**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to respect one resident's rights, when the facility performed Cardiopulmonary Resuscitation on Resident #1, when he/she had a signed Do Not Resuscitate order. This deficient practice affected one of four sampled residents. The facility census was 54. Review of the facility's, undated, Resident Rights Policy showed:- Each resident residing in the facility has the right and will be afforded the right to a dignified existence and self determination;-Each resident will have autonomy and choice to the maximum extent possible;-Resident rights include the right to request, refuse and/or discontinue treatment; -The right to end of life care that respect and follows the resident's stated goals and choices for care and service at the end of the resident's life.Review of Resident #1's admission Minimum Data Set (MDS: a federally mandated assessment tool completed by facility staff) showed: -Some cognitive loss; -Need for partial assistance with Activities of Daily Living (ADLs: tasks completed in a day to care for oneself). -Diagnoses of atrial fibrillation (Afib: irregular and sometimes rapid heart beat) hypertension, and chronic kidney disease.Review of the resident's comprehensive care plan dated [DATE] showed: Code status of DNR, honor his/her wishes.Review of the resident's physician order sheet for [DATE] showed: Code status: DNR (Do Not Resuscitate).Review of the resident's nurse progress notes showed:-[DATE] at 2:40 P.M. The resident was working with therapy, the resident complained of having no energy or strength. The resident slumped over and did not respond. The resident was placed on the floor and CPR was started. The Director of Nursing (DON) called Emergency Medical Services and the resident's family. DNR paperwork was found, CPR continued until EMS arrived at 3:05 P.M. and called time of death. At 4:56 P.M. an area funeral home was on site to pick up the resident.During an interview on [DATE] at 12:47 P.M. Licensed Practical Nurse (LPN) B said: -DNR paperwork was kept in a book at the nurses station; -DNR direction is also found in the resident's electronic medical record; -A picture of a butterfly or a heart should have been on the back of every resident door; -The butterfly signifies DNR and the heart signifies to perform CPR.During an interview on [DATE] at 1:00 P.M. Registered Nurse B said: -DNR paperwork was kept in a book at the nurses station;-The DNR book should be checked immediately when a resident is nonresponsive; -A picture of a butterfly or a heart could be found on the back of every resident door; -The butterfly signified DNR and the heart signified to perform CPR;During an interview on [DATE] at 1:22 P.M. Registered Nurse (RN) A said: -He/She was the charge nurse for Resident #1 on [DATE]; -About 2:45 P.M. the resident was working with Therapy on toilet transfers and had complained he/she was too weak. RN A went to the room to assist with the transfer; -Resident #1 complained of weakness and right arm weakness; -Resident #1 slumped to the left side, was nonresponsive and his/her color was completely white; the resident was moved to lie on the floor. RN A checked the back of the resident's room door, found no butterfly or heart picture, and started CPR; -He/She told staff to get help; -When help arrived it was the DON, who had the DNR paperwork for the resident; -When EMS arrived they pronounced the resident deceased . During an interview on [DATE] at 1:59 P.M. Resident #1's Nurse Practitioner said: -Staff should not have performed CPR; The resident had a DNR; -The resident did not want CPR and staff should have followed his/her wishes; -He/She would expect staff to follow the resident's wishes for no CPR.During an interview on [DATE] at 10:04 A.M. the Director of Nursing said: -He/She would expect staff to check the electronic medical record first, and the DNR book prior to initiating CPR; -Signs in the residents rooms should not be the only indicator to begin or not begin CPR; -He/She would expect staff to honor the resident's wishes.Incident 1783011

Based on observation, interview, and record review the facility failed to ensure staff provided quality of care and treatment in accordance with professional standards of practice when staff failed to reposition one resident and additionally failed to follow physician's orders for this resident to be laid down after lunch (Resident #14's ). This affected one resident out of twelve sampled residents. The facility census was 40. Review of facility policy, Safe Lift, Transfer, and Repositioning Policy, undated, showed: -Transfer and mobility assistance as well as other resident handling and movement tasks will be carried out in accordance with comprehensive nursing and therapy assessments, the Minimum Data Set (MDS) (a federally mandated assessment tool completed by facility staff) and individualized comprehensive care plan, and written instructions pertaining to each individual resident; -Lifting, transferring, or repositioning assistance will be provided in accordance with the resident's care plan absent emergencies or exceptional circumstances. 1. Review of Resident #14's Annual MDS dated , 10/17/24, showed: -He/She was severely cognitively impaired; -He/She was dependent on a wheelchair; -He/She required substantial/maximal assistance with personal hygiene, shower/bathing, upper body dressing, rolling to left and right mobility, sit to lying, lying to sitting, sit to stand, chair to bed transfer, toilet transfer, and tub/shower transfers; -He/She was at risk of development of pressure ulcers; -He/She used a pressure reducing device in chair and his/her bed; -Care areas triggered included pressure ulcers; -Diagnosis included dementia (a condition that causes decline in mental functioning such as ability to think, remember, and reason), Parkinson's disease (a progressive neurological disorder that causes nerve cells in the brain to die leading to movement problems), anxiety, depression, restless leg syndrome (a condition that caused an uncontrollable urge to move legs), muscle weakness, difficulty in walking, and cognitive deficit (a general term for impairments that affect a person's ability to think, learn, remember, and make decisions). Review of care plan, revised 11/7/24, showed: -Transfer: extensive assistance from two staff for transfers with gait belt to wheelchair; may use mechanical lift due to recent decline; -Check him/her every two hours as required for incontinence. -Check and change every two hours and as needed. -He/She had potential for pressure ulcer development due to immobility, dementia, and Parkinson's disease; Review of physician's orders, dated 12/10/24, showed an order with a start date of 5/12/24 directing staff to lay the resident down after lunch to off load buttocks in the afternoon for skin integrity. Review of nurses medication administration record (MAR), dated 12/11/24, showed: -Start date 5/12/24, lay resident down after lunch to off load buttocks in the afternoon for skin integrity. -Completed 12/1, 12/2, 12/3, 12/4, 12/5, 12/6, 12/7, 12/8, 12/9, 12/10; Observation on 12/10/24 at 10:00 A.M. showed resident was sitting up in his/her wheelchair. Observation on 12/10/24 at 12:22 P.M. showed resident taken to his/her room. He/She was not laid down and remained up in wheelchair chair watching television in his/her room. Observation on 12/10/24 at 2:03 P.M. showed resident remained up in his/her wheelchair. During an interview on 12/10/24 at 2:18 P.M, Resident's representative said: -He/She had a sore on his/her bottom; -Resident had become stiff so facility started using a lift to transfer him/her; -The facility staff now placed resident in a reclining wheelchair chair. Observation on 12/11/24 at 7:25 A.M. showed resident was up in his/her wheelchair sitting out in the living room. Observation on 12/11/24 at 8:16 A.M. showed resident completed breakfast and was back in living room sitting in his/her wheelchair. Observation on 12/11/24 at 10:05 A.M. showed resident remained in his/her wheelchair chair sitting in living room. During an interview on 12/11/24 at 10:25 A.M., Certified Nurses Aide (CNA) A said Resident #14 had not been laid down since prior to going to breakfast; Observation showed on 12/11/24 at 10:34 A.M. CNA A took resident in his/her room to be laid down and provided incontinent care. During a continuous observation on 12/12/24 from 7:01 A.M.-11:34 A.M. showed: -7:01 A.M., Resident up in his/her wheelchair leaning at 45 degree angle sitting in living room next to medication cart. -8:43 A.M., Resident back in living room from going to dining room for breakfast, remained in wheelchair. He/She was sat in hallway next to nurses station in living room area. -9:16 A.M., Resident wheeled to his/her room by Certified Medication Technician (CMT) A for medications, resident remained in his/her wheelchair chair -9:23 A.M., Resident remained in his/her wheelchair in his/her bedroom; -9:25 A.M., CMT A exited resident's bedroom -10:30 A.M. Resident remained in his/her wheelchair; -10:52 A.M., Resident remained in his/her wheelchair; -11:10 A.M., Hospice Registered Nurse (RN) arrived to facility to see resident, resident remained in his/her chair during hospice assessment and visit; -11:34 A.M., Hospice RN wheeled resident to dining room for lunch; -Staff did not provide incontinent cares or repositioned the reisdent from his/her wheelchair for three hours and thirty-three minutes. During an interview on 12/13/24 at 7:36 A.M., Certified Medication Technician B said: -He/She would expect residents to be repositioned every two hours; -He/She expected residents in a wheelchair to be also be repositioned every two hours; -He/She expected residents to be provided incontinent care and checked every two hours; During an interview on 12/13/24 at 7:46 A.M., Licensed Practical Nurse (LPN) B said: -He/She expected a resident to be repositioned every two hours or more frequently depending on resident specific surgical needs ; -He/She expected Resident #14 to be repositioned every two hours, but if he/she is sore he/she would expect resident to be repositioned more frequently. During an interview on 12/13/24 at 7:51 A.M., CNA B said: -He/She expected residents to be repositioned every two hours and more frequently for residents who may be on Lasix (A diuretic that removes fluid from the body) when he/she would provide cares more frequently such as hourly; -Resident #A should be laid down after every meal and repositioned every hour to alleviate pressure and prevent him/her from developing open wounds; -He/She would not expect Resident #14 to be up in the chair for four and 1/2 hours without being repositioned. During an interview on 12/13/24 at 8:18 A.M., Director of Nursing (DON) said: -He/she expected residents to be repositioned every two hours; -He/She expected Resident #14 to be repositioned; -Resident #14 helped by moving around a lot; -Resident #14 moved around a lot in his/her chair; -Staff often reposition Resident #14 when they move him/her from room to room; During an interview on 12/13/24 at 10:52 A.M., Administrator said: -He/She expected residents to be repositioned every two hours and as needed; -Some residents can reposition themselves and they will tell us when they are fine and not in need of repositioning; -When resident is not able to reposition themselves we do encourage every two hours turning or repositioning.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #295's Face Sheet (a document meant to be a quick summary of a resident's essential information) showed: -The resident is his/her own person (there is no other person assigned by the resident or the courts that would be responsible for making the resident's healthcare and/or end-of-life decisions). -The resident's Code Status is listed as unknown. -The Advanced Directive reads the resident's code status is listed as DNR. Review of Resident #295's medical record showed: -The resident had a Basic Interview for Mental Status (BIMS) score of 14, indicating the resident is cognitively intact and capable of making his/her needs and desires known. -The resident signed a Code Status Form dated [DATE] and checked the DO NOT RESUSCITATE box. The form was witnessed by LPN C. -The resident's New admission Report Sheet, completed by an unknown staff member, lists the resident's code status as Full Code. -The resident's Medication Administration Record lists the resident's Advance Directive status as both a Full Code and a DNR. Review of Resident #295's care plan updated [DATE] directed staff the resident was to be a FULL CODE. Review of Resident #295's Physician Orders showed a DNR, order dated [DATE]. During an interview on [DATE] at 2:34 P.M., Resident #295 said he/she has a DNR and he/she expects his/her wishes to be honored. During an interview on [DATE] at 8:25 A.M., LPN C said: -If a resident is a DNR, there would be a butterfly sticker on the back of their door. Plus, they would have a purple DNR sheet in the book at the desk. -Resident's Advance Directive paperwork can be found on the computer. -A resident's code status is listed in their care plan, on their face sheet, in provider orders. -The code status listed in all these places are the same. During an interview on [DATE] at 7:55 A.M., LPN B said: -If a resident is a DNR, it would be in the binder at the desk or all over in their chart. -A resident's code status should be the same in each place in their chart. During an interview on [DATE] at 10:52 A.M. the Director of Nursing (DON) said: -If a resident is a DNR status, they would have a physicians order in the computer as well as a DNR form completed in the binder located at each nurse's station. -A resident's advanced directive can be found in the computer on the physician's order sheet, on the face sheet, and when the Medication Administration Record (MAR) is pulled up. -A resident's code status is listed in their care plan. -The code status in the care plan should match the code status in the provider's orders. During an interview on [DATE] at 10:52 A.M., the Administrator said: -A resident's code status is expected to be the same throughout their chart. -Whatever code status is listed in the provider's orders should be the code status in the care plan. 2. Review of Resident #18's Quarterly Minimum Data Set, dated [DATE], showed: - Severe cognitive impairment; - Dependent on staff for activities of daily living (ADLs); - Frequently incontinent of bowel and bladder; - Diagnoses included Alzheimer's disease, aphasia (disorder that makes it difficult to communicate), and high blood pressure. A review of the resident's care plan dated [DATE] showed: - The resident has an ADL self care performance deficit related to limited mobility; - DNR (Do Not Resuscitate) code status. Review of the resident's medical record showed: - Physician's order dated [DATE]: DNR code status; -OHDNR (Out of Hospital Do Not Resuscitate) signed by the resident's husband and physician on [DATE]; -No DPOA paper work was found; -No letter of incapacitation was found. During an interview on [DATE] at 11:45 A.M., the SSD said: -The resident should have a letter of incapacity; -If a resident is deemed incapacitated there should be a letter with that information; -DPOA and incapacitation information should be obtained at admission and placed in the resident's chart; -He/she could not locate the resident's DPOA or incapacity letter.Based on interviews and record review, the facility failed to ensure an invoked (activated by verifying incapacity of the resident to make decisions) Durable Power of Attorney (DPOA) was in place prior to allowing the designated agent to sign Outside of Hospital Do Not Resuscitate (OHDNR, it instructs health care providers not to begin cardiopulmonary resuscitation, or CPR, if the resident's breathing stops or if a resident's heart stops beating) forms which affected two of the 12 sampled residents, (Resident #22 and #18). Additionally they facility failed to ensure Resident #295's code status matched his/her's care plan. The facility census was 40. Review of the facility's undated policy for advance directives, showed: - It is the policy of the facility to comply with applicable law and to promote the right of self-determination by encouraging the use of Advance Directives (a legal document which allows your to plan and make your own end-of-life wishes known in the event your are unable to communicate)and honoring treatment preferences expressed by the resident and/or the resident's representative and their Advance Directives, if those preferences are allowed by law; - Prior to or on admission, the Social Worker or designee will ask the resident or resident's representative, if they have a a Living Will (a written, legal document that spells out medical treatments you wound not want to be used to keep you alive, as well as your preferences for other medical decisions) or DPOA for health care decisions; - All residents will be given written information concerning an individual's rights under state law, to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate Advance Directives; - If the resident has any of these Advance Directives, a copy of the documents will be placed in the resident's medical record and reviewed quarterly, annually and as needed with the resident; - If the resident becomes incapacitated, the resident's representative will be contacted quarterly, annually and as needed; - If the resident is in a coma or incapacitated, the information about Advance Directives shall be given to the family or resident's representative. 1. Review of Resident #22's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE] showed: - Long and short term memory problems; - Lower extremities impaired on both sides; - Dependent on the assistance of staff for toilet use, showers, dressing, personal hygiene and transfers; - Diagnoses included Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), progressive neurological disorder (condition where there is a progressive deterioration in functioning), Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks) and dementia (inability to think). Review of the resident's care plan, revised [DATE] directed staff the resident's code status was a do not resuscitate and the resident wanted to have his/her wishes honored. Review of the resident's face sheet showed the responsible party was the resident's spouse. Review of the resident's medical record showed: - The resident's spouse signed the purple OHDNR form on [DATE] and the physician signed it on [DATE]; - Unable to locate the resident's incapacitation letter in the resident's medial record. During an interview on [DATE] at 2:53 P.M., the Social Services Director (SSD) said he/she was looking for the resident's advance directives and the incapacitation letter. During an interview on [DATE] at 9:41 A.M., the SSD said she found the resident's advance directive but was unable to locate the resident's incapacitation letter. During an interview on [DATE] at 10:52 A.M., the Director of Nursing (DON) said if a resident was not their own person and had a DPOA in place, she would expect there to be an incapacitation letter in the residents medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Observation on 12/10/24 at 9:59 A.M. showed: -A window at the end of the rehab hallway, between resident #294's room and the room across the hall, with grime and debris cracked around its edges. -Resident #296 walking in the rehab hallway with a therapy staff member . The resident was overhead saying, That window needs to be cleaned, it looks disgusting! Observation on 12/10/24 at 9:59 A.M. showed: -A chair at the end of the rehab hallway, between resident #294's room and the room across the hall, with stains on the seat. Observation on 12/11/24 at 2:19 P.M. showed a hole in the carpet in resident #21's room. The hole measured approximately one (1) inch by six (6) inches. The hole had frayed carpet around the edges and was directly in the walking path in front of the bathroom door and posed a trip hazard. During an interview on 12/12/24 at 9:59 A.M., Housekeeping Supervisor said: -Maintenance was responsible to fix and repair walls; -The facility was currently understaffed with only four staff members in housekeeping for whole building; -The floor technician was responsible for vacuuming, maintaining floors, windows, and furniture in facility; -Due to the vacant position of floor technician the facility vacuuming and maintenance of the floors had been overlooked by his/her staff; -His/Her staff was primarily responsible for cleaning of the resident rooms; -The facility floor technician quit and facility had been without a floor technician for approximately a week; -He/She had her staff assist with the floor technician duties following completion of resident rooms; -If residents complained about the noise of the vacuum then he/she expected his/her staff to wait until resident was out of their room to vacuum or respect resident wishes and desires to keep the area quiet and not vacuum but try to hit the area with a broom; -He/She expected his/her staff to deep clean every day; -He/She expected his/her staff to respect resident wishes, if a resident did not want housekeeping in their room he/she expected staff to listen; -Housekeeping staff were expected to clean areas that floor technician missed and furniture in main areas; -The materials found on chairs in halls were cleaned with a steam cleaners; -Housekeeping staff were not allowed to clean the chairs due to risk of spotting the furniture; -He/She communicated with maintenance staff and floor technicians via email if he/she found area that needed addressed; -Resident rooms that were occupied by residents were cleaned daily; -If a room did not get cleaned one day then it was scheduled to be cleaned first the next day; -He/She expected his/her staff to clean resident's bathrooms first and then work their way out of the room by dusting, wiping down furniture items, and attending to the floor; During an interview on 12/13/24 at 9:06 A.M., Assistant Director of Nursing (ADON) B said: -The facility used a website for communication needs that were to be addressed by maintenance; -Nurses and facility administration had access to communicate maintenance needs via the website; -Certified nurses aids are to communicate any maintenance requests to nursing staff and nursing staff are to log the request for maintenance on the website. During an interview on 12/13/24 at 9:10 A.M., Maintenance Technician said: -He/She received work orders through the website work hub; -He/She was able to obtain supplies needed really quickly if did not have them in facility; -He/She was aware of holes in carpet, there is current plans to replace carpet in main areas; -He/She was currently working on resident room needs as first priority; -Facility had a floor technician responsible for cleaning and maintaining facility floors; -The floor technician position had been vacant for approximately one week; -He/She was responsible for wall repairs; -He/She was aware of repair needs required in dining room; -He/She had to get painters from other facility building to come in and paint in dining room. During an interview on 12/13/24 at 10:52 A.M., Administrator said: -She expected to provide a safe, clean, and home like environment for residents; -She expected food carts for room trays to be cleaned and sanitized; -She did not expect food carts to have food and other substances caked to bottom of carts; -She expected floors to be free from holes in carpets and trip hazards; -She expected facility floors to be free from debris, crumbs, and stains; -She expected facility floors to be vacuumed; -She expected walls to be maintained with dry wall patches made and walls painted; -She expected furniture to be free from stains and break down. Based on observation and interviews, the facility failed to maintain a clean, comfortable, and homelike environment when the facility failed to maintain and replace holes in carpet, vacuum and sweep floors, clean stained furniture, repair scraped and missing paint from walls, clean and maintain food and medication carts, replace stained ceiling tiles, and clean facility windows. The facility census was 40. Review of facility policy, Cleaning and Infection Control of Non-Critical, Reusable Resident Care Equipment, undated, showed: -Cleaning-the physical removal of foreign material, e.g. dust, oil, organic material such as blood, secretions, excretions, and micro-organisms -Cleaning reduces or eliminates the reservoirs of potential pathogenic organisms -Cleaning is accomplished with water, detergents/sanitizers, and mechanical action; -Cleaning is a shared responsibility between nursing and housekeeping departments; -All equipment must be cleaned immediately if visibly soiled, and immediately after use on elders with contact precautions regardless of cleaning schedule; -All neighborhoods will set up a schedule for cleaning with specific assignments to ensure tasks are completed; -All horizontal and frequently touched surfaces will be cleaned daily and immediately when soiled; -The Housekeeping manager and the Infection Practitioner must approve all products used for the stages of cleaning/disinfection process; Review of facility policy, quality of care, undated, showed: -Facility is committed to providing high quality of care and services to residents in a safe, respectful, and person-centered environment. -Safety and Security -Ensuring the safety and security of residents is paramount; -Facility adheres to all relevant safety protocols, infection control measures, and emergency procedures to maintain a secure environment. Observation in the dining room on 12/10/24 at 11:29 A.M., showed several areas on all walls where the paint had been scrapped off and was missing from the walls showing white through the dark gray colored paint. One 8 inch by 3 inch area was noted on the back wall by the windows. Observation on 12/10/24 at 12:14 P.M. showed a three tiered metal cart was being used to deliver resident meal trays. The cart was observed to have sticky food like substance caked to the bottom rim of the metal cart unit. The wheels on cart were also observed to be caked in dirt. Observation on 12/11/24 at 8:29 A.M. showed sitting area by patio on east hall had food crumbs located under all four chairs in seating area and the end tables. Observation on 12/11/24 at 8:33 A.M. showed the floor on east hall nurses station had food crumbs, pieces of torn paper, paper clips, and other particles laying on floor. Observation on 12/11/24 at 8:34 A.M. of medication cart on east hall showed the wheels on medication cart were covered and wrapped with appeared to be human hair. The ledges of the bottom of the medication cart also had grime and dirt built up. Observation on 12/11/24 at 8:35 A.M. showed a discolored ceiling tile above sitting area on east hall by patio. Observation on 12/11/24 at 8:37 A.M. showed on east hall there was a 4 inch by 1 inch area that was missing carpet where the blue carpet met white carpet. Areas of frayed carpet were also sticking up where the area of carpet was missing. Observation on 12/11/24 at 8:40 A.M. showed windows on east hall between room [ROOM NUMBER] and 2017 had dirt built up between the screens. Observation on 12/11/24 at 8:43 A.M. showed the stairwell exit door between resident rooms [ROOM NUMBERS] had a spilled sticky substance on it. Observation on 12/11/24 at 8:45 A.M. showed the pillar in the dining area across from room [ROOM NUMBER] had a spilled brown sticky substance on it. Observation on 12/11/24 at 8:49 A.M. showed the white portions of the carpet in the living room area had stains on it. Observation on 12/12/24 at 9:00 A.M. showed crumbs remained under chairs and end tables in on carpeted seating area by the patio on the east hall. Observation on 12/11/24 at 2:23 P.M., showed a PTAC (packaged terminal air conditioner) unit with a black mold-like substance on the fins of the heating/cooling unit in the janitor's closet by room [ROOM NUMBER].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a criminal background check for for five of 10 sampled employees prior to employment start date and evaluate for history of abuse, neglect, exploitation, or misappropriation of resident property in order to prohibit and prevent such abuse, consistent with the applicable requirements at subsection §483.12(a)(3). The facility census was 40. The facility's Abuse, Neglect, and Exploitation Policy stated: - [NAME] Plaza at Briarcliff has developed and implemented this policy and procedure to prohibit abuse, neglect, exploitation, or misappropriation of property by any perpetrator including but not exclusive to any staff member or volunteer of this facility or any contracted agency staff, vendors, another resident, family member, or visitors of the resident or other residents. - The purpose of the components of this policy is to ensure that all residents of this facility will be free of physical, emotional, and sexual abuse, neglectful treatment and misappropriation of funds and resources. -The accompanying procedures are employed to assure total staff adherence to this policy. -The objective of the Abuse policy is to comply with the seven-step approach to abuse and neglect detection and prevention. -Overview of seven components: Screening, Training, Prevention, Identification, Investigation, Protection, Reporting and Response. -It is the policy of [NAME] Plaza at Briarcliff to screen residents prior to moving into the facility as well as employees and volunteers prior to working with residents. -Screening of employee and volunteer components include verification of references, certification and verification of license, criminal background checks, and query of the Family Care Safety Registry. -All potential employees' names will be submitted to Validity Background Checks prior to their employment. Review of the facility's New Hire employee packets reviewed for Employee Disqualification List (EDL), Criminal Background Check (CBC) and Federal Indicator Checks showed: -Five of the 10 employees randomly selected had a date of hire prior to the date CBC results were received. -Maintenance Employee A was hired on 11/07/24. His/Her CBC results were received by the facility on 11/21/24. -Cook C was hired on 10/03/24. His/Her CBC results were received by the facility on 10/07/24. -CNA G was hired on 08/08/24. His/Her CBC results were received by the facility on 08/15/24. -Housekeeper A was hired on 07/11/24. His/Her CBC results were received by the facility on 07/15/24. -Activity Assistant A was hired on 10/11/24. His/Her CBC results were received by the facility on 06/03/24. During an interview on 12/13/24 at 10:52 A.M., the DON said: -An employee's hire date is their first day of orientation. -All background checks are completed by HR/Staffing Coordinator. During an interview on 12/13/24 at 10:52 A.M., the Administrator said: -An employee's hire date is their first day of orientation. -HR ensures all new employees have ben through the EDL, Nurse Aid Certification Check, and runs background checks.

Based on interview, and record review, the facility failed to provide services that met professional standards of quality when staff failed to recognize and report significant weight loss and/or gain. This affected four of the 12 sampled residents (Resident #28, Resident #295, Resident #244, and Resident #294). Facility census was 40. The facility's policy for Monitoring Weights stated: -All residents will be evaluated for weight stabilization and timely identification of weight loss. -Significant weight loss will be defined as: 3% loss in one week, 5% loss in 30 days, 7.5% loss in 90 days, and/or 10% loss in 180 days. -The physician, resident, and/or legal representative will be notified immediately (within 24 hours) of any resident meeting the definition of significant weight loss in this policy and informed on the interventions implemented. -Any resident with significant weight loss will be referred to the Registered Dietician Nutritionist (RDN) for recommendations. -The recommendations of the RDN will be communicated to the resident's primary care physician and family upon receipt of the recommendations. - The policy does not address significant weight gain. The facility's Role of Registered Dietician policy showed the Registered Dietician (RD) will be notified of weight changes weekly either in person, by phone conference, or by fax with a specific request for individualized recommendations. The facility's Preventive Maintenance and Inspection policy stated: -Resident weight scales will be calibrated by a licensed outside contractor quarterly and as needed due to use, wear, and tear. -The facility did not provide the requested scale calibration/inspection logs. 1. Review of Resident # 28's undated Care Plan showed: - The resident requires extensive assistance from staff for most activities of daily living (ADLs) including toileting and transfers. - The resident has a diagnosis of Diabetes. Staff are expected to monitor for signs and symptoms of hyperglycemia (elevated blood sugar), one of which is weight loss. - The resident is taking an antibiotic, which puts him/her at risk for experiencing anorexia (a lack of interest in food and/or eating). Staff are expected to monitor for side effects of this medication every shift. - The resident has a nutritional problem related to moderate malnutrition, diabetes, and Parkinson's disease. Staff are expected to monitor/record/report to the doctor (MD), signs and symptoms of malnutrition, including significant weight loss. - The resident is at risk for dehydration or potential fluid deficit related to diuretic use. Staff are expected to monitor/record/report to the MD, signs and symptoms of dehydration, including recent/sudden weight loss. Review of Resident #28's medical record showed: - On 11/04/24, Resident #28 weighed 173.1 lbs. - On 11/20/24, he/she weighed 142.0 lbs. This calculated to a loss of 31.1 lbs., or 18% in 16 days. - On 11/24/24, Resident #28 weighed 136.2 lbs. This calculated to a loss of another 5.8 lbs., or 4.1% in four days. - On 11/25/24, Resident #28 weighed 139.0 lbs. - On 12/02/24, Resident #28 weighed 138.6 lbs. - On 12/09/24, Resident #28 weighed 137.6 lbs. - In total, Resident #28 lost 35.5 lbs. between 11/04/24 and 12/09/24, or 20.5% in 35 days. - The percentage of weight lost was calculated by the facility's electronic medical record program and the resulting calculation was visible to staff reviewing the resident's weights. - No documentation of notification made to Resident #28's Primary Care Provider related to significant weight loss. - No documentation of notification made to the RD related to specific request for individualized recommendations. 2. Review of Resident #295's Care Plan, revised 12/04/24 showed: - The Resident had a diagnosis of Diabetes and staff are expected to monitor for signs and symptoms of hyperglycemia (elevated blood sugar), one of which is weight loss. - He/She has a potential for nutritional problems related to immobility due to fractures/pain. Staff are expected to monitor/report to the doctor (MD) as needed, signs and symptoms of malnutrition, including significant weight loss. - Is taking two antidepressant medications, Venlafaxine and Mirtazapine. Staff are expected to monitor/document/report to the MD, signs and symptoms of on going depression unaltered by the prescribed medications, which include changes in weight. Review of Resident #295's December Physician Orders showed: - Order Date: 12/04/24, Monitor for side effects, adverse reactions, and behaviors related to antidepressants, anxiolytics (anti-anxiety medications), hypnotic (sleeping medication), and psychotropic medications (medications used for some mental health conditions). Notify Practitioner of and chart any adverse reaction, side effect, or behavior. - Order Date: 12/04/24, Weigh weekly on Monday, change to daily if Congestive Heart Failure (CHF), new diuretic, etc. Notify provider for loss or gain five lbs. or more in seven days. Every day shift every Monday. Review of Resident #295's medical record showed: - On 12/04/24, Resident #295 weighed 188.0 lbs. - On 12/04/24, a Nutritional Assessment was completed on Resident #295. In this assessment staff documented that Resident #295 was at risk for malnutrition. - On 12/05/24, a second Nutritional Assessment was completed on Resident #295. Again, staff documented that the resident was at risk for malnutrition. - On 12/09/24, Resident #295 weighed 176.2 lbs. This calculated to a loss of 11.8 lbs., or 6.2% in five days. - On 12/10/24, a third Nutritional Assessment was completed on Resident #295. In this assessment staff documented that they did not know if the Resident had any weight loss in the last three months and left the assessment incomplete, failing to document a completed nutritional status on the resident. - The percentage of weight gained and lost was calculated by the facility's electronic medical record program and the resulting calculation was visible to staff reviewing the resident's weights. - No documentation of notification made to Resident #295's Primary Care Provider related to significant weight loss. - No documentation of notification made to the RD related to specific request for individualized recommendations. 3. Review of Resident #244's undated Care Plan showed: - The resident is receiving the antidepressant medication duloxetine relating to depression. Staff are expected to monitor/document/report to the doctor (MD), signs and symptoms of depression unaltered by the prescribed medication, one of which is changes in weight. - The resident is at risk for psychosocial well-being problems related to social isolation. Staff are expected to monitor/document/report to the MD, signs and symptoms of depression. - The resident is at risk for nutritional problems related to impaired mobility and risk for malnutrition. Staff are expected to monitor/document/report to the MD, signs and symptoms of malnutrition, including significant weight loss. Review of Resident #244's medical record showed: - On 11/12/24, Resident #244 weighed 146.0 lbs. - On 11/20/24, Resident #244 weighed 139.1 lbs. This calculated to a loss of 6.9 lbs., or 4.7% in seven days. - On 11/27/24, Resident #244 weighed 140.0 lbs. - On 11/27/24, a Nutritional Assessment was completed on Resident #244. In this assessment staff documented that Resident #244 had a normal nutritional status, with no weight loss during the last three months. - On 11/28/24, a Comprehensive Nutritional Assessment was completed on Resident #244. In this assessment staff documented that Resident #244's weight history was not applicable, the resident had no weight change, and that the RD had no recommendations at this time. - On 12/02/24, Resident #244 weighed 146.2 lbs. This calculated to a gain of 6.2 lbs., or 4.4% in five days. - The percentage of weight gained and lost was calculated by the facility's electronic medical record program and the resulting calculation was visible to staff reviewing the resident's weights. - No documentation notification was made to Resident #18's Primary Care Provider related to significant weight fluctuations. - No documentation notification was made to the RD related to specific request for individualized recommendations. 4. Review of Resident #294's undated Care Plan showed: - Resident had potential for nutritional problem related to impaired balance and mobility. Staff are expected to monitor/record/report to the doctor (MD), signs and symptoms of malnutrition including significant weight loss. - Resident had potential for fluid deficit related to diuretic (a medication used to flush fluids from the body) use. Staff are expected to monitor/record/report to the MD, signs and symptoms of dehydration including recent/sudden weight loss. - Resident had a diagnosis of Diabetes and staff are expected to monitor for signs and symptoms of hyperglycemia (elevated blood sugar), one of which is weight loss. Review of December Physician Orders showed: - Start Date: 12/07/24 Torsemide Oral Tablet 20 milligrams (mg) Give one tablet by mouth every 24 hours as needed for diuretic related to unspecified diastolic congestive heart failure (a chronic condition that causes the heart to pump blood less effectively than it used to) administer an additional 20 mg for weight gain of two-three lbs. in one day or five lbs. in one week. - Start Date: 12/07/24 Torsemide Oral Tablet 20 mg Give one tablet by mouth in the morning related to unspecified diastolic congestive heart failure. Review of December's Medication Administration record showed: - The resident was not administered any as needed doses of Torsemide for weight gain between 12/01/24 to 12/13/24 - On 12/08/24 a one time only dose of Torsemide 20 mg was administered to the resident for shortness of air (SOA)/congestion. Review of the medical record showed: - On 12/06/24, Resident #294 weighed 211.4 lbs. - On 12/08/24, Resident #294 weighed 208.4 lbs. This calculated to a loss of 3.0 lbs. in two days. - On 12/10/24, Resident #294 weighed 200.2 lbs. This calculated to a loss of 8.2 lbs., or 3.9% in two days. - In total, Resident #294 lost 11.2 lbs., or 5.29% in four days. - The percentage of weight loss was calculated by the facility's electronic medical record program and the resulting calculation was visible to staff reviewing the resident's weights. - No documentation notification was made to Resident #294's Primary Care Provider related to significant weight loss. - No documentation the provider was made aware of the resident's 3.0 lbs. weight loss prior to administration of the ordered onetime only dose of Torsemide. - No documentation notification was made to the RD related to specific request for individualized recommendations. During an interview on 12/11/24 at 8:25 A.M., LPN C said: - Residents are weighed before breakfast. - If a resident has to be weighed in their wheelchairs, the weight of the wheelchair and whether or not the wheelchair should have the peddles on or off while weight is being obtained, is written on the back of the wheelchair. The weight of the wheelchair is then subtracted from the total weight obtained with the resident in the wheelchair on the scale. -Scales are checked and calibrated regularly but he/she's not sure by whom. He/She thinks it's done by an outside company. -He/She is unaware of any residents currently on the floor with weight loss or weight gain concerns. -If a resident gains or loses three lbs. in 24 hours or five lbs. in one week, staff is supposed to call the doctor. -If staff contacts the doctor it is charted in PCC (the facility's electronic medical record program) -Residents taking diuretics are supposed to be weighed daily. During an interview on 12/11/24 at 9:12 A.M., Speech Language Pathologist A said: -Speech works with the facility's nutritionist and follows the resident's weight. -He/She is not aware of any residents with a weight gain or weight loss concerns. During an interview on 12/11/24 at 8:44 A.M., Maintenance Technician said: -The Maintenance department checks and calibrates scales annually. -Scale checks and calibrations are documented in the maintenance log/compliance book. -He/She doesn't know when scales were last calibrated. During an interview on 12/13/24 at 7:52 A.M. DM A said: -Nutritional Assessments are completed by him/her or another dietary manager. -Comprehensive Nutritional Assessments are completed by the RD. -He/She isn't sure if nutritional assessments are reviewed by nurses or doctors. During an interview on 12/13/24 at 10:52 A.M. the DON said: -There are two Dietary Managers employed with the facility and each of them has a food manager's certification. -Dietary Manager Assessments are completed by the Registered Dietician (RD). -Nutritional Assessments are reviewed by nurses during risk meetings. -If a resident's nutritional assessments or weight shows a decline over time, it would be expected that the dietician and a dietary manager would discuss different processes to be put in place. -Both CNAs and Nurses weigh residents. -Scales are checked and calibrated quarterly. -A total of three pounds gained or lost in one day or five pounds gained or lost in one week would require a call to the Provider. -When a resident is identified as having a significant weight gain or loss they are discussed each week. -An order for a diuretic would not change the parameters laid out in the facility's policy for what would be considered significant weight gain or loss and if those parameters are met, it is expected that staff would contact the provider. During an interview on 12/13/24 at 10:52 A.M. the Administrator said: -Dietary Managers are expected to complete Nutritional Assessments and the RD is expected to complete Comprehensive Nutritional Assessments weekly. -Nutritional Assessments are expected to be completed with 24-48 hours after admission. -Scales are checked and calibrated by an outside company. -Wheelchairs are expected to be weighed each time residents requiring wheelchairs are weighed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of Resident #14's undated Care Plan showed: -Staff were expected to maintain the resident's dignity at the highest level. -The resident required extensive assistance with activities of daily living (ADLs). -The resident required one - two staff members assistance with toileting. -Resident had bladder and bowel incontinence related to dementia, parkinson's disease, and impaired mobility and wore disposable briefs. -Staff were expected to check and change the resident every two hours. -Staff were expected to wash and dry the resident's perineal area with each incontinent episode. Observation of Resident #14's peri care performed by CMT B and CNA A on 12/11/24 at 10:31 A.M. showed: -After removing the resident's soiled brief, staff used a wet wipe to clean a across the resident's pubic bone and down the center of the genitals. Staff failed to clean the skin folds on either side of the genitals. -After running out of gloves, CNA A left the room to get more. -While cleaning the resident's bottom, CNA A's gloves became soiled with fecal matter along the outer side of his/her left pinky finger. CNA A failed to remove the soiled gloves and/or complete hand hygiene. During an interview on 12/13/24 at 10:52 A.M., the Administrator and the Director of Nursing (DON) both agreed and said: -Staff are expected to separate and clean skin folds during peri care. -Staff are expected to complete hand hygiene before and after all resident cares. Based on observation, interview, and record review the facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene when staff did not provide complete perineal care which affected four of 12 sampled residents, (Resident #18, #27, #22 and #14). The facility census was 40. Review of the facility's undated Perineal Care Protocol Policy showed: -Perineal care is very important in maintaining the resident's comfort and should be completed after each incontinent episode; -Provide privacy; -Perform hand hygiene; -Separate all skin folds and cleanse all perineal areas; -Turn resident to the side and wash perineal area buttocks cleaning all areas; -Reposition the resident; -Perform hand hygiene. Review of the facility's undated policy for indwelling catheter protocol, showed: - Procedure for care of an indwelling urinary catheter: - Clean the perineal area and catheter tubing proximal to distal, with warm, soapy water or a disposable cleansing wipe followed by rinsing the area twice daily and after every bowel movement; - Retract the skin fold and the area washed thoroughly, rinse well and replace the skin fold 1. Review of Resident #18's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/26/24, showed: - Severe cognitive impairment; - Dependent on staff for activities of daily living (ADLs); - Frequently incontinent of bowel and bladder; - Diagnoses included: Alzheimer's disease, aphasia (disorder that makes it difficult to communicate), and high blood pressure. A review of the resident's care plan dated 12/2/24 showed: - The resident has an ADL self care performance deficit related to limited mobility; -The resident is dependent on staff for personal hygiene and toileting. Observation on 12/12/24 at 08:37 A.M., showed: -The resident in bed; - Certified Nurses Aide (CNA) A and CNA D removed the resident's brief; - CNA A washed hands and applied clean gloves and used one wipe to clean under the resident's abdominal fold; -CNA A used one wipe to clean down the left groin and a different wipe to clean down right groin; -CNA A used a wipe and wiped down the front of the resident and did not spread the skin and clean all areas that urine or feces had touched; -CNA A and CNA D turned the resident on his/her side and CNA D used a wipe and cleaned the back of the resident; -CNA D did not clean all areas that urine or feces had touched; -CNA A and CNA D washed hands and applied clean gloves and placed a clean brief on the resident; -CNA A and CNA D failed to provide complete perineal care to the resident when they did not spread the skin and clean all areas that urine or feces had touched. During an interview on 12/12/24 at 9:05 A.M., CNA A said: -A different wipe should be used for each cleansing motion when doing peri care; -All areas that urine or feces have touched need to be cleaned; -Staff should spread and clean all areas and skin folds that urine or feces have touched. During an interview on 12/12/24 at 9:09 A.M., CNA D said: -One wipe one swipe is how peri care should be completed; -Staff should spread the skin to clean the front and make sure they clean all areas of the back that urine or feces came in contact with. 2. Review of Resident #27's Quarterly MDS, dated [DATE], showed: - Severe cognitive impairment; - Substantial assistance from staff for ADLs; - Always incontinent of bowel and bladder; - Diagnoses included: Alzheimer's disease, depression and anxiety. A review of the resident's care plan dated 11/22/24 showed: -The resident requires extensive assistance with ADLs; -The resident has bladder incontinence related to Alzheimer's disease. Observation on 12/12/24 at 10:45 A.M., showed: - Registered Nurse (RN) A and CNA F transferred the resident to the toilet and removed the resident's brief; - CNA F washed hands and applied clean gloves and cleaned the backside of the resident; - CNA F washed hands and applied clean gloves and cleaned under the resident's abdominal fold and left and right groin, using a new wipe for each cleansing; -CNA F cleaned the front of the resident and did not spread the skin and clean all the areas that urine or feces had touched; - CNA F and RN A washed hands and applied clean gloves and put a clean brief on the resident; -CNA F did not provide complete perineal care to the resident when he/she did not spread the skin and clean all areas that urine or feces had touched. During an interview on 12/12/24 at 10:52 A.M., CNA F said staff should spread and clean all areas and skin folds that urine or feces have touched. During an interview on 12/12/24 at 10:59 A.M., RN A said: - A new wipe should be used each time staff clean; - Staff should spread and clean all areas and skin folds that urine or feces have touched. During an interview on 12/13/24 at 10:52 A.M. the Director of Nursing (DON) said: -He/she expects staff to separate skin folds and cleanse all areas that urine or feces have touched; -Staff should not use the same area of the wipe to clean different areas of the skin; -He/she expects staff to use one wipe per one swipe. During an interview on 12/13/24 at 10:52 A.M. the Administrator concurred with the DON. 3.Review of Resident' #22's Quarterly MDS, dated [DATE] showed: - Long and short term memory problems; - Lower extremities impaired on both sides; - Dependent on the assistance of staff for toilet use, showers, dressing, personal hygiene and transfers; - Had a urinary catheter (sterile tube inserted into the bladder to drain urine); - Always incontinent of bowel; - Diagnoses included obstructive uropathy ( a condition in which the flow of urine is blocked), Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), progressive neurological disorder (condition where there is a progressive deterioration in functioning), Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks) and dementia (inability to think). Review of the resident's care plan, revised 10/22/24 showed: - The resident required enhanced barrier precaution (EBP, gown and glove use during high-contact resident care activities for residents known to be colonized or infected with MDRO, multi-drug resistant organisms, resistant to one or more classes of antibiotics), as well as those at increased risk of MDRO acquisition). [NAME] and doff gloves and gowns during high-contact cares. Perform proper hand hygiene. Use biohazard trash receptacles for disposal of EBP refuse; - The resident is on antibiotic therapy related to a urinary tract infection (UTI, an infection in any part of the urinary system). Administer medication as ordered; - The resident has an indwelling catheter related to obstructive uropathy. Provide catheter care as needed; - The resident required extensive assistance with activities of daily living (ADL). Extensive assistance of one staff for dressing. Extensive assistance of two staff for toilet use. Dependent on the assistance of two staff for transfers; - The resident is at risk for bladder incontinence related to Alzheimer's disease. The resident used disposable briefs and staff should change as needed. Check the resident every two hours and as required for incontinent care. Review of the resident's urinalysis (UA, a test to analyze urine contents), dated 11/29/24, showed the presence of bacteria indicative of a possible urinary tract infection (UTI). Review of the resident's urine culture and sensitivity (UA with C & S, identifies the amount and type of bacteria present and the medications appropriate to treat the infection), dated 12/2/24, showed the presence of organisms indicative of a possible UTI. Review of the resident's medication administration record, (MAR) dated December 2024, showed an order for Cefdinir dated 12/2/2024 for 300 milligrams (mg) one capsule twice daily for seven days for UTI. Observation on 12/12/24 at 7:09 A.M., showed: - CNA E entered the res room, did not don a gown or wash his/her hands and applied gloves; - LPN A entered the resident's room with the mechanical lift, did not don a gown or wash his/her hands and applied gloves; - CNA E unfastened the resident's brief; - CNA E did not anchor the catheter tubing and used the same area of the wipe and wiped down the catheter tubing; - CNA E did not separate and clean all the skin folds; - CNA E and LPN A turned the resident on his/her side; - CNA E cleaned the buttocks and applied a house barrier cream to the resident's buttocks and placed a clean incontinent brief under him/her; - CNA E removed his/her gloves, did not wash his/her hands and applied gloves; - LPN A And CNA E turned the resident side to side and removed the wet incontinent brief and placed a clean incontinent brief under him/her; - LPN A removed his/her gloves and did not wash his/her hands; - CNA E removed gloves, did not wash his/her hands and applied gloves; - CNA E placed the graduate (a graduated cylinder or container used to collect and measure urine) in a gray basin, unclamped the drainage bag and emptied 250 milliliters (mls.) of urine into the toilet; - CNA E did not clean the port before or after emptying the urine; - CNA E removed gloves and did not wash his/her hands; - CNA E and LPN A used the mechanical lift and transferred the resident from his/her bed to the broda chair (a type of reclining geri-chair); - CNA E washed the resident's face and hands and combed his/her hair; - CNA E did not offer or provide oral care; - LPN A and CNA E washed their hands. During an interview on 12/12/24 at 2:39 P.M., CNA E said: - The catheter tubing should be anchored close to the insertion cite; - The port of the drainage bag should be cleaned with an alcohol wipe; - Should separate and clean all areas of the skin folds; - Should not use the same area of the wipe to clean different areas of the skin; - Should wear a gown and gloves with a resident who had a wound or a catheter; - If you can't wash your hands, should sanitize when you enter the resident's room and between glove changes. Should wash your hands before you leave the room. During an interview on 12/12/24 at 2:57 P.M., LPN A said: - Should separate and clean all areas of the skin where urine or feces had touched; - Should not use the same area of the wipe to clean different areas of the skin; - Should sanitize your hands when you enter the resident's room. Wash your hands after you're done with cares. He/she thought you should wash your hands after sanitizing your hands. Should wash your hands or sanitize between glove changes and before you leave the room. During an interview on 12/13/24 at 10:52 A.M., the DON said: - When staff get the resident up in the morning, the staff should brush the resident's teeth or offer oral care, make sure their hair is brushed or combed, offer hearing aides; - Staff should separate and clean all the skin folds and staff should not use the same area of the wipe to clean different areas of the skin.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of Resident #14's Medical Record showed: -Resident required extensive assistance from two staff members with all transfers. Staff are to use the mechanical lift for transfers due to the resident's recent decline. -The resident is receiving hospice services due to end-stage Parkinson's disease (a disorder of the nervous system that affects movement and worsens over time). -The resident's diagnoses include Unspecified Dementia (a general term for loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life) Generalized Muscle Weakness -The resident is at risk for falls due to deconditioning, It is the goal of the resident/resident's representative and the facility, that the resident remains free of falls. Observation on 12/11/24 at 10:31 A.M. showed: -Mechanical lift transfer of Resident #14 from his/her wheelchair chair to the bed, performed by CMT B and CNA A. The residents bottom was hanging partially over the edge of the sling 's edge and the top edge of the sling was well above the resident's head, forcing his/her chin against his/her chest. This improper sling placement left the resident vulnerable to falling from the sling while in the air. -Staff did not correctly position the resident in the sling prior to raising the sling with the mechanical lift. The resident's arms dangled from either side of the sling, leaving the resident vulnerable to potential impact injury during transfer. During an interview following the transfer on 12/11/24 at 10:31 A.M., CNA A said he/she realized the resident was improperly placed in the sling but they had already begun moving the mechanical lift to the bed and he/she thought it was just better to get him/her there quick. During an interview on 12/13/24 at 10:52 A.M., the Director of Nursing (DON) and Administrator agreed: -Staff are expected to follow manufacturer guidelines when using mechanical lifts. -When staff use a mechanical lift to lift a resident in a sling, the staff are expected to position the resident correctly in the sling and keep the resident stable during the transfer. Based on observation, interview, and record review, the facility failed to ensure staff used proper techniques when transferring four of the 12 sampled residents, ( Resident #18, #27, #28, and #14) during the use of a mechanical lift, and additionally during the use of a gait belt transfer for resident #28. The facility census was 40. Review of the facility's undated Use of Transfer Gait Belt policy showed: - Gait belts will be used when transferring residents who are partially dependent and have some weight bearing capacity; - Explain the procedure to the resident and place the gate belt around the resident's waist; - Ensure the belt is securely fastened and cannot be easily undone; - Staff members need to position one hand on either side of the gate belt with underhand grip and assist the resident forward. Review of the facility's undated Transfer and Repositioning policy showed: - It is the policy of the facility to provide safe and appropriate transfers of residents as to prevent injuries; -All personnel are responsible for implementing this policy; -Resident handling and movement tasks will be carried out in accordance with comprehensive nursing and the individualized care plans; -Lifting equipment will be operated in accordance with manufactures instructions; -Mechanical devices require two staff at all times. Review of the manufactures instructions for the sit to stand mechanical lift dated 2/16/16, showed: -Transfer from the wheel chair: -Push mechanical lift toward the resident; -Open the base of the lift to go around the chair; -Apply the brakes in both rear castors; -Position the resident; -Release the brakes, close the legs of the lift and transfer resident; -Reverse the above procedure when lowering the resident to bed or chair. Review of the undated manufacturer's guidelines for the mechanical lift showed: - Do not lift a resident with the caster brakes on. Always let the lift find the correct center of gravity; - Never perform a lift/transfer with the legs in the closed /transport position (front casters touching); - When lifting, the casters should be left free and un-braked, so that the lift will then be able to move to the center of gravity of the lift. Do not apply the brakes unless parking the lift. 1. Review of Resident #18's Quarterly Minimum Data Set (MDS), A federally mandated assessment instrument completed by facility staff, dated 11/26/24, showed: - Severe cognitive impairment; - Dependent on staff for activities of daily living (ADLs); - Diagnoses included Alzheimer's disease, aphasia (disorder that makes it difficult to communicate), and high blood pressure. A review of the resident's care plan dated 12/2/24 showed: - The resident has an ADL self care performance deficit related to limited mobility; - The resident is dependent on staff for transfers; -The resident is dependent on staff for personal hygiene and toileting. Observation on 12/12/24 at 08:37 A.M., showed: -The resident was in bed; -Certified Nurses Aide (CNA) A brought the mechanical lift into the resident's room; -CNA A pushed the lift to the resident's bed; -The legs of the lift were not spread and the breaks remained unlocked; -CNA A and CNA D hooked the resident up to the sling pad; -CNA A used the control and raised the resident off the bed; -CNA D left the resident and went into the bathroom while CNA A was at the head of the lift opposite the resident; -The resident was suspended in the lift with no staff stabilizing him/her; -The resident was swinging back and forth in the lift; -The staff failed to safely stabilize the resident while he/she was suspended in the lift. During an interview on 12/12/24 at 9:05 A.M., CNA A said: -There should be two nursing staff using the lift at all times; -One staff member operates the controls of the lift and the other stabilizes the resident as they are raised by the lift and while being transferred. -He/She should have stabilized the resident the entire time the resident was up in the lift. During an interview on 12/12/24 at 9:09 A.M., CNA D said: -It takes two staff to use the mechanical lift lift; -One staff runs the control and one staff stabilizes the resident; -He/she should not have left the resident unsupported in the lift. During an interview on 12/12/24 at, 10:43 A.M., Licensed Practical Nurse (LPN) A said when a resident is suspended in the mechanical lift, staff should be stabilizing the resident by guiding the resident in the sling along with the lift. 2. Review of Resident #27's Quarterly MDS, dated [DATE], showed: - Severe cognitive impairment; - Substantial assistance from staff for mobility and transfers - Diagnoses included: Alzheimer's disease, depression and anxiety. Review of the resident's care plan dated 11/22/24 showed: -The resident requires extensive assistance with ADLs; - The resident requires extensive assistance with transfers; -The resident has bladder incontinence related to Alzheimer's disease. Observation on 12/12/24 at 10:45 A.M., showed: -The resident was in his/her room in a wheelchair; -CNA F locked both brakes of the resident's wheel chair; -CNA F brought the sit-to-stand mechanical lift into the resident's room; -CNA F spread the legs of the lift around the resident's wheel chair and locked the brake of the left rear castor; -The right rear castor remained unlocked; -Registered Nurse (RN) A and CNA F hooked the resident up to the lift pad; -CNA F raised the resident up in the lift and unlocked the left rear castor; -CNA F and RN A transferred the resident to the bathroom; -RN A locked the right rear castor on the lift; -The left rear castor remained unlocked; -RN A lowered the resident to the toilet; -CNA F provided peri care; -CNA F and RN A hooked the resident back up to the lift; -RN A unlocked the right rear castor; -The resident was moved back to the living room to his/her wheel chair; -RN A spread the legs of the lift and lowered the resident to the wheel chair; -RN A left both brakes of the rear castors unlocked while lowering the resident to the wheel chair; -CNA F and RN A unhooked the resident from the lift pad. During an interview on 12/12/24 at 10:52 A.M., CNA F said: -The only time time the brakes are to be locked is when the lift is parked; -He/she did not realize he/she only left one of the rear brakes unlocked; -Staff should leave the brakes of the lift unlocked while raising or lowering the resident. During an interview on 12/12/24 at 10:59 A.M., RN A said: -The brakes should be locked on the lift when raising or lowering a resident; -He/she did not realized he/she had only locked one break on the lift. 3. Review of Resident #28's Quarterly MDS dated [DATE], showed: - Moderate cognitive impairment. - Required substantial assistance from staff with dressing and toileting; - Diagnoses included Parkinson 's Disease (a chronic brain disorder that causes movement problems, mental health issues, and other health concerns), high blood pressure, anxiety and depression. Review of the resident's care plan dated 9/20/24 showed: - The resident requires extensive ADL assistance; - The resident is at risk for falls related to Parkinson 's Disease. Observation on 12/13/24 at 8:45 A.M., showed: -The resident was in his/room setting in a wheelchair; -CNA C locked the wheelchair and placed the gait belt around the resident's waist; -CMT D and CNA A stood on each side of the wheelchair; -CNA C grabbed the front of the gait belt with his/her left hand and hooked his/her right arm under the residents left arm; -CMT D grabbed the front of the gait belt with his/her right hand and hooked his/her left arm under the residents right arm; -CNA A and CMT D lifted the resident and transferred him/her to the bed; -CNA A and CMT D failed to do a safe gait belt transfer when they hooked their arms under the resident's arms instead of grabbing the back of the residents gait belt. During an interview on 12/13/24 at 9:32 A.M., CMT D said he/she should have grabbed the back of the resident's gait belt instead of hooking the resident under his/her arm during the transfer. During an interview on 12/13/24 at 9:40 A.M., CNA C said he/she should have grabbed the back of the resident's gait belt instead of hooking the reisdent under his/her arm during the transfer. During an interview on 12/13/24 9:53 A.M., LPN A said: - The gate belt should be placed around the resident's waist; - Staff should grab the gait belt and not the resident when doing a gait belt transfer; - Staff should never grab or put their arm under the resident's shoulder to transfer. During an interview on 12/13/24 at 10:52 A.M. the Director of Nursing (DON) said: -He/she expects staff to have two hands on the gait belt; -No staff should be lifting underneath the arms of the resident; -He/she expects the manufactures guidelines to be followed when using a mechanical lift; -He/she expects the brakes to be unlocked while a resident is in the lift; -He/she would expect staff to ensure they are stabilizing the resident who is up in the lift. During an interview on 12/13/24 at 10:52 A.M. the Administrator concurred with the DON.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure staff provided proper respiratory care when staff failed to date when oxygen tubing and water humidification bottles were exchanged out, and oxygen filters where changed (Resident #244, #28 and #11). This affected three of the 12 sampled residents. The facility census was 40. Review of the facility's Cleaning and Infection Control of Non-Critical, Reusable Resident Care Equipment policy, undated, showed: - Non-Critical Equipment are those items that either touch only intact skin but not mucous membranes or do not directly touch the elder; - Reusable Equipment is a device designed and tested by the manufacturer, that is suitable for reprocessing prior to use on a elder; - All equipment must be cleaned immediately if visibly soiled; Review of the facility's Oxygen Administration policy, undated, showed: - Oxygen concentrators, cylinders and equipment will be kept and maintained in such a way as to be compliant with all relevant health and safety guidelines; - Every shift check and clean oxygen equipment, masks, tubing and canulas; Procedures: - Display warning signs; Care and use of oxygen concentrators: - This equipment is supplied and maintained by the Durable Medical Equipment provider of the facility; - No cleaning or documentation requirements were listed in the policy for this specific equipment; 1. Review of Resident #244's admission Minimum Data Set (MDS, a federally mandated assessment completed by the facility staff), dated 11/18/24, showed: - Cognitive skills moderately impaired; - Supervision for toileting, upper/lower body dressing, footwear, personal hygiene, and transfers; - Diagnosis: Chronic Lung Disease, Cancer, Anemia (blood disorder), Atrial fibrillation (heart condition), Coronary artery disease (heart disease), Deep venous thrombosis (deep vein blood clots), Hypertension (high blood pressure), Cirrhosis (liver disease), Ulcerative Colitis (inflammatory bowel disease): Review of the resident's care plan, revised 11/29/24, showed: - Resident has altered respiratory status/difficulty breathing, COPD (lung disease), emphysema, acute respiratory failure and asthma; - Oxygen per physician order 12/2/24 Review of the resident's POS, dated December 2024 showed the resident did not have an order for oxygen therapy. Observation on 12/11/24 at 7:45 A.M. showed: - There is no date to indicate the last time that the oxygen tubing was cleaned or changed; - The date next to the water canister on the oxygen concentrator reads 11/11/24 ( greater than 30 days ago); During an interview on 12/11/24 at 7:45 A.M., the resident said: - While in the room they have not seen anyone clean or change out any of the oxygen equipment; - Resident uses the oxygen concentrator continuously and gets light headed when not in use; During an interview on 12/12/24 at 3:15 P.M., LPN B said the staff change out tubing and the humidifier canister on oxygen concentrators weekly and indicate the date on the tubing; 3. Review of Resident #28's Quarterly MDS dated [DATE], showed: - Cognitive skills moderately impaired; - Diagnoses included Parkinson 's Disease (a chronic brain disorder that causes movement problems, mental health issues, and other health concerns), high blood pressure, anxiety and depression. Review of the resident's care plan dated 9/20/24 showed: - The resident requires extensive ADL assistance; - The resident is on oxygen therapy related to shortness of breath; - The resident is at risk for altered respiratory status and difficulty in breathing related to sleep apnea and pulmonary fibrosis (a chronic lung disease that causes scarring in the lungs, making it difficult to breathe); - Monitor for signs and symptoms of respiratory distress. Review of the resident's POS dated 12/1/24 through 12/31/24 showed: -Order start date: 10/31/24 Change oxygen tubing weekly and as needed every night shift on Sunday; -The resident's POS did not address the cleaning of the oxygen filters. Review of the resident MAR dated 12/1/24 through 12/31/24 showed to change oxygen tubing weekly as needed every night shift on Sunday. Observation on 12/10/24 at 11:30 A.M. showed: -The resident's oxygen concentrator covered with dust; -The resident's oxygen concentrator filter caked in dust. Observation and interview on 12/11/24 at 3:08 P.M., showed: -The resident's oxygen concentrator covered with dust; -The resident's oxygen concentrator filter caked in dust; - CMT F said he/she is not sure who changes the filters on the oxygen filters; - CMT F said the oxygen concentrators should be clean and the filters should be clean. During an interview on 12/11/24 at 3:10 P.M., CMT E said: -He/she is not sure who is responsible for cleaning the oxygen filters; -Oxygen filters and the concentrator should be free from dust. During an interview on 12/13/24 at 10:52 A.M. the Director of Nursing (DON) said: -The oxygen filters should be changed weekly; -There are no logs to document that the filters have been changed. 2. Review of Resident #11's Quarterly MDS, dated [DATE] showed: - Cognitive skills severely impaired; - Substantial to maximal assist with showers, dressing, personal hygiene and transfers; - Always incontinent of bowel and bladder; - Diagnoses included cancer, congestive heart failure (accumulation of fluid in the lungs and other areas of the body) and dementia (inability to think). Review of the resident's care plan, revised 12/10/24 showed: - The resident had oxygen therapy related to shortness of air. If the resident is allowed to eat, oxygen still must be given to the resident but in a different manner (change from mask to nasal cannula). Return resident to usual oxygen delivery method after the meal; - The resident is at risk for altered respiratory status, difficulty breathing related to respiratory failure, recent pneumonia and heart failure. Provide oxygen as ordered. Review of the resident's POS, dated December 2024 showed the resident did not have an order for oxygen therapy. Observation 12/10/24 at 10:44 A.M., showed: - The resident did not have the nasal cannula in his/her nose; - The filters on both sides of the oxygen concentrator was covered in gray lint. Observation on 12/11/24 at 3:35 P.M., showed the filters on both sides of the oxygen concentrator were covered in gray lint. During an interview on 12/11/24 at 2:51 P.M., Registered Nurse (RN) A said he/she only worked one day a week and was not for sure how often staff were supposed to clean the oxygen filters or when it was supposed to be done. During an interview on 12/12/24 at 2:57 P.M., LPN A said: - He/she did not know there were filters on the oxygen concentrator; - He/she did not know how often the filters should be cleaned.

2. Review of Resident #16's POS, dated December 2024 showed a start date of 11/10/23 - Systane Ultra Ophthalmic Solution 0.4-0.3 %, give one drop in each eye every morning and at bed time for dry eye. Review of the resident's MAR, dated December 2024, showed Systane Ultra Ophthalmic Solution 0.4-0.3 %, give one drop in each eye every morning and at bed time for dry eye. Observation and interview on 12/12/24 at 6:59 A.M., showed: -CMT C administered one eye drop to the resident's left eye and wiped the resident's face with a tissue; -The tip of the applicator touched the resident's upper eye lashes; -CMT C administered one eye drop to the resident's right eye; -The tip of the applicator touched the resident's upper eye lashes; -CMT C did not apply pressure to the inner corner of the resident's left eye after administering the medication; -CMT C did not apply pressure to the inner corner of the resident's right eye after administering the medication; -CMT C said he/she should have applied pressure for two minutes to the inner corner of the resident's right eye and the resident's left eye after administering the medication; -CMT C said the dropper should not have touched any part of the resident's eye. During an interview on 12/13/24 10:43 AM LPN A said: -Staff should apply pressure for two minutes to the inner corner of the resident's eye after administering eye drops. -The dropper should not touch any part of the eye. Based on observation, interview and record review, the facility failed to ensure staff administered medications with a medication rate of less than five percent when facility staff made two medication errors out of 25 opportunities for error resulting in a medication error rate of eight percent which affected two of the 12 sampled residents (Resident #19 and #16). The facility census was 40. Review of the facility's undated policy for medication administration showed, all medications will be administered to every resident by a licensed nurse or a Certified Medication Technician (CMT) and as ordered by a physician in a safe and sanitary manner. The facility did not provide a policy for administration of eye drops. Review of the website, https://webmd.com, for refresh eye drops showed: - To avoid contamination, do not touch the dropper tip to the eye or or any other surface; - Tilt your head back, look up, and pull down the lower eyelid to make a pouch; - Place the dropper directly over the eye and squeeze out one or two drops as needed; - Look down and gently close your eye for one or two minutes. Place one finger at the corner of the eye near the nose and apply gentle pressure. This will prevent the medication from draining away from the eye. Review of manufacturer guidelines for Systane Ultra Ophthalmic Solution 0.4-0.3 % (used to treat dry eye), dated 2023 showed: -Tilt head back and look up; -Pull down lower eyelid and create pocket; -Administer drop into pocket of eyelid; -Apply gentle pressure to the inner corner of the eye for two minutes. 1. Review of Resident #19's Physician's Order Sheet (POS) dated December 2024 showed a start date of 8/11/24 for Refresh Ophthalmic solution 1.4-0.6%, instill one drop in both eyes every morning and at bed time for dry eyes. Review of the resident's medication administration record (MAR) dated December 2024 showed Refresh Ophthalmic solution 1.4-0.6%, instill one drop in both eyes every morning and at bed time for dry eyes. Observation on 12/12/24 at 7:50 A.M., showed: - CMT A washed his/her hands, applied gloves and cleaned the resident's eye lids, removed gloves and washed his/her hands and applied new gloves; - CMT A placed one drop in the resident's left and the tip of the eye dropper touched the resident's eye lid and eye lashes. CMT A applied lacrimal pressure (gentle pressure applied to the inner eye by the nose) for 20 seconds; - CMT A placed one drop in the resident's right eye and the tip of the eye dropper touched the resident's eye lid and eye lashes. CMT A applied lacrimal pressure for 25 seconds. During an interview on 12/12/24 at 9:00 A.M., CMT A said: - The tip of the eye dropper should not touch the resident's eye lid or eye lash; - Lacrimal pressure should be applied for one to two minutes. During an interview on 12/13/24 at 10:52 A.M., the Director of Nursing (DON) said: - The tip of the eye dropper should not touch the resident's eye lashes or eye lids; - Staff should apply lacrimal pressure for one minute.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #193's return MDS., dated 12/5/24, showed he/she entered from a short term general hospital stay. Review of admission record, dated 12/11/24, showed: -He/She admitted to facility 12/5/24; -Diagnoses included fracture of right femur (bone fracture in right leg), delirium due to known physiological condition (a sudden change in mental state that causes confusion, disorientation, and inability to think clearly), urinary tract infection, and chronic kidney disease. Review of physician's orders, dated 12/11/24, showed: -Start date 12/5/24, monitor right hip surgical site for signs and symptoms of infection (redness/pain), directions every morning and at bedtime.; -Start date 12/6/24, Monitor skin tear to left outer hand. Clean with wound cleanser, apply xeroform, and dry dressing until healed. Directions: in the morning. Review of electronic medical record showed: -No assessment for self administration of medications. -12/6/24, admission packet progress note showed patient presented to hospital on 11/11 following a fall with acute onset right hip pain. Resident had a right interchanteric femur fracture. He/She underwent surgery 11/15. Observation on 12/10/24 at 10:10 A.M. of resident room showed an 8 oz (236 milliliter (ml)) bottle of wound cleanser non-ionic disinfectant and 4oz skin-preparation protective spray was sitting in resident's bedroom window. During an interview on 12/13/24 at 7:36 A.M., Certified Medication Technician (CMT) said wound cleansers and medications should be stored in medication room or medication cart. During an interview on 12/13/24 at 7:46 A.M., Licensed Practical Nurse (LPN) B said: -Resident's wound cleansers should be stored in the medication cart; -Resident medications could be left at bedside if they had orders for medications to be left at bedside; -Resident wound cleansers could be stored in resident room in a baggy and should be dated; -Resident #193 could have wound cleansers in his/her room if it was bagged and dated; -If residents wound cleansers were not going to be left in room they should be stored in the medication cart. During an interview on 12/13/24 at 7:59 AM, Assistant Director of Nursing (ADON) B said: -Wound cleansers should not be stored at bedside but the facility did allow storage in resident's bathroom storage closet; -Resident's wound cleansers should not be stored on resident's windowsill; -Wound cleansers should be stored in a baggy in the closet bathroom. During an interview on 12/13/24 at 8:18 A.M., Director of Nursing (DON) said: -He/She expected wound cleansers not be stored in windowsills; -He/She expected residents wound cleansers to be stored in the pantries in the resident bathrooms out of sight or in the medication carts. During an interview on 12/13/24 at 10:52 A.M., Administrator said she did not expect wound cleansers to be left in window sill of a residents room. Based on observation, interview and record review, the facility failed to store and label drugs and biological's in accordance with current accepted professional principles for three (Resident #12, #28, and #193 ) out of the 12 sampled residents when the facility failed to store medications in a locked storage area for Resident #28 and Resident #193. Additionally, the facilty failed to supervise Resident #12 while taking medications. The facility census was 40. Review of facility policy, right to self-administer medications, undated, showed: -A resident may self-administer medications only if approved in writing by the resident's physician and a licensed nurse has determined that the resident can perform the task safely and accurately. -A licensed nurse will assess the resident to determine the resident's ability to self-administer their medications. The findings of the assessment will be documented in the resident's medical record. -The medications that the resident self-administers, will be stored in the resident's room in a locked drawer. The resident, nurse, and certified medication technician (CMT) will have a key to the drawer. Review of the facilty's undated Medication Administration policy showed: -All medications will be administered to every resident by a licensed nurse or CMT as ordered by a physician; -All medications will be administered in a safe and sanitary manner. 1. Review of Resident #12's medical record showed: -admission date 7/30/21; -No assessment for self administration of medications was found. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/17/24, showed: - Cognitive skills moderately impaired; - Substantial assistance with dressing and toileting; - Diagnoses included Parkinson 's Disease (a chronic brain disorder that causes movement problems, mental health issues, and other health concerns), high blood pressure, anxiety and depression. Observation and interview on 12/11/24, at 08:39 A.M., showed: -The resident laying in bed; - No staff present in the resident's room; - A medication cup containing two pills sat on the bedside table; -The resident picked the pills out of the medication cup with his/her fingers and put the pills in his/her mouth; -The resident kept the pills in his/her mouth for approximately two minutes before taking a drink of water; -The resident said he/she did not need supervision to take his/her medication. During an interview on 12/12/24, at 09:10 A.M., CMT C said: - The resident should not have pills setting in his/her room; - Staff should watch residents take all of their medications before leaving the room. During an interview on 12/12/24 10:43 AM Licensed Practical Nurse (LPN) A said: -The resident needs to be supervised while taking medications; -Medications should not be left in the resident's room. 2. Review of Resident #28's medical record showed: -admission date 9/20/24; -No assessment for self administration of medications was found. Review of the resident's admission MDS, dated [DATE], showed: - No cognitive impairment; - Extensive assistance of one with dressing, toileting and bathing; - Diagnoses included Parkinson 's Disease, diabetes (a chronic disease that occurs when the body doesn't produce enough insulin or can't use insulin properly), and arthritis. Observation on 12/10/24 at 08:18 A.M., showed: -The door to the resident's room was open; -The resident laying in bed and a bottle of decongestant nose spray setting on the window. Observation on 12/11/24 at 08:44 A.M., showed: -The door to the resident's room was open; -The resident laying in bed and a bottle of decongestant nose spray setting on the window. Observation on 12/12/24 at 08:10 A.M., showed: -The door to the resident's room was open; - CMT D and CNA C walked in the resident's room and asked the resident how he/she was doing; - The resident laying in bed and a bottle of decongestant nose spray setting on the window. During an interview on 12/12/24 at 09:32 A.M., CMT D said: -The family brings medication in that we do not know about; - The resident does not use this medication; - The nose spray should be kept in the medication cart. During an interview on 12/12/24 10:43 AM LPN A said medications should not be left unsecured in the resident's room. During an interview on 12/13/24 at 10:52 A.M. the Director of Nursing (DON) said: -Medications should not be left unsecured in the resident's room; -Staff should watch residents take their medications. During an interview on 12/13/24 at 10:52 A.M. the Administrator concurred with the DON.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents had a means of directly contacting caregivers when staff failed to identify and correct bathroom call light pull cords that had been wrapped around the handrail on the wall, leaving them inoperable and inaccessible to residents. The facility census was 40. The facility's Call Light, Bed Alarm System policy showed: -Call lights are to be present in all resident rooms and bathrooms. -The policy fails to address the issue of call lights being operable and accessible to a resident lying on the floor in need of help. The facility's Accident Prevention policy showed all staff members will ensure that each resident's environment remains as free from accident hazards as possible. The facility's Incident and/or Accident Protocol showed staff are to assess the environment for safety modifications, clear pathways and ensure the call light was within the resident's reach. The facility's Preventive Maintenance and Inspection policy showed: -Alarms which include personal protective devices such as bed alarms and/or chair alarms, will be calendared for a routine weekly inspection to verify their working order. -Nurses are responsible for any component of alarm verification, such as alert bracelets, the scheduling and documentation correspond to the same standards set for all preventive maintenance of weekly monitoring. Observations on 12/11/24 at 2:19 P.M., 12/12/24 at 9:24 A.M. and 12/13/24 at 9:09 A.M. showed: - In Resident #294, and Resident #21's room and room [ROOM NUMBER], bathroom call light pull cords were wrapped around the handrail on the wall leaving the call light inoperable and inaccessible. - In three common area bathrooms, call light pulls were observed wrapped around the handrail on the wall leaving the call light inoperable and inaccessible. During an interview on 12/13/24 at 10:52 A.M., the Director of Nursing (DON) said: -Call lights should always be within reach and residents should be able to use the call light easily. -Approximately every 30 days, the online call light system checks every room at least once to be sure the light can alert at the desk. -Common area bathrooms are left unlocked and do not require staff assistance to access. -Residents are allowed to use the common area bathrooms and the call light should be within reach. During an interview on 12/13/24 at 10:52 A.M., the Administrator said it is her expectation for call lights to be accessible to residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to store, prepare and serve food in accordance with professional standards of food service safety when staff failed to date the receipt of incoming products in the dry storeroom, label and date used products in the freezer and refrigerator, label and date leftovers in the refrigerator, discard expired leftovers, and monitor refrigerator, freezer and dishwasher temperatures on a daily basis. This had the potential to impact all residents by placing them at risk for food born illnesses. The facility census was 40. Review of the facility's policy Dietary Procedures, undated, showed the evening staff members will check the dates on containers of leftovers and dispose of food found to have been refrigerated for more than four days; A policy on temperature checks in the kitchen was requested and not provided; Observation at 9:00 A.M on 12/10/24 showed: Dry Kitchen Storage Room located on the 1st floor: - Box of pancake mix opened and no opening date written on package; - Seven loose juice cocktail containers sitting out of case package with no date written; - Thickened Orange Juice opened box with no date written; Refrigerator 1st Floor: - Two plastic bags of tortillas opened and not dated; - Raw strawberries in plastic container not dated; - Leftover chicken soup in facility plastic container not dated; - Multiple containers of pudding and yogurt not dated; - Pulpy unknown food in bag dated 10/13 (57 days old); - Raw pickles, Jalapenos, green peppers, onions and squash bagged and undated; - Romaine lettuce dated 12/4 (6 days old) not discarded; - Sharp cheese open bad not sealed, not dated; - Opened hot dogs bagged, no date or label; - Seven unknown condiments stored in facility plastic bottles no dates, not labeled; - Open Jello container not dated; Observation at 9:35 A.M. on 12/10/24 showed: Main Kitchen Dry Storeroom Ground Floor - No received dates on multiple unopened packages of cake mixes and double chocolate cake; - Eight bags of chocolate chip cookie mix undated; - Four rack levels of unopened bread with no received date; - Extra heavy mayonnaise plastic container not dated; - Opened caramel topping Smuckers brand not dated; Freezer - Chicken patties opened and not sealed with no date; - Frozen peas opened box with no date; - Fillets not labeled and not dated; - Dry noodles unsealed and not dated; - [NAME] Spunkmeyer cookie dough opened and uncovered; - Review of dishwashing log shows no temperatures taken on the dishwasher from 12/8 to 12/11 (morning); Observation at 10:02 on 12/11/24 showed: Main Prep Area Kitchen Ground Floor - Refrigerator and Freezer temperature log missing temperature checks from 12/9 to 12/11 - Refrigerator/Freezer checks for 12/12 already entered into the log one day early; Refrigerator Ground Floor - Swiss cheese repackaged undated in a soiled bag; - Sauce unlabeled in facility container with no date; - Lettuce rewrapped with unreadable date on package; - Large unlabeled container of lettuce no date; Interview conducted on 12/10/24 at 9:20 A.M., [NAME] A said: -He has one and a half years' experience working at the facility. - The purpose of the refrigerator on the 1st floor kitchen area is to hold ingredients for cooking. - Policy directs staff to date opened products in bags and containers and store in the refrigerator for later use. - The date on the package is the first use date when opened. - He believes the policy is that after three days any item not used should be discarded. Interview conducted on 12/10/24 at 9:25 A.M., [NAME] B said the reason for all of the undated items in the refrigerator is that with the dishwasher down they have not had time to review the contents of the refrigerator on a daily basis. In an interview on 12/11/24 at 2:33 P.M., DM A said: - The leftover policy is 3-5 days which is mostly for vegetables. - All items need to be labeled and dated with first use date. - Incoming shipments need to have items annotated with receipt date, opened cases need date of when they were opened and expiration is in accordance with the item label. - The staff are to follow milk expiration dates on the package. - Condiments in jugs need to be discarded after 30 days and condiments in facility serving bottles need to be discarded after seven days. - Open items should be labeled and dated. - Temperature logs and dishwasher logs need to be done daily. In an interview on 12/12/24 at 1:30 P.M., RD (Registered Dietician)said the expectation is that leftovers are labeled and dated. Beef could be kept for three to four days and everything else is expected to be discarded sooner than that. Bags with no labels and no dates would be annotated on his/her inspection report for the facility staff to take action. In an interview on 12/13/24 at 10:20 A.M., Administrator said she would expect temperature logs to be maintained daily in the kitchen and leftovers to be sealed, labeled and dated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to provide a safe and comfortable home like environment when the facility's heating system was not able to maintain comfortable temperatures for the residents. The facility census was 82. Review of the facility's undated Environmental Control Failure policy., showed: -In the event of a system failure resulting in either warmer or cooler than desired temperatures the following process will be adhered to: -Notification of Administrator, Nursing On-Call, IT On-Call and Maintenance On-Call will be completed. -Department managers will attempt corrective action. -In the event temperatures cannot be raised with existing equipment, a contract with Sunbelt Heating and Cooling will be activated. -Sunbelt provides and maintains portable heat pumps. These devices are designed to produce a safe and controlled source of either cooling or heating. These devices contain no exposed heating elements as well as electrical safety systems with an electrical requirement of a standard 115v. -While these devices are in active use, temperature checks will be done randomly to ensure temperatures are within regulatory temperature ranges. -Once the standard environmental system (HVAC equivalent) is able to maintain environmental temperatures, the devices will be returned to Sunbelt. -Should the additional portable heat pump devices be inadequate to maintain environmental temperatures within regulatory range, the Administrator will activate the emergency action plan for evacuations. Review of the facility's documentation and temperature audits for the building showed the following: - 1/13/23 Resident room [ROOM NUMBER] at 58 degrees, room [ROOM NUMBER] at 58 degrees, room [ROOM NUMBER] at 60 degrees. - 1/14/23 Resident room [ROOM NUMBER] at 58 degrees, room [ROOM NUMBER] at 58 degrees, room [ROOM NUMBER] at 60 degrees. - 1/15/23 Resident room [ROOM NUMBER] at 58 degrees, room [ROOM NUMBER] at 60 degrees, room [ROOM NUMBER] at 61 degrees. - 1/16/23 Resident room [ROOM NUMBER] at 67 degrees, room [ROOM NUMBER] at 62 degrees, room [ROOM NUMBER] at 62 degrees. Observation of the facility on 1/17/23 at 9:45 A.M., showed: - Each resident hallway contained 2 portable heat pumps that were vented into the ceiling or exterior wall and located at the end of each resident room hallway. - There were a total of 8 portable heat pumps in the building. - The portable heat pumps were leased from outside company to provide additional heat to the resident hallways. - Units are boxed and on wheels, not hot to touch, and blowing warm air out and into the resident hallways. - Extra blankets were identified in resident's rooms. - Resident areas were ranged between 72-76 degrees. During an interviews on 1/17/23 at 10:00 A.M. and 1/19/23 at 2:30 P.M., , the Administrator said: - On 1/13/24 she was notified that the heating system was not keeping up with extreme cold temps. - Extra blankets were provided to all residents. - Saturday the 13th 2 portable heaters were brought in. - Sunday the 14th 5 more portable heaters were brought in. - Monday the 15th another portable heater was brought in for a total of 8 portable heaters in the building. - One resident needed to be temporarily relocated and is now back in their original room. - Residents were monitored closely though out the holiday weekend closely to ensure they were warm and comfortable. - Audits and logs were maintained throughout the weekend to track the resident room temperatures. - She followed the facility policy regarding environmental control failure, which states to obtain portable heat pumps. - She was not aware portable heathers were prohibited in long-term care facilities and she did not considering contacting the Engineering & Consultation Unit to discuss the installation or use of portable heat pumps. - As of today resident room temps are between 72-75 degrees. MO00230367

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure they established and maintained a system that ensured a full, complete and separate accounting according to accepted accounting principles and failed to establish a system that precludes any commingling of resident funds with facility funds. This affected 23 residents (Residents #292, #294, #7, #296, #297, #298, #299, #300, #256, #302, #303. #304, #305, #21, #306, #23, # 308, #309, #41, #310, #13, #319, and #313). The facility's census was 44. Review of the facility's undated Resident Funds Policy showed the facility will, upon written authorization of the resident or their legal representative, manage, safeguard and account for personal funds or money in trust for the resident. The record keeping and other requirements of this section apply only to those personal possessions and funds which the facility accepts to hold in trust for the resident as provided in the facility's policy. The policy directed the following: - An individual record of all transactions involving a resident's personal funds managed by the facility will be maintained in accordance with generally accepted accounting principles in the resident's financial record in the business office; - The resident's fund record will contain the following: *Resident's name as reflected on the social security card *Medical record number *Name of legal representative *admission date or date account opened *Date and amount of each deposit and withdrawal *The balance after each transaction *Receipts for any charges paid to the facility *Receipts for items purchased on behalf of the resident by the facility *Interest accrued on the resident's funds - The business office manager (BOM) will inform the resident and their legal representative when the fund account is coming with in $200.00 to the resource limit set for Medicaid or Medicare; - The resident or their legal representative may review the resident's financial records by making an oral or written request to the business office during office hours; - The BOM will review the resident financial file after the death of a resident, and if managed by the facility, a final accounting of the balance in the resident's account will be prepared; - Within 30 days of the death of a resident, any monies owed the resident will be conveyed to the individual or probate jurisdiction administering the resident's estate. - The policy did not address commingling of resident funds with facility funds; - The policy did not address a final accounting for residents who did not pass away in the facility and the return of money to them upon discharge. Review of the facility's past 12 months of bank statements for the resident trust fund account showed: - Account opened on 12/18/19 with a balance of $500.00; - A current balance of $500.02; with no transactions in the previous 12 months. Review of the facility's Accounts Receivable (A/R) Aging by Service Date report, with a run date of 3/22/23, showed: - Resident #292 discharged on 7/28/21 and had a credit under PPL-S (Private Pay with Levels) of $1,268 in the operating account; - Resident #294 discharged on 12/6/21 and had a credit under [NAME] (Medicare Part A coinsurance from Insurance) of $185; - Resident #7 remained in the facility and had a credit under PP-S (Private Pay) of $10,006.00; the resident also had MCA (Medicare Part A) payment in the amount of $34,603.82; - Resident #296 discharged on 11/8/21 and had a credit under OP (Out Patient Medicare B) of $17.79; - Resident #297 discharged on 5/20/22 and had a credit under PP-S of $3,641.00; - Resident #298 discharged on 1/16/23 and had a credit under PP-S of $289.00; - Resident #299 discharged on 5/6/22 with a credit under PP-S of $639.83; - Resident #300 discharged on 12/13/21 with a credit under OMC (outpatient managed care therapies) of $170.29; - Resident #256 with no discharge date and no other documentation of any other funds paid to the facility by any payer source and had a credit of $46.50; - Resident #302 discharged on 6/7/22 with a credit under OPI (outpatient Medicare Part B coinsurance from insurance) of $184.76; - Resident #303 discharged on 11/10/22 with a credit under [NAME] of $1,023.00 and MCA of $250.37; - Resident #304 discharged on 8/3/20 with a credit under PPL-S of $1258.09; - Resident #305 discharged on 10/31/20 with a credit under PPL-S of $294.31; - Resident #21 remained in the facility and had a credit under PP-S of $11,913.00; the resident also had a MCA payment of $31,792.42; - Resident #306 had a discharge date of 1/20/22 with a credit under PPL-S of $3,345.00; In an interview on 03/23/23 at 2:52 PM the Business Office Manager (BOM) said: -She has been in the position for about a year. - She has been been focusing on the private pays residents and did not know a lot about insurance, Medicare or Medicaid. -She tried to get the money back for Resident #292 but the resident passed away 7/28/21 and nothing has been done since because she has not been able to locate ant family members to return the money to. - Resident #294 was discharged to home and she has a reimbursement of $185.00. She walked into a mess with Med A Co-Insurance and will need to look into this situation and determine how to go about giving the resident his/her refund. - She usually emails an accounts payable processing form to the corporate office. - When she began employment, there were 7 residents that she was aware of that needed a refund. In an interview on 3/23/23 at 05:05 PM the Administrator said she has nothing to do with the operating account and refunds. She trusts the BOM to take care of all of refunds.

Based on observation and interview the facility failed to maintain a safe, clean and comfortable homelike environment. This had the potential the affect all residents in the affected areas. The facility had a census of 44. The requested cleaning policy was not provided. A review of the undated Public Bathroom Cleaning Instructions showed: - Clean the sink and the vanity; - Clean all handles and rails; - Empty trash cans; - Replace toilet paper if low; - Sweep and mop the floor. A review of the undated Cleaning Check list showed: -Ground floor restrooms: o Wipe down walls; o Refill paper products; o Sweep and mop the floor. 1. Observation of the bathroom on the 2nd floor by the social services office on 3/22/23, at 1:52 P.M., showed: -The vent on the ceiling caked with dirt and debris; -Three lights above the mirror covered in dust and debris; -The top of the baseboard around the entire bathroom floor covered with dirt and debris; -The hand rails on the left and back side of the toilet covered in dust; -The wall on the left side of the sink covered with a white substances running down the wall to the floor; -The picture behind the toilet covered in dirt and debris; -The sink coming loose from the wall and leaning out and wobbly; -The floor covered with dirt and debris; -The trash can overflowing with trash. 2. Observation of the bathroom in the basement by the resident salon on 03/22/23, at 4:16 P.M., showed: -The vent on the ceiling caked with dirt and debris; -Three lights above the mirror covered in dust and debris; -The top of the baseboard around the entire bathroom floor covered with dirt and debris; -The hand rails on the left and back side of the toilet covered in dust; -The wall on the left side of the sink with a white substances running down the wall to the floor; -The floor covered with dirt and debris; -The trash can overflowing with trash. 3. Observation of the bathroom in the basement by the salon on 3/23/23, at 8:11 A.M., showed: -The vent on the ceiling continued to be caked with dirt and debris; -Three lights above the mirror continued to be covered in dust and debris; -The top of the baseboard around the entire bathroom floor continued to be covered with dirt and debris; -The hand rails on the left and back side of the toilet continued to be covered in dust; -The wall on the left side of the sink continued to have a white substances running down the wall to the floor; -The floor continued to be covered with dirt and debris; -The trash can continued to be overflowing with trash. 4. Observation of the bathroom the 2nd floor by the social services office on 3/23/23 at 10:31 A.M., showed: -The vent on the ceiling continued to be caked with dirt and debris; -Three lights above the mirror continued to be covered in dust and debris; -The top of the baseboard around the entire bathroom floor continued to be covered with dirt and debris; -The hand rails on the left and back side of the toilet continued to be covered in dust; -The wall on the left side of the sink continued to have a white substances running down the wall to the floor; -The picture behind the toilet continued to be covered in dirt and debris; -The sink continued to be coming loose from the wall; -The floor continued to be covered with dirt and debris; -The trash can continued to be overflowing with trash; -The bathroom had no toilet paper. During an interview on 3/23/23, at 10:35 A.M. , the housekeeping supervisor said: -Both restrooms are used by staff and family; -The housekeeper on shift is responsible for cleaning once in the morning and once in the evening; -There is cleaning list that is checked off as duties are completed; -He/she said she knew the sink in the bathroom by the social service office was loose from the wall and had been for a while; -He/she thought someone had put a work order into maintenance for it; -Maintenance is responsible for checking the worker orders to be completed; -The residents using the salon use the down stairs bathroom; -Maintenance is responsible for clearing the vents; -He/she did not know if a work order had been but into to maintenance about the dirty vents in the both bathrooms; -He/she is responsible for making sure the housekeeping staff are following the checks lists daily and cleaning the bathrooms. During an interview on 3/23/23 10:42 A.M., the Music Therapy Director said: -Sometimes the residents with dementia will use the public bathrooms; -Staff and family of the residents use the bathroom the 2nd floor by the social services office. During an interview on 03/23/23, 12:17 P.M., maintenance staff A said: -He/she is in charge of checking the work orders; -He/she checks the work orders daily; -He/she said if the vent does not have a filter housekeeping is responsible for cleaning it. During an interview of 3/23/23 at 3:04 P.M. the daughter of Resident #18 said: -He/she uses the bathroom on the second floor by the social services office; -The bathroom floor is sticky and dirty; -The bathroom was out of soap for a long time; - The sink is very wobbly and it has been like for over a year; -The downstairs bathroom by the salon is filthy; -The sink in the downstairs bathroom went weeks without being cleaned. During an interview on 3/23/23, 10:33 A.M., the housekeeping supervisor said: -Both restrooms are used by staff and families of the residents; -The housekeeper on shift is responsible for cleaning the bathrooms once in the morning and once in the evening; -There is a cleaning list that is checked off as duties are completed; -He/she said she knew the sink in the bathroom on the second floor by the social service office was loose from the wall and had been for a while; -He/she thought someone put a work order into maintenance for it; -Maintenance is responsible for checking the worker orders to be completed; -Residents using the salon use the down stairs bathroom; -Maintenance is responsible for clearing the vents; -He/she did not know if a work order had been but turned into maintenance about the dirty vents in the both bathrooms; -He/she is responsible for making sure the housekeeping staff are following the checks lists daily and cleaning the bathrooms. During an interview on 3/23/23, at 5:09 P.M., the administrator said: -He/she expects non resident bathrooms to be cleaned daily and as needed; -Housekeeping dusts the outside of the vents but if the vent needs to be taken apart the maintenance department is responsible for doing this; -Housekeeping is responsible for making sure any work order for repairs to the bathrooms are turned into the maintenance department; -Maintenance is responsible for make sure work orders are taken care of and repairs are made; -He/she does not have access to work orders; -On the weekends the facility has a part time housekeeper that cleans the bathrooms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene when staff did not provide complete perineal care which affected four out of 12 sampled residents, (Resident #4, #7, #13, and #18) and when the facility failed to keep Resident #1, #7, #9, and #14 shaved. The facility census was 44. Review of the facility's undated policy for perineal care, showed: - Perineal care is very important in maintaining the residents' comfort and should be done after an incontinent episode; - Perform hand hygiene; -Explain procedure to the resident; -provide privacy; For female residents: - Separate the labia and wash with wipe, moving from front to back on each side of the labia and in the center over the urethra and vaginal opening, using a clean wipe for each stroke For male residents: -Cleanse the penis from the urethral opening to the tip of the penis; -Cleanse the scrotum paying attention to skin folds; -Turn resident to their side; -Cleanse the buttocks and peri-anal area without contaminating the perineal area. Review of the facility's undated Right to Dignity policy showed: -The facility will promote care for residents of the facility in a manner and an environment that maintains and enhances each resident's dignity and respect in full promotion of their individuality; -Residents will be groomed as they wish including facial hair to be shaved trimmed as the resident wishes. Review of the facility's undated Shaving a Resident policy showed: The facility promotes a positive self-image and well being for every resident. 1. Review Resident #1's care plan, dated 2/14/23, showed: - Extensive assistance of one for grooming; - Extensive assistance of one for toileting; - Extensive assistance of one for ambulation; - Staff to acknowledge things that are important to the resident; - The care plan did not address a shaving preference. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/16/23, showed: - Cognitive skills severely impaired; - Extensive assistance of one with dressing and activities of daily living; - Frequently incontinent of bowel and bladder; - Diagnoses included dementia, Alzheimer 's disease and kidney failure. Observation on 3/20/23, at 12:25 P.M., showed: - The resident setting in the TV area in a Broda chair (wheelchair that provide supportive positioning through a combination of tilt, recline, adjustable leg rest angle, wings with shoulder bolsters and height adjustable arms); - The resident had facial hair; - The resident's daughter shaving him/her with an electric razor in the TV area; - Resident #14 was setting in the TV area while Resident #1 was being shaved. During an interview on 3/20/23 at 2:41 P.M., the resident's daughter said: -The facility does not shave him/her as often as he/she would like to be shaved; - He/she said she usually has to come to the facility and shave him/her two times a week; - It is important to his/her that his/her father to be shaved daily. Observation on 3/22/23, at 8:43 A.M., showed: - The resident setting in the TV area in a Broda chair; - The resident had facial hair. Observation on 3/23/23 at 9:10 A.M., showed: - The resident setting in the TV area in a Broda chair; - The resident had facial hair. 2. Review of Resident #7's care plan, dated 10/12/22, showed: - Extensive assistance of one for grooming; - Extensive assistance of two for toileting; - Extensive dependent of two with mechanical lift for transfers; - The care plan did not address a shaving preference. Review of the resident's quarterly MDS, dated [DATE], showed: - No cognitive impairment; - Extensive assistance of one with dressing and activities of daily living; - Frequently incontinent of bowel and bladder; - Diagnoses included Cancer, respiratory failure and heart failure. Observation on 03/21/23 at 8:23 AM, showed: - The resident setting in a wheel chair in his/her room; - The resident had facial hair. Observation on 3/20/23, at 8:57 A.M., showed: - Certified Nurses Aide (CNA) E and CNA G entered the resident's room and explained cares; - CNA E and CNA G washed their hands and applied gloves; - CNA E and CNA G removed the resident's pants and put the bedpan under the resident; - CNA E wiped the rectum and buttocks using a clean wipe each time; - CNA E and CNA G turned the resident over; - CNA E wiped down one groin, used a new wipe and wiped down the other groin, used a new wipe and wiped down the middle; - CNA E and CNA G put a clean incontinent brief on the resident; - CNA E did not separate and clean all the perineal folds. Observation on 03/22/23 at 10:12 AM, showed: - The resident setting in a wheel chair in his/her room; - The resident had facial hair. During an interview on 3/23/23 at 2:41 P.M., the resident said: - He/she does not like to have facial hair; - He/she always trimmed his/her facial hair when he/she lived at home; - The staff are busy so it is hard for them to get to shaving him/her; - He/said she would feel better if he/she was shaved before the hair growth got too bad. 3. Review of Resident #9's care plan, dated 2/14/23, showed: - Extensive assistance of one for grooming; - Extensive assistance of one for toileting; - Extensive assistance of one for ambulation; - Staff to acknowledge things that are important to the resident; - The care plan did not address a shaving preference. Review of the resident's quarterly MDS, dated [DATE], showed: - No cognitive impairment; - Extensive assistance of one with dressing and activities of daily living; - Occasionally incontinent of bowel and bladder; - Diagnoses included Cancer, high blood pressure and depression. Observation on 03/21/23 at 8:50 A.M. showed: - The resident setting in a recliner in his/her room; - The resident had facial hair. Observation on 03/22/23 at 9:15 A.M., showed: - The resident setting in bed in his/her room; - The resident had facial hair. During an interview on 3/23/23 at 3:05 P.M., the resident said: -He/she does not want to have facial hair; -It embarrasses him/her to have facial hair; -He/she has to wait until his/her family to come to the facility to get shaved; -When he/she asks staff to do it they say they don't have time and they will do it later; - It does not get done later; -It would be nice if the the facility had time but they are very busy. 4. Review of Resident #13's care plan, dated 1/18/23, showed: - Extensive assistance of one for grooming; - Extensive assistance of two for toileting; - Resident will remain free from skin breakdown; - Extensive dependent of two with mechanical lift for transfers. Review of the resident's admission MDS, dated [DATE], showed: - No cognitive impairment; - Extensive assistance of one with dressing and activities of daily living; - Incontinent of bowel and bladder; - Diagnoses included osteoporosis, high blood pressure and anemia. Observation on 3/20/23 at 3:46 P.M., showed: - CNA F and CNA G entered the resident's room and explained cares; - CNA F and CNA G washed their hands and applied gloves; - CNA F and CNA G removed the resident's pants and unfastened the wet incontinent brief; - CNA F wiped down one groin, used a new wipe and wiped down the other groin, used a new wipe and wiped down the middle; - CNA F and CNA G put a clean incontinent brief on the resident; - CNA F did not separate and clean all the perineal folds. 5. Review of Resident #14's quarterly MDS, a federally mandated assessment instrument completed by staff, dated 12/30/22, showed: - Cognitive skills severely impaired; - Extensive assistance of one with dressing and activities of daily living; - Frequently incontinent of bowel and bladder; - Diagnoses included Parkinson's Disease, stroke and high blood pressure. Review of the resident's care plan, dated 1/2/23, showed: - Extensive assistance of one for grooming; - Extensive assistance of one for toileting; - Extensive assistance of one for ambulation; - The care plan did not address a shaving preference. Observation on 03/20/23 at 1:10 P.M., showed: - The resident setting in his/her wheel chair in the TV area; - The resident had facial hair. Observation on 03/21/23 at 12:14 P.M., showed: - The resident setting in bed in the dining room; - The resident had facial hair. During an interview on 03/21/23 at 1:05 P.M., the resident's daughter said: -His/her mother would not want facial hair; -His/her mother has always prided himself/herself with taking good care of her face and skin; -He/she expects the staff to shave his/her mother when he/she needs it or before; -He/she has talked to the staff about the shaving and they still continue to let the him/her go unshaven. During an interview on 03/23/23 at 11:36 A.M., CNA E said: - The CNA's are responsibly for shaving the residents; - Staff usually try to shave resident's during their showers; - Staff had not shaved Resident #1, #7, #9 and #14 because the residents did not ask to be shaved; - Residents should be shaved when they choose to be shaved; - He/she should separate and cleanse all areas of the skin where urine or feces has touched; - He/she had not read the residents' care plans. During an interview on 03/23/23 at 12:05 P.M., CNA F said: - Residents should be shaved when they choose; - Anytime staff saw obvious chin whiskers they should shave them; - He/she did not know why Resident #1, #7, #9 and #14 had not been shaved; - The CNA's are responsible for the shaving of residents; - He/she should separate and cleanse all areas of the skin where urine or feces has touched; - He/she had not looked at residents' care plans. During an interview on 3/23/23 at 3:38 P.M., the Director of Nursing (DON) said: -With every shower the staff should offer to shave the resident and more often if needed; -The resident's care plan should indicate if the resident does not want to be shaved; -He/she expects staff to separate and clean all the skin folds where urine or feces has touched; -Staff should not use the same area to clean different areas of the skin, it should be one wipe one swipe; -Staff should not fold the wipe when cleaning; - Staff should cover all reddened areas on the resident 6. Review of Resident #4's quarterly MDS, dated [DATE] showed: - Cognitive skills severely impaired; - Required extensive assistance of two staff for bed mobility, dressing, and toilet use; - Dependent on the assistance of two staff for transfers; - Upper and lower extremities impaired on one side; - Always incontinent of bowel and bladder; - Diagnoses included stroke, cancer, dementia, seizure disorder, and hemiparesis (muscle weakness on one side of the body). Review of the resident's care plan, revised 3/14/23 showed; - The resident required activities of daily living (ADL) assistance related to diagnosis of stroke with left sided weakness, dementia and generalized weakness; - Toileting with extensive assistance of two staff. Observation on 3/22/23 at 10:26 A.M., showed: - CNA B unfastened the wet incontinent brief; - CNA B wiped down one side of groin, used a new wipe and wiped down the other side of the groin, used a new wipe and wiped down the middle skin folds; - CNA B and CNA C turned the resident on his/her side and CNA B removed the wet incontinent brief; - CNA B used the same area of the wipe and cleaned the rectal area and wiped from front to back; - CNA B wiped from front to back with a new wipe each time; - CNA B placed a clean incontinent brief under the resident and the fitted sheet was wet with urine; - CNA B removed the wet fitted sheet; - CNA B did not separate and clean all the skin folds where urine had touched and did not clean the buttocks. During an interview on 3/23/23 at 10:51 A.M., CNA B said: - He/she should have separated and cleaned all areas of the skin where urine had touched; - He/she should not use the same area of the wipe to clean different areas of the skin, it should be one wipe, one swipe. 7. Review of Resident #18's care plan, revised 1/4/23 showed: - The resident required extensive ADL assistance; - Required extensive assistance of two staff for toileting. Review of the resident's significant change in status MDS, dated [DATE] showed: - Cognitive skills intact; - Required extensive assistance of one staff for bed mobility, dressing, and toilet use; - Dependent on the assistance of two staff for transfers; - Upper extremity impaired on one side; - Lower extremity impaired on both sides; - Had a suprapubic catheter (a catheter which enters the bladder through the lower abdomen; - Frequently incontinent of bowel; - Diagnoses included urinary tract infection (UTI) in the last 30 days, hemiparesis, dementia ( impaired ability to remember, think or make decisions that interferes with doing everyday activities), and Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). Observation on 3/22/23 at 12:46 P.M., showed: - CNA C used the same area of the wipe to cleaned around the insertion site of the suprapubic catheter, anchored the tubing and used a new wipe and wiped down the tubing; - CNA C used the same area of the wipe to clean different areas of the skin folds; - CNA C used a new wipe and wiped down one side of the groin, folded the wipe and wiped down the other side of the groin; - CNA C and CNA D turned the resident on his/her side; - CNA D used a new wipe 11 different times and cleaned the rectum with fecal material on each wipe; - CNA D used a new wipe and with the same area of the wipe cleaned both sides of the resident's buttocks; - CNA C and CNA D placed a clean incontinent brief on the resident. During an interview on 3/23/23 at 11:28 A.M., CNA C said: - He/she should have separated and cleaned all areas of the skin where urine had touched; - Should not use the same area of the wipe to clean different areas of the skin, he/she used one wipe and threw it away. During an interview on 3/23/23 at 12:50 P.M., CNA D said: - He/she should have separated and cleaned all the skin folds and cleaned all areas of the skin where urine or feces has touched; - He/she should not have used the same area of the wipe to clean different areas of the skin.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #7's care plan, dated 10/12/22, showed: - Extensive assistance of one for grooming; - Extensive assistance of two for toileting; - Extensive dependent of two with mechanical lift for transfers; - The care plan did not address a shaving preference. Review of the resident's quarterly MDS, dated [DATE], showed: - No cognitive impairment; - Extensive assistance of one with dressing and activities of daily living; - Frequently incontinent of bowel and bladder; - Diagnoses included Cancer, respiratory failure and heart failure. Observation on 3/23/23 at 1:11 P.M., showed: -CNA E and CNA G brought the mechanical lift into the room; -The resident was setting in a wheel chair; -CNA E moved the lift to the wheel chair and the spread the legs of the mechanical lift; -CNA E and CNA G hooked the resident up to the lift pad; -CNA E unlocked the rear casters; -CNA E moved the mechanical lift under the bed and did not open the legs of the lift and locked the rear casters; -CNA E moved the lift legs under the bed and did and spread the legs; -CNA E locked the rear casters and lowered the resident to the bed. 4. Review of Resident #13's care plan, dated 1/18/23, showed: - Extensive dependent of two with mechanical lift for transfers. Review of the resident's admission MDS, dated [DATE], showed: - No cognitive impairment; - Extensive assistance of one with dressing and activities of daily living; - Incontinent of bowel and bladder; - Diagnoses included osteoporosis, high blood pressure and anemia. Observation on 3/21/23, at 8:57 A.M., showed: -CNA F and CNA G brought the mechanical lift into the room; -The resident was setting in a wheel chair; -CNA F and CNA G both washed their hands and applied gloves; -CNA F moved the lift to the wheel chair and spread the legs of the mechanical lift; -CNA F and CNA G hooked the resident up to the lift pad; -CNA F unlocked the rear casters; -CNA F moved the mechanical lift under the bed and did not open the legs of the lift and locked the rear casters; -CNA F moved the lift legs under the bed and did and spread the legs; -CNA F locked the rear casters and lowered the resident to the bed. During an interview on 03/23/23 at 11:36 A.M., CNA E said: -The rear breaks on the mechanical lift should be locked before lifting; -The legs of the lift should be spread before lifting a resident up in the lift. During an interview on 03/23/23 at 11:47 A.M., CNA F said the breaks on the mechanical lift should be locked and the legs should be spread apart before lifting any resident. During an interview on 3/23/23 at 3:38 P.M., the Director of Nursing (DON) said: - When the resident is in the lift, the legs of the lift should be open; - The rear brakes on the lift should be unlocked when staff raise or lower the resident. Based on observations, interviews, and record review, the facility failed to ensure staff used proper techniques to reduce the possibility of accidents or injuries when transferring four of 12 sampled residents, ( Resident #4, #7, #13, and #18) during the use of a mechanical lift transfer. The facility census was 44. Review of the facility's undated policy for mechanical lift transfers, showed in part: - At least two nursing staff will assist in the transfer of a resident when utilizing the mechanical lift; - Roll the lift frame into position with legs in the open position. Legs may be closed to navigate corners or small spaces, but should be in the open position to counter balance resident weight when actively in use with resident; - One staff member operates the lift and the the second staff member guides the movement of the resident while in the lift; - One staff member stands behind the wheelchair to guide the resident's hips back into the seat while the other staff member operates the lift; - The policy did not indicate if the rear casters should be locked or unlocked when the raising or lowering the resident. Review of the undated manufacturer's guidelines for the Joerns Hoyer (mechanical ) lift showed, in part: - DO NOT lift a resident with the caster brakes on. Always let the lift find the correct center of gravity; - Never perform a lift/transfer with the legs in the closed /transport position (front casters touching); - When lifting, the casters should be left free and un-braked, so that the lift will then be able to move to the center of gravity of the lift. DO NOT apply the brakes. 1. Review of Resident #4's quarterly MDS, dated [DATE] showed: - Cognitive skills severely impaired; - Required extensive assistance of two staff for bed mobility, dressing, and toilet use; - Dependent on the assistance of two staff for transfers; - Upper and lower extremities impaired on one side; - Always incontinent of bowel and bladder; - Diagnoses included stroke, cancer, dementia, seizure disorder, and hemiparesis (muscle weakness on one side of the body). Review of the resident's care plan, revised 3/14/23 showed; - The resident required activities of daily living (ADL) assistance related to diagnosis of stroke with left sided weakness, dementia and generalized weakness; - Dependent on the assistance of two staff with the use of the mechanical lift for transfers. Observation on 3/22/23 at 10:26 A.M., showed: - Certified Nurse Aide (CNA) B placed the mechanical lift under the bed with the legs closed; - CNA B and CNA C hooked the lift pad up to the lift and lifted the resident with the legs of the lift in the closed position; - CNA B backed away from the bed with the legs of the lift closed then opened them to go around the resident's wheelchair and lowered the resident into the wheelchair and unhooked the lift sling from the lift. During an interview on 3/23/23 at 10:51 A.M., CNA B said: - The legs of the lift should be closed and leave them closed until you get ready to put the resident into the wheelchair, then open the legs; - The brakes on the lift should locked when raising or lowering the resident. 2. Review of Resident #18's care plan, revised 1/4/23 showed: - The resident required extensive ADL assistance; - The resident required extensive assistance of two staff for transfers. Review of the resident's significant change in status MDS, dated [DATE] showed: - Cognitive skills intact; - Required extensive assistance of one staff for bed mobility, dressing, and toilet use; - Dependent on the assistance of two staff for transfers; - Upper extremity impaired on one side; - Lower extremity impaired on both sides; - Had a suprapubic catheter (a catheter which enters the bladder through the lower abdomen; - Frequently incontinent of bowel; - Diagnoses included urinary tract infection (UTI) in the last 30 days, hemiparesis, dementia ( impaired ability to remember, think or make decisions that interferes with doing everyday activities), and Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). Observation on 3/23/23 at 12:46 P.M., showed: - CNA C opened the legs of the lift and went around the resident's wheelchair and locked the rear brakes on the lift; - CNA C and CNA D hooked the lift pad up to the mechanical lift; - CNA C unlocked the rear brakes, closed the legs of the lift and moved to the resident's bed; - CNA C left the legs of the lift closed, locked the rear brakes and lowered the resident onto the bed; - CNA C and CNA D unhooked the lift sling from the lift. During an interview on 3/23/23 at 11:28 A.M., CNA C said: - He/she closed the legs of the lift when the resident was in the lift and kept them closed when moving with the resident in the lift; - He/she should lock the brakes when hooking the resident up to the lift and when lowering the resident onto the bed on in the wheelchair. During an interview on 3/23/23 at 12:50 P.M., CNA D said: - If the resident was in the lift, the legs of the lift should be open; - He/she should lock the brakes on the lift when raising or lowering a resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to provide adequate staffing to meet the needs of residents due to extended call light response times, causing residents to become incontinent, which affected seven of 12 sampled residents, (Resident # 3, #5, #7, #9, #12, #18 and #253) and call light concerns brought up during resident council. The facility census was 44. Review of the facility's undated policy for silversphere call light system, showed in part: - The facility uses many tools to provide a safe, homelike environment. One took in use is a fully electronic call light system called Silversphere by [NAME]. This system runs through a mobile app, providing privacy and comfort through reduced noise pollution for every resident; - It is the responsibility of every nursing staff member to acquaint themselves with this system, and to respond urgently to all alarms; - Upon arrival for shift, direct care staff must login to the Silversphere system on either a facility provided phone or their own phone as permitted by a supervisor; - Due to the nature of direct care work, it is the preference of this facility that all staff use a facility provided phone when available; - The facility is not responsible for the loss or damage of your personal mobile phones should staff elect to use personal devices while on duty; - The facility provided phones are programmed specifically for call light response and are protected with cases to reduce damage, wear, and tear. All phones must be left on property at the conclusion of a shift or when going to break off facility property. The phones should be returned to the metal charging cage between use and plugged in; - It is the responsibility of all staff to report damaged mobile devices to nursing administration. As devices go down, it is imperative to get them repaired or replaced to ensure a timely response to resident needs; - Agency staff members will be provided a login for use while on duty by a member of the administrative team; - Each nurse's station has a device that presents all active call lights in real time. The device may be a tablet or a dedicated device called the Companion One, Staff should use their mobile/handheld device or these nurse station displays to promptly answer call lights; - The display on either the station or mobile screen will notify staff both of the room number and the type of call light triggered; - The call light may present as a pendent, a bath call, an emergency call or a bed alarm. This information indicates which call light needs to be reset; - Upon entering a resident room, staff must greet the resident, identify themselves, and immediately reset the call light. Do not wait until the completion of cares to reset the light. Should the item be beyond staff abilities, the light should then be re-triggered; - clearing of call lights is dependent upon the type: bed alarm- press the check box on the wall connection until light flashes; emergency alarm- press the check box on the wall connection until light flashes; bath alarm- press the check box on the wall connection mounted in restroom until light flashes; pendants- mobile app reset-select the alarm, press accept:, press reset pendant, press resident pendant button. Staff reset pendant- press the button on the reset device and watch for the light to flash (approximately five seconds) and then press the resident pendant button; - Check-in alarms may trigger on the console device at any time. These are random tests by the Silversphere system to ensure the system is functioning properly. These alarms can only be cleared at the console by selecting the alarm, clearing and acknowledging the alarm; - If a alarm cannot be cleared, a resident must be provided with an emergency bell and nursing administration must be notified immediately; - In the event of power or Internet failure, emergency call bells must be provided to each room until service resumes. Review of facility's undated policy for sufficient nursing staff, showed, in part: - The facility will assure sufficient team members are available in each neighborhood to provide nursing and related services to the residents; - The Director of Nursing (DON) will periodically meet with the licensed nurses to discuss staffing patterns for the units; - The staffing pattern will reflect the assessed needs and preferences of the residents; - The DON will ensure that sufficient direct care staff are available at all times to provide resident care and services. 1. Review of Resident #5's quarterly MDS, dated [DATE], showed: - Moderate cognitive impairment; - Extensive assistance of one with dressing and activities of daily living; - Frequently incontinent of bowel and bladder; - Extensive assistance of two for transfers; - Diagnoses included Rheumatoid Arthritis, anemia and blindness; Review of the resident's care plan, dated 1/11/23, showed: - Extensive assistance of one for grooming; - Extensive assistance of two for toileting; - Extensive dependent of two with mechanical lift for transfers; - Impaired visual function. Review of the resident's call log showed the call light was on for the following amount of time: - 12/14/22 at 10:19 A.M., 35 minutes; - 12/14/22 at 11:16 A.M., 57 minutes; - 12/15/22 at 6:57 P.M., one hour and 11 minutes; - 12/15/22 at 7:24 P.M., 46 minutes; - 12/15/22 at 9:23 P.M., 29 minutes; - 12/16/22 at 6:18 A.M., 35 minutes; - 12/17/22 at 9:38 A.M., 25 minutes; - 12/18/22 at 8:32 A.M., 44 minutes; - 12/18/22 at 7:35 P.M., 45 minutes; - 12/21/22 at 5:58 A.M., one hour and nine minutes; - 12/21/22 at 7:10 A.M., one hour and 55 minutes; - 12/21/22 at 3:35 P.M., 49 minutes; - 12/22/22 at 9:20 A.M., 52 minutes; - 12/22/22 at 3:07 P.M., three hours and 47 minutes; - 12/23/22 at 3:47 P.M., one hour and 19 minutes; - 12/31/22 at 6:01 A.M., one hour and 13 minutes; - 12/31/22 at 10:05 A.M., 27 minutes; - 1/2/23 at 6:39 P.M., 27 minutes; - 1/2/23 at 9:49 A.M., 29 minutes; - 1/4/23 at 7:08 A.M., 40 minutes; - 1/7/23 at 6:45 A.M., 52 minutes; - 1/9/23 at 5:43 A.M., 50 minutes; - 1/13/23 at 11:13 A.M., 49 minutes; - 1/14/23 at 6:42 A.M., 36 minutes; - 1/21/23 at 11:40 A.M., 37 minutes; - 2/3/23 at 8:15 A.M., one hour and 26 minutes; - 2/6/23 at 9:41 A.M., 49 minutes; - 3/1/23 at 6:04 P.M., 49 minutes; - 3/4/23 at 1:03 P.M., 48 minutes; - 3/6/23 at 6:15 P.M., 55 minutes; - 3/8/23 at 6:35 A.M., one hour and 40 minutes; - 3/1/23 at 6:04 P.M., 49 minutes; - 3/2/23 at 11:48 A.M., one hour and 27 minutes; - 3/11/23 at 12:57 P.M., one hour and 21 minutes; - 3/16/23 at 6:43 P.M., 40 minutes; - 3/17/23 at 4:21 A.M., 58 minutes; - 3/21/23 at 12:37 P.M., 20 minutes. During an interview on 3/21/23, at 8:36 A.M., the resident said: -Some times it takes a long time for the staff to answerer the call light; -I know the staff are busy but he/she said she can only hold it for so long; -The staff are good workers they facility just needs more of them. An observation on 3/21/23, from 8:47 A.M., to 9:02 A.M., showed: -The resident setting in a Broda chair (wheelchair that provide supportive positioning through a combination of tilt, recline, adjustable leg rest angle, wings with shoulder bolsters and height adjustable arms) with his/her daughter present; -The resident rang his/her call light at 8:47 A.M.; - 8:55 A.M., CNA E walked by the resident's room and did not answerer light; - 9:59 A.M., the resident's daughter went to the nurses station to get staff; - 9:02 A.M., CNA E shut off the resident's call light and said she would be right back with another staff member to help him/her to the bathroom; - 9:21 A.M. CNA E and hospice staff assisted the resident to the bathroom. During an interview on 3/23/23, at 9:23 A.M., the resident said: -He/she waits anywhere from 45 minutes to over an hour at times after ring pressing the call light; -He/she has had feces in his/her pants because of the long wait for help and it is embarrassing; During an interview on 3/23/23, at 9:30 A.M., the resident's son said: -When he/she comes on the weekends and it can take an hour for the resident's call light to be answered; -He/she usually goes to find staff to help the resident; -Ice water does not get passed and the resident has to wait an hour to be put to bed;weekend staff is worse ice water does not get passed and people don't get put to bed. 2. Review of Resident #3's care plan, revised 2/28/23 showed: - The resident was at risk for bladder incontinence related to reduced mobility. Change incontinent brief as needed; - The resident required extensive activities of daily living (ADL) assistance. Extensive assistance of one staff for ambulation, bathing, dressing, toileting and transfers; - The resident has an alteration in musculoskeletal status related to fracture of the left ankle. Anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance. Review of the resident's admission Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 3/2/23 showed: - admission date - 2/24/23; - Cognitive skills intact; - Required extensive assistance of one staff for bed mobility, transfers, dressing, toilet use, personal hygiene and bathing; - Lower extremity impaired on one side; - Always continent of bowel and bladder; - Diagnosis included fracture. Review of the resident's call log showed the residents call lights was on for the following amount of time: - 2/24/23 at 4:04 P.M., one hour and ten minutes; - 2/25/23 at 10:06 A.M., 40 minutes; - 2/25/23 at 11:38 A.M., 46 minutes; - 2/25/23 at 6:59 P.M., 59 minutes; - 2/26/23 at 2:44 A.M., 25 minutes; - 2/27/23 at 6:59 A.M., 20 minutes - 2/27/23 at 9:25 A.M., 33 minutes; - 2/27/23 at 1:17 P.M., 22 minutes; - 2/28/23 at 12:22 P.M., 47 minutes; - 2/28/23 at 12:36 P.M., 27 minutes; - 2/28/23 at 2:12 P.M., 22 minutes; - 3/1/23 at 6:00 A.M., 21 minutes; - 3/1/23 at 6:16 A.M., 49 minutes; - 3/2/23 at 8:34 A.M., 19 minutes; - 3/2/23 at 12:13 P.M., 43 minutes; - 3/3/23 at 11:26 A.M., 22 minutes; - 3/4/23 at 12:20 P.M., 25 minutes; - 3/4/23 at 5:32 P.M., 21 minutes; - 3/5/23 at 1:47 P.M., 35 minutes; - 3/7/23 at 8:19 A.M., 51 minutes; - 3/7/23 at 4:08 P.M., 16 minutes; - 3/8/23 at 8:07 A.M., 19 minutes; - 3/8/23 at 6:19 P.M., 24 minutes; - 3/10/23 at 6:29 A.M., 26 minutes; - 3/10/23 at 8:11 A.M., 24 minutes; - 3/10/23 at 8:15 A.M., 20 minutes; - 3/10/23 at 5:32 P.M., 22 minutes; - 3/10/23 at 8:38 P.M., 37 minutes; - 3/11/23 at 7:55 P.M., 17 minutes; - 3/11/23 at 12:55 P.M., 33 minutes; - 3/11/23 at 5:57 P.M., 53 minutes; - 3/14/23 at 8:54 A.M., 29 minutes; - 3/14/23 at 9:06 A.M., 17 minutes; - 3/15/23 at 7:49 A.M., 33 minutes; - 3/15/23 at 1:22 P.M., 18 minutes; - 3/16/23 at 10:59 A.M., 50 minutes; - 3/16/23 at 3:38 P.M., 20 minutes; - 3/16/23 at 8:39 P.M., 17 minutes; - 3/17/23 at 10:07 A.M., 26 minutes; - 3/18/23 at 1:56 P.M., 21 minutes; - 3/18/23 at 5:28 P.M., 21 minutes; - 3/20/23 at 7:08 A.M., 21 minutes; - 3/20/23 at 7:02 P.M., 45 minutes; - 3/20/23 at 8:31 P.M., 21 minutes. During an interview on 3/20/23 at 4:45 P.M., the Resident #3 said: - The night staff are horrible; - Call lights can take up to 45 minutes to get answered. 3. Review of Resident #7's care plan, dated 10/12/22, showed: - Extensive assistance of one for grooming; - Extensive assistance of two for toileting; - Extensive dependent of two with mechanical lift for transfers; - The care plan did not address a shaving preference. Review of the resident's quarterly MDS, dated [DATE], showed: - No cognitive impairment; - Extensive assistance of one with dressing and activities of daily living; - Frequently incontinent of bowel and bladder; - Diagnoses included Cancer, respiratory failure and heart failure. Review of the resident's call log showed the call light was on for the following amount of time: - 12/25/22 at 6:08 P.M., 55 minutes; - 12/29/22 at 5:06 P.M., 48 minutes; - 12/31/22 at 12:38 P.M., 37 minutes; - 1/3/23 at 4:47 P.M., one hour and four minutes; - 1/6/23 at 5:20 P.M., 49 minutes; - 1/11/23 at 6:09 A.M., 45 minutes; - 1/13/23 at 12:28 P.M., one hour and seven minutes; - 1/14/23 at 5:54 P.M., 43 minutes; - 1/24/23 at 5:32 P.M., 46 minutes; - 2/2/23 at 4:58 A.M., 46 minutes; - 2/3/23 at 10:38 P.M., 50 minutes; - 2/6/23 at 3:35 P.M., 49 minutes; - 2/7/23 at 4:14 P.M., 47 minutes; - 2/8/23 at 4:12 P.M., 42 minutes; - 2/10/23 at 11:20 A.M., 58 minutes; - 2/11/23 at 4:04 P.M., one hour and 56 minutes; - 3/12/23 at 12:23 P.M., one hour and 16 minutes. During an interview on 3/22/23, at 9:23 A.M., the resident said: -It takes a long time for the staff to answerer his/her call light; it takes an hour to get help: -The told her it takes a while became they have to wit for the mechanical lift -He/she has had an incontinent accident and he/she tells the staff he/she sorry because he/she could not wait to use the bedpan. 4. Review of Resident #9's care plan, dated 2/14/23, showed: - Extensive assistance of one for grooming; - Extensive assistance of one for toileting; - Extensive assistance of one for ambulation; - Staff to acknowledge things that are important to the resident; - The care plan did not address a shaving preference. Review of the resident's quarterly MDS, dated [DATE], showed: - No cognitive impairment; - Extensive assistance of one with dressing and activities of daily living; - Occasionally incontinent of bowel and bladder; - Diagnoses included Cancer, high blood pressure and depression. Review of the resident's call log showed the call light was on for the following amount of time: - 12/14/22 at 6:08 P.M., 55 minutes; - 12/14/22 at 5:06 P.M., 48 minutes; - 12/15/22 at 12:38 P.M., 37 minutes; - 12/16/22 at 4:47 P.M., one hour and four minutes; - 12/17/22 at 5:20 P.M., 49 minutes; - 12/18/22 at 6:09 A.M., 45 minutes; - 12/21/22 at 12:28 P.M., one hour and seven minutes; - 12/31/22 at 7:20 A.M., 34 minutes; - 1/4/23 at 11:49 A.M., 37 minutes; - 1/6/23 at 7:30 P.M., 52 minutes; - 1/7/23 at 9:27 A.M., 28 minutes; - 2/17/23 at 6:52 A.M., 57 minutes; - 2/27/23 at 4:59 P.M., 48 minutes; - 3/15/23 at 7:18 A.M., 56 minutes; - 3/20/23 at 5:39 P.M., 52 minutes; - 3/21/23 at 7:44 A.M., 44 minutes. During an interview on 3/23/23, at 9:04 A.M. the resident said; -He/she waits any where from 30 minutes to over an hour after he/she rings his/her call light for staff to come; He/she said he/she has wet his/her pants several times; -He/she said that makes him/her feel like he/she is a bother and embarrassed. 5. Review #12's admission MDS, dated [DATE], showed: - Moderate cognitive impairment; - Extensive assistance of one with dressing and activities of daily living; - Assistance of one with transfers; - Occasionally incontinent of bowel and bladder; - Diagnoses included Cancer, respiratory failure and heart failure. Review of the resident's care plan, dated 3/1/23, showed: - Extensive assistance of one for grooming; - Extensive assistance of one for toileting; - Extensive assistance of one for ambulation; -Impaired visual function. Review of the resident's call log showed the call light was on for the following amount of time: - 2/25/23 at 8:43 A.M., one hour and 39 minutes; - 2/26/23 at 5:17 P.M., 34 minutes; - 2/28/23 at 5:01 P.M., 50 minutes; - 3/5/23 at 7:30 A.M., 40 minutes; - 3/5/23 at 3:46 P.M., 39 minutes; - 3/7/23 at 8:15 A.M., 53 minutes; - 3/8/23 at 11:08 A.M., 30 minutes; - 3/10/23 at 4:45 P.M., 26 minutes; - 3/11/23 at 2:21 P.M., 25 minutes; - 3/11/23 at 4:51 P.M., 59 minutes; - 3/14/23 at 4:25 A.M., 34 minutes; - 3/14/23 at 11:39 A.M., 38 minutes; - 3/15/23 at 6:23 A.M., 31 minutes; - 3/17/23 at 6:39 A.M., 19 minutes; - 3/18/23 at 8:13 A.M., 20 minutes; - 3/19/23 at 8:59 A.M., 51 minutes. During an interview on 3/20/23, at 3:28 P.M., the resident said: -In the evening and night it takes forever to get a call answered; -He/she timed how long it took staff to answerer the call light and it took 30 to 40 minutes for someone to come; -He/she stopped taking the medication Lasix (a diuretic), because it would make him/her have to go the bathroom and he/she waited so long and would wet in his/her pants. During an interview on 3/23/23, at 11:36 A.M., CNA E said: -The call light systems sounds and is displayed at the nurses desk: -Staff can put an App on their phone or use one of the phones the facility provides that can be signed out at the nurse desk; -He/she to answer the call lights within 15 minutes. During an interview on 3/23/23, at 11:36 A.M., CNA F said: -The call light systems is on the phones the staff carry; -The call light display is at the nurses desk as well; -The residents should not have to wait over five to 10 minutes for the call light to be answered; -Some days take longer because it is busier. During an interview on 3/23/23, at 11:36 A.M., CNA E said: -The call light systems sounds and is displayed at the nurses desk: -Staff can put an App on their phone or use one of the phones the facility provides that can be signed out at the nurse desk; -He/try's to answer the call lights within 15 minutes. During an interview on 3/23/23, at 12:36 P.M., CNA G said: -The staff can add a call light system app on their personal phone or get a little phone at the nurses desk; -Call lights should be answered within 15 minutes; -He/she said some take longer than others. we have a lot of max assistance on this hall, it takes two people to do and it takes ext assistance: -Residents and family have complain and the assistant administrator has told them they need to be answered faster; -There are many residents on this hall that require maximum assistance and it takes longer; -Family have complaint to the the CNA's and the charge nurses. 6. Review of Resident #18's care plan, revised 1/04/23 showed; - The resident was at risk for falls related to deconditioning. Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance. Review of the resident's significant change in status MDS, dated [DATE] showed: - Cognitive skills intact; - Required extensive assistance of one staff for bed mobility, dressing, toilet use and bathing; - Dependent on the assistance of two staff for transfers; - Upper extremity impaired on one side; - Lower extremity impaired on both sides; - Diagnoses included dementia ( impaired ability to remember, think or make decisions that interferes with doing everyday activities), Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). Review of the resident's call log showed the call light was on for the following amount of time: - 1/28/23 at 9:21 A.M., 22 minutes; - 1/29/23 at 6:54 A.M., 38 minutes; - 1/31/23 at 6:03 A.M., 18 minutes; - 2/1/23 at 3:39 P.M., 45 minutes; - 2/2/23 at 6:18 A.M., one hour and 11 minutes; - 2/5/23 at 6:13 A.M., one hour and five minutes; - 2/7/23 at 5:49 A.M., 24 minutes; - 2/9/23 at 11:08 A.M., 16 minutes; - 2/15/23 at 7:52 A.M., two hours and eight minutes; - 2/16/23 at 6:10 P.M., 55 minutes; - 2/17/23 at 1:38 P.M., 24 minutes; - 2/18/23 at 12:53 P.M., two hours and 15 minutes; - 2/19/23 at 5:45 A.M., 38 minutes; - 2/19/23 at 6:27 A.M., 21 minutes; - 2/21/23 at 9:11 A.M., 31 minutes; - 2/22/23 at 5:46 A.M., 47 minutes; - 2/23/23 at 3:13 P.M., 29 minutes; - 2/25/23 at 3:30 A.M., one hour and 16 minutes; - 3/1/23 at 11:42 A.M., 45 minutes; - 3/1/23 at 12:39 P.M., 43 minutes; - 3/1/23 at 4:48 P.M., one hour and four minutes; - 3/3/23 at 6:37 A.M., 46 minutes; - 3/3/23 at 12:00 P.M., 25 minutes; - 3/4/23 at 12:09 P.M., one hour and nine minutes; - 3/5/23 at 11:27 A.M., 24 minutes; - 3/6/23 at 7:23 A.M., 17 minutes; - 3/6/23 at 4:13 P.M., one hour and three minutes; - 3/9/23 at 7:38 P.M., 34 minutes; - 3/10/23 at 8:59 A.M., one hour and 50 minutes to replace battery; - 3/10/23 at 3:43 P.M., 17 minutes; - 3/11/23 at 10:28 A.M., one hour and three minutes; - 3/12/23 at 6:32 A.M., three hours and 55 minutes; - 3/14/23 at 5:49 P.M., 34 minutes; - 3/15/23 at 7:31 A.M., 18 minutes; - 3/16/23 at 8:41 P.M., 16 minutes; - 3/17/23 at 7:14 A.M., 37 minutes; - 3/17/23 at 9:23 A.M., one hour and ten minutes; - 3/17/23 at 6:19 P.M., 16 minutes; - 3/19/23 at 5:51 P.M., 20 minutes; - 3/19/23 at 8:27 P.M., - 3/20/23 at 6:11 P.M., one hour and 33 minutes. During an interview on 3/23/23 at 10:14 A.M., the resident said: - When it took so long for his/her call light to get answered it made him/her feel lost and insecure; - He/he did not feel like there was enough staff to meet his/her needs; - He/she thought staffs response time to call lights was worse on the weekends. 7. Review of Resident #253's care plan, revised 3/20/23 showed: - The resident was a high risk for falls related to deconditioning, and gait/balance problems; - Anticipate and meet the resident's needs; - Be sure call light is within reach and encourage the resident to use it for assistance as needed. Review of the resident's admission MDS, dated [DATE] showed: - The resident was admitted on [DATE]; - Cognitive skills moderately impaired; - Required extensive assistance of two staff for bed mobility, transfers, toilet use, personal hygiene and bathing; - Frequently incontinent of urine; - Occasionally incontinent of bowel; - Diagnoses included diabetes mellitus, congestive heart failure (CHF, accumulation of fluids in the lungs and other areas of the body), high blood pressure and dementia. Review of the resident's call log showed the call light was on for the following amount of time: - 3/18/23 at 4:57 A.M., 16 minutes; - 3/18/23 at 5:34 A.M., 29 minutes; - 3/18/23 at 7:26 A.M., 24 minutes; - 3/18/23 at 9:29 A.M., 16 minutes; - 3/18/23 at 12:09 P.M., 30 minutes; - 3/18/23 at 3:07 P.M., 17 minutes; - 3/19/23 at 7:41 A.M., 29 minutes; - 3/19/23 at 5:23 P.M., 34 minutes. During an interview on 3/20/23 at 3:47 P.M., the resident's family said the staff said they would check on the resident every two hours during the night but that has not happened. During an interview on 3/23/23 at 11:58 A.M., the resident said; - It did not make him/her feel as good as he/she should when it takes so long for the call lights to get answered; - He/she has had an accident waiting for the call light to get answered and did not like it; - He/she had been left on the toilet and when he/she put on his/her call light it took a long time for the staff to get her off the toilet. He/she could not remember the time of day or the staff involved; - He/she did not like it and felt like the staff were too busy to help him/her. 8. Review of the resident council notes, dated 12/28/22 showed: - Unknown resident said there was a long wait for call lights to be answered. Review of the resident council notes, dated January, 2023 showed: - It did not address the call light concerns; - Unknown resident said staff did not help when he/she asked for it, especially when the resident called out to them while they were talking by the resident's door and it made the resident feel ignored. During an interview on 3/23/23 at 7:11 A.M., the Director of Nursing (DON) said: - Call lights response time has been an issue; - She added an extra Certified Nurse Aide (CNA) on each side to help with call lights; - The call light system is Internet based and if the Internet is down, they put bells out for the resident to use; - The facility is phasing out the pendant necklace the residents use. The residents can still use the bed alarm, the emergency call light by their chair and the call light in their bathroom; - Her expectation is the call lights should be answered within 15 minutes or less; - When the call light log showed call cord removed it meant the resident had pulled the call light out and maintenance had to fix it; - When the call light showed replace battery a06c, they are battery operated and the battery would need to be replaced. During an interview on 3/23/23 at 10:38 A.M., Licensed Practical Nurse (LPN) B said: - He/she had worked at the facility for about four years and normally worked the day shift on the rehab side; - Call lights usually take 15-20 minutes or a good 30 minutes to get answered; - When the resident pressed their call light, it would light up on the screen at the desk; - There's an app the staff can put on their work phone, but it's hit and miss if one is available or they can put the app on the tablet. This morning they had one work phone and two tablets; - Medical staff could answer the call lights; - He/she has had family members and residents complain about how long it took for the call lights to get answered; - If the screen showed the battery needed to be replaced, they staff would fill out a work order and maintenance would usually get it changed within six hours. During an interview on 3/23/23 at 10:51 A.M., CNA B said; - The call lights should be answered in a timely manner but did not know what the timeframe would be; - There was a log system at the nurse's station and you could hear it go off if you were up by the nurse's station; - He/she had the app on his/her phone and it would buzz if a call light was going off; - Anyone can answer the call light; - He/she has had residents and family members complain about the length of time it took for a call light to get answered; - He/she would apologize to the resident when he/she answered the call light. During an interview on 3/23/23 at 11:05 A.M., LPN A said: - The call lights should be answered in five minutes or less, but they do not get answered quickly, but they try to; - Before, during and after the meals seems to be when there is when there's a higher frequency of call lights going off; - If you are at the nurse's station, you can hear the call light beeping, if you are at the other end of the hall, you can't hear it beeping so you would have to go and look at the screen; - He/she did not have the app on his/her personal phone and did not carry the work phone. He/she looked at the screen and if the call light had been on for five minutes, then he/she would answer the call light; - He/she did not think they had enough staff to get the call lights answered; - He/she has had residents and family members complain about the length of time it takes for the call lights to get answered and he/she informed the DON. During an interview on 3/23/23 at 11:18 A.M., CNA A said: - You can only hear the call lights beeping if you are close to the nurse's station; - He/she did not use a tablet or the work phone; - He/she checked the monitor at the nurse's station to see if any call light were on; - He/she tried to answer them within ten minutes but did not see any reason for them to be on longer than 20 minutes; - Anyone in nursing can answer the call lights; - The call light go off more around meal times; - If the residents or family members complained about the call lights, he/she would pass it on charge nurse and would apologize to the family. During an interview on 3/23/23 at 11:28 A.M., CNA C said: - He/she had the app on his/her personal phone and it alerted him/her by making a sound and it pop up on the screen of his/her phone; - Call light should answered in three to five minutes but that does not always happen. The call lights should but not be on longer than 15 minutes; - The busiest time is around lunch time; - Residents and family members have complained about how long it took for call lights to get answered and he/she reported it to the charge nurse (CN) and /or the DON. During an interview on 3/23/23 at 3:38 P.M., the DON said: - On 3/15/23 and 3/16/23 she added an extra CNA on each side to help with call lights; - She reviewed the call light logs and said residents call lights were on too long; - Her expectation was for the call lights to be answered in 15 minutes or less.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain the exhaust system to remove bathroom odors. The facility census was 44. The requested vent cleaning policy was not provided. 1. Observation of the bathroom on the 2nd floor by the social services office on 3/22/23, at 1:52 P.M., showed the vent on the ceiling caked with dirt and debris. 2. Observation of the bathroom in the basement by the resident salon on 03/22/23, at 4:16 P.M., showed the vent on the ceiling caked with dirt and debris. 3. Observation of the bathroom in the basement by the salon on 3/23/23, at 8:11 A.M., showed the vent on the ceiling continued to be caked with dirt and debris. 4. Observation of the bathroom the 2nd floor by the social services office on 3/23/23 at 10:31 A.M., showed the vent on the ceiling continued to be caked with dirt and debris. 5. Observation on 3/22/23 at beginning at 8:30 A.M. showed the following vents on the ceiling were caked with dust, lint and debris: - Bathroom by Director of Nursing office on the first floor; - Laundry area by room [ROOM NUMBER]; Laundry area by room [ROOM NUMBER]. During an interview on 03/23/23, 10:35 A.M., the housekeeping supervisor said: -The maintenance department is responsible for clearing the vents; -He/she did not know if a work order had been but into to maintenance about the dirty vents in the both bathroom. During an interview on 03/23/23, 12:17 P.M., maintenance staff A said: -He/she is in charge of checking the work orders; -He/she checks the work orders daily; -He/she said if the vent does not have a filter in housekeeping is responsible for cleaning it. During an interview on 3/23/23, at 3:04 P.M., the daughter of Resident #18 said: -He/she uses the bathroom on the 2nd floor by the social services office and it is dirty; -The downstairs bathroom by the salon is filthy. During an interview on 3/23/23, at 5:09 P.M., the administrator said: -He/she expects non resident bathrooms to be cleaned daily and as needed; -Housekeeping dusts the outside of the vents but if the vent needs to be taken apart the maintenance department is responsible for this; -Housekeeping is responsible for making sure any work order for repairs are turned into the maintenance department; -Maintenance is responsible for make sure work orders are taken care of and repairs are made; -He/she does not have access to work orders; -On the weekends the facility as a part time housekeeper that cleans the bathrooms.

Based on observation, interviews and record review, the facility failed to prepare, distribute and serve food in accordance with professional standards for food service safety and follow proper sanitation and food handling practices to prevent the possibility of foodborne illness when staff placed their thermometer, used to obtain internal food temperatures prior to serving to the residents, directly into their red bucket filled with sanitizer water after they used the water to wash their food preparation table, placed gloved hands into oven mitts repeatedly without removing their gloves and washing their hands, and kept staff's personal drinks in food preparation areas. The facility's census was 44. Review of the food preparation and handling policy on 3/23/23 shows: - Food items will be prepared using methods and techniques designed to preserve maximum nutritive value, enhanced flavor and be free of injurious organisms and substances. - All food handlers will perform handwashing regularly in a designated hand washing sink during each shift and for the following reasons: *on entering kitchen *before handling any food or equipment *after handling any wrapped or unwrapped food, especially raw items *before and after any cleaning procedure *between different tasks *after touching ears, nose, mouth, or hair *after any contact with service users or immediate surroundings *after visiting toilet facilities *after handling waste food or refuse *after eating or smoking - Gloves will be changed and hands washed between preparation of different food items and ANY time the gloves have been contaminated by a potentially soiled surface. - Food and drink must not be consumed in any food preparation or ancillary areas. Review of the staff food and consumption policy on 3/23/23 show: - Staff drinks are to be kept in sealed containers away from resident spaces (they may be kept in the break room, lockers, or other dedicated spaces). 1. Observation on 3/23/23 starting at 9:40 A.M., showed: - Kitchen Manager (KM) in the kitchen preparing the noon meal; he/she washed his/her hands and applied gloves and removed pans of meatballs from the oven and placed them in three pans to take to the nursing units; - After picking a meatball off the floor and putting it into the trash can, KM washed his/her hands and applied clean gloves then put oven mitts on over his/her gloves to put the pan back in the oven; - KM picked up a lid to put on the pan of meatballs, dropped it on the floor, retrieved it from the floor and placed it on the pan then removed his/her gloves and without washing his/her hands put on the oven mitts and put the pan of meatballs back in the oven then washed his/her hands; - [NAME] A chopped fresh parsley wearing gloves, stopped to remove the pans of rice from the oven, applied the oven mitts while still wearing his/her gloves, removed the oven mitts after removing the pans from the oven and resumed chopping the fresh parsley; - KM put gloved hands into the oven mitts and pulled a pan of cooked vegetables from the warmer to place them in the hot carts for transport to the nursing units and without changing gloves or washing his/her hands began to prepare the pureed and mechanical soft foods. During an interview on 3/23/23 at 3:29 P.M. the Dietary Manager (DM), KM and [NAME] A said staff should wash their hands before applying gloves, after using the restroom, handling the trash can lids, handling food, touching your face, clothing, or blowing your nose, and each time you change your gloves. You should change your gloves when moving from one task to another and dirty to clean tasks. Staff should not put gloved hands into the oven mitts and not wash their hands or change their gloves afterwards. 2. Observations on 3/23/23 starting at 9:40 A.M., showed: - Dietary Aide (DA) A walked into the kitchen carrying a large plastic drink cup; he/she placed the drink cup in the dishwashing area and proceeded to begin his/her daily routine; - A plastic drink bottle sat on the lower counter under the food preparation table; [NAME] A drank from the bottle and placed it back on the counter. During an interview on 3/23/23 at 3:29 P.M., DM, KM and [NAME] A said they have a designated spot in the kitchen for drinks and food. They thought it was alright to place their drinks under the food preparation table, but their designated spot should be in the office. If they do not keep their personal food and drink items in the office, they should keep them in the employee break room which is just down the hall. 3. Observations on 3/23/23 starting at 9:40 A.M., showed: - KM preparing the noon meal; he/she had a red bucket setting next to the food preparation table with a white rag in it; - As KM moved from one task to another, he/she used the white rag to clean the food preparation table and replaced it back into the red bucket; green chunks of food floated in the bucket; - KM pulled out a thermometer and began taking temperatures of the food before placing the pan in three different hot carts to be transported to the nursing units; - Between each different food item, KM swished the end of the thermometer in the red bucket then wiped it on a dry rag before placing the thermometer into another food item. During an interview on 3/23/23 at 11:15 A.M., KM said they have been asking for alcohol swaps to clean their thermometers but had not gotten any. Their registered dietitian told them it was alright to place the thermometers in the sanitizer bucket in between food items. During an interview on 3/23/23 at 3:29 P.M., the DM said staff should use alcohol pads to clean the thermometers. Staff should only use the sanitizer buckets for cleaning tables.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to implement their water management policy and procedures to reduce the risk of growth and spread of Legionella (bacteria that causes Legionnaires' disease, a serious type of pneumonia). The facility also failed to ensure facility staff were informed on the facility's Water Management Plan and on safe water temperatures to maintain for the hot water. The facility census was 44. Review of the CMS Quality Safety and Oversight (QSO), dated 6/2/17 and revised on 7/6/18, showed: - Facilities must have water management plans and documentation that, at a minimum, ensure each facility: Conducts a facility risk assessment to identify where Legionella (a [NAME] of pathogenic Gram-negative bacteria that includes the species L. pneumophila, causing legionellosis, all illnesses caused by Legionella, and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system. - The facility should develop and implement a water management program that considers the American Society of Heating Refrigerating and Air Conditioning Engineers (ASHRAE) industry standard and the Center for Disease Control and Prevention (CDC) toolkit. 1. Review of the facility's undated policy titled Legionella Risk Management Policy included the following: - The purpose of this policy is to ensure that as far as possible, all users of this facility are protected from the incidence of Legionnaire's disease. The Director of Environmental Services is responsible for all relevant details regarding roles and responsibilities and testing regimes contained in this policy and procedure. All results will be reported to the Quality Assessment Performance Improvement Committee on a quarterly basis and the Administrator of the facility is responsible for reported all results and findings to the Board of Governance on an annual basis; - It is the policy of this facility to ensure that appropriate precautions for the control of legionella bacteria are identified through a Legionella risk assessment process and appropriate control measures implemented to ensure, so far as is reasonably practicable, the health, safety and welfare of residents, visitors, staff members and volunteers. The minimum standards to be met included but are not limited to: o Carrying out suitable and sufficient Legionella risk assessments; o Description of building water systems; o Identification of areas where Legionella could grow and spread; o Preparation of an action plan or written scheme for preventing or controlling the risk, where appropriate; - Including in plan of any areas where medical procedures may expose residents to water mists including hydrotherapy and respiratory therapy devices; - Implementation, management, monitoring and recording of precautions to include regular inspection, microbiological monitoring, temperature checks, and flushing where appropriate; - Plans to intervene when control limits are not met; - Continuous monitoring of program compliance - Documentation of all monitoring; - Seeking suitable advice and assistance from competent persons and Specialist Consultant, where appropriate; - Appointment of a person or persons to be managerially responsible for water system at each premise; - To otherwise meet the requirements of CMS Center for Clinical Standards and Quality/Survey and Certification Group, Survey and Certification Letter 17-30, dated June 2, 2017 related to: Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaire's Disease; - This facility has established and maintains an infection prevention and control program designed to provide a sage, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections; - The Scope of this policy includes but is not limited to: o Hot and cold water storage tanks; o Water heaters; o Water-hammer arrestors; o Pipes, valves, and fittings; o Expansion tanks; o Water filters; o Electronic and manual faucets; o Aerators; o Faucet flow restrictors; o Showerhead and hoses; o Centrally-installed misters, atomizers, air washers, and humidifiers; o Non-stream aerosol-generating humidifiers; o Infrequently used equipment, including but not limited to eyewash stations; o Ice machines; o Hot tubs/saunas; o Decorative fountains; o Cooling towers; o Medical devices including but not limited to: CPAP machines, hydrotherapy equipment, nebulizing units, heater-cooler units. Procedure (Included) - Factors for internal to buildings that can lead to Legionella growth: o Biofilm: Protects Legionella from heat and disinfectant; provides food and shelter for germs; grows on any surface that is constantly moist and can last for decades; o Scale and sediment: Uses up disinfectant and creates and protected home for Legionella and other germs; o Water temperature fluctuations: Provide conditions where Legionella grows best (77 degrees Fahrenheit (F) to 108F); Legionella can still grow outside this range; o Water pressure changes: Can cause biofilm to dislodge, colonizing downstream devices; o Potential Hydrogen (PH): disinfectants are most effective within a narrow range (approximately 6.5 to 8.5) Many things can cause the hot water temperature to drop into the range where Legionella can grow, including low settings on water heaters, heat loss as water travels through long popes away from the heat source, mixing cold and hot water within the plumbing system, heat transfer (when cold and hot water pipes are too close together), or heat loss due to water stagnation. In Hot weather, cold water ipes can heat up into this range; o Inadequate disinfectant: Does not kill or inactivate Legionella. Even if the water entering you building is of high quality, it may contain Legionella. In some buildings, processes such as heating, storing, and filtering can degrade the quality of the water. There process use the disinfectant the water entered with, allowing the few Legionella that entered to grow into a large number if not controlled; o Water stagnation: Encourages biofilm growth and reduces temperature and levels of disinfectant. Common issues that contribute to water stagnation include renovations that lead to deadlegs and reduced building occupancy, which can occur in hotels during off-peak seasons, for example. Stagnation can also occur when fixtures go unused, like a rarely used show in a hospital room; o Identify Buildings at Increased Risk. Survey/Questionnaire is provided as Appendix A; - Description of Water services Installations; - Showers: All shower heads are cleaned and disinfected on a quarterly basis and logs of cleaning and disinfection processes are logged and logs are kept in the office of the Director of Environmental Services - Description of building water systems using flow diagram (Attached as Appendix B); - On a monthly basis the Environmental Services staff will monitor and log the following: o Condition of water storage and distribution services described and listed in this policy o System water temperatures - Cold water storage and distribution will be measured at 86 degrees F or below after two minutes of running; - Hot water storage of distribution will be measure at 122 degrees F at outlets after one minute of running - System water quality - Potential for exposure to aerosol droplets; - Suitability of written plan for maintenance and monitoring including record keeping; - If any abnormalities are noted during routine, scheduled monitoring, the device will be drained to the sewer system, disinfected with appropriate sanitation, disinfection product and the device will be restarted per manufacturer recommendations. The following sections of the facility's Legionella Risk Management policy were not completed specific to the facility: - Building description; - Incoming mains cold water and distribution; - Cold water heating; - Deadlegs and little used outlets. Review of the facility's Life Safety Code and infection control records showed: - Appendix A was a blank assessment form; - Appendix B was an example of a water flow diagram but was not completed specific to the facility; - Several weeks of the hot water monitoring where the water temperature was logged 103F-108F which included in resident rooms and non-resident use areas; - There were no other records of the water system monitoring or being maintained according to the plan. During an interview on 3/23/23 at 11:40 A.M., the Infection Preventionist said: - Had worked at the facility since June 2021; - Had not seen a water management plan or participated in any meeting regarding the water management program; - There had not been any cases of Legionnaire's disease seen since she had been here. During an interview on 3/23/23 at 11:53 A.M., the Administrator said the facility uses the CDC water management tool kit, for their plan. Maintenance is responsible for monitoring the water program. During an interview on 3/23/23 at 12:09 P.M., Maintenance Staff A said he monitored water temperature for safety of the residents and the water pressure. He had not been trained on what the water temperature needed to be, but based on his own research he wanted to keep the water temperature below 110F. He was not familiar with the facility's water management plan. During an interview on 3/23/23 at 12:14 P.M., the Administrator said the Corporate Maintenance Director told her the facility relied on the city to notify them if there's legionella detected in the potable water then they would shut the water down and use water bottles per the policy. During a phone interview on 3/23/23 at 12:20 P.M., the Corporate Maintenance Director said the facility had a plumbing diagram from construction phase, but they did not have a flow diagram. They did not monitor their water system.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to honor residents' dignity when staff did not answer call lights timely, causing two of 14 sampled residents (Resident #31 and #203) to become incontinent. The facility census was 56. The facility did not provide a policy regarding call light response times or a policy regarding treating a resident with dignity and respect. 1. Review of Resident #31's comprehensive Minimum Data Set (MDS) a federally mandated assessment tool completed by facility staff, dated 1/3/20, showed the following: - Date of admission [DATE]; - Cognitively intact; - Diagnoses included hip and knee replacement and chronic kidney disease; - Required extensive assistance with bed mobility, transfers, dressing, and toilet use; - Was always continent of bowel and bladder. During an interview on 2/11/20 at 8:19 A.M., the resident said he/she: - Has had two bowel incontinence accidents waiting for staff since being admitted to the facility; - Has to wait 15 minutes for call lights to be answered; - Felt embarrassed and bad when it happened - Did not feel like there were enough staff in the facility. Review of the resident's call light record showed the following dates and times were over 15 minutes: - 12/28/19 at 4:40 P.M. (26 minutes); - 12/29/19 at 6:45 P.M. (38 minutes); - 1/7/20 at 5:01 A.M. (17 minutes); - 1/8/20 at 11:46 A.M. (23 minutes); - 1/8/20 at 3:12 P.M. (22 minutes); - 1/8/20 at 4:24 P.M. (34 minutes); - 1/8/20 at 8:27 P.M. (29 minutes); - 1/9/20 at 9:01 A.M. (19 minutes); - 1/11/20 at 7:26 A.M. (19 minutes); - 1/11/20 at 9:14 A.M. (20 minutes); - 1/11/20 at 9:10 P.M. (25 minutes); - 1/12/20 at 7:53 A.M. (20 minutes; - 1/12/20 at 8:16 A.M. (15 minutes). 2. Review of Resident #203's baseline care plan dated 2/9/20 showed: - Date of admission 2/8/20; - Cognitively intact; - Required a one-person physical assist for personal hygiene, toilet use, dressing, and bathing - Always continent of bladder and occasionally incontinent of bowel; During an interview on 2/11/20 at 8:44 A.M., the resident said: - Staff have left him/her on the toilet up to 20 minutes and it causes pain in his/her hips; - He/she has irritable bowel syndrome and has had one episode of diarrhea bowel incontinence because he/she had to wait for staff to take him/her to the bathroom; - He/she was continent when he/she lived in his/her own home but was currently dependent on staff to take him/her to the bathroom; - Staff answered call lights between five and 15 minutes; - It did not make him/her feel very comfortable when he/she was incontinent; - He/she did not feel like the facility had enough staff. Review of the resident's call light record showed the following dates and times were over 15 minutes: - 2/9 at 4:44 P.M. (18 minutes); - 2/10 at 10:10 P.M. (16 minutes). 3. During an interview on 2/13/20 at 11:46 A.M., Certified Nurse Aide (CNA) E said: - If resident pushed the call light/[NAME], staff received a notification on that staff's phone which showed the area of where the resident was. Staff received another notification after five minutes if the light had not been answered or if someone forgot to turn the light/[NAME] off; - Staff are suppposed to answer call lights before the first sound off which occurred after five minutes but he/she tried to answer them within two minutes. During an interview on 2/13/20 at 1:51 P.M., Licensed Practical Nurse (LPN) C said: - Staff should answer call lights as soon as they can; - Sometimes it seemed like they all get pushed at the same time, especially after dinner; - Sometimes staff did not get to residents as fast as what the residents wanted; - Five minutes or less is acceptable timeframe to answer the call lights; - Sometimes it felt like they could not meet that because of everything going on, and everyone asking for assistance at once; - Most of the time, it felt like there was sufficient staff, but there were times they felt short-handed, but the facility did the best they could. During an interview on 2/13/20 at 4:17 P.M., the Facility Director said: - Staff should answer call lights as soon as a staff member is available; - Different situations dictate response times; - He would not want the facility average to be over 20 minutes or so; - He would consider it a problem if residents were becoming incontinent, that should not be the norm. MO166306

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene when staff did not provide complete perineal care, which affected two of 14 sampled residents (Residents #1 and #42), and failed to ensure facility staff did not rely solely on Hospice (end of life care) staff to provided showers for Resident #42. The facility census was 56. Review of the facility's undated perineal care protocol showed, in part: - Perineal care is very important in maintaining the resident's comfort and should be done after an incontinent episode and as a part of the bathing; - Separate the perineal folds and wash with a soapy washcloth/wipe, moving from front to back, on each side of the perineal folds and in the center over the skin folds; - Cleanse from the tip of the skin folds and clean all the skin folds; - Wash the buttocks and peri -anal area without contaminating the perineal folds. 1. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/24/20, showed: - Cognitive skills severely impaired; - Required extensive assistance of two staff for bed mobility, transfers and toilet use; - Frequently incontinent of bowel and bladder; - Diagnoses included dementia and anxiety. Review of the resident's care plan, revised on 1/28/20, showed: - Required assistance with ADLs; - Required extensive assistance of one staff for toilet use. Observation on 2/10/20 at 10:50 A.M., showed: - Certified Nurse Aide (CNA) B transferred the resident onto the toilet; - CNA B removed the resident's wet incontinent brief; - CNA B used a washcloth and with the same area of the washcloth cleaned the top of the resident's buttocks, hips and the front perineal area; - CNA B placed a clean incontinent brief and clean pants on the resident; - CNA A used a different wipe each time and wiped twice front to back; - CNA A assisted the resident to pull up his/her pants and assisted him/her into his/her wheelchair. During an interview on 2/13/20 at 9:26 A.M., CNA A said: - Should clean all areas of the skin where urine or feces has touched. During an interview on 2/13/20 at 9:50 A.M., CNA B said: - Should separate and clean all areas of the skin where urine or feces has touched; - Should not use the same area of the wipe to clean different areas of the skin. 3. Review of Resident #42's care plan, revised on 3/18/19, showed: - The resident is incontinent of bowel and bladder related to unable to make his/her needs known, has a diagnoses of Alzheimer's type dementia; - Check approximately every two hours and as needed; - Provide incontinence care as needed; - Use disposable briefs and change as needed. Review of the resident's quarterly MDS, dated [DATE], showed: - Cognitive skills severely impaired; - Required extensive assistance of two staff for bed mobility, transfers and dressing; - Dependent on the assistance of two staff for toilet use and bathing; - Lower extremities impaired on both sides; - Always incontinent of bowel and bladder; - Diagnoses included Alzheimer's. Observation on 2/12/20, at 10:15 A.M., showed: - CNA B and CNA C used the mechanical lift to transfer the resident from his/her Broda chair (a type of reclining geri-chair) to his/her bed and removed his/her pants and dry incontinent brief; - CNA C used a different wipe and wiped down each side of the resident's groin; - CNA C used a new wipe and wiped down the middle; - CNA C did not separate and clean all areas of the skin folds; - CNA C used the same area of the wipe and cleaned both sides of the resident's buttocks and wiped from front to back; - CNA C placed a clean incontinent brief and pants on the resident and covered the resident with a blanket. During an interview on 2/13/20 at 9:56 A.M., CNA C said: - He/she should not use the same area of the wipe to clean different areas of the skin; - Should separate and clean all areas of the skin. 4. During an interview on 2/13/20 at 4:17 P.M., the Director of Nursing (DON) said: - Staff should clean all areas of the skin; - Should not use the same area of the wipe to clean different areas of the skin. 5. Review of the facility's undated assisting with a shower policy showed, in part: - Based on their comprehensive assessment, staff will ensure that each resident's abilities in ADLs, including showering, will not diminish unless circumstances of the resident's medical condition demonstrates that the decline was unavoidable; - The first time a staff member assists a resident with a shower, the resident's care plan will be reviewed to ensure all preferences of them receiving a shower are honored. Review of Resident #42's quarterly MDS, dated [DATE], showed: - Cognitive skills severely impaired; - Required extensive assistance of two staff for bed mobility, transfers and dressing; - Dependent on the assistance of two staff for toilet use and bathing; - Lower extremities impaired on both sides; - Always incontinent of bowel and bladder; - Diagnoses included Alzheimer's. Review of the resident's care plan, revised on 2/11/20, showed: - The resident had a self-care deficit related to dementia; - Bathing two times a week per resident's/family preference. Review of the resident's shower sheets for December, 2019, showed: - 12/2/19- facility provided the shower; - 12/2/19- bed bath provided by Hospice; - 12/18/19- shower provided by Hospice; - 12/20/19- shower provided by Hospice. - The facility staff did not provide any other showers for the resident. Review of the resident's shower sheets for January, 2020, showed: - 1/8/20- shower provided by Hospice; - 1/13/20- shower provided by Hospice; - 1/22/20- shower provided by Hospice; - 1/27/20- shower provided by Hospice. - The facility did not provide any other showers for the resident. Review of the resident's shower sheets for February, 2020, showed: - 2/3/20- facility provided the shower; - 2/5/20- facility provided the shower; - 2/10/20- facility provided whirlpool tub bath. During an interview on 2/13/20 at 4:17 P.M. the DON said: - The facility did not have a shower aide; - The residents should be getting two showers a week if that's what the resident expected; - If a resident was on Hospice, the facility would be responsible for the showers, unless it's care planned a different way.

Based on observations, interview, and record review, the facility failed to ensure staff provided complete catheter (sterile tube inserted into the bladder to drain urine) care in a manner to prevent infection or the possibility of infection which affected one of 14 sampled residents (Resident #45). The facility census was 56. 1. Review of the facility's undated indwelling catheter protocol showed, in part: - A physician must order the placement of an indwelling catheter including the appropriate and approved indication for use of the catheter with an estimation of the stop date; - Because of the danger of infection when a catheter is introduced, the equipment used must be sterile and should be sterile and should be handled aseptically; - Wash hands immediately before and after any manipulation of the catheter site or drainage bag; - Never allow the bag or tubing to touch the floor; - Empty the Foley bag every shift or when the drainage bag is 2/3 full, to prevent infection and to avoid traction on the catheter from the weight of the drainage bag. - Perform hand hygiene and apply gloves. - Take a clean measuring container to the resident's bedside. - Release port drainage tube from plastic holder on the side of the drainage bag. - Position measuring receptacle under the drainage port. - Release the clamp allowing urine to flow into the measuring container. - When drainage bag is empty, re-clamp port, clean with alcohol wipe and replace port. - Staff emptying the drainage bag should wash hands and apply gloves prior to emptying the bag and wash hands after glove removal. 2. Review of Resident #45's significant change in status Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/17/20, showed: - Cognitive skills moderately impaired; - Required extensive assistance of one staff for bed mobility, transfers and toilet use; - Had a Foley catheter; - Frequently incontinent of bowel; - Diagnoses included cancer. Review of the resident's urinalysis (US, a test to analyze urine contents), dated 1/29/20, showed the presence of bacteria indicative of a possible urinary tract infection (UTI). Review of the resident's urine and culture and sensitivity (UA with C&S, identifies the amount and type of bacteria present and the medications appropriate to treat the infection), dated 1/31/20, showed the presence of organisms indicative of a possible UTI. Review of the resident's order audit report for 2/1/20, showed: - An order for Cipro 250 milligrams (mg), one tablet twice daily for infection for seven days. Review of the resident's physician order sheet (POS), printed on 2/11/20, showed: - Did not have an order for a Foley catheter. Observation on 2/12/20, at 9:19 A.M., showed: - Certified Nurse Aide (CNA) A entered the resident's room, did not wash his/her hands and applied gloves; - CNA A used the gait belt (a special belt placed around the resident's waist to provide a handle to hold onto during a transfer), and transferred the resident from his/her wheelchair onto the toilet; - CNA A emptied the urinary drainage bag into a graduate (measuring device) and cleaned the drainage port tubing with a wipe; - CNA A removed gloves, did not wash his/her hands and applied new gloves; - The resident used the grab bar and stood up; - CNA A wiped front to back multiple times with fecal material on each wipe and used a different wipe each time; - CNA A used a new wipe and with the same area of wipe cleaned different areas of the skin folds; - CNA A used a new wipe and cleaned around the insertion site and with the same area of the wipe cleaned down the catheter tubing, anchored the catheter tubing and used the same area of the wipe and cleaned up and down the catheter tubing; - CNA A cleaned fecal material from the stool riser and the toilet with a wipe; - CNA A pulled the resident's incontinent brief and pants up and assisted him/her into the wheelchair; - CNA A transferred the resident from his/her wheelchair into the bed and placed the drainage bag with a dignity cover over it on the side of the resident's bed; - CNA A removed his/her gloves, did not wash his/her hands and left the room. During an interview on 2/13/20, at 9:26 A.M., CNA A said: - Should have washed and/or sanitized his/her hands when he/she entered the resident's room, before leaving the room, between glove changes and when cleaning fecal material; - He/she should use one wipe per one swipe and should not use the same area of the wipe to clean different areas of the skin; - Should separate and clean all areas of the skin where urine or feces has touched; - Should not clean back and forth on the catheter tubing, should clean from the insertion site down in one swipe. During an interview on 2/13/20 at 4:17 P.M., the Director of Nursing (DON), said: - All areas of the skin should be cleaned and staff should not use the same area of the wipe to clean different areas of the skin; - Staff should clean the tubing from the insertion site outward in one swipe; - Staff should clean the drainage port with an alcohol wipe.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #31's comprehensive MDS, dated [DATE], showed the following: - Date of admission [DATE]; - Cognitively intact; - Diagnoses included hip and knee replacement, and chronic kidney disease; - Received oxygen therapy. Review of the resident's POS for February 2020 showed the resident did not have any orders for oxygen therapy. Review of the resident's treatment administration record (TAR) showed the following orders: - Oxygen 2 to 4 L/NC every shift; - Change oxygen and/or nebulizer tubing weekly and as needed. Review of the resident's care plan showed staff did not include any information regarding oxygen therapy. Observation and interview on 2/11/20 at 8:27 A.M., showed: - The oxygen concentrator's filter was grey with dust and there was not a date on the tubing. - The resident said he/she received oxygen as needed throughout the day and at night; it was usually set on 2 liters per minute. 4. During an interview on 2/13/20 at 10:50 A.M., Registered Nurse (RN) A said: - Nursing was responsible for telling certified nurse aides (CNA) to change oxygen tubing; the tubing should be dated; - CNAs should be clean the filters and should be looking at them every day. 5. During an interview on 2/13/20, at 4:17 P.M., the Director of Nursing (DON) said: - The resident should have a physician's order for oxygen; - The oxygen tubing should be changed weekly and dated and the filters should be cleaned at that time; - The humidified water bottle should not be empty. Based on observations, interviews and record review, the facility failed to assure staff provided proper respiratory care when staff failed to ensure the oxygen concentrator had humidified sterile water, which affected one of 14 sampled residents (Resident #15), failed to properly clean oxygen concentrator filters and failed to date the oxygen tubing, which affected two sampled residents (Resident #15 and #31). The facility census was 56. 1. Review of the facility's undated oxygen administration policy showed, in part: - Oxygen therapy is the administration of oxygen to treat or prevent signs and symptoms of hypoxemia (abnormally low concentration of oxygen in the blood), or medical conditions that are known to clinically improve with oxygen; - Oxygen concentrators, cylinders and equipment will be kept and maintained in such a way as to be compliant with all relevant health and safety guidelines; - Oxygen therapy will be administered or supplied with a prescription from the resident's primary care physician and recorded in each resident's medical record; - Pre-filled disposable humidifiers will be changed weekly; - Label and date the oxygen tubing; - Change the cannula and tubing weekly. 2. Review of Resident #15's admission Minimum Data Set (MDS), dated [DATE], showed: - Cognitive skills for daily decision making moderately impaired; - Required extensive assistance of two staff for bed mobility, transfers and dressing; - Used oxygen; - Diagnoses included congestive heart failure (CHF, a decrease in the ability of the heart to pump blood, resulting in an accumulation of fluid in the lungs and other areas of the body), Alzheimer's disease, dementia and chronic obstructive pulmonary disease (COPD, obstruction of air flow that interferes with normal breathing). Review of the resident's care plan, revised 2/11/20, showed: - The resident received oxygen therapy; - Give medications as ordered by the physician; - Oxygen settings: oxygen at 2 liters (L)/nasal cannula (NC), humidified. Review of the resident's physician order sheet (POS), printed on 2/11/20, showed: - The resident did not have an order for oxygen. Observation on 2/10/20, at 2:40 P.M., showed: - The oxygen tubing was not dated; - The sterile humidified water bottle attached to the oxygen concentrator was empty; - The filter on the oxygen concentrator was covered in gray lint; - The oxygen was set at 4L/NC.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure staff maintained a medication error rate of less than five percent (%). Staff made four medication errors out of 25 possible errors for an error rate of 16%. These errors affected one of 14 sampled residents (Resident #32). The facility census was 56. 1. Review of the facility's undated gastrostomy tube feedings policy showed, in part: - Gastrostomy feedings will be administered in a safe sanitary manner to provide nourishment in the form of liquid, through a tube into the stomach; - Aspirate for gastric residual, then re-insert gastric contents; - The gastric residual of residents fed continuously will be checked every four hours. Review of the facility's undated medication administration policy showed, in part: - All medications will be administered to every resident as ordered by a physician in a safe and sanitary manner; - The only exceptions are those medications to which the physician has placed specific times; - If the resident has difficulty swallowing a tablet, a licensed nurse will determine if the tablet can be crushed for administration; - The licensed nurse will refer to the list of medications that can be safely crushed provided by the consultant pharmacist; - If the medication can be crushed, directions for administering the crushed medication will be added to the medication administration record (MAR); - In the event the medication cannot be crushed, the licensed nurse will notify the physician of the resident's difficulty in swallowing the ordered medication; - Avoid crushing tablets or capsule that the manufacturer states Do Not Crush; - Exception to the Do Not Crush rule: if the physician orders the medication to be crushed and the manufacturer states it should not be crushed, the physician or pharmacist must explain in the medical record why crushing the medication will not adversely affect the resident. 2. Review of the website www.mayoclinic.org for atorvastatin (used to treat high cholesterol)showed: - Swallow the tablet whole; - Do not break, crush or chew it. Review of the website www.drugs.com for metoprolol (used to treat high blood pressure) showed: - Swallow the tablet whole; - Do not crush, chew or break it. Review of the website www.mayoclinic.org for mucus relief (guaifenesin) showed: - Do not crush or chew it. Review of the website www.pennstatehershey.[NAME].com for probiotic (acidophilus) showed: - Swallow the tablet whole; - Do not chew, crush or break it. 3. Review of Resident #32's physician order sheet (POS), printed on 2/13/20, showed: - An order for Jevity 1.5 at 70 milliliters (mL)/hour, 18 hour continuous feed and off from 10:00 A.M. - 4:00 P.M., for therapy; - Crush all medications and administer through percutaneous endoscopic gastrostomy (PEG) tube, (a tube placed in the stomach to provide a route to deliver nutrition, fluids and medications) until changed by physician; - An order for atorvastatin calcium tablet 80 milligrams (mg), one tablet via PEG tube in the morning for hyperlipidemia (elevated levels of lipids and cholesterol); - An order for metoprolol tartrate 25 mg, 12.5 mg via PEG tube every morning and at bedtime for high blood pressure; - An order for probiotic one capsule via PEG tube in the morning for supplement; - An order for mucus relief (guaifenesin) 400 mg, one via PEG tube in the morning for cough. Review of the resident's medication administration record (MAR), printed on 2/13/20, showed: - Atorvastatin 80 mg via PEG tube in the morning for hyperlipidemia; - Mucus relief (guaifenesin) 400 mg, one tablet via PEG tube in the morning for cough; - Probiotic capsule one capsule via PEG tube in the morning for supplement; - Metoprolol tartrate 25 mg, give 12/5 mg via PEG tube every morning and at bedtime for high blood pressure. Observation on 2/12/20, at 7:35 A.M., showed Registered Nurse (RN) B did the following: - Placed the metoprolol 25 mg, 12.5 mg in a plastic pouch and crushed it and placed it in a cup with 30 mL of water; - Placed the atorvastatin 80 mg in a plastic pouch, crushed it and placed it in a cup with 30 mL of water; - Placed the mucus relief (guaifenesin) in a plastic pouch, crushed it and placed it in a cup with 30 mL of water; - Placed the acidophilus in a plastic pouch, crushed it and placed it in a cup with 30 mL of water; - Stopped the continuous feeding, cleaned the port with an alcohol wipe, flushed the port with 50 mL of water and did not check for residual; - Flushed with 10 mL of water before each medication, administered the medication and flushed after each medication with 10 mL of water. During an interview on 2/13/20 at 8:14 A.M., RN B said: - With the type of PEG tube the resident had, you do not have to check for residual; - Should double check to make sure all the medications could be crushed. During an interview on 2/13/20 at 4:17 P.M., the Director of Nursing (DON) said: - Crush information is available on the computer on orders and should have a symbol to show if the medication should be crushed; - If the medication should not be crushed, staff should contact the physician to see if they can change the form.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #31's comprehensive Minimum Data Set (MDS) a federally mandated assessment tool completed by facility staff, dated 1/3/20, showed the following: - Date of admission [DATE]; - Cognitively intact; - Diagnoses included hip and knee replacement, and chronic kidney disease; - Was at risk for pressure ulcers. Review of the resident's care plan, dated 1/28/20, showed: - The resident had skin impairment on his/her right foot, right heal, and right lateral foot but did not include any information about his/her left foot; - The care plan did not include any information about the resident receiving oxygen therapy. Review of the resident's February 2020 physician orders sheet (POS) showed the following active order: - Cleanse and apply skin prep to skin prep (used to as a protective film or barrier to the skin) to skin injuries to right medial foot, right ankle and left ankle, right heel and left heel, first, second, and third and great toe on left food daily every day shift for wound care; May place border dressings on heels if needed but absolutely no abdominal pads and no kerlix (woven gauze used to wound care) as it puts too much pressure on his/her heels; Start date 2/5/20; - The POS did not include any orders for oxygen. Review of the resident's February 2020 treatment administration record (TAR) showed the following orders: - Oxygen 2 to 4 liters per minute by nasal cannula every shift; - Cleanse and apply skin prep to skin prep to skin injuries to right medial foot, right ankle and left ankle, right heel and left heel, first, second, and third and great toe on left food daily every day shift for wound care; May place border dressings on heels if needed but absolutely no abdominal pads and no kerlix as it puts too much pressure on his/her heels; Start date 2/5/20. Review of a wound assessment, dated 2/5/20, showed the resident had pressure ulcers on his/her right and left heels, and abrasions to his/her left and right ankles. During interviews on 2/11/20 at 8:27 A.M., and 2/13/20 at 9:05 A.M., the resident said: - He/she had pressure ulcers on both feet; - Was receiving treatment, sometimes every day, sometimes every other day; - He/she received oxygen as needed throughout the day and at night, it was usually set on 2 liters per minute. 3. Review of an undated facility policy titled Fall Prevention included the following: - Each resident who resides at the facility will be provided care and services that ensure their environment remains as free from accident hazards as possible and each resident receives adequate supervision and assistive devices to prevent accidents. Every resident will be assessed for causal risk factors related to falling at the time of admission, upon return from a health care facility and after every fall in the facility; - On the day of admission, a licensed nurse will assess the resident to determine their risk for falls utilizing the fall assessment form; - Interview the resident and family members to determine factors that may predispose the resident to falls and/or activities that have helped prevent falls in the resident's previous environment; - Ensure optimal communication regarding the resident's condition and potential for falls with other care providers, including but not limited to shift change meetings, briefings, and de-briefings, care plans, etc.; - The interdisciplinary team will develop a plan for services to improve and/or maintain the resident's standing and sitting balance as well as other interventions to reduce the resident's risk for falls. The plan will include specific individualized information regarding the resident's routine and personal habits that may place the resident at risk for falls such as nigh time voiding or night time wondering; - Every team member is responsible for checking the care plan of residents who are at risk for falls when beginning each day and throughout the assigned shift. Review of Resident #41's fall risk assessment, dated 1/13/20, showed staff assessed the resident as at high risk for falls. Review of the resident's comprehensive MDS, dated [DATE], showed: - Date of admission 1/13/20; - Severe cognitive impairment; - Required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene; - Diagnoses included urinary tract infection within the last 30 days, bone fractures, and Alzheimer's disease; - Had a fall that caused a fracture in the six months prior to admission; Review of the resident's care plan, dated 1/22/20, showed: - The resident was at risk for falls due to diminished safety awareness, impaired mobility, incontinence, and history of falls; - Interventions included to ensure the resident had his/her call light within reach and encourage the resident to use it for assistance, the resident needed activities that minimize the potential for falls while providing diversion and distraction, educate family/caregivers about safety reminders and what to do if a fall occurs, and ensure the resident was wearing appropriate footwear non-skid socks or non-skid shoes when ambulating or mobilizing in his/her wheelchair; - The care plan did not say anything about a toileting schedule, making frequent checks, or keeping the resident's bed in a low position, and did not address any falls that occurred at the facility. Review of a nursing note, dated 1/28/20 at 5:19 P.M., showed staff documented: - The resident was found in the kneeling position at his/her bedside; - No apparent injury found; - Nurse supervisor called; resident's family member notified and requested x-rays on his/her bilateral knees; - The on call was notified and relayed that he/she would assess in the morning; - The administrator notified to check the progress notes as notification of incident occurrence. Review of the Multidisciplinary Care Conference document, dated 1/29/20, showed the resident's family member said the resident did not always remember to use his/her call light and needed frequent checks. The family member had concerns with the resident getting up and falling. The document noted that the facility informed the family member that the resident had the right to fall and it could occur right after someone had checked on him/her. Review of an assessment document completed by the facility's Nurse Practitioner (NP), dated 1/28/20, showed: - The resident was admitted to the facility after a stay at a hospital for a fall with a sacral fracture; - The assessment and plan included that the NP would discuss the plan of care with the Director of Nursing (DON) and have nursing staff put the resident on an every two hour toileting schedule and to check on him/her more frequently at night; - Keep bed in low position. Observation and interview on 2/10/20 at 1:57 P.M., the resident's family member said: - The resident had fallen one time since being admitted to the facility; - He/she was found on his/her knees next to bed; there were no injuries; - The facility said they could not do anything but check on him/her every two hours. - The bed was not positioned in a low position. During an interview on 2/12/20 at 11:05 A.M., Certified Nurse Aide (CNA) D said: - He/she was familiar with the resident's care; - The resident did not have any fall precautions and had not fallen while in the facility that he/she knew of. During interview on 2/12/20 at 11:16 A.M. and 1:28 P.M., the DON of the Rehab Unit said: - Staff checked on all residents every two hours; increased monitoring would be more than that; - Care plans should be updated to show an actual fall if a resident falls while in the facility; - The DON or Risk Manager would update the care plans when a fall occurred; - The resident was not on a toileting schedule per the request of the NP and she did not know why; - Increased monitoring was discussed with the family at a care plan meeting; the family requested they peak in on the resident when they are on that side of the hall but they already did that anyway; - There was no documentation of any increased monitoring; - Resident care needs were communicated during shift change but also through the care plans. 4. During an interview on 2/13/20 at 4:17 P.M., the DON said: - Care plans should address the use of catheters; - If a resident has pressure ulcers on both feet, the care plan should reflect that; - The care plans should address the specific needs of the residents. Based on observations, interviews and record review, the facility failed to assure staff used the comprehensive assessment to develop, implement and review a comprehensive person-centered plan of care consistent with the resident's specific conditions, needs and risks, which affected three of 14 sampled residents (Resident #31, #45 and #41). The facility census was 56. 1. Review of Resident #45's care plan, revised 11/27/19, showed: - The resident required activities of daily living (ADL) assistance related to generalized weakness and brain cancer; - Extensive assistance of one staff for toileting; - The care plan did not address the resident's indwelling catheter (sterile tube inserted into the bladder to drain urine). Review of the resident's significant change in status Minimum Data Set (MDS), dated [DATE], showed: - Cognitive skills moderately impaired; - Required extensive assistance of one staff for bed mobility, transfers, and toilet use; - Had a Foley catheter; - Diagnoses included cancer. Observation on 2/10/20 at 2:00 P.M., showed: - The resident lay in bed, covered with a blanket and the drainage bag hung on the side of the bed with a dignity cover over it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. The facility did not provide a policy regarding the treatment of pressure ulcers according to physician orders. Review of Resident #31's comprehensive Minimum Data Set (MDS) a federally mandated assessment tool completed by facility staff, dated 1/3/20, showed the following: - Date of admission [DATE]; - Cognitively intact; - Diagnoses included hip and knee replacement, and chronic kidney disease; - Was at risk for pressure ulcers. Review of the resident's care plan, dated 1/28/20, showed: - The resident had skin impairment on his/her right foot, right heal, and right lateral foot but did not include any information about his/her left foot; - The care plan did not include any information about the resident receiving oxygen therapy. Review of the resident's February 2020 physician orders sheet (POS) included the following active order: - Cleanse and apply skin prep to skin prep (used to as a protective film or barrier to the skin) to skin injuries to right medial foot, right ankle and left ankle, right heel and left heel, first, second, and third and great toe on left food daily every day shift for wound care; may place border dressings on heels if needed but absolutely no abdominal pads and no kerlix (woven gauze used in would care) as it puts too much pressure on his/her heels; start date 2/5/20; - The POS did not include any orders for oxygen. Review of the resident's February 2020 treatment administration record (TAR) showed the following orders: - Oxygen 2 to 4 liters per minute by nasal cannula every shift; - Cleanse and apply skin prep to skin prep to skin injuries to right medial foot, right ankle and left ankle, right heel and left heel, first, second, and third and great toe on left food daily every day shift for wound care; may place border dressings on heels if needed but absolutely no abdominal pads and no kerlix as it puts too much pressure on his/her heels; start date 2/5/20; - Staff did not initial to indicate they completed these treatments on 2/7/20, 2/11/20, or 2/12/20; - The TAR also had a discontinued order for Santyl ointment (used to treat skin ulcers) 250 unit/gram, apply to right heel topically every day shift for wound care; order date 1/25/20, and discontinued 2/12/20. - Staff did not initial to indicate they completed these treatments on on 2/1/20, 2/2/20, 2/7/20, 2/9/20, and 2/11/20. Review of a wound assessment, dated 2/5/20, showed the resident had pressure ulcers on his/her right and left heels, and abrasions to his/her left and right ankles. During an interview on 2/13/20 at 8:30 A.M., RN B said: - The resident went to dialysis Monday, Wednesday, and Friday; - They facility tried to get his/her wound treatments completed in the mornings or right when he/she got back from dialysis; - He/she completed the treatment on 2/11/20 and must not have completed the TAR; - He/she asked another nurse to complete it on 2/12/20 due to the resident being at dialysis when he/she was on duty. During interviews on 2/11/20 at 8:27 A.M. and 2/13/20 at 9:05 A.M., the resident said: - He/she had pressure ulcers on both feet; - He/she was receiving wound treatments, sometimes every day, sometimes every other day. 6. During an interview on 2/13/20 at 4:17 P.M., the DON said: - All insulin bottles and pens should be dated when opened - The resident's pressure ulcers treatments should be completed daily according to physician orders. Based on observations, interviews, and record review, the facility failed to ensure staff followed professional standards of care when staff did not administer Flonase (used to treat seasonal allergies) correctly and failed to administer Restasis eye drops (used to treat dry eyes caused by inflammation, which affected one of 14 sampled residents (Resident #24), failed to obtain an order for oxygen therapy for one sampled resident (Resident #15), failed to date an opened insulin pen for one sampled resident (Resident #201), and failed to provide wound care according to physician orders for one sampled resident (Resident #31). The facility census was 56. 1. The facility did not provide a policy for administration of eye drops or administration of nasal sprays. Review of the facility's undated medication administration policy showed, in part: - All medications will be administered to every resident by a licensed nurse or a certified medication technician (CMT) and as ordered by a physician in a safe and sanitary manner; - For eye medications, use pressure applied to the tear duct inner eye area for one to two minutes following administration of eye drops. Review of the facility's undated insulin pen administration policy showed, in part: - The purpose of this policy is to improve the accuracy of insulin dosing and provide increased resident comfort; - Once the insulin pen has been opened, write the start date on the label. Review of the manufacturer's guidelines for Flonase nasal spray showed, in part: - Blow your nose to clear your nostrils; - Close one nostril; tilt your head forward slightly and keeping the bottle upright, carefully insert the nasal applicator into the other nostril; - Start to breathe in through your nose, and while breathing in, press firmly and quickly down once on the applicator to release the spray; - Repeat in the other nostril. Review of the website www.drugs.com for how to administer Restasis eye drops showed: - Tilt your head back slightly and pull down your lower eyelid to create small pocket; hold the dropper above the eye with the tip down; look up and away from the dropper and squeeze out a drop; - Close your eyes for two to three minutes with head tipped down, without blinking or squinting . - Gently press your finger to the inside corner of the eye for about one minute (lacrimal pressure) to keep the liquid from draining into your tear duct. 2. Review of Resident #15's care plan, revised 2/11/20, showed: - The resident is receiving oxygen therapy; - Oxygen settings: 2 liters (L) via nasal cannula (NC) continuously, humidified. Review of the resident's physician order sheet (POS), printed on 2/11/20, showed: - The resident did not have an order for oxygen therapy. Observation on 2/10/20, at 2:40 P.M., showed: - The resident had oxygen on at 4L/NC. During an interview on 2/13/20, at 4:17 P.M., the Director of Nursing (DON) said: - The resident should have an order for oxygen. 3. Review of Resident #24's POS, printed on 2/11/20, showed: - An order for cyclosporine emulsion (Restasis) 0.05%, instill one drop in both eyes in the morning for dry eyes; - An order for Flonase nasal spray 50 micrograms (mcg), one spray in each nostril in the morning for nasal symptoms. Review of the resident's medication administration record (MAR), printed on 2/13/20, showed: - Cyclosporine emulsion 0.05%, instill one drop in both eyes in the morning fro dry eyes; - Flonase nasal spray 50 mcg, one spray in each nostril in the morning for nasal symptoms. Observation on 2/12/20, at 7:20 A.M., showed: - CMT A entered the resident's room and the resident said he/she would administer the Restasis and the Flonase him/herself; - After the resident administered the eye drop in each eye, he/she used a Kleenex and wiped his/her eyes; - The resident did not apply lacrimal pressure to each eye and CMT A did not give the resident any instructions; - CMT A shook the Flonase bottle and gave it to the resident; - The resident gave him/herself one spray in each nostril; - The resident did not blow his/her nose before administration and did not hold one side of the his/her nostril closed when administering the nasal spray; - CMT A did not give the resident any instructions on how to administer the nasal spray. During an interview on 2/13/20 at 8:27 A.M., CMT A said: - He/she should make sure to follow the manufacturer's guidelines for the nasal spray, have the resident blow their nose beforehand and have the resident hold one side of their nostril closed when administering the nasal spray; - He/she should make sure the resident applied lacirimal pressure for one minute; - He/she should have given the resident instructions on how to use the nasal spray and the eye drops. During an interview on 2/13/20, at 4:17 P.M., the DON said: - Staff should follow the manufacturer's guidelines for the nasal spray; - Staff should make sure the resident applied lacrimal pressure after administering the eye drops and should give the resident instructions. 4. Review of Resident #201's POS, printed on 2/13/20, showed: - An order for Humalog insulin 10 units for three times daily for diabetes mellitus; - An order for Humalog insulin per sliding scale, for blood sugar 61-70, subtract two units of insulin. Review of the resident's MAR, printed on 2/13/20, showed: - Check blood sugars before meals and at bedtime; - Humalog insulin 10 units three times a day for diabetes mellitus; - For blood sugar 61-70, subtract two units of insulin for diabetes mellitus. Observation on 2/12/20, at 11:20 A.M., showed: - Registered Nurse (RN) A obtained the resident's blood sugar of 61; - RN A cleaned the top of the Humalog insulin bottle with an alcohol wipe and drew up 8 units of insulin and administered to the resident; - The bottle of Humalog insulin did not have a date when it was opened. During an interview on 2/12/20, at 11:26 A.M., RN A said: - The insulin bottle did not have a date when it was opened; - The insulin bottle should have been dated when it was opened.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to provide adequate staffing to meet the needs of residents due to extended call light response times, causing residents to become incontinent, which affected four of 14 sampled residents (Resident #1, #31, #41 and #203), and failed to provide wound care according to physician orders for one resident (Resident #31). The facility census was 56. The facility did not provide a policy regarding call light response times. 1. Review of Resident #31's comprehensive Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 1/3/20, showed the following: - Date of admission [DATE]; - Cognitively intact; - Diagnoses included hip and knee replacement, and chronic kidney disease; - Required extensive assistance with bed mobility, transfers, dressing, and toilet use; - Was always continent of bowel and bladder; - Was at risk for pressure ulcers. Review of the resident's care plan, dated 1/28/20, showed: - The resident had skin impairment on his/her right foot, right heal, and right lateral foot but did not include any information about his/her left foot. Review of the resident's February 2020 physician orders sheet (POS) included the following active order: - Cleanse and apply skin prep (used to as a protective film or barrier to the skin) to skin injuries to right medial foot, right ankle and left ankle, right heel and left heel, first, second, and third and great toe on left food daily every day shift for wound care; - May place border dressings on heels if needed but absolutely no abdominal pads and no kerlix (woven gauze used for wound care) as it puts too much pressure on his/her heels; - Start date 2/5/20. Review of the resident's February 2020 treatment administration record (TAR) showed the following orders: - Cleanse and apply skin prep to skin injuries to right medial foot, right ankle and left ankle, right heel and left heel, first, second, and third and great toe on left food daily every day shift for wound care; may place border dressings on heels if needed but absolutely no abdominal pads and no kerlix as it puts too much pressure on his/her heels; start date 2/5/20; - Staff did not initial they completed the indicating treatment was completed on 2/7, 2/11, or 2/12; - Staff did not initial to indicate they completed these treatments on 2/7/20, 2/11/20, or 2/12/20; - The TAR also had a discontinued order for Santyl ointment (used to treat skin ulcers) 250 unit/gram, apply to right heel topically every day shift for wound care, order date 1/25/20, discontinued 2/12/20; - Staff did not initial to indicate they completed this treatment on 2/1/20, 2/2/20, 2/7/20, 2/9/20, and 2/11/20. During interviews on 2/11/20 at 8:19 A.M., 8:27 A.M. and 2/13/20 at 9:05 A.M., the resident said: - He/she had pressure ulcers on both feet; - He/she was receiving wound treatments, sometimes every day, sometimes every other day; - Staff woke him/her up at midnight one time to get wound treatment; - Has had two bowel incontinence accidents waiting for staff since being admitted to the facility; - Has to wait 15 minutes for call lights to be answered; - Felt embarrassed and bad when it happened; - Did not feel like there were enough staff in the facility. Review of the resident's call light record showed the following dates and times were over 15 minutes: - 12/28/19 at 4:40 P.M. (26 minutes); - 12/29/19 at 6:45 P.M. (38 minutes); - 1/7/20 at 5:01 A.M. (17 minutes); - 1/8/20 at 11:46 A.M. (23 minutes); - 1/8/20 at 3:12 P.M. (22 minutes); - 1/8/20 at 4:24 P.M. (34 minutes); - 1/8/20 at 8:27 P.M. (29 minutes); - 1/9/20 at 9:01 A.M. (19 minutes); - 1/11/20 at 7:26 A.M. (19 minutes); - 1/11/20 at 9:14 A.M. (20 minutes); - 1/11/20 at 9:10 P.M. (25 minutes); - 1/12/20 at 7:53 A.M. (20 minutes; - 1/12/20 at 8:16 A.M. (15 minutes). During an interview on 2/13/20 at 8:30 A.M., Registered Nurse (RN) B said: - The resident went to dialysis Monday, Wednesday and Friday; - They tried to get his/her wound treatments completed in the mornings or right when he/she got back from dialysis; - He/she completed the treatment on 2/11/20 and must not have completed the TAR; - He/she asked another nurse to complete it on 2/12/20 due to the resident being at dialysis when he/she was on duty. 2. Review of Resident #203's baseline care plan, dated 2/9/20, showed: - Date of admission 2/8/20; - Cognitively intact; - Required a one-person physical assist for personal hygiene, toilet use, dressing, and bathing; - Always continent of bladder and occasionally incontinent of bowel. During an interview on 2/11/20 at 8:44 A.M., the resident said: - Staff have left him/her on the toilet up to 20 minutes and it causes pain to his/her hips; - He/she has irritable bowel syndrome and has had one episode of diarrhea bowel incontinence because he/she had to wait for staff to take him/her to the bathroom; - He/she was continent when he/she lived in his/her own home but was currently dependent on staff to take him/her to the bathroom; - Staff answered call lights between five and 15 minutes; - It did not make him/her feel very comfortable when he/she was incontinent; - He/she did not feel like the facility had enough staff. Review of the resident's call light record showed the following dates and times were over 15 minutes: - 2/9/20 at 4:44 P.M. (18 minutes); - 2/10/20 at 10:10 P.M. (16 minutes). 3. Review of Resident #41's comprehensive MDS, dated [DATE], showed: - Date of admission 1/13/20; - Severe cognitive impairment; - Required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene; - Diagnoses included urinary tract infection (UTI) within the last 30 days, bone fractures, and Alzheimer's disease; - Had a fall that caused a fracture in the six months prior to admission; - Frequently incontinent of bowel and bladder; - Required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. During an interview on 2/10/20 at 1:57 P.M., the resident's family member said: - He/she did not believe there were enough staff in the facility to provide care to residents; - He/she had been told by facility staff that they were only required to provide one staff for every 10 residents and he/she did not believe that was enough; - Call light wait times were between five and 10 minutes; - Over a week ago, he/she asked a nursing staff to assist the resident with toileting; - The staff was assisting another resident get seated at the dining room table and when he/she went to find the staff to ask again the staff member was still helping the other resident. - When the family member went back to the resident's room, the resident had gotten up and went in to the restroom on his/her own. - The family member had to assist the resident with the toileting needs. Review of the resident's call light record showed the following dates and times were over 15 minutes: - 2/3/2020 at 10:06 A.M. (20 minutes). 4. Review of Resident #1's admission MDS, dated [DATE], showed: - Cognitive skills severely impaired; - Required extensive assistance of two staff for bed mobility, transfers and toilet use; - Frequently incontinent of bowel and bladder; - Diagnoses included dementia and anxiety. Review of the resident's care plan, revised on 1/28/20, showed: - Required assistance with ADLs; - Required extensive assistance of one staff for toilet use. Review of the resident's call log showed the call light was on for the following amount of time: - 2/1/20 at 8:10 A.M., 37 minutes; - 2/1/20 at 1:25 P.M., 29 minutes; - 2/1/20 at 5:58 P.M., 22 minutes; - 2/1/20 at 7:24 P.M., 22 minutes; - 2/3/20 at 11:02 A.M., 27 minutes; - 2/6/20 at 6:18 P.M., 27 minutes; - 2/8/20 at 11:46 A.M., one hour and eight minutes; - 2/9/20 at 4:43 A.M., 19 minutes; - 2/9/20 at 1:30 P.M., 28 minutes. 5. During an interview on 2/11/20 at 10:42 A.M., the Administrator said: - All the residents have call light pendants they wear and they can also use the corded call lights; - When a resident pressed the call light, it goes to the nurses and the CNAs personal cell phone or work phone. There is a phone application (app) the staff can download onto their phones; - At the nurse's console, it shows how long the call light has been going off and it shows up on the app on the staff's phone; - If the call light continues to go off and has not been answered, then it goes out again like a second call but it does not go to the DON. During an interview on 2/13/20 at 9:26 A.M., CNA A said: - He/she tried to answer them as quickly as possible; - Sometimes if he/she was in another resident's room, it might take awhile; - The call lights should be answered immediately or within 14 minutes. During an interview on 2/13/20 at 11:46 A.M., Certified Nurse Aide (CNA) E said: - Staff are supposed to answer call lights before the first sound off which occurred after five minutes, but he/she tried to answer them within two minutes; - If resident pushed a call light/[NAME], staff received a notification on their staff phone which showed the area of where the resident was. Staff received another notification after five minutes if the light had not been answered or if someone forgot to turn the light/[NAME] off. During an interview on 2/13/20 at 1:51 P.M., Licensed Practical Nurse (LPN) C said: - Staff should answer call lights as soon as they can; - Sometimes it seemed like they all get pushed at the same time, especially after dinner; - Sometimes staff did not get to residents as fast as what the residents wanted; - Five minutes or less is acceptable timeframe to answer the call lights; - Sometimes it felt like they could not meet that because of everything going on, and everyone asking for assistance at once; - Most of the time it felt like there was sufficient staff, but there were times they felt short-handed, but the facility did the best they could. During an interview on 2/13/20 at 4:17 P.M., the Facility Director said: - Staff should answer call lights as soon as a staff member is available; - Different situations dictate response times; - He would not want the facility average to be over 20 minutes or so; - He would consider it a problem if residents were becoming incontinent, that should not be the norm.

Based on observations, interviews, and record review, the facility failed to discard expired medications and biologicals stored within the medication cart and medication room, failed to date an opened vial of tuberculin purified protein derivative (skin test used to help diagnose tuberculosis infection), failed to properly label opened, multi-dose medications with dates to indicate when they were opened, which affected one of 14 sampled residents (Resident #45), failed to date opened insulin pens which affected two sampled residents (Residents #31 and #201), and failed to ensure there were no loose pills in the medication cart. The facility census was 56. 1. Review of the facility's destruction of medications by facility, revised 5/13/15, showed, in part: - Facility staff should destroy and dispose of medications in accordance with facility policy and applicable law; - All discontinued and expired medications shall be disposed of and documented appropriately by the facility nursing staff; - All discontinued medications will be immediately located and removed from the resident's active medication storage area and stored in a separate locked area for up to 90 days or as required by applicable law, and then destroyed by a manner in accordance with applicable law, and then destroyed by a manner in accordance with applicable state and federal laws. Review of the facility's undated insulin pen administration policy showed, in part: - The facility will ensure that each resident receives proper and appropriate treatment and care for insulin administration by use of the insulin pen as ordered by their physician; - Once the insulin pen has been opened, write the start date on the label. 2. Observation and interview on 2/12/20, at 9:55 A.M., of the nurse's medication cart on two west showed: - Resident #45 had an opened bottle of morphine sulfate oral solution (used to treat moderate to severe pain), without a date to indicate when staff opened it; - Licensed Practical Nurse (LPN) A said all medications should be dated when opened. Observation on 2/12/20 at 10:06 A.M., of the medication room on two west showed: - Five 10 ounce unopened bottles of sugar-free fiber laxative, expired November 2019; - Resident #45 had an opened bottle of lorazepam (used to treat anxiety) without a date to indicate when it was opened. Observation and interview on 2/12/20 at 11:31 A.M., of the Certified Medication Technician (CMT) rehabilitation medication cart, showed: - One opened lidocaine patch (used to relieve nerve pain), dated 2/11/20, without a label on it to indicate which resident it belonged to; - CMT A said he/she did not know who it belonged to or why it was in the medication cart; - Two small white tablets loose in the drawer of the medication cart; - One oblong green tablet loose in the drawer of the medication cart; - CMT A said the loose pills should be destroyed. Observation and interview on 2/12/20, at 11:49 A.M., of the rehabilitation west first floor medication room, showed: - 10 acetaminophen 650 milligram (mg) suppositories without a pharmacy label to indicate which resident they belonged to; - Registered Nurse (RN) A said he/she did not know who they belonged to; - An opened vial of influenza vaccine for 2018/2019, expired May 2019 and did not have a date when staff opened it; - 21 unopened vials of influenza vaccine for 2018/2019 season, expired May 2019; - One opened vial of tuberculin purified protein derivative did not have a date when staff opened it; - Resident #31 had an opened Novolog (fast-acting insulin) injection flex pen, with an opened dated of 12/28/19; - Resident #201 had opened insulin Lispro (fast-acting) and did not have a date when staff opened it; - Resident #31 had an opened Novolog flex pen and did not have a date when staff opened it; - RN B said expired medications should not be used; they should be destroyed. The insulin pens should have a date when they were opened and if they did not, they should be destroyed and not used. Observation and interview on 2/12/20, at 3:18 P.M., of the CMT East medication cart showed: - Rulox non-constipating antacid suspension with gas relief, the pharmacy label said it was filled on 11/27/18 and should be discarded after 12/4/19; - Opened bottle of daily multi-vitamin, expired August 2019; - LPN B said the over the counter medications should be dated when opened and should not use expired medications. The CMTs check their medication carts for expired medications and the nurses check the nurses' medication carts for expired medications. Insulin, tuberculin purified protein derivative and flu vaccines should be dated when opened. 4. During an interview on 2/13/20, at 4:17 P.M., the Director of Nursing (DON) said: - Insulin should be dated when opened; - The charge nurses check the medication rooms and the medication carts weekly; - If medications are expired, they should be removed and destroyed; - Morphine, lorazepam and tuberculin should be dated when opened; - There should not be any loose pills in the medication cart, they should be identified and destroyed and should not be administered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure staff provided care in a manner to prevent infection or the possibility of infection when they did not change their gloves or wash their hands between dirty and clean tasks, failed to clean the drainage port correctly and failed to disinfect the stool riser and toilet when it became soiled with fecal material, which affected one of 14 sampled residents (Resident #45) and when staff failed to provide a clean barrier to place a urinal on which affected one sampled resident (Resident #48). The facility census was 56. 1. Review of the facility's undated hand hygiene policy showed, in part: - The staff will comply with current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines, as effective hand hygiene reduces the incidence of healthcare-associated infections; - Indications for hand washing: when hands are visibly dirty or contaminated with blood or other body fluids, wash hands with either a non-antimicrobial soap and water or an antimicrobial soap and water; - Hand washing may also be used for routinely decontaminating hands in the following clinical situations: before and after having direct contact with residents, before and after contact with a resident's intact skin such as when assisting the resident with activities of daily living (ADL); before and after contact with body fluids or excretions, mucous membranes, and non-intact skin, even if hands are not visible soiled; when moving from a contaminated body site to a clean body site during resident care; and after removing gloves; - Gloves and hand hygiene: the use of gloves does not eliminate the need for hand hygiene; change gloves during resident care if moving from a contaminated body site to a clean body site; remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before caring for another resident. Review of the facility's undated indwelling catheter protocol showed, in part: - Because of the danger of infection when a catheter is introduced, the equipment used must be sterile and should be sterile and should be handled aseptically; - Wash hands immediately before and after any manipulation of the catheter site or drainage bag; - Empty the Foley bag every shift or when the drainage bag is 2/3 full, to prevent infection and to avoid traction on the catheter from the weight of the drainage bag. - Perform hand hygiene and apply gloves. - Take a clean measuring container to the resident's bedside. - Release port drainage tube from plastic holder on the side of the drainage bag. - Position measuring receptacle under the drainage port. - Release the clamp allowing urine to flow into the measuring container. - When drainage bag is empty, re-clamp port, clean with alcohol wipe and replace port. - Staff emptying the drainage bag should wash hands and apply gloves prior to emptying the bag and wash hands after glove removal. The facility did not provide a policy for cleaning equipment. 2. Review of Resident #45's significant change in status Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/17/20, showed: - Cognitive skills moderately impaired; - Required extensive assistance of one staff for bed mobility, transfers and toilet use; - Had a Foley catheter; - Frequently incontinent of bowel; - Diagnoses included cancer. Observation on 2/12/20, at 9:19 A.M., showed: - Certified Nurse Aide (CNA) A entered the resident's room, did not wash his/her hands and applied gloves; - CNA A used the gait belt (a special belt placed around the resident's waist to provide a handle to hold onto during a transfer) and transferred the resident from his/her wheelchair onto the toilet; - CNA A emptied the urinary drainage bag into a graduate (measuring device) and cleaned the drainage port tubing with a wipe; - CNA A removed gloves, did not wash his/her hands and applied new gloves; - After the resident stood and assisting the resident with perineal care and removing fecal material, CNA A cleaned fecal material from the stool riser and the toilet with a wipe; - CNA A assisted the resident to dress, transferred him/her back to his/her bed and placed the catheter drainage back to the dignity cover beside the bed, then CNA A removed his/her gloves, did not wash his/her hands and left the room. During an interview on 2/13/20 at 9:26 A.M., CNA A said: - Should wash and/or sanitize hands when he/she entered the resident's room, before leaving the room, between glove changes and when cleaning fecal material; - Should clean the port with a wash cloth or a wipe; - Should have cleaned the toilet and the stool riser with a sani-wipe. During an interview on 2/13/20 at 4:17 P.M., the Director of Nursing (DON) said: - Staff should wash their hands after cleaning fecal material; - Staff should wash their hands and/or sanitize their hands when they enter the resident's room, before leaving the room and between glove changes; - The toilet and the stool riser should have been disinfected; - Staff should clean the drainage port with an alcohol wipe. 3. Review of Resident #48's care plan, revised 10/25/19, showed: - The resident had an indwelling Foley catheter (sterile tube inserted into the bladder to drain urine) for neurogenic bladder (dysfunction that results from interference with the normal nerve pathways associated with urination); - Monitor and document Foley output. Review of the resident's admission MDS, dated [DATE], showed: - Cognitive skills intact; - Required extensive assistance of two staff for bed mobility, transfers, and toilet use; - Had a Foley catheter; - Always incontinent of bowel; - Diagnoses included neurogenic bladder, urinary tract infection (UTI) in the last 30 days and Parkinson's disease (progressive nervous system disorder that affects movement). Observation on 2/12/20 at 10:34 A.M., showed CNA B did the following: - Placed the urinal directly on the carpeted floor; - Unclamped the drainage spout and emptied the drainage bag in the urinal; - Cleaned the drainage spout with an alcohol wipe, clamped the spout and replaced it in the sleeve. During an interview on 2/13/20 at 9:50 A.M., CNA B said: - He/she should have placed a barrier under the urinal. During an interview on 2/13/20 at 4:17 P.M., the DON said: - Staff should place the urinal or graduate on a barrier.

Based on observation, record review and interviews, the facility failed to store cookware and dishes in a sanitary area, properly monitor sanitizer buckets and dishwasher temperatures, failed ensure they refrigerated foods that recommended refrigeration after opening, and failed to ensure facility staff used utensils or gloves when filling a cooler with ice that was used for filling residents' cups. The facility census was 56. Review of an undated facility policy titled Food Preparation and Handling Policy included the following: - All food items and products served to residents will be prepared or served from a central kitchen and/or unit kitchen serving area according to standardized recipes. Food items will be prepared using methods and techniques designed to preserve maximum nutritive value, enhanced flavor and be free of injurious organisms and substances; - The kitchen and equipment will be kept clean, neat, orderly and well maintained; - All food items, while being prepared, will be protected against contamination from dust, flies, rodents and other vermin, unclean utensils and work surfaces, unnecessary handling, coughs and sneezes, flooding, drainage and overhead leakage, and any other possible source of contamination; - All food handlers will perform hand washing regularly in a designated hand washing sink during each shift and for the following reasons included: o Before handling any food or equipment; o After handling any wrapped or unwrapped food, especially raw items; o Between different tasks; o After handling waste food or refuse; - Gloves will be worn whenever touching raw food. Food items will never be touched directly without clean gloves in place; - Gloves will be changed and hands washed between preparation of different food items and any time the gloves have been contaminated by a potentially soiled surface; - All foods will be prepared and served with clean tongs, scoops, forks, spoons, spatulas, knives, plastic gloves or other suitable implements to minimize handling and avoid manual contact of food at all points during preparation and service. 1. Observation in the main kitchen on 2/10/20 at 10:16 A.M., showed the following: - Food particles were in the bottom of three plastic tubs under the food preparation table that contained rolling pins, plastic food storage tub lids, and empty condiment bottles. Observation in the main kitchen on 2/12/20 beginning at 7:49 A.M. showed the following: - On a shelf under the food preparation table where clean steam food table trays were stored there were several food particles along the shelf. - The lead cook used a liquid measuring cup taken out of a plastic tub under the food preparation table to measure out milk to add to mashed potatoes, the tub the measuring cup was in contained several food particles in the bottom. Observation on 2/12/20 at 11:33 A.M., in the Rehabilitation Unit's kitchen showed a plastic tub containing steam table lids, a blender part, liquid measuring cup contained several food particles in the bottom. Observation on 2/12/20 at 12:03 P.M., in the Long Term Care kitchen showed the following: - Several clean plates and bowls stored on top of a black rubber drain mat. The mat had several dried food particles in the bottom; - Two opened 19.5 ounce (oz) bottles of Smuckers Plate Scraper sitting on a shelf, that was room temperature. Review of the bottle showed for best quality refrigerate after opening. 2. Observation on 2/12/20 at 9:55 A.M., showed Dishwasher A: - With bare hands, filled resident ice cooler with ice, gripping the ice scoop by placing one hand on the handle and one hand on the front of the scoop with his/her fingers on the inside portion of the scoop; - Scooped several scoopfuls of ice and put them in the cooler until the cooler was full; - His/her fingers came in to contact with ice several times; - The cooler hydration tray to be served to residents on the first floor. Observation on 02/12/20 at 10:09 A.M. Dishwasher A: - With bare hands, put a cooler and ice scoop through the dishwasher; - Used a sanitized cloth to wipe down the cart that the ice was served on; - Sprayed down the sink, touching the sprayer with his/her bare hands; - Placed clean cups in the cart; - With bare hands, filled the resident ice cooler with ice, gripping the ice scoop by placing one hand on the handle and one hand on the front of the scoop with his/her fingers on the inside portion of the scoop; - Scooped several scoopfuls of ice and put them in the cooler until the cooler was full; - His/her fingers came in to contact with ice several times; - The cooler hydration tray to be served to residents on the second floor; - Dishwasher A did not wash his/her hands and did not wear gloves before coming in to contact with the ice. During an interview on 2/12/20 at 1:42 P.M., Dishwasher A said: - He/she should wash his/her hands before touching anything; - After touching something dirty; - He/she had not been washing his/her hands when filling ice coolers because he/she had been washing his/her hands before scooping the ice; - He/she did not think the spray nozzle on the sink was a dirty surface because he/she usually wiped it off. 3. Review of the manufacturer's instructions for Intercon Grade A Sanitizer showed that is recommended a 200-400 parts per million (PPM) mixture. Review of the facility's document titled Three Compartment Sink/Sanitation Bucket Solution Parts Per Million (PPM) Log for February 2020 showed: - The document contained time, PPM, and Initial boxes for breakfast, lunch and dinner and Notes/Action Taken to be filled for each day of the month; - Staff completed the breakfast boxes for 2/1/20 through 2/6/20, and lunch box for 2/1/20; - All the other boxes were blank. Review of the facility's document titled High Temperature Dishwasher Log for February 2020 showed the following: - Report temperatures (temp) higher than 190 degrees Fahrenheit (°F) or below 180°F for the final rinse to a manager; - The document contained signature, time, wash temp, and rinse temp boxes and had the information in three columns to be filled out three times per day; - The document showed none of the days were completed each of the three times; - 2/1/20 through 2/5/20 were completed twice; - 2/6/20 through 2/8/20 were completed once; - All the other dates had not been completed; - 2/1/20 through 2/5/20 rinse temperatures in the first column were ranged from 145°F to 160°F Observation on 2/12/20 at 10:15 A.M., showed one of the sanitizer buckets stored under the food preparation table did not register containing any sanitizer. 4. During interviews on 2/12/20 at 10:15 A.M. and 12:58 P.M., the Director of Dining Services said: - There were checklists for cleaning to be completed twice per day. The plastic tubs should be washed once per week; - The dishwasher rinse cycle should be 180°F and staff should test it twice per day; - She had not been notified of the low dishwasher rinse temperatures and did not know about the them. The staff who was recording the low temperatures had special needs and the night time staff also has usually special needs. She needed to be making sure they are doing it; - Sanitizer buckets should be changed out every two hours; - Staff should wash their hands every time they change gloves and when going from dirty to clean tasks; - Dishwasher A should have worn gloves when filling the cooler and should be washed his/her hands after touching the sprayer nozzle; he/she has been told to wear gloves; - Open food containers should be refrigerated if the container recommends refrigeration after opening; - The facility did not have a policy for sanitizers but they should be maintained according to manufacturer's guidelines; - The facility did not have a policy on dishwasher temperatures but they should be according to food code.