**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interviews, and facility policy, the facility failed to ensure bed hold notice was signed by residents and or the resident's responsible person when residents transferred out of the facility, or on therapeutic leave, and failed to provide written notice of bed hold for 3 of 3 residents reviewed (Residents #3, #11 and #28). The facility reported a census of 32 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #3 documented diagnoses of diabetes mellitus, renal insufficiency and chronic lung disease. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Review of Resident #3's census tab revealed the following information: a. 1/29/25- hospital unpaid leave b. 1/31/25- resident returned to the facility, status active. Review of Progress Notes for Resident #3 revealed the following: a. 1/29/25 at 10:02 PM- resident enroute to hospital via ambulance. Review of the bed hold dated 1/29/24 revealed verbal authorization from Resident #4 but lacked the resident's signature. 2. The MDS assessment dated [DATE] for Resident #11 documented diagnoses of depression, renal insufficiency, and hypertension. The MDS showed the Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. Review of Resident #11's census tab revealed the following information: a. 3/27/25- therapeutic leave b. 4/7/25- resident returned to the facility, status active. Review of Resident #11's Progress Notes revealed the following: a. 3/27/25- resident staying overnight with family. Review of the bed hold dated 3/27/25 revealed verbal authorization from Resident #11 but lacked a resident or representative signature. 3. The MDS assessment dated [DATE] for Resident #28 documented diagnoses of stroke, hypertension and depression. The MDS showed the BIMS score of 14, indicating no cognitive impairment. Review of Resident #28's census tab revealed the following information: 10/1/24- hospital unpaid leave 10/4/24- active Review of Progress Notes revealed the following: 10/1/24 at 6:49 p.m., resident left the facility to the local hospital emergency room (ER) for evaluation. 10/1/24 at 10:40 p.m., resident in local ER 10/4/24 at 1:00 p.m., resident returns from the hospital at this time with new orders. Review of the bed hold dated 10/1/24 revealed verbal authorization from Resident #28 but lacked a resident or resident representative's signature. Review of the facility provided policy titled Bed Hold Policy undated revealed this notice will be provided to the resident or resident representative prior to transfer or within 24 hours in case of emergency transfer. Interview on 4/9/25 at 10:17 a.m., with the Director of Nursing revealed the facility does not get a signature on the bed holds but they do them as the resident is leaving the facility or they call the family the next morning.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, the facility failed to refer 1 resident with a negative Level I result for the Preadmission Screening and Resident Review (PASRR), who was later identified with newly evident or possible serious mental disorder, intellectual disability, or other related condition, to the appropriate state-designated authority for Level II PASRR evaluation and determination for 1 out of 2 residents (Resident #7) reviewed for PASRR requirements. The facility reported a census of 32 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #60 documented diagnoses of anxiety disorder, depression, psychotic disorder and post traumatic stress disorder (PTSD). The MDS included a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. Review of the active diagnosis list in the clinical record revealed the following diagnosis: a. Major depressive disorder b. Post Traumatic Stress Disorder c. Psychotic disorder with delusions d. Anxiety disorder Review of the Order Summary Report signed 4/3/25 by the physician revealed the following diagnosis: a. Psychotic disorder with delusions b. Anxiety disorder c. Major depressive disorder d. PTSD Review of the PASRR dated 1/27/2020 lacked inclusion of psychotic disorder and PTSD. The clinical record lacked an updated PASRR to include psychotic disorder and PTSD. The facility does not have a PASRR policy and follows the Maximus guidelines. Interview on 4/9/25 at 10:23 a.m., with the Director of Nursing revealed the psychotic disorder and PTSD should be on the PASRR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview the facility failed to revise and update care plans to include and address high risk medications and side effects to watch for included in the comprehensive care plans (Resident #5, #7, and #28). The facility reported a census of 32 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #5 documented diagnoses of depression and anxiety disorder.The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Review of Resident #5's April Medication Administration Record (MAR) revealed an order for tramadol as needed for pain with a start date of 1/5/23. Review of Resident #5's Order Summary Report signed and dated 3/3/25 revealed an order for tramadol as needed for pain with an order date of 1/5/23. Review of the Care Plan with a revised date of 4/8/25 lacked non-pharmacological interventions to use prior to the usage of pain medications. 2. The MDS assessment dated [DATE] for Resident #7 documented diagnoses of anxiety disorder, depression, psychotic disorder and post traumatic stress disorder (PTSD). The MDS showed the BIMS score of 15, indicating no cognitive impairment. The MDS revealed resident took opioid medication in the last review period. Review of Resident #7's April MAR revealed an order for hydrocodone-acetaminophen (opioid medication) as needed for moderate to severe pain with a start date of 4/10/24. Review of Resident #7's Order Summary Report signed and dated 4/3/25 revealed an order for hydrocodone-acetaminophen as needed for moderate to severe pain with an order date of 4/10/24. Review of the Care Plan with a revised date of 4/7/25 lacked information regarding usage of opioid medications, side effects to watch for and non-pharmacological interventions to use prior to medications 3. The MDS assessment dated [DATE] for Resident #28 documented diagnoses of anxiety disorder and depression. The MDS showed the BIMS score of 14, indicating no cognitive impairment. The MDS revealed resident took opioid medication in the last review period. Review of Resident #28's April MAR revealed an order for hydrocodone-acetaminphen twice a day with a start date of 3/18/25. Review of Resident #28's Order Summary Report signed and dated 3/3/25 revealed an order for hydrocodone-acetaminophen twice daily with an order date of 12/11/24. Review of the Care Plan with a revised date of 4/7/25 lacked non-pharmacological interventions to use prior to the usage of pain medications. Interview on 4/9/25 at 10:15 a.m., with the Director of Nursing revealed she would expect pain medication to be listed on the care plan along with side effects to watch for with usage, non-pharmacological interventions to try prior to medication usage. Review of the facility provided policy titled Care Plan Policy and Procedure dated 4/1/2020 revealed a complete care plan is completed within 21 days of admission per RAI manual. This plan is to capture a comprehensive evaluation of each resident ' s physical and emotional needs.

Based on observation, clinical record review, staff interview, and per the current Centers for Disease Control and Prevention (CDC) guidelines the facility failed to use Enhanced Barrier Precautions (EBP) to prevent the spread of multidrug-resistant organisms (MDROs) during wound care for 1 out 1 resident reviewed (Resident #3). The facility reported a census of 32 residents. Findings include: Observation on 4/9/25 at 10:26 AM for Resident #3 showed the Infection Preventionist (IP) completed hand hygiene, donned gloves and removed the left lower leg wraps and soiled dressing. The IP discarded the dressing, removed soiled gloves, performed hand hygiene and initiated the dressing change to the left lower leg wound. During the dressing change the IP reported the resident had a history of leg wounds due to peripheral insufficiency. The resident stated, I've had this one for a long time and it's finally getting better, it's almost there. The IP completed the wound care as ordered. The IP failed to don additional Personal Protective Equipment (PPE) in accordance with EBP precautions at any time before or during the dressing change. In an interview on 4/9/25 at 10:54 AM, Resident #3 reported staff failed to wear a protective gown during dressing changes. The resident stated, they used to get dressed up in all that garb when I was in the hospital but not here. The resident reported the next appointment with the wound nurse is tomorrow 4/10/25. In an interview on 4/9/25 at 11:01 AM, the IP reported recently reaching out to regional staff for direction regarding EBP requirements. The IP stated, we had so many people on EBP. The IP explained she received instruction not to use EBP for wound care unless infected with a MDRO. In an interview with the DON on 4/9/25 at 11:28 AM, the DON explained the facility followed Iowa Health Care Association (IHCA) and the latest Centers for Medicare and Medicaid Services (CMS) Quality, Safety & Oversight Group (QSO) dated March 20, 2024. The DON reported EBP is only needed for Multidrug-resistant organisms (MDRO), chronic wounds, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds and venous stasis ulcers. The DON stated, the wound is not considered chronic, it's not over 6 months. The Medical Doctor/Nursing Communication showed staff first notified the physician of Resident #3's left lower leg wound on 1/14/25. The physician ordered the resident to be referred to the wound clinic. The Order Summary Report dated 4/3/25 for Resident #3 identified a diagnosis of Methicillin Resistant Staphylococcus Aureus. The Center for Clinical Standards and Quality/Quality, Safety & Oversight Group Ref: QSO-24-08-NH GUIDANCE Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. EBP are indicated for residents with any of the following: -Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply; or -Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. -Wounds generally include chronic wounds, not shorter-lasting wounds, such as skin breaks or skin tears covered with an adhesive bandage (e.g., Band-Aid®) or similar dressing. Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. The Centers for Disease Control and Prevention website titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), visited 4/9/25, updated 7/12/22, and dated 4/2/24 revealed Enhanced barrier precautions expand the use of PPE and refer to the use of gown and gloves during high contact resident care activities that provide opportunities for transfer of MDROs to staff and clothing. MDROs may be indirectly transferred from resident to resident during these high contact care activities. Nursing home residents with wound and indwelling medical devices are at especially high risk for both acquisition of and colonization with MDROs. The use of gown and gloves for high contact resident care activities is indicated, when contact precautions do not otherwise apply, for nursing home residents with wounds and or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. The Centers for Disease Control and Prevention website titled, Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes dated June 28, 2024 identified question: May nursing homes stop using Enhanced Barrier Precautions if we screen the infected or colonized resident and they test negative for the novel or targeted MDRO. Residents colonized with a novel or targeted MDRO are intended to remain on Enhanced Barrier Precautions for the duration of their stay in a facility. Because MDRO colonization is typically prolonged and follow-up testing to determine clearance may yield false negatives, CDC does not recommend routine retesting of residents with a history of colonization or infection with a MDRO or discontinuation of Enhanced Barrier Precautions after a subsequent negative test.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview the facility failed to identify non-pharmacological interventions and targeted behaviors related to high risk medications in 5 out of 5 sampled residents reviewed (Resident #5, #7, #11, #13 and #28). The facility reported a census of 32 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #11 documented diagnoses of depression, renal insufficiency, and hypertension. The MDS showed the Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. Review of Resident #11's April 2025 Medication Administration Record revealed the following orders: Trazodone(antidepressant medication) daily with a start date of 12/2/24. Duloxetine (antidepressant medication) daily with a start date of 12/3/24. Review of the Care Plan with a revision date of 4/7/25 lacked non pharmacological interventions and targeted behaviors for the antidepressant medications. 2. The MDS assessment dated [DATE] for Resident #5 documented diagnoses of depression and anxiety disorder. The MDS showed the BIMS score of 15, indicating no cognitive impairment. The MDS revealed resident took antianxiety medication and antidepressant medications in the last review period. Review of Resident #5's April Medication Administration Record (MAR) revealed the following orders: a. Lexapro (antidepressant medication) daily with a start date of 2/25/25 b. Lorazepam (antianxiety medication) twice a day with a start date of 2/24/25 Review of Resident #5 ' s Order Summary Report signed and dated 3/3/25 revealed the following orders: a. Lexapro daily with an order date of 2/24/25 b. Lorazepam twice daily with an order date of 2/24/25 Review of the Care Plan with a revised date of 4/8/25 lacked non-pharmacological interventions to use with antidepressant and antianxiety medications and targeted behaviors for usage of antidepressant medication. 3. The MDS assessment dated [DATE] for Resident #7 documented diagnoses of anxiety disorder, depression, psychotic disorder and post traumatic stress disorder (PTSD). The MDS showed the BIMS score of 15, indicating no cognitive impairment. The MDS revealed resident took antipsychotic medication, antianxiety medication and antidepressant medication in the last review period. Review of Resident #7's April MAR revealed the following orders: a. Duloxetine (antidepressant medication) at bedtime with a start date of 8/8/23 b. Duloxetine at bedtime with a start date of 7/17/20 c. Lorazepam daily with a start date of 1/30/25 d. Quetiapine Fumarate (antipsychotic medication) with a start date of 3/18/25 e. Wellbutrin XL (antidepressant medication) with a start date of 2/14/24 Review of Resident #7's Order Summary Report signed and dated 4/3/25 revealed the following orders: a. Duloxetine at bedtime with an order date of 8/8/23 b. Duloxetine at bedtime with an order date of 7/17/20 c. Lorazepam daily with an order date of 1/29/25 d. Quetiapine Fumarate daily with an order date of 3/18/25 e. Wellbutrin XL daily with an order date of 8/7/24 Review of the Care Plan with a revised date of 4/7/25 lacked non-pharmacological interventions and targeted behaviors for the usage of antidepressant medication, antianxiety medication and antipsychotic medication. 4. The MDS assessment dated [DATE] for Resident #13 documented diagnoses of anxiety disorder and depression. The MDS showed the BIMS score of 15, indicating no cognitive impairment. The MDS revealed resident took antipsychotic medication, antianxiety medication and antidepressant medication in the last review period. Review of Resident #13's April MAR revealed the following orders: a. Buspirone (antianxiety medication) daily with a start date of 1/21/25 b. Lorazepam as needed with a start date of 3/10/25 Review of Resident #13's Order Summary Report signed and dated 4/3/25 revealed the following orders: a. Buspirone daily with an order date of 1/21/25 b. Lorazepam as needed with an order date of 3/10/25 Review of the Care Plan with a revised date of 4/8/25 lacked non-pharmacological interventions and targeted behaviors for the usage of antidepressant and antianxiety medications. 5. The MDS assessment dated [DATE] for Resident #28 documented diagnoses of anxiety disorder and depression. The MDS showed the BIMS score of 14, indicating no cognitive impairment. The MDS revealed resident took antianxiety medication and antidepressant medications in the last review period. Review of Resident #28's April MAR revealed the following orders: a. Duloxetine daily with a start date of 12/27/24 b. Xanax (antianxiety medication) with a start date of 12/11/24 Review of Resident #28's Order Summary Report signed and dated 3/3/25 revealed the following orders: a. Duloxetine daily with an order date of 12/11/24 b. Xanax daily with an order date of 12/11/24 Review of the Care Plan with a revised date of 4/7/25 lacked non-pharmacological interventions for usage of antianxiety medications and antidepressant medications and lacked targeted behaviors for the usage of antidepressant medications. The facility does not have a policy on unnecessary medication usage. Interview on 4/9/25 at 10:15 a.m., with the Director of Nursing revealed the resident should have non-pharmacological interventions and targeted behaviors for the high risk medications they are taking and should be listed on the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to assure a discharged resident had a discharge summary that included a recapitulation of the resident's stay for 1 resident reviewed (Resident #30). The facility reported a census of 29 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #30 scored 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident had diagnoses including enterocolitis due to clostridium difficile (c-diff). The Baseline Care Plan Summary dated 12/12/23 documented the resident admitted to the facility related to his c-diff. He was unable to care for himself at home and having as many as 10-12 episodes of diarrhea. He got very weak and unable to clean himself up. He started on a new medication for c-diff. He was very pleasant and said he wanted to get home so he didn't lose his ability to walk and be independent. He had good family support. Physical Therapy would work with the resident to strengthen him. On 1/3/24 at 3:37 p.m. the Progress Notes documented receipt of a signed fax by the physician related to the resident going home on 1/4/24. On 1/4/24 at 10:18 a.m. the Progress Notes documented the resident packed all personal belongings and received discharge paperwork. Home health aware, and the pharmacy had bubble packs ready for the resident to pick up. The resident left the facility at 10:50 a.m. with family. The resident's clinical record lacked a discharge summary including a recapitulation (recap) of the resident's stay. On 4/4/24 at 10:52 a.m. the Director of Nursing (DON) stated they did not do a recap on the resident, and they should have. The undated facility Discharge Summary/Recapitulation Policy documented a discharge summary would be completed for every resident at the time the resident discharged home. A recapitulation of the resident's stay would include diagnoses, treatments, therapies provided as well as a final summary of the resident's status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to assure restorative was completed as planned for 1 resident reviewed (Resident #22). The facility reported a census of 29 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #22 had long and short term memory problems and severely impaired skills for daily decision making. The resident depended on staff for activities of daily living. Diagnoses included Alzheimer's disease, and a seizure disorder. The Care Plan revised 3/15/24 identified the resident had limited physical mobility related to Alzheimer's, anxiety disorder, weakness, immobility, and dependence on staff. The interventions included nursing rehab/restorative: Passive range of motion (ROM) bilateral lower extremities (BLE): ankle flexion (flex)/extension, knee flex/extension, hip flex/extension and hip adduction/abduction x 10 repetitions (reps) 1 time/day 5-7 days/week as the resident tolerated. Nursing rehab/restorative: Passive ROM bilateral upper extremities (BUE): Finger (both hands) flex/extension, wrist (both) flex/extension, elbow (both) flex/extension, shoulder flex/extension & shoulder adduction/abduction x 10 reps 1 time/day 5-7 days/week as the resident tolerated. The POC Response History for Passive ROM bilateral upper extremities (BUE): Finger (both hands) flex/extension, wrist (both) flex/extension, elbow (both) flex/extension, shoulder flex/extension & shoulder adduction/abduction x 10 reps 1 time/day 5-7 days/week as the resident tolerated. The resident did not have upper extremity restorative 5-7 days per week the following weeks: a. 12/10-16/23, 0 times, b. 12/17-23/23, 4 times, c. 12/24-30/23, 4 times, d. 1/7-13/24, 4 times, e. 1/14-20/24, 4 times, f. 1/21-27/24, 3 times, g. 1/28-2/3/24, 3 times, h. 2/4-10/24, 2 times, i. 2/11-17/24, 1 time, j. 2/18-24/24, 3 times, k. 2/25-3/2/24, 4 times, l. 3/3-9/24, 4 times, m. 3/10-16/24, 3 times, n. 3/17-23/24, 4 times, o. 3/24-30/24, 3 times. Days not marked as done were checked not applicable. The POC Response History for Passive range of motion (ROM) bilateral lower extremities (BLE): ankle flexion (flex)/extension, knee flex/extension, hip flex/extension and hip adduction/abduction x 10 repetitions (reps) 1 time/day 5-7 days/week as the resident tolerated. The resident did not have lower extremity restorative 5-7 days per week the following weeks: a. 12/10-16/23, 1 times, b. 12/17-23/23, 4 times, c. 12/24-30/23, 4 times, d. 1/7-13/24, 4 times, e. 1/14-20/24, 4 times, f. 1/21-27/24, 2 times, g. 1/28-2/3/24, 1 times, h. 2/4-10/24, 2 times, i. 2/11-17/24, 5 times, j. 2/18-24/24, 2 times, k. 2/25-3/2/24, 2 times, l. 3/3-9/24, 1 time, m. 3/10-16/24, 3 times, n. 3/17-23/24, 0 times, o. 3/24-30/24, 0 times. Days not marked as done were checked not applicable. On 4/3/24 at 10:40 a.m. the Director of Nursing (DON) stated not applicable could mean refused. But there was no documentation why the resident didn't receive the exercises as often as indicated. She said they would not have had the staff to do them on the weekends. On 4/3/24 at 12:38 p.m. the MDS Coordinator stated she oversaw the restorative program, but she had not done any recent follow ups.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to provide a resident with a urinary catheter, care and services to prevent infection for 1 of 3 residents reviewed (Resident #8). The facility reported a census of 29 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #8 scored 6 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The resident required substantial/maximal assistance with lying to sitting, sit to stand, chair/bed to chair transfer, toilet transfer, and toileting hygiene. The resident had an indwelling urinary catheter. The resident's diagnoses included Parkinson's disease and neurogenic bladder. The Care Plan initiated 4/4/24 documented the resident had an indwelling catheter related to neurogenic bladder and urinary retention. The interventions included observing/recording/reporting the signs and symptoms of urinary tract infection (UTI): pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Staff to provide catheter cares. The resident was on antibiotic therapy related to a UTI. The Medication Administration Record (MAR) for April 2024 included the order for Cefdinir (antibiotic) 300 mg 2 times a day until 4/3/24. On 4/2/24 at 11 a.m. the resident sat in the recliner. The catheter bag hung from the garbage can, over the liner, with trash in the bag. On 4/2/24 at 11:45 a.m. Staff B Certified Nursing Assistant (CNA) and Staff C CNA provided pericare for the resident. Staff washed hands and gloved, sprayed washcloths folded to 1/4 with no rinse cleanser, and pulled the resident's pad back. Staff B wiped down the resident's right groin, turned the cloth, wiped down left groin, turned the cloth, wiped down the front of the genital area and tubing in 1 stroke. The 2 turned the resident to his left and Staff B wiped over the anal area and buttocks, turning the cloth with each wipe. Staff B and Staff C placed an incontinent pad before removing their gloves, then pulled up the residents pants, assisted the resident to sit, then stand and sit in his chair. Staff made the resident comfortable before washing their hands. On 4/2/24 at 2:03 p.m. the resident sat in the recliner, and the catheter bag laid on the floor. On 4/3/24 at 10:43 a.m. the resident sat in the recliner, and the catheter bag hung from the trash can. On 4/3/24 at 10:45 a.m. the Director of Nursing (DON) stated she would expect the catheter bag would not be hung on the trash can. The facility Competency Assessment Catheter Care, Urinary included: For male residents use a washcloth with warm water and soap to cleanse around the genital area, changing the position of the washcloth with each cleansing stroke. With a clean washcloth, rinse with warm water using the same technique. Using a clean washcloth with warm water and soap, cleanse and rinse the catheter from the insertion site to approximately 4 inches outward.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to assure residents and/or their representatives were educated on the options for the pneumonia vaccination and given the opportunity to accept or decline for 1 of 5 residents reviewed (Resident #18). The facility reported a census of 29 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #18 scored 13 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident's diagnoses included chronic obstructive pulmonary (lung) disease (COPD). The clinical record lacked documentation the resident had received a pneumococcal vaccine. The record lacked documentation the facility educated the resident/representative on the pneumonia vaccine. The record lacked a signed consent or refusal. On 4/4/24 at 11:08 a.m. the Director of Nursing (DON) stated she had not offered the resident the pneumonia vaccine. The undated facility Pneumococcal Vaccine Policy documented all residents would be offered the pneumonia vaccine on admission. The risks and benefits would be provided to all residents/representatives.

Based on record review and staff interview, the facility failed to assure residents had access to the most recent COVID-19 Vaccine for 1 of 5 residents reviewed (Resident #6). The facility reported a census of 29 residents. Findings include: The United States (US) Department of Health and Human Services documented the COVID-19 milestones included: On September 11, 2023 the Food and Drug Administration (FDA) approved and authorized the emergency use of the updated Moderna and -BioNTech COVID-19 vaccines formulated to better protect against currently circulating variants. On October 3, 2023 the FDA authorized the updated Novavax COVID-19 Vaccine, Adjuvanted (ingredient used in some vaccines that helped create a stronger immune response) (2023-2024 Formula) for individuals ages 12 and older. On 2/28/24 the Center for Disease Control (CDC) Director endorsed the CDC Advisory Committee on Immunization Practices' (ACIP) recommendation for adults ages 65 years and older to receive an additional updated 2023-2024 COVID-19 vaccine dose. The recommendation acknowledged the increased risk of severe disease from COVID-19 in older adults, along with the currently available data on vaccine effectiveness. Previous CDC recommendations ensured that people who were immunocompromised were already eligible for additional doses of the COVID-19 vaccine. Data continued to show the importance of vaccination to protect those most at risk for severe outcomes of COVID-19. An additional dose of the updated COVID-19 vaccine may restore protection that has waned since a fall vaccine dose, providing increased protection to adults ages 65 years and older. The clinical records for Resident #6 lacked documentation they, or their responsible party had been educated on the 2023-2024 COVID-19 vaccination, been offered, or received a dose of the vaccine. On 4/4/24 at 11:08 a.m. the Director of Nursing (DON) stated some of her residents received the Covid 23-24 vaccine at the clinic, and she did give some at the facility, but she had to get 10 at a time so she had to have enough residents who wanted it. Now she could get less at a time. She had not asked Resident #6 about it yet. The CDC's Stay Up to Date with COVID-19 Vaccines, updated March 7, 2024, documented: The CDC recommended the 2023-2024 updated COVID-19 vaccines to protect against serious illness from COVID-19. Everyone aged 5 years and older should get 1 dose of an updated COVID-19 vaccine to protect against serious illness from COVID-19. People who were moderately or severely immunocompromised may get additional doses of the updated COVID-19 vaccine. People aged 65 years and older who received 1 dose of any updated 2023-2024 COVID-19 vaccine should receive 1 additional dose of an updated COVID-19 vaccine at least 4 months after the previous updated dose. People who were up to date had a lower risk of severe illness, hospitalization and death from COVID-19 than people who were unvaccinated, or who had not completed the doses recommended for them by CDC.

Based on observation, review of the menu, and staff interview, the facility failed to follow the menu as written for 1 meal, and failed to assure menus were reviewed and approved by a dietician. The facility reported a census of 29 residents. Findings include: The noon menu for 4/3/24 included: A 6 ounce lade of creamed chipped beef, A (#8) 4 ounce scoop of mashed potatoes. A 4 ounce serving of green beans, A serving of bread. Staff A [NAME] served the noon meal 4/3/24. When she was done serving the main dining room the serving scoops she used were: A 4 ounce lade of chipped beef, A #12 scoop about 1/3 cup mashed potatoes, A 1/4 cup, 2 ounce green beans, and served 1/2 slice buttered bread. On 4/3/24 at 12:20 p.m. Staff A could not identify the scoop sizes she was using to serve lunch. She said they were all about 1/2 cup. The Dietary Manager (DM) was not completely sure either and they figured out what serving size she used, which were not the servings on the menu. The DM stated Staff A gave extra of the chipped beef gravy on top of the 1/2 cup, but did not give extra for all. The 2019 facility policy Menu Planning documented the nutritional needs of individuals would be provided in accordance with the established national standards adjusted for age, gender, activity level and disability, through nourishing, well balanced diets, unless contraindicated by medical needs. Regular and therapeutic menus would be written by the facility's food and nutrition professional in accordance with the facility's approved diet manual, or purchased from an approved vendor. The registered dietician nutritionist (RDN) or designee would approve all menus. The menus Sunday through Saturday had changes made in writing, none were signed by the dietician. On 4/4/24 at 10:12 a.m. the Administrator stated they were unable to get a dietician for awhile, now they had one from the hospital they were affiliated with. On 4/4/24 at 10:15 a.m. the DM stated the dietician they had started coming less and less, and then not at all, she thought before last March. The company they procured food from sent their menus, so she would email the dietician from the company to make changes. The DM would make changes to the menu if she knew the residents didn't like something. She said they now had the hospital dietician and she came once a month. She did ask for the menus the last time she was there. She did not sign them.

Based on observation and staff interview, the facility failed to assure they stored, prepared, distributed and served food in accordance with professional standards for food service safety. The facility reported a census of 39 residents. Findings include: 1) On 4/1/24 at 9:47 a.m. the stove hood appeared greasy/grimy in the area above where they were cooking. The sprinklers above the oven had greasy feel and fuzz removed. The panel above/in front of the stove hood had fuzz hanging intermittently all the way up. The Dietary Supervisor stated would need to find out when the hood was last cleaned. On 4/4/24 at 10:12 a.m. the Administrator stated they didn't find the oven hood on the cleaning schedule. They did clean it, but did not have a record of when last done. They did clean it on Monday and started a new form. The 2019 facility policy Cleaning Instructions: Hoods and Filters, documented stove hoods and filters would be cleaned according to the cleaning schedule, or at least monthly. 2) During the noon meal service Staff A [NAME] wore the same gloves throughout. She touched many surfaces including the steam table, utensils, menus, the refrigerator doors, and then touched a beef burger, reached in a bag of buns and retrieved one, picked up a tomato slice, and pulled a sandwich from a plastic bag with her hands wearing the same gloves. The 2019 facility policy, Bare Hand Contact with Food and Use of Plastic Gloves included staff would use clean barriers such as single use gloves, tongs, deli paper and spatulas when handling food. Gloves like hands got soiled. Anytime a contaminated surface was touched, gloves must be changed and hands washed. The FDA Food Code 2017 included if used, single use gloves should be used for only one task such as working with ready to eat food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occurred in the operation. 3) When finished serving the main dining room, Staff A temped the foods including the creamed chipped beef at 168 degrees. At 12:23 p.m. Staff C plated food for 5 residents in the North dining room. Staff C removed hot plate holders from the oven and put on trays in the food cart. She plated the food put on the hot plate holders and covered. Staff C closed the cart, and wheeled it to the north dining room. The plates were put on the table for the 3 residents who were there, and removed from the the hot plate. If not there the plated food remained covered and on the hot plate. The last resident arrived in the dining room at 12:43 p.m. The DS temped the mashed potatoes and chipped beef gravy at 120 degrees. The 2019 facility policy, Food Temperatures, documented all food must be cooked to appropriate internal temperatures, held and served at temperatures of at least 135 degrees.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, the facility failed to document an accurate code status for 1 of 16 residents reviewed for advanced directives (Resident #6). The facility reported a census of 26 residents. Findings include: The significant change Minimum Data Set (MDS) assessment tool dated [DATE], documented Resident #6 had diagnoses of hypertension, diabetes mellitus, thyroid disorder, seizure disorder, anxiety disorder, depression, psychotic disorder, and tracheostomy status. The MDS documented [DATE] as the resident's admission date. The Care Plan updated on [DATE] had a focus area for the resident to be a full code. The facility CPR (cardiopulmonary resuscitation) and DNR (do not resuscitate) form signed by the resident's son, who was the decision maker, on [DATE] and by the physician on [DATE] revealed a DNR status requested in the event his heart stopped beating. The Electronic Health Record (EHR) was blank under the code status listed in the resident profile area. In an interview on [DATE] at 10:20 AM, Staff A, Licensed Practical Nurse (LPN) reported she looked at the profile area in the EHR for a residents code status but stated there was also a paper copy of their advanced directive and code status in the front of each residents paper chart at the nurses station. In an interview on [DATE] at 12:15 PM, the Director of Nursing (DON) stated it was the expectation that all residents have a code status identified and available for staff review. The code statuses were to be reviewed and updated in the system with any changes in the appropriate places. The MDS coordinator was responsible to review and update the code status with any changes. The MDS coordinator left in [DATE] and the DON stated she was trying to keep up with this task but had missed this one. She further stated any code status changes go through the staff communication book to make staff ware of the change. In an interview on [DATE] at 2:15 PM, the DON stated the facility did not have a policy on advanced directives but it was the facility practice that if a resident does not have a signed DNR, they are to be considered a full code and treated as such.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews the facility failed to ensure food was labeled with dates after opening, labeled with product after removing from original package and discarded after product expiration date. The facility identified a census of 26 residents. Findings include: 1. An initial kitchen tour conducted on 1/19/23 at 12:43 p.m., of the freezer in kitchen revealed the following open items with no label and no open date ready for service: a. bag of frozen onion rings b. bag of curly fries c. chicken breast d. chicken patty e. fish filets f. frozen round meat g. sausage meat h. sausage patty i. strawberries 2. The following items were stored in the kitchens refrigerator open with no label or open date and ready for service: a. shredded cheddar cheese b. mozzarella cheese 3. The following items were stored in the refrigerator ready for service: a. caramel topping with and open date of 10/22 with and expiration date of 10/22/22 b. open caramel topping with no opening date c. jelled cranberry with an open date of 12/6/22 with and expiration date of 4/30/21 d. unopened summer pasta salad with received date of 12/28/22 with an expiration date of 1/5/23 e. potato salad with a received date of 1/3/23 with no open date f. 3 individual servings of blueberry yogurt with an expiration date of 12/15/22 g. 1 individual serving of blueberry yogurt with and expiration date of 11/28/22 h. open cottage cheese with no open date 4. The following items were stored in the kitchen dry storage ready for service: a. open box of graham crackers with and expiration date of 8/20/22 b. unopened bag of croutons with an expiration of 12/28/22 c. 2 bags of muffin mix with no label and no open date d. 2 open bags of white chocolate chips with a best by date of 12/22 e. 1 unopened bag of white chocolate chips with a best by date of 12/22 f. unopened bag of Reese's peanut butter chips with a best by date of 10/22 g. 2 unopened jars of hot fudge with best by date of 1/20/20 h. 3 boxes of au gratin potatoes with a best by date of 9/23/222 i. sesame oil with an open date of 4/23/22 and best by date of 7/1/22 j. unopened [NAME] sauce with a best by date of 8/31/22 k. open [NAME] cooking wine with a best by date of 8/12/21 l. open [NAME] cooking wine with a best by date of 10/3/22 m. open apple cider vinegar with a best by date of 9/18/22 n. unopened cooking wine with a best by date of 9/8/21 o. unopened box of white cheddar cheez-its with a best by date of 9/9/22 5. The following items were stored in the kitchens freezer in the dry storage area open with no label or open date and ready for service: a. 2 bags of omelets b. bag of garlic bread Review of the facility provided policy titled Dietary: Food Receiving and Storage with a revision date of 2014 revealed the following information: a. Foods shall be received and stored in a manner that complies with safe food handling practices. b. All refrigerated, frozen, and regular food items will be checked periodically for expiration dates. When refilling food items in their respective storage areas, staff should throw out expired food and or cooking products per the manufacturer suggested expiration date. c. Dry foods that are stored in bins will be removed from original packaging, labeled and dated. Such foods will be rotated using a first in - first out system. d. All opened foods stored in the refrigerator or freezer will be covered, labeled and dated. Interview on 1/9/23 at 1:25 p.m., with the Dietary Manager revealed there should not be any expired food in the kitchen and everything should be marked. Interview on 1/10/23 at 3:25 p.m., with the Administrator revealed there should not be expired food in the kitchen and everything should be labeled.