Every finding on record at Rosedale Green

Based on observation, interview, record review, review of the Centers for Medicare and Medicaid (CMS) memorandum, and facility policy review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Observations revealed the facility failed to clean the mechanical lift after use for two of three sampled residents, Resident (R) 1 and R117. Also, R117 had a wound requiring dressing changes but was not in Enhanced Barrier Precautions (EBP). The findings include: Review of the facility's policy titled, Infection Control Policies & Procedures, dated 01/08/2025, revealed shared resident equipment should be disinfected between resident use. Review of the facility's policy titled, Enhanced Barrier Precautions, reviewed/revised 02/05/2025, stated chronic wounds (e.g. wounds that were not following their healing trajectory as determined by the wound care provider), and according to the new regulations effective 04/01/2024, Enhanced Barrier Precautions (EBP) were to be implemented for wounds and/or indwelling medical devices even if the resident was not known to be infected or colonized with a multi-drug resistant organism (MDRO). Per the policy, wounds generally included chronic wounds, not shorter-lasting wounds, such as skin breaks or skin tears covered with an adhesive bandage. The policy stated the regulations did not give exceptions for wounds that were following their healing trajectory. Review of the CMS Center for Clinical Standards and Quality/Quality, Safety & Oversight Group Ref: QSO-24-08-NH, dated 03/20/2024 and effective 04/01/2024, Enhanced Barrier Precautions in Nursing Homes, revealed Enhanced Barrier Precautions (EBP) use was recommended for residents with chronic wounds, not shorter-lasting wounds, such as skin breaks or skin tears covered with an adhesive bandage or similar dressing. The memo also stated chronic wound examples included, but were not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. Review of the list provided by the facility Dressing Changes, not dated, revealed R117 required a dressing change. However, review of the list provided by the facility Resident Enhanced Barrier Precautions [EBP], updated 04/16/2025, revealed R117 was not on the list as being on EBP. 1. Review of R1's 'Face Sheet revealed the facility admitted the resident on 04/20/2006 with diagnoses of urinary tract infection, anxiety, and dementia. Review of R1's annual Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 02/07/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 99, which indicated R1 was unable to complete the interview. Review of R1's Care Plan, dated 03/26/2025, revealed, I am colonized by a Multi-Drug-Resistant Organism (MDRO); therefore, I am on Enhanced Barrier Precautions. The problem start date was 10/14/2024 with an edited date of 04/02/2025 with the intervention listed Utilize ENHANCED BARRIER PRECAUTIONS during high-risk resident care activities. (Dressing, bathing, transfers, toileting, hygiene, changing linen, and during any wound or medical device care). Observation on 04/14/2025 at 2:10 PM revealed State Trained Nursing Assistant (STNA) 1 was observed coming out of R1's room with a mechanical lift who had an Enhanced Barrier Sign posted outside the door. STNA1 placed the mechanical lift into the storage room without disinfection after use. During an interview on 04/14/2025 at 2:10 PM with STNA1, she stated the mechanical lifts got cleaned once a shift, and she was unsure what the policy stated. During an interview on 04/16/2025 at 9:30 AM with STNA6, she stated mechanical lifts should be cleaned before and after each use with purple top Sani-Wipes (a disinfectant wipe) to prevent the spread of infection. During an interview on 04/16/2025 at 9:32 AM with STNA7, she stated mechanical lifts should be cleaned with Sani-Wipes between each resident use for resident safety. 2. Review of R117's Face Sheet revealed the facility admitted the resident on 01/10/2023 with diagnoses to include cellulitis of left toe, dementia, and bursitis of the left hip. Review of 117's quarterly MDS, with an ARD of 03/29/2025, revealed the facility assessed the resident to have a BIMS score of 99, which indicated R117 was unable to complete the interview. Review of R117's Progress Note, dated 03/05/2025, revealed, Patient is currently on a course of Keflex for cellulitis of her left great toe. Her Keflex was extended by wound NP [Nurse Practitioner]. This is a chronic vascular wound. Review of R117's Progress Note, dated 04/15/2025, revealed, Open wound of left great toe, Osteomyelitis of great toe. Plan continue Xeroform dressing daily. Observation on 04/15/2025 at 10:22 AM, revealed STNA4 dressed R117 in pants and a blouse wearing only gloves. Further observation of R117 revealed she had a gauze bandage that was taped to her left great toe. The gauze had a brown colored spot at the tip of the toe, approximately a one-half inch oval shape. STNA4 then used the sit-to-stand lift to transfer R117 to the wheelchair, using the lift pad. Continued observation revealed, after she transferred R117, she removed her gloves and sanitized her hands. She then placed the lift pad on the lift and took the lift to the tub room on the 300 Unit. STNA4 did not disinfect the lift pad or the lift. Observation also revealed there was no EBP signage on R117's door. During interview with STNA4 after the observation, she stated she should have cleaned the lift with a Sani-Wipe. She stated she also should have hung the lift pad on a hook in the shower room. During interview with the Infection Preventionist on 04/17/2025 at 8:42 AM, she stated the mechanical lifts were to be cleaned before and after use. She also said she was involved in updating the infection control policies. During interview with the Assistant Director of Nursing (ADON) on 04/15/2025 at 2:17 PM, she stated staff wore Personal Protective Equipment (PPE) when residents were on Enhanced Barrier Precautions (EBP) only when they were providing care for residents. She stated EBP were for residents who had any portal of entry, chronic wounds, or Multi-Drug Resistant Organisms (MDRO). She further stated residents who had wounds that were following their healing trajectory as determined by the wound care provider, did not need to be in EBP. During interview with the Director of Nursing (DON) on 04/15/2025 at 2:20 PM, she stated only residents with wounds that were chronic and not healing needed to be in EBP. She stated residents who had wounds that were healing did not need to be in EBP. She stated she thought that was what the policy said. During additional interview with the DON on 04/17/2025 at 8:11 AM, she stated she expected staff to disinfect mechanical lifts after use. She stated she received new information, dated 09/2022, on EBP. She stated EBP were to be in place for certain high contact tasks, as listed on the EBP poster. She stated EBP was in place for those who were colonized with MDROs, any indwelling device, and any chronic wounds that were not following their healing trajectory. During interview with the Administrator on 04/17/2025 at 10:55 AM, she stated it was her expectation that staff followed the facility's policy and procedures for EBP. The Administrator stated she expected staff to clean/disinfect the mechanical lifts after each resident use. She also stated the EBP policy was updated when new guidance came out. She stated she and the Administrator at the sister facility,who was a Registered Nurse (RN), received the updates. She stated the infection control policies were reviewed annually, and if something changed, they were updated. 51155

Based on interview, record review and review of the facility's policy and procedure, it was determined the facility failed to implement the comprehensive care plan for one (1) of eight (8) sampled residents (Resident #2). The facility's care plan for Resident #2 documented the requirement for extensive assistance of two (2) staff, and the use of a Hoyer lift, for transferring. However, on 08/30/2021, two staff performed a Stand Pivot transfer with a gait belt, during which the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2 was transferred to the hospital emergency department for wound cleansing and suturing, then returned to the facility. The findings include: Review of the facility's policy titled, Comprehensive Care Plan, originally implemented on 01/01/2018 and most recently revised on 10/20/2019 revealed that a comprehensive person-centered care plan must be developed and implemented for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The policy review further revealed that comprehensive care plans will be prepared by an interdisciplinary team that includes the attending physician, a registered nurse and a nurse aide with responsibility for the resident, a member of the food and nutrition services staff, the resident and resident's representative, to the extent practicable. Policy review also revealed that the plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly assessment. Additionally, policy review revealed that qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions. Record review revealed the facility admitted Resident #2 on 07/03/2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Minimum Data Set (MDS) assessment, dated 07/12/2021 revealed that moving from sitting to lying required maximum assistance, while he/she was completely dependent for chair/bed-to-chair transfers. The assessment review further revealed that assessing the movement from lying to sitting, or sitting to standing is no longer applicable. Review of Resident #2's Comprehensive Care Plan for the category of ADL's, with start date of 07/05/2018, revealed the goal I will not decline with ADLs by next review. His/her care plan included an approach dated 04/05/2021 to accomplish transfers with assist of two (2) and a Hoyer lift. Further review of the care plan revealed an approach dated 07/06/2021 to leave his/her Hoyer lift pad in his/her wheelchair and also states that Resident #2 had non ambulatory status as of 10/24/2019. Additional review of Resident #2's care plan revealed an element for the category of skin, originally dated 07/05/2018, for the prevention of skin tears that includes an approach dated 11/04/2018, to encourage him/her to be careful during care not to bump arms or legs as the skin may tear. Review of Electronic Medical Record (EMR) section Skin Assessment, entry dated 09/04/2021, revealed an addition under surgical wounds, described as a large full thickness laceration noted to right lower leg, fixated with sutures. Review of EMR section, Wound Management, entry dated 08/31/2021 revealed details measuring the wound at 9 centimeters (cm) in length, and 2.5 cm in width, with red color alteration and no exudate. Further review reveals skin tear type description as a partial flap loss, specifically that the flap cannot be repositioned to cover the wound. Interview with CNA #2 on 09/22/2021 at 12:42 PM revealed she just recently started working for the agency in August, but has been a CNA for 5 years, an aide for 9 years. She stated she was working on Resident #2's hallway, along with CNA #3. She stated Resident #2 did not have a pad under him/her like most residents have if they need a Hoyer for transfers, and was helping CNA #3 to transfer him/her out of a wheelchair to bed, by standing and turning with a gait belt. After getting Resident #2 onto the bed, a skin tear was observed and she stated it was our fault, we did use two (2) assist but we should have looked at the care plan. Interview with CNA #3 at 09/22/2021 01:58 PM revealed her statement that she should have read the care plan, but stated when another person calls you to help with their patient, you think they know what their patient needed. She reported the supervisor sent them home for the rest of the shift due to not following care plan procedure. She stated that usually a resident requiring a Hoyer has the pad under them in the chair, so when she didn't see one and hadn't been told differently, she didn't think he/she need a Hoyer. She also stated that CNA #2 had asked her for help with her resident, and they used a gait belt to help Resident #2 stand and pivot to sit down on the bed. CNA #3 stated CNA#2 moved Resident #2's legs up on the bed, then she said to get the nurse, because he/she has a skin tear. Interview with LPN #3 on 09/22/2021 at 06:17 PM revealed she has been employed at the facility since 2016. She further revealed that she had heard the aide asking for her to come Resident #2's room, and when she entered, she found him/her in bed, with a skin tear to right lower leg. She also stated she knew Resident #2 had care plan to be transferred by Hoyer lift and asked how it happened. She stated CNA #2 and CNA #3 were both from an agency and were not as familiar with the residents. LPN #3 stated she had told the aides to follow the care plans but that one of the aides reported the she had problems getting in the care plan. LPN #3 further stated she got an iPad and helped the aide log in. She stated both aides were assigned to that hall, so both were responsible for looking at the care plan for care guidance. Telephone interview with RN #3 at 09/23/2021 at 09:48 AM revealed that he has been an RN with the facility for about ten years and is a nursing supervisor. He stated that LPN #3 reported the incident to him, and requested assistance, after entering Resident #2's room and observing the wound. He stated that he did not know Resident #2's care plan but reviewed it and saw it detailed transfers to be done by using a Hoyer lift. He further stated that, as supervisor, he ended the shifts for the CNAs involved. RN #3 additionally stated that new agency staff also spend at least one shift with facility staff and learning to access the Electronic Medical Record (EMR) is part of that orientation. He further related that if staff experience problems access the EMR, the charge nurse is always available, and have access to care plans. He also related that the nursing supervisor can reset passwords or get staff members access to their accounts, if needed. Interview with RN #1 on 09/23/2021 at 10:33 AM revealed that the profile, which includes the care plan, is the go to source for all resident information, including ADL, for charting, but also the resident profile has the option for reviewing care plan, and is detailed enough to provide everything a staff member needs to know to care for that resident. She further stated that the iPad and software are not difficult to use and that the CNA's are educated that if they have trouble getting in the system, the charge nurse, clinical coordinator, and supervisor can help. She further stated that new staff get a day to shadow and using the medical record system is part of the hands on orientation. RN #1 also stated her expectation is that residents needs will be taken care of safely and that staff will follow policy well as use the resident profile to aid in providing care. RN #1 revealed that Hoyer pads are usually dedicated to a single resident, but are sometimes removed for comfort or skin protection. Observation with RN #1 in attendance on 09/23/2021 at 10:55 AM of use of iPad from log in to reviewing care plan; was a matter of seconds from login through selecting a resident then opening the care plan. Interview with DON on 09/23/2021 at 11:10AM revealed that she was notified by ADON that Resident #2 had sustained a skin tear during transfer and sent to the hospital ED, then CNAs sent home due to not transferring by the care plan. She stated the following morning Resident #2 had returned, and care plan was updated after assessment. DON reported that during interview, CNA #3 stated she was asked to help transfer Resident #2 but was not assigned, and that she had asked CNA #2 if she was sure of the means of transfer, who had confirmed. DON further stated that CNA #2 confirmed to her that she was assigned to Resident #2, but that she had asked another staff member about his/her transfers and was told that Resident #2 only needed a two person assist. DON stated she reminded CNA #2 that the source of care instructions is the care plan. DON stated her expectation is the staff only use the care plan to learn or confirm details of a resident's care. DON related that agency staff receive a New Employee Reference Packet with instructions for how to find specific information. Review of employee records revealed that both CNA #2 and CNA #3 had signed the attestation that they had read and understood everything in the packet. Review of the Packet revealed detailed instructions to review care plan prior to starting shift. DON reported that her incident investigation revealed that the nurse had instructed the aides to go to the care plan for resident care information. DON stated that her expectation is that staff will give quality care and with integrity, and by following care profile. Interview with Administrator on 09/23/2021 at 01:12 PM revealed that she had posed the question of why they had not looked at Resident #2's care plan to both CNAs during the investigation. She further revealed that after the interview she had felt that the incident was not malicious or neglectful, and it was not skills, as both are long term CNAs. She stated that they just didn't look up the care plan prior to conducting the transfer from chair-to-bed. She reported she felt this was not an issue of abuse or neglect, but rather an issue of individuals not meeting the standard of care. She also reported that her expectation is that staff will follow facility policies, resident care plans and look to leadership for guidance when there is a question, in order to give high quality care.

Based on interview, record review and facility policy review, it was determined the facility failed to ensure one (1) of eight (8) sampled residents received adequate supervision and assistive devices to prevent accidents (Resident #2). The facility assessed that Resident #2 was totally dependent for chair-to-bed transfers and was no longer able to rise from sitting to standing as of Minimum Data Set (MDS) assessment dated [DATE]. Resident #2's care plan reflected that a Hoyer lift was required for chair-to-bed transfer as of 04/05/2021. On 08/30/2021, Certified Nursing Assistant (CNA) #2 and CNA #3 transferred Resident #1 from his/her wheelchair to bed with Stand Pivot technique and a gait belt. During this process, Resident #2 sustained a full thickness laceration. He/she was transferred to the hospital for cleaning and suturing the wound, then returned to the facility. The findings include: Review of the facility's policy, titled Transfer Assessment, Resident, most recently updated as of 12/2018, revealed that residents whose condition warrants will be assisted with safe transfers. Policy review further revealed that resident mobility is determined upon admission per nursing and therapy initial observations, then evaluated by therapy when a change in function is reported. Policy review additionally revealed that if a resident cannot bear weight, they are to use the total lift. Residents are comprehensively assessed upon admission, quarterly, and with any significant change in condition with the MDS tool. A standardized Activities of Daily Living (ADL) assessment is employed to accurately document the functional status of residents, including abilities with bed mobility, toileting, and surface to surface transfers, moving from sitting to standing, ambulating in room and ambulating in hallway with turns. Review of the facility New Employee Reference Packet revealed that, at the beginning of a shift, staff should ensure they can sign into Matrix/Care Assist for charting, and that if login problems arise, to inform the Charge Nurse immediately. Review of the Packet also revealed that staff can find care information such as transfer status and diet/feeding assistance needs in Care Assist. Review of Nursing Assistant Orientation Checklist revealed that aides must be checked off on performing resident transfers, using mechanical lifts as well as' charting. The checklist is signed by the orientee, the trainer and the supervisor. Review of employee records revealed that both CNA #2 and CNA #3 signed an agreement that indicated they had read and understood all contents of the Employee Reference Packet. Record review revealed the facility admitted Resident #2 on 07/03/2018 with diagnoses including Alzheimer's disease, Chronic diastolic heart failure, Essential hypertension, [CONDITION(S)] with seizures, [CONDITION(S)], Major depressive disorder, History of Urinary Tract infection, Pulmonary embolism, Muscle weakness, and Repeated falls. Review of Resident #1's Annual MDS assessment, dated 07/12/2021, revealed that his/her Brief Interview for Mental Status (BIMS) resulted in a score of 99, which indicated that he/she was not interviewable. Further review of the MDS assessment revealed Resident #1 was non-ambulatory, and unable to complete the skill of moving from sitting to standing. Additional review of the MDS assessment indicated he/she was unable to accomplish either of these from at least the prior assessment, as evidenced by documentation of not applicable. A rendering of not applicable in the assessment is defined as Not attempted and the resident did not perform this activity prior to the current illness, exacerbation or injury. Further review of the MDS assessments revealed that Resident #2 was completely dependent for chair-to-bed transfers. Review of Resident #2's care plan for the category of ADL, originally dated 07/05/2018 revealed the goal I will not decline with ADLs by next review. His/her care plan included an approach dated 04/05/2021 to accomplish transfers with assist of two (2) and a Hoyer lift. Further review of the care plan revealed an approach dated 07/06/2021 to leave his/her Hoyer lift pad in his/her wheelchair and also states that Resident #2 had non ambulatory status as of 10/24/2019. Additional review of Resident #2's care plan revealed an element for the category of skin, originally dated 07/05/2018, for the prevention of skin tears that includes an approach dated 11/04/2018, to encourage him/her to be careful during care not to bump arms or legs as the skin may tear. Review of EMR section Skin Assessment, entry dated 09/04/2021, revealed an addition under surgical wounds, described as a large full thickness laceration noted to right lower leg, fixated with sutures. Review of medical EMR section, Wound Management, entry dated 08/31/2021 revealed details measuring the wound at 9 centimeters (cm) in length, and 2.5 cm in width, with red color alteration and no exudate. Further review reveals skin tear type description as a partial flap loss, specifically that the flap cannot be repositioned to cover the wound. Review of EMR documents received from hospital emergency department (ED) discharge revealed that Resident #2 was admitted on [DATE] subsequent to a laceration of the right lower extremity, requiring stitches. The instructions included wound care and to have sutures removed on 09/09/2021. Review of EMR documents from Extended Wound Care Service Line revealed that Resident #2 also sustained a full thickness laceration previously with initial care documented on 04/07/2021, which confirmed FM #1's statement. This wound was also described as a full thickness laceration to the right lower extremity measuring 12.0 cm long, 1.0 cm wide and 0.1 cm deep. Review of progress note, dated 08/30/2021 at 06:30 PM revealed that LPN #3 was called to Resident #2's room by a CNA. The note stated the resident was noted to be lying in bed with his/her pants on and a large skin tear to right lower outer leg. The note further described the wound as an area with depth noted, then covered with towel that was soaked in normal saline to maintain skin moisture. Review of the progress note additionally revealed that Resident #2 did yell out and had facial grimaces. Continued review of this progress note revealed that LPN #3 observed a small amount of bleeding which was stopped by applying pressure to area, then covered the area with a dressing and secured with tape. Added review of the progress note revealed that LPN #3 placed a call to the Nurse Practitioner (NP) and to the supervisor. Review of progress note, dated 08/31/2021 at 12:32 AM revealed Resident #2 returned to facility from the hospital via ambulance and required a three persons assist to transfer him/her from stretcher to bed, and that a draw sheet was used to accomplish such. Further review revealed oxycodone acetaminophen 5/325mg one tablet had been administered to Resident #2 for pain, as well as prophylactic [MEDICATION(S)] to prevent infection. Continued review of progress note revealed new care orders and that Family Member (FM) #1 had been notified of the incident. Interview with FM #1, child of Resident #2 on 09/21/2021 at 08:10 PM, revealed that this event represented the third skin tear in less than a year. FM #1 stated that a conversation with care coordinator to change from Sara Steady to transfer by Hoyer lift had already occurred months before this incident. FM #1 stated this care change was because Resident #2 had already sustained two skin tears from using the Sara Steady, as well as the fact that he/she has end stage dementia and no longer can follow cues to stand. FM #1 further stated she had asked for them to only use the Hoyer lift, but the evening of 08/30/2021, two aides from an agency, Primetime, lifted Resident #2 without a lift at all, just one aide under each arm to transfer to bed. She additionally stated that the aides noticed resident's leg had caught on something so they had checked it and found the wound. FM #1 stated this is according to the Director of Nursing's (DON) report to her. FM #1 further stated this wound was not a skin tear but a total depth laceration, just below knee to just above ankle. She additionally stated that the laceration curves, then another place above it had missing tissue, about the diameter of a golf ball, not as deep but tissue missing. The two aides were sent home but called back the next day to interview with the DON about what happened. FM #1 stated thinking well of the nurses in the facility and the leadership, but would like her parent, or any other resident, to not have to go through that with avoidable wounds. She also stated she would like to see the facility have a clear set of standards for transfers, and for communication with signage in the room/above the bed, or a computer on a rolling cart to be able to see care plan more expediently, a color coded system, or something to make it simpler to always know the orders for care. Interview with Assistant Director of Nursing (ADON) on 09/22/2021 at 11:26 AM revealed she was not involved in the investigation with Resident #2, but did develop training the following day to reeducate on transfers and skin tear prevention. She also revealed she began Pocket Sheets, a tool that aides now receive at the beginning of each shift detailing transfer needs, diet/feeding assist needs. She further reported that this training included a video portion as well as a didactic piece. She stated that every room now has a gait belt in place. Interview with CNA #2 on 09/22/2021 at 12:42 PM revealed she just recently started working for the agency in August, but has been a CNA for 5 years, an aide for 9 years. She stated she was working on Resident #2's hallway with CNA #3, and reported that I had the front and she had the back. She stated Resident #2 did not have a pad under her like most residents have for a Hoyer, and was helping the CNA #3 to transfer him/her out of wheelchair to bed, by standing and turning with a gait belt. She also stated she did not touch his/her legs at all. After getting Resident #2 onto the bed, CNA #2 stated that CNA #3 sent her for the nurse and reported there was a skin tear, stating it was our fault, we did use 2 assist but we should have looked at the care plan. She further stated that when the nurse came in, she observed the skin tear and asked what happened, then called the supervisor and then arranged Resident #2 went to the hospital. CNA #2 reported this facility is the first assignment with the agency and also reported surprise that some of the aides don't really give report. She further reported that she sometimes get report from the nurse, that there is a communication problem for the aides and stated that she now goes to the nurse or the supervisor. Interview with CNA #3 at 09/22/2021 01:58 PM revealed her statement that she should have read the care plan, but stated when another person calls you to help with their patient, you think they know what their patient needed. She reported the supervisor sent them home due to not following procedure, but were able to return to work under Teachable Moments. She stated that usually a resident requiring a Hoyer has the pad under them in the chair, so when she didn't see one and hadn't been told differently, she didn't think he/she need a Hoyer. She further stated that the nursing leaders have been doing Teachable Moments for education. CNA #3 also every unit now has a paper sheet that has how to transfer each resident, their diet and that kind of care information, but stated even that can have mistakes, such as not being updated with a resident room change. She also stated that CNA #2 had asked her for help with her resident, also they used a gait belt to help Resident #2 stand and pivot to sit down on the bed. CNA #3 stated CNA#2 moved Resident #2's legs up on the bed, then she said to get the nurse, because he/she has a skin tear. CNA #3 reported that LPN #3 had commented immediately that this is the third skin tear that has happened and that her family would be upset. CNA #3 stated that she had about two hours of facility orientation on the first, then went to her assigned floor, and worked a double shift that first night. Interview with [NAME] LPN #3 on 09/22/2021 at 06:17 PM revealed she has been employed at [NAME] since 2016. She further revealed that she had heard the aide asking for her to come Resident #2's room, and when she entered, she found him/her in bed, with a skin tear to right lower leg. She also stated she knew Resident #2 was to be transferred by Hoyer lift and asked how it happened. She reported that she checked to be sure bleeding was stopped, observed that it appeared to be a full thickness laceration and notified the supervisor on duty, RN #3. LPN #3 called for transport to the hospital, the physician and his/her family. LPN #3 related that the nurses do report at change of shift, while the aides usually go room to room. She stated CNA #2 and CNA #3 were both from an agency and were not as familiar with the residents. LPN #3 stated she had told the aides to follow the care plans but that one of the aides reported the she had problems getting in the care plan, so she got the iPad and helped her log in. She stated both aides were assigned to that hall, so both were responsible for looking at the care plan for care guidance. Telephone interview with RN #3 at 09/23/2021 at 09:48 AM revealed that he has been an RN with the facility for about ten years and is a nursing supervisor. He stated that LPN #3 reported the incident to him, and requested assistance, after entering Resident #2's room and observing the wound. He stated they assessed the wound, cleansed and dressed the wound, then arranged for him/her to be transferred to the hospital. He stated that he did not know Resident #2's care plans but reviewed it and saw it detailed transfers to be done by using a Hoyer lift. He further stated that, as supervisor, he ended the shifts for the CNAs involved. He also stated that he reported the incident to the ADON. RN #3 stated the agency staff are given a day of orientation, including information about the facility policies, but that he is not a participant in developing or providing that education. RN #3 additionally stated that new agency staff also spend at least one shift with facility staff and learning to access the Electronic Medical Record (EMR) is part of that orientation. He further related that if staff experience problems access the EMR, the charge nurse is always available, and have access to care plans. He also related that the nursing supervisor can reset passwords or get staff members access to their accounts, if needed. Interview with RN #1 on 09/23/2021 at 10:33 AM revealed that the profile is the go to source for all resident information, including ADL, for charting but also the resident profile has the option for reviewing care plan, it is detailed enough to care for the resident, providing everything a staff member needs to know to care for that resident. She further stated that the iPad and software are not difficult to use. She stated that the CNA's are educated that if they have trouble getting in the system, the charge nurse, clinical coordinator, and supervisor can help. She further stated that new staff get a day to shadow and using the charting system is part of the hands on orientation. She further revealed that the charge nurse watches for staff needing help, particularly if they are new. RN #1 additionally revealed that she is not certain about facility orientation but believes it includes facility policies. She also stated her expectation is that residents needs will be taken care of safely and that staff will follow policy well as use the resident profile to aid in providing care. RN #1 revealed that Hoyer pads are usually dedicated to a single resident, but are sometimes removed for comfort or skin protection. Observation with RN #1 in attendance on 09/23/2021 at 10:55 AM of use of iPad from log in to reviewing care plan; was a matter of seconds from login through selecting a resident then opening the care plan. Interview with DON on 09/23/2021 at 11:10AM revealed that she was notified by ADON that Resident #2 had sustained a skin tear during transfer and sent to the hospital ED, then CNAs sent home because of not transferring by the care plan. She stated the following morning, Resident #2 had returned, and care plan was updated after assessment. DON further revealed she contacted FM #2, who asked why he/she was transferred the way he/she was and the actual details were communicated about the incident. She also revealed that she called the CNAs and interviewed. DON reported that CNA #3 stated she was asked to help transfer Resident #2 but was not assigned, CNA #2 was assigned, and that CNA #3 stated she asked CNA #2 if she was sure of the means of transfer, and had confirmed. DON reported that CNA #3 stated they had seen the blood, pulled up the pants leg then called the nurse. DON further stated that CNA #2 confirmed to her that she was assigned to Resident #2, and that she had asked another staff member about his/her transfers and was told that Resident #2 only needed a two person assist. DON stated reminded CNA #2 that the source of care instructions is the care plan. DON stated her expectation is the staff only use the care plan to learn or confirm details of a resident's care. DON related that agency staff receive a reference packet with instructions for how to find specific information, and DON stated she interviewed CNA #2's preceptor about what was covered for EMR, and he had stated that she had, in fact, been taught EMR access. DON stated she interviewed multiple staff in order to determine if this was widespread problem, and found that staff knew how to find relevant resident information, but also conducted a care competency check off for accessing care plan/resident profile. She further stated that CNA #2 and CNA #3 had been assigned to the facility for about a week at the time of incident, with starting date of 08/23/2021. DON also provided agency training records for both CNAs. DON also stated that each resident who requires mechanical lift typically has a dedicated lift pad but she stated she asks if a resident is able, and that the staff remove the pad for comfort and skin protection when sitting. DON provided a copy of the New Employee Reference Packet which detailed instructions to review care plan prior to starting shift, CNA staff to give shift to shift report, quick summary of issues with residents, by exception. DON further stated that if the staff are newer, the typical practice is walking room to room for hand off of care and that they have nurse-to-aide report on high risk residents in the group. She also stated the charge nurses are accustomed to having agency staff and providing that report with them. She additionally stated CNAs are oriented to the structure of the household during new employee orientation, including where to find information needed for care, how to find your nurse. DON reported that her incident investigation revealed that the nurse had instructed the aides to go to the care plan for care information. DON stated that her expectation is that staff will give quality care and with integrity, and by following care profile. She reported she had felt there was some integrity in the CNAs at least asking for guidance. She further reported she had reviewed with them how to access care plans on their return to work. Interview with Administrator on 09/23/2021 at 01:12 PM revealed that she had posed the question of why they had not looked at Resident #2's care plan to both CNAs during the investigation. She further revealed that after the interview she had felt that the incident was not malicious or neglectful, and it was not skills, as both are long term CNAs. She stated that they just didn't look up the care plan prior to conducting the transfer from chair-to-bed. She further stated there was confusion from the family about how the transfer had transpired, whether the mechanical lift had been used or not. She additionally stated that the investigation had not revealed the source of the laceration, We are not for sure what caused the laceration. We looked for rough edges or missing pieces from the wheelchair or the bedframe and were not able to confirm what surface caused the injury. DON also stated that the shift workload was consistent with any other day, with no other incidences that might have consumed so much time that made anyone feel in a rush. She reported she felt this was not an issue of abuse or neglect, but rather an issue of individuals not meeting the standard of care. She also reported that her expectation is that staff will follow facility policies, resident care plans and look to leadership for guidance when there is a question, in order to give high quality care.

Based on interview, record review, review of the facility's Policy, and review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated (MONTH) (YEAR), it was determined the facility failed to develop and implement the Comprehensive Care Plan for each resident to meet the resident's medical, and nursing needs that are identified in the comprehensive assessment for one (1) of thirty-three (33) sampled residents (Resident #95). Review of Resident #95's Comprehensive Care Plan (CCP), revised 07/17/19, revealed the resident was to use the walker whenever up and should not try to transfer or walk alone. According to the facility Gait Belt Policy, undated, staff was to use gait belts for residents that did not have a steady gait while ambulating or transferring; however, Resident #95's CCP was not developed with an intervention for use of the gait belt. On 07/23/19, State Registered Nurse Aide (SRNA) #2 did not implement Resident #95's CCP related to ensuring the resident utilized the walker, nor did she use the gait belt when she transferred the resident from the bed, then ambulated the resident to the bathroom. Upon entering the bathroom, the resident sustained [REDACTED]. On 07/23/19 at approximately 12:10 PM, LPN #1 obtained a physician's orders [REDACTED]. routine. On 07/23/19 at approximately 2:15 PM, Resident #95 was transferred to the Hospital and admitted with a [DIAGNOSES REDACTED]. (Refer to F-689) The findings include: Review of the facility's Comprehensive Care Plan Policy, dated 01/10/18, revealed it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the resident's comprehensive assessment. Further review of the Policy, revealed specific resident problems would be addressed in the Care Plan, and information in the Care Plan was derived from resident assessments. Per Policy, all disciplines have access to the Care Plan. Interview with the Minimum Data Set (MDS) Nurse, on 10/11/19 at 11:06 AM, revealed the Resident Assessment Instrument Version 3.0 Manual, was used as a guide for developing and implementing the CCP. Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated (MONTH) (YEAR), revealed the Comprehensive Care Plan is an interdisciplinary communication tool and must include measurable objectives and time frames and must describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Further review revealed the services provided or arranged must be consistent with each resident's written Plan of Care. Review of Resident #95's clinical record revealed the facility admitted the resident on 11/18/11, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 05/23/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of three (03) out of fifteen (15), revealing severe cognitive impairment. Further review revealed the facility assessed the resident as requiring extensive assistance (resident involved in activity and staff providing weight bearing support) of one (1) staff for bed mobility, transfers, toilet use and personal hygiene. Per the MDS Assessment, the resident was continent of bowel and frequently incontinent of bladder. Review of Resident #95's Comprehensive Care Plan (CCP), initiated 11/21/11 and revised revised 07/17/19, revealed the resident had the potential for falls related to history of falls, forgetfulness, medication use and balance falters without walker. The goal revealed the resident would be free of any fall related injuries. There were several interventions including assist the resident away from the table after meals; redirect if going into another resident's room; call light within reach and encourage use for assistance; remind resident to ask for assistance with transfers when feeling weak or tired or during the night; and remind resident as often as necessary to use the walker whenever up and not to transfer or walk alone. However, the Care Plan was not developed with a specific intervention to use a gait belt for transfers and ambulation. Interview with the Administrator, on 10/10/19, revealed the facility was unable to submit for review Resident #95's Nursing Assistant's Kardex (Nurses Aide Care Plan) which was in affect on 07/23/19, as it was not a part of the permanent record. Review of Resident #95's Accident/Incident Report, signed on 07/23/19 at 6:01 PM, by LPN #1, revealed Resident #95 sustained a fall with injury on 07/23/19 at 7:30 AM, in the resident's bathroom. According to the Report, the resident was assisted out of bed by SRNA #2, who took the resident to the bathroom. Per the Report, the resident turned to sit on the toilet and sat on the floor in front of the toilet, and there was no equipment used during the event. Further review revealed there was no injury or deformity noted, Range of Motion (ROM) per usual, and positive pulses. The resident complained of leg pain and Tylenol was administered. Additional review of the Report, revealed the Physician and the responsible party was notified on 07/23/19 at 9:15 AM. Further, the resident was transferred to the emergency room (ER) on 07/23/19. Review of Resident #95's Hospital Discharge Summary, dated 07/26/19, revealed the resident was admitted on [DATE], after sustaining a fall in the nursing home resulting in a [MEDICAL CONDITION] Femoral Neck. Further review revealed the resident underwent [REDACTED]. According to the Summary, the resident tolerated the procedure and his/her post op course was without complications. Per the Summary, the resident was discharged to the nursing home and needed to follow up with Orthopedics. Instructions included WBAT (Weight Bearing As Tolerated) with post op hip precautions. Interview on 10/11/19 at 8:52 AM, with SRNA #2, revealed the SRNAs utilized the Kardex (Nurse Aide Care Plan) as a reference for providing care to residents which included the type of assistance and assistive devices needed to transfer and ambulate a resident. Per interview, this Kardex was on the I-PAD tablet computer. Per interview, she was assigned to Resident #95 on 07/23/19, and was aware the resident was care planned to require one (1) staff and the walker for transfers, toileting and ambulation. Further, she was aware she needed to use a gait belt to transfer and ambulate the resident as per facility policy. However, she stated on 07/23/19 at approximately 7:30 AM, she transferred the resident from bed and then ambulated the resident without a gait belt or walker to the bathroom, by holding both of the resident's hands while she (SRNA #2) walked backwards facing the resident. Additional interview revealed she did not follow the resident's CCP or Kardex related to using a walker to transfer and ambulate the resident, even though the walker was in the resident's room. Further, she did not follow facility protocol related to using a gait belt for Resident #95 while transferring and ambulating the resident. Interview with Licensed Practical Nurse (LPN) #1, on 10/11/19 at 9:15 AM, revealed she was assigned to Resident #95 on 07/23/19, and was alerted by SRNA #2 about 7:30 AM, that the resident sustained [REDACTED]. Per interview, she immediately entered Resident #95's restroom, and observed the resident was on the floor. She stated she assessed the resident to include checking his/her skin for any bruising, or swelling, and also assessed his/her range of motion (ROM). Per interview, she also obtained the resident's vital signs and assessed him/her for pain. She stated she did not identify the resident had sustained any injury and the resident did not complain of pain. Per interview, she assisted SRNA #2 with lifting the resident off the floor and onto the toilet. LPN #1 stated a little while later SRNA #2 alerted her the resident was complaining of left leg pain, and she administered Tylenol which was ordered as needed (PRN). Further, the resident continued to complain of pain and staff identified the resident was not crossing his/her legs as usual. She stated at approximately 12:00 PM, she notified the Physician and obtained an order for [REDACTED]. Additional interview with LPN #1, revealed SRNA #2 informed her she did not use the gait belt as per protocol, nor did she ensure the resident used the walker as per the CCP and Kardex, when she transferred the resident from the bed and ambulated the resident to the bathroom. Per interview, if SRNA #2 had implemented Resident #95's CCP related to ensuring the resident used the walker, and if the gait belt had been utilized, this fall with major injury may have been avoided. Interview with the Clinical Care Coordinator Nurse, on 10/11/19 at 12:10 PM revealed the SRNAs utilized the Kardex (Nurse Aide Care Plans) per the I-Pad tablet computer, as a reference for providing care. Per interview, the Kardex was created from the CCP and therefore included interventions related to technique and equipment needed for transfers and ambulation. She stated SRNA #2 did not implement the CCP or Kardex related to ensuring Resident #95 used the walker, nor did she use the gait belt as per protocol, on 07/23/19. Per interview, the resident sustained [REDACTED]. Interview with the Minimum Data Set (MDS) Nurse, on 10/11/19 at 11:06 AM, revealed he followed CMS guidelines and the RAI Manual when developing or revising Care Plans. Per interview, the SRNAs had access to the CCP and specific items rolled over to the Kardex (Nurse Aide Care Plan) such as transfer technique and any adaptive equipment needed such as walkers. Per interview, the SRNAs used the CCP and the Kardex as a guide for providing care to residents. He further stated gait belts were not care planned because staff was knowledgeable it was facility policy to use gait belts for any residents who had an unsteady gait. Additionally, he stated all staff should provide care as per the CCP to ensure the residents received necessary care to meet their needs and to ensure the residents' safety. Interview with the Director of Nursing (DON), on 10/11/19 at 1:45 PM, revealed it was her expectation standards of practice, regulations, and the facility's policy be maintained related to development and implementation of the care plan. She acknowledged Resident #95's CCP interventions related to ensuring the resident used a walker for transfer and ambulation should have been implemented on 07/23/19 in an attempt to prevent falls. Further, she acknowledged the CCP should be developed to include any special safety devices or adaptive equipment utilized for transfers and ambulation. Interview with Administrator, on 10/11/19 at 2:15 PM revealed she expected the facility's policies and regulations to be followed related to developing and implementing the CCP. Per interview, it was important to use the gait belt for assistance with transfers and ambulation as per facility protocol; however, she acknowledged Resident #95's CCP was not developed with this intervention. Further interview revealed Resident #95's CCP should have been implemented related to ensuring the resident used the walker on 07/23/19, in an attempt to prevent injury.

Based on observation, interview, record review, and review of facility Policies, it was determined the facility failed to ensure adequate supervision and assistive devices to prevent accidents for one (1) of ten (10) sampled residents reviewed for falls out of a total sample of thirty-three (33) residents (Resident #95). Resident #95 was assessed by the facility to require the extensive assist of one (1) staff for transfers, ambulation, and toileting per the Quarterly Minimum Data Set (MDS) Assessment, dated 05/23/19. According to the Comprehensive Care Plan, revised 07/17/19, the resident was to use the walker whenever up and should not try to transfer or walk alone. Per the facility Gait Belt Policy, undated, staff was to use gait belts with residents that did not have a steady gait while ambulating or transferring. However, on 07/23/19 at 7:30 AM, State Registered Nurse Aide (SRNA) #2 transferred the resident from the bed and ambulated the resident to the bathroom without a gait belt or the use of the walker. Instead, SRNA #2 walked backwards in front of the resident, while facing the resident, and holding both the resident's hands. Upon entry to the bathroom, the resident started to urinate and sustained a fall. After the fall, Resident #95 was assessed by Licensed Practical Nurse (LPN) #1 with no injuries noted, and LPN #1 and SRNA #2 manually transferred the resident from the floor to the toilet. Subsequently, after SRNA #2 provided incontinence care to the resident, she independently transferred the resident from the toilet to the wheelchair, and at that time the resident complained of pain in the left leg. SRNA #2 immediately informed LPN #1, who did not complete another assessment of the resident, but administered Tylenol (medication to relieve mild to moderate pain). At approximately 12:10 PM, LPN #1 obtained a physician's orders [REDACTED]. On 07/23/19 at approximately 2:15 PM, Resident #95 was transferred to the Hospital and admitted with a [DIAGNOSES REDACTED]. (Refer to F-656) The findings include: Review of the facility's Fall Management Policy, undated, revealed care and assistance will be provided to maintain the resident's highest practicable level of well-being, which includes minimizing the risk for falls. Further review revealed Individual resident needs for staff assistance and equipment during toileting, transfer, ambulation and all activities of daily living will be assessed and addressed as appropriate via the RAI (Resident Assessment Instrument) process to determine if residents are at risk (for falls) and implement interventions to minimize the risk for falls. Additionally, the Fall Committee will review each resident who had a fall as well as the interventions that are in place to minimize the risk of falls, and shall try to determine the root cause of the fall. Review of the facility's Gait Belt Policy, undated, revealed gait belts are to be used with residents that do not have a steady gait while ambulating or transferring for the purpose of safety. Review of the facility's Accidents/Incidents Policy, undated, revealed the facility would take necessary precautions to minimize the incidence of accidents and incidents involving residents, staff, and visitors. Review of Resident #95's medical record revealed the facility admitted the resident on 11/18/11, with [DIAGNOSES REDACTED]. Review of the Observation Detail List Report, dated 04/02/19, under the section titled, Fall Risk, revealed the resident scored a thirteen (13) indicating the resident was at high risk for falls. The risk factors included: change in gait pattern when going through doorway; ambulatory but incontinent; medications; history of falls; and cognitive issues. Review of Resident #95's Quarterly Minimum Data Set (MDS) Assessment, dated 05/23/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of three (03) out of fifteen (15) revealing severe cognitive impairment. Continued review revealed the facility assessed the resident as requiring extensive assistance (resident involved in activity and staff providing weight bearing support) of one (1) staff for bed mobility, transfers, toilet use and personal hygiene. The facility further assessed the resident as continent of bowel and frequently incontinent of bladder. Review of the Comprehensive Care Plan, initiated 11/21/11, revised 07/17/19, revealed the resident had the potential for falls related to history of falls, forgetfulness, medication use and balance falters without walker. The goal stated the resident would be free of any fall related injuries. Interventions included assist the resident away from the table after meals; redirect if going into another resident's room; call light within reach and encourage use for assistance; remind resident to ask for assistance with transfers when feeling weak or tired or during the night; and remind resident as often as necessary to use the walker whenever up and not to transfer or walk alone. However, the Care Plan was not developed with a specific intervention to use a gait belt for transfers and ambulation. Interview with the Administrator, on 10/10/19, revealed the facility was unable to review or print Resident #95's Nursing Assistant's Kardex (Nurse Aide Care Plan) which was in effect on 07/23/19, as it was not a part of the permanent record. Review of Resident #95's Progress Note, dated 07/23/19 at 7:30 AM, completed by LPN #1, revealed Resident #95 was taken to the bathroom by SRNA #2, and when the resident went to sit on the commode, he/she sat in the floor in front of the commode instead. Per the Note, the resident complained of pain in the left leg, and the leg was not bruised, or bleeding and there was no deformity. Further review revealed the resident was given Tylenol for pain, and the nurse would monitor the resident. Review of the subsequent Progress Notes, dated 07/23/19 at 12:10 PM, completed by LPN #1, revealed the resident continued to complain of pain in the left leg. Resident usually crossed his/her legs, but did not today. Per the Note, a message was sent to the on call Physician and an order was received to obtain an X-ray of the resident's left hip and pelvis. Resident's Daughter informed. Call placed to obtain an X-ray. Per the Note, Radiology was at the facility at 1:51 PM and performed an X-ray. Review of the Imaging Result Report, dated 07/23/19, revealed a Sub Capital [MEDICAL CONDITION] Neck with Varus angulation and overriding. Pelvic ring intact. Impression: Sub Capital [MEDICAL CONDITION] Femoral Neck. Review of the Progress Note, dated 07/23/19 at 2:01 PM, revealed a message was sent out to the Physician. Per the Progress Note, dated 07/23/19 at 2:15 PM, the resident was transferred to the hospital for evaluation and treatment related to the X-ray results. Review of Resident #95's Progress Note, dated 07/23/19 at 5:56 PM, completed by the Clinical Care Coordinator, revealed the fall that occurred on this date at 7:30 AM was reviewed. Staff present with resident were interviewed. Staff entered room to assist resident to bathroom and up for the day. Resident sat on the side of the bed, and staff assisted to ambulate by hand to the bathroom without difficulty. Resident began to turn to sit onto the commode and sat down on the floor in front of the toilet. Staff was unable to determine if the resident's leg gave out when the resident sat on the floor. X-ray obtained and resident sent to emergency room (ER) for evaluation. Spoke with ER at this time, and Orthopedics to evaluate in the AM (morning). Review of Resident #95's Accident/Incident Report, completed on 07/23/19 at 6:01 PM, by LPN #1, revealed Resident #95 sustained a fall with injury on 07/23/19 at 7:30 AM, in the resident's bathroom. Per the Report, the resident was assisted out of bed by SRNA #2, who took the resident to the bathroom. The resident turned to sit on the toilet and sat on the floor in front of the toilet. Further, there was no injury or deformity noted, Range of Motion (ROM) per usual, and positive pulses. Per the Report, the resident complained of leg pain and Tylenol was administered. Additional review of the Report, revealed there was no equipment used during the event. Further review of the Report, revealed the Physician and the responsible party were notified on 07/23/19 at 9:15 AM. Per the Report, the resident was sent to the emergency room (ER) on 07/23/19. This Report was not signed by the Director of Nursing (DON) or Administrator. Per the Accidents/Incident Post Fall Observation/Root Cause Analysis, completed 07/23/19 at 5:59 PM, by LPN #2, revealed the resident's usual ambulatory status was assist times one (1) as the resident displayed poor safety awareness and judgement and had a history of [REDACTED]. Further, the Plan of Care to prevent further falls would be re-evaluated when the resident returned from the hospital. This was not signed by the Director of Nursing (DON) or Administrator. Review of the Hospital Discharge Summary, dated 07/26/19, revealed Resident #95 was admitted on [DATE], after sustaining a fall in the nursing home resulting in a [MEDICAL CONDITION] Femoral Neck. Per the Summary, the resident underwent [REDACTED]. The resident was discharged to the nursing home and needed to follow up with Orthopedics. Continued review of the Summary, revealed instructions for WBAT (Weight Bearing As Tolerated) with post op hip precautions. Interview on 10/10/19 at 11:42 AM, with SRNA #2, revealed she used the Kardex, which was on the I-PAD tablet computer as a reference for providing care to residents which included the type of assistance and assistive devices needed to transfer and ambulate a resident. Per interview, her normal routine prior to Resident #95's fall on 07/23/19, was to assist the resident out of bed, and walk with the resident to the bathroom, and assist him/her with washing up. She stated she was aware the resident was to be transferred and ambulated with a gait belt and walker; however, on the morning of 07/23/19, she assisted the resident out of bed and walked with the resident to the bathroom by holding both the resident's hands while she (SRNA #2) walked backwards facing the resident. Per interview, she did not use the gait belt, nor did she ensure the resident was using the walker. Further, after the resident entered the bathroom, all of a sudden he/she started urinating and started to fall. Per interview, she tried to lower the resident to the floor; however, was unable to do so. Additional interview with SRNA #2, revealed she immediately went to get LPN #1, who took the resident's vital signs and checked his/her range of motion. Per interview, the resident had no complaints at that time. Further, interview revealed after LPN #1 assessed the resident, she and LPN #1 manually lifted the resident up and sat him/her on the toilet. Per interview, after she finished providing incontinence care, she transferred the resident independently from the toilet to the wheelchair and during the transfer, the resident said, Ouch and started complaining of left leg pain. Continued interview revealed she notified LPN #1 of the resident's complaints of pain, and the nurse did not assess the resident again, but did give the resident Tylenol. Per interview, she then pushed the resident in the wheelchair to the dining room for breakfast. Further interview with SRNA #2, revealed after breakfast she pushed the resident in his/her wheelchair into the television room as was the normal routine. She stated she noticed later on that day at approximately 12:00 PM, the resident was not crossing his/her legs as usual, and had further complaints of pain, and she reported this to LPN #1. She further stated LPN #1 called the Physician and received an order to obtain an X-ray. Per interview, after the X-ray was obtained, the resident was transferred to the hospital. SRNA #2 further stated she felt bad about the incident as she had not used the gait belt, nor was the resident using the walker when she was ambulating the resident, and the resident sustained [REDACTED]. Interview with Licensed Practical Nurse (LPN) #1, on 10/10/19 at 11:28 AM, and on 10/11/19 at 9:15 AM, revealed she was assigned to Resident #95 on 07/23/19. Per interview, on that date about 7:30 AM, SRNA #2 alerted her to come quickly to Resident #95's restroom because the resident had sustained a fall. LPN #1 stated she immediately entered the resident's restroom, assessed the resident, and obtained vitals. Per interview, the resident had no outward rotation, no shortening of the lower extremities, no bruising or swelling, and did not complaint of pain with her assessment. Additional interview with LPN #1, revealed a little later on the morning of 07/23/19, she was alerted by SRNA #2, the resident complained of left leg pain and she gave the resident Tylenol, but did not reassess the resident. Further, the resident complained of pain again that morning; however, she was waiting to see if the Tylenol was going to be effective. Per interview, at approximately 12:00 PM, staff noticed the resident was not crossing his/her legs as he/she normally did. She stated she then notified the Physician and obtained an order for [REDACTED]. Continued interview with LPN #1, revealed SRNA #2 informed her she did not use the gait belt, nor did she ensure the resident used his/her walker on the morning of 07/23/19, when she assisted the resident to the bathroom. LPN #1 stated SRNA #2 informed her, she had ambulated the resident to the bathroom by holding the resident's hands. Per interview, the resident was care planned to use the walker for transfers and ambulation at the time of the fall. Further, it was facility protocol to ensure the gait belt was used for transfers and when ambulating residents so the resident's weight could be managed and distributed, and to help prevent injury to residents or staff. Additional interview revealed since the resident returned from the hospital, he/she was no longer ambulatory, but was up in the wheelchair a lot and wore Hip abductors twenty- four (24) hours a day. Observation of Resident #95, on 10/08/19 at 11:30 AM and 10/09/19 at 12:20 PM, revealed the resident was in the television room sitting in the wheelchair with Hip Abductors in place to the resident's knees. When the Surveyor attempted to interview the resident, he/she just smiled and looked around. Review of Resident #95's Progress Note, dated 07/26/19 at 2:44 PM, completed by the Clinical Care Coordinator, revealed the resident returned to the facility via wheelchair van, and the resident's Daughter was with the resident. Per the Note, the resident was Assist to transfer to bed Weight Bearing as Tolerated (WBAT). Skin assessment performed, and dry bandage to left lateral hip with twenty (20) staples present and edges well approximated. No discoloration noted with scant amount of red scabbing observed near the staples. Further review of the Note, revealed the Daughter stated the family had discussed the resident's overall condition and cognition decline and were considering changing the resident's code status. Will be in to visit on Monday 07/29/19, to revisit and possibly make changes on that date. Discussed Resident's medications upon return, verbalized understanding. Interview on 10/11/19 at 8:30 AM, with the Clinical Care Coordinator for the House Hold Unit 4, where Resident #95 resided, revealed prior to Resident #95's fall on 07/23/19, the resident could walk with a walker and one (1) staff, and a gait belt was to be used for transfer and ambulation. She further stated SRNA #2 did not use a gait belt, nor did she ensure the resident used the walker when transferring and ambulating the resident on 07/23/19. Per interview, it was facility protocol to use gait belts when transferring or ambulating residents because if a resident's balance was off, it was easier to stabilize the resident who was wearing a gait belt. Per interview, Resident #95 was no longer ambulatory. Review of the Physician order [REDACTED]. Review of the Physician's Progress Note, dated 08/19/19 at 3:28 PM, revealed Resident #95's Daughter was at the resident's bedside. Per the Note, the resident had a progressive downhill course since his/her hospital stay with dementia symptoms, apathy, and reduced intake. Daughter feels resident would not wish to go through further hospitalization s, tests, etc. We agree to treat symptoms aggressively for comfort and dignity, change to comfort and palliative regimen. Interview with the Director of Nursing (DON), on 10/11/19 at 1:45 PM, revealed she did not work at the facility at the time of Resident #95's fall, as she just started at the facility in (MONTH) 2019. Per interview, she expected the facility's policy and protocols, regulations and standards of practice to be maintained related to accidents/injuries and falls. She stated she also expected staff to provide necessary supervision and a safe environment to all residents. Per interview, it was her expectation for the gait belt to be placed on the residents requiring assistance and ensure necessary assistive devices were used related to transfers and ambulation. Interview with Administrator, on 10/11/19 at 2:15 PM revealed she expected regulations and facility policies to be followed in order to prevent accidents and injuries. Additionally, she expected the staff to use the gait belts on all residents unless contraindicated and to implement the residents' care plans regarding adaptive equipment. Per interview, the gait belt was a tool to assist with safe transfers and ambulation and if not used, a fall could occur. Per interview, all falls were discussed with the clinical team each morning and the clinical team made an attempt to identify the root cause of the falls. Per interview, from there appropriate interventions were discussed to prevent accidents/injuries or falls of the same nature. When questioned if administrative staff had reviewed this fall and had identified the root cause, she stated SRNA #2 should have used a gait belt and the walker when transferring and ambulating the resident, and acknowledged this root cause should have been documented on the Post Fall Observation/Root Cause Analysis form. Additional interview, revealed the interdisciplinary team had identified there was a recent increase in falls and a falls committee was created in (MONTH) 2019 to meet twice a week. Per interview, the facility had also implemented a manager on duty for each shift to check on residents who were at high risk for falls to try to identify fall hazards and minimize falls.

Based on interview, record review, review of facility Policy, and review of the Centers for Medicare and Medicaid Resident Assessment Instrument (RAI) User Manual Version 1.16, it was determined the facility failed to submit Minimum Data Set (MDS) Assessments to the Centers for Medicare and Medicaid Services (CMS) within the required timeframe for one (1) of thirty-three (33) sampled residents (Resident #1). Resident #1's Quarterly MDS Assessment, with an Assessment Reference Date (ARD) of 08/31/19, was not submitted to CMS until 10/10/19. The findings include: Review of the facility's Resident Assessment Instrument Policy, undated, revealed the resident assessment will be completed as per regulatory standards. These regulations define and set time frames for resident assessment and the development of plans of care based on identified individual resident needs. Review of the Centers for Medicare and Medicaid, Resident Assessment Instrument (RAI) User Manual Version 1.16, dated (MONTH) (YEAR), Chapter 5 Submission and Correction of MDS Assessments, revealed comprehensive assessments must be transmitted electronically within fourteen (14) days of the Care Plan Completion Date (V0200C2 + 14 days). All other MDS assessments must be submitted within fourteen (14) days of the MDS Completion Date (Z0500B + 14 days). Review of Resident #1's medical record revealed the facility admitted the resident on 03/08/17 with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly MDS Assessment, revealed an Assessment Reference Date (ARD) of 08/31/19. However, further review of the MDS Assessment, revealed the MDS Assessment was not submitted to CMS until 10/10/19. Interview with MDS Coordinator #1, on 10/11/19 at 11:06 AM, revealed he had worked at the facility for fifteen (15) years as MDS Coordinator. He stated after completing Resident #1's Quarterly MDS Assessment, he failed to hit the finalization button for transmission. Further interview revealed Resident #1's MDS Assessment had not been transmitted during the fourteen (14) day window after completion of the assessment. He further stated Resident #1's MDS Assessment was a late submission and facility policy was not followed. Interview with the Director of Nursing (DON), on 10/11/19 at 1:45 PM, revealed it was her expectation for MDS Assessments to be submitted on time as per the RAI manual. Interview with the Administrator, on 10/11/19 at 2:15 PM, revealed Resident #1's MDS Assessment should have been transmitted in the allotted fourteen (14) day timeframe. Additional interview revealed it was her expectation for the Assessments to be completed and submitted , as per the RAI Manual.

Based on observation, interview and record review, it was determined the facility failed to provide a safe, functional, sanitary, and comfortable environment for one (1) of thirty-three (33) sampled residents (Resident #108). Observation of Resident #108's wheelchair, on 10/09/19 at 10:54 AM and on 10/10/19 at 11:49 AM, revealed the spokes on both wheels of the wheelchair and the bar across the back of the seat of the wheelchair were soiled and discolored with a dried substance. The Findings Include: Review of the facility Supplies and Equipment Policy, undated, revealed Nursing Service personnel must use assigned equipment and supplies with care to promote safety. Continued review of the Policy, revealed if equipment was reusable it would be cleaned as recommended by the Manufacturer. Standard cleaning/disinfection will be with bleach solution as appropriate after resident use, and prior to next resident, and when visibly soiled. Review of the HH1 (Household One) Wheelchair Cleaning Schedule, dated September, 2019, revealed Resident #108's wheelchair was scheduled to be cleaned on 09/04/19 and 09/20/19. Review of the HH1 (Household One) Wheelchair Cleaning Schedule, dated October, 2019, revealed Resident #108's wheelchair was scheduled to be cleaned on 10/03/19. Review of Resident #108's clinical record revealed the facility admitted the resident on 07/27/18, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 08/14/19, revealed the facility assessed Resident #108 as having a Brief Interview for Mental Status (BIMS) score of fourteen (14) out of fifteen (15), indicating the resident was cognitively intact. Further review revealed the facility assessed the resident as utilizing a wheelchair and requiring extensive assistance of one (1) person for transfers and locomotion on and off the unit. Observation of Resident #108, on 10/09/19 10:54 AM, revealed the resident was in the day area in his/her wheelchair. Further observation of the resident's wheelchair revealed the spokes on both wheels of the wheelchair and the bar across the back of the seat of the wheelchair were soiled and discolored with a dried substance. Observation on 10/10/19 at 11:49 AM, of Resident #108's wheelchair, revealed the spokes of both wheels and the bar across the back of the seat continued to be soiled and discolored with a dried substance. Resident #108 was questioned during this observation about the wheelchair and the resident asked if it was lunch time, and did not answer questions related to the wheelchair. Interview with State Registered Nurse Aide (SRNA) #15, on 10/10/19 at 11:55 AM, revealed there was a cleaning schedule and wheelchairs were typically cleaned on third shift. Continued interview revealed Resident #108's wheelchair was dirty. Interview with SRNA #14, on 10/11/19 at 9:45 AM, revealed when staff noticed a resident's wheelchair was dirty, staff should ensure the wheelchair was cleaned. Interview with the Director of Nursing (DON), on 10/11/19 at 9:30 AM, revealed wheelchair cleaning was typically done on third shift, but she was unsure if it was done weekly or how often each resident's wheelchair was cleaned. Further interview revealed wheelchairs should be cleaned more often as needed if spills or if soiling was observed. Per interview, if wheelchairs were not clean, it could be an infection control issue and/or dignity issue. Subsequent interview with the DON, on 10/11/19 at 2:01 PM and 10/11/19 at 3:43 PM, revealed it was her expectation staff follow the wheelchair cleaning schedule. However, she stated the facility did not have documentation for the staff to sign, to indicate residents' wheelchairs had actually been cleaned on the scheduled cleaning days. Interview with the Administrator, on 10/11/19 at 5:05 PM, revealed it was her expectation for staff to clean each resident's wheelchair as per the cleaning schedule. Further interview revealed if a resident's wheelchair was soiled between scheduled cleaning dates, she expected the wheelchair to be cleaned outside the scheduled dates. The Administrator stated staff should have been documenting the wheelchairs were cleaned, and there should have been a Quality Assurance Tool in place to ensure the wheelchairs were being cleaned as scheduled. Further, it was important resident wheelchairs were clean for sanitation and infection control purposed and for resident dignity.

Based on observation, interview, record review and review of the facility's Policy, it was determined the facility failed to ensure each resident receives services with reasonable accommodation of resident needs and preferences for one (1) of thirty-three (33) sampled residents (Resident #220). Observation of Resident #220, on 10/08/19, revealed the resident's feet and legs hung over the end of the bed approximately twelve (12) inches. The findings include: Review of the facility Policy, titled Accommodation of Needs, implemented on 01/01/18, revealed the facility would treat each resident with respect and dignity and would evaluate and make reasonable accommodations for the individual needs and preferences of a resident. Continued review revealed the facility would make reasonable accommodations to individualize the resident's physical environment including their personal bathroom and bedroom and the common living areas within the facility. Further review revealed based on individual needs and preferences, the facility would assist the resident in maintaining and/or achieving independent functioning, dignity, and well-being to the extent possible. Review of Resident #220's medical record revealed the facility admitted the resident on 09/24/19 with [DIAGNOSES REDACTED]., Right Ankle and Foot with Neuroarthropathy and Chronic Pain. Review of Resident #220's Admission Minimum Data Set (MDS) Assessment, dated 09/30/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fourteen (14) out of fifteen (15), indicating the resident was cognitively intact. Continued review revealed the facility assessed the resident to be seventy-seven (77) inches tall. Further review revealed the resident was receiving scheduled pain medication and reported he/she was in almost constant pain. Per the MDS Assessment, the resident utilized a wheel chair or walker for mobility. Observation of Resident #220, on 10/09/19 at 8:35 AM, revealed he/she was moaning, grimacing, and attempting to reposition himself/ herself in the bed, and the head of the bed was elevated about forty-five (45) degrees. Further observation revealed the resident's head was approximately four (4) inches from the top of the mattress and his/her feet and lower legs hung off the foot of the bed approximately twelve (12) inches. Interview with Resident #220, on 10/09/19 at 8:35 AM, revealed he/she was moaning because he/she could not find a comfortable position. Continued interview revealed he/she did not like his/her feet to hang over the end of the bed, as it caused pain and a lack of sleep and rest. Further interview revealed he/she was unaware he/she could request a longer bed or bed extension. Resident #220 stated he/she had mentioned being uncomfortable in the short bed to a staff member; however, did not recall who he/she spoke to about this. Observation of Resident #220, on 10/10/19 at 8:25 AM, revealed the resident was was moaning and moving around in the bed with his/her legs hanging off the foot of the bed. Interview with Licensed Practical Nurse (LPN) #3, on 10/10/19 at 11:40 AM, revealed she was Resident #220's primary nurse and admitted the resident to the facility. Continued interview revealed the resident was sitting upright in a wheel chair during the assessment. Further interview revealed when the resident was in his/her bed, she realized the resident's feet were hanging off the bed, so she removed the footboard. She stated, even with the footboard removed, the resident's ankles would rest on the metal bracket holding the foot of the mattress on the bed. Per interview, the resident should have been ordered a longer bed when he/she was admitted . Interview with the Unit Manager (UM) for the 700 Unit, on 10/11/19 at 9:30 AM, revealed she was unaware Resident #220 was too tall for the bed and needed a longer bed. Continued interview revealed the resident should have received the longer bed when he/she was admitted due to his/her height. Further interview revealed nursing should have notified maintenance to request a longer bed to accommodate the resident. Interview with the Director of Nursing (DON), on 10/11/19 at 1:45 PM, revealed she had only seen Resident #220 out of his/her bed and did not realize how tall the resident was or that he/she needed a longer bed. Per interview, a resident may experience increased pain if the bed did not accommodate a resident's height. Continued interview revealed the facility's process was for the resident to be assessed at admission to see if the resident needed a larger or longer bed, and then maitenance was to be notified of the need for the specific type bed. The DON further stated an average male was five (5) foot eleven (11) inches tall. Per interview, if a resident's height was in excess of this height, that would indicate the need for a longer bed. She stated the facility had a few longer beds available and also had the ability to rent beds to accommodate a resident's needs. She stated it was very important for the residents to be comfortable in bed in order to provide restful sleep and to prevent contractures. Interview with the Administrator, on 10/11/19 at 3:45 PM, revealed she had not seen Resident #220 in his/her bed and was not aware of the need for a longer bed. Per interview, the facility was responsible for accommodating the resident's physical needs and if a resident required a longer bed, the longer bed should be made available to the resident. Further, she stated it was important residents were comfortable in bed because rest was important to recovery.

Based on observation, interview, and review of the facility's Policy, it was determined the facility failed to ensure the safe storage, handling and consumption of foods brought to residents by family and other visitors. This affected Resident #167 and Resident #94. Observation on [DATE], revealed Resident #94 and Resident #167's personal sized refrigerators were visibly soiled and contained expired food items. The findings include: Review of the facility's Policy, titled Resident Refrigerators, dated [DATE], revealed it is the policy of the facility to ensure safe and sanitary use of any resident room refrigerators. Continued review revealed housekeeping staff will clean the refrigerators as needed and discard any food items that were out of compliance. Further review revealed leftover foods are to be dated upon receipt and discarded within three (3) days. Foods with use by dates shall be discarded accordingly. Any food with potential concerns (i.e. smell, packaging, appearance, frozen foods are not solid to touch) shall be discarded. Food shall be in covered containers or securely wrapped. 1. Observation on [DATE] at 1:30 PM, of Resident #94's personal in room refrigerator, revealed a facility provided dessert was in a dessert cup unwrapped, unlabeled and undated. Continued observation revealed the dessert had dried out and had surface cracks. 2. Observation on [DATE] at 1:38 PM, of Resident #167's personal in room refrigerator, revealed two (2) snack trays with apples, carrots, nuts, and cheese and a package of deli cheese slices. Continued observation revealed the trays were stamped with the date of (MONTH) 27, 2019 and the deli cheese slices were dated [DATE]. Further observation revealed the cheese slices had a foul odor. Additional observation revealed a spilled liquid substance in the bottom of the refrigerator under the cheese slices. Interview with State Registered Nurse Aide (SRNA) #7, on [DATE] at 5:00 PM, revealed the nursing staff did not monitor the refrigerators. Interview with the Director of Dining Services, on [DATE] at 5:14 PM, revealed housekeeping was responsible for monitoring the residents' personal refrigerators. Continued interview revealed monitoring was necessary to prevent foodborne illnesses. Interview with the Director of Housekeeping, on [DATE] at 2:30 PM, revealed it was housekeeping's responsibility to check the personal refrigerators three (3) times per week and log the checks. Continued interview revealed housekeeping staff were to clean the refrigerators as needed for spills. Further interview revealed staff were to place a label with the date on any food items brought into the facility. Per interview, any opened food was to be labeled and dated with a use by date and discarded after three (3) days. If a product was marked use by, the facility used this date marked on the item. Per interview, any food item that was marked with a sell by date, was discarded seven (7) days after that date. She stated any food with an odor was thrown out. She further stated the staff were to explain to the residents what was being thrown out and why. If a resident becomes upset, the facility will replace the food item. Per interview, it was important to dispose of food appropriately because a resident could become sick if a spoiled food was consumed. Interview with the Unit Manager for the 500 Household , on [DATE] at 9:30 AM, revealed the refrigerators were checked and cleaned by the housekeeping department. Continued interview revealed the refrigerators should be maintained appropriately for the health of the resident. Interview with the Director of Nursing (DON), on [DATE] at 1:45 PM, revealed housekeeping monitored the personal refrigerators. Continued interview revealed any food that was opened should be labeled and dated and discarded after seventy-two (72) hours. Interview with the Administrator, on [DATE] at 3:45 PM, revealed the housekeeping department was responsible to monitor the food in the resident personal refrigerators to ensure items, which had exceeded a safe date, or food items brought from home were discarded appropriately. Continued interview revealed this was important to ensure appropriate food safety and to ensure residents did not become sick from food borne illnesses.

Based on observation, interview, record review, review of facility investigation, and review of the facility policy, it was determined the facility failed to ensure the resident(s) self-determination through support of resident choices for two (2) of five (5) sampled residents (Resident #2 and Resident #3). Resident #2 and Resident #3 reported a concern of being treated disrespectfully by State Registered Nursing Assistant (SRNA) #4 and not being assisted to bed as requested and preferred. The findings include: Review of the facility's Accommodation of Needs Policy, dated 01/01/18, revealed the facility should make efforts to reasonably accommodate the needs and preferences of the resident as they make use of their physical environment. Review of the facility's Resident Rights Policy, dated 01/01/18, revealed all residents will be treated equally regardless of age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, or gender identity or expression. Review of the facility's Investigating Abuse, Neglect and Misappropriation Policy, dated 10/01/16, revealed it is the policy of the facility that each resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. Continued review revealed the facility has a zero tolerance concerning any type of abuse or neglect of its residents or misappropriation of their property. All allegations and reports of resident abuse, neglect, mistreatment, and misappropriation of resident property shall be promptly and thoroughly investigated. 1) Review of the facility investigation revealed, on 02/01/19 resident #2 reported to the day shift State Registered Nursing Assistants (SRNA) that SRNA#4 spoke to her in a disrespectful manner and did not put her to bed in a timely manner on 01/31/19. At the time the allegation was reported by Resident #2, SRNA #4 was off duty and not working. Continued review of the investigation revealed, SRNA #4 was suspended during the facility's investigation. Per the investigation, Resident #2 was assessed to have a Brief Interview of Mental Status Score (BIMS) of fifteen (15) out of fifteen (15), indicating intact cognition. Per review, during the investigation Resident #2 revealed that over time he/she had issues with SRNA #4. Resident #2 described SRNA #4's behaviors as rude and as having an attitude and ignoring the resident when he/she would ask questions. According to Resident #2, on 01/31/19 at around 6:20 PM, he/she requested SRNA #4 to assist him/her to bed. Per investigation, SRNA #4 did not respond to his/her question and did not return to assist him/her to bed until 8:40 PM. Further interview revealed Resident #2 reported he/she did not put the call light on to ask for assistance because SRNA #4 told him/her as she was leaving the resident's room at 6:20 PM, and don't be hitting those buttons Review of the medical record revealed the facility admitted Resident #2 on 11/02/18 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) Assessment, dated 11/14/18, revealed the facility assessed the resident as having a Brief Interview of Mental Status (BIMS) of fifteen (15) out of fifteen (15) indicating the resident to be cognitively intact. Observation of Resident #2, on 02/14/19 at 12:30 PM, revealed the resident to be alert and oriented sitting up in a wheelchair in his/her room watching television. Resident #2 was pleasant, cooperative, and willing to talk about the alleged allegation. Resident #2 was able to communicate effectively and clearly during the interview. Interview with Resident #2, on 02/14/19 at 12:30 PM, revealed SRNA#4's treatment of [REDACTED]. Continued interview revealed Resident #2 asked SRNA #4 to be repositioned and SRNA #4 become confrontational asking Resident #2 if he/she thought she could not do her job. Further interview revealed on 01/31/19, Resident #2 requested to be assisted to bed at approximately 6:25 PM by SRNA #4. Per interview, SRNA #4 asked resident #2 if she could wait to be assisted to bed until she (SRNA) went on a break and told Resident #2 to not use her call light that she would be back. Further interview with Resident #2 revealed SRNA #4 came back at approximately 8:40 PM and assisted Resident #2 to bed. 2) Review of the medical record revealed the facility admitted Resident #3 on 08/03/15 and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 12/06/18, revealed the facility assessed the resident as having a BIMS of six (6) out of fifteen (15), indicating the resident had severe cognitive impairment; however, she was interviewable. Observation of Resident #3, on 02/14/19 at 5:09 PM, revealed Resident #3 was sitting at the dining table in close proximity to Resident #2. Resident #3 agreed to an interview at the dining table prior to other residents arriving. Further observation revealed his/her speech was slow and deliberate. Resident #3 asked Resident #2 if this was about SRNA #4 and how he/she was treated. Interview with Resident #3, on 02/14/19 at 5:09 PM, revealed he/she usually had no problems with the SRNAs except with SRNA #4. Resident #3 reported on one occasion, he/she requested to be assisted to bed at 9:00 PM; however, SRNA #4 did not return until approximately 10:00 PM to assist him/her to bed. Continued interview revealed SRNA #4 was short with him/her and had an attitude, stating it was not what she said, but how she acted towards me. Resident #3 admitted to screaming at SRNA #4. Further interview revealed SRNA #4 told him/her that someone else was going to have to assist him/her to bed and that no one was going to scream at her (SRNA #4). Per interview, SRNA #4 did return and assist Resident #3 to bed. Interview with SRNA #3, on 02/14/19 revealed, she has taken care of Resident #2 and she did not remember Resident #2 complaining of being treated disrespectfully by any of the SRNAs in the facility. Continued interview revealed, Resident #3 had reported to her that SRNA #4 had left him/her up in the chair when he/she had requested to be assisted to bed. SRNA #3 was not sure of the date this occurred. Interview with SRNA #4, on 02/26/19 at 10:44 AM, revealed she was not aware there was any situation with Resident #2. Continued interview revealed she took care of him/her as she usually did on her shift. Per interview, Resident #2 did not complain to her. Further interview revealed she assisted Resident #2 to bed as usual. SRNA #4 stated, I do not think there was a problem, there were no issues between us as far as I am aware. SRNA #4 ended the conversation abruptly saying she did not have anything else to say and had to hang up. Interview with LPN #1, on 02/14/19 at 2:40 PM, revealed Resident #2 is assisted with transfers by one staff and at times with the Sara Lift. Continued interview revealed she was aware Resident #2 reported to an aide she was spoken to disrespectfully and was left up in the chair when she wanted to go back to bed. Per interview, she had no further knowledge of the incident. Interview with the Clinical Coordinator (CC) for households seven (7) and eight (8), on 02/14/19 at 2:50 PM, revealed on 02/01/19, Resident #2 reported the incident to the LPN on duty and he reported the incident to her. Per interview, Resident #2 reported on 01/31/19, he/she requested to be assisted to bed at 6:25 PM and SRNA #4 asked if she could go on her break first. Per interview, Resident #2 reported that SRNA #4 told her not to use her call light, that SRNA #4 got into her personal space, close to her face. Per the CC, Resident #2 reported that SRNA #4 did not assist him/her back to bed until past 9:00 PM. Further interview revealed, the incident was immediately reported to the Director of Nursing (DON) and the Administrator and they immediately started an investigation and reported it to the state. The SRNA was taken off the schedule pending the investigation and she has not been back. Additional interview with the Clinical Coordinator revealed, as a part of the investigation, she interviewed resident #3, and Resident # 3 told her that SRNA #4 left him/her in the Hoyer Lift too long one day and also left him/her in the chair when he/she wanted to go to bed. This was approximately a month prior to this incident. Interview with Social Worker, on 02/14/19 at 5:25 PM, revealed she spoke to Resident #2 and Resident #2 reported he/she felt SRNA #4 was being disrespectful, and it had a lot to do with her attitude and body language. Continued interview revealed, she also spoke with Resident #3 and felt his/her situation was disrespectful as well. Further interview revealed SRNA #4 is no longer at the facility. Interview with the Director of Nursing (DON), on 02/14/19 at 6:15 PM, revealed Resident #2 reported the incident to the staff the following morning. Per interview, Resident #2 had asked to be assisted to bed for the evening. Continued interview revealed SRNA #4 requested to go on her break first. Resident #2 asked SRNA #4 how long she would be and SRNA #4 did not answer the resident; however, as she was leaving the room, told Resident #2 not to touch the buttons, meaning the call light. Per interview, SRNA #4 returned about two (2) hours later to assist Resident #2 to bed. Further interview with the DON revealed Resident #2 stated during their interview that she was nervous about the situation, but felt it was more disrespect than anything else. Per the DON, several staff interviewed Resident #2 and his/her story did not change. The DON stated, staff are trained to report any incident of neglect, abuse, or disrespect immediately to their supervisor, the supervisor will then report it on to Administration. Per the DON, the facility does not tolerate resident abuse or staff being disrespectful to a resident. Interview with the Administrator, on 02/14/19 at 6:30 PM, revealed it was her expectation for her staff to follow the facility's policies for Resident Abuse and Resident Rights. She stated staff had just recently received training. Continued interview revealed she was notified of the allegation by the DON. Per interview, Resident #2 is alert and oriented. She stated the facility had no reason to believe Resident #2's statements were not true; however, the facility conducted a thorough investigation of the allegation. During their investigation and interviewing other staff, they were lead to believe there were other dynamics going on with SRNA #4 and other staff. Further interview revealed the facility always errors on the side of the resident, it seemed clear-cut in this instance. Per interview, the facility does not tolerate staff being disrespectful to a resident. Per interview, the Resident Care Plans do include resident preferences.

Based on observation, interview, and review of facility Policy, it was determined the facility failed to store food in accordance with professional standards for food service safety. Observation on the 200, 400, 600 and 700 Units, revealed food products in the kitchenette refrigerators and freezers, were in plastic bags which were not labeled, dated or sealed. In addition, expired bread was found in the bread drawer in the 200 Unit kitchenette. The findings include: Review of the facility Food storage Policy, revised [DATE], revealed all food items must be securely closed, labeled and dated. 1. Observation on [DATE] 10:20 AM of the 200 unit kitchenette, revealed a bag of expired dinner rolls with an expiration date of [DATE] in the bread drawer. Further observation revealed the standup freezer contained a gallon zip lock bag of plain and chocolate chip cookie dough with no date or label; a gallon zip lock bag of veggie mix (broccoli and cauliflower) with no date or label; and a gallon zip lock bag of meat balls with no date or label. 2. Observation on [DATE] at 11:04 AM, of the 400 unit kitchenette, revealed the standup freezer contained a dozen breadsticks in a bag with a tie, with no label or date. 3. Observation on [DATE] 8:15 AM, of the 700 Unit Kitchenette refrigerator, revealed it contained Heinz Ketchup, Heinz Mustard, Hersheys Syrup, White Chocolate Mocha Coffee Creamer in the refrigerator which had been opened and was not marked with the open date. Also, the refrigerator freezer contained Sausage Patties, Hash Browns, Cauliflower, Sausage links, Onion Rings Chicken tenders, Waffles, and Tater tots which were opened and not marked with the open date. Additionally the Hash browns, cauliflower, onion rings and sausage links were in opened bags which were not sealed. Interview with Dietary staff #2, on [DATE] at 8:15 AM, revealed it was important to follow facility policy related to food storage for the health and safety of the residents. Continued interview revealed food was to be labeled with the opened date in order for staff to be aware of when the food would expire in order to dispose of foods on their expiration dates. Per interview, if the food products were not disposed of upon expiration, the food could be served to the residents which could cause illness. Additional interview revealed food products should be properly sealed when stored to prevent contamination to the products. 4. Observation on [DATE] at 2:05 PM, on Unit 600, Household 8, revealed a freezer in the storage area contained two (2) sealed unopened bags of twelve (12) waffles which were not in the original container and were not labeled or dated. Interview on [DATE] at 2:16 PM, with the Dietary Manager, revealed If food items were not in their original container, they were to be labeled with the food name and the use by date. She further stated once food items were opened, they were to be labeled with a use by date. The Dietary Manager stated the use by date was to be marked on the food item package to ensure staff did not use expired items. Further interview revealed all food in the refrigerator and freezer was to be sealed.

Based on observation, interview, record review, review of the facility's Policy and review of the Centers for Medicare and Medicaid Services (CMS), Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to ensure the Comprehensive Plan of Care was reviewed and revised for one (1) of thirty-one (31) sampled residents (Resident #18). The facility assessed Resident #18 in a Wound Assessment linked Note dated 06/25/18, as having red blanchable areas to the lateral and inner right foot. physician's orders [REDACTED]. However, there was no documented evidence the Comprehensive Care Plan was revised to include treatment/interventions including skin prep and Heel Lift Boots related to the resident's skin impairment. The findings include: Review of the facility's Care Planning-Care Conference Policy, with no revision date, revealed each discipline would assess the resident, noting facts and observations to use for revision of the care plan as necessary. Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated (MONTH) (YEAR), revealed the care plan must be reviewed and revised periodically, and the services provided or arranged should be consistent with each resident's written plan of care. Continued review of the Manual, revealed the care plan was driven not only by identified resident issues and/or conditions, but also by a resident's unique characteristics, strengths, and needs. Furthermore, a care plan based on a thorough assessment and effective clinical decision making, was compatible with current standards of clinical practice that provide a strong basis for optimal approaches to quality of care and quality of life needs of individual residents. A well developed and executed assessment and care plan: re-evaluates the resident's status at prescribed intervals (quarterly, annually, or if a significant change in status occurs) using the RAI and then modifies the individualized care plan as appropriate and necessary. Review of Resident #18's clinical record revealed the facility admitted the resident on 01/26/18, with [DIAGNOSES REDACTED]. Review of Resident #18's Quarterly Minimum Data Set (MDS) Assessment, dated 05/04/18, revealed the facility assessed the resident as having severely impaired cognition. Continued review of the MDS Assessment, revealed the facility assessed the resident as having no pressure ulcers and as at risk for developing pressure ulcers. Review of Resident #18's Comprehensive Care Plan, revised 05/18/18, revealed the resident was at risk for skin breakdown related to limited mobility, lab values, incontinence, medication use. The goal stated the Resident would not develop any pressure areas by next review. Interventions included, but were not limited to turn and reposition every two (2) hours when in bed, and help avoid friction and shearing. Review of Resident 18's Wound Assessment linked Note, dated 06/25/18 at 10:39 AM, revealed the resident had a reddened, blanchable two (2) centimeter (cm) x one (1) cm, area with no depth to the lateral surface of the right foot near the little toe; and a reddened, blanchable one (1) cm x one (1) cm area with no depth to the right inner foot near the great toe. Review of Resident #18's physician's orders [REDACTED]. Review of Resident #18's Treatment Administration Record (TAR), dated 06/25/18 through 08/15/18, revealed interventions to apply skin prep to the resident's medial, lateral and heel skin surfaces every shift; and Heel Lift Boots on both feet when in bed. However, further review of the Comprehensive Care Plan, revealed there was no documented evidence the Comprehensive Care Plan was revised to include treatment/interventions including skin prep and Heel Lift Boots related to the resident's skin impairment identified on 06/25/18. Observation of Resident #18, on 08/14/18 at 10:27 AM, revealed the resident was lying in bed on his/her right side under the covers with knees bent. Two (2) blue Heel Lift Boots were stacked together on the fall mat on the floor on the right side of the resident's bed. Observation on 08/14/18 at 3:10 PM, revealed staff assisted Resident #18 to bed; however, once the resident was in bed, the Heel Lift Boots were not placed on the resident's feet. Further observation, on 08/14/18 from 3:17 PM until 3:31 PM, revealed the resident was in bed and the resident's blue Heel Lift Boots were noted to be on top of the chest of drawers. Observation of Resident #18, on 08/15/18 at 9:30 AM, revealed the resident was lying in bed on his/her left side, under a sheet and blanket; and the outlined shape of a Heel Lift Boot was noted. Continued observation revealed one (1) blue Heel Lift Boot was on the fall mat on the floor near the foot of the bed. Observation of Resident #18, on 08/15/18 at 10:00 AM, revealed Licensed Practical Nurse (LPN) #1 and State Registered Nurse Aide (SRNA) #1 removed the sheet and blanket from the resident's bilateral lower extremities, revealing the resident was wearing non-skid socks to both feet. There was a pillow under the resident's calves; however, the resident's bilateral heels were touching the mattress and the resident was not wearing the Heel Lift Boots. A Skin Assessment performed by LPN #1, revealed the resident had a reddened circular area, the size of a quarter to the bony prominence of the bunion on the right foot, which was blanchable. Also, the length of the inner right foot had several small circular reddened areas, the size of a pencil eraser, which were also blanchable when staff palpated. The resident's two (2) Heel Lift Boots were in the chair by the chest of drawers. Continued observation revealed after the Skin Assessment, the resident was repositioned, the bed linens were pulled up, the bed was lowered to the lowest position, and the call light was placed in reach. However, staff did not attempt to place the Heel Lift Boots on the resident before exiting the room at 10:10 AM. Interview with SRNA #1, on 08/15/18 at 10:15 AM, revealed she was assigned to Resident #18 and was aware the resident was supposed to wear Heel Lift Boots at all times when in bed. Further interview revealed she should have placed the Heel Lift Boots on Resident #18's feet after the skin assessment. Continued interview revealed the SRNA's used the computerized Care Plan as a reference in providing care. SRNA #1 was unaware if the computerized Care Plan the SRNAs used to provide care for Resident #18 had interventions for Heel Lift Boots, but stated the Comprehensive Care Plan should have reflected the intervention for the resident to wear Heel Lift Boots when in bed. Interview with LPN #1, on 08/15/18 at 10:12 AM, revealed Resident #18 was receiving a skin prep treatment to his/her feet twice daily and Heel Lift Boots were to be worn at all times when the resident was in bed as extra protection per physician's orders [REDACTED]. Further interview revealed Resident #18's Comprehensive Care Plan should have been revised to include treatment and interventions including Heel Lift Boots. Interview with Care Coordinator #1, on 08/16/18 at 2:57 PM, revealed the computerized Comprehensive Care Plan was the reference staff used for providing care. She stated she was responsible for updating Care Plans with new physician's orders [REDACTED]. She further stated she gained information related to revising the Care Plans from the Morning Meetings where changes in residents' condition and care were discussed and from reviewing new physician's orders [REDACTED].#18's Comprehensive Care Plan should have been revised to include the change in skin condition to his/her feet requiring protective treatment and the intervention for the Heel Lift Boots. Interview on 08/16/18 at 3:55 PM, with the Director of Nursing, revealed it was important to revise the Comprehensive Care Plan in order to provide the most current up to date treatment and care for the residents. She stated the Clinical Coordinator was responsible for revising Care Plans after reviewing new physician's orders [REDACTED]. Per interview, the Care Plan was the reference staff used in providing care. Further interview revealed devices and treatments ordered related to a change in skin condition or as a preventative measure should be care planned. Additional interview revealed Resident #18's Comprehensive Care Plan should have been revised with interventions for treatment and Heel Lift Boots due to the change in skin condition. Interview with the Administrator, on 08/16/18 at 4:09 PM, revealed the Comprehensive Care Plan should be evaluated for effectiveness and revised in order for staff to provide appropriate quality of care. Per interview, the Care Coordinators were responsible for revising Care Plans and it should not take more than a few days for the Care Plan to be revised related to new physician's orders [REDACTED].

Based on observation, interview, and review of the facility's Policy, it was determined the facility failed to ensure proper storage of drugs. Observation on 08/14/18, of the 700 Unit medication cart , revealed one (1) bottle of [MEDICATION NAME] 2% eye drops which was expired by thirteen (13) days. The findings include: Review of the facility Medication Storage in the Facility Policy, undated, revealed outdated medications are immediately removed from stock, disposed of according to procedures for medication disposal and reordered from pharmacy, if a current order exists. Review of the pharmaceutical package insert for [MEDICATION NAME] 2% eye drops, revised (MONTH) 2014, revealed the medication was to be disposed of twenty-eight (28) days after opening. Observation on 08/14/18 at 4:00 PM, of the 700 Unit medication cart, revealed one (1) bottle of [MEDICATION NAME] 2% eye drops (medication used to treat [MEDICAL CONDITION]) which was marked as opened on 07/04/18. Licensed Practical Nurse (LPN) #3 was observed to remove the medication from the cart. Interview with LPN #3, on 08/14/18 at 4:10 PM, revealed she removed the bottle of [MEDICATION NAME] 2% eye drops from the medication cart because the bottle was expired. Per interview, the [MEDICATION NAME] 2% eye drops had an opened date of 07/04/18, thus the medication was expired by thirteen (13) days. Continued interview revealed the expired medication should not be used as it could have possible negative effects or could be less effective. Per interview, medication should be disposed of upon expiration which in the case of the eye drops, was twenty-eight (28) days after the medication was opened. Continued interview revealed she would reorder the medication from pharmacy as there was a continued prescription for the medication. Interview with the Clinical Coordinator of the 700 Unit, on 8/15/18 at 3:00 PM, revealed expired medications should be pulled from the medication carts because they could be ineffective or they could have the potential to cause harm. Per interview, if there was a continued prescription for the medication, it should be re-ordered from pharmacy. Continued interview revealed it was her expectation for nursing staff to follow the medication storage policy and procedures and all package inserts/guidelines for the safety of the residents. Interview with the Pharmacist, on 08/15/18 at 16:40 PM, revealed expired medications should not be used and should be pulled from the medication carts and disposed of per facility policy to prevent any negative outcomes such as ineffective medication or possible bacterial infection. Per interview, it was his expectation staff follow facility policy related to storage of medications. Interview with the Assistant Director of Nursing (ADON), on 08/16/18 at 1:30 PM, revealed it was her expectation staff followed policy related to disposing of expired medications. Continued interview revealed this was important for the efficacy of the medication and therefore the safety of the residents. Interview with the Administrator on 08/16/18 at 2:00 PM, revealed it was her expectation nursing staff follow policy related to proper storage of medication. Continued interview revealed she would expect staff to dispose of expired medications as administration of expired medications may cause negative outcomes for the residents. Per interview, administration of expired medication could also result in a medication error.

Based on interview, record review, and review of facility Policy, it was determined the facility failed to ensure the residents' environment remains as free from accidents and hazards as is possible for one (1) of five (5) sampled residents, Resident #2. On 9/28/17, Resident #2 sustained a cut to the leg requiring the resident to be transferred to the hospital emergency room after a temporary drywall barrier which was not attached properly fell on the resident. The findings include: Review of the facility's Policy titled Accidents and Incidents, undated, revealed the facility would take the necessary precautions to minimize the incidence of accidents and incidents involving residents. Review of the facility's Policy titled, Resident Safety, undated, revealed it was facility policy to create the safest environment possible for residents and staff should report all faulty equipment immediately. Review of the Collaborative Document between Rosedale Green and the Company remodeling the facility, dated 7/21/15, revealed comply with requirements of authorities having jurisdiction for erecting structurally adequate barricades, including warning signs and lighting; and maintain temporary egress from existing occupied facilities as indicated and as required by authorities having jurisdiction. Review of the Contractors Contract with the facility, section G 6 Safety and special requirements, undated, revealed the contractors were responsible for project safety and must comply with requirements for work in an occupied building so as not to endanger or disrupt residents. Review of the Project Safety Requirements, undated, revealed good housekeeping was mandatory and all workers must do their part to clean up their work area and keep conditions safe; and when working outside the construction zone, the safety of the resident must be priority. Record Review of the Construction Weekly Job site Safety Meeting Report, dated September 28, 2017 from 2:00 PM to 3:00 PM, revealed safety and health suggestions and comments were offered by employees; Corridor work must have watch for all barricades and tools posted. Construction doors must be closed. Review of Resident #2's medical record revealed the facility admitted the resident on 6/28/17, and readmitted the resident on 10/23/17, with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fourteen (14) out of fifteen (15) indicating the resident was cognitively intact. Interview with Resident #2, on 10/25/17 at 4:30 PM, in dining area of household #8, revealed in late September, he/she was coming down the hallway in the wheelchair toward the dining room when he/she ran into the wall, and the wall fell over and cut his/her right lower leg. Continued interview revealed the wall that fell over was part of the construction site and was a temporary wall. The resident stated the cut was almost healed now and had not required stitches. Per interview, he/she felt the construction should have been more sound. Resident #2's spouse was present at the time of interview and concurred with the resident's statements. Review of the facility Incident report, dated 09/28/17, revealed Resident #2 ran into the drywall and the drywall fell over and hit the resident's right leg. Per the Report, the resident sustained [REDACTED]. Further review of the Report, revealed the incident occurred on 09/28/17 at 12:30 PM; the family was notified at 1:16 PM; and the physician was notified at 1:24 PM. Review of the Nurse's Progress Notes dated 9/28/17 at 12:30, documented by Licensed Practical Nurse (LPN) #1, revealed Resident #2 was going up the hallway, ran into the drywall, and the dry wall fell over and hit the resident on his/her right leg. Per the Note, the resident had a laceration to his/her right shin with a moderate amount of bloody drainage, and a pressure dressing was applied. Subsequent Nurse's Progress Notes, dated 9/28/17, revealed at 12:35 PM, a call was placed to 911; at 12:45 911 was there to transfer the resident to the Hospital; at 1:16 the family was notified; and at 1:24 PM the Nurse Practitioner was notified of the incident. Subsequent Nurse's Progress Notes dated 09/28/17 at 3:52 PM, revealed the resident returned to the facility with a [DIAGNOSES REDACTED]. Interview with LPN #1, on 10/26/17 at 11:30 AM, revealed on 09/28/17, Resident #2 was self propelling in the wheelchair down the hallway from his/her room to the common area when he/she ran into a piece of drywall that was a barrier wall between the construction zone and the livable zone in the unit. Per interview, the drywall fell over onto the resident and cut his/her right lower leg. Further interview revealed he could not get the bleeding to stop and thought the area might need sutures and he had the resident transferred to the hospital emergency room . Per interview, the resident's wound did not need sutures and the resident returned later with a dressing and orders to clean the wound; apply a dry dressing; and contact the primary care physician. Interview on 10/25/17 at 2:00 PM, with the General Contractor in charge of the facility's remodeling project, revealed the facility had been in a total remodeling project which included all units or households in the building for the past twenty-five (25) months and he had been in charge of the project on the construction side. Continued interview revealed the incident with Resident #2 happened when a construction worker failed to properly secure a temporary drywall barrier from a construction zone to a livable zone. Per interview, this happened when a worker went to get more materials and did not attach the barrier securely, thus enabling the drywall to fall on the resident when the resident ran into the unsecured drywall barrier. Continued interview revealed the drywall should have been securely fastened and should not have moved when the resident hit the barrier with the wheelchair. He further stated the facility and the construction company had a safety plan and safety meetings related to the construction were conducted. He further stated the construction company and the facility met after the incident to discuss the cause of the accident in order to protect the residents. Interview was conducted with the Assistant Administrator, and the Executive Director, on 10/26/17 at 4:30 PM. The Assistant Administrator revealed the facility had a safety plan involving the renovation of the building and met with the construction company on a regular weekly basis and also as needed, to discuss any safety concerns involving residents. Further interview revealed after the incident involving Resident #2, the facility worked with the construction company to do a thorough investigation to determine what occurred and re-educate construction staff and facility staff as to what to do to ensure resident safety if an unsafe situation was reported. He further stated the facility also hired a representative to facilitate communication between the construction staff and the facility; however, if the situation was critical involving resident safety the facility staff would speak directly with the construction staff. Per interview with the Assistant Administrator, it was both the facility's and the construction company's responsibility to ensure the safety of the residents during the renovation process. The Executive Director, verified the facility had a safety plan involving the renovation of the building and met with the construction company on a regular weekly basis and also more often to discuss safety concerns. Further interview revealed after Resident #2's injury, the Executive Director met with the contractors and provided them with bullet points on her expectations to ensure a plan of correction and prevent further injury to residents related to construction during the renovation of the facility.

Based on observation, interview, and review of facility policies, it was determined the facility failed to prepare, and distribute food under sanitary conditions. Observation of the kitchen on 06/07/16 and 06/08/16, revealed staff was working in the kitchen without hair fully covered. In addition, observation on 06/08/16, revealed staff checked food temperatures by piercing the thermometer through the foil covering and plastic wrap. The findings include: 1. Review of the facility, General Dietary Personnel Policy, revised 02/28/07, revealed employees in dietary must wear some form of hair protection. Further review revealed either a hair net or a cap must cover the hair. Observation of the kitchen on 06/07/16 at 1:20 PM, revealed Server #3, Dietary Aide #1, Dietary Aide #2 and the Dining Director were working in the serving line and their hair nets did not cover all of their hair, as their bangs and hair on the sides and base of the neck was exposed. Further observation on 06/08/16 at 5:10 PM, revealed Cook #2 and Dietary Aide #2 were working in the kitchen and bangs and hair above the forehead was exposed. Interview with Server #1 on 06/09/16 at 2:47 PM, and Cook #1 on 06/09/16 at 3:05 PM, revealed hair should be completely covered when working in the kitchen, as uncovered hair could potentially get into food and wouldn't be sanitary. Interview with Cook #1, on 06/09/16 at 3:05 PM, Server #2 on 06/09/16 at 3:11 PM, Server #3 on 06/09/16 at 3:16 PM, Server #4 on 06/09/16 at 3:25 PM, Cook #2 on 06/09/16 at 4:15 PM and Waitress #1 on 06/09/16 at 4:35 PM, revealed hair should be completely covered when working in the kitchen at all times to prevent the possibility of hair falling into food. 2. Review of the facility Food Cooking and Holding Temperatures Policy, undated, revealed each food item should have a pocket thermometer placed in it so that staff could be constantly watching the temperature of the food throughout the meal service. Interview with the Dietary Manager, on 06/09/16 at 5:14 PM, revealed the facility did not have a policy regarding the correct procedure for taking food temperatures. Observation of the lunch tray line in the kitchen on 06/08/16 at 11:39 AM, revealed Server #3 did not remove the plastic wrap or the aluminum foil covering the prepared food prior to taking the food temperatures, but inserted the thermometer directly through the aluminum foil and plastic wrap. Interview with Server #3, on 06/09/16 at 3:16 PM, revealed she thought food should be covered to keep in the heat and she punctured a hole in the aluminum foil and plastic wrap covering to take food temperatures. She further stated she had not thought about the possibility of cross contaminating food by puncturing a hole in the aluminum foil or plastic wrap. Observation of the portable steam table tray line on the Autumn Woods Unit on 06/08/16 at 12:26 PM, revealed Server #2 was serving food out of trays which were partially covered with aluminum foil and plastic wrap, while the food thermometers remained inserted through the aluminum foil and plastic wrap. Interview with Server #2, on 06/09/16 at 3:11 PM, revealed she did not realize she was not supposed to puncture the aluminum foil or plastic wrap to take temperatures. Interview with Server #1 on 06/09/16 at 2:47 PM, Cook #1 on 06/09/16 at 3:05 PM, and Server #4 on 06/09/16 at 3:25 PM, revealed all dietary staff was to take food temperatures by pushing the thermometer through the aluminum foil and plastic wrap covering to ensure the food would stay warm. Interview with Cook #2, on 06/09/16 at 4:15 PM, revealed she had previously pushed the thermometer through the food to hold the heat in while taking food temperatures, but the Dietary Manager had informed her today to lift the corner of the foil up to take a temperature. Interview with Waitress #1, on 06/09/16 at 4:35 PM, revealed the aluminum foil should not be punctured but lifted in the corner to insert a clean thermometer into the food directly. Interview with the Dietary Manager, on 06/09/16 at 5:14 PM, revealed staff had been taking temperatures by removing a corner of the foil until recently, when they staff started puncturing the aluminum foil and the plastic wrap. She stated she would need to re-educate and train staff to put the thermometer to the side of the food tray with the corner of the foil or plastic wrap lifted. Further interview with the Dietary Manager, revealed dietary staff were trained upon hire and were aware all hair had to be covered while working in the kitchen including mustaches, as hair could fall into food, or get on utensils or plates. Interview with the Registered Dietician, on 06/09/16 at 5:38 PM, revealed dietary staff should be aware of how to wear hairnets properly, and they all had been trained upon hire to do so. Interview with the Director of Nursing (DON) on 06/09/16 at 5:48 PM, revealed it was her expectation for staff to wear hair nets correctly in the kitchen to prevent hair from getting into food. Further interview revealed food should be prepared in sanitary conditions. Interview with the Administrator, on 06/09/16 at 6:04 PM, revealed it was her expectation for facility policies to be followed to prevent contamination of food, and for food to be prepared and served under sanitary conditions.

Based on observation, interview and review of the facility's policy, it was determined the facility failed to ensure food was stored under sanitary conditions as evidenced by observation of insects in the kitchen by the dishwasher area. The findings include: Review of the facility's policy titled: Food Storage last revised date 04/26/10, revealed food was kept safe and stored by methods designed to prevent contamination. Observation with the Dietary Manager (DM), on 06/17/15 at 2:54 PM, revealed two (2) insects were observed near the dishwasher area. The insects were trapped in a plastic cup, by the surveyor, and given to the Dietary Manager. In addition, another insect was observed in the area at approximately 3:00 PM. Interview, on 06/17/15 at 3:00 PM, with Dietary Aide #1 revealed she only worked in the dish room area occasionally and had not seen any insects and cleaned the floor twice a day. Interview with the DM, on 06/17/15 at 3:11 PM and at 3:20 PM, revealed there was not supposed to be any insects in the kitchen and as soon as someone saw a bug they were supposed to call pest control. The DM reported there was potential the bugs could get into food, it was an infection control issue and was going to report the insect sighting to the housekeeping supervisor to call pest control. Further observation and interview with the DM and Dietary Director, on 06/17/15 at 3:35 PM, revealed there were a few bread particles on the floor by the cooking area. The DM revealed the area was supposed to cleaned by the day cook prior to the end of the shift, but didn't appear like it was cleaned and that could attract bugs. The Dietary Director revealed insects were not supposed to be in the kitchen area and they mopped floors at night and day shift was supposed to sweep the floors before they left at 2:30 PM. Interview, on 06/18/15 at 11:05 AM with the Dietary Aide #2 revealed they swept the floor around the baking and cooking areas routinely, but had not swept the area behind the machines yesterday (06/17/15) because it was hard to sweep around the machines. Further interview with the Dietary Aide revealed she had never seen any bugs, but sweeping helped keep food sources away from bugs. Interview, on 06/18/15 at 12:30 PM with the Pest Control Technician revealed the insects were roaches which probably came in with food products brought into the facility. He stated food products and grease can attract bugs and it was important to keep the area clean. He reported they came twice a month and the kitchen looked clean. Interview, on 06/19/15 at 6:09 PM, with the Administrator revealed she had been made aware they had some bugs down in the kitchen by the dishwasher area, but not the food preparation area, during the survey. The Administrator revealed they kept food covered and wrapped to prevent contamination but there was the potential of an infection control concern with the bugs. Further interview revealed bugs were one reason it was important to keep the kitchen clean and follow the cleaning protocol.

Based on observation, interview, record review, and review of facility's policies, it was determined the facility failed to establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection for nine (9) of twenty-nine (29) sampled residents (Residents #1, #3, #6, #7, #9, #10, #16, #26, and #27) and fifteen (15) unsampled residents (Unsampled Residents A, B, C, D, E, F, G, H, I, J, K, L, M, N, O, and P). The facility failed to have an effective system in place to monitor the disinfection of the whirlpool (w/p) tubs. Interviews with staff on the First and Second floors of the facility revealed they were unaware of how to properly disinfect the five (5) whirlpool tubs in the facility and were not using the disinfectant per manufacturers recommendations. There was no evidence of staff education on hire or ongoing related to disinfecting of the tubs. In addition, there was no system in place to ensure the chemical in the tubs was at the right level and no person was responsible for checking the amount of cleaning chemical in the tubs. Interviews and record reviews revealed the following residents were using the whirlpool tubs: Unsampled Residents A, B, C, D, E, F, G, H, I, J, K, L, M, N, O and P and Residents #3, #7, #9, #10, and #27. Also, observation of Resident #10 revealed Foley catheter tubing was touching the floor on two (2) separate occasions. Observation of indwelling urinary catheter irrigation for Resident #10 revealed the Licensed Practical Nurse (LPN) irrigated the catheter with Normal Saline; however, then attached the used urinary drainage tubing to the catheter instead of allowing the fluid to drain back into the basin as per facility policy. In addition, the nurse raised the urinary drainage bag above body level causing the urine to backflow after the catheter irrigation. After the irrigation of the indwelling urinary catheter, the nurse then without removing the soiled gloves and washing hands, adjusted the side rail and lowered the bed using the bed control with the same soiled gloves. In addition, observation of indwelling urinary catheter care for Resident #10, revealed the Certified Nursing Aide (CNA) failed to pull the resident's foreskin back down after catheter care, and failed to wash her hands after the procedure, prior to exiting the room. Observation during initial tour revealed four (4) rooms with Oxygen tubing or Hand Held Nebulizer's (HHN's) tubing not bagged and not in use during the tour. Resident #16 was to be in contact isolation for Clostridium Difficile (C-Diff) (a very contagious bacterial organism that causes an infection of the intestinal tract); however, there was no signage on the door or Personal Protective Equipment (PPE) readily accessible. In addition, the CNA caring for the resident was unaware the resident was to have precautions related to[DIAGNOSES REDACTED]. Also, although the resident had stopped having loose stools and was being treated with medication, the Physician was not notified when the resident again started having loose stools. Resident #26 was being treated for [REDACTED]. Observation of a dressing change for Resident #6 revealed the nurse placed the clean dressing on the table prior to the dressing change instead of using a barrier. Observation revealed poor handwashing and glove use during a skin assessment for Resident #1. The findings include: Review of facility's Nursing Infection Control Procedures, undated, revealed proper infection control procedures must be maintained at all times to ensure the well being and safety of the Residents. Our residents are highly susceptible to illnesses due to chronic health conditions, weakened immune systems, poor nutritional/fluid intake and inadequate sleep, etc. If we are not careful in the practices we use, we can increase the risk of spreading infections to the residents and throughout the facility. 1. Review of Facility's Cleaning and Disinfecting of Whirlpool/Tub policy and procedure, undated, revealed all equipment must be cleaned and sanitized after each resident's use to insure a safe and sanitary environment for all residents. Review of the procedure revealed staff should empty the tub and remove any visible debris. Whirlpool tubs have sanitizer set by manufacturer to mix with the correct amount of water as it is sprayed from the hose connection. Sanitizer solution is two (2) oz per gallon of water: Spray all hard surfaces with sanitizer spray using a clean cloth to remove any debris noted, then spray that area again (after removal of debris) with sanitizer. After all areas are sanitized let tub air day. The tub is now ready for use. Review of the section for Alternate Sanitizer revealed to empty the tub of water and remove any visible debris. Clean tub thoroughly with 1:10 bleach solution. Wipe all hard surfaces and let set two (2)-three (3) minutes. Rinse thoroughly. The tub is now ready for use. Continued review for Alternate Sanitizer revealed to empty tub of water and remove any visible debris. Clean tub thoroughly. Wipe all hard surfaces with Sani-Cloth Germicidal Disposable Wipe. Let Germicidal solution set for 2 minutes on all hard surfaces. Rinse thoroughly. The tub is now ready for use. Review of the Arjo Symphony Manufactures Recommendations for Operating and Daily Maintenance, undated, revealed to disinfect the tub, the procedure should be followed at the beginning of the day, after each bath and at the end of the day. (1) Open the panel cover and check that the Arjo Disinfection/Cleaner has an ample supply and the hose was connected. (2) Drain bath water and rinse sides and bottom of empty tub with clean luke warm water from the white resident shower. (3) Detach the disinfectant spray handle from the hook. (4) Close the drain. (5) Press the disinfectant spray button and spray disinfectant around the bath surface. (The disinfectant pump will run for maximum of five (5) minutes, but could be stopped when desired by pressing the disinfectant spray button). (6) Allow two (2) minutes for the disinfectant to kill microorganisms. (For complete disinfection, read the instructions on the container). Use a soft bristled brush or disposable clothes/paper towels to scrub the bath surfaces. If a brush was used, it should be soaked in disinfectant, rinsed in cold water and air dried after use. (7) Open the drain and rise tub surfaces with clean water from the white handled shower. (8) Wipe the tub with a clean cloth to remove excess water. Review of the Arjo Rhapsody/Primo Manufactures Recommendations revealed the Operating and Product Care Instructions, dated March 2003, stated the Arjo Cen-Kleen IV, a chemical, should only be used for optimal performance for this whirlpool/Stillbath and Hydrosound. Continued review of the manufactures recommendations revealed the procedure for disinfecting the tub should be performed before the first bath of the day and then after every resident. Continued review of the Manufactures Recommendations stated staff should make sure that there was an appropriate mixture of disinfectant liquid to the water by means of checking the flow meter or state of the water (for example the smell, foam). Further review of the Recommendations stated staff would (1) Raise the bath tub to convenient working height, by pressing arrow up button on the control panel. (2) Scrub and rinse tub and accessories, if necessary, to remove visible tissue residue or fluids before disinfection. (3) Close the drainage plug. (4) Remove inlet screen and clean it separately. (5) Remove the turnable hydromassage nozzle (Just pull it out). (6) Insert the treatment hose in the hydromassage outlet. (7) Press the automatic disinfection button. Automatic disinfection starts. The hydromassage equipment will be rinsed with Cen-Kleen IV for about ten (10) seconds. (8) Direct the disinfectant spray handle against the bottom of the bath tub. (9) Spray all the bath tub, the foot rest, the pillow and lift with mattresses, if any, with the disinfectant sprayer. (10) Spray into the surface overflow outlet and into the holes where the inlet screen and hydromassage nozzle were placed. (When the treatment hose was used, spray the outside too.) (11) Press the disinfectant button, and place the disinfectant spray handle under the lid. (12) Scrub the tub using the disinfectant at the bottom of the bath tub. (13) Let the Cen-Kleen IV take effect according to the recommendation label on the bottle. Recommended contact time was ten (10) minutes for Arjo Cen-Kleen IV. The system would be blocked for using as long as the LED on the disinfection button was on. (14) Open the drainage plug. (15) The hydromassage equipment was automatically rinsed with water when the preset disinfections/cleaning time has elapsed since the automatic disinfection button was pressed the first time. (16) When disinfection was finished: (Remove the treatment hose from the quick coupling by pushing the hose while pulling the hose bracket.) (17) Press the button for resident shower on the control panel, and rinse bath tub and accessories carefully with the resident shower. (18) Examine tub and accessories to ensure removal of disinfectant. Repeat rinse as needed. (19) Press the button for resident shower on the control panel. (20) Insert the cleaned inlet screen, and make sure that the area without holes was directed downward. (21) Examine tub and accessories for visible damage. (22) Let the pillow dry with the suction cups upward at the bottom of the bath tub. (23) After the last cleaning/disinfection for the day, dry the bath tub and accessories. Review of the Cen-Kleen IV Cleaner and Disinfectant instructions for use, undated, revealed the Cen-Kleen IV was a concentrated product and should be diluted for final use. Staff was to apply two (2) ounces (oz.) of Cen-Kleen IV per one gallon of water with a contact time of ten (10) minutes. Review of the Classic Whirlpool Disinfectant Cleaner, undated, revealed the Classic was to be diluted with two (2) ounces of cleaner per gallon of water with a contact time for disinfection of ten (10) minutes and a Sanitizing time of thirty (30) seconds. Review of the Super Sani-Cloth Germicidal Disposable Wipe Instructions, undated, revealed it was a Premoistened nonwovens durable wipe containing a quaternary/alcohol based solution. It was recommended for use of non-porous surfaces and equipment made of stainless steal, plastic, Formica and glass. Some organisms were removed from the surface by thoroughly wiping the surface with the wipe; however, most remaining organisms were killed within two (2) minutes by exposure to the liquid in the wipe. Observation, interviews with the residents and staff, and review of the facility's Whirlpool Schedule, revealed Unsampled Residents A, B, C, D, E, F, G, H, I, J, K, L, M, N, O, and P and Residents #3, #7, #9, #10, and #27 utilized the Whirlpools. Additionally, Resident #10 was being treated for [REDACTED]. Observation and interview with CNA #3, on 06/17/15 at 9:55 AM, on Willow Glen within the Women's bathroom, which had the Arjo Symphony Whirlpool model revealed CNA #3 was demonstrating to CNA #12 and several nursing assistants on how to disinfect the Whirlpool. CNA #3 was observed to turn the water on from the back of the whirlpool, not from the tub. She reported she had turned the water on this way for over three (3) years. She continued to instruct CNA #12 and the nursing assistants on cleaning the whirlpool by stating, there was no chemical in the whirlpool, after checking to see if there was any chemical in it, she then turned on the water from the whirlpool and pressed the disinfectant knob, she reported there must have been chemical in the whirlpool since water was coming out of it. She reported the disinfectant would not work if there was no disinfectant in it. CNA #3 reported it was the responsibility of the Nurse Manager to change the disinfectant when it was low and/or out. Interview and observation with CNA #12, on 06/17/15 at 10:30 AM, in Willow Glen's Men's Bathroom, which had the Arjo Rhapsody/Primo Whirlpool Model, revealed she used the whirlpool last week, but did not recall it not working, when attempting to cut the disinfectant on. She reported she normally assist the CNA's with whirlpools and thus did not have to clean the whirlpool. She reported she would clean the whirlpool by sanitizing the tub and rinsing well, additionally, she stated she would spray the disinfectant in the tub, but would immediately rinse it out with water. She reported there was no waiting period for allowing the disinfectant to sit on the surface of the tub. Interview with CNA #4, on 06/17/15 at 11:03 AM, on Willow Glen Men's Bathroom, revealed CNA #4 was unsure how the Whirlpool Jets were cleaned. She reported Maintenance/Housekeeping was responsible for ensuring the whirlpool had disinfectant in it. She reported that after spraying the disinfectant, staff should wait two (2) minutes before spraying the tub down with water. CNA #4 reported it was important to ensure the whirlpool was cleaned correctly due to infection control. Interview with CNA #5, on 06/17/15 at 11:15 AM, and observation/interview at 2:30 PM, the same day, within Willow Glen Men's Bathroom, revealed it was Maintenance responsibility for checking and replacing the disinfectant to the whirlpool. Continued interview with CNA #5 revealed she did not know how to clean the jets, but would find out from management. Further interview with CNA #5 revealed she would aim the disinfectant at the jet and let it sit for a few minutes before wiping it down. CNA #5 reported it was important to keep the whirlpools clean due to possible contamination. Additional interview/observation at 2:30 PM with CNA #5 revealed, CNA #5 was observed demonstrating an in-service to two (2) other CNA's (CNA #6 and CNA #13) on how to disinfect the whirlpool. CNA #13 reported she had been at the facility for four (4) months and reported this was the first time she had been trained on cleaning the whirlpool. Continued observation revealed that CNA #6 was unable to provide a demonstration on the proper technique to clean the whirlpool according to the manufacturer's recommendations. CNA #5 was observed to intervene, showing CNA #6 how to clean the jets. CNA #5 instructed CNA #6 on how to turn on the water from the whirlpool, then showing him how to turn the disinfectant on to disinfect the tub. Further interview with CNA #5 revealed, the Assistant Director of Nursing (ADON) refilled the whirlpool with disinfectant, due to the whirlpool not having disinfectant, approximately two (2) hours prior to the inservice/demonstration. Interview with Licensed Practical Nurse (LPN) #2, on 06/17/15 at 4:38 PM, on Willow Glen, revealed she was aware of residents who received a whirlpool bath, but had never used the whirlpool to assist the residents with whirlpool baths. She reported she had not received any inservices on the whirlpool and cleaning/disinfecting the tubs. Continued interview revealed she thought Housekeeping was in charge of refilling the disinfectant. Further interview revealed it was important to disinfect the whirlpool due to infection control, to prevent the spread of diseases. Interview with Registered Nurse (RN) #1/Unit Manager, on 06/17/15 at 5:00 PM, located on Willow Glen, revealed the Staff Development Coordinator provided inservice on cleaning the whirlpools. She reported she was informed of the whirlpool policy on 06/17/15 and was informed that staff should check the whirlpool to ensure disinfectant was present in the whirlpool before using it. She stated that if there was no solution present, staff would need to notify their supervisor or Unit Manager. She reported the Unit Manager or Clinical Coordinator should mix the mixture for the CNA's. Continued interview with RN #1 revealed it would be her expectation that staff would use the solution provided to them to put disinfectant in the whirlpool. She reported her unit used the Classic Cleaner. If the unit was out of the Classic, she reported she would expect her staff to use the Sani-Cloth, and thirdly (3rd), she would expect them to use a bleach solution. She reported she was not familiar with the Manufactures Recommendation for use, but would expect the policy would reflect the Manufactures Recommendations. Continued interview with RN #1 revealed it was important to clean the whirlpool correctly because of infection control purposes. Interview with CNA #7 on 06/17/15 at 2:40 PM, within the Autumn Wood Women's Bathroom, revealed she was unsure how long the disinfectant tank was broken on her unit. She reported she would use Sani-Wipes to wipe the whirlpool and allow the product to sit on the tub for two (2) minutes then would rinse out with water. She reported she used the Sani-Wipes to clean the outside of the jets. Continued interview with CNA #7 revealed residents who normally used the whirlpool were those who required a full body lift, or those who could not easily stand in the shower. She further stated there were; however, some that preferred the whirlpool. Interview with CNA #8 on 06/17/15 at 3:04 PM, on Autumn Wood, within the women's bathroom, revealed that there should not have been residue near the drain that was identified while inspecting the whirlpool with CNA #8. He reported the process for cleaning the whirlpool was to use a washcloth, Sani-Wipes and/or a bleach solution from housekeeping, and rinse with hot water. He reported it was important to ensure the whirlpool was cleaned correctly because,it could lead to sickness, by not properly cleaning the whirlpool. Interview with CNA #9, on 06/17/15 at 3:27 PM, within Autumn Wood Women's bathroom, revealed the whirlpool was last used by her on 06/16/15. She reported she did not know the disinfectant solution was empty and was not familiar with how to clean the jets. She reported it was very important to disinfect and clean the whirlpool correctly or the residents could get an infection. She reported she would clean the whirlpool only if she thought the whirlpool was dirty by using Sani-Cloth wipes and a washcloth to clean the tub. She later reported she should clean the tub before and after each use. Interview with Licensed Practical Nurse (LPN) #1, on 06/17/15 at 4:12 PM, located on Autumn Wood, revealed he inserviced a select few on cleaning the whirlpool with Sani-Wipes approximately six months ago. He reported the whirlpool had not been working for approximately six months due to a leakage in the disinfectant bottle. He reported Maintenance was notified and Maintenance notified a private contractor. Continued interview revealed Housekeeping was in charge of changing and ordering the disinfectant, adding it was important to clean the whirlpool correctly because of infection control reasons. Interview with Registered Nurse (RN) #3/ Unit Manager, located on Autumn Wood, on 06/17/15 at 3:45 PM, revealed that staff received training upon hire for whirlpool use and cleaning. She reported she was unaware of how the jets were cleaned or what disinfectant was used to disinfect the whirlpool. Continued interview with RN/Unit Manager #3 revealed that staff should have notified her if there was no disinfectant. Additionally, she reported staff had not informed her that the whirlpool needed a disinfect for the past fourteen (14) months she had been the Unit Manager. She further stated the nurses, nurse managers, and housekeeping should be checking to ensure the whirlpool had disinfectant. She reported she would close the Whirlpool until she was better informed on the proper cleaning of the whirlpool. Interview with Nurse Manager #4, located on Magnolia Springs, on 06/18/15 at 12:00 PM, revealed out of order sign was placed on the whirlpool today and will stay on it until staff can verify proper cleaning and use of whirlpool. She was unsure how the whirlpool was cleaned. She stated CNA's and Housekeeping check disinfectant then check with him/her when it runs out and he/she would contact Maintenance and Central Supply. Continued interview revealed she was unsure who mixed the disinfectant and replaced it in the tub. She revealed that infection control could be an issue, adding it wasNasty. She reported her expectations would be for staff to look at disinfectant and if unsure of procedure then find out. Interview with RN #2, located on Magnolia Springs, on 06/18/15 at 12:22 PM, revealed that she had not used the whirlpool. She reported she was unsure of how to use it correctly. Further interview from RN #2 revealed the Whirlpool should be cleaned before and after use. RN #2 reported this was important due to infection control. Continued interview with RN #2 revealed she was unsure of who would be responsible for refilling the disinfectant. Interview with CNA #14, on 06/18/15 at 11:30 AM, located on Millers Crossing, revealed the unit had an Arjo Rhapsody/Primo Whirlpool Model. She reported the whirlpool should be cleaned before and after each use. She stated she did not know how to replace the disinfectant, but would notify maintenance or Central Supply. While demonstrating the cleaning of the whirlpool, debris was found in the cap of the whirlpool tub, she reported that should not have been there. After spraying the disinfectant, CNA #14 did not allow the chemical to set adding she would immediately rinse the tub out with water. She stated Millers Hall used the Cen-Kleen IV. Interview with LPN/Unit Manager/MDS #3, on 06/18/15 at 11:50 AM, located on Millers Crossing, revealed everyone was in-serviced regarding the whirlpool on 06/17/15. She reported the current policy did not reflect how long the chemical should set on the surface of the whirlpool tub and reported there was some conflict regarding the chemical's use for Millers Hall. She reported the ADON wrote the policy, thus she would be the one to answer the discrepancy in the Manufactures Recommendation and the Facility's Policy. Continued interview with the acting Unit Manager revealed it would be her expectation that the debris in the whirlpool should not have been in the whirlpool and that it was cleaned correctly due to infection control concerns. Interview with Housemaker #3, on 06/17/15 at 11:40 AM, revealed she was not responsible for changing the disinfectant in the whirlpool. She reported that was the responsibility of the CNAs. Interview with the Homemaker Manager, on 06/17/15 at approximately 12:30 PM, revealed her staff was not responsible for ordering or cleaning the whirlpool, adding she did not know which chemical staff used to clean out the Whirlpool. She reported the responsibility was nursing. Interview with the Director of Maintenance, on 06/17/15 at 10:05 AM, revealed nursing staff maintained the whirlpools. He reported his job was to repair any maintenance concerns, not to clean or order disinfectant for the units. Interview with ARJO service technician on 6/19/15 at 1:15 PM, revealed he recommended the facility used ARJO's cleaning products due to no animal fats used. He stated the facility has since ordered two and a half cases of Cen-Kleen and it should arrive the following morning. Continued interview with the Service Technician revealed he serviced the whirlpools once a year to provide maintenance and, as needed, for problems with the whirlpool throughout the year. The Service Technician reported the whirlpool jets were disinfected throughout by using the yellow sprayer. He stated the chemical used for the whirlpool would clean the jets automatically. Additionally, he stated when spraying the whirlpool with bleach spray or Sani-Wipes, it would not clean the jets, therefore, he reported the jets were not being disinfected by the bleach spray or sani-wipes. Continued interview with the Service Technician revealed that the disinfectant sprayer would continue to work without solution in it; however, staff should check to see if any chemicals were in the whirlpool by checking the smell, soapy foam, and/or looking to see if any chemical/solution was in the whirlpool. Interview with Staff Development Coordinator, on 06/19/15 at 12:45 PM, revealed that training related to cleaning the whirlpool was discussed in class to new employees. She reported she reviewed the manufacturer recommendations with the staff. Continued interview with the Staff Development Coordinator revealed she instructed the staff on, how to check disinfectant level, how to fill with water, apply disinfectant, scrub or wipe down, allow to sit two (2) to ten (10) minutes, depending on what type of cleaner, how to hook up sprayer to jet, and how to clean the filter. The Staff Development Coordinator reported a returned demonstration was not a part of her training, she only provided the information to staff verbally. Further interview with the Staff Development Coordinator revealed, the preceptor's (seasoned CNA's) on the unit would continually provide in-service/demonstrations on cleaning the whirlpools to new employees. She reported the facility ensures the preceptors know how to clean the tubs based on their evaluations, before they show other CNA's how to clean it. Additionally, she reported there was no quality assurance monitoring done to ensure that the process was being done correctly. The Staff Development Coordinator reported it was important the whirlpool was cleaned correctly to prevent cross contamination. She reported the process for ensuring the whirlpools had disinfectant would be to notify their supervisor who would obtain the disinfectant from Central Supply. She reported the CNA should check to see if the whirlpool had disinfectant in it prior to cleaning the whirlpool. Interview with the Assistant Director of Nursing (ADON)/Infection Control Nurse, on 06/19/15 at 11:36 AM, revealed staff was trained how to clean the whirlpool upon hire. She reported staff was to follow the Manufactures Recommendations when it came to disinfecting the whirlpools. The ADON reported she would look at the current policy to see where the discrepancy with the Manufacture's Recommendations were. She reported she could not make any changes to the policy on her own. Continued interview with the ADON revealed staff should not have used the whirlpool if there was no disinfectant in the whirlpool tub to clean it. She reported it was important to clean the tub effectively to prevent the transferring of infections. Interview with the DON, on 06/19/15 at 1:35 PM, revealed she was not aware of the concerns related to the whirlpool and was not familiar with the policy. She reported staff was in serviced on how to disinfect the whirlpools, adding if we audited this, it was not done correctly. She reported it was important to ensure the whirlpool was cleaned correctly due to infection control. She further stated the Infection Control should do yearly competency related to disinfecting the whirl pools. Interview with the Administrator, on 06/19/15 at 5:45 PM, revealed she did not know when the facility began using the Classic disinfectant as opposed to the recommended disinfectant by the Arjo Company, Cen-Kleen IV. She reported she has since ordered the Cen-Kleen IV and that would be used for all of the whirlpools. Continued interview with the Administrator revealed that the cleaning of the Whirlpool should be completed by the Manufactures Recommendation. She reported it was important to clean the Whirlpool correctly because of infection control. 2. Review of the facility's policy Review of Nursing Infection Control Procedures, undated, revealed the dignity bag (bag containing the urinary drainage bag) and the Foley catheter tubing should not be allowed to touch the floor. Review of Resident #10's medical record revealed the facility admitted the resident on 03/24/09 with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE], revealed the facility assessed the resident as having short/long term memory loss. Observation, on 06/17/15 at 8:45 AM, revealed Resident #10 sitting in his/her wheelchair in the television area with the urinary catheter tubing laying on the floor under his/her wheelchair. State Agency Surveyor showed CNA #11 the catheter tubing on the floor and CNA #11 corrected the problem by removing the urinary tubing from the floor. Interview with CNA #11 on 6/17/15 at 8:45 AM, revealed the urinary catheter tubing should not have been on the floor due to germs and bacteria on the floor. Observation on 06/19/15 at 5:00 PM revealed Resident #10 sitting in his/her wheelchair in the hall with the urinary catheter tubing laying on the floor under his/her wheelchair. Interview with Unit Manager #3 and observation of Resident #10 on 6/19/15 at 5:05 PM, revealed the catheter tubing should not be touching the floor because of infection control. 3. Review of the facility's Catheter Care policy and procedure, revised 11/19/11, revealed care would be provided to residents with the presence of urinary catheters in a manner that would minimize risks of complications. The procedure stated do not hold catheter bag above bladder level. To minimize the risk of cross contamination, do not handle any equipment such as door knobs, call lights, or Resident's personal belongings with gloves. Wash your hands. Wearing gloves does not mean you don't have to wash your hands. Review of the facility's Catheter Irrigation policy and procedure, undated, revealed the nurse was to disconnect the catheter from the drainage tubing and cover the open end of the drainage tubing with a protector cap. Next, insert the syringe into the catheter opening and slowly instill the Normal Saline. Remove the syringe and allow the solution to drain into the collection basin. Repeat as necessary until flow returns easily. Remove the protector cap, clean the end of the drainage tubing with alcohol swab and reconnect to catheter. Observation on 06/18/15 at 3:40 PM of Resident #10 receiving catheter irrigation performed by LPN #1, revealed the nurse disconnected the indwelling urinary catheter from the urinary drainage tubing and irrigated the indwelling urinary catheter with fifty (50) milliliters (mls) of Normal Saline (NS) with a syringe. After irrigating with the NS he reattached the catheter to the urinary drainage tubing to allow NS to drain back into the urinary bag, instead of utilizing a basin per facility policy. LPN #1 repeated this procedure again; however, this time a new urinary bag was attached, after he/she sent the Certified Nursing Assistant (CNA) out of the room to find a new bag. LPN #1 was noted to lift the urinary bag higher than the Resident #10's bladder to show the surveyor the urine in the bag. After finishing the procedure, he left the contaminated gloves on and touched the side rail and lowered the bed using the bed control. Interview with LPN #1, on 06/18/15 at 4:05 PM, revealed he could not ensure that one hundred (100) cc's was returned during urinary catheter irrigation after irrigating and allowing the fluid to drain back into the used urinary drainage bag which already contained urine. He stated he had not been taught to empty the urine into a basin during irrigation, and had not been observed performing catheter irrigations since in nursing school which was years ago. Further interview revealed he could see how it was an infection control concern to raise the urinary catheter bag above the resident's bladder . LPN #1 also explained, gloves should have been removed and hands washed before touching the side rail and bed control after performing the catheter irrigation. Interview with the DON, on 06/19/15 at 1:35 PM, revealed that urinary catheter tubing should not be on the floor. She Stated during urinary catheter irrigation that urine was suppose

Based on interview, record review and review of the facility's policy, it was determined the facility failed to ensure the Physician was immediately notified when there was a significant change in the resident's physical status for two (2) of twenty-nine (29) sampled residents. Resident #16 was being treated for [REDACTED]. Diff) and review of bowel records revealed the resident had formed stools; however, when episodes of loose watery stools re-occurred the facility failed to inform the physician of the change in stool status. Resident #6's 06/07/15 weight was flagged as out range by the facility's computer system and when the weight of 163 pounds was compared to prior weights there was significant weight loss; however, the facility failed to notify the resident's Physician of the weight change. The findings include: Review of the facility's policy: Change of Resident Condition, Family and Physician Notification, revised date 03/02/13, revealed it was the expectation the Physician was notified, as soon as feasibly possible, regarding any significant change in the resident's physical status regardless of code status. Further policy review revealed the notification of the Physician should be documented in the medical record. 1. Observation on 06/16/15 at 10:45 AM of Resident #16 in his/her room, revealed a sign on the door which stated Listed Infections and Conditions Requiring Contact Precautions. Interview with Certified Nurse Aide (CNA) #10, at the same time as the observation revealed the sign may be with relationship to contact precautions; however, she was not aware if Resident #16 was considered to have contact precautions. Review of the clinical record for Resident #16 revealed on 06/09/15, the facility readmitted the resident with [DIAGNOSES REDACTED]. There was no documented evidence that the physician was notified when resident's symptoms returned for possible [MEDICAL CONDITION]; however, additional review of the resident's June 2015 Vitals Report dated 06/17/15 for Bowel Movements, revealed the resident had stool episodes on 06/12/15 at 7:15 AM listed as Continent Loose Consistency; 06/12/15 at 11:50 AM listed as Continent Loose Consistency; 06/15/15 at 5:52 PM listed as Continent Loose Consistency; and 06/16/15 at 4:22 PM listed as Incontinent Loose-Liquid Consistency. Interview, on 06/16/15 at 4:52 PM, with CNA #12 revealed she was not sure if the resident was under contact precautions. She further stated she had not worn a protective gown when she assisted the resident to the toilet. She stated she just informed Resident #16 had [MEDICAL CONDITION] on 06/16/15. Interview, on 06/16/15 at 4:58 PM, with Nurse Manager #4 revealed Resident #16 did not actively have diarrhea but was under contact precautions. She stated the nurse managers put contact precautions on the door and were expected to notify staff in the huddle room of the resident's condition. She stated the resident was not actively infected with [MEDICAL CONDITION] but was still taking [MEDICATION NAME]. Interview, on 06/16/15 at 5:13 PM, with the Assistant Director of Nursing (ADON), who also served as the Infection Control Nurse, revealed the resident was admitted to the facility with active [MEDICAL CONDITION]. She stated the resident was put on contact precautions and all staff was notified in the facility Huddle meeting. She stated Resident #16 no longer needed contact precautions, but standard precautions, because he/she had no active episodes of diarrhea. She stated the resident's use of [MEDICATION NAME], required regular standard precautions. Further interview, on 06/17/15 at 5:41 PM, with the ADON, revealed she had not been made aware that the resident's symptoms had returned. She stated the facility's process was to notify the physician to continue with contact precautions. She stated based on the observed Vitals Report for Bowel Movements the resident may still have [MEDICAL CONDITION]. She stated the facility failed in its process to notify her and the physician when the symptoms of [MEDICAL CONDITION] returned for Resident #16. She concluded the concern for the resident and the other resident's for failure to notify the physician and for failure to follow the facility's process, was the possibility of infection due to contact of [MEDICAL CONDITION] and improper contact precautions. Interview, on 06/17/15 at 6:13 PM, with the Director of Nursing (DON) revealed the facility failed to notify the physician of Resident #16's returned symptoms for [MEDICAL CONDITION]. She stated facility staff should have reported when changes occurred for the resident and the nurses should have asked questions with regard to the Vitals Report for Bowel Movements upon review. She stated it was her expectation that the resident receive additional testing at the point of returned symptoms and this would possibly occur through notification to the resident's primary care physician. The Charge Nurse, Nurse Manager and the MDS Nurse should have been aware that the resident's symptoms had returned and the nurse should have notified the physician. She stated it was her expectation that the facility nurses notify the physician once they became aware of the resident's recurring symptoms. 2. Review of the facility's policy: Weight Changes, revised date 11/11/13, revealed changes in weight were monitored, addressed, and communicated to the physician. The policy noted weights were done at least monthly and the last weight was compared to prior weights to determine progressive weight changes. Further review of the policy revealed the facility defined significant weight loss as a 5% change in one (1) month, a 7.5% change in three (3) months, and a 10% change in six (6) months. Review of the medical record revealed Resident #6 was admitted by the facility on 06/21/11 with [DIAGNOSES REDACTED]. The medical record noted the resident was palliative care, 04/24/15, with no aggressive treatment per family wishes. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 05/05/15, revealed the facility assessed the resident as severely cognitively impaired. Resident #6's comprehensive care plan revealed the resident was a significant weight loss risk and had a nutrition care plan developed which included monthly weights. Record review of Resident #6's vitals report of weights revealed on 06/07/15 the resident's weight was 163 pounds and was flagged, by the system, because the percent weight change in thirty (30) days was not in the acceptable range. Further review of the weights revealed the prior weight, recorded 05/20/15, was 174 pounds, and the percentage difference of 6.3% was a significant weight loss, per the facility's definition. In addition, there was a three (3) month significant weight loss of 11.9% (03/01/15 weight was 185 pounds) and a six (6) month significant weight loss of 17.7% (12/13/14 weight was 198 pounds). Further medical record review of resident progress notes revealed no documentation the Physician or the facility's Dietician were notified of the significant weight loss. Interview, on 06/18/15 at 1:09 PM, with Certified Nursing Assistant (CNA) #13 and at 06/19/15 at 4:47 PM with CNA #14 revealed residents were weighed at least monthly and entered into the system by CNA's. CNA #13 and #14 revealed resident weights were entered into the system and they were to notify nursing the if the weight was flagged as out of range. Interview, on 06/18/15 at 1:08 PM, with Licensed Practical Nurse (LPN) #4 revealed the CNAs notified the nurse if the system flagged a weight as being out of range and the floor nurse notified the Unit Manger of the out of range weight. Interview, on 06/19/15 at 5:00 PM, with LPN #4 revealed if the resident's weight was out of range they were supposed to notify the Dietician and Physician to determine if interventions were needed. LPN #4 revealed they documented the Physician was notified regarding the weight change. Interview, on 06/19/15 at 4:24 PM, with Registered Nurse (RN) #4/Unit Manager (UM) revealed if the resident's entered weight was out of range, a weight change of 4% or more from the prior weight, it flagged in the system and the CNA notified the nurse. RN #4/UM revealed the facility's process was not followed because the physician was not notified Resident #6's weight change. Further interview revealed it was important to notify the Physician because of the impact on the resident's nutrition and the the opportunity of a treatment change. Interview, on 06/19/15 at 10:30 AM, with the facility's Dietician revealed based on the 06/07/15 weight of 163 pounds, Resident #6 had significant weight loss compared to prior weights at intervals of one (1) month, three (3) months, and six (6) months. The Dietician revealed nursing was supposed to notify the Dietician and Physician of significant weight loss. Interview on 06/19/15 at 5:13 PM, with the Director of Nursing (DON) revealed the system was not followed because when the out of range weight was identified the Physician and Dietician were not notified to determine possible interventions.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to ensure a safe, clean and comfortable environment. Observation of the shower rooms on the 2nd floor revealed cracked flooring, cracked tile in the corners of the shower stall, safety strips missing on the floor, lime build up on the faucets, and leaking pipes behind the whirlpool. In addition, the whirlpool would not turn on from the tub and there was lime on the faucet in the shower. Furthermore, during tour rooms 209 and 228 had lime build up around faucets. The findings include: Review of the facility's policy titled, Bath room Cleaning and Raised Toilet Seats revised 02/12/13, revealed it was the facility's policy to provide proper care and cleaning to bath rooms. Continued review revealed, the proper methods and procedures for cleaning bathrooms were necessary to prevent the spread of harmful bacteria. Further review of the policy revealed staff should provide a One-Step disinfectant that should be left on clean surfaces and allowed to air dry for at least ten (10) minutes. Additionally, it was the policy to wash the basin and pipe under the wash basin. Review of the facility's policy titled, Work Orders, Maintenance, dated 10/01/2008, revealed maintenance work orders would be completed in order to establish a priority of maintenance service. Continued review of the policy revealed in order to establish a priority of maintenance service, work orders must be completed and reviewed by the maintenance department. It would be the responsibility of each staff member to fill out work orders when an area of concern was noted. A supply of work orders would be maintained in each neighborhood, dietary department, front office, laundry, and the therapy department. The Director of Maintenance would assign maintenance staff to pick up, review, and complete the work orders on a daily basis. Work orders that were not completed immediately would remain in the work order book (yellow copy) until the replacement part had arrived, or the necessary repair was completed. Additional review of the Facility's Policy revealed the Director of Maintenance was responsible for this policy. Observation of the shower rooms on the second floor on the initial tour of the facility, on 06/16/15 revealed cracked flooring, cracked tile in the corners of the shower stall, safety strips missing from the floor, lime build up on the faucets, leaking pipes behind the whirlpool, and a lime build up was noted on a faucet in the shower room. Furthermore, during tour observations on 06/16/15, rooms 209 and 228 had lime build up around faucets in those rooms. Observation on the first floor on unit one (1) revealed two tiles with cracked corners in the second shower in the Women's shower room and a sharp piece of material on the floor board sticking out of the entrance to the second shower of the Men's shower room. Interview with Certified Nurse Aide (CNA) #1, on 06/16/15 at 6:10 PM, revealed the one piece of the safety strip from the facility's second floor men's shower room, located on Autumn Woods, was missing. She reported all of the strips should have been pulled up and replaced, continued observation revealed a cracked tile on the corner of the shower stall. CNA #1 reported this was a safety concern because a resident could have a skin tear related to getting to close to the cracked tile. CNA #1 stated the safety strips were important so residents would not slip while in the shower. Continued interview with CNA #1 revealed there was a hole/dent in the flooring of the shower room. She reported she would normally put a towel over the hole to keep residents from falling. Additional interview with CNA #1 revealed a work request would be filled out for repairs if she noticed concerns with needed repairs throughout the facility, but added she did not fill out a maintenance request for the concerns noted within the bathroom. CNA #1 reported that based on her observation of the bathroom, it was not a homelike environment for the residents. Interview with CNA #3, on 06/17/15 at 9:55 AM, located in the women's bathroom of Willow Glen, revealed that while demonstrating to other CNA's in training on the procedure for cleaning the whirlpool, she was observed to go behind the whirlpool, using the valve near the pipes, to turn on the water. She reported she had done this for over three (3) years and was told by previous staff to turn the water on from the back of the tub. Further interview with CNA #3 revealed a maintenance request should have been completed adding, this did not create a homelike environment for the residents. Interview with Unit Manager #4, on 06/18/15 at 12:00 PM, located on Magnolia Springs, revealed she considered the two (2) cracked tiles outside the shower in the Women's Shower Room to be a hazard to the residents. She reported the cracked tile could result in a skin tear. Unit Manager #4 then placed a chair in front of cracked tiles to ensure the residents would not be injured. Further interview with Unit Manager #4 revealed the sharp piece sticking outside the shower room could result in a skin tear or a fall, adding it was not homelike or safe for the residents. Interview with Housemaker #3, on 06/17/15 at 11:40 AM, revealed housekeeping was responsible for cleaning the scaling around the faucet in the bathrooms, adding it was a part of their daily cleaning schedule. Continued interview with Housemaker #3 revealed she did not know how long it took for the scaling to build up, but added it was important it was cleaned because, it did not look good and it did not create a homelike environment for the residents. Interview with the Housemaker Manager, on 06/17/15 at approximately 12:30 PM, revealed it would be her expectation that staff would clean the faucets everyday and if they need other chemicals to clean the scaling off of the faucets, she would provide it to them. She reported she has asked her staff to check all of the residents' rooms and the shower rooms for scaling of the faucets. Continued interview with the Housemaker Manager revealed it did not create a homelike environment for the residents. Interview with Director of Maintenance, on 06/17/15 at 10:05 AM, revealed while in Willow Glen's women's shower/bathroom, it had been awhile since the shower floor fall strips had been taken up and replaced. He reported the broken tile outside of the shower must have occurred when a wheelchair ran over it, but would expect staff to report the broken tile to him if there were any areas in the shower that needed to be repaired. Continued interview with the Maintenance Director revealed he was not certain how long the whirlpool, located on Willow Glen, was leaking water in the back of the whirlpool, but reported it had been awhile and he was looking for a piece to replace it. He reported he had to replace the lines on the whirlpools for both Willow Glen, women's bathroom, and Autumn Woods, women's bathroom. Further interview with the Maintenance Director revealed staff should complete work order books, which were located at all Nursing stations and that someone from maintenance checked the books several times a day for work requests. Additionally, he reported he would expect staff to notify him for problems concerning maintenance. He stated he should have been notified of all maintenance concerns. The Maintenance Director reported housekeeping was responsible for the cleaning of the lime buildup around the faucets. He reported he would want the bathrooms to be homelike for his family, so he would expect the same for the residents. Interview with Director of Nursing (DON), on 06/19/15 at 1:35 PM, revealed that plumbing with leaking water, scaling on the bathroom faucets, and other facility maintenance/housekeeping concerns was not a homelike environment for the residents. She reported anyone could fill out a maintenance request at the nurses station; however, she was unsure how frequently maintenance checked the work order book. The DON reported it would have been her expectation of staff that they would fill out work requests when a problem was noted. Interview with the Administrator, on 06/19/15 at 5:45 PM, revealed it would be her expectation that staff would fill out work orders when they noticed maintenance was required. She reported this was important for the safety and cleanness of the residents.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure the Comprehensive Plan of Care was revised for one (1) of twenty-nine (29) sampled residents (Resident #26). Resident #26's Care Plan was not revised related to contact precautions and [MEDICAL CONDITIONS] (a very contagious bacterial organism that causes an infection of the intestinal tract). The findings include: Review of Resident #26's clinical record revealed the facility admitted the resident on 05/30/15 and readmitted the resident on 06/13/15 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #26 as having a Brief Interview for Mental Status of a eight (8) out of fifteen (15) indicating cognitive impairment. Review of the Resident Progress Notes dated 06/16/15, at 8:17 PM, revealed Resident #26 had foul smelling loose bowel movement (BM), the Physician was notified and orders were received to send a stool to the lab to test for [MEDICAL CONDITIONS] (a very contagious bacterial organism that causes an infection of the intestinal tract). Review of the laboratory data revealed the stool specimen was collected on 06/17/15 and was reported on 06/17/15 as [DIAGNOSES REDACTED] positive. Further review of the Resident Progress Notes, dated 06/17/15 at 5:36 PM, revealed Resident #26 had positive results for [MEDICAL CONDITION], and a message was left for the Physician. Review of the Notes dated 06/17/15 at 6:38 PM, revealed a message was received from the Physician related to the positive [MEDICAL CONDITION] results with new orders received for [MEDICATION NAME] 500 milligrams (mg) three (3) times a day for ten (10) days (antibiotic medication), [MEDICATION NAME] 250 mg two (2) times a day for ten (10) days ([MEDICATION NAME]) and contact isolation until loose stool resolves. Review of Resident #26's physician's orders [REDACTED]. Review of the Comprehensive Plan of Care, dated 06/01/15, revealed no documented evidence the Care Plan was revised related to the [DIAGNOSES REDACTED]. Observation, on 06/18/15 at 5:10 PM, revealed there was no signage on the resident's door to alert staff, family, and visitors of the need to see the nurse before entering the room. In addition, there was no personal protective equipment (gloves, gowns) outside the resident's door accessible for use. Interview with Certified Nursing Assistant (CNA) #14, on 06/18/15 at 5:10 PM, revealed she had been assigned to Resident #26 since 7:00 AM that morning. She stated she was aware the resident had [MEDICAL CONDITION] and was in contact isolation and she was to use contact precautions, although there was no signage on the resident's door. Continued interview revealed after reviewing the CNA Care Plan, there was no contact precautions noted to alert the CNA's. She stated she knew the resident had [MEDICAL CONDITION] from the morning report which she received from the nurse and also she received report from the CNA who was going off duty. Interview, on 06/18/15 at 5:25 PM, with Registered Nurse (RN) #2, revealed she was assigned to Resident #26 and was aware the resident was on contact isolation precautions for [MEDICAL CONDITION]. She stated Resident #26 was receiving [MEDICATION NAME] (antibiotic medication) and the staff was to wear gloves when caring for the resident as well as gowns if the resident had [MEDICAL CONDITION] or if there was a large amount of stool and staff would also need to wear a gown to make the bed and change bed linens. Further interview revealed there should be signage on the door stating see nurse before entering to alert visitors, staff, and family of the precautions needed. RN #2 stated visitors would need to wear a gown if they went in to visit and were at risk if there was no signage on the door. Continued interview revealed the Care Plan should have been revised to include interventions related to the [MEDICAL CONDITION]. The MDS Coordinator was unable to be interviewed related to being off on leave. Interview with the Director of Nursing (DON), on 06/19/15 at 1:30 PM, revealed for any MDRO and [MEDICAL CONDITION], there should be signage on the door in order to alert family and visitors of the need to check with the nurse before entering. Further interview revealed gowns were available for use and kept at the nurses station and she did not think it was necessary to always wear a gown for incontinence care or changing bed linens for a resident with [MEDICAL CONDITION]; however, review of the facility Contact Precautions Policy, revealed a gown was needed to enter the room of a resident who had diarrhea caused by [MEDICAL CONDITION] if substantial contact with the resident or environmental surfaces was anticipated. Continued interview revealed the MDS Coordinators revised the Care Plans and Resident #26's Comprehensive Plan of Care should have been revised related to the resident's [DIAGNOSES REDACTED].