Every finding on record at Courtyard Rehabilitation by Harborview

Based upon observations, interviews, and record reviews, the facility failed to ensure proper infection control prevention measures for 3 out of 4 residents observed during medication administration opportunities. (Resident #61, #65, and #33)The findings include:An observation of medication administration was conducted on 08/26/2026 at 08:00 AM with Staff A, Registered Nurse. Staff A failed to clean the blood pressure cuff and stethoscope after checking the blood pressure of Resident #61 prior to administering medications. Staff A returned the blood pressure cuff and stethoscope to the bottom drawer of the medication cart.An observation of medication administration was conducted on 08/26/2026 at 08:20 AM with Staff Nurse A. Resident #65 voiced concerns of feeling hot, sweaty, and jittery. Staff A confirmed that Resident #65 was diabetic and recommended checking Resident #65's blood sugar based on the resident's stated symptoms. Staff A removed the glucose monitor from the top drawer of the medication cart, gathered supplies, and checked Resident #65's blood sugar. Upon returning the glucose monitor to the cart, Staff A removed a sanitary wipe from the container, laid the wipe on top of the medication cart, placed the glucose monitor on top of the wipe, then wrapped the wipe around the glucose monitor and set it aside for 2 minutes prior to returning it to the medication cart.An observation of medication administration was conducted on 08/26/2026 at 08:35 AM with Staff B, Registered Nurse. Staff B was observed removing medications from the medication cart, preparing medications, and administering medications to Resident #33. Staff B checked the resident's blood pressure with a blood pressure wrist cuff prior to administering medications. Staff B did not clean the blood pressure wrist cuff prior to returning it to the medication cart drawer or perform hand hygiene after medication administration.A further observation of medication administration was conducted on 08/26/2026 at 08:50 AM with Staff B. Staff B did not perform hand hygiene prior to preparing Resident #33's medication. Staff B did not perform hand hygiene prior to administering medications or after administering medications.An interview was conducted at approximately 9:00 AM on 8/26/2026 with Staff Nurse B, who confirmed that hand hygiene was not performed and should have been performed prior to preparing, administering, and after administering medications.An interview was conducted with the Director of Nurses, (DON) on 08/26/2026 at 03:50 PM. The DON confirmed that staff nurses are to perform hand hygiene when preparing medications to be administered, prior to administering medications to residents, and after administration of medications. The DON confirmed that staff nurses are aware and have been educated on proper blood glucose monitor cleaning measures. Glucose monitors are to be cleaned prior to checking a resident's blood sugar and after each use of the blood glucose monitor. On 08/26/2026 at 11:13 AM, a review of the facility's policy titled Hand Hygiene, under the infection control program, dated June 2025, was conducted. The policy stated, Handwashing and hand hygiene shall be regarded by this center as a means of preventing the spread of infections. The facility policy outlined when and how often staff should wash their hands or perform hand hygiene. Section 2D stated, Hand hygiene should be performed before preparing or handling medications.A review of the policy titled Cleaning and Disinfection of Resident Care Items and Equipment, dated September 2022, revealed Resident care equipment, including reusable items and durable medical equipment, will be cleaned and disinfected according to current Centers for Disease Control (CDC) recommendations for disinfection and the Occupational Safety and Health Administration (OSHA) bloodborne pathogens standards. Number 5 states, Reusable items are cleaned and disinfected or sterilized between residents, including stethoscopes and durable medical equipment.A review of the policy titled Cleaning Blood Pressure Cuffs, dated June 2025, stated, The purpose of this policy and procedure is to prevent cross-contamination when cleaning a blood pressure cuff. The policy outlined steps for cleaning the blood pressure cuff.A review of the policy titled Diabetes Care-Equipment and Use, dated June 2025, revealed under section 9 the process for cleaning the blood glucose monitor by thoroughly disinfecting the glucometer by wiping the top, bottom, and sides, and avoiding saturation of the meter test strip port. Be familiar with the amount of time the disinfection solution is to remain in contact with the equipment, how long active cleaning/wiping should be performed to ensure complete disinfection; or ensure at least 5 minutes of contact time with the disinfecting agent. Allow the monitor to air dry.

Based upon observations, interviews and review of facility kitchen policy, the facility failed to provide clean and sanitary conditions in food service areas to prevent contamination of food and food storage areas. The facility failed to follow proper sanitation guidelines for kitchen equipment. The findings include: On 5/12/25 at 10:40 AM an initial observation tour of the kitchen area was conducted with the Dietary Manager. The dishwasher area had a black hose across the floor, connected to the opposite wall of the dish room to a dishwasher leaking water, with water flowing onto the floor. A clear plastic covering was observed over the hose and faucet connector. The Dietary manager stated it's been like that becuase they can't find a hose to fit the connection properly. (photo obtained) It was also noted that a discolored black substance was on the wall behind and in between the dish room area where dishes entered into thedishwasher. A red bucket was observed on the floor under the dish room sink, with a drainage area observed to have a dark discolored substance around the drainage grate and floor tiles. A discolored black substance was noted below the table on pipes, tile floor, and wall. A discolored area with a rust like appearance with black colored particles was observed on the wall, the aluminum backing, and on the top covering of the dishwasher table. The table on the opposite side of the dishwasher where the dishes exit was observed with a brownish discolored substance on the table, underneath the table on the bottom shelf where a bin of multiple bowls was stacked into it, sitting on a rust like discolored shelf. Upon exiting the dishwasher area, a dietary cart was observed sitting in the kitchen area with a clear plastic container of unidentifiable items and a bin with multiple bowls stacked inside the bin at different angles on the top shelf of the cart, the bottom shelf contained an oblong aluminum container with a paint brush and miscellaneous items stacked into it with yellow food particles observed on the railing of the cart. The stove and oven appeared to have cooking pans stacked on top of the burners, and beside the burners. A dark discoloration was observed on the range, around the burners, and on the backsplash of the stove. The oven doors appeared to have a grease like brown substance on them. The fryer baskets next to the stove and oven had food particles along the side of the fryer splash guard with a black and brown discoloration on it and in the grooves of the fryer. One fryer basket had food left in the basket. The standing mixer had multiple items stacked on top of it with attachments sitting in the bowl, dried food particles on the attachments. The food prep table shelves were observed with miscellaneous items sitting on them. The shelves have a rust-like appearance. The food warmer and tray line table have a rust like appearance on the doors, shelves, and bottom of the table. The glass surrounding the top of food warmer had food particles splattered on them. The floor tiles under and bedside the refrigerator near the drain lines appear to be greenish black, with drain areas noted with cracked tile surrounding the drain, with dark brown, black discoloration surrounding drain and on the exposed pipes from the refrigerator. The ice machine was observed to be full of ice, but the lid was noted with a foam like seal with a discolored black, dark green substance on it. Inside the ice machine on the back and sides of ice machine a discolored black substance was noted on them. The Dietary Manager revealed that the dietary staff is responsible for the daily cleaning of all kitchen equipment and is done on a daily basis. When asked about cleaning logs for the kitchen, the Dietary Manager responded, We don't do the cleaning logs, its just part of our daily chores to do. When asked about the last time the kitchen was cleaned and floors cleaned, she responded that maintenance is supposed to come pressure wash the floors, but she did not know when it would happen next. On 5/12/25 at 11:45 AM, a dining room observation revealed 22 residents were in the dining room. A staff member entered the dining room sorting and distributing meal tickets without washing her hands. A dietary staff member from the kitchen brought a dietary cart into the dining room. The cart was observed with multiple filled glasses with ice in them. The glasses did not have any lids sitting on top of the cart. A staff member filled glasses with tea and distributed them to residents without washing her hands. A second staff member entered the dining room at 12:05 PM using appropriate hand sanitizer prior to and in between each resident she served. Staff member B (a Registered Nurse) entered the dining room area without washing or sanitizing her hands and assisted a resident with opening his milk carton using her bare hands and uses her index finger to pull and open the milk carton for resident to drink his milk from the spout of the milk carton. Then she proceeded to another resident at another table and performed the same task without washing or sanitizing her hands. Staff member J (another Registered Nurse) entered the dining room and observed residents being served meals and assised as needed without washing or sanitizing her hands. Hand-sanitizer dispensers were available for staff on the walls in the dining room in between the kitchen dietary doors and the opposite wall. A follow-up kitchen tour was completed on 5/13/25 and 5/14/25 with the Dietary Manager and Staff Member G (Dietary). They revealed that cleaning is done on a daily basis, but no cleaning schedule is posted. The manager stateds everyone knows what they need to do. An interview was conducted on 5/14/25 with the Dietitian. She revealed her expectation of cleaning and sanitation practices of the kitchen and that food service areas should be up to state and federal standards or above those standards. Upon describing and sharing findings of the kitchen and food service areas on day one of the survey, she acknowledged that the kitchen and food service areas were not up to or above state and federal guidelines. Policy and procedures for cleaning and sanitation of food services areas on 5/13/25 stated, food service staff will maintain the sanitation of the dining and food service areas through compliance with a written comprehensive cleaning schedule. Procedure for cleaning and sanitation: the food service manager will record all cleaning and sanitation tasks needed for the department, a cleaning schedule will be posted for all cleaning tasks, and staff will initial the tasks as completed. Ice machine policy revealed ice will be produced and handled in a manner to keep it free from contamination with the procedure listing to include ice machines will be maintained in a clean and sanitary condition to prevent ice contamination. Policies for food safety and sanitation revealed that all local, state, and federal standards and regulations are followed in order to assure a safe and sanitary food service department. Food service managers responsibility included sanitary conditions are maintained in the storage, preparation, and serving areas. Personnel follow sanitary practices and follow proper cleaning and sanitizing instructions for all kitchen equipment. Cleaning schedules are posted and followed. Regular inspections are made by the food service manager or designee to assure food safety. A review of policy for maintenance of dish machine stated, the dish machine will be regularly cleaned and de-limed as needed. Dish machine general cleaning in-service includes deliming of the machine should take place once a week to prevent scale build up and keep water flowing properly.

Resident #45 An observation of Resident #45 was conducted on 5/12/25 at 1:14 PM. Signage indicating contact precautions were in place and that staff should clean hands then don gown and gloves prior to entering the room were observed on the resident's room door. Employee C (agency Certified Nursing Assistant) was observed to enter Resident #45's room to serve the resident's lunch meal. Employee C did not don a gown or gloves prior to entering the resident's room. Employee C was observed to touch the resident's overbed table with her bare hands while serving the resident's lunch meal. A review of Resident #45's record revealed a current physician's order for contact isolation beginning on 5/11/25. The record revealed the resident was placed on contact isolation due to ESBL bacteria (extended-spectrum beta-lactamase) being detected in the urine. An interview was conducted with Employee C on 5/12/25 at 2:55 PM. She stated she forgot to apply a gown and gloves prior to entering Resident #45's room to serve the lunch meal. An interview was conducted with Employee D (Infection Preventionist) on 5/14/25 at 10:06 AM. Employee D stated all staff should don a gown and gloves when entering the contact precautions room to serve trays, especially if they make contact with the resident or environmental surfaces. She stated the facility provides this education to agency staff when they are utilized in their package for working in the facility. A review of Employee C's temporary Certified Nursing Assistant education packet revealed she had education regarding infection control prevention and hand hygiene competency dated 2/4/25. The education did not specifically speak to contact precautions however; the instructions were on the resident's door. Review of the facility policy for Categories of Isolation Precautions (November 2019) revealed staff should wear a gown and gloves when entering a contact precautions isolation room. Based on observations, interviews and facility policy review, the facility failed to implement contact isolation procedures for 1 of 1 resident sampled for contact isolation (Resident #25) and failed to implement infection control techniques for 1 of 1 resident sampled for enteral feeding. (Resident # 204) The findings include: Resident #204 Resident #204's medical record revealed a physician's order to give a bolus of enteral feeding (a medical procedure that provides nutrients directly into the gastrointestinal (GI) tract through a tube). The physician's order stated Enteral Feed Order five times a day; Enteral Feeding: Nutren 1.5 bolus 1 carton 5x/day with 150cc H2O flush before and after each feeding. On 5/13/25 at 4:15 PM, an observation was conducted with Staff A, Licensed Practical Nurse (LPN). She was observed washing her hands and donning clean gloves. She had a container on a clean towel over the bedside table. She grabbed the container with the left hand and touched the bathroom door with the right hand. She filled the container with water from the bathroom's sink. She proceeded with the feeding after filling the container with tap water without changing gloves. On 5/13/25 at 6:02 PM, an interview was conducted with Staff A, LPN. She stated she takes responsibility of her actions and states she should have changed gloves after touching the bathroom's sink. A review of facility policy Feeding Systems dated October 2019 was conducted. Policy stated Protective barriers that may be needed: handwashing and gloves (as indicated). Facility policy further stated Procedure guidelines for bolus feedings: wash hands.

Based on observations and staff interviews, the facility failed to ensure each resident bedroom was equipped to provide full visual privacy for 2 of 19 sampled resident rooms. (rooms [ROOM NUMBERS]) The findings include: An observation of room [ROOM NUMBER] bed B (occupied) was conducted with the Director of Environmental Services on 5/14/25 at 2:41 PM. The privacy curtain was measured and it was about 4 feet too short in width to provide full privacy. He stated he was not aware of a facility process to check the curtains to ensure they provided full visual privacy to the resident. An observation of room [ROOM NUMBER] bed B (occupied) was conducted with the Director of Maintenance on 5/14/25 at 4:23 PM. The privacy curtain was measured and the curtain was about 4 feet too short in width to provide full visual privacy to the resident. An interview was conducted with the Administrator on 5/14/25 at 4:28 PM. She stated she was not sure of the facility process for checking privacy curtains and the housekeeping director was new and had started in January.

Based on observations and interview, the facility failed to maintain a safe and clean environment for 7 of 62 occupied rooms. (Rooms 314, 316, 404, 405, 407, 409, 411) The findings include: On 2/19/24 at 12:30 PM, during the initial tour of the facility, the following environmental issues were observed: In occupied room [ROOM NUMBER], a rusted toilet seat riser was in use inside the bathroom. In occupied room [ROOM NUMBER], the drawer and armoire had layers of paint peeling. In occupied room [ROOM NUMBER], a brown substance was observed on the wall. In occupied room [ROOM NUMBER], the dresser and armoire had peeled off layers of paint and there was a hole on the wall. In occupied room [ROOM NUMBER], the wall and ceiling had bubbled paint and a water-like stain around the ceiling and air conditioning unit. In occupied room [ROOM NUMBER], there was paint peeling on the wall and the toilet seat riser inside the bathroom was rusted. In occupied room [ROOM NUMBER], there was a rusted toilet seat riser inside the bathroom. (Photographic evidence was obtained of all above issues) On 2/22/24 at 10:15 AM, a follow up tour was conducted with the Maintenance Director. He stated the toilet seat risers in rooms 314, 409 and 411 will be replaced with new ones. He further stated the peeling layers on the furniture on room [ROOM NUMBER] will be fixed and the hole on the wall repatched and paint over, as well as the brown-colored stain on room [ROOM NUMBER] will be cleaned and painted over. Upon looking at the bubbled paint on rooms [ROOM NUMBERS], he stated the facility will need to investigate the cause of it and will make some repairs.

Based on observations, staff interviews, and resident record review, the facility failed to implement and follow the recommendations of the Registered Dietician (RD) for 1 of 1 residents sampled for enteral feeding. (Resident #64) The findings include: On 02/21/24 at 9:05 AM, an interview with Staff B, a Licensed Practice Nurse (LPN), was conducted. Staff B stated that Resident #64's used to receive continuous enteral feeding (24 hours a day). She stated the enteral feeding was changed some time in January 2024. Resident #64's Treatment Administration Record (TAR) was reviewed with Staff B. The TAR revealed, on 01/11/2024, an entry for Jevity 1.5 (a nutritional supplement) to be infused at 65 ml/hr for 20 hours a day (to be discontinued between 10:00 am and 2:00 pm). This order was confirmed with Staff B. On 02/21/24 at 9:57 AM, an interview was conducted with Staff A, a licensed practical nurse (LPN) and unit manager. Staff Member A stated that the tube feeding is now scheduled to run at 22 continuous hours per day. Staff Member A then accessed Resident #64's electronic medical record (EMR) and realized the resident's enteral feeding was ordered for 20 hours per day. Staff Member A stated she must have confused the continuous feed with another resident. On 02/21/24 at 10:00 AM, an additional review of Resident #64's EMR revealed a dietary progress notes from the RD dated 02/06/2024, which identified the resident to be overweight / borderline obese with a BMI (body mass index) higher than desired for a bed bound and tube fed resident. The resident's current weight was documented at 174 pounds with a BMI of 29.9. The RD estimated the resident's nutritional needs, based on current weight adjustment, and documented a target weight of 133 lbs. The RD's recommendations indicated to decrease Jevity rate to 55 mL/hr and change water flush to 45 mL/hr. Weekly weights for 3 weeks and draw CMP (Comprehensive Metabolic Panel - lab work). Additional review of the record revealed a failure to identify the completion of weekly weights and failed to include the results of a CMP. On 02/21/24 at 10:39 AM, Resident #64 was observed in bed in high position with a tube feed infusing at 65 ml/hr. On 02/22/24 at 10:13 AM, a follow-up interview was conducted with Staff B, LPN, to inquire about the procedure for new dietitian recommendations. Staff B indicated that when the dietitian made recommendations, these were communicated to the unit manager who processed them from there. Staff B, LPN was unsure of the entire process as she was not involved in that part. On 02/22/24 at 10:20 AM, a follow-up interview was conducted with Staff A, LPN, to clarify the process when new recommendations were received from the dietitian. Staff A indicated that the dietitian emailed the Interdisciplinary team (IDT), which included upper management. The unit manager on the applicable unit would then take the recommendations to the provider for orders, and the unit manager would then put the new orders in the EMR. She acknowledged that the current dietitan recommendations did not match the current order.

Based on observation, staff interview, and facility policy review, the facility failed to maintain blood glucose monitoring equipment in accordance with the facility policy and manufacturer's instructions for 2 of 4 sampled blood glucose machines. (machines 1 and 2 on 300 north medication cart) The findings include: An observation of the north 300 hall medication cart was conducted in the presence of employee D (licensed practical nurse) on 8/5/21 at approximately 9:35 AM. A bottle of Assure platinum blood glucose strips was in the cart and dated opened 8/4/21. Review of the glucose control logs for machine #1 and #2 for 300 north cart revealed the controls had not been documented since July 31, 2021. An interview was conducted with the Director of Nursing (DON) on 8/5/21 at approximately 9:46 AM. She stated the controls for the glucose machine should be checked when a new bottle of strips is opened, she confirmed the bottle of strips was opened on 8/4/21 and no controls were documented since 7/31/21 for machines 1 and 2 on the 300 north medication cart. Review of the Assure dose control solution manufacturer instructions (revised 3/14) revealed the solution was intended for use with Assure Pro, Assure Platinum, Glucocard vital or ReliOn prime blood glucose meter and test strips as a quality control check to verify the accuracy of blood glucose results. Use control solution before testing with the system for the first time, when you open a new bottle of test strips, whenever you suspect the meter or test strips may not be functioning properly, if test results appear to be abnormally high or low or are not consistent with clinical symptoms, the test strip bottle has been left open or has been exposed to light, temperatures below 39 degrees Fahrenheit or above 86 degrees Fahrenheit, or humidity levels above 80%, to check your technique, when the meter has been dropped or stored below 32 degrees Fahrenheit or above 122 degrees Fahrenheit, and each time the batteries are changed. Review of the facility policy for Blood Glucose Monitoring (last reviewed 5/24/18) revealed quality control assessment and calibration shall be completed as recommended. Actual performance of the blood glucose monitoring device shall be performed as outlined in the manufacturer's manual.

Based on observation, record review, and interview the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 7 of 64 rooms observed. (Rooms 206, 209, 212, 314, 316, 324 and 404) The findings include: On 02/11/2020 at approximately 10:00 AM, a tour the facility was conducted with the facility Maintenance Director and the Administrator. The following observations and interviews were obtained: In room [ROOM NUMBER], the window side wall next to Bed B had a cluster of deep scrapes that revealed several layers of material behind the paint including drywall and plaster. The area was approximately 1.5 feet in length by 1.5 feet in height. In room [ROOM NUMBER], the wall behind Bed A had 3 deep vertical scrapes that exposed several layers of material behind the paint including drywall and plaster. The 3 scrapes were approximately 6-8 inches long and were surrounded by other smaller scrapes. There was also a horizontal hole in the wall approximately 6 inches wide and 2 inches tall. In room [ROOM NUMBER], the wall in between the air conditioning unit and the window had a patch of paint and drywall missing that was approximately 2.5 feet in length and 6 inches in height. room [ROOM NUMBER] had a small gap between the wall and the air conditioning unit and ripped drywall covering near the soap dispenser on the wall. In room [ROOM NUMBER], the wall behind bed A had several scratches on the wall and the wall and floor behind bed A as well as a pole designed to support a tube feed pump were covered in a brownish substance which appeared to be dried formula for tube feeding. room [ROOM NUMBER] had a small gap between the wall and the air conditioning unit and the baseboard near the air conditioning unit was pulled away from the wall. room [ROOM NUMBER] had a hole the size and shape of the door handle on the wall behind the door and multiple small holes in the wall in the bathroom between the toilet and the sink. (photographic evidence obtained) On 2/11/20 at approximately 10:00AM, an interview and observations were conducted with the Maintenance Director and the Administrator. The administrator provided a list of scheduled repairs for the building which did not include the concerns identified in rooms 206, 209, 212, 314, 316, 324, or 404. During these observations the administrator and maintenance director confirmed each concern identified and stated those issues had not been previously identified by staff on weekly building rounds. The housekeeping director was also present for the observation of room [ROOM NUMBER] and agreed the wall, floor, and pole were not cleaned properly.

Based on record review and interview, the facility failed to document in the medical record, the basis for discharge for 1 of 3 residents sampled for transfer/discharge (resident #1). The findings were: A review of Resident #1's medical record was conducted. Resident #1 was hospitalized on (MONTH) 20, (YEAR). The facility did not accept the resident back into the facility and officially discharged the resident on (MONTH) 13, (YEAR). During the review of the medical record, there was no evidence of a physician's orders [REDACTED].#1 to be discharged from the facility. On (MONTH) 8, (YEAR) at approximately 3:23 pm, an interview was conducted with the Director of Nursing. She stated that she had looked through Resident #1's medical record and stated there was no documentation from the physician as to the rationale for not accepting the resident back into the facility. On (MONTH) 8, (YEAR) at approximately 3:57 pm, an interview was conducted with the Administrator. He stated Resident #1's official discharge date was on (MONTH) 13, (YEAR) and the basis for discharge was due to not having a private room for the resident and not having one-to-one staff for the resident. He also stated that he did not have documentation of basis for discharge from a physician. On (MONTH) 8, (YEAR) at approximately 4:03 pm, an interview was conducted with the Infection Control Nurse/Assistant Director of Nursing. She stated the facility did not have documentation from a healthcare provider stating that the resident could be readmitted . She stated that it was a group decision (facility staff and corporate) not to readmit Resident #1 based on the CDC information and facility policy. A copy of email correspondence provided by the facility between the DON and the Administrator dated (MONTH) 14, (YEAR) revealed that the Administrator stated to the DON that Basically we need to tell the hospital we cannot meet his clinical needs. A review of the facility's policy entitled, Transfer/Discharge Notice, Policy Statement, Documentation, Paragraph 2 stated the following: Documentation of resident transfers or discharges in the medical record will be made by the following: a. the resident's physician when transfer or discharge is necessary; and b. a physician when transfer or discharge is necessary.

Based on record review and interview, the facility failed to notify a representative of the Office of the State Long-Term Care Ombudsman of the transfer of 4 of 6 residents sampled for transfer/discharge notification (Residents #2, 4, 5, and 6) and failed to give a discharge notice in writing to the resident and the resident ' s representative for 1 of 3 residents sampled for transfer/discharge (Resident #1). The findings were: A record review was conducted of the facility's Status Change report dated (MONTH) 1 - 31, (YEAR). This status change report showed all residents transferred and/or discharged from the facility during the month of (MONTH) (YEAR). Resident #2 was transferred to the hospital on (MONTH) 14, (YEAR) and returned to the facility on (MONTH) 21, (YEAR). Resident #4 was transferred to the hospital on (MONTH) 6, (YEAR) and returned to the facility on (MONTH) 8, (YEAR). Resident #5 was transferred to the hospital on (MONTH) 16, (YEAR) and returned to the facility on (MONTH) 20, (YEAR). Resident #6 was transferred to the hospital on (MONTH) 7, (YEAR) and returned to the facility on (MONTH) 10, (YEAR). Additionally a review of the facility ' s Discharge and Transfer Form Ombudsman Fax Log was conducted. This log denoted Ombudsman notification of residents that were transferred from the facility. The Status Change report and the Discharge and Transfer Form Ombudsman Fax Log was compared and it was found that the Ombudsman was not notified of the above transfers. On (MONTH) 8, (YEAR) at approximately 1:50 pm, an interview was conducted with Staff B, Admissions and Marketing. Staff B stated that she send notifications to the Ombudsman once a month for resident transfers and discharges. Staff B stated she sent the Ombudsman notification for the (MONTH) transfers on (MONTH) 5, (YEAR). She also stated that if the resident's name was not on the Discharge and Transfer Form Ombudsman Fax Log, the Ombudsman was not notified. Additionally she stated, the Ombudsman was not notified of the transfers of Residents #2, 4, 5, and 6. A review of the facility's policy entitled, Transfer/Discharge Notice, Policy Statement, Guideline, Paragraph 3 stated the following: The facility will send a copy of the transfer or discharge notice to a representative of the Office of the State Long-Term Care Ombudsman. A record review of Resident #1's medical record was conducted. Resident #1 was hospitalized on (MONTH) 20, (YEAR). The facility did not accept the resident back into the facility and officially discharged the resident on (MONTH) 13, (YEAR). During this review, there was no evidence of a discharge notice. On (MONTH) 8, (YEAR) at approximately 3:57 pm, an interview was conducted with the Administrator. He stated that Resident #1 was officially discharged on (MONTH) 13, (YEAR) and that he did not give the resident an official discharge notice. On (MONTH) 8, (YEAR) at approximately 4:09 pm, an interview was conducted with Resident #1 ' s daughter. She stated that her family never received a discharge notice from the facility.

Based on record review and interview, the facility failed to complete a discharge summary for 1 of 3 residents sampled for transfer/discharge (Resident #1). The findings were: A record review of Resident #1' s medical record was conducted. During this review, there was no evidence of a discharge summary for the resident's discharge date of (MONTH) 13, (YEAR). On (MONTH) 8, (YEAR) at approximately 3:57 pm, an interview was conducted with the Administrator. He stated Resident #1' s official discharge date was on (MONTH) 13, (YEAR). He also stated that a discharge summary was not completed for the resident. On (MONTH) 8, (YEAR) at approximately 4:05 pm, an interview was conducted with the Director of Nursing. She stated Resident #1 was officially discharged on (MONTH) 13, (YEAR), but a discharge summary was not completed. On (MONTH) 8, (YEAR) at approximately 4:07 pm, an interview was conducted with Staff A, Medical Records personnel. She stated a discharge summary was done when the resident went to the hospital on (MONTH) 20, (YEAR), but not when the resident was discharged from the facility.

Based on observation, resident and staff interview and record review, the facility failed to ensure residents with limited range of motion received range of motion exercises for 3 of 3 residents sampled for mobility (#14, 31, and 50), and received splinting for 1 of 3 residents sampled (#14). Findings Include: Resident #31 Resident #31's medical record was reviewed and revealed restorative services ordered 4/27/2017 for the resident. The orders were for positioning to geri-chair 4 hours per day, passive range of motion: upper body and lower body exercise 3 sets of 20 repetitions daily, as well as splints to left knee to be applied after passive range of motion 7 days per week. The resident's restorative range of motion (Passive) care plan was reviewed. The problem identified the resident having contractures of left hand, arm, and leg and implemented 4/13/2017 with a last revision date of 10/10/2017. The goal was for the resident to maintain current level of range of motion. Approaches included bilateral upper and lower extremity exercises, 3 sets of 20 repetitions, 7 times weekly. Additionally, the resident's restorative self-transfer care plan was reviewed. The resident was identified with an actual decline in the ability to self-transfer on 7/1/2017. The last revision was 10/10/2017. The goal for the resident was to maintain transfer abilities. Approaches to the goal included maintaining an upright position in his geri-chair for 4 hours daily. Resident #31 was observed on 12/11/2017 at 12:38 PM and 2:20 PM in bed. Again on 12/12/2017 at 9:07 AM, 12:27 PM, and 2:31 PM, the resident was in bed. The resident was observed seated in the geri-chair on 12/12/2017 at 8:42 AM only. At 10:10 AM and 1:25 PM, the resident was in bed. An interview was conducted with the resident on 12/13/2017 at 10:10 AM and at 1:25 PM. During both interviews the resident stated the staff had not performed his exercises with him. An interview was conducted with the restorative nurse (D) on 12/13/2017 at 10:20 AM. She confirmed resident #31 was on the restorative program for positioning in his geri-chair for 4 hours per day as well as for passive range of motion exercises to his upper and lower body daily. She stated the certified nurse aides (CNAs) were responsible for the passive range of motion exercises while the restorative aides were responsible for applying the resident's splints. She produced the December 2017 daily record for restorative. The resident had no documentation for positioning in the geri-chair on 12/1/17, 12/5/17, 12/6/17, 12/7/17, 12/8/17, 12/11/17 or 12/12/17. The resident was documented as refused on 12/3/17, 12/4/17, 12/9/17, and 12/10/17. Additionally, the upper and lower body exercises were blank on 12/1/17, 12/5/17, 12/6/17, 12/7/17, 12/11/17, and 12/12/17 with no documentation for refusals. CNA E was assigned to resident #31 and was interviewed on 12/14/2017 at 10:34 AM. She stated the resident does refuse care at times. She confirmed the range of motion exercises are attempted in the morning when she arrives. She confirmed that blank spaces on the restorative form were indicative of care not being provided. She stated, To be honest, I get busy and sometimes forget to document the care was done. It was a lot easier when it was in the kiosk because it would trigger us to actually do the care. It would alert us we needed to do it. Resident #14 On 12/11/17 at approximately 11:00am, resident #14 was observed sitting in a wheelchair in his bedroom. At the time, the resident was wearing a hospital gown. The resident was observed to have right hand and finger contractures with no splints observed to be in place. An observation of the left hand was not made on that visit. Again on the same day at approximately 4:42pm, the resident was observed again not to be wearing splints on either of his hands. The resident's left hand was observed in a fist. When asked about splints being applied to his hands the resident was unable to provide an answer. On 12/12/17 at approximately 9:52 AM and 3:54 PM, resident #14 was observed to be dressed and sitting in his wheelchair across from the south hall nurse's station. At the time of these observations, the resident was not observed to be wearing splints. A medical record review was conducted for resident #14 in the electronic and paper record. The Medication Administration Record [REDACTED]. The first order read, apply left wrist splint while in bed at nights. Apply gentle range of motion (ROM) to bilateral hands/wrists prior to splint application. May remove as needed for hygiene or comfort. The second order read, apply right finger splint at all times. Apply gentle ROM to bilateral hands/wrists prior to splint applications. May remove as needed for hygiene or comfort. Review of the restorative service delivery records for the month of August, September, and December of 2017 revealed there to be missing staff signatures on several days across several shifts to indicate the resident's splints weren't applied and range of motion was not performed. There were no concerns for the month of November. Documentation for the month of October was never provided upon request from this surveyor. On 12/13/17 at approximately 12:11 PM, an interview was conducted with registered nurse Staff H. She revealed that restorative certified nursing assistants (CNAs) applied splints for resident# 14 during the day shift and the assigned CNAs were responsible for applying splints that were ordered to be applied on the evening and night shifts. She confirmed that resident #14 should have bilateral splints applied and passive range of motion performed daily. On 12/13/ at 1:42pm, an interview was conducted with restorative CNA Staff F. She revealed that her and another restorative CNA were responsible for applying resident #14's splint to his left hand that should be worn during the day, and the evening shift was responsible for application of the right hand splint. When asked why resident #14 was observed on 2 consecutive days without the left hand splint, Staff F confirmed that she had not applied the resident's splints nor did she document a note as to why the splints were not applied. Staff F also confirmed that she did not document that she had performed range of motion for the resident. Staff F was questioned about the various missing staff signatures indicating range of motion and splint applications had been performed. Staff F confirmed that staff should be documenting refusals, or that the tasks had been completed, and stated, There is no excuse for the missing documentation. All staff, including myself, should be documenting at a minimum by the end of their shift in the restorative book that splints have been applied and range of motion performed. We should also be documenting the resident's refusals and if the treatment was withheld. Resident #50 Review of resident #50's medical record revealed the resident to have hand contractures (onset date: 3/1/2007) and contractures to the resident's knee and hip (onset 5/23/2008). Further review revealed a daily restorative nursing program for passive range of motion (PROM) was started on 11/19/2015. A review of resident #50's care plan revealed the resident to have a plan for range of motion (active) and/or (active assisted). The plan stated the resident was at risk for developing an impairment in functional joint mobility related to weakness, neurological deficit, and decreased ability to self-perform activities of daily living independently, with an intervention to provide active assisted range of motion. Review of resident #50's restorative service delivery record for December 2017 indicated the resident should be receiving range of motion (ROM) three times daily. There were missing signatures to indicate staff had not performed ROM for the resident 5 days on the 11pm-7am shift; 2 days on the on 7am-3pm shift; and 4 days on 3pm-11pm shift. The facility could not provide evidence that the resident was offered or received ROM for those days where documentation was blank. Review of resident #50's restorative service delivery record for September 2017 revealed no documentation on the following shifts: 18 days on 3pm-11pm shift; 4 days on 7am-3pm shift; and 4 days on 11pm-7am shift. Review of resident #50's restorative service delivery record for August 2017 revealed no documentation on the following shifts: 17 days on 3pm-11pm shift; 4 days on the 7am-3pm shift; and 3 days on the 11pm-7am shift. The facility was unable to provide evidence that the resident was offered or received ROM for those periods where documentation was blank. Records for the months of October and November 2017 were never provided upon request. An interview was conducted with resident #50 on 12/12/17 at 10:14am. Resident #50 stated, Staff used to come in and provide me some exercises to my hands, but that hasn't happened in a while either. An interview was conducted with restorative CNA Staff F on 12/13/2017 at 1:42pm. She confirmed that staff had not documented that ROM was performed for resident #50 on several occasions. She stated, if ROM was performed the staff would have initialed the sheet and documented the amount of time ROM was performed, so if it wasn't written it didn't happen. On 12/13/7 an interview was conducted with the Restorative Licensed Practical Nurse Staff D. She confirmed that there was missing data, and stated, I try to look at restorative documentation daily and I noticed that there had been missing documentation and notified nurses and CNAs to ensure they were documenting. When asked how often she expectede staff to document restorative programs, she stated, documentation should be completed daily, no exceptions.

Based on observation, resident and staff interview and record review, the facility failed to implement the plan of care for 3 of 3 residents sampled for mobility (#14, 31, and 50), and for 1 of 4 residents sampled for accidents (#21). Findings Include: Resident #31 Resident #31's restorative range of motion (Passive) care plan was reviewed. The problem identified the resident having contractures of left hand, arm, and leg and implemented 4/13/2017 with a last revision date of 10/10/2017. The goal was for the resident to maintain current level of range of motion. Approaches included bilateral upper and lower extremity exercises, 3 sets of 20 repetitions, 7 times weekly. Additionally, the resident's restorative self-transfer care plan was reviewed. The resident was identified with an actual decline in the ability to self-transfer on 7/1/2017. The last revision was 10/10/2017. The goal for the resident was to maintain transfer abilities. Approaches to the goal included maintaining an upright position in his geri-chair for 4 hours daily. Resident #31 was observed on 12/11/2017 at 12:38 PM and 2:20 PM in bed. Again on 12/12/2017 at 9:07 AM, 12:27 PM, and 2:31 PM, the resident was in bed. The resident was observed seated in the geri-chair on 12/12/2017 at 8:42 AM only. At 10:10 AM and 1:25 PM, the resident was in bed. An interview was conducted with the resident on 12/13/2017 at 10:10 AM and at 1:25 PM. During both interviews the resident stated the staff had not performed his exercises with him. An interview was conducted with the restorative nurse (D) on 12/13/2017 at 10:20 AM. She confirmed resident #31 was on the restorative nursing program. She produced the December 2017 daily record. The resident had no documentation for positioning in the geri-chair on 12/1/17, 12/5/17, 12/6/17, 12/7/17, 12/8/17, 12/11/17 or 12/12/17. The resident was documented as refused on 12/3/17, 12/4/17, 12/9/17, and 12/10/17. Additionally, the upper and lower body exercises were blank on 12/1/17, 12/5/17, 12/6/17, 12/7/17, 12/11/17, and 12/12/17 with no documentation for refusals. Certified Nurse Aide (CNA) E was assigned to resident #31 and was interviewed on 12/14/2017 at 10:34 AM. She confirmed that blank spaces on the restorative form were indicative of care not being provided. Resident #21 Review of resident #21's record revealed a current plan of care for falls with a nursing intervention dated 3/5/17 for non-skid tape to floor beside table. The record revealed the resident had falls on 10/4/17 and 11/6/17 with no injuries and a fall on 9/18/17 resulting in hospitalization and a pelvic fracture. Observations of resident #21 were conducted on 12/12/17 at 4:25 PM and 12/13/17 at 8:09AM. The resident was sitting in her wheelchair in her room. No non-skid tape was observed to be on the floor in the room. Further observation of resident #21's room was conducted with the Registered Nurse Risk Manager on 12/13/17 at 12:25 PM. The Risk Manager (RM) observed and confirmed no non-skid tape was on the floor in resident 21's room. The RM reviewed the record and confirmed the intervention was current and should have been in place. Resident #14 A review of the care plans for resident #14 indicated a restorative range of motion (passive) plan to be in place as well as plans of care related to contracture management and splint application. The plans of care revealed the resident had impaired functional ability related to contractures of the resident's bilateral hands and wrist, weakness, dementia, and decreased ability to self-perform activities of daily living (ADLs). Interventions included performance of passive range of motion (PROM) to the resident's bilateral hands and wrists prior to splint application, referring the resident to the restorative nursing program and initiating programs as indicated, and restorative splinting programs for bilateral splints to be applied to the resident's hands and wrists as indicated. A medical record review was conducted for resident #14 in the electronic and paper record. The Medication Administration Record [REDACTED]. The first order read, apply left wrist splint while in bed at nights. Apply gentle range of motion (ROM) to bilateral hands/wrists prior to splint application. May remove as needed for hygiene or comfort. The second order read, apply right finger splint at all times. Apply gentle ROM to bilateral hands/wrists prior to splint applications. May remove as needed for hygiene or comfort. Review of the restorative service delivery records for the month of August, September, and December of 2017 revealed there to be missing staff signatures on several days across several shifts to indicate the resident's splints weren't applied and range of motion was not performed. There were no concerns for the month of November. Documentation for the month of October was never provided upon request from this surveyor. On 12/11/17 at approximately 11:00am, resident #14 was observed sitting in a wheelchair in his bedroom. At the time, the resident was wearing a hospital gown. The resident was observed to have right hand and finger contractures with no splint in place. An observation of the left hand was not made on that visit. On the same day at approximately 4:42pm, the resident was observed again not to be wearing splints on either of his hands. The resident's left hand was observed in a fist. When asked about splints being applied to his hands the resident was unable to provide an answer. On 12/12/17 at approximately 9:52 AM, resident #14 was observed to be dressed and sitting in his wheelchair across from the south hall nurse's station. At the time of this observation, the resident was not observed to be wearing splints. On the same day at approximately 3:54 PM, the resident was observed again in the hallway sitting across from the south hall nurse's station with no splints in place. On 12/13/17 at approximately 12:11 PM, an interview was conducted with registered nurse Staff H. She revealed that restorative certified nursing assistants (CNAs) applied splints for resident# 14 during the day shift and the assigned CNAs were responsible for applying splints that were ordered to be applied on the evening and night shifts. She confirmed that resident #14 should have bilateral splints applied and passive range of motion performed daily. On 12/13/ at 1:42pm, an interview was conducted with restorative CNA Staff F. She revealed that her and another restorative CNA were responsible for applying resident #14's splint to his left hand that should be worn during the day, and the evening shift was responsible for application of the right hand splint. When asked why resident #14 was observed on 2 consecutive days without the left hand splint, Staff F confirmed that she had not applied the resident's splints nor did she document a note as to why the splints were not applied. Staff F also confirmed that she did not document that she had performed range of motion for the resident. Staff F was questioned about the various missing staff signatures indicating range of motion and splint applications had been performed. Staff F confirmed that staff should be documenting refusals, or that the tasks had been completed, and stated, There is no excuse for the missing documentation. All staff, including myself, should be documenting at a minimum by the end of their shift in the restorative book that splints have been applied and range of motion performed. We should also be documenting the resident's refusals and if the treatment was withheld. Resident #50 A review of resident #50's care plan revealed the resident to have a plan for range of motion (active) and/or (active assisted). The plan stated the resident was at risk for developing an impairment in functional joint mobility related to weakness, neurological deficit, and decreased ability to self-perform activities of daily living independently, with an intervention to provide active assisted range of motion. Review of resident #50's restorative service delivery record for December 2017 indicated the resident should be receiving range of motion (ROM) three times daily. There were missing signatures to indicate staff had not performed ROM for the resident 5 days on the 11pm-7am shift; 2 days on the on 7am-3pm shift; and 4 days on 3pm-11pm shift. The facility could not provide evidence that the resident was offered or received ROM for those days where documentation was blank. Review of resident #50's restorative service delivery record for September 2017 revealed no documentation on the following shifts: 18 days on 3pm-11pm shift; 4 days on 7am-3pm shift; and 4 days on 11pm-7am shift. Review of resident #50's restorative service delivery record for August 2017 revealed no documentation on the following shifts: 17 days on 3pm-11pm shift; 4 days on the 7am-3pm shift; and 3 days on the 11pm-7am shift. The facility was unable to provide evidence that the resident was offered or received ROM for those periods where documentation was blank. Records for the months of October and November 2017 were never provided upon request. An interview was conducted with resident #50 on 12/12/17 at 10:14am. Resident #50 stated, Staff used to come in and provide me some exercises to my hands, but that hasn't happened in a while either. An interview was conducted with restorative CNA Staff F on 12/13/2017 at 1:42pm. She confirmed that staff had not documented that ROM was performed for resident #50 on several occasions. She stated, if ROM was performed the staff would have initialed the sheet and documented the amount of time ROM was performed, so if it wasn't written it didn't happen. On 12/13/7 an interview was conducted with the Restorative Licensed Practical Nurse Staff D. She confirmed that there was missing data, and stated, I try to look at restorative documentation daily and I noticed that there had been missing documentation and notified nurses and CNAs to ensure they were documenting. When asked how often she expectede staff to document restorative programs, she stated, documentation should be completed daily, no exceptions.

Based on observation, staff interview and clinical record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) for one of three residents reviewed for dental status (#73). Findings include: Resident #73 was interviewed on 12/13/17 at approximately 8:45 AM. During this interview, the resident was noted to be missing multiple teeth and those she had remaining were blackened. On 12/13/17 at approximately 12:55 PM the day shift registered nurse charge nurse stated the resident came to facility in May 2017, and had the noted dental problems at time of admission. A review of the resident's MDS admission assessment with an assessment reference date of May 15, 2017 indicated there were no dental concerns for the resident, and the resident did not trigger for a CAA (Care Area Assessment) for care plan consideration based on the assessment. The next quarterly MDS was done 8/10/17 and indicated no dental problems. The 11/16/17 quarterly MDS also indicated no dental concerns. An interview was conducted with the Registered Nurse MDS Coordinator on 12/13/17 at 2:05 PM. She provided the original dental assessment completed by a licensed practical nurse on 5/8/17 which indicated there were no dental concerns. A review of resident record indicated a dental visit was completed 10/16/17 for a comprehensive oral evaluation; 16 teeth were noted on the exam as missing.

Based on observations, staff interview and record review, the facility failed to ensure the environment remained free from accident hazards, and failed to ensure all care planned interventions to help prevent falls were in place for 1 of 4 residents reviewed for falls (#21). The findings include: Observations of resident #21 were conducted on 12/12/17 at 4:25 PM and on 12/13/17 at 8:09AM. During both observations, the resident was seen sitting in her wheelchair in her room. There was no non-skid tape observed to be on the floor in the room. Further observation of resident #21's room was conducted with the Registered Nurse Risk Manager on 12/13/17 at 12:25 PM. The Risk Manager (RM) observed and confirmed no non-skid tape was on the floor in resident 21's room. Review of resident #21's record revealed a current plan of care for falls with a nursing intervention dated 3/5/17 for non-skid tape to floor beside table. The RM reviewed the record and confirmed the intervention was current and should have been in place. The record revealed the resident had falls on 10/4/17 and 11/6/17 with no injuries and a fall on 9/18/17 resulting in hospitalization and a pelvic fracture.

Based on observation, staff interview and policy review, the facility failed to ensure staff followed appropriate hand hygiene practices during 1 of 3 observations of incontinent care (observation of resident #63) and failed to follow the facility policy for transmission based precautions for 1 of 2 sampled residents (resident #163). The findings include: An observation of incontinent care for resident #63 was conducted with employee B and C (Certified Nursing Assistants) on 12/11/17 at 10:46AM. The staff performed the care, employee C removed gloves and left the room then went to the pantry in the hallway, touched the coded lock to enter the code and washed her hands in the pantry. Employee B did not remove her gloves and left the room carrying a bag of garbage in her gloved hand. An interview was conducted with employee B on 12/14/17 at approximately 8:25 AM. Employee B confirmed she did not remove her gloves after performing care for resident #63 and left the room with gloved hands. She confirmed she should have washed her hands prior to leaving the room. Review of the facility policy for hand hygiene revealed the facility considered hand hygiene the primary means to prevent infections. Use alcohol-based hand rub containing at least 62% alcohol; or alternately, soap (antimicrobial or non-antimicrobial) and water after contact with a resident's intact skin, after contact with blood or body fluids and after removing gloves. Resident #163 On 12/11/17 at 10:10 AM a three drawer bin was observed in the hallway to the left of the door for the room of resident #163. There was a sign on top of the bin stating, Please see a nurse before entering resident room. An interview was conducted with licensed practical nurse (LPN) A at the time of observation. The LPN stated that resident #163 was admitted [DATE]. LPN A stated resident #163 had some diarrhea so they were sending out a stool sample to check for ,[MEDICAL CONDITION].-Difficile ([MEDICAL CONDITION]) infection (a contagious infection which causes diarrhea). It was noted the resident did have a roommate. At 11:45 AM on 12/11/17 the previously noted sign was posted on the door of the room. Resident #163 was in her bed. She stated she used the toilet and there was no bedside commode. She stated her roommate also used the toilet. Brown splatters were observed on the toilet surface (photographic evidence obtained). Resident #163 stated she had been having diarrhea since her admission on 12/8/17, and stated she had so many antibiotics in the hospital, she suspected it was related. On 12/13/17 at approximately 10:20 AM, nurse A was interviewed. She verified the roommate of resident #163 did use the toilet, and staff assisted her to the bathroom. When asked if they use bedside commodes for residents they are testing for [MEDICAL CONDITION], staff A said that with past admissions, resident #163 had a bedside commode at times. Nurse A was asked if bedside commodes were available in the facility. She verified bedside commodes were available, and they were maintained in the storage unit outside. Staff A later stated in a interview, at 10:39 AM on 12/13/17, that she spoke with the aide who worked with resident #163 on 12/11/17. She reported the aide told the LPN that (per her understanding of facility policy) the aide wiped down the toilet after resident #163 used it with bleach wipes. The facility policy entitled, [MEDICAL CONDITION] (revised July 2014) was reviewed. This policy stated, Resident with diarrhea and suspected [DIAGNOSES REDACTED]icile infection will be placed on Contact Precautions while awaiting laboratory results. The policy indicated there would be a dedicated commode for each resident. The facility infection preventionist was interviewed on 12/14/17 at 9:05 AM. She verified the facility policy was to have a separate commode for residents while awaiting the lab results for the [MEDICAL CONDITION] and that a resident awaiting lab results should have been provided a separate commode. She also stated she was not aware of any policy in the facility wherein the residents would share the commode with wiping the commode with bleach between uses.

Based on observation, staff interview and record review, the facility failed to assist residents during dining who required assistance for 2 of 5 residents sampled for activities of daily living observations. (#142 and #146) The findings are: 1. Observation of resident #142 on 12/14/16 at 8:55am am found resident #142 in bed sleeping. The resident's breakfast tray was sitting on the over-bed table untouched. No food had been eaten, and no liquids touched except for coffee which had spilled on the tray and on the resident's abdomen and soaked his shirt. Staff entered room at 9:01 AM to pick up tray and did not discuss the untouched food with the resident. Interview with staff I on 12/14/16 at 9:25 AM indicated he ate 50% of food and 75% of liquids, then staff I documented he ate 40% and drank 240 cc of fluids. The interview and documentation were both inconsistent with observations. Resident #142 was observed in Speech Therapy (ST) for lunch on 12/14/16 at 12:30 PM and 12/15/16. ST was assessing the resident's eating ability. Interview with ST indicated Resident #142 has had a decline in the last few days. He has been coughing and was sent out to the hospital for evaluation. He is scheduled for a [MEDICATION NAME] Swallow in a few weeks due to swallowing issues. He was evaluated for swallowing difficulties and his diet has been downgraded to a mechanical soft with nectar thick liquids. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated he needs supervision, oversight, and encouragement/ cueing with eating. The plan of care dated 9/26/16 indicates he needs supervision with eating. Interview with Staff A, his nurse, on 12/14/16 at 3:45 PM indicated he has had a decline. He is coughing more and is confused. He used to be able feed himself, but now he needs assistance to eat. Interview with Staff K aide who cares for him indicated on 12/15/16 at 1:42 PM we are assisting him to eat now. This started last week with his decline. Interview with Dietician J on 12/15/16 at 10:21 AM indicated on 12/12/16 he started having chewing and swallowing problems. He is being seen by ST. 2. Observation of resident #146 on 12/13/16 during lunch at 12:10 pm found resident eating with her fingers. Staff L was present in the dining room supervising and did not intervene to assist. The resident spilled food on herself and on wheelchair and floor. At one point staff did hand a spoon to the resident and she used it for a few seconds and then continued to eat with her fingers in front of staff without staff assistance. Observation of lunch on 12/14/16 at 12:22 PM noted resident #146 holding her plate on her chest and eating using the fingers of her other hand. There was food on her blouse. Staff A was sitting in a chair in the dining room supervising. She did not intervene to assist resident #146. Interview with Staff M at 1:42 PM on 12/15/16 indicated resident #146 needs set up for meals and she feeds herself. Interview with Staff N on 12/15/16 at 1:42 PM said resident #146 is set up only and the care plan needs to be changed if she is using her fingers to eat. Review of Minimum Data Set (MDS) assessment dated [DATE] indicates resident #146 needs extensive assistance with eating with one person physical assist. Review of care plan dated 12/12/16 for activities of daily living under eating section indicated resident needs extensive assist for eating with intervention to supervise.

Based on observation, staff interview and record review, the facility failed to implement the dining plan of care to supervise and assist residents during dining for 2 of 5 residents sampled for activities of daily living observations. (#142 and #146) The findings are: 1. The plan of care dated 9/26/16 for Resident #142 indicates he needs supervision with eating. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated he needs supervision, oversight, and encouragement/ cueing with eating. Observation of resident #142 on 12/14/16 at 8:55am am found resident #142 in bed sleeping. The resident's breakfast tray was sitting on the over-bed table untouched. No food had been eaten, and no liquids touched except for coffee which had spilled on the tray and on the resident's abdomen and soaked his shirt. Staff entered room at 9:01 AM to pick up tray and did not discuss the untouched food with the resident. Interview with staff I on 12/14/16 at 9:25 AM indicated he ate 50% of food and 75% of liquids, then staff I documented he ate 40% and drank 240 cc of fluids. The interview and documentation were both inconsistent with observations. Resident #142 was observed in Speech Therapy (ST) for lunch on 12/14/16 at 12:30 PM and 12/15/16. ST was assessing the resident's eating ability. Interview with ST indicated Resident #142 has had a decline in the last few days. He has been coughing and was sent out to the hospital for evaluation. He is scheduled for a [MEDICATION NAME] Swallow in a few weeks due to swallowing issues. He was evaluated for swallowing difficulties and his diet has been downgraded to a mechanical soft with nectar thick liquids. Interview with Staff A, his nurse, on 12/14/16 at 3:45 PM indicated he has had a decline. He is coughing more and is confused. He used to be able feed himself, but now he needs assistance to eat. Interview with Staff K aide who cares for him indicated on 12/15/16 at 1:42 PM we are assisting him to eat now. This started last week with his decline. Interview with Dietician J on 12/15/16 at 10:21 AM indicated on 12/12/16 he started having chewing and swallowing problems. He is being seen by ST. 2. Review of care plan for resident #146, dated 12/12/16, for activities of daily living under eating section indicated resident needs extensive assist for eating with intervention to supervise. Review of Minimum Data Set (MDS) assessment dated [DATE] indicates resident #146 needs extensive assistance with eating with one person physical assist. Observation of resident #146 on 12/13/16 during lunch at 12:10 pm found resident eating with her fingers. Staff L was present in the dining room supervising and did not intervene to assist. The resident spilled food on herself and on wheelchair and floor. At one point staff did hand a spoon to the resident and she used it for a few seconds and then continued to eat with her fingers in front of staff without staff assistance. Observation of lunch on 12/14/16 at 12:22 PM noted resident #146 holding her plate on her chest and eating using the fingers of her other hand. There was food on her blouse. Staff A was sitting in a chair in the dining room supervising. She did not intervene to assist resident #146. Interview with Staff M at 1:42 PM on 12/15/16 indicated resident #146 needs set up for meals and she feeds herself. Interview with Staff N on 12/15/16 at 1:42 PM said resident #146 is set up only and the care plan needs to be changed if she is using her fingers to eat.

Based on observations, staff interviews, and record review the facility failed to follow their infection control policy for (2) of (3) residents sampled for isolation. (#83, #176) The findings are: Observation during tour on 12/13/16 at approximately 10:00 am found an isolation cart outside resident #83 and #176 room. The cart was equipped with gowns, gloves and masks. A sign was posted on the door instructing visitors to speak with facility staff before entering. Interview with staff A on 12/15/16 at 9:00 am indicated resident #176 in bed A has a [DIAGNOSES REDACTED].#83 in bed B has a [DIAGNOSES REDACTED]. Review of facility policy Contact Precaution, General Infection Control Practices dated August 2010 states if a resident has[DIAGNOSES REDACTED] and Scabies they will be placed in Contact Isolation and the staff must use personal protection equipment, gloves, gowns before entering resident's room. On 12/15/2016 at 9:00 AM and 11:08 AM Staff A was observed walking into room [ROOM NUMBER] without gown or gloves. During interview with the resident #83 on 12/15/16 at approximately 10:10 am Staff B came into the room without gown and gloves. She indicated she was there to provide am care to both residents. She couldn't tell the surveyor why the residents were in isolation. Interview with Staff C and D on 12/15/16 at 1:17 pm indicated if a resident is in Contact Isolation staff is to wear gloves and gown. Interview with Staff E and F on 12/15/16 at 1:20 pm indicated if a resident is in Contact Isolation staff are to wear gloves, gown and shoe protectors in room. Both stated they are inserviced yearly on infection control. Interview with Infection Control Nurse on 12/15/16 at 2:10 pm indicated residents with Scabies and[DIAGNOSES REDACTED] are to be placed in Contact Isolation and are to wear protective equipment.

Based on record review, staff interviews and policy reviews, the facility failed to appropriately document and monitor the use of as needed medications (prn) in accordance with the facility policy for 1 of 5 sampled residents. (#15) The findings include: Review of resident #15's medical record was conducted on 10/30/2013. The record revealed the resident received [MEDICATION NAME] 7.5 mg by mouth at bedtime 20 times the month of October 2013. The Medication Administration Record (MAR) for October 2013 revealed only the administration and times for 12 of the doses was documented. The documentation for these 12 doses did not contain the reason the medication was administered or the resident's response to the medication. The behavior flow sheet October 2013 for [MEDICAL CONDITION] was also reviewed and revealed the 3pm -11pm shift was left blank 8 days. The MAR indicated the [MEDICATION NAME] was administered on 10/3, 4, 5, 6, 10, 11, 12, 13, 14, 15, 16, 19, 25, 29/2013. The behavior flow sheet for [MEDICAL CONDITION] for all of these dates reveals the resident either had no [MEDICAL CONDITION] or the documentation was blank and not complete. An interview was conducted with the South Unit Manager on 10/30/2013 at approximately 11:07 AM. She stated the nurses are to initial the MAR and document on the back why they gave the prn and if the medication was effective. She reviewed the nurses notes and the resident's MAR and confirmed the documentation for the [MEDICATION NAME] to be incomplete. An interview was conducted with the Director of Nurses on 10/31/2013 at approximately 10:42 AM. She stated the staff are to monitor the use of hypnotics on the behavior sheets each shift. The facility policy for Guidelines for Charting and Documentation were reviewed on 10/31/2013. #9 of the policy stated Use of PRN Medications: Summarize the use of PRNs with reason for usage, effects, and frequency of use. The facility policy for the Behavior Management Program was reviewed on 10/31/13. The policy stated a copy of the Behavior Management Plan and a Behavioral Monitoring Form/Psychoactive Medications will be in the MAR. Nurses are to document each behavior each time it occurs, the intervention used, the precipitating factor(s), and the outcome of the intervention on the monitoring sheet. It is the responsibility of the clinical manager to ensure the nurses are completing the Behavior Monitoring Form/Psychoactive Medications correctly.