Based on interview and record review, the facility staff failed to ensure six Nurse Aide's ((NA) NA A, NA B, NA C, NA D, NA E, and NA F) of eight completed the nurse aide training program within four months of his/her employment in the facility. The census was 56. 1. Review of the facility's policies showed the facility did not provide a policy for NA qualifications. 2. Review of NA D's personnel file showed a hire date of 04/06/22. Review showed the NA file did not contain documentation the NA completed the required nurse aide training program. During an interview on 09/17/24 at 1:04 P.M., the administrator said this employee is 96% done with his/her classes. He/She said he/she is behind because he/she tried out another unit for three and half weeks before returning to nursing care. 3. Review of NA F's personnel file showed a hire date of 06/12/23. Review showed the NA file did not contain documentation the NA completed the required nurse aide training program. During an interview on 09/17/24 at 1:04 P.M., the administrator said the employee is on step 93 of 120 steps of the on-line program. He/She said he/she is not sure why it has taken the NA over the required 120 day times frame to complete the classes. 4. Review of NA E's personnel file showed a hire date of 11/20/23. Review showed the NA file did not contain documentation the NA completed the required nurse aide training program. During an interview on 09/17/24 at 1:04 P.M., the administrator said the employee is behind because he/she wanted to try out a different area for two weeks before returning to nursing work. 5. Review of NA C's personnel file showed a hire date of 01/18/24. Review showed the NA file did not contain documentation the NA completed the required nurse aide training program. During an interview on 09/17/24 at 1:04 P.M., the administrator said the NA is done with the on-line classes and is waiting for his/her test to be scheduled. He/She said he/she had just finished the classes on-line. 6. Review of NA A's personnel file showed a hire date of 02/21/24. Review showed the NA file did not contain documentation the NA completed the required nurse aide training program. During an interview on 09/17/24 at 1:04 P.M., the administrator said the NA was hired as a NA then wasn't sure if he/she wanted to be in nursing and tried out a different area. He/She said they have since decided they do want to do nursing and are currently on step 85 of 120 on their on-line classes. 7. Review of NA B's personnel file showed a hire date of 04/05/24. Review showed the NA file did not contain documentation the NA completed the required nurse aide training program. During an interview on 09/17/24 at 1:04 P.M., the administrator said he/she is not sure where this employee is at in the program, but they are enrolled in it. He/She said he/she sets the employees up with the on-line program upon hire and he/she gets weekly reports for where they are at in the program. He/She is reponsible for monitoring where they are at in the program and responsible for ensuring they complete the program on time. He/She said the employees work at their own pace and that is sometimes harder to mange compared to when emploees were taught in the class room. He/She does not know why this employee has not completed the program. 8. During an interview on 09/17/24 at 10:26 A.M., the clinical supervisor said the administrator signs them up for the classes, ensures they have completed the program in the four months and keeps track of where they are in the program. During an interview on 09/17/24 at 1:04 P.M., the administrator said he/she is responsible for ensuring the new hires nurse aides complete the nurse aide training. He/She is aware new hires need to complete the nurse aide training within the 120 days from hire. He/She said they were having issues with the online classes not recognizing them as a site for the nurse aide hours. He/She said it is harder to ensure they complete the required hours through the on-line program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (LD- a serious type of pneumonia (lung infection) caused by Legionella bacteria, which places all residents of the facility at risk of exposure which could lead to illness. Facility staff failed to implement an enhanced barrier precautions (EBP) system for one (Resident #33) of two sampled residents with wounds when facility staff failed to wear appropriate personal protective equipment (PPE) during high-contact care activities and place PPE in close proximity. The facility census was 56. 1. Review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification (S&C) letter 17-30, dated 06/02/17 and revised on 06/09/17, showed: -The bacterium Legionella can cause a serious type of pneumonia called LD in persons at risk. Those at risk include persons who are at least [AGE] years old, smokers, or those with underlying medical conditions such as chronic lung disease or immunosuppression. Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including hospitals and long-term care facilities. Transmission can occur via aerosols from devices such as shower heads, cooking towers, hot tubs, and decorative fountains; -Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water; -CMS expects Medicare certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. An industry standard calling for the development and implementation of water management programs in large or complex building water systems to reduce the risk of legionellosis was published in 2015 by American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE). In 2016, the Centers for Disease Control and Prevention (CDC) and its partners developed a toolkit to facilitate implementation of this ASHRAE Standard (https://www.cdc.gov/legionella/maintenance/wmp-toolkit.html). Environmental, clinical, and epidemiological considerations for healthcare facilities are described in this toolkit; -Surveyors will review policies, procedures, and reports documenting water management implementation results to verify that facilities: -Conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system; -Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens; -Specify testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained. Review of the facility's Water Management Program, showed the program did not contain policies related to water management. Review showed the program did not contain control measures or corrective actions. Review of the facility's water management documentation showed four water heaters were identified as temperature permissive areas where Legionella could grow. Review showed two of the four water heaters were identified as not having recirculating pumps. Review showed the monitoring procedure for water heaters was weekly temperature checks. Review showed weekly water temperature check log sheets did not contain an acceptable range for water temperatures. Review showed the plan did not include a temperature range or corrective actions to address out of range water temperatures. During an interview on 09/19/24 at 9:30 A.M., the maintenance director said he/she and housekeeping staff are responsible for cleaning water fixtures and running water faucets weekly. The maintenance director said he/she checks water temperatures weekly. The maintenance director said he/she did not flush the four large water heaters. The maintenance director said he/she was not aware of any water management policies. During an interview on 09/19/24 at 1:15 P.M., the administrator said he/she and the maintenance director were responsible for the water management program. The administrator said there were not policies or an overall plan related to water management. The administrator said he/she did not know two of four water heaters did not have recirculating pumps. The administrator said if water temperatures were not high enough, water should not be used until the issue was corrected. The administrator said there was no policy to identify correct water temperature range, but water should be between 105 and 120 degrees Fahrneheit. 2. Review of the facility's EBP policy, dated September 2022, showed: -EBP refer to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO (Multi-drug resistant organism, bacteria resistant to antibiotics) as well as those that increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices); -Clear signage will be posted on the door or wall outside of the resident room indicating the type of precautions, required personal protective equipment (PPE), and the high-contact resident care activities that require use of gown and gloves; -An order for EBP will be obtained for residents with wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO; -Make gowns and gloves available immediately outside the resident's room; -High-contact resident care activities include: dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (urinary catheters), and wound care (any skin opening that requires a dressing. 3. Review of Resident #33's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 06/19/24, showed staff assessed the resident as: -Impaired Cognition; -One unhealed stage III pressure (full-thickness tissue loss) wound; -Received pressure ulcer care to include a non-surgical dressing to the feet; -Diagnosis of diabetes, anemia (low iron) and dementia. Review of the Physician Order Sheet (POS), dated September 2024, showed an order on 08/22/24 to cleanse the left heel wound with wound cleanser, cover with a petroleum dressing, and followed by a border gauze pad daily. Observation on 09/16/24 at 11:29 A.M., showed a sign on the resident's door said EBP, wear gloves and gown for the following high-contact resident care activities: dressing, bathing, transferring, changing linens, personal hygiene, changing briefs and assisting with toileting, device care, urinary catheter care, wound care - any skin opening requires a dressing. PPE was not located outside the resident room. Observation on 09/16/24 at 1:30 P.M., showed Nurse Aide (NA) I and NA E transfered the resident to the bed from the wheelchair. NA I and NA E did not wear a gown during the transfer. A sign was located on the resident's door EBP, wear gloves and gown for the following high-contact resident care activities: dressing, bathing, transferring, changing linens, personal hygiene, changing briefs and assisting with toileting, device care, urinary catheter care, wound care - any skin opening that requires a dressing. PPE not located outside the resident room. Observation on 09/17/24 at 09:41 A.M., showed Registered Nurse (RN) L and Licensed Practical Nurse (LPN) K provided wound care to the resident and did not wear a gown. A sign was located on the resident's door, EBP, wear gloves and gown for the following high-contact resident care activities: dressing, bathing, transferring, changing linens, personal hygiene, changing briefs and assisting with toileting, device care, urinary catheter care, wound care - any skin opening that requires a dressing. PPE not located outside the resident room. Observation on 09/18/24 at 08:11 A.M., showed a sign on the resident's door read: EBP, wear gloves and gown for the following high-contact resident care activities dressing, bathing, transferring, changing linens, personal hygiene, changing briefs and assisting with toileting, device care, urinary catheter care, wound care - any skin opening that requires a dressing. PPE not located outside the resident room. 4. During an interview on 09/16/24 at 1:30 P.M., NA E said he/she does not use a gown when transferring this resident because he/she does not have an infection. NA E said the resident recently had Coronavirus disease (COVID-19) (a contagious disease caused by the SARS-Cov-2 virus) and the sign just wasn't removed yet. He/She said he/she was educated on EBP but they only have to use a gown when a resident has a catheter. During an interview on 09/17/24 at 8:48 A.M., Nurse Aide (NA) I said staff do not use extra PPE when just transferring this resident. He/She said the resident does not need the extra PPE and there are not any residents in that room that require it. He/She said he/she was educated on EBP. During an interview on 09/17/24 at 9:41 A.M., RN L said EBP have not been implemented for all wounds yet, just residents with catheters. He/She said that if the resident has a draining wound, EBP would be implemented. The resident does not have a draining wound and does not need EBP at this time. During an interview on 09/18/24 at 8:21 A.M., the Infection Preventionist (IP) said he/she was aware the regulation was in effect but wanted to start slowly to get the staff used to it before implementing fully. An in-service has been conducted by the facility, the health department and the Quality Improvement Program of Missouri (QIPMO) nurse regarding EBP and should include the use of signs and PPE outside of the resident rooms. During an interview on 09/19/24 at 8:30 A.M., LPN K said residents with wounds and catheters should have EBP used during care because they are higher risk of having bacteria introduced through the staff. Staff are instructed to use gowns and gloves. He/She said the process was started last month and was just using the extra precautions on those with catheters and not wounds until this week. He/She said PPE should be located outside the resident rooms for easier access. During an interview on 09/19/24 at 10:31 A.M., the DON said EBP has been fully implemented now and should be performed, as the sign says, during high-contact care activities. During an interview on 09/19/24 at 10:57 A.M., the Administrator said there should be a sign on the door and PPE outside the door for residents on EBP. He/She said EBP was put into place for residents with MDRO and anyone with catheters and should include the use of gown and gloves. He/She said that the Infection Control Assessment and Research (ICAR) team came to the facility and did an infection control survey and education and was instructed it was ok to start the process slowly. The administrator said the facility then had a COVID outbreak which delayed everything. He/She said he/she knew the regulation was in effect and had no other good reason it was not implemented. He/She said he/she just read the regulation at the end of July.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to develop and implement a comprehensive person-centered care plan for two residents (Resident #4, and #50). The facility census was 62. 1. Review of the facility's policy titled, Comprehensive Care Plans, dated September 2022, showed staff were directed to do the following: -It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment; -The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally-competent and trauma-informed; -The comprehensive care plan will be developed within seven days after the completion of the comprehensive Minimum Data Set (MDS), a federally mandated assessment tool. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team (IDT), or in accordance with the resident's preferences, will also be addressed in the plan of care; -The comprehensive care plan will describe, at a minimum, the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being and resident specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identity, as indicated; -The comprehensive care plan will include measurable objectives and timeframe's to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. 2. Review of Resident #4's admission Minimum MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Diagnosis of dementia; -Care Area Assessments (CAA) did not trigger for cognitive loss/dementia. Review of the resident's medical record showed diagnoses of unspecified dementia, cognitive communication deficit, and unspecified symptoms and signs involving cognitive function and awareness. Review of the resident's care plan, dated 07/28/23, showed no direction for staff in regard to the resident's cognition or dementia. 3. Review of Resident #50's admission MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Required limited assistance from one staff member for personal hygiene; -Required extensive assistance from one staff member for bed mobility, transfers, dressing and toileting; -Required setup assistance for eating; -Very important to listen to music he/she likes, and to keep up with the news; -Somewhat important to be around animals, such as pets, to do things with groups of people, to do a favorite activity, and to go outside to get fresh air when the weather is good; -Not very important to have books, magazines, and newspapers to read or to participate in religious services or practices. Review of the resident's medical record, showed staff documented the resident enjoyed watching television, including comedy shows and football, spending time with his/her family, listening to rock and roll music and attending afternoon activities with assistance from staff. Review of the resident's Physician's Order Sheets (POS), dated 06/01/23, showed a code status order of Full Code (if found without a heart beat, and not breathing, all resuscitation procedures will be provided to keep them alive) order. Review of the resident's care plan, dated 07/28/23, showed no direction for staff in regard to Activities of Daily Living (ADLs), code status, or activity preferences for the resident. During an interview on 09/08/23 at 9:50 A.M., Licensed Practical Nurse (LPN) J said the care plan directed staff on the type of care the resident needed and their preferences. The LPN said the MDS Coordinator was responsible for reviewing and revising the care plans but the nurses could update the care plans with changes. The care plans were updated after a change in resident condition, falls, and on a quarterly basis, and should include code status, ADL needs, activity preferences and a pertinent diagnoses, such as dementia. During an interview on 09/08/23 at 10:34 A.M., Certified Nurse Aide (CNA) B and Nurse Aide (NA) C said the care plans provide guidance for staff on how to care for the residents. During an interview on 09/08/23 at 10:49 A.M., the MDS Coordinator said he/she was responsible for updating and revising the care plans, but the nurses could update them. He/She obtained the information in the care plans by reviewing the residents' medical records, and interviewed with staff and residents or their family. He/She updated the care plans after each MDS assessment, and with changes in resident condition. The care plans should address pertinent diagnoses such as dementia, code statues, ADL needs and activity preferences. The MDS coordinator said he/she started the position in June and he/she noticed some of the care plans had not been reviewed and revised. During an interview on 09/08/23 at 11:55 A.M., the Administrator and Director of Nursing (DON) said the care plan should direct staff in the type of care the resident required, and should be updated with a change in status and quarterly. They said the care plan should be updated by the department head in which the change had occurred. They said they expected the care plan to address ADLs, codes status, activity preference, and pertinent diagnoses such as dementia. They said information in the care plan should be based on the Care Area Assessment (CAA) report.

Based on observation, interview and record review, facility staff failed to maintain a safe, clean, comfortable and homelike environment, when staff failed to maintain resident equipment and rooms in good repair for five residents (Resident #20, #23, #41, #50 and #57). The facility census was 62. 1. Review of the facility's policy titled, Safe and Homelike Environment, dated October 2017, showed staff were directed to do the following: -In accordance with resident's rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible; -The facility will maintain a clean environment; -The facility will provide and maintain bed and bath linens that are clean and in good condition; -Report any furniture in disrepair to Maintenance promptly; -Report any unresolved environmental concerns to the Administrator. Review of the facility's Night Shift Wheelchair Cleaning Schedule, undated, showed: -Rooms 100 through 209 on Mondays; -Rooms 300 through 404 on Tuesdays; -Rooms 500 through 511 on Wednesdays; -Rooms 600 through 612 on Thursdays; -Pick up any not done on Fridays. Further review, showed the cleaning schedule had boxes for staff to document the wheelchairs had been cleaned. No boxes had been marked. 2. Observation 09/06/23 at 9:48 A.M., showed Resident #20 sat in his/her wheelchair in his/her room. The wheelchair had built up dry food on the frame by the back wheels. Observation 09/07/23 at 9:10 A.M., the resident's wheelchair had built up food debris on the frame by the back wheels. Observation on 09/08/23 at 8:40 A.M., the resident sat in his/her wheelchair in a community area. The wheelchair had dried food debris stuck to the frame by the back wheels. 3. Observation on 09/06/23 on 9:10 A.M., showed Resident #23's wall by the bed had several areas of missing and chipped paint and black scratch marks on the floor. Observation on 09/07/23 at 10:14 A.M., showed the wall by the bed had several areas of missing and chipped paint and black scratch marks on the floor. Observation on 09/08/23 at 11:32 A.M., showed the wall by the bed had several areas of missing and chipped paint and black and scratch marks on the floor. 4. Observation on 09/06/23 at 9:04 A.M., showed Resident #41 sat in his/her wheelchair, at the nurse's station. The front left corner of the resident's pressure reducing cushion and wheelchair frame had a dried, crusty, yellow substance built up on it. Observation on 09/08/23 at 9:54 A.M., showed the resident's pressure cushion and wheelchair frame had the same dried, crusty, yellow substance on it. 5. Observation on 09/05/23 at 11:58 A.M., showed Resident #50's wheelchair armrest had pieces of the cover missing. Observation on 09/07/23 at 1:27 P.M., showed the resident's wheelchair had debris on the wheels and a worn armrest. Observation on 09/08/23 at 11:25 A.M. showed the resident's mattress worn with small tears. During an interview on 09/08/23 at 11:33 A.M., Certified Nurse Aide (CNA) B said he/she knew the resident's mattress was worn and he/she reported it to the Assistant to the Director of Nursing (ADON) last week. 6. Observation on 09/07/23 at 9:11 A.M., showed Resident #57's mattress worn with small tears and the floor tiles with scratch marks down the center. Observation on 09/08/23 at 11:27 A.M., showed Licensed Practical Nurse (LPN) J pulled back the fitted sheet from the resident's mattress. The mattress was worn with a few small tears and the floor tiles had scratch marks down the center. During an interview on 09/08/23 at 11:27 A.M., LPN J said he/she did not know if hospice provided the mattress, but the condition of the mattress should have been reported to maintenance. During an interview on 09/08/23 at 9:50 A.M., Licensed Practical Nurse (LPN) J said staff should document maintenance issues in the maintenance log. The LPN said he/she had not noticed any rooms with environmental concerns. The aides cleaned the wheelchairs in the evening or as needed, and staff should inspect the condition of the wheelchairs with any transfers. The LPN said it was disgusting to have food sitting on a wheelchair for four days. During an interview on 09/08/23 at 10:34 A.M., CNA B and Nurse Aide (NA) C said staff should report environmental concerns to the charge nurse, Director of Nursing (DON) or the Administrator. They said they had not noticed any rooms in disrepair, but had noticed residents with torn wheelchair armrests, including Resident #50. They said the wheelchairs were supposed to be cleaned every night, but they had noticed dirty wheelchairs and had reported it to the supervisor. During an interview on 09/08/23 at 11:45 A.M., the Maintenance Supervisor said staff should document environmental or equipment issues on the board located at the nurses station. He/She said he/she was responsible for ordering wheelchair parts, and new mattresses. The maintenance supervisor said no one had reported any issues with Resident #50's wheelchair or mattress or Resident #57's mattress. He/She said he/she knows about Resident #23's wall because he/she repaired it on a regular basis. He/She said the facility received bids to replace the flooring in the common area, but not the resident rooms. Rooms were inspected around the middle of each month. During an interview on 09/08/23 at 11:55 A.M., the Administrator and the DON said staff were directed to report environmental concerns and equipment in disrepair to the maintenance department. The DON said the wheelchairs are cleaned monthly and as needed, by the night shift CNAs. The DON said the night shift charge nurse should ensure the wheelchairs were cleaned, and he/she had just educated staff on 07/17/2023 in regard to cleaning wheelchairs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to review and revise the plan of care for three residents (Resident #22, #23, and #41). The facility census was 62. 1. Review of the facility's policy titled, Comprehensive Care Plans, dated September 2022, showed staff were directed to do the following: -It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment; -The care planning process will include process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally-competent and trauma-informed; -The comprehensive care plan will be developed within seven days after the completion of the comprehensive Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care; -The comprehensive care plan will describe, at a minimum, the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being and resident specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identity, as indicated; -The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment; The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. 2. Review of Resident #22's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Required extensive assistance from two staff members for bed mobility, transfers and toilet use; -Required extensive assistance from one staff member for dressing, bathing and personal hygiene; -Only able to stabilize with staff assistance during transfers; -Used a wheelchair; -Diagnoses of Stroke, Parkinson's disease (brain disorder that causes uncontrolled movements with decreased balance and coordination), and seizure disorder. Review of the resident's care plan, revised 07/10/2023, showed staff did not document the resident's preference, to get out of bed to eat lunch and dinner with his/her spouse in the dining room. Review of the facility's Meal Times, undated, showed the resident's lunch begins at 11:30 A.M. During an interview on 09/06/23 at 9:32 A.M., the resident said he/she preferred to get up and eat lunch with his/her spouse in the dining room. The resident said his/her spouse did not live in the same part of the facility and came over to eat lunch and dinner with him/her. Observation on 09/06/23 at 12:25 P.M., showed the resident remained in his/her room and waited for staff to assist him/her to the dining room so to eat with his/her spouse. Observation on 09/06/23 at 12:31 P.M., showed the resident's spouse sat alone at a table in the dining room. The resident's spouse had finished his/her meal. During an interview on 09/06/23 at 12:31 P.M., the resident's spouse said he/she came to the facility to eat lunch and dinner with the resident, but he/she was now finished. The spouse said the resident did not make it to lunch today because staff did not help the resident get out of bed. During an interview on 09/06/23 at 12:29 P.M., Nurse Aide (NA) C and Certified Nurse Aide (CNA) B said, We are so far behind and just now getting the resident up, because there is only two of us to get all of these people up. During an interview on 09/08/23 at 11:19 A.M., the MDS Coordinator said the resident's care plan should include that he/she eats with his/her spouse, because it is the resident's preference and individualized to him/her. During an interview on 09/08/23 at 12:11 P.M., the Director of Nursing (DON) said the resident gets very upset, if he/she does not get to have lunch or dinner with his/her spouse. It should probably be on his/her care plan. 3. Review of Resident #23's Significant Change in Status (SCSA) MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Diagnosis of Dementia. Review of the resident's medical record showed the resident had diagnoses of unspecified dementia, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. Review of the resident's care plan dated, 02/21/23, showed no direction for staff in regard to the resident's diagnosis of dementia. The care plan had not been reviewed or revised since 02/21/23. 4. Review of Resident #41's admission MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Physical and verbal behaviors directed towards others four to six days out of the seven day look back period (period of time used to complete the assessment); -Received Antipsychotic medication seven out of the seven days in the look back period; -Received Hypnotic medication two out of seven days in the look back period; -Received Antidepressant medication seven out of seven days in the look back period; -Diagnosed with Alzheimer's disease, anxiety disorder and depression. Review of the resident's Physician Note, dated 08/23/23, showed a new diagnosis of senile psychosis with a new order for Haldol (an antipsychotic medication). Review of the resident's Physician Order Sheets (POS), showed orders dated 08/23/23 for Haldol 5 milligrams (MG) once a day and Haldol 2 mg once a day. Review of the resident's care plan, revised 08/07/23, showed no direction for staff in regard to Haldol use, or medication side effects and behaviors to monitor for. During an interview on 09/08/23 at 9:50 A.M., Licensed Practical Nurse (LPN) J said the care plan directed staff on the type of care the resident needed and their preferences. LPN J said the MDS Coordinator was responsible for reviewing and revising the care plans but the nurses could update the care plans with changes. The care plans were updated quarterly and with any change in the residents condition. Care plans should include a diagnosis of dementia, and that Resident #22 likes to eat meals with his/her spouse. During an interview on 09/08/23 at 10:34 A.M., Certified Nurse Aide (CNA) B and Nurse Aide (NA) C said the care plans provided guidance for staff on how to care for the residents. During an interview on 09/08/23 at 10:49 A.M., the MDS Coordinator said he/she was responsible for updating and revising the care plans, but the nurses could update them. The information in the care plans was obtained by reviewing the residents' medical records, and interviews with staff and residents or their family. The care plans were updated after each MDS assessment, and with changes in resident condition. Care plans should address pertinent diagnoses such as dementia, and new mental health diagnoses as well as interventions for monitoring for effectiveness with the start of medications. The MDS coordinator said he/she started the position in June and he/she noticed some of the care plans had not been reviewed and revised. During an interview on 09/08/23 at 11:55 A.M., the Administrator and Director of Nursing (DON) said the care plan should direct staff in the type of care the resident required, and should be updated with a change in status and quarterly. They said the care plan should be updated by the department head in which the change had occurred. They said they expected the care plan to address pertinent diagnoses such as dementia. The DON said a new psychotic disorder diagnosis, and a new antipsychotic medication should be on the care plan. There should be interventions on the care plan and they should be measurable and resident specific.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to ensure three residents (Residents #23, #35 and #50), who were unable to complete their own activities of daily living (ADLs) (showering/bathing, dressing, and personal hygiene), received the necessary care and services to maintain good personal hygiene. The facility census was 62. 1. Review of the facility's policy titled, Activities of Daily Living (ADLs), Supporting, dated March 2018, showed staff were directed to do the following: -Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs; -Residents who are unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene; -Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care). 2. Review of Resident #23's Significant Change in Status (SCSA) Minimum Data Set (MDS), a federally mandated assessment tool, dated 06/28/23, showed staff assessed the resident as follows: -Severe cognitive impairment; -Required total assistance from one staff member for personal hygiene. Review of the resident's care plan, dated 02/21/23, showed staff documented the resident required extensive assistance with personal care and oral hygiene. Observation on 09/05/23 at 12:04 P.M., showed the resident's thumb nails long and uneven in length. Observation on 09/06/23 at 9:09 A.M., showed the resident's thumb nails long and uneven in length. The resident's facial hair was unkempt and his/her hair was disheveled. Observation on 09/06/23 at 9:52 A.M., showed Registered Nurse (RN) D provided care to the resident's hand. The resident's nails were long and the RN did not provide nail care. Observation on 09/07/23 at 11:54 A.M., showed the resident's thumb nails long and uneven in length, he/she had unkempt facial hair and his/her hair was disheveled. Observation on 09/07/23 at 3:10 P.M., showed the resident's thumb nails long and uneven in length. 3. Review of Resident #35's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment; -Required limited assistance from one staff member for personal hygiene. Review of the resident's medical record showed a diagnosis of the resident's need for assistance with personal care. Review of the resident's care plan, dated 03/21/23, showed staff documented the resident required extensive assistance with some ADLs related to a diagnosis of frontotemporal neurocognitive disorder (brain disorder), dementia, history of stroke and hallucinations. Required assistance for shaving his/her facial hair when unable to complete the task. Observation on 09/06/23 at 1:41 P.M., showed the resident had long fingernails, long nose hair and long hairs on his/her neck. Observation on 09/07/23 at 8:58 A.M., showed the resident had long fingernails, long nose hair and long hairs on his/her neck. Observation on 09/08/23 at 11:36 A.M., showed the resident had long fingernails, long nose hair, and long hairs on his/her neck. 4. Review of Resident #50's admission MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Required limited assistance from one staff member for personal hygiene. Review of the resident's care plan, dated 08/21/23, showed no direction for staff in regard to the resident's ADL care needs. Observation on 09/05/23 at 11:58 A.M., showed the resident had long nose hairs, and disheveled hair. Observation on 09/06/23 at 12:25 P.M., showed the resident had disheveled and greasy hair, long nose hairs and debris on the front of his/her shirt. Observation on 09/06/23 at 3:46 P.M., showed the resident had disheveled and greasy hair, long and uneven nails, long nose hairs and debris on the front of his/her shirt. Observation on 09/07/23 at 1:25 P.M., showed the resident had disheveled and greasy hair, long nose hairs and debris on the front of his/her shirt. During an interview on 09/08/23 at 9:50 A.M., Licensed Practical Nurse (LPN) J said there were only two Certified Nurse Aides (CNAs) providing care for the residents. The LPN said there was not enough staff to provide care for the residents. The resident's hair should be brushed when staff get them out of bed, and the aides should provide shaves including nose hair trimming, and nail care as need. The podiatrist provided nail care for residents with more difficult cases. The LPN said resident #23 had long nails, but he/she was diabetic, so a nurse should trim the nails. The resident's hands were contracted, so there was a concern with the long nails digging into his/her hands. LPN J said when staff placed the washcloth in the resident's hand, they should be checking if the resident needed his/her nails trimmed. During an interview on 09/08/23 at 10:34 A.M., CNA B and Nurse Aide (NA) C said they do not feel there was enough staff to provide care for the residents, and because of this some of the residents did not receive the care they needed. Nail care, hair brushing and nasal hair did not always get done. They said they did notice Resident #50's unbrushed hair. They said staff should brush the resident's hair when assisting them out of bed. They said some of the residents had long nose hair and the aides should be trimming it. During an interview on 09/08/23 at 11:55 A.M., the Administrator and the Director of Nursing (DON) said the bath aide or CNA provided nose hair trimming, nail care, and shaves when needed. They said volunteers came in once a month to trim the residents' nails and activity staff trimmed nails every other week. They said the nurses provided nail care for residents who were diabetic. They said staff should brush the residents' hair when they get them out of bed. If staff notice hygiene concerns, they should provide the necessary care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to transfer two residents (Resident #22 and #20) in a safe manner, and failed to properly propel two residents (Resident #15 and #48) in wheelchairs in a manner to prevent accidents. The facility census was 62. 1. Review of the facility's policy titled, Safety and Supervision of Residents, dated July 2017, showed staff were directed to do the following: -Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards, and try to prevent avoidable accidents; -The care team shall target interventions to reduce individual risks related to hazards in the environment, including inadequate supervision and assistive devices; -Due to complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures to include, safe lifting and movement of residents. Review of facility's Hoyer Instruction Manual, undated, showed staff are directed to ensure the legs of the hoyer lift base were opened and locked and the lift was in position, before the patient was lifted. 2. Review of Resident #22's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 07/04/23, showed staff assessed the resident as: -Severe cognitive impairment; -Required extensive assistance from two staff members for bed mobility, transfers and toilet use; -Required extensive assistance from one staff member for dressing, bathing and personal hygiene; -Only able to stabilize with staff assistance during transfers; -Used a wheelchair; -Diagnoses of stroke, Parkinson's disease (brain disorder that causes uncontrolled movements and decreased balance and coordination) and seizure disorder. Review of the resident's care plan, revised 07/10/2023, showed staff documented the resident required the assistance of one to two staff members for transfers and was unsteady at times with a history of falls. Observation on 09/06/23 at 10:14 A.M., showed Nurse Aide (NA) C and Certified Nurse Aide (CNA) B entered the resident's room with a mechanical lift. The NA opened the base of the lift and pushed it up to the resident's wheelchair, secured the lift sling to the lift, lifted the resident from his/her wheelchair, closed the base of the lift with the resident suspended in the air, and pushed the lift toward the resident's bed, while the CNA stabilized the resident. The right leg of the lift became stuck on the bed frame at the foot of the bed, and the lift abruptly stopped. The NA kicked the right leg of the lift free from the bed frame, and continued to transfer the resident. During an interview on 09/08/23 at 8:51 A.M., NA C said staff were supposed to open the mechanical lift legs after lifting the resident. During an interview on 09/08/23 at 8:53 A.M., CNA B said staff had been trained to close the mechanical lift legs as the resident was moved closer to their bed. 3. Review of Resident #2's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Totally dependent on two staff members for transfers; -Required extensive assistance from two staff members for bed mobility, locomotion on and off the unit, dressing, toilet use and personal hygiene; -Required extensive assistance from one staff member for locomotion on the unit; -Only able to stabilize with staff assistance during transfers; -Uses a wheelchair; -Had two or more non-injury falls since last assessment; -Diagnoses of dementia, anxiety disorder and depression. Review of the resident's care plan, revised 07/27/2023, showed staff documented the resident had a history of falls while in the facility. Resident required a mechanical lift with two staff members for transfers. Observation on 09/07/23 at 4:00 P.M., showed CNA E and Restorative Aide (RA) F slid a mechanical lift under the frame of the resident's bed with the base closed. The CNA lifted the resident, pulled the lift out from under the bed, and with nothing under the resident, the CNA pushed the lift approximately six feet with the base of the lift closed. The CNA did not open the legs of the lift until he/she lowered the resident in to a wheelchair. During an interview on 09/07/23 at 4:03 P.M., CNA E said he/she had been taught to pull the resident out from his/her bed and then open the legs of the lift to transfer the resident to the wheelchair. The CNA said he/she did not open the lift legs before lifting the resident, because the legs get caught on the resident's bed frame. The CNA said he/she was supposed to have the legs of the lift open before lifting residents, so the residents do not tip over. During an interview on 09/08/23 at 12:11 P.M., The Director of Nursing (DON) said staff should open the legs of the lift when they begin to lift the resident. The legs of the lift should be open when the resident was lifted in the air, and should not be closed until the resident was being lowered. The DON said if the mechanical lift legs were closed, it was dangerous for the resident because the lift could tip over. 4. Review of Resident #15's Significant Change in Status (SCSA) MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Required extensive assistance from two staff members for locomotion on unit; -Required supervision from one staff member for locomotion off unit; -Used a wheelchair. Observation on 09/08/23 at 9:58 A.M., showed NA C propelled the resident in a wheelchair down the hallway. The resident's foot hung between the foot pedals and dragged the floor. 5. Review of Resident #48's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Required supervision from one staff member for locomotion on unit; -Required extensive assistance from one staff member for locomotion off unit; -Used a wheelchair. Observation on 09/08/23 at 9:52 A.M., showed CNA K propelled the resident in a wheelchair down the hallway, without foot pedals. The resident held his/her feet up. During an interview on 09/08/23 at 9:50 A.M., Licensed Practical Nurse (LPN) J said staff should use foot pedals anytime they propelled a resident in a wheelchair. The LPN said he/she had seen staff propelling residents without foot pedals, and it could cause injury to the residents. During an interview on 09/08/23 at 10:34 A.M., CNA B and NA C said staff should always use foot pedals when propelling a resident in a wheelchair, and should ensure the resident's feet were on the foot pedals. They said the resident could be injured if their feet touched the ground. During an interview on 09/08/23 at 11:55 A.M., the Administrator and the DON said staff were educated to always use foot pedals when propelling a resident, and should ensure the resident's feet were on the foot pedals. They said the resident could be injured if foot pedals are not used, or if the resident's feet were not placed on the pedals correctly.

Based on observation, interview, and record review, facility staff failed to remove soiled gloves and/or properly wash hands and provide an environment to prevent the spread of bacteria and other infection causing contaminants during the provision of wound care for one resident (Residents #1). Additionally staff failed to remove soiled gloves and/or properly wash hands during incontinence care for one resident (Resident #22). The facility census was 62. 1. Review of the facility's policy titled, Wound Care, dated October 2018, showed staff were directed to do the following: -Use disposable cloth (paper towel is adequate) to establish clean field on resident's over bed table. Place all items to be used during procedure on the clean field; -Dress wound. Pick up sponge with paper and apply directly to area. [NAME] tape with initials, time, and date and apply to dressing. Be certain all clean items are on a clean field; -Discard disposable items into the designated container. Discard all soiled laundry, linen, towels, and washcloths into the soiled laundry container. Remove disposable gloves and discard into designated container. Wash and dry hands thoroughly; -Review showed no direction for staff in regard to providing multiple wound treatments, glove changes and hand hygiene. Review of the facility's policy titled, Hand Hygiene, dated May 2021, showed staff were directed to do the following: -Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice; -Wash hands with soap and water whenever they are visibly soiled; -The use of gloves does not replace hand hygiene, if task requires gloves, perform hand hygiene prior to donning gloves and immediately after removing gloves. 2. Observation on 09/05/23 at 2:34 P.M., showed Registered Nurse (RN) D provided wound care for Resident #1. The RN placed the bandage tape and dressing packages directly on the resident's bed linens, without a protective barrier, packed a wound on the resident's buttocks, then packed a different wound on the buttocks and applied dressings to both wounds without changing gloves or performing hand hygiene between wound care. The RN changed gloves, performed hand hygiene, cut and applied tape to the dressings, removed gloves, disposed of the wound care packaging, returned the same roll of bandage tape to the storage area, and placed scissors in his/her pocket, without sanitization. During an interview on 09/08/23 at 9:50 A.M., Licensed Practical Nurse (LPN) J said staff should place wound care supplies on a protective barrier, if not the supplies could be contaminated. Supplies should not be placed directly on bed linens. The LPN said staff should perform hand hygiene and change gloves between providing treatments to wounds at different sites because of the risk of cross contamination. During an interview on 09/08/23 at 11:55 A.M., the Administrator and the Director of Nursing (DON) said wound care supplies should be put on a clean surface, such as a protective barrier, or on a sanitized bed side table. They said the supplies should not be sat on bed linens because of contamination concerns. They said staff should perform hand hygiene and glove changes between each wound to prevent cross contamination. 3. Observation on 09/06/23 at 10:14 A.M., Nurse Aide (NA) C and Certified Nurse Aide (CNA) B entered the resident's room, washed their hands and applied gloves. The NA picked up the resident's catheter bag and placed it on the bed frame, and wiped his/her face with the same gloves on. The NA rolled the resident to his/her right side, while the CNA removed the resident's soiled brief. The NA then rolled the resident on their back, wiped the resident's perineal folds multiple times from back to front with the same wipe, and wiped the resident's perineal area in a circular motion with the same wipe. The NA and CNA rolled the resident back on to his/her right side, and the NA with the same gloves on, pulled a new wipe and wiped feces off of the resident. With the same gloves on, the NA helped the CNA apply cream to the resident's perineal folds, and touched the resident's clean brief and clothes. During an interview on 09/08/23 at 10:40 A.M., NA C said staff should change gloves and wash their hands, anytime they are dirty. The NA said he/she had been taught to wipe from front to back, and to fold the wipe with each swipe. The NA said he/she did not change gloves, or wipe front to back because he/she was in a hurry. During an interview on 09/08/23 at 10:40 A.M., CNA B said he/she is training NA C. The CNA said staff should provide perineal care before they move to the resident's backside. The CNA said after wiping feces, staff should should wash hands and change gloves. The CNA said staff should use a new wipe per swipe. The CNA said if a NA does something incorrectly he/she was supposed explain the process, so the NA did it correctly the next time. The CNA said he/she was in a hurry and did not notice the NA used the same wipe several times and did not change his/her gloves. The CNA said he/she should have noticed it. During an interview on 09/08/23 at 12:11 P.M., the DON said during incontinence care, he/she expected staff to wash hands, apply gloves and clean the resident front to back. The DON said when using disposable wipes to provide care, one swipe per wipe was best. The DON said he/she expected staff to change gloves and wash hands after incontinence care and before they handled the resident's clean brief and clothing. The DON said if the staff did not change gloves and wash their hands before touching clean briefs, the staff could transfer bacteria and cause infections. The DON said if staff provided bowel incontinence care and then moved to the front perineal area without washing their hands and changing their gloves, it could cause a Urinary Tract Infection (UTI).