Based on observation, interview, and record review, the facility failed to ensure one of 12 sampled residents (Resident #15) received necessary assistance with activities of daily living (ADL). Resident #15 was dependent on a mechanical lift and two staff for transfers and required assistance with all his/her ADL's. Facility staff failed to reposition the resident every two hours and to provide timely perineal care. The facility census was 40. The facility did not provide a policy for timing and repositioning and perineal care for a resident's. 1. Review of Resident # 15's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by the facility staff), dated 12/27/24, showed: - He/She had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive deficit; - Diagnoses included: Cerebral Palsy (is a disorder that affects movement, muscle tone and posture); - He/She required assistance from staff to transfer, toileting needs, and get to dressed; - He/She was incontinent of bowel and bladder. Review of the resident's face sheet showed the following diagnoses: Dysphagia, oral phase (difficulty swallowing) and weakness. Review of the resident's Activities of Daily Living (ADL) care plan, dated 11/26/19, showed: - The resident was dependent on a mechanical lift and two staff for transfers; - The resident's required assistance with all his/her ADL's. Review of the residents skin care plan, dated 11/26/19, showed: - The resident was incontinent of urine; - The staff were supposed to assist the resident's with perineal care; - The resident's had compromised skin integrity between his/her thighs. During an interview on 2/23/25 at 10:32 A.M., the Resident said: - He/She had a sore on his/her inner right thigh; - It took a while for staff to change him/her; - He/She he had been up since 7:00 A.M. this morning and has not been repositioned or changed since; - He/She was wet. Observation on 2/23/25 at 1:52 P.M., showed: - The resident's was in his/her room in his/her wheel chair; - Certified Nurse Aide (CNA) C and CNA I entered the resident's room with the mechanical lift; - The CNA's assisted the resident in bed using the mechanical lift; - The resident had a strong urine smell; - CNA C provided perineal care; - The resident had saturated through an incontinence brief, his/her pants, and the mechanical lift sling; - The resident's bottom was red and appeared irritated. During an interview on 2/23/25 at 1:52 P.M., CNA C said: - He/She was trained to complete rounds every two hours; - Rounds included repositioning residents, and cleaning residents if they are wet or soiled; - Resident #15 was supposed to be repositioned every two hours; - He/She came on duty at 7:00 A.M. and did not reposition or change the resident's before now; - He/She should have ensured the resident's was dry and repositioned every two hours and as needed. During an interview on 2/23/25 at 2:03 P.M., CNA I said: - Cares were last provided for the resident at 7:30 A.M. for Resident #15; - Cares included repositioning and ensuring the resident was clean and dry; - The resident should have been changed earlier. During an interview on 2/26/25 at 10:50 A.M., Licensed Practical Nurse (LPN) B said: - Resident #15 was incontinent of bowel and bladder; - The staff do not change the resident's like they are supposed to; - He/She expected the resident to be repositioned and perineal care provided every two hours and as needed; - The resident's really needed to be laid down every two hours because of his/her skin breakdown and incontinence. During an interview on 2/27/25 at 12:28 P.M., the Quality Assurance (QA) nurse said he/she expected the staff to provide repositioning and perineal care every two hours and as needed for resident's that need help. The staff should not have left Resident #15 sitting in his/her wheel chair from 7:30 A.M. to 1:52 P.M. with out repositioning and providing perineal care. During an interview on 2/27/25 at 3:10 P.M., the Administrator said staff should have repositioned Resident #15 and provided perineal care every two hours. It was not acceptable to let the resident's sit in his/her wheel chair for more that six hours without repositioning and cleaning the resident's.

Based on interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, or psychosocial well-being for one of three sampled residents (Resident #7) when staff failed to obtain a physician ordered blood transfusion in January 2025 for an anemic resident in a timely manner. The blood transfusion was not carried out until fourteen days after it was ordered. The facility census was 43. Review of facility policy titled Physician Orders, undated, showed physician's orders must be signed by the physician and dated when such order was signed. Review of facility policy titled Lab Reporting Guidelines, undated, showed: -Guidelines will be followed to ensure that lab recommendations are completed timely; -Nurse will received the lab for a lab draw; write a telephone order and document the order on the physician order sheet (POS) or note the order on the POS when written by the physician. -The nurse will document on the lab report that the physician had been notified to include how they were notified, when (time and date) and the nurse's signature; -The lab report will be placed in the medical record under the lab section; -When any new orders were received, this will again be documented on the 24 hour report. 1. Review of Resident #7's Annual Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 11/22/24, showed: -They had moderate cognitive impairment; -They were dependent on a wheelchair; -They took an antiplatelet medication (a medication that prevents blood platelets from sticking together and forming blood clots); -Diagnoses included: Arthritis hypercalcemia (condition where there is high level of calcium in the blood), anemia, and high blood pressure. Review of care plan, dated 12/7/24, showed the resident: -had cognitive loss and their DPOA (Durable Power of Attorney) had been invoked by two physicians; -their designated family member directed health care needs. Review of physician's orders showed: -Faxed order, dated 1/16/25, Type and cross 2 units PRBC (packed red blood cells) and transfuse, pre-treat with Tylenol 650 mg (milligram) by mouth and Benadryl 12.5 mg 30 minutes prior to start. Give Lasix (a water pill) 40 mg intravenous (IV) x 1 between units, for diagnosis anemia . Review of the resident's medical record showed no documentation the physician orders were carried out. Review of progress notes, dated 12/1/25-2/11/25, showed: -On 1/17/25, physician ordered a blood transfusion due to low hemoglobin levels; -On 1/27/25, resident returned to the facility from hospital appointment to have blood transfusion. Hospital did not have right blood type in stock so the resident did not receive transfusion. -On 1/30/25, Resident received 1 unit of packed red blood cells (PRBC). During an interview on 2/11/25 at 1:40 P.M., Family Representative A said: -Resident had experienced some fatigue that physician had been concerned about; -Resident did not receive a blood transfusion right away in January when it was ordered; -They were unsure why a delay occurred in the resident receiving the blood transfusion. During an interview on 2/11/25 at 11:48 A.M., Licensed Practical Nurse (LPN) A said: -Laboratory results went directly to the resident's physician; -The facility staff did not receive the resident's lab results unless they specifically requested them; -There should have been some documentation in the progress notes on the care resident received. During an interview on 2/11/25 at 2:15 P.M., Physician's Registered Nurse (RN) A said: - The resident had Complete Blood Count (CBC) (a medical test that measures the number and types of various cells in the blood) drawn on 1/16/25 and their hemoglobin was 7.5 g/dl; -The physician sent an order for blood transfusion to occur and for facility to pre-treat resident with Tylenol and Benadryl; -He/she called the facility to notify them of the orders and faxed the orders on 1/16/25 by 5:00 P.M.; -The hospital outpatient said the facility dropped the resident off on 1/27/25 without an appointment and they did not have the resident's blood type on hand; -The resident did not get the transfusion until 1/30/25; -When the physician's office sends orders to the facility- the facility staff are able to call the hospital to schedule the transfusion; -Without the blood transfusion the resident had a risk of having their hemoglobin levels drop further and experience additional fatigue. During an interview on 2/11/25 at 2:20 P.M., LPN A said: -He/she was unsure why resident's blood transfusion was delayed in January. -BOM (Business office manager) was the person who scheduled appointments and arranged transportation to appointments for residents; -When the BOM is out of facility the Human Resources (HR) staff person is supposed to cover for the BOM. During an interview on 2/11/25 at 3:10 P.M., BOM said: -Faxes were received on the fax machine located in the main business office of facility; -She takes faxes to the west nurses station; -The nurses were responsible for writing any orders and appointments that need made on the faxed orders received; -Faxes were then brought back to him/her in the front office for scheduling of appointments; -He/she was responsible for scheduling appointments for the residents; -Paperwork and orders did sometimes get missed; -Resident #1's paperwork said family was going to schedule resident's appointment; -He/She contacted Resident #1's family member and they advised they were not taking care of appointment for transfusion; -The facility driver took the resident to his/her transfusion appointment on 1/27/25 and all the pretransfusion mapping was completed at that time but transfusion did not occur because the hospital did not have the resident's blood type on hand; -He/She took resident back to outpatient clinic on 1/30/25 for the transfusion; -When he/she was not working in facility the HR staff was their back up regarding checking faxes and taking phone calls and writing down appointments. During an interview on 2/11/25 at 3:30 P.M., Family Representative B said: -They did not agree or tell facility they would take resident to their second blood transfusion due to the extensive time commitment of 3-6 hours that the transfusions took to complete; -There was a communication break between administration and nurses at the facility. During an interview on 2/11/25 at 3:23 P.M., Physician said he/she expected their order for blood transfusion to be carried out within 5-7 days. During an interview on 2/11/25 at 3:50 P.M., Director of Nursing said he/she expected physicians orders to be carried out as soon as possible. During an interview on 2/11/24 at 4:11 P.M., Administrator said: -He/she expected facility staff to follow physicians orders; -Physician's orders were received in main office at fax machine and were taken to the west nurses station charger nurse; -The charge nurse took orders off fax and entered them into electronic medical record; -Physician then electronically signed the orders in electronic medical record; -Business Office Manager makes resident appointments; -When BOM was out of facility the Administrator or HR staff made appointments. MO248336

Based on observation, interview, and record review, the facility staff failed to ensure a resident (Resident #15) with limited range of motion (ROM) to his/her left hand received treatment to prevent further ROM loss. The facility census was 40. Review of the facility's undated policy titled, Range of Motion, showed: - ROM was suppose to be provided to prevent contractures from becoming worse; To maintain normal ROM; - The facility staff can provide passive range of motion (PROM) for residents that cannot complete it themselves; To simulate circulation. Review of Resident #15's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by the facility staff), dated 12/27/24, showed: - He/She had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive deficit; - Diagnosis included: Cerebral Palsy (is a disorder that affects movement, muscle tone and posture); - He/She required assistance from staff to transfer, with toileting needs, and to dress; - He/She was incontinent of bowel and bladder. Review of the resident's face sheet showed the following diagnoses: Dysphagia, oral phase (difficulty swallowing) and weakness. Review of the resident's Activities of Daily Living (ADL) care plan, dated 11/26/19, showed: - The resident was dependent on a mechanical lift and two staff for transfers; - The resident's required assistance with all his/her ADLs; - The resident's care plan did not address decreased ROM for the resident's left hand. Review of the resident's Physician Order Sheet (POS) dated 2/25 showed the resident did not have an order for ROM services or a device to prevent decreased ROM. Observation on 2/23/25 at 10:32 A.M., showed: - The resident had a contracture to his/her left hand; - The resident's fingers curled in and the resident was not able to straighten them; - The resident did not have a device to prevent his/her fingers from curling in. During an interview on 2/23/25 at 10:32 A.M., the resident said: - He/She did not have any thing to help his/her fingers from curing in; - The staff did not help him/her with ROM and did not provide PROM; - He/She would like to receive ROM so he/she does not lose more function of his/her hand. During an interview on 2/26/25 at 10:00 A.M., Certified Nurse Aide (CNA) C said: - The facility did not have staff to provide ROM for Resident #15; - He/She was not told to provide PROM for the resident with cares. During an interview on 2/26/25 at 10:50 A.M. Licensed Practical Nurse (LPN) B said: - There was no ROM program at the facility; - The CNAs were supposed to complete ROM with cares. During an interview on 2/27/25 at 3:10 P.M., the Administrator said: - The facility did not have a current ROM program; - The CNAs can complete PROM with cares; - The CNAs should be doing PROM and stretching with Resident #15 when they provide care.

Based on observation, interview, and record review, the facility failed to prevent a significant weight loss for one of 12 sampled resident's (Resident #15), when the facility did not provide the resident with his/her physician ordered Magic Cup (a nutritional supplement that contains additional calories and protein for persons experiencing involuntary weight loss) daily at lunch. The facility census was 40. The facility did not provide a significant weight loss policy. Review of Resident #15's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by the facility staff), dated 12/27/24, showed: - He/She had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive deficit; - Diagnoses included: Cerebral Palsy (is a disorder that affects movement, muscle tone and posture) and dysphagia (difficulty swallowing); - He/She required assistance from staff to transfer, with toileting needs and to dress; - He/She received a therapeutic diet and a mechanically altered diet; - He/She had weight loss. Review of the resident's face sheet showed the following diagnoses: Dysphagia, oral phase and weakness. Review of the resident's nutrition status care plan, dated 2/25/20, showed: -The resident was at risk for weight loss; -The resident was on a pureed diet with honey thick liquids. Review of the resident's Physician Order Sheet (POS), dated February 2025, showed the following physician orders: - 9/5/24: Pureed food with honey thick liquids due to dysphagia; - 9/5/24: Magic Cup with lunch daily for weight loss. Review of the resident's weights showed the following: - 9/2/24: 248.4 pounds (lbs); - 10/3/24: 242.6 lbs; - 11/3/24: 234.4 lbs; - 11/30/24: 232.4 lbs; - 12/2/24: 224.2 lbs; - 1/1/25: 224 lbs; - 2/1/25: 222.2 lbs; - Decreased 26.2 lbs and 10.5% of the resident's body weight over the past 6 months. Review of progress notes in the electronic medical record (EMR) showed the following: - 11/15/24: The Registered Dietician (RD) documented: The reason for consult was for the resident's weight change. The resident's current diet order was pureed with honey thickened liquids, Magic Cup with lunch daily. The resident's intake at meals was 51-75% of meals consumed. The resident's current weight was 234.4 pounds with a 3.4% in weight loss over the past 30 days; - 12/11/24: The RD documented: The reason for the consult was for the resident's weight change. The resident's current diet order was pureed with honey thickened liquids. Magic Cup with lunch daily. The resident's meal intake was 51-75%. The resident's weight was 224.2 lbs; - 1/8/25: The RD documented: The reason for the consult was for weight change. The resident's current weight was 224.0 lbs. - 2/6/25 The RD documented the reason for the consult was for weight change. The resident's current was weight: 222.2 lbs. the resident's weight on 8/5/24 247.4 lbs indicating the resident lost 10.2% of his/her weight over the past six months. The resident's weight loss appears to have halted since last seen. The current interventions remain appropriate, and no changes warranted at this time. Observation on 2/23/25 at 12:12 P.M., showed: - The resident was at the dining table; - The staff served the resident his/her lunch meal and did not give the resident a Magic Cup; - The resident ate approximately 50% of his/her meal and left the dining room. Observation on 2/24/25 at 12:08 P.M., showed: - The resident was served his/her lunch meal; - The resident was not served a Magic Cup; - The resident consumed approximately 75% of his/her meal. Observation on 2/25/25 at 12:26 P.M., showed: - The staff served the resident his/her lunch meal; - The staff did not provide a Magic Cup to the resident; - The resident consumed approximately 75% of his/her meal. During an interview on 2/26/25 at 3:48 P.M., the Dietary Manager (DM) said he/she expected the resident to receive his/her Magic Cup as it was ordered by the physician. During an interview on 2/26/25 at 10:50 A.M., Licensed Practical Nurse (LPN) B said: - He/She expected the staff to provide the resident a Magic Cup at lunch, because it was ordered; - He/She was not aware the resident was not receiving the Magic Cup; - He/She was not aware the resident had significant weight loss; - There was lack of communication between nursing and dietary. During an interview on 2/27/25 at 12:28 P.M., Quality Assurance (QA) Nurse A said -The facility had monthly risk meetings that include the RD; -The resident's weights are discussed during the meetings; - He/She expected staff to provide Resident #15 his/her Magic Cup as ordered. During an interview on 2/27/25 at 3:10 P.M. the Administrator said she expected staff to give Resident #15 his/her Magic Cup as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to store nebulizer machine masks in a bag when not in use for two residents (Resident # 15 and #38) of 12 sampled residents. The facility census was 40. The facility did not provide a policy for nebulizer masks. 1. Review of Resident #15's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by the facility staff), dated 12/27/24, showed: - He/She had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive deficit; - Diagnosis included: Cerebral Palsy (is a disorder that affects movement, muscle tone and posture). Review of the resident's face sheet showed the following diagnoses: Dysphagia, oral phase (difficulty swallowing), bronchitis, and weakness. Review of the residents Physicians Order Sheet (POS), dated February 2025, showed an order dated 9/16/24 for Ipratropium-Albuterol (a liquid medication inhaled to treat breathing problems) 0.5 milligram (MG)- 3 MG per 3 milliliter (ML) nebulizer four times daily. Observation on 2/23/25 at 10:32 A.M., in the resident's room showed a nebulizer machine sitting on the sink with the mask resting in the sink bowl, not covered. Observation on 2/23/25 at 1:52 P.M., showed the resident's nebulizer machine was sitting on the sink with the mask lying on the sink bowl with no cover. Observation on 2/23/25 at 2:40 P.M., showed the resident was using the nebulizer mask to receive a breathing treatment. Observation on 2/25/25 at 9:20 A.M., showed the residents nebulizer mask was sitting directly on the sink. During an interview on 2/26/25 at 10:50 A.M., Licensed Practical Nurse (LPN) B said: - Nebulizer masks are supposed to be placed in a plastic bag when not in use; - Nebulizer masks should not be placed directly on the sink or the sink bowl. During an interview on 2/27/25 at 12:28 P.M., the Quality Assurance (QA) nurse said: - He/She expected nebulizer masks to be in bags when not in use. 2. Review of Resident's #38's quarterly MDS, dated [DATE], showed: - He/She had a BIMS score of 15, indicating no cognitive deficit; - Diagnoses included: Heart failure and chronic obstructive pulmonary disease (COPD, a disease that affects how a person breaths). - He/She required some assistance with activities of daily living (ADLs). Review of the resident's POS, dated February 2025, showed the following orders: - 11/13/24: albuterol sulfate 2.5mg/ 3 ml (0.83%) per nebulizer two times daily to treat COPD; - 11/13/24: change nebulizer tubing monthly. Observation on 2/23/25 at 11:44 A.M., showed: - The resident was sitting in his/her recliner; - The resident's nebulizer machine was sitting directly on a side table with no barrier and the nebulizer mask was sitting on a towel, not in a bag. Observation on 2/24/25 at 11:20 A.M., showed the resident's nebulizer was was sitting directly on a towel and not in a bag. During an interview on 2/27/25 at 12:28 P.M. the Quality Assurance (QA) nurse said: - He/She expected nebulizer masks to be in bags when not in use.

Based on observation, interview, and record review, the facility failed to document identification and use of possible alternatives prior to use of Halo side rails (a circular bed rail used for repositioning and bed mobility); failed to document assessing risk versus benefits of Halo side rail use; failed to obtain informed consent for the use of Halo side rails prior to installation; and failed to complete ongoing assessments to ensure the side rails were appropriate for use for one resident, and do not pose an entrapment risk (Resident #6), in a sample of 12 residents. The facility census was 40. Review of the facility provided, undated, Bed Rails policy showed: -Once a bed rail observation is completed the facility will review the associated risks and benefits with the resident and/or resident representative. After the review is complete, the resident and/or resident representative will sign the consent line and the nurse will sign as well. -Educate the resident/legal representative on the benefits and risks of bed rails; -Develop a care plan that outlines the medical factors necessitating bed rails and an explanation of how the use of bed rail is intended to treat a specific resident's condition; -Staff should follow manufacturer's recommendations and specifications for applicable bed rails, mattresses, and bed frames; -Staff will conduct regular inspections of all bed frames, mattresses, and bed rails to identify areas of possible entrapment. When purchased separately the facility will select equipment that are compatible. Review of Resident #6's Quarterly minimum data set (MDS), a federally mandated assessment completed by the facility staff, dated 2/8/25, showed: -Brief Interview of Mental Status (BIMS) of 4, indicating significant cognitive deficit; -Dependence on staff for Activities of Daily Living (ADLs: tasks performed in a day to care for oneself); -Substantial assistance on staff to roll side to side; -Diagnoses of Alzheimer's Disease (a progressive brain disorder that effects memory and thinking, leading to the inability to complete daily tasks), high blood pressure, cognitive communication deficit (difficulty communicating because of impaired brain function), anxiety (constant feeling of nervousness, worry or fear), depression (constant feeling of sadness, loss of interest and low energy), and need for assistance with personal care. Review of the resident's Functional Abilities Assessment completed, 1/31/25, showed the resident required substantial/maximal assistance for rolling left and right. Review of the resident's Comprehensive Care Plan, dated 2/20/25, showed: -He/She had Halo rails (a circular, bed mobility device) times two for repositioning, with a start date of 11/3/22. Review of the resident's medical record showed: -No side rail assessment for use, entrapment, or to ensure the rails remain functional and safe; -No consent for use of rails. Observation on 02/24/25 at 9:34 A.M., showed: -He/She was in bed on his/her back -Quarter rails on his/her bed to both sides, in the up position. During an interview on 02/27/25 at 11:32 A.M., Licensed Practical Nurse (LPN) B said: -Therapy decided on use of rails for residents; -He/She had never completed an assessment for bed rails or Halos; -He/She was aware of an assessment tool for the use of rails, in the electronic health record system; -The electronic health record system had a template consent and assessment tool for use of rails; -He/She had no idea who completes the entrapment assessments; -Resident #6 does have 2 Halos and an air mattress; he/she did not know if they were compatible. During an interview on 02/27/25 at 12:28 P.M., the Quality Assurance Nurse said: -Side rail application is done by maintenance; -Nursing leadership or Administration would determine if the side rail is needed; -Entrapment zones must be assessed, and informed consent must be obtained -She would expect entrapment assessments to be completed at initiation of the rail, quarterly, and/or a change in the resident's function; -She would ask the medical equipment company for the compatibility of the air mattresses and the side rails. During an interview on 02/27/25 at 3:10 P.M., the Administrator said: -Side rails have to be assessed, for resident specific use, by the charge nurse or possibly therapy to start the process; -Maintenance would get the Halo rails, measure for the entrapment spaces, and then install them; -She would expect the charge nurse or the Director of Nursing to complete the initial use assessment; then communicate that information on a maintenance request; -Entrapment measurements are done every 6 months by maintenance; -There was no maintenance staff and assessments have not been completed; -She would expect if a family or hospice brought in a bed with rails, for the same process to be completed; -She would expect rails to be checked at least monthly, or if the resident complains of them being loose, to ensure they are secured correctly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #32 Quarterly MDS, dated [DATE], showed: -Brief Interview of Mental Status (BIMS) of 99 indicated significant cognitive loss. -Dependent on staff for Activities of Daily Living (ADL's: tasks completed in a day to care for oneself, such as bathing, eating, and personal hygiene). -Diagnoses of Cerebral Infarction (a condition where blood flow to part of the brain is interrupted,causing cells to die), chronic pain, Anxiety Disorder (excessive feelings of fear, worry and nervousness), Chronic Obstructive Pulmonary Disease (COPD: a lung disease that causes air flow obstruction and breathing difficulty), Dementia (a decline in mental ability that effects memory , thinking and behavior), Malignant Neoplasm of the Liver (cancerous tumor that originated in the liver). Review of the Resident Comprehensive Care Plan, dated 10/10/24, showed: -He/She had lost his/her decisional capacity and is invoked as of 4/6/2023. -He/She depended on the Durable Power of Attorney(DPOA) for health and finance to carry out wishes. Review of the resident electronic and paper medical record showed: -The DPOA document did not indicate if one or two physicians were needed to determine incapacity. -Letter of incapacity dated 1/31/23 signed by one physician. -No second letter of incapacity signed by another physician. 4. During an interview on 02/27/25 at 12:28 P.M., the Quality Assessment Nurse said: - 2 physicians should sign the letter of incapacitation unless the Power of Attorney form says otherwise. -A Do Not Resuscitate (DNR) form should not be signed by the Power of Attorney designee unless the resident has been declared incapacitated. During an interview on 02/27/25 at 3:10 P.M., the Administrator said: -Incapacity letters require two physician signatures unless otherwise stated; -She would not expect a DNR signed by the DPOA prior to the signature of the incapacitation letter. Based on record review and interview the facility failed to ensure that Advance Directives for three Residents (Resident #3, #19, and #32) were lawful when a Designated Power of Attorney signed an out of hospital Do Not Resuscitate (OHDNR) form prior to two residents (Residents #3 and #19) being declared incapacitated to sign. Additionally, the facility failed to ensure that one resident (Resident #32) had 2 physician letters of incapacitation prior to the Power of Attorney designee making decisions for him/her. There were 12 total sampled residents. The facility census was 40. The facility did not provide the requested policy on Advance Directives. 1. Review of Resident #3's Quarterly minimum data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 02/07/25, showed: -Severe cognitive impairment; -Dependent on staff for transfers, bathing, locomotion, toileting and eating; -Incontinent of bowel and bladder; -Diagnoses included dementia, high blood pressure, and urinary tract infection. Review of the resident's care plan, dated 02/20/25, showed: -Assistance for activities of daily living (ADLs); -Visual impairment; -The resident is a DNR (Do not resuscitate) code status. Review of the resident's medical record showed: -Durable power of attorney (DPOA) document signed by the DPOA 02/02/19; -The DPOA did not indicate if one or two physicians were needed to determine incapacity; -Capacity verification form dated 11/16/22 signed by only one physician, the DPOA and the Social Service Director (SSD); -The capacity form showed the resident had no capacity on 11/16/22; -Incapacitation letter, dated 05/08/24, that was signed by two physicians; -OHDNR signed by DPOA on 01/15/22 before the resident was deemed incapacitated. 2. Review of Resident #19's Quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Partial assistance for transfers, bathing, locomotion, toileting and eating; -Incontinent of bowel and bladder; -Diagnoses included dementia, depression, and anxiety. Review of the resident's care plan, dated 02/20/25, showed: -Assistance for ADLs; -The resident had dementia; -The resident was a DNR code status. Review of the resident's medical record showed: -DPOA document signed by DPOA on 11/27/18; -The DPOA document did not indicate if one or two physicians were needed to determine incapacity; -Incapacitation letter dated 01/24/19 that was signed by two physicians; -OHDNR signed by DPOA on 01/07/19 before the resident was deemed incapacitated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain the walls, hallways, ceilings and floors in a clean and homelike environment. Furthermore the facility failed to ensure furnishings were in good repair and temperatures in the dining room remained at a comfortable level. This had the potential to effect all residents. The facility census was 40. The facility did not provide a policy for cleaning, maintenance of the facility and care of furnishings, or temperatures. 1. Observations on 2/19/25 at 10:30 A.M., showed: -Main dining room thermostat read 61 degrees Fahrenheit; -All doors to the main dining room were closed; -Window blinds in the dining room and attached hallways were drawn; -White blankets were rolled up and placed at the threshold of the doors leading to the courtyard. Observation on 2/19/25 at 11:22 A.M., showed: -Main dining room thermostat read 60 degrees Fahrenheit During an interview on 2/19/25 at 10:05 A.M., Resident #9 said: -He/She did not mind eating in the lobby because it was a comfortable temperature; -The main dining room was too cold to eat there, for a few weeks. During an interview on 2/19/25 at 11:15 A.M., Resident #92 said: -The dining room had been too cold to eat meals in for weeks; -He/She missed eating and visiting with her friends in the dining room. During an interview on 2/19/25 at 12:32 P.M., Resident #18's family member said: -The heat in the dining room had not worked for over a week. During an interview on 2/19/25 at 3:00 P.M., the Administrator said: -The facility has not employed a maintenance supervisor for a month or more;The transportation driver assists with maintenance where he/she can; -The heat in the dining room had been checked by the Maintenance Director for the facility management company; -The dining room heater cannot keep up with the cold weather; -Residents eat in their rooms and assist diners eat in the lobby area; -She does not know when the heat will be fixed. 2. Observations beginning on 2/25/25 at 12:37 P.M., showed: -The dining room floor tile cracked, with missing pieces, tiles loose with jagged edge; -Dead bugs, dust and debris in light fixtures; -Packaged Terminal Air Conditioner (PTAC: which is a self-contained heating and cooling system designed to be mounted through a wall), in courtyard hall had dust and debris inside the vent, pieces of the plastic vent cover were missing and broken; -Fire doors to 100 hall had chipped covering, with exposed wood underneath and white water damage like staining to lower half of the door; -Fire doors to service hall had large chips in Formica, with exposed wood underneath; -Corner sheetrock at service hall had large slash and gouge in sheetrock with peeling paint. Observation on 02/27/25 at 8:58 A.M., showed: -Television room at the end of the 400 hall had multiple gouges and scratches in the lower 1/3 of the sheetrock. -Glass table lamp had visible layer of dust and debris; -400 hallway had multiple gouges and scratches in the pain and sheetrock along the entire hall; -Hand rail end cap off at room [ROOM NUMBER] caused sharp edge; -Hand rail end cap loose at room [ROOM NUMBER] and opposite end cap was missing causing sharp edge; -Hand rail end cap missing at room [ROOM NUMBER]; -Hand rail end cap missing at room [ROOM NUMBER]; -Hand rail end cap loose at room [ROOM NUMBER]; -The small handrail at the corner of the dining hall and 400 hall was loose; -The handrail between room [ROOM NUMBER]-410 was loose; -Hand rail end cap was missing at room [ROOM NUMBER], caused a sharp edge; -Hand rail end cap at room [ROOM NUMBER] was missing, and caused a sharp edge; -Hand rail end cap at room [ROOM NUMBER] was off and laying on top of the handrail; -Hand rail at end of 500 hall with red, U shaped, sharp pronged metal piece with exposed two inch screw in the middle, was lying on top of the handrail. Observation on 02/27/25 at 9:06 A.M., showed: -Nurse station TV area had multiple gouges and scratches in the dry wall and paint; -Lobby area light fixtures had dead bugs, dust, and debris in lights; -PTAC unit had dust and debris in the vent and on the unit; -Multiple ceiling can lights had cobwebs; -Second PTAC unit had a broken grate and dust and debris in the vent; -The glass billboard had dried, white drips on the glass; -Long fluorescent lights had exposed bulbs; -The nurses station had scuffed and chipped paint, -The flooring carpet had multiple stained and discolored areas, -The seams of the carpet are approximately 1/4 inch apart with dust and debris in them. -The shower room on the 500 hall had dark, black mold like substance that covered 1/4 of the lower shower wall and grout of the shower and floor, exposed wires with ends capped in outlet cutout by tub, the ceiling had multiple brown water stains, and the lights had dead bugs, dust, and debris in them; -The 500 hall had multiple gouges, scratches, and chips in the paint and drywall along the entirety of the hall; -Treatment cart had rhinestone gems in partial star and curve shapes on the back of the cart, some gems were missing and a sticky/gummy substance was left behind, and had glitter letters half peeled off on the back of the cart and left a sticky/gummy uncleanable surface; -Hallway from lobby to dining room had black scuff marks along lower third of the wall; -Windows in halls to dining room had cobwebs, dust and debris; -Hallway from lobby to dining room PTAC unit had dirt and debris in the vent, cracked plastic vent cover; the wall above the unit had broken wooden trim, leaving a sharp edge, peeling sheetrock and chipped/flaking paint; -Dining room windows had dirt, dust, debris and cobwebs; lower third of the walls had nicks and scratched paint; the rolling stools (used to sit on to assist resident with meals) had cracked vinyl covering and exposed padding underneath; cabinet doors were sprung and hanging crookedly; the tile grout was black in multiple areas with a thick crusty substance; the small serving bowls/dishes, on the prep cart, had dust and debris in them and on the storage tray, the steam table had white crusty/dusty substance on the bottom shelf; the storage chart had white crusty/dusty substance on the bottom shelf and legs; the white prep table had cobwebs, dirt and debris on it and hanging from the legs and corners. During an interview on 2/19/25 at 12:32 P.M. Resident #18 family member said: -Nothing gets fixed around the facility; -There is no maintenance personnel. During an interview on 02/26/25 02:52 P.M., Housekeeping/Laundry Aide A said: -High dusting (such as lights, and corners) should be completed by any housekeeping staff who have time to get it done. -High dusting was not assigned to anyone specifically. -The staff assigned to the hall were responsible for all cleaning. -There was no deep cleaning list for common areas of the building. -The Dining room was deep cleaned weekly; spot cleaning was done after each meal; -Carpets are vacuumed daily if there was time to do it. -He/She did not know when carpets were shampooed or who was responsible for that. During an interview on 02/19/25 at 3:00 P.M., the Administrator said: -The facility had been without a Maintenance supervisor or staff for over a month; -The transportation driver helps fix things as he/she has time to do it. During an interview on 02/27/25 at 12:28 P.M., the Quality Assurance Nurse said: -The facility was having maintenance struggles and there was no current maintenance staff. -The Administrator looks at things as she can. -The part time van driver can work on work orders as time allows; -She would expect communication between the administrator and maintenance to complete work orders. During an interview on 02/27/25 at 3:10 P.M., the Administrator said: -The Maintenance Director is responsible for upkeep and repairs. -There was not a Maintenance Director for over a month; -The van driver completes things as times allows and that he can do; -Staff fill out work order; the van driver picks them up and does what he can to complete them; -High dusting in the dining room would be maintenance; the rooms and halls would be housekeeping; -Carpets would cleaned when there was a stain; the housekeeping supervisor runs a carpet cleaner on different halls on different days. MO#249706

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents had complete, accurate and individualized care plans, to address the specific needs of the residents, for five of 12 sampled residents (Residents #28, #92, #11, #15, and #36). The facility census is 40. Review of the facility provided, undated, policy Care Planning showed the facility Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. Review of the facility provided, undated policy Care Area Assessments showed Care Area Assessments (CAAs) will be used to develop individualized care plans. 1. Review of Resident #28 Quarterly Minimum Data Set (MDS, a federally mandated assessment completed by facility staff), dated 1/3/25, showed: -Brief Interview of Mental Status (BIMS) of 0 indicated severe cognitive impairment; -No behaviors; -Moderate assistance for Activities of Daily Living (ADLs: tasks completed in a day to care for oneself); -No falls; -No pressure areas; -Chair alarm used daily; -Bed alarm not used; -Diagnoses of: Memory Deficit after cerebral infarction (loss of memory after stroke: when blood flow to a part of the pain is blocked, causing loss of cells), Sick Sinus Syndrome (a condition where the heart's natural pacemaker does not function properly), Need for assistance with personal care, History of falling, Delirium (a sudden change in mental state). Review of the resident's medical record showed: -9/26/24 Elopement Assessment completed with a score of 8, indicated an increased risk for elopement; -1/09/2025 progress note showed the resident had an open area to his/her buttock. Review of the resident's Comprehensive Care Plan, dated 2/25/25, showed: -The resident had a risk for falls: keep his/her call light within reach, ensure appropriate non-skid footwear, encourage him/her to ask for assistance; -No care plan for use of an alarm; -No care plan for elopement; -No care plan for pressure ulcers. During an interview on 02/24/25 at 10:36 A.M., Certified Nurse Aide (CNA) B said: -The resident was an elopement risk; -The orange dot on his/her name plate indicated the elopement risk. Observations on 02/24/25 at 10:31 A.M., showed: -Resident was sitting up in his/her wheelchair, self propelling chair; -Alarm pad lying under incontinent padding on bed, attached to alarm box; -Name plate at door has orange quarter size dot. Observation on 02/25/25 at 11:10 A.M., showed: -Resident was sitting up in his/her wheelchair, self propelling chair; -Alarm pad lying under incontinent padding on bed, attached to alarm box. During an interview on 02/27/25 at 9:37 A.M., Licensed Practical Nurse B said: -Orange stickers on the door indicate elopement risk. -The resident's care plan should say they are an elopement risk, have wounds, and anything pertinent in order to provide care to the resident. 2. Review of Resident #92 admission MDS, dated [DATE], showed: -BIMS of 15 indicated no cognitive loss -Diagnoses of: fall with injury, osteoarthritis (a condition where the cushion at the ends of the bones (cartilage) breaks down, leading to pain/, stiffness and loss of movement), high blood pressure, atrial fibrillation (a irregular and rapid heart beat), urinary incontinence (involuntary loss of urine), heart failure (the heart cannot pump enough blood to meet the needs of the body), and pain. Review of the resident's baseline care plan, dated 2/5/25, showed: -Psychosocial needs will be addressed in a manner consistent with the resident's overall health and life goals. -No care plan for pressure ulcers or skin concerns. Review of the resident's Physician order sheet showed an order, dated 2/19/25, to apply zinc to open area twice a day until healed, obtained by the Director of Nursing. During an interview on 2/19/25 at 11:15 A.M., Resident #92 said he/she had sores on his/her bottom. Observation of Resident #92 on 2/19/25 at 11:40 A.M., showed he/she had a dime sized open area to the left buttock and a pencil eraser sized area to the right buttock, with red peeling skin surrounding the open wounds. During an interview on 2/19/25 at 11:40 A.M. Certified Nurse Aide (CNA) G said: -The resident had an open area for at least a week. -He/She had notified the nurse. During an interview on 2/19/25 at 11:59 A.M. LPN C said he/she was not aware of resident #92 open area. During an interview on 02/27/25 at 11:32 A.M. LPN B said care plans should be updated with changes as the change occurred. 3. Review of Resident #11's quarterly MDS, dated [DATE], showed: - The resident had a BIMS score of 14, indicating little cognitive deficit; - Diagnoses included: Diabetes Mellitus (DM) type II; - He/She was completely dependent on staff for toileting needs, showers, and to get dressed: - He/She was incontinent of bowel and bladder; - He/She was a risk for the development of pressure ulcers (PU), but had none; - He/She had skin break down on his/her buttocks. Review of the Braden Scale (a form completed by the facility staff to determine the resident's risk for developing a wound), dated 1213/24, showed the resident at a high risk of developing a wound. Review of the January 2025 progress notes showed the following: - 1/5/25: LPN A documented on a skin assessment that the resident had an open area to his/her bottom; - 1/9/25: LPN B documented on the monthly summary that the resident had fragile, warm, and dry skin. LPN B did not document any further details about the resident's skin breakdown; -1/12/25: LPN B completed a skin assessment, the resident continued to receive a treatment for redness on the buttocks and a small open area, will fax the resident's physician for new orders. Review of the resident's February 2025 skin assessments showed the following: - 2/2/25: LPN A documented on a skin assessment the resident had an existing non-foot skin issue. - 2/16/25: LPN A documented on a skin assessment the resident's bottom was red and had an open area. Review of the resident's skin care plan, dated 8/26/22, showed: - The resident had a chronic to his/her buttock that sometimes appeared to be open and sometimes appeared to be closed; - The care plan did not include the resident's current PU. Observation on 2/25/25 at 8:14 A.M. showed: - The resident was lying in his/her bed; - Licensed Practical Nurse (LPN) A entered the resident's room to complete wound care; - The resident had a wound to his/her bottom that was 6 centimeters (CM) long by 0.3 CM wide; - The center of the wound had a dark brown area that measured 2 CM long by 1.75 CM wide. During an interview on 2/25/25 at 8:14 A.M., LPN A said: - The wound appeared to be in worse condition than last week; - Any of the nurses can update the resident's care plan. During an interview on 2/27/25 at 11:39 A.M., The MDS Coordinator said: - He/She helps with care planning, but most care plans and updates are completed by the nurses; - The resident's care plan should have included his/her wound to his/her buttocks. During an interview on 2/27/25 at 3:10 P.M. the Administrator said she would expect the resident's wound to be care planned with current interventions. 4. Review of Resident #15's quarterly MDS, dated [DATE], showed: - He/She had a BIMS score of 15, indicating no cognitive deficit; - Diagnoses included: Cerebral Palsy (is a disorder that affects movement, muscle tone and posture). - He/She required assistance from staff to transfer, toileting needs and get dressed; - He/She received a therapeutic diet and a mechanically altered diet; - He/She had weight loss. Review of the resident face sheet showed the resident had the following diagnoses: Dysphagia, oral phase (difficulty swallowing) and weakness Review of the residents Physician Order Sheet (POS), dated February 2025, showed an order dated 9/5/24 for pureed food with honey thick liquids. Review of the residents weights showed the following: - 9/2/24- 248.4 pounds (lbs); - 10/3/24- 242.6 lbs; - 11/3/24- 234.4 lbs; - 11/30/24- 232.4 lbs; - 12/2/24- 224.2 lbs; - 1/1/25- 224 lbs; - 2/1/25 222.2 lbs; - Decreased 26.2 lbs and 10.5% of the resident's body weight over the past 6 months. Review of the resident's nutrition status care plan, dated 2/25/20, showed: -The resident was at risk for weight loss; - The resident was on a pureed diet with honey thick liquids; - The residents significant weight loss was not addressed in the resident's care plan. During an interview on 2/27/25 at 3:10 P.M. the Administrator said the resident's significant weight loss should have been included in his/her care plan. 5. Review of Resident #36's quarterly MDS, dated [DATE], showed: - The resident had a BIMS score of four, indicating severe cognitive deficit; - The resident required assistance with eating, toileting and getting dressed; - The resident was 72 inches tall and 148 pounds; - The resident had a mechanically altered diet; - The MDS did not indicated the resident had a significant weight loss. Review of the resident's POS, dated February 2025, showed an order dated 12/2/24 for nectar thick liquids. Review of the residents weight log showed the following: -10/29/24 153.6 lbs; 11/3/24 152.6 lbs; 12/3/24 157 lbs; 1/1/25 156.4 lbs; 2/1/25 147.6 lbs; - The resident decreased 9.4 pounds and 5.98% in the past 2 months. Review of the resident's undated comprehensive care plan showed the facility staff did not address the resident's weight loss. 6. During an interview on 02/27/25 at 11:39 A.M., the MDS Coordinator said: -Most of the care plan is completed by the Charge Nurses; -Resident specific care plans should include weight loss, the use of a nebulizer and oxygen, fall status and prevention interventions, psychosocial stuff, residents receiving hospice services, magic cup orders, contractures, wounds and skin issues; -Primary care plans are related to the day to day care, behavioral issues; -Communication was challenging; he/she was not always notified of changes; better communication between departments would ensure relevant information gets added to the resident care plans; -He/She checks morning notes for changes. During an interview on 02/27/25 12:28 P.M., the Quality Assurance Nurse said: -She would expect Nebulizers, urinary tract infections, wounds and weight loss to be care planned for each individual resident; -She expected every nurse to be able to access, update and utilize the care plan; -The facility had a MDS coordinator that goes between other facilities; -The charge nurses need more education to increase their comfort with care planning. During an interview on 02/27/25 03:10 P.M the Administrator said: -She would expect any one can and would update a care plan, -The MDS Coordinator ensure the information is in the care plan; -She expected the CNA staff to report any changes to the Charge Nurse and the Charge Nurse to update the care plan; -She expected the care plan to be a snapshot of the specific resident and the care they require.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide meaningful activities to meet the needs for three of 12 sampled residents (Resident #6, #28, and #92). The facility did not have an employee responsible for the activity program and did not have a system to inform all residents in advance of available activities, including location and time, which had the potential to impact all residents in the facility. The facility census was 40. The facility did not provide a policy regarding Activities. Review of the facility provided Resident Right policy, dated April 2006, showed: -The resident has the right to a dignified existence and self determination. A Facility must protect and promote the rights of each resident. --Right to participate in activities. --Resident Rights are to be fully respected and adhered to. The facility did not provide an activity calendar. 1. Review of Resident #6 admission Activity Assessment, dated 3/14/20, showed: - He/She liked 1:1 (1 staff to 1 resident) activities, independent leisure activities, and small group activities; -Preferred activities included: cards/games, sports/exercise, music, spiritual/religious, walking/wheeling outdoors, and watching TV. Review of the resident's Annual Activity Assessment, dated 5/3/24, showed: -He/She liked 1:1 and large group activities; -Preferred activities included: exercise/sports, music, and watching TV. Review of the resident's Annual Minimum Data Set (MDS: a federally mandated assessment tool completed by facility staff), dated 8/6/24, showed Activity preferences: -Very important for music -Somewhat important to keep up with the news, do things with groups of people, do favorite activities, go outside and get fresh air and to participate in religious practices. Review of Resident #6 Quarterly MDS, dated [DATE], showed: -Brief Interview of Mental Status (BIMS) of 4, indicated significant cognitive deficit -Dependence on staff for Activities of Daily Living (ADLs: tasks performed in a day to care for oneself) -Diagnoses of Alzheimer's Disease (a progressive brain disorder that effects memory and thinking, leading to the inability to complete daily tasks), Hypertension, Cognitive Communication Deficit (difficulty communicating because of impaired brain function), Anxiety (constant feeling of nervousness, worry or fear), Depression (constant feeling of sadness, loss of interest and low energy) and Need for assistance with personal care. Review of the resident's Comprehensive Care Plan, dated 2/18/25, showed: -Problem: Resident involved in activities one third or less of the time related to he/she can not communicate very well due to his/her speech; -Adjust the intensity, frequency, and/or duration of activities to accommodate his/her energy level and tolerance. -Encourage him/her to become involved with activities that he/she enjoys; listening to the radio -Involve him/her with those who have shared interests; -Offer him/her opportunities to get to know others through activities such as shared dining, afternoon refreshments, monthly birthday parties, reminiscence groups, etc. Review of the resident's Activity Attendance calendar showed: -No activity attendance in January. -No February Calendar provided. Observations on 02/24/25 at 9:38 A.M., showed: -Music played in his/her room, the resident was not in his/her room. -The resident sat in his/her wheelchair, in the hallway, 2. Review of Resident #28 Quarterly MDS, dated [DATE], showed: -Brief Interview of Mental Status (BIMS) of 0 indicated severe cognitive impairment; -No behaviors; -Moderate assistance for ADLs -Diagnoses of: Memory Deficit after cerebral infarction (loss of memory after stroke: when blood flow to a part of the pain is blocked, causing loss of cells), Sick Sinus Syndrome (a condition where the heart's natural pacemaker does not function properly), need for assistance with personal care, history of falling, and delirium (a sudden change in mental state). Review of the resident's Annual Activity Assessment, dated 10/1/24, showed his/her interests were crafts/arts, watching television, exercise/sports, music, talking/conversing, reading/writing and spiritual/religious activities. Review of the resident's Comprehensive Care Plan, dated 2/25/25, showed he/she needed one on one visits for socialization, and emotional support. Review of the resident's Activity Attendance calendar showed: -No activity attendance in January. -No February calendar provided. Observation on 02/24/25 at 10:31 A.M., showed: - the television on in the resident's room, -The resident sat in a wheelchair, in the hallway, with his/her head down and eyes closed. Observation on 02/25/25 at 11:10 A.M., showed: - The resident sat up in a wheelchair in the hallway. The resident looked around. No activities were being provided. 3. Review of Resident #92 admission Minimum Data Set (MDS: a federally mandated assessment tool completed by facility staff), dated 2/17/25, showed: -Brief Interview of Mental Status (BIMS) of 15 indicated no cognitive loss -Activity preference: Somewhat important to have books, newspapers, and magazines to read, listen to music,be around animals such as pets, keep up with the news, do things with groups of people,do favorite activities, go outside to get fresh air when the weather is good, and participate in religious services or practices. -Diagnoses of: fall with injury, Osteoarthritis (a condition where the cushion at the ends of the bones (cartilage) breaks down, leading to pain, stiffness and loss of movement), Hypertension (high blood pressure), Atrial Fibrillation (a irregular and rapid heart beat), Urinary Incontinence (involuntary loss of urine), Heart Failure (the heart cannot pump enough blood to meet the needs of the body), and pain. Review of the resident's baseline care plan, dated 2/5/25, showed psychosocial needs will be addressed in a manner consistent with the resident's overall health and life goals. Review of the Resident's Activity Assessment, 2/5/25, showed: -Preferred program of 1:1; -Preferred music, reading/writing, watching TV, and talking/conversing. During an interview on 2/19/25 at 11:15 A.M., the resident said: -There is nothing to do at the facility. -He/She just stays in his/her room and watches television. -He/She gets lonely and bored. -He/She has told staff he/she gets lonely and bored. Observation on 2/19/25 at 11:15 A.M. showed the resident sat in his/her room, in the recliner, no music on, TV was not on, and one puzzle book lying on the table next to the resident. 4. Observation on 2/19/25 at 10:30 A.M., showed small group of three residents doing exercises in the lobby area, lead by a resident. No staff were involved. Resident #6, Resident #28 and #92 were not in attendance. Observations on 2/19/25 from 12:00 P.M. to 2:50 P.M., showed no activity offered or provided for all residents. Observations on 2/23/24 from 9:44 A.M. to 1:39 P.M., showed no activity offered or provided for all residents Observation on 02/23/25 at 10:32 A.M., showed no activity calendar in any of the resident's rooms. Observation on 02/23/25 at 10:41 AM showed no activity calendar posted in the hallways or lobby area. During an interview on 2/19/25 at 11:40 A.M., Certified Nurse Aide (CNA) D said: -Resident volunteers provide Bingo or exercise group occasionally. -There is no Activity personnel, as he/she was moved to the floor as an aide. During an interview on 2/19/25 at 3:00 P.M., the Administrator said: -There was no Activity Director. -The plan was to move a CNA staff member to Activity Director the first of March. -Volunteers provide bible study and BINGO. During an interview on 02/27/25 at 12:28 P.M., the Quality Assurance Nurse said: -She would expect someone to visit with resident's if he/she said he/she was lonely; -She would expect activities to be done daily. During an interview on 02/27/25 at 3:10 P.M., the Administrator said: -All staff have stepped in to help with the activities, but no one was assigned. -The previous Activity Director was moved to the floor as an aide; -A resident volunteer leads exercise. -One on one visits are completed with the Social Service visits. -She would expect visits to increase for someone who was lonely. -For residents who cannot leave their room she would expect daily visits. -There are books and magazines and a variety of things to be offered. -No one made me aware that a resident was sad because he/she could not see his/her friend during meals. -She expected staff to assist and activities to be done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure appropriate care and services were provided to residents to prevent the development and/or deterioration of pressure ulcers (PU) for four of 12 sampled residents (Resident #28, #92, #11, and #15). Facility staff failed to ensure the physician was notified of the PU and treatment obtained timely for one resident (Resident #92). The facility failed to ensure PU precautions were adhered to for one resident, resulting in the resident developing a PU (Resident #15), and failed to thoroughly assess and document assessments and measurements, and update the physician to obtain treatment orders for a new pressure ulcer for (Resident #92) and when a PU deteriorated for (Resident #11). Furthermore, the facility failed to follow their protocol assessment and documentation of skin issues when nurses did not consistently document and/or sign shower sheets at the time of a shower for two residents (Resident #28 and #92). The facility census was 40. Review of the facility's undated policy Pressure Ulcer Care and Prevention showed: -Purpose is to prevent and treat further breakdown of pressure sores. -The nurse is responsible for implementing measures to prevent pressure ulcers; -Change bed linen promptly whenever wet or soiled; -Keep sheets dry, free of wrinkles and free of debris; -Turn the resident every 2 hours and position with pads or pillows for protection; -Assist the resident at mealtimes to assure adequate nutrition; -Offer fluids frequently for adequate hydration. Review of the facility's undated Wound Protocol document showed: -Develop a turning and repositioning schedule, at least every two hours while in bed and at least hourly in a chair; -Encourage Fluids; -Thoroughly document all wound information such as type, location, stage, length, width, depth and drainage; -Notify appropriate personnel of all new pressure ulcers. Review of the facility's Skin Monitoring: Comprehensive CNA Shower Review showed: -Perform a visual assessment of a resident's skin, report any abnormal looking skin to the charge nurse immediately. Forward any problems to the Director of Nursing for review. Use this form to show exact location and description of the abnormality. -Signature areas for the Certified Nurse Aide completing the shower, the Charge Nurse, and the Director of Nursing; -Areas for documentation of Charge Nurse Assessment, and Intervention. 1. Review of Resident #28 Quarterly MDS, dated [DATE], showed: -Brief Interview of Mental Status (BIMS) of 0 indicated severe cognitive impairment; -Moderate assistance for Activities of Daily Living (ADL's: tasks completed in a day to care for oneself); -Incontinent of urine and bowel; -At risk for PU; -No PU; -Diagnoses of: Memory Deficit after cerebral infarction (loss of memory after stroke: when blood flow to a part of the pain is blocked, causing loss of cells), Need for assistance with personal care, history of falling, and delirium (a sudden change in mental state). Review of the resident's Comprehensive Care Plan, dated 2/25/25, showed: -He/She needs assistance with ADL's; -No care plan for risk of PU or actual PU. Review of the resident's bath sheets, dated January 2025, showed: -1/1/25: no skin issues; -1/7/25: Decubitus (damage to the skin and underlying tissues caused by prolonged pressure; a bedsore or pressure ulcer) to right and left buttocks. Signed by Charge Nurse: Licensed Practical Nurse (LPN) A on 1/8/25; -1/10/25: Decubitus to right and left buttocks. No charge nurse assessment.; Signed by Charge Nurse: LPN A on 1/13/25; No DON signature; -1/17/25: Decubitus to right and left buttocks. No charge nurse assessment; Signed by Charge Nurse: LPN A on 1/17/25; No DON signature; -1/21/25: Decubitus to right and left buttocks. No charge nurse assessment; Signed by Charge Nurse: LPN A on 1/22/25; No DON signature; -1/24/25: Decubitus to right and left buttocks. No charge nurse assessment; No charge nurse signature; No DON signature; -1/27/25: Decubitus to right and left buttocks. No charge nurse assessment; Signed by Charge Nurse: LPN A on 1/27/25; No DON signature; -1/31/25: Decubitus to right and left buttocks. No charge nurse assessment; Signed by Charge Nurse: LPN A on 1/31/25; No DON signature. Review of the Resident's progress notes showed: -On 01/09/2025 at 10:11 A.M., Reported from Hospice Nurse the resident had two PU on his/her top right buttock and left inner buttock. Hospice gave order for areas to be cleansed with soap and water, pat dry, and apply zinc cream twice a day and as needed; -On 01/09/2025 at 3:40 P.M., Nurse was informed that the resident had an open area to his/her bottom. He/She found an area at the top of the resident's inner left buttock that was covered with slough (a non-living, yellow or white material in wounds, made of dead cells and other debris), unstageable (the stage of a pressure ulcer is unknown because the wound bed is covered by dead tissue), measuring 0.8 centimeters (cm) in length x 0.9 cm width x 0.1 cm depth. Wound edges and surrounding skin appeared as dry skin. Physician was in the facility and gave an order to discontinue (DC) zinc and start cleansing the area with soap and water, pat dry, apply Santyl (prescription medicine that removes dead tissue from wounds so they can start to heal) applied nickel thick to wound bed, apply border gauze dressing, and change daily. An air cushion was added to his/her recliner. Staff will assist him/her turning side-to-side during the night to keep pressure off of the open area. He/She had a pressure reduction cushion to his/her wheelchair. An air mattress was requested from hospice. -On 01/12/2025 at 2:33 P.M., The area on the resident's buttocks was cleansed and zinc was applied. Open area was barely visible and without drainage. The area appeared to be a stage 2 (a shallow open sore that has partially broken the skin's second layer); -On 01/14/2025 at 10:37 A.M., Hospice nurse DC' d the Santyl order to stage 2 ulcer. New order received to cleanse the pressure ulcer with soap and water, apply thera honey (a medical product used in wound care to promote healing) gel nickel thick, apply breathable dressing, and change daily; -No other progress notes in regards to wounds. Review of the resident's bath sheets, dated February 2025, showed: -2/3/25: Decubitus to right and left buttocks. No charge nurse assessment; No charge nurse signature; No DON signature; -2/7/25: Decubitus to left buttock and discoloration to right buttock. No charge nurse assessment. Signed by LPN B on 2/9/25; No DON signature; -2/7/25: Decubitus to left buttock and discoloration to right buttock. No charge nurse assessment. Signed by LPN B on 2/14/25; No DON signature; -2/10/25: Decubitus to left buttock and discoloration to right buttock. No charge nurse assessment. Signed by LPN A on 2/10/25; No DON signature; -2/19/25: Decubitus to left buttock and discoloration to right buttock. No charge nurse assessment. No charge nurse signature; No DON signature; -2/24/25: Decubitus to left buttock and discoloration to right buttock. No charge nurse assessment. Signed by LPN A on 2/24/25; No DON signature. Review of the resident's physician order sheets, dated February 2025, showed an order for Pressure Ulcer Care: Cleanse PU to left inner buttock with soap and water, apply thera honey gel nickel thick to wound bed, apply breathable border gauze dressing, change daily, ordered on 1/14/25. Review of the resident's monthly summary, dated 2/15/25, showed no skin issues. Review of the resident's medical record from January 2025-February 2025, showed no wound assessments documented. Observations on 02/24/25 at 10:31 A.M.,to showed the resident in the hall sitting up in his/her wheelchair with a cushion in the wheelchair. Observations on 02/24/25 at 12:00 P.M., showed -Facility staff transported the resident in the wheelchair to the dining room. Staff did not assist the resident with incontinence care or reposition the resident. -He/She was placed at the dining room table with his/her meal in front of him/her Observations on 02/25/25 at 9:10 A.M. to 11:58 A.M., showed -The resident sat up in his/her wheelchair in the hall. -At 11:58 A.M. the resident was transported to the dining room and placed at the dining room table. Facility staff did not change or reposition the resident before transporting them to the dining room. Observation on 02/25/25 at 12:17 P.M., showed: -The resident sat in the dining room in his/her wheelchair; -He/She was asleep at the table and had slid down toward the front of the wheelchair with his/her shoulders below the handle level of the wheelchair. Observation and interview on 2/26/25 at 4:47 P.M., showed: -The resident assisted to stand by staff and staff removed his/her slacks and incontinent brief; -The resident had open wound to left upper buttock fold that was a half dollar in size with white/yellow slough, the skin at the edge of the wound was peeling and dry; -The resident said the area hurts when he/she was cleansed and hurts at times when he/she was sitting. During an interview on 2/26/25 at 4:47 P.M. CNA F said: -The resident complains of pain to his/her bottom; -The resident has had the open area for awhile, not sure exact date; -He/She puts cream on the resident when he/she provided incontinent care. During an interview on 2/27/25 11:32 AM LPN B said: -The resident would take himself/herself to the bathroom and did not get himself/herself cleansed well; -His/Her wound was difficult to heal because of his/her incontinence; -His/Her wound was closed last month and is now open again. 2. Review of Resident #92 admission MDS, dated [DATE], showed: -admission date of 2/4/25; -Brief Interview of Mental Status (BIMS) of 15 indicated no cognitive loss; -Occasionally incontinent; -No wounds; -No risk for skin issues; -Diagnoses of: fall with injury, osteoarthritis (a condition where the cushion at the ends of the bones (cartilage) breaks down, leading to pain, stiffness and loss of movement), urinary incontinence (involuntary loss of urine), heart failure (the heart cannot pump enough blood to meet the needs of the body), and pain. Review of the resident's baseline care plan, dated 2/5/25, showed: -Psychosocial needs will be addressed in a manner consistent with the resident's overall health and life goals; -No care plan for skin issues. Review of the resident's medical record for February 2025 showed no order for wound care. Review of the resident's Comprehensive CNA Shower Review sheets showed: -2/11/25 scattered bruising; signed by LPN A 2/11/25, no DON signature; -2/14/25 open areas to right and left buttocks; signed by LPN B 2/14/25; no DON signature; During an interview on 02/19/25 at 11:15 A.M., the resident said: -He/She had sores on his/her bottom; -The sores were not there when he/she admitted to the facility; -The sores burn and hurt badly; -He/She had the sores because he/she wets his/her pants, because he/she is unable to get to the bathroom without staff assistance and has had to wait 30 minutes or more for his/her call light to be answered. Observation on 2/19/25 at 11:40 A.M., showed: -He/She was sitting in his/her recliner, no pressure relieving cushion in place; -CNA D cleansed the resident's buttocks with cleansing wipes; -He/She had a dime sized open area to left upper buttock; -He/She had a pencil eraser size open area to right upper buttock; -Surrounding skin red, inflamed and peeling; -The resident complained of pain and burning with cleansing. During an interview on 2/19/25 at 11:40 A.M., CNA G said: -The resident had the open area for several days; -He/She had told the nurse about the area the previous week. During an interview on 02/19/25 at 11:59 A.M. LPN C said: -He/She was not aware the resident had open areas; -He/She was not told in report that the resident had open areas. During an interview on 02/26/25 at 10:05 A.M. the resident primary care physician said: -He/She had received a fax on 2/7/25 to approve admission medications; -He/She had received a fax on 2/13/25 in regards to pain and request for pain gel; -He/She saw the resident on 2/23/25 at the hospital and noted the resident had open wounds; -He/She was not notified by the facility of open wounds on the resident. 3. Review of Resident #11's quarterly MDS, dated [DATE], showed: - The resident had a BIMS score of 14, indicating very little cognitive deficit; - Diagnoses included: Diabetes Mellitus (DM) type II, multiple sclerosis (a disease in which the immune system eats away at the protective covering of the nerves) and wound. - He/She was completely dependant on staff for toileting needs, showers, and to get dressed; - He/She was incontinent of bowel and bladder; - He/She was a risk for the development of PU, but had none; - He/She had skin break down on his/her buttocks. Review of the resident's skin care plan, dated 8/26/22, showed the resident had a chronic wound to his/her buttock that sometimes appeared to be open and sometimes appeared to be closed. Review of the Braden Scale (a tool completed by facility staff to determine the resident's risk for PU development), dated 12/13/24, with a score of 12, indicating the resident was a high risk for the devolvement of a PU. Review of the resident's skin assessment, dated 1/5/25, showed LPN A documented on a skin assessment the resident had an open area to his/her bottom. Review of the resident's monthly summary, dated 1/9/25, LPN B documented the resident had fragile, warm, and dry skin. LPN B did not document any further details about the resident's skin breakdown. Review of the residents skin assessment, dated 1/12/25, showed LPN B completed a skin assessment, the resident continued to receive a treatment for redness on the buttocks and a small open area, will fax the resident's physician for new orders, no new orders were obtained. Review of the residents record showed the facility staff did not complete a skin assessment during the weeks of 1/19/25 and 1/26/25. Review of the resident's skin assessment dated [DATE] showed LPN A documented on a skin assessment the resident had an existing non-foot skin issue. Review of the resident's record showed the facility staff did not complete a skin assessment during the week of 2/9/25. Review of the resident's skin assessment and monthly summary, dated 2/16/25, showed: - LPN A documented on a skin assessment the resident's bottom was red and had an open area; - LPN A documented on the monthly summary the residents skin condition was good, warm and dry; - LPN A did not document any further details about the resident's skin breakdown. Review of the resident's POS, dated February 2025, showed the following orders: - 2/19/25: Barrier cream with collagen powder apply to buttocks' two times per day and as needed; - 2/15/25: Wound care team consult for the wound on the resident's bottom. Review of the medical record from January 2025 through February 2025, showed the facility staff did not document wound assessments and did not document the physician was notified of the resident's wound. Observation on 2/25/25 at 8:14 A.M., showed: - The resident lay in his/her bed; - LPN A entered the resident's room to complete wound care; - LPN A measured the resident's open wound to his/her bottom that was 6 CM long by 0.3 CM wide; - The center of the wound had a dark brown area that measured 2 CM long by 1.75 CM wide, LPN A described as eschar (a dry crusted layer of dead tissue that forms over a wound); - The wound had an area of dark pink moist skin that surrounded the wound from the gluteal cleft and both buttocks. During an interview on 2/25/25 at 8:14 A.M., LPN A said: - The wound appeared to be in worse condition than last week, because the wound looked larger than last week; - The wound was a Stage II PU; - There was an order for a wound care team to evaluate the resident's wound, but they have not been in yet; - The facility nurses complete the resident's skin assessments weekly and provides the resident's wound care as the physician has ordered it. During an interview on 2/26/25 at 10:50 A.M., LPN B said: - The resident's eschar was a new development; - The resident's wound improved for a time and then has gotten worse; - The facility staff have tried a lot of things for the resident's wound; - The facility had experienced more wounds within the last couple of months. 4. Review of Resident # 15's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by the facility staff), dated 12/27/24, showed: - He/She had a BIMS score of 15, indicating no cognitive deficit; - Diagnoses included: Cerebral Palsy (is a disorder that affects movement, muscle tone and posture). - He/She required assistance from staff to transfer, toileting needs and get dressed; - He/She was incontinent of bowel and bladder; - He/She was at risk for the development of a PU but did not have a current PU. Review of the resident's face sheet showed the following diagnoses: dysphagia, oral phase (difficulty swallowing) and weakness. Review of the resident's Activities of Daily Living (ADL) care plan, dated 11/26/19, showed: - The resident was dependent on a mechanical lift and two staff for transfers; - The resident's required assistance with all his/her ADL's. Review of the residents skin care plan, dated 11/26/19, showed: - The resident was incontinent of urine; - The staff were supposed to assist the resident's with perineal care; - The resident's had compromised skin integrity between his/her thighs. Review of the resident's Braden Scale, dated 12/23/24, showed the facility staff assessed the resident had a score of 17, indicating the resident was at mild risk of the development of a PU. Review of the resident's POS, dated February 2025, showed the following orders: -11/26/24: Vitamin A&D ointment mixed with zinc, apply to the perineal area as needed to treat red skin; -8/22/24: Cleanse the resident's right inner thigh area, pat dry, apply barrier cream and then abdominal (ABD) pad for comfort daily. Review of the resident EMR showed the following: - 2/2/25 Facility staff documented on a monthly summary, the resident's skin was in good condition, warm and dry; - 2/4/25 Facility staff documented a skin assessment the resident's skin was intact. During an interview on 2/23/25 at 10:32 A.M. the Resident said: - He/She had a sore on his/her inner right thigh; - It took a while for staff to change him/her; - He/She had been up since 7:00 A.M. this morning and had not been repositioned or changed since; - He/She was wet. Observation on 2/23/25 at 1:52 P.M. showed: - The resident's was in his/her room in his/her wheel chair; - CNA C and CNA I entered the resident's room with the mechanical lift; - The CNA's assisted the resident in bed using the mechanical lift; - The resident's had a strong urine smell; - CNA C provided perineal care; - The resident's has saturated trough an incontinence brief, his/her pants and the mechanical lift sling; - The resident's bottom was red and appeared irritated; - The resident had an open area to his/her back of upper right thigh; - CNA C applied a large amount of a zinc based ointment to the open area. During an interview on 2/23/25 at 1:52 P.M., CNA C said: - He/She was trained to complete rounds every two hours; - Rounds included repositioning residents and cleaning resident's if they are wet or soiled; - Resident #15 was supposed to be repositioned every two hours; - He/She came on duty at 7:00 A.M. and did not reposition or change the resident's before now; - He/She should have ensured the resident's was dry and repositioned every two hours and as needed. During an interview on 2/23/25 at 2:03 P.M., CNA I said: - Cares were last provided for the resident at 7:30 A.M. for Resident #15; - Cares included repositioning and ensuring the resident was clean and dry; - The resident should have been changed earlier. During an interview on 2/26/25 at 10:50 A.M., LPN B said: - The resident's wound to his/her upper right thigh was chronic; - The resident was incontinent of bowel and bladder; - He/She expected staff to reposition and clean the resident every two hours and as needed; - He/She did not think the staff change and reposition the resident like they were supposed to; - Staff should not have left the resident for more than six hours with out cleaning and repositioning him/her. During an interview on 2/27/25 at 12:28 P.M., the Quality Assurance (QA) nurse said he/she expected the staff to provide repositioning and perineal care every two hours and as needed for resident's that need help. The staff should not have left Resident #15 sitting in his/her wheel chair from 7:30 A.M. to 1:52 P.M. with out repositioning and providing perineal care. During an interview on 2/27/25 at 3:10 P.M., the Administrator said staff should have repositioned Resident #15 and provided perineal care every two hours. It was not acceptable to let the resident's sit in his/her wheel chair for more that six hours without repositioning and cleaning the resident's. 5. During an interview on 2/19/25 at 2:08 P.M., Certified Nurse Aide (CNA) F said: -There are multiple residents with open areas. Resident#28, #92, #11, and #15 was among them; -He/She told the nurse and Administration about the residents open areas. During an interview on 2/19/25 at 2:39 P.M., CNA C said: -Staff have to choose between baths and residents who need help being turned and repositioned every 2 hours; -He/She cannot get everything done with the staff available. During an interview on 2/19/25 at 3:10 P.M. CNA B said staff cannot get everything done and resident's have open areas, because there was not enough help. During an interview on 2/26/25 at 10:50 A.M., LPN B said: - There seem to be a lot more wounds in the past couple of months; - He/She did not think the aids were cleaning and repositioning resident like they were supposed to; - Several residents have open areas and redness on their bottoms; - He/She expected staff to clean and reposition residents that were not able to complete the task themselves every two hours and as needed; - Some of the aides left resident up in their wheel chairs from before breakfast until after lunch without cleaning the resident or repositioning the resident. During an interview on 2/27/25 at 3:10 P.M., the Administrator said she expected staff to reposition resident's every two hours and as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide adequate staffing to reposition and provide incontinence care for three residents who were at risk for pressure ulcers (Residents #28, #92, and #15), failed to answer the call light in a timely manner resulting in incontinence for one resident (Resident #92), and failed to provide two showers per week to one resident (Resident #28) as a standard of care. Additionally, the facility failed to ensure enough staff were in the dining room to assist residents who required assistance during meals, resulting in one staff member going between two tables to assist eight residents who needed nutritional assistance. The facility census was 40. The facility did not supply a policy on staffing. Review of staff schedules showed: -January 14th: day shift staff included 1 Licensed Practical Nurse (LPN), 1 Certified Medication Technician (CMT), and 4 Certified Nurse Aides (CNA); Night shift included: 1 Registered Nurse (RN), 2 CNAs and 1 Nurse Aide (NA); -February 18th: day shift staff included 1 LPN, 1 CMT, and 3 CNAs; Night shift included: 2 CNAs and 1 NA; -February 19th showed: day shift staff included the Director of Nursing (DON), 2 CMTs, and 3 CNAs; Night shift included: 2 CNAs and 1 NA -February 23rd: Day shift staff included 1 Licensed Practical Nurse (LPN), 1 CMT and 4 CNAs; Night shift included: 1 RN and 2 CNAs; -February 24th: Day shift staff included: 1 LPN, 1 CMT, and 4 CNAs, Night shift included: 1 RN, 2 CNAs and 1 NA; -February 25th: Day shift staff included: 1 LPN, 1 CMT, and 5 CNAs, Night shift included:1 LPN and 2 CNAs; -February 26th: Day shift staff included 1 LPN, 1 CMT, and 4 CNAs, Night shift included: 1 LPN and 2 CNAs. 1. Review of Resident #28 Quarterly minimum data set (MDS), a federally mandated assessment completed by the facility staff, dated 1/3/25, showed: -Brief Interview of Mental Status (BIMS) of 0 indicating severe cognitive impairment; -Moderate assistance for Activities of Daily Living (ADLs: tasks completed in a day to care for oneself); -Incontinent of urine and bowel; -At risk for pressure ulcers; -No pressure ulcers; -Diagnoses of Memory Deficit after cerebral infarction (loss of memory after stroke: when blood flow to a part of the pain is blocked, causing loss of cells), Sick Sinus Syndrome (a condition where the heart's natural pacemaker does not function properly), need for assistance with personal care, history of falling, and Delirium (a sudden change in mental state). Review of the resident's Comprehensive Care Plan, dated 2/25/25, showed: -He/She needs assistance with ADLs. Review of the resident's bath sheet showed: -He/She was scheduled for Tuesday/Friday baths; -No bath on 1/3, 1/14, and 2/18. Review of the resident's progress notes showed: -On 01/09/2025 at 10:11 A.M., reported from Hospice Nurse the resident had two pressure ulcers on his/her top right buttock and left inner buttock. Hospice gave order for areas to be cleansed with soap and water, pat dry, and apply zinc cream twice a day and as needed. -On 01/09/2025 at 3:40 P.M., nurse was informed the resident had an open area to his/her bottom. He/She found an area at the top of the resident's inner left buttock that was covered with slough (a non-living, yellow or white material in wounds, made of dead cells and other debris), unstageable (the stage of a pressure ulcer is unknown because the wound bed is covered by dead tissue), measuring 0.8 centimeters (cm) in length x 0.9 cm width x 0.1 cm depth. Wound edges and surrounding skin appeared as dry skin. Physician was in the facility and gave orders to discontinue (DC) zinc and start cleansing the area with soap and water, pat dry, apply Santyl (prescription medicine that removes dead tissue from wounds so they can start to heal) applied nickel thick to wound bed, apply border gauze dressing and change daily. An air cushion was added to his/her recliner. Staff will assist him/her turning side-to-side during the night to keep pressure off of the open area. He/She had a pressure reduction cushion to his/her wheelchair. An air mattress was requested from hospice. Review of the resident's January monthly summary showed no skin issues. Review of the resident's physician order sheets, dated February 2025, showed: -Pressure Ulcer Care: Cleanse pressure ulcer to left inner buttock with soap and water, apply therahoney gel, nickel thick to wound bed, apply breathable border gauze dressing, change daily. Ordered on 1/14/25. Observations on 02/24/25 at 10:31 A.M., showed: -The resident was in the hall sitting up in his/her wheelchair; -The resident had a cushion in his/her wheelchair. Observation on 02/25/25 from 9:10 A.M. to 11:58 A.M., showed -The resident was sitting up in his/her wheelchair in the hall; -The resident had a cushion in his/her wheelchair. -He/She was not repositioned, freshened up, or moved. Observation on 02/25/25 from 12:17 P.M. to 1:30 P.M., showed -The resident was sitting in the dining room in his/her wheelchair; -He/She was asleep at the table; -He/She was slid down toward the front of the wheelchair with his/her shoulders below the handle level of the wheelchair. -The resident had a cushion in his/her wheelchair. Observation and interview on 2/26/25 at 4:47 P.M., showed: -The resident was assisted to stand by staff; His/her slacks and saturated incontinent brief were removed; -The resident had an open wound to the left upper buttock fold, half dollar in size with white/yellow slough, the skin at the edge of the wound was peeling and dry. -The resident complained of pain to the area. During an interview on 2/27/25 11:32 AM, LPN B said: -The resident would take himself/herself to the bathroom and did not get himself/herself cleansed well; -CNA staff do not have enough time to get everything done; -Staff do the best they can to get all the residents cleaned up and taken care of; -His/Her wound was difficult to heal, because of his/her incontinence; -His/Her wound was closed last month and is now open again 2. Review of Resident #92 admission MDS, dated [DATE], showed: -admission date of 2/4/25; -BIMS of 15 indicating cognitively intact; -Occasionally incontinent; -No wounds; -No risk for skin issues; -Diagnoses of fall with injury, osteoarthritis (a condition where the cushion at the ends of the bones (cartilage) breaks down, leading to pain, stiffness and loss of movement), hypertension (high blood pressure), atrial fibrillation (a irregular and rapid heart beat), urinary incontinence (involuntary loss of urine), heart failure (the heart cannot pump enough blood to meet the needs of the body), and pain. Review of the resident's baseline care plan dated 2/5/25 showed: -Psychosocial needs will be addressed in a manner consistent with the resident's overall health and life goals. During an interview on 02/19/25 at 11:15 A.M., the resident said: -He/She had sores on his/her bottom; -The sores were not there when he/she admitted to the facility; -The sores burn and hurt badly; -He/She had the sores because he/she wets his/her pants, because he/she was unable to get to the bathroom without staff assistance and has to wait 30 minutes or more, every evening, for his/her call light to be answered; -He/She knows how long he/she waits, because he/she can see the clock. Observation on 2/19/25 at 11:40 A.M., showed: -The resident was sitting in his/her recliner, -He/She had a dime sized open area to left upper buttock; -He/She had a pencil eraser sized open area to right upper buttock; -Surrounding skin red, inflamed, and peeling. -The resident complained of pain and burning to the areas. 3. During an interview on 2/19/25 at 2:08 P.M., Certified Nurse Aide (CNA) F said: -There are multiple residents with open areas; -Most residents don't get two showers a week, because there was not enough staff to do everything that needed to be done, such as turning and repositioning residents, and the residents were getting wounds. During an interview on 02/27/25 09:59 AM, CNA F said he/she was trying to get all the baths done during the shift, because later they would not have enough staff and the residents would not get a bath for a while, up to a week. During an interview on 2/19/25 at 2:39 P.M., CNA C said: -If he/she and his/her partner were able to get residents turned and repositioned every 2 hours on a shift, then the residents do not get baths; -He/She had to choose between completing baths and residents who need help being turned and repositioned every 2 hours; -He/She cannot get everything done with the staff available. During an interview on 2/19/25 at 3:10 P.M., CNA B said: -Staff cannot get everything done and multiple residents have open areas because there was not enough help. 4. Review of Resident #15's quarterly MDS dated [DATE], showed: - He/She had a BIMS score of 15, indicating no cognitive deficit; - Diagnosis included Cerebral Palsy (is a disorder that affects movement, muscle tone and posture); - He/She required assistance from staff to transfer, toileting needs, and to dress; - He/She was incontinent of bowel and bladder. Review of the resident's face sheet showed the following diagnoses: Dysphagia, oral phase (difficulty swallowing), and weakness. Review of the resident's Activities of Daily Living (ADL) care plan, dated 11/26/19, showed: - The resident was dependent on a mechanical lift and two staff for transfers; - The resident's required assistance with all his/her ADLs. During an interview on 2/23/25 at 10:32 A.M., the resident said: - He/She had a sore on his/her inner right thigh; - The facility could use more staff because it took a while for staff to change him/her; - He/She he had been up since 7:00 A.M. this morning and has not been repositioned or changed since; - He/She was wet. Observation on 2/23/25 at 1:52 P.M., showed: - The resident was in his/her room in his/her wheelchair; - Certified Nurse Aide (CNA) C and CNA I entered the resident's room with the mechanical lift; - The CNAs assisted the resident in bed using the mechanical lift; - The resident had a strong urine smell; - CNA C provided perineal care; - The resident had saturated through an incontinence brief, his/her pants, and the mechanical lift sling; - The resident's bottom was red and appeared irritated. During an interview on 2/23/25 at 1:52 P.M., CNA C said: - He/She was trained to complete rounds every two hours; - Rounds included repositioning residents, and cleaning residents if they were wet or soiled; - Resident #15 was supposed to be repositioned every two hours; - He/She came on duty at 7:00 A.M. and did not reposition or change the resident's before now; - He/She should have ensured the resident was dry and repositioned every two hours and as needed. During an interview on 2/23/25 at 2:03 P.M., CNA I said: - Cares were last provided for the resident at 7:30 A.M. for Resident #15; - Cares included repositioning and ensuring the resident was clean and dry; - There was not enough staff to keep up with the residents cares; - The resident should have been changed earlier. 5. Observation on 2/23/25 at 12:02 P.M., showed: - Two CNAs in the dining room passing trays to residents; - There were eight residents at two assist dining tables; - One CNA sat in a rolling chair at each table and rolled between the residents to assist them; - No more staff came to the dining room to help. Observation on 2/24/25 at 12:08 P.M., showed: - There were eight residents at two assist dining tables; - One CNA sat in a rolling chair at each table and rolled between the residents to assist them; - No more staff came to the dining room to help. 6. During an interview on 2/25/25 at 8:38 A.M., CNA C said: - The facility does not have enough staff working to complete his/her job; - The facility has had a lot of wounds lately because there is not enough staff to lay residents in bed, reposition them and clean them up every two hours; - The facility does not usually have a shower aide; - The CNAs on the floor are responsible for complete residents showers in addition to all their other tasks; - The facility does not have enough staff to serve the residents at meal time; - The facility does not have enough staff to assist the residents that need assistance during meals and typically have one CNA at each of the assist dining tables to go from resident to resident. During an interview on 02/27/25 at 3:10 P.M., the Administrator said: -She believed there was plenty of staff to get all cares done with the residents; -New staff had been hired on in the past month; -She was not aware of multiple wounds in the building; -She was not aware residents were not receiving two baths weekly.

Based on interview and record review, the facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day seven days a week. The census was 70. The facility did not provide a policy on staffing. Observation and interview on 02/23/25 at 9:44 A.M., showed: -Licensed Practical Nurse (LPN) B was the Charge Nurse; -He/She was the only nurse at the facility; -He/She was the only nurse the previous day; -There was no RN in the facility. Review of the daily staffing sheets showed no RN on: July 2024: 6th, 7th, 20th, and 21st; August 2024: 3rd, 4th, 17th, and 18th; September 2024: 1st, 14th, 15th, and 24th; No staffing sheets provided for October; November 2024: 16th, 17th, 23rd, 28th, 29th, and 30th; December 2024: 1st, 6th, 7th, 8th, 14th, 15th, 21st, 22nd, 24th, 26th, 27th, 28th, 29th, 30th, and 31st; January 2025: 4th, 5th, 11th, 12th, 15th, 18th, 19th, 25th, and 26th; February 2025: 1st, 2nd, 22nd, 23rd, and 26th. Observation of on-line staffing services showed an advertisement for a full time RN. During an interview on 02/27/25 at 12:28 P.M., the Quality Assurance Nurse said: -He/She was the Interim Director of Nursing (DON) from December 20, 2024 until February 3, 2025. -Another RN was hired for the DON position. During an interview on 02/27/25 at 3:10 P.M., the Administrator said: -She was aware there were multiple days without a RN; -She had advertisements out for a DON for 3 years; She had advertisements out for charge nurses; -She added referral and sign on bonuses, and increased wages, but no applications were received; -She had not applied for a waiver. During an interview on 3/17/25 at 10:57 A.M., the Medical Director said: -He was not aware there were days without an RN in the facility; -Not having an RN in the facility could be detrimental to resident care in certain situations.

Based on interview and record review, the facility failed to ensure nurse aides had a yearly performance review, with resulting individually based education plans, for three nurse aides employed longer than 12 months. The facility census was 40. The facility did not provide a policy for education, and Nurse Assistant Training. Review of personnel records showed: -Certified Nurse Aide (CNA) D, Date of Hire 11/22/00, Annual Education Quiz completed 6/7/24. No competency assessment and training plan. -CNA E, Date of Hire 10/21/22, Annual Education Quiz completed 6/6/24. No competency assessment and training plan. -CNA F, Date of Hire DOH 9/17/01, Annual Education Quiz completed 6/6/24. No competency assessment and training plan. During an interview on 02/27/25 at 12:28 PM, the Quality Assurance Registered Nurse said trainings and tracking were completed by nurse leadership. During an interview on 02/27/25 at 3:10 P.M., the Administrator said: -The previous Director of Nursing (DON) completed the last competency. -He/She did not know the date of the last competency. -He/She expects the DON to complete yearly competency education. -He/She did not know where the tracking was kept

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure staff prepared foods in a way to meet the needs of individual residents, when they did not ensure the puree (a texture-modified diet in which all foods have a soft, pudding-like consistency) food had a smooth and appropriate consistency and failed to ensure the mechanical soft diet contained meat that was ground and easy to chew. This affected two residents who had orders for a pureed diet (Residents #6, and #15) and one resident (Resident #3) who had an order for a mechanical soft diet. The facility census was 40. Review of the facility's policy titled, Types of Diets, dated, May 2015, showed: -Mechanical soft diet is a regular diet modified using chopped or ground meat; -Puree diet foods are blended to mashed potato consistency or altered to meet the needs of the residents. 1. Review of Resident #6's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 02/08/25, showed: -Severe cognitive impairment; -Severe visual impairment; -Dependent on staff for transfers, bathing, locomotion, toileting and eating; -Diagnoses included dementia, heart failure, and high blood pressure. A review of the resident's care plan, dated 02/20/25, showed: -The resident was on a pureed diet. A review of the resident's Physician Order Sheet (POS), dated February 2025, showed the resident had an order for a pureed diet. 2. A review of Resident #15's Quarterly MDS, dated [DATE], showed: -No cognitive impairment; -Substantial assistance of staff for transfers, bathing, locomotion, toileting and eating; -Diagnoses included depression, stroke, and high blood pressure. A review of the resident's care plan, dated 01/02/25, showed: -The resident was on a pureed diet. A review of the resident's POS, dated February 2025, showed the resident had an order for a pureed diet. 3. Review of Resident #3's Quarterly MDS, dated [DATE], showed: - Severe cognitive impairment; - Dependent on staff for activities of daily living; - Supervision with eating; - Mechanical altered diet; - Diagnoses included dementia, high blood pressure, and urinary tract infection. Review of the resident's care plan dated, 02/20/25, showed: -The resident has impaired decision making related to dementia; -Mechanical soft diet. Review of the resident's POS, dated, February 2025, showed: -11/07/22, mechanical soft diet. Observation of meal preparation for lunch on 02/25/25, at 11:31, A.M., showed: - [NAME] A began preparing the pureed lunch meal; - [NAME] A did not use a recipe to prepare the pureed lunch meal; - He/She placed two cups of yellow rice into the food processor; - He/She turned on the food processor and began adding butter and blended until it was the desired consistency; - The mixture was thick with visible pea sized chunks in it; - [NAME] A placed two cups of spinach into the food processor; - He/She turned on the food processor and blended until it was the desired consistency; - The mixture was watery and ran off the spoon; - [NAME] A began preparing the mechanical soft lunch meal; - [NAME] A placed a cooked tuna patty into the food processor; - He/She turned on the food processor and blended until it was the desired consistency; - He/she added butter to the mixture; - The mixture was dry, tough, and hard to chew. Observation on 02/25/25, at 12:18 P.M. showed: -Resident #6 and #15 were served pureed meals that were thick and had chunks in it; -Resident #3 had difficulty chewing the mechanical soft meat. Observation of the puree lunch meal test tray on 02/25/25, at 12:56 P.M., showed: -The tuna patty melt was dry and hard to chew; -The yellow rice was dry, hard and had no flavor; -The pureed yellow rice was dry and had no flavor; -The spinach was watery and ran off the spoon. During an interview on 02/25/25 at 02:17 P.M., [NAME] A said: - Pureed foods should have a pudding like consistency and not be hard to chew; - Pureed foods should not be watery; -Mechanical soft foods should not be dry and hard to chew. - Food should have a good flavor and should not be dry. During an interview on 02/25/25 at 02:30 P.M., the Dietary Manager (DM) said: - Pureed foods should have a pudding like consistency and not be hard to chew; - Pureed foods should not be watery; -Mechanical soft foods should not be dry and hard to chew; - Food should have a good flavor and should not be dry. During an interview on 03/05/25, at 10:17 A.M., the Registered Dietitian (RD) said: - He/She expects pureed foods to have a pudding like consistency and not be hard to chew; -Mechanical soft foods should not be dry and hard to chew. - Food should have a good flavor and should not be dry; - He expects the dietary staff to ensure the food is palatable. During an interview on 03/05/25 at 01:38 P.M., the Administrator said: -She expects the food to be palatable and balanced; -She expects diet orders to be followed.

Based on observation, interview, and record review, the facility failed to ensure the Dietary Manager (DM) had the appropriate competencies and skills sets to carry out the functions of the food and nutrition service. The facility census was 40. The facility did not provide the requested job description for the Dietary Manager. Review of the DM's personnel file showed: -Date of hire 10/04/2023; -No certification for food service management or dietary manager was found. During an interview on 02/24/25 at 11:32 A.M., the DM said: -He had been the DM for six months; -He has worked as a dietary aide, but does not have any managerial experience; -The facility was getting ready to start on his DM training; -He has not completed his/her DM's course. During an interview on 02/27/25 at 03:10 P.M., the Administrator said: -She would expect the DM to know all regulations related to the kitchen; -The DM had not completed the dietary training yet; -She would expect the DM to have the training completed. During an interview on 03/05/25 at 12:43 P.M., the Registered Dietitian (RD) said: -The facility is trying to work on training the DM; -He would expect the DM to have the required training to manage the kitchen.

Based on observation, interview, and record review, the facility failed to ensure staff stored food in a sanitary manner and to maintain the kitchen in a sanitary manner. The food facility census was 40. Review of the facility's policy, General Dish Room Sanitation, dated, May 2015, showed: -Dish rooms must be maintained in a clean and sanitary condition; -Items must be stored inverted (upside down) to prevent contamination. Review of the facility's policy, Cleaning Floors, dated, May 2015, showed: -Floors will be cleaned after every meal; -The dietary department must keep the floors of the kitchen free from soil and clutter. Review of the facility's policy, Refrigerators and Freezers, dated, May 2015, showed: -The floors of walk in refrigerators and freezers should be swept and mopped weekly; -Food should be stored at least 6 inches above the floor. Review of the facility's policy, Dishwashing, dated, May 2015, showed: -Check chemical dispensers for proper operation and an adequate supply of chemical. Review of the facility's policy, Wet Mopping, dated, May 2015, showed: -Dietary floors should be kept in good repair; -Cracked tiles should be repaired and replaced. Observation of the kitchen on 02/23/25 at 09:50 A.M., showed: -The hand washing sink in the kitchen was dirty with dirt and grime in the basin; -The handles on the hand washing sink were covered with dirt and debris; -A white bucket of dirty water containing debris was sitting under the hand washing sink; -The dish room floor was covered in dirt and debris; -There was a black substance on the outside of the dishwasher and under the dishwasher on the floor; -The paint was peeling off the ceiling in the dish room. Observation on 02/23/25 at 09:50 A.M., showed Dietary Aide (DA) A put a water pitcher, three glasses, and a coffee cup on to a dish rack and put the rack in the dishwasher; -The dishes ran through a wash and rinse cycle; -DA A removed the dish rack with the washed dishes from the dishwasher; -DA A did not check the sanitizer in the dishwasher before or after using the dishwasher. Review of the dishwasher sanitation and temperature log dated, February 2025, showed: -No entry indicating staff checked the sanitizer level on 02/01/25 at lunch; -No entry indicating staff checked the sanitizer level on 02/02/25 at lunch; -No entry indicating staff checked the sanitizer level on 02/05/25 at lunch; -No entry indicating staff checked the sanitizer level on 02/06/25 at lunch; -No entry indicating staff checked the sanitizer level on 02/07/25 at lunch. During an interview 02/23/25 at 10:01 A.M., DA A said: -The sanitizer should be checked before running the dishwasher at every meal; -The sanitizer level should be recorded on the sanitation and temperature log before running the dishwasher; -He/She did not know why entries were missing on the temperature and sanitation log. Observation of the serving area in the dining room on 02/23/25 at 10:12 A.M., showed: -The outside of the refrigerator was covered in dirt and debris; -The handle was covered in a brown sticky substance; -The inside and bottom of the refrigerator was covered with food debris and a brown sticky substance; -A table behind the steam table with multiple glass cups and bowls, setting face up with dirt and debris in them; -Plastic bowls setting on the table behind the steam table setting face up with dirt and debris in them; -The glass on the steam table covered in splattered food debris and smudges; -The inside left corner of the steam table with a puddle of black sticky liquid in the corner; -The steam table was on and steam was coming from under the lids on the steam table; -The lids had food debris on them; -The control knobs of the steam table were covered in sticky, brown grime with food debris stuck to them; -Dirty masking tape was hanging down from each of the control knobs on the stream table; -There were multiple tiles missing from the floor next to the steam table; -The trash can next to the hand washing sink in the serving area with no lid. Observation of the kitchen on 02/23/25 at 10:52 A.M., showed: -The walk in cooler had a wet substance the size of a basketball on the floor; -Undated zip lock bag of hamburger patties; -Undated zip lock bag of hotdogs; -A box of health shakes setting on the floor; -A package of opened and undated Brussels sprouts; -The floor of the cooler was sticky and covered with food debris; -Multiple black spots on the ceiling outside of the walk in cooler the size of nickels; -Dry storage showed a clear plastic container of thickener with the dates 09/25/24 - 10/25/24 written on the lid; -16 ounce clear plastic container of flour with the dates 08/16/24 to 10/24/24 written on the lid; -An open package of sugar with no date; -The inside of the microwave covered in dirt and debris; -Floors of the kitchen were covered in dirt and debris. Observation of the kitchen on 02/25/25 at 08:25 A.M., showed: -A rack of pots and pans stored face up; -A plastic container of whisks and spoons with dirt and debris in the bottom; -The ceiling of the kitchen with dust on it; -A black piece of plastic hanging from the sky light over the dish drying rack. During an interview on 02/25/25 at 1:25 P.M., the Dietary Manager (DM) said: -The kitchen should be clean and sanitary; -There should be no food stored on the floor in the cooler; -Food should have a date it was put into storage; -All food should be stored in a closed container; -The thickener and flour in the dry storage should have been discarded according the the dates on the containers; -The kitchen staff clean the kitchen, including the floors; -The floors in the kitchen should be swept and mopped daily; -The dietary staff tries to work on it together, but sometimes there is not enough time; -The kitchen staff is responsible for keeping the service area and the steam table clean in the dining room; -The dishwasher sanitizer should be checked three times a day and recorded on the log in the dish room; -Maintenance is in charge of repairs in the kitchen and the dining room; -The facility does not have a full time maintenance man at this time. During an interview on 02/27/25 at 03:10 P.M., the Administrator said: -She expects the kitchen to be clean and in good repair; -She expects foods to be stored appropriately; -There should not be food on the floor; -The dietary staff is in responsible for cleaning the kitchen; -Maintenance is responsible for the repairs in the kitchen; -The facility does not have a full time maintenance man right now. During an interview on 03/05/25 at 12:43 P.M., the Registered Dietitian (RD) said: -He expects the kitchen to be clean and sanitary; -He expects the kitchen to in good repair; -He expects the sanitizer in the dishwasher to be checked three times a day and recorded on the log in the dish room; -He expects dishes to be stored in a manner to prevent contamination; -He expects food to be stored in a safe manner.

2. Review of the facility provided, undated policy Gloves showed: -Wear gloves when it can be reasonably anticipated that hands will be in contact with mucous membranes (moist, inner linings of body cavities such as the nose, eyes, throat, etc), non-intact skin, any moist body substances (blood, sweat, tears, urine, etc) or surfaces soiled with these substances; -Use examination gloves for procedures involving contact with mucous membranes, for other resident care or diagnostic procedures that do not require sterile gloves. Review of Resident #23 Quarterly Minimum Data Set (MDS: A federally mandated assessment tool completed by facility staff) showed: -Brief Interview of Mental Status of 13, indicated very little cognitive deficit; -Partial to moderate assistance of staff for Activities of Daily Living (ADLs: tasks completed in a day to care for oneself); -Diagnosis of Dementia (a decline in mental ability severe enough to interfere with daily life), Anxiety (excessive worry, fear and nervousness that interferes with daily life), hypertension (high blood pressure), and dry eye. Review of the resident's physician orders for February 2025 showed, Artificial tears 1 drop each eye for dry eye. Observation on 02/26/25 at 12:43 P.M. showed: -Certified Medication Technician (CMT) B did not apply gloves. -CMT B administered one drop of Artificial Tears into the resident's right eye, held pressure to the inner corner of the eye with a tissue for one minute, then applied one drop into the resident's left eye. During an interview on 02/26/25 at 12:43 P.M., CMT B said -He/She should have worn gloves to administer eye drops; -He/She just did not think and gave the eye drops after administering oral medications. During an interview on 02/27/25 at 12:28 P.M., the Quality Assurance Nurse said she would expect gloves to be worn when administering eye drops. During an interview on 02/27/25 03:10 P.M the Administrator said she would expect staff to follow infection control guidelines. Based on observation, interview, and record review, the facility failed to develop and implement water management policy and procedures to reduce the risk of growth and spread of Legionella (bacteria that causes Legionnaires' disease, a serious type of pneumonia) which had the potential to affect all residents who resided at the facility. Furthermore, the facility failed to follow infection control guidelines when one staff administered eye drops for one resident (Resident #23) without the use of gloves. The facility census was 40. The facility did not provide a Legionella policy. 1. Review of the facility's records showed they did not have an implemented water management plan. During an interview on 2/25/25 at 3:50 P.M. the Administrator said: - The facility had not had a maintenance employee for over a month; - The maintenance employee would assess the building water systems; - The maintenance employee would document water testing and monitoring; - She was not able to find the facility water management plan.

Based on interview and record review, the facility failed to establish an infection prevention and control program that included an antibiotic stewardship program (a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use) that included antibiotic use protocols and a system to monitor antibiotic use. The facility census was 40. The facility did not provide an Antibiotic Stewardship policy. The facility did not provide Antibiotic Stewardship Program documentation that should include: - Protocols to optimize the treatment of infections by ensuring that residents who require an antibiotic are prescribed the appropriate antibiotic; - Procedures to reduce the risk of adverse events, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use; - Procedures to promote and implement a facility-wide system to monitor the use of antibiotics including a system of reports related to monitoring antibiotic usage and resistance data; - Designated appropriate facility staff accountable for promoting and overseeing antibiotic stewardship; - Accessing pharmacists and others with experience or training in antibiotic stewardship; - Implementation of a policy or practice to improve antibiotic use; - Regular reporting on antibiotic use and resistance to relevant staff such as prescribing clinicians and nursing staff; - Educate staff and residents about antibiotic stewardship. Review of the Infection Control binder showed the following: - January 2025 showed 10 infections, six urinary tract infection (UTI), one eye infection, one tooth infection, and two sialoadentis (infection of the salivary glands); - February 2025 showed 11 infections, eight UTIs, two respiratory infections, and one skin infection. - The infections were tracked on a color coded facility map, but no evidence was presented to show the facility staff determined the root cause analysis for the infections; - There was no evidence the facility provided the staff with infection control education. During an interview on 2/25/25 at 3:00 P.M., the Administrator said he/she did not have a current Infection Preventionist.

Based on interview and record review, the facility failed to hire an Infection Preventionist (IP). The facility census was 40. The facility did not provide and Infection Preventionist policy. Review of the Infection Control binder showed it did not include an IP training or certification. During an interview on 2/25/25 at 3:00 P.M. the Administrator said; - The Director of Nursing (DON) said he/she completed the IP course, but had not produced certification indicating the DON had completed the task; - The facility did not have a current IP; - She knew the facility was suppose to have an IP.

Based on interview and record review, the facility failed to ensure three Certified Nursing Assistants (CNAs), of 7 sampled staff had a minimum of 12 hours of documented yearly in-service education (which should have included abuse, neglect, and dementia cares). This had the potential to affect all of the residents. The facility census was 40 residents. The facility did not provide a policy for education or and Nurse Assistant Training. Review of personnel records showed: -Certified Nurse Aide D, Date of Hire 11/22/00, Annual Education Quiz completed 6/7/24. No other education/in-service records; -CNA E, Date of Hire 10/21/22, Annual Education Quiz completed 6/6/24. No other education/in-service records; -CNA F, Date of Hire 9/17/01, Annual Education Quiz completed 6/6/24. No other education/in-service records; -Nurse Aide A, Date of Hire 10/3/24, no education/in-service records. During an interview on 02/27/25 at 12:28 PM the Quality Assurance Registered Nurse said: -Training, documentation of training, and tracking are completed by nurse leadership; -Yearly trainings for CNAs are based on a calendar year, set up by nursing Leadership; -Outside vendors, such as hospice, will also provide education for staff at times; -Ultimately the documentation, tracking and training schedule were the responsibility of the Director of Nursing (DON). During an interview on 02/27/25 at 3:10 P.M. the Administrator said: -The previous DON completed the last competency; -Education is completed by combination of the DON and the Leadership Team; -He/She expects tracking of all trainings, such as a checklist of all of the employees with their individual components; -She would expect the DON to document and track all training. -He/She did not know where the tracking and attendance records are.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review the facility failed to prevent compromised skin integrity for two of 4 sampled residents, (Resident #1 and Resident #2) when the staff did not alert the charge nurse when Resident #1 had open areas to the back of his/her upper right thigh and did not ensure the resident was turned to his/her side after cares. The staff did not ensure Resident #2 was turned to his/her side when the resident was found to have dark red buttocks after cares were provided. The facility census was 39. Review of the undated pressure ulcer care and prevention policy showed: - The purpose of the policy was to prevent and treat further breakdown of pressure ulcers; - Observe the resident's skin. Areas that remain reddened after pressure has been relieved is at risk for developing into a pressure ulcer; - Use pressure relieving devices; - Reposition resident's every two hours. 1. Review of Resident #1's annual Minimum Data Set, (a federally mandated assessment completed by the facility staff), dated 4/4/254 showed: - He/She had a brief interview for mental status (BIMS) score of 15, indicating no cognitive deficit; - Diagnoses included: Diabetes Mellitus ( a condition in which the body does not process blood sugar properly), obesity, and dependence on staff for cares; - He/She was at risk for the development of a pressure ulcer; - He/She had moisture associated skin damage (MASD, a condition in which the skin integrity declines due to being exposed to moisture for an extended period of time); - There was a pressure reducing device for his her wheel chair and bed; - He/She was incontinent of bowel and bladder; - The resident was dependent on the mechanical lift for transfers; - He/She was dependent on the staff to transfer, get dressed, clean self after an incontinent episode. Review of the resident's skin care plan dated 3/15/23 showed: - He/She was at risk of developing a pressure ulcer because of his/her incontinence and immobility; - The staff were supposed to avoid shearing (scraping the top layer of skin off that happens often during turning and transferring) when reposition the resident; - The staff were supposed to keep the resident dry and clean as possible to minimize the resident's skin exposure to moisture. Observation on 6/21/24 at 1:46 P.M. showed: - Certified Nurse Aide (CNA) A and CNA B entered the resident's room with the mechanical lift. The resident was sitting in his/her wheel chair on top of a mechanical lift sling; - CNA A and CNA B transfer the resident from his/her wheel chair to the resident's bed; - The resident's wheel chair had a pressure reduction device but the resident's bed did not; - The resident was saturated with urine through his/her brief and clothing and had a strong urine odor; - CNA B said the resident wet through his/her pants; - CNA A tuned the resident to his/her side to provide perineal care; - The resident's buttocks were dark red; - The back of the resident's upper right thigh had three open areas approximately 0.5 centimeter (CM) wide and 2 CM long and no measurable depth; - The resident yelled owe when CNA A wiped the area with a moistened wipe; - CNA A and CNA B complete perineal care; - CNA A and CNA B cover the resident, leave him/her lying on his/her back and raised the head of the bed in an upright position; - CNA A and CNA B go directly to another resident's room; - Neither CNA reported the open area's to the charge nurse. During an interview on 6/21/24 at 2:00 P.M. the resident said: - His/Her right leg had hurt for a few days; - He/She did not know if the staff told the nurse; - He/She did not now if the staff put medicine on his/her leg. During and interview on 6/21/24 at 2:05 P.M. Licensed Practical Nurse (LPN) A said: - He/She expected the CNA's to report red and open areas to him/her immediately; - The CNA's did not report to him/her the resident had a red bottom or open areas; - LPN A would have expected the CNA's to turn the resident to his/her side and not leave him/her on his/her back while in bed. During an interview 6/21/24 at 2:15 P.M. CNA A said: - He/She was trained to report red areas and open areas to the charge nurse immediately; - He/She was trained to reposition residents every two hours and as needed if the resident was not able to reposition themselves; - Resident #1 was not able to reposition him/herself; - He/She should have reported the residents red bottom and open areas to the charge nurse immediately. During an interview on 6/21/24 at 2:41 P.M. The Director of Nursing (DON) said: - She expected the CNA's to report the resident's red bottom and open areas to the charge nurse immediately; - She expected the CNA's to position the resident so he/she would not be resident on the compromised skin areas. 2. Review of Resident #2's quarterly MDS dated [DATE] showed: - He/She had a BIMS score of 0, indicating severe cognitive impairment; Diagnoses included: Dementia ( a disease that affects the brain compromising memory and cognitive function), anxiety and need for assistance with personal cares; - He/She required a wheel chair; - He/She was at risk for the development of a pressure ulcer; - He/She had a pressure reducing device to his/her wheel chair and bed and was on the repositioning program; - He/She was dependent on the staff to transfer with a mechanical lift, repositioning, hygiene and bathing; - He/She was incontinent of bowel and bladder. Review of the resident's skin care plan date 3/13/24 showed: - The resident was at risk for skin breakdown due to immobility; - The staff were supposed to keep the residents skin clean and dry as possible. Observation on 6/21/24 at 1:18 P.M. showed: - The resident in his/her room in a Broda wheel chair (a chair that provides comfortable seating for the resident), sitting on a mechanical lift sling; - CNA C and CNA D enter the resident's room with the mechanical lift; - CNA C and CNA D assist the resident to his/her bed with the mechanical lift; - CNA C rolled the resident to his/her side to provide perineal care; - The resident had dark red buttocks; - The CNA's completed perineal care, covered the resident with a blanket and left the resident lying on his/her back with out offloading the pressure to the resident's buttocks; - The CNA's did not apply moisture barrier cream to the residents buttocks; - Both CNA's exited the resident's room. During an interview on 6/21/24 at 1:18 P.M. CNA D said: - He/She was trained to reposition the resident every 2 hours; - It was difficult to turn the resident while he/she was in bed because the resident had a low air loss mattress (an air mattress that fluctuates air pressure); - The resident's buttocks are always red in color; - They were supposed to apply moisture barrier cream to the resident's bottom when they saw it was red; - They did not apply moisture barrier cream after he/she completed cares on the resident; - He/She was supposed to turn the resident on their side after providing cares. During an interview on 6/21/24 at 2:05 P.M. LPN A said: - The CNA's did not report to him/her the resident's buttocks were red. - The resident often had red buttocks; - It was protocol to apply moisture barrier cream to the resident's bottom if the CNA saw redness to the resident's bottom. During an interview on 6/21/24 at 2:41 P.M. the DON said: - She expected the CNA's to report Resident #2's red buttocks immediately to the charge nurse; - She expected the CNA's to turn the resident to his/her side to decrease the pressure to the resident's buttocks. During an interview on 6/24/24 at 11:30 A.M. The administrator said: - She expected the staff to reposition residents that could not reposition themselves every two hours and as needed; - She expected the staff to report red areas and opens area to the charge nurse immediately; - She expected staff to use moisture barrier cream when the staff see red areas. MO237231 MO237773

Based on interview, record review, and facility policy review, the facility failed to notify the physician when blood pressure medication was held for 1 (Resident #41) of sampled 3 residents reviewed for notification of change. Specifically, the facility held Resident #41's blood pressure medication on three occasions when the resident's blood pressure (BP) was outside the physician-ordered parameters, with no notification made to the physician. Findings included: An undated facility policy titled, Condition Change, Resident (Observing, Recording and Reporting) (Includes Fall or Injury) revealed 6. Notify physician of condition change, need for treatment orders and/or medication order changes. A Resident Face Sheet revealed the facility admitted Resident #41 on 02/06/2023. According to the Resident Face Sheet, the resident had a medical history that included a diagnosis of essential (primary) hypertension. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/08/2024, revealed Resident #41 had a Brief Interview for Mental Status (BIMS) score of 2, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #41 had active diagnoses that included hypertension and coronary artery disease and received a diuretic medication (a medication used to remove excess fluid from the body). Resident #41's Care Plan, last reviewed/revised on 05/08/2024, did not include a Problem area that addressed hypertension. Resident #41's May 2024 Medications Flowsheet revealed the transcription of the following orders: - an order started on 05/11/2023 for hydrochlorothiazide (a diuretic medication) 12.5 milligrams (mg), one tablet once a day for a diagnosis of Essential (primary) hypertension; and - an order started on 05/26/2023 to check the resident's BP twice a day and hold the BP medication if the systolic BP was lower than 120 or the diastolic BP was lower than 65. An untitled document revealed twice a day BP readings for Resident #41. The resident's BP values were documented as the following: 05/03/2024 AM (morning) BP 113/61, 05/09/2024 AM BP 93/51, and 05/18/2024 AM BP 87/50. Resident #41's May 2024 Medications Flowsheet revealed documentation that indicated staff held the resident's hydrochlorothiazide on 05/03/2024, 05/09/2024, and 05/18/2024. There was no documented evidence the physician was notified the resident's BP was below the ordered parameters. Resident #41's Progress Notes revealed no evidence the physician was notified when the resident's hydrochlorothiazide was held due to their BP being below the physician-ordered parameters on 05/03/2024, 05/09/2024, or 05/18/2024. Registered Nurse (RN) #4 was interviewed on 05/23/2024 at 6:19 AM. RN #4 stated if BP medications were held due to not meeting physician-ordered parameters, she expected the certified medication technician (CMT) to notify her. RN #4 reviewed Resident #41's medications flowsheet and stated she had not been notified of the resident's BP and added she would have expected to have been notified. On 05/23/2024 at 12:31 PM, a telephone interview was held with the Director of Nursing (DON). The DON stated she expected the CMTs to report Resident #41's BPs to the nurse. A telephone interview was held with the Medical Director (MD) on 05/23/2024 at 2:15 PM. He stated Resident #41's primary care physician (PCP) was out of town, but he was willing to answer questions. The MD said the order for the resident's BP medication to be held should have been followed, and if the medication was held, the resident's physician should have been notified. The MD stated he was sure the resident's PCP had no knowledge of Resident #41's BPs and would have adjusted the medications had he known. The Administrator was interviewed on 05/23/2024 at 6:24 AM. The Administrator stated she expected BP to be taken prior to the administration of BP medications and if the parameters were not met as ordered by the PCP, then the medication should not be given, and the CMT should notify the nurse. The Administrator stated the charge nurse was responsible for notifying the PCP.

Based on observation, interview, and facility document review, the facility failed to ensure residents' rooms were maintained in a homelike manner for 2 (Resident #13 and Resident #17) of 43 total residents who resided in the facility at the time of survey. Specifically, Resident #13 and Resident #17's closet doors were missing. Findings included: On 05/22/2024 at 12:43 PM, the Administrator stated the facility did not have a general maintenance policy. An observation on 05/21/2024 at 3:53 PM revealed Resident #17's closet was missing a door on the right side. During concurrent interview and observations with the Maintenace Supervisor (MS) on 05/21/2024 beginning at 5:06 PM, the MS said that for any maintenance issues, staff should report the concern to the MS or Administrator, and the MS would generate a work order. While touring the facility with the MS, an observation was made of Resident #13's room on 05/21/2024 at 5:12 PM. Resident #13's closet was missing a door on the right side, and the resident's clothing was exposed. At the time of the observation, the MS denied knowledge of the concern and said no one had reported it to him. An observation on 05/21/2024 at 5:16 PM revealed Resident #17's closet was missing a door on the right side. At the time of the observation, the MS again denied knowledge of the concern. The MS further stated he did not know if he could use a door from a room that was not in use but said he would check. A Maintenance Work Order, dated 04/04/2024 at 10:30 AM, revealed a work order for Resident #17's room. The work order indicated, Closet door is falling off barely hanging. Per the work order, maintenance staff began working on the problem on 04/08/2024 at 11:30 AM and completed the work order on 04/08/2024 at 12:10 PM. The Work done section indicated maintenance staff, Checked room for door/Went looking around for closet door cannot find the door. The MS signed as having completed the work order. During an interview on 05/22/2024 at 9:22 AM, Resident #13 stated their closet door had been gone for a while and was taken off because it was hanging, and the facility did not want it to fall. During an interview on 05/22/2024 at 9:28 AM, Certified Nurse Assistant (CNA) #5 stated she had seen missing closet doors in residents' rooms. CNA #5 further stated Resident #13's closet door had been missing for approximately a year. During an interview on 05/22/2024 at 9:47 AM, Resident #17 stated their closet door was breaking off and barely hanging when they initially moved into their room approximately seven months prior. Resident #17 further stated maintenance staff took the door off so that it would not fall but never said anything about replacing it. The Administrator (ADM) was interviewed on 05/23/2024 at 11:08 AM. The ADM stated when maintenance concerns were identified, the staff member who identified the concern should complete a work order form and leave it on the clip board at the nurses' station. Per the ADM, maintenance staff checked the clipboard for work orders every morning and started addressing any reported issues. The ADM said she expected staff to report maintenance concerns on the work order forms, maintenance staff to follow-up on the work-orders and make necessary repairs, and for maintenance staff to turn work orders into the ADM once they were completed. The ADM stated that the MS's hire date was 04/04/2024 and they were the only maintenance person in the building at that time, so she believed the signature on the 04/04/2024 work order regarding Resident #17's closet door was the MS's signature. The ADM further stated she would have expected the MS to take doors from an unoccupied resident room to replace any broken ones.

Based on interview, record review, and facility policy review, the facility failed to develop a care plan addressing the use of a psychotropic medication for 1 (Resident #34) of 6 sampled residents reviewed for unnecessary medications. Specifically, the facility failed to develop a care plan addressing Resident #34's use of antipsychotic, antidepressant, and antianxiety medications, including information regarding target behaviors and monitoring for potential side effects of the medications. Findings included: An undated facility policy titled, Drug Review indicated, 5. Medications should not show unnecessary or excessive use and should have a diagnosis to support them. The section of the policy addressing Reviewing Antipsychotic Drugs, specified, 1. Antipsychotic drugs should only be given when necessary to treat a specific condition. 2. Review all charts of residents receiving the following drugs. Check for one or more specific diagnoses or conditions for antipsychotic drugs including: a. Schizophrenia b. Schizo-affective disorder c. Delusional disorder d. Psychotic and mood disorders (including mania and depression) e. Acute psychotic episodes f. Brief reactive psychosis g. Schizophrenia-form disorder h. Atypical psychosis i. Tourette's disorder j. Huntington's disease k. Organic mental syndromes (including dementia) with associated psychotic features as defined by: 1. Behavior (biting, kicking, scratching) which cause the resident to present a danger to themselves, others, and/or interfere with staff's ability to provide care. 2. Psychotic symptoms (hallucinations, paranoia, delusions) that cause the resident frightful distress. 3. Short term (seven days) symptomatic treatment of hiccups, nausea, vomiting or pruritus. 3. Review nurse's notes and/or behavior forms for charting of behavior, to assure that there is indication of more antipsychotic use: a. Simple pacing b. Wandering c. Poor self-care d. Restlessness e. Crying out, yelling or screaming f. Impaired memory g. Anxiety h. Depression i. Insomnia j. Unsociability k. Indifference to surroundings l. Fidgeting and nervousness m. Uncooperativeness n. Any indication for which the order is on a PRN [as needed] basis. 4. Develop an interdisciplinary care plan to evaluation behavior pattern in relationship to current medication administration. Resident #34's Resident Face Sheet revealed the facility admitted the resident on 04/05/2021 with diagnoses that included major depressive disorder, Alzheimer's disease, and anxiety disorder due to known physiological condition. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/03/2024, revealed Resident #34 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. The MDS revealed the resident did not experience hallucinations or delusions and did not exhibit any behaviors during the seven-day assessment look-back period. According to the MDS, the resident was taking antipsychotic, antianxiety, and antidepressant medications, all of which had an indication for use noted. A review of Resident #34's Physician Order Report for the timeframe from 04/22/2024 through 05/22/2024 revealed the following orders: - an active order dated 07/18/2022 for quetiapine tablet (an antipsychotic medication), 25 milligrams (mg), one-half tablet twice a day for a diagnosis of Dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance; - an active order dated 07/18/2022 for sertraline tablet (an antidepressant medication), 100 mg, administer 200 mg (two tablets) orally at bedtime for a diagnosis of anxiety disorder due to known physiological condition; and - an active order dated 01/18/2023 for lorazepam tablet (an antianxiety medication), 0.5 mg, administer one-half tablet (0.25 mg) twice a day for a diagnosis of anxiety disorder due to known physiological condition. Resident #34's Care Plan revealed a Problem area, started on 10/19/2021, addressing behavioral symptoms, that indicated the resident was at high risk for elopement. Another Problem area, started on 11/19/2021, indicated the resident had a diagnosis of anxiety. An intervention started on 11/19/2021 directed staff to utilize medications as prescribed by the resident's physician. The Care Plan did not address Resident #34's use of psychotropic medications, including their ordered quetiapine, lorazepam, or sertraline, and did not include interventions related to target behaviors or potential side effects associated with the use of these medications. During an interview on 05/23/2024 at 11:46 AM, Licensed Practical Nurse (LPN) #18 stated many nurses did not know how to access the care plans in the electronic health record (EHR). During a follow-up interview on 05/23/2024 at 2:57 PM, LPN #18 stated residents' care plans should be updated with resident-specific information by the nurses ; however, she said nurses had not been trained regarding care plans. LPN #18 stated medication monitoring and target behaviors should be included in residents' care plans. During a telephone interview on 05/23/2024 at 5:17 PM, the Director of Nursing (DON) stated residents' care plans should include target behaviors related to prescribed medications. She stated she was the acting MDS Coordinator. The DON stated she would like to get the nurses involved in the care planning process, but said when she spoke with them, the nurses said they had never done them before. During an interview on 05/23/2024 at 6:19 PM, the Administrator (ADM) stated care plans should reflect the purpose of medications and the behaviors specific to the resident. The ADM stated the MDS Coordinator, currently the DON, was responsible for care plans, but any nurse could update care plans.

2. A Resident Face Sheet revealed the facility admitted Resident #34 on 04/05/2021. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disorder (COPD), major depressive disorder, muscle weakness, repeated falls, Alzheimer's disease, age-related osteoporosis, and anxiety disorder. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/03/2024, revealed Resident #34 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS revealed the resident did not refuse care during the assessment period. The MDS revealed the resident required partial/moderate assistance with showers/bathing. Resident #34's Care Plan, included a problem statement dated 10/03/2022 that indicated the resident had a diagnosis of Alzheimer's disease with late onset and dementia. Interventions directed staff to redirect the resident as needed and call the resident's Durable Power of Attorney (DPOA) to assist as needed. Resident #34's Care Plan did not address the resident's daily care needs for bathing or personal hygiene. The facility's shower scheduled revealed Resident #34 was scheduled for a shower on Mondays and Wednesdays. Resident #34's Skin Monitoring: Comprehensive CNA [Certified Nurse Aide] Shower Review forms for 03/2024 revealed the resident received two showers the first week of March on 03/06/2024 and 03/08/2024, two showers the second week of March on 03/12/2024 and 03/15/2024, no showers the third week of March (03/17/2024 through 03/23/2024), and one shower the fourth week of March, on 03/26/2024, which was 11 days since the last documented shower. Resident #34's Skin Monitoring: Comprehensive CNA Shower Review forms for 04/2024 revealed the resident received two showers the first week of April on 04/01/2024 and 04/05/2024, one shower the second week of April on 04/09/2024, two showers the third week of April on 04/17/2024 and 04/19/2024, one shower the fourth week of April on 04/23/2024, and no showers the week of 04/28/2024 through 05/06/2024. According to the documentation, the resident did not have a shower from 04/24/2024 through 05/06/2024. Resident #34's Skin Monitoring: Comprehensive CNA Shower Review forms for 05/2024 revealed the resident received one shower the week of 05/12/2024 through 05/18/2024, on 05/07/2023. Resident #34's Progress Notes for the timeframe from 04/24/2023 through 05/21/2024 revealed no documented evidence the resident refused showers/bathing or any additional shower/bathing documentation. During an interview on 05/20/2024 at 11:10 AM, Resident #34 stated they were unsure how often they received a shower or bath, but stated they did not get one every week. During an interview on 05/23/2024 at 10:06 AM, CNA #17 stated she worked at the facility as an agency contracted CNA and worked as the shower aide three days a week. She stated that during 02/2024 and 03/2024, she was pulled to help provide resident care and only provided resident showers approximately two days per week. She stated during that time, residents received at least one shower a week. CNA #17 stated they had a daily schedule to follow. She stated if someone's shower was not completed, she let staff know and offered to come in an extra day to complete resident showers. She stated a shower sheet was completed after each shower or bath, documenting skin concerns or any abnormalities noticed during bathing. She stated she turned her shower sheets into the nurse and told the nurse of any issues that needed attention. CNA #17 stated shower sheets should always be filled out after assisting a resident with bathing. She stated Resident #34 never refused showers and preferred two showers a week. During an interview on 05/23/2024 at 6:19 PM, the Administrator stated shower documentation should include refusals and multiple offers to assist the resident to shower by different staff. The Administrator stated the CNAs working the hallway should provide showers when a shower aide was not present. MO235269 Based on interview, record review, and facility document and policy review, the facility failed to provide showers as scheduled/preferred for 2 (Resident #34 and Resident #37) of 5 sampled residents reviewed for activities of daily living (ADL). Findings included: An undated facility policy titled, Daily Care Needs indicated, 2. Before beginning care, check the bathing schedule and resident's care plan. Make note of special problems or special care needed by each resident. Resident care plans are individualized and give specific instructions on care. 1. A Resident Face Sheet revealed the facility admitted Resident #37 on 03/08/2023. According to the Resident Face Sheet, the resident had a medical history that included unspecified dementia, generalized muscle weakness, myocardial infarction (heart attack), and chronic obstructive pulmonary disease. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/17/2024, revealed Resident #37 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident did not reject care during the assessment period. The MDS indicated Resident #37 required partial/moderate staff assistance (helper lifts, holds, or supports the trunk or limbs, but provides less than half the effort) with showers or bathing. Resident #37's Care Plan included a problem statement with an initiation date of 11/17/2023 that indicated the resident had socially inappropriate/disruptive behavioral symptoms and often declined care, especially on shower days. Interventions directed staff to reapproach or ask another caregiver to assist (initiated 11/17/2023). The facility's shower scheduled revealed Resident #37 was scheduled for a shower on Mondays, Wednesdays, and Fridays. A Concern/Grievance Report dated 10/11/2023 revealed Family Member (FM) #8 had filed a grievance on behalf of Resident #37. The grievance indicated that Resident #37 had not received a shower in a week. The facility follow-up indicated that the resident had a shower on 10/03/2023 and eight days later on 10/11/2023 when the grievance was received. The grievance report revealed the facility's resolution was to ensure the resident's refusals were documented on a shower sheet and if the resident refused, staff should offer to shower the resident again, or have another staff member offer a shower. A Concern/Grievance Report dated 02/23/2024 indicated FM #8 filed another grievance related to Resident #37 not receiving a shower that week. On the back of the report, the facility indicated staff assisted Resident #37 with a shower on Monday: however, there were no sheets to back it up as of this writing. According to the report, the facility needed Certified Nurse Aides (CNAs) or Certified Medication Technicians (CMTs) to complete a shower/bath sheet, which included the date they assisted the resident. The Administrator stated in an interview on 05/21/2024 at 2:24 PM that the CNAs documented resident showers on the Skin Monitoring: Comprehensive CNA Shower Review forms and there was no bathing/shower documentation in residents' electronic medical records. Resident #37's 02/2024 Skin Monitoring: Comprehensive CNA Shower Review forms revealed that on 02/07/2024 Resident #37 was hospitalized . Shower review forms indicated of the possible 11 opportunities for Resident #37 to receive a shower in 02/2024, the resident received three showers during the month, 02/15/2024, 02/23/2024, and 02/28/2024. Resident #37's 03/2024 Skin Monitoring: Comprehensive CNA Shower Review forms indicated of the 13 opportunities for Resident #37 to receive a shower that month, Resident #37 only received six showers or a whirlpool bath on 03/06/2024, 03/08/2024, 03/13/2024, 03/18/2024, 03/23/2024, and 03/27/2024. Resident #37's 04/2024 Skin Monitoring: Comprehensive CNA Shower Review forms indicated of the 13 opportunities for Resident #37 to receive a shower that month, Resident #37 only received four showers or whirlpool bath on 04/07/2024, 04/12/2024, 04/21/2024, and 04/27/2024. Resident #37's 05/2024 Skin Monitoring: Comprehensive CNA Shower Review forms revealed Resident #37 had received a whirlpool bath on 05/04/2024 and a shower on 05/10/2024, one time per week, not three times as scheduled. An interview was held with Resident #37 on 05/20/2024 at 10:28 AM. Resident #37 stated they had not received many showers and stated there had been weeks when they received no showers. Resident #37 stated they had complained about not getting showers and was not given a reason why they were not provided. Resident #37 stated that when FM #8 called the facility and complained, the resident received a shower the next day. A telephone interview was held with FM #8 on 05/21/2024 at 9:12 AM. FM #8 stated that when she had concerns, the facility's response was dependent upon the staff member she spoke with. FM #8 stated the only time Resident #37 refused showers was when the weather was cold outside. FM #8 stated employees had reported that only a few residents received their showers, which was only because their family kept a check on the residents. FM #8 stated when they inquired why Resident #37 had not received showers, the answer was there was not enough staff to shower the residents. CNA #7 was interviewed on 05/22/2024 at 10:55 AM. CNA #7 stated no showers had been given that day due to the workload that morning. CNA #7 stated the night shift CNAs did not get residents up and dressed for breakfast as they should, and it put everyone in a rush. CNA #7 stated sometimes Resident #37 told family members they had not received a shower when in reality, the resident refused their shower. CNA #7 stated there was a shower book at the nurse's station that listed which days the resident was supposed to receive a shower, and most residents required a shower twice per week. CNA #7 stated that when a shower was completed, the CNA completed a shower sheet and documented in the electronic medical record. CNA #7 stated that even if a resident refused a shower, the shower sheet had to be completed and the sheet had to indicate the resident had refused. CNA #1 was interviewed on 05/22/2024 at 11:23 AM. CNA #1 stated she did not think there was enough staff and stated there was not always enough time to give showers. The CNA stated showers had not been given that day due to being busy answering call lights. CNA #2 was interviewed on 05/22/2024 at 11:52 AM. CNA #2 stated there were staff that came in specifically to provide residents' showers and stated the CNAs assigned to provide resident care did not complete showers. CNA #2 stated residents' showers were based on their care plans, and some residents got one shower per week and other residents received two showers per week. CNA #2 stated residents had not always received showers as scheduled and only received showers when staff were available. CNA #2 stated she had not heard Resident #37 state they were not receiving showers. Nursing Assistant (NA) #12 was interviewed on 05/23/2024 at 5:13 AM. NA #12 stated Resident #37 had not refused care on the night shift. NA #12 stated Resident #37 refused care from certain day shift staff, but she had no knowledge of Resident #37 refusing showers. CNA #17 was interviewed on 05/23/2024 at 10:32 AM. CNA #17 stated that when she worked she mostly gave showers to the residents. CNA #17 stated there was a shower schedule to follow and residents were scheduled for two showers per week but were able to get more showers if requested. CNA #17 stated that in addition to the shower sheets being completed after a shower, there was also a book with a list of resident names and staff placed a check mark by the resident's name when they assisted the resident with a shower. CNA #17 checked the book and confirmed Resident #37 had no check marks by their name. CNA #17 reviewed the shower schedule and stated she was unaware Resident #37 was scheduled for three showers per week; however, she stated other CNAs showered Resident #37. CNA #17 stated that when Resident #37 returned from the hospital, CNA #17 reminded the resident of someone at the hospital and the resident now had issues with her; subsequently, she had not provided showers to Resident #37. Licensed Practical Nurse (LPN) #6 was interviewed on 05/23/2024 at 10:26 AM. LPN #6 stated there were two shower aides who reported to the Administrator and the Director of Nursing (DON). LPN #6 stated the CNAs were no longer reporting to the nurses when a resident refused a shower. She stated there was a staff member in the front office that kept up with when showers were given. LPN #6 stated if a resident refused a shower the CNAs were to complete a shower sheet and write refused on the sheet. LPN #6 stated Resident #37 refused a lot of things, including showers. Registered Nurse (RN) #4 was interviewed on 05/23/2024 at 4:53 AM. RN #4 stated Resident #37 had not complained about lack of showers. RN #4 stated Resident #37 refused most showers due to wanting a whirlpool bath. RN #4 stated the staff person who worked the day shift could give whirlpool baths but did not know if the staff on the night shift could use the whirlpool tub. The Human Resources (HR) staff member was interviewed on 05/23/2024 at 10:52 AM. The HR staff member stated that when she received the shower sheets from the CNAs she transcribed the information to a ledger and kept track of when residents received showers. The HR staff member stated if a resident refused a shower, the CNA was expected to complete a shower sheet and document on the sheet the resident had refused. The HR staff member stated that when showers were not given, she was expected to notify the nurse on the hall. The HR staff member stated she was unaware Resident #37 was scheduled for three showers per week and was unable to recall whether she had spoken to the nurse to alert the nurse Resident #37 had not received scheduled showers. The HR staff member reviewed the shower sheets for Resident #37 and acknowledged Resident #37 had not received two showers per week. The HR staff member could not explain the lack of follow-up regarding Resident #37 having not received showers and stated she was unaware the resident's family had concerns about the resident not receiving showers. A telephone interview was held with the DON on 05/23/2024 at 12:31 PM. The DON stated residents were scheduled for showers as the resident desired and the expectation was to give showers as the residents wished. The DON stated the nurse and CNA documented refusal of showers on the shower sheets. The DON stated she spoke with Resident #37 and the resident had not mentioned any problems with receiving showers. An interview was held with the Administrator on 05/23/2024 at 6:24 PM. The Administrator stated if a resident refused a shower, a shower sheet was completed and was given to the nurse. The Administrator stated that when the shower aides were not working, she expected the CNAs providing care to shower residents. The Administrator stated Resident #37 refused a lot of things and last fall 2023, the team planned to have the resident sign the shower sheets when the resident refused. The Administrator stated HR logged the showers for residents and the log was reviewed in the morning meeting, and HR should have reported the resident was missing showers.

Based on interview, record review, review of an American Heart Association (AHA) blood pressure publication, and facility policy review, the facility failed to provide care and treatment in accordance with professional standards of practice and the comprehensive care plan for 1 (Resident #32) of 5 sampled residents whose medication regimen was reviewed. Specifically, on 04/06/2024 when Resident #32's blood pressure (BP) met the criteria for hypertensive crisis as defined by the AHA, nursing staff did not re-evaluate the resident or consult with the resident's physician. Findings included: An undated facility policy titled, Condition Change, Resident (Observing, Recording, and Reporting) (Includes Fall or Injury) indicated the purpose of the policy was To observe, record, and report and condition change to the attending physician so that proper treatment can be implemented. The policy revealed, 6. Notify physician of condition change, need for treatment orders and/or medication order changes. An AHA publication titled, Understanding Blood Pressure Readings, last reviewed 05/17/2024, revealed a Normal blood pressure was a systolic reading (upper number) less than 120 millimeters of Mercury (mmHg) and a diastolic reading (lower number) less than 80 mmHg. The AHA publication revealed a hypertensive crisis was a systolic reading higher than 180 mmHg and/or a diastolic reading higher than 120 mmHg. The AHA publication indicated, In hypertensive crisis, you need immediate medical attention. The AHA publication further indicated, In hypertensive crisis, you need medical attention. Wait five minutes after your first reading. Take your blood pressure again. If your readings are still unusually high, contact your health care professional immediately. A Resident Face Sheet revealed the facility admitted Resident #32 on 11/21/2023. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of bradycardia (slow heart rate) and essential (primary) hypertension. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/05/2024, revealed Resident #32 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS revealed the resident had an active diagnosis of hypertension. Resident #32's Care Plan included a Problem area, started on 12/23/2023, that indicated the resident was at risk for a high blood pressure episode like a heart attack or stroke due to high BP and a heart arrythmia. The goal was for the resident to have no complications from high BP. Interventions started on 12/23/2023 directed staff to monitor for signs or symptoms of high BP and report to the charge nurse and to monitor vital signs and notify the physician of any abnormalities. Written documentation of daily BP checks for April 2024 revealed Resident #32's BP was being monitored daily. According to the documentation, Resident #32's blood pressure met the criteria for hypertensive crisis on 04/06/2024 when the resident's blood pressure reading was 189/113 mmHg. Resident #32's Progress Notes for April 2024, revealed no documentation regarding the resident's elevated blood pressure, that the resident's blood pressure was reassessed, or that the resident's physician was notified of the resident's high blood pressure reading. During an interview on 05/23/2024 at 10:06 AM, Certified Nurse Aide (CNA) #17 stated she took residents' vital signs and documented them for the nurse. She stated if a there was a significant change in a resident's vital signs, she would let the nurse know and take the resident's vital signs again. She stated in her past experience, nurses reevaluated the vital signs, and the charge nurse would report to the Director of Nursing (DON) and the physician. During an interview on 05/23/2024 at 11:46 AM, Licensed Practical Nurse (LPN) #18 stated if there was a discrepancy, a resident's blood pressure should be rechecked. She stated Certified Medication Technician (CMT) #19 had documented Resident #32's blood pressure readings and was usually pretty good about notifying a nurse when needed. During a telephone interview on 05/23/2024 at 4:21 PM, CMT #19 stated if there were no specific orders regarding BP for parameters for a resident, she still notified the nurse of any abnormal readings. During an interview on 05/23/2024 at 5:17 PM, the DON stated she expected the staff member who obtained abnormal blood pressure readings to report them to the nurse. The DON stated the nurse should review all vital signs and reassess residents with abnormal vital signs. She stated no concerns had been brought to her attention regarding Resident #32.

Based on observation, record review, interview, and facility policy review, the facility failed to keep medication secure for 1 (Resident #30) of 1 sampled resident reviewed for accident hazards and failed to thoroughly investigate a fall and failed to implement fall interventions to prevent falls for 1 (Resident #28) of 1 sampled resident reviewed for falls. Findings included: 1. An undated facility policy titled, Medications, Self-Administration, Self Storage, Leave at Bedside, indicated, A physician's order will be obtained for each medication to be kept at the bedside. The policy also indicated, If the resident does not provide a locked box, the facility must provide a locked area for the medications. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/12/2024, revealed the facility admitted Resident #30 on 09/01/2020. The MDS revealed Resident #30 had active diagnoses that included hypertension, seizure disorder, anxiety, and depression. The MDS revealed Resident #30 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS revealed that Resident #30 had impaired vision and saw large print, but not regular print in newspapers or books, and the resident wore corrective lenses. Resident #30's Care Plan, last reviewed/revised on 04/15/2024, revealed it did not include information that resident had received orders to keep medications at their bedside or to self-administer medications. Resident #30's Physician Order Report, for the timeframe from 04/21/2024 through 05/21/2024, revealed an order for ciclopirox gel (an antifungal medication) 0.77 percent (%) to be applied topically to the toenail at bedtime, with a start date of 07/15/2022. The order did not indicate the medication could be kept at the resident's bedside. The Physician Order Report also included an order for clotrimazole-betamethasone lotion (a cortisone medication to treat fungal infections) 1-0.05% to be applied topically to the resident's hands three times a day as needed, with a start date of 09/19/2023. The order indicated that the medication could be kept at the resident's bedside. An observation on 05/20/2024 at 9:46 AM revealed ciclopirox gel 0.77% in Resident #30's room. During an interview at the time of the observation, Resident #30 stated the medication was used for itching everywhere except their eyes. Resident #30 stated they were unsure if the staff knew the medication was in the room. Two containers of clotrimazole-betamethasone dipropionate lotion was also observed in the resident's room at that time. Resident #30 stated the nurse had left the lotion at their bedside so the lotion could be applied before putting on compression stockings. Resident #30 stated they were shocked when the nurse left two containers of the same medication in the room. Resident #30 was interviewed on 05/20/2024 at 10:29 AM. Resident #30 stated their physician had ordered the ciclopirox and had ordered that the medication could be kept at their bedside. Resident #30 stated they used the medication for itching on their hands. Resident #30 stated the clotrimazole-betamethasone lotion was also used on their hands and that they administered the medications independently. Resident #30 stated there was a resident that lived on the hall that tried to come into their room but so far, the resident had been stopped prior to entering the room. Resident #30 stated they had not been assessed to determine if they were safe to administer the medication and no instructions had been received to keep the medications out of sight in a dresser drawer or a locked box. Resident #30 stated they had used the medications prior to admission and had kept the medications in their room since admission. Certified Nurse Aide (CNA) #7 was interviewed on 05/22/2024 at 11:17 AM. CNA #7 stated if she saw medication left at a resident's bedside, she would notify a nurse. She stated she considered pills, creams, or any other medication that was physician-ordered and even over-the-counter cough drops as medication that should not be kept at a resident's bedside. CNA #7 stated she had seen physician-ordered medication in Resident #30's room and stated that the medication had been in the resident's room for as long as she remembered. CNA #7 stated the CNAs applied the medication when the resident requested and stated that the resident was independent and probably also applied the medication. CNA #7 stated she had not reported that Resident #30 had the medication at their bedside because she had not thought about it. CNA #2 was interviewed on 05/22/2024 at 12:20 PM. The CNA stated if she saw medications at a resident's bedside, she would ask the resident and the nurse if the medications were supposed to be at their bedside. She stated Resident #30 had a prescription cream at their bedside that the CNAs helped to apply. CNA #2 stated the medication had been at the bedside for a long time and the nurses were aware the medication was at Resident #30's bedside. Registered Nurse (RN) #4 was interviewed on 05/23/2024 at 5:00 AM. RN #4 stated she was only allowed to leave medications at a resident's bedside if the resident had been assessed and the physician had ordered the medications to be left at the bedside. RN #4 stated Resident #30 had clotrimazole-betamethasone at their bedside that was used on the resident's hands. RN #4 stated she was unsure if Resident #30 had an order for the medication to be left at their bedside and was unsure if the resident had been assessed for self-administration. RN #4 stated that previously, Resident #30's medications had been kept in the treatment cart and she had applied the medication for Resident #30. RN #4 stated she was unaware of how long the medication had been in the resident's room. A telephone interview was held with the Director of Nursing (DON) on 05/23/2024 at 12:31 PM. The DON stated medication should not be left at a resident's bedside unless the resident had an order for self-administration and no other residents were able to get to the medication. The DON stated a resident required an assessment for self-administration prior to self-administration of medications. The DON stated she was unaware of any residents whose medications were left at their bedside. The DON stated if staff saw medications at a resident's bedside, she expected the staff check to ensure the resident was allowed to have the medication at their bedside. The DON stated medications left at the bedside, on a hall with wandering residents was not safe. She stated she was used to residents having a locked box in their rooms for medications. The Administrator (ADM) was interviewed on 05/23/2024 at 6:53 PM. The ADM stated she expected that before medications were left at a resident's bedside, staff obtained a physician's order and assessed the resident for self-administration. The ADM stated the danger of leaving medications in a room would be a wandering resident getting the medications. 2. An undated facility policy titled, Condition Change, Resident (Observing, Recording and Reporting) (Includes Fall or Injury), revealed Guidelines included Complete an incident, accident or risk management report per facility guidelines. A Resident Face Sheet revealed the facility admitted Resident #28 on 07/08/2019. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of generalized muscle weakness, vascular dementia, difficulty walking, embolism and thrombosis (blood clots) of the arteries in the lower extremities, and a right femur (a leg bone) fracture. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/26/2024, revealed Resident #28 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident had severe cognitive impairment. The MDS indicated the resident required some help from staff with indoor mobility (ambulation). The MDS also indicated Resident #28 had a history of falling. Resident #28's Care Plan included a problem statement, with a start date of 11/26/2019, that indicated Resident #28 was at risk for falls related to impaired mobility. The Care Plan indicated that Resident #28 had an actual fall at the facility on 02/29/2024 that resulted in a fracture of the resident's right hip. Interventions directed staff to use a floor mat on the floor next to the resident's bed (initiated 08/11/2023), place the resident's bed in the lowest position (initiated 08/11/2023), and make sure all necessary personal items were within reach (initiated 08/09/2023). Resident #28's Fall Risk Assessment, dated 01/04/2024, revealed Resident #28 had sustained one or more falls in the previous six months. The assessment indicated the resident was a High Fall Risk. Resident #28's Event Report regarding a fall on 02/08/2024 at 9:30 AM revealed the resident had an unwitnessed fall in their room and was observed on the floor. The Event Report revealed Non-injury. The Event Report revealed the Event details, Possible Contributing Factors, Mental Status, Neurological Check, and the Interventions sections were not completed. The Event Report revealed, under the Notes section, the nurse documented that Resident #28 was found lying on the floor next to the resident's bed. The note indicated the resident stated that they had been fighting in their sleep again and indicated that the resident had a history of bad dreams and had thrown their self out of bed before. The note indicated a fall mat was placed by the resident's bedside and indicated that the bed was in a low, locked position, and their call light was within reach. There were no witness statements that indicated when Resident #28 was last seen or the condition the resident had been in at the time they were seen. Resident #28's Progress Notes revealed a note, dated 02/29/2024 at 12:32 PM, that revealed at 12:10 PM staff found Resident #28 lying on the floor. The note indicated that the resident was observed to have an open area to the top of their head and the resident complained of right hip pain. The note indicated the resident's right leg seemed to be shorter than the left and the resident was sent to the hospital for an evaluation. Resident #28's Event Report regarding the fall on 02/29/2024 at 12:07 PM, created by Licensed Practical Nurse (LPN) #9, revealed that while Resident #28 was in their room the resident had an unwitnessed fall after going to the bathroom and then going to the sink. The Event Report indicated that the resident experienced severe pain, painful/limited range of motion of the upper extremities, abnormal body alignment, and a laceration/puncture. The report indicated there was rotation, deformity, or shortening of the right lower extremity. The Event Report revealed immediate interventions included immobilization or splinting of the area and direct pressure applied to the wound. The Event Report revealed preventative interventions included adjusting the bed to the lowest position, placement of a fall mat, a physical/occupational therapy consultation, shoes with non-skid soles, and instructions for staff to ensure necessary items were within reach of the resident. The Event Report indicated that Resident #28 was sent to the emergency department for an evaluation and treatment. Resident #28's Progress Notes revealed a note, dated 02/29/2024 at 2:38 PM, that revealed the hospital reported to the facility the resident had a right hip fracture. Resident #28's Progress Notes revealed a note, dated 03/05/2024 at 5:30 PM, that indicated Resident #28 was readmitted to the facility. An observation on 05/21/2024 at 10:27 AM revealed Resident #28 was lying in bed. The left side of the bed was against the wall. The bed was in the low position. There was no fall mat on the floor next to the resident's bed. On 05/22/2024 at 8:33 AM, Resident #28 was observed lying in bed. No fall mat was observed by the resident's bed. An interview was held with LPN #9 on 05/23/2024 at 3:51 PM. LPN #9 stated fall prevention interventions for Resident #28 included non-skid socks. LPN #9 stated she had been working when Resident #28 fell and fractured their hip. LPN #9 stated a certified nurse aide (CNA) found the resident and was unsure if the CNA had to write a statement of what was seen, but normally statements from witnesses were not completed for falls. LPN #9 stated there was a risk meeting held to determine why a resident fell and added the floor nurse on duty at the time of a resident's fall was not a part of the risk meetings. LPN #9 stated there had not been a fall mat used for Resident #28. LPN #9 stated the intervention of a fall mat was care planned for Resident #28 but not implemented because no one followed up and placed the fall mat. Certified Nurse Aide (CNA) #2 was interviewed on 05/22/2024 at 2:09 PM. CNA #2 stated new fall prevention interventions were communicated verbally by the nurse or a note would be left at the CNA desk. CNA #2 identified Resident #28 as being at risk for falls. CNA #2 identified the interventions for Resident #28 as an alarm, a low bed, and stated that the resident's door was left open. CNA #2 stated there was a fall mat in Resident #28's room under the bed and added that the mat should be on the floor next to the bed when the resident was in bed. Certified Medication Technician (CMT) #11 was interviewed on 05/22/2024 at 3:36 PM. CMT #11 stated she did not work on the shift when Resident #28 fell and broke their hip. CMT #11 stated fall prevention interventions were communicated by the nurse, the DON, or the Administrator (ADM). CMT #11 stated she had no knowledge of the fall prevention interventions for Resident #28 and added that she had not seen a fall mat by the resident's bed. LPN #6 was interviewed on 05/22/2024 at 2:44 PM. LPN #6 stated that when a resident fell, she was supposed to complete all needed paperwork, which included initiating an event report and initiate neurological checks. She stated that she was also expected to notify the resident's family. She stated that facility staff assessed the resident for 72 hours following a fall. LPN #6 stated nurses were expected to implement interventions to prevent further falls at the time of the fall. LPN #6 stated the new interventions were kept in a communication book at the CNA desk. LPN #6 stated it was the responsibility of the Director of Nursing (DON) to make sure the fall prevention interventions were used as care planned and stated there was no other follow-up to make sure the interventions were used. LPN #6 stated she was unaware of current fall prevention interventions in place for Resident #28. LPN #6 stated the nurses had access to the care plans for residents, but she was unsure what the fall care plan for Resident #28 included as interventions but stated that Resident #28 should have a fall mat in place. LPN #6 stated that when completing an event report, each section was expected to be completed. LPN #6 stated witnesses were listed but she had not seen witness statements. Registered Nurse (RN) #4 was interviewed on 05/23/2024 at 4:32 AM. RN #4 stated that when a resident fell, the nurses assessed the resident, an event report was initiated in the electronic medical record, and assessments were on-going for 72 hours. RN #4 stated all sections of the event report were expected to be completed but added she was unsure if an immediate intervention was expected to be placed to prevent further falls. RN #4 stated if a resident was a fall risk, a magnetic leaf was placed on the resident's door frame to their room. RN #4 identified Resident #28 as a fall risk. RN #4 stated fall prevention interventions for Resident #28 included not leaving the resident alone while using the toilet. RN #4 stated she had no knowledge where to find the interventions for Resident #28. RN #4 stated she had not seen a fall mat at Resident #28's bedside and stated a fall mat was not needed since the resident had not fallen out of bed. She stated that she had not been informed that the resident fell out of bed 02/08/2024. Nurse Aide (NA) #12 was interviewed on 05/23/2024 at 5:04 AM. NA #12 stated information about fall interventions could be found in Resident #28's care plan. NA #12 stated she had not seen a fall mat by Resident #28's bed. NA #12 stated there was not a book that included fall interventions for residents and stated any new fall interventions initiated were communicated verbally from staff to staff. A telephone interview was held with the DON on 05/23/2024 at 12:31 PM. The DON stated she expected event reports to be completed in their entirety by the nurse on duty at the time of the event. The DON stated she expected a new intervention to be placed each time a resident had a fall. The DON stated all staff were responsible for making sure fall interventions were used. The DON stated it was her opinion that a fall mat was not appropriate for Resident #28 but if a fall mat was on the care plan, then a fall mat should be in place when the resident was in bed. She stated that without the incident report being completed, there was not an adequate and complete investigation for the fall. The DON stated Resident #28's diagnosis of post-traumatic stress disorder and bad dreams were likely the root cause of the resident's fall and agreed the interventions used had not addressed the root cause. The DON stated she expected staff to meet after a fall to discuss when the resident was last seen and what had happened and expected that information to be included in a progress note. The ADM was interviewed on 05/23/2024 at 6:24 PM. The ADM stated that when a resident fell, she expected an intervention to be implemented to prevent further falls. She stated the event report should be fully completed and closed. The ADM stated the DON was responsible for making sure event reports had been completed. She stated she expected any care planned interventions to be used consistently and added it was a team effort to make sure interventions were implemented. The ADM stated the purpose of a fall investigation was to determine what occurred and included the time of the fall, if the fall was observed, what happened, interviews to determine when the resident was last seen, and the condition of the resident. The AMD stated interviews should be recorded either in the event report or the nurse's notes.

Based on observation, interview, record review, and facility policy review, the facility failed to monitor and record fluid intake for 1 (Resident #28) of 3 sampled residents reviewed for nutrition, who had a physician's order for a fluid restriction. Findings included: A facility policy titled, Fluid Restriction, dated 05/2015, specified, 2. The DSM [Dietary Supervisor/Manager] or designee will consult with nursing staff to determine amounts of fluid to be given at meals, medication passes and at bedside. According to the policy, 6. Input/Output (I/O) records will be completed daily by the nursing department on all residents with fluid restriction prescriptions. A Resident Face Sheet revealed the facility admitted Resident #28 on 07/08/2019. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of end-stage renal disease and edema. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/26/2024, revealed Resident #28 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident had severe cognitive impairment. The MDS revealed the resident had an active diagnosis of renal insufficiency, renal failure, or end-stage renal disease. The MDS indicated Resident #28 received hemodialysis services while a resident. Resident #28's Care Plan, included a problem statement dated 07/12/2022 that indicated the resident was on dialysis for renal failure. Interventions directed staff to monitor and record the resident's intake of food and fluids (initiated 07/12/2022). Resident #28's Physician Order Report for the timeframe from 04/23/2024 through 05/23/2024 indicated Resident #28 had an order for a 1500 milliliter (ml) fluid restriction that started on 04/24/2024 and was discontinued on 05/22/2024 (when the dialysis center transferred the resident to the hospital). Resident #28's medical record revealed no documented evidence the facility monitored and recorded the resident's fluid intake. An observation was made on 05/20/2024 at 1:58 PM. Resident #28 was eating lunch. On the resident's overbed table, a clear cup was observed holding 300 ml of water. An observation was made on 05/21/2024 at 1:03 PM. Resident #28 had consumed 100% of the lunch provided. On the resident's tray was an eight-ounce empty cup. Resident #28 stated the cup had contained a fruit flavored drink. Resident #28 stated they had been informed of the fluid restriction and they tried to adhere to the fluid restriction. Certified Nursing Assistant (CNA) #2 was interviewed on 05/22/2024 at 2:09 PM. CNA #2 stated Resident #28 received a mechanical soft diabetic diet and had no limitation on fluids, except for orange juice. CNA #2 stated if a resident was on a fluid restriction the information should be in the electronic medical record. CNA #2 stated she was not aware that Resident #28 was on a fluid restriction. CNA #2 stated at one time, the certified medication technicians (CMT) kept track of residents' fluid consumption, but they did not keep track anymore. CNA #2 stated she was unaware how much fluid Resident #28 drank from day to day and was unable to report what the resident had consumed. Licensed Practical Nurse (LPN) #6 was interviewed on 05/22/2024 at 2:44 PM. LPN #6 stated Resident #28 went to dialysis every Monday, Tuesday, and Wednesday. LPN #6 stated she was aware that Resident #28 was on fluid restriction but was unsure how much the resident was allowed to drink per day. LPN #6 stated the facility had not kept very good track of Resident #28's fluid intake, and they had not determined the amount of fluids that dietary and nursing would provide daily. LPN #6 stated Resident #28 had a cup at their bedside, and CNAs provided ice water. LPN #6 stated there was no process in place for tracking fluids for residents on a fluid restriction and was unable to say where the fluid consumed by Resident #28 was recorded on a daily basis. In addition, LPN #6 stated it was unclear who was responsible for calculating and monitoring the resident's 24-hour fluid intake; however, she stated the nurses probably should report to the physician when the resident exceeded the ordered fluid amount. LPN #6 stated she was unaware whether the resident's physician was aware Resident #28's fluid consumption was not recorded. LPN #6 stated she had no knowledge of how much fluid the resident drank on any day. Registered Nurse (RN) #4 was interviewed on 05/23/2024 at 4:44 AM. RN #4 stated she arrived for work at 6:30 PM and put 240 ml of water in Resident #28's cup for use during the night shift. RN #4 stated the facility did not document fluid intake for Resident #28, which was a problem because she had no idea what Resident #28 had consumed on the previous shift. RN #4 stated there was no way of knowing how much fluid Resident #28 consumed in a 24-hour period. A telephone interview was held with the Dialysis Facility Administrator (DFA) on 05/23/2024 at 2:11 PM. The DFA stated the dialysis center dietician assessed Resident #28's fluids week by week and discussed fluids and laboratory results with the resident. The DFA stated the resident's laboratory results had not been good. The DFA stated they sent Resident #28 to the hospital from dialysis due to shortness of breath. The DFA added that for the past few weeks the dialysis center had issues removing fluid from the resident due to a low blood pressure. She stated Resident #28 had congestive heart failure and other co-morbidities that could impact the resident's fluid build-up. The DFA stated the facility had not provided any fluid intake records; however, the dialysis center had no concerns about Resident #28's fluid intake. The Administrator was interviewed on 05/23/2024 at 6:24 PM and stated she expected Resident #28's fluid intake to be recorded and shared between shifts. The Administrator stated she was unaware there was no documentation of the resident's fluid intake.

Based on interview, record review, and facility policy review, the facility failed to communicate with a dialysis provider for 1 (Resident #28) of 1 sampled resident reviewed for dialysis services. Findings included: An undated facility policy titled, Dialysis, Care of A Resident Receiving, indicated, Communication between the Facility and Dialysis Unit included, The Dialysis Communication Record will be sent with the resident on each dialysis visit. All care concerns in the last 24 hours will be addressed, including last medications given and facility contact person. The dialysis unit will complete the lower portion of the report to include weight prior to and after dialysis, any labs completed, medication given, follow up information and any new physician orders. The lower portion will be signed by the dialysis nurse and returned to the facility. These records will be maintained in the medical record. A Resident Face Sheet revealed the facility admitted Resident #28 on 07/08/2019. According to the Resident Face Sheet, the resident had a medical history that included a diagnosis of end-stage renal disease. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/26/2024, revealed Resident #28 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident had severe cognitive impairment. The MDS indicated active diagnoses included end-stage renal disease. The MDS indicated Resident #28 received dialysis services while a resident. Resident #28's Care Plan included a problem statement initiated 07/12/2022, that indicated the resident had renal dialysis for renal failure. The care plan included approaches that informed staff the resident attended dialysis on Mondays, Wednesdays, and Fridays (initiated 09/16/2022). Resident #28's Physician Order Report, for the timeframe from 04/23/2024 through 05/23/2024, indicated an order for Resident #28 to attend dialysis three times a week, Mondays, Wednesdays, and Fridays, with a start date of 04/17/2024 and an end date of 05/22/2024. Licensed Practical Nurse (LPN) #6 was interviewed on 05/22/2024 at 2:44 PM. LPN #6 stated Resident #28 attended the dialysis clinic on Mondays, Wednesdays, and Fridays, leaving the facility around 10:00 AM and returning between 1:00 PM and 2:00 PM. LPN #6 stated that prior to that day there had been no communication report that was sent to dialysis and added she had been given the report on 05/22/2024 to start using. A telephone interview was held with the Director of Nursing (DON) on 05/23/2024 at 12:31 PM. The DON stated communication between the facility and the dialysis center was completed with a form that was filled out and sent to the dialysis center and then the dialysis center sent the form back. The DON stated if an emergent situation arose, she expected the parties to call each other. A telephone interview was held with the Dialysis Facility Administrator (DFA) on 05/23/2024 at 2:11 PM. The DFA stated that every once in a while, the dialysis center received a form requesting Resident #28's weight, but not often. The DFA stated she had received a communication form the day prior and stated that it was a surprise. The DFA stated that the center usually called the facility and verbally relayed what had occurred in dialysis. The DFA stated she spoke with LPN #6 on 04/23/2024 about monitoring the resident's heart rate and reviewed medications with the LPN. The DFA stated that when the resident's blood pressure was low, she called and request the resident's blood pressure medication be held. The Administrator (ADM) was interviewed on 05/23/2024 at 6:24 PM. The ADM stated communication between the facility and the dialysis center was expected to be documented in the progress notes or include any fax in the medical record.

Based on interview, record review, and facility policy review, the facility failed to ensure residents' medication regimen was free of unnecessary medications for 2 (Resident #34 and Resident #41) of 6 residents reviewed for unnecessary medications. Specifically, the facility failed to specify the target behaviors for which antipsychotic medications were prescribed, failed to monitor for potential adverse drug reactions, and failed to complete behavior tracking for Resident #34 and Resident #41 to ensure continued use of an antipsychotic was indicated. Findings included: An undated facility policy titled, Drug Review indicated, 5. Medications should not show unnecessary or excessive use and should have a diagnosis to support them. The section of the policy addressing Reviewing Antipsychotic Drugs, specified, 1. Antipsychotic drugs should only be given when necessary to treat a specific condition. 2. Review all charts of residents receiving the following drugs. Check for one or more specific diagnoses or conditions for antipsychotic drugs including: a. Schizophrenia b. Schizo-affective disorder c. Delusional disorder d. Psychotic and mood disorders (including mania and depression) e. Acute psychotic episodes f. Brief reactive psychosis g. Schizophrenia-form disorder h. Atypical psychosis i. Tourette's disorder j. Huntington's disease k. Organic mental syndromes (including dementia) with associated psychotic features as defined by: 1. Behavior (biting, kicking, scratching) which cause the resident to present a danger to themselves, others, and/or interfere with staff's ability to provide care. 2. Psychotic symptoms (hallucinations, paranoia, delusions) that cause the resident frightful distress. 3. Short term (seven days) symptomatic treatment of hiccups, nausea, vomiting or pruritus. 3. Review nurse's notes and/or behavior forms for charting of behavior, to assure that there is indication of more antipsychotic use: a. Simple pacing b. Wandering c. Poor self-care d. Restlessness e. Crying out, yelling or screaming f. Impaired memory g. Anxiety h. Depression i. Insomnia j. Unsociability k. Indifference to surroundings l. Fidgeting and nervousness m. Uncooperativeness n. Any indication for which the order is on a PRN [as needed] basis. 1. Resident #34's Resident Face Sheet revealed the facility admitted the resident on 04/05/2021 with diagnoses that included major depressive disorder, Alzheimer's disease, and anxiety disorder due to known physiological condition. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/03/2024, revealed Resident #34 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. The MDS revealed the resident did not experience hallucinations or delusions and did not exhibit any behaviors during the seven-day assessment look-back period. According to the MDS, the resident was taking an antipsychotic medication. Resident #34's Care Plan revealed a Problem area, started on 10/19/2021, addressing behavioral symptoms, that indicated the resident was at high risk for elopement. Another Problem area, started on 11/19/2021, indicated the resident had a diagnosis of anxiety. An intervention started on 11/19/2021 directed staff to utilize medications as prescribed by the resident's physician. The Care Plan did not address Resident #34's use of an antipsychotic medication and did not include interventions related to target behaviors or monitoring for potential adverse drug reactions associated with the use of an antipsychotic medication. A review of Resident #34's Physician Order Report for the timeframe from 04/22/2024 through 05/22/2024 revealed an active order dated 07/18/2022 for quetiapine tablet (an antipsychotic medication), 25 milligrams (mg), one-half tablet twice a day for a diagnosis of Dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance. The order did not specify any targeted behaviors for which the medication was prescribed. The Physician Order Report did not include an order for behavior tracking or monitoring for adverse drug reactions. Resident #34's Medications Flowsheets and Treatment Flowsheets for March 2024, April 2024, and May 2024 revealed no documentation regarding any target behaviors associated with the use of quetiapine, no behavior tracking information, and no monitoring for adverse drug reactions related to the use of quetiapine. Resident #34's Progress Notes for the timeframe from 04/24/2023 through 05/21/2024 revealed there was no documentation of routine, ongoing behavior tracking. Resident #34's Nuse TAR [treatment administration record] Flowsheet for May 2024 revealed the transcription an order started on 05/10/2024 for behavior monitoring every shift, that included monitoring for yelling, hallucinations, hitting, biting, pacing, crying, rejection of care, disrobing, wandering, rummaging, sexual inappropriateness, exit-seeking, sleep disturbances, isolating self, delusions, crawling out of bed, disruptive noises, cursing, paranoia, and OTHER/DESCRIBE. However, the Nurse TAR Flowsheet contained no documentation of the completion of behavior monitoring each shift as ordered. During an interview on 05/23/2024 at 5:32 AM, Registered Nurse (RN) #4 stated she had worked at the facility since the end of March 2024. She stated she was familiar with Resident #34. She stated the resident wandered and could be vocally assertive if they felt their needs were not being met. RN #4 said she had not seen the resident's Nurse TAR Flowsheet with information about behavior monitoring and interventions prior to 05/23/2024. During an interview on 05/23/2024 at 11:46 AM, Licensed Practical Nurse (LPN) #18 stated behaviors were not tracked very well at the facility. She stated nursing staff did not have time to complete behavior documentation. She stated Resident #34's Nurse TAR Flowsheet with information about behavior monitoring and interventions was not in their chart until the morning of 05/23/2024. LPN #18 confirmed the resident had been receiving quetiapine since July 2022. LPN #18 further stated she had never completed any behavior monitoring for the resident and was unsure why the resident was receiving an antipsychotic medication. During a telephone interview on 05/23/2024 at 2:15 PM, the Medical Director (MD) stated Resident #34's primary physician was out of town, but he was willing to answer questions. The MD stated dementia with agitation or anxiety was not an appropriate indication for use of an antipsychotic medications and said wandering was not a behavior that warranted the use of an antipsychotic mediation. The MD further stated he expected staff to monitor and document all behaviors exhibited by residents. During a telephone interview on 05/22/2024 at 12:31 PM, the Director of Nursing (DON) stated if a resident received an antipsychotic medication, behavior monitoring should be documented on the medication flowsheets and reflect anytime a behavior occurred. The DON said there should also be a progress note related to any behaviors exhibited by residents. The DON said a diagnosis of dementia with anxiety was not sufficient to warrant the use of an antipsychotic medication. She further stated a target behavior was a behavior a medication was being used to stop or reduce and indicated target behaviors should be specified. During a follow-up telephone interview on 05/23/2024 at 5:17 PM, the DON stated Resident #34 received medication that required behavior monitoring. The DON confirmed there was no behavior monitoring for Resident #34 until she printed out the forms after the concern was brought to her attention. 2. A Resident Face Sheet revealed the facility admitted Resident #41 on 02/06/2023. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of unspecified dementia with agitation, unspecified altered mental status, and anxiety disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/08/2024, revealed Resident #41 had a Brief Interview for Mental Status (BIMS) score of 2, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #41 had delusions and wandered four to six days during the seven-day assessment look-back period. According to the MDS, the resident received an antipsychotic medication. Resident #41's Care Plan included a Problem area, started on 05/08/2024, that indicated the resident received a psychotropic medication. The Problem area identified the psychotropic medication as an antipsychotic medication but did not specify which one or why the medication was prescribed. An approach dated 05/08/2024 directed staff to Assess/record effectiveness of drug treatment. Monitor and report signs of sedation, anticholinergic and/or extrapyramidal symptoms. Other Problem areas, started on 02/06/2024, indicated the resident had cognitive loss/dementia and anxiety disorder. Resident #41's Physician Order Report contained an order, started on 04/18/2023, for quetiapine tablet (an antipsychotic medication) 25 milligrams (mg), give one-half tablet (12.5 mg) at bedtime for a diagnosis of Unspecified dementia, unspecified severity, with agitation. According to the Physician Order Report, this order was discontinued on 03/07/2024. Resident #41's Progress Notes contained a Nurses note, dated 03/07/2024 at 6:31 PM, that indicated the resident's physician rounded and provided a new order to increase Resident #41's quetiapine to 25 mg at bedtime for dementia with agitation. Resident #41's April 2024 and May 2024 Medications Flowsheets revealed transcription of the order for Resident #41 to receive 25 mg of quetiapine at bedtime, started on 03/08/2024. The Medications Flowsheets reflected documentation that indicated the resident received the medication daily as ordered, but there was no documentation regarding any target behaviors associated with the use of quetiapine, no behavior tracking information, and no monitoring for adverse drug reactions related to the use of quetiapine. An observation was made on 05/21/2024 at 1:05 PM. Resident #41 was in the assisted dining room moving food around on a plate with a fork. Licensed Practical Nurse (LPN) #13 stated Resident #41 had been drowsy throughout the meal. Certified Nurse Aide (CNA) #7 was interviewed on 05/22/2024 at 11:13 AM. CNA #10 stated that recently it seemed Resident #41 was sleeping more. CNA #10 said she had wondered if the resident had been given a new medication. CNA #10 further stated the only behavior she was aware Resident #41 exhibited was wandering. CNA #1 was interviewed on 05/22/2024 at 11:38 AM. CNA #1 stated the only behavior exhibited by Resident #41 was wandering. CNA #1 stated she had noticed Resident #41 recently slept more during the day, but she had not reported the increased sleep to anyone because she had not thought much about the resident sleeping more. CNA #2 was interviewed on 05/22/2024 at 12:13 PM. CNA #2 stated Resident #41 wandered into other resident's rooms and even opened closed doors during care for other residents. CNA #2 stated Resident #41 was not aggressive and had no other behaviors. CNA #2 stated she had noticed the resident was sleeping more but she had not reported the increased sleep to anyone, adding the nurses could see the resident was sleeping more just as she had noticed. Nursing Assistant (NA) #12 was interviewed on 05/23/2024 at 5:19 AM. NA #12 stated Resident #41 had no aggressive or threatening behaviors and indicated the only behavior she had observed from Resident #41 was wandering. Registered Nurse (RN) #4 was interviewed on 05/23/2024 at 5:23 AM. RN #4 stated any behaviors exhibited by residents were either recorded on the medication flowsheets or in the nursing progress notes. RN #4 stated Resident #41 was not aggressive and had not exhibited any behaviors that could harm themself or others. RN #4 reviewed Resident #41's record for 05/2024 and stated the only behavior documented for the resident was wandering. The SSD was interviewed on 05/23/2024 at 9:42 AM. The SSD stated she was not familiar with the term target behaviors. The SSD stated antipsychotic medications were used for residents that exhibited delusions, hallucinations, and psychosis. The SSD stated Resident #41 had been prescribed an antipsychotic for dementia and had to be redirected. The SSD stated the nurses were expected to monitor for behaviors and document any behaviors exhibited by the resident in the progress notes or the medication flowsheets. The SSD added Resident #41 had no aggressive behaviors and had no threatening behaviors toward themself or others. The SSD reviewed the progress notes and care plan for Resident #41 and stated she found no documentation of behaviors for Resident #41 that supported the increase in the resident's antipsychotic medication and agreed there was no target behavior specified. LPN #6 was interviewed on 05/23/2024 at 2:44 PM. LPN #6 stated behaviors were either documented by the nurses on the medication flowsheets or in the progress notes. During a telephone interview on 05/22/2024 at 12:31 PM, the Director of Nursing (DON) stated if a resident received an antipsychotic medication, behavior monitoring should be documented on the medication flowsheets and reflect anytime a behavior occurred. The DON said there should also be a progress note related to any behaviors exhibited by residents. She further stated a target behavior was a behavior a medication was being used to stop or reduce and indicated target behaviors should be specified. During a telephone interview on 05/23/2024 at 2:15 PM, the Medical Director (MD) stated Resident #41's primary physician was out of town, but he was willing to answer questions. The MD stated dementia with agitation or anxiety was not an appropriate indication for use of an antipsychotic medications and said wandering was not a behavior that warranted the use of an antipsychotic mediation. The MD further stated he expected staff to monitor and document all behaviors exhibited by residents. The Administrator was interviewed on 05/23/2024 at 6:24 PM. The Administrator stated that all resident behavior needed to be documented so the physician had an accurate picture of what was going on with a resident. The Administrator stated if Resident #41's antipsychotic medication was increased in the absence of behaviors, the charge nurse should have discussed the issue with the DON.

Based on interview and record review, the facility failed to provide pneumococcal vaccine to 1 (Residents #8) of 5 residents reviewed for vaccinations. Findings included: A Resident Face Sheet revealed the facility admitted Resident #8 on 08/01/2019 and readmitted the resident on 03/04/2022. According to the Resident Face Sheet, the resident had a medical history that included a diagnosis of acute upper respiratory infection. Resident #8's Pneumococcal Immunization Informed Consent revealed the resident's responsible party (RP) gave consent for the resident to receive a pneumococcal vaccine on 09/26/2022. The Pneumococcal Immunization Informed Consent was signed and dated by the resident's RP on 09/26/2022. Resident #8's Immunization: Consent or Refusal form revealed the resident's RP gave consent for the resident to receive a pneumococcal vaccine 09/18/2023. The Immunization: Consent or Refusal form was signed and dated by the resident's RP on 09/18/2023. Resident #8's Preventative Health Care vaccination record revealed no evidence the resident had received a pneumococcal vaccination. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/08/2024, revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. The MDS indicated the resident was not up to date on their pneumococcal vaccine. During an interview on 05/23/2024 at 6:48 PM, Resident #8 stated they could not recall if they had received or been offered a pneumococcal vaccine. During a telephone interview on 05/23/2024 at 5:17 PM, the Director of Nursing (DON) stated pneumococcal vaccinations were offered upon admission and if accepted were then ordered and administered. She stated the pneumococcal vaccine should be offered to all residents unless their physician determined it was contraindicated. The DON said she was unaware of any residents who requested a vaccination that had not received it. During an interview on 05/23/2024 at 6:19 PM, the Administrator stated she was unable to find any records that a pneumococcal vaccination was administered to Resident #8. She stated the consent was present, but the vaccination had never been administered. The Administrator stated she meant to review the pneumococcal consents in November of 2023 but had failed to follow up and provide the vaccinations. She stated the former DON, who was responsible for the coordination of the vaccination program, did not follow through with the vaccinations during their employment.

Based on observation and interview, the facility failed to ensure essential kitchen equipment was maintained in a safe operating condition. The deficiency affected 2 of 3 ovens, 1 of 2 freezers, and 1 of 1 food steamers in the kitchen. Findings included: The Administrator was interviewed on 05/22/2024 at 12:43 PM. The Administrator stated that the facility had no general maintenance policy. 1. An observation of the kitchen was conducted on 05/20/2024 at 9:48 AM with the Dietary Supervisor (DS). During this observation, a drip pan was observed inside of the walk-in freezer, positioned under the motor fan, and filled with ice. The pipes attached to the freezer's motor fan were covered with ice. During an interview at the time of the observation, the DS stated that staff had to throw away the drip pan about every day and replace it with a new one to catch the dripping water. An observation of the walk-in freezer was conducted with the Maintenance Supervisor (MS) on 05/21/2024 at 4:55 PM. The observation revealed ice build-up around the top of the door, across the ceiling, and on the pipes attaching to the fan motor. A plastic drip pan was observed positioned under the fan motor half filled with ice. The right-side of the walk-in freezer floor was covered with frost. During an interview at the time of the observation, the MS stated that he was unaware of an ice buildup in the freezer and confirmed that it was a safety hazard. He stated that someone looked at the freezer but was not sure what they were doing about it. An Invoice dated 01/14/2024 revealed a vendor serviced the facility's walk-in cooler/freezer, indicating that adjustments were made to the thermostat for the walk-in freezer. The Invoice indicated Found No Other Apparent Issues. During an interview on 05/21/2024 at 10:31 AM, Dietary Aide (DA) #15 confirmed that there had been ice buildup on the floors and boxes of the walk-in freezer. DA #15 stated that he did not think it had not been fixed. During an interview on 05/21/2024 at 10:55 AM, the Dietary Manager Assistant (DMA) confirmed that there was a slow drip in the deep freezer. The DMA further stated that the ice buildup on the floors of the deep freezer was from staff neglecting to empty the drip pan. 2. An observation on 05/21/2024 at 11:37 AM, revealed the door of Oven 2 was observed hanging from the hinges and unable to close correctly. During an interview at the time of the observation, the Dietary Manager Assistant (DMA) stated that the door was broken, and they were just using the oven to keep food warm. An observation of Oven 2 was conducted on 05/21/2024 at 4:53 PM with the Maintenance Supervisor (MS). The observation revealed the door was unable to close/function properly. During an interview at the time of the observation, the MS stated he was unaware that the door of Oven 2 was not functioning as designed. During an interview on 05/21/2024 at 10:31 AM, Dietary Aide (DA) #15 stated the facility only had one of their three ovens working properly. DA #15 stated Oven 1 stopped working the day prior and a maintenance staff told them not to use it and the door handle for Oven 2 was broken and was rarely used. During an interview on 05/21/2024 at 10:55 AM, the DMA confirmed an oven was not working due to a faulty on/off switch. During an interview on 05/23/2024 at 1:48 PM, the Dietary Supervisor (DS) stated that one of the ovens was not heating correctly, so they only used it to warm the food. 3. During an observation on 05/21/2024 at 4:51 PM, the steamer in the kitchen was not in working order. During an interview at the time of the observation, the Maintenance Supervisor (MS) stated that no one had reported to him that the steamer was broken, and he did not know what was wrong with it. He stated that he heard it broke over a year ago, but he had only worked at the facility since April (2024). During an interview on 05/21/2024 at 10:31 AM, Dietary Aide (DA) #15 stated that the kitchen steamer broke about a month ago and it was reported to the DS, but he did not think it had not been fixed. During an interview on 05/21/2024 at 10:55 AM, the Dietary Manager Assistant (DMA) stated a quote to repair the steamer was received but nothing had been done to fix it. The Administrator (ADM) was interviewed on 05/23/2024 at 11:08 AM. The ADM stated that the staff member who identified an issue with equipment needed to complete a work order. The ADM further stated that the expectation was for staff to complete work orders for maintenance, and for the maintenance staff to follow up with repairs and to turn in work orders when completed. The ADM stated that a vendor had looked at the fan in the walk-in freezer. She stated that when she talked to the vendor the day prior, he did not know about the ice or frost on the floor and door but thought it may be due to the door not being shut.

Based on observation, interview, and facility policy review, the facility failed to ensure staff stored food for residents in a sanitary manner. Specifically, the facility failed to label, date, and discard left over food. This had the potential to affect 43 of 43 residents who received nourishment from the facility kitchen. Findings included: A facility policy titled, Food Safey Requirements, undated, indicated, Proper Labeling and Dating of all foods. All foods will be considered as leftovers unless in the original container with an expiration date. Leftovers will be discarded after the third (3rd) storage day. An observation of the kitchen was conducted on 05/20/2024 at 9:37 AM with the Dietary Supervisor (DS). More than 50 heavily frosted freezer storage bags that contained left over food items were observed in the facility's deep freezer. Forty-two of the freezer storage bags were dated ranging from 03/17/2024 to 04/14/2024 with no description of the contents. Ten of the freezer storage bags did not contain a proper date or description of the contents. During an interview on 05/20/2024 at 9:41 AM, the DS stated she was aware of the problem and said the Dietary Manager Assistant (DMA) had come to work to assist in discarding the items. The DS confirmed there were over 50 freezer storage bags that needed to be discarded. The DS stated it was her expectation for all stored left-over items to contain a description and date. During an interview on 05/21/2024 at 10:31 AM, Dietary Aide (DA) #15 stated left over food items should be labeled with a time, date, and description of the contents. DA #15 further stated that left over items should be discarded if not used within three or four days. During an interview on 05/21/2024 at 10:55 AM, the DMA stated that all stored leftovers should contain a date, label, and a use by date in which the item should be used. The DM further stated that all staff members were responsible for discarding expired items. A follow-up kitchen observation was conducted on 05/21/2024 at 11:04 AM. During this observation, the following items were observed in the walk-in deep freezer: One freezer storage bag of French toast sticks labeled with no date, one freezer storage bag of pancakes with no description or date, one freezer storage bag of sliced apples labeled with no date, four freezer storage bags of diced green peppers labeled and dated 05/13/2024, and one freezer storage bag of rib meat patties with no description or date. The following was observed in the walk-in refrigerator: One freezer storage bag of cooked bacon with no description or date and one freezer storage bag of shredded cheese with no description or date. The Administrator (ADM) was interviewed on 05/23/2024 at 11:08 AM. The ADM stated their expectation was that left over food be labeled and dated when stored. The ADM said the facility had a three-day storage policy and any food stored beyond that time should be discarded.

Based on interview and facility document review, the facility failed to maintain a water management program to minimize the risk of Legionella in the facility's water supply. This had the potential to affect all 43 residents who resided in the facility. Findings included: During an interview on 05/22/2024 at 11:15 AM, the Administrator stated the facility did not have a policy for general maintenance. The facility's Monthly Water Management Checklist, dated 05/06/2024, revealed, the date of the last annual cleaning and control measure checks were on 05/06/2024 and included the following systems and fixtures: showerheads/hoses, water heaters, hot tubs/saunas, pipes, valves, and fittings, ice machines, eye wash stations, aerators, and heating and air conditioning units. The checklist revealed a visual inspection of the areas showed no signs of biofilm or sediment. The checklist revealed no documented evidence the electric and manual faucets, hot and cold-water storage tanks, or the water on closed wings/halls had an annual cleaning or monthly control measure checks. In addition, the checklist revealed no documented evidence the facility had a system to assess the water systems using text and flow diagrams. During an interview on 05/22/2024 at 3:24 PM, the Maintenance Supervisor stated he had been with the facility for approximately one month. He stated he completed the monthly checklist but had received no training regarding Legionella. He stated an Independent Environmental Consultant was in the facility recently to show him the facility's sprinkler systems but did not share anything with him regarding the facility water system or the water flow of the facility. During a telephone interview on 05/23/2024 at 4:29 PM, the Independent Environmental Consultant stated he trained the facility Maintenance Supervisor. He stated he went over every line item on the Monthly Water Management Checklist with the Maintenance Supervisor the previous month, and the water checks that had to be done monthly. He stated that during the visual checks he looked for scale and build-up. He stated there was no test kit used to check for biofilm; the pipes had to be cleaned and monitored for calcium build-up. He stated he had never seen a map of the facility pipes, but the facility was supposed to have one. He stated he did not think there was a place where water could stand but without a map it would be hard to know for sure. During a telephone interview on 05/23/2024 at 5:17 PM, the Director of Nursing (DON), who was also the facility's Infection Preventionist, stated she had been the DON since March 2024 and had not discussed Legionella during infection control meetings. She stated she knew what Legionella was and that it could develop in standing water. During an interview on 05/23/2024 at 1:37 PM, the Administrator stated she believed the Maintenance Supervisor monitored the facility water for Legionella. She stated the facility's Independent Environmental Consultant completed the checklist to monitor for Legionella and trained the facility's Maintenance Supervisor on how to monitor the water system.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to ensure they maintained all mechanical, electrical and patient care equipment in safe operating condition when they did follow up on maintenance requests to repair one resident's bed (Resident #5) did not lock, when they did not maintain their mechanical lift and when they did not maintain their exhaust fan in the kitchen. The facility census was 50. The facility did not provide a policy regarding completing maintenance requests or maintaining resident and essential equipment. 1. Review of the maintenance request form dated 3/10/23 showed staff wrote: - room [ROOM NUMBER]; - Repairs needed: fall risk and the bed does not lock. Review of Resident #5's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/11/23, showed: - A Brief Interview for Mental Status (BIMS) score of 11 indicating moderate cognitive deficits; - Limited assistance from staff with all activities of daily living (ADLs), including transferring from one surface to another; - One non-injury fall during the assessment period. Observation on 5/5/23 at 2:30 P.M., showed Certified Nurse Aide (CNA) E attempted to lock the bed in room [ROOM NUMBER]. He/she manipulated the locks on the bed in the down position and moved the bed back and forth, side to side. CNA E said maybe he/she unlocked the bed and he/she manipulated the locks on the wheels to the up position and the bed still moved back and forth and side to side. During an interview on 5/5/23 at 4:30 P.M., the administrator said she did not have any documentation to show any bed inspections had been completed on any of the beds. 2. Review of the maintenance request from dated 3/15/23 showed: - Room #: Kitchen; - Repairs needed: Exhaust fans will not turn on in the kitchen. Observation and interview on 4/26/23 at 2:45 P.M., showed and the Dietary Manager (DM) said: - The exhaust fan over the commercial stove did not work; - The DM said the exhaust fan was broken and not working. They had an issue when some sweet potatoes bubbled over in the oven, causing a large amount of smoke in the kitchen. She tried to turn the fan on but nothing happened. The kitchen filled with smoke and they had to open doors and place fans to get the smoke out. She did not believe the fan had worked properly as long as she had been in the DM position, about a year. There is a belt broken on top. During an interview on 4/28/23 at 4:00 P.M., the administrator said she did not know the exhaust fan had not been working until they had the sweet potatoes bubble over in the oven. The fan was broken and needed to be replaced. She did not have any documentation to show when the fan belt would be replaced. 3. Review of a maintenance request form, dated 3/7/23 showed staff wrote the (mechanical) lift was not wanting to turn correctly, wheel sticking. Observation and interview on 5/5/23 at 2:30 P.M. showed and CNA E said: - Staff used a lift labeled for Resident #4 provided by a hospice provider; - CNA E said the lift they were using on the [NAME] hall belonged to Resident #4 from his/her hospice provider but they use it for all residents. They moved the other lift to the 200 hall and it still was not safe when used, the lift stuck when they tried to use it. During an interview on 5/5/23 at 4:30 P.M., the administrator said the lift in question was an old lift and had a crank wheel. She felt the lift was functioning correctly but staff just did not like to use it. Staff should not be using Resident #4's lift for all residents. She did not have any documentation to show when the lifts owned by the facility had been inspected. MO217503

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to ensure their call light system functioned properly when it did not sound at the centralized staff work area. This affected all residents who resided on the 400 and 500 halls of the facility. The facility census was 50. The facility did not provide a policy regarding call lights. Review of maintenance request forms showed: - 3/27/23 room [ROOM NUMBER] needs a call light in room; - 3/27/23 room [ROOM NUMBER] resident's call light is not working, will not go off; - 4/15/23 west hall - all, call lights do not sound. 1. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/17/23, showed: - admitted [DATE]; - A Brief Interview for Mental Status (BIMS) score of 15 meaning the resident had no cognitive deficits; - Extensive staff assistance with bed mobility, transferring from one surface to another, moving on and off the nursing unit, dressing, personal hygiene and toilet use; - Always continent of bowel and bladder; - Had fallen in the last two to six months prior to admission; - Had two non-injury falls since admission. Review of the facility event summary reported, dated 3/26/23 to 4/26/23, showed: - 4/2/23 at 10:16 A.M., unwitnessed, non-injury fall; status completed, closed 4/7/23; - 4/4/23 at 3:32 P.M., unwitnessed fall in room; status in progress, closed 4/13/23. Review of the progress notes for the 4/4/23 fall showed staff documented an unwitnessed fall in resident room and the resident was sent to the emergency department at the local hospital as a result of the injuries. Review of the event report, dated 4/4/23 at 3:32 P.M. showed: - Unwitnessed fall in room; - Notes: 4/4/23 11:01 P.M. resident arrived back to facility at approximately 8:00 P.M. from hospital after being evaluated related to falls. Recommended ice as needed. Continue medication as previously ordered. Follow up with physician in three days. Resident is alert and oriented, neuros intact, range of motion is baseline, and bruising to left knee, back and forehead from falls. During an interview on 4/27/23 at 4:15 P.M., Resident #1 and his/her spouse said the call light had not sounded for a while. Where his/her room was located, the light could not be seen from the nurses' station. On 4/4/23, he/she turned on the call light to use the bathroom but when no one came, he/she got up and fell. A nice young man found him/her on the floor when walking by the room. The call light had not sounded for a while. 2. During an interview on 4/26/23 at 12:15 P.M., License Practical Nurse (LPN) A said their call light system on the [NAME] halls had not been working properly. The light came on outside the room and at the nurses' station, but the system did not have an audible sound. At least one resident had fallen as a result of the call light not sounding, Resident #1. Resident #2's call light had not been working so the cord had been removed. Observation and interview on 4/26/23 at 12:20 P.M. showed a red light on at the [NAME] hall nurses' station call light board but no audible sound. The call light in Resident #2's room had pulled away from the wall. No cord was attached to the box and the box had been pulled away from the wall. The resident said staff gave him/her a small bell to ring if he/she needed anything but the call light in the bathroom worked. During an interview on 4/26/23 at 2:00 P.M., Certified Nurse Aide (CNA) A said call lights on the [NAME] hall were not working. He/she thought the bathroom light sounded at the nurses' station but he/she knew the room lights did not. The lights come on but there was no sound at the nurses' station. Observation and interview on 4/26/23 at 2:10 P.M., showed and CNA B said: - CNA B sat on the floor behind the nurses' station, looking up at the call light board; - He/she said he/she sat there on the floor watching the board so they would know when a call light went off since they could not hear them at the board. They had completed work orders for the call lights but nothing had been done. - The Administrator came down and tested some of the lights and said they worked so she would not pay someone to come up from the south to fix them. During an interview on 4/28/23 at 4:15 P.M., the Administrator said the call lights worked. She personally went and tested all of them when staff first reported the call lights not working and they all sounded at the nurses' station. No one had reported any residents falling as a result of the call light not working. She needed to call Marmic, their fire alarm vendor, to come look at them if they are not working. During an interview on 5/5/23 at 2:15 P.M., Resident #3 said over the weekend, Resident #4 had fallen, or slid, out of his/her wheelchair. He/she pulled the call light but no one came. Resident #3 laid on the floor for about an hour before he/she got up to go out in the hall to find staff. The call lights had not been sounding for a while. He/she believed the lights in the bathrooms worked but not in the rooms. During an interview on 5/5/23 at 2:30 P.M.: - CNA C said the call lights had not been working for about a month or two, probably around 3/15/23; - CNA D said Resident #1 fell because his/her call light did not sound; when he/she fell is when we realized they were not working. He/she could not remember which fall as the resident had fallen several times since admission; - CNA D said they had been without maintenance staff for two to three months; the previous maintenance man had been in once since he quit in February that he/she knew of. During an interview on 5/5/23 at 2:40 P.M., the Marmic representative said he believed the call light issues all stemmed from room [ROOM NUMBER]'s call light. When staff pulled the call light in that room out of the wall, it shorted out the whole system and caused it to not have an audible sound when the lights in the rooms were activated. MO217503

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public when they did not ensure all areas of the facility were maintained in good repair, did not ensure wall mounted heating, ventilation and air conditioning (HVAC) units functioned properly, did not follow up on maintenance requests timely, did not maintain unused portions of the building, and did not maintain water pipes which carried water throughout the building to ensure they did not deteriorate to the point of disrepair or develop a black mold-like substance. The facility failed to ensure they employed staff to oversee the repair of all identified environmental issues. The had the potential to affect all facility residents and affected all portions of the building. The facility census was 50. 1. Review of the previous Maintenance Director's (MD) personnel file showed he submitted his letter of resignation on 2/17/23 and his last day of employment would be 2/26/23. Review of the MD's time clock punches from January 2023 through May 2023 showed he last clocked in for work on 2/28/23. 2. Review of the maintenance requests form (MRF) dated 3/5/23 showed staff wrote the nurses' station bathroom sink would not drain. During an interview on 5/5/23 at Certified Nurse Aide (CNA) C said the sink did not drain and the previous MD finally came back in and fixed it but it did not drain for almost two months. 3. Review of the MRF dated 3/6/23 showed staff wrote Resident #6's furnace and air conditioning was not working. Staff completed a second MRF the same day which said the resident's heat was not working. They had turned it off, unplugged it and reset it - still nothing. During an interview on 5/5/23 at 2:30 P.M., Certified Nurse Aide (CNA) E said Resident #6's HVAC system did not work and had not for a long time. He/she filled out a MRF but they had not MD to do any work around the facility. The resident would get very hot when the temperatures got warmer. Observation and interview on 5/5/23 at 2:45 P.M., showed and the resident said: - His/her had not been working for quite some time. No one but the nursing staff had attempted to do anything to fix it. - The room felt stuffy and a warm temperature. 4. Review of the MRF dated 3/7/23 showed staff wrote in room [ROOM NUMBER], the strip between the bathroom and room came off. Observation on 5/5/23 at 2:20 P.M. showed no strips on the floor between the bathroom and the resident room. 5. Review of the MRF dated 3/10/23 showed center hall leaking water at storage closet 21. Nurse could smell mold. Ceiling tile falling out. Water running down electrical wires. Observation on 4/26/23 starting at 12:00 P.M., showed: - The double doors by resident room [ROOM NUMBER] closed with a sign which read Please do not enter. Thank you. - Four ceiling tiles were missing, and another with a large section of the tile missing and a brown water ring stain on the remaining intact tile; - In the space above, water pipes and sprinkler pipes were visible as well as the roof deck through an attic access panel that was not in place. - A black mold-like substance could be seen on the outside of the gray wrapping which covered the water pipe; there was also a white mold-like substance encircling the black areas on the gray wrapping on the water pipe. - A strong mold and/or mildew odor could be detected in the hallway around where the attic space was exposed; - Closet 21, directly under the areas where the ceiling tiles were missing, emitted a strong mold and/or mildew odor when the door was opened which caused the surveyor's chest to become tight and begin to cough. The ceiling had discolored areas where the sheetrock ceiling and wall had been wet. During an interview on 4/26/23, Licensed Practical Nurse (LPN) A said about two weeks after the last resident moved off the transitions unit the ceiling fell in and the roof collapsed. Observation on 4/26/23 at 2:28 P.M. showed the roof on the portion of the building where the ceiling tiles were missing was flat. During an interview on 4/26/23 at 3:09 P.M., the Business Office Manager (BOM) said a sprinkler pipe broke. The sprinkler vendor came out and did the work. The pipes busted and the tiles came down. They did have leaks in the roof when it rained, knew they had them in the dining room and the skylight on the 300 hall broke during the last rain. During an interview on 4/28/23 starting at 12:00 P.M., the Administrator said they had a leak in the room, not a collapse. The sprinkler vendor came out to make sure it was not a sprinkler head or pipe busted. The roof was under warranty so the corporation had someone come out and fix it. She did not know when that was. She thought maybe the first work had been completed in 2020. Observation on 4/28/23 starting at 12:30 P.M. showed all of the ceiling tiles had been replaced on the center hall. Removing the ceiling tiles exposed the attic space above which consisted of a sheetrock ceiling with an attic access panel which did not latch and opened into the attic space above. A gray protective coating covered the water pipe which ran the length of the hallway just above the ceiling tiles. A black mold-like substance and a white powdery mold-like substance could be seen from the floor. When rubbed with a rubber glove and a paper towel both substances came off easily. Observation and interview on 4/28/23 at 1:45 P.M., showed and the administrator said: - In closet #21, a water damaged ceiling and water rings around the light switch. The room still emitted a strong odor of mold and/or mildew. - She did not realize there had been water damage in the closet. She did not know if the areas on the pipe were mold or only the tape around the pipe. The pipe appeared to be wet. They had a company come out and do work on the roof after the rain when water was seen but it all went through their corporate office because it was warranty work. She did not know when they came or when she had called them. She understood areas that looked like mold needed to be taken care of as this can be harmful for residents, staff and visitors. Review of a business card and two Post-it notes provided by the administrator on 5/5/23 showed: - The business card for a roofing company; - The first note had a phone number, the date 3/23/23 and (a representative from the roofing company) sent an email (electronic mail) to his production team and he will call me when they say they are coming here. - The second had the name of the roofing company representative, the name of the roofing company, 2 guys 1PM and a phone number. This Post-it note did not include a date of when they were coming. 6. Review of the MRF showed: - 3/13/23 room [ROOM NUMBER], toilet seat coming off hinges; - 4/13/23 room [ROOM NUMBER], sink has busted plumbing! Water has been turned off! Observation and interview on 5/5/23 at 2:00 P.M. showed and Resident #3 said: - No toilet seat on the toilet in room [ROOM NUMBER] and a portable commode sitting over the top of the toilet. - A sign over the sink which read DO NOT USE SINK! Busted plumbing and dated 4/13/23. - The resident said staff removed the toilet seat because it had broken so badly it was dangerous to use. They put that thing over the top of it to fix it. The sink had been broken for a couple of weeks. He/she cannot wash his/her hands after using the bathroom since the sink is broken. They cannot keep staff; he/she felt sorry for the previous MD, he never got help. They ran him ragged. 7. Review of the MRF dated 3/20/23, showed room # 204 and #209, locks in bathroom need removed. Observation and interview on 5/5/23 at 2:00 P.M. showed: - In room [ROOM NUMBER], the doorknob was coming off the bathroom door. The resident said it had been like that for a while. - In room [ROOM NUMBER], an out of order sign hung on the bathroom door; the door knob did not work. 8. Observations and interview on 4/28/23 starting at 2:10 P.M., showed and the Administrator said the following on the unused portion of the building: - The floors of the entire unit covered with dirt and grime; trash and equipment piled in multiple rooms on the unit; cobwebs covered most walls and windows; dead bugs littered the floors; furniture belonging to staff stored in several rooms; - In multiple bathrooms, along outside walls, a black mold-like substance could be seen along the top of the walls were they met the ceilings as well as ceiling tiles in these bathrooms; - In the shower room just off the transitions unit, behind the shared medication room the wall appeared to have shifted and shower tiles had popped off the gypsum board from the base of the bathtub all the way to the ceiling. The crack extended from the outside wall across the length of the bathtub and made a jagged line which lead directly to a large hole in the ceiling where rafters and insulation could be seen from the floor below. The paint and sheetrock had peeled away from the opening and hung down into the room. - The administrator said she saw the areas and they would fix it. 9. Observation on 4/26/23 starting at 2:40 P.M. and on 4/28/23 at 2:45 P.M. in the basement area or boiler room showed a large network of metal water pipes suspended from and running along the ceiling of the room. The pipes appeared rusted and in some places had deteriorated to the point where beads of water could be seen seeping from the underside of the pipes. In other places, the outer layers of the pipes had deteriorated and rusted so much so that where the suspension brackets stabilized the pipes in place appeared to be several inches smaller than the larger areas of the pipes. On the floor underneath the pipes was littered with rust shavings from the pipes above and water stood on the floor under the leaking pipes. During an interview on 4/28/23 at 2:45 P.M., the administrator said she had seen the moist pipes and reported them to her team who would tell her what they wanted to do. 10. During an interview on 5/5/28 at 4:00 P.M., the administrator said they have tried to hire a new MD but could not get applicants and when they did they could not get them hired. She knew there were issues with the building and they were doing the best they could trying to fix what they could on their own. She had attempted to have the previous MD come back in to work some days as he promised he would but he had had some family matters come up and had not been able to. MO217503

Based on interview and record review, the facility failed to protect one resident's right to be free from abuse when Registered Nurse (RN) A, who was witnessed by two staff members, slapped Resident #1 with an open hand across the mouth. The facility census was 54. Review of the undated facility policy titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property showed the following: - It is the policy of this facility that each resident will be free from abuse. Review of the undated facility policy titled Abuse Prohibition showed the following: - This facility will train employees on issues related to abuse prohibition practices; - The residents will be protected from the alleged offender; - The alleged perpetrator will be immediately removed and the resident protected; - The facility will protect the resident and other residents from continuing abuse; - All employees who have been alleged to commit abuse will be suspended immediately. Review of Resident #1's significant change in condition Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 1/20/23, showed: - A Brief Interview of Mental Status (BIMS) of 00, which indicates severe cognitive impairment; - Verbal behaviors such as yelling, and cursing, directed at others; - Extensive assistance with bed mobility, transfers, bathing, eating, dressing and toileting; - Diagnoses included Alzheimer's disease, bipolar disorder (episodes of mood swings ranging from depressive lows to manic highs) and diabetes mellitus (a disease that results in high blood sugar). Review of facility staffing sheets showed: - 1/19/23 RN A worked as the charge nurse for the night shift; - 1/20/23 RN A worked as the charge nurse for the day shift. Review of facility time clock punches for RN A showed: - 1/19/23 clocked in at 6:30 P.M. and clocked out at 7:00 A.M. on 1/20/23; - 1/20/23 clocked back in at 7:00 A.M. and clocked out at 7:30 P.M. Review of the facility's investigation, dated 1/27/23, showed: - CNA A informed the administrator on 1/23/23 that on 1/20/23 he/she and CNA G witnessed RN A slap Resident #1 in the face; - The investigation was started 1/23/23 at 3:00 P.M.; - The Department of Health and Senior Services (DHSS) notified 1/23/23 at 5:00 P.M.; - RN A was suspended from the facility 1/23/23; - A Mini In - Service Sheet, dated 1/24/23, signed by facilty staff, with the following information written on it: o Topic: Abuse and Neglect; o Presenter: The acting Director of Nursing's name; o Description of information presented: Reporting abuse by employees and mandated reporting; - CNA A wrote he/she and CNA G who and CNA A? were doing bed checks and getting residents up. Resident #1 started to wake up moving around and trying to stand so RN A was trying to hold him/her back; RN A thought the resident was trying to bite him/her so he/she hit him/her by his/her mouth and said don't bite me. Reported to Licensed Practical Nurse (LPN) A. - CNA G wrote on Friday morning, 1/20/23, CNA A and I witnessed RN A slap Resident #1 in the face. He/she was trying to button the resident's shirt from behind and I think he/she thought the resident was going to bite him/her, so he/she slapped him/her and told him/her to stop that. Told LPN A on Friday night, not sure when; CNA A started talking about it. The resident did not have any marks on his/her face. CNA A was closer to the resident and was helping button the shirt for RN A. - RN A was terminated on 1/27/23. During an interview on 2/1/23 at 2:53 P.M., RN A said: - He/she worked over 40 hours last week; - On 1/19/23 and into 1/20/23, he/she worked 24 hours straight; - He/she worked a 12 hour shift on 1/19/23 then on 1/20/23 he/she worked the second 12 hour shift in a row as the nurse for the whole house; - The administrator knew he/she worked 24 hours straight because she could not get anyone else to work the shifts; - At least once month he/she worked a double shift and the administrator knew this; - He/she was in charge of scheduling and no one would pick up the open shifts so since he/she was the acting Director of Nursing (DON) he/she had to cover the shifts; - On the morning of 1/20/23, he/she helped morning staff get Resident #1 up; - As he/she buttoned Resident #1's shirt, the resident started to smack and pinch him/her; - He/she did not smack or hit Resident #1; - He/she did not know why the staff would say that he/she hit Resident #1; - He/she called into the facility mid-afternoon on 1/23/23 to tell the Administrator his/her physician wanted him/her to be off work due to knee issues and was told at that time about the the allegations. The Administrator told him/her he/she was suspended pending the investigation but then told him/her he/she needed to work because the other nurse had called in and there was no other nurses to work overnight on 1/23/23; - The Administrator did not give him/her any special instructions regarding the care of Resident #1; - The Administrator officially suspended him/her the next morning at the end of his/her shift. Review of facility time clock punches for RN A showed: - 1/23/23 clocked in at 6:25 P.M. and clocked out at 7:08 A.M. on 1/24/23. During an interview on 2/3/23 at 9:15 A.M., RN B said: - RN A worked on the night shift on 1/23/23; - He/she worked the day shift on 1/23/23 and gave report to the on-coming nurse, RN A at 6:30 P.M.; - He/she came back to work on the next day, 1/24/23 and received report from the off-going nurse, RN A, at 7:00 A.M. During an interview on 2/2/23 at 3:20 P.M., Certified Nurses Aide (CNA) A said he/she witnessed RN A slap Resident #1 in the mouth on 1/20/23. During an interview on 2/1/23 at 3:59 P.M., the Director of Operations (DOP) said RN A did not work on 1/23/23 after being suspended. During an interview on 2/2/23 at 11:59 A.M., the Administrator said: - She suspended RN A on the afternoon of 1/23/23, around 2:00 P.M.; - RN A did not work that night; she did not know RN A was working until she walked out of her office at 6:00 P.M. and saw her at the nurses' station. - She instructed RN A to not be in the room with Resident #1 alone and always have a CNA in the room with him/her. During an interview on 2/1/23 at 3:20 P.M., RN B said: - He/she has noticed RN A be grouchy with the staff; - He/she did not report RN A's behavior to anyone. During an interview on 2/3/23 at 9:45 A.M., Licensed Practical Nurse (LPN) A said: - RN A has been grouchy with the staff; - Over the last two months, RN A has been more forgetful; - RN A is in charge of the schedule and there have been more errors. During an interview on 2/3/23 at 10:31 A.M., the acting DON said: - The administrator called her on 1/23/23 at 5:00 P M. and told her she suspended RN A; - On 1/31/23 at 8:00 A.M., the DOP told her RN A worked after being suspended; - She did not know why the administrator allowed RN A to work; - RN A should not have been allowed to work after being suspended. MO213044

Based on observation, interview and record review, the facility failed to follow their policy to prevent further potential for staff to resident abuse while an investigation was in progress when they allowed Registered Nurse (RN) A to work a 12-hour overnight shift as the only nurse at the facility after being suspended for reportedly slapping Resident #1 in the face. The facility also failed to educate staff on the facility abuse prevention policy that included recognizing and reporting signs of staff burnout, frustration and stress as it could lead to mistreatment of residents. This had the potential to affect all residents. The facility census was 54. Review of the undated facility policy titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property showed the following: - It is the policy of this facility that each resident will be free from abuse; - New and existing nursing home staff will be at trained at hire, yearly and as needed on the following elements: o Prohibiting and preventing all forms of abuse; o Recognizing signs of abuse; o Reporting abuse; o Recognizing signs of staff burnout, frustration and stress as it could lead to maltreatment of residents; o Staff will be taught the signs and symptoms of burnout; o Staff should report any signs and symptoms of burnout to their supervisor; o Staff that are identified with burnout may need time off or referral for assistance. Review of the undated facility policy titled Abuse Prohibition showed the following: - This facility will train employees on issues related to abuse prohibition practices; - The residents will be protected from the alleged offender; - The alleged perpetrator will be immediately removed and the resident protected; - The facility will protect the resident and other residents from continuing abuse; - All employees who have been alleged to commit abuse will be suspended immediately. Review of Resident #1's significant change in condition Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 1/20/23, showed: - A Brief Interview of Mental Status (BIMS) of 00, which indicates severe cognitive impairment; - Verbal behaviors such as yelling, and cursing, directed at others; - Extensive assistance with bed mobility, transfers, bathing, eating, dressing and toileting; - Diagnoses included Alzheimer's disease, bipolar disorder (episodes of mood swings ranging from depressive lows to manic highs) and diabetes mellitus (a disease that results in high blood sugar). Review of the resident's care plan dated 1/27/23, showed: - He/she has experienced trauma and needs assistance to address the impacts of the trauma; - Staff will maintain safety and dignity during post-traumatic episodes; - He/she needs the assist of two staff with dressing, toileting, hygiene and transfers. Review of facility staffing sheets showed: - 1/19/23 RN A worked as the charge nurse for the night shift; - 1/20/23 RN A worked as the charge nurse for the day shift. Review of facility time clock punches for RN A showed: - 1/19/23 clocked in at 6:30 P.M. and clocked out at 7:00 A.M. on 1/20/23; - 1/20/23 clocked back in at 7:00 A.M. and clocked out at 7:30 P.M. During an interview on 2/1/23 at 2:53 P.M., RN A said: - As he/she buttoned Resident #1's shirt, the resident started to smack and pinch him/her; - He/she did not smack or hit Resident #1; - He/she called into the facility mid-afternoon on 1/23/23 to tell the Administrator his/her physician wanted him/her to be off work due to knee issues and was told at that time about the allegations. The Administrator told him/her he/she was suspended pending the investigation but then told him/her he/she needed to work because the other nurse had called in and there was no other nurses to work overnight on 1/23/23; - He/she worked over 40 hours last week; - On 1/19/23 into 1/20/23, he/she worked 24 hours straight; - He/she worked a 12 hour shift on 1/19/23 then on 1/20/23 he/she worked the second 12 hour shift in a row as the day shift charge nurse for the whole house; - The administrator knew she/he worked 24 hours because she could not get anyone else to work the shifts; - At least once a month he/she worked a double shift (24 hours straight); - He/she was in charge of scheduling and no one would pick up the open shifts so since he/she was the acting Director of Nursing (DON) he/she had to cover the shifts; - No one from administration had talked to him/her about burnout; they only made statements like We're so glad you can do this. During an interview on 2/3/23 at 9:15 A.M., RN B said - He/she worked the day shift on 1/23/23 and gave report to the on-coming nurse, RN A at 6:30 P.M.; - RN A worked on the night shift on 1/23/23; - He/she came back to work on the next day, 1/24/23 and received report from the off-going nurse, RN A, at 7:00 A.M. During an interview on 2/2/23 at 3:20 P.M., CNA A said: - He/she has not been inserviced or educated by the facility on recognizing signs of staff burnout, frustration and stress; - No facility staff have checked on him/her to see how he/she is handling any stresses at work. Review of facility time clock punches for RN A showed on 1/23/23 clocked in at 6:25 P.M. and on 1/24/2023 at 7:08 A.M. he/she clocked out. During an interview on 2/2/23 at 11:59 A.M., the Administrator said: - She suspended RN A on the afternoon of 1/23/23, around 2:00 P.M.; - She did not know RN A was working until she walked out of her office at 6:00 P.M. and saw her at the nurses' station. - She instructed RN A to not be in the room with Resident #1 alone and always have a CNA in the room with him/her. Review of nurses' notes for Resident #1 showed RN A charted on 1/24/23 at 5:18 A.M. the resident slid out of his/her wheelchair. During an interview on 1/31/23 at 11:26 A.M., Certified Medication Technician (CMT) A said: - He/she has not been inserviced or educated by the facility on recognizing signs of staff burnout, frustration and stress; - No administrative staff have checked on him/her to see how he/she is handling any stresses at work. During an interview on 1/31/23 at 11:45 A.M., CNA C said: - He/she was inserviced last week on how to report abuse; - He/she has not been inserviced or educated by the facility on recognizing signs of staff burnout, frustration and stress; - No administrative staff have checked on him/her to see how he/she is handling any stresses at work. During an interview on 1/31/23 at 12:15 P.M., Housekeeper A said: - He/she has not been inserviced or educated by the facility on recognizing signs of staff burnout, frustration and stress; - No administrative staff have checked on him/her to see how he/she is handling any stresses at work. During an interview on 1/31/23 at 1:00 P.M., Dietary Aide A said: - He/she has not been inserviced or educated by the facility on recognizing signs of staff burnout, frustration and stress; - No administrative staff have checked on him/her to see how he/she is handling any stresses at work. During an interview on 1/31/23 at 1:35 P.M., CNA D said: - He/she was inserviced on how and when to report abuse last week but it did not address burnout of staff; - He/she has not been inserviced or educated by the facility on recognizing signs of staff burnout, frustration and stress; - No administrative staff have checked on him/her to see how he/she is handling any stresses at work. During an interview on 1/31/23 at 1:42 P.M., CNA F said: - He/she has not been inserviced or educated by the facility on recognizing signs of staff burnout, frustration and stress; - No facility staff have checked on him/her to see how he/she is handling any stresses at work. During an interview on 2/1/23 at 3:10 P.M., CNA B said: - He/she works 60 hours a week at the facility; - The management does not come out of the office to check on us or or our work load; - He/she has not been inserviced or educated by the facility on recognizing signs of staff burnout, frustration and stress; - No administrative staff have checked on him/her to see how he/she is handling any stresses at work. During an interview on 2/1/23 at 3:20 P.M., RN B said: - He/she has not been inserviced or educated by the facility on recognizing signs of staff burnout, frustration and stress; - The administration never comes out of the offices to see how the employees are handling stress or anything else; - No administrative staff have checked on him/her to see how he/she is handling any stresses at work. During an interview on 2/3/23 at 9:45 A.M., Licensed Practical Nurse (LPN) A said: - He/she has not been inserviced or educated by the facility on recognizing signs of staff burnout, frustration and stress; - No administrative staff have checked on him/her to see how he/she is handling any stresses at work. During an interview on 2/3/23 at 10:31 A.M., the acting DON said: - The administrator called her on 1/23/23 at 5:00 P M. and told her she suspended RN A; - On 1/31/23 at 8:00 A.M., the DOP told her RN A worked after being suspended; - She did not know why the administrator allowed RN A to work; - RN A should not have been allowed to work after being suspended; - She did an in-service with all staff on abuse on 1/23/23 but could not remember if she discussed recognizing and reporting burnout. Review of the Mini In-service form, presented by the acting DON and dated 1/24/23, showed: - Topic: Abuse and Neglect; - Description of Information Presented: *Reporting abuse- all employees are mandated reporters *Employees must report any abuse or suspisicion of abuse immediately to the administrator. *If adminstrator is not available, report to DON or your immediate supervisor; *Failure to report can make employees just as responsible for the abuse in accordance with state law; - The Mini In-service form did not indicate the acting DON educated staff on burnout, watching for the signs of burnout or reporting the signs of burnout to administration. During an interview on 2/3/23 at 11:59 A.M., the Administrator said: - She allowed RN A to work on 1/23/23 because they did not have another nurse to cover the night shift on 1/23/23; - She notified the DOP that RN A was working on 1/23/23 after he/she was suspended; - She had not other nurses to pull from; - She did not know RN A had worked 24 hour shifts on multiple occasions; - They always go out and check on their staff to monitor them for burnout; maybe not using that term but ask how they are doing; - No staff had reported having concerns about RN A's not being fit for duty or complained about him/her being gruff with them or residents. - RN A should not have been allowed to work after being suspended because of an allegation he/she physicially abused a resident. MO213044

Based on record review and interviews, the facility failed to thoroughly investigate in a timely manner allegations of misappropriation of residents' narcotic medications when they did not follow policy and immediately begin the investigation and did not interview all staff who had access to the controlled drugs. The facility's census was 53. Review of the facility's undated Abuse Policy showed it is the policy of this facility that each resident will be free from Abuse. Abuse can include misappropriation of resident property. The investigation is the process used to try to determine what happened. The designated facility personnel will begin the investigation immediately. All allegations of abuse will be reported no later than two (2) hours to State Survey Agency and if applicable, law enforcement. The procedure for investigating misappropriation of resident property consisted of at least the following: - The facility staff will complete an active search for missing items including documentation of the investigation; - An interview with the person or persons reporting the incident; - Interviews with any witnesses to the incident; - A review of the resident medical record if indicated; - An interview with staff members having contact with the resident during the relevant periods or shifts of the alleged incident; - The follow-up investigative notes will be submitted via fax or as directed by Department of Health & Senior Services (DHSS) within five days of the initial report. - All events listed under the identification section of this manual will be initially investigated on the facility's incident report forms. This is done by the charge nurse, assistant director of nursing (ADON), director of nursing (DON) or the administrator. The investigation of the incident begins immediately. Review of the QA Nurse's witness statement, dated 1/9/23 at 4:05 P.M., showed: - Administrator notified writer two narcotic sheets were found in a nurse's bag left in the medication room. Narcotic cards were not found. One sheet had 15 (pills) left; second sheet had 19 (pills) left. - Upon further investigating, writer identified Licensed Practical Nurse (LPN) B was logging in the Stat-Safe (used as the facility's emergency medication kit) staff using other nurses' usernames and password; - To log into Stat-Safe, policy is to use two licensed nurses to removed narcotics. - LPN B's picture (Stat-Safe photographs whomever logs in to retrieve medications) shows no other nurse was in room while he/she was retrieving narcotics. - Administrator reported narcotic sheets, officer came in and took report. LPN B came in and gave statement. Review of the facility's Administrator's Summary of Investigation Process of Incident, signed by the Administrator on 1/9/23 showed: - LPN A notified her (did not indicate the date notified) he/she found a bag with narc sheets in it and the bag belonged to LPN B. I asked if the narc count was good or off and he/she stated it was good. 6:41 P.M. I asked if any resident had gone without medications and he/she said no, they had other cards of the medication. The bag was to be locked in the administrator's office and not discussed between staff. - On Tuesday (1/2/23) the Director of Operations (DOP) and administrator reviewed the two sheets and they appeared to be the subject discussed and investigated on 12/15/22. We began to review processes and asked the Quality Assurance (QA) nurse to come and assist. - The QA nurse came on Thursday (1/5/23) for performance in practice (PIP) review and in reviewing discovered what appeared to be potential diversion of narcotics. LPN B was removed from the scheduled pending the investigation completion. - LPN B was interviewed and stated both verbally and in writing he/she did not and would not steal anything from these residents. He/she left the bag of medical equipment (stethoscope, blood pressure cuff, etc.) locked in the medication room, where multiple people had access to it, as his/her last bag of equipment was taken. He/she stated he/she did not put any narc sheets in the bag. - The summary did not include any investigation surrounding the count sheets, the remaining medication on each sheet or any interviews with staff who may have access to the medication cards between 12/23/22 when the DON last administered the medication from Resident #2's narc sheet and 1/1/23 when LPN A administered the first doses from the new cards for both residents' narcotics. Review of the facility's licensed nurse and CMT schedule for December 2022 and January 2023 showed five staff had access to the narcotics between 12/23/22 and 1/1/23. Review of the facility's complete investigation, provided to DHSS via email on 1/9/22 at 5:12 P.M., showed only one staff, LPN B provided a written statement regarding the missing narcotics. The investigation did not include: - Any interviews with Resident #2 who staff assessed as being alert and oriented; - Any interviews with any other residents regarding their pain medications; - Any interviews with any of the other licensed nurses who had access to the narcotics and LPN B's bag between 12/23/22 and 1/1/23; - Any interviews with any of the CMTs who had access the LPN B's bag in the medication room between when he/she worked on 12/29/22 and 1/1/23. During an interview on 1/10/23 at 10:05 A.M., the Administrator, QA Nurse and DOP said they had tried to keep the investigation quiet. They did not feel they could prove who took the medications. They called the QA Nurse in because they had investigated the same issues in December and could not prove anything. They did not interview anyone except LPN B. They never found the medication cards, only the top portion of one of the cards and the two count sheets that were found in a LPN B's bag. They have changed their process for receiving narcotics now and label the top of each card as 1 of however many they receive, but they just never found the other cards for either of these residents' medications. During a telephone interview on 1/17/23 at 12:26 P.M., LPN A said: - He/she immediately called the Administrator to report finding narcotic count sheets in a staff members bag. - He/she did not give a statement regarding finding the count sheets or the missing narcotics, he/she only called the Administrator when he/she found the bag. - He/she put the bag in the Administrator's office as she requested. During an interview on 1/10/23 at 1:05 P.M., RN A said: - No one had talked to him/her until today about the medications or LPN B's bag before today. He/she worked between 12/23/22 and 1/1/23. During an interview on 1/10/23 at 1:22 P.M., LPN E said: - No one had talked to him/her about any missing narcotics prior to today. During a telephone interview on 1/17/23 at 12:21 P.M., CMT A said: - No one had asked him/her about any missing medications or allegations of staff diverting medications until today. During an interview on 1/10/23 at 3:16 P.M., the QA Nurse said: - She spoke to CMTs, residents and licensed nurses about the missing narcotics, but did not document the information anywhere; - She did not realize the last dates the medications had been given from the cards were dates prior to 1/1/23 or that LPN B did not work the day the count sheets were found in the bag. - She did not talk to any of the residents because she thought none of them were alert and oriented; she did not realize Resident #2 had a BIMS of 15. During a telephone interview on 1/17/23 at 5:48 P.M., Police Officer A said: - They had been called to the facility to take a report of possible drug diversion on 1/9/23. - He spoke with Administration and they said they could not prove who took the medications at this point. - The facility did not report they thought they had two cards of narcotics missing with 26 pills between the two cards, only that they believed a staff member diverted two pills from their stat-safe. During a telephone interview on 1/23/23 at 4:55 P.M., the Administrator said she did not interview additional staff, because LPN A was the only one who had access to LPN B's bag. The QA Nurse was looking at the process and they only focused on what she was finding. MO212161

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Refer to Event LX7F13 Based on observation, interview and record review, the facility failed to ensure residents were treated in a dignified way that a reasonable person would expect. This affected two of 4 sampled residents (Resident #1 and Resident #2). The facility census was 55. Review of the facility provided policy Resident Rights showed in part: -The resident has a right to a dignified existance, and self determination. The facility must protect and promote the rights of each resident. Resident rights are to be fully respected and adhered to. Review of Resident #1 Annual Minimum Data Set (MDS a federally mandated asseessment tool completed by facility staff) dated 8/17/22 showed: -Brief Interview of Mental Status (BIMS) of 15, which indicates no cognitive defecit. -Verbal behaviors such as yelling, and cursing, directed at others 1-3 days. -No significant risk for injury from behaviors. -Extensive assistance with Activities of Daily Living (ADLs: activities related to personal care. They include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating.) -Feeling bad about him/herself 7-11 days of 14 days. -Diagnosis of Cerebral Palsy (a group of disorders that affect a person's ability to move and maintain balance and posture), Diarrhea, Urge Incontinence (occurs when you have a strong, sudden need to urinate that is difficult to delay.The bladder then squeezes, or spasms, and you lose urine.), Major Depressive Disorder. Review of the Resident's care plan dated 8/24/22 showed: -He/she has behaviors of urinating and defecating self for attention. -Accusing staff of not assisting him/her to the toilet and soiling him/herself. -He/she will follow toileting schedule. -Remind of toileting schedule -Public Administrator (PA) had television removed dated 8/24/22 -PA notified of behaviors and requested staff remove the resident's tablet dated 9/19/22 Review of the resident's progress notes showed in part: - 9/6/22 the resident saw urology with an order for a catheter.Guardian notified, feels the resident is soiling him/herself as a behavior and declined the use of a catheter. - 9/14/22 CNA requested to change as resident was soiled, the resident refused, staff reminded resident the next step was to have his/her radio removed. -9/16/22 resident educated on need to follow plan of care for his/her needs. 9/19/22 resident lied to staff stating he/she was clean and dry when he/she was soiled. Spoke with Guradian and Kindle is to be removed. -11/9/22 the resident's kindle has been put away for PA. During an interview on 11/16/22 at 11:35 A.M. Public Administrator (PA) A said: -He/she is had the tablet/TV taken away because the resident won't go to the bathroom when staff try to take him/her. -Until he/she can do what's asked, and behave, he/she will not get her tablet back. -If he/she is going to act like a 3 year old then he/she can be treated like a 3 year old. During an interview on 11/16/22 at 2:01 P.M, the resident said: -Staff take his/her tablet or TV when he/she soils him/herself. -He/she didn't say it was ok to take the TV or tablet. -He/she is not a baby. -He/she cannot always make it to her room at the scheduled toileting time. Review of Resident #2 Quarterly MDS dated [DATE]. -BIMS of 15, which indicates no cognitive defecit. -No behaviors -Independent for ADLs. -No mood indicators. -Diagnosis of Schizophrenia (a serious mental disorder in which people interpret reality abnormally), anxiety disorder, antisocial disorder (a challenging type of personality disorder characterised by impulsive, irresponsible and often criminal behavior), Post Traumatic Stress Disorder (PTSD:a mental health condition that's triggered by a terrifying event - either experiencing it or witnessing it. Symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event.) Review of the resident's care plan dated 9/30/22 showed: -Approach dated 7/14/22 of cell phone is restricted for 30 days July 14th-August 14th. -His/her care team and guardian will reevaluate in 30 days. Review of the resident's medical record showed: -Progress note dated 7/13/22 : guardian directed resident to surrender his/her cell phone related to unsafe usage. The resident was educated how to use the cordless phone -No progress notes of unsafe phone use. -Progress note dated 8/29/22 showed: guardian requested to continue the resident's cell phone restriction and revisit the issue in 4-6 weeks. -No notes returning cell phone to the resident. During an interview on 11/16/22 at 1:39P.M. the resident said: -His/her cell phone was taken for 2 months. -There was no plan, or discussion, it was just taken. -The phone was taken because a friend brought him/her things. -The staff don't believe anything he/she says. -The phone has not been taken since the original incident. -The staff tell him/her they will take the phone if he/she does something wrong, nothing specific. During an interview on 11/16/22 at 2:15 P.M. Certified Medication Technician (CMT) A said: -He/she is not aware of things being taken. -During an interview on 11/16/22 at 2:19 P.M. Certified Nurse Aide (CNA) A said: -If the resident doesn't follow the rules his/her TV or tablet get taken. -The resident messes him/herself for attention. -Staff don't take the tablet or TV, the Social Service Director does. -Not sure of other things being taken. During an interview on 11/16/22 at 3:30 P.M. the Transitions Director said: -There are multiple notes about unsafe behaviors. -Both resident's PA's or Guradians are ok with the behavior modification. -Residents still have rights, but the facility does what the PA/Guradian wants. During an interview on 11/16/22 at 3:37 P.M. the Social Service Director said: -Removal of items is for behavior modification. -PA/Guardians are ok with the removal of the residents belongings. -Residents do have rights. -Staff notify him/her of behaviors. During an interview on 11/17/22 at 9:55 A.M. PA B said: -He/she was not aware the phone or it's privilages were being used as a take away and give back situation. -He/she wound not give the facility the power to just take his/her phone without discussing it with him/her first. During an interview on 11/16/22 at 3:15 P.M. during exit the Administrator said: -Residents have rights, but if there is a Guardian/PA the facility makes a plan of action with them. -One resident has his/her tablet taken for consequences of his/her behavior. -Another resident had his/her cell phone taken for unsafe use. -Both residents understand the modifications. During an interview on 12/5/22 at 9:48 A.M. Registered Nurse (RN) A said: -the SSD takes resident's belongings such as tablets or TV often. -Staff will tell the resident they are going to tell the SSD on him/her. -He/she stops staff when telling residents they are going to tell the SSD. -He/she has repoted to the Administrator that things are being taken and staff are saying the above but nothing has been done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to maintain records and assist one of 15 sampled residents (Resident #40) with obtaining prescription eyeglasses. The facility census was 57. The facility did not provide a policy regarding vision/eye glasses. 1. Review of Resident #40's comprehensive Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 6/24/22, included the following: - Date admitted [DATE]; - Cognitively intact; - Indicated corrective lenses (contacts, glasses, or magnifying glass) for vision. Review of the resident's care plan dated 7/5/22 showed staff did not include any information regarding the resident's vision or need to wear corrective lenses. During an interview on 8/3/22 at 8:18 A.M. the resident said: - He/she went to get new glasses because he/she could to get a new pair every two years and it had been over four years. - His/her current glasses were not sufficient anymore. His/her vision has gotten worse and could not read with the glasses he/she had. -When he/she got back to the facility from the appointment, the Administrator told him/her Medicaid would not pay for them; During an interview on 8/5/22 at 9:32 A.M. the resident said: - He/she was not sure what month the appointment was but when he/she went back and picked out frames is when the Administrator said he/she was not qualified yet to receive new glasses; - He/she got current glasses around 2016 when he/she was living at a Residential Care Facility. Review of the resident's medical record showed the following: - An physician order to see an eye doctor, the order was dated 12/2/21; - Nurse note dated 12/28/21 by Licensed Practical Nurse (LPN) C that indicated the resident had an eye appointment. The resident was given a prescription for new glasses and also indicated the resident could use +1.50 over the counter reading glasses. Resident was instructed to report changes or worsening of vision. Orders complete for one year; - No other documentation was found in the records regarding the resident receiving any new glasses. During an interview on 8/5/22 at 8:22 A.M. the Interim Director of Nursing (DON) said: - She had not see anything in the resident's records about the eye appointment. - Social Services Designee would be responsible to assist residents with getting glasses through Medicaid. - Interim DON was not familiar with Resident #40 wanting new glasses; - BOM A would schedule the appointment and Social Services Designee would make sure the resident received them; During an interview on 8/5/22 at 9:12 A.M. the Social Services Designee said: - She did not know anything about Resident #40's needing glasses but said the Transitions Program Director might know; - The resident had not come to her about glasses but the resident would probably go to the Transition Program Director. During an interview on 8/5/22 at 9:33 A.M. the Transition Program Director said: - She did not remember anything about the resident's appointment regarding glasses. - Vision needs should be reviewed during quarterly care plan meetings. - The Social Services Designee is responsible to assist residents when going through insurance, she did not. - She knew residents on Medicaid could get an appointment annually and new frames and lenses every two years; - BOM A would have record of the appointment and any assistance provided; During an interview on 8/5/22 at 9:35 A.M., BOM A said: - The resident had an appointment on 12/28/21; - BOM A found a nurse note that showed the resident received a prescription for new glasses but she did not see anything else she would have needed to follow up with. During an interview on 8/5/22 at 9:40 A.M. the Administrator said: - She remembered the resident coming up and looking for information for glasses but she did not remember any specifics on it. During an interview on 8/5/22 at 9:45 A.M., BOM A said: - She just called the optometry provider they said they did give the resident a prescription but the resident said he/she was going to go get something cheaper so they suggested 150+ over the counter; - They did not order glasses for the resident.; - They did not say anything about it not being covered yet. During an interview on 8/17/22 at 11:10 A.M. LPN C C said: - He/she confirmed he/she read the nurse note but did not remember the situation or what happens to glasses prescriptions when they were received or if they resident ever gave it to anyone. During an interview on 8/05/22 at 1:16 P.M. the Interim DON said: - She would expect what happened with the prescription to be documented in the nurse notes; - If a resident receives a prescription, the resident may not provide the prescription to nursing. - If the resident wanted to hold off on obtaining new glasses because of the cost, that should have been documented in the residents medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure correct installation, use, and maintenance of bed rails, assess the residents for entrapment, review risks and benefits with the resident and/or resident representative and obtain informed consent prior to installation, and obtain physician orders for. This affected four of 15 sampled residents (Resident #1, #5, #15, and #46). The facility census was 57. Facility did not provide requested copies of policy regarding halo and half rail entrapment assessments, informed consents, and orders for side rails or halos. 1. Review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by the staff, dated 7/25/22 showed in part: - Brief Interview for Mental Status (BIMS, a cognitive assessment tool used to determine the resident's ability to make choices) score of 00, indicating that the resident has a severe cognitive deficit. - Diagnosis in part of bile duct cancer, digestive cancer, restlessness/agitation, need for assistance, depression, weakness, difficulty swallowing, urinary tract infect (UTI), pain, falls, and communication deficit. - Resident has mood and behaviors. - Important for resident to voice choices regarding Activities of daily Living (ADLs, the act(s) of taking care of oneself); - Requires significant assistance with ADLs. Resident is able to propel self in wheelchair. - Incontinent of bowel and bladder. - Has as needed (PRN) pain meds. Fall risk, risk for pressure ulcers, has pressure reducing device for bed. - Has medications of antidepressant(s) and diuretics, (medication to remove excess fluid from the body), - Not receiving any therapies. - MDS shows resident does not have bed rails. Review of resident's care plan (CP) dated 5/6/19 showed in part: - Resident has a lift chair to assist with getting up, - A CP dated 10/19/22 administer PRN meds for my anxiety. - A CP plan dated for 5/6/19 needing assistance with transfers and ADLs. - No interventions or mention of side rails. Observations on 8/3/22 at 9:55 A.M. showed the resident had a half rail at the head of bed on right side. Review of residents' Physician Order Sheets (POS) dated 6/5/22 - 8/5/22 showed no order for the use of half rails. Record review on 8/5/22 showed facility did not have an entrapment assessment on admission or quarterly, consent for, and no physician orders for half rail. Review of Resident #5's quarterly MDS, dated [DATE] showed in part: - BIMS of 04, indicating that the resident has a severe cognitive deficit. - Diagnoses of Alzheimer's (ALZ), a head injury without loss of consciousness, pain, feeding difficulties, UTI, weakness, falls, communication deficit, depression, anxiety, difficulty swallowing, assistance with ADLs. - Incontinent of bowel and bladder. - Resident has depressed mood; - Requires significant assistance with most ADLs; - At risk for pressure ulcers; - Has pressure reducing device for bed; - Resident did not use bed rails. Review of residents' CP dated 2/11/22 showed: - At risk for falls. Ensure resident is positioned correctly; - On 1/19/21, resident is a mechanical device to transfer with an two staff assisting; - No interventions or mention of side rails. Observation on 8/2/22 at 3:28 P.M. showed the resident had two halos rails on the bed with the right side halo not secured. During an interview on 8/2/22 at 3:28 PM the resident said he/she used the halos to aid in positioning him/herself in bed. He/she did not know the rail on the right was not secured. Record review on 8/5/22 showed showed no entrapment assessment on admission or quarterly, consent for, and no physician orders for halos. Review of Resident #15's quarterly MDS dated [DATE] showed in part: - BIMS of 14, indicating no impairment of cognition. - Diagnoses in part of epilepsy, weakness, pain, diverticulosis (the inner layer of your intestine pushes through weak spots in the outer lining. This pressure makes them bulge out, making little pouches. Most often it happens in your colon, the lower part of your large intestine.) UTI, and a history of incontinence; - One person assist with walker and two person assist with showers. - Has had two non-injury falls and one minor injury fall since last MDS. - Has pressure reducing device for bed - No therapies listed. - Has no restraints but does have a pressure pad alarm to sound when resident tries to move, stand, or reposition. - Did not indicate the resident used bed rails. Observation on 8/2/22 at 3:00 PM showed the resident had halo rails attached to bed. During an interview on 8/2/22 at 3:00 PM, the resident said he/she used the halos to aid in repositioning. Review of the resident's POS dated 7/1/22 - 8/3/22 showed no order for the resident's halo rails. During the record review on 8/5/22 showed the facility did not have an entrapment assessment on admission or quarterly and no physician orders for halos. 3. Review of Resident #46's significant change in status MDS dated [DATE] showed in part: - BIMS of 15, indicating no impairment to cognition. - Resident has some behaviors with the occasional refusal of cares/assistance. - It is importance for resident to choose preferences regarding ADLs. - Requires extensive assistance with most ADLs. Able to propel self in wheelchair. - Incontinent of bowel and bladder. - Diagnoses of bipolar and cerebral palsy. - May cough and/or choking with meals and fluids. - Has scheduled pain medications; - At risk for pressure ulcers; - Has three Stage II pressure ulcers. Has pressure reducing device in bed and wheelchair. - Skin issues related to moisture associated skin damage. - Medications for antidepressant, anticoagulant, diuretic, and opioid. - Did not indicate the resident used bed rails. Observations on 8/2/22 at 2:13 P.M. showed the resident had two halo rails with the one on the left side broken. During an interview on 8/2/22 at 2:13 PM the resident said he/she used halo rails to aid with repositioning. He/she did not know the left side halo was broken. Record review on 8/5/22 showed facility did not have an entrapment assessment on admission or quarterly, consent for, and no physician orders for halos. 4. During an interview on 8/5/22 at 2:38 PM the Interim Director of Nursing (DON) said side rail assessments are done on admission, quarterly, and then with changes in ability. The MDS Coordinator is responsible for getting these done. Everyone in nursing should be monitoring that rails are in good working order.

Based on observations, interviews, and record review, the facility failed to post accurate and current nurse staffing information, per shift, on a daily basis. The facility census was 57. The facility did not provide a policy for posting nurse staffing information. 1. Observation on 8/2/22 at 10:35 A.M., and at various times from 8/3/22 to 8/5/22, showed three different sheets with the nurse staffing posted on a clipboard on the wall across from the South Nurses' station, showed: - The first sheet was dated 12/2/22. Census was 64. Licensed staff: Registered Nurse (RN): days- one for eight hours; Licensed staff: Licensed Practical Nurse (LPN): 6:00 A.M. to 6:00 P.M.- two for 24 hours; 6:00 P.M. to 6:00 A.M. - two for 24 hours; Non licensed staff: Certified Medication Technician (CMTs), Certified Nurse Aides (CNAs) and nurse aides (NAs):days: 6:00 A.M. to 2:00 P.M.- three for 24 hours; 6:00 A.M. to 6:00 P.M.- six for 72 hours; evening shift: one for eight hours; nights- 6:00 P.M. to 6:00 A.M. - five for 60 hours; - The second sheet was dated 12/6/21. Census was 64. Licensed staff: RN: days -1 for eight hours; Licensed staff: LPN: days- 6:00 A.M., to 6:00 P.M. - two for 24 hours; nights- 6:00 P.M. to 6:00 A.M. - two for 24 hours; Non-licensed staff: CMT, CNA and NA for days- 6:00 A.M. to 6:00 P.M.- three for 36 hours, 6:00 A.M. to 2:00 P.M.- two for 16 hours; nights- one for 12 hours; - The third sheet was dated 12/16/2. Census was 65. Licensed staff: RN: days -1 for eight hours; Licensed staff: LPN: days- two for 24 hours; nights: two for 24 hours; Non-licensed staff: CMT, CNA and NA for days- four for 32 hours; from 6:00 A.M. to 6:00 P.M.- five for 60 hours; evening shift- one for eight hours; nights- five for 60 hours. During an interview on 8/5/22 at 8:15 A.M., Certified Nurse Aide (CNA) A said: - He/she worked for an agency; - The nurse staffing was posted on pink paper at the South nurse's station and then he/she realized what he/she was talking about was the daily assignment sheets; - He/she did not know where the staffing sheets were located. During an interview on 8/5/22 at 8:20 A.M., Resident #45 said: - He/she did not know where the nurse staffing was posted. During an interview on 8/5/22 at 8:33 A.M., Resident #43 said: - He/she did not know where the nurse staffing was posted. During an interview on 8/5/22 at 8:51 A.M., the Interim Director of Nursing (DON) said: - The nurse staffing is posted on the clipboard across from the South Nurse's station; - The night nurse is responsible to make sure it has been done; - She looked at it a couple of months ago but doesn't remember what it said; - It should be current and up to date. During an interview on 8/5/22 at 10:52 A.M. Licensed Practical Nurse (LPN) B said: - The nurse staffing is posted at the South Nurse's station; - He/she thought the South Charge Nurse (CN) was responsible to keep it updated. During an interview on 8/5/22 at 6:11 P.M., the Administrator said: - Night charge nurse is responsible for posting daily nurse staffing.

Based on observations, interviews, and record review, the facility failed to ensure staff administered medications with a medication error rate of less than 5%. Facility staff made five medication errors out of 30 opportunities for error which resulted in a medication error rate of 16.66%, which affected four of 15 sampled residents, (Resident #19, #46 and #6). The facility census was 57. Review of the facility's undated medication administration guidelines, showed, in part: - It is the purpose of this facility that residents receive their medications on a timely basis and in accordance with established policies; - The person administering the drugs must chart medications immediately following the administration. The date, time administered, dosage, etc. must be entered in the medical record and signed by the person entering the data; - If there is doubt concerning the administering of medications, the physician's order must be verified before the medication is administered. 1. Review of Resident #19's physician order sheet (POS), dated August 2022, showed: - Start date: 8/2/22 - Boost high protein (food supplement) liquid, 120 milliliters (ml.) with meals at 7:00 A.M., 12:00 P.M., and 5:00 P.M. for nutritional deficiency. Review of the resident's medication administration record (MAR), dated August 2022, showed: - Boost high protein, (food supplement), 120 ml. with meals at 7:00 A.M., 12:00 P.M. and 5:00 P.M. for nutritional deficiency. Observation and interview on 8/4/22 at 8:59 A.M., showed: - The resident was in bed and said he/she had already ate his/her breakfast; - The resident drank all of the supplement. During an interview on 8/5/22 at 8:51 A.M., the Interim Director of Nursing (DON) said: - If the supplement was ordered to be given with meals then it should be given with the meal. 2. The facility did not provide a policy for administration of Flonase nasal spray or inhalers. Review of the undated package leaflet for Flonase nasal spray, showed, in part: - Shake the bottle gently; - Blow your nose to clear the nostrils' - Close one side of the nostril. Tilt your head forward slightly and carefully insert the nasal applicator into the other nostril; - Start to breathe in through your nose, and while breathing in, press firmly and quickly down one time on the applicator to release the spray; - Repeat in the other nostril; - Wipe the nasal applicator with a clean tissue and replace the cap. Review of Resident #46's POS, dated August 2022 showed: - Start date:12/30/19 - Fluticasone propionate spray 50 micrograms (mcg.) one spray twice daily for seasonal allergies. Review of the the resident's MAR, dated August 2022, showed: - Fluticasone propionate spray, 50 mcg. one spray twice daily for seasonal allergies. Review of the label on the Bevespi aerosphere, showed: - 9-4.8 mcg. inhale two puffs twice daily in the morning and the evening for chronic obstructive pulmonary disease (obstruction of air flow that interferes with normal breathing). Filled on 5/31/22; - Review of the resident's POS and MAR for August showed there was not an order for the Bevespi inhaler. Observation and interview on 8/422 at 9:11 A.M., showed: - CMT A did not have the resident blow his/her nose, did not shake the bottle, did not close one side of the resident's nostril and administered one spray to each nostril; - CMT A gave the resident one spray and said he/she only gets one spray. During an interview on 8/5/22 at 8:51 A.M., the Interim DON said: - The staff should follow the manufacturer's guidelines for administering nasal spray; - There should be an order for the inhaler; - If the order said two sprays then the staff should have administered two sprays. If the staff thinks the resident only needs one spray, then he/she should contact the physician for a clarification of the order.

Based on observations, interviews and record review the facility failed to follow the physician's order for a renal diet when staff served the resident a regular diet which affected one of 15 sampled residents, (Resident #3). The facility census was 57. Review of the facility's policy for diet orders, dated May 2015, showed, in part: - Diet orders prescribed by the attending physician shall be reviewed monthly by Dietary Service Manager (DSM) to assure that the diet orders in the resident's chart and the dietary meal cards are accurate; - Nursing will be responsible for written notification to the dietary department of changes and additions in diets or eating habits. Review of the facility's policy for monthly diet audits, dated May 2015, showed, in part: - Monthly audits will be conducted by the DSM; - The diet summary report will be obtained from nursing when pharmacy monthly summary reports are received by the facility; - The diet cards will then be audited by comparison to the diet summary sheet, noting any discrepancies on the sheet; - After all discrepancies have been noted on the summary report, the noted errors should be compared to the resident's chart; - Errors in communication should be taken to the Director of Nursing (DON); - The diet cards should then be corrected if needed. 1. Review of Resident #3's significant change in status Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/19/22 showed: - Cognitive skills severely impaired; - Required extensive assistance of one staff for bed mobility, transfers, dressing, toilet use and personal hygiene; - Upper extremity impaired on one side; - Diagnoses included diabetes mellitus, obstructive uropathy (a condition in which the flow of urine is blocked), acute kidney failure and chronic kidney disease. Review of the resident's physician order sheet (POS), dated August 2022, showed: - Start date: 12/30/19 - 7/12/22 (discontinued)- regular diet; - Start date: 7/12/22 - renal diet. Observation and interview on 8/4/22 at 7:53 A.M., Resident #3 said: - The staff brought the resident his/her room tray; - The resident had scrambled eggs, two slices of bacon, a blueberry muffin, and two small glasses of apple juice; - The resident said he/she could not eat the bacon because he/she did not have any teeth; - He/she did not know if he/she was on any special diet. During a telephone interview on 8/4/22 at 2:39 P.M., the Registered Dietician (RD) said: - For a renal diet, the staff should encourage protein, no bananas, and no orange juice; - Staff should monitor fluids; - can have half of a cup of milk, then no dairy; - Should not have any food high in potassium (bananas, potatoes or tomatoes). Observation and interview on 8/5/22 at 8:05 A.M., Dietary Aide A said: - As far as he/she was aware, the resident was on a regular diet; - The resident's meal card showed the resident was on a regular diet; - He/she used the residents' meal cards when he/she prepared their plate. During an interview on 8/5/22 at 8:51 A.M., the Interim Director of Nursing (DON) said: - The resident was on a renal diet; - The resident's meal card should say he/she was on a renal diet and have specific instructions.

Based on observation, interview and record review, the facility failed to maintain residents' dignity when they served the residents their meals on Styrofoam plates, bowls, cups and plastic silverware which affected all residents who participated in meal service. (Resident #17, #19, #45, #49) and all residents who ate in the facility and failed to ensure residents' personal information was kept confidential The facility census was 57. Review of the facility's policy for meal service sequencing, dated May 2015, showed, in part: - Meal service sequencing is used in a facility to assure that all residents at a table are served at the same time; - The policy did not specify what type of dinnerware should be used. 1. Observation on 8/2/22 at 12:00 P.M., showed: - The staff were passing out packages of plastic silverware with a napkin and a package of salt and pepper in it; - The residents were served on Styrofoam plates, bowls and cups; - Resident #17 said the staff use the plastic silverware and Styrofoam dishes because the dietary staff do not want to wash the dishes; - Staff passed the hall trays on Styrofoam plates and bowls and used plastic silverware. Observation and interview on 8/3/22 at 7:50 A.M., showed: - Staff served Resident #19 his/her room tray on Styrofoam plate with plastic silverware; - He/she said he/she would prefer to have his/her meals on regular dishes; Observation on 8/3/22 at 7:52 A.M., showed: - All residents in the main dining room were served on Styrofoam plates, cups and had plastic silverware. During an interview on 8/3/22 at 8:27 A.M., Resident #45 said: - He/she had his/her meal served on Styrofoam dishes and plastic silverware; - He/she would prefer to have his/her meals on regular dishes with real silverware; - It made him/her feel cheap using the Styrofoam dishes and plastic silverware all the time. During an interview on 8/3/22 at 9:27 A.M., Resident #49 said: - He/she had his/her meal served on Styrofoam dishes and plastic silverware; - He/she would prefer to eat his/her meals on regular dishes and silverware; Observation on 8/4/22 at 7:45 A.M., showed: - The room trays on the 400 hall and 500 hall were on regular plates but had plastic silverware and Styrofoam bowls. During an interview on 8/5/22 at 8:05 A.M., the Dietary Aide A said: - He/she was the [NAME] and dietary aide; - They are using Styrofoam and plastic silverware because there is not enough staff in the dietary department to wash all the dishes. During an interview on 8/5/22 at 8:51 A.M., the Interim Director of Nursing (DON) said: - The staff should not be serving the residents' meals on Styrofoam plates, bowls cups or using plastic silverware; - The staff should be using regular dishes, cups, glasses and silverware; - She thought the staff were using the Styrofoam to get done earlier with clean up; - She thought they had been using the Styrofoam off and on since July. During an interview on 8/5/22 at 10:52 A.M., Licensed Practical Nurse (LPN) B said: - The dietary staff were using the Styrofoam and plastic silverware because they have not had enough staff in the kitchen to cook the food, prepare, serve and clean up afterwards; - He/she thought the facility had been using Styrofoam dishes and plastic silverware since COVID-19 (a new respiratory virus, caused by a novel (or new) coronavirus that has not previously been seen in humans); - Some days the kitchen staff will use regular dishes, but nine times out of ten the residents are served on Styrofoam dishes and plastic silverware. During an interview on 8/5/22 at 6:11 P.M., the Administrator said: - Real plates, silverware, etc should be used during meal service. - Disposable meal ware is being used because they do not have sufficient dietary staff to wash the dishes.

Based on record review and interview, the facility failed to provide residents receipts for each transaction from the Resident Trust Fund (RTF) and failed to maintain signed authorization from residents/representatives to manage resident funds. This affected three of 15 sampled residents (Residents #13, #38, and #40). The facility census was 57. Review of the facility policy titled Guidelines for Maintaining the Resident Trust Fund Account, revised 8/4/22, did not show information regarding providing a receipt to the resident for each transaction. 1. Review of Resident #38's ledger showed the following: - Withdrawal of $20 on 7/11/22; - There was an initial from the resident showing he/she received the funds but there was no copy that a receipt had been provided. 2. Review of Resident #40's RTF records included the following: - Withdrawal of $10.00 on 1/19/22; - There was an initial from the resident showing he/she received the funds but there was no copy that a receipt had been provided. 3. Review of Resident #13's RTF records included the following: - Agreement Concerning Management of Personal Funds dated 4/13/21 and signed by the resident showed he/she did not want the facility to manage his/her funds; - Records showed the resident had funds in the facility's RTF and did not have an updated authorization. 4. During an interview on 8/5/22 at 10:47 A.M. Business Office Manager A said: - She provided residents receipts if they make a cash deposit but she had never provided a receipt when cash was withdrawn; - She did not have an update authorization for Resident #13, her records showed the facility began managing his/her funds in July 2021.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure staff had an Out of Hospital Do Not Resuscitate form (OHDNR, it instructs health care providers not to begin cardiopulmonary resuscitation, (CPR), if the resident's breathing stopped or if the resident's heart stopped beating) for two of 15 sampled residents (Resident #49 and #42) and failed to ensure the code status matched the physician's order sheet (POS) and the resident's face sheet for two of 15 sampled residents, (Resident #43 and #21).The facility census was 57. Review of the facility's undated policy for advance directives, showed, in part: - The facility will respect advance directives in accordance with state law; - Upon admission of a resident to the facility, the social services designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate an advance directive; - Upon admission of a resident, the social service designee will inquire of the resident, and/or his/her family members, about the existence of any written advance directives; - Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record under the advance directive tab. 1. Review of Resident #49's face sheet showed: - The resident was admitted [DATE]; - The resident had a Durable Power of Attorney (DPOA, activated by verifying incapacity of the resident to make decisions); - The resident had a Health Care Directive (specifies a resident's preferences about measures that are used to prolong life when there is a terminal prognosis); - Did not indicate if the resident had been declared incapacitated (deprived of capacity or natural power); - The resident was a Do not Resuscitate (DNR). Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE] showed: - The resident's admission date was [DATE]; - Cognitive skills severely impaired; - Required limited assistance of one staff for bed mobility, transfers, dressing toilet use and personal hygiene; - Diagnoses included high blood pressure, diabetes mellitus and neurogenic bladder ( the nerves that carry messages back and forth between the bladder and the spinal cord and brain do not work they way they should). Review of the resident's care plan, revised [DATE] showed: - The resident was a DNR per his/her choice. Review of the resident's physician order sheet (POS), dated [DATE] showed: - Start dated: [DATE] - Code status: DNR. Review of the resident's electronic medical record showed no OHDNR form signed by the resident or their representative. The facility did not provide a copy 2. Review of Resident #43's face sheet showed: - The resident's admission dated was [DATE]; - The resident had a DPOA; - The resident was a DNR. Review of the resident's purple OHDNR form showed: - The DPOA signed the form on [DATE]; - The physician signed on [DATE]. Review of the resident's care plan, revised [DATE] showed: - The resident was DNR per his/her choice. Review of the resident's significant charge in status MDS, dated [DATE], showed: - Cognitive skills moderately impaired; - Independent with bed mobility, transfers, dressing, toilet use and personal hygiene; - Diagnoses included anxiety and thyroid disorder. Review of the resident's POS, dated [DATE], showed: - Start date: [DATE]: Code status: Full code. 3. Review of Resident #21's face sheet showed: - The resident was admitted [DATE]; - The resident had a DPOA; - The resident had a Health Care Directive; - The resident had been declared incapacitated; - The resident was a DNR. Review of Resident #21's quarterly assessment MDS dated [DATE] showed the following: - Brief Interview for Mental Status (BIMS) score was a nine (indicates moderate cognitive impairment); - Required one person assist with grooming and personal hygiene; - Always continent of bowel and bladder; - Diagnosis included high blood pressure, anoxic brain damage (brain damaged caused by a complete lack of oxygen to the brain), high cholesterol and depression). Review of the resident's care plan, updated on [DATE], showed: -The resident was a DNR per his/her choice. Review of the resident's POS, dated [DATE] showed: - Start date: [DATE]: Code status: Full code. Review of the resident's OHDNR form showed: - It was signed by the resident's DPOA on [DATE]; - It was signed by the physician on [DATE]. 4. Review of Resident #42's face sheet showed: - The resident was admitted [DATE]; - The resident had a DPOA; - The resident had a Health Care Directive; - The resident had been declared incapacitated; - The resident was a DNR. Review of the resident's care plan, updated on [DATE], showed: - The resident was a DNR per his/her choice. Review of the resident's significant change in status MDS, dated [DATE], showed the following: - Brief Interview for BIMS score was a seven (indicates severe cognitive impairment); - Diagnosis included high blood pressure, atrial fibrillation (irregular, rapid hear rate that causes poor blood flow)and memory deficit following stroke. Review of the resident's current POS, dated [DATE], showed the following: - No order for code status. Review of the resident's electronic medical record showed no OHDNR form. The facility was unable to provide a copy of the form. 5. During an interview on [DATE] at 8:15 A.M., Certified Nurse Aide (CNA) A said: - He/she would look in the computer for the resident's code status. During an interview on [DATE] at 8:51 A.M., the Interim Director of Nursing (DON) said: - The resident should have an order for their code status; - If the resident did not have a physician's order for their code status, they would be considered a full code; - The resident should have an OHDNR if they are a DNR; - If the face sheet said the resident was a DNR and they have an OHDNR signed but the POS said the resident was full code, it would need to be reviewed. She would consider the resident to be a full code until it was verified. During an interview on [DATE] at 9:25 A.M., CNA B said: - He/she would look at the dot by the resident's door; - A round red dot meant the resident was a DNR, a round green dot meant the resident was a full code. During an interview on [DATE] at 10:52 A.M., the Social Services Designee, said: - He/she updated the resident's code status as it was needed; - If a resident went from a full code to a DNR, he/she would take care of it; - On admission, he/she asked the resident/family what the resident's code status was going to be; - The Charge Nurse (CN) would send the resident's orders to his/her physician and once the physician ordered the code status, the CN would put it on the POS; - If the resident's code status changed, the face sheet would be updated. During an interview on [DATE] at 10:52 A.M., Licensed Practical Nurse (LPN) B said: - If he/she was by the resident's room, he/she would look at the dot by the resident's door. A round red dot meant the resident was a DNR, a round green dot meant the resident was a full code; - There should be a physician's order for the resident's code status; - If the resident's face sheet said the resident was a DNR, and the resident had a signed OHDNR form but the POS said the resident was a full code, it would need to be clarified. Until it was clarified, he/she would consider the resident to be a full code.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews, the facility failed to provide a safe, clean, and homelike environment for residents. The facility census was 57. 1. Review of Resident #40's comprehensive Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated [DATE], included the following: - Date admitted [DATE]; - Cognitively intact. During an interview on [DATE] at 10:52 A.M. the resident said: - His/her floor was embarrassing. Staff do come in and mop it but it was beyond mopping. He/she had even been on his/her hands and knees trying to scrub it; - He/she did not walk around bare foot on his/her own floor because it was dirty. Observation of the resident's room showed: - 1 inch () by 4 inch hole in the wall behind the door; - Large brown discoloration on the floor under the resident's bed and around the toilet and brown around the base of the toilet. 2. Observation on [DATE] beginning at 10:00 A.M. showed the following: - room [ROOM NUMBER]- The floor was discolored black and was sticky; - room [ROOM NUMBER]- The entire floor was discolored; - room [ROOM NUMBER]- The entire floor was discolored; - room [ROOM NUMBER]- The entire floor was discolored and was sticky; - room [ROOM NUMBER]- Bathroom floor was discolored yellow; - room [ROOM NUMBER]- The entire floor was discolored; - room [ROOM NUMBER]- The floor was discolored; - A 4 foot ( ' ) by four inch () area along the base of the wall, the baseboard was removed exposing a long hole in the wall outside of room [ROOM NUMBER]. - The carpet in front of the double doors to the service hall in the Transitions hall wall was discolored; - Beachball sized brown stain in the carpet outside housekeeping storage closet by room [ROOM NUMBER]; - room [ROOM NUMBER]- Black discolored around the base of the toilet. - room [ROOM NUMBER]- The sink was clogged with brown water sitting in it that was more than half full. The floor had dirt and grime and debris; - room [ROOM NUMBER]- Dried liquid on the resident's floor and there was brown around the base of the toilet; - Ceiling tiles in the hall by room [ROOM NUMBER] had up to a beach ball sized stain on them. Observation on [DATE] beginning at 10:20 A.M. showed the following: - room [ROOM NUMBER]- The floor was sticky; - room [ROOM NUMBER]- The floor was discolored black and was sticky; - room [ROOM NUMBER]- The floor was sticky. 3. During an interview on [DATE] at approximately 12:30 P.M. the Maintenance Director said The baseboard outside of room [ROOM NUMBER] was caused by a dishwasher leak. He was waiting to make sure the dishwasher was repaired before repairing the wall. During an interview on [DATE] beginning at 11:00 A.M. the Maintenance Director said: - The floors were sticky because of what the previous floor technician used. He had fixed one floor so far. He was fixing them as a resident discharged /expired rather than moving a lot of residents; - The facility did not have a floor technician anymore and had not had one since April or [DATE]. 4. During an interview on [DATE] at 10:50 A.M. the Housekeeping Supervisor said: - She cleans the floors and was able to get some of it up but she thought the floors needed to be re-waxed; - The facility only had two housekeepers since the end of June, they should be cleaning rooms daily but they were actually doing them about every other day 5. During an interview on [DATE] at 4:15 P.M. the Maintenance Director said: - For maintenance needs, staff should fill out a work order which was kept at each nurse station. He checked them daily and triaged them and tried to get to the that same day. It used to be a good system but it was lacking on both sides now. Usually maintenance needs was communicated to him from staff in passing. - Maintenance of the facility could be better. There could be more maintenance staff and floor techs; - The floors were a mess and needed work. 6. During an interview on [DATE] at 6:15 P.M. the Administrator said: - She had gotten complaints regarding the maintenance of the building, specifically the floors. During Covid-19 outbreak they increased floor solution and they had just received nozzles to reduce the solution since now they were not in outbreak. - Other complaints were usually regarding heating/ cooling. - The Maintenance Director tried to re-buff and thinks stripped and re-waxed the floors that were dirty from power chairs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Review of Resident #2's MDS dated [DATE] showed: -admission date was 7/14/21; -A Brief Interview for Mental Status (BIMS) score of 15, which indicated little to no cognitive impairment; -Diagnoses included: muscle weakness, difficulty walking, pulmonary hypertension (a type of high blood pressure that affects the arteries in the lungs and the right side of the heart), urinary tract infection, and asthma. -His/Her weight was 317 pounds. Review of the resident's electronic medical record (EMR) showed staff documented the resident weighed: -270 pounds (#) on 7/14/2021; -279# on 11/29/21; -294# on 1/5/22; -292# on 2/1/22; -275# on 3/2/22. Review of Certified Family Nurse Practitioner (FNP-C) A's report dated 3/2/22 showed: -The resident has gained several pounds since her admission in July 2021; -The resident would like to return home but feels weight loss is necessary before doing so. Review of the resident's EMR showed staff documented the resident weighed: -274# on 4/5/22; -304# on 5/2/22; -316# on 6/12/22. Review of the Registered Dietician's (RD) EMR progress note dated 6/15/22 showed: -Resident #2 had weighed 316 lbs., which was a 15.3% gain in 68 days. -She recommended staff encourage resident to moderate intake. -She referred the issue to the Interdisciplinary Team (IDT). Review of the resident's care plan last updated 7/27/22 showed: -There was not a goal or approach for weight loss added. During an interview on 8/3/22 at 10:40 A.M. Resident #2 said: -He/She has a goal of returning home but feels he/she needs to lose weight first; -He/She has gained a lot of weight since his/her admission to the facility; -He/She has spoken with staff about his/her goal of losing weight. During an interview on 8/5/22 at 10:10 A.M., the Social Worker said: -She was aware that the resident has a weight loss goal. -The resident's weight loss goal should be included as part of the care plan. During an interview on 8/5/22 at 10:15 A.M. the MDS Coordinator said: - The resident's weight loss goal should be included as part of the care plan. During an interview on 8/5/22 at 2:51 P.M. the DON said: -If a resident has a weight loss goal, staff should include it as part of the care plan. -She is aware of and has spoke with the resident about his/her 15% weight gain but failed to document the conversation. -Care plans are updated quarterly and with significant changes. During an interview on 8/5/22 at 6:20 P.M. the Administrator said: -If a resident has a weight loss goal, staff should include it as part of the care plan. -Care plans are updated quarterly and with significant changes. 3. Review of Resident #42's care plan, updated on 5/19/22, showed: -Monitor ability to perform ADLs and assist as needed; -Required assistance of one to two staff for bathing; -Required assistance of one staff for personal hygiene and oral care; -No care plan addressing anticoagulant use was found. Review of the resident's significant change in status MDS dated [DATE] showed the following: - BIMS score was a seven (indicates severe cognitive impairment); - Anticoagulant therapy; - Diagnoses included high blood pressure, atrial fibrillation (irregular, rapid hear rate that causes poor blood flow)and memory deficit following stroke. Review of the resident's current POS, dated August 2022, showed the following: - An order for Eliquis (anticoagulant/blood thinner) 2.5 milligrams (mg), with a start date of 7/29/21, take one tablet two times daily. During an interview on 8/5/22 at 12:15 P.M., the MDS coordinator said: -Resident #42's anticoagulant therapy should be care planned. -He/she has not time to update careplans. During an interview on 8/5/22 at 2:51 P.M., the Interim DON said: -Resident #42's anticoagulant therapy should be care planned; -Nursing should make sure the use of anticoagulants are initialed in the residents' care plan; -The MDS coordinator is responsible for ensuring the care plans are correct and updated. 4. Review of Resident #51's care plan, updated on 5/25/22, showed: -Monitor ability to perform ADL's and assist as needed; -Required assistance of one to two staff for bathing; -Required assistance of one staff for personal hygiene and oral care; -No care plan addressing wound care was found. Review of Resident #51's quarterly MDS dated [DATE] showed the following: - BIMS score was a 15 (no cognitive impairment); - At risk for pressure ulcers; - Diagnosis included high blood pressure, depression and stage II pressure ulcer of coccyx, Review of the resident's current POS, dated August 2022, showed the following: -Cleanse wound on coccyx with wound cleanser, pat dry, skin prep peri wound, pack with Iodoform (antiseptic wound packing), apply Tegaderm (clear film dressing used to cover wounds) on Sunday/Tuesday/Friday and as needed. During an interview on 8/5/2022 at 12:15 P.M., the MDS coordinator said: -Resident #51's wound should be care planned. -He/she has not time to update care plans. During an interview on 8/5/2022 at 2:51 P.M., the Interim DON said: -Resident #51's wound should be care planned; -Wound care should be included in the resident's care plan; -The MDS coordinator is responsible for ensuring the care plans are correct and updated. 2. Review of Resident #37's significant change in status MDS dated [DATE] showed: -Diagnoses of chronic pain, osteoporosis (a disease that causes the bones to become weak and brittle), open wound on left foot, urinary tract infection, muscle wasting and weakness. -The resident is unable to complete a Brief Interview for Mental Status (BIMS, a structured evaluation aimed at evaluating aspects of cognition in elderly patients, due to poor cognition.) The resident has poor short-term and long-term memories. -The resident is totally dependent on staff for activities of daily living, including bathing, dressing, and personal hygiene. -He/she has an indwelling catheter and is incontinent of bowel. -He/she received scheduled and as needed pain medication and displays indicators of pain on a daily basis. -He/she is at risk for developing pressure ulcers and has one stage II (the skin breaks open, wears away, or forms an ulcer, which is usually tender and painful. The sore expands into deeper layers of the skin. It can look like a scrape (abrasion), blister, or a shallow crater in the skin) on the left foot. -The resident is receiving hospice care. Review of the resident's comprehensive care plan, dated 8/1/22, showed: -No care plan addressing the resident's pain and need for pain management. -No care plan addressing the resident is receiving hospice care. Observation of the resident on 8/2/22 at 3:02 P.M. showed: -The resident was laying in bed in his/her room, making repetitive comments that his/her legs were hurting. Staff entered the room and administered pain medication. During an interview on 8/5/22 at 10:15 A.M., the MDS coordinator said: -A resident's pain and need for pain management should be care planned. -Hospice care should also be care planned. During an interview on 8/5/22 at 2:51 P.M., the Interim Director of Nursing (DON) said: -Pain, pain management and hospice care should all be care planned. -The MDS coordinator is responsible for ensuring the care plans are correct and updated. Based on observations, interviews and record review, the facility failed to develop and implement comprehensive person-centered care plans consistent with resident rights that include measurable objectives and timeframes to meet the resident's medical, nursing and psychosocial need for five of 15 sampled residents (Residents #37, #40, #20, #42, and #51). The facility census was 57. Review of the facility's undated Comprehensive Care Plan policy, showed: - An individualized comprehensive care plan that includes measurable goals and time frames will be developed to meet the resident's highest practicable physical, mental and psychosocial well-being. - A well developed care plan will be oriented to: Preventing avoidable declines in functioning or functional levels. Managing risk factors to the extent possible or indicating the limits of such interventions. Evaluating treatment of measurable goals, timetables and outcomes. Assessing and planning for care to meet the resident's medical, nursing, mental and psychosocial needs. Addressing additional care planning areas that are relevant to meeting the resident's needs in the long-term care setting. 1. Review of Resident #40's comprehensive Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 6/24/22, included the following: - Date admitted [DATE]; - Cognitively intact; - No noted nutritional needs or issues. Review of the resident's physician order sheet for July 2022 showed the resident was on a regular diet. There was also an order dated 7/18/22 that the resident may follow up annually as needed with regard to his/her gastric sleeve. Review of a Registered Dietitian Note dated 7/19/22 showed the resident had a gastric sleeve surgery in the past five years but had not had a follow up appointment in the past year and recommended a follow up be made. Review of the resident's care plan dated 7/5/22 showed the resident was on a no added salt diet with regard to Congestive Heart Failure. The care plan did not indicate that the resident had a gastric sleeve. During an interview on 8/2/22 at 10:52 A.M. the resident said he/she was on a weight loss program after a weight loss surgery but his/her weight had plateaued because the food does not address his/her nutritional needs. During an interview on 8/5/22 at 1:13 P.M. the Interim Director of Nursing (DON) said: - She would expect the gastric sleeve information to be included in the resident's care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Facility failed to provide a policy addressing following physicians' orders. Review of Resident #2's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/26/22, showed: -admission date was 7/14/21; -BIMS score of 15, which indicated little to no cognitive impairment; -Diagnoses included: muscle weakness, difficulty walking, pulmonary hypertension (a type of high blood pressure that affects the arteries in the lungs and the right side of the heart), urinary tract infection, and asthma. During an interview on 8/3/22 at 10:40 A.M., the resident said: -She has a goal of returning home but feels she needs to lose weight first; -She has gained a lot of weight since her admission to the facility; -She has spoken with staff about her goal of losing weight Review of the resident's electronic medical record (EMR) showed the resident had physician orders dated 7/15/21 with an open end date for: - Breakfast intake to be monitored and percentage eaten recorded daily; - Lunch intake to be monitored and percentage eaten recorded daily; - Dinner intake to be monitored and percentage eaten recorded daily. Review of the resident's EMR showed staff only documented meal percentages for 57 out of 177 meals from 6/5/22 through 8/3/22. During an interview on 8/5/22 at 9:32 A.M., Certified Nursing Assistant (CNA) B said: - Certified medication technicians (CMT) are responsible for recording meal intake but CNAs help out when the CMTs are busy. During an interview on 8/5/22 at 9:35 A.M., Certified Medication Technician A said: - CMTs are responsible for recording meal intake percentages for every resident at every meal during their shift; - CNAs will help with recording meal intake percentages if the CMTs are busy. During an interview on 8/5/22 at 10:00 A.M., Licensed Practical Nurse (LPN) B said: -CMTs are responsible for recording percentage of meals eaten for every resident at every meal; -If CMTs are busy, CNAs can assist with this task; -The charge nurse is responsible for making sure percentage of meals eaten is recorded on every shift; -They can pull a report to see which residents do and do not have meals recorded; -If meal percentages are not recorded by the end of shift he/she will instruct the CMTs and CNAs not to leave their shift until the task is complete. During an interview on 8/5/22 at 2:50 P.M. the DON said: - She expected all meals be monitored and percentage eaten recorded for every resident at every meal; -She knew sometimes the evening meals do not get recorded because of the lack of staff. During an interview on 8/5/22 at 6:20 P.M. the Administrator said: -She expected all physician orders to be followed. Based on observation, interview, and record review, the facility failed to provide the professional standards of following doctors orders regarding medications. This affected one of fifteen sampled residents (Resident #1). The facility also failed to ensure they followed their procedures for sending medications with one sampled resident (Resident #40) when he/she left the faciity on pass causing him/her to miss multiple doses of evening medications and failed to follow physicians' orders regarding monitoring and recording percentage of meals eaten which affected one sampled resident (Resident #4). Facility census was 57. Facility failed to provide a policy addressing following physicians' orders. 1. Review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by the staff, dated 7/25/22 showed in part: - Brief Interview for Mental Status (BIMS, a cognitive assessment tool used to determine the resident's ability to make choices) score of 00, indicating that the resident has a severe cognitive deficit. - Diagnoses in part of, bile duct cancer, digestive cancer, restlessness/agitation, need for assistance, depression, weakness, difficulty swallowing, urinary tract infect (UTI), pain, falls, and communication deficit; - Resident has mood and behaviors; - Important for resident to voice choices regarding Activities of daily Living (ADLs, the act(s) of taking care of oneself); - Requires significant assistance with ADLs. Resident is able to propel self in wheelchair; - Incontinent of bowel and bladder; - Has as needed (PRN) pain meds. Fall risk, risk for pressure ulcers, has pressure reducing device for bed; - Has medications of antidepressant(s) and diuretics, (medication to remove excess fluid from the body); - Resident is not receiving any therapies; - MDS shows resident does not have bed rails. Review of resident's care plan (CP) dated 5/6/19 showed in part; - Resident has a lift chair to assist with getting up, - A CP dated 10/19/22 administer PRN meds for my anxiety. - A CP plan dated for 5/6/19 needing assistance with transfers and ADLs. Observation on 8/3/22 at 8:52 A.M. showed Resident #1 wandered frequently throughout the hallway. The resident was getting into the trashcans and drawers of nursing supplies which sat outside another resident's room. The resident was argumentative with staff and not easily redirected. He/she propelled him/herself in wheelchair. Observation on 8/3/22 at 9:58 A.M. showed: - The resident lay in his/her bed and talking to him/herself. Has the television on with old western show playing. During an observation on 8/4/22 at 3:52 P.M., showed: -The resident lay in bed resting; - The resident has been in his/her room, in bed, most of the day. During an observation on 8/5/22 at 9:44 A.M. showed the resident resting in bed. Review of residents' physician order sheets (POS) dated 6/5/22 through 8/5/22 showed in part; - Sertraline (an antidepressant) 25 milligrams (mg), take 12.5 mg (half a tablet) once a day; - Melatonin (a sleep aid) 5 mg at bedtime; - Trazadone (used to treat depression) 25 mg at bedtime as needed (PRN); - Ativan (used to treat anxiety) 0.5 mg daily PRN. Review of August 2022 medication administration record (MAR) showed in part: - Staff administered Ativan 0.5 mg daily PRN. On 8/1/22 at at 10:00 P.M., and on 8/3/22 two times. Review of July 2022 MAR showed in part; -Ativan 0.5 mg four times a day as needed for anxiousness. - Staff handwrote on the MAR D/C (discontinued) and changed the order to daily (one time a day) PRN. Staff did not included a date of when the order changed. During an interview on 8/4/22 at 5:13 P.M., the Director of Nursing (DON) said; - Expected staff to check medication card with the MAR - Expected staff to give the medication per resident request, if applicable. Expected the other nurses to do the same. 4. Review of the facility's undated form, signed by the Transitions Program Director, titled Procedure for Resident Pass, showed the following: - Responsible part must sign resident out; - Nurse/CMT makes copies of all medication cards before given to responsible party; - Nurse/CMT review medications with responsible party and obtain signatures; - Upon return, the responsible party must sign resident back in. Resident is not to return to their room until nurse has checked them in. Nurse/CMS make copies of all medication cards, compare with copies when they left. Certify they took their medication correctly. Document in the progress notes. If there are errors, notify the DON, Transition Program Director, Physician, and Guardian. - Nurse: o Must approve all new items residents bring into the facility (electronics, clothing, food, etc.) go through their bags; o If resident smokes ask them for all tobacco products then secure them in the medication room o Urinalysis (drug) and alcohol swab test. Document results, if positive, make a copy of test; call Administrator, DON, and Transition Program Director and administer a second test; o Complete the bottom portion of the pass document and file in resident ' s chart; - Always document their departure and return. Review of Resident #40's comprehensive MDS, dated [DATE], included the following: - Date admitted [DATE]; - Cognitively intact. During an interview on 8/22/22 at 10:52 A.M. the resident said he/she: - Went to a visit with his/her dad on Friday; - Gave staff a two day notice so they could have his/her medications ready. When he/she went to get the medications Friday, they were not all there; - He/she was missing his/her inhalers and a sleep aide and he/she could not sleep without it and did not sleep over the weekend; - Also did not get his/her Tylenol (medication used to treat pain. The nurse (Licensed Practical Nurse (LPN) C, on duty was on the medication cart. When he/she said his/her medications were not there the nurse said he/she did not have time to help him/her; - He/she was embarrassed because his/her family member was there. Review of the resident ' s medical records showed the following: - Late entry progress note dated 7/30/22 be LPN F that the resident left on 7/29/22 and was expected to return on 7/31/22. There was no documentation of the resident ' s return on 7/31/22; - Request for Off-Site Pass form showed the request was made on 7/27/22 for the resident to leave on 7/29/22 and return on 7/31/22, the pass was approved; - The lease of responsibility for leave of absence documentation was signed by the person receiving the resident on 7/29/22 at 11:54 A.M. and was documented that the resident returned at 5:20 P.M. but the form did not show the date; - No record was found or provided to show copies of the medications that were sent with the resident, received when the resident returned, nor was there any documentation of the resident being drug or alcohol tested. Review of the resident's POS, dated 8/4/22, showed the following: - The resident was prescribed 18 medications to be given between 8:00 P.M. and 10:00 P.M., including: o Albuterol Sulfate inhaler (used to treat shortness of breath); o Melatonin 5 mg (used to treat insomnia); o Trazadone 100 mg (medication used to treat depression and used to assist with sleeping); - The resident was also prescribed as needed medications to include Tylenol 325 mg, and Vistaril 50 mg (used to treat anxiety). During an interview on 8/3/22 at 4:22 P.M., the Transition Program Director said: - There was an issue with the resident getting his/her medications before he/she went on pass; - It was LPN C's responsibility to ensure the resident had all his/her medications before leaving on pass; - LPN E, who was working the [NAME] hall, went over the medications with the resident; - The resident told her he/she called the facility over the weekend and he/she did not get his/her Trazadone and over the counter (OTC) and vitamins. The resident said he/she talked to LPN C who told him/her to take an extra Visteril but the resident said he/she did not do that; - The resident had a lot of fear due to a history of medication seeking; - The resident was pretty upset about it; - When a resident in the Transition Program came back from pass, staff were supposed to do a drug test, LPN C did not test the resident. LPN C told the resident he/she was negative, without testing him/her and told the resident he/she was fine and to go back to his/her room; - It would be LPN C's responsibility to go over the medications with the resident when he/she returned from pass to ensure properly they were properly taken, but LPN C did not properly screen the resident when he/her returned from pass according to the program's policy; - When the resident returned, he/she was on edge, loud, high anxiety, and fearful, which the resident said was because he/she did not sleep but also fear of retaliation regarding his/her medications; - Nursing staff did not document when the resident left on pass or that he/she returned; - The proper procedure when a resident left on pass was that that the medications would be reviewed with the resident and whomever picked up the resident, then that person would sign that they assume the responsibility for the resident and would take the medications. Staff should also take copy of medication cards that were sent and then make another copy when of the card when the resident returned. The drug test should be documented in the nurse progress notes. If the test was positive then they make copy. If they re-test and it was positive again then they would send the resident for a blood test. - CMT C may have set the resident's medications up. CMTs set up medication and the nurses would set up the narcotic medication; - When she approved a pass, she would give a copy of the pass to the nurse, CMT, Business Office Manager (BOM) and keep a copy for herself. She asked for the request for a pass was given 48 hours in advance so she could get the pass approved and to get the guardian's signatures. That also gave the nurse and CMT time to properly set up the medications. During an interview on 8/4/22 at 7:39 A.M., CMT B said: - When a resident goes on pass, he/she would get a copy of the request, it was usually just for residents in the Transition Program. He/she then would make copies of all medications and count the medication and write the count on the cards for each medication so they can count them when the resident returned from pass to ensure they took their medication properly. If the medication was OTC he/she would write how many they are sending with the resident; - Resident #40 was going on Pass on Friday 7/29/22 and returning Sunday, 7/31/22 by 7:00 P.M.; - He/she received a call on Friday from LPN C when resident went out around 11:00 A.M and asked how to set up the resident's medications. CMT B should have set up the medication on Thursday but he/she did not. - He/she knew for a fact that the resident did not get all his/her medications. The resident did not get any night time medications, or his/her 4:00 P.M. medications; - LPN C was working on the insulin cart, medication cart and narcotic cart. Facility management did this quite often. They would try to make nurses be charge nurse over the whole building and pass medications, take care of falls or actively dying residents, especially during the night shifts, and that was not adequate and not fair. Staffing was the worst he/she has seen it. During an interview on 8/4/22 at 8:04 P.M. LPN C said he/she: - Was passing day medications because they did not have a CMT on duty; - Had gotten about half the medications ready for the resident. The resident's family member came around lunch to pick up the resident; - Was behind passing day medications and was having to do insulin and narcotic medications as well and had to do two Tuberculosis tests and read one; - Told the resident he/she could not stop to assist with his/her medications and that someone else was going to have to do that; - Asked that the Transition Program Director at least start the process of getting everything ready; - Had to call CMT B because he/she was not sure what all he/she had to do; - Knew he/she had to make copies of the medications being sent; - Got day-time medication cards but completely missed night-time medications; - The resident called later Friday after leaving and reported he/she did not get all his/her medications. LPN C told the resident he/she she would take responsibility; - Before the resident left the resident told him/her that the bag of medication felt light; - Did not suggest taking a substitution for any missing medication; - Apologized to the resident for it; - Was on duty when the resident came back to the facility and did receive him/her back; - The Transition Program Director did get LPN E to finish up checking the resident out before leaving so he/she was not sure what went on after that; - When a resident went on pass, the CMTs were typically responsible for getting the resident's medications ready to go. The Nurse's role was to typically make sure the family signed out the resident. the family would sign out the resident who whomever they leave with and staff were supposed to get copies of their information. He/she was not sure who did that on Friday. - When a resident came back from pass he/she would give an alcohol test and a drug test and check with the resident to see if they had brought back anything back that was new. He/she would also check the only the narcotic card to make sure card was correct which the narcotic the resident was sent with was correct but did not check the other medications; - When the resident returned he/she said he/she did not have a good time but did not report it was because of not getting his/her medications or did not report any distress. During a phone interview on 8/16/22 at 1:57 P.M., LPN E said: - He/she got pulled away from what he/she was doing on the [NAME] hall to assist the resident with his/her medication before leaving on pass. By the time he/her got up to the front to assist the resident, the resident had gone through the medication and said he/she got them all; - He/she spent like three minutes with the resident. - He/she went through the medication that the resident already had, but he/she did not go to the MAR and check on everything; - The resident knows his/her medications and said he/she had them; - Whoever pulled the medications did not pull the night ones; - Knew he/she should have checked them; - It was his/her fault because he/she did not double check the medication being sent. During an interview on 8/05/22 8:38 A.M. the Interim DON said: - She was aware of the incident regarding the resident not getting all of his/her medications after the fact; - Between LPN C and the CMT, they missed giving the resident his/her night-time medications; - Generally staff know ahead of time when a resident was going on pass and, she assumed staff knew ahead of time that Resident #40 would be going on pass; - Depending on how long the resident was going to be gone depends on whether staff gave the whole medication card or they repackage in an envelop of medication. They also make copies of the medication cards when sending the cards. - She would expect the correct medications to be sent; - When a resident returned from pass staff should check to see if he/she brought anything new that would need to be checked. A drug and alcohol test should be given and the results should be recorded. Staff should also recount the medications when they come back. There should be a progress note of when the resident returned regarding time and tests. If anything was out of ordinary call then staff would call the Transition Program Director and herself.

Based on observation, interview and record review the facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene for two of 15 sampled residents, Resident #13 and Resident #21. The facility census was 57. Review of the facility's undated policy for baths or showers showed included: - The purpose was to maintain skin integrity, comfort and cleanliness. 1. Review of Resident #13's care plan, revised 6/1/22 showed: - The resident required assistance with ADLs; - The resident needed assistance of one staff in the shower. Review of the resident's significant change in status Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/22/22, showed: - Cognitive skills intact; - Required extensive assistance of two staff for bed mobility, transfers and toilet use; - Required extensive assistance of one staff with dressing; - Did not address bathing; - Lower extremities impaired on both sides; - Had a colostomy (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon); - Diagnoses included diabetes mellitus, bipolar (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), ulcerative colitis (UC, chronic, inflammatory bowel disease that causes inflammation in the digestive tract), high blood pressure and congestive heart failure (CHF, accumulation of fluid in the lungs and other parts of the body). Review of the resident's shower sheets for May 2022 showed: - 5/9/22- the resident was in the hospital; - The staff documented they provided showers on 5/11, 5/16, 5/27, and 5/30. Review of the resident's shower sheets for June 2022 showed; - The staff documented the resident was provided a shower on 6/2, 6/6, 6/24, 6/27, and 6/30. Review of the resident's shower sheets for July 2022 showed; - The staff documented providing the resident a shower on 7/7, 7/8, 7/18, and 7/26. The facility did not provide any shower sheets for the month of August. Observation and interview on 8/2/22 at 2:28 P.M., the resident said he/she did not always get his/her showers but not much he/she could do about it. The resident's hair appeared greasy. During an interview on 8/5/22 at 2:38 P.M., the Interim Director of Nursing (DON) said: - There was a shower schedule; - They have a part time shower aide on the South side; - The Administrator has been monitoring the residents to make sure they are getting their showers; - In May, they had a COVID -19 (a respiratory disease caused by a novel coronavirus) outbreak, the showers were not provided due to residents relocating to the COVID unit. 2. Review of Resident #21's quarterly assessment Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/13/22, showed the following: - Brief Interview for Mental Status (BIMS) score was a nine (indicates moderate cognitive impairment); - Required one person assist with grooming and personal hygiene; - Always continent of bowel and bladder; -Diagnoses included high blood pressure, anoxic brain damage (brain damaged caused by a complete lack of oxygen to the brain), high cholesterol and depression. Review of the resident's care plan, updated on 6/23/22, showed: - Monitor ability to perform activities of daily living (ADLs) and assist as needed; - Required assistance of one to two staff for bathing; - Required assistance of one staff for personal hygiene and oral care. Observation on 8/2/22 at 12:30 P.M. showed: - The resident's hair was uncombed and unkept. Observation on 8/3/22 at 12:55 P.M. showed: -The resident's hair was uncombed and unkept. Observation on 8/4/22 at 12:42 P.M. showed: - The resident's hair was uncombed and unkept. During an interview on 8/5/22 at 1:15 P.M. the resident said: - He/she needs help combing the back of his/her hair; - He/she wants to look nice when he/she goes to the dining room; - Staff does not offer him/her help with combing his/her hair; During an interview on 8/5/22 at 1:28 P.M. CNA B said: - Staff assist the resident with combing his/her hair; -Some days, he/she does it him/herself but the staff make sure it is combed. During an interview on 8/5/22 at 6:11 P.M. the Director of Nursing (DON) said; -He/she expected staff to assistant residents with grooming according to their preferences.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure staff used proper transfer techniques to reduce the possibility of accidents or injuries when transferring one of fifteen sampled residents (Resident #46) when they failed to use the proper lift sling during a transfer with the mechanical lift and when staff failed to ensure the low air loss mattress was set on the correct setting for Resident #37. The facility census was 57. Review of the facility's policy for Hydraulic Lift (Hoyer Lift) undated, showed, in part: Guidelines 1. Open lift to widest point and set the brakes. 2. Roll resident on his/her side away from you. Avoid unnecessary exposure. 3. Place widest seat part under the residents' buttocks and thighs so that the lower edge of the seat is under knees. 4. Place narrow part of the seat just above the small of the residents back. 5. Roll resident toward you and position slings comfortably. 6. Position seat sling and elevate head of bed to facilitate hook up. 7. Move the lift to bedside with base under the bed. Guide handles next to bed. Overhead bar should be directly over resident. 8. Attach S hooks of the chain to the loops on the seat hanger. Be sure to insert the open end of the hooks away from the resident to the outside of the sling for safety. 9. Attach S hooks of the backrest if seat has a backrest. 10. At this point, check to be sure all hooks are secure and evenly placed so the resident is balanced. Position seat close to the knees for safety. 12. Residents arms 15 be on the outside of the chains, if possible. 14. Position wheel chair and lock brakes. 15. Swing residents feet of the bed. 16. When resident has been lifted clear of bed, grasp bar and move to chair. 17. Push gently on knees to correct position and maintain balance as resident is being lowered into chair. Lower resident slowly. Review of the manufactures instructions with the InvaCare Reliant 450 shows in part; -Using the sling, Use an Invacare approved sling that is recommended by the individuals' doctor, nurse, or medical assistant, for the comfort and safety of the individual being lifted. - When connecting slings equipped with color coded straps to the patient lift, the shortest of the straps MUST be at the back of the patient for support. Using long section will leave little or no support for the patents back. The loops of the sling are colored coded and can be used to place patient in various positions. The colors make it easy to connect both sides of the sling equally. Make sure that there is sufficient head support when lifting a patient. - Lifting the patient - When using an adjustable base left, the legs MUST be in the maximum opened/locked position before lifting the patient. When elevated a few inches off the surface of the stationary object, and before moving the patient, check again to make sure that the sling is properly connected to the hooks of the hanger bar. Patients arms should be inside of the straps. -During transfer, with patient suspended in a sling attached to the lift, DO NOT roller caster over uneven surfaces that would cause the patient to tip over. Use steering handle on the mast at all times to push or pull the patient lift. - InvaCare does not recommend locking the rear caters of the patient lift when lifting an individual. Doing so could cause the lift to tip and endanger the patient and assistants. InvaCare does recommend that the rear casters be left unlocked during lifting procedures to allow the patient lift to stabilize when the patient is initially lifted from the chair or bed. -Transferring the patient- Wheel chair wheel locks MUST be in the locked position before lowering the patient into the wheelchair for transport. Two assistants are recommended for positioning the patient in the wheelchair. InvaCare slings are based on length of patient, width of patient, ad weight of patient. Per InvaCare manual a black piping sling is an XXL, a blue piping sling is an XL, a green piping sling is a large, and a purple piping sling is a medium. Review of Resident #46 significant change in status Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 06/30/2022, showed in part: - Brief Interview for Mental Status (BIMS, a cognitive assessment tool used to determine the resident's ability to make choices) score of 15, indicating that the resident has no cognitive impairment. - Required extensive assistance of two staff for bed mobility, transfers, toilet use, dressing and personal hygiene; - Diagnosis include in part; Cerebral palsy, Weakness, bowel and bladder incontinence, Depressions, mood and behaviors. Facility failed to provide the requested care plan (CP) for resident. During an observation on 08/03/22 at 08:15 AM with CNA D and CNA E showed; -The hoyer is an Invaare Reliant 450 model. -Staff used a blue piping sling. - Staff did not lock wheelchair. - Hoyer was placed under the residents' bed with the hoyer legs closed. -The tops hooks of the sling were placed closest to residents shoulders and the bottoms hooks were placed on the farthest link at the hips. - Staff picked up resident with hoyer legs closed, only opened hoyer legs D opened the legs of the hoyer. During and interview on 08/03/2022 at 08:40 AM with CNA D and CNA E states; -When asked which color piping on the sling to use for each resident CNA E states honestly I don't know. - CNA D states just get one that fits States may have to try different ones initially until one is found that fits the resident. Then continue to use the same colored sling from then on out. - CNA D states that the hooks are placed nearest the resident for the top (head) and farthest away at the bottom (thighs) During an observation on 08/04/22 at 3:52 PM with CNA A and CNA C showed; -The hoyer is an Invaare Reliant 450 model. - Staff place a sling with green piping. - The legs on the hoyer were closed while under the bed and while pulling resident out to the middle of the floor. - When transferring resident from bed to wheel chair, the hoyer was pulled across the floor, to nearly the door, before opening the legs of the hoyer and placing the wheelchair under resident. - Staff did not lock the brakes on the wheelchair. -After lowering resident to wheelchair, staff had to pick resident back up due to wheelchair moved and had to reposition resident. During an interview on 08/03/2022 at 4:00 PM with CNA A and CNA C states; -CNA C states the resident sling is based on the color of the piping. - CNA A states that if the resident was in the seated position the hooks are placed closest to resident. If the resident is lying down then the hooks are placed farthest away from the resident. - CNA A states having access to residents care plan (CP) to see which sling resident is to have. - CNA C states having had an in service for the hoyer during her yearly education. - CAN A states doing an in service on the hoyer in February. - Both CNA's state they rely on resident information and changes during shift report. - Both CNA's state that the communication during shift reports are not done well. During an interview on 08/04/22 at 5:13 PM the Interim Director of Nursing, (DON) said: - The expectations regarding the hoyer use is that there is a list that explains the color of piping on each sling. - Staff should look at the resident to determine the size of sling. - They uses trial an error on a resident on admission then able to document which sling size to use for each resident.2. The facility did not provide a policy or manufacturer guidelines for low air loss mattresses. Review of Resident #37's care plan, revised 5/23/22 showed: - It did not address the resident's use of the low air loss mattress. Review of the resident's significant change in status MDS, dated [DATE] showed: - Cognitive skills moderately impaired; - Dependent on the assistance of two staff for bed mobility, transfers, dressing toilet use and personal hygiene; - Upper and lower extremities impaired on both sides; - Had a catheter (sterile tube inserted into the bladder to drain urine); - Always incontinent of bowel; - Weight 145 pounds, no weight loss or gain; - Had a Stage II (a partial thickness loss of skin layer that presents clinically as an abrasion, blister, or shallow crater) pressure ulcer (an area of localized damage to skin and underlying tissue caused by pressure, shear, friction and/or a combination of these); - Diagnoses included high blood pressure, anxiety, urinary tract infection (UTI) in the last 30 days, open wound left foot and chronic pain. Review of the resident's physician order sheet (POS) dated August 2022, showed: - Start date: 6/21/22- Three [NAME] Hospice consult related to health decline; - No order for a low air low mattress. Observation on 8/4/22 at 12;51 P.M., showed: - The resident was in bed with a fall matt on one side of the bed; - The Proactive low air loss mattress was set on 180 pounds. During an interview on 8/4/22 at 1:17 P.M., Certified Medication Technician (CMT) B said: - The low air loss mattress should be set by what the resident weighs; - He/she weighed a lot less than 180 pounds; - The Hospice Nurse sets the low air loss mattress; - He/she thought the CNAs would make sure it was on the correct setting. During an interview on 8/5/22 at 8:51 A.M., the Interim DON said: - The low air loss mattresses are usually set by the resident's weight; - The Hospice Nurse sets the low air loss mattresses up; - If the resident weighed around 135 pounds, it should not be set on 180 pounds; - She would expect the nurse to check the settings or the CMTs; - It should be documented in the nurse's notes; - The scale has been broken for over 45 days. A new one has been ordered and it should be on its way. During an interview on 8/5/22 at 9:43 A.M., Licensed Practical Nurse (LPN) B said: - He/she has worked at the facility for about three years; - He/she does not know who is responsible to check the low air loss mattresses for the correct setting; - He/she has never checked the low air loss mattresses for the correct settings and does not know where it would be documented; - The scale has been broken for the last two to three months. They have ordered a new one and it's supposed to be on its way.

Based on observations, interviews and record review, the facility failed to discard expired medications and biological's stored within the medication cart and medication rooms, failed to ensure staff did not place food in the medication refrigerator in the [NAME] medication room, failed to ensure staff dated opened medications and food containers and disposed of expired food, failed to record refrigerator temperatures in the [NAME] medication room, failed to ensure there were no loose pills in the medication cart. This affected three of 15 sampled residents (Resident #43, #45, #46) and had the potential to affect all residents within the facility. The facility census was 57. Review of the facility's undated policy for storage of medications, showed, in part: - All mobile medication carts must be under visual control of the staff at all times when not stored safely and securely. Carts must be either in a locked room or otherwise made immobile; - Drugs must be stored at appropriate temperature levels. Drugs required to be stored at room temperature must be stored between 59 and 86 degrees Fahrenheit (F) (5-30 degrees Celsius (C). Drugs stored in a refrigerator must be stored between 36 and 46 degrees F (2-8 degrees C); - No discontinued, outdated, or deteriorated drugs or biological's may be retained for use. All such drugs must be returned to the issuing Pharmacy or destroyed in accordance with established guidelines; - An unattended medication cart must remain locked at all times. In the event the nurse is distracted from the task of passing medications by some unforeseen occurrence, the cart must be locked before leaving it, or secured in a locked medication room. Observation on 8/4/22 at 9:44 A.M., of the [NAME] medication room showed: - Had two free standing oxygen tanks just inside the doorway; - The black refrigerator which belonged to the residents, had an opened bottle of Ranch dressing with Resident #45's name on it and it expired 12/30/21; An opened container of Smooth Ranch Dip and did not have a name on it to indicate who it belonged to; an unopened six inch turkey and ham sub sandwich lunchable, expired 6/18/22 and did not have a name on it; Resident #46 had three yogurts, expired 8/7/22. The black refrigerator did not have a temperature log on it. The Interim Director of Nursing (DON) said she didn't know who the sandwich belonged to, all food should have names on them, there shouldn't be any expired food in the refrigerator, she did not know where the location of the temperature logs, the Certified Medication Technicians (CMTs) should check the temperatures on the refrigerators and document daily; - The medication refrigerator had a temperature log for September 2021 and had 14 dates documented out with 60 opportunities. The temperature log for October 2021 had 14 dates documented out of 62 opportunities. Did not have any current temperature logs on the refrigerator. There was an opened container of applesauce and did not have a name or date on it, an unopened container of fruit cocktail without a name on it. The Interim DON said there should not be any food in the medication refrigerator and the food should be dated and have names on them. Observation on 8/4/22 at 10:19 A.M., of the day CMT medication cart showed: - An opened bottle of house stock multi-vitamin daily (supplement), opened 3/4/21, expired 6/22; - An opened bottle of house stock enteric coated aspirin (ECASA, used for the treatment and prevention of cardiac disease) and expired 6/22; - An opened house stock bottle of Oyster shell calcium (used to treat low calcium levels), expired 6/22; - An opened house stock bottle of Vitamin E (used for the immune system), expired 6/22; - An opened house stock bottle of aspirin (ASA, used to relieve minor pain), expired 7/22; - An opened house stock bottle of meclizine (used for dizziness and lightheadedness), expired 7/22; - An unopened house stock bottle of Docu liquid stool softener laxative, expired 4/22; - An opened house stock bottle of ear wax drops, expired 8/21; - An unopened house stock package of 24 hour allergy relief tabs, expired 6/22; - Resident #43 had an unopened container of probiotic acidophilus (used to promote the growth of good bacteria in your body), expired 6/22; - One round pink pill and one round white pill were loose in the drawer of the medication cart. During an interview on 8/4/22 at 10:38 A.M., the Interim DON said: - The oxygen tanks should not be in the medication room. They should not be in the medication room in a holder; - The black refrigerator is for the resident's who don't have one in their room. The food should be dated and have names on them; - All refrigerators should have temperature logs and thermometers; - The day CMTs should check for outdated food, medications and the temperatures; - There should not be any loose pills in the medication cart. - The CMTs and nurses should check them at least monthly for expired medications and should check when they are passing the medications.

Based on interviews, observation and record review, the facility failed to employ a qualified dietary manager for food and nutrition services with accredited education in food service management. The facility census was 57. 1. Record review of the facility's dietary staffing scheduled showed the facility did not currently employ a qualified dietary manager. During an interview on 8/5/22 at 3:00 P.M., Dietary Aide A said: -There is not currently a dietary manager. -He/she is doing their best to manage the kitchen and cook meals. -If he/she needs direction or has a question, he/she goes to the administrator. During an interview on 8/5/22 at 6:11 P.M., the Administrator said: -The facility does not currently have a dietary manager and has been without one for quite some time.

Based on observation, interview and record review, the facility failed to ensure staffing was sufficient to serve meals in a timely manner and maintain the cleanliness of the kitchen. This has the potential to affect all residents of the facility. The facility census was 57. During the entrance interview on 8/02/22 at 9:42 AM, the administrator said: -Meal times are as follows: -Breakfast at 7:15 A.M. - Lunch at 12:00 P.M. - Dinner at 5:15 P.M Observation of the facility on 8/2/222 at 9:45 A.M., showed: -No meal times are posted in the facility. Observations of meal service in the facility showed: -8/2/22 The first resident was served lunch at 12:35 P.M. -8/3/22 The first resident was served breakfast at 7:28 A.M. -8/4/22 The first resident was served lunch at 12.41 P.M. During an interview on 8/2/22 at 11:23 A.M., Resident #25 said: -He/she never knows when meals are going to be served. -Meals are always late. During an interview on 8/2/22 at 2:26 P.M., Resident #2 said: -He/she has to wait a long time for food, meals are always late. -He/she will usually go to the dining room at meal time, wait for several minutes. - He/she will then return to his/her room and watch TV for a while and then go back to the dining room and still wait to be served. Observation of the kitchen on 8/2/22 at 9:43 A.M., showed: -The stovetop and griddle is dirty with food debris and grease. -There is food debris and trash (gloves, paper towels, food wrappers) on the floor, in corners and between and under appliances and prep tables. -Food debris/crumbs on the trays being used to store clean cooking utensils. -Brown drips and grime on the walls above the dish sink. -Doors of the kitchen are dirty with visible grime/grease. -Outside surface of the grease trap is dirty with food debris and grease. -Plastic tub containing envelopes of gravy mix is dirty with dust and crumbs. -Floor of the dry storage room is sticky and dirty with crumbs and dust. -Floor of the walk in freezer is dirty with food debris and food packaging. -Brown debris and dust/dirt on pipes going from sanitizer container and grease trap to the sink. -Can opener is dirty with food debris. -Top of the inside of the microwave is dirty with food debris and grease. -Front of the two door refrigerator is dirty with drips and food debris. Interview on 8/5/22 at 3:00 P.M., Dietary Aide A said: -There is no cleaning schedule for the kitchen. -There is usually only one or two staff members to cook and serve all the meals. - There is usually not time to clean the kitchen as it should be cleaned, especially when there is only one staff member working in the kitchen. - He/she acknowledged the kitchen is not clean. -The kitchen staff are using disposable dishes and silverware as there is not enough staff to wash dishes between meals and prepare the next meal in time. During an interview on 8/5/22 at 6:11 P.M., the Administrator said: -The kitchen should be clean. - Food debris should not be on the floor, no spills on the floor, no dust on things. -There should be a cleaning schedule, and staff should be following this schedule. -Meals should be served 10-15 minutes of the time scheduled. -Disposable meal-ware is being used as their are not enough dietary staff to wash the dishes. - Real plates and silverware should be used during meal service. -The facility does not currently have a dietary manager and has been without one for quite some time.

Based on observation, record review and interviews, the facility failed to assure they prepared foods in the appropriate manner when staff did not follow a recipe for pureed foods and prepared pureed food more than 90 minutes before the scheduled meal services. The facility census was 57. The facility did not provide a policy regarding pureed foods. Observation of a pureed test tray on 8/3/2022 at 12:22 P.M. showed: -Pureed Chicken: 132.5 degrees Fahrenheit. The texture is smooth but has little flavor. -Potatoes: 143.4 degrees Fahrenheit. The consistency is very thick, a spoon stood up. They are very sticky in the mouth and difficult to swallow, with a bitter flavor. -Green Beans 114.2 degrees Fahrenheit. They are lukewarm with a thick gel-like texture, with little flavor. -Bread Stick: 97.7 degrees Fahrenheit. It felt cold in the mouth, with a very sticky consistency. Observation of the kitchen on 8/4/22 at 10:30 A.M, showed: -The pureed food was in metal containers in the steam warmer. During an interview on 8/5/22 at 3:00 P.M., Dietary Aide A said: -He/she did not use a recipe when making the pureed food for lunch on 8/3/22. -He/she thinks there are recipes somewhere in the kitchen but is not sure where to find them. -He/she was not aware he/she should be using a recipe when making pureed food. -He/she acknowledged that the pureed food was made at least 90 minutes before the lunch meal service and stored in the steam warmer. -He/she said this was done to save time in preparing the lunch meal service. During an interview on 8/4/2022 3:20 PM, the Registered Dietician said: -Pureed food should be a smooth consistency, no lumps, like light mashed potatoes/pudding. -There are recipes for all meals, including pureed foods, available in the kitchen. Staff are expected to be following all recipes. During an interview on 8/5/22 at 6:11 P.M., the Administrator said: -Food should be served at safe and palatable temperature. -Pureed food should be the appropriate texture and consistency. -Recipes provided by dietician should be followed.

Based on observation, interviews, and record review, the facility failed to ensure staff stored food in a sanitary manner and failed to maintain the kitchen in a sanitary manner. This has the potential to affect all residents residing in the facility. The facility census was 57. Review of the facility's Storage of Dry Food and Supplies policy, dated May 2015, showed: -The Dietary Department will store dry food and supplies according to facility guidelines and state regulations. -The storeroom must be neat and orderly. Shelving is kept clean and free of rust and chipped paint. -Metal or plastic containers with tight fitting covers, labeled top or side, must be used for storing open products. -Open boxes are to be effectively re-sealed. Bulk crackers, cereal, cookies, pasta, etc., are to be stored and properly labeled in sealed containers. Food-grade plastic bags are to be tightly closed after opened. -Date stock with date of delivery. -Food is to be stored a minimum of six inches above the floor and 18 inches from the ceiling and sprinkler heads. -Contents of open cases will be stored on shelves. Review of the facility's Refrigerator and Freezer Temperatures policy, dated May 2015, showed: -Temperatures should be checked regularly in all refrigerators, at least every morning and every night. -Refrigerator and freezer temperatures will be logged twice daily. Review of the facility's Dishwashing Temperatures policy, dated May 2015, showed: -The dish machine temperatures will be recorded for the wash and rinse cycle daily for chemical sanitized (in addition to a sanitizer test strip), or as directed by the Consultant Dietician. Review of the facility's Receiving and Storage of Food policy, dated May 2015, showed: -The Dining Services Manager is responsible for receiving and storing food and nonfood items. -Follow the rule of First In, First Out (FIFO) -Keep all foods in clean, undamaged wrappers or packages. Do not reuse single-use containers for direct food storage. Reseal open boxes effectively. -Keep storage areas clean and dry. Review of the facility's undated Food Safety Requirements policy showed: -Food items not fully consumed, or food items intended for later resident consumption, shall be stored in an appropriate container, with adequate label and date, and stored in designated refrigerator. -All foods will be considered as leftovers unless in the original container with an expiration date. Leftovers will be discarded after the third (3rd) storage day. Observation of the kitchen on 8/2/22 at 9:43 A.M., showed: -Stove and griddle cooktop are dirty with grease and food debris -There are food debris and paper matter (paper towels, gloves, food wrappers) are on the floor and under/ between appliances and prep tables. This includes a hotdog on the floor in between prep tables, located behind the stove. -Crumbs and food debris on trays used to store clean cooking utensils. -Food debris and drippings on the side of prep tables. -Floor of the kitchen is sticky. -Brown rust drips down the wall from the box containing the fire extinguisher. -Dry wall cracking/chipping next to the office and dry storage room. -Large piece of fabric hanging down from the skylight, above racks storing bread products. -Three bin sink is dirty with food debris, grime, and pieces of food wrappers. -Large trash can with no lid. -Large, uncovered tub under the sink to the right of the steam warmer, is full of dirty towels. -Walls above sinks are dirty with brown drips and food debris. -The basin under the steam warmer was overflowing with water and dripping to the floor. The outside surfaces of the steam warmer are dirty with drips and food debris. -Paint is peeling from the wall above the sinks. -Outside surfaces of the grease trap are dirty with grease, dust and food debris. -Brown debris/dust/grease on pipes going from sanitizer container and grease trap to the sink. -Can opener dirty with food debris. -Top of the inside of the microwave dirty. Dry Storage: -Plastic tub storing envelopes of dry gravy mix is dirty with dust and food debris. -Open bag of dry rotini pasta, no label or date. -Open bag of dry egg noodles, no label or date. -Sealed bag of Fiesta seasoning, no date. -Open bag of tortilla chips, no date. -Open container of garlic salt, no date. -Open container of parsley flakes, no date. -25 pound bag of milk powder, open to air, no date. -Open container of cinnamon, no date. -Open container of oregano, no date. -Open container of paprika, no date. -Large trash can, no lid. -5 gallon container with unknown brown powder, no label or date. -5 gallon container of flour dated 1/21/21 -5 pound container of honey, no date. -7 bags of frosted shredded wheat cereal, no labels or dates. -Floor is sticky. Walk-In Refrigerator: -Handle of refrigerator is sticky with food debris. -Floor of refrigerator is dirty with food debris and paper matter. -Large plastic container of fruit salad, no label or date. -One gallon container of unknown food, no label or date. -Zip-lock bag of hotdogs, no label or date. -Plastic container of ham, no date. -Two plastic containers of soup, no label or dates. -One plastic container of shredded lettuce, no label or date. -One plastic container sliced tomatoes, no label or date. -Open bottle of soda, no label or date. -Open gallon container of soy sauce, no date. -Plastic container of pickles, open to air, no date. -Open container of tuna salad, no date. -Two sealed bags of lettuce salad, brown and wilted, no date. -Box of cantaloupe, stored on the floor. -No temperature logs located. Walk-In Freezer: -Floor of freezer dirty with food debris and paper matter (food wrappers). -Box of frozen broccoli stored on the floor. -Boxed of frozen corned beef stored on the floor. -Open bag of frozen hamburger patties, no date. -Open bag of frozen strawberries, no date. -Four frozen pies, covered in foil, no date. -Large zip-lock bag containing a ham with freezer burn, no label or date. -Open bag of unknown patties, no label or date. -Open bag of Italian sausages with freezer burn, dated 3/8/22. -Box of frozen peach cobbler, stored on floor, no date. -Bag of frozen chicken breast patties, open to air, no label or date. -Open Bag frozen blueberries, no date. -Vents in the freezer are dirty with gray matter and dust. -Paint is pealing from the pipes leading from the cooling unit. -No temperature logs are located. Two Door Fridge: -Front is dirty with unknown drips and food debris. -Five large pitchers of unknown drinks, no label or date. -No temperature logs located. Ice Machine: -Dark matter on white parts of the machine lid. Two Door Freezer: -Open, undated frozen bottle of soda. -Bag of frozen biscuits, open to air, no label or date. -Bag of frozen bread rolls, open to air, no date. -Open bag of chicken nuggets, no label or date. -No temperature logs located. Dish room: -Ceiling vents dirty with gray matter and dust. -Large trash can with no lid. -Paint peeling from the walls around the skylight. -Area under the sink is dirty with food debris, paper matter. -Floor is sticky. Back Dish Storage Room: -Floor is sticky. -Paint peeling off walls in the corners. Observation of the Main Dining Room on 8/2/222 at 10:45 A.M., showed: -Large trash can with no lid. -Floor in the serving area is dirty with food debris and dust. -Open bag of hamburger buns on plate warmer, no date. Fridge/Freezer: -Open container of vanilla ice cream, no date. -Open one gallon container of barbeque sauce, no date. -Open one gallon container of ranch dressing, no date. -No temperature logs located. Observation of kitchen on 8/3/22 at 9:00 A.M., showed: -Floor is dirty with food debris and paper matter. -Countertop of front prep table is dirty with unknown liquid. Observation of kitchen on 8/4/22 at 10:30 A.M., showed: -Floor is dirty with food debris, food wrappers, dirty drinking cup. -Dirty water with ice and food debris standing in first bin of three bin sink. -Large pile of empty cardboard boxes on floor in front of smaller sink. -Basin under steam warmer is overflowing with water, dripping onto the floor. -Disposable cups and paper matter under the ice machine and two door freezer. -Drip pan under griddle cooktop is dirty with grease and food debris. -Inside of ovens dirty with food debris. -Top of oven dirty with dust and food debris. -Prep table behind stove has several rusted places and a side panel is falling off. -Hotdog on the floor between prep tables behind stove. Dry Storage Room: -Storage racks have several areas of rust. -25 pound bag of thickener, open to air, no date. -No granulated white sugar or artificial sweetener located. During an interview on 8/5/22 at 3:00 P.M., Dietary Aide A said: -Food should be labeled with the name and date the item was put in storage. Open food/left over food can be stored for 3 days and then should be thrown away. -He/she does not know how long food can be stored in the steam warmer before services. -There should not be a film on the top of the pureed food when serving to residents. -There is no Dietary Manager. The Administrator is responsible for monitoring and ordering inventory. -Temperature logs should be done on the refrigerators and freezers. There are temperature logs somewhere in the kitchen, but is unsure where they are. -There is no cleaning schedule for the kitchen. -Food should be sealed or covered. -If the kitchen is out of needed items, staff should inform the administrator. -The sanitizer solution and dishwasher solution should be tested, but is unsure how often. He/she does not know how to test the solution and has not been doing it. During an interview on 8/4/2022 at 3:20 P.M., the Registered Dietician said: -He/she has been the Registered Dietician at the facility for about 2 years, and comes to facility two times per month. -He/she was last in facility on 7/18/2022. At that time, kitchen cleanliness was lacking, and he/she made concerns known to the Administrator. -He/she expects the kitchen to be clean, including floors, surfaces, ceiling, vents, dish area, fridge, freezers, dry storage. Also including behind/beneath appliances and prep tables. -There should be no food debris or trash on the floor. -Food should be labeled, including date opened. Prepared food can be held for 3 days then disposed. During an interview on 8/5/22 at 6:11 P.M., the Administrator said: -Outdated food should be removed thrown away. -Kitchen should be clean. Food debris should not be on the floor, no spills on the floor, no dust on things. -There should be a cleaning schedule, and there should be freezer and refrigerator temperature logs. Dietary staff are responsible for doing and documenting temperatures. Food should not be stored open to air or on the floor. - The dietary manager is responsible for monitoring and ordering of inventory. -The facility does not currently have a dietary manager and has been without one for quite some time.

Based on record review and interview, the facility failed to ensure they developed and implemented a Quality Assurance and Performance Improvement (QAPI) plan and implement appropriate plans of action to correct identified quality deficiencies as part of their Quality Assessment and Assurance (QAA) committee. The facility census was 57. 1. When the QAPI plan was requested, the Administrator provided a copy of a Template that had not been completed to be individualized to the facility. When the Administrator provided the plan she acknowledged it was a template. 2. Review of the facility's morning meeting notes dated 4/18/22 included the following: - The QAPI items included: o Meal intake not being done; o Meal intake sheets re-done for each side; o Certified Medication Technician (CMT) will record on paper log including room trays; o CMT/designee will chart. If designee, charge nurse to be notified. - A Performance Improvement Project for the deficient practice was not in the records. Record review did not show a pip and how the facility was monitoring correction of the deficiency. During an interview on 8/05/22 at 3:14 P.M. the Administrator said: - QAA committee meetings were held monthly, Doctor comes quarterly except when he/she had COVID-19 which has happened; - Deficiencies were identified and reviewed during morning stand up and documented.

Based on record review and interview, the facility failed to maintain a quality assessment and assurance (QAA) committee that meets at least quarterly and as needed and contains the minimum required members. The facility census was 57. The facility did not provide a policy regarding the QAA committee. 1. Review of the facility's QAA committee records showed the medical director had not attended a QAA committee meeting since January 2022. During an interview on 8/5/22 at 3:43 P.M. the Administrator said: - QAA meetings were held monthly and the Medical Director came quarterly except when he/she had COVID-19; - The Medical Director did not attend in April due to having COVID-19, he/she did not attend in May because it conflicted with his/her schedule and did not attend in June, he/she did not respond to a text. The facility did not have a meeting in July.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of the facility's undated policy on Diabetic Infection Control showed in part; - Purpose: to prevent the resident to resident transmission of blood borne pathogens; - Hand Hygiene: gloves are to be worn when performing finger sticks and changed between residents. Remove and discard gloves in appropriate receptacles after each procedure that involves potential exposure to blood or body fluids, including finger stick blood sampling. - Perform hand Hygiene (i.e. hand washing with soap and water or use of an alcohol based hand rub) immediately after removal of gloves and before touching other medical supplies intended for use on another resident. - Blood glucose meters: Environmental surfaces, such as glucometer, will be decontaminated anytime contamination with blood or body fluids occurs or is suspected using an EPA-registered disinfectant. Training and oversight: Annual training on diabetic infection control and glucometer use procedure will be completed. Review of the facility's policy on Medication administration, undated, showed in part: - Guidelines: bring cart to resident room, knock before entering, introduce yourself, explain to resident what you are going to do, wash hands, read label three times, administer medication, remain in room while the resident takes the medication, record medication administration. Discard disposable items and clean reusable items. 5. Review of Resident #38's significant change in status MDS, dated [DATE], showed: - Cognitive skills intact; - Diagnoses included diabetes mellitus. Review of the resident's care plan, dated 7/3/22, showed: - Blood glucose monitoring before meals and at bedtime; Review of the resident's current physician order sheet (POS), dated August 2022, showed the following - Blood glucose monitoring before meals and at bedtime for diabetes mellitus; Observation on 8/5/22 at 11:38 A.M., showed: - Licensed Practical Nurse (LPN) C wiped his/her hands with a bleach wipe, used the same bleach wipe to clean the glucometer and the basket containing the diabetic supplies; - LPN C set the glucometer on top of the basket containing the diabetic supplies. - LPN C applied clean gloves, took the glucometer, lancet, alcohol pad and the accucheck strip and entered the resident's room; - LPN C used the lancet to obtain the accucheck from the resident's left thumb without cleaning the thumb with an alcohol pad; - LPN C wiped the resident's left thumb off with the alcohol pad. 6. Review of Resident #35's significant change in status MDS, dated [DATE], showed: - Cognitive skills intact; - Diagnoses included diabetes mellitus. Review of the resident's care plan, dated 6/23/22, showed: - Blood glucose monitoring as ordered by the physician. Review of the resident's current POS, dated August 2022, showed the following: - Blood glucose monitoring before meals and at bedtime for diabetes mellitus. Observation on 8/5/22 at 11:50 A.M., showed: - LPN C wiped his/her hands with a bleach wipe, used the same bleach wipe to clean the glucometer and the basket containing the diabetic supplies; - LPN C set the glucometer on top of the basket containing the diabetic supplies: - LPN C applied clean gloves, took the glucometer, lancet, alcohol pad and the accucheck strip and entered the resident's room; - LPN C cleaned the resident's second digit of his/her left hand with an alcohol pad and obtained the accucheck; - LPN C wiped the resident's second digit of his/her left hand with the same alcohol pad he/she used clean the finger before obtaining the accucheck. 7. Review of Resident #47's August 2022 POS showed: - Ativan (an antianxiety medication) 1 mg, give three times a day (TID). Observation on 8/4/22 at 8:54 A.M., showed Licensed Practical Nurse (LPN) C preparing to administer the resident's Ativan. Without washing his/her hands or using hand sanitizer, he/she popped the resident's medication from the bubble pack into a cup, went to retrieve a cup of pudding from the nurses' station returned to the medication cart and crushed the medication and placed it into the pudding. LPN C went into the resident's room and administered the medication. He/she did not sanitize or wash his/her hands before or after administering the medication to the resident. 8. During an interview on 8/5/22 at 12:58 P.M., LPN C said: - Sanitizer or hand washing should be used instead of using the bleach wipes to clean his/her hands; - A separate bleach wipe should be used to clean glucometer and the basket; - The glucometer should be placed on a clean surface after cleaning it instead of the basket that had been wiped with the same bleach wipe used on his/her hands and the glucometer; - An alcohol pad should be used to clean Resident #36's thumb before obtaining the blood for the accucheck; - A previously used alcohol pad should not be used on any resident to wipe away residual blood from any accucheck stick. During an interview on 8/5/22 at 3:42 P.M., the interim DON said: - She expected staff to use appropriate hand hygiene during medication pass. -Hand hygiene (using alcohol based sanitize or washing hands in the sink with soap and water) should be used instead of using bleach wipes to sanitize hands; -The glucometer should not be set on top of the basket containing the diabetic supplies; -The glucometer should be placed on a clean surface after being sanitized with the bleach wipe; - An alcohol pad should be used to clean Resident #36's thumb before obtaining the blood for the accucheck; - A contaminated alcohol pad should not be used on Resident #35's finger; - A new alcohol pad or cotton ball should be used on any resident to wipe away blood during any accucheck. Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections when the facility failed to ensure staff followed their policy to provide a Two-Step Purified Protein Derivative (PPD) Tuberculosis (TB, a highly contagious lung disease) skin test for three sampled residents (Resident #13, #45, #49) and failed to follow their policy that all staff would receive a Two-Step PPD TB skin test upon hire. This effected 6 of 10 staff members sampled. Additionally, the facility failed to ensure staff did not handle medications with their bare hands, which affected Resident #20 and failed to follow proper infection control practices when staff did not wash hands during medication pass and blood glucose monitoring to prevent the spread of infection which affected four residents (Residents #38, #35, and #47). The facility's census was 57. 1. Review of the facility's undated guidelines for screening for tuberculosis in long term care facilities, showed, in part: - The control and prevention of tuberculosis in the elderly must be accomplished in order to eliminate tuberculosis as a public health problem; - It is therefore important for each facility to have a tuberculosis control program in place. This must include the documentation of the tuberculosis status of each resident of each long term care facility; - This can be accomplished by screening residents on admission; - All residents new to long-term care who do not have documentation of a previous skin test reaction >10 millimeters (mm), or a history of adequate treatment of tuberculosis infection or disease, shall have the initial test of a Mantoux PPD two - step skin test to rule out tuberculosis within one month prior to or one week after admission; - If the initial result is 0-9 mm, the second test, which can be given after admission, should be given at least one week and no more than three weeks after the first test; - The result of the second test is used as the baseline; - The two-step test is recommended due to the booster phenomenon (when people are tuberculin skin tested many years after infection, they may have a negative reaction. This skin test may stimulate (boost) their ability to react to tuberculin, causing a positive reaction to subsequent tests), which can occur at any age, but is more pronounced with increased age; - It is important to also perform an evaluation to determine if signs or symptoms of tuberculosis (unexplained weight loss, fever, and persistent cough) are present; - Once a tuberculosis disease is ruled out, it is important to record the result of the skin test in millimeter(mm), in a prominent place on the resident's medical record; - Including the skin test result at the same place and in the same manner as the resident's allergies is appropriate; - Residents are to be evaluated, at least annually to assure absence of signs and symptoms for tuberculosis disease. Review of Resident #45's electronic medical record showed: - The resident was admitted on [DATE]; - The resident's first step TB test was administered on 11/18/19 and read on 11/20/19 and was 0 mm. (negative); - The resident's second step TB was administered on 12/6/19 and no documentation to show staff read the test. Review of Resident #13's electronic medical record showed: - The resident was admitted [DATE]: - The resident's first step TB was administered on 4/15/21, no documentation to show staff read; - No documentation to show staff administered the second step TB. Review of Resident #49's electronic medical record showed: - The resident was admitted on [DATE]; - No documentation to show staff completed the first or second step TB. During an interview on 8/5/22 at 8:51 A.M., the Interim Director of Nursing (DON) said: - Staff should complete and document residents' TB testing. 2. Review of the facility's undated TB Screening for Long Term Care Employees policy showed: - Upon hire, the First Step of the Two Step PPD TB test will be administered before the employee begins work. The results of the first step will be read 2-3 days after administration. - The Second Step of the Two Step PPD TB test will be administered within 1-3 weeks of the first step. The results of the second step will be read 2-3 days after administration. - All PPDs will be documented on the Employee Immunization record, including new hires and annual administration. - All employees will be screened annually for TB. Review of the Employee TB test records on 8/3/22 showed: - Cook/Dietary Aide C: Date of Hire 5/26/20, no record of TB screening found in employee file. - Licensed Practical Nurse (LPN) D: Date of Hire 11/3/20. First Step TB test documented 4/3/21, no documentation of a Second Step found in the employee file. - Maintenance Director: Date of Hire 10/14/19. First Step TB test documented 9/30/19. No documentation of the Second Step found in the employee file. - CMT C: Date of Hire 10/22/19. First Step TB test documented 9/15/19. No documentation of the Second Step found in the employee file. - Cook/Dietary Aide A: Date of Hire 7/29/22. No record of TB screening found in employee file. - CNA G: Date of Hire 7/6/22. First Step TB test documented 6/3/22. No documentation of the Second Step found in the employee file. During an interview on 8/5/2022 at 6:11 P.M., the Administrator said: - All staff should be current with the TB screenings. - All employee files are to be up to date with documentation of staff TB screenings. 3. Review of Resident #20's quarterly MDS, dated [DATE], showed: - Cognitive skills moderately impaired; - Limited assistance of one staff for bed mobility, transfers, dressing, toilet use and personal hygiene; - Diagnoses included high blood pressure, anxiety and depression. Review of Resident #20's physician's order sheet (POS), dated August 2022, showed: - Start date: 4/22/20 - metoprolol tartrate 100 milligram (mg) twice daily for high blood pressure. Review of Resident #20's medication administration record (MAR), dated August 2022, showed: - Metoprolol tartrate 100 mg twice daily for high blood pressure. Observation on 8/4/22 at 9:01 A.M., showed: - CMT A did not wash or sanitize his/her hands. CMT A popped a metoprolol tartrate out of the bubble pack (a package holding and displaying medication in a clear plastic case sealed to a sheet of cardboard) and the pill hit the medication book and landed on the surface of the medication cart; - CMT A picked the pill up with his/her bare hands, placed it in a medication cup with other medication and administered the medication to the resident. During a telephone interview on 8/6/22 at 9:45 A.M., CMT A said: - He/she should not have picked the pill up with his/her bare hands; - He/she should have discarded the pill and got a new one out of the bottle. During an interview on 8/5/22 at 8:51 A.M., the Interim DON said; - Staff should have thrown the pill away; - Staff should not pick the pill up with his/her bare hands and give it to the resident.

Based on interview and record review, the facility failed to maintain an ongoing an antibiotic stewardship program that promotes the appropriate use and includes a system of monitoring to improve resident outcomes and reduce antibiotic resistance. The facility census was 57. The facility did not provide a policy and procedure regarding an antibiotic stewardship program. During an observation and interview on 8/5/22 at 8:51 A.M., the Interim Director of Nursing (DON) said: - She had completed the online training for an Infection Preventionist but was not able to locate it; - She had been in the DON position for about 6 months. - She did not know where the previous DON had placed the Antibiotic Stewardship book; - She looked through several different binders and finally found the Antibiotic Stewardship book but it did not have anything in it; - She said it should be updated and current. - Review of the Antibiotic Stewardship book showed it was empty.