 30-day discharge notices due to the concern of the resident's safety. Review of the nurses note dated 03/17/19 at 5:33 P.M. a resident witnessed Resident #13 exit the doors in her wheelchair and go down the sidewalk in front of the building. The resident alerted staff who brought her back into the facility. Review of the 03/17/19 investigation revealed there were three nurses and six State Tested Nurse Aide (STNA's) on duty. There were statements obtained by three nurses and two STNA's. Registered Nurse (RN) #75's statement indicated he went out to retrieve her and she had made it to the visitor parking lot. A head to toe assessment was completed and she was found without injury. There was no investigation provided for the 07/30/18 incident. Interview with Resident #63 on 05/23/19 at 8:30 A.M. said she saw Resident #13 outside by the pond in March 2019 and went and got help. She said she knew some residents who wander but should not get out of the facility but did not know all who could not be out unattended. She said she went inside and got staff immediately. Interview with Licensed Practical Nurse (LPN) #122 on 05/23/19 at 9:32 A.M. verified she authored the 07/30/18 progress note when Resident #13 was found outside. She was not able to recall what resident found her, couldn't remember how long she was out of the facility unattended. She did say Resident #13 wanted to go outside all the time because that's what she loved to do. She verified that she did not write a witness statement for the incident. Interview with the Administrator on 05/23/19 at 9:40 A.M. indicated they reached out to the family regarding an alternative locked facility but they absolutely refused. She indicated several things were done such as monitoring for urinary tract infections and medication changes. She said that did not work so they re-approached the family and again they refused. She said they were in process to obtain a Wanderguard system (departure alert system) but there were Federal hoops to go through. She said they had 15 minute checks in place when she left unattended on 07/30/19. She said the resident exit seeks when the daughter leaves and did not know how they could have prevented it. Interview with the family on 05/23/19 at 1:22 P.M. voice being upset thinking the state wanted her mother out of the facility. It was explained to them the facility was responsible to provide enough supervision to keep her safe. The Regional Nurse #600 interjected saying the facility would provide one to one supervision until the Wanderguard system could be installed. The family also offered a suggestion of when staff takes the smokers outside to take Resident #13 outside also. Review of the elopement policy and procedure revised in December 2007 indicated staff shall investigate and report all cases of missing residents. If an employee discovers that a resident was missing from the facility, he/she shall determine if the resident was out on an authorized leave or pass; if the resident was not authorized to leave, initiate a search of the building and premises; if the resident was not located, notify the administrator and the director of nursing services, the resident's legal representative, attending physician, law enforcement, officials and as necessary volunteer agencies and emergency management, rescue squads etc.; provide search teams with resident identification information and initiate an extensive search of the surrounding area. When the resident returns to the facility, the director of nursing services or charge nurse shall: examine the resident for injuries; contact the attending physicians and report findings and conditions of the resident; notify the resident's legal representative, notify search teams that the resident has been located, complete and file an incident report and document relative information in the resident's medical record. Review of the wandering, unsafe resident policy revised in August 2014 indicated the staff would strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who were at risk for elopement. The staff would identify residents at risk for harm because of unsafe wandering (including elopement); assess at-risk individuals for potentially correctable risk factors related to unsafe wandering; the care plan would indicate the resident was at risk for elopement or other safety issues; interventions to try to maintain safety, such as a detailed monitoring plan would be implemented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, policy review and interview, the facility failed to ensure indwelling urinary catheters were only used with medical justification and proper technique was used while providing catheter care to prevent urinary tract infections. This affected two (Residents #17 and #51) of four residents reviewed for urinary catheters. The facility identified eight residents with indwelling or external urinary catheters. The facility census was 69. Findings include: 1. Review of Resident #17's medical record revealed a diagnosis of urinary retention. A hospital after care summary for hospitalization from 03/10/19 to 03/14/19 which indicated a urinary catheter was inserted 03/13/19. An updated admission history and physical (H&P) list of principal problems indicated Resident #17 had chronic kidney disease but did not indicate urinary retention as a problem. Documentation from the hospital dated 03/28/19 indicated Resident #17 presented to the emergency department due to abdominal pain. Resident #17 reported she had been experiencing lower abdominal pain for the past two weeks and she complained of pain from her Foley catheter. Resident #17's son stated Resident #17 had the catheter for management of a subdural hematoma following a fall from a wheelchair at the nursing facility, on 03/10/19. The most recent Foley catheter justification assessment dated [DATE] indicated the catheter was justified for treatment of acute urinary retention. On 05/19/19 at 11:02 A.M., Resident #17 was observed sitting in a wheelchair in her room with urinary catheter tubing observed. Resident #17 complained of constant lower abdominal pain and questioned if it was related to catheter use and/or a urinary tract infection. Review of a Minimum Data Set (MDS) 3.0 note dated 05/19/19 at 6:41 P.M. indicated Resident #17 had an indwelling Foley catheter. Discomfort to the bladder region had been voiced in the past as well as since Foley placement. The note indicated Resident #17 had an extensive history of recurring urinary tract infections. On 05/20/19 at 2:40 P.M., State Tested Nursing Assistant (STNA) #85 stated Resident #17 did complain of pain at times and it was usually related to her urinary catheter. STNA #85 stated Resident #17 did not like the catheter. On 05/21/19 at 11:18 A.M., Registered Nurse (RN) #135 stated Resident #17 had the urinary catheter placed sometime in 2019 while in the hospital and Resident #17 returned with a diagnosis of urinary retention. RN #135 was uncertain if there had been any attempts to remove the urinary catheter since its insertion. RN #135 stated Resident #17's skin was intact. On 05/21/19 at 2:40 P.M., Resident #17 was observed sitting in her wheelchair in her room complaining of abdominal pain and pain down the right leg. Resident #17's roommate stated the physician was in to visit Resident #17 and told her they could try to take her catheter out. On 05/21/19 at 3:30 P.M., STNA #77 exited Resident #17's room and stated she thought when Resident #77 was assisted to bed the urinary catheter came out and she had to inform the nurse. Meanwhile, STNA #79 informed Resident #17 she was going to clean around the catheter. Resident #17 was adamant now that the urinary catheter was out it was not going to be re-inserted. STNA #77 returned to Resident #17's room stating she had informed the nurse of the catheter coming out. STNA #77 stated to Resident #17 she knew Resident #17 had been wanting the catheter out forever. Review of a nursing note dated 05/21/19 at 3:50 P.M. indicated at 3:35 P.M. during a physician visit, Resident #17 stated she wanted her urinary catheter out. Resident #17 reported the catheter was causing her discomfort. The physician made the nurse aware that nursing could notify Resident #17's family and remove the urinary catheter. If no voiding was noted, the catheter would be re-inserted due to urinary retention. On 5/21/19 at 6:13 P.M., RN #135 verified she was unable to find any documentation of attempts to remove the catheter although it was brought to her attention the catheter assessment indicated it was for acute urinary retention. RN #135 verified Resident #17 had multiple complaints of discomfort as a result of catheter use. On 05/22/19 at 9:47 A.M., Resident #17 was sitting in the wheelchair in her room with no catheter observed. Resident #17 stated she had been able to void but continued to have bladder pain. Review of a nursing note dated 05/22/19 at 7:11 A.M. revealed Resident #17 voided throughout the night without difficulty. Review of a nursing note created 05/22/19 at 2:00 P.M. indicated the physician was notified Resident #17 had complaints of discomfort and pain where her catheter was. Resident #17 was reported to have urinated throughout the night. Resident #17 was incontinent of urine when she was assisted from bed that morning. Subsequent observations on 05/23/19 at 8:00 A.M. 8:30 A.M. and 8:38 A.M. and on 05/28/19 at 7:14 A.M. revealed no urinary catheter. 2. Review of Resident #51's medical record revealed diagnoses of dementia and history of urinary tract infections. On 03/27/19, a physician order was written for an indwelling Foley catheter for wound healing. A care plan initiated 03/28/19 indicated Resident #51 had an indwelling Foley catheter related to recurring urinary tract infections, renal blockage due to calculus, and skin breakdown. Interventions included cleansing the perineal area front to back. A wound evaluation dated 05/16/19 indicated Resident #51 had a stage IV (full thickness tissue loss extending into the muscle, tendon or even bone) pressure ulcer on the sacrum. On 05/21/19 at 3:45 P.M., STNA #77 was observed providing catheter care to Resident #51. While washing the left side of the labia, STNA #77 was observed washing the area from front to back then repeating the process in the same area with the same part of the washcloth. When the perineum was rinsed, the center was rinsed front to back then using the same area of the washcloth, the procedure was repeated. When drying the resident, the left labia was dried using the same technique. On 05/21/19 at 3:55 P.M., STNA #77 verified the observation and that she had not used proper technique. Review of the facility's Urinary Catheter Care policy, revised September 2014, indicated when providing catheter care for a female resident, one area of the washcloth was to be used for each downward, cleansing stroke. The position of the washcloth was to be changed with each downward stroke. Next, change the position of the washcloth and cleanse around the urethral meatus With a clean washcloth, rinse with warm water using the same technique.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, review of manufacturer information and interview, the facility failed to ensure timely response to tube feed pump alarms and to provide tube feeding in a manner which would prevent bacterial growth in the solution. This affected one (Resident #51) of one resident reviewed for tube feedings. The facility identified four residents receiving tube feedings. Findings include: Review of Resident #51's medical record revealed diagnoses including dementia, adult failure to thrive, severe protein-calorie malnutrition and difficulty swallowing. A 30-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #51 had short and long term memory problems and severely impaired cognitive skills for daily decision making. The MDS indicated Resident #51 was dependent for eating and received 51% or more of her total calories through tube feeding or parenteral. On 05/14/19 an order was written for Osmolite 1.5 at 45 milliliters per hour (ml/hr) with 190 ml water flush every six hours. On 05/19/19 at 2:54 P.M., Resident #51 was observed with a tube feeding solution running through a pump at 45 ml/hr. The Kangaroo bag (bag used to hold tube feed solution) was dated 5/19/19 at 6:00 A.M. with no name of the feeding solution or rate or how much volume of feeding was placed in the bag when it was hung. On 5/20/19 at 7:53 A.M., the feed pump was beeping with a message of flow error . The Kangaroo bag was labeled Osmolite 1.5 at 45 ml/hr and dated 05/20/19 at 3:00 A.M. The solution was up to the 900 ml mark. At 7:56 A.M., the Director of Nursing (DON) met with two surveyors outside Resident #51's room where the pump alarm could be heard. The beeping pump was not addressed. At 7:58 A.M., Corporate Nurse #601 was standing at the nursing station where the beeping tube feed pump could be heard and did not address it. At 8:12 A.M., State Tested Nursing Assistant (STNA) #91 was heard telling Resident #51 he was going to straighten her up in the bed and then would tell the nurse about the tube feed pump beeping. At 8:38 A.M. the tube feed pump continued to beep and no nurse was observed addressing the alarm beeping. At 8:42 A.M., STNA #91 stated he had reported the beeping tube feed pump had been reported to Resident #51's nurse but had not seen her respond. At 8:43 A.M., the tube feed pump stopped beeping. On 05/20/19 at 9:48 A.M., Registered Nurse (RN) #73 verified STNA #91 had informed her of Resident #51's tube feed pump beeping but she was administering medication and was unable to respond when it was reported to her. On 05/20/19 at 1:31 P.M., Resident #51 continued to receive tube feeding from the same bag dated 05/20/19 at 3:00 A.M. On 05/21/19 at 10:59 A.M., Resident #51 was receiving tube feeding via a pump. The Kangaroo bag was labeled Isosource 1.5 with a date of 05/20/19 at 3:00 A.M. The writing appeared to be the same and written at the same angle as the bag hung the day before. There was approximately 700 ml of solution in the bag. Licensed Practical Nurse (LPN) #129 stated Kangaroo bags were supposed to be changed every day. On 05/21/19 at 11:10 A.M., a ready to hang bag of Isosource 1.5 (closed system) was hanging on the tube feed pole and running at 45 ml/hr. At 2:37 P.M., the tube feed solution was at the 800 ml line. On 05/21/19, a request was made for a can/carton of the Osmolite 1.5 to determine proper hanging time for the solution. At 7:30 P.M., the Director of Nursing (DON) provided a carton of eight ounces of Jevity 1.5 stating it was what staff filled the Kangaroo bag with and it was equivalent to Osmolite 1.5 and Isosource 1.5. The DON stated when the cartons were opened they were good for 48 hours, referring to the label on the carton. The label indicated once the carton was opened, it could be reclosed and refrigerated for use within 48 hours. The label indicated for tube feeding the product should be fed at room temperature using a feeding pump or syringe. Avoid contamination during preparation and use. It was brought to the DON's attention that the 48 hours was for product that was refrigerated. On 05/22/19 at 9:30 A.M., the manufacturer of the tube feeding guidelines were reviewed with RN #135. The [NAME] guidelines for tube feeding included not hanging the formula at the bedside for prolonged periods. Ready to use formula that was poured from a can into a feeding reservoir could hang between 8-12 hours. On 05/22/19 at 9:57 A.M., Resident #51's Kangaroo bag was labeled Osmolite 1.5 and dated 05/22/19 at 5:30 A.M. The bag had between 750-800 ml of solution in it. At 12:11 P.M. the bag was slightly above the 700 ml mark. At 1:05 P.M., the tube feed bag was observed with the DON and she provided an interchange list indicating Jevity 1.5 was interchangeable with Isosource 1.5. The Osmolite was interchangeable with Isosource HN. On 05/23/19 at 8:00 A.M., Resident #51's Kangaroo feeding bag was labeled Osmolite 1.5 hung at 4:00 A.M. on 05/23/19. Approximately 850 ml of supplement was in the bag (greater than 12 hours worth). On 05/23/19 at 8:54 A.M., a phone interview with Representative #602 from [NAME] Nutrition verified to prevent growth of bacteria, when a tube feed formula was poured into a bag to be administered via a tube feed pump, the formula should hang no longer than 8-12 hours. On 05/22/19 at 1:53 P.M., Dietitian (RD) #111 was interviewed and stated the calories, protein and fluid were similar in Osmolite, Isosource and Jevity.

Based on record review and interview, the facility failed to ensure the facility had a signed contract with the off-site hemodialysis company providing services for facility residents. This affected two residents (Resident #18 and #37) of two residents receiving hemodialysis. Findings include: Review of the dialysis agreement between the outpatient dialysis clinic and the facility revealed the agreement was not signed and did not have any dates as when the agreement went into effect. Interview with the Administrator on 05/21/19 at 3:27 P.M. indicated she was not aware the agreement was not signed and would get a signed copy from the corporate office. Additional requests for a copy of the signed contract were given on 05/21/17 at 5:15 P.M. and 05/22/19 at 11:47 A.M. without success. The facility identified Residents #18 and #37 as the residents receiving dialysis.

Based on record review and interview, the facility failed to ensure the facility had a signed contract with the off-site hemodialysis company providing services for facility residents. This affected two residents (Resident #18 and #37) of two residents receiving hemodialysis. Findings include: Review of the dialysis agreement between the outpatient dialysis clinic and the facility revealed the agreement was not signed and did not have any dates as when the agreement went into effect. Interview with the Administrator on 05/21/19 at 3:27 P.M. indicated she was not aware the agreement was not signed and would get a signed copy from the corporate office. Additional requests for a copy of the signed contract were given on 05/21/17 at 5:15 P.M. and 05/22/19 at 11:47 A.M. without success. The facility identified Residents #18 and #37 as the residents receiving dialysis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Observation of finger stick blood glucose testing and medication administration was conducted 05/21/19 at 8:00 A.M. for Resident #59. The observation revealed LPN #506 prepared oral medications and one injectable for the resident, obtained a glucometer device and needed supplies from the medication cart and entered the resident's room. LPN #506 donned gloves and checked the resident's blood sugar by the finger stick method, administered the oral medications and one subcutaneous injection Byetta, then removed the gloves. LPN #506 returned to the medication cart and without washing her hands or sanitizing her hands or the glucometer placed the glucometer on top of the medication cart and removed insulin for Resident #59 from the cart, drew up two insulin medications for the resident and placed the glucometer into the right upper drawer of the cart. LPN #506 donned gloves, administered the two insulin injections to Resident #59, removed the gloves and exited the resident room without washing or sanitizing hands. The nurse then opened the drawer of the cart, removed the glucometer and wiped the device off using one Super Sani-wipe Germicidal wipes pulled from a large multi wipe container and placed the glucometer back in the drawer of the cart. An interview was conducted with LPN #506 following the observation. During the interview LPN #506 confirmed the nurse did not wash or sanitize her hands after administering injections to Resident #59. Upon query LPN #506 stated the facility practice was to sanitize glucometers before and after each use as the device was used for multiple residents. LPN #506 confirmed the glucometer was placed into the medication cart after use without sanitizing it before returning to the resident's room to administer additional injections. Continued interview revealed LPN #506 revealed the nurse always used Sani-wipes to clean glucometers. LPN #506 stated the nurse wiped off the front and back of the glucometer and placed the glucometer in the drawer to air dry. Review of the Super Sani-wipes directions for use printed on the container with LPN #506 revealed for sanitizing clean the object and ensure the object remained wet for two minutes. LPN #506 confirmed she did not follow directions for appropriate sanitizing of the glucometer. Review of the facility Blood Sampling- (Finger Sticks) procedure dated 2001, revised 2014 revealed following the manufacturer's instructions, clean and disinfect reusable equipment after each use. Review of the facility provided Cleaning and Disinfecting the Glucose Monitoring device procedure provided by the facility revealed Super Sani-Cloth germicidal wipes could be used to clean the glucometer to prevent the transmission of blood borne pathogens, please read the manufacturer's instructions before using the wipes on the meter. This concern was shared with the facility Director of Nursing on 05/21/19 at 12:40 P.M. Based on observations, interviews, record and policy review, the facility failed to maintain appropriate infection control practices during a dressing change for two residents (Residents #14 and #59) and one resident (Resident #59) observed during medication administration. This affected three of nine residents reviewed for infection control Findings include: 1. Review of the medical record revealed Resident #14 was admitted to the facility on [DATE] with diagnoses including disease of the digestive system, major depressive disorder, osteoporosis, kyphosis, hyperlipidemia, polyarthritis, severe obesity, insomnia, anxiety disorder and chronic pain syndrome. Review of the Minimum Data Set 3.0 (MDS) dated [DATE] indicated Resident #14 required limited assistance of one person for bed mobility, toilet use, supervision and set up for transfers. Her continence status declined to frequently incontinent for bladder and bowel. She was identified as having an unhealed pressure ulcer/injury identified as a Stage II (Partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister.) Review of the wound evaluation dated 05/16/19 indicated the pressure ulcer Stage II was located on the right buttock measuring 0.7 centimeters (cm) x 0.5 cm x 0.1 cm and was in house acquired and improving. On 05/20/19 at 4:53 P.M. Licensed Practical Nurse (LPN) #128 was observed providing a dressing change to the pressure ulcer for Resident #14. LPN #1128 was observed washing his hands at the sink and then turned the faucets off with wet hands prior to applying gloves. LPN #128 removed the old dressing and again removed his gloves, washed his hands and turned the water off at th faucet with his wet hands and applied clean gloves. 2. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE] with diagnoses including pseudobulbar affect, non-displaced fracture of the sixth cervical vertebrae, disorder of bone density and structure, anxiety disorder, insomnia, major depressive disorder recurrent, restlessness and agitation, dementia without behavioral disturbance, difficulty walking, osteoarthritis, polyarthritis and osteoporosis. Review of the quarterly MDS 3.0 dated 04/02/19 indicated she had no pressure ulcers. On 05/21/19 at 9:00 A.M. LPN #128 was observed to do the dressing change to Resident #25's foot. He provided privacy by closing the door and pulling the curtain. He used a paper towel and placed on a side table and put a roll of stretch gauze and other supplies on top. He washed his hands at the sink in Resident #25's room. He turned off the faucet with his wet hands. Resident #25 was seated in wheelchair in her room with non skid strips under her feet. LPN #128 removed gloves from his pockets and applied them. He then removed her right sock. He did not create a clean field under her feet. He rested her right heel on the dirty floor. There was no dressing to remove. LPN #128 said he thought maybe she had a shower and it was removed then. He cleansed the area between her fourth and fifth toes with normal saline. He opened a package with a cotton swab pre-soaked with iodine. He rubbed the cotton swab between the toes and threw it in an unlined trash can that was filled with food and paper products. Without washing his hands he took off the right glove and removed the scissors from his pocket. He threw the glove into the unlined trash can. He placed the scissors on the paper towel. He then pulled another glove out of his pocket and put it on. He cut a piece of medical foam and put it between her toes. He wrapped her foot with stretch gauze and applied a pre-dated piece of tape to secure the wrap. Interview with LPN #128 on 05/21/19 at 9:20 A.M. indicated he kept the gloves in his pocket because the resident rooms were not equipped with the sized gloves he needed and verified they would not have been considered clean. He verified he did not create a clean field under the resident's foot, no liner for the trash can, not cleansing the scissors that were stored in his pocket and that he shut off the water with his wet hands instead of with a paper towel. Review of the handwashing/hand hygiene policy and procedure revised in August 2015 indicated after washing and rinsing the hands dry them thoroughly with paper towel and then turn off faucets with a clean, dry paper towel. Review of the wound care policy and procedure revised in October 2010 indicated to place a disposable cloth on an over bed surface and be certain all clean items were on the clean field; place a disposable cloth under the wound to serve as a barrier.

Based on review of Resident Council meeting minutes, interviews and policy review, the facility failed to provide timely responses and resolutions to all Resident Council concerns. Of the 14 months of Resident Council meeting minutes reviewed, concerns regarding cleanliness of the facility were identified six times, food concerns were identified six times, ice and water availability concerns were identified three times, staffing concerns were identified three times, laundry not being available was identified two times, and concerns regarding the outside environment were identified two times. This had the potential to affect all 69 residents residing in the facility. Findings include: Review of the Resident Council meeting minutes from 03/28/18 through 04/24/19 revealed residents had numerous repetitive concerns over many months. A breakdown of the concerns by months are as follows: Residents had concerns about the cleanliness of the facility during the following months: 05/30/18, 07/25/18, 08/29/18, 09/26/18, 11/29/18, and 03/12/19. Residents had concerns about food including timeliness and variety during the following months: 06/28/18, 07/25/18, 09/26/18, 11/29/18, 02/27/19, and 03/12/19. Residents had concerns about ice and water not being passed enough during the following months: 05/30/18, 10/31/18, and 11/29/18. Residents had concerns about consistency and availability of staff during the following months: 05/30/18, 07/25/18, and 03/12/19. Residents had concerns about showers not being completed during the following months: 11/29/18 and 03/12/19. Residents had concerns about laundry not being returned during the following months: 07/25/18 and 11/29/18. Residents had concerns about the outside environment during the following months: 06/28/18 and 09/26/18. Further review of Resident Council minutes revealed the Council was displeased with the minutes from the previous month on 11/29/18, and it was not documented whether residents were pleased or not during the months of 07/17/18, 09/26/18, and 12/26/18. The Resident Council minutes also had concern forms generated for each concern which was given to the appropriate department, and the form stated it needed to be returned within three days. Of the 22 generated forms, only five were dated when completed and of these five, only three were completed within three days. None of the forms were dated as to when the information was conveyed to the Resident Council. During the survey Resident Council meeting, held on 05/20/19 at 10:13 A.M., Residents #20, #33, and #59 verified the ongoing concerns and stated the correct department responded to their concerns, however the concerns did not seem to be resolved and continued to reoccur month to month. Review of the facility policy titled, Resident Council, revised April 2017, does not address a time for response of Resident Council concerns back to the Resident Council. Interview with the Administrator on 05/21/19 at 1:54 P.M. revealed the Resident Council meeting minutes and concerns are discussed in the morning meeting following Resident Council, however the Administrator indicated she could not speak to the lack of communication between the Activity Director (who normally runs the Resident Council) and residents and staff. The Administrator verified the Resident Council concern forms were not dated upon return or upon conveyance to residents and stated the facility was currently in process of trying to find a new Activity Director.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 7. Review of the medical record for Resident #28 revealed an admission date of 04/25/16. Diagnoses included acute bronchitis, heart failure, generalized muscle weakness and chronic obstructive pulmonary disease. Review of Resident #28's comprehensive MDS assessment, dated 04/03/19, revealed the resident had intact cognition. The resident required extensive assistance of two staff for transfers, dressing toileting, and dressing and a one-person physical assist with bathing. Review of Resident #28's medical record revealed the resident was scheduled for tub bath every Monday, Wednesday and Saturday in the late morning Review of Resident #28's shower documentation from 04/25/19 to 05/25/19 revealed the resident failed to receive tub bathes or showers on 04/29/19, 05/01/19, 05/03/19, 05/06/19, 05/08/19, 05/10/19, 05/13/19, 05/15/19, 05/17/19, 05/20/19, 05/022/19 and 05/24/19. The resident had one documented refusal of a shower or bath during this period on 04/26/19. Resident received a shower/tub bath twice during this period on non-scheduled days: Tuesday 04/30/19 and Thursday 05/23/19. Interview with the Assistant Director of Nursing (ADON) on 5/28/19 at 4:56 P.M. verified Resident #28 failed to receive an adequate number of required showers as scheduled. Review of the facility policy titled Bathing: Shower dated 10/2010 revealed the purposes of this procedure are to promote cleanliness, provide comfort to the resident, and to observe the condition of the residents skin. 5. Review of the medical record revealed Resident #18 was initially admitted to the facility on [DATE] with diagnoses including type two diabetes with foot ulcer, chronic osteomyelitis of right ankle and foot, congestive heart failure, and end stage renal disease. Review of Resident #18's May 2019 physician orders revealed Resident #18 to currently be non weight bearing to the right lower leg and to require a mechanical lift for transfers. Resident #18's medical record revealed a five-day admission MDS assessment, with an Assessment Reference Date (ARD) of 04/17/19, which revealed Resident #18 to be cognitively intact. The admission MDS also revealed Resident #18 to require extensive assist of two people for transfers, extensive assist of one person for personal hygiene, and was independent with bathing once in the tub. Resident #18's medical record revealed a preference for bed baths and showers during the evenings on Monday, Wednesday, and Fridays. Further medical record review revealed Resident #18 received a shower or bed bath on the following ten dates: 03/17/19 at 3:28 A.M., 04/03/19 at 1:49 A.M., 04/16/19 at 8:49 P.M., 04/21/19 at 1:05 A.M., 04/27/19 at 7:36 P.M., 05/06/19 at 1:04 A.M., 05/10/19 at 7:22 P.M., 05/12/19 at 9:16 P.M., 05/14/19 at 12:27 A.M., and 05/16/19 at 2:45 A.M. Resident #18's medical record revealed Resident #18 had refused a shower/ bed bath, a shower/ bed bath was not available, or a shower/ bed bath was not applicable on the following 33 dates: 03/15/19 at 12:07 A.M., 03/18/19 at 11:45 P.M., 03/24/19 at 12:49 A.M., 03/25/19 at 11:50 P.M., 03/27/19 at 10:39 P.M., 03/28/19 at 8:16 P.M., 03/29/19 at 11:34 P.M., 03/31/19 at 10:08 P.M., 04/02/09 at 2:56 A.M., 04/04/19 at 7:06 P.M., 04/05/19 at 11:29 P.M., 04/06/19 at 11:41 P.M., 04/07/19 at 9:05 P.M., 04/08/19 at 10:03 P.M., 04/09/19 at 9:44 P.M., 04/11/19 at 12:55 A.M., 04/12/19 at 8:34 P.M., 04/14/19 at 1:05 A.M., 04/15/19 at 1:37 A.M., 04/18/19 at 3:59 A.M., 04/22/19 at 10:38 P.M., 04/23/19 at 11:10 P.M., 04/24/19 at 2:36 A.M., 04/26/19 at 9:24 P.M., 04/29/19 at 10:59 P.M., 05/02/19 at 2:40 A.M., 05/03/19 at 5:59 A.M., 05/04/19 at 3:51 A.M., 05/05/19 at 3:03 A.M., 05/07/19 at 2:28 A.M., 05/08/19 at 8:45 P.M., 05/18/19 at 1:48 A.M., and 05/20/19 at 5:48 A.M. Interview with Resident #18 on 05/20/19 at 09:25 A.M. revealed Resident #18 stated she was supposed to receive showers three days a week and she does not get them. Resident #18 further stated she must go out to dialysis and appointments and she had refused in the past, however she was concerned she does require more showers than she receives. Staff interview with STNA #501 on 05/20/19 at 6:10 A.M. revealed STNA #501 had worked with only one STNA on each unit. STNA #501 stated when only one STNA was staffed on each unit, showers were unable to be completed secondary to the need to be able to supervise other residents and to respond to call lights. Staff interview with STNA #502 on 05/20/19 at 6:28 A.M. revealed STNA #502 had also worked with only one STNA on each unit. STNA #502 stated secondary to residents needs, it was impossible to get everything done. STNA #502 also stated the ability to give resident showers when one STNA was working was dependent on the nurse working as some of the nurses did not help or did not answer call lights so showers could not be given because there would be nobody to answer the needs of the other residents. Staff interview with STNA #503 on 05/20/19 at 2:37 P.M. revealed the facility had two STNA's identified as specific shower STNA's who worked Monday through Friday, however due to low staffing, the two shower STNA's usually worked on the units and were not able to complete showers. During staff interview on 05/21/19 at 12:15 P.M., the Director of Nursing (DON) verified Resident #18 had received only ten showers or bed baths out of 43 opportunities from 03/15/19 through 05/20/19 per computer documentation. Review of the facility policy titled, Activities of Daily Living, revised March 2018, indicated residents would be provided with care, treatment and services to ensure that their activities of daily living do not diminish unless the circumstances of their clinical condition demonstrate that diminishing ADL were avoidable. Appropriate care and services will be provided for residents who are unable to carry out ADL independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with bathing, dressing, grooming and oral care. If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident was refusing or declining care. Interventions to improve or minimize a resident's functional abilities, will be in accordance with the resident's assessed needs, preferences, and stated goals. 6. Review of the medical record revealed Resident #32 was initially admitted to the facility on [DATE] with diagnoses including major depressive disorder, urinary tract infections, chronic vaginitis, overactive bladder, and bipolar disorder. Resident #32's medical record revealed a quarterly MDS assessment with an ARD of 04/05/19 which indicated Resident #32 had intact cognition, required total dependence of two people for transfers, extensive assistance of two people for hygiene, and was dependent for bathing. Resident #32's ADL plan of care dated 01/31/15 and preferences plan of care dated 01/22/16 stated Resident #32 required a mechanical lift with transfers and would prefer a sponge bath when a full bath or shower could not be tolerated, and her following morning routine preference upon rising was to shower, get dressed, and have breakfast. Resident #32's medical record revealed under the STNA task section for Resident #32 to receive a bath as necessary and her scheduled bathing preference was daily showers. Further review of Resident #32's medical record revealed Resident #32 received a shower or tub bath on the following 12 dates: 04/21/19 at 3:11 P.M., 04/22/19 at 7:28 A.M., 04/24/19 at 9:17 A.M., 04/27/19 at 8:30 A.M., 04/30/19 at 8:38 A.M., 05/02/19 at 11:02 A.M., 05/08/19 at 3:27 P.M., 05/10/19 at 11:53 A.M., 05/12/19 at 8:07 A.M., 05/13/19 at 11:30 A.M., 05/15/19 at 4:40 P.M., and 05/19/19 at 1:29 P.M. Resident #32's medical record revealed Resident #32 with her shower or bed bath either listed as not applicable, refused, or with nothing listed on the following 18 dates: 04/23/19 at 11:13 A.M., 04/25/19 at 5:35 P.M., 04/26/19, 04/28/19 at 7:26 A.M., 04/29/19 at 9:36 A.M., 05/01/19 at 2:58 P.M., 05/03/19, 05/04/19 at 6:42 A.M., 05/05/19 at 11:10 A.M., 05/06/19, 05/07/19 at 3:18 P.M., 05/09/19 at 2:16 P.M., 05/11/19 at 3:18 P.M., 05/14/19 at 3:21 P.M., 05/16/19, 05/17/19, 05/18/19 at 1:26 P.M., and 05/20/19 at 11:33 A.M. Interview with Resident #32 on 05/20/19 at 8:43 A.M. revealed Resident #32 stated she was supposed to get a shower every day and this does not happen. Resident #32 further stated the reason she required daily showers was because she had urinary problems, and sweats heavily at night. Resident #32 also stated she had gone to physician and other appointments outside of the facility where she had attempted to mask her body odor with perfume, however stated this just made the smell worse. Staff interview with STNA #501 on 05/20/19 at 6:10 A.M. revealed STNA #501 had worked with only one STNA on each unit. STNA #501 stated when only one STNA was staffed on each unit, showers were unable to be completed secondary to the need to be able to supervise other residents and to respond to call lights. Staff interview with STNA #502 on 05/20/19 at 6:28 A.M. revealed STNA #502 had also worked with only one STNA on each unit. STNA #502 stated secondary to resident's needs, it was impossible to get everything done. STNA #502 also stated the ability to give resident showers when one STNA was working was dependent on the nurse working as some of the nurses did not help or did not answer call lights so showers could not be given because there would be nobody to answer the needs of the other residents. Staff interview with STNA #503 on 05/20/19 at 2:37 P.M. revealed the facility had two STNA's identified as specific shower STNA's who worked Monday through Friday, however due to low staffing, the two shower STNA's usually worked on the units and were not able to complete showers. During staff interview on 05/21/19 at 12:15 P.M., the DON verified Resident #32 had received only 12 showers or bed baths out of 30 opportunities from 04/21/19 through 05/20/19 per computer documentation. Review of the facility policy titled, Activities of Daily Living, revised March 2018, indicated residents would be provided with care, treatment and services to ensure that their activities of daily living do not diminish unless the circumstances of their clinical condition demonstrate that diminishing ADL were avoidable. Appropriate care and services will be provided for residents who are unable to carry out ADL independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with bathing, dressing, grooming and oral care. If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident was refusing or declining care. Interventions to improve or minimize a resident's functional abilities, will be in accordance with the resident's assessed needs, preferences, and stated goals. 9. An interview was conducted 05/20/19 at 8:05 A.M. with Resident #9. During the interview the resident revealed he resided in the facility for more than five years and voiced one concern that he did not receive his showers as per his preference. The resident stated he requested a shower five days a week and only received one shower the previous week. An interview was conducted on 05/20/19 at 3:00 P.M. with facility STNA #70. STNA #70 revealed the STNA was a regular care giver for Resident #9 and stated the resident preferred a tub bath on night shift five times a week. STNA #70 revealed the resident decided daily if he wanted the tub bath, a shower or bed bath and any type of bath provided would be documented in the electronic record and on shower sheets turned in to the nurse. Record review revealed Resident #9 was admitted to the facility 02/07/12 with diagnoses including chronic obstructive pulmonary disease, hypertension, chronic kidney disease, polyarthritis, syncope, restlessness and agitation, and dementia with behavioral disturbances. Review of a significant change MDS 3.0 assessment dated [DATE] revealed Resident #9 had moderate cognitive impairment and was totally dependent on staff for bathing. Review of the resident's care plan revealed Resident #9 preferred a tub bath in the evening hours. Continued record review revealed electronic documentation for the past 30 days from 04/22/19 to 05/21/19 the resident received a tub bath 05/07/19, 05/13/19 and 05/20/19. The resident had four documented refusals. Review of facility provided shower sheets revealed additional documentation the resident received a shower on 04/23/19, a tub bath on 04/26/19, a bed bath on 04/27/19 and a shower on 04/30/19. During an interview with the facility DON on 05/21/19 at 12:20 P.M. the resident's concern was shared and his shower documentation was reviewed. The DON confirmed Resident #9 preferred and was scheduled for a daily bath and documentation revealed the resident received only seven baths/showers in the past 30 days, one per week since 04/30/19. The DON confirmed other daily documentation of not applicable was also captured on the electronic record. The DON confirmed the resident was dependent on staff for bathing and did not receive bathing as per the plan of care. 10. Observation conducted 05/19/19 at 8:50 A.M. on the initial facility tour revealed Resident #13 seated in a wheelchair in the resident's room. Resident #13 was wearing pajamas and eating breakfast. There were no identified grooming concerns. Upon query at the time of the observation the cognitively impaired resident stated yes breakfast was good and yes when permission was requested to observe the conditions of the resident's room and bathroom but the resident was unable to answer screening questions and not interview-able. During a family interview conducted 05/19/19 at 11:40 A.M. to 12:15 P.M. the family revealed they visited daily. The family expressed concern the resident was to receive a daily bath and had not been bathed in the past three days. Record review revealed Resident #13 was admitted to the facility 08/08/17 with diagnoses including convulsions, transient ischemic attack, restlessness, agitation, fracture lower leg, major depressive disorder, anemia, hypertension, cardiomegaly, aphasia, anxiety disorder, and dementia with behaviors. Review of the most recent quarterly MDS 3.0 assessment dated [DATE] revealed the resident had severe cognitive impairment and was totally dependent for bathing. Review of an admission Evaluation dated 05/09/19 at 4:47 P.M. revealed the resident returned from the hospital and in Section 8 Preferences the nursing documentation revealed the resident preferred a bath in the morning, seven days a week. Review of facility provided shower sheets for the past 30 days from 04/22/19 to 05/21/19 revealed Resident #13 received a shower on 4/23/19, a tub bath 4/27/19, a shower 4/30/19 and a shower 5/12/19. The facility was unable to provide additional electronic documentation the resident received a daily bath as per her preferences. During an interview with the facility DON on 05/21/19 the family concern of daily bathing not provided was shared and the resident's shower sheets were reviewed. The DON confirmed the shower sheet documentation revealed the resident was showered on 04/30/19 and again on 05/12/19. The DON revealed electronic record [NAME] documented some additional showers and baths, stated 05/05/19 to 05/09/19 the resident was in the hospital, confirmed several days there was missing documentation and some days documentation indicated a daily bath was not applicable. Following the shower sheet and electronic record review the DON confirmed Resident #13 did not receive daily bathing as per the resident's preference. Based on interview, record review, review of Resident Council minutes and policy review, the facility failed to provide showers to eight (Resident's #13, #18, #25, #28, #32, #33, #40, and #70) of 10 residents reviewed for activities of daily living, one (Resident #9) of two residents reviewed for choices. The facility census was 69. Findings include: 1. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE] with diagnoses including pseudobulbar affect, nondisplaced fracture of the sixth cervical vertebrae, anxiety disorder, insomnia, major depressive disorder recurrent, restlessness and agitation, and dementia without behavioral disturbance. Review of the significant change comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] and quarterly MDS 3.0 dated 04/02/19 revealed she had moderate impairment in daily decision making. She required the extensive assistance of two plus persons for personal hygiene. Review of the admission assessment dated [DATE] indicated her preference was a shower three times per week in the mornings on Monday, Wednesday and Friday. Review of the plan of care related to activities of daily living revealed Resident #25 required one staff participation with bathing and to provide her a sponge bath when a shower could not be tolerated. Review of the State Tested Nurse Aide (STNA) documentation indicated she preferred a bath or shower every night. Review of the last 30 days of data revealed not applicable was documented for 14 days and refused was marked for one day. (April 26 and 30, 2019 and May 1, 2, 5, 6, 7, 9, 10 11, 13, 16, 17 and 20, 2019). Review of the bathing activity record revealed she received one shower in February 2019 (02/05/19) and seven showers in March 2019 (03/01/19, 03/04/19, 03/08/19, 03/11/19, 03/13/19, 03/15/19 and 03/26/19). Interview with Resident #25's family on 05/19/19 at 12:45 P.M. indicated there was not enough staff to provide the care. She said residents were often wet when she visited. 2. Review of the medical record revealed Resident #33 was admitted to the facility on [DATE] with diagnoses including post polio syndrome, vertigo and osteoporosis. Review of the annual comprehensive MDS 3.0 assessment dated [DATE] and review of the quarterly MDS 3.0 dated 04/05/19 indicated she was alert, oriented and independent in daily decision making ability. She displayed no psychosis or behavioral symptoms. Choice in what to wear, taking care of personal belongings, the type of bathing and going outside to get fresh air were very important to her. She required the physical help for bathing. Review of the admission assessment dated [DATE] indicated her preferences prior to coming to the facility were daily showers in the morning. She indicated she would like to receive three showers per week at the facility on Monday, Wednesday and Friday. Review of the activity of daily living plan of care indicated Resident #33 required assistance with bathing/showering and as necessary would be provided a sponge bath when a shower could not be tolerated. Review of the bathing activity record revealed she refused on 03/04/19 but received seven showers in March 2019, six showers in April 2019 and three showers in May 2019. Review of the STNA documentation revealed she was scheduled for showers on Mondays, Wednesdays and Fridays in the morning. Review of the data for the last 30 days revealed she received three showers on 04/30/19, 05/02/19 and 05/22/19 and should have received 12. Interview with Resident #33 on 05/19/19 at 10:40 A.M. said she had had only one shower in the last week and she was supposed to get a shower every Monday, Wednesday and Friday. 3. Review of the medical record revealed Resident #40 was admitted to the facility on [DATE] with diagnoses including surgical after care, presence for right artificial knee joint, fibromyalgia, pulmonary hypertension, presence of prosthetic heart valve, peripheral vascular disease, diabetes with hypoglycemia and complications, disorder of the adrenal gland and obstructive sleep apnea. Review of the annual comprehensive MDS 3.0 assessment dated [DATE] indicated she was alert, oriented and independent in daily decision making ability. She had no symptoms of psychosis or behaviors. It was very important to her to choose her clothing, care for personal belongings, choose the type of bath, choose own bedtime. She required the supervision and one person physical assistance for personal hygiene and bathing. Review of the admission assessment dated [DATE] indicated her preferences were daily showers prior to admission but indicated she would like to receive three showers per week in the morning on Sunday, Monday and Wednesday. Review of the shower documentation provided by the facility indicated she preferred morning showers Mondays, Wednesdays and Fridays. Review of the documentation revealed in the last 30 days she received eight showers on 04/23/19, 04/27/19, 04/28/19, 05/02/19, 05/13/19, 05/15/19, 05/19/19 and 05/22/19 out of the 13 she should have been provided. Review of the bathing activity records for March 2019 indicated she was provided six of 13 showers and for April 2019 she was provided four of 13 showers scheduled. Interview with Resident #40 and her daughter on 05/22/19 from 12:00 P.M. to 1:15 P.M. voiced concerns that she was not receiving her scheduled showers because there was not enough staff. The resident said there was a bath aide but she was often called to the floor to work. She said she has only received two showers since surgery and one was because her son requested she receive one. He returned in an hour to confirm it. 4. Review of the medical record revealed Resident #70 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including gastrostomy, congestive heart failure chronic embolism and thrombosis, peripheral vascular disease, osteoporosis, edema, cellulitis of left lower limb, iron deficiency anemia, vitamin D deficiency, disorder of lung, colon cancer, acute and chronic respiratory failure with hypercapnia and hypoxia. Review of the MDS 3.0 assessment dated [DATE] indicated she was alert, oriented and independent in daily decision making. She displayed no indicators of psychosis. She displayed verbal behaviors directed toward others on one to three days of the seven-day assessment reference period. She required the physical assistance of one person for bathing. Review of the activity of daily living plan of care revealed she required the assistance of staff for bathing and toileting. Review of the admission assessment indicated she preferred a tub bath every other day and she received three in the last 30 days (05/03/19, 05/07/19 and 05/17/19). Review of the activity of daily living plan of care indicated she required the assistance of staff for bathing and toileting Interview with Resident #70 on 05/19/19 at 11:24 A.M. said she had been wet all night and was not able to reach her call light. She said she needed attention and no one was helping her. She said she had not received a bath since before her surgery. Interview with RN #88 and STNA #85 on 05/19/19 at 11:30 A.M. verified Resident #70's incontinence brief was heavily soiled with urine. Confidential interviews with staff revealed they were fearful of reprisal including termination from the administrator. Three RN's and five STNA's were interviewed between 05/10/19 at 6:10 A.M. and 05/28/19 at 2:17 P.M. all reported they facility did not provide enough personnel to be able to meet the residents basic needs such as bathing. Review of the Resident Council minutes dated 11/29/18 and 03/12/19 revealed residents voiced concerns they were not receiving their showers. Review of the activities of daily living, supporting policy revised in March 2018 indicated residents would be provided with care, treatment and services to ensure that their activities of daily living (ADL)do not diminish unless the circumstances of their clinical condition demonstrate that diminishing ADL were avoidable. Appropriate care and services will be provided for residents who are unable to carry out ADL independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with bathing, dressing, grooming and oral care. If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident was refusing or declining care. Interventions to improve or minimize a resident's functional abilities, will be in accordance with the resident's assessed needs, preferences, stated goals Review of the shower/tub bath policy and procedure revised October 2010 indicated the following information should be recorded in the resident's activity of daily living and/or medical record: date and time the shower/tub bath was performed, name of the person who assisted, all assessment data, how the resident tolerated it, if the resident refused, the reason why and the intervention taken and a signature and title of the person recording the data.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident, family and staff interviews, record review and policy review, the facility failed to provide sufficient staffing levels to consistently provide care and services to assure resident safety and meet the basic care needs of the residents. This affected 19 (Residents #1, #2, #6, #9, #10, #13, #17, #18, #20, #25, #26, #32, #33, #40, #56, #59, #60, #63, and #70) and had the potential to affect all 69 residents who resided in the facility. Findings include: 1. Review of the Resident Council meeting minutes from 03/28/18 through 04/24/19 revealed residents had numerous staffing related concerns over many months. A breakdown of the concerns by months is as follows: a). Residents had concerns about showers not being completed during the following months: 11/29/18 and 03/12/19. b). Residents identified concerns related to staffing and services provided by State Tested Nurse Aides (STNA)'s during the following months: 05/30/18, 07/25/18, 10/31/18, 11/29/18, and 03/12/19. During the survey Resident Council meeting, held on 05/20/19 at 10:13 A.M., Residents #20, #33, and #59 verified the ongoing concerns and stated the correct department responded to their concerns, however the concerns did not seem to be resolved and continued to reoccur month to month. Interview with the Administrator on 05/21/19 at 1:54 P.M. revealed the Resident Council meeting minutes and concerns were discussed in the morning meeting following Resident Council, however the Administrator indicated she could not speak to the lack of communication between the Activity Director (who normally ran the Resident Council) and residents and staff. The Administrator also stated the facility was currently in process of trying to find a new Activity Director. 2. Interviews from 05/20/19 to 05/27/19. with Registered Nurse (RN) #73, Licensed Practical Nurses (LPN) #119, #127, #128, and STNAs #70, #77, #79, #80, #8, #91, #501, #502, and #503 revealed when asked about staffing, stated they felt the facility was often short staffed and found it very difficult to deliver adequate care to the residents because of the staffing levels. 3. Interviews on 05/20/19 and 05/21/19 with twelve alert and oriented residents (Resident #6, Resident #2, Resident #13, Resident #17, Resident #18, Resident #25, Resident #26, Resident #32, Resident #33, Resident #56, Resident #60, Resident #63, and Resident #70), indicated they thought the facility did not have enough nurses and aides. They stated they had to wait excessive amounts of time to have the call lights answered and/or receive care. 4. Interviews with Residents and/or Families (#17, #18, #26, #32, #60, and #70) during the screening portion of the survey from 05/19/19 at 10:56 A.M. to 05/20/19 at 9:23 A.M. yielded concerns including: a). The facility was short-handed with aides. b). There was no one to toilet or put them to bed on 05/18/19. c). At times there was one aide to one side of the building, and residents have had to wait up to 40 minutes to go to the bathroom. d). There were concerns related to residents having to stay in bed because there was not enough staff to get them up. e). There were concerns related to not being checked on during the night, and call lights were being left out of reach. f). Staffing at night was being referred to as horrible with complaints of waiting over a half hour to get help. 5. Confidential interviews with staff revealed they were fearful of reprisal including termination from the Administrator. Three RN's and five STNA's were interviewed between 05/10/19 at 6:10 A.M. and 05/28/19 at 2:17 P.M. all reported the facility did not provide enough personnel to be able to meet the resident's basic needs such as bathing. 6. On 05/23/19 at 1:00 P.M. review of the staffing tool, posted staffing information, staffing schedules and employee punch detail reports from 05/12/19 through 05/18/19 with the facility's Assistant Director of Nursing (ADON) with oversight by the Administrator revealed the facility failed to meet the minimum daily direct care requirement of 2.50 hours on 05/12/19, with a total of 2.43 hours. The ADON verified there was not sufficient staff on 05/12/19 to meet the minimum daily direct care requirement of 2.50 hours. 7. Interview with Resident #1 and Resident #63 on 05/28/19 at 1:30 P.M. and 1:45 P.M. reported they missed two smoke breaks on 05/27/19 because there were not enough staff to take them outside. 8. Confidential interviews, due to fear of reprisal, with 18 staff between 05/20/19 from 5:46 A.M. to 05/28/19 at 2:17 P.M. verified they felt there was not enough staff to provide care to the residents as evidenced by the following comments: a). Staff were not able to provide showers when only one aide and one nurse were scheduled on a side. They indicated with one aide, they were absolutely not able to provide care and respond to call lights/requests. b). There were a lot of call offs, and they were not replaced causing staff to be mandated to work beyond their scheduled shift. c). There was not enough staff to turn and reposition residents as needed. d). Showers were not always completed, and at times staff would provide bed baths instead of showers. e). Staff were not able to provide restorative services because of having to work as a STNA on the floor. Staff appeared nervous and some were tearful while being interviewed. 9. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbance, advanced bilateral non-exudative age-related macular degeneration, anxiety disorder, restlessness and agitation, blindness in one eye and low vision in the other eye, major depressive disorder and aphasia following cerebrovascular disease. Review of the elopement risk assessment dated [DATE] indicated Resident #13 was at moderate risk for elopement. The note indicated Resident #13 was actively expressing a desire to leave the facility but was able to be re-directed at that time. She was placed on 15-minute checks for safety. The elopement risk assessment dated [DATE] identified her at high risk and on 01/23/19 she was identified at moderate risk for elopement. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated she was moderately cognitively impaired, and she displayed no psychosis or behavioral symptoms. Review of the plan of care related to Resident #13 stated she was at risk for elopement/wandering. The plan of care indicated she had a history of attempts to leave the facility unattended, had packed her belongings and indicated she was going home, had impaired safety awareness and was difficult to redirect/distract at times from intent to leave. The interventions included to attempt to distract her, offer pleasant diversions, structured activities, food, conversation, television and books; identify a pattern of wandering; monitor her location as needed; 30-minute safety checks and document the wandering behavior and attempted diversional interventions in the behavior log. Review of the social service note dated 07/25/18 at 10:54 A.M. indicated a meeting was held with the family regarding Resident #13's risk for elopement and possible consideration to have her transferred to a locked unit. The family refused the idea of a transfer and asked if 15-minute checks could continue and they would work with the facility in any way so long as the resident was not moved to a locked unit. It was noted the Director of Nursing agreed with 15-minute checks to visualize her safety at that time. Review of the nurse's progress note dated 07/30/18 at 4:35 P.M. Resident #13 was found outside the facility by another resident. The resident was placed on one to one observation for the remainder of the night. Review of the social service note dated 09/14/18 at 12:14 P.M. indicated another meeting was held with the family regarding falls and continuous exit seeking behavior. The family was educated regarding the need for a secured dementia unit. The family refused the idea of a transfer. It was noted educated was provided for immediate and 30-day discharge notices due to the concern of the resident's safety. Review of the nurses note dated 03/17/19 at 5:33 P.M. a resident witnessed Resident #13 exit the doors in her wheelchair and go down the sidewalk in front of the building. The resident alerted staff who brought her back into the facility. Review of the 03/17/19 investigation revealed there were three nurses and six STNA's on duty. There were statements obtained by three nurses and two STNA's. RN #75's statement indicated he went out to retrieve her and she had made it to the visitor parking lot. A head to toe assessment was completed, and she was found without injury. There was no investigation provided for the 07/30/18 incident. Interview with Resident #63 on 05/23/19 at 8:30 A.M. said she saw Resident #13 outside by the pond in March 2019 and went and got help. She said she knew some residents who wander but should not get out of the facility but did not know all who could not be out unattended. She said she went inside and got staff immediately. Interview with LPN #122 on 05/23/19 at 9:32 A.M. verified she authored the 07/30/18 progress note when Resident #13 was found outside. She was not able to recall what resident found her and could not remember how long she was out of the facility unattended. She did say Resident #13 wanted to go outside all the time because that's what she loved to do. She verified she did not write a witness statement for the incident. Interview with the Administrator on 05/23/19 at 9:40 A.M. indicated they reached out to the family regarding an alternative locked facility, but they absolutely refused. She indicated several things were done such as monitoring for urinary tract infections and medication changes. She said that did not work so they re-approached the family and again they refused. She said they were in process of obtaining a Wanderguard system (departure alert system), but there were Federal hoops to go through. She said they had 15-minute checks in place when she left unattended on 07/30/19. She said the resident exit seeks when the daughter leaves and did not know how they could have prevented it. Interview with the family on 05/23/19 at 1:22 P.M. voiced being upset thinking the State wanted her mother out of the facility. It was explained to them facility was responsible to provide enough supervision to keep her safe. The Regional Nurse #600 interjected saying the facility would provide one to one supervision until the Wanderguard system could be installed. The family also offered a suggestion of when staff takes the smokers outside to take Resident #13 outside also. 10. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including muscle weakness, difficulty in walking, spastic hemiplegic cerebral palsy and hemiplegia affecting left non-dominant side. Review of the annual comprehensive MDS 3.0 assessment dated [DATE] indicated she was alert, oriented and independent in daily decision-making ability. She did not have symptoms of psychosis or behaviors. She received five days of restorative transfer services during the assessment period. Review of the plan of care initiated on 04/27/18 related to having impairment with self-transfer due to limited mobility and weakness indicated the interventions included a restorative active range of motion program to bilateral lower extremities six to seven days per week for 15 minutes and a restorative transfer program for six to seven days per week for 15 minutes. Review of the restorative quarterly review dated 04/29/19 indicated Resident #10 attended the therapy gym after breakfast. She was able to tolerate the current number of repetitions and the program would continue as outlined. Review of the restorative data records revealed Resident #10 was marked not applicable on 12 days in March 2019, 15 days in April 2019 plus one blank and 11 days in May 2019 plus one blank. Interview with restorative STNA #77 on 05/28/19 at 2:05 P.M. indicated when she was not able to get restorative services completed when working on the unit she would mark not applicable. She verified restorative services were not always provided as planned. On 05/29/19 at 8:49 A.M. Resident #10 was seated in her wheelchair in the doorway of her room. She was very difficult to understand and drooled when she tried to speak. She indicated she received restorative services and the rest was unintelligible. 11. Review of the medical record revealed Resident #33 was admitted to the facility on [DATE] with diagnoses including post-polio syndrome, vertigo and osteoporosis. Review of the comprehensive MDS 3.0 assessment dated [DATE] indicated she was alert, oriented and independent in daily decision-making ability. She had no symptoms of psychosis or behaviors. She received five days of restorative active range of motion Review of the restorative assessment dated [DATE] indicated active range of motion to bilateral upper extremities six to seven days per week and ambulation six to seven days per week. Review of the restorative quarterly review dated 04/05/19 indicated she was compliant with bilateral upper extremity and bed exercises. The restorative program remained appropriate. Review of the plan of care related to restorative services initiated on 07/28/17 indicated she was at risk for decline in functional range of motion related to limited mobility, pain in her left shoulder and latent complexities of polio syndrome. The interventions included to provide active range of motion for bilateral upper extremities 15 minutes per day six to seven days per week. Review of restorative data revealed Resident #33 was marked as not applicable or was blanks for four days and marked as refusing service on four days in March 2019. She was marked as not applicable for four days and had five blanks for April 2019 and was marked as not applicable for five days, not available for one day and had 10 blanks for May 2019. Interview with Resident #33 on 05/19/19 at 10:40 A.M. said the facility did not have enough staff to provide her restorative services. She said the restorative aide was being pulled to the floor as an STNA and couldn't provide service. Interview with the restorative STNA #77 on 05/28/19 at 2:05 P.M. indicated when she was not able to get restorative services completed when working on the unit she would mark not applicable. She verified restorative services were not always provided as planned. 12. Interview with Residents and/or Families (#6, #9, #13, #18, #25, #32, #33 and #70) between 05/19/19 at 10:40 A.M. and 05/20/19 at 9:25 A.M. voiced concerns they were not receiving showers as planned as evidence by: a). Review of the medical record revealed Resident #25 was admitted to the facility on [DATE] with diagnoses including pseudobulbar affect, non-displaced fracture of the sixth cervical vertebrae, anxiety disorder, insomnia, major depressive disorder recurrent, restlessness and agitation and dementia without behavioral disturbance. Review of the significant change MDS 3.0 comprehensive assessment dated [DATE] and quarterly MDS 3.0 assessment dated [DATE] revealed she had moderate impairment in daily decision making. She required the extensive assistance of two plus persons for personal hygiene and total dependence of two plus persons. Review of the admission assessment dated [DATE] indicated her preference was a shower three times per week in the mornings on Monday, Wednesday and Friday. Review of the plan of care related to activities of daily living revealed Resident #25 required one staff participation with bathing and to provide her a sponge bath when a shower could not be tolerated. Review of the STNA documentation indicated she preferred a bath or shower every night. Review of the last 30 days of data revealed not applicable was documented on 14 days and refused was documented on one day. (04/26/19, 04/30/19, 05/01/19,05/02/19, 05/05/19, 05/06/19, 05/07/19, 05/09/19, 05/10/19, 05/11/19, 05/13/19, 05/16/19, 05/17/19, and 05/20/19). Review of the bathing activity record revealed she received one shower in February 2019 (02/05/19) and seven showers in March 2019 (03/01/19, 03/04/19, 03/08/19, 03/11/19, 03/13/19, 03/15/19 and 03/26/19). Interview with Resident #25's family on 05/19/19 at 12:45 P.M. indicated there was not enough staff to provide the care. She said residents were often wet when she visited. b). Review of the medical record revealed Resident #33 was admitted to the facility on [DATE] with diagnoses including post- polio syndrome, vertigo and osteoporosis. Review of the annual comprehensive MDS 3.0 assessment dated [DATE] and review of the quarterly MDS 3.0 assessment dated [DATE] indicated she was alert, oriented and independent in daily decision-making ability. She displayed no psychosis or behavioral symptoms. Choice in what to wear, taking care of personal belongings, the type of bathing and going outside to get fresh air was very important to her. She required physical help for bathing. Review of the admission assessment dated [DATE] indicated her preferences prior to coming to the facility was daily showers in the morning. She indicated she would like to receive three showers per week at the facility on Monday, Wednesday and Friday. Review of the activity of daily living plan of care indicated Resident #33 required assistance with bathing/showering and as necessary would be provided a sponge bath when a shower could not be tolerated. Review of the bathing activity record revealed she refused on 03/04/19 but received seven showers in March 2019, six showers in April 2019 and three showers in May 2019. Review of the STNA documentation revealed she was scheduled for showers on Mondays, Wednesdays and Fridays in the morning. Review of the data for the last 30 days revealed she received three showers on 04/30/19, 05/02/19 and 05/22/19 and should have received 12. Interview with Resident #33 on 05/19/19 at 10:40 A.M. said she had had only one shower in the last week and she was supposed to get a shower on Monday, Wednesday and Friday. c). Review of the medical record revealed Resident #40 was admitted to the facility on [DATE] with diagnoses including surgical after care, presence for right artificial knee joint, fibromyalgia, pulmonary hypertension, presence of prosthetic heart valve, peripheral vascular disease, diabetes with hypoglycemia and complications, disorder of the adrenal gland and obstructive sleep apnea. Review of the annual comprehensive MDS 3.0 assessment dated [DATE] indicated she was alert, oriented and independent in daily decision-making ability. She had no symptoms of psychosis or behaviors. It was very important to her to choose her clothing, care for personal belongings, choose the type of bath, choose own bedtime. She required the supervision of one-person physical assistance for personal hygiene and bathing. Review of the admission assessment dated [DATE] indicated her preferences were daily showers prior to admission but indicated she would like to receive three showers per week in the morning on Sunday, Monday and Wednesday. Review of the shower documentation provided by the facility indicated she preferred morning showers Mondays, Wednesdays and Fridays. Review of the documentation revealed in the last 30 days she received eight showers on 04/23/19, 04/27/19, 04/28/19, 05/02/19, 05/13/19, 05/15/19, 05/19/19 and 05/22/19 out of the 13 she should have been provided. Review of the bathing activity records for March 2019 indicated she was provided six of 13 showers and for April 2019 she was provided four of 13 showers scheduled. Interview with Resident #40 and her daughter on 05/22/19 from 12:00 P.M. to 1:15 P.M. voiced concerns that she was not receiving her scheduled showers because there was not enough staff. The resident said there was a bath aide, but she was often called to the floor to work. She said she had only received two showers since surgery and one was because her son requested she receive one. He returned in an hour to confirm it. d). Review of the medical record revealed Resident #70 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including gastrostomy, congestive heart failure chronic embolism and thrombosis, peripheral vascular disease, osteoporosis, edema, cellulitis of left lower limb, iron deficiency anemia, vitamin D deficiency, disorder of lung, colon cancer, acute and chronic respiratory failure with hypercapnia and hypoxia. Review of the MDS 3.0 dated 05/07/19 indicated she was alert, oriented and independent in daily decision making. She displayed no indicators of psychosis. She displayed verbal behaviors directed toward others on one to three days of the seven-day assessment reference period. She required the physical assistance of one person for bathing. Review of the activity of daily living plan of care revealed she required the assistance of staff for bathing and toileting. Review of the admission assessment indicated she preferred a tub bath every other day and she received three in the last 30 days (05/03/19, 05/07/19 and 05/17/19). Review of the activity of daily living plan of care indicated she required the assistance of staff for bathing and toileting Interview with Resident #70 on 05/19/19 at 11:24 A.M. said she had been wet all night and was not able to reach her call light. She said she needed attention, and no one was helping her. She said she had not received a bath since before her surgery. Interview with RN #88 and STNA #85 on 05/19/19 at 11:30 A.M. verified Resident #70's incontinence brief was heavily soiled with urine. e). Resident #18 was initially admitted to the facility on [DATE] with diagnoses including type II diabetes with foot ulcer, chronic osteomyelitis of right ankle and foot, congestive heart failure, and end stage renal disease. Review of Resident #18's May 2019 physician orders revealed Resident #18 was currently non-weight bearing to the right lower leg and required a mechanical lift for transfers. Resident #18's medical record revealed a five-day admission MDS 3.0 assessment, with an Assessment Reference Date (ARD) of 04/17/19, which revealed Resident #18 to be cognitively intact. The admission MDS also revealed Resident #18 to required extensive assist of two people for transfers, extensive assist of one person for personal hygiene, and was independent with bathing once in the tub. Resident #18's medical record revealed a preference for bed baths and showers during the evenings on Monday, Wednesday, and Fridays. Further medical record review revealed Resident #18 received a shower or bed bath on the following ten dates: 03/17/19 at 3:28 A.M., 04/03/19 at 1:49 A.M., 04/16/19 at 8:49 P.M., 04/21/19 at 1:05 A.M., 04/27/19 at 7:36 P.M., 05/06/19 at 1:04 A.M., 05/10/19 at 7:22 P.M., 05/12/19 at 9:16 P.M., 05/14/19 at 12:27 A.M., and 05/16/19 at 2:45 A.M. Resident #18's medical record revealed Resident #18 with refused a shower/ bed bath, a shower/ bed bath was not available, or a shower/ bed bath was not applicable on the following 33 dates: 03/15/19 at 12:07 A.M., 03/18/19 at 11:45 P.M., 03/24/19 at 12:49 A.M., 03/25/19 at 11:50 P.M., 03/27/19 at 10:39 P.M., 03/28/19 at 8:16 P.M., 03/29/19 at 11:34 P.M., 03/31/19 at 10:08 P.M., 04/02/09 at 2:56 A.M., 04/04/19 at 7:06 P.M., 04/05/19 at 11:29 P.M., 04/06/19 at 11:41 P.M., 04/07/19 at 9:05 P.M., 04/08/19 at 10:03 P.M., 04/09/19 at 9:44 P.M., 04/11/19 at 12:55 A.M., 04/12/19 at 8:34 P.M., 04/14/19 at 1:05 A.M., 04/15/19 at 1:37 A.M., 04/18/19 at 3:59 A.M., 04/22/19 at 10:38 P.M., 04/23/19 at 11:10 P.M., 04/24/19 at 2:36 A.M., 04/26/19 at 9:24 P.M., 04/29/19 at 10:59 P.M., 05/02/19 at 2:40 A.M., 05/03/19 at 5:59 A.M., 05/04/19 at 3:51 A.M., 05/05/19 at 3:03 A.M., 05/07/19 at 2:28 A.M., 05/08/19 at 8:45 P.M., 05/18/19 at 1:48 A.M., and 05/20/19 at 5:48 A.M. Interview with Resident #18 on 05/20/19 at 09:25 A.M. revealed Resident #18 stated she is supposed to receive showers three days a week, and she does not get them. Resident #18 further stated she must go out to dialysis and appointments, and she had refused in the past, however she was concerned she does require more showers than she received. Staff interview with STNA #501 on 05/20/19 at 6:10 A.M. revealed STNA #501 had worked with only one STNA on each unit. STNA #501 stated when only one STNA was staffed on each unit, showers were unable to be completed secondary to the need to be able to supervise other residents and to respond to call lights. Staff interview with STNA #502 on 05/20/19 at 6:28 A.M. revealed STNA #502 had also worked with only one STNA on each unit. STNA #502 stated secondary to resident's needs, it was impossible to get everything done. STNA #502 also stated the ability to give resident showers when one STNA was working was dependent on the nurse working as some of the nurses did not help or answer call lights so showers could not be given because there would be nobody to answer the needs of the other residents. Staff interview with STNA #503 on 05/20/19 at 2:37 P.M. revealed the facility had two STNA's identified as specific shower STNA's who worked Monday through Friday, however due to low staffing, the two shower STNA's usually worked on the units and were not able to complete showers. During staff interview on 05/21/19 at 12:15 P.M., the Director of Nursing (DON) verified Resident #18 had received only ten showers or bed baths out of 43 opportunities from 03/15/19 through 05/20/19 per computer documentation. f). Resident #32 was initially admitted to the facility on [DATE] with diagnoses including major depressive disorder, urinary tract infections, chronic vaginitis, overactive bladder, and bipolar disorder. Resident #32's medical record revealed a quarterly MDS assessment with an ARD of 04/05/19 which indicated Resident #32 had intact cognition, required total dependence of two people for transfers, extensive assistance of two people for hygiene, and was dependent for bathing. Resident #32's ADL plan of care dated 01/31/15 and preferences plan of care dated 01/22/16 stated Resident #32 required a mechanical lift with transfers and would prefer a sponge bath when a full bath or shower could not be tolerated, and her following morning routine preference upon rising was to shower, get dressed, and have breakfast. Resident #32's medical record revealed under the STNA task section for Resident #32 to receive a bath as necessary and her scheduled bathing preference was daily showers. Further review of Resident #32's medical record revealed Resident #32 received a shower or tub bath on the following 12 dates: 04/21/19 at 3:11 P.M., 04/22/19 at 7:28 A.M., 04/24/19 at 9:17 A.M., 04/27/19 at 8:30 A.M., 04/30/19 at 8:38 A.M., 05/02/19 at 11:02 A.M., 05/08/19 at 3:27 P.M., 05/10/19 at 11:53 A.M., 05/12/19 at 8:07 A.M., 05/13/19 at 11:30 A.M., 05/15/19 at 4:40 P.M., and 05/19/19 at 1:29 P.M. Resident #32's medical record revealed Resident #32 with her shower or bed bath either listed as not applicable, refused, or with nothing listed on the following 18 dates: 04/23/19 at 11:13 A.M., 04/25/19 at 5:35 P.M., 04/26/19, 04/28/19 at 7:26 A.M., 04/29/19 at 9:36 A.M., 05/01/19 at 2:58 P.M., 05/03/19, 05/04/19 at 6:42 A.M., 05/05/19 at 11:10 A.M., 05/06/19, 05/07/19 at 3:18 P.M., 05/09/19 at 2:16 P.M., 05/11/19 at 3:18 P.M., 05/14/19 at 3:21 P.M., 05/16/19, 05/17/19, 05/18/19 at 1:26 P.M., and 05/20/19 at 11:33 A.M. Interview with Resident #32 on 05/20/19 at 8:43 A.M. revealed she was supposed to get a shower every day, and it did not happen. Resident #32 further stated the reason she required daily showers was because she had urinary problems, and sweats heavily at night. Resident #32 also stated she had gone to physician and other appointments outside of the facility where she had attempted to mask her body odor with perfume, however stated this just made the smell worse. Staff interview with STNA #501 on 05/20/19 at 6:10 A.M. revealed STNA #501 had worked with only one STNA on each unit. STNA #501 stated when only one STNA was staffed on each unit, showers were unable to be completed secondary to the need to be able to supervise other residents and to respond to call lights. Staff interview with STNA #502 on 05/20/19 at 6:28 A.M. revealed STNA #502 had also worked with only one STNA on each unit. STNA #502 stated secondary to resident's needs, it was impossible to get everything done. STNA #502 also stated the ability to give resident showers when one STNA was working was dependent on the nurse working as some of the nurses did not help or answer call lights so showers could not be given because there would be nobody to answer the needs of the other residents. Staff interview with STNA #503 on 05/20/19 at 2:37 P.M. revealed the facility had two STNA's identified as specific shower STNA's who worked Monday through Friday, however due to low staffing, the two shower STNA's usually worked on the units and were not able to complete showers. During staff interview on 05/21/19 at 12:15 P.M., the DON verified Resident #32 had received only 12 showers or bed baths out of 30 opportunities from 04/21/19 through 05/20/19 per computer documentation.

Based on observation, interview and document review, the facility failed to ensure resident's food preferences were accommodated and appealing substitutions of similar nutritive value were provided to all 67 residents receiving food from the kitchen. Findings include: On 05/19/19 at 11:49 A.M. the main dining room was observed for the lunch meal. Each table had a caddy in the center with a laminated card identifying the always available items. The items were listed as pizza, hamburger/cheeseburger, hot dog cottage cheese and fruit plate, grilled cheese, peanut butter and jelly, deli sandwich and side salad. The laminated cart had pictures of pizza and a cheeseburger and also a note at the bottom indicating to see the menu board for the daily alternative. The lunch meal on 05/19/19 consisted of roast beef, mashed potatoes with gravy, carrots and apple crisp. A couple of residents requested a cheeseburger and another requested a cottage cheese plate. There was no other daily alternative observed. Observation of the menu board on 05/19/19 lacked indication of an alternative. Interview with Resident #60's family on 05/19/19 at 1:00 P.M. reported her beverage of choice was ginger ale. He said she was receiving it regularly but was told now she could only get ginger ale if she was sick. He said she did not drink much water but staff only pass ice water once in a while. Interview with Resident #40 and her daughter on 05/22/19 at 12:00 P.M. reported all of the meals were high in carbohydrates. She had diabetes and had to order other stuff. She said if she asked for a salad, she was told it was not on the menu and she could not get one as a meal. She did say she could get a small side salad that came in a small bowl. She felt salad as a meal was a better choice then a hamburger, hot dog or their regular meals with all of the gravy and carbohydrates. They said they were informed that salad was limited by the State because of budget cuts. She said she would request vegetables, but often they were out or they were overcooked. The resident said the kitchen puts gravy on everything and felt the facility should offer a chef salad every day with egg. They were also upset the facility limited snacks between meals. They provided a copy of a letter sent out indicating effective 05/01/19 the dietary department would no longer be providing snacks in between meals. The letter indicated each resident received a money stipend as determined by the Department of Job and Family Services. This money was to be used to purchase snacks, cigarettes or personal care items that you prefer over what was issued by the facility. Please note there will continue to be a snack cart provided during the evening hours with a selection of items that were diet appropriate. Please do not ask a State Tested Nurse Aide (STNA) or dietary staff member for snack food items as they will no longer be provided between meals. Interview with Resident #63 on 05/19/19 at 3:39 P.M. said she was upset they took the chef salad and other items off the menu. She said she did not like the regular menu items and was relying on snacks. She said she preferred to choose a chef salad as a meal as a healthy choice. She said she had gone to Resident Council in the past but nothing was ever resolved. She indicated if you wanted a snack between meals you would have to pay for it. Interview with Resident #12 on 05/28/19 said the menu's were nasty and all carbohydrates. She said she used to order a chef salad at lunch and dinner but they took it away and she could not have it anymore. Interview with Dietary Manager #112 on 05/21/19 at 10:37 A.M. verified pizza was taken off the always available menu. She said chef salads were not on the anytime menu but residents routinely ordered them. She said they were now part of the menu being service one time per month and residents could no longer get one for a meal, the same as a pizza. She verified the residents were upset with the changes. She said if they wanted a salad as a meal they could only get a small bowl side salad. She indicated the Administrator informed her of the changes and it was due to the budget. She also indicated she did not want to get into trouble for saying this. She confirmed the anytime menu currently posted at each table listed pizza at the top of the list. On 05/21/19 at 1:00 P.M. the Administrator and Dietary Manager #112 approached the survey team. The Administrator had the Dietary Manager recant the information she had provided related to budget cuts. The Administrator reported their were not budget cuts in dietary in the last three years and dietary was always over budget. She reported the pizza was taken off the anytime menu because some residents were only requesting pizza for lunch and dinner. She said removing it from the menu was in hopes they would make healthier choices. She said a chef salad was never on the anytime menu but acknowledged residents were requesting them. She said again it was not allowed so residents would make better choices. She said as far as substitutions were concerned left overs were available as were items from the anytime menu which included hamburgers and hot dogs. Interview with Registered Dietitian (RD) #111 on 05/22/19 at 2:06 P.M. said he was in the facility one day per week. He indicated a diabetic diet the facility followed was a low concentrated sweets diet. Dietary had a form listing the substitutes and allowances to provide for diabetics. He said alternates and preferences were to be followed because excessive carbohydrates would increase blood sugar levels. He said they should avoid cakes, cookies and ice cream. He said if they were served items they felt were inappropriate they could choose a hamburger, fruit, salads and vegetables. He said he often heard complaints of the taste of the food because it was not what they were used to at home. He said when he visited weekly he completed food rounds. RD #111 said he was unaware chef salads were not available to the residents. He was aware that several residents enjoyed them. He said if the residents wanted chef salads it should be an option for them. He also indicated pizza should be allowed as an option. He said he was not made aware these items were no longer available to the residents. Further interview with RD #111 on 05/28/19 at 11:25 A.M. regarding the letter that was sent to residents and families regarding snacks. He said the Regional Dietitian had sent out the letter. He was not involved or aware. He said he believed each resident was provided two beverages per meal but agreed they were provided more if they wanted it. He said he understood that residents were not eating the main meal and taking extra snack food items. He said he thought it was a budget issue. He confirmed he was not consulted. He said he had to speak with residents about their weight gains and offer education and hope they would follow his advice. He was asked about similar nutritive meals being offered. He said the always available list was the nutritive alternate. Confidential interviews with staff who were fearful of retaliation between 05/20/19 at 6:28 A.M. and 05/28/19 at 12:45 P.M. indicated residents were no longer permitted to have pizza, chef salad and no longer permitted to have ginger ale unless they were vomiting. There were also limits on fluids. On 05/29/19 at 11:00 A.M. STNA #503 was observed to come to the kitchen to request a nutritional supplement for Resident #13 per the daughter's request. Dietary Manager #112 said no because the supplement was ordered with breakfast, lunch and dinner. STNA #503 appeared frustrated. The surveyor intervened and asked if someone wanted a beverage between meals what could she have. She then offered a milk to be taken to the resident. Review of the medical record revealed she was ordered Ensure Plus three times a day. There was no specific order for it to be provided at meals. Review of Resident Council minutes since June 2018 revealed residents complained about food during the following meetings on 03/12/19, 02/27/19, 11/29/18, 09/26/18, 07/25/18 and 06/28/18. Review of the Food Committee minutes since May 2018 revealed in May 2018 (no date listed) residents wanted more toppings for salads and fresh fruit for desserts, on 08/30/18 they did not want soup and sandwich every day, on 10/30/18 they asked for better ingredients in their salad, on 12/27/18 the residents would like different choices for the always available menu, on 02/27/19 they wanted more homemade Jello, fresh fruit and salad choices. The residents were notified the always available menus were changing to tossed salad, baked potato, soup of the day, chicken or ham salad, which would be alternated through the week, on 03/28/19 requesting more fruit on the snack cart and on 04/25/19 changes to selective menus were discussed. Review of the four week menu cycle revealed a chef salad was offered once during week one and cheese pizza was offered once during week four.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and policy review, the facility failed to prevent cross contamination in the kitchen. This had the potential to affect all 67 residents. Findings include: On 05/21/19 beginning at 10:25 A.M. the puree process was observed for the lunch meal. [NAME] #136 was observed using gloved hands to remove three [NAME] that were soaking in a milk bath, dip them into a flour mixture and place them on the flat top grill. [NAME] #136 positioned the coated [NAME] using tongs which knocked off the coating from the gloves. She squeezed liquid butter onto the grill and used her soiled gloved hand to add onion rings onto the butter to saute. [NAME] #136 used tongs to turn and flip the [NAME] then placed one liver onto a white dinner plate and put a probe thermometer into the liver to measure the temperature. Blood was observed coming from the liver onto the white plate. [NAME] #136 returned the liver to the grill and continued to cook them and the onion. After a period of time she placed all three cooked [NAME] onto the bloody plate and measured the temperature. These three [NAME] were placed into the food processor to puree by Dietary Manager (DM) #112. [NAME] #136 then put the same soiled gloved hands into oven mitts to pull a pan of cooked green beans from the oven with DM #112 overlooking. DM #112 acknowledged problems with infection control during the observation and indicated she would provide training. Review of the handwashing/hand hygiene policy and procedure revised in August 2015 indicated to wash hands with soap and water when visibly soiled.

Based on record review, review of Quality Assurance Performance Improvement (QAPI) plan, and interview, the facility failed to implement and revise quality improvement projects to address residents' concerns regarding failure of staff to provide showers. This had the potential to affect all 69 residents. Findings include: During the annual survey, review of records, review of resident council minutes, interviews and policy review, the facility failed to provide showers for nine (Resident's #9, #13, #18, #25, #28, #32, #33, #40 and #70) of ten residents reviewed for activities of daily living. Review of the facility's QAPI plan, reviewed 02/01/19, revealed QAPI activities would cross service areas and departments and members would work together to assure all concerns were addressed and the team would strive to continuously improve the provided services. When a need was identified, corrective actions plans or performance improvement projects would be implemented to improve processes, systems, outcomes and satisfaction. During an interview with the Administrator on 05/29/19 at 12:33 P.M., she stated one of the concerns identified for which an action plan was developed was shower concerns which were identified in November 2018. The facility had two shower aides, one who worked each side, when the concern was identified. The QAPI plan involved placing the two shower aides together to provide showers as a team. The prior Director of Nursing (DON) and State Tested Nursing Assistant (STNA) supervisor were responsible for oversight of the program. The prior DON terminated employment with the facility 05/03/19 and it was determined the plan to pair up the shower aides was unsuccessful in ensuring residents were receiving showers as scheduled so the facility reverted back to having a shower aide for each side of the facility, making no other changes.