Based on observation, interviews, and the Centers for Disease Control (CDC) guidance, the facility failed to ensure vaccines were stored in a refrigerator without a freezer compartment for 1 of 3 medication storage refrigerators. Finding: A review of the United States (U.S.) Centers for Disease Control and Prevention: Vaccine Storage and Handling Toolkit dated 3/24/24 stated .Do not store any vaccine in a dormitory-style or bar-style combined refrigerator/freezer unit under any circumstances. On 2/11/25 at 4:00 p.m., during an observation of the First Floor Unit's Medication Room, a surveyor observed a dormitory style refrigerator (small combination refrigerator/freezer unit that is outfitted with one exterior door). The refrigerator contained several vials of purified protein derivative (for tuberculosis testing), and unit dose syringes of pneumococcal and influenza vaccines. On 2/11/25 at 4:20 p.m., the finding was confirmed by the charge nurse and the Infection Preventionist. On 2/12/25 at 10:15 a.m., the finding was discussed with the Administrator.

5. Review of Resident #26's current ADL self-care performance deficit care plan lacked interventions which included the assistance needed for him/her in the area of personal hygiene, lower and upper body dressing, bathing and shower transfers. On 2/11/25 at 2:08 p.m., the finding was discussed with the Director of Nursing. Based on record review and interview, the facility failed to ensure a person-centered comprehensive care plan was developed in the area of Activities of Daily Living (ADL's) to meet the preferences and goals which included interventions for assistance needed for each resident to attaining or maintaining his or her highest practicable quality of life for 6 of 14 residents care plans reviewed. (Residents 6, 11, 21, 47, 55, 26, and 61) Findings: 1. Review of Resident #6's current ADL self-care performance deficit care plan lacked interventions which included the assistance needed for him/her in the area of eating, personal hygiene, transfers, lower body dressing, bathing, toileting, bed mobility and ambulating. 2. Review of Resident #11's current ADL self-care performance deficit care plan lacked interventions which included the assistance needed for him/her in the area of eating, personal hygiene, lower body dressing, bathing and oral hygiene. 3. Review of Resident #21's current ADL self-care performance deficit care plan lacked interventions which included the assistance needed for him/her in the area of eating, personal hygiene, transfers, lower body dressing, bathing, toileting, bed mobility and ambulating. 4. Review of Resident #47's current ADL self-care performance deficit care plan lacked interventions which included the assistance needed for him/her in the area of personal hygiene, lower body dressing, bathing, toileting hygiene and oral hygiene. On 2/11/25 at 1:49 p.m., during an interview, the Licensed Practical Nurse Manager for the first floor stated, in the beginning of the year the Minimum Data Set assessments for GG - Functional Abilities were changed, which also changed the residents care plans. This change failed to update the residents' care plan to include the personalization for the assistance needed for each resident to attain or maintain his/her functional abilities. Review of Resident #55s current ADL self-care performance deficit care plan lacked interventions which included the assistance needed for him/her in the area of personal hygiene, lower and upper body dressing, bathing and shower transfers. On 2/11/25 at approximately 3:00 p.m. the finding was discussed with the Director of Nursing 6. Review of Resident #61's current ADL self-care performance deficit care plan lacked interventions which included the assistance needed for him/her in the area of eating, personal hygiene, transfers, lower body dressing, bathing, toileting and bed mobility. On 2/11/25 at approximately 2:00 p.m. a surveyor discussed the above findings with the Unit Director who confirmed that this information didn't automatically transfer with the new Electronic Medical Record system and would need to be added.

Based on record reviews, observations and interviews the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation by failing to ensure that two people who are authorized to administer medications signed the Shift Count page indicating that they counted all controlled substances at the change of shift for multiple shifts, on 2 of 2 units reviewed. Findings: A review of the facility's Shift Count policy and procedure dated: 2/3/2000, stated under Procedure, 1. All schedule II-V medications will be counted at the change of each shift by the off-going and the on-coming nurse. 3. If the count is correct, the keys change hands and the shift count sheet is signed by both nurses. On 2/11/25 at 11:00 a.m., during a medication storage observation of the Second Floor Medication Room, a surveyor reviewed the Controlled Substance Books and Shift Counts which indicated the facility counts at the change of each shift, approximately 3 times a day. The person authorized to administer medications coming on duty or the person authorized to administer medications going off duty both failed to sign the Shift Count page of the Controlled Substances Book that indicated the controlled substances count was completed on multiple days. On 2/11/25 at 11:45 a.m., the surveyor confirmed the findings with the Unit Manager. On 2/11/25 at 3:30 p.m., the findiing was discussed the findings with the Administrator. On 2/11/25 at 4:00 p.m., during a medication storage observation of the First Floor Medication Room, a surveyor reviewed the Controlled Substance Books and Shift Counts. The person authorized to administer medications coming on duty or the person authorized to administer medications going off duty both failed to sign the Shift Count page of the Controlled Substances Book that indicated the controlled substances count was completed on multiple days. On 2/11/25 at 4:20 p.m., the surveyor confirmed the findings with the Charge Nurse. On 2/12/25 at 10:15 a.m., the surveyor discussed that multiple days on both units were missing staff signatures for verification and completion of the controlled medication count on the following dates: 6/16/24, 9/13/24, 10/2/24, 10/3/24, 11/3/24, 11/6/24, 11/16/24, 11/23/24, 12/2/24, 12/12/24, 12/29/24, 1/3/25, 1/18/25, 1/24/25, 1/25/25, 1/26/25 (both units), 1/27/25, 2/9/25, and 2/10/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews, and facility policy, the facility failed to implement interventions outlined in resident's care plan in the area of Activities of Daily Living (ADL) for 1 of 5 residents reviewed during complaint investigations. (Resident 2). Findings: On 9/13/2024 at 10:19 a.m., the Department of Licensing received a complaint indicating ADL care was not being provided to Resident 2 as stated in the care plan. Review of facility policy Comprehensive Care Plans dated 9/3/94 states It is the policy of Pinnacle Health & Rehab [NAME] to develop a comprehensive care plan for each resident, based on the needs identified in the comprehensive assessment .Each resident's plan of care describes the services being furnished to attain or maintain the resident's highest practical level of functioning . Resident 2 was admitted on [DATE] and has diagnoses to include Parkinsons disease and is dependent on facility staff for all ADL needs. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident 2 had a Brief Interview for Mental Status (BIMS) of 11 of 15 indicating he/she has moderate cognitive impairment Review of R2's care plan, most recently updated on 8/27/24 revealed Problem: [Resident 2 has an ADL self-care performance deficit r/t Parkinson's with tremors and weakness. Goal: [Resident 2] and [his/her] family want [him/her] to maintain current level of function. Intervention: Staff assist with adls (Refer to tasks documentation); Oral hygiene and denture cleaning after each meal and bedtime; Toilet or change resident every 3-4 hours. Turn and reposition every two hours . Further review of Resident 2's entire clinical record lacked evidence that the above interventions were completed as written. During an interview on 10/2/24 at 12:14 a.m., Certified Nursing Assistant (CNA)1 indicated that Resident 2 needs total care with all ADL's. CNA1 further indicated Resident 2 doesn't really refuse much of anything, but if a resident refuses to do something, they should be reapproached to try again at a later time, if they still refused, inform the nurse and document the refusal in clinical record. During a review of Resident 2's clinical record with a surveyor on 10/1/24 at 3:15 p.m., the Administrator confirmed above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and policy review, the facility failed to provide a sanitary environment to help prevent the development and transmission of disease and infection on 1 of 2 rooms observed (room [ROOM NUMBER]). Findings: Review of facility policy Infection Prevention and Control dated 5/2023 states it is the policy of [Facility] to maintain and active infection prevention and control program (IPCP). The program is designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection. Observation of shared sink in room [ROOM NUMBER] on 10/1/24 at 9:07 a.m., and 1:10 p.m., revealed the following items unlabeled and available for use: 2 deodorant bottles, 2- 8 ounce bottles of body wash, 1 bottle of mouthwash, 1 can of shaving cream. 1 opened can of ginger ale, 1 electric razor, approximately 8 razors held together with a rubber band, one small, soiled basin, and 1 white paper cup containing 1 toothbrush. During an interview on 10/1/24 at 9:20 a.m., Resident 3 confirmed his/her personal hygiene items are on the sink and he/she can independently use them, stating he/she just grabs what he/she needs and is unsure who it belongs to because they're not labeled. During an interview on 10/1/24 at 1:00 p.m., Resident 2 indicated that he/she does have personal items on the shared sink, but his/her family are the ones that retrieve it for him/her. During an interview on 10/1/24 at 1:10 p.m., Licensed Practical Nurse (LPN)1 and a surveyor entered room [ROOM NUMBER] and confirmed personal items were on shared sink, unlabeled and available for use. The above was discussed with Administrator on 10/1/24 at 3:10 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews, and facility policy, the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 5 residents records reviewed during complaint investigations (Resident 2). Findings: On 9/13/2024 at 10:19 a.m., the Department of Licensing received a complaint indicating ADL care was not being provided to Resident 2 as stated in the care plan. Review of facility policy Activities of Daily Living dated 1/1/95 states .Activities of daily living include bathing, dressing, ambulation and transfer, eating, and use of speech, language or other functional communication systems.the care plan will identify any unique needs or special treatment and services necessary to maintain or improve functional ability. Resident 2 was admitted on [DATE] and has diagnoses to include Parkinson's disease and is dependent on facility staff for all ADL needs. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident 2 had a Brief Interview for Mental Status (BIMS) of 11 of 15 indicating he/she has moderate cognitive impairment. Review of Resident 2's care plan, most recently updated on 8/27/24 revealed Problem: [Resident 2 has an ADL self-care performance deficit r/t Parkinson's with tremors and weakness. Goal: [Resident 2] and [his/her] family want [him/her] to maintain current level of function. Intervention: Staff assist with adls (Refer to tasks documentation); Oral hygiene and denture cleaning after each meal and bedtime; Toilet or change resident every 3-4 hours. Turn and reposition every two hours . Review of Resident 2's clinical record [task] lacked documented evidence Resident 2 was provide oral hygiene and denture cleaning as follows: after breakfast on 9/2/24, 9/3/24, 9/4/24, 9/5/24, 9/6/24, 9/8/24, 9/9/24, 9/10/24, 9/11/24, 9/12/24, 9/14/24, 9/15/24, 9/16/24, 9/17/24, 9/18/24, 9/19/24, 9/23/24, 9/27/24, 9/28/24, 9/29/24. After lunch on 9/7/24, 9/8/24, 9/9/24, 9/11/24, 9/13/24, 9/14/24, 9/16/24, 9/20/24, 9/21/24, 9/22/24, 9/23/24, 9/25/24, 9/26/24, 9/27/24, or 9/28/24. after dinner on 9/2/24, 9/3/24, 9/4/24, 9/5/24, 9/6/24, 9/7/24, 9/8/24, 9/9/24, 9/10/24, 9/11/24, 9/12/24, 9/13/24, 9/14/24, 9/15/24, 9/16/24, 9/17/24, 9/18/24, 9/22/24, 9/26/24, 9/27/24, or 9/28/24, and at bedtime on 9/2/24, 9/18/24, 9/19/24, 9/20/24, 9/21/24, 9/23/24, 9/25/24, 9/29/24, or 9/30/24. Review of Resident 2's clinical record [task] Toilet or change resident every 3-4 hours(total of 5-6 times daily) revealed Resident 2 was toileted 1 (one) time on 9/14, 2 (two) times on 9/2/24, 9/7/24, 9/8/24, 9/9/24, 9/11/24, 9/16/24, 9/23/24, 9/27/24, 9/28/24 and 9/30/24, and was toileted 3 (three) times on 9/3/24, 9/4/24, 9/5/24, 9/6/24, 9/10/24, 9/12/24, 9/13/24, 9/15/24, 9/17/24, 9/18/24, 9/19/24, 9/20/24, 9/21/24, 9/22/24, 9/24/24, 9/25/24, 9/26/24 and 9/29/24. Review of Resident 2's clinical record [task] Turn and Reposition (per care plan total of 12 times daily) revealed Resident 2 was turned/repositioned 1 (one) time on 9/14/24, 2 (two) times 9/7/24, 9/8/24, 9/9/24, 9/11/24, 9/16/24, 9/23/24, 9/27/24, 9/28/24 and 9/30/24. 2 (two) times on 9/3/24, 9/4/24, 9/5/24, 9/6/24, 9/10/24, 9/12/24, 9/13/24, 9/15/24, 9/17/24, 9/18/24, 9/19/24, 9/20/24, 9/21/24, 9/22/24, 9/24/24, 9/25/24, 9/29/24 and 9/26/24. During an interview on 10/2/24 at 12:14 a.m., Certified Nursing Assistant (CNA)1 indicated that Resident 2 needs total care with all ADL's. CNA1 further indicated Resident 2 doesn't really refuse much of anything, but if a resident refuses to do something, they should be reproached to try again at a later time, if they still refused, inform the nurse and document the refusal in clinical record. During a review of Resident 2's clinical record on 10/1/24 at 3:15 p.m., the Administrator confirmed above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to adequately maintain maintenance services necessary to maintain in good repair and sanitary condition of arm rests of resident's wheelchair, ceiling tiles in hallways and common areas, and thresh-hold of elevator entrance. Findings: 1. On 11/13/2023, at 10:37a.m. surveyor observed wheelchair arms cracked for Resident #5, in room [ROOM NUMBER], creating an uncleanable surface. 2. On 11/14/2023 at 2:00p.m. during an environmental tour with Director of Facilities Management, the following were observed: First floor: Three stained ceiling tiles above the microwave area in the Main Dining Room Three stained ceiling tiles, just outside of the elevator on the first floor Second floor: Three stained ceiling tiles just outside the elevator in the main hallway Three stained ceiling tiles in the 300-wing hallway just outside of room [ROOM NUMBER] 3. On 11/14/2023 at approximately 3:00p.m. surveyor observed thresh-hold floor plate exiting the elevator was buckled in two different places allowing a gap and creating a trip hazard. On 11/14/2023 at approximately 3:05p.m. all the above were reported and confirmed with the Director of Facilities Management and Administrator.

Based on observations, record reviews, and interviews, the facility failed to ensure proper medication and biological storage temperatures for 2 of 3 medication refrigerators in 1 of 2 medication storage rooms. Finding: On 11/14/2023 at 1:00 p.m., a surveyor observed the 2 medication refrigerators in the first-floor medication storage room. The upper refrigerator contained insulin, and 2 locked boxes for controlled liquid medications. The second refrigerator contained tuberculin purified protein derivative, influenza, and pneumococcal vaccines. Observation of the temperature logs for the medication refrigerators noted multiple shifts were lacking documentation. The Certified Nursing Assistant-Medications confirmed the finding. On 11/15/2023 at 9:50 a.m., a surveyor observed the first-floor medication room and refrigerator temperature logs with a Licensed Practical Nurse who stated the temperatures are to be checked and documented by a licensed nurse at every shift change. A review of the temperature logs lacked evidence of temperature monitoring of medication room refrigerators as follows: November 1-15, 2023, noted incomplete documentation for 5 of 43 shifts. October 1-15, 2023, noted incomplete documentation for 11 of 45 shifts. The facility did not provide evidence of temperatures being monitored from October 16-31, 2023. September 1-30, 2023, noted incomplete documentation for 27 of 90 shifts. August 1-31, 2023, noted incomplete documentation for 30 of 90 shifts. A review of the facility's Immunization Vaccine Storage and Handling Policy and Procedure, with a revision date of 7/2023, stated 6. Refrigerator/freezer temperatures are checked at the change of each shift by a licensed nurse, as part of the medication count process. Temperatures must be within the range of 36-46 degrees Fahrenheit. On 11/15/2023 at 10:30 a.m., the finding was confirmed by the Administrator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interview, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and in a sanitary condition, on 2 of 2 floors (First and Second), and hallways, for 1 of 1 environmental tour. Findings: On 3/2/22 at 10:00 a.m., during the Environmental Tour with the Nurse Managers of the first and second floors, the following was observed: First-floor: The common hallways of the first-floor nursing unit were observed with a dark, dirty buildup along the edges and in the corners. The floors in rooms 131-138 have a dark, dirty buildup, in the corners, in the bathrooms around the toilet bases, and under the sinks. room [ROOM NUMBER] - The wall to the left of the light switch, is noted to have ripped sheetrock on the corner. The sink vanity has a large light-colored stain. room [ROOM NUMBER]- At the entrance to the room, the rubber strip under the door is coming loose. The wall next to the door frame has peeling paint with exposed sheetrock, the sink vanity has four (4) rusted screw heads, creating an uncleanable surface. The area next to the closet is missing a board over the heater, where a cable wire is observed with a loose cover plate and exposed insulation. room [ROOM NUMBER]-B, the floor mat had exposed foam and the zipper tab is broken creating a sharp edge. room [ROOM NUMBER]-B, has a loose board on the edge of the closet over the heater. On 3/2/22 at 10:30 a.m. the surveyor confirmed the first-floor environmental observations with the Nurse Manager. Second-floor: The common hallways of the second-floor nursing unit are observed with a dark, dirty buildup along the edges and in the corners. The floors in rooms 231- 238 are observed to have a dark, dirty buildup, in the corners, in the bathrooms around the toilet bases, and under the sinks. room [ROOM NUMBER]-the sink vanity is observed with broken laminate edges, exposing the wood, creating an uncleanable surface with sharp edges. The heater is observed with areas of rust. room [ROOM NUMBER]-the sink vanity is observed with broken laminate edges, exposing the wood, creating an uncleanable surface with sharp edges. room [ROOM NUMBER]-the sink vanity is observed with broken laminate edges, exposing the wood, creating an uncleanable surface with sharp edges. The elevated surface of the Nurses' station is observed with three strips of duct type tape. The Nurse Manager stated that it had been that way for a while. In addition, the lower surface of the counter has strips of blue painter's type tape on the laminate edges, all creating an uncleanable surface. On 3/2/22 at 11:30 a.m. the surveyor confirmed the second-floor environmental observations with the Nurse Manager.