**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accurately code the Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, for one resident (Resident #55) out of 18 sampled residents. The facility census was 76. Review of the facility's policy titled, Certifying Accuracy of the Resident Assessment, revised November 2019, showed: - The information captured on the assessment reflects the status of the resident during the observation (look back) period for that assessment. 1. Review of Resident #55's medical record showed: - An admission date of 11/03/23; - Diagnoses of chronic inflammatory demyelinating polyneuritis (neurological disorder that affects peripheral nerves and nerve roots), polyneuropathy (peripheral nerve disorder that affects nerves throughput the body), paraplegia (paralysis affecting all or parts of lower part of body), muscle weakness, major depressive disorder (disorder that causes a persistent feeling of sadness or loss of interest), diabetes mellitus (DM - elevated levels of sugar in the blood), and anxiety (a feeling of fear, dread, and uneasiness); - Had post-traumatic stress disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event); - Care plan, last revised 01/24/25, addressed PTSD with triggers; - Brief Trauma Questionnaire, dated 11/03/23, showed PTSD with past therapies and coping methods. Review of the resident's annual MDS, dated [DATE], showed: - PTSD diagnosis not addressed. During an interview on 02/07/25 at 9:25 A.M., the MDS Coordinator said PTSD should have been addressed for Resident #55. If a resident had a diagnosis like diabetes that was not mentioned by the physician for 60 days, then he/she did not address the diagnosis on the MDS assessment. During an interview on 02/07/25 at 12:20 P.M., the Director of Nursing (DON) and Administrator said they would expect the MDS to accurately reflect the resident's condition and diagnoses at the time of the assessment.

Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness when the facility failed to utilize pasteurized eggs to prepare fried eggs without a congealed yolk for seven residents (Residents #13, #42, #53, #54, #56, #57 and #63) out of 15 sampled residents. These practices had the potential to affect all residents. The facility census was 76. Review of the facility's policy titled, Hair Restraints, dated 2016, showed: - 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. The facility did not provide a policy on the use of pasteurized (a process of food preservation in which packaged foods are treated with mild heat) eggs. 1. Observations on 02/04/25 at 11:20 A.M., and 02/07/25 at 10:58 A.M., of the kitchen showed: - Dietary Aide (DA) B served food from the steam table with hair partially unrestrained from the outside of a hairnet; - DA C prepared food with hair partially unrestrained from the outside of a hairnet; - An emptied disposable towel dispenser near the personal hygiene sink; - A 4 foot (ft.) section of vinyl baseboard peeled away from the wall behind the garbage disposal sink; - Six 4-inch (in.) x 12 in. ceiling diffusers (one of the few visible parts of an air conditioning system) with dust buildup and a brown substance on the front exterior surfaces near the food shelves and food preparation areas; - 14 1 ft. x 1 ft. vinyl floor tiles missing under the front food preparation counter along the wall. During an interview on 02/07/25 at 11:15 A.M., DA B said he/she tried to keep his/her hair under the hairnet and had been trained to keep hair restrained. During an interview on 02/07/25 at 11:20 A.M., DA C said he/she tried to keep his/her hair entirely under the hairnet and it was the expectation for dietary workers. During an interview on 02/07/25 at 11:25 A.M., the Dietary Manager (DM) said the dietary workers hair should be kept entirely inside of the hairnets. 2. Observations on 02/04/25 at 11:30 A.M., and 02/07/25 at 11:08 A.M., of the walk-in refrigerator showed: - No pasteurized shell eggs; - Six boxes with 15 dozen non-pasteurized eggs, dated 01/28/25; - One partially full box with non-pasteurized eggs, dated 01/14/25; - The refrigerator door gasket covered with a black substance; - The interior lower right front wall section near the door with an approximate 1 ft. diameter (dia.) hole in the thin metal surface layer with a 1 in. ice build-up; - The interior lower right side wall section with approximately 10 ft. by 1 ft. hole in the thin metal surface layer with a 1 in. ice build-up, 3. Observation of the dining room on 02/04/25 at 11:58 A.M., showed Resident #42 ate a partially full plate with three chopped yellow eggs prepared fried with an uncongealed (become liquid again or to thaw) yolk. During an interview on 02/04/25 at 11:20 A.M., DA A said the fried eggs were requested over easy and over medium by the residents. He/she had fried eggs this morning that were not well done for a resident and used unpasteurized shell eggs. There had been no training about only using pasteurized eggs. During an interview on 02/04/25 at 12:16 P.M., the DM said normally there were no less than twelve residents that order fried eggs. The eggs should be fried at least medium, but the resident this morning had runny, uncongealed yolks. The cooks were expected to use pasteurized eggs if they were going to be fried runny. They had not had the pasteurized eggs available since they ran out over one week ago, and the staff wanted to stick with the residents' choices on preparation of the fried eggs. During an interview on 02/04/25 at 12:35 P.M., DA B said he/she fried eggs over easy or over medium with the yolk a little runny this morning. He/She fried about 34 eggs in a skillet, but he/she wasn't sure how many residents were served the eggs. He/She was not trained to use only pasteurized eggs if they were to be fried a little runny. The eggs were taken from the partially full box with unpasteurized shell eggs, dated received on 01/28/25. A separate container with unpasteurized eggs was emptied this morning and the box had been removed from the kitchen. During an interview on 02/04/25 at 12:56 P.M., the Administrator said the policy for use of pasteurized eggs showed the residents should only be served fried eggs made from pasteurized eggs. The facility should only be ordering pasteurized eggs. The pasteurized eggs should have been used for the fried eggs today. There were several residents served eggs that were undercooked, the residents will be put on high awareness for the risk of food borne illness. The Director of Nursing (DON) had been made aware of the concern. During an interview on 02/06/25 at 8:37 A.M., the DON said she was aware the dietary department had served undercooked fried shell eggs that were non-pasteurized. They should not have been served undercooked and the residents were put on high awareness. The physician was contacted about the situation. The non-pasteurized eggs will be replaced with pasteurized shell eggs. The residents will only be served eggs that are cooked fully until we receive pasteurized eggs. During an interview on 02/04/25 at 01:25 P.M., Resident #13 said his/her eggs were served fried with a runny yolk this morning. During an interview on 02/04/25 at 1:30 P.M., Resident #63 said his/her fried eggs were received today and the yellow was still a little runny. Fried eggs had been served cold to his/her room about two weeks ago when the new cook started. He/She always ordered eggs fried over easy. During an interview on 02/07/25 at 11:22 A.M., Resident #56 said he/she was served fried eggs over easy this week on Tuesday, he/she prefers them that way, since then the eggs have been fried well done. During a group interview on 02/07/25 at 11:27 A.M., Residents #53, #54, and #57 said they were served eggs over easy and runny on Tuesday because that is their preference for fried eggs. They have been okay with having the eggs well done until the eggs are replaced with pasteurized eggs. 4. Observations of the dining room area on 02/07/24 at 10:58 A.M., showed: - Ice machine drain pipe not aligned over the floor drain and water dripped on the floor with one missing vinyl floor tile with scattered debris; - An 8 ft. wooden base cabinet with a damp black substance near the floor in the baseboard area; - The floor below dishwasher with scattered debris and a sticky film. During an interview on 02/07/25 at 11:30 A.M., the DM said issues with the walk-in refrigerator should be repaired. There should not be holes in the interior or ice buildup. The floors should be kept clean under appliances and ceiling vents should be clean and not have a brown substance. The floor should be in good repair and not have missing tiles. During an interview on 02/07/25 at 11:59 A.M., the Maintenance Director said he/she was aware of issues that were in need of repair including refrigeration, ventilation, and cabinetry, in the dining and kitchen areas. The damage will be repaired, and it should not be in that condition. The ice machine drain was adjusted so it didn't drip on the floor. The water caused damage to the wooden cabinet next to the ice machine and it will be repaired or replaced. The walk-in refrigerator should not have ice buildup or holes on the interior and it will need some repairs. The diffusers will be cleaned and repaired. During an interview on 02/07/25 at 12:45 P.M., the Administrator said the kitchen and dining area should be kept in good repair and the staff should be wearing hairnets that keep their hair fully restrained. The ceiling vents should be clean, the floor in the kitchen should not be missing tiles, and the dining room vanity will be repaired by the maintenance department. Maintenance would also need to look into repairing issues with the walk-in refrigerator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure staff treated residents with dignity and in a respectful manner by leaving two residents (Resident #69 and #225) out of nine sampled residents exposed during care. The census was 74. Review of the facility's policy titled Dignity, revised February 2022, showed: - Residents are treated with dignity and respect at all times; - Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. 1. Review of Resident #69's medical record showed: - admission date of 11/03/23; - Diagnoses of paraplegia (paralysis of the legs and lower body), general weakness, chronic inflammatory demyelinating polyneuropathy (CIDP) (a neurological disorder that involves progressive weakness and reduced senses in the arms and legs), neurogenic bladder (condition that results in lack of bladder control due to a brain, spinal cord or nerve problem), and sacral (the bottom of the spine, between the bottom of the lumbar spine and tailbone) decubitus (damage to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/15/23, showed: - Required substantial/maximal assist to totally dependent on staff for dressing, bed mobility, transfers, and toileting; - Had an indwelling urinary catheter; - Always incontinent of bowel. Observation of the resident on 12/13/23 at 3:39 P.M., showed: - The resident lay in bed; - Certified Nursing Assistant (CNA) D and CNA E entered the room to perform incontinent care, catheter care, and range of motion; - CNA D and CNA E did not pull the curtain or close the blind to the window; - Through the window, the outside courtyard and an exit door could be seen; - CNA D and CNA E failed to provide privacy during incontinent care, catheter care, and range of motion for the resident. Observation of the resident on 12/13/23 at 3:49 P.M., showed: - The resident lay in bed; - Licensed Practical Nurse (LPN) K entered the room to perform wound care; - LPN K did not pull the curtain or close the blind to the window; - Through the window, the outside courtyard and an exit door could be seen; - LPN K failed to provide privacy during wound care for the resident. During an interview on 12/14/23 at 9:30 A.M., LPN K said with any care, the window shade and/or curtain should be pulled. 2. Review Resident #225's medical record showed: - An admission date of 11/03/23; - Diagnoses of amputation of right first and second toes, type 2 diabetes mellitus (a disease in which the body's ability to produce or respond to the hormone insulin is impaired), generalized weakness, general pain, history of occluded right proximal superficial artery (a condition involving partial or complete blockage of blood flow through an artery that runs the length of the thigh), history of occluded right posterial (back) tibial artery (a condition involving partial or complete blockage of an artery that carries blood to the back compartment of the leg and plantar (sole) surface of the foot), depression, anxiety, and history of falls. Review of the resident's admission MDS, dated [DATE], showed: - Required substantial/maximal assist to totally dependent on staff for dressing, bed mobility, transfers, and toileting; - Frequently incontinent of bladder and bowel. Observation of the resident on 12/12/23 at 6:20 P.M., showed: - The resident lay in bed; - LPN R, CNA P, and CNA Q did not pull the curtain or close the door; - LPN R, CNA P, and CNA Q performed wound care for the resident; - The resident's abdomen was exposed and visible from the hallway; - LPN R, CNA P, and CNA Q failed to provide privacy during wound care for the resident. During an interview on 12/14/23 at 9:30 A.M., LPN K said with any care the window shade or curtain should be pulled. During an interview on 12/14/23 at 9:35 A.M., CNA F said all curtains, blinds and doors should be closed or pulled when care was provided for a resident. During an interview on 12/14/23 at 9:45 A.M., the Director of Nursing (DON) said with any care, the window shade, curtain, or door should be pulled or closed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to complete ongoing re-evaluations for the continued need of a restraint (a device that limits a person's movement) for three residents (Residents #6, #30, and #46) out of three sampled residents. The facility census was 74. The facility failed to provide a restraint policy. 1. Review of Resident #6's medical record showed: - An admission date of 06/23/21; - Diagnoses of dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning), weakness, confusion, anemia (a condition in which the blood doesn't have enough healthy red blood cells), degenerative joint disease (a type of arthritis that occurs when flexible tissue at the ends of bones wears down), and difficulty walking; - Required assistance of one staff for toileting; - No documentation of a physician's order for a bed alarm; - No documentation of a restraint assessment. Review of the resident's quarterly Minimum Data Set (MDS) (a federally mandated assessment instrument completed by the facility staff), dated 09/18/23, showed: - Bed and chair alarms not used; - Wander guard (a roam alert that can trigger alarms and lock monitored doors to prevent the resident leaving unattended) used daily. Review of the resident's care plan, revised 09/25/23, showed: - The resident at risk for falls; - No documentation of a bed alarm as an intervention. Observations of the resident on 12/11/23 at 2:40 P.M., 12/12/23 at 3:21 P.M., and 12/13/23 at 4:13 P.M., showed: -The resident lay in bed with a bed alarm attached to a pad under his/her back; -The resident was unable to remove the bed alarm. 2. Review of Resident #30's medical record showed: - An admission date of 02/02/23; - Diagnoses of dementia, transient cerebral ischemic attack (TIA) (a neurologic deficit that produces stroke symptoms that resolve within 24 hours), essential tremor, and memory loss; - Required assistance of one to two staff for toileting; - No documentation of a physician's order for the bed and chair alarms; - No documentation of a restraint assessment. Review of the resident's quarterly MDS, dated [DATE], showed a bed and chair alarm used for the resident. Review of the resident's care plan, revised on 11/09/23, showed: - The resident at risk of falls and poor safety awareness; - An intervention of a chair and bed alarm, dated 02/10/23. Observations of the resident on 12/11/23 at 11:58 A.M., 12/12/23 at 9:50 A.M., 12/12/23 at 10:48 A.M., and 12/13/23 at 10:30 A.M., showed: - The resident sat in a wheelchair with a chair alarm attached to the back of the wheelchair and to a pressure pad under the resident's thighs and buttocks; - The resident was unable to remove the chair alarm. Observation of the resident on 12/12/23 at 10:57 A.M. showed: - The resident lay in bed with a bed alarm attached to a pad under his/her back; - The resident was unable to remove the bed alarm. 3. Review of Resident #46's medical record showed: - An admission date of 01/25/21; - Diagnoses of dementia, osteoporosis (a condition in which bones become weak and brittle), anxiety (intense, excessive and persistent worry and fear about everyday situations), depression (a mood disorder that causes persistent feeling of sadness and loss of interest) and insomnia (a common sleep disorder, including falling asleep, staying asleep or getting good quality sleep); - Required assistance of one staff for toileting; - No documentation of a physician's order for the bed and chair alarms; - No documentation of a restraint assessment. Review of the resident's quarterly MDS, dated [DATE], showed a bed and chair alarm used daily. Review of the resident's care plan, revised 11/07/23, showed: - The resident at risk for falls; - An intervention for bed and chair alarms, dated 02/14/23; Observations of the resident on 12/11/23 at 3:09 P.M., 12/12/23 at 9:09 A.M., 12/12/23 at 2:15 P.M., and 12/13/23 at 1:52 P.M., showed: - The resident sat in a wheelchair with a chair alarm attached to the back of the wheelchair and to a pressure pad under the resident's thighs and buttocks; - The resident was unable to remove the chair alarm. During an interview on 12/13/23 at 4:37 P.M., the Director of Nursing (DON) said she would not necessarily expect to see an order for a bed/chair alarm since they were considered nursing interventions. During an interview on 12/14/23 at 9:45 A.M., the DON said assessments or decision trees should be completed in order to show why the resident required an alarm and ensure it wasn't a restraint.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to identify, assess and provide supportive interventions for two residents (Resident #69 and #70) with a diagnosis of post-traumatic stress disorder (PTSD) (a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event) out of two sampled residents. The facility's census was 74. The facility did not provide a PTSD policy. 1. Review of Resident #69's medical record showed: - Date of admission of 11/03/23; - Diagnosis of PTSD; - Trauma assessment dated [DATE] shows resident to trigger for PTSD. Review of the resident's Physician Order Sheet (POS), dated December 2023, showed: - An order for amitriptyline (an antidepressant medication) 25 milligram (mg) one tablet by mouth twice a day for depression, dated 11/03/23; - An order for Trazodone (an antidepressant medication) 50 mg one tablet at bedtime for insomnia (inability to sleep), dated 11/03/23. Review of the resident's care plan, dated 11/16/23 showed: - PTSD with interventions not addressed; - The resident's past trauma or any triggers that would cause the resident to experience behaviors not addressed; - Interventions for how the facility would address any behaviors if they occurred or how the facility would provide support to the resident not addressed. During an interview on 12/11/23 at 1:18 P.M., Resident #69 said he/she had PTSD from his/her past war time experiences. 2. Review of #70's medical record showed: - Date of admission [DATE]; - Diagnoses of PTSD; - Review of Brief Trauma Questionnaire, dated 09/06/23, showed the resident triggered for PTSD; - Signed on 09/06/23 by the Social Services Director (SSD). Review of the resident's admission Minimum Data Set (MDS) (a federally mandated process for clinical assessment of all residents in certified nursing homes), dated 09/13/23, showed the resident with a diagnosis of PTSD. Review of the resident's Monthly Summary, dated 10/19/23, showed: - Little interest or pleasure in doing things; - Feeling or appearing down, depressed, or hopeless; - Trouble falling or staying asleep, or sleeping too much; - Moving/Speaking so slowly other people notice or being so fidgety or restless; - Being short-tempered, easily annoyed. Review of the resident's care plan, dated 09/19/23, showed: - PTSD with interventions not addressed; - The resident's past trauma or any triggers that would cause the resident to experience behaviors not addressed; - Interventions for how the facility would address any behaviors if they occurred or how the facility would provide support to the resident not addressed. During an interview on 12/11/23 at 4:25 P.M., Resident #70 said he/she had PTSD and had nightmares all the time about dead bodies in Vietnam. Observation of the resident on 12/11/23 at 4:25 P.M., showed the resident was tearful and anxious when he/she talked about Vietnam and and his/her nightmares. During an interview on 12/13/23 at 2:47 P.M., Licensed Practical Nurse (LPN) O said he/she would expect a resident's care plan to address PTSD. During an interview on 12/13/23 at 5:39 P.M., the Director of Nursing (DON) said it would depend on the level of PTSD if there would be psychiatry notes in a resident's medical record. Resident #70 was emotional at times. She would expect a diagnosis of PTSD to be addressed on a resident's care plan.

Based on observation, interview, and record review, the facility failed to maintain adequate infection control practices to prevent the transmission of infection when staff demonstrated poor hand hygiene for eleven residents (Resident #17, #22, #30, #36, #43, #49, #50, #65, #69, #175 and #225) out of 12 sampled residents and one resident (Resident #15) outside the sample. The facility also failed to maintain adequate infection control practices during catheter (a tube inserted into the bladder to drain urine) care for two residents (Resident #36 and #69), emptying of the catheter drainage bag for one resident (Resident #69), and proper placement of a catheter drainage bag for one resident (Resident #36) out of three sampled residents. Review of the facility's policy titled,Handwashing/Hand Hygiene, dated August 2019, showed: - All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections; - All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors; - Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies; - Perform hand hygiene before applying non-sterile gloves; - Use an alcohol-based hand rub containing at least 62 percent (%) alcohol; or, alternatively, soap and water for the following situations: before and after direct contact with residents, before preparing or handling medications, before moving from a contaminated body site to a clean body site during resident care, after contact with a resident's intact skin, and before and after assisting a resident with meals. Review of the facility's policy titled, Personal Protective Equipment, dated September 2010, showed: - When gloves are indicated, use disposable single-use gloves; - Wash hands after removing gloves. 1. Observation on 12/12/23 at 11:50 A.M., of the feeding assistance provided for Resident #15 showed: - CNA F sat between Resident #15 and Resident #30 in the dining room; - CNA F altered picking up the spoon and drinks for Resident #15 and Resident #30 when offering bites of food and drinks to each resident; - CNA F used a spoon to bring a chip to Resident #30's mouth, then used his/her bare finger to push the chip into the resident's mouth; - CNA F used his/her bare fingers to hold down Resident #15's sandwich to cut it into smaller pieces; - CNA F altered between touching Resident #15's and Resident's #30's food and drinks while touching Resident #15's food with his/her bare hands and did not perform hand hygiene; - CNA F failed to use hand hygiene between feeding the residents and touched Resident #15's and Resident #30's food with his/her bare hands. 2. Observation of incontinent care provided for Resident #17 on 12/13/23 at 10:23 A.M., showed: - The resident lay in bed; - Certified Nurse Aid (CNA) G and CNA H did not perform hand hygiene and put on gloves; - CNA H cleaned the resident's front peri area and rolled the resident to his/her right side; - CNA H did not perform hand hygiene or remove his/her gloves, removed the incontinent pad from under the resident, placed a Hoyer lift (a mechanical lift) pad under the resident, and positioned the resident's pants; - CNA H did not perform hand hygiene or remove his/her gloves, and cleaned the resident's face with a wash cloth; - CNA H removed the gloves but did not perform hand hygiene; - CNA H failed to change gloves and perform hand hygiene during incontinent care. During an interview on 12/14/23 at 9:29 A.M., CNA H said when providing peri care, he/she should wash/sanitize his/her hands after taking off gloves. If gloves were soiled, he/she would change gloves. 3. Observation on 12/11/23 at 11:58 A.M., of the feeding assistance provided for Resident #30 showed: - Nurse Assistant (NA) M sat between Residents #30 and #15 in the dining room; - With his/her bare hand, NA M picked up Resident #30's grilled cheese and handed it to the resident twice; - With his/her bare hand, NA M picked up a chip and handed it to Resident #30; - NA M fed Resident #15 in between touching Resident #30's food with his/her bare hands and did not perform hand hygiene; - NA M failed to use hand hygiene between feeding the residents and touched Resident #30's food with his/her bare hands. Observation of incontinent care for Resident #30 on 12/12/23 at 11:30 A.M., showed: - CNA C and CNA D did not perform hand hygiene and put on gloves; - CNA C and CNA D transferred the resident from the wheelchair to the toilet; - CNA D removed the resident's urine soaked brief, CNA C grabbed it and handed it to CNA D; - Wearing the same gloves, CNA C tightened the gait belt (an assistive device used to help someone transfer) around the resident's waist, put a clean brief on the resident, held the resident's hands, and assisted the resident to stand; - CNA D removed the gloves, did not perform hand hygiene, and put on clean gloves; - CNA D performed incontinent care for the resident, removed the gloves, but did not perform hand hygiene; - Wearing the same gloves CNA C pulled the resident's clean brief and pants up; - Wearing the same gloves, CNA C assisted the resident back to the bed; - Wearing the same gloves, CNA C touched the resident's blanket, pillow and the resident's glasses when he/she removed them; - CNA C and CNA D failed to change gloves and perform hand hygiene during incontinent care. Review of the facility's policy titled, Catheters Insertion and Care, revised on August 2022, showed: - The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections (an infection in any part of the urinary system); - Empty the collection bag at least every eight hours using a separate, clean collection container for each resident. Avoid splashing, and prevent contact of the drainage spigot (a valve that keeps urine from draining out) with the nonsterile container; - Use aseptic technique (a collection of practices designed to avoid the introduction and transfer of germs and contaminants during medical processes) when handling or manipulating the drainage system; - Be sure the catheter tubing and drainage bag are kept off the floor; - Cleanse and rinse the catheter from the insertion site to approximately four inches outward. 4. Review of Resident #36's Physician order sheet (POS), dated 12/1/23, showed: - An order for a Foley (a type of indwelling catheter) catheter to drain via gravity with catheter care every shift, dated 8/26/23. Observations of the resident on 12/11/23 at 3:30 P.M., and 4:44 P.M., and 12/12/23 at 2:58 P.M., 4:00 P.M., 5:23 P.M., and 6:25 P.M., showed the resident's catheter drainage bag attached to the side pocket of the recliner with the bottom of the catheter drainage bag resting on the floor; - The facility failed to keep the catheter drainage bad from resting on the floor. 5. Observation of incontinent care provided for Resident #49 on 12/13/23 at 11:13 A.M., showed: - The resident lay in bed wearing a urine soaked brief; - CNA J, wearing gloves, cleaned the resident's front peri area and rolled the resident to his/her right side; - CNA J, wearing the same gloves, cleaned the resident's left hip, buttock and a small smear of fecal material from the resident; - CNA J removed his/her gloves, did not perform hand hygiene, and put on gloves; - CNA J placed a clean brief under the resident, then rolled the resident to his/her back and fastened the brief; - CNA J and CNA B repositioned the resident in his/her bed; - CNA J repositioned the resident's bed linens; - CNA J failed to change gloves and perform hand hygiene during incontinent care. 6. Observation of incontinent care provided for Resident #50 on 12/13/23 at 10:35 A.M., showed: - The resident lay in bed wearing a urine soaked brief; - CNA H touched the urine soaked brief with his/her gloved hand; - CNA G cleaned the resident's right hip, buttock and a large amount of fecal material from the resident; - CNA G removed the soiled brief; - Without removing the gloves or performing hand hygiene, CNA G positioned the clean brief under the resident; - CNA G and CNA H assisted the resident to his/her back; - CNA H cleaned the resident's front peri area and fastened the brief; - CNA G wearing the same gloves, touched the resident's clean clothes, the Hoyer lift, and the resident's hands; - CNA H removed the gloves, failed to perform hand hygiene, and removed the resident's bed linens with his/her bare hands; - CNA G and CNA H failed to change gloves and perform hand hygiene during incontinent care. 7. Observation of incontinent care performed for Resident #65 on 12/13/23 at 10:55 A.M., showed: - The resident lay in bed wearing a urine soaked brief; - CNA I, while wearing gloves, cleaned the resident's front peri area, then rolled the resident to his/her left side; - CNA I, wearing the same gloves, cleaned the resident's right hip, buttock and a small amount of fecal material from the resident; - CNA I removed his/her gloves, did not perform hand hygiene, and put on gloves; - CNA I placed the clean brief under the resident, rolled the resident to his/her back, fastened the brief and repositioned the resident's bed linens; - CNA I failed to change gloves and perform hand hygiene during incontinent care. 8. Observation of incontinent and catheter care performed for Resident #69 on 12/13/23 at 3:39 P.M., showed: - CNA D and CNA E did not perform hand hygiene and put on gloves; - CNA D cleaned the resident's front peri area; - CNA D performed catheter care and wiped toward the resident's catheter insertion site; - Wearing the same gloves, CNA D performed range of motion on both of the resident's legs. The resident's left leg had a bandage around the knee and one on the heel; - Wearing the same gloves, CNA D emptied the resident's catheter bag into a urinal with the drainage port freely hanging inside and touching the sides of the urinal; - CNA E rolled the resident onto his/her left side and CNA D performed incontinent care with fecal material on the resident's back peri area. The resident had a sacral (above the tailbone) wound not covered with a dressing; - CNA D, wearing the same soiled gloves, touched the resident's clean linens and thigh; - CNA D failed to change gloves and perform hand hygiene during incontinent and catheter care, and perform appropriate catheter care. 9. Observation of a medication pass on 12/13/23, showed: - At 5:26 P.M., Certified Medication Technician (CMT) N exited a resident's room without performing hand hygiene, and obtained medications for Resident #175; - At 5:29 P.M., CMT N administered medications to Resident #175 and did not perform hand hygiene after administering the medications; - At 5:30 P.M., CMT N obtained and administered medications for Resident #43 and did not perform hand hygiene after administering the medications; - At 5:34 P.M., CMT N obtained medications for Resident #22; - CMT N failed to perform hand hygiene before and after administering medications to residents. During an interview on 12/13/23 at 5:45 P.M., CMT N said he/she didn't perform hand hygiene between all of the residents' medication passes. Hand hygiene should be performed between residents and he/she usually did it but had been nervous. 10. Observation of incontinent care for Resident #225 on 12/14/23 at 9:18 A.M., showed: - The resident lay in bed; - CNA J cleaned the resident's front peri area and collected fecal material on his/her glove; - CNA J removed the gloves, failed to perform hand hygiene, and put on new gloves; - CNA J continued to clean the resident's front peri area, and collected fecal material on his/her gloves; - CNA J removed the gloves, sanitized his/her hands, and put on new gloves; - CNA J wiped fecal material down the catheter towards the insertion site; - Wearing the same gloves, CNA J retrieved a new wipe and cleaned down the resident's legs; - Wearing the same gloves, CNA J assisted the resident to to roll onto his/her right side, and removed the soiled sheet and the incontinent pad from the bed; - Wearing the same gloves, CNA J placed a clean sheet on the bed, wiped the soiled mattress with an incontinent wipe, and placed clean wipes on top of the clean sheet; - Wearing the same gloves, CNA J picked up the peri wash bottle, sprayed the resident's buttocks with the peri wash, and cleaned the resident's buttocks; - CNA J removed the gloves, sanitized his/her hands, and put on clean gloves; - Wearing the same gloves, CNA J folded a clean sheet and an incontinent pad, and placed them under the resident; - Wearing the same gloves, CNA J touched the resident's oxygen tubing; - CNA J removed the gloves, did not perform hand hygiene, and put on new gloves; - CNA J put a bottom sheet, a draw sheet, and an incontinent pad onto the bed with fecal material on the back of each of them; - Wearing the same gloves, CNA J touched the resident's right hand and body to assist the resident to roll onto his/her right side; - Wearing the same gloves, CNA J cleaned fecal material from the resident's buttocks; - Wearing the same gloves CNA J touched the peri wash bottle, assisted the resident to turn to his/her back, and cleaned the resident's front peri area; - Wearing the same gloves, CNA J cleaned the resident's thighs, and touched the resident's shoe; - CNA J removed the gloves, failed to perform hand hygiene, and with his/her bare hands placed a clean gown on the resident, tied and snapped the gown, touched the resident's oxygen tubing and placed the nasal cannula (a device that delivers extra oxygen through a tube to the nose) into the resident's nose, touched the package of wipes, closed the wipe lid, assisted the resident to reposition in the bed, touched the resident's pillow, and touched the resident's clean blanket when he/she unfolded it and placed it on the resident; - CNA J change gloves and perform hand hygiene during incontinent and catheter care, and perform appropriate catheter care. During an interview on 12/14/23 at 9:55 A.M., Registered Nurse (RN) L said hand hygiene should be done prior to entering a resident room. Gloves should be put on prior to performing peri care. Hand hygiene and gloves should be changed when going from dirty to clean care. Hand hygiene should be completed before moving to the next resident. During an interview on 12/14/23 at 9:30 A.M., Licensed Practical Nurse (LPN) K said hands should be washed/sanitized between glove changes. Glove changes should happen between clean and dirty care. Catheter care should be done from the insertion point down. Hands should be sanitized between residents when passing medications. Staff should not touch food with bare hands when feeding residents. During an interview on 12/14/23 at 9:35 A.M., CNA F said gloves should be changed between dirty and clean care. Hands should be sanitized between glove changes and catheter care should go from the insertion site and away. Food shouldn't be touched with bare hands. During an interview on 12/14/23 at 9:45 A.M., the Director of Nursing (DON) said hands should be washed/sanitized between glove changes. Glove changes should happen between clean and dirty care. Catheter care should be done from the insertion point and down. Hands should be sanitized between residents when passing medications. Staff should not touch food with their bare hands when feeding residents. During an interview on 12/14/23 at 10:05 A.M., CNA J said during incontinent care, he/she should wipe from front to back, using one wipe once and throw it away. If gloves were soiled, then the gloves should be changed. With catheter care, he/she should wipe from one side out, other side out, wipe in-between from front to back, then another wipe to clean the catheter from top to bottom. He/She should then change gloves, sanitize hands, put on new gloves, continue cleaning with a wipe, and changing gloves if soiled. Should sanitize hands with glove changes. If clean linens became soiled during the process, they would need to be replaced with new linens. He/She would expect a mattress to be disinfected if soiled. He/She would expect gloves not visibly soiled to be changed before touching other items in the room.

Based on observation and interview, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This deficient practice had the potential to affect all residents. The facility census was 74. The facility did not provide a dietary policy. Observations on 12/11/23 at 11:07 A.M., of the kitchen showed: - The top of the commercial range covered in food debris and a buildup of a brown substance; - The front door panel and the handle of the commercial range covered with a brown sticky substance; - An air vent located on the ceiling located near the entrance door covered with a dark brown substance; - 10 ceiling fluorescent light fixtures with no covers. Observation on 12/11/23 at 11:10 A.M., of the dry storage room showed one 6 pound (lb.) dented can of fruit mix on the canned food rack. Observation on 12/13/23 at 8:22 A.M., of the walk-in refrigerator showed: - A large bag of several boiled eggs, not dated; - Six bowls of chocolate pudding covered with plastic wrap, not dated; - 13 glasses of juice, covered with plastic wrap, not dated; - 11 pieces of cake in a small storage box, not labeled or dated; - One 5 lb. bag of shredded cheese, opened and not dated; - One large bag of salad mixture, opened and not dated. Observation on 12/13/23 at 8:29 A.M., of the ice machine in residents' dining room showed two filters on the top portion of the ice machine with a build up of dust and debris. During an interview on 12/14/23 at 8:50 A.M., Dietary Aide (A) said if anything was opened and placed in the refrigerator, it should be labeled and dated at that time. During an interview on 12/14/23 at 8:56 A.M., the Dietary Manager (DM) said he/she would expect staff to pull any dented cans and send back to the supplier. Maintenance comes through and checks the vents. He/She was unsure who was responsible for the ice machine, but the kitchen staff did clean the filters. The light covers had been like that for years. He/She was aware the stove needed cleaned, it was on the weekly cleaning schedule, and should have been done already. Staff had been asked to clean the stove as scheduled. During an interview on 12/14/23 at 10:05 A.M., the Administrator said she expected the dietary staff to clean the stove on a weekly schedule. She was aware the stove was dirty and had told the staff to get it cleaned. The maintenance staff was responsible for checking the vents and things like that in the kitchen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to reevaluate one resident (Resident #1), of seven sampled residents, for readmission to the facility when the resident was being discharged from the hospital after being sent for a psychological evaluation. The facility census was 74. Review of the facility's policy titled, Transferor Discharge, Facility-Initiated Policy, dated 10/2022, showed the following: -Once admitted to the facility, residents have the right to remain in the facility. Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notifications and orientation, and documentation as specified by this policy; -Facility initiated transfer or discharge means a transfer or discharge which the resident objects to, or did not originate through a resident's verbal or written request, and/or is not in alignment with the resident's stated goals for care and preferences; -A resident's declination of treatment is not grounds for discharge, unless the facility is unable to meet the needs of the resident or protect the health and safety of others. The facility will document that the resident or, if applicable, resident representative, received information regarding the risks of refusal of treatment and that staff conducted the appropriate assessment to determine if care plan revisions would allow the facility to meet the resident needs or protect the health and safety of others; -If discharge is initiated by the facility after an emergency transfer to the hospital, the reason for discharge is based on the resident's status at the time the resident seeks return to the facility (not at the time the resident was transferred to acute care); -If a resident exercises his or her right to appeal a transfer or discharge notice he or she will not be transferred or discharged while the appeal is pending, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility; -If the facility determines that the resident cannot return to the facility, the medical record will indicate that the facility made efforts to, ascertain an accurate status of the resident's condition, which can be accomplished via communication between hospital and facility staff and/or through visits by the facility staff to the hospital-find out from the hospital the treatments, medications, and services the facility would need to provide to meet the resident's needs upon returning to the facility. If the facility is unable to provide treatments, medications, and services needed, the facility may not be able to meet the residents needs and work with the hospital to ensure the resident's condition and needs are within the facility's scope of care, based on its facility assessment, prior to hospital discharge. 1. Review of Resident #1's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date of 07/23/18 and readmission date of 07/18/23; -Diagnoses included autonomic neuropathy (damage to the nerves that control autonomic body functions), stress incontinence (sudden loss of urine), IBS (Irritable bowel syndrome), fatigue (feeling of constant exhaustion), S/P (Surgical) DEEP Brain Stimulator placement (surgical procedure in which electrodes are implanted in to certain brain areas), end of battery life of deep brain stimulator, difficulty walking, depression (persistent feeling of sadness or loss of interest), atherosclerosis of native coronary artery without angina pectoris (disease that starts when fats, cholesterols and other substances collect on the inner walls of the heart arteries), chronic low back pain, bipolar disorder (extreme mood swings), dementia (loss of memory and abstract thinking), anxiety (sudden feelings of intense fear or terror), and mood disorder (distorted emotional state or mood distorted or inconsistent with your circumstances). Review of the resident's care plan, dated 07/18/23. showed the following: -Cognitive loss, communication and dementia; -Extensive assist with all adult daily living skills; -Most medications have been discontinued because of refusals to take them; -Has become more combative and have had altercations with other resident resulting in need to be monitored frequently and staff to intervene if one happens; -Report any changes in mood or behavior. Send resident to the emergency room if resident is combative with other residents and notify Administrator and Director of Nursing (DON); -Frequent observation and place monitoring device on resident due to wandering. Review of the resident's nurse's note dated 05/16/23, at 4:15 P.M., showed the resident was transferred via staff and facility van to psychiatric hospital for psychological evaluation. Review of the resident's medical record showed on 05/17/23 the facility mailed a notice of discharge for emergency situation to the resident's family member by certified mail based on current condition. Review of the resident's social services' note, dated 05/23/23, showed the following: -SSD received notice the resident is set to discharge on [DATE]; -The SSD informed the psychiatric hospital that he/she would verify that the decision to discharge was still what the medical director felt was the best in the safety of the residents in the facility. The hospital said they needed notification by 4:30 P.M.; -SSD called the hospital back to inform them the facility was standing by the decision to not bring the resident back to the facility. (The SSD did not document an assessment of the resident's current condition to determine if the resident could safely return to the facility.) Review of the resident's records, 05/24/23 to 07/17/23, staff did not document an assessment of the resident's current condition to determined if the resident could safely return to the facility. Review of the resident's nurse's note, dated 07/18/23, showed the following: -At 5:00 P.M., the resident arrived to facility via emergency medical services; -Resident alert to self, but stated he/she does not recognize some faces; -Code alert bracelet placed on left ankle; -Family member brought in medications and clothes for resident; -Resident refused nystop powder, became agitated at the nurse and acted like he/she was going to hit the nurse; -Resident did wander to unit 2 and was going in and out of rooms, staff redirected back to unit 1. During an interview on 08/01/23, at 12:10 P.M., Licensed Practical Nurse (LPN) A said he/she did not know if the resident was discharged or only sent out for a psych evaluation. During interviews on 08/01/23, at 12:20 P.M. and 1:52 P.M., LPN B said the following: -He/she hasn't dealt with an emergency discharge, but assumes it would be similar to a regular discharge; -When a resident discharges, staff do medication reconciliation, explain meds to the family, pass the discharge summary around to each department so they can fill out their part; -The resident was discharged due to an altercation, and sent out for a psych evaluation, -If the hospital called and wanted to send a resident back after the facility completed an emergency discharge, he/she would notify the DON and Administrator for direction. During interviews an on 08/01/23, at 12:20 P.M. and 1:52 P.M., LPN C said the following: -Haven't done an emergency discharge, with a regular discharge he/she makes copies of the resident's physician's order sheet, transfer sheet, any current labs and history and physical; -The resident was sent out for a psychological evaluation. He/she did not know if it was an emergency discharge. He/she did overhear that the facility didn't want to take the resident back and hoping they would find another place; -If the hospital called and wanted to send a resident back after the facility completed an emergency discharge, he/she would get a hold the DON or Administrator for direction. During interviews on 08/01/23, at 12:31 P.M. and 1:42 P.M., the Social Services Director (SSD) said the following: -When a resident is discharged they are given a notice. He/she is pretty sure this is done within 24 hours. The ombudsman and family are also notified. This is documented under the social services notes; -The resident was sent to a psychiatric hospital for an evaluation. After the resident was sent out, emergency discharge paperwork was done. He/she does not know why that was done; -If the hospital wants to send them back, would re-evaluate to see if facility could take the resident back and ask for records to see if they could return; -If facility sent an emergency discharge, the facility wouldn't be able to take a resident back if the hospital calls wanting to send them back. During an interview on 08/01/23, at 12:45 P.M., the DON said the following: -The administrator dealt with most of things regarding the resident; -We were concerned about the safety of other residents so the resident was sent to hospital for a psych evaluation. This was ordered by the facility physician; -The hospital doctor felt the behaviors were related to a UTI, so he/she wrote a script for an antibiotic; -When there's an emergency discharge, staff send papers with the resident, and certified letters are mailed to the family, and ombudsman in 30 days. The letters were mailed to the resident's family and the ombudsman; -The resident was sent to the psychiatric hospital for a psychological evaluation; -The resident is on a new medication that's a patch seems to be helpful and some better. During an interview on 08/01/23, at 1:00 P.M., the Administrator said the following: -Resident was sent to a psychiatric hospital for an evaluation due to behaviors; -Admin and the DON had a discussion after sending the resident and decided the best thing would be to do an emergency discharge. The facility physician was also involved; -Resident was sent to Lakeland on 05/16/23 due to facility could not meet the resident's needs and ensure safety of other residents; -Mailed the family and ombudsman a certified discharge letter and hand delivered to the physician. During an interview on 08/01/23, at 2:02 P.M., the Administrator and DON said the following: -If the hospital wants the resident to return to the facility staff would look at the documentation and go from there. They essentially do a reevaluation to determine if the resident is a fit to come back to the facility; -Staff had not seen the documentation on the resident. MO00221619

Based on interviews and record review, the facility failed to ensure all allegations of possible abuse were reported within two hours to the State Survey Agency (Department of Health and Senior Services - DHSS) when staff failed to report an allegation of abuse made by resident (Resident #1) that a staff member (Certified Nurse Aide (CNA A)) made threats to harm the resident. The facility census was 61. Record review of the facility's policy titled, Abuse Investigation and Reporting, revised July 2017, showed the following: -All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management; -An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but no later than two hours if the alleged violation involves abuse or has resulted in bodily serious bodily injury. 1. Record review of Resident #1's face sheet (admission data) showed the following: -admission date of 11/29/22; -Diagnoses included Type II diabetes (impairment in the way the body regulates and uses sugar), morbid obesity, legally blind, post traumatic stress disorder (PTSD - a mental health condition that's triggered by a terrifying event), traumatic brain injury (TBI - an injury that affects how the brain works), paraplegia (paralysis of the legs and lower body), and seizures (a sudden, uncontrolled burst of electrical activity in the brain). Record review of the resident's care plan, revised on 12/21/22, showed the following: -New below/above the knee amputation on right side; -Assisted to complete daily living activities of care; -The resident has potential for pain. Record review the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 12/29/22, showed the following: -Cognitively intact; -Verbal behavioral symptoms directed towards others and rejection of care; -Limited assist/one person for transfers, bed mobility, dressing, toileting, personal hygiene, and bathing. Record review of the resident's physician's progress note, dated 1/10/23, said the following: -Recently had a verbal confrontation with one of the staff members; -The resident said one of the staff members was being rude to him/her; -He/she has had a couple of issues like this since he/she has been in the facility; -At that point he/she refused any of his/her medications or the staff to come into his/her room; -It is difficult to fully understand what transpired between him/her and one of the staff at the nursing home; -Nursing management is interviewing all involved parties. Record review of the facility's investigation, dated 1/08/23, showed the facility completed an investigation of the allegation of verbal abuse. Record review of DHSS records showed the facility did not self-report the allegation of possible abuse. During an interview on 2/05/23, at 2:35 P.M., Certified Medication Tech (CMT) B said the following: -The resident told CMT B that CNA A was going to knock the resident out. CMT B was told this by the resident about three to four weeks ago and it had happened the night before; -The resident also told Registered Nurse (RN) H and he/she reported it to the Administrator and Director of Nursing (DON); -If the allegation the resident made is true, it would be considered verbal abuse; -When abuse is reported or witnessed, he/she tells the charge nurse first thing; -The abuse is to be reported to the state in two hours. During an interview on 2/05/23, at 3:25 P.M., CNA A said the following: -The resident made a comment to staff that he/she threatened the resident; -The resident told Licensed Practical Nurse (LPN) F that CNA A had threatened that if the resident didn't knock something off, CNA A was going to take him/her to the ground; -If a resident is threatened by staff, this would be verbal abuse; -If observe or resident reports abuse, would tell the charge nurse and write a statement. During an interview on 2/05/23, at 4:05 P.M., LPN F said the following: -The resident did not complain to him/her about CNA A, but rather told the night nurse that something had happened; -He/she was present during the time the alleged incident took place, but he/she did not hear anything; -The night nurse called the following day and said he/she had to make an incident report; -If abuse is reported, staff is to inform the Director of Nursing (DON) and Administrator, and begin the abuse forms; -Required to report to the state in two hours; -If a resident is threatened, would consider that abuse or dignity and respect. During an interview on 2/05/23, at 2:50 P.M., LPN E said the following: -The resident did not say CNA A had threatened him/her, but didn't want CNA A around him/her because they had words. The LPN did not know what that involved; -If a resident is threatened, that would be dignity and respect and could also be verbal abuse; -If the LPN seen or had abuse reported, he/she would tell DON; -The home has two hours to report suspected abuse to the state. During an interview on 2/05/23, at 2:40 P.M., Certified Med Tech (CMT) C said the following: -If abuse is reported or observed, he/she would tell the charge nurse; -If a staff member threatened to harm a resident, this would be considered verbal abuse or dignity and respect; -The home has one hour to report allegations of abuse to the state. During an interview on 2/05/23, at 2:40 P.M., CNA D said the following: -If abuse is reported or observed, he/she would tell the charge nurse; -If a staff member threatened to harm a resident, this would be considered verbal abuse or dignity and respect; -He/she Is not sure of the timeframes to report to the state, but needs to be immediately. During an interview on 2/05/23, at 3:53 P.M., Registered Nurse (RN) G said the following: -If staff threaten a resident, this would be verbal abuse and possibly dignity and respect too; -If abuse is reported staff have an abuse/neglect packet that's completed and investigate. Staff call the DON and Administrator so they can do their portion, the alleged perp is suspended; -Abuse should be reported to the state within two hours. During an interview on 2/06/23, at 1:15 P.M., RN H said the following: -He/she took the complaint of the incident from the resident; -The resident came to his/her desk on 01/07/23 or 01/08/23, complaining about CNA A; -The resident said CNA A had threatened to take the resident down. The resident said LPN F was present when this occurred; -The resident came back again 20 minutes later and changed his/her story and said LPN F wasn't present when the incident occurred; -The RN texted the Administrator and began the paperwork for investigating allegations of abuse; -When RN H has a report of abuse allegations, he/she notifies the Administrator and/or the DON; -They direct him/her to complete paperwork for the investigation and the DON does his/her part; -If staff said this to a resident, it would be verbal abuse or dignity and respect; -State should be notified of abuse allegations in 30 minutes. During an interview on 2/05/23, at 2:55 P.M., the Social Services Director (SSD) said the following: -If a resident is threatened, this would be considered verbal abuse or dignity/respect; -If a resident reports being threatened, he/she would go to his/her supervisor to notify them, visit with the staff and any witnesses; -The facility has two hours to notify state of any allegations of abuse. During an interview on 2/05/23, at 4:25 P.M., the DON said the following: -The incident involving the resident and CNA A was reported to the DON on 1/7/23 or 1/8/23; -The resident reported it to the day or night shift nurse and that nurse reported it to the DON; -DON requested the nurse complete an investigation, when the investigation was completed it was deemed no threat of harm; -The resident gave two different versions of the incident. One said he/she didn't stop this shit, CNA A was going to put the resident down, the next version just said put him/her down; -He/she feels like it's something that should have been reported to the state, but it was not reported. During an interview on 2/05/23, at 4:50 P.M., Administrator and DON said the following: -The incident involving the resident and CNA A was reported to RN H on 1/8/23, he/she then reported it to the DON, and the DON to the Administrator; -The resident said that CNA A was going to put him/her down; -If a staff did say to a resident to stop their shit or they're going to put them down, that would be verbal abuse and/or dignity and respect; -Did not call the state to report the incident; -Allegations of abuse should be reported to the state within two hours. MO00213579

Based on interview and record review, the facility failed to document following-up on physician orders in a timely manner when the physician ordered a referral for a stump sock (special sock worn over an amputation stump) and a knee brace for one resident (Resident #1). The facility census was 61. Record review showed the facility did not provide a policy regarding following physicians' orders. 1. Record review of Resident #1's face sheet (admission data) showed the following: -admission date of 11/29/22; -Diagnoses included Type II diabetes (impairment in the way the body regulates and uses sugar), morbid obesity, legally blind, post traumatic stress disorder (PTSD - a mental health condition that's triggered by a terrifying event), traumatic brain injury (TBI - an injury that affects how the brain works), paraplegia (paralysis of the legs and lower body), and seizures (a sudden, uncontrolled burst of electrical activity in the brain); -Resident discharged to home on 2/1/23. Record review of the resident's Physicians' Order Sheets (POS) showed the following: -An order, dated 12/07/22, to refer resident for a stump sock; -An order, dated 12/19/22, for knee hinged adjustable brace, monitor placement and skin daily. (What was the date of the order?) Record review of the resident's care plan, revised on 12/21/22, showed the following: -New below/above the knee amputation on right side; -Assisted to complete daily living activities of care; -The resident had potential for pain; -Observe for additional assistive devices as needed. Record review the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 12/29/22, showed the following: -Cognitively intact; -Verbal behavioral symptoms directed towards others and rejection of care; -Limited assist/one person for transfers, bed mobility, dressing, toileting, personal hygiene, and bathing. Record review of the resident's January 2023 Medication Administration Record (MAR) showed the following: -An order, dated 12/19/22, for left knee hinged adjustable brace in place, monitor placement and skin daily. Staff documented an X each day of the week (indicating the brace was not placed). Record review of the resident's Physicians' Order Sheets (POS) showed the following: -An order, dated 1/23/23, to give resident ACE wraps to do his/her own stump compression. Record review of the resident's January 2023 MAR showed the order for the resident ACE wrap was not added. Record review of resident's nurse practitioner's progress note, dated 1/06/23, showed the following: -Above knee amputation of right lower extremity. Resident continues to participate in physical therapy. Will check with Physical Therapy (PT) regarding stump shrinker. Record review of physician's progress note, dated 1/16/23, showed the following: -Chief complaint from resident is he/she is needing a compression sleeve for his/her right knee to eventually help him/her fit a prosthetic. He/she is also needing an adjustable knee brace for his/her left knee; -Resident is in need of a stump shrinking sleeve device. This is medically necessary to help him/her prepare for prosthetic device in the future; - Resident is also needing an adjustable knee brace for his/her left knee due to the new significant increase in activity and weight bearing on the left due to the loss of the right lower leg. Record review of the resident's January 2023 nurses' notes showed staff did not document that the referral for the stump sock had been followed-up on. During an interview on 2/05/23, at 2:50 P.M., Licensed Practical Nurse (LPN) E said the following: -The LPN doesn't think the resident wore a brace on his leg or a stump shrinker; -The facility ordered a hinge brace, but it hadn't come in before the resident left. Record review of the resident's medical record showed staff did not document ordering the resident's knee brace. During an interview on 2/05/23, at 2:55 P.M., the Social Services Director (SSD) said the following: -When the resident came to the facility orthopedics had not set up and appointment for a stump shrinker; -Residents are generally taken to a local town to be fitted for a strump shrinker; -The resident wasn't taken to the appointment as they were waiting for his/her stump to heal. During an interview on 2/05/23, at 3:53 P.M., Registered Nurse (RN) G said the following: -When a physician writes an order the nurse that's rounding with the physician would get a medical device if the facility has one on hand, the nurse would be responsible for communicating or initiation from the pharmacy or durable medical equipment supply; -Don't usually have long to wait, sometimes that also depends upon insurance; -If the resident requires a referral then the nurse would notify central services of the need for the equipment. Once the submission for the appointment has been completed social services does the appointments and he/she would become responsible; -If social services brings the resident back with an order, it's the nurse's responsibility to make sure that order gets completed. During an interview on 2/06/23, at 1:15 P.M., RN H said the following: -Never got the knee brace for the resident, that's why the X was on the MAR. The DON saw it and asked physical therapy and they said it's nursing; -Physician said the resident had a stump shrinker, but he/she never saw it; -There was an order on the treatment sheet for the stump shrinker, no one knew who ordered it; -Take a copy of the order and put in the Social Services Director's box or medical records; -Don't know who follows up on orders to make sure it's done. During an interview on 2/05/23, at 4:05 P.M., Licensed Practical Nurse (LPN) F said the following: -When the physician writes an order on the physician's order sheet, whoever takes the order would be responsible. If it's a phone order it would be that person. If it's an order while the physician is here, it would be the nurse rounding with the physician or the charge nurse; -A stump shrinker would need to be ordered through the pharmacy. The resident had an order for a stump shrinker, as far as he/she knew the resident did get the stump shrinker; -If a resident is referred to a doctor for something then social services sets up the appointments and they notify nursing of the appointments and those are added to the calendars at the nurses' stations; -Charge nurse should follow up to make sure the resident got the stump shrinker. During an interview on 2/05/23, at 4:25 P.M., the Director of Nursing said the following: -The resident came into the facility with a brace and he/she believes the resident was using it. From what therapy said, it didn't fit well; -The physician writes the order, the charge nurse makes a copy of the order, and it's put in the social services box; -The DON sent the order to the provider and information for an appointment. The provider requested additional information. He/she could not recall the date of this contact; -Physician's orders should be carried over to the MAR; -Social Services and charge nurse should follow up to make sure the appointment took place and the resident got the stump shrinker; -The DON was scheduling the appoint for both the stump shrinker and a new leg brace; -He/she believes this was around the end of January; -He/she said it's a long time to wait from 12/7/22 to the end of January to get an appointment for the stump shrinker and the leg brace; -Therapy does the stump shrinker sometimes, but since the resident was larger, PT said the resident would need to be fitted for one. During an interview on 2/05/23, at 4:50 P.M., the Administrator and DON said the following: -The physician writes an order for the resident, the nurse gets the order and goes over that with the charge nurse; -Social services sets up the appointment for the resident. If the resident comes back with an order, that's given back to the charge nurse and he/she follows through to make sure the order is filled; -Doesn't know if the order for the stump shrinker for the resident was followed through on, he/she doesn't think the resident ever got the stump shrinker; -There should be documentation on the attempts staff make to set up appointments. During an interview on 2/06/23, at 1:05 P.M., the resident's physician said the following: -He/she writes the order and the nurse takes care of it, they review, and fax to where it needs to go; -DON follows up on that and social services too; -If it takes a while to get a response from a referral, nursing should probably follow up. It can take anywhere from a week to three months to get an appointment scheduled; -The staff were using ace wraps temporarily because they knew the resident didn't have a strump shrinker so they did the best we could; -The resident did have a knee brace that didn't fit right so he/she needed a new one that was going to be done when he/she got the stump shrinker. MO00213579

Based on interview and record review, the facility staff failed to ensure an admission Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff) was completed for one resident (Resident #140 ). The facility census was 52. 1. Record review of Resident #140's face sheet (admission data) showed the following information: -admission date of 5/6/21; -Diagnoses included chronic kidney disease stage four (kidneys are moderately or severely damaged and not working as they should, the last stage of kidney failure), chronic anemia (lack of healthy red blood cells to carry adequate oxygen to the body's tissues), and altered mental status. Record review of the resident's MDS records showed staff completed an entry record for the resident on 5/6/21. Record review of the resident's MDS records showed staff had not completed the resident's admission MDS assessment. During an interview on 10/14/21, at 2:38 P.M., the MDS/Care Plan Coordinator said the following: -The resident's admission MDS assessment was due 5/19/21; -The resident's admission MDS assessment was not completed; -The resident's comprehensive care plan was not completed. -She had MDS assessments caught up until 5/2021 before she left the facility in 6/2021 and returned 8/20/21; -The Assistant Director of Nursing (ADON) completed the MDS assessments 6/2021 to the end of 8/2021; -MDS admission assessments should be completed within 14 days; -MDS assessments are late and not completed; -She submits the completed MDS assessments to CMS. During interviews on 10/15/21, at 1:05 P.M., and 10/19/21, at 2:38 P.M., the administrator said the following: -The prior MDS coordinator was interim and did three jobs; -The current MDS coordinator is behind on MDS assessments due to she worked the floor; -MDS assessments are not completed and late. During an interview on 10/15/21, at 1:23 P.M., the ADON said she was aware the MDS assessments were late and not completed. She had been in training for a couple of months.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to complete a comprehensive care plan to address the specific needs of two residents (Resident #13 and Resident #140). The facility census had a census of 52. 1. Record review of Resident #13's face sheet (basic admission information sheet) showed the following information: -admission date of 6/25/21; -Diagnoses included hypertension (HTN - high blood pressure), history of colon cancer, history of stroke, and dementia with behavioral disturbance. Record review of the resident's initial care plan, dated 6/24/21, showed the following information: -Assistance required with dressing, grooming, and toileting of one staff person; -Alert and oriented to self and family; -Keep pathways clear of obstructions at all times; -History of migraines, -Monitor for signs and symptoms of headache or other signs of pain. Record review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 7/7/21, showed the following: -Moderately impaired cognitive skills; -Wandering behavior marked as occurred four to six days, but less than daily; -Independent with eating; -Weight 117 lbs. Record review of the resident's medical record showed staff did not create a comprehensive care plan for the resident. During an interview on 10/14/21, at 2:38 P.M., the MDS/Care Plan Coordinator said the following: -The resident admitted on [DATE]; -Staff did not complete a comprehensive care plan for the resident. During an interview on 10/19/21, at 10:53 A.M., the Dietary Manager said the staff did not complete the resident's comprehensive care plan. 2. Record review of Resident #140's face sheet showed the following information: -admission date of 5/6/21; -Diagnoses included chronic kidney disease stage four (kidneys are moderately or severely damaged and not working as they should, the last stage of kidney failure), chronic anemia (having low levels of red blood cells), and altered mental status. Record review of the resident's MDS record showed staff did not complete an admission assessment. Record review of the resident's initial care plan, dated 5/6/21, showed the following: -Call light within reach at all times; -Provide briefs for dignity; -Assist of one with gait belt for transfers and ambulation; -The resident needs turned every two hours; -Foley catheter (tube placed in bladder to drain urine) care every shift and as needed; -Foley catheter change as needed and monthly. Record review of the resident's medical record showed staff did not complete the resident's comprehensive care plan. During an interview on 10/14/21, at 2:38 P.M., the MDS/Care Plan Coordinator said staff did not complete the resident's comprehensive care plan. During an interview on 10/19/21, at 10:53 A.M., the Dietary Manager said staff did not complete the resident's comprehensive care plan. 3. During an interview on 10/14/21, at 2:38 P.M., the MDS/Care Plan Coordinator said the following: -Comprehensive care plans should be completed by the 14th day; -She speaks with staff members, residents, family to develop care plans; -Comprehensive care plans are late and not completed. 4. During an interview on 10/15/21, at 1:05 P.M., and 10/19/21, at 2:38 P.M., the administrator said the following: -Comprehensive care plan should be completed within 21 days; -Comprehensive care plans are not completed and late; -Care plans show staff how to care for the residents.

Based on interview and record review, the facility failed to obtain ordered labs in a timely lab order and failed to have parameters for administration of digoxin (a drug used to treat irregular heartbeat and some types of heart failure) in place for one resident (Resident #140). The facility census was 52. Record review of the facility's policy titled, Test Results, revised April 2007, showed the following: -The resident's attending physician will be notified of the results of diagnostic tests; -Results of laboratory, radiological, and diagnostic tests shall be reported in writing to the resident's attending physician or to the facility; -Should the test results be provided to the facility, the attending physician shall be promptly notified of the results; -The director of nursing services, or charge nurse receiving the test results, shall be responsible for notifying the physician of such test results; -Signed and dated reports of all diagnostic services shall be made a part of the resident's medical record. Record review of the facility's policy titled, Medication Orders, dated September 2003, showed the following: -The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders; -A current list of orders must be maintained in the clinical record of each resident; -Orders must be written and maintained in chronological order; -Telephone or verbal orders may be accepted by a licensed nurse only; -Telephone or verbal orders must be recorded on the physicians order sheet (POS) when received and must be recorded by the nurse receiving the order. Record review of the facility's Corporation Best Practice, undated, showed the following: -Digoxin - Before giving, check apical (pulse site on the left side of the chest over the pointed end of the heart) pulse for one minute. If pulse rate is below 60, please notify physician and hold medication. Record review of Mosby's 2021 Nursing Drug Reference showed the following: -Check pulse for one minute before administering the medication. If pulse is less than 60 beats per minute in a an adult, check again in one hour. -If pulse remains below 60 beats per minute call the prescriber; -Monitor product levels. 1. Record review of Resident #140's face sheet (admission data) showed the following: -admission date of 5/6/21; -Diagnoses included atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), chronic kidney disease stage 4 (kidneys are moderately or severely damaged and not working as they should, the last stage of kidney failure), chronic anemia (deficiency of red blood cells), altered mental status and cerebravascular accident (stroke). Record review of the resident's admission care plan, dated 5/6/21, showed the following: -The resident was at home and had altered mental status; -The resident at the facility for rehab and may go home. Record review of the resident's telephone order, dated 5/6/21, showed an order to complete blood count lab(CBC - set of laboratory tests to provide information about cells in the blood), complete metabolic panel lab (CMP -blood test that measures sugar level, electrolyte (regulates nerve and muscle function), fluid balance, kidney and liver function) and vitamin D level labs. Record review of the resident's May 2021 physician order sheet (POS) showed the following: -An order, dated 5/6/21, for digoxin 0.125 milligrams (mg) one tablet by mouth (PO) daily (no parameters listed); -An order, dated 5/6/21, for labs of CBC, CMP, Vitamin B12 level, Vitamin D level, folate (measures the amount of folate (vitamin) in the blood), thyroid stimulating hormone (TSH-signals the thyroid gland to make hormones), and fasting lipid panel on next lab draw. Record review of the resident's medical record showed staff did not document obtaining the labs, the reason why the labs were not obtained, or notifying the physician the labs were not obtained and parameters needed for the digoxin medication. Record review of the resident's October 2021 POS showed the following: -An order, no date, showed CBC, CMP, Vitamin B12 level, Vitamin D level, folate, TSH, and fasting lipid panel with next lab draw; -An order, dated 5/6/21, digoxin 0.125 mg one tablet PO daily. (The order did not address when to hold the medication.) Record review of the resident's October 2021 medication administration record (MAR) showed the following: -An order, dated 5/6/21, for digoxin 0.125 mg one tablet PO daily. (The order did not address when to hold the medication.). During an interview on 10/19/21, at 10:22 A.M., Certified Medication Technician (CMT) L said the following: -Staff should monitor resident's on digoxin for a low pulse; -Staff should inform the charge nurse if a resident's pulse is too low and whether to hold the medication; -Charge nurse should notify the physician for direction if a resident's pulse is low; -The resident's October 2021 MAR showed an order for digoxin 0.125 mg one tablet PO daily with no parameters (when to hold the medication) listed; -She informs the nurse if the resident has a pulse under 60; -Signs and symptoms of a low pulse include non responsiveness. During a phone interview on 10/19/21, at 12:10 P.M., the medical director said the following: -CBC and CMP labs should be done every three months; -Staff should have completed the labs when the resident was admitted ; -The pharmacy and interdisciplinary team should discuss residents' medications and labs; -The main thing is to obtain the resident's initial lab and determine where the resident is at; -The lab results could determine reason for the resident's weight loss and apathy (lack motivation to do anything); -Staff should have digoxin parameters for administration. During an interview on 10/19/21, at 12:23 P.M., Registered Nurse (RN) D said the following: -Labs are listed on the POS; -Staff should typically inform medical record staff who keeps track of the ordered labs; -She is unsure who orders the lab; -Staff should fill out a requisition form; -Nurse should fill out the lab form and log in the requisition lab book. During interviews on 10/19/21, at 11:20 A.M., 11:50 A.M., and 12:38 P.M., and the Director of Nursing (DON) said the following: -Staff should monitor resident's on digoxin for pulse each time they administer the medication; -Residents pulse should not be under 60; -Staff should hold the medication and inform the charge nurse if a resident's pulse is under 60; -The charge nurse should inform the physician if a resident's pulse is under 60; -The resident's October 2021 POS and MAR should have parameters for the digoxin order; -The laboratory comes to the facility daily; -The labs ordered on 5/6/21 was not completed; -She is unsure how the 5/6/21 ordered lab was missed; -The resident has had no labs drawn since 5/6/21; -The resident should have had the ordered lab on 5/6/21 completed; -The 5/6/21, telephone order states lab on the next lab draw which means the next time the lab is in the facility; -Staff should fill out a lab requisition form, fax the form to the lab, and the lab comes to the facility; -The Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff) coordinator, administrator and medical record staff review the telephone orders for physician orders and ordered labs daily in the clinical meeting. She checks the computer for completed labs daily; -The lab audited the charts once per month, but have not since coronavirus precautions; -Lab requisition book is at the nurses' desk and a tab has each date of the month; -She prints the lab order form and places it with the requisition form and when done the lab signs the log and destroys the form; -She prints the lab results when completed. During an interview on 10/19/21, at 12:45 P.M., the medical record staff said the following: -Nurses complete new admissions; -She takes any lab results and places them in the physician folder for him to review on Friday; -Nurses review the POS at the beginning of the month and make sure a lab was completed; -She will look for the lab if staff request. During an interview on 10/19/21, at 1:32 P.M., the pharmacy consultant said the following: -He comes to the facility once per month to review the residents' medications; -He reviews the diagnosis such as A-fib or congestive heart failure for residents on digoxin; -He recommends parameters on digoxin if the resident has history of low heart rate. It is a good practice to always monitor the heart rate. During an interview on 10/19/21, at 2:38 P.M., the Administrator said the following: -Staff should have followed up with parameters for the digoxin order for the resident; -Staff should check residents pulse rate who take digoxin and if below 60, hold the medication and notify the nurse and physician; -The nurse calls the lab for any admit labs for a new admission; -The nurse fills out the lab requisition form; -Nurses should monitor labs and look at the lab tracking log; -Medical record staff and the DON print the lab results; -The facility has a lab tracking log and clinical meeting daily to monitor ordered labs. Staff copy the requisition and review it the next day; -She expects staff to have ordered the 5/6/21 lab for the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to consistently provide assistance for an oppenus (a splint designed to maintain the thumb in a position to oppose the other fingers) splint for one resident (Resident #140) for his/her right hand in order to prevent further decline in range of motion. The facility's census was 52. Record review of the facility's policy titled 'Assistive Devices and Equipment, revised January 2020, showed the following: -The facility maintains and supervises the use of assistive devices and equipment for residents; -Certain devices and equipment that assist with resident mobility, safety and independence are provided for residents; -These may include (but are not limited to) specialized eating utensils and equipment; safety devices for the bathroom (grab bars, toilet risers, bedside commodes); and mobility devices (wheelchairs, walkers and canes); -Recommendations for the use of devices and equipment are based on the comprehensive assessment and documented in the resident care plan; -Staff and volunteers are trained and demonstrate competency on the use of devices and equipment prior to assisting or supervising residents. 1. Record review of Resident #140's face sheet (admission data) showed the following: -admission date of 5/6/21; -Diagnoses included atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), chronic kidney disease stage 4 (kidneys are moderately or severely damaged and not working as they should, the last stage of kidney failure), altered mental status and cerebravascular accident (stroke). Record review of the resident's admission care plan, dated 5/6/21, showed the following: -The resident was at home and had altered mental status. The resident is at the facility for rehab and may go home; -Physical, occupational and speech therapy to evaluate and treat; -Pain assessment is ongoing. Record review of the resident's occupational therapy (OT) Discharge summary, dated [DATE], showed a splint/orthotic (branch of medicine that deals with the use of artificial devices such as splints and braces) recommendation for the resident to wear an oppenus splint on right hand and on right wrist. Record review of the resident's functional maintenance program form, dated 8/2/21, showed an OT staff documented the following: -The splint in the resident's room. Pump it up to the resident's tolerance; -The resident should wear the splint between breakfast and lunch. Record review of the resident's care plan showed staff did not add the use of the splint to the resident's care plan. Record review of the resident's August 2021 physician order sheet (POS) and treatment administration record (TAR) showed no order for the splint recommended for use by OT. Record review of the resident's history and physical, dated 8/27/21, showed the following: -The resident admitted to the facility after a hospitalization for a stroke, weakness, chronic kidney disease stage four, and need for strengthening; -Right sided weakness. Record review of the resident's restorative nursing care delivery record, dated August 2021, showed the following: -Splint in room (pump up to the resident's tolerance; wear splint between breakfast and lunch); -Restorative aide documented the resident wore the splint on the following days: 8/1/21, 8/5/21, 8/7/21, 8/9/21, 8/12/21, 8/13/21, 8/15/21, 8/17/21, 8/19/21, 8/21/21, 8/26/21, 8/28/21 and 8/30/21; -Staff documented on 8/24/21 the resident was not in the facility; -Staff did not document why staff did not apply the splint the rest of the month. Record review of the resident's restorative nursing care delivery record, dated September 2021, showed the following: -Splint in room (pump up to the resident's tolerance; wear splint between breakfast and lunch); -Restorative aide documented the resident wore the splint on the following days: 9/2/21, 9/4/21, 9/6/21, 9/9/21, 9/10/21, 9/12/21, 9/16/21, 9/18/21, 9/19/21, 9/20/21, 9/24/21, 9/26/21, 9/29/21, and 9/30/21; -Staff documented on 9/23/21 resident sick and did not wear the splint; -Staff did not document why staff did not apply the splint the rest of the month. Record review of the resident's September 2021 POS and TAR showed no order for a splint for the resident. Record review of the resident's restorative nursing care delivery record, dated October 2021, showed the following: -Splint in room (pump up to the resident's tolerance; wear splint between breakfast and lunch); -Restorative aide documented the resident wore the splint on the following days: 10/2/21, 10/4/21, 10/7/21, 10/9/21, and 10/11/21; -Staff documented on 10/14/21, the resident was not in the facility; -Staff did not document why the splint was not applied on 10/1/21, 10/3/21, 10/5/21, 10/6/21, 10/8/21, 10/10/21, 10/12/21, 10/13/21. Record review of the resident's October 2021 POS and TAR showed no order for a splint for the resident. Observations on 10/12/21, at approximately 12:30 P.M. through 2:00 P.M., showed the resident in his/her room with a contracture (permanent tightening of the muscles, tendons, skin and nearby tissues that cause the joints to shorten and become very stiff) of right hand with no splint or brace on the resident's hand. Observation on 10/14/21, at 9:38 A.M., showed the resident in his/her room in his/her bed on his/her right side. The resident did not have a splint/brace on the resident's right arm or wrist. During interviews on 10/15/21, at 8:26 A.M. and 1:22 P.M., Certified Nurse Aide (CNA) O said he/she has not seen a splint or flat, pump type device, for the resident's right hand. During an interview on 10/15/21, at 8:56 A.M., Registered Nurse (RN) D said the following: -He/she was unaware of a brace for the resident's right hand; -The resident's brace is not on the October 2021 TAR; -He/she does not recall education about the resident's brace; -The splint should be on the resident's TAR so staff know to put it on him/her. Observation on 10/15/21, at 10:23 A.M., showed the resident in his/her wheelchair in his/her room with no hand splint on his/her right hand or wrist. During an interview on 10/15/21, at 10:26 A.M., Certified Medication Technician (CMT) L said he/she has never seen or been told about a hand splint for the resident's hand and wrist. During an interview on 10/15/21, at 10:30 A.M., the Dietary Supervisor said she has never seen a splint on the resident's right hand or wrist. During an interview on 10/15/21, at 10:07 A.M., the Restorative (RST) Aide said the following: -At 10:22 A.M., the RST aide looked through the resident's room and did not find the splint; -Therapy staff give her a sheet for the OT functional maintenance program; -Therapy staff tell her what type of exercise and how often required for the resident; -She is suppose to make sure the splint is on the resident's hand and wrist; -Staff should document on the TAR of the resident's splint wear. During an interview on 10/15/21, at 9:52 A.M., the Occupational Therapy (OT) Staff said the following: -The physician writes an order for an OT evaluation; -The resident was last seen for OT 7/16/21 for contracture management; -The OT discharge summary showed recommendation for the resident to wear a splint on the right hand and wrist; -OT staff give staff a room schedule to watch for redness, reason for the splint and wearing schedule; -OT staff should make recommendation to the physician in which they will write an order. During an interview on 10/15/21, at 9:56 A.M., the Physical Therapy Staff said the following: -He/she has worked full time at the facility since first of August 2021; -The facility has a restorative program; -Therapy staff complete a form and give to the director or rehab or the restorative aide of the therapy discharge; -Therapy staff writes the recommendations such as walking, exercise program or contracture management; -Therapy staff educate the restorative aide and nursing staff on managing the contracture; -RST staff should take over the plan. During interviews on 10/15/21, at 11:55 A.M., and on 10/19/21, at 2:38 P.M., the Director of Nursing (DON) said the following: -Staff should get a physician order for an evaluation for a contracture; -Staff should bring her the purchase order if a brace is recommended; -She assesses the resident upon admission for contractures and informs OT staff for an evaluation; -OT staff completes the discharge summary and gives to her for purchase of recommended device; -It has been awhile since she has seen the splint on the resident's hand and wrist; -She signed a purchase order for a flat apparatus that pumps up to what the resident can tolerate in his/her hand; -The residents' splint for his/her right hand should be on the resident's care plan. During an interview on 10/15/21, at 11:55 A.M., the Administrator said she is unaware of a splint for the resident's hand and wrist. During an interview on 10/15/21, at 1:23 P.M., the Assistant Director of Nursing (ADON) said she has not seen a pump or splint for the resident's right hand. During an interview on 10/18/21, at 11:02 A.M., CNA N said he/she has seen the splint in the resident's right hand a few times. He/she did not see the splint in the resident's hand at all last week. The resident normally has it on at breakfast and lunch. During an interview on 10/18/21, at 11:23 A.M., RN K sand the following: -He/she has not seen changes with the resident's range of motion; -He/she has seen the resident wear the splint and can maneuver it enough to knock it out of his/her hand. During interviews on 10/18/21, at 12:15 P.M., and 10/19/21, at 11:03 A.M., the MDS/Care Plan Coordinator said the following: -She is not familiar with the resident's splint for his/her right hand; -The resident's splint should be on the care plan.

2. Record review of the Resident #23's face sheet showed the following: -admission date of 9/12/16; -Diagnoses included generalized weakness, hypertension (high blood pressure), and diabetes mellitus (condition that occurs when the body cannot use glucose (type of sugar) normally). Record review of the resident's progress note dated 10/9/21, at 5:10 P.M., showed the following: -A nurse documented the resident to return from the hospital on comfort care; -The resident returned to the facility by ambulance at approximately 5:45 P.M. and the nurse assessed the resident; -The resident has a catheter in place draining to gravity with yellow urine. Nurse contacted the physician of the resident's insulin orders and order for bipap. (Staff did not document the physician regarding a order for his/her catheter.) Record review of the resident's October 2021 Physician's Order Sheet (POS), medication administration record (MAR), and treatment administration record (TAR) showed no order for the resident's Foley catheter or catheter care. Record review of the resident's progress note dated 10/10/21, 3:00 P.M. to 11:00 P.M. shift, showed the resident's Foley catheter patent (open, unobstructed) and drained per gravity with dark yellow urine. The resident is on antibiotic therapy with no adverse effects noted. Record review of the resident's progress notes, dated 10/11/21 to 10/12/21, showed staff documented monitoring the resident's Foley catheter. During interviews on 10/15/21, at 8:56 A.M. and 11:33 A.M., Registered Nurse (RN) D said the following: -Residents should have an order for a catheter; -Staff should provide catheter care every shift, change the catheter bag weekly and change the catheter monthly; -The resident was readmitted from the hospital with the catheter; -He/she does not see an order for the catheter, to change the catheter monthly or catheter care on the October 2021 POS or treatment record; -Staff should know the size and type of the catheter in case they need to change the resident's catheter. During an interview on 10/15/21, at 11:55 A.M., the DON said the following: -Staff should provide catheter care every shift and the catheter care should be on the resident's POS and TAR; -Staff should have an order for the resident's catheter which should be on the POS: -The catheter order should have the size and type of catheter on the POS; -The catheter order should be changed monthly.; -The resident was readmitted from the hospital with a catheter and staff should have obtained an order; -The resident's catheter order and catheter care was not on the resident's POS until 10/15/21. During an interview on 10/15/21, at 11:55 A.M., the administrator said she expects staff to have clarified a physician order for the resident's catheter and catheter care upon readmission from the hospital. During an interview on 10/18/21, at 11:23 A.M., RN K said the following: -Nurses should contact the physician for any questions or orders they need from the physician; -Nursing staff use an application on the phone to send messages, ask questions or obtain orders when the physician is not at the facility; -Nurses should write the physician order on the resident's POS and MAR; -Nursing staff should clarify an order for a catheter; -Catheter orders should include how often to change the catheter, catheter care and the size of the catheter; -Nurses should know the size of the catheter in case they have to replace the resident's catheter; -She was not aware the resident did not have an order for his/her catheter; -Administration reviews all physician orders at the morning meeting. Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #23) had an order for a catheter (a sterile tube inserted into the bladder to drain urine) and that staff took steps to prevent possible infection when staff allowed one resident's (Resident #140) catheter bag and tubing to touch the floor. The facility census was 52. Record review of the facility's policy Urinary Catheter Care, revised September 2014, showed the following: -Be sure the catheter tubing and the drainage bag are kept off the floor; -Changing indwelling catheters or drainage bags at routine, fixed intervals was not recommended. Change catheters and drainage bags based on clinical indications such an infection, obstruction or when the closed system was compromised. 1. Record review of Resident #140's face sheet showed diagnoses included stage four chronic kidney disease (severe kidney damage) and urinary tract infection (UTI). Record review of the resident's admission care plan, dated 5/6/21, showed the following: -Foley (indwelling urinary catheter - a tube inserted into the bladder to drain the urine) catheter care every shift and PRN (as needed); -Foley catheter change PRN (as needed) and monthly. Observation on 10/13/21, at 11:30 A.M., showed the resident lying on his her right side in the low bed with the urinary catheter bag lying on the floor. Observation on 10/14/21, at 12:42 P.M., showed the resident's urinary catheter bag and tubing lying on the floor by the low bed. During interview on 10/15/21, at 11:50 A.M., Certified Nurse Aide (CNA) C said the following: -The resident's urinary catheter bag was not to lay on the floor; -The catheter bag can hang on the low bed without touching the floor. During interview on 10/15/21, at 12:05 P.M., Licensed Practical Nurse (LPN) A said the following: -Urinary catheter bags were not to lay on the floor; -For a low bed, staff can attach the catheter bag to the bed frame and put a towel below the bag so it will not touch the floor. During interview on 10/15/21, at 12:20 P.M., the Assistant Director of Nursing (ADON) said the following: -No urinary catheter bag is to lay on the floor; -Some resident's have a low bed and they were to place a towel beneath the catheter bag if it was on the floor. During interview on 10/15/21 at 12:47 P.M., the Director of Nursing (DON) said the following: -Urinary catheter bags should not hang or lie on the floor; -If a resident had a low bag, staff were to attach the catheter to a pole and the bag was not touch the floor.

Based on observation, interview, and record review, the facility staff failed to consistently provide nutritional interventions, implement new interventions, and inform the physician of weight loss for two residents (Resident #13 and Resident #140) with a significant weight loss. The facility census was 52. Record review of the facility's policy titled Food and Nutrition Services, revised October 2017, showed the following: -Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident; -The multidisciplinary staff, including nursing staff, the attending physician and the dietitian will assess each resident's nutritional needs, food likes, dislikes and eating habits, as well as physical, functional, and psychosocial factors that affect eating and nutritional intake and utilization; -Nursing personnel, with the assistance of the food and nutrition services staff, will evaluate (and document as indicated) food and fluid intake of residents with, or at risk for, significant nutritional problems; -Variations from usual eating or intake patterns will be recorded in the resident's medical record and brought to the attention of the nurse; -A nurse will evaluate the significance of such information and report it, as indicated, to the attending physician and dietitian. Record review of the facility's policy titled Interdepartmental Notification of Diet (Including changes and reports), revised October 2017, showed the following: -Nursing services shall notify the physician and dietitian when a nutritional problem (examples, weight loss, pressure ulcer, eating problem) has been identified and shall collaborate with the dietitian and physician to initiate an appropriate process of clinical review for causes of the nutritional problem. 1. Record review of Resident #13's face sheet (admission data) showed the following: -admission date of 6/25/21; -Diagnoses include hypertension (high blood pressure), personal history of colon cancer, major depressive disorder and dementia with behavioral disturbance. Record review of the resident's temporary care plan, dated 6/24/21 (staff dated incorrectly), showed the following: -The resident has dementia with behavioral disturbance; -Regular diet; -Staff to offer snacks and fluids between meals; -Weekly weight for four weeks and then monthly and as needed (PRN). Record review of the facility's weight loss/gain report spreadsheet, dated June 2021, showed staff documented a weight of 124.2 pounds (lbs). (The report did not specify what day staff obtained the weight.) Record review of the resident's dietary services care plan, dated 6/25/21, showed the following: -Weight at 124.2 lbs; -Regular diet and snacks as desired; -Review within 90 days. Record review of the resident's June 2021 physician order sheet showed the following: -An order, dated 6/25/21, for a regular diet; -An order, dated 6/25/21, for weight on admit and then weekly for four weeks and then monthly and PRN. Record review of the facility's weight loss/gain report spreadsheet for July 2021 showed staff documented a weight of 114 lbs. (The report did not specify what day staff obtained the weight. This is a 8.2% weight loss.) Record review of the resident's July 2021 physician order sheet (POS) showed the following: -Order, no date, for regular diet; -Order, no date, for weight on admit and then weekly for four weeks and then monthly and PRN. Record review of the resident's medical record showed staff did not document in the record of the resident's weekly weights. Record review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 7/7/21, showed the following: -Moderately impaired cognitive skills; -Wandering behavior marked as occurred four to six days, but less than daily; -Independent with eating; -Weight 117 lbs; -Weight loss; -Not on physician prescribed weight loss regimen. Record review of the Dietary Manager's (DM) progress note, dated 7/7/21, showed the following: -Weight at 117 lbs; -The resident receives a regular diet and snacks; -The resident does not eat very good, maybe 60%; -The resident roams the facility; -Continue to monitor and adjust as needed. Record review of the resident's medical record showed staff did not document notifying the resident's physician regarding the weight loss. Record review of the resident's dietary services care plan, dated 7/7/21, showed the following: -Weight at 114 lbs; -Regular diet and snacks as desired; -Review within 90 days. (Staff did not document any new interventions due to the resident's weight loss.) Record review of the Registered Dietitian (RD)'s nutritional assessment, dated 7/28/21, showed the following: -July 2021 weights 120 lbs, 114 lbs, 117 lbs; -Resident admitted to facility on 6/25/21 at 124.2 lbs. The resident is down 10.2 lbs in one month, 8.2% significant weight decrease, but up six pounds since then; -emergency room on 7/27/21 and now has cast to left arm; -Appetite good to fair; -Staff works to encourage intake; -Resident is very active walking the halls; -Continue to encourage meals and snacks as resident allows. Record review of the resident's medical record showed staff did not document notifying the resident's physician regarding the weight loss. Record review of the resident's August 2021 physician order sheet showed the following: -Order, no date, for regular diet; -Order, no date, to see resident's chart for monthly weights. Record review of the facility's weight loss/gain report spreadsheet for August 2021 showed staff documented a weight of 111.6 lbs. (The report did not specify what day staff obtained the weight.) Record review of the physician's progress note, dated 8/6/21, showed the following: -Follow up from arm fracture; -The resident is doing fair lately; -The resident used a splint for left arm fracture; -The resident is able to stay active; -The resident eats and drinks well. (The physician's note did not address any weight concerns.) Record review of the physician's progress note, dated 8/13/21, showed the following: -The resident had a fall with no major injuries; -The left wrist fracture is healing with no problems; -The resident eats and drinks well. (The physician's note did not address any weight concerns.) Record review of the resident's physician's progress note, dated 8/20/21, showed the following: -Recent fall. The resident had no major injuries; -The resident eats and drinks well. (The physician's note did not address any weight concerns.) Record review of the RD's nutritional assessment, dated 8/26/21, showed the following: -August 2021 weight of 111.6 lbs and 112.2 lbs. Weight down 12.6 lbs since admission, 10.1% change. (Staff did not document any new interventions.) Record review of the resident's medical record showed staff did not document notifying the resident's physician regarding the weight loss. Record review of the resident's September 2021 physician order sheet showed the following: -An order, no date, for regular diet; -An order, no date, to see resident's chart for monthly weights. Record review of the facility's weight loss/gain report spreadsheet for September 2021 showed staff documented a weight of 101.4 lbs. (The report did not specify what day staff obtained the weight.) Record review of dietary communication, dated 9/22/21, showed a nurse signed the form to please give resident yogurt with meals. Record review showed this intervention was not added to a care plan. Record review of the RD's nutritional assessment, dated 9/29/21, showed the following: -In 9/2021 weight at 101.4 lbs. Weight down 10.2 lbs in one month 9.1% significant weight change; -Weight is down 22.8 lbs in three months, 18.4% significant weight change; -The resident is very active walking halls; -Medications received Remeron (antidepressant); -Recommendation of house shakes with meals three times a day (TID); -Recommendation of two calorie 60 milliliter (ml) TID with medication pass. Record review of the dietary communication from nursing, dated 10/1/21, showed diet order for house shakes TID with meals. Record review of the resident's October 2021 POS showed the following: -An order, no date, for regular diet; -An order, dated 10/1/21, for house shakes TID with meals; -An order, dated 10/1/21, for two calorie 60 ml TID with medication pass. Record review of the resident's October 2021 medication administration record (MAR) showed staff documented administration of two calorie 60 ml TID with medication pass. Record review of the physician's progress note, dated 10/1/21, showed the following: -Follow up for fall with no major injuries; -The resident eats and drinks well. (The physician's note did not address any weight concerns.) Record review of the resident's temporary care plan showed, update on 10/1/21, showed the following: -House shakes three times per day with meals and two calorie 60 milliliters (ml) TID with medication pass; -The resident has had a weight loss; -Encourage snacks of choice and fluids in reach and encourage. Record review of the resident's medical record showed staff did not document meal intakes for the residents. Record review of the facility's weight loss/gain report spreadsheet for October 2021 showed staff documented a weight of 97 lbs. (The report did not specify what day staff obtained the weight.) Record review of the resident's dietary services care plan, dated 10/13/21, showed the following: -Weight at 98.4 lbs; -Regular diet and snacks as desired; -Review within 90 days. Observation of the resident on 10/14/21, at 11:44 A.M., showed the resident in the dining room at table feeding self lunch meal with no difficulties. There was no yogurt for the resident with the meal. During an interview on 10/15/21, at 8:26 A.M., Certified Nurse Aide (CNA) O said the resident does not eat much at all. Staff encourage snacks. Interventions for the resident include protein shakes and a boost drink. During an interview on 10/15/21, at 8:56 A.M., Registered Nurse (RN) D said the resident sometimes eats in his/her room and dining room. The resident has dementia. Record review of the RD's visit, dated 10/18/21, showed the following: -On 10/16/21 weight at 98.4 lbs; -On 10/17/21 weight at 98 lbs. During interviews on 10/15/21, at 10:30 A.M., and on 10/18/21, at 12:39 P.M., the Dietary Manager (DM) said the following: -She was not aware of an intervention for the 6/2021 to 7/2021 ten lb weight loss; -On 9/22/21 yogurt with meals was ordered; -On 10/1/21 house shake was started; -Staff discussed the resident's weight loss in quality assurance meeting. The resident wanders and lost his/her spouse; -She would expect more interventions in place for the weight loss. During an interview on 10/15/21, at 11:55 A.M., the Director of Nursing (DON) said she was aware of the resident's ten lb weight loss from June to July. The resident's spouse passed away during that time and the registered dietician (RD) ordered extra supplements. During an interview on 10/18/21, at 11:02 A.M. CNA N said the following: -The resident has lost weight and does not eat much; -The resident's family brings in snacks to the resident; -The resident feeds himself/herself; -The resident receives protein shakes. During an interview on 10/18/21, at 11:16 A.M., Certified Medication Technician (CMT) L said the following: -The resident receives two calorie TID during the medication pass; -Staff do not document resident's meal intake; -The resident is doing better with the weight loss; -The resident drinks and likes the 2 calorie med pass; -The resident asks for a yogurt whenever he/she goes by CMT L's medication cart and eats half of the yogurt. During an interview on 10/18/21, at 12:58 P.M., the RD said the following: -The resident lost weight last month and is on health shakes and two calorie supplement with meals; -The resident's admission weight was 124.2 lbs and lost 10.2 lbs from 6/20/21 to 7/2021; -She considers this a significant weight loss; -The resident had gained 6 lbs the week of July 2021; -On 10/1/21 health shakes and two calorie ordered; -On Sunday 10/17/21, the resident weighed 98 lbs. 2. Record review of Resident #140's face sheet showed the following: -admission date of 5/6/21; -Diagnoses included chronic kidney disease stage 4 (kidneys are moderately or severely damaged and not working as they should, the last stage of kidney failure), chronic anemia (deficiency of red blood cells), altered mental status. and cerebravascular accident (stroke). Record review of the resident's POS, dated 5/6/21, showed the following: -An order, dated 5/6/21, for pureed diet with nectar thickened liquids; -An order, dated 5/6/21, for weight on admit then weekly for four weeks and as needed. Record review of the resident's dietary service care plan, dated 5/6/21, showed the following: -Adequately nourish and hydrate while at the facility; -No weight listed; -Regular pureed diet and snacks. Record review of the resident's dietary progress note, dated 5/6/21, showed the following: -The resident's weight is 126 lbs; -The resident is new and receives a regular pureed diet and nectar thickened liquids; -Continue to monitor and adjust as needed. Record review of the resident's admission care plan, dated 5/6/21, showed the following: -The resident was at home and had altered mental status; -The resident at the facility for rehab and may go home; -Pureed diet with nectar thickened liquids; -Snacks of choice, may need to ask dietary for overnight snack and keep in the medication room refrigerator; -The resident needs monitored at meals. Record review of the resident's progress note dated 5/9/21, no time, showed a nurse documented the resident had a fair appetite. Record review of the resident's progress notes showed no other documentation of poor appetite, weight loss, or physician notified of weight loss. Record review of the resident's speech therapy evaluation and plan and treatment, dated 5/13/21 through 6/5/21, showed skilled services for dysphagia (difficulty swallowing) to assess and evaluate the least restrictive oral intake and minimize risk of aspiration. Record review of the resident's dietary progress note, dated 5/14/21, showed the following: -The resident's weight is 126 lbs; -The resident receives a regular pureed diet and nectar thickened liquids; -The resident eats all meals in his/her room due to COVID restrictions; -The resident eats about 20% of meals; -Continue to monitor and adjust as needed. Record review of the facility's weight/vital signs sheet for 5/2021 showed staff documented a weight of 126 lbs. (The report did not specify what day staff obtained the weight.) Record review of the physician's progress note, dated 5/25/21, showed the following: -Resident denies fever and weight loss. Record review of the resident's RD nutritional assessment, dated 5/26/21, showed resident on pureed nectar thickened diet and continue current diet. Record review of the resident's June 2021 POS showed the following: -An order, no date, for pureed diet with nectar thickened liquids; -An order, no date, for weight on admit then weekly for four weeks then monthly and PRN. Record review of the facility's weight/vital signs sheet for 6/2021 showed staff documented a weight of 98.8 lbs. (The report did not specify what day staff obtained the weight. This is a 21.6% weight loss.) Record review of the resident's medical record showed staff did not document notification of the physician and RD regarding the resident's weight loss. Record review of the resident's medical record showed staff did not update a care plan with the weight loss or new interventions. Record review of the resident's physician's history and physical, dated 6/15/21,showed the following: -Follow up due to fall with no injury on 6/8/21; -Left hand contracture which the facility will order; -Resident denies fever or weight loss; -Continue current managed care. (The physician's note did not address any weight concerns.) Record review of the resident's July 2021 POS showed the following: -An order, no date, for pureed diet with nectar thickened liquids; -An order, no date, for weight on admit then weekly for four weeks and as needed. Record review of the resident's speech therapy updated plan of treatment, dated 6/5/21 through 7/3/21, showed treatment approaches may include treatment of swallowing dysfunction and/or oral function for feeding and evaluation of oral and pharyngeal (hollow tube inside the neck) swallow function. Record review of the facility's weight/vital signs sheet for 7/2021 showed staff documented a weight of 92 lbs.(The report did not specify what day staff obtained the weight. This is an additional 6.88% weight loss.) Record review of the resident's medical record showed staff did not document notifying the resident's physician regarding the weight loss. Record review of the resident's RD's nutritional assessment, dated 7/7/21, showed the following: -On 7/2021, weight at 92 lbs; -On 6/2021, weight at 98.8 lbs, 96.2 lbs and 95 lbs; -On 5/2021, weight at 126 lbs; -Weight is down 6.8% in one month for July, significant weight loss; -Recommendation of magic cups with meals and bedtime. Record review of the resident's medical record showed staff did not update a care plan with the new intervention. Record review of the resident's July 2021 POS showed an order, dated 7/12/21, for magic cup with meals and at bedtime. Record review of the nurse practitioner's visit, dated 7/22/21, showed the following: -Follow up regarding multiple comorbidities; -No change to plan of care; -Weight at 92 lbs. (The nurse practitioner's note did not address any weight concerns.) Record review of the RD's assessment, dated 7/28/21, showed the following: -On 7/2021 weights at 91.2 lbs, 91.6 lbs, 92 lbs; -Weight is down 6.8% in one month 6.9% change significant weight loss; -BMI 16.19 underweight range; -Resident did not like magic cups; -Recommendation change magic cups to smooth yogurt. Record review of the resident's medical record showed staff did not update a care plan with the new intervention. Record review of the resident's August 2021 POS showed the following: -An order, no date, for pureed diet with nectar thickened liquids; -An order, no date, for weight on admit then weekly for four weeks and as needed; -An order, dated 8/4/21, for smooth yogurt with meals and at bedtime. Record review of the resident's weight/vital sign sheet for 8/2021 showed staff documented weights of 83 lbs and 85.4 lbs. (The report did not specify what day staff obtained the weight. This was a 9.78% weight loss in one month and 34.13% in three months.) Record review of the RD's nutritional assessment, dated 8/26/21, showed the following: -On 8/2021 weights at 84.3 lbs 85.4 lbs, weight is down 7.7% in one month; -Magic cups changed to smooth yogurt as recommended, hopefully resident is ok with this; -Continue to encourage meals and snacks and alternates as resident allows. Record review of the resident's medical record showed staff did not document notifying the resident's physician regarding the weight loss. Record review of the physician's history and physical, dated 8/27/21, showed the following: -The resident admitted to the facility after hospitalization for stroke, weakness and chronic kidney disease stage four; -The resident eats and drinks well; -Problem loss of appetite. (The physician's note did not address weight loss.) Record review of the resident's weight/vital sign sheet for 9/2021 showed staff documented weight of 82.8 lbs. (The report did not specify what day staff obtained the weight. This was a 3.04% weight loss in one month.) Record review of the resident's medical record showed staff did not document notifying the resident's physician regarding the weight loss. Record review of the physician's progress note, dated 9/10/21, showed the following: -Low blood pressure; -The resident eats and drinks about the same; -Problem list included loss of appetite; -Adjust blood pressure medications and discontinue Lasix (medicine to treat excessive fluid accumulation). (The physician's note did not address weight loss.) Record review of the resident's August 2021 POS showed an order, dated 9/10/21, to discontinue Lasix. Record review of the RD's nutritional assessment, dated 9/29/21, showed the following: -On 9/2021,at 82.8 lbs -On 8/2021, at 83 lbs; -Weight stable since last month; -On 9/10/21, Lasix discontinued; -Continue to encourage meals and snacks and alternates as resident allows. Record review of the resident's medical record showed staff did not document meal intakes for the residents. Observations on 10/13/21, from 12:20 P.M. to 1:05 P.M. (continuous), of the resident in his/her room for lunch time shoed: -At 12:20 P.M., the resident was seated in his/her recliner with the lunch tray covered and on bedside table out of reach; -At 12:30 P.M., CMT L took medicine to the resident that was in yogurt. The CMT did not offer to assist the resident; -At 12:37 P.M., staff did not offer assistance to the resident; -At 12:53 P.M.; a CNA entered the resident's room and walked out of room; -At 1:14 P.M.; the CNA sat by the resident and offered assistance to eat; -At 1:20 P.M. the CNA asked the resident if he/she was finished eating, the resident nodded yes; -The resident ate approximately 25% of his/her meal. Observations on 10/13/21,at 5:12 P.M. showed the resident in his/her room for dinner meal: -At 5:18 P.M., staff delivered the dinner tray to the resident's room and sat in on the bedside table; -At 5:19 P.M., a CMT went into the resident's room and helped roommate with a blanket; -At 5:33 P.M., a CNA went into the resident's room and set up the resident's tray; -At 5:36 P.M., a CNA assisted the resident with eating. The resident ate with no difficulty. During an interview on 10/15/21, at 8:26 A.M., CNA O said the following: -The resident had a weight loss; -The resident has good days and bad days of eating; -The resident can feed himself/herself. During an interview on 10/15/21, at 8:56 A.M., RN D said the following: -He/she is not aware of the resident's significant weight loss; -The resident feeds himself/herself; -He/she observes the resident feed himself/herself. During interviews on 10/15/21, at 10:30 AM, and on 10/18/21, at 12:39 P.M., the DM said the following: -The resident's weight 5/21/21 was 126 lbs; -Unaware of interventions in place from 5/21 to 6/21 for the weight loss of 126 to 92 lbs; -She would consider this a severe weight loss; -Staff make the resident milkshakes with protein powder and give to the resident, but she does not document this; -She discussed the weight loss with the RD of the resident's bedsores and need to get protein, but nothing of the severe weight loss; -Staff should have talked sooner of the resident's weight loss. During an interview on 10/15/21, at 11:55 A.M., the DON said she would consider a weight of 126 lbs to 92 lbs a severe weight loss. It depends on the day of how the resident eats. She talked to the physician today of the weight loss. Observation on 10/15/21, at 8:52 A.M., showed the resident sat in his/her wheelchair in the dining room. The resident had scrambled eggs, oatmeal, ready care carton and glass of juice was 1/2 drank. The resident's plate showed approximately 25% eaten. During an interview on 10/18/21, at 11:02 A.M., CNA N said the following: -He/she is aware of the resident's weight loss; -Staff try to get the resident to eat; -The residents loves chocolate shakes; -The resident feeds himself/herself at times, depends on the mood he/she is in; -Staff give the resident a snack when he/she eats 25% of his/her meal. The resident normally eats 25% of breakfast and lunch; -Staff give the resident chocolate ice cream and strawberry/banana yogurt; -The resident has not been a big eater since his/her admission and has eaten 25% since admission; -The resident has no pressure areas; -The resident will tell the staff when he/she if full. During an interview on 10/18/21, at 11:16 A.M.,CMT L said the following: -The resident has good days of eating and other days cannot get him/her to eat; -He/she sees staff feed the resident. During an interview on 10/18/21, at 11:23 A.M., RN K said the following: -The resident has had a weight loss; -The resident is good feeding himself/herself; -He/she did not realize the resident had that big of a weight loss; -She observes staff assist the resident eat; -The resident tells staff when he/she is full. During an interview on 10/18/21,at 12:15 P.M., the MDS/Care Plan Coordinator said the following: -She was not aware of the resident's May/June weight loss; -She has not completed the resident's admission MDS or comprehensive care plan; -Weight loss concerns should be on his/her care plan. During an interview on 10/18/21, at 12:58 P.M., the RD said the following: -The resident's admission weight was 126 lbs; -The 6/2021 weight was 98.8 lbs which is a significant weight loss; -On 7/7/21, she recommended the magic cups and in August 2021 changed magic cups to yogurt; -On the 6/30/21 RD visit, she did not have the weights on the visit and did not calculate the weights at the time. She would have wanted staff to inform her of the weight loss; -She made an extra visit on 7/7/21 and addressed the resident's weight loss and the first intervention was magic cups with meals and at night; -On 8/17/21, the magic cups were changed to smooth yogurt; -She is unsure if the resident's 126 lbs is accurate due to the decrease was such a dramatic drop from one month to the next weight. During interviews on at 10/18/21, at 2:23 P.M., and on 10/19/21, at 12:10 P.M., the medical director said the following: -On 10/15/21, he talked with staff about the resident's weight loss; -He started at the facility August 2021 and is not familiar with the resident's May 2021 to June 2021 weight loss. During an interview on 10/19/21, at 2:38 P.M. the administrator said the following: -Staff should have reweighed the resident's 5/21/21 weight of 126 lbs and the weight of 98.8 lbs on 6/21/21; -Staff should have called the physician with the weight loss; -Staff do not document meal intakes of residents; -On 7/12/21, magic cups were ordered; -She is pretty sure they discussed the weight differences on the resident; -Staff give the resident extra snacks and the resident goes to the dining room. During an interview on 10/19/21, at 2:38 P.M., the corporate nurse said staff should do meal intake documentation on the resident. 3. During an interview on 10/15/21, at 8:26 A.M., CNA O said the following: -Staff should report to the nurse of three to five lb weight loss or gain; -He/she weighs the resident at their shower time and documents the weight on a bath sheet and gives to the charge nurse; -Staff do not document meal intakes; -Staff should observe the residents' meal trays for how they ate. Staff should inform the nurse if a resident has not eaten; -He/she tells the DON or Assistant Director of Nursing (ADON) of an update for a resident's care plan; -The care plan should have an area for weight loss. 4. During an interview on 10/15/21, at 8:56 A.M., RN D said the following: -The bath aide weighs the resident once per week for four weeks if new admit and then monthly; -The nurse aides should inform the nurses if a resident is not eating; -Staff do not document resident meal intakes;. -interventions for weight loss include supplemental shakes. 5. During interviews on 10/15/21, at 10:30 A.M., and on 10/18/21, at 12:39 P.M., the DM said the following: -She receives the weight sheets once per month which come from the medical record staff person; -The bath aides weigh residents and give weights to the medical record staff; -Staff review the weights at the quality assurance meeting; -She reviews the weight loss and weight gains, talks to the resident and nurse of reasons for weight loss such as water weight or no appetite; -Weight loss interventions include house supplements or a 'breeze' drink; -Staff used to document meal intakes and do not anymore; -She monitors the residents' meal consumption when she does the dishes after meals; -Staff inform her if a resident did not eat. She informs the nurse; -The RD comes to the facility once per month; -The care plan teams meets once per month. The administrator, medical record staff person, DM, MDS Coordinator, and DON discuss the weights; -She receives the MDS assessments and care plan due dates. She reviews the resident's medical chart for weights and if a problem, talks with the nurse; -She writes updates for nutrition on the resident's care plan; -Weight loss should be on the care plan. 6. During interviews on 10/15/21, at 11:55 A.M., and on 10/19/21, at 2:38 P.M., the DON said the following:- -The bath aide weighs the resident during the scheduled bath time and turns it into the medical record staff person; -Medical record staff compiles the weights for the month; -Staff should speak to the physician if a resident has a significant weight loss; -The physician reviews the resident's medications or orders a supplement to stimulate the resident's appetite; -Staff should tell the charge nurse if they find residents' clothes are not fitting; -Charge nurse should call the physician and document in the nurses' notes of a residents' weight loss. 7. During an interview on 10/18/21, at 11:02 A.M., CNA N said the following: -Staff should tell the nurse if a resident does not eat. The nurse will give the resident an ensure drink or shake; -The bath aide tells staff and the nurse if a resident has a weight loss; -Staff try to get the residents to eat; -Staff do not document residents' meal intakes, Staff should observe the amount of food eaten when they take out the meal tray and inform the nurse if needed. 8. During an interview on 10/18/21, at 11:16 A.M., CMT L said the following: -Staff weigh residents when they receive their shower; -The bath aide weighs the residents and informs the nurse of the weight; -The nurse will inform staff if a resident needs to eat and drink more; -The RD reviews the resident's chart and if needed writes and order for 2 cal and a shake at meals; 9. During an interview on 10/18/21, at 11:23 A.M., RN K said the following: -Bath aides weigh the residents on their bath days; -A weight sheet is in front of the medical chart; -Nurse should transcribe the weight from the bath sheet to the weight sheet in the nurse MAR and then the copy of bath sheet gets forwarded to the DON; -When he/she makes the list for the physician for weekly rounds, he should give list of weight loss or gain; -The physician speaks with the RD or dietary staff; -Interventions include 2 cal with meals and certain snacks; -Staff do not document a percentage of meals eaten by residents, the aides tell the nurse if a resident has not eaten good; -Nurses inform the physician who may order an appetite stimulant. 10. During an

2. Record review of Resident #27's face sheet (a document that gives a resident's information at a glance) showed the following: -admission date of 9/07/21; -Diagnoses included chronic obstructive pulmonary disease (COPD -chronic bronchitis and emphysema, a pair of two commonly co-existing diseases of the lungs in which the airways become narrowed. This leads to a limitation of the flow of air to and from the lungs causing shortness of breath), obesity, diastolic congestive heart failure (CHF - a condition in which the heart can't pump enough blood to the body's other organs), hypertension (high blood pressure), hyperlipidemia (elevated cholesterol), and generalized weakness. Record review of the resident's admission Minimum Data Set (a federally mandated assessment instrument completed by facility staff), dated 9/14/21, showed the resident did receive oxygen administration. Record review of the resident's care plan, dated 9/21/21, showed the following: -Oxygen administration was at six liters per minute (LPM)/nasal cannulas (NC); -Monitor oxygen levels every shift and as needed and report to nurse any complaint of shortness of breath. Record review of the resident's physician's orders, dated 9/27/21, showed an order that directed facility staff to administer oxygen at six to ten liters per minute via NC as needed for shortness of breath. Observation on 10/12/21, at 2:20 P.M., showed the resident in bed and upper torso tilted at a 90 degree angle with oxygen on at six liters/nasal cannula (NC) running with no humidity bottle on the oxygen concentrator. The oxygen tubing was not labeled and/or dated. There was not a bag on the concentrator to put tubing in when not in use. Observation on 10/13/21, at 9:28 A.M., showed the resident sitting on the bed with oxygen on at six liters/NC running with no humidity bottle on the oxygen concentrator. The oxygen tubing was not labeled and/or dated. There was not a bag on the concentrator to put tubing in when not in use. Observation on 10/13/21, at 5:14 P.M., showed the resident sitting on the bed with oxygen on at six liters/NC running with no humidity bottle on the oxygen concentrator. The oxygen tubing was not labeled and/or dated. There was not a bag on the concentrator to put tubing in when not in use. Observation on 10/14/21, at 9:13 A.M., showed the resident sitting on the bed with oxygen on at six liters/NC running with no humidity bottle on the oxygen concentrator. The oxygen tubing was not labeled and/or dated. Observation on 10/14/21, at 1:49 P.M., showed the resident sitting on the bed with oxygen on at six liters/NC running with no humidity bottle on the oxygen concentrator. The oxygen tubing was not labeled and/or dated. There was not a bag on the concentrator to put tubing in when not in use. During in interview on 10/15/21, at 10:19 AM, LPN J said the following: -Staff have to have physician orders for administering oxygen and it should be on POS when to change oxygen tubing; -Put a bag on the concentrator so the resident can put tubing in the bag when they are not using it; -The bag should have a date and initial on the bag; -Standard protocol is to change tubing weekly. It should be logged in treatment book when the tubing is changed with the date and initials of the nurse who changed it; -A nurse or CNA can change the tubing out on Sunday nights; -Staff know who and when the tubing was changed out by dates and initials; - If there are no initials or date, it is taken that staff did not change the tubing. During an interview on 10/15/21, at 10:28 A.M., the DON said the following: -If the resident's oxygen level was consistently running low, call the doctor and get prn order for oxygen; -The doctor would write orders to check 02 every shift and change the tubing on Sunday every week; -The tubing should be dated should be dated; -If it was not dated, it wasn't done; -If there is no date, then it should be replaced and dated; -If there are no physician orders for changing tubing, we just do it weekly on Sunday evenings; -If they don't get it done on Sunday evenings, then they pass it to night shift; -If the tubing or nebulizers are not dated or initialed, they don't know if it is getting done; -She would expect it to be changed and dated, and put a bag on the side so the resident can put the tubing in it if not using oxygen. Based on observation, interview, and record review, the facility failed to ensure staff changed oxygen equipment per professional standards for two residents (Resident #27 and Resident #32) and failed to ensure one newly admitted resident (Resident #27) had a physician's order for oxygen use. The facility census was 52. Record review of the facility's policy Oxygen Administration, revised October 2010, showed the following: -Verify there was a physician's order for oxygen administration. Staff to obtain a physician's order for the rate of flow and route of administration of oxygen (by tank, concentrator, nasal cannula, mask, etc.); -Turn on the oxygen flow at the rate of two to three liters per minute unless otherwise ordered; -Periodically re-check water level in humidifying jar. Be sure there was water in the humidifying jar and the water level was high enough that the water bubbles as oxygen flows through; -Document the rate of oxygen flow, route, and rationale, the frequency, and duration of treatment; -Document the reason for prn (as needed) administration of oxygen; -Cannulas and mask should be changed weekly; -O2 (oxygen) cannula/mask should be stored in a plastic bag when not in use. 1. Record review of Resident #32's face sheet (a document that gives a resident's information at a glance) showed the following: -admission date of 9/17/21; -Diagnoses that included Type II diabetes mellitus (disease in which the body's ability to produce or respond to the insulin is impaired elevating levels of glucose in the blood and urine, spinal arthritis, esophageal stricture (abnormal tightening of the esophagus), hypertension (elevated blood pressure), obstructive sleep apnea (intermittent airflow blockage during sleep), and gastroesophageal reflux disease (a condition in which acidic gastric fluid flows backward into the esophagus, resulting in heartburn). Record review of the resident's admission Minimum Data Set (a federally mandated assessment instrument completed by facility staff), dated 9/17/21, showed the resident did not receive oxygen administration. Record review of the resident's care plan, dated 9/20/21, showed staff did not care plan oxygen administration. Record review of the resident's physician's orders, dated 9/27/21, showed an order that directed facility staff to administer oxygen at two liters per minute via NC (nasal cannula) as needed for shortness of breath. Record review of the resident's care plan showed staff did not add the oxygen usage to the care plan. Observation on 10/13/21, at 9:00 A.M., showed the resident in bed with oxygen on at three liters/nasal cannula (NC) running with no water in the humidity bottle on the oxygen concentrator. The oxygen tubing was not labeled and/or dated. Observation on 10/15/21, at 11:45 A.M., showed the resident's oxygen on at three liters/NC. During an interview on 10/15/21, at 11:50 A.M., Certified Nurse Aide (CNA) C said the following: -The nurse aides were to make sure the oxygen concentrator was working and the oxygen tubing attached correctly to the concentrator; -He/she had seen a humidity (sterile water) bottle on some of the concentrators, but some of the concentrators do not have humidity bottles; -A nurse tells them if they can turn up the oxygen level, but they don't do this unless the nurse tells them; -The resident's oxygen level varied and they could turn the oxygen level up; -The nurse labels the oxygen tubing, but the nurse aides do not do this. During interview on 10/15/21, at 12:05 P.M., Licensed Practical Nurse (LPN) A said the following: -The nurses changed the oxygen tubing weekly on Sunday evenings. Staff were to label the tubing with tape and the date the tubing and the humidity bottle were changed; -If a resident's oxygen level was three liters and the physician's order was for two liters oxygen, staff should turn the oxygen level down and monitor the resident's oxygen saturation level (normal blood oxygen level is 95-100%); -They should check the nurses' notes and call the physician to see if this level had changed; -The resident's oxygen saturation level was low last week and they turned up the resident's oxygen level; -They were to call the physician for a change in the order. During interview on 10/15/21, at 12:20 P.M., the Associate Director of Nursing (ADON) said the following: -Oxygen tubing should never be on the floor since the floor is dirty; -Staff were to label and change the oxygen tubing as needed; -Staff were to change the oxygen tubing monthly and as needed; -Some of the oxygen concentrators did not have humidity bottles, but nurses were to check and refill the humidity bottles with sterile water when they were empty; -Usually oxygen was ordered for two-four liters per nasal cannula. The physician will specify the level; -They check the resident's pulse oximetry and if it is low on two liters oxygen per NC, they would call the physician; -If the order for oxygen was ordered PRN (as needed), and they were on oxygen constantly, they were to check the pulse oximetry per shift; -He/she did not know how the resident's oxygen level was turned up to three liters per NC when ordered for two liters per NC as needed. During interview on 10/15/21, at 12:50 P.M., the Administrator said the following: -Staff were to change oxygen tubing weekly on Sunday evenings and this was on the nurses' calendar; -Staff were to tape and date the oxygen tubing when they changed the tubing; -If a resident had orders for two liters oxygen as needed, then staff needed to call the physician to request to increase the oxygen level to three liters and continuous; -The resident should be on more liters of oxygen and on continuous oxygen due to his/her condition.

Based on interview and record review, the facility failed to ensure two residents (Resident #9 and Resident #21) received their second injection of the Coronavirus Disease 2019 (COVID-19 - an infectious disease caused by severe acute respiratory syndrome) Coronavirus 2 (SARS-CoV-2)) vaccine in a timely fashion. The facility census was 52 residents. Record review of the facility's policy titled COVID-19 Vaccination Policy, undated, showed the following: -The Centers for Disease Control and Prevention (CDC) recommends vaccination of all workers in healthcare settings. Vaccination programs are effective in protecting employees and patients and preventing the spread of communicable disease. The purpose of this policy is to describe our facility's policy on vaccinations, especially COVID-19 vaccinations, to protect our employees and patients; -This policy is intended to comply with federal, state and local laws. It is based upon guidance provided by the CDC, public health, and licensing authorities, as applicable; -This facility will work closely with the government selected vendors to ensure all residents and employees have the opportunity to receive the COVID-19 vaccination series; -Facility staff will provide education regarding the vaccine to all interested residents and employees. Record review of the CDC guidelines, updated 10/18/21 showed the following: -If you receive a COVID-19 vaccines that require two shots, you will both shots to get the most protection; -The timing between your first and second shots depends on which vaccine your received; -You should get your second shot as close to the recommended three week or four week interval as possible. However, your second dose may be given up to six weeks (42 days) after the first dose, if necessary. 1. Record review of Resident #9's face sheet (admission data) showed the following: -admission date of 6/15/21; -Diagnoses included history of breast cancer, osteoporosis, and osteoarthritis (type of arthritis that occurs when flexible tissue at the ends of bones wear down). Record review of the facility's resident vaccination spreadsheet showed the following: -On 8/24/21, the resident received his/her first injection of a two shot COVID-19 vaccination; -The pharmacist consultant to administer the second injection on the next visit. Record review of the resident's medical record, on 10/15/21, showed staff did not document the resident had received his/her second injection of the COVID-19 vaccine. Staff did not document a reason why the resident did not receive the second injection. During interviews on 10/15/21, at 11:55 A.M., and on 10/19/21, at 2:38 P.M., the Director of Nursing (DON) said the resident's second COVID vaccination is late and should be done. During interviews on 10/15/21, at 11:55 A.M., and on 10/19/21, at 2:38 P.M., the Administrator/Infection Preventionist (IP) said the resident's second COVID vaccination is late and should be done. She thought it was done September 2021. During a phone interview on 10/19/21, at 2:02 P.M., the pharmacist consultant said the resident should receive his/her second dose. 2. Record review of Resident #21's face sheet showed the following: -admission date of 8/17/21; -Diagnoses included pulmonary embolism (one or more arteries in the lungs become blocked by a blood clot), osteoarthritis, and hypertension (HTN - high blood pressure). Record review of the facility's resident vaccination spreadsheet showed the following: -On 5/21/21, the resident received the first injection of a two injection COVID-19 vaccine; -The pharmacist consultant to administer the second injection on the next visit. Record review of the resident's medical record, on 10/15/21, showed staff did not ensure the resident received his/her second injection of the COVID-19 vaccine. Staff did not document why the second injection was not received. During an interview on 10/14/21, at 9:27 A.M., the resident said he/she got the first vaccine for COVID, but has not got the second one. He/she wants the second dose and is not sure why he/she has not received the second dose. During interviews on 10/15/21, at 11:55 A.M., and on 10/19/21, at 2:38 P.M., the DON said the resident's second COVID vaccination is late and should be done. During interviews on 10/15/21, at 11:55 A.M., and on 10/19/21 at 2:38 P.M., the Administrator/IP said the resident's second COVID vaccination is late and should be done. During a phone interview on 10/19/21, at 2:02 P.M., the pharmacist consultant said the resident should receive their second dose. 3. During an interview on 10/15/21, at 8:56 A.M., Registered Nurse (RN) D said the following: -The facility should have the list of vaccinated residents; -She is unsure how the facility monitors the first and second injection received for residents; -The DON or administrator monitor the COVID vaccinations. 4. During an interview on 10/15/21, at 9:37 A.M., the Social Service Director (SSD) said the following: -The administrator and DON monitor the COVID vaccines; -She logs the vaccines for staff on the required website; -The DON logs the COVID vaccine and informs the pharmacist when to come to the facility and administer the second injection. 5. During interviews on 10/15/21, at 11:55 A.M., and on 10/19/21, at 2:38 P.M., the DON said the following: -Social services gives information, upon a resident's admission, to staff of the resident's COVID vaccination status; -The SSD asks the resident if they would like the COVID vaccine; -Staff contacts the pharmacist if a resident wants the COVID vaccine; -If the pharmacy gives the first COVID-19 vaccine, the pharmacy contacts the facility when they give the second injection; -The second injection should be done four to six weeks later; -She has now taken over monitoring of the due dates of COVID vaccines; -Staff call the pharmacist consultant if a resident requests the COVID vaccine and comes to the facility the following week. 6. During interviews on 10/15/21, at 11:55 A.M., and on 10/19/21, at 2:38 P.M., the Administrator/IP said the following: -The pharmacist consultant comes to the facility and gives the COVID-vaccines; -When COVID vaccines first started, the medical record staff made the spreadsheet; -The second injection should be due 28-30 days after the first injection. 7. During a phone interview on 10/19/21, at 2:02 P.M., the pharmacist consultant said the following: -It is preferred to have the second injection four weeks after the first injection, but anytime between four to six weeks after the first dose; -It is clinically recommended to administer the second dose if the second injection is missed at the four week mark; -The facility gives him/her a list of residents who need the COVID vaccination; -He/she expects staff to inform the pharmacy of residents who are due for the 2nd injection; -The facility is responsible to inform the pharmacy of residents who are due for the 2nd injection; -He/she administers the COVID vaccinations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff) were completed a minimum of every three months for eight residents (Resident #1, Resident #6, Resident #12, Resident #18, Resident #19, Resident #189, Resident #190 and Resident #191). The facility census was 52. Record review of the facility's Resident Assessments policy, revised November 2019, showed the following: -A comprehensive assessment of every resident's needs is made at intervals designated by Omnibus Budget reconciliation Act (OBRA) and Prospective Payment System (PPS) requirements; -The Resident Assessment Coordinator is responsible for ensuring that the Interdisciplinary Team conducts timely and and appropriate residents assessments and reviews according to the following requirements; -Quarterly Assessment to be conducted not less frequently that three months following the most recent OBRA assessment of any type. 1. Record review of Resident #1's face sheet (admission data) showed the following: -admitted on [DATE]; -Diagnoses included unsteady gait, cerebrevascular accident (CVA-stroke), and lethargy (lack of energy). Record review of the resident's MDS assessments showed the following information: -Staff encoded a quarterly MDS assessment for the resident on 7/15/21 into the facility system, but had not completed the assessment. During an interview on 10/14/21, at 2:38 P.M., the MDS/Care Plan Coordinator said staff did not complete the resident's quarterly MDS assessments that were due on 7/15/21 and 10/14/21. 2. Record review of Resident #'6's face sheet showed the following: -admitted on [DATE]; -Diagnoses included depression, bipolar disorder (disorder associated with episodes of mood swings), and hypothyroidism (underactive thyroid). Record review of the resident's MDS assessments showed the following information: -Staff failed to complete the required quarterly due on 9/3/21. During an interview on 10/14/21, at 2:38 P.M., the MDS/Care Plan Coordinator said staff did not complete the resident's quarterly MDS assessment due on 9/3/21. 3. Record review of Resident #12's face sheet showed the following: -admitted on [DATE]; -Diagnoses included atrial fibrillation (a-fib (abnormal heart rate), depression, anxiety, and morbid obesity. Record review of the resident's MDS assessments showed the following information: -Staff failed to complete the resident's quarterly MDS due on 5/4/21; -Staff failed to complete the the resident's annual MDS assessment due on 8/17/21. During an interview on 10/14/21, at 2:38 P.M., the MDS/Care Plan Coordinator said staff did completed the resident's quarterly MDS assessment due on 5/4/21 and annual assessment due on 8/17/21. 4. Record review of Resident #18's face sheet showed the following: -admitted on [DATE]; -Diagnoses included difficulty walking, a-fib, and constipation. Record review of the resident's MDS assessments showed the following information: -Staff failed to complete the resident's quarterly MDS assessment due on 8/6/21. During an interview on 10/14/21, at 2:38 P.M., the MDS/Care Plan Coordinator said the resident's quarterly MDS assessment due on 8/6/21 was not completed. 5. Record review of Resident #19's face sheet showed the following: -admitted on [DATE]; -Diagnoses included HTN, anxiety, and pressure ulcer stage one (intact skin with a localized area of non-blanchable erythema (redness)) of right buttock. Record review of the resident's MDS assessments showed the following information: -Staff completed an admission MDS assessment on 5/11/21; -Staff did not complete the resident's quarterly MDS assessment due on 8/10/21. During an interview on 10/14/21, at 2:38 P.M., the MDS/Care Plan Coordinator said staff did not complete the resident's quarterly MDS assessment due on 8/10/21. 6. Record review of Resident #189's face sheet showed the following: -admitted on [DATE]; -Diagnoses included difficulty walking with recent fall, altered mental status, lymphedema (localized swelling of the body), dementia, and atherosclerosis (disease of the arteries by plaque). Record review of the resident's MDS assessments showed the following information: -Staff completed a comprehensive MDS assessment on 01/29/21; -Staff did not complete the resident's quarterly MDS assessment due on 5/7/21 and 8/6/21. During an interview on 10/14/21, at 2:38 P.M., the MDS/Care Plan Coordinator said staff did not complete the resident's quarterly MDS assessments due on 5/7/21 and 8/6/21. 7. Record review of Resident #190's face sheet showed the following: -admitted on [DATE]; -Diagnoses included HTN, osteoporosis, dementia, anxiety, insomnia, and depression. Record review of the resident's MDS assessments showed the following information: -Staff completed a comprehensive MDS assessment on 2/1/21; -Staff did not complete the resident's quarterly MDS assessment due on 5/3/21 and 8/3/21. During interviews on 10/14/21, at 11:22 A.M. and 2:38 P.M., the MDS/Care Plan Coordinator said the staff did not complete the resident's quarterly MDS assessments due on 5/3/21 and 8/3/21. 8. Record review of Resident #191's face sheet showed the following: -admitted on [DATE]; -Diagnoses included anxiety, Alzheimer's type dementia, and insomnia. Record review of the resident's MDS assessments showed the following information: -Staff completed the resident's quarterly MDS assessment due on 11/20/20 and 2/19/21; -Staff did not complete the resident's quarterly MDS assessment due on 5/21/21; -Staff did not complete the resident's annual MDS assessment due on 7/28/21. During an interview on 10/14/21, at 2:38 P.M., the MDS/Care Plan Coordinator said staff did not complete the resident's quarterly MDS assessment, due on 5/21/21, and annual MDS assessment, due on 7/28/21. 9. During interviews on 10/14/21, at 11:22 A.M. and 2:38 P.M., the MDS/Care Plan Coordinator said the following: -She was the DON and MDS/Care Plan Coordinator for January 2021. She left the facility June 2021; -She returned to the facility as the MDS/Care Plan Coordinator the end of August 2021; -She had MDS assessments caught up until June 2021, before she left the facility; -The Assistant Director of Nursing (ADON) completed the MDS assessments 6/2021 to the end of 8/2021; -MDS assessments are late and not completed; -She submits the completed MDS assessments. 10. During interviews on 10/15/21, at 1:05 P.M., and on 10/19/21 at 2:38 P.M., the administrator said the following: -She took over as administrator in January 2021; -The prior MDS coordinator was interim and did three jobs; -The current MDS coordinator is behind on MDS assessments due to she worked the floor; -MDS assessments to be completed include quarterly and annual assessment; -MDS assessments are not completed and late. 11. During an interview on 10/15/21, at 1:23 P.M., the ADON said she was aware the MDS assessments were late and not completed. She had been in training for a couple of months and did not complete the MDS assessments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident's choice of code status (the level of medical interventions a resident wishes to have if their heart or breathing stops) was clearly and consistently documented throughout the resident's medical record for three residents (Resident #7, Resident #21 and Resident #139). The facility census was 52. Record review of the facility's policy titled Advance Directives, revised 12/2016, showed the following: -Advance directives will be respected in accordance with state law and facility policy; -Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive is he or she chooses to do so; -The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive; -Changes or revocations of a directive must be submitted in writing to the administrator. The administrator may require new documents if changes are extensive. The care plan team will be informed of such changes and/or revocations so that appropriate changes can be made in the resident assessment and care plan; -The Director of Nursing (DON) services or designee will notify the attending physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care;. 1. Record review of Resident #7's face sheet (admission data) showed the following: -admission date of [DATE]; -Diagnoses included atrial fibrillation(abnormal heart rate) with rapid ventricular response (lower heart chambers beat to fast), congestive heart failure (CHF - a weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues), hypokalemia (low potassium), and hypertension (HTN - high blood pressure). Record review of the resident's Outside the Hospital Do Not Resuscitate (DNR - do not attempt cardiopulmonary resuscitation (CPR - an emergency procedure that is performed when a person's heartbeat or breathing has stopped)) (OHDNR) form, dated [DATE], showed the following: -The resident's representative's signed the form; -The resident's physician's signed the form on [DATE]. Record review of the resident's care plan, dated [DATE], showed the following: -Code status of full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep alive). Record review of the resident's current physician's order sheet (POS) showed the resident code status as a DNR. During an interview on [DATE], at 12:41 P.M., the administrator and DON said the resident's care plan should have been updated to show a DNR code status because of the change of code status by the representative. 2. Record review of Resident #21's face sheet showed the following: -admission date of [DATE]; -Diagnoses included pulmonary embolism (one or more arteries in the lungs become blocked by a blood clot), osteoarthritis (type of arthritis that occurs when flexible tissue at the ends of bones wear down), and HTN. Record review of the resident's OHDNR form, dated [DATE], showed the following: -The resident's representative's signed the form; -The resident's physician's had not signed the form. Record review of the resident's care plan, dated [DATE], showed the following: -Code status full code; -See physician order sheet (POS) for code status; -Ensure code status is updated yearly or with a significant change in condition. Record review of the resident's [DATE] POS showed the resident's code status as full code. During an interview on [DATE], at 8:56 A.M., Registered Nurse (RN) D said the following: -The resident is full code; -The physician did not sign the DNR form; -The [DATE] POS has full code; -He/she is not sure of the resident's code status; -He/she said since the resident's representative signed the DNR on [DATE] he/she would assume the resident is DNR. 3. Record review of Resident #139's face sheet showed the following: -admitted on [DATE]; -Diagnoses include dementia, multiple falls, HTN, and chronic kidney disease. Record review of the resident's OHDNR form, dated [DATE], showed the following: -The resident's representative's signed the form; -The resident's physician signed the form on [DATE]. Record review of the resident [DATE] and [DATE] POS showed staff marked out full code status and documented DNR. Record review of page one of the [DATE] and [DATE] POS showed the resident's code status as full code. Record review of the resident's care plan, updated [DATE], the resident's code status as full code. Record review of the resident's [DATE] POS showed the resident's code status as full code. During an interview on [DATE], at 9:37 A.M., the Social Service Director (SSD) said the resident's [DATE] POS showed full code and the DNR was signed [DATE] and the physician signed on [DATE]. 4. During an interview on [DATE], at 8:26 A.M., Certified Nurse Aide (CNA) O said the following: -He/she is unaware of where to find a resident's code status; -The facility used to have red stickers on resident charts for DNR code status; -He/she would get the nurse if he/she finds a resident unresponsive. 5. During an interview on [DATE], at 8:56 A.M., RN D said the following: -Staff find a resident's code status in the chart; -Staff should look at the first page of the POS to find a resident's code status; -The facility used to have colored stickers for code status; -The DNR should be under the legal document tab in the chart; -Nursing completes the DNR and after the resident or representative signs it, it should go to medical records; -He/she is unsure how the physician gets the DNR form to sign. 6. During an interview on [DATE], at 9:37 A.M., the SSD said the following: -She filed medical records until [DATE] when she became the SSD; -She asks the family, resident or durable power of attorney (DPOA) on admission of their code status; -She makes a copy of the signed DNR form and places the original DNR form in a folder for the physician to sign when he is at the facility once per week; -She puts the original DNR form in the resident's chart after the physician signs it; -The original DNR should be back in the chart after the physician has signed; -The nurse should document the code status on the POS the day the family or resident signs the form; -Staff should find the code status on the POS and the legal document section; -She is unsure of who puts the code status on the care plan; -The nurse should make code status changes on the revocation on the DNR form and update the POS and care plan if a resident/representative requests a code status change. 7. During an interview on [DATE], at 12:15 P.M., the MDS/Care Plan Coordinator said the following: -She reviews the physician orders and code status when she updates a resident's care plan; -Code status should match throughout the residents' medical record. 8. During interviews on [DATE], at 11:55 A.M., and on [DATE], at 2:38 P.M., the Director of Nursing (DON) said the following: -Nurses should ask a resident's code status upon admission; -The DPOA or resident's representative signs the DNR form if the resident is unable to sign; -Staff should make a copy for the resident's chart and put the original form to medical records for the physician to sign; -Medical records brings the original form to the resident's medical record after the physician signs; -Code status should be on the POS and care plan; -She would expect a resident's code status to match throughout the resident's medical record. 9. During interviews on [DATE], at 11:55 A.M., and on [DATE], at 2:38 P.M., the administrator said the following: -Staff make a copy of the signed DNR and place it in the resident's chart and send the original form to medical record for the physician to sign; -Medical record staff should file the physician signed original DNR form in the resident's chart; -The resident's code status should be documented on the POS and care plan; -She would expect a resident's code status to match throughout the resident's medical record.

Based on observation, record review, and interview, the facility staff failed to maintain the nutritive value of the the pureed diets when staff did not ensure serving sizes met the approved menu for five residents on pureed diets. The facility census was 52. Record review of the facility's Pureed Diet policy, dated 2017, showed the following: -The Pureed Diet is designed for individuals who have difficulty in swallowing or who cannot chew foods of the dental soft (mechanical soft) consistency; -With the proper selection of foods, the pureed diet meets, the current Dietary Reference Intakes/Recommended Dietary Allowances/Adequate Intakes, Food and Nutrition Board, Institute of Medicine, National Academy of Science, for individuals ages 31 years and older; -Serve with appropriate scoop number or divide equally to provide number of portions. All of the pureed food must be used in order to deliver the correct nutrient density to each individual. If the recipe was altered, the scoop size may also need to be altered. In some cases a volume chart may be used to approximate portioning. Record this information on the recipe with the date and your initials. Review altered pureed recipes with the Registered Dietitian. Record review of the Dining RD.com recipe, dated 2021. Health Technologies (Consulting Dietitians), Incorporated, for Pureed Creamy Chicken Spaghetti recipe, showed to portion with a #6 scoop (5.33 ounces (oz)). 1. Observations on 10/15/21, at 11:30 A.M., showed the following: -Dietary Aide (DA) E scooped the creamy chicken spaghetti out of the pan and into the blender with a slotted spoon without measuring the amount he/she put in the blender; -The creamy chicken spaghetti was blended to a pudding consistency; -DA E served the pureed creamy chicken spaghetti with a #12 scoop (2.67 ounces) for the residents on puree diets. During an interview on 10/15/21, at 12:30 P.M., DA E said the following: -The food should be plated per amount on the recipe; -The recipe will have the scoop size to serve the food; -He/she goes by the recipe for the scoop size for servings; -He/she used a #12 scoop for the pasta, but should have used a #6 scoop. During an interview on 10/15/21, at 1:24 P.M., the Dietary Manager said the following: -She expects the staff to follow recipes; -The recipe called for a white #6 scoop size and should have not used the green #12 scoop. During an interview on 10/18/21, at 12:58 P.M., the Registered Dietician said the following: -She comes to the facility once a month unless they call her; -Puree meals are important to residents who can't eat a regular diet; -Staff should follow the recipe for amount serve and consistency; -Scoop sizes for servings are on the recipes; -If the recipe call for #6 scoop, that is what staff should use; -The correct scoop size is what gives the residents the adequate calories.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of the Resident #23's face sheet showed an admission date of 9/12/16. Record review of the resident's progress note, dated 10/9/21, no time, showed a nurse documented the resident returned to the facility by ambulance at 5:45 P.M. Record review of the resident's medical records showed the resident had not received a COVID-19 vaccination. Record review of the resident's care plan, revised 10/15/21 showed staff did not care plan quarantine due to return to the hospital, or the infection control processes in place. Observation on 10/13/21, beginning at 9:01 A.M., showed the following: -Certified Nurse Aide (CNA) M sat in a chair in the resident's room and assisted the resident to eat the lunch meal. CNA M's surgical mask was down below his/her nose; -The resident and the CNA were within six feet of each other; -The CNA pulled his/her surgical mask down below his/her mouth and talked to the resident for under a minute; -The CNA pulled his/her surgical mask back up. The surgical mask fell down below his/her nose. During an interview on 10/13/21, at 9:02 A.M., the DON stood in the hallway outside the resident's door and said the resident came back from the hospital this past weekend and was on general isolation. She said anytime a resident is sent out to the hospital, they are on 14 day observation when return. During an interview on 10/13/21, at 9:10 A.M., LPN A said staff should wear a gown, gloves, N95 mask with a surgical mask over their N95 mask and goggles or glasses to enter the resident's room. The resident was in the hospital and not COVID-positive. The resident is quarantined at least ten days. During an interview on 10/13/21, at 10:00 A.M., CNA M said this morning he/she did not have a gown or N95 mask on in the resident's room. He/she did not know the resident was a readmission from the hospital and had not been informed by facility staff. He/she did not see the isolation cart outside the resident's door. During an interview on 10/13/21, at 9:57 A.M., CNA N said the following: -Staff should wear appropriate PPE for residents on precautions; -The nurses inform staff of new admissions and COVID positive residents. During an interview on 10/13/21, at 10:05 A.M., CNA M said the following: -Isolation carts are outside the rooms for new admissions; -New admissions are on observation for 10 to 14 days; -Staff should wear a gown, gloves, N95 with a surgical mask over the N95 with new admissions and wear facemasks appropriately. During an interview on 10/15/21, at 8:26 AM., CNA O said the following: -Staff should wear gloves, gown, goggles and N95 mask for residents who are new admissions; -Staff should wear facemasks covering the mouth and nose all the time; -Staff should not talk to a resident with their mask down. During an interview on 10/15/21, at 8:56 A.M., RN D said the following: -Staff should wear gown, gloves, N95 mask and goggles with residents on 14 day quarantine; -Staff should not talk to a resident with their mask down. During interviews on 10/13/21, at 10:44 A.M., and on 10/19/21, at 2:38 P.M., the DON said the following: -Staff placed new admissions from the hospital or home on 14 day isolation; -Staff should wear a N95 mask, gown and gloves for residents on 14 day isolation; -Residents should wear a N95 mask outside of their room if on 14 day observation; -Staff should not talk to a resident with their mask down. During an interview on 10/19/21, at 2:38 P.M., and on 10/22/21, at 10:35 A.M., the administrator/ICP said the following: -Staff should wear N95 mask in a resident's room on 14 day observation; -Staff should wear masks appropriately covering their mouth and nose; -Staff should not talk to a resident with their mask down; -Per the facility policy and CDC guidelines, staff should wear N95 mask in room for 14 day observation. Based on interview and record review, the facility failed to maintain an effective infection control program during a Coronavirus Disease 2019 (COVID-19 - an infectious disease caused by severe acute respiratory syndrome) Coronavirus 2 (SARS-CoV-2)) pandemic by not providing a safe environment for residents when the facility failed to ensure one resident (Resident #85) maintained quarantine precautions for 14 days when admitted from the hospital and failed to ensure staff used proper PPE (personal protective equipment) when assisting one quarantined resident (Resident #23). The facility census was 52. Record review of the Centers for Disease Control (CDC) Infection Control Guidelines, updated 09/10/21, showed the following: -Quarantine is when one is exposed to COVID-19 virus; -All unvaccinated residents who are new admissions and readmissions should be placed in a 14 day quarantine, even if they have a negative test upon admission; -Unvaccinated residents should generally be restricted to their rooms, even if testing is negative and cared for by health care personnel using an N95 or higher-level respirator, eye protection (goggles or a face shield that covers the front and sides of the face), gloves, and gown. They should not participate in group activities; -If no additional cases are identified during the broad-based testing, room restriction and full PPE use by HCP caring for unvaccinated residents can be discontinued after 14 days and no further testing is indicated. Record review of the updated guidance for healthcare workers from the Centers for Disease Control and Prevention (CDC) titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel during the Coronavirus Disease 2019 (COVID-19) Pandemic, updated on 09/10/2021, showed the following: -Implement source control measures; -Source control refers to use of respirators or well-fitting facemasks or cloth masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing; -Source control options for health care personnel (HCP) include a NIOSH-approved N95 or equivalent; or higher-level respirator or a respirator approved under standards used in other countries that are similar to NIOSH-approved N95 filtering facepiece respirators (note: these should not be used instead of a NIOSH-approved respirator when respiratory protection is indicated); or a well-fitting facemask; -Source control and physical distancing (when physical distancing is feasible and will not interfere with provision of care) are recommended for everyone in a healthcare setting. This is particularly important for individuals, regardless of their vaccination status, who live or work in counties with substantial to high community transmission. Record review of the facility's policy titled COVID-19 Policy and Procedure, undated, showed the following: -Based on the identified risk for our frail elderly from the COVID-19 virus, aggressive infection control measures will be implemented to prevent introduction of the virus to residents, staff, and visitors; -Each facility's infection control preventionist (ICP) will have the responsibility for ensuring proper isolation and other procedures are followed. Administration will validate ICP is utilizing current CDC recommendations and guidance's; -Order and safe guard sufficient isolation/PPE and supplies (masks/gloves/gowns/hand washing and sanitization supplies). Record review of CDC's COVID Data Tracker showed the following: -From 10/12/21 to 10/18/21, the county's transmission rate was substantial. -From 10/19/21 to 10/20/21, the county's transmission rate was moderate. Record review of the CDC guidance for healthcare workers, titled Facemask Do's and Don'ts, dated 06/02/20, showed the following: -Do secure the bands around the ears; -Do secure the straps at the middle of the head and the base of the head; -Don't wear the facemask under the nose or mouth; -Don't wear the facemask around the neck. 1. Record review of Resident #85's face sheet (a document that gives a resident's information at a glance) showed an admission date of 10/1/21. Record review of the resident's medical records showed the resident had not received a COVID-19 vaccination. Record review of the resident's admission Minimum Data Set (a federally mandated assessment instrument completed by facility staff), dated 10/8/21, showed the following: -Intact cognition; -Locomotion off unit such as to the dining room did not occur; -Had a walker; -On isolation or quarantine for active infectious disease at the facility. Record review of the resident's care plan, dated 10/11/21, showed the following: -Occupational therapist (OT) to work with activities of daily living (ADL - dressing, grooming, bathing, eating, and toileting) re-training; -Able to ambulate independently with minimal assistance of one person supervision; -Use a walker for all ambulation; -One standby assist for all ambulation. (Staff did not care plan a 14-day quarantine for COVID-19.) Record review of the resident's October 2021 physician's orders showed the following: -An order, dated 10/1/21, to obtain Covid-19 testing as needed per nasal swab per Center for Medicare and Medicaid Services (CMS) guidelines; -An order, dated 10/1/21, to check temperature every shift; -An order, dated 10/1/21, to monitor for signs and symptoms of fever, cough, shortness of breath, dyspnea (feeling not able to breathe), and sore throat. Record review of the resident's nurses' notes showed the following: -On 10/3/21, the resident took a shower this morning by him/herself. Staff instructed the resident on using the call light in the shower if assistance needed. (The shower room is located down the 200 hall across from the nurses' station.); -On 10/4/21, OT assisted the resident to the shower room; -On 10/8/21, OT assisted the resident with his/her shower and walked the hall with PT (physical therapy); -On 10/11/21, the resident walked with therapy in the hallway and took a shower this morning. (Based on admission date, the 14-day quarantine would have been in effect until 10/14/21. Staff did not document what infection control processes were in place for these activities.) Observation on 10/12/21, at 12:30 P.M., showed the following: -Outside the resident's room was plastic drawer bins with red bags, and PPE gowns, surgical masks, gloves, and face shields; -There was no signs on door of quarantine; -The resident's room door was open; -The resident was on the bed fully dressed; -The resident's family member (visiting) sat by the bed wearing a surgical mask, gown, and gloves. The resident did not wear a mask. During an interview on 10/12/21, at 12:30 P.M., the resident said he/she was in isolation because of coming from the hospital. During an interview on 10/13/21, at 9:58 A.M., Licensed Practical Nurse (LPN) A said the following: -Staff would find out in report when there was a new admission to the facility; -For new admissions, a resident was to quarantine for ten days. If a resident was COVID-19 positive from the hospital or admitted from home, the resident would quarantine 10-14 days if they were showing symptoms of COVID-19; -Staff were to use PPE of gowns, gloves, goggles, N95 masks, and booties (shoe coverings) for the feet; -No staff had talked to him/her about what to wear in the quarantine rooms. Observation on 10/13/21, at 10:00 A.M., showed no signs on the resident's room door to indicate quarantine room. The door was open. Observation on 10/13/21, at 11:54 A.M., showed the resident, not wearing a mask, walk down the 200 hall with OT. During an interview on 10/13/21, at 11:55 A.M., OT F said he/she walked with the resident down the hall to the shower room to take a shower. The resident was up on his/her own in the room. He/she was helping the resident with walking. Observation on 10/13/21, at 5:30 P.M., showed the resident was in the dining room at a table by him/herself and eating dinner. The resident did not wear a mask while in the halls when he/she walked to and from the dining room. (Based on admission date, the 14-day quarantine would have been in effect until 10/14/21.) Record review of the resident's nurses' notes showed the following: -On 10/13/21, on the evening shift, the resident goes to the dining room at times for meals. (Based on admission date, the 14-day quarantine would have been in effect until 10/14/21. Staff did not document what infection control processes were in place for these activities.) During an interview on 10/14/21, at 3:37 P.M., Registered Nurse (RN) B said the resident was in the 14th day of quarantine until 12 midnight tonight. During an interview on 10/14/21, at 4:45 P.M., the resident said the following: -He/she was admitted to the facility on [DATE] from the hospital; -When he/she was admitted , the staff person told him/her that quarantine meant he/she couldn't leave their room; -The staff said the quarantine would be four to seven days; -He/she took a shower each day in the shower room down the hall across from the nurse's station. Since he/she had been at the facility, he/she took 14 showers; -He/she wore a mask, used his/her walker and went to the shower room; -The physical therapy staff watched him/her shower and assisted him/her as needed; -After the seven days since he/she was admitted to the facility, he/she went to therapy and walked two laps around the hallways and did not wear a mask; -At night, they do things different since he/she went to dinner in the dining room; -In the last couple of days, the kitchen staff asked him/her if he/she was having supper in the dining room; -His family member wore a gown, gloves and mask, but no one in the ding room wore the gown and gloves; -He/she felt there was a lack of communication between the different nursing shifts at the facility about the quarantine period. During an interview on 10/18/21, at 1:15 P.M. and 1:30 P.M., the Social Service Director (SSD) said the following: -When a resident was admitted from the hospital, the resident is placed in a quarantine room for 14 days; -The resident is tested for COVID-19 once per week, but not sure about this with their vaccination status; -When the resident is admitted , the social service department tells the family about putting on a gown, gloves, glasses or face shield, and N95 mask to visit the resident; -They do ask the resident not to go out in the hall and the family were to maintain a six foot distance while visiting the resident in the room; -Therapy staff were not to walk the resident up and down the hall even with mask on while in quarantine; -He/she was not sure about bathing or showers; -In the past, the facility staff would disinfect the shower or tub before and after their shower and the resident would be the last shower of the day. She did not know what they did now since she did not work on the floor. -He/she talked to the resident and his/her family member and made them aware the resident would be quarantined for 14 days and then would be moved off the short 200 hall and would have access to other parts of the facility; -The facility should follow the CDC guidelines for quarantine since it was a fairly high positivity rate in the county. During an interview on 10/18/21, at 1:40 P.M., PT G said the following: -While a resident was on quarantine, the resident stayed in their room; -Physical therapy staff were to put on a gown, mask, and face shield to go into the resident's room to do therapy; -When a resident was on quarantine, they try to do as much in the resident's room but no one comes down to the therapy room; -They knew a resident was quarantined, when there were quarantine signs on or next to the resident's room door. They talk to nursing staff just in case; -They do use the facility PPE unless they need a larger pair of gloves because they do run out of room in the bins by the resident's door; -The resident was not to walk down the hall during quarantine to get a shower; -The therapy staff thought the quarantine was over since the resident asked them to go take a shower. During an interview on 10/18/21, at 1:53 P.M., Registered Nurse (RN) D, charge nurse said the following: -A newly admitted resident to the facility would be in quarantine for 14 days; -They were to put on a gown, face shield, glasses or goggles, N95 mask, gloves, and booties; -The resident was to eat in his/her room and not go out of the quarantine room; -If a resident was on therapy services, the therapy was to do the exercises in the resident's room; -He/she did not know who was responsible to put the quarantine signs up on the resident's door but knew the nurse's aide or nurse was to get the room ready for a new admission; -He/she didn't think the resident in quarantine could go to the shower room; -The resident ate in his/her room. During an interview on 10/13/21, at 10:44 A.M., the Director of Nursing (DON) said the following: -The 200 hall was generally the COVID-19 hall for isolating residents; - For precaution, they had bins with gloves, goggles, gown, foot booties, and red trash cans-one for the resident's laundry; -Any new admissions from home and/or the hospital were to be on 14 day isolation; -All staff were to wear a gown and N95 mask, but there was no COVID-19 outbreak at the moment; -While on observation, all staff and visitors wear PPE since they don't know about transmission; -On day 14 of quarantine, a resident can go out of the room with therapy with an N95 mask like to walk with therapy staff. During an interview on 10/18/21, at 2:25 P.M., the physician said the following: -They follow the CDC precautions; -For a new admission to the facility, the resident was placed on observation and on isolation for two weeks; -There should be a sign on the resident's door about quarantine and the PPE staff were to use; -When entering a resident's room, staff were to wear an N 95 mask, goggle or face shield, gown, and gloves; -Since COVID-19 is air borne, the resident's room door is to be closed when the resident is Covid positive; -The resident was on two weeks isolation precautions and not four to seven days like the resident thought. During an interview on 10/19/21, at 3:20 P.M., the administrator and DON said the following: -A new admission from the hospital is placed in isolation for COVID-19 precautions; -The resident remains on precautions for 14 days; -Educational information is on the cart or zip tied to the resident's door; -If resident was in quarantine, they were not to do therapy outside the room, but in the room; -If a resident was to go out of the quarantine room and go down the hall, they were to wear N95 mask, gown, and booties to the shower room.