**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect Resident #1's right to be free from abuse when Resident #2 grabbed Resident #1 by the hair and jerked his/her head around. Facility census was 78. Review of the facility policy titled, Abuse and Neglect, dated 9/29/2017, showed: -The residents of the facility have the right to be free from physical abuse. Residents of the facility must not be subjected to abuse or neglect by anyone. It is the responsibility of our employees, facility consultants, attending physicians, family members, visitors, etc., to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source, and theft or misappropriation of resident property to the facility management team. Our facility will not condone resident abuse by anyone. - If a resident is observed/accused of abusing another resident, our facility will implement the following actions: -Remove the aggressor from the situation of the aggressor is still in the area in which the incident occurred. -Temporarily separate the resident from other residents as a therapeutic intervention to help lower the agitation. -Determine the environment or possible triggers leading up to the incident. -Initiate a discussion with the resident if possible to determine the cause of the agitation. -Determine if the resident's emotional needs such as boredom, depression, or loneliness are being met. - Notify the family or responsible party. -Notify the resident's Physician. -Document the behavior and interventions. -Use the Consulting Psychiatric Services when appropriate and available. -Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. -Physical abuse includes hitting, slapping, pinching, and kicking. 1. Review of Resident #1's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by staff) dated 1/22/2025, showed: -The resident's diagnoses included: Dementia (a group of thinking and social symptoms that interferes with daily functioning), senile degeneration of the brain (a general term for a group of neurological disorders that cause a decline in cognitive function), Bells Palsy (a condition that causes sudden weakness in the muscles on one side of the face), anxiety disorder (a mental health disorder characterized by severe, ongoing anxiety that interferes with daily activities), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life); - He/She has moderate difficulty hearing, clear speech, usually understands others and usually makes self understood; -He/She scored one on the Brief Interview for Mental Status (BIMS, a structured evaluation aimed at evaluating aspects of cognition in elderly patients). This score indicated severely impaired cognitive abilities; -He/She has displayed no behaviors. Review of Resident #1's comprehensive care plan, dated 2/26/2025, showed: -He/She had dementia and senile degeneration of the brain. -He/She is slow to process information and have word finding problems. -He/She has anxiety and does not remember he/she lives at the facility. -Keep the resident away from Resident #2. 2. Review of Resident #2's annual MDS, dated [DATE], showed: -Diagnoses included: Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), severe dementia, generalized anxiety disorder major depressive aphasia (a language disorder that affects a person's ability to communicate); -He/She has adequate hearing, clear speech, understands others and makes self understood; -He/She scored 3 on the BIMS. This score indicates severely impaired cognitive abilities; -He/She has displayed no behaviors. Review of the resident's comprehensive care plan, dated 2/25/2025, showed: -The resident has physical and verbal behavioral symptoms directed toward others at times (calling names, cussing, hitting, kicking, pushing, scratching, grabbing). -Allow distance in seating (arms length) other residents around resident. -Avoid over-stimulation. Keep away from Resident #1. -Seat Resident #2 where constant/near constant observation is possible. -When he/she becomes physically abusive, keep distance between him/her and others (staff, other residents, visitors). Review of Resident #2's progress notes showed: -2/24/2025 at 6:33 P.M.: Resident #2 was brought back from the dining room, he/she had been telling another resident he/she needs to go to the hospital, yelling take him/her to the hospital. Resident #2 was in the area by the nursing station and he/she was wanting the resident next to him/her, Resident #1, to not be crazy over the baby doll. Resident #1 came up behind Resident #2, grabbed Resident #1's ponytail, and shaking Resident #1's head all around and would not let go. Staff assisted Resident #2 to his/her room and assisted to bed. Staff notified the resident's families and physician of the incident; -2/24/2025 at 6:55 P.M.: Resident #2 has been placed on 15 minute checks related to behaviors; -2/24/2025 at 7:05 P.M.: Resident #2 will be separated and supervised while around other residents. During an interview on 3/31/25 at 10:34 A.M., CNA A stated: -He/she was working the evening of 2/24/25. Resident #2 had just come back from dinner and was sitting at the nurses station, near Resident #1. -CNA A was cleaning a wheelchair and facing away from the residents. CNA A heard Resident #1 scream. CNA A turned around and saw Resident #2 had a hold of Resident #1's hair and pulling his/hear head around. -CNA A went toward the residents and the charge nurse also got up from behind the desk to separate the residents. CNA A helped Resident #2 to let go of Resident #1's hair and assisted Resident #2 to his/her room. During an interview on 3/31/25 at 4:01 P.M., Licensed Practical Nurse (LPN) A said: -He/She was working of 2/24/25. Between 6:30 and 7:00 P.M., both residents were sitting by the nurses station. LPN A heard Resident #1 yell and looked up at the residents. Resident #2 had come up behind Resident #1, had grabbed Resident #1's hair and was pulling his/her head around. LPN A and CNA A assisted in separating the residents, and Resident #2 was assisted to his/her room. Resident #1 was assessed and there were no injuries noted; -Earlier in the evening, Resident #2 became upset at dinner, yelling at another resident that they needed to get away from the table and staff brought Resident #2 back to the nurses station; -Resident #2 does have to be monitored for behaviors, as he/she yells at other residents and can be mean. Review of the facility investigation, dated 2/26/2025, showed: -On the evening of 2/24/2025, staff at the nurses station heard a scream. Upon investigation, found Resident #2 holding onto Resident #1's ponytail and shaking his/her head around; -Certified Nurses Assistant (CNA) A said that around 6:15 P.M. - 6:30 P.M., he/she was washing a wheelchair when he/she heard a loud scream come from Resident #1. When CNA A looked over, Resident #2 had a very tight grip on Resident #1's hair. The charge nurse stepped in and removed Resident #2's hand from Resident #1's hair. No one else witnessed the incident. During an interview on 3/17/2025 at 1:07 P.M., the Director of Nursing said staff responded appropriately to the incident. During an interview on 3/17/2025 at 1:07 P.M., the Administrator said staff responded appropriately to the incident. During a follow up interview on 3/31/25 at 9:50 A.M., the Administrator and Director of Nursing said: -As defined by the facility policy, abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Physical abuse includes hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment; -The Director of Nursing stated that the incident was reported to the state agency because it is her understanding that resident to resident altercations be reported; -The Administrator stated that the facility reported the resident to resident altercation to the state agency because the facility should report any and all resident to resident altercations. During an interview on 3/31/25 at 11:56 A.M., the Physician said: -He/She was notified by the facility of the incident; -He/She is unsure who gave the order for Resident #2 be placed on 15 minute checks for observation. He/She did not give that order; -Resident #2's actions toward Resident #1 are abuse. MO250135

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to provide proper infection control when facility staff did not immediately place one resident (Resident #23) on contact isolation precautions after readmitting to the facility with a positive test for influenza (a highly contagious respiratory illness of nose, throat, and lungs) A, did not have signage in place for (Resident #23) when on transmission based precautions, and did not cover clean laundry during transportation to prevent contamination. The facility census was 78. Review of facility policy, infection prevention and control policy and program, dated 3/12/21, showed: -Staff will reference the Centers for Medicare and Medicaid Services (CMS) guide and Center for Disease Control and Prevent (CDC) guidelines. These references will serve as the facilities guidelines to infection control. Review of CDC guidance titled interim guidance for influenza outbreak management in long-term care and post-acute care facilities, dated September 2024, showed: -Ill residents should be placed on droplet precautions with room restriction and be excluded from participating in group activities as prescribed below: -Droplet Precautions should be implemented for residents with suspected or confirmed influenza for 7 days after illness onset or until 24 hours after the resolution of fever and respiratory symptoms, whichever is longer, while a resident is in a healthcare facility. -Placing ill residents in a private room. If a private room is not available, place (cohort) residents suspected of having influenza residents with one another; -Wear a facemask (e.g., surgical or procedure mask) upon entering the resident's room. Remove the facemask when leaving the resident's room and dispose of the facemask in a waste container. If resident movement or transport is necessary, have the resident wear a facemask (e.g., surgical or procedure mask), if possible. 1. Review of Resident #23's Quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 12/11/24, showed: -Cognition intact; -He/She was dependent on a wheelchair; -He/She required substantial or maximal assistance with toileting and lower body dressing; -Resident required partial to moderate assistance with personal hygiene, bathing rolling left and right, sit to lying and lying to sitting on side of bed mobility; -He/She was dependent for transfers to the toilet or shower, sit to stand transfers and chair to bed transfers; -Diagnoses included: Dementia, diabetes, high blood pressure, depression and weakness. Review of physician's orders, dated 1/19/25-2/19/25, showed: -Started 2/17/25, ended 2/19/25, levogloxacin tablet (tab); 750 milligram (mg); amount (amt): 1 tab; oral, diagnosis: bronchiectasis, once a day: 7:00 A.M.-10:00 A.M.; -Started 2/17/25, ended 2/18/25, oseltamivir capsule; 30mg; amt: 1 cap by mouth, diagnosis: influenza due to other identified influenza virus with other respiratory manifestation, twice a day 7:00 A.M.-10:00 A.M., and 6:00 P.M.-9:00 P.M.; -Started 2/17/25, ended 2/19/25, prednisone tablet; 20mg; amt: 2 tabs; oral, diagnosis: influenza due to other identified influenza virus with other respiratory manifestations, once a day, 7:00 A.M.-10:00 A.M. Review of census report showed resident discharged from facility on 2/13/25 and returned 2/17/25. Review of nursing progress notes for the month of February., showed: -2/13/25 at Licensed Practical Nurse (LPN) E wrote resident's family member came to nurse regarding concern for residents breathing. Residents oxygen saturations on room air was 82%. Physician was notified and resident was sent to the hospital for evaluation and treatment. Resident's family member called the facility later to advise that the resident was admitted to hospital with influenza type A. -2/17/25 at 1:45 P.M., LPN D wrote resident returned to facility. Report was received from hospital indicating resident had been admitted on [DATE] for shortness of air and testing positive for influenza A. During an interview on 2/18/25 at 9:03 A.M. resident said they just got out of the hospital after having influenza. Observation on 2/18/25 at 9:03 A.M. showed resident had no transmission based precautions in place inside or outside of residents room or posted on residents door. Observation on 2/18/25 at 9:44 A.M. showed resident had a three drawer cart added outside their room with gloves, masks, gowns and hand sanitizer. There was no posting on door to indicate why precautions were being followed for this resident room. Observation on 2/18/25 at 9:54 A.M. showed two red barrels were now located outside resident's room. Observation on 2/18/25 at 9:56 A.M. showed two hospice workers pushing two red barrels into residents room from the hallway. Observation on 2/18/25 at 9:57 A.M. showed Nurse Aide (NA) A and Certified Nurse Aide (CNA) C outside resident's doorway and advising resident that they were asked to keep residents door closed and asking for residents consent to close their bedroom door. Observation on 2/19/25 at 8:31 A.M. showed no signage on resident's door. Personal protective equipment remained outside residents room. During an interview on 2/19/25 at 8:31 A.M., Resident said he/she was on quarantine but did not know why. Observation on 2/19/25 at 8:31 A.M. showed two red barrels were in residents room had gowns sticking out over top of container and the lids would not fit on the barrels due to the overflowing containers of doffed personal protective equipment. During an interview on 2/19/25 at 8:33 A.M., CNA C said: -The resident had been hospitalized for influenza; -The resident was on droplet precautions until they were symptom free; -He/she was not sure how long resident was on precautions. During an interview on 2/20/25 at 10:35 A.M., CNA E said: -Resident had influenza currently; -Resident had been hospitalized a week ago with influenza A and returned to facility yesterday; -When residents had influenza staff were to be gowning up and gloving before all cares; -He/She determined the difference between transmission-based precautions and enhanced barrier precautions by the signage on the residents door; -The residents on transmission-based precautions had a sign that read stop and check with nurse prior to entering resident room; -He/She was not sure why resident did not have a sign indicating stop on their door to their room. During an interview on 2/20/25 at 10:51 A.M., CNA G said he/she did not know difference between transmission based precautions and enhanced barrier precautions; During an interview on 2/20/25 at 2:08 P.M., Infection Preventionist said: -He/She worked in the facility full time as the facility infection preventionist; -Resident #23 returned to facility from hospitalization on 2/17/25; -Transmission based precautions should have been implemented on 2/17/25 for Resident #23; -He/She had to work as a nurse on the floor on 2/17 and did not know Resident #23 had returned to facility; -He/She did not know expectation for transmission-based precautions when the resident #23 returned to facility with influenza and had a roommate in same room; -Resident #23's roommate had been residing in the same room with resident on transmission based precautions; -Resident #23's roommate had been in dining room and out and about in facility while Resident #23 was on isolation precautions in their room; -Facility in past would offer open single rooms to residents who were on transmission-based precautions or move residents into rooms with residents on same transmission based precautions. During an interview on 2/20/25 at 2:08 P.M., Director of Nursing (DON) said: -When resident has influenza, they expected signage on resident door that read to stop see the nurse; -Facility did not put on their signage what precaution the resident was on; -Resident #23 was coming off transmission-based precautions on 2/21, because they tested positive for influenza on 2/13/25; -The red barrels or doffing containers in transmission-based precaution rooms should not be overflowing; -Red barrels or doffing containers were emptied at end of each shift; During an interview on 2/21/25 at 1:15 P.M., DON said: -She expected transmission-based precaution signage to be posted outside resident's door; -Facility used a sign that said stop and see the nurse; - She expected doffing barrels to be covered and not overflowing During an interview on 2/21/25 at 1:15 P.M., Administrator said: -He/She expected facility policy to be followed; -He/She expected a stop see the nurse sign posted on resident doors on transmission based precautions. 2. Facility did not provide a policy on linen transport. Review of CDC guidance, Laundry and Bedding Guidelines for Environmental Infection Control In Health Care facilities, Parameters of the laundry process, dated 2003, showed: -Placing clean linen in a properly cleaned cart and covering the cart with disposable material or a properly cleaned reusable textile material that can be secured to the cart. Observation on 2/19/25 at 9:35 A.M. showed Laundry Aide A transporting clean laundry to include resident gowns, clean underpads, and resident clothes being wheeled on an uncovered metal cart down 200 hall way and returning clean items to resident rooms and linen storage closets. Observation on 2/19/25 at 9:46 A.M. showed Laundry Aide A transporting clean laundry including resident clothes on hangars that were uncovered. Observation on 2/19/25 at 2:22 P.M. showed Laundry Aide A transporting clean linens including underpads and blankets in an uncovered metal cart. During an interview on 2/20/25 at 2:57 P.M, Laundry Aide B said: -The metal carts were used for clean laundry carts only -Clean laundry was transported to resident rooms using metal cart; -Clean laundry in metal cart were not covered prior to transport to hallways and resident rooms. During an interview on 2/21/25 at 1:15 P.M., DON said she expected laundry to be protected clean laundry to be protected from contamination. During an interview on 2/21/25 at 1:15 P.M., Administrator said she did not expect clean laundry to be protected from contamination during transport.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure assure staff treated residents in a manner that maintained their dignity, when staff did not serve all residents who sat at the same table during meals, which affected any resident who ate in the dining room, and failed to ensure one of the 18 sampled residents, (Resident #47), was free of facial hair. The facility census was 78. Review of the facility's policy titled, Resident Rights, revised 8/22, showed staff were directed to do the following: - The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility; - A facility must treat each resident with respect and dignity and care of each resident in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life, recognizing each resident's individuality; - The facility must protect and promote the rights of the resident. 1. Review of Resident #47's Quarterly minimum data set (MDS), dated [DATE], showed: -The resident is severely cognitively impaired; -The resident displayed no behavioral symptoms directed towards others including hitting, kicking, pushing, scratching, or grabbing; -The resident required partial to moderate assistance with personal hygiene including shaving; -The resident was dependent on a wheelchair; -The resident required substantial or maximal assistance with rolling left and right; -The resident was dependent to move from sitting to lying, lying to sitting on side of bed, sit to stand transfers, chair to be transfers, and toilet transfers; -Diagnoses included: dementia (a decline in thinking, memory, or reasoning that interferes with daily life), Alzheimer's disease (a progressive brain disorder that causes memory loss, thinking problems, and behavioral changes), muscle weakness, hearing loss, reduced mobility. Review of care plan, revised 12/6/24, showed: -Staff are directed to provide assistance with hygiene; -The resident preferred hospice staff provide showers twice weekly. The facility staff will provide showers as requested or needed. Observation on 2/18/25 at 10:12 A.M. showed resident had one inch long facial hair coming out of his/her chin. Observation on 2/19/25 at 8:26 A.M. showed resident had facial hair on their chin. Observation on 2/21/25 at 10:44 A.M. showed resident had quarter inch facial hair on their chin. During an interview on 2/20/25 at 10:35 A.M., Certified Nurse Aide (CNA) E said: -The resident liked to be shaved; -The reisdent's facial hair is shaved every time staff provide a shower; -Hospice staff provides the residents showers; -Last week the resident was not shaved so facility staff completed residents shaving while the reisdent was up in his/her reclining wheelchair. During an interview on 2/21/25 at 9:57 A.M., Licensed Practical Nurse B said: -Female residents should have their facial hair trimmed; -The resident did not always let staff shave them because they would swat at staff members; -The hospice and facility staff will attempt to shave resident; -Facility staff did not document when they provided shaving to resident because hospice did all of residents showers; -The resident had been declining steadily and stopped talking in last few months; During an interview on 2/21/25 at 10:24 A.M., CNA H said the hospice staff shaved resident and they shave residents when showered. During an interview on 2/21/25 at 1:15 P.M., Director of Nursing said: -He/she expected female residents to be free from facial hair; -Shaving was provided to residents during bathing; -The resident could be challenging with their moods and at times would be resistive to cares; -She expected for staff to care plan residents who may resist cares, including shaving. During an interview on 2/21/25 at 1:15 P.M., Administrator said she did not expect female residents to want their facial hair to be shaved or removed due to the change of times in our culture. 2. Observation of 400-500 hall dining room on 2/18/25 showed: - 12:05 P.M. three residents served all at different tables with other residents at those tables not being served; - 12:10 P.M. lunch service continues to be random as to who receives their meal and the tables are not all served at the same time leaving residents at each table watching others eat in front of them while they wait; Review of resident #22's admission MDS, dated [DATE], showed: - Cognitive skills for daily decision making intact; - Diagnosis included: Hypertension (high blood pressure), GERD (acid reflux), diabetes (chronic disease when body can't produce insulin), hyperlipidemia (high cholesterol), thyroid disorder (a condition where the thyroid gland produces an abnormal amount of thyroid hormones), arthritis (joint pain, swelling, and stiffness), osteoporosis (bone disease); Observation of 100-300 Hall dining room on 2/19/25 showed: - 12:19 P.M. Resident #22 with a plate of food in front of them, no other residents at their dining table have been served; - 12:27 P.M. Residents at the table still have not been served (8 min elapsed since first person served); During an interview on 2/19/25 at 12:20 P.M., when asked about meal service, Resident #22 said he/she is frustrated, I don't know how they determine who gets served, it's all random. During an interview on 2/19/25 at 2:49 P.M. with the Resident Council, residents said: - Resident #38 felt it was confusing how residents are served at meals; - Resident #13 said it was frustrating how meal service is conducted when serving; - Resident #51 said they don't know when they are going to get served; - Resident #75 said the meal service selection of when residents are served doesn't make sense; - Resident #17 said it's like the staff chooses who gets fed at random; During an interview on 2/20/25 at 1:30 P.M., the Administrator and DON said all residents sitting at a table should be served meals at the start of dining service at the same time before moving onto a new table unless there is a diabetic resident that needs to be served;.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain the privacy of two of the 18 sampled residents, (Resident #43 and #73), when staff failed to post signage at the front door or outside each sampled resident's room to indicate 24 hour camera surveillance was in progress and failed to obtain consents from the responsible parties of the sampled residents. The facility census was 78. The facility did not provide a policy for video surveillance with or without audio. 1. Review of Resident #73's care plan, dated 9/20/24, did not address the use of video surveillance with audio. Review of the Resident's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, completed by facility staff, dated 11/20/24, showed: - Cognitive skills intact; - Dependent on the assistance of staff for toilet use, and transfers; - Required substantial to maximum assistance with showers, dressing, and personal hygiene; - Had a urinary catheter (sterile tube inserted into the bladder to drain urine); - Always incontinent of bowel; - No falls; - Diagnoses included cancer, diabetes mellitus, neurogenic bladder ( a dysfunction that results from interference with the normal nerve pathways associated with urination), Congestive Heart Failure (CHF, accumulation of fluid in the lungs and other areas of the body) and Coronary Artery Disease (CAD, a disease in which there is a narrowing or blockage of the coronary arteries). Review of the resident's Physician Order Sheet, (POS), dated 1/19/25 - 2/19/25, did not include an order for video surveillance with audio. Observation on 2/18/25 at 10:17 A.M., showed: - The resident sat in a Broda chair (reclining geri chair) in his/her room and the over the bed table was placed in front of him/her with a video monitor on it. Also had a monitor on the resident's bedside table and on the window ledge; - Did not have a sign outside the resident's room to indicate video monitoring with audio was in use; - No signage was posted at the entrance to the facility to indicate video/camera surveillance was in use; - The video monitor was at the nurse's station and the volume was turned down so you were unable to hear what was being said in the resident's room. Observation on 02/19/25 at 1:51 P.M., showed Certified Nurse Aide (CNA) A was on the phone with the resident's family because the recording device was not working correctly. A family member planned to fix it later in the day. 2. Review of Resident #43's Annual MDS, dated [DATE] showed: - Cognitive skills severely impaired; - Required substantial to maximum assistance with toilet use, showers, and transfers; - Frequently incontinent of bowel and bladder; - Diagnoses included Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and , eventually, the ability to carry out the simplest tasks), non-traumatic brain dysfunction ( causes damage tot he brain by internal factors, such as a lack of oxygen, exposure to toxins or pressure from a tumor), arthritis and depression; - No falls. Review of the resident's care plan, dated 12/17/24 showed the resident had dementia (inability to think) which affected his/her safety skills and had a history of falls. The resident's daughter brought a V-tech baby monitor with screen so staff were able to keep an eye on the resident. Review of the resident's POS, dated 1/19/25 - 2/19/25, showed and order dated 1/4/21 for a VTECH monitor, on at shifts continuous for frequent falls. Review of the resident's medical record showed he/she did not have a consent signed by the responsible party for 24 hour camera surveillance. Observation on 2/18/25 at 9:43 A.M., showed: - A video monitor on the counter by the resident's sink; - No signage was posted outside the resident's room to indicate camera monitoring was in progress; - No signage was posted at the entrance to the facility to indicate camera surveillance was in use; - The VTECH monitor at the nurse's station showed the resident sat in the wheelchair in his/her room. During an interview on 2/19/25 at 7:46 A.M., the Director of Nursing (DON) said: - Resident #73 had several daughters and they wanted an audio camera so they could talk to him/her. Resident #73 was the only resident with audio on the video monitoring; - Resident #43 did not have audio on his/her video monitor. During an interview on 2/20/25 at 11:30 A.M., Licensed Practical Nurse (LPN) A said: - It should be care planned for a resident to have video surveillance; - They did not have a physician's order for video surveillance because the family had requested it; - Did not know there should be a sign about video surveillance outside the resident's room. During an interview on 2/20/25 at 1:11 P.M., CNA D said they were told about the video monitoring device by their charge nurse. During an interview on 2/21/25 at 12:15 P.M., the DON said: - The video monitoring devices are just baby monitors; - The family put the monitors in the residents' room, not the facility. - She never thought of the need to post signs or notify anyone about it; - She considered the device to be a communication tool; - She did not think a physician's order for video monitoring was needed; - Resident #73 used the device also for his/her family to call him/her.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Review of Resident #6's Quarterly MDS, dated [DATE], showed: - Cognitive skills moderately impaired; - Lower extremity impaired on one side; - Dependent on the assistance of staff for toilet use, showers, dressing, personal hygiene, and transfers; - Always incontinent of bowel and bladder; - One fall, no injury; - Diagnoses included stroke, depression, hemiplegia (paralysis affecting one side of the body) and chronic obstructive pulmonary disease (COPD, obstruction of air flow that interferes with normal breathing). Review of the resident's care plan, revised 2/7/25 showed: - The last care conference was 10/31/24; - The next care conference was scheduled for 1/24/25. During an interview on 2/18/25 at 10:59 A.M., the resident said he/she was not for sure if they had been invited to or attended their care plan meeting. 6. Review of Resident #12's admission MDS, dated [DATE], showed: - Cognitive skills moderately impaired; - Required partial to moderate assistance for toilet use, dressing and personal hygiene; - Required supervision or touch assistance with transfers; - Occasionally incontinent of urine; - Always continent of bowel; - No falls; - Diagnoses included depression, high blood pressure, arthritis, and atrial fibrillation (A-fib, an irregular heartbeat that occurs when the electrical signals in the atria (the two upper chambers of the heart) fire rapidly at the same time). Review of the resident's care plan, revised 11/26/24, showed the plan did not address when the resident's care conference was scheduled. During an interview on 2/18/25 at 11:18 A.M., the resident said he/she was not for sure if they had been invited or attended their care plan meeting. During an interview on 2/20/25 at 8:25 A.M., the MDS/Care Plan Coordinator said: - He/she was not for sure if Resident #12 had attended any care plan meetings; - He/she did not document if the resident was invited or if they attended; - He/she was unable to find a care conference for Resident #12; - Resident #6 had a care conference in October and was not for sure why they did not have one in January. Based on observations, interview, and record review, the facility failed to ensure staff developed and updated care plans consistent with resident's specific conditions and needs which affected five of eighteen sampled residents (Resident #23, #47,#71, #6 and #12 ), and failed to invite and document quarterly care plan meetings were held for three residents (Resident #23, #6, and #12). The facility additionally failed to provide an accurate care plan when a resident had multiple transfer types listed in the care plan and did not reflect the resident's current non-ambulatory status for one resident (Resident #47) and failed to ensure wheelchair use was care planned for one resident (Resident #71). The facility census was 78. Facility did not provide a policy on comprehensive care plans. 1. Review of Resident #23's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 12/11/24, showed: - Cognitively intact; - Dependent on a wheelchair for mobility; - Required partial to moderate assistance with personal hygiene, bathing rolling left and right, sit to lying and lying to sitting on side of bed mobility; - Dependent for transfers to the toilet or shower, sit to stand transfers and chair to bed transfers; -Diagnoses included: Dementia, diabetes, high blood pressure, and depression. Review of care plan, dated 9/12/24, showed the care plan was last updated on 9/12/24 when visual function and pressure ulcer/injury were added. During an interview on 2/18/25 at 9:05 A.M. the Resident said: -He/She did not think they had care plan meetings; -His/her daughter and granddaughter sometimes participated in their care. Review of the electronic medical record showed: -The last care conference was held on 3/29/23; -The next care conference was scheduled for 6/22/23. During an interview on 2/20/25 at 3:08 P.M., MDS Coordinator said: -He/She offered resident care plan meetings but they did not think resident came to meetings; -The last care plan conference was held March 2023; -When the resident's family member came to facility he/she talked to everyone while they were here; - The residents family member did not share any reason to have a care plan meeting held; - Care plan notes showed resident's family member had participated via phone March of 2023 for resident's care plan meeting. 2. Review of Resident #47's Quarterly MDS, dated [DATE], showed: - Severely cognitively impaired; - Dependent on a wheelchair and staff assist for mobility; transfers, and all ADLS (Activities of daily living); -Diagnoses included: Dementia. Review of care plan, dated 12/6/24, showed: -Hospice ordered the resident a reclining chair, dated 10/10/23; - Two staff are to assist with transfers with a gait belt, use a mechanical lift to transfer the reisdent in and out of bed, and use a sit to stand lift to transfer the resident when toileting, dated 10/10/23; -Ensure the reisdent wears non-skid footwear is worn, dated 10/10/23; -Ensure pathways are free and clear of clutter, dated 10/10/23 -Re-educated staff on proper gait belt use, dated 10/10/23; -Ensure the residents walker stays within him/her and is in reach, dated 10/10/23; -The care plan did not reflect the resident's current total dependence for all transfers via mechanical lift and that he/she was no longer ambulatory. Observation on 2/21/25 at 10:33 A.M. showed hospice staff used a mechanical lift to place the resident in their bed. During an interview on 2/21/25 at 9:57 A.M. Licensed Practical Nurse (LPN) B said: -The resident was transferred by a mechanical lift; -The resident had declined steadily and was no longer able to stand for transfers. During an interview on 2/21/25 at 10:24 A.M., CNA H said: -The resident was transferred by use of a mechanical lift; -The resident had not used the sit to stand mechanical lift on over eleven or twelve months; -The resident had not been able to stand and pivot for a long time; During an interview on 2/21/25 at 1:15 P.M., the Director of Nursing said a resident who was dependent on a mechanical lift for transfers should have a care plan that reflected the resident's current need for assistance. 3. Review of Resident #71's admission MDS, dated [DATE], showed: - Severe cognitive impairment; - Did not use a mobility device; - Independent with walking up to 150 feet; - Independent with chair to bed transfers and sit to stand transfers; - Diagnoses included: Dementia, Back fracture,anxiety, dementia and history of falling. Review of care plan, dated 2/6/25, showed: - He/She wandered safely within specified boundaries; - He/She walked independently, had dementia, and required staff to remind them to use their walker; -He/She had difficulty processing information due to dementia and get easily distracted; -There was nothing care planned regarding use of a wheelchair. Observation on 2/19/25 at 9:33 A.M. showed the LPN A pushed resident from the dining room to the nurses station in their wheelchair. Observation on 2/19/25 at 9:57 A.M. showed the resident was pushed by hospice staff in their wheelchair to the shower room. Observation on 2/19/25 at 11:28 A.M. showed the CNA C pushed resident down hallway to the nurses station in their wheelchair. Observation on 2/20/25 at 12:48 P.M. showed the Social Services Designee pushed resident out of dining room in their wheelchair. During an interview on 2/21/25 at 9:57 A.M., LPN B said the resident would self-propel in their wheelchair; During an interview on 2/21/25 at 10:24 A.M., CNA H said the resident would self-propel themselves in their wheelchair. 4. During an interview on 2/20/25 at 3:08 P.M., MDS Coordinator said: -The facility had care plan meetings; -Social Service designee sent out care plan meeting letters to families and hospice monthly; -Social Service designee would notify residents of their care plan meetings by handing them a letter; -The facility did not have any documentation when a resident did not want to attend their care plan meeting; -The facility did not have any written documentation showing who participated in care plan meetings; -He/She expected resident's care plans to reflect the resident's current level of care status. During an interview on 2/20/25 at 3:20 P.M., Social Services Designee said: -He/She sent letters out to resident families or DPOA the month prior to the designated care plan meetings; -When residents were their own person they would hand deliver a letter about the care plan to the resident; -The care plan letters that were sent by facility did not have a designated date and time of meetings; -The letters only indicated that the DPOA could call if they wanted to have a meeting; -MDS Coordinator would document when care plan meetings were held; -He/She did not write care plans; -Care plans were not occurring quarterly with each resident; -Care plans only occurred if the DPOA requested the meetings; -Care plans should be updated with any new interventions to the residents cares; -The resident's care plan should be updated more frequently if significant changes occur with the resident. During an interview on 2/21/25 at 1:15 P.M., Director of Nursing said: -She expected care plan meetings to be offered quarterly and as needed with changes; -She expected residents to be invited to their care plan meetings; -Majority of their residents did not want to participate in their care plan meetings; -Facility staff have had care plan meetings every week; -Facility staff did not document those care plan meetings; -Facility should document if resident was invited to their care plan meeting and declined to participate in the meeting. -She expected care plans to be individualized and be current to residents care needs; -She expected that by looking at the resident's care plan; they could tell whom that resident was, and what care was needed to be provided to the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure staff provided professional standards of quality in care. when staff failed to utilize the electronic medical record to verify orders when providing wound care for one of the 18 sampled residents, (Resident #72) and when obtaining blood sugars and administering insulin for two residents (Resident #49 and #11) and additionally when staff failed to obtain physician's orders for wound treatment for Resident #5. The facility census was 78. Review of the facility's undated policy titled, Medication Administration, showed staff were directed to do the following: - Medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so; - Personnel authorized to administer medications do so only after sufficient information regarding the resident's condition and expected outcomes of medication therapy is known; - Medications are prepared, administered, and recorded only by licensed nursing, medical, pharmacy, or other personnel authorized by state laws and regulations; - Medications are administered in accordance with written orders of the attending physician; - Residents are identified before medication is administered: check identification band; check photograph attached to medical record, header card, or facility approved location; call resident by name; if necessary, verify resident information with other facility personnel; - Only the licensed or legally authorized personnel who prepare medication may administer it. This individual records the administraion on the resident's Medication Administration Record (MAR) at the time the medication is given; - During routine administration of medications, the medication cart is kept in the doorway of the resident's room, with open drawers facing inward and all other sides closed. No medications are kept on the top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by; - Prior to administration, the medication and dosage schedule on the resident's MAR is compared with the medication label. Review of the facility's undated policy titled, Ten Rights for Administration of Medications, showed staff were directed to do the following: - The right resident: before preparing the medication, identify each resident according to the facility's policies and procedures; - The right drug: verify each drug against the MAR before administering. Verify in at least three ways, such as by the drug's size, shape, color, or label; - The right dose and dosage form: verify against the MAR. 1. Review of Resident #49's Physician Order Sheet (POS), dated 1/19/25 - 2/19/25, showed: - Order date: 7/9/21 - Accu checks ( a blood glucose meter that monitors blood sugars) before meals and at bedtime for diabetes mellitus. Review of the resident's MAR, dated 1/20/25 - 2/19/25 showed and order with a start date of 7/9/21 - Accu checks before meals and at bedtime for diabetes mellitus. Review of the resident's care plan, dated 7/9/24 showed: - The resident was diabetic and took insulin at night if the resident's blood sugar was greater than 300; - Monitor blood sugars before meals and at bedtime. Observation on 2/19/25 at 11:08 A.M., showed: - At 11:15 A.M., Registered Nurse (RN) A obtained the resident's blood sugar and discarded the supplies appropriately; - RN A did not have a computer with him/her and did not verify the resident's order prior to obtaining the resident's blood sugar. During an interview on 2/19/25 at 11:18 A.M., RN A said: - He/she normally did not take the computer with him/her when obtaining blood sugars because the resident had been at the facility for so long. 2. Review of Resident #11's Care Plan, dated 1/3/25 showed: - The resident was on Fiasp insulin before meals and took Lantus (long acting) insulin at bedtime; - Monitor blood sugars before meals and at bedtime. Review of the resident's POS, dated 1/20/25 - 2/20/25, showed: - Start date: 3/20/20 - Check blood sugars before meals and at bedtime; - Start date: 11/17/24 - Fiasp Flex touch (fast acting) insulin pen, 10 units twice daily for diabetes mellitus. Review of the website, https:// www.medicalnews.com for the use of Fiasp insulin pen showed: - Fiasp is a rapid-acting insulin which should be taken at mealtimes; - Take at the start of the meal or within 20 minutes. Review of the resident's MAR, dated 2/6/25 - 2/20/25 showed: - Check blood sugars before meals and at bedtime; - Fiasp Flex touch insulin pen, 10 units twice daily for diabetes mellitus. Observation on 2/19/25 at 11:25 A.M., showed: - Licensed Practical Nurse (LPN) A obtained the resident's blood sugar and administered insulin to the resident; - LPN A did not have a computer with him/her and did not verify the resident's order prior to obtaining the resident's blood sugar or administering the insulin. During an interview on 2/19/25 at 3:08 P.M., LPN A said: - He/she should have looked at the computer to verify the order to check blood sugars and administer the insulin; - He/she did not have a laptop, just a computer at the nurse's desk. 3. Review of Resident #72's POS, dated 1/19/25 - 2/19/25 showed: - Start date: 12/18/24, discontinue (dc) date: 1/22/25; clean wound to right posterior hip, with wound cleanser, apply collagen powder (used to promote healing and tissue regeneration) to wound bed, calcium alginate (dressings used to treat wounds with moderate to heavy drainage), cover daily and as needed; - Start date: 2/19/25 - Collagen powder to right posterior hip wound and cover daily and as needed; - The order did not specify how much Collagen powder to use. Review of the resident's MAR, dated 1/20/25 - 2/19/25 showed and order with a start date of 2/19/25 for Collagen powder to right posterior hip wound and cover daily and as needed. Review of the resident's care plan, revised 2/13/25 showed: - The resident was at risk for a pressure ulcer (damage to an area of the skin caused by constant pressure on the area for a long time) due to moisture and limited mobility. Observation and interview on 2/20/25 at 1:42 P.M., showed: - LPN B washed his/her hands at the sink at the nurse's station and donned gloves then cleaned the surface of the south treatment cart, removed gloves and sanitized; - LPN B placed a piece of foil on the cart and placed the wound supplies on it; - LPN B sprinkled a little bit of Collagen powder in a med cup and said they are supposed to cover the wound bed and since it is done daily, he/she knew how much to put in the cup; - LPN B took the treatment cart to the resident's room and completed the wound treatment; - LPN B said they usually look at the computer before they do the wound treatments but he/she did not do that this time; - He/She is the wound nurse though so he/she knows the orders. - LPN B did not check the computer prior to starting the wound treatment and did not have a computer during the treatment. During an interview on 2/21/25 at 12:15 P.M., the Director of Nursing (DON) said; - He/she did not expect the staff to have a tablet to to verify the orders, the staff check the orders at the computer at the nurse's desk and then do the treatments, obtain blood sugars or administer insulin; - The orders will not change while the staff are doing the blood sugars; - The nurses look at the computer all day long; - The nurses should check the orders, obtain the blood sugars, administer insulin or do the wound treatment. The nurses know what they are supposed to do. 4. Review of Resident #5's Quarterly MDS dated [DATE] showed: - admission to the facility on 7/10/24; - BIMS score of 14, indicating no cognitive deficit; - Diagnoses include: Heart Failure, high blood pressure; - Requires assistance for set up and clean up for meals; - Requires assistance or set up for toileting hygiene and dressing; - Requires partial/moderate assistance for showering/bathing. - Resident requires a walker for mobility; Review of resident's progress notes dated 12/14/24 showed: - Resident has an area on their right lower leg. It is draining a little, area cleansed A&D ointment applied and covered. Resident lower leg is red and slightly ware to touch. Resident told to elevate their leg as much as possible. The area is 1 cm x 2 cm. Review of the resident's physician order sheet (POS), dated, 2/19/25, showed no orders relating to wound care or bandage for resident's right calf; Review of the resident's medication administration record (MAR), dated, 2/1-2/19 2025, showed no record of bandage change or cares for resident's right calf wound; Review of the resident's care plan, showed: - 7/24/24 resident is on Anti-Coagulant and staff should observe for signs of active bleeding; - 7/24/24 resident is at risk for pressure ulcer and staff should perform a skin inspection every shift during cares and use moisture barrier ointments as needed; During an interview on 2/20/25 at 5:25 P.M., Primary Physician stated: - Wound was due to a dermatology issue and it was taking a long time to get an appointment from the dermatologist and he/she was aware of the situation; - Was not aware that there were no orders for the care of the bandage and wound on resident's right calf; - He/she said there should be some order for care of the wound and that they would review the issue on the next visit; During an interview on 2/21/25 at 1:30 P.M., Administrator and DON said the nursing staff are not expected to date the bandages when they are changed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure staff provided quality of care and treatment in accordance with professional standards of practice when staff failed to reposition two residents and provide incontinent care to dependent residents (Resident #47 and #72) This affected two residents out of eighteen sampled residents. The facility census was 78. Facility did not provide policy on positioning. 1. Review of Resident #47's Quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 12/26/24, showed: - Cognition severly impaired; - Dependent on a wheelchair for mobility and dependent of staff for turning, repositioning and transfers; - Total assist of all ADLS; - Diagnoses included: Alzheimer's disease (a progressive brain disorder that causes memory loss, thinking problems, and behavioral changes), muscle weakness, and reduced mobility. Review of care plan, revised 12/6/24, showed: -Decreased mobility and required staff dependence for turning and repositioning; High risk for skin injury and pressure sores. -Inspect skin daily with cares and report potential problems. -Keep bony prominences from direct contact with one another with pillows and wedges; -Keep clean and dry as possible; -Minimize exposure to moisture; -Report any signs of skin breakdown (sore tender , red, or broken areas). Review of physician's orders, dated 2/19/25, showed: -Start date 11/11/22, heel protectors on in bed; -Start date 11/21/23, admit to hospice Observation on 2/18/25 at 10:18 A.M. showed resident up in a reclining wheelchair. Air pressure mattress observed on residents bed. Sign hanging above resident's bed showed heel protectors on while in bed. Observation on 2/19/25 at 8:25 A.M. showed resident up in reclining wheelchair. Observation on 2/19/25 at 9:42 A.M. showed resident was sleeping and remained up in reclining wheelchair. Observation on 2/19/25 at 1:17 P.M. showed resident was was seated in reclining wheelchair at nurses station. Continuous observation on 2/20/25 at 7:40 A.M.-11:50 P.M. showed: -8:03 A.M., resident pushed down hallway by Certified Nurse Aide (CNA) F and returned to resident's room. Resident remains up in their reclining wheelchair with call light in reach. -9:05 A.M., resident remains in their reclining wheelchair, resident had not been laid down or repositioned in the chair. -9:44 A.M., observation showed hospice staff entered residents room for visit, resident was not repositioned or laid down. -10:21 A.M., resident remained up in reclining wheelchair, had not been repositioned or taken out of chair -11:49 A.M., resident remained sitting in reclining wheelchair, had not been repositioned or taken out of reclining wheelchair; -11:50 A.M., CNA E said they had no room in dining room currently for resident to be assisted to dine and resident would remain in their room. During an interview on 2/20/25 at 10:35 A.M., CNA E said Resident #47 would not get laid down until after lunch and had been up in their reclining wheelchair since prior to breakfast. During an interview on 2/21/25 at 10:24 A.M., CNA H said: -Resident #47 stayed in broda chair most of the day; did not really lay down and stayed in chair most of the day; -Resident was laid down at 8:30 A.M. and got back up right away. During an interview on 2/15/25 at 1:15 P.M., Director of Nursing (DON) said Resident #47 would need help to be repositioned by staff. During an interview on 2/21/25 at 1:15 P.M., Administrator said: -Resident #47 should be repositioned if resident allows staff; -Resident could be resistive to cares. 2. Review of Resident #72's Quarterly MDS, dated [DATE], showed: -Cognition severly impaired and unable to make needs known; - Dependent on a wheelchair for mobility; - Total assist of all ADLS, dependent of full staff support to include incontinent care, turning, positioning and transfers; -High risk of skin injury and pressure ulcers, and did have a stage 1 or higher pressure ulcer; -Documented one stage 4 pressure ulcer- A full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling; -Dcoumented 1 unstageable pressure ulcer - slough and/or eschar: known but not stageable due to coverage of wound bed by slough and/or eschar; -Had a pressure reducing device for chair, bed, were on a turning/repositioning program, nutrition or hydration intervention to manage skin problems, pressure ulcer care, application of nonsurgical dressings (with or without topical medications) other than to feet, and applications of ointments/medications other than to feet; -Received hospice care; -Diagnoses included: Alzheimer's ), collapsed vertebra and unspecified pain. Review of care plan, revised 2/13/25, showed: -Staff assist resident up in reclining wheelchair for meals and as tolerated. -Resident was two assist with Hoyer lift for transfers. -Resident was at risk for pressure ulcer due to moisture and limited mobility; -He/She was incontinent of bowel and bladder; -Dependent on staff for all cares. -Laydown after every meal. -Turn and reposition at least every 2 hours and as needed. Review of physician's orders, dated 2/19/25, showed: -Started 5/6/24, admit to hospice care; -Started 2/19/25, collagen powder to right posterior hip wound and cover daily and as needed, once a day. Observation on 2/19/25 at 1:19 P.M. showed resident up in reclining wheelchair. During a continuous observation on 2/20/25 from 8:03 A.M.-11:50 A.M., showed: -8:03 A.M., Resident pushed down to their room by CNA F and placed in their room. Resident remained in their reclining wheelchair with call light in reach; -9:33 A.M., Resident remained up in their reclining wheelchair, had not been repositioned; -10:23 A.M., Resident remained seated in reclining wheelchair, had not been repositioned; -10:48 A M., CNA B entered resident's room and reclined residents wheelchair to add a blanket between resident's legs. CNA B placed resident's reclining back in upright position. During an interview on 2/20/25 at 10:35 A.M., CNA E said: -Resident #72 was one of the residents that would stay up in their chair until after lunch; -Resident was placed in their chair prior to breakfast. During an interview on 2/21/25 at 10:24 A.M., CNA H said: -Resident #72 should be repositioned every two hours; -Resident was laying in bed now and they were about to get her back up out of bed. During an interview on 2/21/25 at 1:15 P.M., DON said Resident #72 required assistance with being repositioned and was unable to reposition themselves. 3. During an interview on 2/20/25 at 10:35 A.M., CNA E said: -Residents should be repositioned every two hours; -Residents in broda chairs were up in their chairs from before breakfast until right after lunch, then staff give residents a little nap time by laying them down, and residents come back up for dinner; During an interview on 2/20/25 at 10:51 A.M., CNA B said: -Residents should be repositioned every two hours at a minimum; -Depending on resident's orders they are sometimes repositioned sooner than every two hours. During an interview on 2/21/25 at 9:57 A.M. Licensed Practical Nurse (LPN) B said residents need to be repositioned every two hours. During an interview on 2/21/25 at 10:24 A.M., CNA H said residents should be respositioned every two hours. During an interview on 2/21/25 at 1:15 P.M., Director of Nursing said: -She expected residents to be positioned every two hours; -She expected residents in reclining wheelchairs to be offered incontinent care every two hours; -Incontinent care and repositioning offered before lunch and after lunch; -Expected repositioning to occur when residents were not able to move themselves. During an interview on 2/21/25 at 1:15 P.M., Administrator said she expected residents to be repositioned every two hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to ensure residents remained free from accident hazards when staff pushed residents in their wheelchairs without foot pedals for four (Resident #1, #68, #71, and #58) residents. This affected four of eighteen sampled residents. The facility census was 78. Facility did not provide a policy on accidents. 1. Review of Resident #1's Quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 12/19/24, showed: -Cognition severly impaired; -No impairment to upper or lower extremities; -Required assistance for Activities of Daily living to include transfers, mobility, hygiene needs. -Diagnoses included: Alzheimer's osteoarthritis , low back pain, unsteadiness on feet, and dementia Review of care plan, revised 9/12/24, showed: -He/She was ambulatory with assist; -Ensure assistive devices were available and in good condition (example included wheelchair); -Ensure proper footwear when they ambulated; -Resident was at risk of falls, and recently had a fall that fractured their pelvis; -He/She had cognitive impairment and could be impulsive which increased their risk for falls; -He/She had an anti roll back device on wheelchair; Observation on 2/18/25 at 10:42 A.M. showed resident self-propelled in their room. Resident had no leg rests observed on their wheelchair. Observation on 2/19/25 at 12:26 P.M. showed Certified Nurse Aide (CNA) C pushed resident's wheelchair into the dining room. Residents tops of their feet were dragged on the floor as staff pushed resident down the hall toward the dining room. Resident observed with no foot pedals on their wheelchair. During an interview on 2/21/25 at 9:57 A.M., Licensed Practical Nurse (LPN) B said: -Resident self-propelled themselves in their wheelchair; -Resident had an auto lock brake on their wheelchair and an anti-tip device in place because they had a history of falling when getting into their chair. During an interview on 2/21/25 at 10:24 A.M., CNA H said: -Resident could self-propel themselves in their wheelchair; -Staff would push resident without foot pedals because resident could hold their feet up. During an interview on 2/21/25 at 12:15 P.M., Director of Nursing (DON) said: -Resident could walk and took off on their own in their wheelchair; -The resident should not have foot pedals on their wheelchair because resident could hold their feet up while being pushed in wheelchair. 2. Review of Resident #58's quarterly MDS, dated [DATE], showed: -Cognition severly impaired; -He/She had no upper or lower extremity impairment; - Dependent on a wheelchair; -Required substantial or maximal assistance with toileting, bathing, lower body dressing putting on and off footwear, rolling left and right, sit to lying, lying to sitting on side of bed, sit to stand transfers, chair to bed transfers, tub transfers, and toilet transfers; - Required partial to moderate assistance wheeling fifty feet with two turns in wheelchair; -Diagnoses included: dementia, Alzheimer's Disease, and muscle weakness. Review of care plan, revised 8/29/24, showed: -Resident used their wheelchair for mobility and propelled themselves, resident would loose their way so staff needed to assist them; -Resident needed assistance to their destinations during the day; -He/She had dementia and did not ambulate, but propelled themselves in their wheelchair. Observation on 2/19/25 at 10:13 A.M. showed resident being pushed by CNA D down center hall without foot pedals on their wheelchair. Observation on 2/19/25 at 1:13 P.M. showed LPN C pushed resident out of dining room with no foot pedals on resident's wheelchair. Observation on 2/20/25 at 7:27 A.M. showed CNA E pushed resident out of their room with no foot pedals and proceeded to push resident from their room to the dining room. During an interview on 2/21/25 at 10:24 A.M., CNA H said: -Resident held their feet up well while staff were pushed them in their wheelchair. During an interview on 2/21/25 at 9:57 A.M., LPN B said: -Resident would self-propel in their wheelchair; -Resident had no falls from their wheelchair. 3. Review of Resident #68's Quarterly MDS, dated [DATE], showed: - Cognition was severely impaired; -He/She had functional limitation in range of motion on both sides of lower extremities; -He/She was dependent on a wheelchair; -He/She was dependent for mobility of sitting to lying, lying to sitting on side of bed, sit to stand, chair to bed transfers, toilet transfers, and tub/shower transfers; -Resident required substantial/maximal assistance rolling left and right; -Diagnoses included: dementia, advanced age, unspecified pain. Review of care plan, dated 1/20/25 , showed: -He/She had senile degeneration of the brain and dementia, were not able to bare weight anymore, and their legs were contracted at the knees; -Resident relied on others for their needs and cares; -Was at risk for falls and had a history of falls with fractures; -Took medication that could affect their level of consciousness, and had dementia with lack of safety skills; -Staff to ensure foot rests were set aside when not being propelled. Observation on 2/18/25 at 10:26 A.M. showed resident's foot pedal was observed under the sink in their resident room. Observation on 2/18/25 at 11:17 A.M. showed resident was sitting in front of nurses station with no foot pedals on their wheelchair. Observation on 2/19/25 at 10:00 A.M. showed CNA F pushed resident from dining room to nurses station. Resident had no foot pedals on their wheelchair. Feet were on the ground as they was pushed. Resident was wearing socks and white sandals. Observation on 2/19/25 at 2:08 P.M. showed CNA D pushed resident down hallway to their room. Resident did not have foot pedals on their wheelchair. Residents feet were observed touching the floor. Resident taken into their bedroom. Observation on 2/19/25 at 2:17 P.M. showed CNA D pushed resident out of their room and down the hallway with no foot pedals on their wheelchair. Resident was placed in front of nurses station. Residents feet were observed moving back and forth in a walking motion as resident was pushed down the hallway. Observation on 2/20/25 at 8:53 A.M. showed hospice staff A pushed resident down hallway to their room with no foot pedals on residents wheelchair. Observation on 2/20/25 at 9:32 A.M. showed hospice staff B pushed resident out of their room in their wheelchair, their feet were observed skimming across the floor as they pushed resident down hallway toward the nurses station. During an interview on 2/21/25 at 10:24 A.M., CNA H said: -Resident could not keep their feet up very well; -Resident had foot pedals on their wheelchair. Observation on 2/21/25 at 9:57 A.M., showed LPN B said: -Resident would self ambulate in their wheelchair; -Resident slid out of her chair on 2/7/25 and it was determined that the foot pedals were the cause of the fall. 4. Review of Resident #71's admission MDS, dated [DATE], showed: -Severe cognitive impairment; - Did not use a mobility device; - Independent with walking up to 150 feet; - Independent with chair to bed transfers and sit to stand transfers; Diagnoses included: Dementia, displaced fracture of seventh cervical vertebra (a broken bone in the seventh cervical vertebra in the neck), anxiety, and history of falling. Review of care plan, dated 2/6/25, showed: - He/She would wander safely within specified boundaries; - Resident was at risk for falls; - Walked independently and had dementia, and required staff to remind them to use their walker; - Had difficulty processing information due to dementia and get easily distracted; -Required staff to set up, cueing, support and assistance level for activities of daily living; -There was nothing care planned regarding use of wheelchair. Observation on 2/19/25 at 9:33 A.M. showed LPN A pushed resident from dining room to nurses station without foot pedals on their wheelchair. Observation on 2/19/25 at 9:57 A.M. showed resident was pushed by hospice staff without foot pedals to shower room. Observation on 2/19/25 at 11:28 A.M. showed CNA C pushed resident down hallways to nurses station without foot pedals on wheelchair. Observation on 2/20/25 at 12:48 P.M. showed Social Services Designee pushed resident out of dining room with no foot pedals on residents wheelchair. During an interview on 2/21/25 at 9:57 A.M., LPN B said the resident would self-propel in their wheelchair. During an interview on 2/21/25 at 10:24 A.M., CNA H said: -Resident could hold their feet up well when staff push them in their wheelchair; -Resident could self-propel themselves in their wheelchair. 5. During an interview on 2/20/25 at 10:35 A.M., CNA E said: -Some residents could hold their feet up on their own and push themselves around -Before we move a resident without their foot pedals we ask the resident if they could hold their feet up; -Staff would make sure the residents foot pedals are out; -Residents should have foot pedals when being pushed in their wheelchairs; -They sometimes could not locate foot pedals because residents would hide their foot pedals under their beds. During an interview 2/20/25 at 10:51 A.M., CNA G said: -Residents could be pushed without foot pedals on their wheelchairs if the resident could hold their feet up; -He/She knew which residents were able to hold their feet up on their own; -A resident would ask for foot pedals when they felt they needed them by saying they were weak on that day; -He/She did not worry about residents hurting or falling cause they would notify staff if they needed their foot pedals; -Foot pedals were not something on the care cards they use for knowing resident specific cares; During an interview on 2/21/25 at 9:57 A.M., LPN B said: -Residents could be pushed in their wheelchairs without foot pedals if the resident could hold their feet up; -Many residents self-propelled themselves in their wheelchairs; -Foot pedals could create a fall hazard for some residents to have them on their wheelchairs. During an interview on 2/21/25 at 10:24 A.M., CNA H said: -Foot pedal use was dependent on whether the resident could lift their feet for facility staff while they pushed them. During an interview on 2/21/25 at 1:15 P.M., Director of Nursing (DON) said: -The facility had multiple residents who self-propel themselves in their wheelchairs; -He/She expected residents being pushed in their wheelchairs and was dependent on staff for mobility had the ability to hold their feet up; -Foot pedals on wheelchairs should be individualized per resident preference; -Residents could obtain skin tears from their foot pedals and it could increase the residents fall risk by having foot pedals on their wheelchair. During an interview on 2/21/25 at 1:15 P.M., Administrator said: -The expectation for residents having foot pedals on their wheelchairs was dependent on the individual resident situation; -She had multiple residents who obtained skin tears as a result of their foot pedals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure staff provided proper respiratory care when staff failed to date when oxygen tubing was cleaned and left oxygen tubing lying on the ground for two residents (Resident #44, #21) resulting in possible exposure to bacteria during oxygen usage. Additionally the facility failed to keep water in the oxygen humidifier for proper humidity control for one resident (Resident #44) resulting in minor discomfort. This affected two of 18 sampled residents. The facility census was 78. Review of the facility's Oxygen administration policy not provided; 1. Review of Resident #44's Annual Minimum Data Set (MDS, a federally mandated assessment completed by the facility staff), dated 12/2/24, showed: - Cognitive skills intact; - Minimal difficulty hearing, clear speech, makes self understood, has clear comprehension, and impaired vision; - Diagnoses: Anemia, heart failure, high blood pressure, diabetes, seizure disorder, asthma, and cataracts. Review of the resident care plan, revised 12/3/24, showed: - Resident requires oxygen therapy with exertion due to dyspnea (shortness of breath) on exertion, COPD (chronic obstructive pulmonary disease). Staff will administer oxygen at 2L via nasal canula during exertion; - Oxygen per physician order 12/2/24 Review of the resident's Physician Order Report, dated 1/19 - 2/19/25, showed an order for Oxygen 2 Liters per nasal cannulat and adjust to keep O2 saturation percentage over 90% with exertion; Review of the resident's Medications Administration History, dated 1/1 - 2/19/25, showed: - No record of Oxygen administration or cleaning of tubing; Review of the resident's Treatment's Administration Record, dated 1/1 - 2/19/25, showed: - No record of Oxygen administration or cleaning of tubing; Observation on 2/18/25 at 4:09 P.M. showed: - Oxygen tubing lying on the resident's floor, water container in oxygen humidifier 1/3 full, no dates on tubing or water bottle indicating last change or cleaned date; Observation and interview on 2/21/25 at 8:55 A.M. showed oxygen tubing lying on the resident's floor, water container completely empty while resident is using the oxygen humidifier and oxygen tubing is inserted in resident's nose; - The resident said their nose hurt slightly due to it being very dry; 2. Review of Resident #21's Significant Change in Status MDS, dated [DATE], showed: - Resident was cognitively moderately impaired; - Independent for eating; - Set-up assistance for oral hygiene; - Partial/moderate assistance for toileting, bathing, and dressing; - Supervisor for personal hygiene; - Diagnosis: atrial fibrillation (heart rhythm disorder), coronary artery disease (condition in which the arteries that supply blood to the heart become narrowed or blocked), heart failure, peripheral vascular disease (narrowing and blockage of arteries), GERD (acid reflux), MRDO (resistant to multiple antibiotics), diabetes (chronic disease when body can't produce insulin), hyperlipidemia (high cholesterol); Review of resident's care plan, revised 2/11/25, showed no care planning for oxygen therapy at night; Review of resident physician orders dated 11/29/24, showed an order for O2 2L/NC while sleeping, no end date; Observation on 2/21/25 at 9:10 A.M. showed oxygen tubing lying on the ground with nose cannula completely exposed and making contact with the dirty surface of the floor. No dates of last tube change or cleaning were taped to the tubing; During an interview on 2/20/24 at 12:45 P.M., CMT B said maintenance cleans the filters on the oxygen humidifiers in resident's rooms. Tubes and water cannisters get cleaned weekly. There are orders on the MAR or TAR to change and date the tubing. Tubing is not to be left on the floor and staff are to Ziplock bag the tubing so it doesn't touch the floor. The proper name for the device is an O2 nasal cannula. Water level should be at least above the minimum line on the water cannister and the water helps prevent residents from getting a bloody nose from dry oxygen; During an interview on 2/21/24 at 1:30 P.M., the administrator and DON said: - Oxygen tubing and nasal cannula should not be on the ground; - When oxygen tubing is cleaned or changed staff should put a piece of tape with their initials and date to show when it was changed;

Based on observation, interview, and record review, the facility failed to ensure staff maintained a medication error rate of less than five percent when nursing taff made two medication errors out of 25 opportunities for error, which resulted in a medication error rate of 8%, which affected two of the 18 sampled residents, (Resident #64 and #11). The facility census was 78. Review of the facility's undated policy titled, Medication Administration, showed staff were directed to do the following: - Medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so; - Personnel authorized to administer medications do so only after sufficient information regarding the resident's condition and expected outcomes of medication therapy is known; - Medications are prepared, administered, and recorded only by licensed nursing, medical, pharmacy, or other personnel authorized by state laws and regulations; - Medications are administered in accordance with written orders of the attending physician; - Residents are identified before medication is administered: check identification band; check photograph attached to medical record, header card, or facility approved location; call resident by name; if necessary, verify resident information with other facility personnel; - Only the licensed or legally authorized personnel who prepare medication may administer it. This individual records the administration on the resident's Medication Administration Record (MAR) at the time the medication is given; - During routine administration of medications, the medication cart is kept in the doorway of the resident's room, with open drawers facing inward and all other sides closed. No medications are kept on the top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by; - Prior to administration, the medication and dosage schedule on the resident's MAR is compared with the medication label. Review of the facility's undated policy titled, Ten Rights for Administration of Medications, showed staff were directed to do the following: - The right resident: before preparing the medication, identify each resident according to the facility's policies and procedures; - The right drug: verify each drug against the MAR before administering. Verify in at least three ways, such as by the drug's size, shape, color, or label; - The right dose and dosage form: verify against the MAR. 1. Review of the website, https://www.clevelandclinic.org for the administration of artificial tears showed: - Wash your hands; - Tilt your head backward, look up and pull down your lower eyelid with your finger; - With the other hand, position the bottle over your open eye and squeeze out the correct number of drops; - Don't touch the tip of the bottle or let it touch your eye; - Close your eye and keep it closed for a little while; - Put a finger on the part of your eye nearest to your nose to keep the medicine in your eye; - Avoid rubbing your eyes right after using artificial tears. Review of Resident #64's Physician's Order Sheet (POS), dated 2/5/25 - 3/5/25 showed: - Start date: 11/3/23 - Geri Care Artificial Tears, instill one drop in both eyes twice daily for dry eyes. Review of MAR, dated 2/6/25 - 2/20/25, showed: - Start date: 11/3/23 - Geri Care Artificial Tears, instill one drop in both eyes twice daily for dry eyes. Observation on 2/19/25 at 8:57 A.M., showed: - Certified Medication Technician (CMT) A washed his/her hands, and donned gloves; - The resident pulled down both lower eyelids; - CMT A placed one drop in the left eye and one drop in the right eye; - The tip of the eye dropper touched the resident's eye lids and eye lashes; - The resident closed his/her eyes for 30 seconds; - CMT A removed gloves and washed his/her hands. During an interview on 2/19/25 at 12:18 P.M., CMT A said: - The tip of the eye dropper should not touch the resident's eye lids or eye lashes. During an interview on 2/21/25 at 12:15 P.M., the Director of Nursing (DON) said: - The tip of the eye dropper should not touch the eye lid or eye lashes. 2. Review of the website, https:// www.medicalnews.com for the use of Fiasp insulin pen showed: - Fiasp is a rapid-acting insulin which should be taken at mealtimes; - Take at the start of the meal or within 20 minutes. Review of Resident #11's plan, dated 1/3/25 showed: - The resident was on Fiasp insulin before meals and took Lantus (long acting) insulin at bedtime; - Monitor blood sugars before meals and at bedtime. Review of the resident's POS, dated 1/20/25 - 2/20/25, showed: - Start date: 3/20/20 - Check blood sugars before meals and at bedtime; - Start date: 11/17/24 - Fiasp Flex touch (fast acting) insulin pen, 10 units twice daily for diabetes mellitus. Review of the resident's MAR, dated 2/6/25 - 2/20/25 showed: - Check blood sugars before meals and at bedtime; - Fiasp Flex touch insulin pen, 10 units twice daily for diabetes mellitus. Observation on 2/19/25 at 11:31 A.M., showed: - Licensed Practical Nurse (LPN) A obtained the resident's blood sugar which was 243; - At 11:43 A.M., LPN A administered Fiasp insulin, 10 units to the resident and informed the dietary staff the resident had taken his/her insulin; - At 12:14 P.M., the resident had his/her tray and started eating, 31 minutes after he/she received the fast acting insulin. During an interview on 2/19/25 at 3:08 P.M., LPN A said after the resident received fast acting insulin, they should be served a meal within 15 minutes. During an interview on 2/21/25 at 12:15 P.M., the DON said the resident should be served their meal immediately after getting the insulin.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Observation on 2/19/25 at 8:19 A.M., of the North medication cart and the North medication room showed: - One loose oblong while capsule in the medication drawer; - Resident #44 had an opened bottle of Age Related Eye Disease Studies (AREDS), an eye vitamin and mineral supplement, expired 1/25; - Resident #44 had an opened bottle of Coreg 3.125 milligrams (mg.) (used to treat high blood pressure), expired 1/16/25. During an interview on 2/19/25 at 12:18 P.M., Certified Medication Technician (CMT) A said: - The CMTs check the medication carts and the medication rooms at least weekly and the pharmacist comes in monthly; - Should not have any loose pills in the medication drawer, it should be destroyed; - Should not use expired medications, they should be destroyed. During an interview on 2/21/25 at 12:15 P.M., the DON said there should not be any loose pills or expired medication in the medication carts or the medication rooms, they should be destroyed. 3. Observation on 2/18/25 at 11:14 A.M. showed the medication treatment cart was left with key in the lock. Cart is located parked outside nurses station and no staff was observed near the cart. There was a sharps container resting on top of the medication treatment cart. Observation on 2/18/25 at 11:16 A.M. showed Licensed Practical Nurse (LPN) C obtained cart with key in it and pushed medication treatment cart down 200 hallway to a resident room. Observation on 2/18/25 at 2:45 P.M. showed medication treatment cart is parked beside nurses station with key left in the lock. No staff observed near the medication cart. During a continuous observation of medication treatment cart on 2/19/25 at 9:35 A.M.-10:35 A.M., showed: -9:35 A.M., showed medication treatment cart was left with key in lock on unit. Staff were observed sitting down at nurses station. Medication treatment cart was outside of nurses station accessible to residents. -9:36 A.M., showed LPN A obtained treatments from cart, removed key from cart. Key was observed left hanging on blue lanyard on side of trash can on the cart. -9:44 A.M., Observation showed key in treatment cart - blue lanyard in the key lock. -10:02 A.M. showed medication treatment cart was left unattended with key in the lock of the medication cart. LPN A observed walking up to the treatment cart and obtained a topical cream out of cart. LPN A walked away from cart and left key remaining in treatment cart. -10:10 A.M., key to cart remained in lock of medication treatment cart, no staff members near cart; -10:22 A.M., key to cart remains in lock of treatment cart with no staff members directly at cart; -10:27 A.M., LPN A returned to medication treatment cart. LPN A opened cart, cut off ace bandage with scissors, and removed key from the lock of cart. Key was left hanging on side of cart from trash can on a blue lanyard. Observation on 2/19/25 at 2:33 P.M. showed medication treatment cart had key left in lock with no staff around medication cart. Observation on 2/20/25 at 11:53 A.M. showed the medication treatment cart had key left in lock, the blue lanyard remains attached to the key to the side of the cart. No staff near cart or accessing treatment cart. The medication cart was parked outside of nurses station. Observation on 2/20/25 at 3:18 P.M. showed key was left in treatment cart on lanyard, no staff observed near the cart. Observation on 2/21/25 at 9:56 A.M. showed treatment cart was unattended with key left in the lock on cart. The key remains attached to blue lanyard which lanyard connects to side of cart by trash can. During an interview on 2/21/25 at 9:57 A.M., LPN B said: -The medication treatment cart key should no be left in treatment cart lock; -The treatment cart contained medicated treatments; -The facility always left the key hanging on the side of the treatment cart. During an interview on 02/21/25 10:47 A.M., LPN A said: -Medication treatment card should be locked; -Licensed Nursing staff should not leave the key stuck in treatment cart lock; -The medication treatment cart should not be left unlocked and unattended; -He/She always leaves the key hanging on side of treatment cart on blue lanyard. During an interview on 2/21/25 at 1:15 P.M., Director of Nursing said: -She expected the medication treatment cart to be secured and locked when it was unattended; -Staff should be within arms reach if it the medication treatment cart was left unsecured; -She expected the medication cart key not be left in the lock and the cart to be unattended; -The treatment key could be left hanging on the medication treatment cart if staff was standing at the treatment cart perparing a medication treatment; -She expected staff to pull key out of the lock when they were not at treatment cart. Based on observation, interview and record review, the facility failed to store medications in a locked storage area to ensure medications for two residents (Residents #5, #44) were inaccessible to unauthorized staff and residents and failed to keep medications secured when the key was left in the lock of the medication treatment cart. Additionally the facility, failed to destroy expired and loose medications in the medication room and cart. This affected two out of 18 sampled residents. The facility census was 78. Review of facility Policy and Procedure for Physicians Orders, revised 1/15/12, showed - An interdisciplinary team determines the resident's ability to self-administer medications by means of a skill assessment; - If the resident demonstrates the ability to safely self-administer medications, a further assessment of the safety of bedside medication storage is conducted; - A physician order is obtained to self-administer medications if the storage and skill assessment has been approved for the resident by the interdisciplinary team. The order is recorded on the Medication Administration Record (MAR); - Noncompliant residents are informed by the nurse or nurse supervisor that they may not self-administer medications or treatments; -Update the residents care plan quarterly of the resident's knowledge and ability to self-administer medications; Review of facility policy, medication storage in the facility, undated, showed: -Medications and biologicals are stored safely, securely, and properly following the manufacturer or supplier recommendations. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. -Medication carts are locked or attend by person with authorized access;; -External medications including ointments for skin irritations and medication for application to wounds should be kept in a treatment cart, or in a separate drawer in the medication cart which is labeled as such. 1. Review of Resident #44's Annual Minimum Data Set (MDS, a federally mandated assessment completed by the facility staff), dated 12/2/24, showed: - Cognitive skills intact; - Minimal difficulty hearing, clear speech, makes self understood, has clear comprehension, and has impaired vision; - Independent for eating, oral hygiene, and toileting; - Substantial/maximal assistance needed for bathing and dressing - Diagnosis: Anemia (blood disorder), heart failure, hypertension (high blood pressure), GERD (acid reflux), pneumonia, diabetes, hyperlipidemia (high cholesterol), seizure disorder, asthma (chronic lung disease), cataracts (clouding of the lens of the eye): Review of resident's care plan dated, 12/3/24, showed: - Resident's vision is highly impaired due to Macular degeneration and Glaucoma; - No record of resident being allowed to self-administer medications; Review of resident's Physician Order Report (POR), dated 1/19 - 2/19/25, showed: - No orders for Refresh eye drops; Observation of resident room on 2/20/25 at 7:46 AM., showed: - 0.5 oz bottle of Refresh Tears at bedside within reach of resident; During an interview on 2/20/25 at 7:48 A.M., the resident said: - His/her daughter [NAME] the bottle around 1/21/25 after a medical procedure and that he/she uses the medication when their eyes get dry; 2. Review of Resident #5's Quarterly MDS dated [DATE] showed: - admission to the facility on 7/10/24; - Cognition intact; - Diagnoses include: Heart Failure, Hypertension (high blood pressure); - Requires staff to provide medications. Review of Resident care plant revised, 1/17/25, showed: - No orders for self-administrator of medication; Observation of resident room on 2/20/25 at 11:15 A.M., showed: - One plastic med cup sitting in front of the resident containing 3 pills (2 white and 1 blue); During an interview on 2/20/25 at 11:16 A.M., resident said: - Staff came into his/her room and gave them their morning medication and when he/she asked the staff member what pills they were, the staff member did not reply and left the room; - The resident said he/she would not take the last three pills until they knew what they were; During an interview on 2/20/25 at 11:45 A.M., CMT B said: - Medications at beside are not allowed unless the resident has an order and this would apply even to over the counter medications; - If he/she saw medications at bedside they would confiscate them and put them in the med storage room; - He/she administered medications to Resident #5 on the morning pass of 2/20/25 and had given the resident their medications. He/she left the room thinking the resident had taken all of their pills but said they must have been mistaken since the resident still had 3 pills at bedside when the surveyor entered the room at 11:15 A.M. that same morning; - He/she said the CMT is supposed to make sure the resident takes all of their medications prior to leaving the room or take them and destroy them if the resident refuses to take the medication; During an interview on 2/21/25 at 12:15 P.M., the DON said: - They would not expect resident's to have over the counter medications at bedside without an order; - They would expect resident's without a bedside order for medications to take all of their medications before the med tech leaves the room;

Based on interview and record review, the facility failed to provide required state approved training for paid feeding assistants which affected 18 residents. The facility census was 78. 1. A policy on paid feeding assistants was not provided for review. Review of a list of paid feeding assistants provided by the facility, dated 2/20/25, showed 5 feeding assistants with no state approved formal paid feeding assistant training. During an interview on 2/20/24 at 3:30 P.M., Nurse Aide (B) said: - He/she did not attend any formal state approved course for feeding assistant but instead got one on one training with the DON and experienced staff members; - He/she has been a feeding assistant for a few months and assists residents on the floor with meals; During an interview on 2/20/24 at 5:00 P.M., Director of Nursing (DON) said: - Each feeding assistant goes through one on one training over a very specific list of topics before going to the floor; - She was not aware of the requirement of a state approved training course for paid feeding assistants but would investigate and get her staff enrolled.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to store, prepare and serve food in accordance with professional standards of food service safety when staff failed to date the receipt of incoming products in the dry storeroom, label and date used products in the freezer and refrigerator, label, date and dispose of leftovers in the refrigerator, monitor refrigerator and freezer temperatures on a daily basis, and follow sanitation requirements for cleanliness, handwashing and hairnets in the kitchen and dining room. This affected all residents by putting them at risk for a food borne illness. The facility census was 78. Review of facility policy Hair Restraints for Dining Service, revised 10/26/21, showed: - Hair restraints shall be worn by all Dining Services staff when in food production, dishwashing areas or when serving food from the steam table. Hair restraints must be worn in the kitchen at all times; - Hair restraints, hats, and/or beard guards shall be used to prevent hair from contacting exposed food, any facial hair that is longer than the eyebrow shall require coverage with a beard guard in the production and dishwashing areas; Review of facility policy Food Storage, revised 10/26/21, showed: - All food will be stored on shelves. No food will be stored directly on any floor surface; - Perishable foods will be stored either in the walk-in cooler/refrigerator or the freezer. Cooler will maintain a temperature of 37-40 degrees F, freezer will be maintained at 0 degrees F; - All food stock will be rotated and consumed in the sequence obtained, First in - First out; - All opened or prepared foods will be stored in air tight/ sealable containers; - All containers will be labeled and dated; - Quality Control: the temperature of both the cooler and freezer will be checked twice daily, a log will be maintained to record the temperatures, the Dietary Manager (DM) will verify that these checks are done; - Food storage areas will be checked on a weekly basis to ensure that foods are being dated when opened and foods are being discarded in a timely manner. All food dates will be checked prior to each use; - Food Storage Times: Cooked meat or poultry (3 days), luncheon meat opened (4 days), Juices & Fruit Drinks (7 days) 1. Continuous observation in the kitchen on 2/18/25 showed: - 8:45 A.M. hand washing station did not have paper towels to dry hands off; Food Prep Area: - (5) Bags of cereal opened with no dates or labels; - Plastic cups stored face up; - Floor need middle area near stove has old food debris and stains; - Top of dishwasher has dirt buildup; - (6) Broken tiles throughout kitchen area, trip hazard and sanitation issue; - Sauerkraut in colander/strainer has loose metal strainer wires exposed and the metal sealing around the utensil is coming off which can house bacteria, metal introduction into food, and safety issue; - Weekly cleaning schedule posted but is blank for 2/16 and 2/17 and shows not completed; - 11:30 A.M. [NAME] (B) does not have beard covered with hair net; - Kitchen area very cluttered and unorganized with (3) carts blocking a door; - Kitchen prep area has very little working surfaces due to utensils and dishware not stored and taking up space; - Broken ice chest with various random items stored in it lying on top of a clean dish cart; - The temperature log for the refrigerator and freezer are not up to date; Dry Storeroom: - Bag of rice opened and undated; - Bag of graham cracker crumbs, opened and undated; - Box of sprinkles, opened and undated; - 1000 island dressing containers (3) no receipt dates; - Dented can of nacho cheese used to hold door open to storeroom; - Single servings of applesauce loose with no dates; - No dates on Oreo cookie case boxes, honey bun case boxes, or Ritz bits cracker case boxes, unable to determine if first in first out is followed by this receipt and storage system; - (3) large plastic containers of heavy-duty mayo no dates; Freezer - Opened, resealed fish parts no label or date; - Red raspberry sherbet opened, no date; - Loose bags of peas (5), green beans (10), brussel sprouts (5), unopened, no dates; - Frozen french fries, resealed no dates; - Large frozen turkey in corner of freezer lying on the floor; - Bowl of single serving sherbet on the ground, no label or covered; - Single serving package of pudding on the ground; - Box of pork chops uncovered and exposed in box to air; - Frozen meat raw on the ground; - (2) single serving sherbet on ground under rack; - No thermometer to read in the freezer to record temperature; Refrigerator - Virginia ham package 32oz undated; - [NAME] onion (raw and rotten) hanging off shelf grid; - Leftover expired corn beef dated 2/6 (12 days old); - Leftover expired oven roasted turkey breast dated 2/13 (5 days old); - (3) cannisters of cottage cheese no dates unopened; - Leftover expired thick and easy nectar opened 2/5 (13 days old); - Spilled oil under three storage racks; Continuous observation in the 100-300 hall dining room on 2/18/25 showed: - 12:04 P.M. Staff member in dining room wipes mouth with the back side of their gloved hand, continues serving; - 12:07 P.M. Dietary staff passing trays to residents wearing gloves and not changing them between each tray of food passed out. Staff member touches back of he chair, a wheelchair and then enters kitchen to pour drinks and opens and closed the refrigerator without hand washing; - Dishwasher (A) in kitchen has a beard cover that is positioned under the beard and not covering the exposed hair; - Staff member in kitchen has a beard cover but it does not cover moustache or sideburns; - Dietary staff resting their gloved hands-on serving surfaces between residents; - 12:09 P.M. Staff are not changing gloves or sanitizing between serving resident meals; - 12:10 P.M. CNA (I) assisting resident in drinking bends over resident's food cups and staff member's beard is touching resident's straw that is in one of their food cups; - 12:22 P.M. Dining Assistant (B) comes out of kitchen and serves resident, goes back to the serving counter still wearing gloves and does not wash hands upon entry to kitchen. CNA (I) comes out of kitchen and serves resident, re-enters kitchen, does not wash hands, still wearing same gloves; - 12:23 P.M. CNA (I) waiting for next tray and still hasn't washed hands, goes back into the kitchen and gets a new plate and serves resident and returns to kitchen, no hand washing; - 12:33 P.M. CNA (I) continues to enter and exit kitchen serving meals and not washing hands or changing gloves; Continuous observation in the 400-500 hall dining room on 2/18/25 showed: - 12:10 P.M. CMT (B) without gloves on or washing their hands touched a resident's silverware to help them to eat; - 12:21 P.M. Ice water pre-staged in dining room are in glasses which are not covered and open to the air and dust; Continuous observation in the 400-500 hall dining room on 2/19/25 showed: - 11:56 A.M. Dining Assistant (A) pushed food cart from kitchen to dining room with gloved hands, handled dirty electrical cord at bottom of cart and plugged it into socket. Started serving drinks to residents without washing hands or changing gloves; - Dining Assistant (A) served residents fresh fruit cups at a table and left to serve another table. Residents from the first table said they didn't want the cups so the Dining Assistant (A) removed the two fruit cups and put them back into the stock of fruit cups that were handled out to the rest of the residents; Continuous observation in the kitchen on 2/20/25 at 9:10 A.M. showed: - Dented can still holding open door to storeroom; - Monday morning cleaning log now signed off, 2/16, 2/18, & 2/19 cleaning log is blank as completed; - (4) carts around dishwashing station causing a cluttered environment with trip hazards; - Tubing from the sanitizer next to the stove is unconnected and lying on the floor in the walking path, trip hazard; - Front and side of stove has dried food stains on the surfaces and appears not cleaned for some time; Storeroom [ROOM NUMBER] - Bread on trays with no receipt dates; - (5) 5lb containers of peanut butter, no dates; - Dirty dust mop stored next to bottled water and bread; - Plastic ware utensils stored on shelf open and not covered; Refrigerator - Opened and resealed turkey meat no dates; - Carton of whipping cream unsealed with no date; - Snack box of cheese sticks, fresh fruit and Ensure boxes with no dates on the non-fruit items; Continuous observation during lunch preparation in the kitchen on 2/20/25 showed: - 10:20 A.M. no paper towels at the hand washing station; - Bread stored on top of menu books against the wall; - DM enters kitchen from hallway without hand washing and picks up dessert containers of food and stores them; - Dining Assistant (B) washes hands at washing station but turns off faucet with bare hand contaminating his/her hands in the process because there were no paper towels; - Dining Assistant (C) changed gloves but did not wash hands; - 10:45 A.M. [NAME] (A) pulls up pants with gloved hands then touches frozen/defrosting meat in sink, puts on new pair of gloves without washing hands; - [NAME] (A) working with raw meat while wearing gloves, removes gloves and grabs tin foil to cover meat without washing hands, outside of tin foil is now contaminated; During an interview conducted on 2/20/25 at 10:05 A.M., the DM said: - They expect that daily cleaning is done and deep cleaning is conducted every 3 months by wiping down walls and shelves and getting behind equipment; - The cooks, aides and the DM are doing the daily cleaning and expectations are that equipment, countertops and floors are cleaned including the steam table and sweeping and moping the floors; - If the cleaning log is not signed off the DM doesn't know if the daily cleaning has been completed; - The policy on dented cans is to not use them but they don't put any marking on them and there's nothing to stop someone from grabbing the dented can holding the door open and using it when the DM is not around; - It is expected that no food items will be stored on the ground and all incoming material is put away in two hours; - It is expected that received dates are put on all items incoming into the storeroom; - Opened boxes of cans and food also get a date when the case carton is opened; - All refrigerator and freezer temperatures are monitored by the administrator and maintenance through a computer system and they no longer record temperatures daily or check to see if the food temperatures are being maintained visually; During an interview on 2/20/25 at 1:45 P.M., Dietician said: - Would expect kitchen surfaces and floor to be cleaned daily; - Would expect the pathways through the kitchen to be free of clutter and trip hazards; - Would expect refrigerators, freezers and storerooms to not have food containers or items on the floor; - Would expect packages to have open dates placed on the outside of each package; - Would expect daily temperature checks for the freezer and refrigerator to be monitored and recorded daily one to two times; - Would expect leftovers to be kept 3 days only before disposing of and in accordance with published policies; - Would expect all packaged food items to be labeled as to their contents; - Cups should be stored upside down; During an interview on 2/20/25 at 2:40 P.M., Maintenance Supervisor said: - The Administrator implemented a new temperature application that monitors the refrigerator and freezer. The monitoring program is not officially online and there is no policy, but he has a phone application he can open to see the temperatures and it should send an alarm to him if the temperatures are out of specification. The system hasn't been tested as far as he knows and he doesn't check the temperatures daily or record what they are during the day; During an interview on 2/21/25 at 11:21 A.M., Dishwasher (A) said: - Hairnet requirements are to cover all the hair on your head including beard and mustache; - He/she has had training in hygiene, proper handling of utensils, and drink handling; - Their job covers doing the dishes, passing out halls trays and sometimes serve meals in the dining room but no food preparation; - Observation during the interview showed that Dishwasher (A) was wearing a beard net in the kitchen but did not cover up his/her moustache; During an interview on 2/21/25 at 1:30 P.M., Administrator said: - Staff members should wash their hands and/or don gloves prior to touching a resident's silverware to assist them in eating; - Pre-staged drinks should not be left uncovered and sitting in the dining room; - If staffs gloves become dirty, torn, or contaminated at meal service staff members need to wash their hands after taking off the gloves and put on fresh gloves; - It is expected that kitchen personnel with wear hair coverings and beard nets to cover all hair longer than their eyebrows; - Staff should wash their hands upon entering the kitchen each time; - She expects paper towels to be available at the hand washing station in the kitchen; - She expects cooking utensils to be in good repair and report to the administrator if they are not; - She expects that staff members annotate on boxes when items are received into the kitchen but if they are removed from the cartons no dates are required; - She expects leftovers to have storage dates and labels; - She expects opened containers in storage to be resealed tightly with open dates and food labels affixed; - She would not expect food items to be stored on the ground; - Cans with visible dents should be sent back or disposed of immediately; - There is a temperature monitoring application in place that is not completely finished. There are sensors in the freezer and the refrigerator to notify staff when it's out of specification. It's is not completely documented in the QAQI process and no one is recording temperatures and there have been no checks to verify the temperatures are accurate between the program and the actual temperature sensors. She would not expect to have thermometers in the freezer or refrigerator anymore with the application in place. There is no plan in place if the sensors fail because there's no reason to believe that technology will fail in this process; - There will also be checks in the application to make sure daily cleaning is signed off by staff.

Based on observations, interviews, and record reviews, the facility failed to revise comprehensive person centered care plans, when the facility failed to develop and revise an oral intake dietary care plan for Resident #67 who was previously dependent upon nourishment by a percutaneous endoscopic gastrostomy tube (PEG-tube, a tube inserted through the belly that brings liquid nourishment, hydration and medication directly to the stomach). The facility census was 68. The facility did not provide a policy on care plans. 1. Review of Resident #67's admission Minimum Data Set (MDS), A Federally mandated assessment completed by facility staff, dated 8/25/23, showed: -Brief interview mental status (BIMS) score, a mandatory tool used to screen and identify the cognitive condition of residents upon admission into long term care facility, showed level 9, indicating moderately impaired cognition; -Diagnoses included moderate protein-calorie malnutrition, dysphagia (difficulty swallowing foods or liquids) following a stroke, encephalopathy (a brain disease that alters brain function or structure), and a brain aneurysm; -Eating was indicated as not applicable; -Received 51 percent intake by artificial route. Review of base line care plan, dated 8/18/23, showed: -Long-term care due to safety requiring daily nursing cares, medication management, and percutaneous endoscopic gastrostomy (PEG) tube; -admitted from local hospital following bleeding in space that surrounds the brain. -Diagnosis of hemiplegia (paralysis of limbs on the left side of body) and speech slightly delayed, very soft spoken, and alert & oriented. -admitted with peg tube placed in right upper quadrant, nothing by mouth (NPO) status, continuous feeding Osmolite 1.2 @ 55ml/hr, 100 ml H2O (water) flush every 4 hrs, all meds via (through) tube, indwelling urinary catheter (a tube that is inserted into the bladder to drain the uring outside of the body) in place and patent (flowing without difficutly), no skin issues. Review of care plan, dated 8/31/23, showed: -No update made to the resident's care plan when resident was removed from NPO (nothing by mouth status) on 9/27/23 and started pureed diet; -He/she was still nothing by mouth, dependent on staff for all hydration via peg tube; -Maintain nothing by mouth status, was still care planned. -He/she had a aneurysm rupture causing a subarachnoid hemmorhage (brain bleed) and had left hemiplegia. A PEG tube placed due to swallowing problem. He/she was nothing by mouth and received all nutrition fluids and medication through his/her peg tube; -Osmolite 1.2 at 55 milliliters/hour continuous. Review of physicians ordered dated 10/26/23, showed: -Nothing by mouth discontinued on 9/27/23; -Started pureed diet on 9/27/23; -Ended pureed diet on 10/16/23; -Started mechanical soft diet on 10/16/23; -Started Osmolite 1.5 kilocalorie/milliliter; amount 200 mililiters; gastric tube with Special Instructions: BOLUS (single large dose) three times a day at 8:00 P.M., 12:00 A.M., and 4:00 A.M. on 10/23/23 During an interview and observation on 10/23/23 at 12:39 P.M., resident viewed with a feeding tube in place. He/She said it ran once a day and was now eating meals orally. He/She said the feeding tube had been in place for three months but was trying to get off of it due to getting nauseated. Review of the resident's electronic medical record., showed: -On 10/23/23 at 1:14 P.M., Received orders from physician to change Osmolite 1.5 cal to bolus of 200ml three times daily during the night shift. Resident had not been tolerating larger amounts of osmolite and then was unable to eat any food because he/she felt too full. Resident was drinking fluids orally, so flush was reduced to 30 cubic centimeter (cc) after each bolus feeding. -On 10/17/23 at 12:50 P.M., Dietician Recommendations: discontinue current enteral feedings and replace with Osmolite 1.5 360ml bolus four times a day 6pm-10pm-02am-06am- followed with 150cc H2O flush after each. -On 10/16/23 at 4:00 PM, physician completed new orders to change diet to mechanical soft, thin liquids, small bites drinks after bites. Stop tube feeding at 6am-6pm daily to increase his/her appetitie. Resume Osmolite 60ml/hr from 6pm-6am. -On 10/10/23 at 1:42 P.M., oral diet advanced to Pureed with swallow precautions following swallow eval. Resident did not like pureed food, trial of mechanical soft noted. Enteral regimen continued Osmolite 1.5 @ 55ml/hr, 150ml H2O flush q4hr. Resident asked for tube feeding to be paused multiple times daily to allow for eating/smoking. Would d/c (discontinue) current enteral regimen (tube feeding plan), start Osmolite 1.5 boluses of 360ml QID (Four times a day), with 150ml H2O flush after each to allow for increased oral intake/wt gain. -On 10/10/23 at 1:12 P.M. He/She asked for his/her tube feed to be paused multiple times a day to go smoke or go visit with family. His/Her appetite was much better on those days, but he/she was not having as much tube intake on those days. -On 10/3/23 at 2:53 P.M., Resident had been tolerating a pureed diet with thin liquids very well. He/She preferred to eat in his/her room for most meals. Today he/she asked about advancing his/her diet, as he/she did not like the pureed food. -On 9/28/23 at 8:39 A.M., Resident tolerated chocolate malto meal a thicker texture this morning. Tolerated small sips of water and few of coffee. -On 9/21/20 at 12:03 P.M., Order faxed for flexible endoscopic evaluation of swallowing. -Review of scanned written doctor's orders and reports showed: -On 9/20/23, swallow study ordered 9/20/23 -On 9/21/23, pureed diet ordered 9/27/23 to start for 2 weeks -On 9/25/23, swallow study recommended solids including minced and moist, mechanical soft, no mixed textures, liquids: thin via cup only, avoid straws at all times. Resident to be upright 90 degrees during, 60 minutes after meals, and snacks. Resident to avoid straws at this time. Review of facility care cards showed resident's diet was nothing by mouth due to he/she had a feeding tube. During an interview on 10/25/23 at 8:15 A.M., Certifed Nurses Aide (CNA) A said: -He/She did not look at care plans; -He/She would know resident specific cares by looking at care cards; -The Director of Nursing (DON) updated care cards. During an interview on 10/26/23 at 10:33 A.M., Certified Medication Technician (CMT) B said: -He/She did not do anything to assist with coordination of care plans; -He/She did not look at care plans; -He/She would suggest to a nurse if a care plan needed updated or changed. During an interview on 10/26/23 at 10:46 A.M., Restorative Aide (RA) A said: -He/She would read information in care plan, if there was something new on resident. During an interview on 10/26/23 at 10:47 A.M., Registered Nurse (RN) B said: -He/She did not update care plans; -He/She would notify the MDS Coordinator if something in care plan needed changed. During an interview on 10/26/23 at 12:52 P.M., MDS Coordinator said: -He/She would update care plans if there was a change in resident diets; - The resident's care plan updated, he/she was 100% tube fed and was recently switched; -He/She had not received the resident's dietary recommendation back yet; -Care plans are updated when nurses or DON advise him/her of a change; -There was a place in the electronic medical record that staff can notify him/her of order changes; -He/She reviewed report sheets to know of care plan updates. During an interview on 10/26/23 at 2:16 P.M., the DON said: -Care plan updating is a collaborative effort; -MDS coordinator and DON do most care plan updating; -He/She would not expect nurses to update care plans or add in interventions; -Care cards are updated weekly for staff; -Expected care plans to be updated in a reasonable time but depends on situation; -He/She would expect dietary intake changes to be care planned with seven days. During an interview on 10/26/23 at 2:40 P.M., the Administrator said: -He/She believed everything in physician's order was just a part of resident's overall care plan and did not want to duplicate; -Care plans should be updated with any significant change in resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #18's Quarterly MDS dated [DATE], showed: -No cognitive impairment; -Independent with eating; -Dependent for bed mobility and for bed to chair transfer/chair to bed transfers, no effort by the resident was used to complete the activity; -Indwelling catheter; -Incontinent of bowel; -Diagnoses included, high blood pressure, paraplegia (paralysis of the legs and lower body) and anxiety. Review of Resident #18's Physician Order Sheet dated [DATE] showed: -Admit to the facility on [DATE]; -Regular diet; -Full code; -Change catheter bag weekly on Sunday; -Record catheter output every shift; -Apply tubi grips to both legs, on in the morning and off at night (elasticized tubular bandage used to provide support); -May crush medications; -Doxycycline Monohydrate ( used to treat bacterial infections )100 mg, give one capsule daily. Review of the Resident's electronic medical record showed no baseline/initial care plan was completed. During an interview on [DATE] at 11:44 A.M. Licensed Practical Nurse (LPN) B said: - The MDS Coordinator completes the baseline care plan. -The admitting nurse may do an initial information sheet and print it for the aides, if resident comes in on weekend. -Charge Nurses do not update the care plan. Changes should be communicated to the MDS Coordinator by an email or phone call. During an interview on [DATE] at 12:52 PM the MDS Coordinator said: -Baseline care plans should be completed within 48 hours. -The baseline care plan is a form in the EHR (Electronic Health Record). -If he/she is not in the facility the charge nurses should complete the baseline care plan. -He/she usually gets it completed within 72 hours at the most. During an interview on [DATE] at 1:04 P.M. Courtesy Tech. B said: -Most information about the residents, he/she had found out on his/her own while working. -He/she should have access to the kiosk (a computer station for charting) as he/she charts meals. -He/she accessed the kiosk once to view a care plan. -He/she has worked in the facility for over two years. During an interview on [DATE] at 2:16 P.M. the Director of Nursing said: - The Charge nurse who admits the resident is the one responsible for the baseline/initial care plan. -An initial care plan should be in the resident's chart. -An initial care plan must be done so aides know how to care for that person. -He/she cannot think of a reason that a baseline care plan would not be completed. During an interview on [DATE] at 2:40 P.M. the Administrator said: -A baseline care plan is to be completed within 24 hours of admission. -Charge nurses should complete it upon admission unless the MDS Coordinator is available. -Completion of the baseline care plan is part of the admission nursing checklist. -The initial care plan is a paper form that is scanned into the electronic health record when completed. -There is no Medical Records person, so scanning information into the record is a group effort. Based on observation, interview and record review the facility failed to develop and implement a base line care plan consistent with the resident's specific conditions, needs and risks to provide effective person centered care that met professional standards of quality care within 48 hours of admission to the facility and failed to ensure the resident and representative, if applicable, were informed of the initial plan for delivery of care and services by receiving a written summary of the baseline care plan for two of the 17 sampled residents (Resident #45, and #18). The facility census was 68. The facility did not provide a policy on Baseline Care Plans. 1. Review of Resident #45's admission Minimum Data Set (MDS: A Federally mandated assessment tool completed by facility staff) showed: -Brief Interview of Mental Status (BIMS) of 99, indicated significant cognitive deficit. -Wandered daily. -Wandering placed the resident at significant risk of being in potentially dangerous places or positions. -Occasional incontinence of bladder. -Diagnoses of Adjustment Disorder with mixed anxiety and depressed mood (feeling worried, anxious,overwhelmed, and depressed), Dementia with behavioral disturbances (a brain disorder that causes loss of skills and abilities with symptoms of anxiety, agitation and depression). Alzheimer's Disease (a progressive brain disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment appropriately) Insomnia (a sleep disorder characterized by trouble falling asleep, staying asleep, or getting good quality sleep), hypertension (high blood pressure) Atrial Fibrillation (fast, irregular heart beat ) Review of Resident #45's Physician Order Sheets for September showed: -Admit to the facility on [DATE] with Hospice services. -Regular diet. -Full code (if resident is found without pulse or respiration, Cardiopulmonary Resuscitation (CPR) will be started/attempted) -Skilled Therapy services for neuromuscular re-education ( a series of therapeutic techniques to restore normal function of nerves and muscles, to include movement, balance, coordination) -Xarelto (a blood thinning medication used to treat Atrial Fibrillation) 20 milligrams (mg) once a day. -Sertraline (an antidepressant medication) 50 mg once a day. -Trazadone (antidepressant medication) 50 mg once a day at bedtime. -Seroquel (an antipsychotic medication used to treat Dementia with behavioral disturbance) 12.5 mg three times daily. -Risperidone (an antipsychotic medication) 0.5mg twice a day. -Ativan (an antianxiety medication) 0.5mg three times a day as needed for anxiety. Review of the current care card (a guide sheet of resident needs updated weekly by the Director of Nursing) dated [DATE] does not show wandering or elopement risk. Review of the Resident's electronic medical record showed no baseline/initial care plan was completed. During an interview on [DATE] at 1:10 PM Restorative Aide B said: -He/she thinks risk for elopement /wandering might be on the care cards at the desk -He/she had access to the kiosk to get a care plan only if more in depth information on a resident was needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #67's admission MDS dated [DATE], showed: -BIMS score of 9, indicating moderately impaired cognition; -Diagnoses included Chronic Obstructive Pulmonary Disease (COPD) (A lung disease that blocks airflow and made it difficult to breathe.), sixth nerve palsy right eye-lateral rectus palsy (occurs when the sixth cranial nerve is damaged or doesn't work right causing eye to turn inward toward nose), and hypertension (high blood pressure). -Vision is adequate seeing fine detail, including regular print in newspapers/books; -He/she did not wear corrective lenses; -He/she did not have current tobacco use; Review of care plan, dated 8/31/23, showed: -Smoking not care planned; -Vision issues not address in care plan. During an interview and observation on 10/23/23 at 12:41 PM, Resident said: -He/she is a smoker; -He/she used to be monitored but is not allowed to go out independently during smoke breaks. -Wearing an eye patch over right eye; -He/she had a stroke and now he/she has double vision. Now he/she wears an eye patch to help improve double vision problems. Review of electronic medical record showed: -Smoking assessment completed 10/4/23 indicated he/she was a safe smoker and could follow facility smoking policy. Review of facility smoking, vaping, and tobacco use policy, dated 4/1/2020, showed -Residents will have smoking risk observation done upon admission and quarterly to evaluate whether the resident is a safe smoker; -If resident is deemed to be a safe smoker, they will not need to be supervised while smoking; -If resident is an unsafe smoker, they must be supervised in designated smoking area; -Unsupervised smokers may smoke outside in the circle drive area; -Residents (both safe and unsafe) may smoke outside the 300 hall exit, an area known as the gazebo. Unsafe smokers must always be supervised by staff. Review of care cards did not address resident eye patch or being smoker. During an interview on 10/25/23 at 8:15 A.M., CNA A said: -He/she did not look at care plans; -He/she would know resident specific cares by looking at care cards; -The Director of Nursing updated care cards. During an interview on 10/26/23 at 10:33 A.M., CMT B said: -He/she did not do anything to assist with coordination of care plans; -He/she did not look at care plans; -He/she would suggest to a nurse if a care plan needed updated or changed. During an interview on 10/26/23 at 10:46 A.M., RA A said: -He/she would read information in care plan if there was something new with a resident. During an interview on 10/26/23 at 10:47 A.M., Registered Nurse (RN) B said: -He/she did not update care plans; -He/she would notify MDS Coordinator if something in the care plan needed changed. During an interview on 10/26/23 at 12:52 P.M., MDS Coordinator said: -He/she would update care plans if there was a change in resident diets; -Care plans are updated when nurses or Director of Nursing advise him/her of change; -There is a place in the electronic medical record that staff can notify him/her of order changes; -He/she reviews report sheets to know of care plan updates. During an interview on 10/26/23 at 2:16 P.M., the DON said: -Care plan updating is a collaborative effort; -MDS coordinator and DON do most care plan updating; -He/she would not expect nurses to update care plans or add in interventions; -Care cards are updated weekly for staff; -Expects care plans to be updated in a reasonable time but depends on situation; -He/she would expect dietary intake changes to be care planned with seven days. During an interview on 10/26/23 at 2:40 P.M., the Administrator said: -He/she had believes everything in physician's order is just a part of resident's overall care plan and did not want to duplicate; -Care plans should be updated with any significant change in resident. 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 two of the 17 sampled residents (Residents #58, and #67). The census was 68. The facility did not provide a policy on Care Plans. 1. Review of Resident #58's significant change Minimum Data Set (MDS: A Federally mandated assessment tool completed by facility staff) dated 7/18/23., showed: -Brief Interview of Mental Status (BIMS) score of 99, indicated severe cognitive deficits. -He/she wanders 1-3 days. -Independent for Activities of Daily Living. -Always continent of bowel and bladder. -Diagnoses of : Vascular Dementia with psychotic disturbance (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain causing the person to have difficulty distinguishing what is real and what is not), wandering (traveling aimlessly from place to place), Anxiety disorder (persistent and excessive worry that interferes with daily activities), vertigo (a sensation that you or things around you are moving or spinning) Review of the resident's physician orders for October 2023 showed: -Do Not Resuscitate (DNR: do not attempt cardiopulmonary resuscitation if resident is found to have no heartbeat and no respirations). Review of the resident's Comprehensive Care Plan dated 9/21/23 showed: -The resident has Vascular Dementia, mood disorder and anxiety. He/she wants to attend activities that he/she would enjoy participating in. He/she feels like he/she needs to keep looking, walking or going. He/she needed staff assistance to divert energy and attention. -No care plan addressed the resident's tendency to exit seek, open exit doors, or entrance into other resident's rooms. -No care plan addressed the resident's DNR status. Review of the Care Cards (a flow sheet used to communicate needs between staff) updated 10/23/23 does not show that Resident #58 wanders or is an elopement risk. Review of Nurse Progress Notes showed: -On 4/08/2023 at 10:30 P.M. the Resident had been restless during the evening. He/she opened 400 hall door once setting off the alarm. He/she did not go outside. The resident went to the door a second time, but did not open it. Staff redirected him/her and got him/her settled into bed. -On 7/07/2023 at 6:57 P.M. the resident had been ambulating about the facility all day. That p.m. he/ she was very tired and continued to walk around. On 8/27/2023 at 10:18 A.M. the resident was very anxious, pacing and fidgeting more so than usual. Family was in the facility and reported he/she complained of back pain. As needed medication was administered for pain. Observations on 10/24/23 at 10:28 A.M. showed the resident walking throughout the building and entering and exiting other resident rooms. Observation on 10/25/23 at 8:56 A.M. showed the resident opening the back dining room doorway, leading to outside stairs. Certified Medication Technician (CMT) A responded to the door alarm; redirected the resident to the breakfast table. Observations on 10/25/23 between 11:10 A.M. and 11:30 AM showed Resident #58 opened the courtyard door. CMT B responded when the door alarmed. CMT B redirected the resident away from the door by telling him/her it was time to get a jacket because it was raining outside. CMT B then walked away from the resident. The resident then returned to the door, pushing it open again and stepped into the courtyard. CMT B returned to the alarming door and redirected the resident inside the building, telling him/her he/she needed a jacket to be outside. The resident then walked down the hall and CMT B returned to the medication cart. During an interview on 10/26/23 at 11:44 A.M. Licensed Practical Nurse (LPN) B said: -He/she was not aware of any elopement risk assessment. He/she only knows a resident is an elopement risk if that is noted in records for new residents. There is no book or any symbol to indicate residents who are an elopement risk. He/she tries to redirect the resident if he/she is at one of the doors. He/she does not know if there are specific interventions to use for Resident #58. During an interview on 10/26/23 at 12:52 PM the MDS Coordinator said: -He/she is the only one who updates care plans. -Care Plans should be individualized. -He/she has been out of the facility recently. -Code status should be care planned. During an interview on 10/26/23 at 1:10 P.M. Restorative Aide (RA) B said elopement risk and wandering might be on the care cards at the nurses station. He/she has access to the care plan if he/she needs more information on a resident. Residents who are a full code have a green dot on the door. During an interview on 10/26/23 at 2:16 P.M. the Director of Nursing (DON) said: -Care plans should be resident specific. -Care plans should include code status. -Updates to the care plan are made by him/her and the MDS Coordinator. During an interview on 10/26/23 at 2:40 P.M. the Administrator said: -Physician's orders should be care planned. -Care plans should be specific to each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Review of Resident #19's admission MDS, dated [DATE], showed: -BIMS of 11 showed moderate cognitive impairment. -Diagnoses included chronic kidney disease (gradual loss of kidney function over time), obstructive sleep apnea, retention of urine, chronic obstructive pulmonary disease (COPD) (a group of lung diseases that block airflow and make it difficult to breathe). -Received respiratory treatments Review of physician's orders, dated [DATE], showed: -No order for oxygen concentrator. Review of care plan, dated [DATE], showed: -Make sure he/she wears oxygen at night at 2 liters per minute via nasal cannula. During an observation and interview on [DATE] at 3:20 P.M. observed an oxygen concentrator with tubing dating 10/23. Resident stated he wears oxygen at night. Review of electronic medical record showed: -Oxygen saturation reading taken [DATE] at 7:51 A.M. showed 98% -Oxygen saturation reading taken [DATE] at 7:01 A.M. showed 93% Review of hospice book on [DATE] at 10:31 A.M. showed the following orders: -admitted to hospice on [DATE]; -[DATE], 02 at 2-5 liters PRN (as needed) comfort; -[DATE], 5 liter 0 2, ordered by Medical Director. During an interview on [DATE] at 10:33 A.M., CMT B said: -Hospice communicates with nurse before and after visit; -Physician's orders are required for someone to have oxygen; -Oxygen orders should be same for facility and hospice During an interview on [DATE] at 10:46 A.M., Restorative Aide (RA) A said resident wore oxygen at night when he/she is sleeping. During an interview on [DATE] at 10:47 A.M., RN B said: -Hospice orders and physician's orders should match each other; -Hospice stops by desk first thing upon arriving to building, and provides a sheet of paper to fill out to include any new orders and any PRN medications we have used with resident. During an interview on [DATE] at 11:44 A.M., LPN B said: -He/she had to have a doctors order for oxygen or to change oxygen levels on a resident. During an interview on [DATE] at 2:16 P.M., Director of Nursing (DON) said: -Oxygen therapy is a standing order from our medical director; -Oxygen orders should be listed in physician's orders; -There would be a progress note of why oxygen is being used; -Orders are sometimes received electronically; -He/She would expect telephone orders to be in computer. Based on observation, record review and interviews, the facility failed to provide care and treatment in accordance with professional standards of practice when staff failed to discontinue a physician's order for a Do Not Resuscitate (DNR) code status after a new physician's order for a Full Code status was received for Resident #18 and additionally failed to discontinue a physician's order for a Full Code status after a new physician's order for a DNR code status was received for Resident #64, and failed to document a diagnosis for a medication used by Resident #41 and when the facility failed to obtain a physician's orders for oxygen for Resident #16 and Resident #19. The facility census was 68. Review of the undated facility provided policy for Physician Orders showed in part: -It is imperative that we have clear and concise communication between the physician and nursing staff in order to reduce errors in executing a physician's plan of treatment. If an order is not clear, contact the physician for clarifications. Make sure the order is transcribed into the electronic chart. Review of facility policy titled, Resident Care Policies, showed -Medical orders for patient care: The medial orders are written by the resident's physician and renewed monthly, following discussion with the supervising nurse. The Director of Nursing will carefully review orders and see that they are properly followed. 1. Review of Resident #18's Quarterly Minimum Data Set (MDS: a federally mandated assessment tool completed by facility staff) dated [DATE], showed: -No cognitive impairment; -Independent with eating; -Dependent for bed mobility and for bed to chair transfer/chair to bed transfers, no effort by the resident was used to complete the activity; -Indwelling catheter; -Incontinent of bowel; -Diagnoses included, high blood pressure, paraplegia (paralysis of the legs and lower body) and anxiety. Review of the resident's care plan dated, [DATE] showed the resident was a Full Code. Review of the resident's Physician Order Sheet (POS), dated [DATE] through [DATE], showed: - Start date: [DATE] - Full Code with end date; - Start date: [DATE] - DNR with no end date. Observation and interview on [DATE], at 02:15 P.M., showed: -The resident had a green dot on the name plate outside of his/her room; -The resident said she is a Full Code and want's Cardiopulmonary Resuscitation - (CPR -an emergency procedure to preserve life). 2. Review of Resident #41's Quarterly MDS dated [DATE], showed: -Severe cognitive impairment; -Independent with eating; -Dependent for bed mobility and for bed to chair transfer/chair to bed transfers, no effort by the resident was used to complete the activity; -Incontinent of bowel; -Diagnoses included, high blood pressure, heart failure and Diabetes Mellitus ( disease, involving inappropriately elevated blood sugar levels). Review of the resident's care plan dated, [DATE] showed: -Assistance of two staff with transfers and toileting; -Report signs of urinary tract infection; -The care plan not address the use of antibiotics. Review of the resident's POS, dated [DATE] through [DATE], showed: - Start date: [DATE] - Cephalexin (antibiotic used to treat infections) 500 milligrams (mg), give one capsule, three times a day; -No diagnosis for the use of the medication was found. During an interview on [DATE], at 2:32 P.M., Licensed Practical Nurse (LPN) B said: -All medications should have a diagnosis to show why they are given; -When new orders are received form the physician, the old orders should be discontinued; -Resident's should only have one order for code status. 3. Review of Resident #16's quarterly MDS dated [DATE] showed: -Brief Interview of Mental Status (BIMS) of 9, indicated some cognitive deficit. -No shortness of breath and no use of O 2. -Limited to extensive assistance of staff with Activities of Daily Living (ADL's: tasks done within a day to care for oneself such as bathing, toilet use, eating, moving from one point to another) -Diagnoses of Dementia (a progressive disease of the brain that effects the ability to understand and complete normal tasks), Adult failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, and impaired immune function), history of mouth cancer, Bipolar disorder (a serious mental illness that causes unusual shifts in mood, ranging from extreme highs to lows) , Adjustment disorder with mixed anxiety and depressed mood, (excessive reactions to stress that involve negative thoughts, strong emotions and changes in behavior including nervousness, agitation, and sadness or hopelessness), Chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems). Review of Physician's orders in the electronic health record for [DATE] showed: -Assess at least daily for signs and symptoms (s/s) of COVID 19 and record temperature and Saturation of Peripheral Oxygen (SpO2: the percent of Oxygen blood is carrying thorough the body) level. When in outbreak status assess resident twice daily for s/s of COVID 19 and record temperature and SpO2 level. If s/s consistent with COVID 19, test resident immediately. Order date of [DATE]. -No order for Oxygen (O 2). -Review of the resident's paper chart showed: -Order to transport to area hospital dated [DATE]. -No order for O 2. Review of the resident's nurse progress notes showed: -[DATE] at 10:21 A.M. the resident tested positive for covid after he/she stated he/she did not feel well. The resident was placed on transmission based precautions: Isolation in his/her room. No need for oxygen -[DATE] at 1:55 P.M. the resident was lethargic, O 2 75% (normal saturation is 96-100%) on 2 liters (L) of O 2 per nasal cannula (a small tube that fits into the nose and delivers O 2) O 2 increased to 3 L with a saturation of 92%. Dr notified and orders received to send to the hospital. During an interview on [DATE] at 11:44 A.M. Licensed Practical Nurse B said -Nurses have to get a physician's order to apply O 2. Any changes in the L per minute must be ordered by the physician. 4. Review of Resident #64 quarterly MDS dated [DATE] showed: -BIMS of 15, indicated no cognitive deficit. -Moderate assistance with ADL's. -Diagnoses of Chronic Kidney disease (a disease where the kidneys are damaged and cannot filter as they should), obesity, history of falls, Hypertension, mild Asthma (a disease that affects the lungs causing repeated episodes of wheezing, breathlessness, chest tightness, and nighttime or early morning coughing). Obstructive Sleep Apnea (a sleep disorder that causes partial collapse of the airway and low O 2 saturation) Review of the resident's October Physician order sheets showed: -Full code (if the resident is found to have no heartbeat and no respiration Cardiopulmonary Resuscitation (CPR) must be started) dated [DATE] -Do Not Resuscitate (DNR: if the resident is found to have no heartbeat and no respiration, no CPR will be attempted or initiated) dated [DATE] During an interview on [DATE] at 11:44 A.M. LPN A said: -Every Physician order should have a diagnosis for use. If a code order changes the orders should be updated, just like every other order when the doctor updates it. -He/she was not aware the resident had two code orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to ensure they assessed residents for risk of entrapment from bed rails prior to installation and failed to ensure the bed's dimensions were appropriate for the resident's size and weight for four of the 18 sampled residents (Residents #17, #19, #27 and #40 ). The facility also failed to review the risk and benefits with the resident or the resident's representative and obtain informed consent prior to installation on one of eighteen sampled resident (Resident #19). The facility census was 68. The facility did not provide a policy on side rail assessments or entrapment assessments. 1. Review of Resident #17's quarterly minimum data set (MDS) a federally mandated assessment completed by facility staff, dated 9/6/23, showed: -Brief Interview Mental Status (BIMS), a mandatory tool used to screen and identify the cognitive condition of residents upon admission into a long term care facility, of 15, showed cognitively intact. -Diagnoses included: spastic quadriplegic cerebral palsy (a permanent neuromuscular disorder causing spastic movements in all four limbs), unspecified abnormal involuntary movements, spondylosis of cervical spine (a condition of spinal cord damage caused by generation in the neck), dysarthria and anarthria (the most severe speech disorder that is caused by problems controlling the muscles used for speech resulting in inability to produce clear, articulate speech) and generalized muscle weakness.; -Bed rails used daily; Review of physician's orders showed: -Started on 6/9/22, 1/4 rails to both right and left sides of bed due to assisting resident with bed mobility and ability to assist in his/her own ADL's and to facilitate the resident's feeling of safety. To be re-evaluated every six months. Review of the resident's care plan, dated 6/30/22, showed: -Problem: He/she had spastic quadriplegic cerebral palsy and had a lot of abnormal involuntary movements, with a history of moving so much that the resident had fallen out of bed and onto the floor. He/she had almost fallen out of the shower chair and their reclining chair. Because of this the resident preferred to not have a shower, and only wanted bed baths. This places him/her at an increased risk for falls. -The resident required 1/4 side rails on both sides of bed to assist with bed mobility and assist him/her with activities of daily living (ADL's) and he/she liked feeling safe. -Problem: He/she had 1/4 bed rails bilaterally to his/her bed. This helps him/her be more independent with bed mobility and assisting with his/her own cares. He/she is alert and orientated and he/she was aware of the risks with having bed rails. He/she knew to call and have turning self. The bed rails allow the resident to feel safe due to spastic movements. He/she was still at risk for entrapment. -Assure medical record contains documentation of medical condition, justifying the use of bed rails every six months. -Bedrail assessment to be completed every six months. -Ensure and monitor for entrapment during cares. Ensure positioning in bed after cares are complete to avoid possible entrapment. -Explain negative outcomes such as entrapment and injury. -He/she had bedrails bilaterally to assist him/her with bed mobility during cares. -Obtain physician order before applying restraint. Review of electronic medical record showed: -Evaluation for use of side rails completed 5/31/23 for balance deficit, unable to support trunk in upright position, knees buckle, requested rails, and resident's fear of rolling out of bed; -Verbal informed consent was completed by resident on 5/31/23; -On 5/31/23 a bed rail order for 1/4 partial rails x 2 for bed mobility was provided. Review of excel spreadsheet provided by Director of Nursing (DON) showed mattress measurements taken from September 2022 to October 2023 with same measurements of 26.5 x 17.5. Observation on 10/27/23 at 10:25 A.M. showed complete side rails used on both sides of the bed. During an interview on 10/25/23 at 10:00 A.M., the DON said: -He/she completed entrapment assessments on Resident #17 only; -He/she had a excel spreadsheet and every month he/she measured Resident #17's mattress dimensions; -Maintenance staff did not do entrapment assessments for Resident #17. During an interview on 10/26/23 at 10:33 A.M., Certified Medication Technician (CMT) B, said Resident #17 had side rails because it would be very dangerous without them as he/she is a very floppy person and was able to roll self over. During an interview on 10/26/23 at 10:46 A. M., Restorative Aide (RA) A said Resident #17 used rails to pull themselves up in bed and used for bed mobility. 2. Review of Resident #19's admission MDS, dated [DATE], showed: -BIMS of 11, showed moderate cognitive impairment; -Diagnoses included diabetes mellitus (group of diseases that result in too much sugar in the blood), chronic kidney disease (gradual loss of kidney function over time), obstructive sleep apnea, retention of urine, chronic obstructive pulmonary disease (COPD) (a group of lung diseases that block airflow and make it difficult to breathe); Review of physician's orders, dated 10/26/23, showed: -No orders for side rails. Review of care plan, dated 10/9/23, showed: -Encourage to use hand rails and grab bars when needed. Review of electronic medical record showed: -No evaluation for use of bed rails; -No informed consent of side rail use; -No physician's scanned order of side rails. During an observation and interview on 10/23/23 at 3:19 P.M., Resident #19 had cane rails on both sides of his/her bed. During an interview on 10/26/23 at 10:33 A.M., Certified Medication Technician (CMT) B, said Resident #19 used cane rail for bed mobility. During an interview on 10/26/23 at 10:46 A. M., Restorative Aide (RA) A said he/she did not know why Resident #19 had cane rail on bed. 3. Review of Resident #27's quarterly MDS, dated [DATE], showed: -BIMS of 13 showed cognitively intact; -Diagnoses included cerebral palsy (a congenital disorder of movement, muscle tone, or posture), generalized muscle weakness, reduced mobility, cognitive communication deficit, and low back pain; -Independent with sitting to standing, upper body dressing, rolling, toilet use; -Substantial/maximal assistance with bathing. Review of physician's orders dated 10/26/23 showed: -On 11/8/22 ordered 1/8 cane rail to right side of bed to help resident with transfers and bed mobility. Review of care plan dated 10/5/23 showed: -He/she requested a cane rail on the right side of my bed to assist him/her with bed mobility, and independence. Review of electronic medical record showed: -Side rail assessment completed 11/8/22 recommended to assist with mobility and balance; -On 5/31/23, scanned written ordered for 1/8 cane rail obtained from Medical Director. During an observation and interview on 10/23/23 at 1:17 P.M., the resident was observed with cane rail on right side of bed and said it helped him/her with standing up as his/her balance was not good. During an interview on 10/26/23 at 10:33 A.M., Certified Medication Technician (CMT) B, said the resident would use cane rail to sit him/herself up and readjust self in bed. During an interview on 10/26/23 at 10:46 A. M., Restorative Aide (RA) A said he/she did not know the resident had a cane rail. 4. Review of Resident #40's Quarterly MDS dated [DATE], showed: - The resident had severe cognitive impairment; -The resident was independent with eating; -The resident requires moderate assistance for bed mobility, toileting, and for bed to chair transfer/chair to bed transfers, some effort by the resident was used to complete the activity; -The resident is occasionally incontinent of bowel and bladder; -Diagnoses included, dementia, high blood pressure and heart failure. Review of the resident's care plan dated, 3/23/22 showed: -The resident has a history of falls; -The resident is independent with transfers and ambulation; -The resident has bilateral cane rails for mobility and transfers on his/her bed. Review of the resident's POS, dated 9/26/23 through 10/26/23, showed: - admitted to the facilty on 3/16/23; - Start date: 5/18/21 [NAME] rails for positioning in bed. -Review of the resident's medical record showed no entrapment assessment was found. Observation on 10/23/23 at 03:37 P.M., showed: -The resident in his/her room laying in bed; -The resident's bed had a cane rail at the head of left side of the bed in the up position; Observation and interview on 10/24/23 at 01:37 P.M., showed: -The resident in his/her laying in bed; -The resident's bed had a cane rail at the head of the left side of the bed in the up position; -The resident said he/she used the rail to hang his/her call light on. During an interview on 10/24/23, at 2:32 P.M., RA B said: -The resident uses the rail for positioning and getting out of bed; -He/she did not know if an entrapment assessment had been done. During an interview on 10/24/23, at 2:45 P.M., RA A said: -The resident uses the rail for positioning in bed; -He/she did not know if an entrapment assessment had been done. During an interview on 10/25/23 at 7:26 A.M., Maintenance Supervisor said: -He/she only installed one kind of rails which were the 1/8 cane rails; -Some side rails that are on beds are not installed by him, but rather by hospice; -He/she did not do any type of measurements of beds and side rails; -He/she did not complete entrapment assessment. During an interview on 10/25/23 at 10:00 A.M., the Director of Nursing (DON) said: -Nurses complete side rail assessments annually and on admission for residents with 1/8 cane rails; -He/she did entrapment assessment on Resident #17 only; -Maintenance staff did not complete entrapment assessments; -1/8 cane rails in facility are strictly used for bed mobility; -Maintenance staff completed visual assessments monthly for residents with 1/8 cane rails; -Maintenance did not write down or check cane rail and mattress measurements; -Nurses complete the official side rail assessments; During an interview on 10/26/23 at 11:00 A.M., the DON said: -Spoke with Maintenance supervisor and he/she did look at beds as part of his assessments; -He/she looked at bed rails as part of her rounds and checked positioning, bed rails, 1/8 cane rails, and make sure if they have 1/8 cane rails that they can reach them; -Facility did not document visual assessments. During an interview on 10/26/23 at 2:40 P.M., the Administrator said: -He/she did not have entrapment process in place -Facility completed side rail assessments; -Only one resident in facility has 1/4 side rails, remaining rails in facility are 1/8 cane rails; -Maintenance completed check on a monthly basis of side rails.

Based on record review and interview, the facility failed to failed to implement their 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) when they failed to develop and implement a water management plan. The facility census was 68. Review of the facility's policy for Legionella Disease, dated October 1, 2023, showed: -This policy outlines measures to prevent and control Legionella disease; -Management: o the facility management is responsible for implementing and maintaining and effective Legionella disease preventions and control program; o Designate a Legionella control officer responsible for overseeing the program; -Prevention and Control Measures: o regularly assess and maintain the facility's water systems, including plumbing, and water heaters; -Education and Training: o Provide education and training to staff of Legionella prevention -Establish a system for reporting and investigating suspected or confirmed Legionella. 1. During an interview on 10/26/23 at 11:44 A.M., the Maintenance Director said: -There is no one person responsible for monitoring for Legionella; -There is a team in place that consists of the Director of Nursing (DON), the administrator and himself/herself; -He/she does not check the potential of hydrogen (pH-the figure of expressing the acidity or alkalinity of a solution) of the water system; -He/she checks the water temperatures every day; -When a room is not in use, the toilets are flushed and the water in the sink is ran; -He/she does not keep documentation on the empty rooms; -There has been no education provided to the staff at the facility on Legionella; -The facility does not have a plan in place to monitor for Legionella. During an interview on 10/26/23 at 12:58 P.M. the DON/Infection Preventionist said: -He/she did not know Legionella was a thing until just a few weeks ago; -He/she was just starting on the policy and was getting a plan together to monitor this; -The facility has not started monitoring for Legionella at this time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to complete regular inspection of all bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for four of the 18 sampled residents with side rails placing these resident's at risk for injury (Residents #17, #19, #27, and #40). The facility census was 68. The facility did not provide policy on side rail assessments or entrapment assessments. Review of the Food and Drug Administration's (FDA) document entitled Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment dated March 10, 2006 showed: -Population most vulnerable to entrapment are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movements -Facilities and manufacturers determine the level of risk for entrapment and take steps to mitigate the risk -Evaluate the dimensional limits of the gaps in hospital beds is one component of an overall assessment and mitigation strategy to reduce entrapment. -Term 'entrapment' describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail mattress, or hospital bed frame. -Bed rails, also called side rails, may be an integral part of the bed [NAME] or they may be removable and at times are used either as a restraint, a reminder, or an assuasive device. -Bed rails may consist of one full-length rail per side or one or more, shorter rails per side, may be a fixed height or adjustable in height, and may move as the head or foot sections of the bed are raised or lowered. -Many beds currently in use may no longer have the original mattress or bed rails, and ma present an entrapment hazard by increasing or creating gaps or spaces between various components of the bed system. -Reducing the risk of entrapment involves a multi-faceted approach that includes bed design, clinical assessment and monitoring, as well as meeting patient, resident , and family needs for vulnerable patients. -Evaluating the dimensional gaps limits of gaps in hospital beds may be one component of a bed safety program which includes a comprehensive play for patient and bed assessment. -Bed safety programs may also include plays for the reassessment of hospital bed systems -Reassessment may be appropriate when 1) there is a reason to believe that some components are worn (e.g. rails wobble, rails have been damaged, mattresses are softer) and could cause increased spaces within the bed system, 2) when accessories such as mattress overlays or positioning poles are added or removed, or 3) when components of the bed system are changed or replaced (e.g., new bed rails or mattresses). -FDA recommends that healthcare facilities a risk-benefit analysis to ensure that steps taken to mitigate the risk of entrapment do not create different, unintended risks or reduce clinical benefits available to patients using legacy beds. Such steps may include checking with bed system manufactures to identify compatible mattresses, rails, and accessories. -Three key body parts at risk for life-threatening entrapment in the seven zones of a hospital bed system are the head, neck, and chest. -Head: To reduce the risk of head entrapment, openings in the bed system should not allow the widest part of a small head be trapped. FDA head breadth dimension of 120 millimeters (mm) (4 and 3/4 inches (in)) -Neck: To reduce the risk of neck entrapment, opening sin the bed system should not allow a small neck to become trapped. FDA recommends 60 mm (2 and 3/8 in) as an appropriate dimension for neck diameter. -Chest: Openings in a bed system should be wide enough not to trap a large chest through the openings between split rails. FDA dimension of 318 mm (12 and 1/2 in) -Potential zones for entrapment: -Zone 1: Within the Rail -Zone 2: Under the Rail, Between the Rail Supports or Next to a Single Rail Support -Zone 3: Between the Rail and the Mattress -Zone 4: Under the Rail, at the Ends of the Rail -Zone 5: Between Split Bed Rails -Zone 6: Between the End of the Rail and the Side Edge of the Head or Foot Board -Zone 7: Between the Head or Foot Board and the Mattress End -FDA recommends dimensional limits for zones 1-4 due to the majority of entrapments reported to the FDA have occurred in these zones. The hospital be dimensional limit recommendations are as follows: -Zone 1: less than 120 mm -Zone 2: less than 120 mm -Zone 3: less than 120 mm -Zone 4: less than 60 mm 1. Review of Resident #17's quarterly minimum data set (MDS) a federally mandated assessment completed by facility staff, dated 9/6/23, showed: -Brief Interview Mental Status (BIMS)score, a mandatory tool used to screen and identify the cognitive condition of residents upon admission into a long term care facility, of 15, showed cognitively intact. -Diagnoses included: spastic quadriplegic cerebral palsy (a permanent neuromuscular disorder causing spastic movements in all four limbs), unspecified abnormal involuntary movements, spondylosis of cervical spine (a condition of spinal cord damage caused by generation in the neck), dysarthria and anarthria (the most severe speech disorder that is caused by problems controlling the muscles used for speech resulting in inability to produce clear, articulate speech) and generalized muscle weakness.; -Bed rails used daily; Review of physician's orders showed: -Started on 6/9/22, 1/4 rails to both right and left sides of bed due to assisting resident with bed mobility and ability to assist in his own ADL's and to facilitate the residents feeling of safety. To be re-evaluated every six months. Review of care plan, dated 6/30/22, showed: -Concern identified: Spastic quadriplegic cerebral palsy with abnormal involuntary movements. History of involuntary movements that he/she had fallen out of bed -Preferred bed bath over shower, related to concerns with falling, unless at hair appointment then will be up in recliner chair. -Resident is at risk for falls. -He/she required 1/4 side rails on both sides of bed to assist with bed mobility and to assist self with activities of daily living (ADLs) this additionally helped the resident feel safe. -Problem: He/she had 1/4 bed rails bilaterally to his/her bed. This helps him/her be more independent with bed mobility and assisting with his/her own cares. He/she is alert and orientated and he/she was aware of the risks with having bed rails. He/she knew to call and have someone there before turning myself, but they make him/her feel safe due to spastic movements. He/she was still at risk for entrapment. -Assure medical record contains documentation of medical condition justifying the use of bed rails every six months. -Bedrail assessment to be completed every six months. -Ensure and monitor for entrapment during cares. Ensure positioning in bed after cares are complete to avoid possible entrapment. -Explain negative outcomes such as entrapment and injury. -He/she had bedrails bilaterally to assist him/her with bed mobility during cares. -Obtain physician order before applying restraint. Review of electronic medical record showed: -Evaluation for use of side rails completed 5/31/23 for balance deficit, unable to support trunk in upright position, knees buckle, requested rails, and fear of rolling out of bed; -Verbal informed consent was completed by resident on 5/31/23; -On 5/31/23 a bed rail order for 1/4 partial rails x 2 for bed mobility was provided. Review of excel spreadsheet provided by Director of Nursing showed mattress measurements taken from September 2022 to October 2023 with same measurements of 26.5 x 17.5. Observation on 10/27/23 at 10:25 A.M. showed complete side rails used on both sides of the bed. During an interview on 10/25/23 at 10:00 A.M., the Director of Nursing (DON) said: -He/she completed entrapment assessments on Resident #17 only; -He/she had a excel spreadsheet and every month he/she measured Resident #17's mattress dimensions; -Maintenance staff did not do entrapment assessments for Resident #17. 2. Review of Resident #19's admission MDS, dated [DATE], showed: -BIMS of 11 showed moderate cognitive impairment; -Diagnoses included diabetes mellitus (group of diseases that result in too much sugar in the blood), chronic kidney disease (gradual loss of kidney function over time), obstructive sleep apnea, retention of urine, chronic obstructive pulmonary disease (COPD) (a group of lung diseases that block airflow and make it difficult to breathe); Review of physician's orders, dated 10/26/23, showed: -No orders for side rails Review of care plan, dated 10/9/23, showed: -Encourage to use hand rails and grab bars when needed Review of electronic medical record showed: -No evaluation for use of bed rails; -No informed consent of side rail use; -No physician's scanned order of side rails. During an observation and interview on 10/23/23 at 3:19 P.M., Resident #19 had cane rails on both sides of his/her bed. 3. Review of Resident #27's quarterly MDS, dated [DATE], showed: -Bims of 13 showed cognitively intact; -Diagnoses included cerebral palsy (a congenital disorder of movement, muscle tone, or posture), generalized muscle weakness, reduced mobility, cognitive communication deficit, and low back pain; -Independent with sitting to standing, upper body dressing, rolling, toilet use; -Substantial/maximal assistance with bathing. Review of physician's orders dated 10/26/23 showed: -On 11/8/22 ordered 1/8 cane rail to right side of bed to help resident with transfers and bed mobility. Review of care plan dated 10/5/23 showed: -He/she requested a cane rail on the right side of my bed to assist him/her with bed mobility, and independence. Review of electronic medical record showed: -Side rail assessment completed 11/8/22 recommended to assist with mobility and balance; -On 5/31/23, scanned written ordered for 1/8 cane rail obtained from Medical Director. During an observation and interview on 10/23/23 at 1:17 P.M., Resident #27 was observed with cane rail on right side of bed and stated it helped him/her with standing up as his/her balance was not good. 4. Review of Resident #40's Quarterly MDS dated [DATE], showed: - The resident has severe cognitive impairment; -The resident is independent with eating; -The resident requires moderate assistance for bed mobility, toileting, and for bed to chair transfer/chair to bed transfers, some effort by the resident was used to complete the activity; -The resident is occasionally incontinent of bowel and bladder; -Diagnoses included, dementia, high blood pressure and heart failure. Review of the resident's care plan dated, 3/23/22 showed: -The resident has a history of falls; -The resident is independent with transfers and ambulation; -The resident has bilateral cane rails for mobility and transfers on his/her bed. Review of the resident's POS, dated 9/26/23 through 10/26/23, showed: - admitted to the facilty on 3/16/23; - Start date: 5/18/21 [NAME] rails for positioning in bed. -Review of the resident's medical record showed no entrapment assessment was found. Observation on 10/23/23 at 03:37 P.M., showed: -The resident in his/her room laying in bed; -The resident's bed had a cane rail at the head of left side of the bed in the up position; Observation and interview on 10/24/23 at 01:37 P.M., showed: -The resident in his/her laying in bed; -The resident's bed had a cane rail at the head of the left side of the bed in the up position; -The resident said he/she used the rail to hang his/her call light on. During an interview on 10/24/23, at 2:32 P.M., RA B said: -The resident uses the rail for positioning and getting out of bed; -He/she did not know if an entrapment assessment had been done; -He/she did not know if a bed rail inspection had been done. During an interview on 10/24/23, at 2:45 P.M., RA A said: -The resident uses the rail for positioning in bed; -He/she did not know if an entrapment assessment had been done; -He/she did not know if a bed rail inspection had been done. During an interview on 10/25/23 at 7:26 A.M., Maintenance Supervisor said: -He/she only installed one kind of rails which were the 1/8 cane rails; -Some side rails that are on beds are not installed by him but rather by hospice; -He/she did not do any type of measurements of beds and side rails; -He/she did not complete entrapment assessment. During an interview on 10/25/23 at 10:00 A.M., the Director of Nursing (DON) said: -Nurses complete side rail assessments annually and on admission for residents with 1/8 cane rails; -He/she did entrapment assessment on Resident #17 only; -Maintenance staff did not complete entrapment assessments; -1/8 cane rails in facility are strictly used for mobility; -Maintenance staff completed visual assessments monthly for residents with 1/8 cane rails; -Maintenance did not write down or check cane rail and mattress measurements; -Nurses complete the official side rail assessments; During an interview on 10/26/23 at 11:00 A.M., the DON said: -Spoke with Maintenance supervisor and he/she did look at beds as part of his assessments; -He/she looked at bed rails as part of her rounds and checked positioning, bed rails, 1/8 cane rails, and make sure if they have 1/8 cane rails that they can reach them; -Facility did not document visual assessments. During an interview on 10/26/23 at 2:40 P.M., the Administrator said: -He/she did not have entrapment process in place -Facility completed side rail assessments; -Only one resident in facility has 1/4 side rails, remaining rails in facility are 1/8 cane rails; -Maintenance completed check on a monthly basis of side rails.

Based on observation, record review, and interviews, the facility failed to store, prepare, and serve food in accordance with professional standards of food service safety when staff failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety. This had the potential to impact all residents in the facility. The facility census was 68. Facility posted meal times included: Breakfast 7:00 A.M., hall trays at 9:00 A.M.; lunch at 12:00 P.M., hall trays start at 11:30 A.M., and supper at 5:00 P.M. with hall trays at 4:30 P.M. Review of facility policy- Three Sink Method of Sanitizing, dated 10/31/16, included: -In using a chemical sanitizer, the sanitizer must be mixed at the proper concentration of 200 parts per mission (PPM). During an observation on 10/23/23 at 11:15 A.M. showed sanitizer bucket tested at 0 parts per mission (PPM). During an interview on 10/26/23 at 8:47 A.M., Dietary Aide B said: -He/she did not do any changing of sanitizer buckets; -He/she did wash dishes using sanitizer machine and did not know how to test to ensure dishwasher is working properly. During an interview on 10/26/23 at 8:55 A.M., Dietary Aide C said: -There is a three sink method that is followed for sanitation including chemicals added and the right temperature is maintained; -He/she tested sanitizer buckets by using sanitizer strips; -Sanitizer strip are supposed to show 200 ppm; -He/she tested dishwasher before, during, and after use; -A log book is maintained of all sanitizer readings. During an interview on 10/26/23 at 9:20 A.M., [NAME] A said: -Sanitizer bucket is changed every couple of hours; -Test strips are used to test the sanitizer bucket. Review of facility policy- Food Storage, dated 10/26/21, included: -All food stock will be rotated and consumed in the sequence obtained. First in-first out. -Close attention will be paid to open dates marked on all products. No new food will be brought into the building on a date that is beyond any dates marked on the product. -Perishable foods will be held no longer than the time frames listed on the attached schedule. The schedule will be posted outside both the cooler and the freezer. -Prior to use of food, the dietary cooks will check dates to ensure the food is not expired. -Food storage areas will be checked on a weekly basis to ensure that foods are being dated when opened and foods are being discarded in a timely manner. All food dates will be checked prior to each use. -Food storage items -Luncheon meats - opened package or deli sliced - refrigerator 4 days -Hot dogs - freezer - 1 to 2 months -Leftovers - 3 days Review of facility policy, untitled, undated, showed -Dispose of uneaten leftovers -Properly handled leftovers usually be kept in refrigerator for three to four days. If not eaten within that time, they should be discarded. During an interview on 10/26/23 at 8:47 A.M., Dietary Aide B said: -He/she began employment on 9/1/23; -He/she had no meetings on food service or training's since starting employment; During an observation on 10/23/23 at 11:15 A.M., showed: In walk in cooler: -Opened box of bologna lunch meat covered with saran wrap dated opened 10/18, use by 10/22 -Opened, 2% milk undated with no opened date; -Opened, white cranberry juice undated with no opened date; -Opened, demi danish box with four danishes removed with no opened date; -Two cottage cheese in serving cups sitting on tray with saran wrap with no use by or opened date; -Two containers of peaches in a serving cup covered with saran wrap with no use by or opened date; In dry storage room: -Opened and undated bag carton Italian special elbow macaroni ; -Opened and undated creamy classic mashed potatoes; -Opened and undated complete pancake mix in 5 lb box; In walk in freezer: -Opened and undated box of hot dogs, exposed to freezer burn with no cover; -Opened and undated frozen carrots. During an interview on 10/26/23 at 8:47 A.M., Dietary Aide B said: -There is stickers for dating food which he/she would write what item is, when it was stored, and circle what day item should be changed; -He/she is unsure when leftover or opened food items should be discarded. During an interview on 10/26/23 at 8:55 A.M., Dietary Aide C said: -Food should be dated when received off truck and opened; -Juices and drinks are dated for one week due to going through them real fast; -If food is expired it is thrown out -Do not usually save leftovers, a tray is left out for employees to eat; -He/she did not know how long items could be stored in fridge after it was cooked; -Any item that has been opened should have a date; -Any item that goes in cooler had to have a date; -Old items on shelf are brought forward and new items placed in back of shelves; -He/she had worked in kitchen for eight years -His/her training involved learning how to make drinks, setting up North hall for meal sure, and ensuring North hall always had coffee; -Food safety means ensuring foods are at right temperature, ensuring residents do not get burned, making sure food is right temperature when gets to residents at table, and ensuring dating food. During an interview on 10/26/23 at 9:20 A.M., [NAME] A said: -Food should be dated whenever it is opened; -Food items are also dated when they arrive off the food delivery truck; -Leftovers can be kept and stored for three days During an interview on 10/26/23 at 9:31 A.M., the Dietary Manager said: -When storing foods fevering had to be wrapped, labeled, dated -Food should be dated with date it is received and an opened date -Items that come in boxes with date already on it we do not add an additional date to; -Food should be thrown out three days from when it has been opened. During an interview on 10/26/23 at 2:40 P.M., the Administrator said: -Food should be dated when opened -Aware some items arrive with dates on box and they go by storage dates on box Review of facility policy on Hot Food Temperature Requirements, dated 8/12/08, included: -Major causes of foodborne illnesses are improper cooking, cooling, reheating, hot holding, and cold holding of foods. when hot foods are held in the temperature danger zone (41 degrees-135 degrees Fahrenheit), disease-causing organisms that are naturally present in the foods as well as those introduced through incidental contamination, will grow more rapidly ad progressively. A larger number of disease causing organisms increases the risk of possible foodborne illness. That is why hot foods must be maintained at or above 135 degrees Fahrenheit at all times. -Hot hold all foods at or above 135 degrees and check temperatures frequently. -Always check final temperatures with a probe thermometer. During a continuous observation on 10/24/23 from 11:09 P.M.-12:45 P.M. showed: -Cook A did not temperature check foods prior to plating meals from steam table at 11:23 A.M. when hall trays left kitchen at 11:44 A.M. when dining room trays were being plated; -Food temperatures were recorded on food log included turkey sandwiches 40 degrees, coleslaw 45 degrees, mashed potatoes, 150 degrees. During an interview on 10/24/23 at 12:28 P.M., [NAME] A Said: -Food temps are checked before they go on steam table; -He/she documented food temperatures on the log hanging on fridge; During an interview on 10/26/23 at 8:47 A.M., Dietary Aide B said: -He/she did not know anything about temperature checking food During an interview on 10/26/23 at 8:55 A.M., Dietary Aide C said: -Food temperature checks are completed as soon as breakfast, lunch or supper is placed on steam table; -Food is on steam table thirty to forty minutes before food is served -Some foods like noodles will cook on steam table, so cooks do not fully cook them on oven; During an interview on 10/26/23 at 9:31 A.M., the Dietary Manager said: -Food temperature checks should occur when food had been cooked -Food temperature checks should also occur when food is put on steam table -and before food service to ensure food is holding its temperature. -Lunch is usually on the steam table an hour before it is served; -We do hall trays at 11:30 A.M. and [NAME] B temperature checked them at or before 11:30 A.M. prior to food being served to dining room. During an interview on 10/26/23 at 2:40 P.M., the Administrator said: -Food should be temperature checked at beginning of meal and before meal is served. Facility provided no policy on kitchen sanitation. During an observation on 10/23/23 at 11:32 A.M., showed: -Food crumbs on food cart with hot plate food covers -Grease container on griddle was full; -Clear plastic shoe box container full of grease and grime residue sitting next to griddle -Yellow oily substance pooled on floor behind stove/griddle where cook was standing to serve from steam table During an observation on 10/24/23 at 11:11 A.M., showed -Yellow oily substance pooled on floor still present as observed on 10/23/23 During an interview on 10/26/23 at 8:55 A.M., Dietary Aide C said: -Kitchen had cleaning process; -Sweep and mop floors every night and after every meal -Deep clean once or twice a week; During an interview on 10/26/23 at 9:31 A.M., the Dietary Manager said: -He/she delimed dish machine once a week; -Steamer gets delimed once a month; -Grease trap gets cleaned once a week under the dishwasher; -Daily cleaned included wiping off counters, sweeping and mopping, scrubbing sinks; -At end of each day is when most of cleaning is completed -Evening shift sweeps and mops the walk in cooler, ensures all shelves are cleaned -Walls are cleaned once a week -He/she writes a to do list of assignments and magnets the task assignment to the fridge -Grease trap on stove has a hole in back of it and sometimes grease will splatter out off it, the grease will fall out of back of hole. Facility provided no policy on facility utensils for food service. Observation on 10/23/23 at 12:03 P.M. showed dessert of brownies being served on plastic cup lids. During a continuous observation on 10/24/23 from 11:09 P.M.-12:45 P.M. showed: -12:11 P.M., [NAME] A requesting for Dietary Aide to go locate paper plates when ran out of regular plates during food plating; -12:14 P.M., [NAME] A observed cutting tops off of foam food boxes and serving last eight plates on foam to go box food containers; During an interview on 10/24/23 at 11:25 A.M., Dietary Manager said: -He/she did not have enough serving bowls for desserts currently. During an interview on 10/24/23 at 12:13 P.M., [NAME] A said he/she did run out plates. [NAME] A stated during the last few weeks there had been less and less plates available. He/she is unsure if staff are keeping plates in resident rooms or what is going on. During an interview on 10/26/23 at 8:47 A.M., Dietary Aide B said: -Facility is short on silverware; -Facility was short on cups, but more cups had been obtained -Plates are an issue and he/she had seen facility run out of them; -He/she did serve dessert on disposable lids; During an interview on 10/26/23 at 8:55 A.M., Dietary Aide C said: -There was issue with having enough plates for meal service due to COVID; -He/she stated when find out resident had COVID they have to throw away all dishes that were used by that person as it is too hard to wash it, the facility did not run items through sanitizer; During an interview on 10/26/23 at 9:20 A.M., [NAME] A said: -There is shortage of plates, but is unsure why -Utilize disposable utensils and Styrofoam plates and cups for COVID positive residents meal service; During an interview on 10/26/23 at 9:31 A.M., the Dietary Manager said: -He/she is aware of shortage of plates; -He/she believes shortage of plates is related to an increase in census; -Shortage of plates is also related to open dining in which facility did not wake residents for meals and allows them to wake up and have breakfast when they want us, then some breakfast plates are not returned to kitchen prior to lunch service; -Disposable utensils are used for residents on transmission based precautions. During an interview on 10/26/23 at 2:40 P.M., the Administrator said: -He/she was not aware of a shortage of plates Review of handout, when to wash hands, undated, showed: -Wash hand before: beginning work and after breaks, preparing and serving food, putting on or changing gloves, assisting a customer with dining, handling medication. -Wash hands after: using the restroom, touching raw meat, poultry, fish or eggs, or other potentially hazardous foods; eating, smoking, or chewing gum; touching soiled plates, utensils or equipment; sweeping, mopping or wiping counters; touching your nose, mouth or any part of your body; sneezing or coughing; handling trash, money, the phone, or other unclean objects; using chemicals. Review of handout, glove-ology, undated, showed: -Glove use in food service can be a very confusing concept. The following will help you use gloves properly to assure safe food to your customers. -Wash hands thoroughly before and after wearing or changing gloves is most important thing you can do to reduce surface bacteria, sweat, dirt, and grim build-up on skin and under nails. -Scrub with a nail brush 20 seconds before putting on new gloves. -Glove use in itself does not guarantee food safety. always wash hands before and after using disposable gloves. -Glove size is important for safety and comfort. -Use gloves for designated food tasks only. Disposable gloves are task-specific and should never be worn continuously. -Food contact gloves should not be used for non-food tasks such as handling money, garbage removal, cleaning services, etc. -The FDA Food Code stipulates no bare hand contact with ready-to-eat foods; therefore use gloves with salad bar items, fruits, sandwiches, cooked foods, deli meats, cheeses, breads or ice. -Use vinyl, synthetic, or latex gloves when handling food near a heat source cooking area, rather than ply gloves which are not resistant to heat. -If you handle raw meats, poultry, or seafood with gloves on, do Not touch ready-to -eat or cooked foods without washing hands and changing gloves. -Always wash hands between glove changes. -When using a cut resistant glove with ready-to -eat food, wear a disposable glove on top to avoid cross-contamination. -Change gloves after sneezing, coughing, or touching your face or hair. -Always wear gloves if you have a bandage, infection, cut or sore, and avoid direct food handling duties temporarily. -Always remove disposable gloves correctly, grasp at the cuff and peel them off inside out. -FDA food code states that workers wearing artificial nails or fingernail polish must wear disposable gloves. -None-latex gloves are recommended for food workers, to help avoid possible latex allergic reactions Observation on 10/23/23 at 11:52 A.M. showed food service staff entering and leaving kitchen wearing latex gloves, not sanitizing between residents plates being served to them. Aides observed assisting residents with cutting up foods, obtaining drinks, and providing condiments. During a continuous observation on 10/24/23 from 11:09 A.M.-12:45 P.M. showed: -Dietary Aide D entered kitchen, did not wash hands, exited into dining room -Dietary Aide B washed hands, applied gloves, scratched head and hair net with gloved hands, exited kitchen at 11:14 A.M.; -Dietary Aide D entered kitchen, did not wash hands, put dirty dish in sink, left kitchen; -Dietary Aide B entered kitchen wearing gloves, did not wash hands or sanitize, advised cook ready to start meal service to dining room. -Dietary Aide D takes first plate into dining room, re-enters kitchen wearing same gloves. -Dietary Aide B took out second meal plate to dining room, re-enters kitchen wearing same gloves, opens may packet out of box, tears open with gloves, exits kitchen with another plate. -Dietary Aide D takes plate out to dining room, returns to kitchen, did not sanitize, opens up mayo packet places mayo packet on plate on top of steam table, and goes back out into dining room; -Dietary Aide A entered and exited kitchen multiple times while wearing the same gloves and serving residents their meals. Dietary Aide A washed hands only one time at 12:01 P.M. after entering and exiting the freezer. He/she was observed serving multiple residents and assisting with meal service. -Dietary Aide B washed hands at sink and used clean hands to turn off faucet at sink at 12:22 P.M. During an interview on 10/26/23 at 8:47 A.M., Dietary Aide B said: -Hand washing should be completed after serving every three to four residents; -He/she would take off gloves and wash hands; -He/she did help residents cut up their food in between gloves changes; -He/she is aware of cross contamination; -If he/she had gloves on and touched chicken he would need to go change gloves and wash his/her hands or if he/she completed dishes, he/she would need to take gloves off, wash hands, and apply new gloves before served food. During an interview on 10/26/23 at 8:55 A.M., Dietary Aide C said: -He/she had received hand washing training; -His/her hands should be washed every time enters kitchen; -He/she sings the ABC song as he washes hands and ensures washed between fingers, goes up to elbows; -Whenever washed hands then applied gloves prior to taking out plates and drinks for meal service; -If he/she touches resident's items such as their drink cup while serving plates then he/she would take off gloves, wash hands or sanitize and apply new gloves. During an interview on 10/26/23 at 9:20 A.M., [NAME] A said: -He/she completed hand washing training during orientation; -Hand washing should be completed anytime entering the kitchen; -He/she washed hands while singing the happy birthday song, and grabbed papertowel to use to turn off faucet; -Rewashes hands any time there is cross contamination. During an interview on 10/26/23 at 9:31 A.M., the Dietary Manager said: -Employees are to wash hands as frequently as possible and applying gloves; -He/she wants employees to ensure they are not overusing their gloves by changing gloves when changing tasks; -Employees should wash hands every time they change their gloves; -Training is completed every month when the dietician comes into the facility; -He/she did not keep a current log of training with employees. During an interview on 10/26/23 at 2:40 P.M., the Administrator said: -Staff should wash hands between everything touched from clean to dirty; -If staff is touching resident then they should not touch a clean tray and would be expected to wash hands in between; -Gloves are good until touch something is considered dirty.

Based on record review and interviews, the facilty failed to ensure they purchased a surety bond in a large enough amount to cover any loss or theft of the money held by five of five sampled residents (Residents #7, #10, #36, #40, and #262) in the resident trust fund account. The facility census was 62. Review of the facility's surety bond showed the facility had a bond, approved by the Department of Health and Senior Services (DHSS) on 11/18/20, in the amount of $10,000.00. Review of the facility's previous 12-month bank account balances and petty cash held in the facility showed an average monthly balance of $13,740.23. Review of the Resident Funds Bond Worksheet, dated 10/4/21, showed the facility should have a bond amount of at least $21,000.00 to cover the residents' losses in the event of a loss or theft of their money. During an interview on 10/7/21 at 2:27 P.M., the Business Office Manager said they review the account statements yearly and he/she was responsible for making sure the bond amount was sufficient. During an interview on 10/7/21 at 2:33 P.M., the Administrator said facility staff review the account statements and the Business Office Manager was responsible for making sure the bond amount was sufficient.

Based on record reviews and interview the facility failed to ensure they completed a check of the employee disqualification list (EDL) for two staff members (Dietary Aide A and Nurse Aide B), Criminal Background Check (CBC) for one staff member (Nurse Aide B), and Missouri Certified Nurse Aide (CNA) Registry for six staff members (Certified Nurse Aides A and B; Dietary Aide A; Housekeeping Activity Aide A; and Nurse Aides A anb B) of the 10 sampled staff members. The facility census was 62. Review of the facility Abuse and Neglect Prevention and Response Policy and Procedure dated 9/29/17 showed in part: -The facility will screen all employees. Once a supervisor has selected a new employee they will notify the business office to begin the Criminal Background Check (CBC), verification of the Employee Disqualification List (EDL) and check the Missouri CNA Registry. Verifications will be conducted either prior to the first day of employment or on the first day of employment. In no case will an individual be involved in resident care until these checks are done. 1. Review of Certified Nurse Aide (CNA) A's employee record showed: - Date of hire: 5/12/21 - CNA Registry was not checked prior to the start of employment. 2. Review of Dietary Aide (DA) A's employee record showed: -Date of hire: 4/11/21 - CNA Registry was not checked prior to the start of employment. -EDL was not checked prior to date of hire. 3. Review of Housekeeping Aide (HA) A's employee record showed: -Date of hire: 4/14/20 - CNA Registry was not checked prior to the start of employment. 4. Review of Activity Aide A's employee record showed: -Date of hire: 11/14/19 - CNA Registry was not checked prior to the start of employment. 5. Review of Nurse Aide (NA) B's employee record showed: - Date of hire:10/27/20 -CNA Registry was not checked prior to the start of employment. -EDL was not checked prior to employment. -CBC was not checked prior to employment. 6. Review of CNA B's employee record showed: -Date of hire: 4/29/21 -CNA Registry was not checked prior to date of hire. -CBC and EDL completed on 4/29/21 7. Review of NA A's employee record showed: -Date of hire: 8/31/21 -CNA Registry was not checked prior to date of hire. During an interview on 10/07/21 at 11:21 A.M. Director of Nursing (DON) said : -He/she was not aware that the NA registry needed to be checked for all staff. -The CNA Registry has not been checked for anyone who is not in nursing. During an interview on 10/07/21 at 1:14 P.M. the Business Office Manager said: - There is no print out for the EDL on Dietary Aide A. - NA B's EDL was noted missing on quarterly review. -He/she was unable to produce a copy of the EDL. -He/she supplied confirmation number on1/7/21 of 202100700583. -He/she completes a quarterly review of all CBC, EDL and CNA registry checks quarterly. During an interview on 10/07/21 at 2:29 P.M. the Administrator said: - Office manager is responsible for the EDL, CBC and CNA registry checks. -Checks are completed before hire or start in the facility. -He/she was not aware that CNA Registry had to be completed on all employees. - He/she was aware the the Business office Manager was only completing the CNA Registry check for NA's, CNA's or anyone hired for nursing positions. -He/she is aware that one employee does not have the CBC and EDL. -He/she expects the CBC/EDL/CNA Registry to be completed before hire.

Based on observations and interviews, the facility failed to protect food from possible contamination during preparation and service when staff failed to wear hairnets when coming in kitchen to get their own meal, failed to keep all areas of the kitchen clean and free from pests such as flies, failed to store clean dishes in a way to keep free from contaimination, and failed to ensure staff covered and dated foods such as spices, foods in the cooler and foods on the kitchen's shelves. This had the potential to affect all residents. The facility census was 62. Review of facility policy, Hair Restraints for Dining Service, dated 7/31/18, showed hair restraints shall be worn by all dining services staff when in food production, dishwashing areas or when serving food from the steam table. Staff shall wear hair restraints in all food production, dishwashing and serving areas. Hair restraints, hats and/or beard guards shall be used to prevent hair from contacting exposed food. Facial hair is discouraged. Any facial hair that is longer than the eyebrow shall require coverage with a beard guard in the production and dishwashing areas. All those delivering plated foods to residents will pull all long hair back while serving. Hairnets are discouraged due to the institutional look that may interfere with the desired dining room atmosphere. Review of the facility policy, Food Storage, dated 11/02/16, showed in order to prevent any food borne disease, the utmost of care will be exercised in preparing and serving food. The following steps will ensure that all food is stored in safe and healthy manner. The procedures are: - All food will be stored on shelves. - No food will be stored directly on any floor surface. - Perishable foods will be stored either in the walk-in cooler/ refrigerator or the freezer. - All opened or prepared foods will be stored in air tight/sealable containers. - All containers will be labeled and dated. - Perishable foods will be held no longer than the time frames listed on the attached schedule. - This schedule will be posted outside both the cooler and the freezer. 1. Observation on 10/4/21, beginning at 11:40 A.M., the kitchen showed the following: - Two gallons of milk with expiration date of 9/29/21; - A 16 ounce container sour cream with best if used by date of 7/18/21; - One small jar of peanut butter with expiration date of 9/3/21; - One jug of Italian dressing without an expiration date or opened date; - 23 seasonings without an expiration date or opened date; - Cumin seasoning lid covered with dust and grime; - An open box of sausage patties not covered or dated in the freezer; - An undated, open bag of shredded cheese; - An undated open package of sliced ham; - An undated large plastic container containing flour; - An undated large plastic bag with cocoa; - Nosey cups (used for residents who have difficulting drinking from regular glasses) on shelf not stored upside down - Multiple flies flying around the steam table, and stove. During an interview on 10/7/21 at 2:05 P.M., the DM said he expected staff to label and date anything open anything that is left over. 2. Observation on 10/4/21 at 11:30 A.M., showed Courtesy Tech (CT) A came into kitchen to get his/her lunch near the steam table were staff were serving the noon meal without a hairnet. He/she stood between the steam table and where dietary staff prepared drinks for the residents. Observation on 10/5/21 starting at 11:45 A.M., showed: - A sign hung on side of cooler which read Cross this line, it's hair net time seriously. - At 11:45 A.M., Dietary Aide (DA) B wore a beany type hat and his/her long hair hung down the middle of his/her back in a ponytail. His/her hair moved loosely around on his/her back as he/she prepared the steamtable and drinks to take to the back dining room. - At 11:55 A.M., the Director of Nursing (DON) came into the kitchen to get her lunch without a hairnet. She stood between the steamtable and where staff prepared drinks for the residents. - At 12:05 P.M., Social Services came into the kitchen without a hairnet to get her lunch. She stood between the steamtable and where staff prepared drinks for the residents. During an interview on 10/7/21 at 1:35 P.M., DA C said the hairnet policy is for anyone who walks past the refrigerator in the kitchen. During an interview on 10/7/21 at 1:45 P.M., CT A said the expectation for hairnets is to keep hair out of food, drinks, and equipment; to keep things more sanitized. During an interview on 10/7/21 at 2:00 P.M., the Dietary Manager (DM) said the policy on hairnets is for anyone going past the refrigerator, working on serve line or in dining room to wear.