Based on observation, interview, and record review, the facility failed to ensure 1 of 1 resident (R5) had been appropriately assessed for wheelchair size by therapy. Findings include: R5's 1/3/25, annual Minimum Data Set (MDS) assessment identified she had admitted to the facility in January of 2022, with intact cognition. She had no psychosocial behaviors, and required extensive assistance from staff to complete Activities of Daily Living (ADL). R5 had diagnoses of severe morbid obesity, arthritis, and reduced mobility. She had pain that occasionally interfered with her ADL and had a stage II pressure ulcer (characterized by partial-thickness skin loss). R5 was not receiving any therapy. Observation and interview on 3/24/25 at 2:57 p.m., of R5 in her room, identified she was seated in a recliner with her legs elevated. R5 identified she has asked for a new wheelchair. She reported she does not go to any activities or leave her room for anything. She would like to take part in activities but I'm stuck in here because it was so painful to sit in her wheelchair. Interview on 3/26/25 at 2:24 p.m., with the activity aid (AA)-A identified R5 used to come out for activities but then started refusing, she said its painful to sit in her wheelchair so she cant come to activities. AA-A identified she had reported the concern to the director of nursing but did not know if anything had been done. Interview on 3/26/25 at 2:28 p.m., with the nursing assistant (NA)-A identified she was aware R5 does not come out of her room because her wheelchair is uncomfortable. NA-A identified she had reported the refusals and the reason given to the director of nursing. Interview on 3/26/25 at 3:52 p.m., with the registered nurse (RN)-A identified she knew R5 refused to come out of her room but was not aware of the reason. She reports she thought that was her normal, she could not recall anyone telling her that it was because of her wheelchair being uncomfortable. R5's current, undated care plan identified R5: 1) Was at risk for feelings of powerlessness related to (r/t) her inability to regain strength and independence to return to her home as she had hoped on admission and was unable to take care of herself independently. R5 was noted to have preferred to stay in her room; resident expresses that she is fearful of falling; at times resident states/seems fearful of motion/movement in lift and in wheelchair. One of R5's goals was she would spend time out of her room as she feels up to it. 2) Was noted to be at risk for impaired individual coping r/t NH placement, impaired mobility, and at times would appear fearful of motion/movement with EZ-stand and when she was in her wheelchair as resident will scream, yell, and/or cry when staff is assisting her in EZ-stand and in her wheelchair, with an intervention to discuss resident fears with resident and inform the charge nurse when R5 was upset, screaming, yelling and/or crying. 3) Has little or no activity involvement r/t disinterest and immobility and physical limitations. Staff were to establish and record R5's prior level of activity involvement and interests by talking with the resident, caregivers, and family on admission and as necessary and required assistance/escort to activity functions. 4) has ADL self-care performance deficit r/t activity intolerance, morbid obesity, impaired mobility. 5) Chronic Pain r/t osteoarthritis, impaired mobility, and morbid obesity with a goal to not have an interruption in normal activities due to pain. Staff were to monitor/document for probable cause of each pain episode and remove/limit causes where possible and monitor resident's existing conditions which may increase pain and or discomfort. 6) has impairment to skin integrity r/t chronic peripheral edema (swelling of limbs),decreased mobility, obesity and refusals to be repositioned every 2 hours. Staff were to identify/document potential causative factors and eliminate/resolve where possible. R5 required a pressure relieving cushion to protect the skin while up in her chair. Review of R5's progress notes and medical record identified there was no mention if R5 had been assessed per the care plan above as to why she refused to be repositioned, or why she declined to be seated in her wheelchair. There was also no indication therapy had been notified to assess R5 for appropriate wheelchair size. Interview on 3/26/25, at 3:56 p.m., with the licensed practical nurse (LPN)-A reported R5 has the right to refuse. She identified she had never asked her why she refused to come out of her room, but she recalled her being uncomfortable sitting on the commode and states she is almost always uncomfortable. Interview on 3/27/25 at 1:54 p.m., with the administrator identified he agreed the facility had not reached out to R5's physician to request an assessment by therapy for an appropriate wheelchair and had no documentation identifying that they had attempted any interventions to improve R5's comfort while sitting in her wheelchair. The administrator identified he would have expected nursing to update R5's physician and request an order for her to be evaluated by therapy. Therapy was unavailable for interview. Review of the facilities undated Accommodation of Needs policy identified the facility would assist the resident in maintaining and/or achieving safe independent functioning, dignity and well-being. The resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, shall be evaluated upon admission and reviewed on an ongoing basis. Staff attitudes and behaviors must be directed towards assisting the resident in maintaining independence, dignity and well-being to the extent possible and in accordance with the residents' wishes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to notify the resident and/or their responsible party, in writing, of the facility's bed hold policy, including potential costs included with the bed hold, at the time of transfer to the hospital for 4 of 4 residents (R1, R8, R15 and R18). Findings include: R1's 3/5/25, end of PPS stay Minimum Data Set (MDS) assessment identified his cognition was intact and he required assistance of 1-2 staff for activities of daily living (ADLS). R1 utilized a wheelchair for mobility and had a chronic indwelling catheter. He had diagnosis of spinal stenosis, kidney failure, peripheral venous insufficiency, weakness and chronic pain. R1's 1/31/25 at 9:29 a.m., progress noted identified a call had been received from the MD that R1 had an elevated WBC and CRP and she would like him evaluated in the emergency department. R18's 2/7/25, quarterly MDS assessment identified her cognition was intact, and she required extensive assistance of 2 staff members for ADLS. She was non-ambulatory and had pressure reducing devices in her bed and chair. R18 utilized a wheelchair for mobility and had experienced a fall due to attempting to self-transfer from her chair to bed. R18's diagnosis list included heart failure, vitamin B12 deficiency, congestive heart failure (CHF), anxiety disorders, high blood pressure (HTN) and hypokalemia. R18's 11/26/24 at 8:03 a.m., progress notes identified an unidentified nursing assistant (NA) had gone to get R18 up for the day and found her unresponsive. R18's respirations were labored, she opened her eyes when spoken to, but was unable to verbally respond. Appropriate notifications were completed with a plan for transfer via ambulance to the ED for evaluation. R18 was admitted to acute care with a diagnosis of CHF exasperation, until she returned on 11/29/24. Review of R1 and R18's medical record identified there was no documentation of a bed hold provided to either the resident or his family members. Interview on 3/27/25 at 12:00 p.m., with the administrator confirmed the facility had not been providing bed holds to residents who were hospitalized and he was in the process of finding forms to be used for this process. R8's 2/21/25, significant change Minimum Data Set (MDS) assessment identified her cognition was intact, she had diagnosis of bi-polar disorder, post-traumatic stress disorder, anxiety, spinal stenosis, hallucinations, and diabetes mellitus. R8 was dependent on staff for transfers, dressing, and hygiene, and used a wheelchair for mobility. Review of R8's hospital course of stay summary identified she was admitted to the hospital on [DATE], with a diagnosis of a urinary tract infection and was discharged back to the facility on 3/24/25. Review of R8's medical record identified there was no documentation [NAME] support a bed hold notice had been provided. R15's 12/20/24, quarterly Minimum Data Set (MDS) assessment identified her cognition was severely impaired, she was dependent on staff for all activities of daily living (ADL)'s, and had diagnosis of hemiplegia (one sided paralysis due to a stroke), dementia, and oropharyngeal dysphagia (impairment in the ability to swallow). R15's 12/8/24, nursing progress note identified she had increased rapid respirations, sounded congested and was coughing. Her physician was notified and R15 was transferred to the hospital via ambulance for evaluation and treatment. R15's medical record lacked documentation a bed hold had been offered to the resident representative. Interview on 3/26/25 at 4:19 p.m., with the administrator identified he agreed with the above findings, and he would expect staff to offer a bed hold to either the resident or the resident representative prior to discharge or transfer to the hospital. Review of the facilities 11/20/19, Notice of Bed Hold policy identified they would provide a bed hold notice to the resident or the responsible party upon admission and at the time of leave.

Based on observation, interview, and document review the facility failed to ensure the hospice plan of care had been integrated with the facility care plan for 2 of 2 residents (R14 and R131) to delineate services provided between the facility and hospice. Findings include: R14's 2/7/25, significant change Minimum Data Set (MDS) assessment identified her cognition was severely impaired and she was dependent on staff to complete all activities of daily living (ADL)'s. R14 had diagnosis of heart failure, arthritis, Alzheimer's disease, chronic pain, and lymphedema. She had vocal indicators of pain, received scheduled pain medication, and had a life expectancy of less than 6 months. Review of R14's current care plan identified she would receive visits from hospice. The care plan lacked any indication when the visits would occur and did not identify what services the facility was to provide nor services the hospice agency was to provide. R131's 3/12/25, admission Minimum Data Set (MDS) identified he had a diagnosis of cancer and was admitted to the facility on hospice with a life expectancy of less than 6 months. Review of R131's care plan identified he was receiving hospice services and had a focus of comfort. The care plan lacked any delineation of what care the hospice agency was to provide verses what care the facility was to provide. Interview on 3/24/25 at 3:15 p.m., with the hospice registered nurse, identified they typically fax the hospice care plan to the facility within 48 hours. She identified they had some communication concerns with the facility staff recently and had to explain to the aids that the bath hospice provides must be in addition to the bathing provided by the facility staff. She also reported the facility aids are responsible for assisting the hospice aid with positioning and dressing when they are at the facility providing a bath, however, at times there are no staff available to assist. Review of the 2016 Comprehensive Person Centered Care Plan policy identified the facility would describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, Incorporate identified problem areas, incorporate risk factors associated with identified problems, reflect the resident's expressed wishes regarding care and treatment goals, and identify the professional services that are responsible for each element of care. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. The interdisciplinary team must review and update the care plan when there has been a significant change in the resident's condition.

Based on observation and interview the facility failed to avoid the potential risk of burns from 1 of 1 unattended Bunn brand coffee warmer used in the dining room. Findings include: Observation on 3/26/25 at 11:30 a.m., as an unknown dietary staff member entered the dining room and switched on the heating elements on a Bunn double element coffee warmer. The warmer was used to place glass coffee pots on during meals to keep the coffee hot. The coffee warmer with glass pots was positioned on a counter within easy reach of a resident walking or in a wheelchair. The warmer was observed to be very hot when a hand was held an inch above the surface, in addition to the glass coffee pots which held hot coffee. Neither dietary or nursing staff were consistently in the dining room, and no one was observed monitoring the coffee to ensure a resident did not attempt to serve themselves. Interview on 3/26/25 at 11:33 a.m. with the certified dietary manager (CDM), reported the Bunn coffee warmer was turned on prior to meals to allow it to become hot before the glass coffee pots were placed on it for service during the meal. She acknowledged the potential for burns if a resident attempted to self-serve coffee or touched the hot plate surface. The CDM reported she would make a change to utilize a pump type coffee server to eliminate the risk of a resident being burned. Interview on 3/26/25 at 11:55 a.m., with the administrator acknowledged the potential hazard the coffee warmer and glass coffee pots presented. He reported this was the system that had been utilized, but he had not identified the potential hazard. The administrator reported the facility would need to utilize a different method for serving coffee in the dining room and acknowledged the CDM had replaced the warmer and glass pots with a pump type pot for safety following the observation. A policy for safety in the dining room was requested, but not provided prior to survey exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R7's annual Minimum Data Set (MDS) dated [DATE], indicated severe cognitive impairment without hallucinations or delusions. R7 had diagnoses of neurocognitive disorder with Lewy bodies, Parkinson's disease with dyskinesia, bipolar disorder, mild dementia, major depressive disorder, and anxiety disorder. R7's physicians orders indicated the following psychotropic medication orders: quetiapine dated 1/9/25 (an antipsychotic). Informed consents regarding risks versus benefits of these medications were not found in the resident record. During interview on 3/25/25 at 4:54 p.m., Director of Nursing (DON) stated she was unaware of the requirement, and this had not been completed. DON stated understanding of the importance of residents and their representatives being aware of the risks verses benefits of the psychotropic medications being prescribed. There was no policy provided related to medication by the end of the survey. R8's 2/21/25, Significant Change Minimum Data Set (MDS) assessment identified her cognition was intact, she had diagnosis of bi-polar disorder, post-traumatic stress disorder, anxiety, and hallucinations. R8 was dependent on staff for transfers, dressing, and hygiene, she used a wheelchair for mobility. R8 took an antipsychotic and an antidepressant on a routine basis. R8's current, undated medication administration record (MAR) identified she was administered Abilify (anti-psychotic) 15mg oral tablet at bedtime and duloxetine HCI (antidepressant) 60 mg oral tablet daily in the morning. R8's medical record identified no documentation that a gradual dose reduction had been attempted since March of 2024. The medical record did not include any documentation that the resident or the resident representative had been educated on the risks and benefits of using psychotropic medications. R28's 2/27/25 admission Minimum Data Set (MDS) assessment identified his cognition was moderately impaired and he required extensive assistance from staff to complete activities of daily living (ADL)'s. R8 had diagnosis of atrial fibrillation, hypertension, and arthritis, but did not have any psychiatric mood disorders. R8 was being administered an antipsychotic on a routine basis. Review of R28's March 2025, medication administration record identified he was being administered quetiapine (antipsychotic) 25 milligrams orally twice daily for disorientation. R28's medical record lacked any documentation of an appropriate diagnosis for the use of an antipsychotic. Interview on 3/26/25 at 1:11 p.m., with the director of nursing identified she does not monitor or review medication for the need of a gradual dose reduction, she also has not completed any informed consents including an explanation of the risks and benefits of using psychotropic medication. she reports that the gradual dose reductions are done by the contracted pharmacist consultant. Interview on 3/27/25 at 11:16 a.m., with the pharmacist consultant identified that she reviewed R8 and R28's medications monthly, she agreed that R8 would be appropriate for a recommendation to have a gradual dose reduction.She also agreed that R28 does not have an appropriate diagnosis documented for the use of an antipsychotic and reports that she must have missed it. She identified she would expect the facility to provide education on risks and benefits to the resident and have that documented in the medical record. Interview with the administrator on 3/27/25, at 3:00 p.m., with the administrator agreed with the above findings and identified he would expect the facility to notify the primary physician when a gradual dose reduction is appropriate. He would also expect the nursing department to ensure residents and/or their representatives were informed of the risks and benefits and alternative treatments available to taking a antipsychotic medication and to ensure residents have an appropriate diagnosis for the use of psychotropic medications. Based on interview and record review the facility failed to obtain informed consents for the use of psychotropic medications for 6 of 6 residents, (R7, R8, R10, R18, R22 and R28). The facility also failed to act upon pharmacy reviews and provide justification for not attempting a gradual dose reduction (GDR) for 2 of 5 residents (R8 and R10) reviewed for unnecessary medications. Findings include: R10's 1/10/25 quarterly Minimum Data Set (MDS) assessment identified her cognition was intact, she was able to make choices to attend activities but required extensive assistance of 1 staff person for activities of daily living (ADLs). R10 had diagnosis of heart failure, high blood pressure, and major depressive disorder. R10's current physician orders identified an order for Venlafaxine (anti-depressant medication) extended release (ER) tablet 150 milligrams (mg) by mouth (PO) daily for major depressive disorder with a start date of 2/20/24. The 2/13/25 physician 60-day routine visit documented a pharmacy concern regarding her Venlafaxine (Effexor) dose, but the family had requested it not be changed. No GDR had been attempted, nor rational documented as clinically contraindicated. R10's paper and electronic medical record failed to provide documentation of the risk's verses benefit of the psychotropic medication to the resident and/or family and no consent for administration of the medication was provided. R18's 2/7/25 quarterly MDS assessment identified her cognition was intact, and she required extensive assistance of 2 staff persons for her ADLs. R18 had pressure reducing devices for both her bed and chair and mobility was via wheelchair due to limited mobility on one side. R18 had diagnosis of congestive heart failure, high blood pressure, arthritis, and anxiety disorder. R18's current physician orders identified an order for Cymbalta DR 30 mg PO every (Q) morning for neuropathy (a condition that affects the nerves, causing damage or dysfunction), depression and anxiety. 12/6/24 was identified as the start date for this medication and the medical record failed to provide documentation of the risk's verses benefit of the psychotropic medication to the resident and/or family and no consent for administration of the medication was provided. R22's 2/7/25 quarterly MDS identified his cognition was intact, he required moderate to extensive assistance with ADLS, and used a walker or wheelchair for mobility. R22 had an indwelling catheter, and received scheduled pain, insulin, antidepressant, anticoagulant, and diuretic medications. He had diagnosis of Type I diabetes, chronic pain, depression, polyneuropathy, urine retention, blood clots of his right lower extremity, swelling, malaise, and a fracture of the leg. R22's current physician orders identified an order for Cymbalta (anti-depressant) 30 mg PO QD started on 3/15/24 for depression/chronic pain syndrome. The medical record failed to provide documentation of the risk's verses benefit of the psychotropic medication to the resident and/or family and no consent for administration of the medication was provided. Interview on 3/26/25 at 2:47 p.m., with the director of nursing (DON), identified there were no consents obtained for residents who received psychotropic medications, and she was not aware this was required. She further reported the facility did not have a policy regarding consents for psychotropic medications.

Based on observation, interview, and document review the facility failed to ensure the use of appropriate personal protection equipment (PPE) was utilized during blood glucose testing, and subsequent insulin administration for 2 of 2 residents (R7 and R22). In addition, the facility failed to ensure mechanical lifts were regularly cleaned and/or disinfected between resident use. Findings include: Observation on 3/25/25 at 11:30 a.m., as licensed practical nurse (LPN)-A prepared to check R7's BS and administer his lunch time insulin. She retrieved the necessary supplies from the medication cart, retrieved a BS strip from the bottle and placed it into the meter, then went to the dining room and informed R7 she needed to check his BS and administer his insulin. R7 voiced agreement and was transported from the dining room to the tub room for privacy. LPN-A asked which finger he would like to use to test. R7 then held up a finger. With her un-gloved hands, she proceeded to use an alcohol wipe to wipe his finger, then dried it with a cotton ball, picked up the automatic lancet, and lanced R7's finger to obtain a drop of blood. LPN-A then took the meter with the strip in place and touched the drop of blood to the strip, then placed the cotton ball on R7's finger. Still using her un-gloved hands, LPN-A picked up the used lancet, cotton ball, and monitor strip and placed them into the left side pocket of her scrub top. LPN-A continued with her un-gloved hands and picked up the insulin pen, applied the needle, dialed the pen to 2 units, primed the pen, then dialed to the ordered 10 units of insulin and administered the dose in R7's left lower quadrant. LPN-A recapped the pen and placed it into the same scrub top pocket with the used blood glucose items. LPN-A transported R7 back to the dining room, and then returned to the medication cart, applied hand sanitizer, and removed the items from her pocket and disposed of the used lancet, cotton ball, and glucose strip into the sharp's container. She placed the meter on the top of the cart, with un-gloved hands, took the insulin pen from her pocket, removed the needle from the pen and disposed in the sharps container. She then obtained a purple labeled Sani wipe, applied gloves and wiped the surface of the meter for disinfection, wrapped the wipe around the meter and identified it would remain on the meter until dry. LPN-A did sanitize her hands after the conclusion of the deficient practice. Observation on 3/25/25 at 11:39 a.m. with LPN-A identified she reported she also needed to administer insulin to R22. LPN-A transported R22 from the dining room to the tub room for privacy, prepared his insulin pen by wiping the tip with alcohol, attaching the needle, priming with 2 units, then dialing the pen to a total of 14 units. R22 requested the insulin be administered into his right upper arm. With her un-gloved hands, she administered the insulin. LPN-A recapped the insulin pen placed it into her scrub top pocket, transported R22 back to the dining room, and returned to the medication cart. She then she removed the used needle from the insulin pen, disposed in the sharps container and returned the insulin pen to the medication cart drawer. She then cleansed her hands with hand sanitizer. Interview on 3/25/25 at 11:43 a.m., with LPN-A reported she should have been wearing gloves and performed hand hygiene, but stated was nervous at being observed and had forgotten. Interview on 3/25/25 at 11:55 a.m., with the director of nursing (DON) identified her expectation for all staff to follow infection control measures including appropriate use of PPE when administering medications, and especially when the administration involved contact with blood. She agreed putting contaminated supplies and pens in her scrub pockets and placing contaminated insulin pens back into the medication carts would contaminate any item the pens came into contact with. Review of the 2001 MED-PASS, Inc (revised April 2019) Administering Medications policy identified staff were to follow infections control policies and procedures (handwashing, antiseptic technique, gloves, and any precautions identified) for all medications being administered. LIFTS Observation on 3/25/25 at 9:04 a.m., CNA in training (CNAT) identified CNAT pushed a Hoyer (total mechanical lift) into a resident room. The door was open as CNAT conversed with the resident and placed the residents designated sling beneath him while he waited for another staff member to assist with the transfer. When another staff member arrived, the door was closed to provide privacy during the transfer from wheelchair to recliner. After the transfer was completed, the residents door was opened and CNAT was observed pushing the hoyer lift out of residents room and down the hall, and into another residents room. The door was again closed while assisting the resident. Interview on 3/25/25 at 9:15 a.m., CNAT confirmed the lift was not cleaned between residents. He stated he was trained to complete cleaning of lifts at the end of each shift, and believed this was their policy. CNAT confirmed neither resident was on EBP. Interview on 3/25/25 at 3:59 p.m., with the director of nursing (DON) who was also the Infection Preventionist, identified lifts were to be cleaned and disinfected between residents regardless of their precaution status. DON stated new staff were trained to clean and disinfect them after each resident use. DON also stated CNAT had received a lot of information all at once, and she had clarified this expectation earlier when CNAT asked her about it. Review of the 2001 MED-PASS, Inc (revised October 2018) Cleaning and Disinfection of Resident-Care Items and Equipment policy identified staff were to clean and disinfect or sterilize reusable or durable medical equipment (DME) between residents.

Based on observation and interview, the facility failed to ensure 1 of 1 exhaust vent located above the gas stove was free from accumulation of dirt and grease that had the potential to contaminate food being prepared and served. This had the potential to affect all 28 residents who received food prepared in the facility kitchen. Findings include: Observation and interview on 3/24/25 at 10:45 a.m., during the initial kitchen tour with the certified dietary manager (CDM). identified a large rectangular vent positioned in the wall above the stove. The vent was covered with a black, thick grease-like substance. The CDM reported the vent had been cleaned by maintenance a couple of months previously and she thought the black substance was likely rust and dust. She also reported she had not noticed how it appeared, but stated it needed to be cleaned. Interview on 3/24/25 at 11:30 a.m., with the Maintenance Supervisor (MS) reported he had replaced the vent a couple of months ago due to rust and paint chipping, but he did not realize how much more dirt and grease had accumulated. He reported he was not able to wipe off the black buildup but had to utilize a heavy degreaser to remove it and would need to put it on his maintenance schedule for regular cleaning. A policy on cleaning of vents and equipment in the kitchen was requested but not provided.

Based on observation, interview and document review the facility failed to ensure staff followed the facility protocols to verify controlled medication count to prevent potential diversion. Findings include: Observation and interview on 6/25/24 at 2:01 p.m., with registered nurse (RN)-A of the locked box within the medication cart that contained the controlled medications. There was a bound narcotic book that listed the residents-controlled medications with a count of that medication and all resident medications were reconciled by 2 licensed nurses. The locked box also contained the emergency kit (Ekit) of controlled medication in a small plastic box that had a plastic numbered tag securing the box closed and a list of medications within the box. RN-A was unable to find any documentation that the Ekit controlled medications had been reconciled. She reported that in the past that was documented in the bound narcotic book and 2 licensed nurses would verify the plastic tag number. She confirmed that without reconciling the Ekit controlled medication tag number each shift a person would not know if the Ekit controlled medication had been tampered with. Interview and observation on 6/25/24 at 2:46 p.m., with licensed practical nurse (LPN)-A revealed that the nurses did not reconcile the Ekit controlled medications that were stored in the locked box within the medication cart. If a nurse would take a medication out of the plastic box, they would fill out a form that they documented the plastic tag number removed, what medication was removed, and the new plastic tag number they applied. The form was then faxed to the pharmacy to notify the pharmacy that a medication had been removed from the Ekit. She reported the forms were kept in the locked box on the medication cart. When she opened the medication cart there were only blank forms in the locked box. She was unable to verify that the Ekit controlled medication plastic box had not been tampered with as she was unsure what the tag number was supposed to be on the Ekit controlled medication box. She agreed there would be no way to know if someone had opened the box and taken something out unless she went back through the old forms that had been faxed to the pharmacy. Interview and observation on 6/25/24 at 2:52 p.m., with the director of nursing (DON) identified the Ekit controlled medication tag on the box should be monitored and documented each shift. The documentation should be located in the front of the bound narcotic book. After examination of the bound narcotic book the DON was unable to find any documentation of the Ekit controlled medication. She retrieved the prior bound narcotic book and that book Identified on page 2 a date of 6/11/23, the Ekit tag number had been transferred from the narcotic book to the new non-narcotic book in the medication room with a line across the entire page, and no signature of who made the note or the change. The DON reported she had no idea who made this change and stated it should have never been changed. Her expectation was that staff reconciled the plastic tag number of the Ekit controlled medication box each shift with the narcotic count completed by 2 licensed staff. She agreed that there would have been no way to identify diversion without monitoring the tag number each shift. She verified the contents of the medication in the Ekit controlled medication box. The DON revealed that the tag numbers for the Ekit controlled medication had not been monitored and documented in the non-narcotic book in the medication room either. Review of the Ekit controlled medication list affixed to the Ekit controlled medication plastic box identified the following medications: morphine sulfate oral solution 20 mg/ml quantity of 30 ml, hydroco/APAP 5-325 mg quantity 6,lLorazepam 0.5 mg quantity 6, tramadol 50 mg quantity 6. Review of the Emergency Kit Replacement Slip documents located in the Ekit book in the medication room identified the last time the Ekit controlled medication box had been opened was on 1/2/24, and lorazepam 0.5 mg 1 tablet had been removed at 5:00 p.m. Forms had also been filled out for removal of medications on 12/13/23, 12/7/23 twice, 9/5/23, 94/23, 8/14/23 twice, and 8/7/23 twice. A policy on controlled medications was requested but not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure 2 of 2 observed nurse aides (NA) (NA-B and NA-C) appropriately cleaned and disinfected 1 of 1 whirlpool tub according to manufacturer's guidelines and use personal protective equipment (gown an gloves) (PPE) while cleaning and disinfecting the whirlpool tub. This affected 2 of 2 current residents (R3 and R11) who utilized the whirlpool tub for bathing. Findings include: Observation and interview on [DATE] at 9:04 a.m., with NA-B on the north unit shower room identified she retrieved a spray bottle labeled Clorox Fuzion cleaner/disinfectant. She then sprayed the inside of the whirlpool tub and had reached for a white long handled brush and scrubbed the inside of the tub. NA-B waited 1 minute and pressed the FILL button. When pressed water came out of the jet and was flushed to the floor of the whirlpool tub down to the drain. She pressed and held the DISINFECT button for 30 seconds. When pressed, a small amount of clear water came from the jet to the floor of the whirlpool down to the drain. She grabbed the brush and scrubbed the interior whirlpool with the water from the floor of the whirlpool tub. She pressed the RINSE button and used the water sprayer to rinse the solution inside the whirlpool for 3 minutes. NA-B was unaware how long the disinfecting the whirlpool would take or if there was any disinfecting solution coming out of the jets at all. NA-B was shown to perform the procedure as noted, however, she felt the spray solution was actually disinfecting the tub. NA-B wore no PPE while performing that task. Review of the posted Cascade Aqua-Aire Tube Operation System guidelines identified staff were to: 1) Close and lock the door. 2) Remove any viable tissue, residue, or fluids from the tub by pressing the SHOWER button and rinsing the inside tub surfaces with the shower sprayer. 3) Press the FILL button and turn the TEMPERATURE control knob to the left to its warmest level to heat the disinfectant solution. 4) Press the FILL button again to turn off the water. 5) Place drain plug over the drain. 6) Press and hold the DISINFECT button. While the disinfect button was held down, the cleaning solution would run through the air injection system and out the air jets. 7) Release the button after seeing solution coming out of all the air jets. 8) Solution that remained in the foot well of the tub should be cleaned with long-handled brush to scrub all interior surfaces of the tub. Staff were to scrub around the door seal area and temperature probe area and allow the disinfectant to stay on surface for 10 minutes. 9) Remove plug from the drain. 10) Finish rinsing the interior surfaces of the tub with the shower sprayer. 11) Press the Aqua-Aire button to start the air blower and run it for 30 seconds and then turn off the air blower. Interview on [DATE] at 9:17 a.m., with housekeeping supervisor stated staff were to be using the Triforce spray bottle solution for cleaning and disinfecting of the whirlpool tub. The whirlpool tub manufacturer identified [NAME] Classic cleaning and disinfecting solution was to be used for the air jet whirlpool tub, but the facility no longer used that product. The facility now used Triforce spray or the Clorox Fuzion spray. The reason the [NAME] products from the manufacturer were not used any longer was staff had no access to the door to where the solution was to be added to the compartment due to a water heater that had been placed near the whirlpool preventing access to the compartment. The compartment was what held the disinfecting solution where a specific amount would have been pumped via automated design, into the tub per manufacturer's instructions. Observation and interview on [DATE] at 12:37 p.m., with NA-C identified she pressed the FILL button on the whirlpool tub and sprayed the inside of the whirlpool for 30 seconds. She reached for the Triforce (bleach) solution spray bottle and sprayed the inside of the whirlpool walls and seat. NA-C noted the solution was to sit on the interior surface with a wet contact time of 5 minutes. The smell of the solution permeated the shower room and was overpowering. She pressed the FILL button and rinsed the whirlpool with shower sprayer for 30 seconds. She stated she would use the brush to scrub the inside of the door when spraying the interior of the tub. She stated the Triforce had an irritating smell. She pressed the DISINFECT knob for 30 seconds. She then stated she would rinse the whirlpool and use the shower sprayer for another 30 seconds. She stated cleaning the whirlpool took 10 minutes total time after each resident bath. She was unaware if the spray cleaner Interview on [DATE] at 5:37 p.m., with director of nursing (DON) stated the maintenance director had planned to relocate the water [NAME] to another area of the facility so staff could access and utilize the correct whirlpool disinfectant solutions as indicated on the whirlpool manufacturer instructions. She stated staff would have to continue to use the available disinfectant spray solution the facility had in place for cleaning and disinfecting the whirlpool until the water heater could be relocated. The DON was unaware if staff were utilizing the correct product or if the products were appropriate to clean and disinfect the whirlpool tubs. The DON agreed staff should wear PPE while performing that task. Interview on [DATE] at 7:35 a.m., with BETCO specialist identified stated the Triforce solution would have a contact time of 3 minutes when wet and should be sprayed on a dry surface. Gloves and eye mask should be worn when using the spray solution and surfaces should be wiped down not rinsed with water after solution had been applied to the surface. The BETCO specialist stated the product was designed for overall cleaning and disinfection of surfaces, but agreed it was not made for the whirlpool tub specifically and could not verify it would reach all surfaces of the tub or around the jets when sprayed on. Observation and interview on [DATE] at 8:04 a.m., with maintenance director identified the facility installed a water heater in the east unit shower room and confirmed the water heater had been installed in the year 2016. He demonstrated as he faced the whirlpool, that to the left of the tub, there is a locked compartment that was to have disinfectant solutions connected to the whirlpool tub tubing. He stated the right side of the tub had another locked compartment and when opened, he could not access the solutions that were originally stationed to the left of the whirlpool. He stated the water heater had blocked access to the left compartment and was aware that had been an issue for staff to replace the disinfectant solution as it was impossible to reach. Further interview on [DATE] at 9:35 a.m., with the maintenance director identified the facility had extra whirlpool tub solution stored in the maintenance director's office that was not in use. He confirmed the solution expired July of 2023 and would not be safe to use for cleaning or disinfection. He stated he was sure the disinfectant cleaner solution connected to the whirlpool had ran dry and therefore when staff pressed the DISINFECT button, only water would have come out of the jet. Further interview on [DATE] at 11:15 a.m., with the DON identified the facility had no formal checklist that would include staff being trained on whirlpool use and cleaning, nor had there been documentation of competencies. She had no copies of employee training accessible on file at the facility to prove that training had been completed. NA's and would be trained on the job alongside other colleagues. Review of the current, Triforce Disinfectant Directions for Use identified staff were to use 1/2 ounce per gallon of water and apply to surfaces allowing them to be wet for 3 minutes. For heavily soiled areas, cleaning prior to disinfection was required. The product was not to be used for areas that may come into contact with any mucous membranes of a body. Review of the undated, hand-typed Whirlpool Cleaning policy identified the whirlpool bath was to be routinely disinfected to ensure appropriate infection control. When a bath was completed, the entire whirlpool was to be swabbed with the whirlpool disinfectant. Staff were to then use a small white hand mop with whirlpool cleaner in a small bottle. The instructions then noted staff were to rinse thoroughly with clear water. When whirlpools were done for the day, staff were to fill a white bucket to the mark FILL TO HERE with water and 4 ounces of whirlpool cleanser and submerge the agitator mechanism in the bucket and let it run for 10 minutes. Staff would then swab the entire tub and chair with whirlpool cleanser and rinse with clear water. There was no indication how old the policy was, what tub the instructions were for, or if the solution or whirlpool tub were the same as when the policy was created. Review of 2020, Training policy identified initial orientation would be given to all employees and the online Healthcare Academy would be provided yearly for employee training. The facility would monitor completion of training and would send the completed training to the administrator. There was no indication training was specific to the facility and not generalized overall training.

Based on observation, interview, and document review, the facility failed to ensure all 25 nurse aides ((NA)-A, NA-B, NA-C, NA-D, NA-E, NA-F, NA-G, NA-H, NA-I, NA-J, NA-K, NA-L, NA-M, NA-N, NA-O, NA-P, NA-Q, NA-R, NA-S, NA-T, NA-U, NA-V, NA-W, NA-X, NA-Y and NA-Z), who bathed or had the potential to bathe residents were appropriately trained and deemed competent to manufacturer's instructions for the cleaning and disinfection of 1 of 1 whirlpool tub. Findings include: Observation and interview on 6/25/24 at 9:04 a.m., with NA-B on the north unit shower room identified she retrieved a spray bottle labeled Clorox Fuzion cleaner/disinfectant. She then sprayed the inside of the whirlpool tub and had reached for a white long handled brush and scrubbed the inside of the tub. NA-B waited 1 minute and pressed the FILL button. When pressed water came out of the jet and was flushed to the floor of the whirlpool tub down to the drain. She pressed and held the DISINFECT button for 30 seconds. When pressed, a small amount of clear water came from the jet to the floor of the whirlpool down to the drain. She grabbed the brush and scrubbed the interior whirlpool with the water from the floor of the whirlpool tub. She pressed the RINSE button and used the water sprayer to rinse the solution inside the whirlpool for 3 minutes. NA-B was unaware how long the disinfecting the whirlpool would take or if there was any disinfecting solution coming out of the jets at all. NA-B was shown to perform the procedure as noted, however, she felt the spray solution was actually disinfecting the tub. NA-B wore no PPE while performing that task. Review of the posted Cascade Aqua-Aire Tube Operation System guidelines identified staff were to: 1) Close and lock the door. 2) Remove any viable tissue, residue, or fluids from the tub by pressing the SHOWER button and rinsing the inside tub surfaces with the shower sprayer. 3) Press the FILL button and turn the TEMPERATURE control knob to the left to its warmest level to heat the disinfectant solution. 4) Press the FILL button again to turn off the water. 5) Place drain plug over the drain. 6) Press and hold the DISINFECT button. While the disinfect button was held down, the cleaning solution would run through the air injection system and out the air jets. 7) Release the button after seeing solution coming out of all the air jets. 8) Solution that remained in the foot well of the tub should be cleaned with long-handled brush to scrub all interior surfaces of the tub. Staff were to scrub around the door seal area and temperature probe area and allow the disinfectant to stay on surface for 10 minutes. 9) Remove plug from the drain. 10) Finish rinsing the interior surfaces of the tub with the shower sprayer. 11) Press the Aqua-Aire button to start the air blower and run it for 30 seconds and then turn off the air blower. Observation and interview on 6/25/24 at 12:37 p.m., with NA-C identified she pressed the FILL button on the whirlpool tub and sprayed the inside of the whirlpool for 30 seconds. She reached for the Triforce (bleach) solution spray bottle and sprayed the inside of the whirlpool walls and seat. NA-C noted the solution was to sit on the interior surface with a wet contact time of 5 minutes. The smell of the solution permeated the shower room and was overpowering. She pressed the FILL button and rinsed the whirlpool with shower sprayer for 30 seconds. She stated she would use the brush to scrub the inside of the door when spraying the interior of the tub. She stated the Triforce had an irritating smell. She pressed the DISINFECT knob for 30 seconds. She then stated she would rinse the whirlpool and use the shower sprayer for another 30 seconds. She stated cleaning the whirlpool took 10 minutes total time after each resident bath. She was unaware if the spray cleaner was an appropriate cleaner and sisinfectant to use with the whirlpool tub. Interview on 6/26/24 on 9:26 a.m., with NA-C stated she received training for cleaning and disinfecting the whirlpool during her orientation from a colleague who no longer works at the facility. She was unsure if the facility had a training checklist or competencies for the whirlpool and had not seen it implemented for new employees at the facility. Interview on 6/26/24 at 9:30 a.m., with NA-D she stated she had attended facility in-services for resident care and infection control procedures. She was unsure of training specified for whirlpool cleaning had been implemented in the facility. Interview 6/26/24 at 9:47 a.m., with NA-E stated she received training on whirlpool tub cleaning and disinfection from a coworker when hired. She received annual education on the Healthcare academy (online continuing education program). She stated one of the online courses had discussed procedures for bathing residents and tub cleaning but they were not specific to the tub the facility used. She stated the course did not explain procedures for the disinfectant and cleaning of whirlpool. During her orientation, she hand hands-on training from a co-worker but had none since. Interview on 6/26/24 at 11:15 a.m., with DON stated the facility had no formal checklist that would include nurse aide staff being trained on whirlpool cleaning and disinfection. She had no copies of employee training accessible on file at the facility to identify training or competencies had been completed. NA'ss and would be trained on the job alongside other colleagues. DON stated she was unaware of in-services held at the facility that was directed at whirlpool use and cleaning. Review of 2020, Training policy identified initial orientation would be given to all employees and the online Healthcare Academy would be provided yearly for employee training. The facility would monitor completion of training and would send the completed training to the administrator. There was no indication training was specific to the facility and not generalized overall training.

Based on interview and document review the facility failed to implement 1 of 1 facility assessment protocol related to ensuring staff competencies were identified and completed respective to staff duties performed. Refer to F726 Findings include: Interview on 6/24/24 at 2:56 p.m., with administrator identified he had spoken to the director of nursing (DON) about the facility assessment just this morning as they were unsure when it had been last updated. She revealed he had just finished working on the facility assessment about a half hour ago and he would provide what they had at this time. He reported he was unable to find the old facility assessment and he started a new one. Interview on 6/25/24 at 4:18 p.m., with nursing assistant (NA)-A identified there was no review of skills or competencies where someone watched them however, they did complete training on-line. Interview on 6/26/24 at 7:46 a.m. with director of nursing (DON) identified department heads had not been completing annual evaluations however, the previous administrator completed evaluations on all the department heads. She identified that was something the facility would be working on. She further revealed she had not completed any skills training or competencies with staff other than the lift company that came in once a year to cover proper use of the mechanical lifts. She also identified she had not completed any competencies with any nursing staff but wished she had more time to do get those types of things. Review of the 6/24/24, facility assessment tool identified staff education and competencies were necessary to support the care needed for the residents, including certifications as applicable. The facility assessment identified a list of training and competencies which was not all inclusive that included communication, resident's rights, abuse, neglect, and exploitation, culture change, and infection control which included procedures for infection control. The infection control competencies included hand hygiene, standard precautions, isolation, use of personal protective equipment, and environmental cleaning.

Based on interview and document review, the facility failed to ensure data submitted to 1 of 1 Quality Assurance Performance Improvement (QAPI) committee was analyzed and documented to ensure areas identified had oversight for their perspective outcomes brought forth. This had the potential to affect all 28 residents. Findings include: Review of QAPI minutes from 6/14/24 identified QAPI was lacking documentation of facility goals and analysis. There was also no response for how facility would meet goals, or that previous goals were evaluated to identify if current measures were met or new processes had been identified. Interview on 6/25/24 at 3:10 p.m., with the director of nursing (DON identified she was agreed there was no analysis of the data brought forth to QAPI, measurable goals set, or if goals were not met, or what actions the facility was going to take to meet their goals. There was no formal process for staff or residents and/or their families to provide feedback to improve areas identified in QAPI. Review of the undated, QAPI Plan policy identified the plan provided guidance for overall quality improvement. The administrator was to assure the plan was reviewed annually by the QAPI committee. QAPI was to review data from areas it believed it needed to monitor on a quarterly basis to ensure systems were being monitored and maintained. The meeting minutes were to be kept with the administrator and shared with residents and resident council and available for staff, residents and family to read. There was no mention of measurable goals, or analysis of data to ensure new areas were identified or if older area benchmarks would be achieved or how compliance would be identified. There was also no evidence the plan had been reviewed to ensure it included all required elements set forth in the regulation.

Based on interview and document review, the facility failed to have evidence of a Performance Improvement Project (PIP) which focused on high risk or problem-prone areas identified thorough and appropriate data collection and analysis and evaluation of the identified concern(s) during QAPI. This had the potential to affect all 28 residents. Findings include: Review of QAPI minutes from 6/14/24 identified No PIP projects were noted. Interview on 6/25/24 at 3:10 p.m., with the director of nursing (DON) identified the facility had not done a PIP project, as their new administrator had opted not to participate in that project. She agreed PIP projects were crucial in identifying high level areas of concern to provide the highest care possible to residents. Review of the undated, QAPI Plan policy identified the plan provided guidance for overall quality improvement. The administrator was to assure the plan was reviewed annually by the QAPI committee. QAPI was to review data from areas it believed it needed to monitor on a quarterly basis to ensure systems were being monitored and maintained. The meeting minutes were to be kept with the administrator and shared with residents and resident council and available for staff, residents and family to read. There was no indication how QAPI would identify PIP projects or how that information would be educated to staff and residents and their families so input could be achieved and PIP measured to see if goals would be accomplished or how compliance would be achieved. There was also no evidence the plan had been reviewed to ensure it included all required elements set forth in the regulation.

Based on interview and document review, the facility failed to notify the county (designated state mental health authority) when 1 of 2 residents (R13) had a new on-set of mental illness. Findings include: R13's 3/3/23, quarterly Minimum Data Set (MDS) assessment identified cognition to be intact with a current diagnosis of paranoid personality disorder. R13's current, undated diagnoses list identified a R13 had a diagnosis of paranoid personality disorder with an effective date of 1/30/23. R13's current, undated care plan identified R13 had experienced impaired individual coping related to paranoid personality disorder with behaviors of yelling, screaming at staff, and hollering out. The care plan included interventions of giving medication as ordered and to observe for any changes in mood, behavior or mental status and report to nurse. R13's current, undated medication administration record (MAR) identified R13 took an antipsychotic medication, Seroquel at 12.5 mg daily for a diagnosis of paranoid personality disorder. R13's 9/2/21 Pre-admission Screening (PAS)-level I, did not identify a diagnosis of paranoid personality disorder and did not indicate a need for a Pre-admission Screening and Resident Review (PASRR)-level II to be completed. Interview on 6/13/23 at 11:29 a.m., licensed social worker (LSW) revealed the facility relied on the hospital to initiate the PAS prior to admission. She revealed the facility does not have a process or policy in place to review the PAS for accuracy when the facility receives them or a process for communication with the county authority when a new diagnosis has been identified. The facility had no policy related to PASRR level I or PASRR level II screenings.

Based on interview and document review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASARR) level I was completed correctly and a level II screening was completed if necessary for 1 of 1 residents (R9) reviewed for PASARR. Finding include: R9's 7/18/18, Initial Pre-admission Screening (PAS) Results indicated that R9 had no major mental disorder diagnosable as listed in the diagnostic and statistical manual of mental disorders (DSM). R9 did not meet the criteria for mental illness (MI) however, final determination would be made by Senior LinkAge Line. Review of 7/18/18, Senior LinkAge Line PAS referral identified the criteria requiring additional assessment related to mental illness had not been met on the PAS/OBRA level I screening. An OBRA level II MI evaluation was not needed for R9. R9's diagnoses list identified on 7/24/18, R9 had an admission diagnosis of bipolar disorder (a mental disorder characterized by periods of depression and periods of abnormally elevated mood that last from days to weeks), 5/20/19 a diagnoses of anxiety disorder, major depressive disorder, and neurocognitive disorder with Lewy Bodies. On 10/1/22 a diagnoses of dementia classified elsewhere with behavioral disturbance. R9's 5/12/23, quarterly, Minimum Data Set (MDS) assessment identified in section A1500 pre-admission screening and resident review (PASARR) has the resident been evaluated by level II PASARR was blank. R9 cognition was moderately impaired, inattention was present and fluctuated, disorganized thinking was present and fluctuated, R9 required extensive assistance with cares, had daily insulin injections, and took an antipsychotic, anticoagulant, and diuretic daily. Section I4800 identified diagnosis of dementia. R9's 8/5/18, MDS identified in sections I5700 anxiety disorder, I54800 depression (other than bipolar), and I5900 manic depression (bipolar disease) as active diagnosis. All MDS's reviewed of R9's identified those same diagnosis. R9's 2/24/23, annual MDS Care Area Assessment (CAA) for psychotropic drug use identified R9 was on Cymbalta for pain. The CAA further identified psychotropic drug use would be addressed on the care plan to avoid complications and minimize risks. R9's undated, care plan identified R9 had impaired coping skills related to alcohol abuse, bipolar, and anxiety disorder. R9 took an antipsychotic medication for bipolar and had target behavior that included inappropriate responses to verbal communication, verbal aggression towards staff/others, verbal abuse of swearing, yelling, threatening staff, inappropriate sexual comments. Interview on 6/12/23 at 4:43 p.m., with the licensed social worker (LSW) identified she did not oversee pre-admission screenings as Senior LinkAge Line completed those prior to a resident admitting to the facility. She revealed she had never came across a resident with a mental illness diagnosis that was not identified on the pre-admission screening. She reported she had never actually reviewed the PASARR form and the residents diagnosis list to ensure a referral was made to the county for a level II screening if needed. Interview on 6/14/23 at 12:47 p.m., with LSW confirmed the facility had no policy for pre-admission screening nor for ensuring a level II screening was completed when indicated. Interview on 6/14/23 at 3:16 p.m., with director on nursing (DON) agreed that residents admitted with a mental health diagnosis should have a level II screening completed to ensure services were obtained if necessary. The facility had no policy related to PASARR level I or PASARR level II screenings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to ensure food items were dated when opened and stored in a sanitary manner for both refrigerated and dry storage items. The facility also failed to ensure the daily chemical concentration for the low temperature dishwasher sanitation was checked and recorded to ensure concentrations were maintained within acceptable levels. This had the potential to effect 24 of the 25 residents who resided in the facility at the time of the inspection. Findings include: Observation on 6/12/23 at 11:45 a.m., of the ([NAME] side by side refrigerator/freezer) noted a large opened package of hotdogs on an upper wire shelf of the refrigerator. An undated, opened container of Tri-pasta salad was on the shelf directly below the hotdogs and the pink colored hotdog liquid had leaked from the package and pooled on top of the Tri-pasta container in addition to the shelf around the container. A large open container of pasteurized eggs was located on the bottom shelf of the refrigerator and the hotdog juice had also dripped through the shelves onto the eggs. The dietary manager (DM) reported she was not certain when the hotdogs had been opened but should have been dated and placed into a Zip lock bag or container to prevent leakage. She reported the Tri-pasta salad had been served over the past weekend and should have been dated when opened and would be discarded due to contamination from the hot dog juice. An open, undated zip lock bag with a cooked hamburger patty was observed on the shelf behind the Tri-pasta salad container. The DM reported she did not know when it had been cooked, or placed in the refrigerator, but reported it should have been placed in a closed container and dated. Both the pasta salad and hamburger patty were immediately discarded, and she removed the package of hotdogs. She then instructed staff to always place opened [NAME] in a closed container and gave direction to staff for the refrigerator and all items to be cleaned due to contamination with the hotdog juice. Observation on 6/12/23 at 11:55 a.m., of the dry storage area, noted 2 opened boxes of Malt-O-Meal on the shelf with spilled cereal around the outside of the boxes. The DM reported once opened the cereal should have been placed into a sealed container or bag and labeled to prevent possible contamination. Observation and document review on 6/12/23 at 12:00 p.m , of the dishwasher area identified a [NAME] AHC, low heat chemical dishwasher. The DM reported the dishwasher was a low temperature, and the chemical sanitation washer and chemical concentration was to be checked each morning with litmus test strips and recorded on the log to ensure the appropriate chemical concentration was provided to sanitize the dishes. Review of the log for June 2023 identified 2 of the 12 days when the concentration was initialed in the 10 parts per million (PPM) column and 5 days when the concentration was recorded as 50 PPM or above. (acceptable parameters for low temperature, chemical sanitation require a wash temperature of 120 degrees F; and the chemical in the final rinse to be 50 ppm (parts per million) hypochlorite (chlorine) on dish surface).4 of the 12 days failed to have any documentation. Interview on 6/12/23 at 12:05 p.m., with the DM reported she had a difficult time with staff being consistent with dating, and storing food items in appropriate containers once opened, and with checking and recording chemical concentrations for the dishwasher. She reported she was not aware of any unacceptable chemical concentrations for the dishwasher and felt it had not been done on the days when nothing had been recorded and had been recorded in the incorrect column on the two days it was recorded as 10 PPM. The May sanitizer log was requested and not provided. The DM reported she had posted signs as reminders and would again reeducate staff on the infection control practices they needed to follow. Interview on 6/12/23 at 1:15 p.m., with the environmental services manager (EVS) reported he had checked the dishwasher intermittently for chemical concentration levels but had not recorded his findings. He stated [NAME] Papers, inc. provided the facility chemicals and came monthly to check the equipment. He provided the documentation for the 1/10/23 check, but reported he was not able to locate the documentation for the months following and the representative was supposed to bring copies of the monthly checks, but none were provided by the end of the survey period. Review of the undated facility policy Storage of Leftovers identified all leftovers in the refrigerator or freezer were to be labeled and dated. Leftovers in the refrigerator were to be used within 3 days or discarded. A policy on checking for chemical concentration for the dishwasher was requested but not provided by the end of the survey period. The DM reported she was not certain the facility had a policy for checking the dishwasher chemical concentration and she was not able to provide one. Review of the CMA dish machine manual identified Low-Temperatures chemical-sanitizing dish machines must not exceed 6% sodium hydrochloride solution (bleach) as the sanitizing agent. Higher levels may damage stainless or components and the directions were to be followed precisely as listed on the litmus paper vial. The test water was to be tested on the bottom of the glasses. Concentration should be 50 PP Minimum to 100 ppm maximum. If concentration is incorrect, staff were to contact the chemical supplier.

Based on interview and document review, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify facility specific concerns, implement an action plan to correct the identified concerns or to to ensure the committee participated in the development and oversight of implementation of systems, and to ensure quality of life and quality of care were maintained for 25 of 25 residents residing in the facility. Findings include: Interview and review of the QAPI meeting quarterly minutes from August of 2022, November of 2022, May of 2023, and February 2023 on 6/14/23 at 9:56 a.m., administrator identified that the QAPI meetings and minutes lacked any identification of facility specific concerns, an action plan for improvement, or an analysis of any actions taken previously. The administrator agreed with the above finding and revealed he was disappointed to learn that the facility had not attempted any performance improvement projects and had not completed any audits or competencies over a minimum of the past year. Review of QAPI Plan last revised 5/2019, identified facility would address key issues, establish goals, identify and prioritize problems and opportunities for improvement, analyze underlying causes, and develop performance improvement activities. The QAPI plan further identified, the committee would gather and review data, complete analysis, and summarize learning's quarterly to determine effectiveness and sustainability of the improvements and to identify new opportunities for improvement.

Based on interview and document review, the facility failed to implement and maintain an infection control program that included thorough data collection, analysis of facility infections, and tracking and trending to reduce the spread of infections within the facility. The facility failed to include in their surveillance viral-like illnesses not treated with an antibiotic for staff or residents. The facility had no process in place to identify and monitor other types of infection in the facility and there was no analysis of the data collected. Findings include: Review of the monthly infection surveillance and staff call-in logs from January through May 2023 identified in: 1) January 2023, had no map that identified infections. There antibiotic flow sheets that identified 2 residents with UTI's, and 2 residents with eye infection. There was no staff call-in log. 2) February 2023, there were 3 residents with UTI's, 2 with pneumonia, and 1 with other infection identified on the facility map. Staff call-in log identified 14 call-ins; 6 related to weather, 1 with shingles, 2 with vomiting, 2 with fever, 3 with general respiratory, and 1 positive with COVID-19. 3) March 2023, there were 2 residents with UTI's, 2 with skin infections, 1 with wound infection, and 1 with respiratory infection identified on the facility map. There was no staff call-in log. 4) April 2023, there were 3 residents with UTI's, 4 with respiratory infection, and 1 with C. Diff identified on the facility map. Staff call-in log identified 10 staff call-ins; 1 with nausea, 2 with general respiratory, 1 with diarrhea, 1 with fever and nausea, 2 with migraine, 1 with sick child, and 2 related to weather. 5) May 2023, there was 1 resident with an UTI, and 2 with respiratory infection. The staff call-in log identified 5 staff call-ins: 2 with vomiting, 1 with general respiratory, 1 with back pain, and one with family emergency. The surveillance included copies of the antibiotic flow sheets for residents prescribed an antibiotic and a map that rooms were colored coded to identify who had what infection. There was no surveillance of viral like infections. Interview on 6/13/23 at 5:10 p.m., with director of nursing (DON) who was also the infection preventionist (IP) identified her analysis of infections was completed monthly on the QA Monthly Meeting form. Review of the QA Monthly Meeting form identified categories of falls, residents with catheters, pressure ulcers, unexplained weight loss, residents with UTI's, COVID cases for staff and residents, VA reports, and miscellaneous. In: 1) January 2023, there was 1 resident listed with an UTI. There were no other infections listed including the 2nd resident with an UTI that had been identified on the infection surveillance log. 2) February 2023, there were 3 residents listed with an UTI, 2 residents with pneumonia, 1 resident with cholecystitis, and 2 staff listed with COVID-19. 3) March 2023, there were 2 residents listed with an UTI, and no other infections identified. 4) April 2023, there was no form completed. 5) May 2023, there was no form completed. The QA monthly meeting form lacked any analysis of infections. Interview on 6/14/23 at 8:17 a.m., with DON revealed there had been illnesses that were not treated with antibiotics since January 2023, however she had not tracked any of those illnesses. Additional interview at 3:16 p.m., with DON confirmed she had not tracked any viral-like infection not treated with an antibiotic and agreed by not monitoring all illnesses there was a potential of missing a pattern or a start of an outbreak. She further confirmed she had not analyzed any infection information that she had collected. She agreed that the QA monthly meeting form where she listed how many infections there had been was not an analysis of the information. Review of the undated, Surveillance for Infections Policy identified the IP would complete ongoing surveillance of infections. By identifying tracking infections, the facility would be able to identify interventions to prevent future infections. The IP should be analyzing the data to identify trends or patterns within the facility. The analysis should be shared at the QAPI meeting. There was no indication the policy had been reviewed annually per the regulation. Review of the undated, Employee Infection Surveillance policy identified that the staff call-ins and their symptoms will be tracked. This information will be monitored and analyzed for any correlation between staff and resident illness. There was no indication the policy had been reviewed annually per the regulation.