Every finding on record at Phelps Health

Based on interview and record review, the facility staff failed to complete the required Minimum Data Set (MDS), a federally mandated resident assessment, within the required timeframe for two of three sampled residents (Residents #2 and #162). The facility census was 10. 1. Review of the facility's MDS Automation policy, revised April 2021, showed: -The MDS will be completed on a timely basis as mandated by Centers for Medicare Services (CMS); -Discharge tracking forms are completed on every resident within five days of dismissal; -The MDS assessments as required are sent to the state through electronic submission every 7-10 days. Review of the Resident Assessment Instrument (RAI) manual 3.0 version 1.18.11, dated October 2023, showed discharge assessment time frames for a resident must be completed no later than 14 days from the date of discharge and submitted by the MDS completion date plus 14 calendar days. 2. Review of Resident #2's Admission MDS, dated [DATE], did not contain a completed discharge assessment within the required time frame. Review of the resident's medical record showed staff documented the resident discharged on [DATE]. 3. Review of Resident #162's admission MDS, dated [DATE], did not contain a completed discharge assessment within the required time frame. Review of the resident's medical record showed staff documented the resident discharged on [DATE]. 4. During an interview on 12/28/23 at 10:46 A.M., the MDS Coordinator said currently he/she is responsible for MDS. He/She said during weekly meetings he/she sets the dates of upcoming due MDS assessments. He/She said when residents are discharged on the weekends their name may fall off the resident list and will fall through the cracks. The MDS Coordinator said if it was not a weekend discharge he/she would need to do research as to why it was not completed. He/She said he/she did not have access to the Internet Quality Improvement and Evaluation System (IQIES), communication system from facility to CMS, until recently and did not know the missing assessment report was available. During an interview on 12/28/23 at 10:52 A.M., the Director of Nursing (DON) said his/her expectation is the MDS be completed timely. He/She was not aware there were late assessments.

Based on observation, interview and record review, facility staff failed to complete entrapment assessments for the use of bed rails for 6 residents (Resident #2, #6, #209, #211, #212, and #214). The facility census was 10. 1. Review of the facility policies provided showed the facility did not have a policy for bedrails/mobility assist devices. Review of the facility's VersaCare Bed Service Manual, revision 5, undated, showed the manual did not address risk of resident entrapment. 2. Review of Resident #2's admission Minimum Data Set (MDS), a federally mandated resident assessment, dated 1/12/23, showed staff assessed the resident as follows: -Cognitively intact; -Required extensive, one person assistance with mobility, transfer, and toileting; -Impairment on one side lower extremity. Review of the resident's medical record, showed the record did not contain the required entrapment assessment specific to the resident. Observation on 1/18/23 at 1:50 P.M., showed the resident in bed, with a quarter side rail on the right side of bed, and a full side rail on the left side in the upright position. Observation on 1/19/23 at 10:30 A.M., showed the resident in bed, with a quarter side rail on the right side of bed, and a full side rail on the left side in the upright position. 3. Review of Resident #6's admission MDS, dated [DATE], showed the staff assessed the resident as follows: -Required extensive, two person assistance with bed mobility, transfers, and toileting; -Required the use of a walker and wheelchair; -Did not use bedrails; -Diagnosis of weakness. Review of the resident's medical record, showed the record did not contain the required entrapment assessment specific to the resident. Observation on 1/17/23 at 1:57 P.M., showed the resident in bed with quarter-length bilateral bed rails in the upright position. Observation on 1/18/23 at 1:50 P.M., showed the resident in bed with quarter-length bilateral bed rails in the upright position. 4. Review of Resident #209's admission record showed staff assessed the resident as follows: -admitted [DATE]; -Cognitively intact; -Required extensive, two person assistance with mobility and toileting; -Required extensive, one person assistance with transfers. Review of the resident's medical record, showed the record did not contain the required entrapment assessment specific to the resident. Observation on 1/17/23 at 11:45 A.M., showed the resident in bed, with quarter-length bilateral bed rails in the upright position. Observation on 1/18/23 at 9:15 A.M., showed the resident in bed, with quarter-length bilateral bed rails in the upright position. Observation on 1/18/23 at 2:00 P.M., showed the resident in bed, with quarter-length bilateral bed rails in the upright position. Observation on 1/19/23 at 10:30 A.M., showed the resident in bed, with quarter-length bilateral bed rails in the upright position. 5. Review of Resident #211's admission record showed staff assessed the resident as follows: -admitted [DATE]; -Diagnosis of weakness, fracture of the left femur (a break in the bone of the thigh), and fracture of the carpal bone (a break in the bone of the wrist). Review of the resident's medical record, showed the record did not contain the required entrapment assessment specific to the resident. Observation on 1/17/23 01:37 P.M., showed the resident in bed with quarter-length bilateral bed rails in the upright position. Observation on 1/18/23 1:50 P.M., showed the resident in bed with quarter-length bilateral bed rails in the upright position. Observation on 1/19/23 10:29 A.M., showed the resident in bed with quarter-length bilateral bed rails in the upright position. During an interview on 1/18/23 at 1:50 P.M., the resident said he/she always has his/her side rails up. The button controls for the bed are on the side rails. Without them up he/she wouldn't be able to reach them. 6. Review of Resident # 212's admission record showed staff assessed the resident as follows: -admitted [DATE]; -Diagnosis of a complicated urinary tract infection, which caused significant weakness. Review of the resident's medical record, showed the record did not contain the required entrapment assessment specific to the resident. Observation on 1/17/23 at 12:48 P.M., showed the resident in bed with bilateral upper quarter side rails in the upright position. Observation on 1/18/23 at 3:45 P.M., showed the resident in bed with bilateral upper quarter side rails in the upright position. Observation on 1/19/23 at 10:33 A.M., showed the resident in bed with bilateral upper quarter side rails in the upright position. During an interview on 1/19/23 at 10:33 A.M., the resident said he/she does not use the side rails for anything. 7. Review of Resident # 214's admission record showed staff assessed the resident as follows: -admitted [DATE]; -Diagnoses of amputation of the toe of the right foot, diabetic infection of the left foot, diabetic ulcer of the left heel, and abscess of the right foot. Review of the resident's medical record, showed the record did not contain the required entrapment assessment specific to the resident. Observation on 1/18/23 at 10:45 A.M., showed the resident in bed with bilateral upper quarter side rails in the upright position. Observation on 1/18/23 at 2:14 P.M., showed the resident in bed with bilateral upper quarter side rails in the upright position. During an interview on 1/19/23 at 10:30 A.M., the resident said he/she does not use the side rails for anything. 8. During an interview on 1/18/23 at 12:56 P.M., the MDS Coordinator said the bed rails are manufactured with the side rails so they do not come off, and patients cannot become entrapped. During an interview on 1/19/23 at 10:25 A.M., Certified Nurse Assistant (CNA) A said all of their residents use side rails. They use them for the control buttons located on the side of the rails. The buttons help the resident move their head, feet, and bed up and down. CNA A said the side rails do not come off the bed, but can lowered when needed. During an interview on 1/19/23 at 10:45 A.M., the MDS Coordinator said if a resident was really small, there might be a risk of entrapment however there have not been any residents admitted that might have this risk. During an interview on 1/19/23 at 10:47 A.M., the Director of Nursing said it was his/her understanding that the beds purchased by the facility have manufactured safety features to prevent entrapment so residents could not be entrapped. 42484 47193

Based on staff interview and record review, facility staff failed to check the Certified Nurses' Assistant (CNA) Registry for all staff to ensure they did not have a Federal Indicator (a marker given by the federal government to individuals who have committed abuse and/or neglect) for eight out of ten sampled employees hired since the last survey. The facility census was 4. 1. Review of the facility's Abuse and Neglect Policy, revised (MONTH) (YEAR), showed facility staff were directed as follows: -Provide components to screen employees for a history of abuse, neglect, or mistreating of patients; -And the facility will not hire a potential employee with a history of abuse, if that information is known to the facility. Further review of the facility's Abuse and Neglect Policy, showed it did not contain direction for the staff in regards to checking the CNA Registry for all staff to ensure they did not have a Federal Indicator for abuse and/or neglect. 2. Review of Registered Nurse (RN) A's employee file, showed the following: -Hire date of 4/8/19 -Staff did not document a CNA registry check. 3. Review of Patient Care Assistant (PCA) B's employee file, showed the following: -Hire date of 4/22/19; -Staff did not document a CNA registry check. 4. Review of Dietary Aide (DA) C's employee file, showed the following: -Hire date of 5/15/19; -Staff did not document a CNA registry check. 5. Review of Housekeeper D's employee file, showed the following: -Hire date of 6/3/19; -Staff did not document a CNA registry check. 6. Review of RN E's employee file, showed the following: -Hire date of 6/7/19; -Staff did not document a CNA registry check. 7. Review of Licensed Practical Nurse (LPN) F's employee file, showed the following: -Hire date of 8/5/19; -Staff did not document a CNA Registry check. 8. Review of Housekeeper G's employee file, showed the following: -Hire date of 8/19/19; -Staff did not document a CNA Registry check. 9. Review of DA's employee file, showed the following: -Hire date of 10/7/19; -Staff did not document a CNA Registry check. 10. During an interview on 11/26/19 at 9:50 [NAME]M., the Human Resources Representative said the CNA Registry is only checked on CNAs that work on the Long Term Care (LTC) unit of the hospital. He/she said he/she was not aware that the hospital was required to check the CNA registry on every employee that had the potential to come in contact with a patient. He/she said he/she was not aware that staff, other than CNAs, were to be checked against the CNA Registry. During an interview on 11/26/19 at 11:00 [NAME]M., the Director of Nursing (DON) said he/she was not aware that the CNA Registry had to be checked on all employees that would have contact with the residents.

Based on observation, interview and record review, facility staff failed to allow sanitized kitchenware to air dry prior to stacking in storage. Facility staff also failed to appropriately sanitize manually washed kitchenware. The facility census was 15. 1. Review of the (YEAR) Food and Drug Administration Food Code, chapter 4 (Equipment, Utensils and Linens), sections 901.11 and 903.11, showed: -901.11 After cleaning and sanitizing, equipment and utensils: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface sanitizing solutions), before contact with FOOD; and (B) (MONTH) not be cloth dried except that utensils that have been air-dried may be polished with cloths that are maintained clean and dry. -903.11 (A) Except as specified in paragraph (D) of this section, cleaned equipment and utensils, laundered linens, and single-service and single-use articles shall be stored: (1) In a clean, dry location; (2)Where they are not exposed to splash, dust, or other contamination; and (3)At least 15 cm (6 inches) above the floor; (B)Clean equipment and utensils shall be stored as specified under paragraph (A) of this section and shall be stored: (1) In a self-draining position that allows air drying; and (2)Covered or inverted; (C) Single-service and single-use articles shall be stored as specified under paragraph (A) of this section and shall be kept in the original protective package or stored by using other means that afford protection from contamination until used; (D) Items that are kept in closed packages may be stored less than 15 cm (6 inches) above the floor on dollies, pallets, racks, and skids that are designed as specified under subsection 4-204.122. Review of the facility's Pot and Pan Washing and Dish Machine Operation policies dated Februrary 2009, showed instruction to allow dishes to air dry before placed in storage. Observation on 11/20/18 at 11:21 A.M., showed 23 metal food preparation and service pans stacked together wet on the pan storage shelves in cooks' station. Observation on 11/20/18 at 11:33 A.M., showed 12 plastic dessert bowls and four black service trays stacked together wet on the storage shelves in the mechanical dishwashing station. During an interview on 11/20/18 at 12:03 P.M., the Certified Dietary Manager (CDM) said dishes should be allowed to air dry prior to stacking in storage and all staff are trained on this requirement. Observation on 11/20/18 at 12:15 P.M., showed Dietary Aide (DA) A, stacked metal food preparation/service pans together wet and placed on storage rack in cook's station. 2. Observation on 11/20/18 at 11:50 A.M., showed DA A washed dishes at the three-compartment sink. Observation showed the DA placed the dishes in the quaternary ammonium sanitizing solution for 10 seconds before he/she removed the dishes and placed them on a rack to dry. Review of the facility's Pot and Pan Washing policy dated (MONTH) 2009, showed instruction to sanitize pots, pans and kitchen utensils in the third sink containing sanitizer. Review showed the policy did not contain instruction regarding how long kithenware should remain in the sanitizer. Review of the quaternary ammonium sanitizer's product labeling showed instruction to immerse food contact surfaces in the solution for at least one minute. During an interview on 11/20/18 at 11:51 A.M., the DA said he/she had worked at the facility for about two years and manually washed dishes should remain in the sanitizer for 15 to 20 seconds. During an interview on 11/20/18 at 12:03 P.M., the CDM said all staff are trained on dishwashing procedures upon hire and sanitizing information is available in the dish station. The CDM said he/she did not know for sure how long the dishes should remain in the sanitizer but thought it was 20 seconds.

Based on observation, interview, and record review, facility staff failed to wash hands between glove changes during care to prevent the spread of infection for four residents (Resident #9, #12, #16 and #18 ). Additionally, staff failed to date and store oxygen tubing in a manner to prevent the spread of infection for one resident (Resident #7) and failed to maintain wound vac tubing in a manner to prevent the spread of infection for one resident (Resident #6). The facility census was 15. 1. According to the Infection Control Guidelines for Long Term Care Facilities (Section 3.0 Body Substance Precautions): *Dirty gloves are worse than dirty hands because micro-organisms adhere to the surface of a glove easier than to the skin of your hands. *Hand washing remains the single most effective means of preventing disease transmission; wash hands whenever they are soiled with body substance and when each resident's care is completed. 2. Observation on 11/20/18, at 9:08 A.M., showed Resident #9 on the bedside commode and Certified nurse assistant (CNA) C provided perineal care. Additional observation showed the CNA removed the glove from the hand he/she cleansed the resident's perineal area with and touched the resident's clothing, wheelchair, gait belt and clean supplies before cleansing his/her hands. The CNA did not wash his/her hands between glove changes to prevent the spread of contaminates that cause infection. Observation on 11/20/18, at 9:29 A.M., showed the resident in the shower room. Additional observation showed CNA C remove the resident's soiled clothing and remove his/her gloves, he/she did not cleanse his/her hands, and put on new gloves. The CNA cleansed the resident's upper body and removed his/her gloves, he/she did not cleanse his/her hands, and put on new gloves. The CNA provided catheter care and removed his/her gloves, he/she did not cleanse his/her hands, and put on new gloves. The CNA cleansed the resident's back perineal area and removed his/her gloves, he/she did not cleanse his/her hands, and put on new gloves. The CNA cleansed the resident's lower body, and removed his/her gloves, did not cleanse his/her hands and touched equipment, clean supplies and assisted the resident to dress. The CNA did not wash his/her hands between glove changes to prevent the spread of contaminates that cause infection. 3. Observation on 11/20/18 at 2:00 P.M., showed RN B apply a dressing to a pressure ulcer on the Resident #12's left heel. He/she changed gloves and washed hands, and touched the floor, a urine pad on a chair, and the bag containing the pad prior to putting his/her gloves back on and then applying the pad to the wound. 4. Observation on 11/20/18, at 8:42 P.M., showed Resident #16 on the bedside commode. Additional observation showed registered nurse (RN) B cleansed the resident's perineal area. Further observation showed the RN removed the glove he/she cleansed the resident with, and touched the resident's clean linens, the bed controls, and moved the resident's bedside table. The RN did not wash his/her hands between glove changes. During an interview on 11/20/18, at 9:26 A.M., the resident said staff wipe his/her bottom and touch his/her water pitcher or clothing with the same gloves. He/She said staff think everything is clean because they wear gloves and they don't think about the gloves get dirty. 5. Observation on 11/20/18 at 11:36 A.M., showed CNA E placed dirty gloves he/she were used to perform peri-care on Resident #18 on top of the bedside table. CNA E did not wash hands between glove changes. 6. During an interview on 11/21/18, at 9:12 A.M., CNA C said staff are expected to wash their hands upon entering and leaving a resident's room. He/She said, I change my gloves often, but I do not wash my hands most of the time when I change my gloves, depending on the circumstance. He/She said staff are expected to cleanse their hands when going from dirty to clean. During an interview on 11/21/18, at 9:34 A.M., RN B said staff are expected to cleanse their hands before and after resident care, between dirty and clean tasks, and with glove changes. He/She said he/she didn't think about what he/she touched after he/she removed his/her gloves. 7. Observation on 11/19/18, at 01:30 P.M., showed Resident #6 in the dining room with his/her wound vac (device used to assist wounds to heal) tubing on the floor. Observation on 11/20/18 at 8:45 A.M., showed the resident's wound vac tubing on the floor. Observation on 11/20/18 at 11:33 A.M., showed the resident's wound vac tubing on the floor. During an interview on 11/20/18 at 11:33 A.M., RN F said it was ok for the tubing to be on the floor since it is contained. 8. Observation on 11/19/18 at 2:12 P.M., showed Resident #7's oxygen tubing undated and the nasal cannula on the floor. Observation on 11/20/18 at 9:15 A.M., showed the resident's oxygen tubing continued to be undated. 9. During an interview on 11/21/18, at 10:36 A.M., the assistant director of nursing (ADON) said staff are expected to cleanse their hands before and after resident care, between dirty and clean tasks, and with glove changes. He/She said oxygen tubing should be changed when it is visibly soiled or if it is contaminated. He/She said when oxygen tubing is not in use, it should be coiled and put in the respiratory bag. He/She said wound vac tubing should not drag on the floor. The ADON said staff are expected to cleanse the glucometer according to the manufacturers recommendations for the glucometer and the wipes.

Based on observation, interview, and record review, facility staff failed to attempt alternative measures before using siderails for two residents (Resident #6 and #8). The facility census was 15. 1. Review of Resident #6's admission MDS, dated [DATE], showed staff assessed the resident as follows; -Cognitively impaired; -Diagnoses; Diabetic Ketoacidosis (DKA), and [MEDICAL CONDITION] Resistant Staphylococcus aureous (MRSA) wound infection; -Required assist of one staff member with the use of a walker to ambulate and transfer. Review of of the resident's care plan dated 11/15/18, shows it directs staff: -Keep both split bedrails up for resident bed mobility and safety to prevent falls; -Required assistance of one staff member to transfer and ambulate. Review of the resident's admission assessment, dated 11/15/18, shows it did not contain documentation of alternatives used prior to use of bedrails. Review of the resident's Consent for Use of Side Rails, dated 11/15/18, showed the staff recommended use of 1/4 upper siderails for security, mobility aid, and safety. Observation on 11/19/18, at 1:09 P.M., shows the resident's top two siderails in the up position on his/her bed. 2. Review of Resident #8's admission MDS, dated [DATE] , assessed the resident as: -Cognitively impaired; -[DIAGNOSES REDACTED]. -Generalized weakness with limited range of motion (ROM), to right upper extremity/shoulder. Review of the resident's care plan, dated 11/08/18 , shows it directs staff: -Keep split bedrails up x2 for resident bed mobility and safety to prevent falls; -The resident has impaired mobility related to stroke diagnosis; -Requires assistance of two staff members to transfer. Review of the resident's admission assessment, dated 11/08/18, shows it did not contain documentation of alternatives used prior to the use of siderails. During an observation on 11/19/18, at 01:31 P.M., showed the resident's top two siderails are up on his/her bed. 3. During an interview on 11/21/18 at 8:50 A.M., Certified Nursing Assistance (CNA) C, said the hospital always uses side rails on the beds to help patients with therapy and move themselves in bed. During an interview on 11/21/18 at 9:15 A.M., Registered Nurse (RN) F, patients are notified of the siderail policy upon admission and they have an option of using them. There are not supposed to be three siderails up, but if they request to have a lower siderail up, we leave one top and bottom siderail up. The hospital does not have beds that do not have siderails. During an interview on 11/20/18 at 2:30 P.M., the MDS Coordinator says the measures that are taken to make sure residents do not become entrapped between the bed mattress and siderails include measuring beds and to make sure they are meeting standards. The facility does not try other measures before using siderails. The facility does not have beds that do not have siderails. The facility has used a bedside sitter on occasion. During an interview on 11/21/18, at 10:36 A.M., the assistant director of nursing said staff complete an entrapment assessment on admission. He/She said staff are supposed to only use upper two bedrails, and if a resident is an entrapment risk the resident should be close to the desk. He/She said the facility does not have beds without rails, and sitters are not always available, so if the family can sit we ask them.

Based on observation, interview, and record review the facility failed to follow the facility's policy to secure urinary catheters to prevent urethral erosion, catheter associated urinary tract infections, and accidental catheter removal for two residents (Resident #9, and #14) of two residents with urinary catheters. The facility census was 15. 1. Review of the facility's policy Urinary Elimination, Insertion of an Indwelling Urinary Catheter, dated (YEAR), directs the staff to: -Secure indwelling catheter with catheter strap or other securement device, leave enough slack to allow leg movement; -Securing the catheter reduces risk of urethral erosion, catheter associated urinary tract infections, or accidental catheter removal; -Secure catheter tubing to the inner thigh, allow slack in catheter so movement does not create tension on the catheter; -Anchoring the catheter reduces traction on urethra an minimizes urethral injury. 2. Review of Resident #9's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 11/18/18, showed staff assessed the resident as: -Cognitively intact; -Indwelling catheter; -Urinary tract infection in the last 30 days; -Required limited physical assistance of one staff member for bed mobility, transfers, toileting, and hygiene; -Required extensive physical assistance of one staff member for bathing. Review of the resident's care plan, dated 11/5/18, showed it did not contain information about the resident's catheter. Observation on 11/20/18, at 9:08 A.M., showed the resident in his/her room on a bedside commode. The resident's catheter tubing pulled taut, connected to the drainage bag with urine visible, connected to the bed. Additional observation showed the resident's catheter tubing hung free, and was not secured to the resident's leg. Certified nurse assistant (CNA) C assisted the resident to transfer to his/her wheelchair. Further observation showed the resident grabbed the catheter tubing and said, Oh, that's pulling. The staff did not follow the facility's policy and secure the catheter tubing in a manor to prevent trauma and infection. Observation on 11/20/18, at 9:29 A.M., showed the resident in the shower. The resident's catheter pulled taut during the shower, and is not secured to the resident's leg. The staff did not follow the facility's policy and secure the catheter tubing in a manner to prevent trauma and infection. 3. Review of Resident #14's admission MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Indwelling catheter; -Required limited physical assistance of one staff member for toileting, and hygiene; -Required extensive physical assistance of one staff member for bed mobility, transfers, and bathing. Review of the resident's care plan, dated 11/5/18, shows staff inserted a urinary catheter on 11/6/18 for [MEDICAL CONDITION]. The care plan did not contain directions to the staff on specific care and maintenance for the catheter. Observation on 11/19/18, at 2:06 P.M., showed the resident sat in his/her chair. His/Her catheter drainage bag was attached to his/her chair. During an interview on 11/19/18, at 2:06 P.M., the resident said he/she does not have his/her catheter secured to his/her leg with a strap, tape or device. He/She said he/she does not have anything connecting the catheter to his/her leg, so he/she just holds on to the tubing when he/she moves so it doesn't pull, because that hurts. During an interview on 11/20/18, at 10:12 A.M., the resident said he/she does not have anything connecting the catheter to his/her leg. During an interview on 11/21/18, at 9:24 A.M., the resident said he/she asked the nursing staff last night for a catheter strap. He/She said staff said they looked in the utility room and could not find a catheter strap or device of any kind. 4. During an interview on 11/21/18, at 9:12 A.M., CNA C said the stat lock (adhesive device to secure catheter) never fit right, and the new ones don't fit. He/She said Resident #9, complained that the catheter pulls. He/She said if the facility had a device that worked, the catheter wouldn't pull. He/She said they do not stock leg straps and he/she does not know why they don't have something. During an interview on 11/21/18, 9:16 A.M., registered nurse (RN) D said the facility does not have stat locks because they haven't found a stat lock to work with the catheter bags, and they don't usually use tape. During an interview on 11/21/18, at 10:06 A.M., the MDS coordinator said staff are expected to secure residents' catheters with the stat lock device to prevent trauma and infection. He/She did not know the facility did not have a stat lock device to fit the current catheters. During an interview on 11/21/18, at 10:36 A.M., the assistant director of nursing (ADON) said staff are expected to secure urinary catheter tubing to the resident's leg to prevent trauma and infection.

Based on interview and record review, the facility staff failed to have a facility-wide assessment to determine what resources, staff, and training are necessary to care for its residents competently during both day-to-day operations and emergencies. The census was 15. Review of the Resident Census and conditions of residents, dated 11/19/18, showed the staff identified residents with the following needs: -three residents with indwelling or external catheters; -four residents occasionally or frequently incontinent of bladder; -five residents occasionally or frequently incontinent of bowel; -one resident with intellectual and/or developmental disability; -three residents with signs and symptoms of depression; -three residents with a psychiatric diagnosis; -two residents with a dementia diagnosis; -15 residents that ambulate with an assistive device; -one resident with pressure ulcers; -four residents with preventative skin care; -one resident receiving [MEDICAL CONDITION] therapy; -two residents with intravenous therapy; -one resident with respiratory care; -nine residents with injections; -15 residents with rehabilitative services; -four residents on psychoactive medications; -five residents on antibiotics; -seven residents with advance directives. During an interview on 11/21/18, at 10:45 A.M., the Minimum Data Set (MDS) Coordinator said he/she did not see a facility assessment. During an interview on 11/21/18, at 2:12 P.M., the director of nursing (DON) said he/she did not think the facility completed a facility assessment. During an interview on 11/21/18, at 2:35 P.M., the MDS coordinator said he/she pulled a sample of a facility assessment from CMS to get the assessment started. During an interview on 11/21/18, at 10:36 A.M., the assistant DON (ADON) said the facility participates in the hospital's emergency preparedness but did not have the needs identified on the unit specifically, or any document that fulfills the requirements of the facility assessment. He/She said the the facility assessment is not completed, the facility staff just started it.

Based on observation, interview, and record review, facility staff failed to complete an entrapment assessment and obtain a consent for side rail use for seven residents with side rails (Residents #1, #2, #3, #4, #5, #6, and #7). The facility census was 13. 1. Review showed the facility did not have a policy to direct staff to assess entrapment risk or obtain consent for siderail use. 2. Review of Resident #1's Patient Rounds documentation, dated 9/12/17, showed staff documented the resident with two side rails raised. Review of the resident's Shift Assessment documentation, dated 9/13/17 showed staff documented the resident with two side rails raised. Observation on 9/12/17 at 11:45 A.M., showed the resident not in his/room. Observation showed the resident's bed with two upper side rails raised. Observation on 9/12/17 at 3:13 A.M., showed the resident in his/her room in the recliner. Observation showed the resident's bed with two upper side rails raised. Observation on 9/13/17 at 6:39 A.M., showed the resident in his/her room in the recliner. Observation showed the resident's bed with two upper side rails raised. Observation on 9/13/17 at 12:05 P.M., showed the resident in his/her room in the recliner. Observation showed the resident's bed with two upper side rails raised. Further review of the resident's medical record showed staff did not document an entrapment assessment or obtain a consent to use side rails from the resident or their representative. 3. Review of Resident #2's Shift Assessment documentation, dated 9/11/17, showed staff documented the resident with two side rails raised. Review of the resident's Patient Care Rounds documentation, dated 9/12/17, showed staff documented the resident with two split side rails raised. Observation on 9/12/17 at 11:46 A.M., showed the resident lay in his/her bed with two upper side rails raised. Observation on 9/12/17 at 3:15 P.M., showed the resident lay in his/her bed with two upper side rails raised. Observation on 9/13/17 at 6:40 A.M., showed the resident lay in his/her bed with two upper side rails raised. Observation on 9/13/17 at 12:06 P.M., showed the resident in his/her recliner in his/her room. Observation showed the resident's bed with the two upper side rails raised. Further review of the resident's medical record showed staff did not document an entrapment assessment or obtain a consent to use side rails from the resident or their representative. 4. Review of Resident #3's Patient Rounds documentation, dated 9/12/17, showed staff documented the resident with two side rails raised. Review of the resident's Shift Assessment documentation, dated 9/13/17 showed staff documented the resident with three side rails raised. Observation on 9/12/17 at 2:45 P.M., showed the resident in his/her room in his/her bed. Observation showed the resident's bed with two upper side rails raised. Observation on 9/13/17 at 6:42 A.M., showed the resident in his/her room in his/her bed. Observation showed the resident's bed with two upper side rails raised. Observation on 9/13/17 at 8:15 A.M., showed the resident in his/her room in his/her bed. Observation showed the resident's bed with two upper side rails raised. Observation on 9/13/17 at 9:00 A.M., showed the resident in his/her room in his/her bed. Observation showed the resident's bed with two upper side rails raised. Further review of the resident's medical record showed staff did not document an entrapment assessment or obtain a consent to use side rails from the resident or their representative. 5. Review of Resident #4's Patient Rounds documentation, dated 9/12/17, showed staff documented the resident with two side rails raised. Review of the resident's Shift Assessment documentation, dated 9/13/17 showed staff documented the resident with three side rails raised. Observation on 9/12/17 at 12:10 P.M., showed the resident in his/her room in his/her recliner. Observation showed the resident's bed with two upper side rails raised. Observation on 9/13/17 at 6:40 A.M., showed the resident in his/her room in his/her bed. Observation showed the resident's bed with two upper side rails raised. Observation on 9/13/17 at 9:00 A.M., showed the resident in his/her room in his/her bed. Observation showed the resident's bed with two upper side rails raised. Further review of the resident's medical record showed staff did not document an entrapment assessment or obtain a consent to use side rails from the resident or their representative. 6. Review of Resident #5's Patient Rounds documentation, dated 9/12/17, showed staff documented the resident with three side rails raised. Review of the resident's Shift Assessment documentation, dated 9/13/17 showed staff documented the resident with three side rails raised. Observation on 9/12/17 at 12:15 P.M., showed the resident in his/her room in his/her bed. Observation showed the resident's bed with two upper side rails raised. Observation on 9/12/17 at 2:05 P.M., showed the resident in his/her room in his/her bed. Observation showed the resident's bed with two upper side rails raised. Observation on 9/13/17 at 6:37 A.M., showed the resident in his/her room in his/her bed. Observation showed the resident's bed with two upper side rails raised. Observation on 9/13/17 at 9:00 A.M., showed the resident in his/her room in his/her bed. Observation showed the resident's bed with two upper side rails raised. Further review of the resident's medical record showed staff did not document an entrapment assessment or obtain a consent to use side rails from the resident or their representative. 7. Review of Resident #6's Patient Rounds documentation, dated 9/12/17, showed staff documented the resident with three side rails raised. Review of the resident's Shift Assessment documentation, dated 9/13/17 showed staff documented the resident with three side rails raised. Observation on 9/13/17 at 6:45 A.M., showed the resident in his/her room in his/her bed. Observation showed the resident's bed with two upper side rails, and one lower side rail raised. Observation on 9/13/17 at 9:00 A.M., showed the resident in his/her room in his/her bed. Observation showed the resident's bed with two upper side rails, and one lower side rail raised. Further review of the resident's medical record showed staff did not document an entrapment assessment or obtain a consent to use side rails from the resident or their representative. 8. Review of Resident #7's Shift Assessment documentation, dated 9/12/17, showed staff documented the resident with three side rails raised. Review of the resident's Patient Care Rounds documentation, dated 9/13/17 showed staff documented the resident with two side rails raised. Observation on 9/13/17 at 8:13 A.M., showed the resident in bed. Observation showed the resident's left side of his/her bed with two side rails raised and the right side of the bed with one side rail raised. Observation on 9/13/17 at 12:05 A.M., showed the resident in bed. Observation showed the resident's bed with the two upper side rails raised. Further review of the resident's medical record showed staff did not document an entrapment assessment or obtain a consent to use side rails from the resident or their representative. 9. During an interview on 9/12/17 at 1:00 P.M., the Assistant Director of Nursing (ADON) said he/she did not think the facility had an entrapment assessment or consent, and said he/she thought the restraint documentation addressed side rail use. 10. During an interview on 9/13/17 at 11:42 A.M., the Director of Nursing (DON) said the facility does not have an entrapment assessment or consent.

Based on observation, interview and record review, the facility failed to maintain kitchen equipment, floors, walls, and ceiling in a clean and sanitary condition. The facility census was 7. 1. Observation on 7/13/16 at 10:12 A.M., showed red food splatter on the ceiling above the dish washing machine. Further observation showed an excess of food debris and a dry white substance on top of the dish washing machine. Review of the dietary daily cleaning checklists dated 07/06/16 through 07/12/16, showed staff are directed to clean the dish room, including the exterior of the dishwasher, daily. Further review showed staff did not document cleaning the dish room or dish machine as directed. 2. Observation on 07/13/16 at 10:20 A.M., showed the top of the convection oven covered with grease and food debris. Observation also showed an accumulation of grease and dirt on the back wall behind the convection oven. Review of the dietary daily cleaning checklists dated 07/06/16 through 07/12/16, showed staff are directed to clean the convection oven daily. Further review showed staff did not document cleaning the convection oven as directed. 3. Observation on 07/13/16 at 10:23 A.M., showed an accumulation of food debris on the blade and base of the meat slicer. Review of the dietary daily cleaning checklists dated 07/06/16 through 07/12/16, showed staff directed to clean the meat slicer daily. Further review, showed staff did not document cleaning the meat slicer as directed. 4. Observation on 07/13/16 at 10:45 A.M., showed the stand mixer with a brown substance on the mixer hub and an unknown red food splatter on the wire mixing attachment inside the mixer bowl. Review of the dietary daily cleaning checklists dated 07/06/16 through 07/12/16, showed staff are directed to clean the stand mixer daily. Further review, showed staff did not document cleaning the mixer as directed. 5. Observation on 07/13/16 at 12:02 P.M., showed an accumulation of grease, dust, and an unknown red substance on four ventilation covers above the dish washing machine. Review of the dietary daily cleaning checklists 07/06/16 through 07/12/16, showed staff are directed to clean the dish room daily. Further review, showed staff did not document cleaning the dish room or dish machine as directed. 6. During an interview on 07/13/16 at 12:25 P.M., the Dietary Manager (DM) said he/she expects staff to clean all areas and document the cleaning on the cleaning schedule. The DM said he/she expects supervisors to make sure staff complete the cleaning. The DM said he/she is ultimately responsible to ensure all areas are cleaned properly. The DM said he/she does not have daily cleaning schedules for July because the supervisor on duty failed to post them.

Based on record review and interview, the facility's water emergency contracts did not guarantee delivery of water in an emergency situation. The policy did not address the amount of potable water the facility would have available at all times, the amount of non-potable water, a method of distributing water and a method of estimating the volume of water required for each resident and staff daily based on the facility census. The facility census was 7. 1. Review of contract number one of the facility's water emergency contracts, dated 02/22/12, showed the contract did not contain a guarantee of emergency water delivery. Further review showed the contract did not contain how much emergency water would be delivered to the facility. 2. Review of contract number two of the facility's water emergency contracts, dated 02/22/12, showed the contract did not contain a guarantee of emergency water delivery. Further review showed the contract did not contain how much emergency water would be delivered to the facility. 3. Review of contract number three of the facility's water emergency contracts, dated 02/27/12, showed the contract did not contain a guarantee of emergency water delivery. During an interview on 07/13/16 at 9:50 A.M., the Director said she was not aware the water contract needed to guarantee the delivery of emergency water. She said the Plant Operations Director is responsible for the emergency water. During an interview on 07/13/16 at 11:00 A.M., the Plant Operations Director said no other contracts were available for emergency water delivery. He/She said he/she did not know the current contracts did not guarantee emergency water delivery.

Based on observation, interview, and record review, the facility failed to post actual hours worked by both licensed and unlicensed staff directly responsible for resident care per shift on a daily basis. The facility census was 7. 1. Observation on 07/12/16 at 10:30 A.M., showed the facility did not post the actual hours worked by both licensed and unlicensed staff directly responsible for resident care. 2. Observation on 07/13/15 at 10:40 A.M., showed the facility did not post the actual hours worked by both licensed and unlicensed staff directly responsible for resident care. During an interview on 07/13/16 at 10:40 A.M., the Assistant Director said she is responsible for completing and posting the staffing daily. She said the staff posting should include the licensed and unlicensed staff and the shift that each worked. The Assistant Director said she did not know the nurse staffing posting should include the actual hours worked.