**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to provide necessary treatment and services consistent with standards of practice to promote healing of existing pressure ulcers (a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and /or friction) for one resident (Resident #2), who had three Stage IV pressure ulcers (Stage IV pressure ulcer is a full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and or eschar may be visible, but do not obscure the extent of tissue loss. Rolled edges, undermining and or tunneling often occur. Depth varies by location) and was identified at risk for pressure ulcers in a review of 13 sampled residents. The facility census was 37. Review of the facility policy, Wound Prevention and Treatment Documentation, dated 2022, showed the following: -Chart weekly the wound assessment including measurements and description of wound during rounds. This could be on the weekly wound observation tool on electronic medical records (EMR) or on a paper assessment form; -Make a weekly wound progress note for each resident's wounds. Unless the following items have been documented on the assessment form: Include wound status, wound treatments that are ordered, if the resident was having pain and what treatment for pain is, what nutritional and equipment interventions are in place; -Create, or review and revise the wound plan of care weekly; -Log each wound on the wound report weekly, or utilize assessment reports in the EMR; -There must be a system for nurses and direct care staff to report and document new possible skin issues. Assign nurses to complete a weekly skin check and document it, if you have a wound care nurse it is in his/her job description to assist with monitoring them and the bathing sheets for any new areas of skin breakdown. Staff may utilize bath sheets, EMR charting, stop and watch, or report sheets, just make sure that whichever system you use that there is documented notification and follow through of any changes including pain or other signs and symptoms of infection or non-healing issues; -If a new skin issue is noted, charge nurse informs the physician, gets treatment order written and added to administration record; -Pressure wounds are monitored weekly and as needed by the Director of Nursing (DON) or a designee in collaboration with wound consultant teams. Review of the National Pressure Ulcer Advisory Panel (NPUAP) guidelines, dated September 2016, showed the following definitions: -Stage I pressure ulcer is intact skin with localized area of non-blanchable (when you press on the area of redness the redness does not go away) erythema (redness). Presence of blanchable erythema changes in sensation, temperature, or firmness may precede visual changes; -Stage II pressure ulcer is a partial-thickness loss of skin with exposed dermis (the thick layer of living tissue below the top layer of skin that forms the true skin). The wound bed is viable, visible and deeper tissue are not visible. Granulation tissue (new connective tissue), slough (dead tissue in the process of separating from the body which is usually light colored, soft, moist, or stringy), and eschar (dead tissue that sheds or falls off from health skin) are not present; -Stage III pressure ulcer is a full thickness loss of skin, where adipose (fat) is visible in the ulcer and granulation tissue and rolled wound edges are often present. Slough and eschar may be visible, but do not obscure the extent of tissue loss. The depth of tissue damage varies by the location on the body. Undermining and tunneling may occur. Fascia (a thin sheath of fibrous tissue), muscle, tendon, ligament, cartilage or bone are not exposed; -Stage IV pressure ulcer is full-thickness tissue loss with exposed bone, tendon, or muscle, and may include slough or eschar, and often includes undermining and tunneling. 1. Review of Resident #2's Braden Scale Score (a score for evaluating the risk of pressure ulcers to be completed quarterly), dated 10/18/24, showed the resident scored a 16, which indicated the resident was at risk for pressure ulcers. Review of the resident's discharge Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 12/26/24, showed the following: -The resident had one Stage III pressure ulcer and it was present upon admission; -The resident had one Stage IV pressure ulcer and it was present upon admission; -The resident had one unstageable pressure ulcer and it was present upon admission. Review of the resident's significant MDS, dated [DATE], showed the following: -Cognitively intact; -Dependent on staff for toilet hygiene. -Required partial to moderate assistance from staff to roll from left to right and to change from a sitting to lying position and from lying to sitting on the side of the bed; -Dependent on staff to safely come to a standing position from a lying position and with a chair/bed to chair transfer; -The resident had an indwelling catheter; -The resident was always continent of bowel; -The resident had a stage one pressure ulcer or greater, a scar over bony prominence, or nonremovable dressing; -The resident was at risk for pressure ulcers; -The resident had one or more Stage I pressure ulcer (s) or higher; -The resident had no Stage I, Stage II or Stage III pressure ulcers; -The resident had three Stage IV pressure ulcers, and these pressure ulcers were present upon admission; -Pressure care treatment provided. Review of the resident's care plan, revised 2/25/25, showed the following: -The resident was admitted with multiple pressure ulcers (initiated 1/31/24); -The resident was at risk for poor healing and infection related to diabetes and incontinence (revised on 1/31/24) -Encourage the resident to frequently shift weight (revised on 1/31/24); -Dietary consult monthly until wounds are resolved (revised on 1/31/24); -Notify provider of no signs of improvement on current wound regimen (revised 1/31/24) -Pressure reducing cushion in chair and air mattress on bed (revised on 1/31/24); -Wound Care consultant agency to follow as needed (PRN), (revised on 1/31/24); -Notify charge nurse promptly of any new red areas or breakdown who will assess and notify the physician (revised on 1/31/24); -Check resident every two hours and assist with toileting as needed (revised on 1/31/25) -Perform objective pressure ulcer risk took such as Braden quarterly and with a significant change (4/3/24). -The resident was able to transfer with assistance of two staff members and a sit to stand device (revised 7/24/24); - The resident had an indwelling urinary catheter (a sterile tube inserted through the urethra into the bladder to drain urine) related to a stage four pressure ulcer on the coccyx and a history of bladder incontinence (revised on 7/24/24); -Resident can move side to side with assist of mobility bars (revised on 10/30/24) -Presence of wounds on the left and right buttock and right heel (revised on 1/28/25); -The resident will not drink liquid protein when attempts were made by staff (revised on 1/28/25); -The resident had been using an over-the-counter protein drink mix ice cream daily for protein support (revised on 1/28/25); -Liquacel gummies (for abnormal albumin) ordered one gummy per day (revised 1/31/25); Review of the resident's Physician Order Summary Report, dated March 2025, showed the following: -Diagnoses included pressure ulcer to right buttock Stage IV, pressure ulcer of unspecified location of the skin, Stage III, local infection of the skin and subcutaneous tissue, unspecified, malignant neoplasm of the endometrium (cancer in the uterus that can spread); -Cephalexin (antibiotic) 500 mg one tablet daily for seven days for wound infection (start date 3/10/25); -Cleanse left ischium (the lower and back part of hip bone) with Dakins solution (used to treat skin and tissue infections). Apply skin prep to surrounding skin, apply Santyl (a topical enzyme medication used to remove damaged skin aiding the growth of healthy skin) to wound bed nickel thick, pack with calcium alginate (absorbent non-adhesive dressing used for moderate to heavy drainage), cover, change daily and as needed (order date 2/27/25); -Cleanse right ischium with Dakins solution. Apply skin prep to surrounding skin, apply Santyl to wound bed nickel thick, pack with calcium alginate, cover, change daily and as needed (order date 2/27/25); -Wound gel apply to right heel topically as needed to dry wound bed (order date 12/30/24). Review of the resident's Treatment Administration Record (TAR), dated March 2025, showed the following: -Cleanse right heel with Dakins solution. Apply skin prep to surrounding skin, apply Santyl to wound bed nickel thick, cover with calcium alginate, cover with a nonstick pad, wrap with kerlix change daily and as needed, (No start dated indicated); -Staff documented a daily dressing change. Review of the resident's nursing note, dated 3/16/25 at 8:50 A.M., showed the resident had an extreme amount of wound pain. Pain medication administered. Review of the resident's nursing note, dated 3/17/25 at 3:18 A.M., showed the resident remained on an antibiotic for a wound infection. Odor noted. The resident had increased pain, more then normal. Observation on 3/19/25 at 10:12 A.M. showed the following: -Dressings were not in place to the resident's wounds. Registered Nurse (RN) B said staff removed them earlier due to drainage; -The resident lay on a air mattress; -The resident's buttocks were noted to have red creases/ imprints from the bed linens; -RN B washed his/her hands and put on gloves; -RN B cleaned the resident's left ischium wound with a gauze pad soaked with Dakins solution, RN B applied Santyl to the wound bed with a cotton applicator, and cut strips of calcium alginate and packed gently into the wound, followed by a 4x4 and secured with tape; -RN B washed his/her hands and put on gloves; -RN B cleaned the resident's right heel with a gauze pad soaked in Dakins' solution, RN applied Santyl to the wound bed with a cotton applicator, and cut in strips to fit over wound, followed by a nonstick pad, 4x4 gauze pad and secured with tape; -RN B washed his/her hands and put on gloves; -RN B cleaned the resident's right ischium wound with a gauze pad soaked with Dakins solution, RN B applied Santyl to the wound bed with a cotton applicator, and cut strips of calcium alginate and packed gently into the wound, followed by a 4x4 gauze pad and secured with tape; -There was no odor noted to the wounds; -RN B did not measure the wounds; -The resident's skin was noted to have red creases/ imprints of the bed linens to the resident's buttocks area. Review of the resident's nursing notes and skin assessments from 11/5/24 through 3/19/25, showed there was no evidence staff measured the wounds weekly or skin assessments were completed for the resident. During an interview on 3/18/25 at 12:15 P.M. Licensed Practical Nurse (LPN) H said the following: -He/She didn't measure wounds on any of the residents; -He/She thought RN B tried to measure the wounds weekly During an interview on 3/18/25 at 12:30 P.M. and 3/19/25 at 10:30 A.M. RN B said the following: -The nurses are supposed to do weekly skin assessments and wound measurements, but it didn't get done; - He/She couldn't find any wound measurements on Resident #2 in the resident's medical record; -The licensed nurses were short staffed, and charting and other things didn't get done like they were supposed to; -The resident usually stayed in his/her wheelchair most of the day or in his/her recliner. Staff offered to lay the resident down during the day; -Staff assist the resident with repositioning; -The resident refused having an outside wound care company follow him/her. The resident had them follow him/her briefly, but felt the wounds got worse with their care; -The resident was started on an antibiotic recently because the found had a foul odor and increased drainage. During an interview on 3/19/25 at 1:25 P.M. and 3/31/25 at 3:55 P.M. Corporate RN C said he/she would expect all policies and procedures be followed and resident care needs be met. During an interview on 3/19/25 at 4:20 P.M. the Administrator said the following: -He/She started working at the facility on 3/17/25; -He/She wasn't aware the facility didn't have a designated wound nurse; -He/She would expect the staff to follow the facility policy on wound prevention; -Staff should measure all wounds to monitor progress of the wounds and to assure the treatment in place was effective; -He/She would expect communication with the physician regarding wound status; -He/She thought the corporate nurse was filling in as the DON at the facility; -The DON would be responsible for monitoring to assure wounds were being monitored. During an interview on 3/19/25 at 4:00 P.M. and 4/1/25 at 3:30 P.M. the resident's Physician/Medical Director said the following: -She would expect the facility to measure and assess the status of all wounds weekly; -Measurements of a wound was a very important part of monitoring the status of a wound; -She would expect the facility to send him/her a weekly report on the status of all wounds in the facility to ensure the treatment was effective and no changes were needed on wound care; -The facility currently didn't provide him/her with any wound documentation or weekly wound reports on the resident; -She would expect the facility to follow the wound care policy.

Based on interview and record review, the facility failed to act promptly upon the grievances and recommendations of the Resident Council concerning issues of resident care and quality of life in the facility, and failed to provide the Resident Council with responses, actions, and rationale taken regarding their concerns. The facility census was 37. Review of the facility's Administrator Job Description, undated, showed the administrator was to review resident complaints and grievances and make written reports of action taken. The administrator was to discuss such actions with residents and family as appropriate. During an email correspondence on 3/31/25 at 10:42 A.M., the Administrator said he/she was not sure if there was a written policy on council meetings. The facility followed the regulations by holding monthly meetings. Review of the Resident Council Minutes, dated 1/14/25, showed the following: -Televisions were still too loud in some of the rooms, and food was still an issue; -Never have the right size of incontinence briefs; -No water for the oxygen concentrators; -Can the menu's be changed; -Would like more soup, sandwiches and salad; -The veggies were overcooked; -Would like to have regular fried burgers instead of the ones in water; -Coffee, juice and cornbread was not a snack; -There was no documented response by staff to these concerns. Review of the Resident Council Minutes, dated 2/11/25, showed the following: -The meals were still coming out cold, the vegetables were cold, and using too much pepper; -Still getting corn bread on the snack cart; -Resident televisions were still too loud; -There was no documented response by staff to these concerns. Review of the Resident Council Minutes, dated 3/19/25, showed the following: -Concerned with no ice water in the daytime; -Cold food, mostly vegetables; -There was no documented response by staff to these concerns. During an interview on 3/18/25 at 10:05 A.M. Resident #3 said the following: -He/She had no one to go to about his/her concerns; -He/She had issues with getting a shower twice a week, his/her sheets hadn't been changed in a month, and his/her oxygen concentrator never had water for humidification like it was supposed to; -The food at the facility was typically cold. Observation on 3/18/25 at 10:06 A.M. showed the resident had oxygen on and there was no water noted in the humidification bottle attached to the concentrator. During an interview on 3/18/25 at 9:10 A.M. the Social Service Director/Staffing Coordinator/Licensed Practical Nurse A said the following: -He/She gave all the resident concerns from the monthly Resident Council Meeting to the previous Administrator, and each department head. Nothing was ever done to address the residents' issues or concerns; -The residents consistently had complaints about the food and the previous Administrator did not address the issues. During an interview on 3/18/25 at 4:35 P.M. and on 3/19/25 at 4:20 P.M. The Administrator said the following: -He started working at the facility on 3/17/25; -He would expect the facility to follow policies and procedures and the regulatory guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow professional standards of practice for seven residents (Resident #4, #9, #11, #13, #1, #3 and #2 ). Staff failed to follow the physician's orders for droplet precautions (measures taken to prevent the spread of infections transmitted through respiratory droplets) for four residents (Resident #4, #9, #11 and #13). The facility also failed to ensure staff followed physician's orders for medications for three residents (Resident #1, #3 and #2) in a review of 13 sampled residents. The facility census was 37. Review of the facility's policy and procedure, Physician's Orders, dated 2025, showed the following: -It is the policy of the facility to ensure that all physician orders are obtained, documented, and implemented in accordance with federal and state regulations, professional standards, and facility protocols. All orders must be clear, accurate, and carried out in a timely manner to provide safe and effective care for residents; -Any changes or clarifications must be confirmed with the physician and documented accordingly; -Nursing and other appropriate staff must review and acknowledge all new orders; -Orders must be carried out promptly unless contraindicated; -If an order appears unclear or inappropriate, the nurse must contact the prescriber for clarification before implementation; -Regular audits of physician orders will be conducted by the nursing leadership team; -Any discrepancies, errors or delays in order implementation will be reviewed and addressed through staff education and corrective actions. Review of the facility's Infection Control Policy and Procedure, undated, showed the following: -The facility implements evidence-based infection prevention practices to protect resident's, staff, and visitors; -Staff must wear appropriate Personal protective equipment (PPE, gloves, gowns, masks, goggles) based on the transmission risks; -Droplet precautions (measures taken to prevent the spread of infections transmitted through respiratory droplets): For flu/influenza (a common viral infection of the nose, throat and lungs), Respiratory Syncytial Virus (RSV, a common respiratory virus that can affect people of all ages) utilize surgical masks. 1. Review of Resident #4's significant change Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 3/11/25, showed the following: -Severe cognitive impairment; -Diagnoses included pneumonia, heart failure and dementia. Review of the resident's nursing note, dated 3/9/25 at 8:59 A.M., showed the resident was diaphoretic (profuse perspiration) with cough and shortness of breath. Obtained orders for chest X-ray. Review of the resident's Physician Order Summary Report dated March 2025 showed on 3/9/25 an order to obtain a chest X-ray. Review of the resident's radiology report dated 3/9/25 showed the findings included minimal right hazy and patchy pulmonary opacities (areas that appear dense or dark) that may represent infectious/inflammatory (pertaining to infection or response to an infection) process, atelectasis (a condition where part of the lung collapses), or chronic lung condition (a lung condition that is persistent). Review of the resident's Physician Order Summary Report dated March 2025 showed an order on 3/10/25 for droplet precautions until symptoms subside. Review of the Physician Order Summary Report dated 3/11/25 showed an order for Levaquin (antibiotic) 500 milligrams (mg) for seven days for pneumonia. Observation on 3/18/25 through 3/19/25 showed the resident didn't have signage on the door indicating droplet precautions. 2. Review of Resident #9's quarterly MDS dated [DATE] showed the following: -Short and long-term memory impairment; -Cognitive skill for daily decision making was poor; -Diagnoses included dementia and Parkinson's disease (a progressive neurological disorder that affects movement); Review of the resident's progress note, dated on 3/8/25 at 5:36 P.M., showed the resident was noted to have a cough that morning, cough medication administered. Review of the resident's physician's order dated 3/10/25 showed the following: -Droplet precautions until symptoms resolve; -Chest x-ray, Coronavirus Disease 2019 (COVID-19, an acute disease in humans caused by a Coronavirus, which is characterized mainly by fever and cough and is capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions. ) and flu test as previously ordered and notify with abnormal results. Review of the resident's physician order summary dated March 2025 showed the facility didn't transcribe the physician's order for droplet precautions onto the order summary sheet. Review of the resident's nursing note, dated 3/10/25 1:27 P.M., showed the resident continues with nonproductive cough. Review of the resident's nursing note, dated 3/14/25 at 2:00 A.M., showed the resident continued with an occasional cough and was diaphoretic. 3. Review of the Resident #11's quarterly MDS, dated [DATE], showed the following: -Short and long-term memory impairment; -Cognitive skill for daily decision making was poor; -Diagnoses included dementia. Review of the resident's nursing note, dated 3/8/25 at 10:22 A.M., showed the resident was noted to have a deep, barky cough. Review of the resident's physician's order dated 3/10/25 showed the following: -Droplet precautions until symptoms resolve; -Chest X-ray, COVID and flu test as previously ordered and notify with abnormal results. 4. Review of Resident #13's significant change MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Diagnoses included stroke. Review of the resident's physician order dated 3/10/25 showed the following: -Droplet precautions until cough and congestion resolves; -Chest X-ray, COVID and flu test as previously ordered and notify with abnormal results. Review of the resident's notes dated 3/12/25 at 12:24 A.M. showed staff administered as needed breathing treatment due to the resident having an increased, loose cough. During an interview on 3/19/25 at 7:45 A.M. the Social Service Director/Licensed Practical Nurse (LPN) A said the following: -Earlier that month the facility had several residents who were ill with abnormal respiratory symptoms including cough, congestion and fever; -Medical Director/Physician N gave orders for all the residents to be placed on droplet precautions to prevent it from spreading to other residents; -The previous administer told staff not to worry about following the orders for droplet precautions. During an interview on 3/18/25 at 12:30 P.M. Registered Nurse (RN) B said the following: -On 3/10/25 the facility had multiple residents with a horrible cough, congestion, and shortness of breath; -Medical Director/Physician N gave specific orders to place those residents on droplet precautions while the residents were symptomatic to prevent it from spreading to other residents; -The previous Administrator said not to worry about following droplet precautions because there was no definitive diagnosis; -He/She left the order for droplet precautions on each of the resident's charts, but the facility did not follow the order for precautions; -Resident #4 was diagnosed with pneumonia; 5. Review of Resident #1's quarterly MDS dated [DATE] MDS showed the following: -Cognitively intact; -Diagnoses included diabetes (elevated blood sugar). Review of the resident's Order Summary Report, dated March 2025, showed an order for Lispro insulin (rapid acting insulin), inject 10 units before meals. Review of the resident's Medication Administration Record (MAR) dated March 2025 showed the following: -Lispro insulin 10 units, inject 10 units before meals; -On 3/11/25 at 7:00 A.M., Agency Registered Nurse (RN) M documented he/she administered Lispro insulin 10 units; -On 3/11/25 at 12:00 P.M., Agency RN M documented he/she administered Lispro insulin 10 units. During an interview on 3/18/25 at 3:15 P.M. the resident said the following: -Approximately a week ago when RN M, an agency staff, was working and did not give the resident his/her insulin; -The resident's blood sugar ran high normally, and he/she needed his/her insulin; -He/She reported his/her concerns to the Administrator, and he/she thought RN M was fired. 6. Review of Resident #3's quarterly MDS dated [DATE] showed the following: -Cognitively intact; -Diagnoses included stroke, heart failure (the heart is not pumping blood effectively to meet your body's needs) and diabetes (elevated blood sugar). Review of the resident's MAR dated 3/11/25 showed the following morning medications scheduled and documented as administered by RN M: -Aspirin 81 milligrams (mg) one tablet (related to history of a stroke); -Calcitriol 0.25 micrograms (mcg) one tablet (for arthritis); -Cymbalta 60 mg one capsule daily (for depression); -Dapagliflozin 10 mg one tablet (for diabetes); -Multivitamin one tablet (supplement); -ProFe oral capsule give one capsule (for an iron supplement); -Protonix 40 mg delayed release capsule, take one capsule (for reflux disease); -Metoprolol 50 mg give one tablet (blood pressure); -RN M did not document the resident refused any morning medications. Review of the resident's MAR dated March 2025 showed the following: -On 3/11/25, RN M documented he/she administered eight routine morning medications to the resident; -RN M did not document the resident refused any morning medications. During an interview on 3/18/25 at 10:25 A.M. the resident said the following: -An agency staff worked last week, RN M, and RN M brought in the resident's morning medications; -The medications were not correct, and two pills were missing from what the resident normally took in the morning; -He/She questioned RN M about the medications being wrong. RN M got upset with the resident when he/she questioned RN M; -He/She refused his/her medications. He/She told the Administrator about the situation. 7. Review of Resident #2's significant change MDS dated [DATE] showed the following: -Cognitively intact; -Diagnoses included diabetes (elevated blood sugar), and malignant neoplasm of endometrium (cancer in the uterus that can spread). Review of the resident's MAR dated 3/11/25 showed the following morning medications scheduled and documented as administered by RN M: -Acidophilus one capsule (for gastrointestinal); -Amlodipine 10 mg one tablet (for high blood pressure); -Bumex 2 mg one tablet (for swelling in lower extremities); -Cholecalciferol 125 mcg two tablets (supplement); -Ferrous sulfate 325 mg one tablet (iron supplement); -Folic acid one tablet (supplement); -Gemtesa 75 mg one tablet (for overactive bladder); -Liquacel protein gummies (for abnormality of albumin); -Magnesium oxide 200 mg one tablet (for heartburn) ; -Multiple vitamin one tablet (supplement) -Carvedilol 25 mg one tablet (for high blood pressure); -Cephalexin 500 mg one tablet (for wound infection); -Magnesium 400 mg one tablet (supplement for low magnesium); -Gabapentin 400 mg one capsule (for pain); -Zofran 4 mg two tablets (for nausea); -Oxycodone 10 mg one tablet (for severe to moderate pain); -RN M didn't document the resident refused any morning medications. Review of the resident's MAR dated 3/11/25 showed the following: -On 3/11/25 RN M documented he/she administered 14 morning medications to the resident; -RN M did not document the resident refused any medications. During an interview on 3/18/25 at 10:15 A.M. the resident said the following: -RN M, an agency staff member, had worked at the facility a few times; -Last week when he/she worked, RN M attempted to administer him/her medications in the morning and the medications were incorrect; -He/She refused to take the medications from RN M; -He/She was not sure if anything was done about the issue. 8. During an interview on 3/18/25 at 7:15 P.M. Certified Medication Technician (CMT) F said the following: -He/She had multiple complaints from residents about RN M, who was an agency staff member, regarding medication pass on 3/11/25; -The residents said they had missed medications or didn't receive their medications correctly; -The residents who complained were alert and very familiar with their medications. During an interview on 3/19/25 at 7:45 A.M. the Social Service Director/Licensed Practical Nurse (LPN) A said the following: -Resident #1, #2 and #3 reported their medications were administered incorrectly when RN M, an agency staff member, worked at the facility on 3/11/25; -RN M was scheduled to work 3/20/25, 3/21/25 and 3/22/25. During an interview on 3/18/25 at 12:30 P.M. RN B said many of the residents reported concerns with receiving incorrect medications when RN M, an agency staff member, recently worked at the facility. During an interview on 3/19/25 at 1:25 P.M. Corporate RN C said the following: -He/She would expect the facility to follow the physician's orders for droplet precautions, there was a potential for infections to spread if appropriate precautions were not followed; -All medications were to be administered as ordered; -He/She was aware of some concerns that were reported regarding RN M, an agency staff member, that worked at the facility last week during medication pass; -If insulin administration was missed, there was an opportunity for hyperglycemic (high blood sugar) complications. During an interview on 3/19/24 at 12:45 P.M. and 4:20 P.M. the Administrator said the following: -The facility should follow all physician orders; -Staff should follow the facility's policy on physician orders; -He could not locate any documentation of education provided to RN M after the residents complained about getting incorrect medications and/or omission of their medications. During an interview on 3/19/25 at 4:00 P.M. the Medical Director/Physician N said the following: -Recently she .gave orders for droplet precautions for several residents at the facility who had abnormal respiratory symptoms; -She would expect for staff to follow her orders. Precautions were to prevent the spread of any respiratory infections while testing was done for a definitive diagnosis; -She would expect staff to follow physician orders for medications. MO251105 MO251103 MO251104 MO251172

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Cardiopulmonary Resuscitation (CPR, an emergency lifesaving procedure performed when the heart stops beating, consisting of chest compressions and artificial respirations) certified staff were scheduled 24 hours a day seven days a week, failed to develop and implement a policy addressing CPR requirements for staff, and failed to maintain documentation of CPR certifications for staff members. The facility had 13 residents with full code status (residents requested to have full resuscitation efforts/CPR in the event of cardiac arrest). The facility census was 37. During an email correspondence on [DATE] at 12:56 P.M., the Administrator said the facility did not have a policy specific to CPR training or certification. The facility would follow the regulatory requirements. 1. Review of the facility's code status report, dated [DATE]/19/25, showed 13 residents designated as full code status. The facility provided a list of facility employees and agency staff employees' CPR certification cards that had worked since [DATE]. The staffing sheets were compared with the employees that had valid CPR certifications and review showed the following shifts without a staff member who was CPR certified: -On [DATE], night shift; -On [DATE], night shift; -On [DATE], night shift. During an interview on [DATE] at 3:45 P.M. the Human Resource (HR) Director said the following: -The facility had a lot of staff who had either expired certifications or the facility didn't have a current copy of their CPR certifications on file to verify if they were up to date; -The Administrator was responsible for setting up the CPR classes and that had not been done; -He/She had given the previous Administrator a list of staff who had either no CPR certification or expired CPR certifications. During an interview on [DATE] the Social Service Director/Staffing Coordinator/LPN A said the following: -He/She made out the schedule for each shift; -In the past she tried to schedule CPR certified staff each shift. She didn't know which staff members had a current CPR certification or an expired certification; -A CPR certified staff member should be scheduled on each shift. During an interview on [DATE] at 4:20 P.M. the Administrator said the following: -A CPR certified staff member should be scheduled on each shift. -Typically the DON or the HR director should assure all staff members have current CPR certifications.

Based on interview and record review, the facility failed to assure an infection prevention and control program (IPCP) that included an antibiotic stewardship program that addressed antibiotic use protocols and a system to monitor antibiotic use was in place. The facility also failed to have a designated Infection Preventionist (IP). The facility census was 37. Review of the facility's Infection Control Policy and Procedure, dated 2025, showed the following: -The facility implements evidence-based infection prevention practices to protect residents, staff, and visitors; -The facility maintains an Infection Prevention and Control Program (IPCP) overseen by a designated Infection Preventionist (IP) who was trained in infection control; -The IPCP includes: -Surveillance of infections; -Prevention strategies (e.g., hand hygiene, personal protective equipment (PPE, gloves, gowns, masks, goggles use); -Education for staff, residents, and visitors; -Antibiotic stewardship; -Resident with contagious infections are placed on isolation precautions as needed; -Signs are posted outside rooms to indicate precaution levels; -The facility follows an antibiotic stewardship program to prevent antibiotic overuse and resistance; -Antibiotic use is reviewed regularly for appropriateness. During an interview on 3/18/25 at 12:38 P.M. Registered Nurse (RN) B said the following: -The facility currently did not have a functioning antibiotic stewardship program or an IP; -He/She was the IP and was responsible for the program until approximately September 2024; -He/She was the only full time day shift RN and was working multiple hours and could not designate time as the IP and do all of his/her other duties along with overtime hours; -The facility was not currently tracking infections or antibiotic use. During an interview on 3/19/25 at 1:25 P.M. and on 3/31/25 at 3:55 P.M. Corporate RN C said the following: -He/She would expect the facility to follow their policies and procedures for infection control; -He/She was not aware the facility didn't have an IP or a IPCP program in place; -He/She could not find any documentation at the facility regarding tracking antibiotic use or infections. During an interview on 3/19/25 at 4:20 P.M. the Administrator said the following: -He started working at the facility on 3/17/25; -He would expect the facility to have a designated IP or if the facility had a full time Director of Nursing (DON) that could be his/her role; -Part of the DON's role would be to assure the facility had a IPCP in place; -He thought a Corporate RN was filling in as the DON prior to him starting at the facility; -The facility should follow it's policy and procedures regarding infection control in conjunction with the Centers for Disease Control and Prevention (CDC) guidelines.

Based on interview and record review, the facility failed to ensure there was an adequate number of licensed nurses on duty to meet resident needs. The Social Service Director (SSD)/Licensed Practical Nurse (LPN) A was pulled from his/her duties as the Social Services Director, and unable to follow up on resident concerns, to work the floor as the charge nurse on multiple occasions. SSD/LPN A worked a total of 36 consecutive hours due to having no licensed nurse coverage. SSD/LPN A slept in a recliner at the nurse's station while on duty during his/her 36 hour shift. Registered Nurse (RN) B said he/she was leaving employment 3/19/25; he/she was unable to measure wounds weekly per policy, complete routine skin assessments, or complete necessary documentation due to staffing. The facility did not have an Infection Preventionist, designated wound nurse, or an Assistant Director of Nurses due to staffing. The facility census was 37. Review of the facility's policy titled, General Staffing, dated 2025, showed the following: -Licensed Nurse (RN/LPN) 24/7 coverage; -Staffing levels will be adjusted based on acuity needs using the facility assessment; -The facility will develop contingency plans for staffing shortage (e.g., internal float pool, as needed (PRN) staff, and agency contracts). 1. Review of the Facility Assessment, dated 7/8/24, showed the following: -Desired workforce profile included Assistant Director of Nursing (ADON)/LPN; -Administrative Staffing information desired number included Social Service Director/ LPN A; -The facility desired five full time RNs; -The facility desired seven full time LPNs; -Two residents with contractures; -One resident with intellectual and/or developmental disability; -Residents with documented signs and symptoms of depression was 19; -Residents with a documented psychiatric diagnosis was one resident; -Residents with a diagnosis of Dementia or Alzheimer ' s disease was 11 residents; -Residents with pressure ulcers indicated was three residents; -Residents receiving preventive skin care was 41; -Residents receiving Hospice services was one; -One resident on dialysis care; -Residents with respiratory treatments was four; -One resident with tracheostomy care; -One resident requiring suctioning; -Six residents received injections; -Five residents received mechanically altered diets; -Ten residents received rehabilitative services. Review of the facility's staffing sheets dated March 2024 showed the following: -On 3/15/25 SSD/LPN A worked 6:00 A.M. to 6:00 P.M. and was the only Licensed Nurse in the building; -On 3/15/25 SSD/LPN A worked 6:00 P.M. to 6:00 A.M. and was the only Licensed Nurse in the building; -On 3/16/25 SSD/LPN A worked 6:00 A.M. to 6:00 P.M. and was the only Licensed Nurse in the building. During an interview on 3/18/25 at 10:15 A.M. Resident #2 said the following: -The facility did not have enough nursing staff (LPNs and RNs); -He/She was concerned because LPN A recently worked 36 hours straight and he/she was not sure if that was safe for someone to work that many hours and care for the residents; -RN B was always doing double shifts because the facility was short staffed and now RN B was leaving: -He/She was not sure who was going to take care of the residents. The resident became tearful during the conversation. During an interview on 3/18/25 at 10:05 A.M. Resident #3 said the following: -The facility did not have enough nurses; -He/She had no one to go to about his/her concerns; - He/She had issues with getting a shower twice a week, his/her sheets hadn't been changed in a month, and his/her oxygen concentrator never had water for humidification like it was supposed to have. During an interview on 3/18/25 at 3:15 P.M. Resident #1 said the following: -The facility did not have enough nurses; -Recently LPN A worked 36 hours, because there was no one else to work; -LPN A was exhausted. During an interview on 3/18/25 at 7:45 P.M. Resident #8's family member said the following: -The facility did not have enough nurses (RNs/LPNs); -Recently, SSD/LPN A worked 36 hours in a row because there was no one to relieve him/her. During an interview on 3/18/25 on 7:15 A.M. Certified Medication Technician (CMT) F said the following: -He/She worked 36 hours in a row recently over a weekend with the SSD/LPN A; -He/She worked to be available if there was an emergency to assist SSD/LPN A; -SSD/LPN A did not get a round well and it would be hard for him/her to get down the halls quickly in case of an emergency; -SSD/LPN A was physically exhausted and slept some in the recliner at the nurse's station during the 36 hours he/she worked. During an interview on 3/18/25 at 9:10 A.M. the Social Service Director/Staffing Coordinator/Licensed Practical Nurse A said the following: -He/She was unable to fulfill his/her role as the Social Service Director due to consistently being pulled to the floor to work as a LPN; -He/She was unable to follow-up on concerns brought to him/her by the residents; -He/She recently worked three 12 hour shifts in a row, 36 hours total, because the facility had no licensed nurses to relieve him/her. He/She had to nap in a chair at the facility while working because of being so exhausted; -He/She notified corporate staff of being short licensed nurses and was told to reach out to a staffing agency, but he/she was unsuccessful; -Today would be ten days in a row he/she had worked at the facility and physically he/she was unable to be on his/her feet for that many days/hours in a row; -The facility had only one full time RN, RN B, and his/her last day was 3/19/25; -The facility had one as needed (PRN) RN once RN B was gone; -The facility had one full time LPN on night shift and a part time LPN on day shift; -The facility had a contract with a staffing agency, but had been unsuccessful with finding any routine RN/LPN coverage; -Currently, there were multiple holes in the schedule for licensed nurses and he/she was not sure how the facility would get the shifts covered. During an interview on 3/18/25 at 12:30 P.M. RN B said the following: -He/She didn't get wounds measured weekly per policy, routine skin assessments weren't completed and charting and documentation didn't get done like it should due to staffing; -The facility did not have an Infection Preventionist, designated wound nurse, or ADON and lot of things were not getting done; -His/Her last day was 3/19/25. During an interview on 3/19/25 at 1:25 P.M. Corporate RN C said the following: -He/She was aware SSD/LPN A worked 36 hours or three, 12 hour shifts in a row, due to a shortage of licensed nurses; -He/She thought LPN A could respond in an appropriate timeframe if there was an emergency after working 36 hours; -The facility had exhausted all solutions of getting the shifts covered for LPN A and there was nothing else they could do; -The facility had a shortage of licensed nursing staff and there was a potential of things not getting done as they should. During an interview on 3/18/25 at 4:35 P.M. and on 3/19/25 at 4:20 P.M. The Administrator said the following: -He started working at the facility on 3/17/25; -He was not aware that RN/LPN coverage was so critical; -He would expect there to be plenty of licensed staff to care for the residents. MO251105 MO251103 MO251172 MO251142 MO251147 MO251138 MO251121 MO251144

Based on interview and record review, the facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, and failed to ensure the facility had a RN designated as the Director of Nursing (DON) on a full-time basis. The facility census was 37. Review of the Facility Assessment, dated 7/8/24, showed the following: -The administrative staff should include a DON; -The facility desired five full time RNs. Review of the facility's Director of Nursing Staffing policy, dated 2025, showed the following: -The facility must employ a full-time DON; -The DON must be a Licensed Registered Nurse; -The DON was responsible for overseeing operations, quality of care, staff recruitment, retention and education. Review of the facility's General Staffing policy, dated 2025, showed the following: -RN coverage eight consecutive hours/day seven days a week; -Licensed Nurse (RN/LPN): 24/7 coverage; -Staffing levels will be adjusted based on the acuity needs using the facility assessment; -The facility will develop contingency plans for staffing shortages to include internal float pool, as needed (PRN) staff and agency staff. 1. Review of the facility staffing schedules, dated March 2025, showed the following: -On 3/15/25 no RN coverage; -On 3/16/25 no RN coverage. During an interview on 3/18/25 at 9:10 A.M. the Social Service Director/Staffing Coordinator/Licensed Practical Nurse A said the following: -The facility was told to put a RN with Corporate down on paper as the DON on and off since December 2024; -The facility did not have a DON; -There was no RN in the building on 3/15/25 or 3/16/25; -The facility only had one full-time RN, RN B, and his/her last day was 3/19/25; -The facility only had one as needed (PRN) RN employee once RN B left; -The facility worked with a staffing agency, but had been unsuccessful with finding any routine RN coverage. During an interview on 3/18/25 at 12:30 P.M. RN B said the following: -He/She worked a lot of extra hours/overtime at the facility due to no RN coverage; -His/Her last day would be 3/19/25; . -The facility had a DON on paper from Corporate he/she was told, but he/she had only seen someone from Corporate, RN D, in the facility one time since December 2024; -He/She did not know how to get in contact with Corporate RN D. During an interview on 3/19/25 at 1:25 P.M. Corporate RN C said the following: -The facility needed a DON; -The facility had a shortage of licensed nursing staff, including RN's; -He/She would expect the facility to have a full-time DON and a RN on duty eight hours a day, seven days a week. During an interview on 3/24/25 at 11:30 A.M. Corporate RN L said the following: -He/She was the facility's DON from 2/24/25 through 3/7/25, he/she worked five days in the facility during that timeframe; -On 3/7/25 he/she was told by Corporate staff that he/she was no longer needed at the facility and that the facility had RN coverage; -On 3/14/25 he/she was asked to be the the facility's DON on paper again; -He/She was basically available by phone but was not onsite at the facility on a full time basis; -Corporate RN C had been in the building some; During an interview on 3/18/25 at 4:35 P.M. and on 3/19/25 at 4:20 P.M. The Administrator said the following: -He started working at the facility on 3/17/25; -He thought there was a Corporate RN filling in as a DON; -The facility should have a RN on duty eight hours a day, seven days a week in the building; -The facility should have a full-time DON. Full-time would be approximately 40 hours a week on average in the building. MO251105 MO251103 MO251172 MO251142 MO251147 MO251138 MO251121 MO251144

Based on observation, interview, and record review, the facility administration failed to ensure operations including staffing and required regulatory systems necessary for the care and safety of residents were provided. The facility failed to have a full time Director of Nursing (DON), Assistant Director of Nursing (ADON), and an adequate number of licensed nurses to meet the residents' needs. The facility also failed to have an Infectionist Preventionist (IP) or antibiotic stewardship program in place,which included tracking of antibiotic use and infections. Vendors were not paid for supplies or services timely. The facility census was 37. Review of the facility's Administrator Job Description, undated, showed the following: -The primary purpose of the position is to direct the day to day functions of the facility in accordance with current federal, state and local standards and guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality of care can be provided to our residents at all times; -As Administrator you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties; -Plan, organize, implement, evaluate and direct the Facility's programs and activities in accordance with guidelines issued by management; -Develop and maintain written policies and procedures and professional standards of practice that govern the operation of the facility; -Ensure that all employees, residents, family members, visitors, and general public follow the facility's established policies and procedures; -Assume the administrative authority, responsibility, and accountability of directing the activities and programs of the facility; -Review resident complaints and grievances and make written reports of action taken. Discuss such actions with residents and family as appropriate; -Working hours: 40, plus hours a week as needed; -Assist in the recruitment and selection of department directors, supervisors, facility non-licensed staff, consultants, etc. -Must be knowledgeable of reimbursement regulations and nursing practices and procedures, as well as laws, regulations and guidelines pertaining to nursing facility administration. 1. Review of the facility staffing schedules, dated March 2025, showed the following: -On 3/15/25 no Registered Nurse (RN) coverage; -On 3/16/25 no RN coverage. 2. The facility provided a list of facility employees and agency staff employees' CPR certification cards that had worked since March 1, 2025. The staffing sheets were compared with the employees that had valid CPR certifications and review showed the following: -On 3/8/25, night shift, no CPR certified staff; -On 3/9/25, night shift, no CPR certified staff; -On 3/15/25, night shift, no CPR certified staff. 3. Review of the Resident Council Minutes, dated 1/14/25, showed the following: -Televisions were still too loud in some of the rooms, and food was still an issue; -Never have the right size of incontinence briefs; -No water for the oxygen concentrators; -Can the menu's be changed; -Would like more soup, sandwiches and salad; -The veggies were overcooked; -Would like to have regular fried burgers instead of the ones in water; -Coffee, juice and cornbread was not a snack; -There was no documented response by staff to these concerns. Review of the Resident Council Minutes, dated 2/11/25, showed the following: -The meals were still coming out cold, the vegetables were cold, and using too much pepper; -Still getting corn bread on the snack cart; -Resident televisions were still too loud; -There was no documented response by staff to these concerns. Review of the Resident Council Minutes, dated 3/19/25, showed the following: -Concerned with no ice water in the daytime; -Cold food, mostly vegetables; -There was no documented response by staff to these concerns. 4. During an interview on 3/18/25 at 10:05 A.M. Resident #3 said the following: -The facility was short staffed on nurses; -He/She had no one to go to about his/her concerns; -He/She had issues with getting a shower twice a week, his/her sheets hadn't been changed in a month, and his/her oxygen concentrator never had water for humidification like it was supposed to; -The food at the facility was typically cold. 5. During an interview on 3/18/25 at 7:45 P.M. Resident #8's family member said the following: -He/She didn't have much interaction with the Administrator and only saw him a couple times at the facility; -The facility did not have a DON; -The facility ran out of medium size incontinence briefs. He/She went to the store and purchased some for the resident to have since there were none available at the facility. 6. During an interview on 3/18/25 at 10:30 A.M. Nurse Assistant (NA) E said the following: -The facility did not have a DON and the Administrator was never at the facility. He/She had no one to go to with questions except the charge nurses and they were busy; -He/She was currently in Certified Nurse Assistant (CNA) classes but had not received any education at the facility once he/she started working except for watching onboarding videos upon hire; -There was no one to go to with his/her concerns at the facility. 7. During an interview on 3/18/25 at 2:20 P.M. NA G said the following: -He/She started working at the facility in December of 2024; -He/She was not sure who to go to with questions as the facility didn't have DON and the Administrator was seldom at the facility; -He/She was currently in CNA classes and watched some videos upon hire, but had not received any education from anyone. 8. During an interview on 3/19/25 at 3:45 P.M. the Human Resource (HR) Director said the following: -The facility had a lot of staff who had either expired certifications or the facility didn't have a current copy of their CPR certifications on file to verify if they were up to date; -The Administrator was responsible for setting up the CPR classes and that had not been done; -He/She had given the Administrator a list of staff who had either no CPR certification or expired CPR certifications. During an interview on 3/25/25 at 12:47 P.M. a Vendor/Accounts Representative for medical supplies said the following: -The facility was sent out a courtesy letter on 3/14/25 and had until 3/21/25 to pay the past due balance of over $5000 dollars or they would be unable to reorder future supplies until it was paid in full; -The facility account balance was past due 120 days. During an interview on 3/19/25 the Maintenance Supervisor said the following: -He contacted the facility's vendor who was responsible for shredding facility documents and records, as the facility needed items shredded; -He was told the bill was past due and the facility owed approximately $3000 dollars on an outstanding balance and the records couldn't be picked up unless the bill was paid; -He was putting all the records in a shed behind the building and it was getting full; -He was told to switch pest control companies by the Administrator because that bill had not been paid; -The facility had not had a full time DON since the end of December 2024. During an interview on 3/18/25 at 9:10 A.M. the Social Service Director/Staffing Coordinator/Licensed Practical Nurse A said the following: -The facility was told to put a RN with Corporate down on paper as the DON on and off since December 2024; -The facility did not have a DON; -There was no RN in the building on 3/15/25 or 3/16/25; -The facility only had one full-time RN, RN B, and his/her last day was 3/19/25; -The facility only had one as needed (PRN) RN employee once RN B left; -The facility worked with a staffing agency, but had been unsuccessful with finding any routine RN coverage; -In the past he/she tried to schedule CPR certified staff each shift. He/She didn't know which staff members had a current CPR certification or an expired certification; -He/She recently worked three 12 hour shifts in a row, 36 hours total, because the facility had no licensed nurses to relieve him/her. He/She had to sleep in a chair at the facility while working because of being so exhausted; -He/She notified corporate staff of being short licensed nurses and was told to reach out to a staffing agency, but he/she was unsuccessful; -Today would be ten days in a row he/she had worked at the facility and physically he/she was unable to be on his/her feet for that many days/hours in a row; -He/She gave all the resident concerns from the monthly Resident Council Meeting to the Administrator, and each department head. Nothing was ever done to address the residents' issues or concerns; -The residents consistently had complaints about the food and the administrator did not address the issues. During an interview on 3/18/25 at 12:30 P.M. Registered Nurse (RN) B said the following: -He/She had been the Infection Preventionist and he/she resigned from that role around September or October of 2024; -The facility was not tracking infections and also didn't have a current antibiotic stewardship program in place; -The new NAs had no one to go to for training or direction; -Licensed nurses were not receiving any training for the electronic medical system, which caused issues with charting; -He/She tried to measure all pressure ulcers weekly when he/she worked, but it was not done weekly. The facility did not have a designated wound nurse; -He/She asked the Administrator for help from the Corporate office to fill in with some of these roles, but nothing was ever done; -His/Her last day at the facility was 3/19/25. During an interview on 3/19/25 at 2:15 P.M. the Business office Manager (BOM) said the following: -He/She sent any payments that were due through Stampli (an automated software for companies to manage financial workflow and process payments); -The Corporate Business Office Manager made all the payments; -He/She didn't necessarily receive a receipt that something had been paid; -He/She would expect all bills be paid on time. During an interview on 3/19/25 at 3:00 P.M. the Corporate BOM said he/she was not aware of the outstanding bill until today (3/19/25). During an interview on 3/24/25 at 11:30 A.M. Corporate RN L said the following: -He/She was the facility's DON from 2/24/25 through 3/7/25, he/she worked five days in the facility during that timeframe; -On 3/7/25 he/she was told by Corporate staff that he/she was no longer needed at the facility and that the facility had RN coverage; -On 3/14/25 he/she was asked to be the the facility's DON on paper again; -He/She was basically available by phone but was not onsite at the facility on a full time basis. During an interview on 3/19/25 at 1:25 P.M. and on 3/31/25 at 3:55 P.M. Corporate RN C said the following: -The facility had a shortage of licensed nursing staff and there was a potential of things not getting done as they should; -He/She wasn't aware the facility didn't have a ADON; -He/She was not aware of any issues with the bills at the facility being paid; -He/She would expect the facility to follow their policies and procedures for infection control; -He/She was not aware the facility didn't have an IP or a IPCP program in place; -He/She could not find any documentation at the facility regarding tracking antibiotic use or infections; -He/She would expect all policies followed and care needs met. During an interview on 3/18/25 at 4:35 P.M., and on 3/19/25 at 4:20 P.M., and email correspondence on 3/31/25 at 10:42 A.M. the Administrator said the following: -He started working at the facility on 3/17/25; -He would expect there to be plenty of licensed staff to care for the residents. -Typically either the facility would have a Infections Preventionist or the DON would fill that role; -He thought there was a Corporate RN filling in as a DON. The facility should have a full-time DON. Full-time would be approximately 40 hours a week on average in the building; -A CPR certified staff member should be scheduled on each shift. -Typically the DON or the HR director should assure all staff members have current CPR certifications. -He was not aware of any issues with vendors or credit holds. He would expect bills to be paid; -He would expect the facility to follow policies and procedures and the regulatory guidelines; -He was unable to locate any training documentation for the NAs working at the facility. During an interview on 3/19/25 at 4:00 P.M. the facility's Medical Director said the following: -The facility had no leadership; -She would expect all of the administrative roles be filled in the facility; -She would expect follow-up on concerns that arise; -She would expect the facility to have antibiotic stewardship program, someone designated to follow wounds and report to her weekly on progress; -She was concerned if the facility was currently able to meet each of the residents' needs. MO251105 MO251103 MO251172 MO251142 MO251147 MO251138 MO251121 MO251144

Based on interview and record review the facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, and failed to ensure the facility had a RN designated as the Director of Nursing (DON) on a full time basis. The facility census was 44. Review of the Facility Assessment, dated 7/8/24, showed the following: -The administrative staff should include a DON; -The facility desired two full time RNs. Review of the facility's undated Director of Nursing Services policy showed the following: -The nursing services department is under the direct supervision of a registered nurse; -The nursing services department is managed by the Director of Nursing Services. The director is a registered nurse; -The DON is employed full time ( 40 hours per week); -The DON is responsible for recruiting and retaining the number and levels of nursing personnel necessary to meet the nursing care needs of each resident. Review of the facility's undated Staffing policy showed the following: -The facility provides adequate staffing to meet needed care and services for the resident population; -The facility maintains adequate staffing on each shift to ensure that the resident's needs and services are met. Licensed registered nursing and licensed nursing staff are available to provide and monitor the delivery of resident care services. 1. Review of the facility staffing schedules, dated December 2024, showed the following: -On 12/4/24 RN coverage for three hours from 6:00 A.M. until 9:00 A.M.; -On 12/5/24 Corporate RN H was on call via the telephone. No RN coverage in the facility; -On 12/6/24 Corporate RN H was on call via the telephone. No RN coverage in the facility; -On 12/7/24 Corporate RN H was on call via the telephone. No RN coverage in the facility; -On 12/8/24 Corporate RN H was on call via the telephone. No RN coverage in the facility; -On 12/9/24 Corporate RN H was on call via the telephone. No RN coverage in the facility; -On 12/15/24 Corporate RN H was on call via the telephone. No RN coverage in the facility; -On 12/16/24 Corporate RN H was on call via the telephone. No RN coverage in the facility; -On 12/21/24 Corporate RN H was on call via the telephone. No RN coverage in the facility; -On 12/22/24 Corporate RN H was on call via the telephone. No RN coverage in the facility; -On 12/28/24 Corporate RN H was on call via the telephone. No RN coverage in the facility; -On 12/30/24 no RN coverage. Review of the facility staffing schedules, dated 1/1/25 through 1/8/25, showed the following: -On 1/1/25 no RN coverage; -On 1/5/24 no RN coverage. During an interview on 12/30/24 at 10:18 A.M. and 10:43 A.M. and 1/8/24 at 4:05 P.M. the Administrator in Training (AIT) said the following: -The facility's Director of Nursing (DON) quit on 12/29/24; -There was no Registered Nurse (RN) in the building on 12/30/24; -She called a RN to come in but was not sure if he/she would be able to due to childcare issues; -The one full time RN had worked a lot of hours since the DON quit and he/she would get burnt out if they could not find more RNs to hire. During an interview on 12/30/24 at 10:20 A.M. and 1/8/25 at 4:10 P.M. the Administrator said the following: -The facility currently had one full time RN and two RNs worked as needed; -On 12/30/24, there was no RN on duty; -The facility worked with two staffing agencies to try to get RNs hired but had not had any response; -The facility was associated with a corporation but the corporation hadn't sent any help to fill the RN/DON position; -On the days the facility was without a RN on duty in the building, the corporation had a RN available by phone if the facility needed them. The corporate RN was never in the building, only available by phone; -The facility should have a RN on duty eight hours a day, seven days a week in the building; -The facility should have a full time DON; -The facility did not have a policy that directed RN staffing specifically. The facility followed Centers for Medicare and Medicaid Services guidelines. MO244361 MO245027 MO246664 MO246688 MO246744

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure two residents, (Resident #1 and Resident #2), in a review of eight sampled residents, were free from misappropriation of property, when Registered Nurse (RN) A/Former Assistant Director of Nursing (ADON) misappropriated the residents' narcotics. RN A/Former ADON signed as receiving the residents' narcotic medications from the pharmacy. There was no documentation the narcotic medications were administered or destroyed. The narcotic medications were not found in the facility after RN A/Former ADON received the narcotic medications from the pharmacy. The facility census was 39. On 09/09/24 at 4:05 P.M., the administrator was notified of the past noncompliance which began on 07/06/24. On 08/31/24, the Director of Nursing became aware of the violation of misappropriation of resident's narcotic medication. Upon discovery, the facility conducted an investigation, notified appropriate parties, suspended RN A/Former ADON and all facility staff were educated on the facility misappropriation policy. RN A/Former ADON was suspended on 09/02/24. The deficiency was corrected on 09/03/24 after all staff had been inserviced and RN A/Former ADON was no longer employed with the facility. Review of the facility policy titled, Controlled Substances, revised December 2012, showed the following: -Only authorized licensed nursing and/or pharmacy personnel shall have access to Schedule II controlled medications (medications with a high potential for abuse) maintained on premises; -Controlled substances must be counted upon delivery. The nurse receiving the medication, along with the person delivering the medication, must count the controlled substances together. Both individuals must sign the designated controlled substance record; -All keys to controlled substance containers shall be on a single key ring that is different from any other keys; -Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing. Review of the facility policy titled, Investigating Incidents of Theft and/or Misappropriation of Resident Property, revised April 2017, showed the following: -Residents have the right to be free from theft and/or misappropriation of personal property; -Misappropriation of resident property is defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. 1. Review of Resident #1'sface sheett showed the following: -Re-admit to the facility on [DATE]; -Diagnoses included complete traumatic amputation at level between knee and ankle, right lower leg. Review of the resident's individual narcotic record, dated 07/03/24, showed the resident returned with 32 tablets oxycodone-acetaminophen (Schedule II narcotic pain medication) 5-325 milligrams (mg). Review of the resident's Physician's Order Sheet (POS), dated July 2024, showed an order for oxycodone-acetaminophen 5-325 mg, give one tablet by mouth every four hours as needed for pain. Review of the resident's Medication Administration Record (MAR) dated July 2024 (07/03/24 through 07/05/24) showed no documentation staff administered oxycodone-acetaminophen 5-325 mg for pain. (the resident should of had 32 tablets remaining). Review of the resident's Order Audit Report, dated 07/05/24, showed RN A/Former ADON re-ordered the resident's oxycodone-acetaminophen 5-325 mg. Review of a pharmacy delivery receipt, dated 07/06/24 at 3:14 A.M., showed the following: -The pharmacy delivered oxycodone-acetaminophen 5-325 mg, 60 tablets for Resident #1; -Signed by RN A/Former ADON as received. Review of the nurses' cart narcotic sign in log, dated 06/26/24-07/19/24, showed no documentation on 07/06/24, that RN A/Former ADON signed the resident's oxycodone-acetaminophen 60 tablets into the narcotic count/lock box. Review of the resident's Order Audit Report, dated 07/17/24, showed RN A/Former ADON re-ordered the resident's oxycodone-acetaminophen 5-325 mg. Review of the resident's MAR, dated July 2024 (07/05/24 through 07/17/24) showed no documentation staff administered oxycodone-acetaminophen 5-325 mg for pain. (the resident should of had 92 tablets remaining). Review of a pharmacy delivery receipt, dated 07/18/24 at 2:59 A.M., showed the following: -The pharmacy delivered oxycodone-acetaminophen 5-325 mg 60 tablets for Resident #1; -Signed by Licensed Practical Nurse (LPN) G as received. Review of the nurses' cart narcotic sign in log, dated 06/26/24-07/19/24, showed on 07/18/24 LPN G signed the resident'soxycodonee-acetaminophen 60 tablets into the narcotic count/lock box. Review of the resident's MAR, dated July 2024 (07/17/24 through 07/31/24), showed no documentation staff administered oxycodone-acetaminophen 5-325 mg for pain. (the resident should of had 152 tablets remaining). Review of the resident's POS, dated August 2024, showed an order for oxycodone-acetaminophen 5-325 mg, give one tablet by mouth every four hours as needed for pain. Review of the resident's MAR, dated August 2024, (08/01/24 through 08/14/24), showed no documentation staff administered oxycodone-acetaminophen 5-325 mg for pain. (the resident should of had 152 tablets remaining). Review of the resident's Order Audit Report, dated 08/14/24, showed RN A/Former ADON re-ordered the resident's oxycodone-acetaminophen 5-325 mg. Review of the pharmacy delivery receipt, dated 08/15/24 at 2:09 A.M., showed the following: -The pharmacy delivered oxycodone-acetaminophen 5-325 mg 60 tablets for Resident #1; -Signed by RN A/Former ADON as received. Review of the nurses' cart narcotic sign in log, dated 07/19/24-08/19/24, showed no documentation on 08/15/24 that RN A/Former ADON signed Resident #1's oxycodone-acetaminophen 60 tablets into the narcotic count/lock box. At that time, the resident should of had 212 tablets of oxycodone-acetaminophen at the facility. During an interview on 09/05/24 at 11:55 A.M., Resident #1 said the following: -He/She had occasional pain on the right side of his/her stump; -He/She does not complain of pain to staff, had not asked for, or received pain medication. 2. Review of Resident #2's POS, dated August 2024, showed an order for hydrocodone-acetaminophen (Schedule II narcotic pain medication) 5-325 mg, one tablet by mouth every 12 hours as needed for hand pain. Review of the resident's August 2024 MAR showed no documentation staff administered hydrocodone-acetaminophen 5-325 mg for pain. Review of the resident's Order Audit Report showed the following: -On 08/13/24, RN D/IP (Infection Preventionist) re-ordered the resident's hydrocodone-acetaminophen 5-325 mg; -On 8/14/24, RN A/Former ADON discontinued the resident's hydrocodone-acetaminophen 5-325 mg order in the computer system. Review of a pharmacy delivery receipt, dated 08/15/24 at 2:09 A.M., showed the following: -The pharmacy delivered hydrocodone-acetaminophen 5-325 mg 14 tablets for Resident #2. -Signed by RN A/Former ADON as received. Review of the nurses' cart narcotic sign in log, dated 07/19/24 - 08/19/24, showed no documentation on 08/15/24 that RN A/Former ADON signed Resident #2's hydrocodone-acetaminophen 14 tablets into the narcotic count/lock box. During an interview on 09/05/24 at 9:53 A.M., Resident #2 said the following: -He/She does not have much pain; -He/She does not ask for or take anything for pain; -If he/she has pain, he/she doesn't complain about it or request medication for pain. 3. Review of the facility investigation dated 09/02/24 showed the following: -It was reported by RN D/IP and LPN E that there was a missing card of oxycodone-acetaminophen 5-325 for Resident #1; -It was reported that on the previous day there were two cards of oxycodone-acetaminophen 5-325 in the narcotic box and now there was only one card; -This narcotic (oxycodone-acetaminophen for Resident #1) was delivered on 05/20/24 (this card was still located in the narcotic box), 07/18/24, and 08/14/24, and documented into the building by LPN G; -The delivery sheets for these medications were missing from the manifest book along with the sign out sheets for the narcotic and resident daily flow sheets; -It was noted in Resident #1's MAR Resident #1 had not taken this medication in the last two months; -This medication supply had been exhausted three times and reordered three times by RN A/Former ADON; During this investigation two other incidents were noted to have occurred: -On the night shift of 08/14/24, RN A/Former ADON worked the night shift. He/She clocked in at 5:32 P.M. and left at 8:45 A.M. the next morning. RN A/Former ADON received a pharmacy delivery 08/15/24 at 2:09 A.M. and signed for this delivery. Two medications that were included in this delivery were not signed in on the narcotic count sheet. This included a card of Resident #1's oxycodone-acetaminophen 60 tablets and a card of Resident #2's hydrocodone-acetaminophen 14 tablets. The original paperwork showing this delivery had not been located at this time. Duplicates were obtained from the pharmacy; -On the night shift of 07/05/24, RN A/Former ADON clocked in at 5:51 P.M. and left the following morning at 8:16 A.M. RN A/Former ADON received a pharmacy delivery at 3:14 A.M. and signed for this delivery. One medication that was included in this delivery was not signed in for on the narcotic card count sheet. This included a card of Resident #1's oxycodone-acetaminophen 60 tablets. The original paperwork showing this delivery has not been located at this time. Duplicates were obtained from the pharmacy; -Upon investigation the residents involved had not taken any pain medication for several months. The missing narcotics had been ordered in the system only by RN A/Former ADON. Review of RN D/IP's written statement dated 09/05/24 at 3:23 P.M. showed the following: -On Saturday (morning) 08/31/24, he/she counted the nurse cart (held the narcotic medications) with RN A/Former ADON; -He/She noticed that Resident #1 only had one card of oxycodone-acetaminophen with 31 tablets when he/she believed the resident previously had two cards of oxycodone-acetaminophen, of which the first card had 31 tablets and the second card had 60 tablets; -After completion of the narcotic count and report, he/she took LPN E aside and asked if he/she knew why the other card of oxycodone-acetaminophen was gone, LPN E said he/she did not know; -He/She looked through the narcotic manifest and the narcotic destruction binder and found no record of the card of Resident #1's oxycodone-acetaminophen 60 tablets. During an interview on 09/05/24 at 3:08 P.M., RN D/IP said the following: -RN A/Former ADON worked Friday night shift 08/30/24; -Saturday morning (8/31/24), he/she told LPN E something wasn't right with the narcotic count; -Usually Resident #1 had two cards of oxycodone-acetaminophen, but that morning (8/31/24) the resident only had one card in the medication cart/lock box; -LPN E was in charge of the narcotic medications on day shift 08/30/24; -LPN E counted narcotics at change of shift (days to night) with RN A/Former ADON on 08/30/24; two cards of oxycodone-acetaminophen were in the narcotic box for the resident at that time; -RN A/Former ADON was the only nurse with access to the medications (including the narcotics) on Friday night 08/30/24. -She didn't ask RN A/Former ADON about the missing card at the time of the count because she wanted to confirm the second card with LPN E before tipping off RN A/Former ADON. During an interview on 09/05/24 at 3:22 P.M., LPN E said the following: -He/She was the charge nurse on day shift, Friday 08/30/24 and had the keys to the narcotic medications; -RN A/Former ADON was the charge nurse on night shift, Friday 08/30/24; -RN D/IP was the charge nurse on day shift, 08/31/24; -After RN A/Former ADON left the facility the morning of 08/31/24, RN D/IP told him/her the narcotic count wasn't correct; -RN D/IP said he/she did not think the count was correct because when she counted the narcotic medications with RN A/Former ADON on Saturday morning, 08/31/24, there was only one card of Resident #1's oxycodone-acetaminophen in the medication cart/lock box; she was confirming with him/her that there had been two cards previously; -Resident #1 had two cards of oxycodone-acetaminophen in the medication cart/narcotic lock box for a long time; -When he/she counted with RN A/Former ADON on Friday night, 08/30/24, the narcotic count was correct, and Resident #1 had two cards of the medication in the cart/lock box; -When RN D/IP counted with RN A/Former ADON on Saturday morning, 08/31/24, there was only one card of Resident #1's oxycodoneacetaminophenn in the medication cart/lock box. During an interview on 09/05/24 at 4:10 P.M., the Administrator in Training (AIT) said the following: -The pharmacy delivered 60 tablets of -oxycodone-acetaminophen for Resident #1 on 08/15/24. This medication is not accounted for in the narcotic book or in the medication cart. RN A/Former ADON signed he/she received the medication but the medication is not in the facility. RN A/Former ADON ordered Resident #1's oxycodone-acetaminophen four times and the resident doesn't take the medication; -RN A/Former ADON ordered and received hydrocodone-acetaminophen, 14 tablets for Resident #2, and the medication was not in the facility; -RN A/Former ADON ordered Resident #1 and Resident #2's narcotic medications and took the medication from the facility; -Stealing residents' medications was misappropriation of resident property. Review of the DON's written statement, dated 09/05/24 at 3:30 P.M. showed the following: -On 09/01/24, during her investigation, she continued to see RN A/Former ADON had been the only nurse to order medication for Resident #1 (Oxycodone-Acetaminophen); -She looked at Resident #1's MAR and there wasn't any/sufficient documentation to warrant the continued ordering of this medication; -She met with the AIT on 09/02/24. They printed RN A/Former ADON's time cards and pharmacy receipt logs and went through the documentation; -RN A/Former ADON would order Resident #1's oxycodone-acetaminophen on a night shift he/she would work and take the narcotic after signing it in from pharmacy; -RN A/Former ADON would then destroy the documentation and not chart the narcotic into the narcotic flow sheet; -This instance occurred on the night shift of 08/14/24 and 07/05/24; -On 08/30/24, RN A/ADON received a delivery of a narcotic medication (hydrocodone-acetaminophen 84 tablets) for another resident (Resident #9) with two cards of the medication received; -On 08/30/24, RN A/Former ADON only logged in one card of Resident #9's narcotic medication and was able to take Resident #1's card of oxycodone-acetaminophen; -On 08/14/24, RN A/Former ADON also took a card of hydrocodone-acetaminophen 5-325 mg 14 tablets for Resident #2. During an interview on 09/05/24 at 2:30 P.M., the Director of Nursing said the following: -She got a phone call from RN D/IP on Saturday morning 08/31/24. RN D/IP told her something didn't look right in the narcotic box; -Both RN D/IP and LPN E thought Resident #1 had another oxycodone-acetaminophen card but the narcotic count was correct; -She received documentation from the pharmacy and compared pharmacy delivery tickets to RN A/Former ADON's time cards; -On 07/06/24 and 08/15/24, RN A/Former ADON electronically signed for two cards of oxycodone-acetaminophen (120 tablets) for Resident #1 and one card of hydrocodone-acetaminophen 14 tablets for Resident #2; -RN A/Former ADON took Resident #1's Oxycodone-Acetaminophen and Resident #2's Hydrocodone-Acetaminophen and the corresponding pharmacy delivery tickets; -RN A/Former ADON was the only nurse/employee on duty on night shift, 08/30/24, that had access to all residents' medications. MO 241498

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two residents (Residents #40 and #293), in a review of 16 sampled residents, and one additional resident (Resident #35), were treated in a manner to promote dignity and respect, when the facility failed to cover a urinary catheter (a tub inserted into the bladder that drains urine from the bladder into a collection bag outside of the body) collection bag. The facility census was 43. Review of the facility policy, Quality of Life-Dignity, dated August 2009, showed the following: -Each resident shall be care for in a manner that promotes and enhances quality of life, dignity, respect and individuality; -Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by helping the resident to keep urinary catheter bags covered. 1. Review of Resident #40's significant change Minimum Data Set (MDS), a federally mandated assessment required to be completed by facility staff, dated 06/03/24, showed the following: -He/She was cognitively impaired; -He/She was dependent for toileting needs; -He/She had a urinary catheter. Review of the resident's undated Care Plan showed the following: -He/She had a urinary catheter for urinary retention; -Ensure urinary catheter bag cover is used for dignity. Observation on 07/08/24 at 10:35 A.M. showed the resident sat in his/her wheelchair in the common area. Other residents were in the area. The resident's urinary catheter bag, which contained urine, hung under his/her wheelchair and was not covered with a dignity cover. Observation on 07/08/24 at 12:35 P.M. showed the resident sat in his/her wheelchair at a dining room table, eating lunch. Other residents were in the area. The resident's urinary catheter bag, which contained urine, hung under his/her wheelchair and was not covered with a dignity cover. Observation on 07/09/24 at 8:41 A.M. showed the resident sat in his/her wheelchair in the common area. Other residents were in the area. The resident's urinary catheter bag, which contained urine, hung under his/her wheelchair and was not covered with a dignity cover. Observation on 07/10/24 at 8:44 A.M. showed the resident sat in his/her wheelchair in the common area. Other residents were in the area. The resident's urinary catheter bag, which contained urine, hung under his/her wheelchair and was not covered with a dignity cover. Observation on 07/11/24 at 10:39 A.M. showed the resident sat in his/her wheelchair in the common area. Other residents were in the area. The resident's urinary catheter bag, which contained urine, hung under his/her wheelchair and was not covered with a dignity cover. 2. Review of Resident #293's Baseline Care Plan, dated 06/28/24, showed the following: -He/She required minimal assistance with mobility; -He/She had a urinary catheter. Review of the resident's admission MDS, dated [DATE], showed the following: -He/She was cognitively intact; -He/She was independent for toileting needs; -He/She had a urinary catheter. Observation on 07/08/24 at 12:28 P.M. showed the resident sat in his/her wheelchair at a table in the dining room, eating lunch. Other residents were in the area. The resident's urinary catheter bag, which contained urine, hung under his/her wheelchair and was not covered with a dignity cover. Observation on 07/08/24 at 1:34 P.M. showed staff pushed the resident from the dining room to his/her room in his/her wheelchair. The resident's urinary catheter bag, which contained urine, hung under his/her wheelchair and was not covered with a dignity cover. Observation on 07/09/24 at 6:27 A.M. showed Certified Nurse Assistant (CNA) B pushed the resident in his/her wheelchair to the dining room. Other residents were in the area. The resident's urinary catheter bag, which contained urine, hung under his/her wheelchair and was not covered with a dignity cover. Observation on 07/09/24 at 7:11 A.M. showed the resident sat in his/her wheelchair at a table in the dining room, eating breakfast. Other residents were in the area. The resident's urinary catheter bag, which contained urine, hung under his/her wheelchair and was not covered with a dignity cover. Observation on 07/09/24 at 1:49 P.M. showed therapy staff walked with the resident in the hallway. The resident's urinary catheter bag, which contained urine, hung from the resident's walker. The catheter bag was not covered with a dignity cover. Observation on 07/10/24 at 11:45 A.M. showed Nurse Aide (NA) C pushed the resident in his/her wheelchair to the dining room. Other residents were in the area. The resident's urinary catheter bag, which contained urine, hung under his/her wheelchair and was not covered with a dignity cover. Observation on 07/10/24 at 12:18 P.M. showed the resident sat in his/her wheelchair at a table in the dining room, eating lunch. Other residents were in the area. The resident's urinary catheter bag, which contained urine, hung under his/her wheelchair and was not covered with a dignity cover. Observation on 07/11/24 at 11:55 A.M. showed the resident sat in his/her wheelchair at a table in the dining room, waiting for lunch. Other residents were in the area. The resident's urinary catheter bag, which contained urine, hung under his/her wheelchair and was not covered with a dignity cover. 3. Review of Resident #35's quarterly MDS, dated [DATE], showed the following: -He/She was cognitively impaired; -He/She required substantial to maximum assistance for toileting needs; -He/She had a urinary catheter. Review of the resident's undated Care Plan showed he/she had a urinary catheter. Observation on 07/08/24 at 12:34 P.M. showed the resident sat in his/her wheelchair at a table in the dining room, eating lunch. Other residents were in the area. The resident's urinary catheter bag, which contained urine, hung under his/her wheelchair and was not covered with a dignity cover. Observation on 07/09/24 at 07:31 A.M. showed the resident sat in his/her wheelchair at a table in the dining room, eating breakfast. Other residents were in the area. The resident's urinary catheter bag, which contained urine, hung under his/her wheelchair and was not covered with a dignity cover. Observation on 07/11/24 at 9:21 A.M. showed two staff transferred the resident from his/her wheelchair to a recliner in the common room, where other residents were present. The resident's urinary catheter bag, which contained urine, hung under his/her wheelchair and was not covered with a dignity cover. 4. During an interview on 07/11/24 at 11:06 A.M. Nurse Aide (NA) E said urinary catheter bags should always have a dignity cover on them. During an interview on 07/11/24 at 11:11 A.M. CNA F said urinary catheter bags should always have a dignity cover. During an interview on 07/11/24 at 2:51 P.M., the Infection Preventionist/Registered Nurse A said urinary catheter bags should always be in a dignity cover. During an interview on 07/11/24 at 2:42 P.M., the Director of Nursing (DON) said she expected urinary catheter bags to have dignity cover. She was aware of this issue and the facility did not currently have enough dignity covers for all residents with urinary catheters.

Based on record review and interview, the facility failed to maintain a system to ensure the resident trust fund account was managed in accordance with proper accounting principles by not maintaining an accurate accounting of all monies held in the resident trust fund account by not reconciling each month. The facility managed funds for 25 residents. The census was 43. Request for a facility policy regarding the reconciliation of the resident funds account was made and none provided. 1. Record review of the reconciliation of resident funds, provided by the Business Office Manager (BOM), showed no reconciliation for the full resident trust account. 2. Record review of the Corporate Accountant's attempted reconciliation of the resident trust account, for accounts ending in #370665 and #342130, for the period 06/2023 through 06/2024, showed no reconciliations. During an interview on 07/10/24 at 3:37 P.M., the BOM said she only reconciled the petty cash accounts. Corporate staff reconciled the bank accounts. During an interview on 7/11/24 at 9:46 A.M., the Corporate Accountant said the facility BOM reconciled the petty cash only. They only reconciled the two bank accounts. During an interview on 07/16/24 at 9:55 A.M., the BOM said Corporate transfers $1,500 each month to the resident trust account so the account does not go into a negative. During an interview on 07/15/24 at 11:48 A.M., the Facility Management Company Staff said the operating account transfers $1,500 monthly to the resident trust account so there were no negative issues. The reconciliation does not deduct out the amount the facility transfers and the reconciliation does not have a $0 difference/balance. The resident petty cash may have been started with facility funds but no documentation can be located to verify if the petty cash funds start up funds were from the facility or the resident funds. During an interview on 7/16/24 at 2:48 P.M., the Administrator said he expected the resident funds account to be reconciled correctly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to accurately complete comprehensive assessments for three residents (#25, #2, #18) in a review of 16 sampled residents. The facility census was 43. Review of the undated facility policy titled, Minimum Data Set (MDS), Completion and Submission Timeframes, showed the facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. The policy did not address accuracy. Review of the Centers for Medicare and Medicaid Services (CMS) Long Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, version 1.18.11, October 2023, showed the following: -The Omnibus Budget Reconciliation Act (OBRA) regulations require nursing homes that are Medicare certified, Medicaid certified or both, to conduct initial and periodic assessments for all their residents; -The RAI process is the basis for the accurate assessment of each resident; -The treatments, procedures and programs listed in Item O0110, Special Treatments, Procedures, and Programs, can have a profound effect on an individual's health status, self-image, dignity and quality of life; -Code peritoneal or renal dialysis which occurs at the nursing home or at another facility. -Section I shows for physician diagnoses, include progress notes, the most recent history and physical, transfer documents, discharge summaries, diagnosis/ problem list, and other resources as available. If a diagnosis/problem list is used, only diagnoses confirmed by the physician should be entered. Review of the Long Term Care Facility Resident Assessment Instrument User's Manual, Version 3.0, Chapter 3, Section M, defines the different stages of pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) as follows: -Stage II: Partial thickness loss of dermis (the inner layer that makes up skin) presenting as a shallow open ulcer with a red-pink wound bed, without slough (non-viable yellow, tan, gray, green or brown tissue). May also present as an intact or open/ruptured blister; -Stage III: full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining (destruction of tissue or ulceration extending under the skin edges) or tunneling (a passage way of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound). 1. Review of Resident #25's quarterly MDS dated [DATE] showed no documentation the resident received dialysis. Review of resident's POS dated July 2024 showed an order for renal dialysis scheduled Tuesday, Thursday Saturday with a start date 11/13/23. Review of resident's undated Care Plan showed the resident received hemodialysis three times weekly. Observation and interview with resident on 07/08/24 at 11:16 A.M. showed the following: -He/She had been on dialysis for about three years; -He/She goes to dialysis treatment three times weekly. (The resident's MDS completed on 6/20/24 was not accurate and did not identify the resident received dialysis.) 2. Review of Resident #2's physician progress note, dated 6/30/21, showed the resident had diagnoses that included severe intellectual disability (mental retardation). Review of the resident's quarterly MDS, dated [DATE], showed under section A, no documentation the resident had diagnoses that included severe mental illness, mental retardation or other related conditions. Review of the resident's physician progress note, dated 5/22/24, showed his/her diagnoses included severe intellectual disability (mental retardation). During an interview on 7/9/23 at 1:24 P.M., the MDS coordinator reviewed the resident's Physician Progress Note, dated 5/22/24, and said she did not know the resident had intellectual disability (mental retardation) and the MDS was inaccurate. 3. Review of Resident #18's summarization of episode note (entry for readmission information) showed the resident was re-admitted to the facility, from the hospital, on 5/30/24. Review of the resident's nursing admission screening/history, dated 5/30/24, showed staff documented the resident had the following: -Left buttocks- two stage II pressure ulcers; -Coccyx (small triangular bone at the base of the spinal column) - one stage II pressure ulcer. Review of the resident's significant change/ five day MDS, dated [DATE], showed the resident had three stage III pressure ulcers that were present upon admission/entry or reentry. Review of the resident's medical record showed no evidence to support the resident's buttocks or coccyx wounds worsened from a stage II to a stage III. During an interview on 7/10/24 at 1:18 P.M., the MDS coordinator said after reviewing the resident's nursing admission screening/history, dated 5/30/24, the MDS was inaccurate. The resident's pressure ulcers were all stage II and not stage III. 4. During an interview on 07/11/24 at 1:03 P.M., the MDS coordinator said the following: -She was responsible for accurately completing all MDS assessments and used a combination of nursing notes, resident interviews, and visual assessments to complete; -She followed the RAI manual; -Missing Resident #25's dialysis was a complete oversight and error on her part. During an interview on 07/11/24 at 2:42 P.M., the Director of Nursing (DON) said the following: -She was responsible for signing off on the MDS as being completed and she expected the MDS to be accurate; -She expected the MDS to be completed per the RAI manual guidelines and to reflect current resident conditions and diagnoses.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to use appropriate infection control procedures for hand hygiene to prevent the spread of bacteria or other infectious causing contaminates for one sampled resident (Resident #18) and one additional resident (Resident #35); failed to ensure urinary catheter (tube inserted into the bladder to drain urine) drainage bags did not touch the floor for three residents (Residents #35, #40, and #293); failed to utilize the appropriate personal protective equipment (PPE), including gowns, when providing care for residents who required Enhanced Barrier Precautions (EBP) (an infection control intervention designed to reduce transmission ofmulti-drugg-resistant organisms (MDROs) that employs targeted gown and glove use during high contact resident care activities) for six sampled residents (Residents #11, #12, #24, #25, #143, and #293) and one additional resident (Resident #35); and failed to ensure soiled washcloths used to provide incontinence care were disposed in a sanitary manner for one resident (Resident #18), in a review of 16 sampled residents. The facility census was 43. Review of the facility policy, Hand Washing, dated July 2019, showed the following: -It is the policy of this facility that hand hygiene is the primary means to prevent the spread of infection; -The use of gloves does not replace proper handwashing; -Employees must wash their hands for at least 20 second using antimicrobial or non-antimicrobial soap and water under the following conditions: -When hands are visibly soiled (handwashing with soap and water); -Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice); -Before and after assisting a resident with personal care; -Upon and after coming in contact with a resident's intact skin; -Before and after assisting a resident with toileting (hand washing with soap and water); -After contact with a resident's mucous membranes and body fluids or excretions; -After handling soiled or used linens, dressings, bedpans, catheters and urinals; -After handling soiled equipment or utensils; -After removing gloves or aprons. Review of the undated facility policy titled, Enhanced Barrier Precautions, showed the following: -EBPs are utilized to prevent the spread of MDROs to residents; -EBPs are used as an infection prevention and control intervention to reduce the spread of MDROs to residents; -EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply; a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room); c. Face protection may be used if there is also a risk of splash or spray; -Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: c. Transferring; d. Providing hygiene; f. Changing briefs or assisting with toileting; g. Device care or use (central line, urinary catheter,feedingg tube, tracheostomy/ventilator, etc.) and h. Wound care (any skin opening requiring a dressing); --EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization; -EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk; -Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE; -PPE is available outside of the resident rooms. Review of the undated facility policy titled, Urinary Catheter Care, showed the following: -The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections; -Be sure the catheter tubing and drainage bag are kept off the floor. Review of the facility policy, Catheter Care, dated 9/2014 showed to place soiled linen in designated container. 1. Review of Resident #12's physician's orders, dated July 2024, showed the following: -Right stump open area: Apply betadine (antiseptic) and cover with abdominal (ABD) pad cut to fit; -Change daily until healed (start date 7/10/24). Review of the resident's undated care plan showed the following: -Blister opened to right stump; -Apply betadine and ABD until healed. Observation on 7/10/24 at 3:03 P.M. showed the following: -The resident sat on his/her bed; -The Assistant Director of Nursing (ADON) entered the resident's room; -No signage was on the resident's room or door regarding EBP; -The ADON washed her hands and applied gloves; -The ADON did not apply a gown; -No additional PPE other than gloves was noted in the resident's room; -The resident removed the soiled dressing from his/her stump; -The dressing was soiled with yellow-tan drainage and had an odor; -The open wound was approximately the size of a quarter; -The wound bed was moist and mostly covered with yellow slough; -The ADON applied betadine to the wound bed; -The ADON removed her gloves, applied alcohol based hand rub and applied clean gloves; -The ADON applied a clean, dry dressing and secured the dressing with tape. Observation on 7/11/24 at 8:41 A.M. in the resident's room showed the following: -No signage was on the resident's room or door regarding EBP; -No additional PPE other than gloves was noted in the resident's room. During an interview on 7/11/24 at 1:36 P.M. Housekeeper N said the following: -Nursing tells housekeeping when the PPE cart is needed in the resident room then housekeeping puts the cart in the resident's room; -Housekeeping does not put the EBP sign on the resident's room/door; -The resident does not have an EBP sign on his/her door or a PPE cart in his/her room. During an interview on 7/11/24 at 1:35 P.M. the Infection Preventionist/Registered Nurse A (IP/RN A) said the following: -The red EBP signs are available at the nurses' station; -Any nurse can put up the red EBP signs but currently the ADON is responsible and eventually she will be the one responsible. 2. Review of Resident #143's admission care plan dated 7/3/24 showed the following: -Cognitively intact; -Two unstageable pressure ulcers (obscured full-thickness skin and tissue loss) with suspected deep tissue injury in evolution; -Pressure ulcer care. Review of the resident's undated care plan showed the following: -Documented pressure ulcer on right heel; -Use gown and gloves with dressing, bathing, transfers, changing linens, providing hygiene, changing briefs or when caring for wound in his/her room. Review of the resident's physician's orders, dated July 2024, showed an order to cleanse wound to right heel, pat dry, Calmoseptine (barrier cream) to periwound (area around the wound), pack wound with silver alginate (wound dressing with antibacterial silver for moderate to highly exudating (the fluid that is secreted from a wound during the healing process) wounds)) (place inside the wound, do not cover good skin only apply to wound bed) cover with gauze and wrap with Kerlix gauze twice daily (original order dated 6/19/24). Observation on 7/10/24 at 8:30 A.M. in the resident's room showed the following: -The resident sat on his/her bed; -There was a red EBP sign on the wall outside the resident's room; -The wound care consultant and the Assistant Director of Nursing (ADON) entered the resident's room; -The wound care consultant washed his/her hands and applied gloves; -The wound care consultant did not wear a gown; -The wound care consultant assessed the open wound on the resident's right heel; -The wound care consultant cleansed and debrided (process of removing dead tissue) the wound bed; -There was yellow slough (dead cells that accumulate in the wound exudate) present in the wound bed; -There was a moderate amount of bleeding with and after the debridement; -With gloved hands, the ADON applied a dry dressing to the resident's right heel wound and placed the resident's right foot on a disposable pad (the wound continued to bleed); -The ADON did not wear a gown when providing the treatment to the resident's wound. Observation on 7/10/24 at 9:06 A.M. in the resident's room showed the following: -The resident sat on his/her bed; -There was a red EBP sign on the wall outside the resident's room; -IP/RN A entered the room, washed his/her hands and applied gloves; -IP/RN A did not apply a gown; -IP/RN A removed the gauze dressing and cleansed the wound with wound cleanser; -There was a moderate amount of dried blood on and surrounding the wound; -IP/RN A removed her gloves, used alcohol based hand rub and applied clean gloves; -IP/RN A cut the silver alginate (wound treatment preparation), packed it into the wound, covered the wound with a gauze pad and secured the dressing with Kerlix gauze and tape; -IP/RN A removed her gloves and washed her hands. During an interview on 7/10/24 at 3:08 P.M. the ADON said she forgot to wear a gown while performing wound care on Resident #12 and Resident #143. 3. Review of Resident #18's Summary of Episode (readmission information), dated 7/11/24, showed his/her diagnoses included acute kidney failure (when the kidneys suddenly can't filter waste products from the blood) and neuromuscular dysfunction of bladder (when a person lacks bladder control due to brain, spinal cord or nerve problems). Observation on 7/10/24 at 11:48 A.M., showed the following: -Certified Nursing Assistant (CNA) G and Nursing Assistant (NA) C donned Personal Protective Equipment (PPE-gown and gloves) and entered the resident's room; CNA G and NA C did not perform hand hygiene (wash hands with soap and water or use hand sanitizer) before donning PPE; -NA C filled a plastic wash basin with warm water and CNA G performed pericare, including the cleaning of the resident's urinary catheter insertion site, with warm water, body wash and wash cloths; -CNA G placed each soiled cloth on the bedside nightstand. No barrier was used between the nightstand and the cloths; -CNA G dried the resident's peri area with a dry towel and placed the towel on top of the soiled cloths on the nightstand; -CNA G, still wearing soiled gloves, went to a cloth bag hanging on the resident's bathroom door and reached in the bag for a clearplasticc bag; he/she placed the soiled wash cloths and towel in the bag; -CNA G doffed his/her gown and gloves, and without performing hand hygiene with soap and water or using hand sanitizer, went to the resident to adjust his/her bedding; -CNA G and NA C left the room and did not clean the resident's bedside nightstand. Interview on 7/10/24 at 1:30 P.M., showed CNA G said he/she did not realize that he/she had not completed hand hygiene before and after care, before touching the resident or items after procedure. While he/she was doing the care, he/she did not have anywhere to put the soiled items except the nightstand. During an interview on 7/10/24 at 2:38 P.M., the Director of Nursing said she expected the staff topreparee for catheter care by getting the bags for soiled items and barriers prepared and to use hand hygiene before staff begancatheterd care. 4. Review of Resident #25's quarterly MDS, dated [DATE], showed he/she had moisture associated skin damage (MASD). Review of the resident's undated care plan showed the following: -Potential for impaired skin integrity; -Provide skin care per facility guidelines and as needed (PRN). Review of the resident's Physician Order Sheet (POS), dated July 2024, showed the following: -An order for house barrier (a topical cream applied directly to the skin surface to help maintain the skin's physical integrity) to bilateral buttocks every shift and PRN every shift for skin care (original order dated 09/13/23); -An order for collagenase powder (an enzyme derived product used to help the healing of burns and skin ulcers), apply to right gluteal fold topically every day shift for MASD to right gluteal fold, mix collagen powder with A&D ointment apply to area cover with a dressing daily may discontinue when area is healed (original order dated 09/22/23). Observation on 07/08/24 at 11:16 A.M. showed no signage for EBP on or near the resident's room door or wall. No PPE supply cart was available inside or outside the resident's room. Observation on 07/10/24 at 8:51 A.M. showed IP/RN A wore gloves and applied house barrier (collagenase powder and A&D ointment) to the resident's bilateral gluteal fold and crease, where MASD was observed. The resident's skin was blanchable, with an area of maceration along the bilateral gluteal clefts. IP/RN A identified two new open areas on the resident's buttock, one on the right inner thigh, below the gluteal fold, and one on the lower right buttock, above the gluteal fold. Both open areas were bleeding. IP/RN A did not wear a gown when providing care to the resident. 5. Review of Resident #11's quarterly MDS, dated [DATE], showed suctioning and tracheostomy (an opening into the trachea, or windpipe, from outside the neck, to help air and oxygen reach the lungs) were required. Review of the resident's undated care plan showed the following: -At risk for infection related to laryngectomy (a surgery to remove part or all of your larynx, or voice box); -Difficulty with communication related to tracheostomy; -Use gown and gloves with dressing, bathing, transfers, changing linens, providing hygiene, changing briefs or when caring for tracheostomy in his/her room; -Use universal precautions as appropriate. Review of the resident's POS, dated July 2024, showed the following: -Remove laryngectomy tube and clean daily with toothbrush and replace same tube every day and evening shift for secretions (original order dated 02/26/24); -Replace tracheostomy inner cannula every day shift every Wednesday (original order dated 06/05/24); -Replace tracheostomy outer cannula every day shift every 30 days (original order dated 06/12/24); -Suction tracheostomy every six hours to maintain airway (original order dated 04/29/24). Observation on 07/09/24 at 05:30 A.M. showed Licensed Practical Nurse (LPN) H prepared the resident for a breathing treatment when the resident coughed up secretions. LPN H, did not wear gloves or a gown, and cleaned the secretions from the resident's tracheostomy with a tissue. LPN H did wash his/her hands after cleaning the secretions from the resident, and starting the resident's breathing treatment. EBP signage was posted on the wall next to the resident's door and EBP PPE cart was available in the resident's room, under the sink. 6. Review of Resident #40's significant change MDS, dated [DATE], showed he/she had a urinary catheter. Review of the resident's undated Care Plan showed the following: -He/She had a urinary catheter for urinary retention; -The urinary catheter will remain without signs and symptoms of infection; -Ensure the bag isn't touching the floor from the bed or wheelchair placement. Observation of resident's room on 07/08/24 at 10:43 A.M. showed no EBP signage on or near the room door or wall, as directed by facility policy for resident's on EBP. Observation on 07/08/24 at 10:35 A.M., 12:17 P.M. and 12:35 P.M. showed the resident sat in his/her wheelchair in the dining room. The urinary catheter bag hung under the resident's wheelchair and touched the floor. Observation on 07/08/24 at 1:54 P.M. showed the resident lay in bed. The urinary catheter bag was hooked on the side of the resident's bedframe and lay directly on the floor. Observation on 07/09/24 at 5:11 A.M. showed the resident lay in bed. The urinary catheter bag lay directly on the floor. Observation on 07/10/24 at 8:44 A.M. showed resident sat in his/her wheelchair in the common area. The urinary catheter bag hung under the resident's wheelchair and touched the floor. 7. Review of Resident #293's Baseline Care Plan, dated 06/28/24, showed the following: -Active diagnoses of urinary tract infection; -He/She required minimal assistance with mobility; -He/She had a urinary catheter. Review of the resident's admission MDS, dated [DATE], showed the following: -Cognitively intact; -Had a urinary catheter. Observation on 07/08/24 at 11:46 A.M. showed EBP signage was posted on the wall beside the door outside the resident's room. Observation on 07/08/24 at 12:28 P.M. showed the resident sat in his/her wheelchair at a table in the dining room, eating lunch. The urinary catheter bag hung under the resident's wheelchair and touched the floor. Observation on 07/09/24 at 6:27 A.M. showed Certified Nurse Assistant (CNA) B pushed the resident in his/her wheelchair to the dining room. The resident's catheter bag hung under the wheelchair and dragged on the ground. Observation on 07/09/24 at 7:11 A.M. showed the resident sat in his/her wheelchair at a table in the dining room, eating breakfast. The urinary catheter bag hung under the resident's wheelchair and touched the floor. Observation on 07/09/24 at 8:52 A.M. showed the resident sat in a recliner in his/her room. The resident's catheter bag was hooked on the side of the footrest and touched the floor. Observation on 07/09/24 at 2:09 P.M. showed no easily accessible PPE in or around the resident's room. Observation on 07/10/24 at 10:16 A.M. showed CNA I emptied the resident's urinary catheter bag. He/She wore gloves but did not wear a gown. No PPE supply cart was available in or outside of the resident's room. Observation on 07/10/24 at 11:45 A.M. showed NA C pushed the resident in his/her wheelchair to the dining room. The resident's catheter bag hung under his/her wheelchair and dragged on the floor. Observation on 07/10/24 at 12:18 P.M. showed the resident sat in his/her wheelchair at the dining room table, eating lunch. The resident's catheter bag hung under his/her wheelchair and touched the floor. Observation on 07/11/24 at 11:55 A.M. showed the resident sat in his/her wheelchair at the dining room table. The resident's catheter bag hung under this/her wheelchair and touched the floor. 8. Review of Resident #24's significant change MDS, dated [DATE], showed the following: -Cognitively intact; -Dependent for toileting needs; -Intermittent catheterization. Review of the resident's POS, dated July 2024, showed the resident had a urinary catheter. Review of the resident's undated Care Plan showed the following: -He/She had a urinary catheter for retention, placing him/her at risk for UTI; -Use gown and gloves with dressing, bathing, transfers, changing linens, providing hygiene, changing briefs or when performing straight catheter in his/her room. Observation on 07/08/24 at 11:20 A.M. showed EBP signage hung on the wall outside the resident's room, and a PPE cart sat in the hallway below the signage. Observation on 07/09/24 at 8:58 A.M. showed the following: -The resident lay in bed. His/Her catheter bag was hooked on the side of his/her bed frame; -CNA B and CNA J assisted to dress the resident. CNA B wore full PPE (gown, gloves, face shield), while CNA J only wore gloves; -Once the resident was dressed, CNA B emptied the resident's urinary catheter bag; -CNA B and CNA J removed their gloves and washed their hands, assisted to transfer the resident from his/her bed to the wheelchair with a mechanical lift, and then changed the resident's shirt. Neither CNA wore gloves or a gown while transferring or putting on the resident's shirt. -CNA B did not wear gloves and placed the resident's urinary catheter into the dignity bag; -NA K, who was also in the room, stripped the resident's bed, wearing only gloves. 9. Review of Resident #35's quarterly MDS, dated [DATE], showed the following: -Cognitively impaired; -Substantial to maximum assistance for toileting needs; -Has a urinary catheter. Review of the resident's undated Care Plan showed the following: -At risk of UTI due to a urinary catheter for neurogenic bladder; -He/She will be free of signs and symptoms of infection; -Use gown and gloves with dressing, bathing, transfers, changing linens, providing hygiene, changing briefs or when caring for catheter in his/her room. Observation on 07/08/24 10:40 A.M. showed EBP signage was on the wall outside the resident's room door, and a PPE cart was located in the resident's room under the sink. Observation on 07/08/24 at 12:34 P.M. showed the resident sat in his/her wheelchair at a table in the dining room, eating lunch. The resident's catheter bag hung under the wheelchair and touched the ground. Observation on 07/09/24 at 5:09 A.M. showed the resident lay in his/her bed. The resident's catheter bag was hooked on the side of the bed frame and lay directly on the floor. Observation on 07/09/24 at 5:33 A.M. showed LPN H, did not wear gloves or a gown, and placed the resident's urinary catheter bag in a pink basin. He/She did not wash his/her hands before or after handling the urinary catheter bag. Observation on 07/09/24 at 07:31 A.M. showed the resident sat in his/her wheelchair at a table in the dining room, eating lunch. The urinary catheter bag hung under the resident's wheelchair and touched the floor. Observations on 07/10/24 at 10:13 A.M. and 11:15 A.M. showed the resident lay in bed. The resident's urinary catheter bag was hooked on the side of the bed frame and lay directly on the ground. During an interview on 07/11/24 at 11:06 A.M., NA E said the following: -EBP are for residents with tracheostomies, catheters, and infections; -Staff should wear gown, gloves, and mask/goggles, when providing direct care for residents on EBP: -Catheter bags should never touch the ground due to the risk for infection. During an interview on 07/11/24 at 11:11 A.M., CNA F said the following: -EBP are for residents with catheters and infections, like COVID-19; -When providing direct care for residents on EBP,staff shouldd wear gown and gloves, and a mask if needed; -Catheters should never touch the ground; -He/She received a brief one-on-one training about EBP. During interviews on 07/10/24 at 4:04 P.M. and 07/11/24 at 2:51 P.M., the IP/RN A said the following: -She took over as the Infection Preventionist on 6/1/24; -When providing direct care for a resident on EBP, staff should always wear gowns and gloves and staff should use a face shield if there is a potential for body/contaminated fluid exposure, like when emptying a catheter or irrigating a wound; -She had not provided any additionaltrainings for staff since she became the infection preventionist; the Director of Nursing (DON) provided a training prior to this; -She expected staff to change gloves and wash hands if the gloves were soiled, or if staff touched dirty items, before going back to clean items; -She considered providing perineal (the area between the tops of the thighs) care a dirty activity and expected staff to change gloves and wash hands; -Catheter bags should never touch the ground; -For the few residents who had a very low bed due to fall risks, staff should put the catheter in a pink basin as a barrier to the ground; -She made a mistake when providing wound care for two residents and forgot to wear a gown and mask; she remembered when she exited the second room; -She expected all staff to know and follow the appropriate PPE guidelines for EBP. During an interview on 07/11/24 at 2:42 P.M., the DON said the following: -Catheter bags should always be kept off the floor; -She provided EBP training just a few months ago and would expect all staff to know and follow the appropriate PPE guidelines.

Based on observation and interview, the facility to maintain essential kitchen equipment in good working order. The facility census was 43. 1. Observation on 7/8/24 at 1:50 P.M. of the three-compartment sink in the facility kitchen showed the drain pipe for the third sink well (used for sanitizer solution) leaked below the sink into a plastic tub on the floor. The tub was full of water and slowly ran over the edge of the tub into the floor drain. Observation 7/9/24 at 7:49 A.M. of the three-compartment sink showed the sanitizer well sink drain leaked below the sink and water dripped directly on the floor. The tub that had previously caught the dripping water (the day before) had been removed. During interviews on 7/8/24 at 1:53 P.M. and on 7/9/24 at 8:20 A.M., the Dietary Manager said the pipes under the three-compartment sink leaked and the seals were broken. The sink also did not have hot water. Maintenance and the Administrator were aware of these issues. The problems had been ongoing for the last year. The kitchen staff did not currently use the three-compartment sink. Staff used to use the three-compartment sink to wash large items by hand or they would use the sink for washing dishware if the dish machine was broken down. Maintenance had tried fixing the unit in the past, but the repairs never ended up working. She had asked management to fix the three-compartment sink multiple times since she had been employed at the facility (approximately one year). When a piece of equipment broke or was not working, she notified maintenance first and then notified the administrator. During an interview on 7/9/24 at 12:32 P.M., the Maintenance Supervisor said the sink had not worked properly for at least six months. He had tried different repairs in the past but nothing worked. He thought the facility was supposed to replace the three-compartment sink. During an interview on 7/9/24 at 11:35 A.M., the Administrator said the three-compartment sink needed to be replaced. The facility was trying to find someone to custom build the sink due to the size constraints in that portion of the kitchen. The sink had not worked properly for approximately one year.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to complete inspections of bed frames, mattress, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for three residents (Residents #24, #25 and #40), in a review of 16 sampled residents. The facility census was 43. Review of the facility policy, Bed Safety, dated December 2007, showed the following: -The resident's sleeping environment shall be assessed for the interdisciplinary team, considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment; -a. Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks; -b. Review the gaps within the bed system are within the dimension established by the Food and Drug Administration (FDA). Note: The review shall consider situation that could be caused by the resident's weight, movement or bed position; -d. Ensure that bed rails are properly installed using the manufacturer's instructions and other pertinent safety guidance to ensure proper fit (e.g. avoid bowing, ensure proper distance from the headboard and footboard, etc.); -e. Identify additional safety measures for residents who have been identified as having a higher than usual risk for injury including entrapment (e.g. altered mental status, restlessness, etc.); -The maintenance department shall provide a copy of inspections to the Administrator and report results to the Quality Assurance (QA) committee for appropriate action. Copies of the inspection results and QA Committee recommendations shall be maintained by the Administrator and/or Safety Committee. 1. Review of Resident #40's significant change Minimum Data Set (MDS), a federally mandated assessment required to be completed by facility staff, dated 06/03/24, showed the following: -Cognitively intact; -Upper and lower extremity impairment on one side; -Partial/moderate assistance with rolling left/right in bed. Review of resident's undated Care Plan showed he/she was able to roll side to side independently with mobility bars (assist/bed rail). Review of the resident's Bed Rail Assessment, completed 05/28/24, showed the following: -The resident was non-ambulatory; -He/She had an alteration in safety awareness due to cognitive decline; -He/She had poor bed mobility; -Bilateral bed rails; -Bed rails/assist bar indicated and serve as an enabler to promote independence; -No documentation of entrapment zone measurements. Observation on 07/08/24 at 10:43 A.M. showed the resident's bed had assist bars on both sides of the bed in the raised position. Observations on 07/08/24 at 1:54 P.M., on 7/9/24 at 5:11 A.M., and on 07/10/24 at 2:13 P.M., showed the resident lay in bed. The resident had assist bars on both sides of his/her bed in the raised position. 2. Review of Resident #24's significant change MDS, dated [DATE], showed the following: -Cognitively intact; -No impairment of upper or lower extremities; -Substantial/maximal assistance with rolling left/right in bed. Review of the resident's physician order sheets (POS), dated July 2024, showed an order for mobility bars for bed positioning (original order dated 07/19/23). Review of the resident's undated Care Plan showed the following: -He/She expressed desire for bed rails to increase bed mobility; -Need for mobility bars will be assessed quarterly; -Mobility bars bilaterally to facilitate bed mobility. Review of the resident's Bed Rail Assessment, completed 07/03/24, showed the following: -The resident was non-ambulatory; -Has poor bed mobility; -Has expressed a desire to have bed rails/assist bars for safety and/or comfort; -Bilateral bed rails; -Bed rails/assist bar are indicated and serve as an enabler to promote independence; -No documentation of entrapment zone measurements. Observations on 07/09/24 at 5:20 A.M. and 7:10 A.M. showed the resident lay in bed on a low-air loss mattress. The resident had assist bars on both sides of his/her bed in the raised position. 3. Review of Resident #25's quarterly MDS, dated [DATE], showed the following: -Cognition was intact; -Substantial/maximal assistance with rolling left/right in bed. Review of the resident's undated Care Plan showed bilateral bed mobility bars for improved bed mobility. Review of the resident's bed rail assessment, completed on 06/20/24, showed the following: -The resident was non-ambulatory; -Poor bed mobility; -Has expressed a desire to have bed rails/assist bar for safety and/or comfort; -Bilateral bed rails; -Bed rail/assist bar are indicated and serve as an enabler to promote independence; -No documentation of entrapment zone measurements. Observation on 07/08/24 at 11:16 A.M. showed the resident had a low-air loss mattress. The resident had quarter bed rails on both sides of his/her bed in the raised position. 4. During an interview on 07/11/24 at 11:58 A.M., the Maintenance Supervisor said the following: -He put the bed rails/assist bars on the beds; -He measured bed rails/assist bars on placement, but did not have a form or paper he completed and filed/tracked; -He did not check specialty mattress (low air loss, etc) manufacturer guidelines to ensure compatibility with the bed rails; -He did not conduct regular measurement checks for entrapment zones. During an interview on 07/1/24 at 2:42 P.M. the Director of Nursing (DON) said the following: -Maintenance staff was responsible for measuring the entrapment zones; -Measurements should be completed and documented when the bed rails were first placed, then quarterly, or with any bed changes; -Maintenance should also check to ensure bed frames/mattresses are compatible with the bed rails. During an interview on 07/11/24 at 3:12 P.M., the Administrator said the following: -Maintenance and nursing should work together to ensure entrapment zone measurements were completed; -He expected measurements to be completed, tracked, and reported per facility policy.

Based on observation, interview, and record review, the facility failed to maintain the range hood free of a buildup of grease and debris; failed to maintain the air conditioner and microwave free of a buildup of debris; failed to ensure food items were labeled, dated, covered and discarded when expired; failed to ensure a water dispenser and a water dispensing unit was free of a buildup of debris; failed to ensure staff utilized safe food handling practices when preparing ready to eat food items; failed to ensure staff handled ready to eat foods safely; failed to ensure staff wore hair restraints properly; and failed to ensure the ice machine was equipped with an appropriate air gap to prevent back siphonage. The facility census was 43. 1. Review of the undated facility policy, Cleaning Instructions: Hoods and Filters, showed stove hoods and filters will be cleaned according to a cleaning schedule or at least monthly. Observation on 07/08/24 at 10:18 A.M. and on 7/9/24 at 7:49 A.M. showed the range hood had three filters that protected the stove, griddle and fryer. The filters had a heavy buildup of black and dark brown fuzzy debris with yellow and dark brown grease accumulation. The fire suppression system had a buildup of shiny yellow grease with drip formations on the nozzle caps. A sticker on the outside of the range hood showed the hood had been professionally cleaned on 2/19/24. During interview on 7/8/24 at 11:15 A.M., the Dietary Manager said she was unaware dietary was responsible for cleaning the hood filters. The professional company did not clean the filters when they were onsite in February. She had worked in the dietary department for a year and had been the manager for six months. The filters needed to be cleaned. During interview on 7/8/24 at 2:10 P.M., the Maintenance Supervisor said he was unsure when the range hood filters were last cleaned. It had probably been a while since this had been done. 2. Observation on 7/8/24 at 10:25 A.M. and on 7/9/24 at 7:49 A.M. showed an air conditioner sat in the window frame in the kitchen. The exterior vents had a heavy buildup of dark colored fuzzy debris. The cool air blew through the vents towards the microwave and metal food preparation counter. An open plastic container that held large blocks of butter sat uncovered on a tray with the toaster on the metal preparation counter. Observation on 7/8/24 at 10:26 A.M. and on 7/9/24 at 7:49 A.M. showed a microwave sat on a metal preparation counter. Rust-colored debris was visible inside the microwave around the bottom edges of the unit. A large rust-colored area on the top inside center portion of the microwave appeared to have exposed metal and peeling/chipped areas. 3. Review of the facility policy, Food Receiving and Storage, revised July 2014, showed the following: -Foods shall be received and stored in a manner that complies with safe food handling practices; -All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date); -Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day by the Food Service Manager or designee and documented according to state-specific requirements; -All foods belonging to residents must be labeled with the resident's name, the item and the use by date. Observation on 7/8/24 at 10:31 A.M. inside the upright home-type freezer in the kitchen showed the following: -Three black bowls of vanilla ice cream sat uncovered; -A plastic bag of burritos were open to air and not sealed; -An open plastic bag of hamburger patties was open to air and not sealed. Observation on 7/8/24 at 10:40 A.M. inside the reach-in refrigerator showed the following: -A container of macaroni salad was loosely covered with tinfoil and had a resident's first name and room number written on the foil. The item was not dated; -Two small Styrofoam cups contained a white substance and were not labeled or dated; -A large Ziploc bag contained several peanut butter/jelly sandwiches. The bag was not dated; -A bottle of soda had been opened, but was not labeled with anyone's name; -A large plastic pitcher of dark colored liquid was labeled Cran and was dated 6/6. Observation on 7/8/24 at 10:42 A.M. above the water dispenser on the metal shelf showed an open packet of low calorie drink mix that was open to air and unsealed. Observation on 7/9/24 at 7:49 A.M. showed a 2-ounce packet of punch drink mix was open to air and sat upright next to the water dispenser. The mix was open and unsealed. Observation on 7/8/24 at 10:45 A.M. of the triple door reach-in refrigerator showed the following: -A large clear container with a red lid was labeled Chicken noodle 6/29; -A clear plastic pouch/bag of scrambled egg mix was closed with a metal binder clip. The bag was not dated; -A large clear container with a red lid contained shredded cheese and was not dated; -A plastic grocery sack held two egg cartons stacked on top of each other and four loose eggs sat on top of the top carton. The sack of eggs/carton sat on the second to bottom shelf directly over a container of cheese and a cantaloupe. Observation on 7/8/24 at 11:53 A.M. showed the Dietary Manager reheated the chicken noodle in the container dated 6/29 and placed it on a resident's hall tray for the lunch meal. Observation on 7/8/24 at 11:05 A.M. showed a metal shelf above the top of the steam table. The shelf contained the following: -The lid on a 16-ounce container of paprika was open and unsealed; -The lid on a 12-ounce container of basil was open and unsealed; -The lid on a 12.5-ounce container of ginger was open and unsealed; -The lid on a 16-ounce container of pumpkin pie spice was open and unsealed. 4. Observation on 7/8/24 at 10:41 A.M. and on 7/9/24 at 7:49 A.M. showed a tall upright water dispenser sat on the metal preparation counter. The dispensing spout had a buildup of dark colored crusty debris on the edges of the dispenser. A water filter and water line were connected to the unit. The water filter was labeled install 4/6/22 with a black marker. During interview on 7/9/24 at 8:20 A.M., the Dietary Manager said the following: -The water dispenser was cleaned with lime remover once a week; -She was not sure who was responsible for changing the water filter connected to the water dispenser. During an interview on 7/9/24 at 12:32 P.M., the Maintenance Supervisor said the facility purchased and installed the water dispenser in October 2023. He was unsure why the filter had a different date on it. 5. Review of the undated facility policy, Bare Hand Contact with Food and Use of Plastic Gloves, showed the following: -Single-use gloves will be worn when handling food directly with hands to ensure that bacteria are not transferred from the food handler's hands to the food product being served. Bare hand contact with food is prohibited; -Staff will use clean barriers such as single-use gloves, tongs, deli paper and spatulas when handling food; -Gloved hands are considered a food contact surface that can get contaminated or soiled. If used, single use gloves shall be used for only one task (such as working with ready-to-eat food or with raw animal food), used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. Observation on 7/8/24 at 11:10 A.M. showed the Dietary Manager removed some butter from the open container near the toaster and placed the butter in a skillet on the stovetop. Without washing his/her hands, she put on gloves, and removed two pieces of bread from a loaf. She used a knife to butter one slice of bread and placed it face down in the skillet on the stove. She buttered a second slice of bread and placed the slice of bread on the edge of the stove top. She wore the same gloves, opened the refrigerator door by the handle, and brought a container of cheese slices to the preparation counter. Using the same gloves, she removed a cheese slice from the container and placed the cheese on top of the bread slice in the skillet. She then removed the bread slice from the edge of the stove top and placed it on top of the cheese and bread in the skillet. 6. Review of the undated facility policy, Personal Hygiene and Health Reporting, showed hair should be neat and clean. Hair restraints must be worn around exposed foods, in the kitchen or food services areas and dining rooms. Observation on 7/8/24 during the lunch meal service between 11:53 A.M. and 1:01 P.M. and at 2:15 P.M. showed Dietary Staff L placed beverages, nutritional supplements and dessert items on each meal tray. He/She wore a hair restraint; however, the hair restraint did not contain his/her bangs and longer strands of hair on the sides of his/her face that were loose outside of the hair restraint. Observation on 7/9/24 at 7:49 A.M. showed Dietary Staff M wore a hair restraint; however, not all his/her hair from the back and sides of his/her head was contained inside the hair restraint. Dietary Staff M prepared drinks in the kitchen, placed the drinks on breakfast trays and carried the breakfast trays to the kitchen door for facility staff to deliver to residents in the dining room. 7. Observation on 7/8/24 at 2:44 P.M. and on 7/9/24 at 8:04 A.M. of the facility ice machine located in the staff breakroom, showed the approximately 2-inch drain pipe was not equipped with an air gap. The pipe sat down inside the drain and did not have adequate spacing for the required air gap. 8. Observation on 7/8/24 at 2:15 P.M., in the facility kitchen showed the cover over a four-bulb four bulb fluorescent light fixture located above the microwave and food preparation table was cracked and had a 3-inch by 3-inch hole in the cover. During an interview on 7/8/24 at 3:04 P.M., the Maintenance Director said the following: -He was responsible for monitoring the facility light fixtures and covers; -He checks light fixtures and covers on an ongoing basis; -He was unaware of the identified cracked cover with a 3-inch by 3-inch hole; -He expected facility light fixtures and covers to be maintained and without damage. 9. During interview on 7/9/24 at 8:20 A.M., the Dietary Manager said the following: -If family brought in food, snacks or drinks for residents, the food items should be separated from facility foods and labeled/dated; -She was unaware the range hood filters needed to be cleaned. She had just learned this task was dietary's responsibility; -Maintenance staff changed the air conditioner filter and dietary staff cleaned the vents and outside cover either weekly or monthly; -Staff cleaned the microwave every shift. She will look closer at the inside to check the rust color inside. She was unaware of any damage inside the microwave; -Leftovers were good for three days, the date on the label is the date food was placed/stored in the refrigerator; -Pre-packaged foods that have not been opened goes by the manufacturers expiration date, salad dressing and condiments go by expiration date on bottle, if poured into dispensing container it is good for three days; -Shredded cheese was used quickly (usually in two to three days after opening) and she was unsure of how long shredded cheese lasted; -The cooks and aides checked the refrigerators for food labeling dates twice a week; -The four loose eggs were leftover from breakfast yesterday and the carton had been thrown away; -Freezer items should be sealed and dated; -Spice lids should not be open; -Opened drink packets should be sealed; -Any employee that entered the kitchen should wear a hair restraint and all hair should be covered; -She was unaware the ice machine did not have an air gap; -Gloves and handwashing should be performed when touching food items, should switch gloves in between different food items, and after touching dirty items, such as door handles, counter tops, etc. During an interview on 7/9/24 at 12:32 P.M., the Maintenance Supervisor said the following: -Dietary staff were responsible for cleaning the range hood baffle filters regularly and he would assist them if needed; -Dietary staff were responsible for cleaning the air conditioner monthly. He replaced the filters when needed; -He was unaware the microwave had possible rust/debris inside; -He was unaware the ice machine did not have an air gap.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a written notice of discharge with required information to the resident and/or resident representative for one additional resident (Resident #2), in a review of four sampled residents, when the facility initiated a transfer to the hospital and denied the resident re-admission to the facility. The facility census was 38. Review of the facility's undated policy, Transfer or Discharge Notice, showed the following: -Our facility shall provide a resident and/or the resident's representative with a 30-day written notice of impending transfer or discharge; -A resident, and/or his/her representative, will be given a 30-day advance notice of an impending transfer or discharge from our facility; -Under the following circumstances, the notice will be given as soon as it is practicable but before the transfer or discharge: a. The transfer is necessary for the resident's welfare and the resident's needs cannot be met in the facility; b. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; c. The safety of individuals in the facility is endangered; d. The health of individuals in the facility would otherwise be endangered; f. An immediate transfer or discharge is required by the resident's urgent medical needs; g. The resident has not resided in the facility for 30 days; -The resident and/or representative will be notified in writing of the following information: a. The reason for the transfer or discharge; b. The effective date of the transfer or discharge; c. The location to which the resident is being transferred or discharged ; -A copy of the notice will be sent to the Office of the State Long-Term Care Ombudsman. Review of the facility's policy, Transfer or Discharge Documentation, revised December 2016, showed the following: -When a resident is transferred or discharged from the facility, the following information will be document in the medical record: b. That an appropriate notice was provided to the resident and/or legal representative; f. A summary of the resident's overall medical, physical, and mental condition. 1. Review of Resident #2's face sheet showed the following: -admission on [DATE]; -No emergency contact, responsible party or diagnoses. Review of the resident's census report showed admission on [DATE] and stop billing on 9/26/23. Review of the resident's facility progress notes for 9/26/23 at 6:40 P.M., showed staff documented the following: -admitted to room [ROOM NUMBER]-2 at 1:30 P.M.; -Assessments started; -Hospice nurse here and did assessment; -Resident became agitated, exit seeking, cussing, ambulating up hall pushing bedside table, getting into another resident's wheelchair, threatening to break things; -Resident was requesting to go to the local hospital; -Transported to local hospital via emergency medical services at 4:30 P.M. Review of the resident's medical record showed no emergency transfer/discharge or 30 day discharge notice given to or mailed to resident or the resident's representative when transferred to the hospital. During an interview on 10/5/23, at 11:12 A.M., the Ombudsman's office reported they did not have record of a discharge given to the resident by the facility. The facility would have been required to issue a discharge if not willing to receive the resident back to the facility after the hospital transfer. During an interview on 10/5/23, at 11:28 A.M., Licensed Practical Nurse (LPN) A said the following: -He/She, along with Registered Nurse (RN) B, admitted and discharged the resident to and from the facility; -The resident became aggravated and did not want to stay in the facility; -The resident threatened to break things, but had not gotten physically aggressive, just verbally aggressive; -The resident requested to return to the hospital he/she had come from and the physician gave the order to transport; -He/She had tried to call the resident's family member but got no response; -It was discussed by RN B and administration (no one specific) that the resident would not be allowed to return to the facility; -When the hospital called and informed him/her the resident was ready to return to the facility, he/she told the hospital that the administration had discussed it and the resident was not able to return to the facility; -He/She is not sure if a 30-day discharge, or emergency discharge notice had been completed; -He/She completed paperwork to transfer the resident; he/she was not sure if the resident signed the discharge and was not sure if a copy of the paperwork had been sent to the resident representative; -He/She was not sure if the resident was his/her own person or not. During an interview on 10/5/23, at 11:36 A.M., RN B said the following: -The resident had been sent to the hospital and not allowed to return to the facility; -The resident said he/she would not stay at the facility and was getting very agitated the day he/she was admitted ; -The resident was not his/her own person and had a Durable Power of Attorney (DPOA); -He/She has no idea if a 30-day discharge or emergency discharge notice was given to the resident or the resident's DPOA; -He/She was not sure who made the determination that the resident could not return to the facility when the hospital called as he/she was not in the facility when the hospital called. During an interview on 10/5/23 at 12:44 P.M., the facility Social Services Director said the following: -The resident was transferred to the hospital and not allowed to return to the facility; he/she did not know who made that decision or why; -She was not familiar with the resident, but did know the resident did not want to be at the facility and wanted to go back to the hospital; -She thought the resident was his/her own person and able to make decisions; -She mailed the copy of the transfer/discharge agreement to the residents family member who was his/her DPOA; the copy mailed could have potentially been the original transfer/discharge paperwork filled out by nursing when the resident was transferred. During an interview on 10/5/23 at 4:07 P.M., the case manager at the hospital said the following: -The resident's placement at the facility was not a trial placement; this had never been in the discussion; -The hospital did not enter into a verbal agreement for trial placement; this is not a practice the hospital ever participated in. During an interview on 10/5/23/23 at 11:41 A.M., the Director of Nursing (DON) said the following: -The resident had been discharged from the facility and not allowed to return to the facility; it was an administration conversation but ultimately she guessed it was her decision; -There was a verbal agreement between the case worker at the hospital and the facility that the placement would be a 30 day trial placement and if in those 30 days the resident wanted to return to the hospital, he/she would be allowed to return to the hospital; -She did not know the name of the case worker and did not have that agreement in writing; -The night the resident returned to the hospital, she spoke to the emergency room physician and was told the case manager would call the following day; -The case manager did not call the following day; -An emergency discharge notice, nor a 30-day discharge was issued as this was a trial placement and the resident requested to return to the hospital; -The resident was his/her own person and able to make decisions to discharge and return to the hospital. During an interview on 10/5/23 at 11:54 A.M., the administrator-in-training (AIT) said the following: -The facility will follow the wishes of the resident to be discharged ; -The resident did not want to come back to the facility after going to the hospital and did not really want to be at the facility in the first place; -The facility could not keep a resident against his/her wishes if they were able to make their own decisions; -She believes the resident was able to make his/her own decisions; -The facility did not issue an emergency discharge, or 30-day discharge, to the resident because he/she requested to go back to the hospital; -It was the facility decision not to accept the resident back after hospitalization due to his/her desire not to return; -She is not sure if the DPOA had been notified that the resident would not be able to return to the facility; -Depending on the situation, if the facility is not going to accept a resident back, an emergency discharge or 30-day discharge should be issued. During an interview on 10/5/23 at 1:49 P.M., the administrator said the following: -He would expect a resident that is transferred to the hospital to have been issued an emergency discharge if the facility would not accept the resident back to the facility after the hospitalization; -If an emergency discharge was not issued, the resident should be allowed to return to the facility, and if necessary, a 30-day discharge notice given upon return. MO 225042

Based on observation, interview, and record review, the facility failed to ensure the call light in one resident's (Resident #4's) room functioned properly so he/she could alert staff if needed. A sample of 14 residents was selected for review. The facility census was 37. Review of facility answering the call light policy updated 1/12/21 showed the following: -The purpose of this procedure is to respond to the resident's requests and needs; -Be sure that the call light is plugged in at all times; -When the resident is in bed or confined to a chair, be sure the call light is within easy reach of the resident; -Report defective call lights to the nurse supervisor and/or maintenance department, director of nursing and administrator promptly. Other means for the resident to alert staff, such as bells, should be provided for resident use while call light is being repaired/replaced. Ask the director of nursing (DON)/administrator to where items are stored. 1. Review of Resident #4's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument to be completed by the facility, dated 10/21/22, showed the following: -Cognitively intact; -Independent with transfers and ambulation; -History of falls. Review of the resident's handwritten care plan, last revised 11/1/22, showed the following: -Independent with transfers and ambulation; -Can use call light. Observation on 1/9/23 at 10:44 A.M. showed the following: -The resident lay on his/her back in the bed in a private room; -The resident's call light was on the floor under a pile of papers and out of the resident's reach; -The resident said his/her call light did not work; -The call light was tested and did not function; -A second call light for the room was located on the floor and out of the resident's reach. When tested, this call light did not function; -The light outside of the room only illuminated when call light cords were pulled out of wall. During interview on 1/9/23 at 10:50 A.M., the maintenance director said he/she was not aware of the non-functioning call light in the resident's room. Observation on 1/9/23 at 2:55 P.M. showed the same call lights remained in the room and did not function when pushed. Observation on 1/10/23 at 10:45 A.M. showed the same call light cords remained in the resident's room and did not function. During interview on 1/18/23 at 11:30 A.M., the Director of Nursing (DON) said the following: -Call lights should be functioning and in the resident's reach at all times; -If staff were aware of a non-functioning call light, they should replace with a new one or provide a secondary method for the resident immediately; -The facility has bells for residents to use in the event a call light could not be restored; -She was not made aware Resident #4's call light did not function on 1/9 and part of the day of 1/10/23. MO212097

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to promote self-determination through support of resident choice by failing to ensure one resident (Resident #10), in a review of 14 sampled residents, was provided with the opportunity to smoke after the resident made multiple requests. The facility identified Resident #10 was the only resident who smoked in the facility. The facility census was 37. Review of the facility's Resident Smoking Policy, revised December 2016, showed the following: -The facility shall establish and maintain safe resident smoking practices; -Prior to, and upon admission, residents shall be informed of the facility smoking policy, including designated smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences; -Any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking. (The policy did not include a smoking schedule or designate staff to take residents to smoke.) 1. Review of Resident #10's Care Plan, last updated 1/16/22, showed the following: -The resident currently smokes cigarettes; -The resident requires supervision for safety with smoking; -Provide supervision when smoking. Review of the resident's significant change Minimum Data Set (MDS), dated [DATE], showed the resident had moderate cognitive impairment. Observation and interview on 1/9/23, at 11:00 A.M. to 11:30 A.M., showed the following: -Observation showed the resident was at the nurses station. The resident put two of his/her fingers to his/her mouth signaling to every staff member as they approached him/her; -Administrator A saw the resident, and said the resident makes that gesture with his/her hands when he/she wants someone to take him/her to smoke; -Observation showed administrator A and four other staff walked past the resident. No staff took the resident to smoke. Observation on 1/10/23 at 7:45 A.M. to 9:15 A.M., showed the following: -At 7:45 A.M., the resident sat at the nurses station in his/her wheelchair. The resident put two fingers to his/her mouth signaling to staff members as they approached that he/she wanted to smoke. Licensed Practical Nurse (LPN) I told the resident he/she would take him/her out to smoke in 20 minutes or so. The resident continued to sit at the nurses desk; -At 8:00 A.M., the resident put two fingers to his/her mouth and signaled to staff again that he/she wanted to smoke. LPN I said he/she would take him/her to smoke in 20 minutes. LPN I was at the medication cart. Four different staff walked past the resident. The resident gestured he/she wanted to smoke to the staff, but the staff did not respond to the resident; -At 8:46 A.M., LPN I again told the resident he/she would take him/her out to smoke, but it would be 20 or 30 minutes; -At 9:02 A.M., the resident signaled to the Director of Nurses (DON) and the MDS (Minimum Data Set) coordinator that he/she wanted to smoke. The MDS coordinator told the resident someone would take him/her to smoke and then he/she walked away; -At 9:15 A.M., the resident left the nurses desk and went to his/her room. During an interview on 1/11/23, at 8:45 A.M., LPN I said he/she was going to take the resident to smoke after breakfast on 1/10/23, but he/she had things to do and was not able to take him/her before the resident gave up and went to bed. During an interview on 1/11/23 at 3:30 P.M., the resident the following: -He/She usually liked to smoke four or five times a day; -He/She had only been getting to smoke one to two times a day lately; -He/She asked to smoke at four different times with several requests at each time on 1/10/23; -He/She asked after breakfast on 1/10/23 and no one took him/her; -He/She asked several staff to take him/her out to smoke before lunch (on 1/10/23) and no one did; -He/She asked several staff after lunch (on 1/10/23) to take him/her to smoke and no one did; -Sometime after 4:00 P.M., a staff member finally took him/her out to smoke; -He/She asked to smoke after breakfast this morning and after lunch today and no one took him/her out to smoke. During an interview on 1/11/23, at 3:46 P.M., Registered Nurse (RN) C said the following: -The resident liked to smoke after each meal, and staff took him/her if he/she asked again between meals; -The resident can smoke six times a day; -There were no assigned smoke times or specific staff assigned to take the resident to smoke; -It was everyone's job to make sure the resident could smoke; -Lately, the facility did not have enough staff to take the resident to smoke, so the resident might get to smoke four times a day; -He/She did not know the resident was only taken out once around 4:00 P.M. yesterday after several requests to smoke. During an interview on 1/11/22, at 3:30 P.M., administrator A said the facility did not have designated smoking times or designated staff to take the resident to smoke. Any staff could take the resident to smoke, and all staff were responsible to take the resident to smoke when he/she requested. The resident may have to wait to smoke until someone had time to take him/her. During an interview on 1/18/23, at 11:10 A.M., administrator B said the following: -There should be a schedule for the staff to take the residents to smoke based on whatever the facility policy says; -Residents who smoke and need supervision, should be taken outside to smoke at supervised times.

Based on observation, interview, and record review, the facility failed to notify the physician of changes in condition for one resident (Resident #27), in a review of 14 sampled residents. The facility census was 37. Review of the facility's policy, Change in a Resident's Condition or Status, revised May 2017, showed the following: -Our facility shall promptly notify the resident, his/her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.); -The nurse will notify the resident's attending physician or physician on call when there has been a (an): a. Accident or incident involving the resident; b. Discovery of injuries of an unknown source; c. Adverse reaction to medication; d. Significant change in the resident's physical/emotional/mental condition; e. Need to alter the resident's medical treatment significantly; f. Refusal of treatment or medications two (2) or more consecutive times); g. Need to transfer the resident to a hospital/treatment center; h. Discharge without proper medical authority; and/or; i. Specific instruction to notify the Physician of changes in the resident's condition. -A significant change of condition is a major decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting); b. Impacts more than one area of the resident's health status; c. Requires interdisciplinary review and/or revision to the care plan; and d. Ultimately is based on the judgment of the clinical staff and the guidelines outlines in the Resident Assessment Instrument. 1. Review of Resident #27's undated face sheet showed the resident's diagnoses included disorientation, unspecified fall, essential primary hypertension, chronic kidney disease, anxiety disorder, major depressive disorder, and Alzheimer's disease. Review of the resident's Care Plan, revised on 10/31/22, showed the following: -Assist of one with transfers; -Assist with toileting on routine basis, on rising, before and after meals, at bedtime, and as requested; -Front wheeled walker and stand by assist for ambulation; -Incontinent of bladder; -Follow up with physician if resident has skin issues, edema or increased pain. Review of the resident's Significant Change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, completed 11/2/22, showed the following: -Severely impaired cognition; -Requires extensive assistance with assistance of at least one staff member for bed mobility, transfers, walking in room, dressing, toileting, and personal hygiene; -Requires total assistance with at least one staff member for bathing. Review of the resident's progress note dated 1/7/23 at 3:59 P.M., showed the resident was moaning, as needed pain medication given. The resident could not really say where he/she hurt, asked where his/her pain was, said not in pain. Will continue to monitor. Review of the resident's progress note dated 1/7/23 at 5:10 P.M., showed the resident felt warm to staff. The resident's temperature was 100.1 degrees Fahrenheit (normal body temperature can range between 97 and 99) tympanic (taken by a thermometer in the ear). Tylenol already given. Review of the resident's progress note dated 1/8/23 at 16:01 P.M., showed the resident was yelling out to help him/her. The resident said he/she was cold and was physically shaking. Staff took his/her temperature orally, temperature 101.0 F. Staff gave Tylenol. (Review showed no documentation staff notified the resident's physician of the resident's change of condition.) Observation on 1/9/23 at 11:20 A.M. showed the following: -The resident sat in the recliner in his/her room with his/her meal tray on his/her lap. The resident said Help Me; -The resident fell asleep with his/her uneaten meal tray on his/her lap. During an interview on 1/9/23 at 12:27 P.M., Registered Nurse (RN) H said the resident had not been feeling well the past few days and had been running a fever on and off. The resident's physician was not notified. Observation on 1/11/23 at 12:15 P.M. showed the following: -Certified Medication Technician (CMT) E and Registered Nurse (RN) C placed a gait belt around the resident and walked him/her with assistance of two, along with four wheeled walker, to the bathroom; -The resident required total assistance in toileting and dressing; -Both staff assisted the resident to walk back to his/her bed with the wheeled walker and assisted the resident to bed; -CMT E rolled the resident to his/her left side with total assistance. Observation on 1/11/23 at 7:45 P.M. showed the following: -The resident sat in the recliner; -CMT D placed the resident's meal tray on his/her lap and left the room; -The resident took a bite of the food and then fell back asleep with the tray on his/her lap. During an interview on 1/11/23 at 12:15 P.M., CMT E said the following: -The resident required assistance from one staff member up until the last couple of days; -The resident had not been wanting to stand recently so staff have been using two staff for assistance. During an interview on 1/11/23 at 3:40 P.M., CMT D said the following: -The resident had a decline in the last couple of days requiring assistance of two staff members with transfers, ambulating, and dressing; -The resident required assistance from one staff member previously. During an interview on 1/11/23 at 5:25 P.M., Licensed Practical Nurse (LPN) P said the following: -If a resident has a decline or change in condition, staff should notify the physician to get orders; -The resident was not standing for staff within the last two weeks and had a physical decline; -The resident was sleeping more often. During an interview on 1/11/23 at 6:37 P.M., the resident's family member said the following: -He/She had noticed a major change in the resident's condition within the last week, including the resident was sleeping more, had no appetite, required more assistance when getting up and walking; -He/She noticed a decline in the resident's ambulation within the last one to two months where the resident was requiring assistance from two staff members. During an interview on 1/11/23 at 6:48 P.M., the On Call Physician for the resident's primary physician said the following: -No one had called him/her to update or notify him/her of any change in the resident's condition; -There were no notes in the electronic system of any updates. During an interview on 1/11/23 at 6:56 P.M., the resident's primary physician said the following: -He/She last saw the resident on 11/30/22, and remembered the resident was pretty independent; -He/She wasn't in the office today, but had not received notification of any change in the resident's condition on 1/11/23 or any days since he/she last saw the resident on 11/30/22; -He/She would expect the facility to notify him/her in any change in the resident's condition. During an interview on 1/11/23 at 7:16 P.M. and 1/18/23 at 11:10 A.M. the Director of Nursing (DON) said the following: -The only change in condition he/she noticed was the resident's elevated temperature; -He/She would expect staff to notify the physician with a change in condition; -He/She recalled the resident being independent back in November; During an interview on 1/18/23 at 11:10 A.M., administrator B said he/she would expect staff to follow facility policy for notifying the physician.

Based on observation, interview and record review, the facility failed to ensure that residents know how to file grievances for two anonymous residents of 14 sampled residents. Facility census was 37. Review of the facility's policy, Grievance -Voicing and Resolution, effective date May 2019, showed the following: -It is the policy of this home that staff will promptly attempt to resolve grievances the resident may have, including those, which involve the behavior of others. They will be able to voice grievances without fear of reprisal or discrimination. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents and other concerns regarding their stay; -The home will inform each resident upon admission and at least annually of their right to voice grievances in treatment, violation of rights, care, management of funds, or lost clothing without fear of reprisal or retaliation; -The Grievance Official will be the administrator who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigation by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident and coordinating with state and federal agencies as necessary in light of specific allegations; -Grievance will be written on the home's Grievance I Complaint Report Form; -The facility will address each grievance in a reasonable time frame and as necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated; -The facility will accept grievances in written and verbal form; -The facility will keep a Grievance Complaint Log outlining each grievance/complaint and the disposition of the complaint; -The facility will provide acknowledgement of grievance to person who filed complaint; -Upon resolution of the grievance, the follow-up in a timely manner to assure that resolution has been successful; -Completed Grievance I Concern Forms will be filed together in a binder (one binder per year) and separated by month; -Maintain evidence demonstrating the result of all grievances for a period of no less than three years from the issuance of the grievance decision; -The facility policy did not address issuing a written grievance decision to the resident. 1. During resident council meeting on 1/11/23 at 2:10 P.M. anonymous residents said they did not know how to file a grievance. During an interview on 1/12/23 at 9:42 A.M., the social services director said the following: -If any resident has a grievance everything was communicated verbally. Sometimes the problem has already been resolved by the time he/she gets word that something was wrong. He/She does not get written notes from resident council, a verbal report is given in meeting with departments who get a verbal account of their concerns per department, so he/she does not have a written grievance log; -The grievance log was found in his/her office with last written grievance dated 12/29/21. Observation on 1/12/23 at 11:00 A.M. there were no grievance forms available outside of the social service office. During a phone interview on 1/18/23 at 1:00 P.M. the Director of Nursing (DON) said the following: -Social services was responsible for grievances, but anyone can start working on a grievance. Grievances can be filed with anyone and written forms are available outside of the social services office. Residents have been told where forms are located, there was no system in place. During a phone interview on 1/24/23 at 1:29 P.M. the Social Services Director said the following: -Grievance forms are kept behind the nurse's station and in his/her office. If his/her door is closed it is left unlocked and staff know the drawer where grievance forms are kept. Currently there were no grievance forms outside of her door for residents to obtain for themselves. The grievance procedure has been a verbal process since he/she has worked at the facility. During a phone interview on 1/18/23 at 2:00 P.M., administrator B said the following: -He expected staff to follow facility policy; -He had not been in the building to ensure the grievance forms were outside the Social Services office, but that is what he expected in all of his facilities.

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #27) in a review of 14 sampled residents, was free from physical restraint. The facility census was 37. Review of the facility's policy, Use of Restraints, revised April 2017, showed the following: -Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully; -Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls; -Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. 1. Review of Resident #27's face sheet showed he/she had diagnoses that included disorientation, unspecified fall, anxiety disorder, major depressive disorder and Alzheimer's disease. Review of the resident's Significant Change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, completed 11/2/22, showed the following: -Severely impaired cognition; -Requires extensive assistance with assistance of at least one staff member for bed mobility, transfers, walking in room, dressing, toileting, and personal hygiene; -Requires total assistance with at least one staff member for bathing; -One non-injury fall since admission; -No use of restraints; -No recent surgeries or orthopedic procedures. Review of the resident's Care Plan, revised on 10/31/22, showed the following: -At risk for injury related to falls due to weakness, cognitive loss with poor safety awareness; -Assist with toileting on routine basis, on rising, before and after meals, at bedtime, and as requested; -Incontinent of bladder. Observation on 1/9/23 at 10:40 A.M. of the resident in the resident's room showed the following: -The resident was slouched in the recliner with the foot rest in the up position; -His/Her legs dangled off of the foot rest to the side. Observation on 1/9/23 at 2:45 P.M. of the resident in the resident's room showed the following: -He/She sat in the recliner with foot rest up, body shaking saying, I am sick to my stomach; -Certified Nurse Aide (CNA) F came in to check the resident's temperature. The resident said, Help Me after CNA F walked back out of his/her room. Observation on 1/10/23 at 6:14 A.M. of the resident in the resident's room showed he/she was sleeping in the recliner with the foot rest in the up position. Observation on 1/10/23 from 6:14 A.M. through 9:26 A.M. of the resident in the resident's room showed the resident remained in the recliner with the foot rest in the up position. Observation on 1/10/23 at 8:22 A.M. of the resident in the resident's room showed the following: -The resident said, Help Me; -The resident kicked a blanket off of his/her right leg and attempted to push the foot rest down on the recliner unsuccessfully. Observation on 1/10/23 at 11:20 A.M. of the resident in the resident's room showed he/she was asleep in the recliner with the recliner's foot rest in the up position. Observation on 1/10/23 at 3:30 P.M. of the resident in the resident's room showed the he/she was slouched down in his/her recliner with the foot rest in the up position. Observation on 1/11/23 at 11:43 A.M. of the resident in the resident's room showed the resident was slouched in the recliner with the foot rest in the up position. Observation on 1/11/23 at 12:15 P.M. of the resident in the resident's room showed the following: -The resident sat in his/her recliner with the foot rest in the up position; -Certified Medication Technician (CMT) E and Registered Nurse (RN) C came into the resident's room to provide care; -CMT E manually put the foot rest of the resident's recliner in the down position; -CMT E and RN C placed a gait belt around the resident and walked him/her with assistance of two, along with a four wheeled walker, to the restroom. Observation on 1/11/23 at 7:45 P.M. of the resident in the resident's room showed he/she sat in the recliner with the foot rest in the up position. Observation on 1/11/23 at 8:20 P.M. of the resident in the resident's room showed he/she sat in the recliner with the foot rest in the up position. Observation on 1/11/23 at 8:34 P.M. of the resident in the resident's room showed the resident was sleeping in the recliner with the foot rest raised in the up position. During an interview on 1/11/23 at 11:35 A.M., the resident said the following: -He/she was not able to get up by himself/herself; -He/She was unable to put the foot rest of the recliner down by himself/herself; (the resident tried to demonstrate but was unable to put the foot rest of the recliner down by himself/herself). During an interview on 1/11/23 at 6:37 P.M., the resident's family member said the following: -Staff do not want the resident to get out of his/her recliner by himself/herself because they are worried about him/her falling; -The resident was unable to get out of the recliner independently if the foot rest is in the up position. During an interview on 1/11/23 at 12:15 P.M., CMT E said the following: -The resident cannot put the manual footrest down in his/her current recliner; -He/She had been able to use his/her other electric recliner, but it was currently out of order. During an interview on 1/11/23 at 3:40 P.M., CMT D said the resident required staff to assist with manually raising or lowering the foot rest on the recliner; his/her previous electric recliner was broken; he/she was unable to use this current recliner independently. During an interview on 1/11/23 at 11:59 A.M., Licensed Practical Nurse (LPN) I said the following: -The resident has declined; -He/She was independent up until the last couple of months; -He/She requires staff assistance with this recliner/foot rest; -He/She had a power recliner prior to this and was able to get herself up with the power recliner. During an interview on 1/11/23 at 5:25 P.M., LPN P said the following: -A restraint is something that prevents a resident from moving freely or getting up; -A recliner with the foot rest in a raised position would be considered a restraint if the resident was unable to raise or lower the footrest. During an interview on 1/11/23 at 6:48 P.M. and 1/18/23 at 11:10 A.M., the Director of Nursing (DON) said the following: -They do not want Resident #27 to be able to get out of the recliner without assistance because he/she has fallen a lot and has had fractures; -A restraint was something that keeps a limb from free movement; being in a position where they cannot get up out of a chair or a seat would be considered a restraint; -A resident that is unable to get out of a recliner would be considered a restraint. During an interview on 1/18/23 at 11:10 A.M., administrator B said he would expect staff to follow facility policies.

Based on interview and record review, the facility failed to report an allegation of abuse when one resident (Resident #25), in a review of 14 sampled residents, reported someone who staff believed was another resident had hurt him/her. The resident presented with a large bruise on his/her right upper chest area (rib cage to right breast). The facility census was 37. Review of the facility policy Abuse-Reportable Events, dated 5/2019, showed the following: -It is the policy of this home to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/event in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person; -Physical abuse: Physical action within the definition of abuse including but not limited to, hitting, slapping, pinching, and kicking; -Sexual abuse: The non-consensual sexual contact of any type with a resident and the individual acts deliberately; not that the individual has intend to inflict injury or harm. Any touching or exposure of the anus, breast, or any part of the genitals of a resident without the voluntary, informed consent of the resident and with the intent to arouse or gratify the sexual desire of any person and includes but is not limited to sexual harassment, sexual coercion, or sexual assault; -Administrative and licensed staff will be aware of potential situations of abuse during rounds and contact with staff, residents and resident family members; -Incident/Accident Reports will be reviewed by the Administrator and Director of Nurses or designee to identify possible incidents of abuse; -All incident/accidents of unknown origin will be investigated; -Reasonable suspicion of a crime or suspected abuse must be reported immediately to the appropriate state agencies after forming the suspicion but not later than two hours. All other events must be reported within 24 hours to the appropriate state agencies; -Employees are required to report all incidents of possible abuse, mistreatment, or neglect of an resident, crimes against a resident or misappropriation of a resident's property immediately to their supervisor or Senior Staff member. The senior staff member is defined as the highest ranking person in the building at the time of the incident. Highest Administrator, then Director of Nursing, Assistant Director of Nursing, and then charge nurse; -Reporting: a. All alleged allegations of abuse will be reported to the appropriate state agency and to all other agencies as required by regulation; b. Local law enforcement will be notified when a resident has suffered bodily injury because of conduct alleged in the report of abuse, neglect, exploitation or other complaint. The facility's policy did not include that all reports of abuse will be reported to DHSS (state regulatory agency) within two hours of the allegation, and any allegation that does not involve abuse or serious bodily injury is reported within 24 hours to DHSS. 1. Review of Resident #25's annual Minimum Data Set (MDS), a federally mandated assessment, dated 10/13/22, showed the following: -Moderate cognitive impairment; -No delirium, hallucinations, delusions, or behaviors; -Requires supervision and cues for bed mobility, transfers, eating, and toilet use; -Requires supervision and cues with one person physical assist for dressing and hygiene; -Requires physical assist of one staff member for bathing. Review of the resident's Skin Assessment, 10/21/22, showed the resident did not have any skin concerns. Review of the resident's Nurses Notes, dated 10/25/22 at 9:33 A.M., showed the following: -Staff found a bruise while the resident was in the shower room; -The resident has a large bruise on his/her right side from the upper rib cage near the armpit extending to the right chest; -The bruise measures 14.5 centimeters (cm) length, and 6 cm width; -It is yellowing and looks like it may have been there for a few days; -Asked the resident if someone had hurt him/her, and the resident said yes; -The resident said, the next door neighbor; -Asked if who hurt him/her was male or female, and the resident said, it was a (member of the opposite sex); -Reported to charge registered nurse (RN) and the administrator; -Review of this note was struck out and marked incorrect documentation by administrator A and not by the writer. Review of the DHSS database showed the allegation was not reported as required by the facility within two hours. During an interview on 1/12/23 at 2:30 P.M., Certified Medication Technician (CMT) D said the following: -Three to four months ago, the resident was found with a bruise to his/her chest area during cares and it was reported to Licensed Practical Nurse (LPN) I; -LPN I did an investigation; -The administrator struck through LPN I's investigation in the resident's progress notes because she did not like what LPN I had documented and told LPN I that she (the administrator) was to do all of the investigations; -He/She thought the administrator did an additional investigation; -He/She had followed up with the administrator as to her findings, and the administrator told him/her that Resident #25 told the story differently to her; -He/She was concerned because another resident of the opposite sex, Resident #23, frequently tried to hold hands with Resident #25, would rub arms against Resident #25 and had to be reminded to stay away from Resident #25 when he/she tried to be inappropriate with him/her. He/She hoped Resident #23 had not caused the bruise to Resident #25. During an interview on 1/12/23, at 3:15 P.M., Resident #25 did not understand any questions about the situation and repeated the questions back to the surveyor. During an interview on 1/31/23, at 1:34 P.M., LPN I said the following: -He/She was the charge nurse when a certified nurse assistant (CNA) reported the bruise on the resident's right arm pit and chest; -He/She interviewed the resident while he/she assessed him/her, and immediately reported the incident to the Director of Nursing (DON); -The DON had him/her report it to administrator A; -He/She documented what he/she had assessed and what the resident told him/her in the resident's progress notes; -Administrator A came back to him/her and said that next time not to chart anything and just report it to him/her and he/she would take care of it, and that he/she was striking out his/her nurses notes because the resident told administrator A something different and that the resident had fallen; -What he/she documented was what the resident reported to him/her; -If Administrator A had different findings then she could have documented her investigation and findings to explain what she had found; -He/She was concerned about a resident of the opposite sex that had resided on Resident #25's hall, that resident had stalking like behavior with Resident #23; -The other resident was in his/her right mind and Resident #25 had a brain tumor, so he/she had some deficits and could not make adult decisions; -The facility had even involved the ombudsman and moved the other resident off of Resident #25's hall to separate the two residents. During an interview on 1/12/23, at 3:10 P.M., and 4:30 P.M., administrator A said the following: -All allegations of abuse were reported to DHSS within two hours of the allegation; -She and the MDS Coordinator did the investigation; -The incident with Resident #25 was not reported because she spoke with the resident and staff, and they determined the bruising was caused from a fall; -She did not report the bruise because she did not feel like the bruise was from abuse.

Based on interview and record review, the facility failed to complete a thorough investigation when a large bruise was found in the right upper chest area (rib cage to right breast) of one resident (Resident #25) which staff believed could have been the result of physical or sexual abuse. The facility census was 37. Review of the facility policy Abuse-Reportable Events, dated 5/2019, showed the following: -Physical abuse: Physical action within the definition of abuse including but not limited to, hitting, slapping, pinching, and kicking; -Sexual abuse: The non-consensual sexual contact of any type with a resident and the individual acts deliberately; not that the individual has intend to inflict injury or harm. Any touching or exposure of the anus, breast, or any part of the genitals of a resident without the voluntary, informed consent of the resident and with the intent to arouse or gratify the sexual desire of any person and includes but is not limited to sexual harassment, sexual coercion, or sexual assault; -Administrative and licensed staff will be aware of potential situations of abuse during rounds and contact with staff, residents and resident family members; -Incident/Accident Reports will be reviewed by the Administrator and Director of Nurses or designee to identify possible incidents of abuse; -All incident/accidents of unknown origin will be investigated; -Investigation: a. When an employee becomes aware of an allegation or suspicion of abuse the employee should immediately report the allegation or suspicion to the charge nurse on the unit on which the resident resides immediately; b. The charge nurse will: 1. Assess the resident/residents; 2. Notify the Administrator or the person on-call, if after hours, if unavailable the Director of Nursing will be notified, in the event that the charge nurse does not notify the administrator the person aware of the allegation may report directly to the Administrator; 3. Begin taking written statements from the person reporting the allegation or suspicion and any witnesses including staff, family, and/or residents. In certain situations, the person writing the information, along with the person making the statement, if at all possible and a witness to the dictated statement should all sign the completed form; 4. Ask any witness to wait for the Administrator or the person on-call to arrive at the home. If an employee is involved, the employee will be detained and removed from their assigned duties until they are interviewed by the Administrator or person on-call or other appropriate staff; c. The person on-call will: 1. Notify the Administrator and/or Director of Nurses; 2. Review the steps taken in the investigation; 3. Take appropriate action if an employee is involved in the allegation or suspicion of abuse. This will include removing the employee from duty and will be placed on investigative suspension. 4. Accused individuals, not employed by the home, will be denied unsupervised access to the resident. Visits may only be made in designated areas, supervised by staff after approval by the Administrator; 5. Assess all residents who may have been affected by the allegation or suspicion of abuse; 6. Consult with the Administrator and/or Director of Nurses before making reports to state, local police (required for any crimes against a resident), family, attending physician, and any other necessary notification; 7. The Abuse Coordinator will: a. Review all aspects of the investigation as soon as possible; b. Ensure that all reports are complete and appropriate authorities have been notified including the notification of the local law enforcement related to any crimes against a resident; c. Complete the investigation and direct any disciplinary action required; d. Review corrective actions; e. Inform the resident or his/her representative of the findings of the investigation and corrective action taken; f. Refer all occurrences to the QAPI Committee to be analyzed to determine what change or changes are needed, if any, to the facilities policies and procedures to prevent further occurrences. -After investigation, administration will analyze the occurrence to determine what changes, if any, are needed to the policies and procedures to prevent further occurrences. 1. Review of Resident #25's annual Minimum Data Set (MDS), a federally mandated assessment, dated 10/13/22, showed the following: -Moderate cognitive impairment; -Diagnosis hypothyroidism (low function of the thyroid), seizures, anxiety, depression, benign neoplasm of the brain; -No delirium, hallucinations, delusions, behaviors, or rejection of care; -Requires supervision and cues for bed mobility, transfers, eating, and toilet use; -Requires supervision and cues with one person physical assist for dressing, and hygiene; -Requires physical assist of one staff member for bathing. Review of the resident's Skin Assessment, 10/21/22, showed the resident did not have any skin concerns. Review of the resident's Nurses Notes, dated 10/25/22 at 9:33 A.M., showed Licensed Practical Nurse (LPN) I documented the following: -Bruise found by staff while the resident was in the shower room; -Resident has large bruise on his/her right side from the upper rib cage near the armpit extending to the right breast; -Bruise measures 14.5 centimeters (cm) length, and 6 cm width; -It is yellowing and looks like it may have been there for a few days; -Asked resident if someone had hurt him/her and the resident stated, yes; -Resident stated, the next door neighbor; -Asked if who hurt him/her was male or female and the resident stated, it was a man. Review of this note showed it was struck out and marked incorrect documentation; -Reported to Registered Nurse and the administrator. During an interview on 1/31/23, at 1:34 P.M., LPN I said the following: -He/She was the charge nurse when a Certified Nurse Assistant (CNA) reported the bruise on the residents right arm pit and breast; -He/She interviewed the resident while he/she assessed him/her and immediately reported the incident to the Director of Nursing (DON); -The DON had him/her report it to the administrator (ADM) A also; -He/She documented what he/she had assessed and what the resident told him/her in the resident's progress notes; -He/She was concerned about a resident of the opposite sex that had resided on Resident #25's hall, that resident had stalking like behavior with Resident #25; -The other resident was in his/her right mind and Resident #25 had a brain tumor, so he/she had some deficits and could not make adult decisions; -The facility had even involved the ombudsman and moved the other resident off of Resident #25's hall to separate the two residents; -Resident #25 does change his/her story related to his/her cognitive functioning, has had seizures and recent adjustments to his/her medication related to recent seizures, and falls a lot because he/she is unsteady and forgets his/her walker but he/she felt like the ADM should have looked into all possible causes and investigated the situation more in depth because of the issues with the other resident who had relationship issues with Resident #25. During an interview on 1/12/23 at 2:30 P.M., CMT D said the following: -Three to four months ago, Resident #25 was found with a bruise to his/her breast area during cares and it was reported to LPN I; -LPN I did an investigation; -He/She was concerned because another resident of the opposite sex, Resident #23, frequently tried to hold hands with Resident #25, would rub arms against Resident #25 and had to be reminded to stay away from Resident #25 when he/she tried to be inappropriate with him/her; he/she hoped Resident #23 had not caused the bruise to Resident #25. Review of the facility Summary of Investigation/findings, dated 10/27/22, showed the following: -During the investigation the resident commented that this happened when at the garage; -The resident has not been out of the facility at any garage since admission to the facility on 4/15/21; -Call placed to the resident's POA and family member , and the family member stated that they had a neighbor with a garage, the resident has not been at the garage and the neighbor would not harm the resident; -In discussing with the CNA's the resident had stumbled into the door frame of the bathroom door; -With investigation the discolored area on the resident did match up to the area to the bathroom; -Resident uses a walker for mobility; -Often he/she will leave her walker and start walking by himself/herself; -The resident is unstable at times; -The resident then stated to the MDS coordinator the he/she did stumble against the door frame to the bathroom; -Resident takes himself/herself to the bathroom and self propels around the facility with assistive devices of the walker; -The conclusion of the investigation was that no abuse occurred. -Plan of Corrective Action: Remind the resident to always use his/her walker and continue to monitor; -The Investigation findings was signed by the DON and the ADM A. The facility did not have any written statements, list dates or times of any staff interviews, list dates or times of any resident interviews. The facility did not document the investigation as directed by the facility policy. During an interview on 1/12/23, at 2:55 P.M., the DON said she did not conduct the investigation for the resident, so would have to ask MDS Coordinator and ADM, they did the investigation. During an interview on 1/12/23, at 3:10 P.M., and 4:30 P.M., the ADM said the following: -All allegations of abuse are reported to DHSS within two hours of the allegation; -She and the MDS Coordinator did the investigation, the MDS Coordinator (was not working on 1/12/23) has the investigation but she was able to find the summary of findings; During an interview on 2/6/23, at 3:00 P.M., the MDS Coordinator said the following: -She did not do the investigation, Administrator A did all of the investigation and decision making; -She did not know that the resident told LPN I that a neighbor of the opposite sex hurt him/her; -Administrator A told her that the roommate and a CNA witnessed the resident falling into a door frame and they she had notified the residents responsible party and asked the MDS Coordinator to write up a summary saying that; -She did not know if the Administrator used all of the forms in the policy or got statements from other residents or staff; -She did not know anything about LPN I's report of what the resident at the time, but heard some things about it weeks later. The facility did not locate the investigation notes and statements.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a comprehensive assessment within 14 calendar days after admission to the facility for one resident (Resident #87), in a review of 14 sampled residents. The census was 37. Review of the Long-Term Care Facility RAI User's Manual, version 3.0 showed the admission assessment is a comprehensive assessment for a new resident and, under some circumstances, a returning resident that must be completed by the end of the fourteenth day, counting the date of admission to the nursing home as day one if this is the resident's first time in this facility. 1. Review of Resident #87's face sheet showed he/she was admitted the facility from the hospital on [DATE]. Review of the resident's Minimum Data Set (MDS), a federally mandated assessment completed by facility staff on 1/12/23 showed the facility completed an entry MDS (not a comprehensive assessment) on 12/16/22. Review showed no documentation staff completed a comprehensive assessment as of 1/12/23. During interview on 1/18/23 at 12:20 P.M., the MDS Director said the following -The facility did not have a policy for completing comprehensive assessments; -admission comprehensive assessments should be completed within 14 days of admissions per the Resident Assessment Instrument manual.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a significant change status assessment (SCSA) Minimum Data Set (MDS), a federally mandated assessment, required to be completed by facility staff, for two residents (Residents #21 and #37), in a review of 14 sampled residents. This assessment should have been completed within 14 days after the facility determined, or should have determined, there had been a significant change (major decline or improvement in the resident's status) in the resident's physical or mental condition which had an impact on more than one area of the resident's health status and required interdisciplinary review and/or revision of the care plan. The facility census was 37. Review of the Long Term Care Facility RAI User's Manual, version 3.0 showed a significant change is a decline or improvement in a resident's status that: -Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, is not self-limiting; -Impacts more than one area of the resident's health status; -Requires interdisciplinary review and/or revision the care plan. -Significant Change in Status Assessment (SCSA) was appropriate if there was a consistent pattern of changes, with either two or more areas of decline, or two or more areas of improvement. This may include two changes within a particular domain (e.g., two areas of Activity of daily living (ADL) decline or improvement). 1. Review of Resident #21's significant change MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Diagnosis of unspecified dementia, benign prostatic hyperplasia (BPH) (enlarged prostate that blocks the flow of urine), chronic stage 3 renal (kidney) insufficiency, diabetes mellitus (inability to control blood sugar), arthritis and depression; -Corrective lenses vision; -Independent requires set up from staff for bed mobility, transfer, walk in room, not in corridor, on unit, and eating; -Requires extensive physical assistance of one staff member for dressing, toilet use, hygiene, and bathing; -Uses a walker. Review of the resident's quarterly MDS, dated [DATE], showed the following changes in the resident's condition; -No corrective lenses vision; -164 lbs (11 lb. weight gain). Review of the resident's quarterly MDS, dated [DATE], showed the following: -No corrective lenses vision; -Requires supervision and cues from a staff member to walk in the corridor; -Requires supervision and cues by one staff member physical assist to walk in his/her room, locomotion on and off unit, and dressing; -Requires limited physical assistance of one staff member for bed mobility, and transfers; -Requires extensive assistance of one staff member for toilet use, hygiene, and bathing. The facility staff did not complete a significant change assessment when the resident's MDS showed change to vision, and several declines in ADL's. 2. Review of the Resident #37's admission MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Indwelling catheter; -Bedrails were not used. Observation on 1/09/23 at 11:32 A.M., of the resident showed the following: -He/She did not have an indwelling catheter; -Bed rails were on located on the left and right sides of the bed. During an interview on 1/09/23 at 11:32 A.M., the resident said the following: -His/Her catheter had been taken out during his/her last hospital admission; he/she had been hospitalized from [DATE] to 12/27/22; -He/She was incontinent of bowel and bladder and required the assistance of staff for cares; -He/She had bedrails since he/she had been at the facility; he/she used them to help with turning. Review of the resident's significant change MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Indwelling catheter; -Bedrails were not used; (The facility had not updated the resident's MDS to reflect the removal of the indwelling urinary catheter, that the resident was incontinent of bowel and bladder and required staff assistance or included the use of bedrails). During an interview on 1/18/23, at 11:10 A.M., the MDS Coordinator said the following -She completes the resident MDS's according to the RAI manual; -Significant change in status assessment should be completed with two or more changes, positive or negative, that do not resolve on their own. During and interview on 1/18/23, at 11:10 A.M., the Director of Nursing (DON) said the following: -The MDS Coordinator completes the MDS's; -She is expected to code the items on the MDS according to the RAI manual; -She does not know when to do the significant change MDS's, but knows if there are two or more significant changes in ADL's diet and those kind of items then the SCSA is completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide accurate comprehensive assessments to reflect the resident's status for two residents (Residents #28, and #21), in a review of 14 sampled residents. The inaccuracy had the potential to negatively affect the person-center care plan and services the facility provided to the resident. The inaccuracies included coding of pressure wounds, activities of daily living (ADL's), pneumococcal vaccines, and indwelling urinary catheter and ostomies ( is a stoma created surgically that allows bodily waste to pass through the abdomen into a prosthetic). The facility census was 37. Review of the Resident Assessment Instrument (RAI) manual, a manual with guidance on how to complete MDS assessments, dated 10/1/19, showed the following: -Ulcer staging should be based on the ulcer's deepest anatomic soft tissue damage that is visible or palpable. If a pressure ulcer's tissues are obscured such that the depth of soft tissue damage cannot be observed, it is considered to be unstageable. Review the history of each pressure ulcer in the medical record. If the pressure ulcer has ever been classified at a higher numerical stage than what is observed now, it should continue to be classified at the higher numerical stage. Nursing homes that carefully document and track pressure ulcers will be able to more accurately code this item. -Pressure ulcers do not heal in a reverse sequence, that is, the body does not replace the types and layers of tissue (e.g., muscle, fat, and dermis) that were lost during pressure ulcer development before they re-epithelialize. Stage 3 and 4 pressure ulcers fill with granulation tissue. This replacement tissue is never as strong as the tissue that was lost and hence is more prone to future breakdown. Clinical standards do not support reverse staging or backstaging as a way to document healing, as it does not accurately characterize what is occurring physiologically as the ulcer heals. For example, over time, even though a Stage 4 pressure ulcer has been healing and contracting such that it is less deep, wide, and long, the tissues that were lost (muscle, fat, dermis) will never be replaced with the same type of tissue. Previous standards using reverse staging or backstaging would have permitted identification of such a pressure ulcer as a Stage 3, then a Stage 2, and so on, when it reached a depth consistent with these stages. Clinical standards now would require that this ulcer continue to be documented as a Stage 4 pressure ulcer until it has completely healed. -Unstageable Pressure Ulcers Related to Slough (Non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed) and/or Eschar (Dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/ edges of the wound). -Stage 2 pressure ulcers by definition have partial thickness loss of the dermis. Granulation tissue (Red tissue with cobblestone or bumpy appearance; bleeds easily when injured), slough, and eschar are not present in Stage 2 pressure ulcers. -Stage 3 pressure ulcers have full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough and/or eschar may be present but does not obscure the depth of tissue loss. 1. Review of Resident #28's Care Plan, dated 10/4/21, showed the following: -admission to the facility on 8/5/21; -Diagnosis include diabetes mellitus, stroke with weakness on one side, Parkinson's disease ( progressive disorder that affects the nervous system and the parts of the body controlled by the nerves) disease, and depression; -Resident has deep tissue ulcers on great toes bilaterally and a blister on his/her left heel; -Assess the pressure ulcer for location, stage, size, presence/absence of granulation tissue and epitheliazation weekly; -Change dressings as ordered to wounds; -Pressure reducing mattress to bed; -Use pillows to reduce pressure on heels. Review of the resident's Vaccination Record, undated, showed the resident had the pneumoccocal vaccine Pneumovax 23 on 2/21/20. Review of the resident's significant change MDS, dated [DATE], showed the following: -Moderate cognitive impairment -Two unstageable pressure ulcers present, unstageable due to slough and/or eschar. Review of the resident's quarterly MDS, dated [DATE], showed the resident had two Stage 2 pressure ulcers. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Independent with hygiene but requires physical assist of one staff member to complete hygiene. ( The resident can not be independent and require physical assist with a task) During an interview on 1/09/23, at 3:45 P.M., the resident said he/she developed wounds at the facility on his/her big toes, they are healed, there may be a scab on his/her big toe, he/she was not sure. He/She did not have wounds anywhere else. The MDS on 5/6/22, showed backstaged wounds. Unstageable wounds covered in eschar and/or slough can not be staged at a two. Eschar and/or slough cannot be present in a Stage 2 pressure ulcer and pressure ulcers cannot be back staged. The residents ADL's were also inaccurately coded on 12/16/22. 2. Review of Resident #21's Care Plan, dated 11/10/21, showed the following: -Diagnosis include dementia, coronary artery disease, benign prostatic hyperplasia (BPH)(enlarged prostate that blocks the flow of urine), chronic stage three kidney insufficiency, diabetes mellitus (inability to control blood sugar), arthritis, and depression; -Indwelling urinary catheter related to BPH with obstruction of urine; -Monitor for signs and symptoms of urinary tract infection; -Change catheter bag weekly; -Change 16 coude (curved or angled catheter tip) urinary catheter monthly; -Keep catheter as a closed system as much as possible; -Position urinary bag below the level of the bladder; -Provide catheter care every shift and as needed; -Use a catheter strap to assure enough slack is left in the catheter between the meatus and strap. Review of the resident's immunization record in his/her hard chart (did not match the electronic health record), showed the resident received a pneumoccocal vaccine (Pneumovax or PPSV23) on 2/21/20. The resident's medical record did not include any evidence the resident was offered or declined a pneumococcal conjugate vaccine (e.g., PCV13, PCV15, PCV20) as recommended by the CDC 1 year after the PPSV23. The medical record showed no evidence of a contraindication for the vaccination. Review of the resident's significant change MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Indwelling urinary catheter and ostomy marked; -Pneumococcal vaccination is not coded (blank). (The resident did not have an ostomy and the pneumococcal vaccination was blank) Review of the resident's quarterly MDS, dated [DATE], showed the pneumococcal vaccine was offered and declined. Review of the medical record showed no evidence the pneumococcal conjugate vaccine was offered and declined. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Requires supervision/cueing and physical assistance of one staff member for ambulation in his/her room, locomotion on and off the unit and dressing; -Indwelling urinary catheter and condom catheter; -Pneumococcal offered and declined. (The resident would not need physical assistance of one staff member if he/she only required supervision/cueing) Review of the resident's electronic health record did not contain evidence the pneumococcal conjugate vaccine was offered and declined. The resident's medical record did not contain any evidence of orders or documentation that the indwelling urinary catheter was ever removed or that a urinary condom catheter was ever attempted. Review of the resident's significant change in status MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Pneumococcal vaccine: not eligible. Review of the resident's electronic health record did not contain evidence the pneumococcal conjugate vaccine was contraindicated for the resident. During an interview on 1/18/23, at 11:10 A.M., the MDS Coordinator said the following -She completes the residents MDS's according to the RAI manual; -It is important that the MDS is accurate because it guides the development of the specific care needs and the residents care plan; -She has had another staff member help with MDS's. If there were some inaccuracies or changes to the way information was coded, this may have caused errors in coding. During an interview on 1/18/23, at 11:10 A.M., the Director of Nursing (DON) said the following: -The MDS Coordinator completes the MDS's; -The MDS Coordinator is expected to code the items on the MDS according to the RAI manual.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to complete a comprehensive care plan within 21 days for one resident (Residents #87) of 14 sampled residents, after admission to the facility. The census was 37. Review of the facility policy, titled Care Plans, Comprehensive Person-Centered, last revised 12/2016 showed the following: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; -The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident; -The Care plan interventions are gathered as part of the comprehensive assessment; -Each residents' comprehensive person-centered care plan will be consistent with the resident's rights to participate in the development and implementation of his/her plan of care; -The comprehensive, person-centered care plan will include measurable objectives and time frames. 1. Review of Resident #87's face sheet showed he/she was admitted to facility from an acute care hospital on [DATE]. Review of the resident's medical record showed no documentation that the resident had a comprehensive care plan. During interview on 1/18/23 at 12:20 P.M., the MDS Coordinator said the following: -She was responsible for ensuring care plans were up to date; -admission comprehensive assessments should be completed within 21 days of admission; -Care plans were not up to date as she had been pulled to the floor to work. During and interview on 1/18/23, at 11:10 A.M., the Director of Nursing (DON) said the following: -The MDS Coordinator completes the MDS; -She is expected to complete the items on the MDS and complete the care plans according to the RAI manual.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to turn and reposition one resident (Resident #37), who had a pressure ulcer (an injury to skin and underlying tissue resulting from prolonged pressure on the skin, most often on bony areas of the body), and failed to report and treat a reddened coccyx (small, triangular bone at the base of the spine) for one resident (Resident #18), in a review of 14 sampled residents. The facility census was 37. Review of the facility's policy titled Repositioning, revised May 2013, showed the following: -The purpose of this procedure is to provide guidelines for the evaluation of resident repositioning needs, to aid in the development of an individualized care plan for repositioning, to promote comfort for all bed- or chair-bound residents and to prevent skin breakdown, promote circulation and provide pressure relief for residents; -General guidelines; -Repositioning is a common, effective intervention for preventing skin breakdown, promoting circulation, and providing pressure relief; -Evaluation of a resident's skin integrity after pressure has been reduced or redistributed should guide the development and implementation of repositioning plans. Such plans should be addressed in the comprehensive plan of care consistent with the resident's needs and goals; -Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning; -Positioning the resident on an existing pressure ulcer should be avoided since it puts additional pressure on tissue that is already compromised and may impede healing; -Interventions; -A turning/repositioning program includes a continuous consistent program for changing the resident's position and realigning the body. (A program is defined as a specific approach that is organized, planned, documented, monitored and evaluated); -Frequency of repositioning a bed- or chair-bound resident should be determined by: a. The type of support surface used; b. The condition of the skin; c. The overall condition of the resident; d. The response to the current repositioning schedule and; e. Overall treatment objectives; -Residents who are in bed should be on at least an every two hours repositioning schedule; -For residents with a Stage I or above pressure ulcer, an every two hours repositioning schedule is inadequate; -Residents who are in a chair should be on an every one hour repositioning schedule; -If ineffective, the turning and repositioning frequency will be increased. Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, Chapter 3, Section M, defines the different stages of pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) as follows: -Stage 1: an observable, pressure related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in skin temperature, tissue consistency, sensation, and/or a defined area of persistent redness; -Stage 2: Partial thickness loss of dermis (the inner layer that makes up skin) presenting as a shallow open ulcer with a red-pink wound bed, without slough (non-viable yellow, tan, gray, green or brown tissue). May also present as an intact or open/ruptured blister; -Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. 1. Review of Resident #37's face sheet showed the resident's diagnoses included spinal stenosis in thoracic region (thoracic spinal stenosis occurs when the spinal canal through which the spinal cord travels or the opening through which nerve roots exit the spinal canal narrows), Stage 3 pressure ulcer of the sacral region (bones at the bottom of the spine), type 2 diabetes mellitus, morbid obesity, osteomyelitis (bone infection) of vertebra in the lumbar region (bones in the lower portion of the spine), unspecified fracture of unspecified thoracic vertebra (bones in the middle portion of the spine from the base of the neck to the ribs). Review of the facility's Medication Review Report, dated 11/13/22-1/31/23, showed an active order to turn the resident every two hours. Use offloading wedge for positioning. Review of the resident's admission Minimum Data Sheet (MDS), a federally mandated assessment instrument completed by facility staff, completed 11/21/22, showed the following: -Moderately impaired cognition; -Required extensive assistance with help from two or more staff members for bed mobility, dressing and personal hygiene; -Required total assistance from two or more staff members for transfer by means of mechanical lift; -He/She had two stage III pressure ulcers; -At risk for developing pressure ulcers; -Was on a turning and repositioning program. Review of the resident's care plan, dated 11/22/22, showed the following: -The resident has a pressure ulcer sacral region stage II or potential for pressure ulcer development related to history of ulcers and immobility; -The resident prefers to be position on my (specify location). Review showed no documentation to show the resident's positioning needs. Review of resident's undated handwritten care plan showed the following: -Needs extensive help with bed mobility; -Transfers are total lift with Hoyer lift (mechanical lift); -Does not walk and needs wheelchair; -Incontinent of bowel and bladder; -Pressure ulcers buttocks, stage 3; Review showed no documentation of resident's repositioning needs. Review of the resident's skin evaluation dated 12/27/22, showed the following: -He/She has a stage 2 pressure ulcer on coccyx measuring 1.7 cm in length X 1 cm wide; -He/She has a stage 2 pressure ulcer on left buttock measuring 1.1 cm in length X 0.2 cm wide. Observations on 1/10/23 showed the following: -At 6:20 A.M., the resident lay in bed on his/her back with his/her eyes closed. A sign above the resident's bed indicated the resident needed to be turned on his/her side every two hours; -At 7:30 A.M., the resident lay in bed on his/her back with his/her eyes closed; -At 7:50 A.M., the resident lay in bed on his/her back with his/her eyes closed; -At 8:05 A.M., the resident lay in bed on his/her back with his/her eyes closed; -At 11:00 A.M., the resident sat in his/her wheelchair. During an interview on 1/10/23 at 11:00 A.M., Certified Medication Technician (CMT) E said the following: -He/She just got the resident out of bed and into his/her wheelchair for lunch; -He/She had not repositioned the resident on his/her shift (day shift) (prior to getting the resident out of bed). (The resident remained positioned on his/her back for at least 4 hours and 30 minutes. Observation on 1/10/23 at 1:37 P.M. showed the resident sat in his/her wheelchair on a cushion. Observation on 1/10/23 at 1:40 P.M., showed Certified Medication Technician (CMT) E and CMT D used a Hoyer lift to transfer the resident from his/her wheelchair to his/her bed. Observation on 1/10/23 at 1:46 P.M. showed the following: -The resident lay on his/her back in bed; -The resident was incontinent of urine and his/her incontinence brief was soaked; -Wound care completed by Licensed Practical Nurse (LPN) I; -When staff positioned the resident on his/her side for wound care treatment, the stage 2 wound on coccyx appeared to be the size of dime and appeared to be pink around the edges with no odor; -The resident's skin on his/her buttock had creases from his/her brief and the skin was red. Observation on 1/10/23 at 2:10 P.M. showed the resident lay in bed on his/her back. Observation on 1/10/23 at 4:08 P.M. showed the following: -The resident lay in bed on his/her back; -The resident was not wearing an incontinence brief and was incontinent of bowel and bladder; -The resident's bottom sheet and pad were soaked completely through and the mattress was wet underneath the resident's feet; -The resident's buttock had creases in his/her skin and was red; -Staff provided incontinence care for the resident. During interview on 1/10/23 at 4:08 P.M. and 6:15 P.M. CNA N (who was responsible for the resident's care on 1/10/23) said the following: -His/Her shift started at 2:00 P.M.; -The resident was on his/her back in bed at 2:00 P.M.; -He/She did not reposition the resident (prior to putting the resident to bed at 4:08 P.M.); -Getting all of the tasks completed was difficult when he/she was responsible for multiple halls; this included the repositioning of residents. During an interview on 1/18/23 at 1:05 P.M., the Director of Nursing (DON) said the following: -Staff try to reposition high risk residents every hour; if the resident is not a severe risk, they reposition the resident every two hours; -Examples of high risk resident would be a resident who already had a pressure ulcer or had diagnosis of diabetes; -She would always expect staff to follow physician orders for repositioning. 2. Review of Resident #18's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated 10/6/22, showed the following: -Memory problem; -Required extensive assistance from one staff for transfers and bed mobility; -Always incontinent of bladder and bowel; -Used a wheelchair for mobility; -At risk for pressure ulcers. Review of the resident's Braden scale (assessment used to determine risk for pressure), dated 10/6/22, showed the resident was at low risk for developing pressure ulcers. Review of the resident's care plan, dated 1/16/22, showed the following: -At risk for pressure ulcers related to incontinence, poor appetite and weight loss; -The resident will maintain or develop clean and intact skin by the review date; -The resident needs pressure relieving/reducing mattress, pillows, sheepskin padding to protect the skin while in bed; -Keep skin clean and dry, minimize moisture; -Report any signs of skin breakdown (sore, tender, red, or broken areas) to charge nurse. Review of the resident's Physician Order Sheet (POS), dated January 2023, showed the following: -Diagnoses included Alzheimer's (a progressive disease that destroys memory and other important mental functions) and Parkinson's disease (disorder of the central nervous system that affects movement, often including tremors); -Up with assist of one to two, may be up in wheelchair; -At risk for pressure ulcers related to incontinence, poor appetite and history of weight loss; -Keep skin clean and dry as possible. Minimize skin exposure to moisture; -Report any signs of skin breakdown (sore, tender, red or broken areas). Do skin assessment during bathing paying particular attention to bony prominences. Report to charge nurse. Observation on 1/10/23 at 8:45 A.M. showed the following: -Certified Medication Technician (CMT) E assisted the resident to bed and performed perineal care on the resident who had been incontinent of urine; -He/She rolled the resident to his/her left side; -The resident's coccyx (small, triangular bone at the base of the spine) area was reddened; -CMT E said the resident gets this way frequently and they use barrier cream; -He/She opened the drawer and did not find barrier cream; -He/She finished cares and fastened the resident's new incontinence brief and pulled up the resident's pants; -CMT E left the resident positioned on his/her back and said he/she would report the redness to the charge nurse. During interview on 1/11/23 at 11:45 A.M., Registered Nurse (RN) C said no staff had reported the resident's reddened coccyx to him/her. He/She would expect staff to report this immediately after it was observed. Observation on 1/11/23 at 11:57 A.M. showed the following: -The resident lay in bed; -RN C entered and observed the resident's reddened coccyx which measured 7.7 centimeters (cm) by 2.4 cm. RN C said the area was a Stage 1 (Intact skin with non-blanchable redness of a localized area usually over a bony prominence) pressure ulcer to the coccyx; -He/She applied a generic calmoseptine cream (barrier cream); -He/She said the physician only wanted to be notified if the skin was open. During interview on 1/12/23 at 1:53 P.M., CMT E said the following: -He/She had forgotten to report the resident's redness to the nurse; -When staff noted reddened skin on a pressure area, it should be reported to the charge nurse immediately; -If a barrier cream is to be used, but not available in the room, staff should obtain the needed cream, return it to the resident's room and apply it. During an interview on 1/18/23 at 1:05 P.M., the Director of Nursing (DON) said the following: -RN C was in charge of wounds; -He/She would expect if staff found redness on a pressure point that they would report it immediately and apply a barrier cream; -He/She would expect staff to retrieve barrier cream if not in room and apply it to the reddened area. MO211661 Surveyor: [NAME], Konnie

Based on observation, interview, and record review, the facility failed to ensure staff assisted one resident (Resident #18) to reposition and be propelled in a wheelchair safely in a review of 14 sampled residents. The facility failed to ensure wheelchair footrests were in place when propelling Resident #18 in a wheelchair and improperly repositioned him/her in the chair. The facility census was 37. The facility did not provide a policy that addressed transfers, proper lifting techniques, gait belt use or wheelchair safety. 1. Review of Resident #18's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated 10/6/22, showed the following: -Memory problem; -Required extensive assistance from one staff for transfers and locomotion; -Used a wheelchair for mobility. Review of the resident's January 2023 Physician Order Sheet (POS) showed the following: -Diagnoses included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and Parkinson's disease (disorder of the central nervous system that affects movement, often including tremors); -Up with assist of one to two. May be up in wheelchair. Review of the resident's care plan, dated 1/16/22, showed the following: -The resident was at risk for injury related to falls due to Lewy Body dementia (affects a persons ability to think, reason and process information), poor balance and poor safety awareness; -The resident did not walk and used a wheelchair. Observation on 1/9/23 at 12:12 P.M. showed staff propelled the resident in his/her wheelchair to his/her room without foot rests on the wheelchair. The resident's feet dragged on the floor intermittently. Observations on 01/10/23 showed the following: -At 6:15 A.M., Certified Nurse Assistant (CNA) F propelled the resident from his/her room, up the hall without foot rests, to a recliner by the nurse's desk; -At 8:20 A.M., the resident sat in his/her wheelchair in the common area and wore grippy socks. Certified Medication Technician (CMT) D propelled the resident in the wheelchair from the common area to the middle of the 200 hall to be weighed, and then propelled him/her back to the dining room without foot rests. The resident's feet slid along the floor; -At 8:25 A.M., the resident sat in a recliner in the common area. CMT E and CNA F stood on either side of the resident and without the use of a gait belt, placed an arm under the resident's arms, grabbed the waist of the resident's pants and lifted the resident up/back in the chair; -At 8:45 A.M.,CNA E propelled the resident in his/her wheelchair from the dining room to the resident's room without footrests. The resident's feet touched the floor. During interview on 1/12/23 at 1:47 P.M., CMT D said the following: -Staff should not push residents in a wheelchair without foot rests, especially if the resident's feet were dragging or the resident was not wearing shoes; -When repositioning residents in a chair, staff should not be lifting residents under the arms or by the waist of their pants. Staff should apply a gait belt, stand the resident to a walker (if necessary), and have them sit back in the chair. During interview on 1/12/23 at 1:53 A.M., CMT E said staff should not push residents in a wheelchair without foot rests because their feet could go under the wheels of the chair. During interview on 1/12/23 at 2:30 P.M , Registered Nurse (RN) S said the following: -Staff should not push residents in wheelchairs without foot rests; -If staff need to reposition a resident in a chair, staff should assist the resident to stand and have them sit back down; -Staff should not lift residents under the arms when repositioning a resident. During interview on 1/18/23 at 11:10 A.M., administrator B said the following: -The facility did not have a policy for wheelchair use; -He expected staff to put foot rests on prior to propelling a resident in a wheelchair; -If residents cannot keep their feet on the foot rest, therapy has a padded attachment which covers the leg/foot -He expected staff to reposition residents in a chair by using a gait belt.

Based on interview and record review the facility failed to ensure gradual dose reductions were conducted for one resident (Resident #4), in a review of five sampled residents, who were ordered and received pyschotropic medications. The census was 37. Review of the facility policy, titled Medication Regimen Review, last revised 4/2007 showed the consultant pharmacist shall review the medication regimen of each resident at least monthly. The consultant will perform a medication regimen review (mrr) for every resident in the facility. The primary purpose of this review is to help the facility maintain each resident's highest practicable level of functioning by helping them utilize medications appropriately and prevent or minimize adverse consequences related to medication therapy to the extent possible. Review of the facility policy, titled Tapering Medications and Gradual Drug Dose Reduction, last revised 4/2007 showed the following: 1. After medications are ordered for a resident, the staff and practitioner shall seek an appropriate dose and duration for each medication that also minimized the risk of adverse consequences; 2. All medications shall be considered for possible tapering. Tapering that is applicable to antipyschotic medications shall be referred to as Gradual Dose Reduction (GDR); 3. Residents who use antipsychotic drugs shall receive GDR's and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; 1. Periodically the staff and practitioner will review the continued relevance of each resident's medications; 2. The Attending Physician and staff will identify target symptoms for which a resident is receiving various medications. The staff will monitor for improvement in those target symptoms, and provide the physician with that information; 3. The staff and practitioner will consider tapering of medications as one approach to finding an optimal dose or determining whether continued use of a medication is benefiting the resident; 7. The time frames and duration of tapering attempts should be based on relevant factors including other medications that the resident is taking, underlying causes of symptoms, individual risk factors, and pharmacologic characteristics of the medications. Some medications (e.g., antidepressants, sedative/hypnotics, opioids) may need more gradual tapering in order to minimize withdrawal symptoms or other adverse consequences; 11. Within the first year after a resident is admitted on an antipsychotic medication or after the resident had been started on an antipsychotic medication, the staff and practitioner shall attempt a GDR in two separate quarters (with at least one month between the attempts), unless clinically contraindicated. After the first year, the facility shall attempt a GDR at least annually, unless clinically contraindicated. 1. Review of Resident #4's care plan, dated 7/25/21, showed the following: -History of hallucinations (having seen, heard, touched, tasted or smelled something that was not there) and delusions (altered reality); -Pharmacist consultant review required; -Review resident's medications for continued need at least quarterly. Review of the resident's progress notes showed the following: -On 9/7/22 the pharmacy consultant documented a Medication Regimen Review (MRR)- chart reviewed for irregularities; Recommendation made to the Medical Doctor (MD); See report for details; -On 11/13/22, the pharmacy consultant documented a MRR- chart reviewed for irregularities; Recommendation made to the MD; See report for details. Review of the resident's January 2023 Physician Order Sheet (POS) showed the following: -Diagnoses included paranoid schizophrenia (includes delusions and hallucinations), depression (mood disorder) and pyschosis (mental disorder characterized by a disconnection from reality); -Haldol (used to treat mood disorder) five milligrams (mg) by mouth four times daily (order date of 3/13/22); -Trazadone hydrochloride (anti-depressant)100 mg by mouth at bedtime (order date of 3/13/22). The facility did not provide reports from the pharmacist consultant or physician responses from the pharmacist recommedations for the resident. During interview on 1/12/23 at 2:30 P.M. Registered Nurse (RN) C said the following: -Pharmacy consultant recommendations are faxed to the medical director who is supposed to sign them and send them back; -All recommendations must go through the medical director and it can sometimes take awhile. During an interview on 1/18/23 at 2:40 P.M., administrator B said he would expect staff to follow facility policies.

Based on observation, interview and record review the facility failed to ensure administration of insulin pens according to manufacturers' recommendations for one additionally sampled resident (Resident #12) out of 14 sampled, and 16 additionally sampled residents to ensure the prescribed insulin dose was administered. The facility census is 37. Review of the facility's policy Medication Administration, dated revised December 2012, showed medications must be administered in accordance with the physicians orders. Review of the manufacturer's instructions at www.mynovoinsulin.com showed the following for administration with an insulin flexpen: 1. Check your insulin type. Make sure the insulin is clear and colorless do not use if it looks cloudy or colored. 2. Attach a new needle: Pull off the paper tab. Push and twist the needle on until it is tight. Pull off both needle caps, do not throw away the outer needle cap. 3. Prime your pen: Turn the dose selector to to select 2 units. Hold the pen upright (vertical), press and hold the dose button until the dose counter shows 0. Make sure a drop appears. (to ensure insulin flow) 4. Select your dose: Turn the dose selector to select the number of units you need to inject. 5. Give your injection: First wipe the skin with an alcohol swab and let it dry before you inject your dose. Insert the needle in the thigh, upper arm, or abdomen. Press and hold the dose button. After the dose counter reaches 0, slowly count to 6. (to ensure full dose is delivered) 6. Remove the needle: Carefully remove the needle and place it in a sharps container. Replace the pen cap. 1. Review of Resident #12's Physician's Order Sheet, dated January 2023, showed the following: -Diagnosis of Type II diabetes (inability to control blood sugar); -Novolog 100 units/milliliter (ml) inject 15 units subcutaneously (fatty tissue) in the morning before breakfast -Tresiba FlexTouch Solution Pen-injector 100 units/ml inject 26 unit subcutaneously one time a day. Observation on 1/10/23, at 9:30 A.M., showed the following: -Registered Nurse (RN) C said the resident had finished eating breakfast so he/she could administer the resident's insulin; -RN C removed the insulin pens from the medication cart; -He/She removed the cap from the Novolog flexpen and attached the needle; -With the caps on the needle the RN dialed the pen to one and leaving the pen horizontal pressed the dose button to 0 (the RN could not visualize the drop); -The RN then turned the dial to 15 and placed the pen on the medication cart; -The RN removed the cap from the Tresida flexpen and attached the needle; -With the caps on the needle RN C dialed the pen to one and leaving the pen horizontal pressed the dose button to 0 (the RN could not visualize the drop); -RN C then turned the dial to 26; -RN C brought both pens to the resident sitting in his/her recliner; -RN C wiped the resident's abdomen below the naval to the right side of the abdomen with an alcohol swab; -RN C inserted the Novolog flexpen into the resident's skin and pressed the dose button until it reached 0 and pulled out the needle. He/She did not hold for six seconds before removing the needle, a large drop of clear liquid was visible on the resident's skin; -RN C inserted the Tresida flexpen into the resident's skin and pressed the dose button until it reached 0 and pulled out the needle. RN C did not hold for six seconds before removing the needle; - RN C did not prime the insulin with 2 units, did not visualize the drop from the needle when he/she primed the pen, and did not hold the needle in the resident's skin for six seconds after the dose button reached 0 to ensure the full doses of insulin were administered. During an interview on 1/11/23, at 3:46 P.M., RN C said the following: -To administer insulin with a flex pen staff are expected to Verify the correct pen, remove the cap and screw the needle on, turn the dose selector to 1 unit, push the button to prime the needle, dial the dose needed, explain to the resident what you are doing, cleanse the injection site with an alcohol swab, insert the needle, press the dose button and wait 15 seconds before removing the needle from the residents skin; -He/She was behind and rushed on 1/10/23 because they had another resident go to the hospital so he/she did not hold the needle in the skin long enough. During and interview on 1/18/23, at 11:10 A.M., the DON said the following -To administer insulin with a flex pen staff are expected to:Verify the correct pen, remove the cap, clean the rubber stopper on the top of the pen with alcohol, select the dose of insulin needed, rotate sites (administer in different locations abdomen, thigh, arm), then document what the dose as administered; -To prime the needle on a flex pen you use two cubic centimeters (cc), the purpose for priming the needle is to ensure insulin is coming out; -To ensure the resident gets the entire dose staff are expected to hold the needle in the residents skin for 10 seconds prior to withdrawing the needle.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide a clean, comfortable, and homelike environment by failing to maintain walls, floors, ventilation fans, and wheelchairs in good repair. The facility census was 37. Review of the facility policy, Quality of Life - Homelike Environment, last revised May 2017, showed residents are provided with a safe, clean, comfortable and homelike environment. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. 1. Observation on 01/09/23 between 9:50 A.M. and 3:45 P.M., showed the following: -In resident room [ROOM NUMBER], several brown stains on the floor in the bedroom, and the independently motorized bathroom ventilation fan did not work; -In resident room [ROOM NUMBER], the independently motorized bathroom ventilation fan did not operate and was covered with dust on the interior portion of the fan; -In resident room [ROOM NUMBER], 21 large floor tiles were cracked; -In resident room [ROOM NUMBER], the independently motorized bathroom ventilation fan did not operate and was covered with dust on the interior portion of the fan; -In resident room [ROOM NUMBER], several floor tile were cracked and stained; -In resident room [ROOM NUMBER], the independently motorized bathroom ventilation fan did not operate and was covered with dust on the interior portion of the fan; -In resident room [ROOM NUMBER], the bathroom light cover was missing, the wall under the window had deep scratches in the paint exposing the dry wall underneath, and the floor tiles were separating and had a dark brown debris between them; -In the corridor between room [ROOM NUMBER] and the smoke barrier doors, the floor tiles were separating and had a brown substance in between the tiles. -In resident room [ROOM NUMBER], several floor tiles were cracked, and the independently motorized bathroom ventilation fan did not work; -In resident room [ROOM NUMBER], several floor tile were cracked. -In resident room [ROOM NUMBER], the independently motorized bathroom ventilation fan did not operate and was covered with dust on the interior portion of the fan; -In resident room [ROOM NUMBER], the independently motorized bathroom ventilation fan did not operate and was covered with dust on the interior portion of the fan. -In resident room [ROOM NUMBER], the floor tiles were raised at the seams, the floor tiles in front of the closet were buckled with high raised areas and were separated. The floor tiles around the whole room were brown where the tiles met. There were deep gouges in the wall where the bed should be by the window (no bed at this time), and deep gouges exposing crumbling dry wall under the window. The edge of wall by the sink had an approximately 2 feet length of exposed metal corner where the dry wall and paint has fallen off the wall. Observation on 1/11/23 at 12:45 P.M. in resident room [ROOM NUMBER] showed the following: -A dark brown stain on the floor under the sink in the bedroom; -The grout between the tiles under the sink was dirty; -A black substance on the floor where the floor tile in the bedroom met the flooring in the bathroom. The floor tile to the left of the bathroom door was raised; -The floor tile by the bed was brown and discolored with chipped corners; -The base of the toilet in the bathroom was cracked. Observations on 1/10/23 at 6:45 A.M., 1/11/23 at 10:22 A.M., and on 1/12/23 at 1:45 P.M., in resident room [ROOM NUMBER] showed darker and lighter brown spots (ranging from pencil eraser to dime sized and some smeared) on the floor between the first bed in the room and the wall. Observation on 1/9/23, at 11:08 A.M., showed most of the vinyl on Resident #10's wheelchair was gone. Small pieces of vinyl were left on both arm rests with sharp edges and the foam was exposed. The seat of the wheelchair was cracked and exposed the material under the vinyl. The wheelchair smelled strongly of urine. Observation on 1/9/23, at 12:20 P.M., showed the following: -The seat of Resident #10's wheelchair was visibly wet with urine, and had a crack in the vinyl seat of the wheelchair; -The wheelchair had a strong urine odor. During an interview on 1/12/23, at 10:42 A.M., Certified Medication Technician (CMT) E said the resident's wheelchair holds the urine smell because the seat is cracked. During interview on 01/10/23 at 11:58 A.M., the maintenance supervisor said he was responsible for maintaining the bathroom ventilation fans. He was not aware of the fans that were not working or were covered with dust that were found during the inspection. During interview on 01/10/23 at 1:12 P.M. and 12:27 P.M., administrator A said she was aware of the condition of the floor tiles in the resident room. The facility does not redo any flooring in a room until a resident is moved out of the room. The facility has obtained bids for new flooring, however, they cannot do anything without corporate approval. She had not heard back from corporate yet. She expected the bathroom ventilation fans to work properly and to be dust free. During and interview on 1/18/23, at 11:10 A.M., administrator B said the restorative aide, nursing or therapy inspected the wheelchair arm rests and seats. The restorative aide, nursing or therapy would be responsible to report the wheelchairs that needed repairs to maintenance. Maintenance would send the request to the administrator to order parts. Wheelchair seats and wheelchair arm rest were to be in good repair.

Based on interview and record review, the facility failed to complete required pre-employment screenings for two employees in a review of nine newly hired employees. The facility failed to review the Nurse Aide (NA) Registry for a Federal indicator (which would disqualify an individual from working in the facility) for Transport Aide T, and failed to request a criminal background check and complete an Employee Disqualification List (EDL) check prior to hire for Licensed Practical Nurse (LPN) U. The facility also failed to develop a policy and procedure to address reviewing the Nurse Aide Registry for a Federal indicator and for requesting a criminal background check prior to hire. The facility census was 37. Review of the facility policy, Registry of Nurse Aides, revised January 2008, showed the following: -Policy Statement: Certified nurse aide licenses shall be verified through the Registry of Nurse Aides; -Policy Interpretation and Implementation: 1. All certified nurse aides applying for a nurse aide position must present to the HR Director, or other designee, a copy of his/her registration number; 2. The HR Director, or other designee, is responsible for contacting the State Nurse Aide Registry to determine the validity of the individual's certification status; 3. Should the facility find that an individual is not on the register, that individual must enroll in a nurse aide training program. If the individual has been terminated from another facility for resident abuse, the nurse aide will not be employed and/or will be terminated from employment, whichever case may apply; Review showed the facility's policy did not address reviewing the NA registry for all potential hires prior to hire. Review of the undated facility policy, New and Current Employee, Contractors, Vendors, Physicians, and Other Healthcare Practitioners Exclusions Screening Policy and Procedure, showed the following: -PROCEDURE : The following screening procedures will be conducted by the facility; 1. Employee Screening Prior to Hire; A. Prior to the hiring of any facility employee, the Human Resources Department will screen all potential employees by: iv. Reviewing the Missouri Employee Disqualification List (EDL) maintained by the Department of Health and Senior Services; v. The Human Resources Department shall notify the Compliance and Ethics Officer and the Facility's legal counsel of any matches found during any of the above screening processes. If a potential employee is determined to be an excluded individual, the individual will no longer be eligible for hire. 1. Review of Transport Aide T's employee file showed the following: -Date of hire 11/10/22; -NA registry check completed 11/16/22 (six days after his/her date of hire). 2. Review of Licensed Practical Nurse (LPN) U's employee file showed the following: -Date of hire 11/5/22; -No documentation staff requested a criminal background check or checked the EDL prior to LPN U's date of hire; -Family Care Safety Registry (a registry maintained by the Missouri Department of Health and Senior Services for facilities to utilize for completion of the criminal background check and EDL check) check requested 1/10/23 (the date the employee file documentation was requested and 67 days after date of hire); During an interview on 1/18/23 at 11:10 A.M., the Director of Nursing (DON) said the FCSR and NA Registry checks are expected to be done on all staff prior to employment. During an interview on 1/18/23 at 11:10 A.M., administrator B said he expected that all facility policies be followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop a plan of care consistent with resident's specific conditions, needs, and risks to provide effective person-centered care for three residents (Resident's #13, #21 and #28), in a review of 14 sampled residents. The facility census was 37. Review of the facility Care Plans, Comprehensive Person-Centered policy dated December 2016, showed the following: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; -1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident; -2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment; -8. The comprehensive, person-centered care plan will: a. Include measurable objectives and time frames; b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; -9. Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan; -10. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process; -12. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS); -13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change; -14. The Interdisciplinary Team must review and update the care plan: a. When there has been a significant change in the resident's condition; b. When the desired outcome is not met; c. When the resident has been readmitted to the facility from a hospital stay; and d. At least quarterly, in conjunction with the required quarterly MDS assessment. 1. Review of Resident #13's care plan showed the following: -On 6/21/22, the resident has his/her own teeth that are in poor condition; -On 6/21/22, at risk for COVID exposure; -On 10/18/22, the resident has altered dentition with broken/carious teeth; -The care plan did not address bed rails. Review of the resident's facility assessment for side rails, dated 9/14/22, showed the following: -The resident had expressed a desire to have siderails; -Siderails were indicated; -Bilateral (both sides) siderail placement was recommended. Review of the resident's progress notes showed the following: -On 12/15/22 at 4:25 P.M., staff documented the resident returned from a dental appointment and his/her top teeth were extracted and a temporary plate put in (mouth); -On 1/5/23 at 4:08 P.M., staff documented the resident tested positive for COVID-19. Observations on 1/9/23 at 10:40 A.M. and 1/9/23 at 3:15 P.M., of the resident and the resident's room door, showed the following: -An isolation precautions sign on the resident's door; -The resident was noted to have facial bruising on the left side of his/her face. During an interview on 1/9/23 at 3:15 P.M., the resident said the following: -He/She had recently had all of his/her upper teeth pulled and an upper denture plate was put in his/her mouth. He/She could do most things him/herself, but his/her mouth was still sore and sometimes he/she needed help putting in his/her upper plate; -He/She had recently been diagnosed with COVID and was having to stay in his/her room; -He/She had bedrails on his/her bed and he/she used them to help get up from her recliner and position in bed. Review of the resident's care plan showed the following: -No update to show the resident now had a partial plate; -No update to show the resident had tested COVID positive and was on isolation precautions; -No update to show the resident utilized bed rails. 2. Review of Resident #21's care plan, dated 1/16/22 with undated hand written interventions, showed the following: -Diagnoses of dementia, anemia, chronic stage 3 renal (kidney) insufficiency, diabetes mellitus (inability to control blood sugar), arthritis, and depression; -The resident has slow persistent weight loss, prefers to sleep through meals; -Will have no weight loss in next 90 days; -One soda daily; -Two Cal (concentrated nutritional supplement) 60 cubic centimeters (cc) two times daily; -Weekly weight, report to charge nurse; -Encourage to come out to the dining room for meals; -Offer snacks between meals; -Dietitian to review. Review of the resident's Physician's Orders, dated 3/11/22, showed the following: -Low concentrated sweets diet; -Weigh weekly on Tuesdays. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Requires set up for eating; -Supervision, set up an cues for bed mobility; -164 pounds (lbs). Review of the resident's Physician Order Sheet, dated 5/24/22, showed house supplement with medication pass two times a day 60 cc. Review of the resident's weight summary, dated 6/9/22, showed the resident's weight was 164.4 lbs. Review of the resident's weight summary, dated June 2022, showed no weekly weights obtained between 6/10/22 and 6/21/22. Review of the resident's care plan, updated 6/21/22, showed the following: -Nutritional risk related to therapeutically altered diet and history of gradual weight gain; -Resident's nutritional status will remain stable through next review on 9/16/22; -Calorie protein support (high concentrated protein supplement) 60 cc twice daily; -Encourage appropriate intake of food and fluids; -Low concentrated sweet diet; -Weight as ordered; -Record meal intake. Review of the resident's Nutrition/Dietary Note, dated 6/21/22, showed the following: -Quarterly review weight 164.4 lbs; -Gradual gains noted related to intakes and use of supplement; -Intakes 75-100 %; -House supplement 60 cc two times daily; -Monitor and follow up as indicated. Review of the resident's weight summary, dated 7/5/22, showed the resident weighed 161.8 lbs. The resident's care plan did not show evidence it was reviewed or updated after the resident lost 2.6 lbs. Review of the resident's [NAME], last reviewed 7/22/22, showed the resident is on a regular diet and eats independently. Review of the resident's nurses notes, dated 7/31/22, showed the resident continues with poor appetite. Review of the resident's nurses notes, dated 8/4/22, showed the resident did not come out to supper and has not been eating his/her snacks, did not drink much this shift, encouragement given this shift. Review of the resident's nurses notes, dated 8/5/22, showed the staff notified the resident's responsible party the he/she was not eating well, has a poor appetite and did not consume any of the evening meal. Review of the resident's weight summary, dated 9/7/22, showed the resident weighed 156.8 lbs. The resident's care plan did not contain evidence it was reviewed or updated after the resident lost 7.6 lbs. since 6/21/22, and 5 lbs since 7/5/22. Review of the resident's weight summary, dated 9/8/22-10/8/22, showed the resident weighed 152.4 lbs on 10/8/22. There were no weekly weights between 9/8/22 and 10/7/22. The resident's care plan did not contain evidence it was reviewed or updated after the resident lost 12 lbs. since 6/21/22, and 9.4 lbs since 7/5/22. Review of the resident's significant change MDS, dated [DATE], showed the resident weighed 152 lbs. After the significant change in status MDS the care plan did not show review or revision for nutrition. On 6/9/2022, the resident weighed 164.4 lbs. On 12/8/2022, the resident weighed 151.6 pounds which is 12.6 lbs, a -7.79 % insidious weight loss. The care plan did not include any updates about any gradual weight loss, any new or revised interventions to address the weight loss, or evidence that the care plan was reviewed regarding the residents nutrition. Observation on 1/11/23, at 11:35 A.M., showed the following: -Unidentified staff delivered the resident's meal tray; -The staff member put the resident's tray on his/her bedside table and took off the lids covering the resident's food and left the room; -The resident struggled to get to a sitting position to eat; -The resident sat unbalanced and had to hold himself/herself up with one arm pushing against his/her mattress while he/she used the other hand to feed himself/herself; -When the resident needed to use two hands to unwrap his/her silverware and when he/she tried to pick up his/her sandwich the resident fell to the right side. -The resident fell to the side five times during the course of his/her meal and had to catch himself/herself; -The resident consumed 25% and then said he/she was tired and lay down in the bed. 3. Review of Resident #28's Care Plan, dated 10/4/21, showed the following: -admission to the facility on 8/5/21; -Diagnosis include diabetes mellitus, stroke with weakness on one side, Parkinson's disease ( progressive disorder that affects the nervous system and the parts of the body controlled by the nerves) disease, and depression; -Resident has deep tissue ulcers on great toes bilaterally and a blister on his/her left heel; -Assess the pressure ulcer for location, stage, size, presence/absence of granulation tissue and epithelialization weekly; -Change dressings as ordered to wounds; -Pressure reducing mattress to bed; -Use pillows to reduce pressure on heels. Review of the resident's significant change MDS, dated [DATE], showed the following: -Moderate cognitive impairment -Two unstageable pressure ulcers (pressure ulcer covered by slough and eschar (dead tissue or debris that occludes a wound bed)) present, unstageable due to slough and/or eschar. Review of the resident's quarterly MDS, dated [DATE], showed the resident had two Stage 2 pressure ulcers (partial thickness loss wound caused by pressure that does not extend past the dermis. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -No unhealed pressure ulcers present. During an interview on 1/09/23, at 3:45 P.M., the resident said he/she developed wounds at the facility on his/her big toes, they are healed, there may be a scab on his/her big toe, he/she was not sure. He/She did not have wounds anywhere else. The resident's care plan continued to show the resident had deep tissue ulcers on the great toes bilaterally and a blister on the left heel. The care plan did not show the wounds had healed. During interview on 1/18/23 at 12:20 P.M., the MDS Coordinator said the following: -She was responsible for ensuring care plans were up to date; -admission comprehensive assessments should be completed within 21 days of admission; -Care plans were not up to date as she had been pulled to the floor to work. During and interview on 1/18/23, at 11:10 A.M., the Director of Nursing (DON) said the following: -The MDS Coordinator completes the MDS's; -The MDS Coordinator is expected to complete the items on the MDS and complete the care plans according to the RAI manual; -Care plans are expected to be completed with as much information and knowledge as we have at the time it is completed; -She expects staff to update the care plans with changes like falls or new wounds within 21 days. -Accidents and bowel and bladder incontinence should be included on the care plan.

Based on interview and record review, the facility failed to follow physician's orders for labs, nutritional supplements and daily and weekly weights for five residents (Resident #4, #13, #24, #29, and #37) in a review of 14 sampled residents. The facility census is 37. During an interview on 1/18/23, at 11:00 A.M., the Director of Nursing said the facility may not have a policy for following physician orders for tests and procedures but it was like the one the facility had for medications. The staff are expected to follow all physician's orders and if there is an issue call the physician or the medical director for concerns or further direction. 1. Review of Resident #4's care plan, dated 7/25/21, showed the following: -Risk for dehydration; -Monitor labs as ordered; -Potential for complications related to diabetes mellitus (chronic condition that affects the way the body processes blood sugar); -Hgb A1C (measurement of blood glucose for three months) every three months. Review of the resident's January 2023 Physician Order Sheet (POS) showed the following: -Diagnoses included coronary artery disease (damage or disease in the heart's major blood vessels), hyperlipidemia (elevated cholesterol) and diabetes mellitus II; -Complete Metabolic Panel (CMP-evaluated kidney and liver function), Complete Blood Count (CBC-used to look at overall health) and Hemoglobin A1C (A1C-) every six months (March and September) ( order date of 4/3/22); -Microalbumin (test to detect blood protein in the urine) and Lipids (measure of cholesterol in blood) yearly in March (order date of 4/3/22). Review of the resident's medical record on 1/12/23 showed no documentation staff obtained ordered labs (CMP, CBC, Hgb A1C, microalbumin and lipids) in September 2022. 2. Review of the Resident #24's face sheet showed the resident's diagnoses included combined systolic (congestive) and diastolic (congestive) heart failure, anemia (a condition in which the body does not have enough healthy red blood cells), hyperlipidemia (elevated concentrations of lipids or fats within the blood.), hypertension (high blood pressure), and atherosclerotic (a common condition that develops when a sticky substance called plaque builds up inside the arteries) heart disease of native coronary artery without angina pectoris (chest pain). Review of the resident's January 2023 POS showed the following: -An order dated 6/5/22 for labs to be drawn every six months, to start in August 2022: CMP and CBC; -An order dated 6/5/22 for yearly lab to start in August 2022, including a lipid test. Review of the residents' medical record on 1/12/23 showed no documentation staff obtained labs (CMP, CBC and lipid) in August of 2022 as ordered. 3. Review of Resident #29's face sheet showed the resident's diagnoses included type 2 diabetes mellitus with diabetic neuropathy, essential (primary) hypertension, obesity, vitamin deficiency, vitamin b-12 deficiency, anemia, folate deficiency anemia, and hypokalemia (low potassium level in the blood). Review of the resident's January 2023 POS showed orders for the following: -Weekly weights to be obtained every seven days, order date of 3/15/22; -Labs to be drawn every six months, to start in May 2022 including CMP, CBC, and A1C ; order date of 4/3/22; -Yearly lab to start in May 2022 including Thyroid Stimulating Hormone (TSH; a blood test that measures this hormone. TSH levels that are too high or too low may be a sign of a thyroid problem.) and a microalbumin (Micro/Alb; a test to detect very small levels of a blood protein (albumin) in the urine). Review of the resident's medical record showed no documentation staff obtained labs (CMP, CBC, A1C, and TSH) in May of 2022 as ordered. Review of the resident's weight summary report showed the following: -No weekly weight documented for the week of 3/20/22 through 3/26/22; -No weekly weight documented for the week of 3/27/22 through 4/2/22; -No weekly weight documented for the week of 4/17/22 through 4/23/22; -No weekly weight documented for the week of 5/8/22 through 5/14/22; -No weekly weight documented for the week of 5/15/22 through 5/21/22; -No weekly weight documented for the week of 7/31/22 through 8/6/22; -No weekly weight documented for the week of 9/18/22 through 9/24/22; -No weekly weight documented for the week of 9/25/22 through 10/01/22; -No weekly weight documented for the week of 10/9/22 through 10/15/22; -No weekly weight documented for the week of 10/23/22 through 10/29/22; -No weekly weight documented for the week of 10/30/22 through 11/5/22; -No weekly weight documented for the week of 11/13/22 through 11/19/22; -No weekly weight documented for the week of 11/20/22 through 11/26/22; -No weekly weight documented for the week of 11/27/22 through 12/3/22; -No weekly weight documented for the week of 12/11/22 through 12/17/22; -No weekly weight documented for the week of 12/18/22 through 12/24/22; -No weekly weight documented for the week of 12/25/22 through 12/31/22; -No weekly weight documented for the week of 1/1/23 through 1/7/23; -No weekly weight documented for the week of 1/8/23 through 1/12/23. 4. Review of Resident #37's face sheet showed his/her diagnoses included diabetes, morbid obesity, Crohn's disease of both the small and large intestine (a lifelong form of inflammatory bowel disease (IBD). The condition inflames and irritates the digestive tract - specifically the small and large intestines. Crohn's disease can cause diarrhea and stomach cramps), diarrhea and hypertension. Review of the resident's January 2023 POS showed the an order for daily weights; order date of 11/14/22; Notify of weight gain over three pounds in 24 hours or over five pounds in one week. Review of the resident's weight summary report showed the following: -No weekly weight documented for the week of 11/20/22 through 11/26/22; -No weekly weight documented for the week of 11/27/22 through 12/3/22; -No weekly weight documented for the week of 12/11/22 through 12/17/22; -No weekly weight documented for the week of 12/18/22 through 12/24/22; -No weekly weight documented for the week of 1/1/23 through 1/7/23; -No weekly weight documented for the week of 1/8/23 through 1/12/23. 5. Review of Resident #13's facility diagnoses page showed the resident had diagnoses that included iron deficiency anemia, gastro-esophageial reflux disease (GERD) (stomach disorder), pressure ulcers, vitamin D deficiency and diarrhea. Review of the resident's dietitian review note, dated 12/11/22, showed the following: -November and December weight loss evaluations, gradual weight loss since readmit in September; -Recommend adding house supplement 60 milliliters (ml) three times daily (TID) for additional calorie support. -The resident's physician agreed to the recommendation and signed the order on 12/14/22. Review of the resident's December 2022 POS showed no documentation staff transcribed the order to the physician orders. Review of the resident's December 2022 medication administration record (MAR) showed no documentation staff administered the ordered house supplement. Review of the resident's December 2022 treatment administration record (TAR) showed no documentation staff administered the ordered house supplement. Review of the resident's January 2023 POS showed no documentation staff transcribed the ordered supplement to the physician orders. Review of the resident's January 2023 MAR showed no documentation staff administered the ordered house supplement. Review of the resident's January 2023 TAR showed no documentation staff administered the ordered house supplement. During an interview on 1/10/23 at 3:35 P.M., Certified Medication Technician (CMT) D said the following: -He/She was not aware Resident #37 was supposed to have daily weights; -He/she had not completed weekly weights forever as he/she has been too busy. During an interview on 1/10/23 at 3:23 P.M., Registered Nurse (RN) C said the following: -If a resident was ordered a house supplement, it was given with medication passes; -The MAR/TAR directed him/her as to who had ordered supplements and that was where it was documented if residents were given supplements; -He/She did not think Resident #13 was to receive the house supplement; he/she did not have an order for one. During an interview on 1/12/23 at 2:30 P.M. RN S said labs should be completed as ordered. During an interview on 1/12/23 at 3:40 P.M and 1/18/23 at 11:30 A.M. the Director of Nursing (DON) said the following: -She expected staff to follow physician orders; -After searching, she said they had no lab results for Resident #4 for the month of September 2022, for Resident #29 for May of 2022 or Resident #24 for August of 2022. MO211661

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Review of the Resident #37's admission MDS, completed 11/21/22, showed the following: -Moderately impaired cognition; -Required extensive assistance with help from two or more staff members for personal hygiene. Review of resident's undated hand written care plan showed the resident needed extensive help with grooming. Observation on 1/11/23 at 12:45 P.M., showed the following: -The resident had very long, curling toenails on both feet; -The resident's fingernails were long with pink polish that was faded and peeling. 7. During an interview on 1/12/23, at 10:42 A.M., CMT E said the residents were supposed to get two showers a week, but when there are only two aides for 37 residents, the staff does what they can. Not all the residents' showers get done. During an interview on 1/11/23, at 3:46 P.M., Registered Nurse C said the following: -The aides cannot get all their showers, nail care, hair care, oral care, and activity of daily living (ADL) care completed if there are only two aides to 37 residents; -The staff try to wash up the residents in bed, clean arm pits and perform pericare, but they cannot do everyone's shower, shaves, nails, etc. During an interview on 1/10/23, at 3:35 P.M. and 1/18/23, at 11:10 A.M., the Director of Nursing (DON) said the following: -The facility tries to set up the schedule the resident had at home; -No specific amount of baths/showers are required for each resident; just clean and taken care of; -Minimum amount of showers was once a week, but to the residents liking; -When there are two aides on the day shift, the staff would not be able to complete all of the showers, shaves, and nail care. The staff may have to pass these tasks on to the next shift; -If a resident refuses a bed bath or shower, then staff should come back later, and/or try another staff member; -Staff are expected to document refusals on the shower sheets; -Shaving should be to the resident's preference. Some residents need to be shaved every day, and some may need shaved every couple of days; -Staff should shave female residents with showers or as needed when facial hair is getting long; -Nail care is expected to be to the resident's preference; -The podiatrist trimmed all residents' toe nails every 90 days; -Staff document if they complete nail care on the shower sheets and communicate to the nurse if he/she needs to trim nails; -Staff are expected to offer oral care in the morning before breakfast and at bedtime; -If a resident had issues, they could require oral care more frequently after meals and sometimes before; -The CNAs are responsible for ADL care, and the nurse is responsible to ensure it gets done. During an interview on 1/18/23 at 11:10 A.M., administrator B said he/she would expect staff to follow facility policies. 4. Review of Resident #27's Care Plan, revised on 10/31/22, showed the resident prefers to receive a shower. Review of the resident's Significant Change Minimum Data Set (MDS), dated [DATE], showed the following: -Severely impaired cognition; -Requires extensive assistance with assistance of at least one staff member for personal hygiene; -Requires total assistance with at least one staff member for bathing. Review of the resident's shower sheets from December 2022 showed the following: -The resident received a shower on 12/5/22, 12/8/22, and 12/12/22; -No documentation the resident received a shower on 12/13/22 through 12/18/22 (six days); -The resident received a shower on 12/19/22; -No documentation the resident received a shower on 12/20/22 through 12/31/22 (12 days). Review of the resident's shower sheets for January 2023 showed the resident received a shower on 1/2/23 and 1/5/23. Observation on 1/9/23 at 10:40 A.M. showed the following: -The resident sat in a recliner in his/her room; -His/Her fingernails were long and dirty; -His/Her hair was uncombed. During an interview on 1/11/23 at 11:59 A.M., Licensed Practical Nurse (LPN) I said the following: -The resident requires staff assistance; -He/she refuses showers frequently. Observation on 1/11/23 at 12:15 P.M. in the resident's room showed the following: -The resident sat in the recliner in his/her room; -His/Her fingernails long and dirty; -His/Her hair was uncombed. 5. Review of Resident #14's baseline care plan, dated 3/7/22, showed the following: -Dependent for grooming tasks; -Not marked for dentures. Review of the resident baseline care plan dated 3/7/22 showed it did not address the resident's dental status and did not direct oral care needed or assistance. Review of the resident's significant change in condition MDS, dated [DATE], showed the following: -Oral hygiene: Substantial/Maximal assistance. Helper does more than half the effort; -Edentulous (no natural teeth). Review of the resident's POS, dated January 2023, showed diagnoses included Alzheimer's disease and dysphagia (difficulty swallowing) Observation on 1/10/23 at 6:45 A.M. showed the following: -The resident lay on his/her back in the bed; -CNA F entered the room and performed morning cares for the resident; -The resident wore dentures and an empty denture cup sat on the countertop; -CMT D entered the room, assisted with transferring the resident and morning cares, and pushed the resident out of the room without performing or offering oral care to the resident. During interview on 1/24/23 at 2:07 P.M., CNA F said staff should provide oral care on all shifts, in the morning and after meals. Dentures should be cleaned or the resident's mouth should be swabbed with a toothette. Based on observation, interview, and record review, the facility failed to complete activities of daily living (ADL) for dependent residents to ensure six residents (Residents #10, #21, #14 #18, #27, and #37), in a review of 14 sampled residents, were clean and groomed. The census was 37. Review of the facility policy, Showers, last revised December 2010, showed the purposes of the procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. The following information should be recorded on the resident's ADL record and/or in the resident's medical record. 1. Date and time of the shower; 2. The name and title of the individual(s) who assisted the resident with the shower; 3. All assessment data (e.g. reddened areas, sore etc., on the resident's skin) obtained during the shower; 4. If the resident refused the shower, the reason why and the intervention taken; 5. The signature and title of the person recording the data. Review of the facility policy, Care of Fingernails/Toenails, last revised October 2010, showed the following: -Nail care includes daily cleaning and regular trimming; -Proper nail care can aid in the prevention of skin problems around the nail bed; -Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his/her skin; -Stop and report to the nurse supervisor if there is evidence of ingrown nails, infections, pain or if nails are too hard or thick to cut with ease. -Document the date and time the nail care was given, the name and title of the individual who administered the nail care, if the resident refused the treatment, the reason and any interventions taken and the signature and title of the person recording the data. 1. Review of Resident #10's Care Plan, last reviewed 4/16/22, showed the following: -Diagnoses included Alzheimer's disease (a type of dementia) and schizophrenia (mental illness characterized by racing thoughts hallucinations and delusions); -Requires supervision/cues for bathing and grooming; -Requires extensive physical assistance for dressing and transfers; -Frequently incontinent of bowel and bladder, and requires assist of one with toilet use; -The resident does not like to change clothing at times; -Keep clean and dry as possible. Review of the resident's significant change Minimum Data Set (MDS), a federally mandated assessment instrument, dated 10/26/22, showed the following: -Moderate impaired cognition; -No behaviors or rejection of care; -Requires extensive physical assistance of one staff member for transfers, toilet use, hygiene and bathing. Review of the resident's shower schedule showed the resident was scheduled for two showers a week on Tuesday and Friday (alternate days Saturday and Sunday). Review of the resident's Shower Sheets, dated 10/1/22-10/31/22, showed the following: -Staff documented the resident received showers on 10/2/22, 10/4/22 with nails trimmed, and 10/9/22; -No documentation the resident received a shower on 10/10/22 through 10/17/22 (eight days); -The resident received a shower on 10/18/22 and 10/22/22; -No documentation the resident received a shower on 10/23/22 through 10/31/22 (nine days). Review of the resident's Shower Sheets, dated 11/1/22-11/30/22, showed the following: -No documentation the resident received a shower on 11/1/22 through 11/28/22 (37 days since his/her last documented shower on 10/22/22); -Staff documented the resident received a shower on 11/29/22. Review of the resident's Shower Sheets, dated 12/1/22-12/31/22, showed no evidence the resident received a shower on 12/1/22 through 12/31/22 (32 days since his/her last documented shower on 11/29/22). Review of the resident's Shower Sheets, dated 1/1/23-1/10/23, showed the following: -No documentation the resident received a shower on 1/1/23 or 1/2/23; -On 1/3/23, staff documented the resident refused a shower (35 days since the residents last documented shower on 11/29/22); -The resident received a shower on 1/5/23. Observation on 1/9/23, at 11:16 A.M., showed the following: -The resident sat in his/her wheelchair at the nurses desk; -The resident had long unkempt facial hair; -There was yellow substance built up in the resident's facial hair; -The resident had long fingernails with a brown debris under the nails; -The resident had a strong odor of urine. Observation on 1/9/23, at 12:20 P.M., showed the following: -Certified Medication Technician (CMT) E followed the resident into his/her room; -CMT E removed the resident's soiled incontinence brief and feces fell from the brief onto the toilet seat and the floor; -The resident sat on the toilet seat; -The seat of the resident's wheelchair was visibly wet; -The wheelchair had a strong urine odor; -CMT E cleaned the center area of the resident's buttocks with disposable wet wipes. The CMT did not clean the resident's outer buttocks, thighs, or front perineal area that were in contact with the resident's wet and soiled brief; -CMT E put a clean brief on the resident and assisted the resident to stand and walk to his/her bed; -CMT E did not clean all of the resident's skin that came in contact with feces and urine. During an interview on 1/12/23, at 10:42 A.M., CMT E said the following: -Staff was expected to clean all of the resident's skin that came into contact with urine and feces; -He/She thought he/she cleaned all the areas of the resident's skin, but could not see everywhere he/she was cleaning and keep the resident steady while the resident was standing at the toilet; -The residents are supposed to get two showers a week, but when there are only two aides for 37 residents, the staff do what they can. All the showers do not get done. Staff try to wash up the residents the best they can. 2. Review of Resident #21's Care Plan, last updated 7/22/22, showed the following: -Diagnosis of dementia; -The resident is forgetful and confused at times; -Requires extensive physical assist for bathing and grooming. Review of the resident's shower schedule showed the resident was scheduled for two showers a week on Tuesday and Friday (alternate days Saturday and Sunday). Review of the resident's Shower Sheets, dated 10/1/22-10/31/22, showed the following: -Staff documented the resident received a shower on 10/4/22; -No documentation the resident received a shower on 10/5/22 through 10/13/22 (nine days); -The resident received a shower on 10/14/22 and 10/18/22; -No documentation the resident received a shower on 10/19/22 through 10/31/22 (13 days). Review of the resident's significant change MDS, dated [DATE], showed the following: -Severe cognitive impairment; -No behavior issues or rejection of care; -Requires extensive physical assist of one staff member for hygiene,and bathing. Review of the resident's Shower Sheets, dated 11/1/22-11/30/22, showed no evidence the resident received a shower in November. Review of the resident's Shower Sheets, dated 12/1/22-12/31/22, showed the following: -No documentation the resident received a shower on 12/1/22 through 12/15/22; -Staff documented the resident received a shower on 12/16/22 (59 days since his/her last documented showed on 10/18/22); -No documentation the resident received a shower on 12/17/22 through 12/31/22 (15 days). Review of the resident's Shower Sheets, dated 1/1/23-1/10/23, showed staff documented the resident received a shower on 1/3/23. Observation on 1/09/23, at 12:27 P.M., showed the following: -The resident walked down the hall with therapy staff; -The resident had long unkempt facial hair, dry flaky skin, and long fingernails with brown debris under the nails. During an interview on 1/9/23, 1:45 P.M., the resident's responsible party/family member said he/she would like the resident to be bathed twice a week. The facility tells him/her the resident refuses baths but he/she is not sure if the resident refuses or not. During an interview on 1/11/23, at 1:55 P.M., the resident said the following: -He/She does not always get a bath; -Sometimes he/she goes a lot of days without a bath; -He/She wants a bath a couple times a week and to shave daily, unless he/she decides he/she wants facial hair. 3. Review of Resident #18's care plan dated 1/16/22 showed the following: -Required extensive assist with grooming; -The resident is not always able to complete simple decisions regarding daily routine/care at times. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Memory problem; -Required extensive assistance from one staff for personal hygiene; -Total dependence on one staff for bathing. Review of the resident's Physician Order Sheet (POS), dated January 2023, showed the resident's diagnoses included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and Parkinson's disease (disorder of the central nervous system that affects movement, often including tremors). Observation on 1/10/23 at 8:45 A.M. showed the following: -CMT/Certified Nurse Assistant (CNA) E assisted the resident to bed after breakfast and did not offer oral care; -The resident had whitish/gray facial hairs under his/her nose, on his/her chin and at the corners of his/her mouth. Observation on 1/11/23 at 10:32 A.M. showed the resident sat in a recliner by the nurse's station. The resident had a tan, dried substance on his/her chin and around his/her mouth. The resident had whitish/gray facial hair under his/her nose, on his/her chin and at the corners of his/her mouth. During interview on 1/12/22 at 1:53 P.M., CMT/CNA E said the following: -Staff should provide oral care every morning, after meals and at bedtime; -CNAs were responsible for providing showers, and should shave residents on shower days and as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an on-going activities program for three resident (Residents #21, #25, and #37), in a review of 14 sampled residents, to ensure the residents had meaningful activities or activity material available to meet their interests and support their psychosocial needs. The facility also failed to provide meaningful activities program in the evenings and on the weekends as directed by facility policy, and failed to provide residents with a schedule of activities that readily available to encourage involvement in scheduled activities. The facility census was 37. Review of facility policy, Activity Programs, revised August 2006, showed the following: -Policy Statement: Activity programs designed to meet the needs of each resident are available on a daily basis; -1. Our activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs; -2. Activities are scheduled 7 (seven) days a week and residents are given an opportunity to contribute to the planning, preparation, conducting, cleanup, and critique of the programs; -3. Our activity programs consist of individual and small and large group activities that are designed to meet the needs and interests of each resident and include, as a minimum: a. Activities that stimulate the cardiovascular system and assist with range of motion, such as exercise, movement to music, wheelchair basketball/volleyball, etc., are offered five to seven times per week; b. Intellectual activities that are mentally stimulating, such as current events, trivia, word games, book reviews, educational movies, etc., are provided five to seven times per week; c. Weather permitting, at least one activity a month is held away from the facility; d. Weather permitting, outdoor activities are held on a regular basis; e. At least one evening activity is offered per week, depending on population needs; f. Spiritual programming is scheduled to meet the religious needs of the residents; g. At least two group activities per day are offered on Saturday, Sunday and holidays; h. At least four group activities are offered per day Monday through Friday; i. Creative and expressive activities, such as arts and crafts, ceramics, painting, drama, creative writing, poetry and music, are available on a regular basis to meet the needs of residents; j. Social activities are scheduled to increase self-esteem, to stimulate interest and friendships, and to provide fun and enjoyment. Activities include, but are not limited to, daily coffee social, birthday and holiday parties, entertainment, candlelight dinner, country breakfast, cultural and theme events (Cinco de Mayo, Western Day, Crazy Hat Day, etc.); k. Participation in community groups and religious organizations are encouraged based on the needs of the resident population. -4. Activities are not necessarily limited to formal activities being provided only by activities staff. Other facility staff, volunteers, visitors, residents, and family members may also provide the activities; -5. Activities participation for each resident is approved by the Attending Physician based on information in the resident's comprehensive assessment; -6. Scheduled activities are posted on the resident bulletin board. Activity schedules are also provided individually to residents who cannot access the bulletin board (e.g., bed bound or visually impaired residents); -7 Individualized and group activities are provided that: a. Reflect the schedules, choices and rights of the residents; b. Are offered at hours convenient to the residents, including evenings, holidays and weekends; c. Reflect the cultural and religious interests, hobbies, life experiences, and personal preferences of the residents; and d. Appeal to men and women as well as those of various age groups residing in the facility; -8. Residents are encouraged, but not required, to participate in scheduled activities; -9. Adequate space and equipment are provided to ensure that needed services identified in the resident's plan of care are met. 1. Review of the Activity Calendar, dated January 2023, showed the following: -1/1/23: There are cards and movies by the nurses station; -1/2/23: 10:00 A.M. nail care, 11:00 A.M.-1:00 P.M. mail, 2:00 P.M. games; -1/3/23: 10:00 A.M. room visits, 11:00 A.M.-1:00 P.M. mail, 2:00 P.M. craft; -1/4/23: 10:00 A.M. room visits, 11:00 A.M.-1:00 P.M. mail, 2:00 P.M. bingo; -1/5/23: 10:00 A.M. popcorn, 11:00 A.M.-1:00 P.M. mail, 2:00 P.M. painting (the activities for this day were canceled); -1/6/23: 10:00 A.M. games (canceled), 11:00 A.M.-1:00 P.M. mail, 2:00 P.M. singing with guests (the activities for this day were canceled); -1/7/23: There are cards and movies by the nurses station; -1/8/23: There are cards and movies by the nurses station; -1/9/23: 10:00 A.M. room visits, 11:00 A.M.-1:00 P.M. mail, coloring packets (the activities for this day were canceled); -1/10/23: 10:00 A.M. shopping for residents, 11:00 A.M.-1:00 P.M. mail, 2:00 P.M. trivia (the activities for this day were canceled); -1/11/23: 10:00 A.M. room visits, 11:00 A.M.-1:00 P.M. mail, 2:00 P.M. bingo (the activities for this day were canceled); -1/12/23: 10:00 A.M. popcorn, 11:00 A.M.-1:00 P.M. mail, 2:00 P.M. crafts. (The Activity Director said in-room Bingo was provided this day instead of crafts); -1/13/23: There are cards and movies by the nurses station; -1/14/23: There are cards and movies by the nurses station; Review showed no organized weekend activities, including two group activities, as directed by facility policy. Review showed the facility did not provide four group activities daily during the week and did not provide religious activities as directed by policy. 2. Review of Resident #21's Care Plan, dated 1/16/22, showed the following: -Diagnosis of unspecified dementia, arthritis, and depression; -The resident has memory/recall problem related to dementia, alert and can make simple decisions; -Needs assistance with complex decisions; -Inform him/her of group activity so he/she can decide what to attend; -Provide activities of preference in room. Review of the resident's significant change Minimum Data Set (MDS), a federally mandated assessment instrument, dated 2/9/22, showed the following: -Severe cognitive impairment; -No mood or behavior issues; -It is very important to the resident to attend his/her favorite activities; -It is somewhat important to the resident to go outside and attend religious activities. Review of the resident's daily activity attendance, dated October 2022, showed the following: -The resident participated in a one-on-one activity on nine out of 31 days (10/4, 10/7, 10/10, 10/13, 10/17, 10/19, 10/25, 10/28 and 10/31). The attendance record did not identify what the one-on-one activities included; -The resident participated in Bingo/games on the 10/5 and 10/26. Review showed no documentation the resident attended activities on 20 of 31 days in October. The resident's activity attendance record did not show any religious activities, going outside, and only two group activities. Review of the resident's significant change MDS, dated [DATE], showed it was somewhat important to the resident to do activities with groups of people and to go outside. Review of the resident's daily activity attendance, dated November 2022, showed the following: -The resident participated in a one-on-one activity on seven out of 30 days (10/3, 10/7, 10/11, 10/15, 10/18, 10/21 and 10/29). The attendance record did not identify what the one-on-one activities included; -The resident participated in Bingo/games on 10/2; -The resident participated in coffee/chat time on 10/1, 10/10, and 10/21. Review showed no documentation the resident attended activities on 20 of 30 days in November. The resident's activity attendance record did not show any religious activities, going outside, and only four group activities. Review of the resident's activity attendance, dated December 2022, showed the following: -The resident participated in a one-on-one activity on nine out of 31 days (10/1, 10/6, 10/9, 10/14, 10/16, 10/20, 10/23, 10/28, and 10/30). The attendance record did not identify what the one-on-one activities included; -The resident participated in Bingo/games on the 10/7 and 10/28; -The resident participated in coffee and chat time on the 10/7 and 10/22; -The resident participated in a parachute activity on 10/23. Review showed no documentation the resident attended activities on 20 of 31 days in December. The resident's activity attendance record did not show any religious activities, going outside, and only five group activities. The resident did not have an activity attendance log for January 2023. Observation on 1/9/23 at 11:16 A.M., showed the resident lay in bed with his/her sheet over his/her head. There was no activity calendar or activity schedule in the resident's room. Observation on 1/9/23, at 2:15 P.M., showed the resident lay in bed with his/her sheet over his/her head. Observation on 1/10/23 at 10:30 A.M., showed the resident lay in bed with his/her sheet over his/her head. During an interview on 1/10/23 at 11:20 A.M., the resident said if there is nothing to do, he/she just takes a nap. The staff come and get him/her when there are things to do once in a while. He/She would like to have more to do, but there was not much to do there. Observations while onsite at the facility throughout the survey from 1/9/23 through 1/11/23 showed the facility did not have scheduled activities. The resident did not participate or attend any activities. During an interview on 1/12/23, at 11:44 A.M., the Activity Director said the resident needs lots of encouragement to come out of the room. He/She sleeps a lot and has the sheet over his/her head. He/She usually enjoys activities if he/she comes out. If no one goes to get the resident, he/she does not come out. He/She tries to stop in and visit with the resident. 3. Review of Resident #25's Care Plan, dated 9/6/21, showed the following: -Provide activities of preference in room or social distance in the dining room; -The resident is very social and loves to read and visit with staff and peers; -Encourage and assist to use facility library; -Encourage him/her to be involved with group activities; -Give the resident a monthly calendar; -Involve the resident with other residents with shared interest; -Visit with resident during care; -Provide activities of preference in room or social distanced in dining room. Review of the resident's annual MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Diagnoses include anxiety and depression; -No delirium, hallucinations, delusions, behaviors, or rejection of care; -Very important to do favorite activities; -Somewhat important to have books newspapers and magazines to read; listen to music he/she likes, be around animals, do things with groups of people, and participate in religious services/practices. Review of the resident's daily activity attendance, dated October 2022, showed the following: -The resident participated in a one-on-one activity on seven out of 31 days (10/3, 10/6, 10/10, 10/13, 10/19, 10/23, and 10/27). The attendance record did not identify what the one-on-one activities included; -The resident participated in parties/socials on the 10/28 and 10/31; -The resident participated in ball toss on 10/4 and 10/24. Review showed no documentation the resident attended activities on 21 of 31 days in October. The resident's activity attendance record did not show any religious activities, activities with animals, and only four group activities. Review of the resident's daily activity attendance, dated November 2022, showed the following: -The resident participated in a one-on-one activity on eight out of 30 days (11/2, 11/4, 11/8, 11/14, 11/18, 11/22, 11/25, and 11/29). The attendance record did not identify what the one-on-one activities included; -The resident participated in reading/writing on 11/1, 11/3, 11/4, 11/9, 11/17, 11/22, 11/27, and 11/28; -The resident participated in nail care on the 11/7 and 11/21; Review showed no documentation the resident attended activities 14 of 30 days in November. The resident's activity attendance record did not show any religious activities, activities with animals, and no group activities. Review of the resident's activity attendance, dated December 2022, showed the following: -The resident participated in a one-on-one activity on eight out of 31 days (12/1, 12/5, 12/12, 12/14, 12/20, 12/23, 12/26, and 12/29). The attendance record did not identify what the one-on-one activities included; -The resident participated in party/social event on the 12/23; -The resident participated in Pledge (no description of this activity) on the 12/27 and 12/30. Review showed no documentation the resident attended activities 21 of 31 days in December. The resident's activity attendance record did not show any religious activities, activities with animals, and only three group activities. The resident did not have an activity attendance for January 2023. Observation on 1/9/23, at 10:49 A.M., showed the resident sat at a table by the nurses desk. Observation on 1/9/23 at 2:20 P.M., showed the resident stood at a table with his/her walker at the nurses desk. Observation on 1/10/23 at 8:30 A.M., showed the resident did not have an activity calendar in his/her room. Observation on 1/10/23 at 8:45 A.M., showed the resident sat at a table by the nurses desk. Observation on 1/10/23 at 10:34 A.M., showed the resident sat at a table by the nurses desk. Observations while onsite at the facility throughout the survey from 1/9/23 through 1/11/23 showed the facility did not have scheduled activities. The resident did not attend or participate in any activities. During an interview on 1/12/23, at 11:44 A.M., the Activity Director said the resident likes to do activities most of the time. He/She will entertain himself/herself at times. He/She likes to sit at the table near the nurses desk and see what was going on. 4. Review of Resident #37's facility's admission packet documentation, dated 11/14/22, showed the following: -He/She enjoyed group activity and Bingo; -His/Her current hobbies included Bingo. Review of the resident's admission MDS dated [DATE], showed the following: -Moderately impaired cognition; -Needs extensive assistance with help from two or more staff members for bed mobility, dressing and personal hygiene; -Needs total assistance with help from two or more staff members for transfer by means of Hoyer lift; -Somewhat important to have books, newspapers and magazines to read; -Very important to keep up with the news; -Very important to go outside. Review of residents' care plan dated 11/22/22 showed no documentation regarding activities. Review of the resident's daily activity attendance, dated November 2022, showed the following: -Watch/listen to TV was marked as an activity every day from 11/15/22 through 11/30/22; -One-on-one was marked for an activity on 11/15/22, 11/18/22, 11/25/22, 11/28/22 and 11/30/22. Review showed no documentation the resident participated an any other activities during the month of November. Observation on 1/09/23 at 11:32 A.M., showed the following: -The resident was awake in his/her bed; -The television in the room was turned off; -There were no books, newspapers or magazines visible in the room; -There was no activity calendar in his/her room. During an interview on 1/09/23 at 3:05 P.M., the resident said he/she liked to participate in Bingo and play cards. Observation on 1/10/23 at 1:37 P.M., showed the resident sat in a wheelchair in his/her room. The resident was awake. The television in the room was turned off and there were no books, newspapers or magazines in the room visible in the room. The resident did not have an activities calendar in his/her room. During an interview on 1/11/23 at 11:59 A.M., the Activity Director said the following: -The resident will sometimes participate in Bingo; -He/She will visit one-on-one with the resident. Observation on 1/11/23 at 12:45 P.M., showed the resident lay awake in his/her bed. The television in the room was turned off and there were no books, newspapers, or magazines in the room. Observations while onsite at the facility throughout the survey from 1/9/23 through 1/11/23 showed the facility did not have scheduled activities. The resident did not attend or participate in any activities. 5. During resident council meeting on 1/11/23 at 2:10 P.M. several residents in attendance said the facility did not have any activities on Saturdays and Sundays. There were no activity calendars. It had been three months since the last activity calendar was available. Observation on 1/11/23 at 2:10 P.M. in the dining room showed there was no activity calendar posted. During an interview on 1/11/23 at 2:10 P.M., one anonymous resident said it was boring on the weekends (due to lack of activities). During an interview on 1/10/23, at 2:44 P.M., administrator A said the following: -The Activity Director had not been at work since last Thursday (1/5/23) so most of the activities were canceled, and the facility had an outbreak of COVID so music was canceled on 1/6/23; -There wasn't anyone to cover for activity staff when they were gone, but there were games in the dining room if residents wanted them; -There are no monthly activity calendars; the activity staff posted activities for each day; -The residents do not receive individual calendars. The calendar is on the bulletin board in the dining room, it is updated each day; -Since there are active cases of COVID, most of the residents do not go to the dining room. During an interview on 1/12/23, at 11:44 A.M., the Activity Director said the following: -He/She had been out for medical needs since 1/5/23 and just returned today (1/12/23) so he/she did not know what the facility did for activities during that time; -He/She was the full time activities staff and was also a CNA and helped on the floor and in the kitchen; -He/She also transported residents to their appointments; -The residents did in-room Bingo this morning (1/12/23). The residents get Bingo cards, then he/she goes room to room with five numbers at a time; -Lately, she has not done monthly activities schedules/calendars. With staffing issues, things change all the time so she puts the activity for the day on the bulletin board; -She attempts to do one-on-one activities twice a week individually with residents; -There are games and activity items in a cabinet in the dining room if residents want to do an activity on the weekend; -The administrator has not allowed any of the local church groups to come in to provide religious services for the residents because of COVID, she said it was a corporate policy. During an interview on 1/18/23 at 1:00 P.M., the Director of Nursing (DON) said she expected there to be meaningful activities for the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to consistently monitor a resident's weight, ensure interventions to address weight loss, including supplements and snacks, were consistently implemented, or re-evaluate interventions for effectiveness for two residents (Residents #13 and #21) with weight loss. The facility also failed to ensure meals were set up for two residents (Resident #21 and #27) of 14 sampled residents. The facility census was 37. Review of the facility's policy, Hydration, revised September 2012, showed the following: -The staff, with the physician's input, will identify individuals with signs and symptoms (for example, delirium, lethargy, increased thirst, etc.) or lab test results (for example, hypernatremia, azotemia, etc.) that might reflect existing fluid and electrolyte imbalance. They will report this information promptly to the Attending Physician; -The physician will adjust treatments based on specific information (lab results, level of consciousness, etc.) relevant to that individual. Review of the facility's policy, Resident Nutrition Services, revised November 2015, showed the following: -Each resident shall receive meals, with preferences accommodated, prompt meal service and appropriate feeding assistance; -Nursing personnel will evaluate food and fluid intake in resident with, or at risk for, significant nutritional problems. Nursing staff will assess and document the amounts eaten a indicated for individuals with or at risk for, impaired nutrition; -Significant variations from usual eating or intake patterns must be recorded in the resident's medical record The Nurse Supervisor and/or Unit Manager shall evaluate the significance of such information a d report it, as indicated, to the Attending Physician and Dietitian. 1. Review of Resident #21's care plan, dated 1/16/22 with undated hand written interventions, showed the following: -Diagnoses of dementia, anemia, chronic stage 3 renal (kidney) insufficiency, diabetes mellitus (inability to control blood sugar), arthritis, and depression; -The resident has slow persistent weight loss, prefers to sleep through meals; -Will have no weight loss in next 90 days; -One soda daily; -Two Cal (concentrated nutritional supplement) 60 cubic centimeters (cc) two times daily; -Weekly weight, report to charge nurse; -Encourage to come out to the dining room for meals; -Offer snacks between meals; -Dietitian to review. Review of the resident's Physician's Orders, dated 3/11/22, showed the following: -Low concentrated sweets diet; -Weigh weekly on Tuesdays. Review of the resident's quarterly Minimum Data Set, (MDS), a federally mandated assessment instrument completed by facility staff and dated 5/5/22, showed the following: -Severe cognitive impairment; -Requires set up for eating; -Supervision, set up an cues for bed mobility; -164 pounds (lbs). Review of the resident's Physician Order Sheet, dated 5/24/22, showed house supplement with medication pass two times a day 60 cc. Review of the resident's weight summary, dated 6/9/22, showed the resident's weight was 164.4 lbs. Review of the resident's weight summary, dated June 2022, showed no weekly weights obtained between 6/10/22 and 6/21/22. Review of the resident's care plan, updated 6/21/22, showed the following: -Nutritional risk related to therapeutically altered diet and history of gradual weight gain; -Calorie protein support (high concentrated protein supplement) 60 cc twice daily; -Encourage appropriate intake of food and fluids; -Low concentrated sweet diet; -Weight as ordered; -Record meal intake. Review of the resident's Nutrition/Dietary Note, dated 6/21/22, showed the following: -Quarterly review weight 164.4 lbs; -Gradual gains noted related to intakes and use of supplement; -Intakes 75-100 %; -House supplement 60 cc two times daily; -Monitor and follow up as indicated. Review of the resident's weight summary, dated June 2022, showed no weekly weights obtained between 6/22/22 and 6/30/22. Review of the resident's weight summary, dated 7/5/22, showed the resident weighed 161.8 lbs. Further review showed no other weekly weights documented for the resident in July 2022. The resident's care plan did not show evidence it was reviewed or updated after the resident lost 2.6 lbs. Review of the resident's nurses notes, dated 7/31/22, showed the resident continues with poor appetite. Review of the resident's nurses notes, dated 8/4/22, showed the resident did not come out to supper and has not been eating his/her snacks, did not drink much this shift, encouragement given this shift. Review of the resident's quarterly MDS, dated [DATE], showed the resident weighed 162 lbs. Review of the resident's nurses notes, dated 8/5/22, showed the staff notified the resident's responsible party the he/she was not eating well, has a poor appetite and did not consume any of the evening meal. Review of the resident's weight summary, dated 7/6/22-9/6/22, showed no weight for August 2022, and no weekly weight. Review of the resident's weight summary, dated 9/7/22, showed the resident weighed 156.8 lbs. The resident's care plan did not show evidence it was reviewed or updated after the resident lost 7.6 lbs. since 6/21/22, and 5 lbs since 7/5/22. Review of the resident's weight summary, dated 9/8/22-10/8/22, showed the resident weighed 152.4 lbs on 10/8/22. There were no weekly weights between 9/8/22 and 10/7/22. The resident's care plan did not show evidence it was reviewed or updated after the resident lost 12 lbs. since 6/21/22, and 9.4 lbs since 7/5/22. Review of the resident's significant change MDS, dated [DATE], showed the resident weighed 152 lbs. Review of the resident's weight summary, dated 11/9/22-12/7/22, showed no evidence weekly weights were obtained or recorded. On 6/9/2022, the resident weighed 164.4 lbs. On 12/8/2022, the resident weighed 151.6 pounds, a 12.6 lbs., 7.79 % insidious weight loss. Review of the resident's undated [NAME] showed the resident was on a regular diet and ate independently. There was no evidence of quarterly dietitian reviews from 6/23/22-1/11/23. Weekly weights were not completed, and a monthly weight for August 2022 was not recorded. Observation on 1/11/23, at 11:35 A.M., showed the following: -Unidentified staff delivered the resident's meal tray; -The staff member put the resident's tray on his/her bedside table and took off the lids covering the resident's food and left the room; -The resident struggled to get to a sitting position to eat; -The resident sat unbalanced and had to hold himself/herself up with one arm pushing against his/her mattress while he/she used the other hand to feed himself/herself; -When the resident need to use two hands to unwrap his/her silverware and when he/she tried to pick up his/her sandwich the resident fell to the right side; -The resident fell to the side five times during the course of his/her meal and had to catch himself/herself; -The resident consumed 25% and then said he/she was tired and lay down in his/her bed. 2. Review of Resident #27's face sheet showed the resident's diagnoses included disorientation, traumatic cataract (clouding of the eye), anxiety disorder, major depressive disorder, vitamin deficiency, Alzheimer's disease, and aphasia (loss of ability to understand or express speech). Review of the resident's Significant Change MDS dated [DATE], showed the following: -Severely impaired cognition; -No natural teeth; -Independent with setup help only for eating. Review of the resident's Care Plan, revised on 10/31/22, showed the following: -Encourage appropriate intake of food and fluids, offer substitutes for dislikes; -He/She feeds himself/herself with encouragement; -He/She is at nutritional risk related to history of weight loss; -Serve diet as ordered, weight as ordered, record meal intake, encourage appropriate intake of food and fluid, offer substitutes for dislikes; -Regular diet. Review of the resident's weight summary report on 12/8/22 showed the resident weighed 115.8 pounds. Observations on 1/9/23 showed the following: -At 11:20 A.M., the resident sat in a recliner in his/her room. The resident's meal tray was on the resident's lap. The resident had not taken any bites of his/her food. The resident said, help me. No staff was in the resident's room to assist or encourage the resident to eat; -At 11:25 A.M., the resident fell asleep with his/her uneaten meal on the tray on his/her lap; -At 12:00 P.M., the resident was asleep in his/her recliner. The resident's uneaten meal sat on the tray on the resident's lap; -At 12:15 P.M., the resident said, help me. Staff removed the uneaten meal tray from the resident's room and did not provide the resident with encouragement to eat. Observations on 1/10/23 showed the following: -At 7:50 A.M., the resident was awake in his/her recliner. The resident's uneaten breakfast sat on a tray on his/her lap. Licensed Practical Nurse (LPN) I removed the resident's uneaten breakfast tray off of the resident's lap and placed it on the bedside table out of the resident's reach; -At 8:50 A.M., Certified Nurse Assistant (CNA) F entered the resident's room, and said to the resident, You didn't eat your breakfast. The resident's uneaten meal was on the bedside table out of the resident's reach. CNA F did not offer to assist the resident with his/her meal or place it in the resident's reach. Observation on 1/10/23 at 9:00 A.M. showed Dietary Staff L removed the resident's uneaten breakfast from the resident's room without any attempt to encourage the resident to eat. Review of Certified Medication Technician (CMT) D's handwritten weight for the resident on 1/11/23 at 8:25 P.M. showed the resident weighed 107.6 pounds (an 8.2 pound weight loss since 12/8/22). Observation on 1/11/23 at 12:15 P.M. showed the following: -The resident sat in the recliner in his/her room. The resident's lunch sat on a tray on his/her lap. The resident had taken bites of his/her fruit cocktail and pieces of fruit were spilled on his/her shirt; -A Styrofoam cup of water (with no lid or straw) sat on the beside table out of the resident's reach; -CMT E and Registered Nurse (RN) C assisted the resident to the bathroom; -The resident said, Can I have a drink? I'm thirsty! four times while staff assisted him/her in the bathroom; -The resident's lips and skin appeared very dry; -CMT E handed the resident a can of soda and the resident took a big drink and coughed and had soda running out of his/her mouth; -RN C removed the lunch tray from resident's bedside table. Staff did not offer to assist the resident to eat before removing the resident's meal tray from the room. During an interview on 1/11/23 at 5:25 P.M., Licensed Practical Nurse (LPN) P said the following: -If a resident is unable to make his/her needs known, staff should go in every hour to hydrate and watch for signs and symptoms of dehydration. If the resident can talk, staff should provide hydration whenever the resident asks; -The resident has no interest in eating or drinking; -The resident was sleeping more often. During an interview on 1/9/23 at 11:20 A.M., Certified Nurse Aide (CNA) F said the resident says help me all of the time and doesn't eat much. During an interview on 1/11/23 at 7:16 P.M., the Director of Nurses (DON) said the following: -If a resident wants assistance with eating, staff would assist him/her; -She would expect staff to provide encouragement for the resident to eat or drink. Observation on 1/11/23 at 7:45 P.M. showed the following: -The resident sat in his/her recliner in the dark. The resident's uneaten dinner tray sat on the bedside table out of the resident's reach. The resident's silverware was still wrapped and his/her crackers were unopened; -CMT D entered the resident's room, offered to open the resident's crackers, and placed the resident's meal tray on the resident's lap and left the room; -The resident said, Oh, I'm going to eat it ALL; -He/She scooped soup away from him/her to try to get soup onto the spoon with his/her left hand (right hand in a wrist splint); -The resident took a bite, moaned and said, Oh, Thank You, Oh Help Me; -He/She fell back asleep with the tray on his/her lap after only one bite of soup. Observation on 1/11/23 at 8:20 P.M. showed the following: -CMT D entered the resident's room to awaken the resident; -CMT D asked the resident if the soup was good, and the resident replied, I'm not doing too good with it; -CMT D left the room without offering to assist the resident; -The resident scooped another bite of soup away from him/her to get soup on the spoon and took one bite before falling back asleep. Observation on 1/11/23 at 8:34 P.M. showed the following: -The resident was asleep in the recliner with his/her supper tray on his/her lap; -CMT D and the DON entered the resident's room; -CMT D said to the resident, I suppose you want me to feed you? The first bite is free, it's on you after that; -CMT D gave the resident a bite of soup, and the resident said, It's cold; -CMT D offered to heat up the soup, and the resident responded, You don't have to do that; -CMT D left the room to heat the soup, returned and sat the soup in front of the resident on the tray on his/her lap; -The resident asked, What is that? CMT D responded, That's your soup. The resident said Oh, thank you; -CMT D and the DON left the room; -The resident scooped another bite away from body with his/her left hand and took one bite of soup; -The resident fell back asleep. 3. Review of Resident #13's facility diagnoses page showed the resident had diagnoses that included iron deficiency anemia, gastro-esophageal reflux disease (GERD) (stomach disorder), pressure ulcers, vitamin D deficiency and diarrhea. Review of the resident's facility weight summary report showed staff documented the resident's weights as the following: -9/7/22, 145.4 pounds (lb); -9/13/22, 144.6 lbs; -10/8/22, 132.6 lbs; -10/18/22, 134.8 lbs -11/8/22, 134.0 lbs; -12/8/22, 130.2 lbs; (The resident had had a 10.45% weight loss from 9/7/22 to 12/8/22) Review of the resident's dietitian review note, dated 12/11/22, showed the following: -November and December weight loss evaluations, gradual weight loss since readmit in September; -Recommend adding house supplement 60 milliliters (ml) three times daily (TID) for additional calorie support. -The resident's physician agreed to the recommendation and signed the order on 12/14/22. Review of the resident's medical record, including his/her December 2022 POS, December 2022 medication administration record (MAR), December 2022 treatment administration record (TAR), January 2023 POS, January 2023 MAR and January 2023 TAR showed no documentation staff administered the ordered house supplement. During an interview on 1/11/23, at 8:22 P.M., Certified Nurse Assistant/Certified Medication Technician (CNA/CMT) D said the following: -He/She had not been able to do weekly and daily weights because of staffing, he/she is lucky to get monthly weights completed; - Resident #21 needs assistance with set up for his/her meals, the resident gets protein supplements twice a daily; -Staff are expected to assist any resident in their room to ensure they are sitting and stable and have a table or flat surface to eat on; -If residents do not eat a significant amount staff should assist the resident and offer to heat up their food if it is cold; -He/She said the facility has not had their weekly meetings to review weights in over a year. They used to have weekly meetings to review weights, wounds and falls. During an interview on 1/18/23 at 11:10 A.M., administrator B said he/she would expect staff to follow facility policies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the Resident #37's admission MDS dated [DATE], showed the following: -Moderately impaired cognition; -Required extensive assistance from two or more staff members for bed mobility; -Required total assistance from two or more staff members for transfer by means of mechanical lift. Review of the resident's care plan, revised 11/22/22, showed the following: -The resident was at high risk for falls; -The resident required a mechanical lift with two staff to assist for transfers. Review of residents' bed rail assessment, dated 1/11/23, showed the following: -A bed rail assessment was completed on 12/27/22; -No side rail placement was recommended; -Bed rail/assist bar was not indicated at this time. Review of facility's undated, hand written care plan on 1/11/23, showed no documentation the resident used bed rails. Observation on 1/09/22 at 11:32 AM showed the resident lay in bed awake with 1/8 bed rails located on both sides of the resident's bed in the raised position. Observation on 1/10/23 at 6:20 A.M. showed the resident lay in bed sleeping, with 1/8 bed rails located on both sides of the resident's bed in the raised position. Observation on 1/11/23 at 12:45 P.M. showed the resident lay in bed awake, with 1/8 bed rails located on both sides of the resident's bed in the raised position. Review of resident's medical record on 1/11/23 showed the following: -No documentation the facility assessed the resident's risk for entrapment from the bed rails prior to installation; -No documentation the facility obtained informed consent for the use of the bed rails. 3. Review of Resident #13's bed rail assessment, dated 9/14/22, showed the following: -A bed rail assessment was completed on 9/14/22; -Bilateral bed rails recommended; -Bed rail/assist bar indicated and would serve as an enabler to promote independence; -The resident expressed a desire to have bed rails/assist bar. Review of the resident's quarterly MDS, completed 12/16/22, showed the following: -Moderately impaired cognition; -Used walker and wheelchair mobility devices; -Independent with bed mobility and transfers. Review of the resident's current care plan, dated as last revised 6/21/22, showed the resident was at risk for falls. Review showed no documentation the care plan was updated to address the resident's bed rails after the assessment was completed on 9/14/22. Observation on 1/09/22 at 10:40 A.M. showed the resident had 1/8 bed rails on both sides of his/her bed in the raised position. Observation on 1/10/23 at 4:03 P.M. showed the resident had 1/8 bed rails on both sides of his/her bed in the raised position. Observation on 1/11/23 at 12:25 P.M. showed the resident had 1/8 bed rails on both sides of his/her bed in the raised position. Review of resident's medical record on 1/11/23 showed no informed consent was obtained prior to initiation of bed rails, entrapment zone measurements, or quarterly assessment for bed rail use performed. 4. During an interview on 1/12/23, at 2:55 P.M., the Director of Nursing said the following: -The facility has a bed rail assessment and the licensed staff is expected to complete the assessment on admission and quarterly; -The bed rail assessment does not identify if the resident is at risk for entrapment; -The staff is expected to document interventions tried prior to installing the bed rails; -The facility does not have an informed consent for bed rails use. 1. Review of Resident #21's Care Plan, revised 7/19/22, showed the following: -Diagnosis include dementia; -Forgetful and confused; -At risk for falls related to impaired balance, adverse reactions from psychotropic medications, unaware of safety needs and cognitive loss; -At risk for low blood sugars which include symptoms of increased confusion, numbness of fingers and toes, rapid heartbeat, nervousness, tremors, faintness and dizziness. Review showed no documentation the resident's care plan addressed the use of bed rails on the resident's bed. Review of the resident's significant change in status Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/4/22, showed the following: -Severe cognitive impairment; -Required extensive physical assistance from one staff for transfers; -Required limited physical assistance from one staff for bed mobility. Observation on 1/09/23, at 1:31 P.M., showed the resident in his/her bed. The resident's left side of the bed was against the wall. The resident had a 1/8 bed rail raised on the right side of the bed. Observation on 1/11/23, at 11:35 A.M., showed the following: -Staff delivered the resident's meal tray to the resident's room; -The resident was in his/her bed with one 1/8 bed rail in the raised position on the right side of his/her bed; -The resident struggled to get to a sitting position as he/she used the bed rail; -The resident sat unbalanced and had to hold himself/herself up with one arm pushing against his/her mattress while he/she used the other hand to feed himself/herself; -When the resident needed to use two hands to unwrap his/her silverware, and when he/she tried to pick up his/her sandwich, the resident fell to the right side; -The resident fell to the side five times during the course of his/her meal and had to catch himself/herself; -The resident was unable to sit upright without pushing up on the mattress or holding the bed rail. Review of the resident's medical record showed no documentation staff completed an entrapment assessment, attempted interventions prior to the installation of bed rails, or obtained informed consent for the use of the bed rails. Based on observation, interview, and record review, the facility failed to assess residents for risk of entrapment, document attempted alternatives prior to installing a bed rail, and failed to obtain informed consent with risks prior to installing and using a bed rail for three residents with bed rails (Residents #13, #21 and #37), in a review of 14 sampled residents. The facility census was 37. Review of the facility policy, Bed Safety, dated December 2007, showed the following: -Our facility shall strive to provide a safe sleeping environment for the resident; -1. The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment; -2. To try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, footboard, and bed accessories), the facility shall promote the following approaches: a. Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks; b. Review that gaps within the bed system are within the dimensions established by the FDA (Note: The review shall consider situations that could be caused by the resident's weight, movement or bed position.); c. Ensure that when bed system components are worn and need to be replaced, components meet manufacturer specifications; d. Ensure that bed side rails are properly installed using the manufacturer's instructions and other pertinent safety guidance to ensure proper fit (e.g., avoid bowing, ensure proper distance from the headboard and footboard, etc.); and e. Identify additional safety measures for residents who have been identified as having a higher than usual risk for injury including entrapment (e.g., altered mental status, restlessness, etc.); -3. The maintenance department shall provide a copy of inspections to the Administrator and report results to the Quality Assurance (QA) Committee for appropriate action. Copies of the inspection results and QA Committee recommendations shall be maintained by the Administrator and/or Safety Committee; -4. The facility's education and training activities will include instruction about risk factors for resident injury due to beds, and strategies for reducing risk factors for injury, including entrapment; -5. If side rails are used, there shall be an interdisciplinary assessment of the resident, consultation with the Attending Physician, and input from the resident and/or legal representative; -6. The staff shall obtain consent for the use of side rails from the resident or the resident's legal representative prior to their use; -7. After appropriate review and consent as specified. above, side rails may be used at the resident's request to increase the resident's sense of security ( e.g., if he/she has a fear of falling, his/her movement is compromised, or he/she is used to sleeping in a larger bed); -8. Side rails may be used if assessment and consultation with the attending physician has determined that they are needed to help manage a medical symptom or condition, or to help the resident reposition or move in bed and transfer, and no other reasonable alternatives can be identified; -9. Before using side rails for any reason, the staff shall inform the resident and family about the benefits and potential hazards associated with side rails; -10. When using side rails for any reason, the staff shall take measures to reduce related risks; -11. Side rails shall not be used as protective restraints. Should a protective restraint be used, our facility's protocol for the use of restraints shall be followed; -12. The use of physical restraints on individuals in bed shall be limited to situations where they are needed to treat a resident's medical symptoms, and only after being reviewed by authorized individuals; -13. The staff shall report to the Director of Nursing and Administrator any deaths, serious illnesses and/or injuries resulting from a problem associated with a bed and related equipment including the bed frame, bed side rails, and mattresses. The Administrator shall ensure that reports are made to the Food and Drug Administration or other appropriate agencies, in accordance with pertinent laws and regulations including the Safe Medical Devices Act.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide adequate staffing and oversight to ensure residents that required staff assistance were clean and free of body odors or had their nails trimmed for four residents (Resident #10, #21, #27 and #37) in a review of 14 sampled residents. The facility also failed to provide adequate staffing to ensure the right to self determination for one sampled resident (Resident #10) when there were not staff available to take the resident outside to supervise his/her smoking. The facility failed to provide adequate staffing to complete weekly weights for three resident (Resident #37, #29 and #21), two of which had weight loss. The facility failed to provide enough staff to ensure one resident (Resident #37), who had pressure injuries, was turned or repositioned every two hours to prevent further injury. The facility failed to ensure four residents' (Resident #87, #13, #21 and #28) care plans were completed or updated with changes when the Minimum Data Sheet (MDS)(a federally mandated assessment instrument completed by facility staff) Coordinator was pulled to the floor to work and could not complete her duties timely. The facility also failed to identify the number of Certified Nurse Assistants to provide adequate care for the resident population in the facility assessment. The facility census was 37. Review of the Facility Assessment, dated 1/2/23, showed the the following: -Staffing levels and competencies to provide care appropriate for the resident population in nursing: -One Director of Nursing; -One Minimum Data Set (MDS) Coordinator; -Four Registered Nurses (RN); -Four Licensed Practical Nurses (LPN); -Did not specify the number of Certified Nurse Assistants. 1. Review of Resident #10's Care Plan, dated 1/16/22, showed the following: -Diagnosis include Alzheimer's disease (a type of dementia), schizophrenia (mental illness characterized by racing thoughts hallucinations and delusions), hypertension (high blood pressure), drug induced subacute dyskinesia (involuntary movements caused by psychotropic drug use). -The resident currently smokes cigarettes; -The resident requires supervision for safety with smoking; -Provide supervision when smoking. Review of the resident's Care Plan, last reviewed 4/16/22, showed the following: -Requires supervision/cues for bathing, grooming; -Requires extensive physical assistance for dressing, and transfers; -Frequently incontinent of bowel and bladder, and requires assist of one with toilet use; -Resident does not like to change clothing at times; -Keep clean and dry as possible. Review of the resident's significant change MDS, dated [DATE], showed the following: -Moderate impaired cognition; -No behaviors or rejection of care; -Requires extensive physical assistance of one staff member for bed mobility, transfers, toilet use, hygiene and bathing. Review of the resident's Shower schedule showed the resident was scheduled for two showers a week on Tuesday and Friday (alternate days Saturday and Sunday). Review of the resident's Shower Sheets, dated 10/1/22-10/31/22, showed the following: -Staff documented the resident received showers on 10/2/22, 10/4/22 with nails trimmed, 10/9/22, 10/18/22, and 10/22/22. -The resident's medical record did not contain evidence the resident received showers between 10/10/22 -10/17/22 (seven days), and 10/23/22-10/31/22 (eight days). Review of the resident's Shower Sheets, dated 11/1/22-11/30/22, showed the following: -Staff documented the resident received showers on 11/29/22. -The resident's medical record did not contain evidence the resident received showers between 11/1/22 -11/28/22 (28 days plus the eight days the end of October total of 36 days). Review of the resident's Shower Sheets, dated 12/1/22-12/31/22, showed no evidence the resident received a shower. Review of the resident's Shower Sheets, dated 1/1/23-1/10/23, showed the following: -1/3/23 staff documented the resident refused a shower; -The resident received a shower on 1/5/23. Observation and interview on 1/9/23, at 11:00 A.M. to 11:30 A.M., showed the following: -Observation showed the resident was at the nurses station. The resident put two of his/her fingers to his/her mouth signaling to every staff member as they approached him/her; -Administrator A saw the resident, and said the resident makes that gesture with his/her hands when he/she wants someone to take him/her to smoke; -Observation showed administrator A and four other staff walked past the resident. No staff took the resident to smoke. Observation on 1/9/23, at 11:16 A.M., showed the following: -Resident in his/her wheelchair at the nurses desk; -The resident had long unkempt facial hair; -There was yellow substance built up in beard and on his/her face; -The residents had long fingernails with brown substance under them; -The resident had a strong odor of urine. Observation on 1/9/23, at 12:20 P.M., showed the following: -Certified Medication Technician (CMT) E followed Resident #10 into his/her room; -CMT E removed the resident's soiled brief, feces fell from the brief on to the toilet seat and the floor; -The resident's seat of the wheelchair was visibly wet; -The wheelchair had a strong urine odor. Observation on 1/10/23 at 7:45 A.M. to 9:15 A.M., showed the following: -At 7:45 A.M., the resident sat at the nurses station in his/her wheelchair. The resident put two fingers to his/her mouth signaling to staff members as they approached that he/she wanted to smoke. Licensed Practical Nurse (LPN) I told the resident he/she would take him/her out to smoke in 20 minutes or so. The resident continued to sit at the nurses desk; -At 8:00 A.M., the resident put two fingers to his/her mouth and signaled to staff again that he/she wanted to smoke. LPN I said he/she would take him/her to smoke in 20 minutes. LPN I was at the medication cart. Four different staff walked past the resident. The resident gestured he/she wanted to smoke to the staff, but the staff did not respond to the resident; -At 8:46 A.M., LPN I again told the resident he/she would take him/her out to smoke, but it would be 20 or 30 minutes; -At 9:02 A.M., the resident signaled to the Director of Nurses (DON) and the MDS (Minimum Data Set) coordinator that he/she wanted to smoke. The MDS coordinator told the resident someone would take him/her to smoke and then he/she walked away; -At 9:15 A.M., the resident left the nurses desk and went to his/her room. During an interview on 1/11/23, at 8:45 A.M., LPN I said he/she was going to take the resident to smoke after breakfast on 1/10/23, but he/she had things to do and was not able to take him/her before the resident gave up and went to bed. During an interview on 1/11/23 at 3:30 P.M., the resident the following: -He/She usually liked to smoke four or five times a day; -He/She had only been getting to smoke one to two times a day lately; -He/She asked to smoke at four different times with several requests at each time on 1/10/23; -He/She asked after breakfast on 1/10/23 and no one took him/her; -He/She asked several staff to take him/her out to smoke before lunch (on 1/10/23) and no one did; -He/She asked several staff after lunch (on 1/10/23) to take him/her to smoke and no one did; -Sometime after 4:00 P.M., a staff member finally took him/her out to smoke; -He/She asked to smoke after breakfast this morning and after lunch today and no one took him/her out to smoke. During an interview on 1/11/23, at 3:46 P.M., Registered Nurse (RN) C said the following: -The resident liked to smoke after each meal, and staff took him/her if he/she asked again between meals; -The resident can smoke six times a day; -Lately, the facility did not have enough staff to take the resident to smoke, so the resident might get to smoke four times a day. 2. Review of Resident #21's care plan, dated 1/16/22 with undated hand written interventions, showed the following: -Diagnoses of dementia, anemia, chronic stage 3 renal (kidney) insufficiency, diabetes mellitus (inability to control blood sugar), arthritis, and depression; -The resident has slow persistent weight loss, prefers to sleep through meals; -Will have no weight loss in next 90 days; -Weekly weight, report to charge nurse. Review of the resident's Care Plan, last updated 1/22/22, showed the following: -Diagnosis of unspecified dementia, chronic stage 3 renal (kidney) insufficiency, diabetes (inability to control blood sugar, arthritis, and depression; -The resident has slow persistent weight loss, prefers to sleep through meals; -Will have no weight loss in next 90 days; -Weekly weight, report to charge nurse; -Resident is forgetful and confused at times; -Requires extensive physical assist for bathing, and grooming; -Supervision for dressing, transfers. Review of the resident's Shower schedule showed the resident was scheduled for two showers a week on Tuesday and Friday (alternate days Saturday and Sunday). Review of the resident's Physician's Orders, dated 3/11/22, showed orders for weekly weights on Tuesdays. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Requires set up for eating; -Supervision, set up an cues for bed mobility. Review of the resident's weight summary, dated 6/9/22, showed the resident's weight was 164.4 lbs. Review of the resident's weight summary, dated June 2022, showed no weekly weights obtained between 6/10/22 and 6/21/22. Review of the resident's care plan, updated 6/21/22, showed the following: -Nutritional risk related to therapeutically altered diet and history of gradual weight gain; -Resident's nutritional status will remain stable through next review on 9/16/22; -Encourage appropriate intake of food and fluids; -Weight as ordered. Review of the resident's weight summary, dated June 2022, showed no weekly weights obtained between 6/22/22 and 6/30/22. Review of the resident's weight summary, dated 7/5/22, showed the resident weighed 161.8 lbs. Further review showed no other weekly weights documented for the resident in July 2022. Review of the resident's weight summary, dated 7/6/22-9/6/22, showed no weight for August 2022, and no weekly weight. Review of the resident's weight summary, dated 9/7/22, showed the resident weighed 156.8 lbs. The resident lost 7.6 lbs. since 6/21/22, and 5 lbs since 7/5/22. Review of the resident's weight summary, dated 9/8/22-10/8/22, showed the resident weighed 152.4 lbs on 10/8/22. There were no weekly weights between 9/8/22 and 10/7/22. The resident's care plan did not contain evidence it was reviewed or updated after the resident lost 12 lbs. since 6/21/22, and 9.4 lbs since 7/5/22. Review of the resident's Shower Sheets, dated 10/1/22-10/31/22, showed the following: -Staff documented the resident received showers on 10/4/22, 10/14/22, and 10/18/22. -The resident's medical record did not contain evidence the resident received showers between 10/5/22 -10/13/22 (eight days), and 10/19/22-10/31/22 (twelve days). Review of the resident's weight summary did not show evidence of weekly weights from 10/8/22-11/3/22. Review of the resident's significant change MDS, dated [DATE], showed the resident weighed 152 lbs. Review of the resident's weight summary, dated 11/9/22-12/7/22, showed no evidence weekly weights were obtained or recorded. Review of the resident's significant change MDS, dated [DATE], showed the following: -Severe cognitive impairment; -No behavior issues or rejection of care; -Requires limited physical assist of one staff member for bed mobility, and dressing; -Requires extensive physical assist of one staff member for transfer,s toilet use, hygiene, and bathing; -Indwelling urinary catheter (tube that drains the bladder) and condom catheter. Review of the resident's Shower Sheets, dated 11/1/22-11/30/22, showed no evidence the resident received a bath in November. Review of the resident's Shower Sheets, dated 12/1/22-12/31/22, showed the following: -Staff documented the resident received showers on 12/16/22; -The resident's medical record did not contain evidence the resident received showers between 12/1/22 -12/15/22 (fifteen days total 57 days since last documented bath on 10/18/22), and 12/17/22-12/31/22 (fourteen days). Review of the resident's Shower Sheets, dated 1/1/23-1/10/23, showed staff documented the resident received a shower on 1/3/23. Observation on 1/09/23, at 12:27 P.M., showed the resident had long, unkempt facial hair, dry skin flaking, and long fingernails with brown substance under them. During an interview on 1/11/23, at 1:55 P.M., the resident said the following: -He/She does not always get a bath; -Sometimes he/she goes lots of days without a bath; -He/She wants a bath a couple times a week and to shave daily, unless he/she decides he/she wants a beard. 3. Review of Resident #27's Care Plan, revised on 10/31/22, showed the resident prefers to receive a shower. Review of the resident's Significant Change Minimum Data Set (MDS), dated [DATE], showed the following: -Severely impaired cognition; -Requires extensive assistance with assistance of at least one staff member for personal hygiene; -Requires total assistance with at least one staff member for bathing. Review of the resident's shower sheets from December 2022 showed the following: -The resident received a shower on 12/5/22, 12/8/22, and 12/12/22; -No documentation the resident received a shower on 12/13/22 through 12/18/22 (six days); -The resident received a shower on 12/19/22; -No documentation the resident received a shower on 12/20/22 through 12/31/22 (12 days). Review of the resident's shower sheets for January 2023 showed the resident received a shower on 1/2/23 and 1/5/23. Observation on 1/9/23 at 10:40 A.M. showed the following: -The resident sat in a recliner in his/her room; -His/Her fingernails were long and dirty; -His/Her hair was uncombed. Observation on 1/11/23 at 12:15 P.M. in the resident's room showed the following: -The resident sat in the recliner in his/her room; -His/Her fingernails long and dirty; -His/Her hair was uncombed. 4. Review of Resident #37's face sheet showed the resident's diagnoses included spinal stenosis in thoracic region (thoracic spinal stenosis occurs when the spinal canal through which the spinal cord travels or the opening through which nerve roots exit the spinal canal narrows), Stage 3 pressure ulcer of the sacral region (bones at the bottom of the spine), type 2 diabetes, morbid obesity, osteomyelitis (bone infection) of vertebra in the lumbar region (bones in the lower portion of the spine), unspecified fracture of unspecified thoracic vertebra (bones in the middle portion of the spine from the base of the neck to the ribs), Crohn's disease of both the small and large intestine (a lifelong form of inflammatory bowel disease (IBD). The condition inflames and irritates the digestive tract - specifically the small and large intestines. Crohn's disease can cause diarrhea and stomach cramps) diarrhea and hypertension. Review of the resident's admission MDS, completed 11/21/22, showed the following: -Moderately impaired cognition; -Required extensive assistance with help from two or more staff members for personal hygiene. -Required total assistance from two or more staff members for transfer by means of mechanical lift; -He/She had two stage III (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling) pressure ulcers; -At risk for developing pressure ulcers; -Was on a turning and repositioning program. Review of the resident's care plan, dated 11/22/22, showed the following: -The resident has a stage II (Partial thickness loss of dermis (the inner layer that makes up skin) presenting as a shallow open ulcer with a red-pink wound bed, without slough (non-viable yellow, tan, gray, green or brown tissue). May also present as an intact or open/ruptured blister;) pressure ulcer on his/her sacral region (area at the base of the spine) and potential for pressure ulcer development related to history of ulcers and immobility; (Review showed no documentation to show the resident's positioning needs). Review of resident's undated handwritten care plan showed the following: -Needs extensive help with bed mobility and grooming; -Transfers are total lift with Hoyer lift (mechanical lift); -Does not walk and needs wheelchair; -Incontinent of bowel and bladder; -Pressure ulcers buttocks, stage III; (Review showed no documentation of resident's repositioning needs). Review of the resident's skin evaluation dated 12/27/22, showed the following: -He/She has a stage 2 pressure ulcer on coccyx measuring 1.7 cm in length X 1 cm wide; -He/She has a stage 2 pressure ulcer on left buttock measuring 1.1 cm in length X 0.2 cm wide. Review of the resident's January 2023 POS showed orders for the following: -Daily weights; order date of 11/14/22; Notify of weight gain over three pounds in 24 hours or over five pounds in one week; -Turn the resident every two hours; Use offloading wedge for positioning. Review of the resident's weight summary report showed the following: -No weekly weight documented for the week of 11/20/22 through 11/26/22; -No weekly weight documented for the week of 11/27/22 through 12/3/22; -No weekly weight documented for the week of 12/11/22 through 12/17/22; -No weekly weight documented for the week of 12/18/22 through 12/24/22; -No weekly weight documented for the week of 1/1/23 through 1/7/23; -No weekly weight documented for the week of 1/8/23 through 1/12/23. Observations on 1/10/23 showed the following: -At 6:20 A.M., the resident lay in bed on his/her back with his/her eyes closed. A sign above the resident's bed indicated the resident needed to be turned on his/her side every two hours; -At 7:30 A.M., the resident lay in bed on his/her back with his/her eyes closed; -At 7:50 A.M., the resident lay in bed on his/her back with his/her eyes closed; -At 8:05 A.M., the resident lay in bed on his/her back with his/her eyes closed; -At 11:00 A.M., the resident sat in his/her wheelchair. Observation on 1/10/23 at 1:37 P.M. showed the resident sat in his/her wheelchair on a cushion. Observation on 1/10/23 at 1:40 P.M., showed Certified Medication Technician (CMT) E and CMT D used a Hoyer lift to transfer the resident from his/her wheelchair to his/her bed. Observation on 1/10/23 at 1:46 P.M. showed the following: -The resident lay on his/her back in bed; -The resident was incontinent of urine and his/her incontinence brief was soaked; -Wound care completed by Licensed Practical Nurse (LPN) I; -When staff positioned the resident on his/her side for wound care treatment, the stage 2 wound on coccyx appeared to be the size of dime and appeared to be pink around the edges with no odor; -The resident's skin on his/her buttock had creases from his/her brief and the skin was red. Observation on 1/10/23 at 2:10 P.M. showed the resident lay in bed on his/her back. Observation on 1/10/23 at 4:08 P.M. showed the following: -The resident lay in bed on his/her back; -The resident was not wearing an incontinence brief and was incontinent of bowel and bladder; -The resident's bottom sheet and pad were soaked completely through and the mattress was wet underneath the resident's feet; -The resident's buttock had creases in his/her skin and was red; -Staff provided incontinence care for the resident. Observation on 1/11/23 at 12:45 P.M., showed the following: -The resident had very long, curling toenails on both feet; -The resident's fingernails were long with pink polish that was faded and peeling. During an interview on 1/10/23 at 11:00 A.M., Certified Medication Technician (CMT) E said the following: -He/She just got the resident out of bed and into his/her wheelchair for lunch; -He/She had not repositioned the resident on his/her shift (day shift) (prior to getting the resident out of bed). (The resident remained positioned on his/her back for at least 4 hours and 30 minutes. During interview on 1/10/23 at 4:08 P.M. and 6:15 P.M. CNA N (who was responsible for the resident's care on 1/10/23) said the following: -His/Her shift started at 2:00 P.M.; -The resident was on his/her back in bed at 2:00 P.M.; -He/She did not reposition the resident (prior to putting the resident to bed at 4:08 P.M.); -Getting all of the tasks completed was difficult when he/she was responsible for multiple halls; this included the repositioning of residents. 5. Review of Resident #29's face sheet showed the resident's diagnoses included type 2 diabetes mellitus with diabetic neuropathy, essential (primary) hypertension, obesity, vitamin deficiency, vitamin b-12 deficiency, anemia, folate deficiency anemia, and hypokalemia (low potassium level in the blood). Review of the resident's January 2023 POS showed orders for weekly weights to be obtained every seven days, order date of 3/15/22; Review of the resident's weight summary report showed the following: -No weekly weight documented for the week of 3/20/22 through 3/26/22; -No weekly weight documented for the week of 3/27/22 through 4/2/22; -No weekly weight documented for the week of 4/17/22 through 4/23/22; -No weekly weight documented for the week of 5/8/22 through 5/14/22; -No weekly weight documented for the week of 5/15/22 through 5/21/22; -No weekly weight documented for the week of 7/31/22 through 8/6/22; -No weekly weight documented for the week of 9/18/22 through 9/24/22; -No weekly weight documented for the week of 9/25/22 through 10/01/22; -No weekly weight documented for the week of 10/9/22 through 10/15/22; -No weekly weight documented for the week of 10/23/22 through 10/29/22; -No weekly weight documented for the week of 10/30/22 through 11/5/22; -No weekly weight documented for the week of 11/13/22 through 11/19/22; -No weekly weight documented for the week of 11/20/22 through 11/26/22; -No weekly weight documented for the week of 11/27/22 through 12/3/22; -No weekly weight documented for the week of 12/11/22 through 12/17/22; -No weekly weight documented for the week of 12/18/22 through 12/24/22; -No weekly weight documented for the week of 12/25/22 through 12/31/22; -No weekly weight documented for the week of 1/1/23 through 1/7/23; -No weekly weight documented for the week of 1/8/23 through 1/12/23. 6. Review of Resident #87's face sheet showed he/she was admitted to facility from an acute care hospital on [DATE]. Review of the resident's medical record showed no documentation that the resident had a comprehensive care plan. 7. Review of Resident #13's care plan showed the following: -On 6/21/22, the resident has his/her own teeth that are in poor condition; -On 6/21/22, at risk for COVID exposure; -On 10/18/22, the resident has altered dentition with broken/carious teeth; -The care plan did not address bed rails. Review of the resident's facility assessment for side rails, dated 9/14/22, showed the following: -The resident had expressed a desire to have side rails; -Side rails were indicated; -Bilateral (both sides) side rail placement was recommended. Review of the resident's progress notes showed the following: -On 12/15/22 at 4:25 P.M., staff documented the resident returned from a dental appointment and his/her top teeth were extracted and a temporary plate put in (mouth); -On 1/5/23 at 4:08 P.M., staff documented the resident tested positive for COVID-19. Observations on 1/9/23 at 10:40 A.M. and 1/9/23 at 3:15 P.M., of the resident and the resident's room door, showed the following: -An isolation precautions sign on the resident's door; -The resident was noted to have facial bruising on the left side of his/her face. During an interview on 1/9/23 at 3:15 P.M., the resident said the following: -He/She had recently had all of his/her upper teeth pulled and an upper denture plate was put in his/her mouth. He/She could do most things him/herself, but his/her mouth was still sore and sometimes he/she needed help putting in his/her upper plate; -He/She had recently been diagnosed with COVID and was having to stay in his/her room; -He/She had bed rails on his/her bed and he/she used them to help get up from her recliner and position in bed. Review of the resident's care plan showed the following: -No update to show the resident now had a partial plate; -No update to show the resident had tested COVID positive and was on isolation precautions; -No update to show the resident utilized bed rails. 8. Review of Resident #28's Care Plan, dated 10/4/21, showed the following: -admission to the facility on 8/5/21; -Diagnosis include diabetes mellitus, stroke with weakness on one side, Parkinson's disease ( progressive disorder that affects the nervous system and the parts of the body controlled by the nerves) disease, and depression; -Resident has deep tissue ulcers on great toes bilaterally and a blister on his/her left heel; -Assess the pressure ulcer for location, stage, size, presence/absence of granulation tissue and epithelialization weekly; -Change dressings as ordered to wounds; -Pressure reducing mattress to bed; -Use pillows to reduce pressure on heels. Review of the resident's significant change MDS, dated [DATE], showed the following: -Moderate cognitive impairment -Two unstageable pressure ulcers (pressure ulcer covered by slough and eschar (dead tissue or debris that occludes a wound bed)) present, unstageable due to slough and/or eschar. Review of the resident's quarterly MDS, dated [DATE], showed the resident had two Stage 2 pressure ulcers (partial thickness loss wound caused by pressure that does not extend past the dermis. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -No unhealed pressure ulcers present. During an interview on 1/09/23, at 3:45 P.M., the resident said he/she developed wounds at the facility on his/her big toes, they are healed, there may be a scab on his/her big toe, he/she was not sure. He/She did not have wounds anywhere else. The resident's care plan continued to show the resident had deep tissue ulcers on the great toes bilaterally and a blister on the left heel. The care plan did not show the wounds had healed. During an interview on 1/10/23, at 3:15 P.M., Resident #28 said the following: -There are not enough staff; -The facility has a hard time retaining CNA's; -There are days with only two CNA's on duty, those are the days they do not get to your baths; -You feel bad to even ask for anything on those days; -The CNA staff try hard but cannot duplicate themselves. During an interview on 1/10/23 at 3:35 P.M. and 1/11/23 at 8:22 P.M., Certified Nurse Assistant/Certified Medication Technician (CNA/CMT) D said the following: -He/She had not been able to do weekly and daily weights because of staffing, he/she was lucky to get monthly weights completed; -He/She was not aware Resident #37 was supposed to have daily weights; -He/she had not completed weekly weights forever as he/she has been too busy. During an interview on 1/12/23, at 10:42 A.M., CMT E said the resident's are supposed to get two showers a week but when there are only two aides for 37 resident's the staff does what they can, all the showers do not get done. During an interview on 1/11/23 at 11:57 A.M. and 3:46 P.M., Registered Nurse (RN) C said the following: -Staff are overworked, there were only two CNA's for the whole building. On weekends, they have one nurse, one CMT and two CNA's; -The aides cannot get all their showers, nail care, hair care, oral care, and activity of daily living (ADL) care completed if there are only two aides for 37 residents; -The facility needed a minimum of three aides on day shift to get close to getting everything done the right way; -In November 2022 staffing was hit and miss; -During December 2022 and up to today the facility usually had two aides on day shift; -The staff try to wash up the residents in bed and cleanse arm pits and perform pericare, but they cannot do everyone's shower, shaves, nails etc.; -One day in October he/she was the only nurse on the floor with only two aides; -The staffing has been awful. During interview on 1/18/23 at 12:20 P.M., the MDS Coordinator said the following: -She was responsible for ensuring care plans were up to date; -admission comprehensive assessments should be completed within 21 days of admission; -Care plans were not up to date as she had been pulled to the floor to work. During an interview on 1/10/23 at 3:35 P.M. and 1/18/23 at 11:10 A.M., the Director of Nursing (DON) said the following: -The facility does not have a specific staffing policy or a policy to address minimal staffing expectations; -When there are two aides on the day shift, the staff would not be able to complete all of the showers, shaves, and nail care. The staff may have to pass these tasks on to the next shift; -The CNAs are responsible for ADL care, and the nurse is responsible to ensure it gets done. -The facility requires at least one RN, two LPN's, and three to five CNA's on day shift and usually one CMT; -The facility requires at least one LPN and a CMT but usually have two nurses, and three to four CNA's on evening shift; -The facility requires at least one LPN, and two CNA's on night shift; -If the facility only has two CNA's on days, a department head would pass ice, and assist with feeding; -When there are two aides on day shift they would not be able to complete all of the showers, shaves, and nail care, and might have to pass on to the next shift. During an interview on 1/12/23, at 11:15 A.M., administrator A said the following: -The facility has struggled to maintain CNA staff; -All staff are expected to pitch in and help if there are only two aides on days and evening shifts. MO212097 MO209597

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a physician response to a pharmacist recommendation for two residents (Resident #13 and #21) and failed to ensure one resident (Resident #37) had a pharmacy review for one month, in a review of five sampled residents. The facility census was 37. Review of the facilities Medication Regimen Reviews policy, dated April 2007, showed the following: -The Consultant Pharmacist shall review the medication regimen of each resident at least monthly; -1. The Consultant Pharmacist will perform a medication regimen review (MRR) for every resident in the facility; -2. Routine reviews will be done monthly; -3. Reviews for short-stay individuals (those who are expected to stay for 30 days or less) will be done as needed to identify individuals with high-risk medications and those who may be experiencing adverse consequences from their medications; -4. Additional reviews for long-stay individuals will be done as indicated or as requested by the Physician and staff to help manage drug regimens and identify and address suspected or confirmed adverse consequences; -7. The Consultant Pharmacist will document his/her findings and recommendations on the monthly drug/medication regimen review report; -8. The Consultant Pharmacist will provide a written report to physicians for each resident with an identified irregularity. If the situation is serious enough to represent a risk to a person's life, health, or safety, the Consultant Pharmacist will contact the Physician directly to report the information to the Physician, and will document such contacts. If the Physician does not provide a pertinent response, or the Consultant Pharmacist identifies that no action has been taken, he/she will then contact the Medical Director, or-if the Medical Director is the Physician of Record-the Administrator; -10. Copies of drug/medication regimen review reports, including physician responses, will be maintained as part of the permanent medical record. 1. Review of Resident #13's face sheet showed his/her diagnoses included chronic diastolic (congestive) heart failure (CHF) (In diastolic CHF, the ventricles cannot relax, expand, or fill with enough blood.), hyperlipidemia (Elevated concentrations of lipids or fats within the blood.), pulmonary hypertension (high blood pressure that affects arteries in the lungs and in the heart), atherosclerotic (when plaque builds up inside your arteries.) heart disease of native coronary artery without angina pectoris (chest pain), Non-ST elevation (NSTEMI) myocardial infarction (A type of heart attack involving partial blockage of one of the coronary arteries, causing reduced flow of oxygen-rich blood to the heart muscle.). Review of the resident's December 2022 Physician Order Sheets (POS), showed an order for Olmesartan Medoxomil (medication to lower blood pressure) 5 milligram (mg), give 2 tablets by mouth two times a day for high blood pressure; order date of 09/13/22. Review of the residents' progress notes dated 12/21/22 at 8:23 P.M. showed the pharmacy consultant documented a Medication Regimen Review (MRR)- chart reviewed for irregularities; Recommendation made to the Medical Doctor (MD); See report for details. Review of the pharmacy consultant's MMR report, dated 12/21/22, showed a recommendations for the resident's Olmesartan medication, stating the medication should be dosed once daily and to please consider adjusting the frequency to daily to reduce the risk of adverse side effects such as hypotension. Review of a prescriber fax notification form, dated 12/22/22 at 2:00 P.M., showed the following: -Use this form to notify prescriber of observation/problems that may require new/changed order(s); -Attention primary care physician; -Regarding pharmacy recommendation; -Please respond and fax back; -Registered Nurse (RN) C signed and dated he/she prepared and faxed the form. Review on 1/12/23 of the pharmacy consultant's MMR report, dated 12/21/22, recommending the resident's Olmesartan medication dose to be changed to once daily, showed the following: -No documentation in the physician/prescriber response section; -No documentation of the physician signature. Review of the prescriber fax notification form, dated 12/22/22 at 2:00 P.M., showing the physician was faxed with the pharmacy recommendation showed the following: -No documentation in the physician/prescriber response section; -No documentation of the physician signature. Review of the resident's January 2023 POS, showed an order for Olmesartan Medoxomil 5 mg, give 2 tablets by mouth two times a day for high blood pressure; order date of 09/13/22. Review of the resident's medical record showed no documentation facility staff followed up on the fax sent to the resident's physician to ensure it was received or a response to the pharmacy recommendation received. 2. Review of Resident #37's face sheet showed the resident's diagnoses included spinal stenosis in thoracic region (thoracic spinal stenosis occurs when the spinal canal through which the spinal cord travels or the opening through which nerve roots exit the spinal canal narrows), Stage 3 pressure ulcer (full thickness skin loss) of the sacral region (bones at the bottom of the spine), type 2 diabetes mellitus, morbid obesity, osteomyelitis (bone infection) of vertebra in the lumbar region (bones in the lower portion of the spine), unspecified fracture of unspecified thoracic vertebra (bones in the middle portion of the spine from the base of the neck to the ribs), Crohn's disease (can cause diarrhea and stomach cramps), urinary tract infection, diarrhea, fracture of thoracic vertebra, weakness, pain. Review of the resident's facility medical record showed no documentation a pharmacy review had been completed for the resident for December 2022 and the facility was unable to provide any documentation a review had been completed for the resident for this time period. 3. Review of Resident #21's face sheet, showed the following: -Diagnosis include gastroesophageal reflux disease (GERD), allergic rhinitis (an allergic response causing itchy, watery eyes, sneezing, and other similar symptoms), and generalized anxiety. Review of resident's significant change Minimum Data Set (MDS), a federally mandated assessment, dated 2/9/22, showed the following: -Severe cognitive impairment; -Antianxiety and diuretic medications daily. Review of the resident's Physician's Orders Sheet (POS), dated 3/11/22, showed an order for Hydroxyzine (a medication used for anxiety that also has mucosal drying out effects) 25 milligram (mg) every six hours as needed for allergic rhinitis, with an end date of 3/19/22. Review of the resident's POS, dated 3/17/22, showed the following: -Hydroxyzine 25 milligram (mg) every six hours as needed for allergic rhinitis, with no stop date; -Omeprazole (medication to reduce the amount of stomach acid) Delayed Release 20 mg daily for GERD. Review of the resident's Pharmacist Note to Attending Physician, dated 3/21/22, showed the following: -The resident has been receiving Omeprazole 20 mg every day for over a year; -Consequences of chronic proton pump inhibitors (PPIs)(are medicines that work by reducing the amount of stomach acid made by glands in the lining of your stomach) include the potential increased risk of hypocalcemia (low calcium) and hypomagnesemia (low magnesium), leading to a higher incidence of hip, wrist or spine fractures; -This warning as well as the increased risk for infections such as pneumonia and clostridium difficile (infection of the bowel) reinforces the importance of evaluating each resident for continued use; -According to Beers criteria, any elderly patients on PPI therapy should be transitioned to H2-receptor antagonists after eight weeks of PPI treatment; -Please evaluate if the resident continues to need treatment for GERD, if not please consider a trial discontinuation of omeprazole at this time; -If therapy is needed, consider replacing their PPI with Famotidine (histamine H2-receptor antagonists that decreases the amount of acid produced by the stomach) 20 mg daily. There is not directive to continue omeprazole, to discontinue omeprazole, or to replace omeprazole with famotidine, and the physician did not sign the recommendation. Review of the resident's Pharmacist Note to Attending Physician, dated 4/21/22, showed the following: -End date required for this psychotropic order despite indication: Hydroxyzine 25 mg every six hours as needed; -Psycho active medications must be limited to a 14 days duration unless the physician documents a clinical rationale for the extension and provides a specific duration of time (for example 90 days). There is no directive to continue hydroxyzine, to discontinue hydroxyzine, or a clinical rationale with a duration of therapy, or a signature from the physician. Review of the resident's Consultant Pharmacist's Medication Regimen Review Recommendations Pending Final Response for Outcomes entered between 4/1/22 and 6/23/22, showed the following: -The residents PRN order for hydroxyzine was re-entered after discontinuation in March and has no end date and the diagnosis changed from allergic rhinitis to anxiety which had an end dated of 3/19/22; -Please clarify the diagnosis and have the physician address the recommendation addressing the end date; -The resident has been receiving omeprazole 20 milligram (mg) every day for over a year; -Consequences of chronic proton pump inhibitors (PPIs)(are medicines that work by reducing the amount of stomach acid made by glands in the lining of your stomach) include the potential increased risk of hypocalcemia and hypomagnesemia, leading to a higher incidence of hip, wrist or spine fractures; -This warning as well as the increased risk for infections such as pneumonia and clostridium difficile reinforces the importance of evaluating each resident for continued use; -According to Beers criteria, any elderly patients on PPI therapy should be transitioned to H2-receptor antagonists after eight weeks of PPI treatment; -Please evaluate if the resident continues to need treatment for GERD, if not please consider a trial discontinuation of omeprazole at this time; -If therapy is needed, consider replacing their PPI with Famotidine 20 mg daily. The resident's Consultant Pharmacist's Medication Regimen Review Recommendations Pending Final Response for Outcomes, showed it was faxed on 9/15/22 to the physician. Review of the resident's Pharmacist Note to Attending Physician, dated 10/24/22, showed the following: -The resident has been receiving omeprazole 20 milligram (mg) every day for over a year; -Consequences of chronic proton pump inhibitors (PPIs)(are medicines that work by reducing the amount of stomach acid made by glands in the lining of your stomach) include the potential increased risk of hypocalcemia and hypomagnesemia, leading to a higher incidence of hip, wrist or spine fractures; -This warning as well as the increased risk for infections such as pneumonia and clostridium difficile reinforces the importance of evaluating each resident for continued use; -According to Beers criteria, any elderly patients on PPI therapy should be transitioned to H2-receptor antagonists after eight weeks of PPI treatment; -Please evaluate if the resident continues to need treatment for GERD, if not please consider a trial discontinuation of omeprazole at this time; -If therapy is needed, consider replacing their PPI with famotidine 20 mg daily. This recommendation is the same recommendation from 3/21/22. There is not physician response or physician signature. Review of resident's significant change MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Antidepressant, antianxiety and diuretic medications daily. During an interview on 1/10/23, 02:26 P.M., and 1/11/23 at 1:45 P.M., the Director of Nursing (DON) said the following: -The pharmacist does monthly reviews of all the residents; -The pharmacist sends the recommendations to the facility; -The primary care physician has a folder in a box at the facility they put documents in for him to sign per his request as he comes to the facility every other Wednesday. He has a stack of papers that he needs to respond to and/or sign; -There is no one assigned to make sure all recommendations are responded to; -When the physician responds to a recommendation the charge nurse carries through the order; -She did not have a signed copy of the physicians' response to the medication record recommendations sent by the consulting pharmacist. During an interview on 1/18/23 at 2:40 P.M., administrator B said he would expect staff to follow facility policies.

5. Observation on 1/10/23, at 11:03 A.M., showed the following: -In the nurse medication cart, one open vial of Lantus (long acting insulin) for Resident #5 with 1/3 of the medication gone from the vial. The vial was not labeled with a date it was opened. The vial did not contain the date filled by the pharmacy; -In the medication cart, one Novolog flex pen for Resident #12 with 50 units used. The flex pen did not have the date opened. The pen did not contain a label of when it was filled from pharmacy. Review of Drugs.com showed the following: -Store opened vial of Lantus in a refrigerator or at room temperature and use within 28 days. -Store opened Novolog injection pen at room temperature (do not refrigerate) and use within 28 days. During an interview on 1/10/23, at 11:03 A.M., RN C said the following: -Staff should date all insulin when opened; -Most insulin expires 28 days after opening. During an interview on 1/18/23, at 11:10 A.M., the DON said the following: -Insulin was good for 28 days (after opened); -Staff are expected to mark the date they opened the insulin on the vial or pen; -Staff are expected to inspect the date opened prior to administering insulin. MO212097 Based on observation, interview, and record review, the facility failed to ensure medications were stored and secured in a medication cart for two residents (Residents #13 and #87), in a review of 14 sampled residents, and for two additional residents (Residents #31 and #16). The facility staff also failed to label multi-use insulin vials and pens when opened to ensure they were used within 28 days of opening for two additional resident's (Residents #5 and #12). The facility census was 37. 1. Review of Resident #13's facility face sheet showed his/her diagnoses included keratoconjunctivitis sicca (dry eye that occurs when tears aren't able to provide adequate moisture) and primary biliary cirrhosis (an autoimmune disease that causes progressive destruction of the bile ducts). Review of an untitled document, provided by the facility on 1/9/23, showed the resident was on isolation precautions due to COVID-19. Review of the resident's January 2023 Physician Order Sheets (POS) showed orders for the following: -GenTeal Tears (an eye drop used to provide temporary relief from dry eye symptoms of burning and irritation), instill one drop in both eyes two times daily related to keratoconjunctivitis sicca; -Sodium chloride solution 5% (a medication to reduce eye swelling), instill one drop in both eyes two times daily related to primary biliary cirrhosis; -No documentation of an order stating the resident could keep the medications at his/her bedside. Observations on 01/09/23 at 11:16 A.M., 01/10/23 at 6:22 A.M., 01/11/23 at 7:22 P.M. and 01/12/23 at 4:18 P.M. showed an open bottle of GenTeal Tears eye drops and an open bottle of sodium chloride solution 5% eye drops sat on the counter in the resident's room. 2. Review of Resident #16's facility face sheet showed his/her diagnoses included dry eye syndrome, macular degeneration (eye disease that causes vision loss), nasal congestion and conjunctivitis (inflammation or infection of the outer membrane of the eyeball and the inner eyelid) of the right eye. Review of an untitled document, provided by the facility on 1/9/23, showed the resident was on isolation precautions due to COVID-19. Review of the resident's January 2023 POS showed orders for the following: -Polyvinyl alcohol solution (a medication used to relieve dry, irritated eyes) 1.4%, instill one drop in both eyes three times daily for dry eyes related to dry eye syndrome; -Saline spray solution, one spray both nostrils every four hours as needed (PRN) for nasal congestion; -Systane gel (a gel eye drop used to provide extended relief from dry eye irritation and provides a protective layer over the eyes) 0.4 - 0.3% (polyethyl glycol - propyl glycol), instill two drops in both eyes every 12 hours PRN for acute atopic conjunctivitis of the right eye; -Dextran 70 - hypromellose solution (a medication used to relieve dry, irritated eyes) 0.1 - 0.3%, instill two drops in both eyes every 12 hours PRN dry eyes; -No documentation of an order stating the resident could keep the medications at his/her bedside. Observation on 01/11/23 at 4:30 P.M. showed an open bottle of polyvinyl alcohol solution 1.4% eye drops, an open bottle of saline nasal spray solution, an open bottle of Systane Gel 0.4 - 0.3% eye drops and an open bottle of Dextran 70 - hypromellose solution 0.1 - 0.3% eye drops sat on the counter in the resident's room. 3. Review of Resident #31's facility face sheet showed his/her diagnoses included chronic obstructive pulmonary disease (lung disease). Review of an untitled document, provided by the facility on 1/9/23, showed the resident was on isolation precautions for COVID-19. Review of the resident's January 2023 POS showed orders for the following: -Proventil high flow aerosol (HFA) solution (an inhaled medication that relaxes muscles in the airways and increases air flow to the lungs) 108 micrograms (mcg), two puffs inhaled every eight hours PRN for shortness of breath related to COPD; -Incruse Ellipta aerosol powder (an inhaled medication to control and prevent symptoms caused by ongoing lung disease), breath activated, inhale one puff in the morning related to COPD; -No documentation of an order stating the resident could keep the medications at his/her bedside. Observation on 01/11/23 at 4:35 P.M. showed a Proventil HFA inhaler and an Incruse Ellipta inhaler were in an unlocked cabinet in the resident's room. 4. Review of Resident #87's facility face sheet showed his/her diagnoses included dry eye syndrome and dementia. Review of an untitled document, provided by the facility on 1/9/23, showed the resident was on isolation precautions due to COVID-19. Review of the resident's January 2023 POS showed orders for the following: -Albuterol sulfate (an inhaled medication used to prevent and treat wheezing and shortness of breath caused by breathing problems), Aerosol Powder, breath activated, 108 mcg, inhale two puffs every six hours PRN for shortness of breath; -Artificial Tears, instill two drops in both eyes every day related to dry eye syndrome; -Advair Diskus (an inhaled medication used to treat asthma and COPD), Aerosol Powder, breath activated, 250 - 50 mcg, one puff inhaled twice daily related to shortness of breath; -No documentation of an order stating the resident could keep the medications at his/her bedside. Observation on 01/11/23 at 4:40 P.M. showed an open bottle of Artificial Tears eye drops, an Advair Diskus inhaler and an albuterol sulfate inhaler sat on the counter in the resident's room. During an interview on 1/12/23 at 1:45 P.M., Certified Medication Technician (CMT) D said the following: -He/She thought the residents with COVID-19 had their inhalers and such in their rooms; -There was no place in the residents' rooms to lock up medications; -Medications were being left unlocked and unattended in all of the COVID-19 positive residents' rooms. During an interview on 1/11/23 at 4:15 P.M., Registered Nurse (RN) S said the following: -Residents who were COVID-19 positive had some of their medications left in their rooms, because he/she thought once the medications entered the room, they could not come out; -The medications left in the COVID-19 positive residents' rooms were not locked, but should be kept in a cabinet above the closet, out of reach of the resident; this cabinet was not lockable; -If medications were in a resident's room, the resident should have an order that the medications can be kept at bedside. During an interview on 1/18/23 at 11:10 A.M., the Director of Nursing (DON) said the following -All medications should be secured; locked up; -She was not aware medications were being left unsecured in the COVID-19 positive resident rooms; -A physician order would be required to keep medications at bedside.

Based on observation, interview, and record review, the facility failed to follow the spreadsheet menu and recipes to prepare and serve the pureed entree for the lunch meal on 3/28/23. The facility identified five residents on a pureed diet. The facility census was 37. Review of the undated facility policy Standardized Recipes showed the following: -Standardized recipes shall be developed and used in the preparation of foods; -Only tested, standardized recipes will be used to prepare foods; -Standardized recipes will be adjusted to the number of portions required for a meal; -The Food Services Manager will maintain the recipe file and make it available to Food Services staff as necessary. Review of the spreadsheet lunch menu for 3/28/23, provided by the facility, showed residents on a pureed diet were to receive a pureed breaded fish sandwich with cheese on a hamburger bun. The menu did not identify the portion size of the entree. During an interview on 3/28/23 at 11:00 A.M., Dietary Staff D said the residents on a pureed diet would receive the pureed hamburger as their entree; there was no pureed fish prepared for the meal service. Review of the recipe binders on 3/28/23, 3/29/23 and 3/30/23 showed no recipe for pureed hamburgers. Observation during meal service on 3/28/23 between 11:00 A.M. and 1:24 P.M. showed the following: -A container of pureed hamburger sat on the steam table; a 2 and 3/8 scoop was in the container; -Staff served the residents on a pureed diet one scoop of the pureed hamburger. During an interview on 3/28/23, at 3:12 P.M., the Dietary Manager said the following: -There were five residents in the facility that received a pureed diet; -She prepared the pureed hamburger for the noon meal; she did not prepare a pureed fish sandwich as listed on the menu; -She could not locate a recipe for pureed hamburgers in the recipe book; -In preparing the pureed hamburger for the five residents on a pureed diet, he/she used three, 4-ounce hamburger patties, two slices of bread, and 1/2 cup milk; -Each resident on a pureed diet should have received a 3-ounce scoop of the hamburger mixture. Staff used the 2 and 3/8 scoop because they did not have a 3-ounce scoop; -She thought each resident was to receive 3 ounces of meat; using three patties would have been 12 ounces; if five residents needed a pureed portion, 15 ounces of meat would have been needed; -She should have used at least six slices of bread; During an interview on 3/30/23 at 4:18 P.M., the administrator said she expected kitchen staff to have recipes available and to follow the recipe and portion sizes as instructed.

Based on observation and interview, the facility staff failed to failed to serve food at a safe and appetizing temperature. The facility census was 37. Review of the facility's policy Food Preparation and Handling, revised July 2014, showed the following: -The danger zone for food temperatures is between 41 degrees Fahrenheit (F) and 135 degrees F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause food borne illness; -Potentially hazardous foods include meats, poultry, seafood, cut melon, eggs, milk, yogurt and cottage cheese; -The longer foods remain in the danger zone the greater the risk for growth of harmful pathogens. During an interview on 1/11/23, at 11:44 A.M., Resident # 28 said the hot food is cold sometimes and the cold food is warm. The food is not great. Observation on 1/11/23, at 12:12 P.M. of the test tray provided by dietary staff after the last resident was served, showed the chicken salad sandwich was 62 degrees F; During an interview on 1/11/23, at 12:17 P.M., Dietary Staff K said the following: -If he/she has time the day before he/she will prepare cold foods for the next day so it has time to chill and get down to the 40's (degrees F); -If he/she gets an item prepared during breakfast he/she can get the temps down in the 40's (degrees F)as well; -He/She does not have a cooling table so he/she would have to put the food on ice on a tray or something of that nature if the cold food starts getting warm; -He/She did not put the food on ice; -He/She thought he/she could serve it fast enough it wouldn't have time to get warm; -Cold foods should be 42 degrees F or less when served. Observation on 1/11/23, at 6:05 P.M., of the test tray provided by dietary staff after the last resident was served, showed the following the lettuce salad with tomatoes, cheese and ranch salad dressing was 78 degrees F. During an interview on 1/11/23, at 6:35 P.M., Dietary Staff J said the following: -Cold foods should be 42 degrees F or below when they are served; -He/She should have placed the metal bowl of salad in an ice tray.

Based on observation, interview, and record review, the facility failed to provide bedtime snacks for all residents and failed to ensure snacks that were provided were in accordance with the resident's diet orders. The facility census was 37. Review of facility policy, Resident Nutrition Services, revised November 2015, showed the following: -Meal hours shall be scheduled at regular times to assure that each resident receives at least three meals per day; -Snacks are available to the residents 24 hours a day; -The resident may request snacks as desired, or snacks may be scheduled between meals to accommodate the resident's typical eating patterns. 1. Review of Resident #37's face sheet showed the resident's diagnoses included type 2 diabetes mellitus and morbid obesity. Review of resident's care plan, dated 11/15/22, showed the resident was to receive a low concentrated sweets diet (avoiding food with a lot of sugar or high calorie sweeteners). Review of resident's physician order sheet dated January 2023, showed the resident was to receive a low concentrated sweets diet. Observation on 1/11/23 at 8:45 P.M. showed Certified Nurse Assistant (CNA) N passed snacks on the 100 and 200 hallways. He/She did not go to every room and offer a bedtime snack. He/She started down the Resident #37's hallway and the only snack option was brownies. CNA N offered and gave the resident a brownie for a bed-time snack. Observation on 1/11/23 at 8:47 P.M., showed the resident ate the brownie. 2. During resident council meeting on 1/11/23 at 2:10 P.M., several residents in attendance affirmed they did not receive bedtime snacks and would eat a snack if one was offered. Observation on 1/11/23 at 7:45 P.M. showed the following: -Dietary Aide M pushed a cart out of the kitchen; -The cart contained six bananas, eight brownies and a half gallon of lemonade; -Dietary Aide M left the cart behind nurses' station. During an interview on 1/11/23 at 7:45 P.M., Dietary Aide M said the following: -He/She prepares a snack tray every evening when his/her shift is ending; -Snacks normally consisted of cookies or baked goods and a drink left over from lunch; -He/She puts the snack tray behind the nurses' desk. During an interview on 1/11/23 at 7:51 P.M., Resident #24 said he/she normally did not get offered a bedtime snack and would eat a bedtime snack if offered During an interview on 1/11/23 at 7:55 P.M., Resident #13 said the following: -He/She was not offered a bedtime snack tonight; -He/She normally did not get offered a bedtime snack; -He/She would eat a bed time snack if offered. During an interview on 1/11/23 at 7:45 P.M., Licensed Practical Nurse (LPN) P said he/she normally asked residents if they wanted a snack when passing medications, but tonight he/she asked a CNA to take the cart around to each room. During an interview on 1/18/23 at 1:00 P.M., the Director of Nursing (DON) said the following: -Staff should offer bedtime snacks to all residents; -There was pudding and applesauce in the medication room, and there was usually peanut butter and jelly sandwiches with names on them in the medication room for diabetic residents; -She was not sure if there were any sandwiches in the medication room on the night of 1/11/23; -Staff know who the diabetic residents are and which residents need a special diet; -Diabetic resident should not be offered a brownie as the only snack option for bedtime snack.

Based on interview and record review, the facility failed to develop an antibiotic stewardship program and a system to monitor appropriate antibiotic use. The facility failed to fully complete the antibiotic tracking done from 6/1/22 through 12/31/22. The facility census was 37. Review of the facility's Surveillance for Infections, last revised August 2014, showed the following: -The Infection Preventionist (IP) will conduct ongoing surveillance for Healthcare-Associated Infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions; -Purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and HAIs, to guide appropriate interventions, and to prevent future infections; -When infection or colonization with epidemiologically important organisms is suspected, cultures may be sent, if appropriate, to a contracted laboratory for identification or confirmation; -Cultures will be further screened for sensitivity to antimicrobial medications to help determine treatment measures; -The charge nurse will notify the attending physician and the IP of suspected infections; -The IP and the physician will determine if laboratory test are indicated, and whether special precautions are warranted; -The IP will determine if the infection is reportable; -If transmission-based precautions or other preventative measures are implemented to slow or stop the spread of infection, the IP will collect data to help determine the effectiveness of such measures; -The surveillance should include a review of any or all of the following information to help identify possible indicators of infections: laboratory records, skin care sheets, infection control rounds or interviews, verbal reports from staff, infection documentation records, temperature logs, pharmacy records, antibiotic review and transfer log summaries. Review of the facility's Infection Control Log, dated 9/1/22 through 10/31/22, showed the following: -Seven residents were listed; One resident had a urinary tract infection, two residents had abscesses, one resident had a wound infection, one resident for cellulitis, one resident had a preoperative for tooth extraction, and one resident had conjunctivitis (eye infection); -Two residents had an onset date listed and five did not; -None of the entries had information if a culture had been done; -None of the entries identified an organism; -The name of the antibiotic used was listed for each entry, three had a resolved date; -Isolation required, HAI's, and re-cultured date left blank with no data. Review of the facility's Infection Control Log, dated 10/1/22 through 10/31/22, showed the following: -Five residents were listed; one resident with infection pneumonia, two residents with urinary tract infections, one resident with a left wrist fracture infection, and one resident with a left breast boil; -Three residents had an onset date listed and two did not; -None of the entries noted if a culture had been done; -None of the entries identified an organism; -The name of the antibiotic used was listed for each entry, two had a resolved date; -Isolation required, HAI's, and re-cultured date left blank with no data. Review of the facility's Infection Control Log, dated 11/1/22 through 11/30/22, showed the following: -Four residents were listed; one with infection related to pressure ulcer, and three residents with urinary tract infections; -Two residents had an onset date listed and two did not; -Three of the entries showed the hospital did a culture, but only one of the entries had an organism identified; -The name of the antibiotic used was listed, and only one had a resolved date; -Isolation required, HAI's, and re-cultured date left blank with no data. Review of the facility's Infection Control Log, dated 12/1/22 through 12/31/22, showed it included five residents for positive COVID-19 (infection caused by the SARS-CoV-2 virus) test. The log did not identify any other infections or antibiotic use. During an interview on 1/12/23, at 1:03 P.M., the Director of Nursing said the facility did not have an antibiotic stewardship program or a system to monitor appropriate antibiotic use. The facility logs infections and the antibiotics used. During an interview on 1/12/23, at 1:03 P.M., the Infection Preventionist (IP)/ Licensed Practical Nurse (LPN) R said the following: -The facility did not have an antibiotic stewardship policy or an antibiotic use protocol; -She logged antibiotic use on the Infection Control Logs, but did not list many details; -She did not track much or have a place to document discussions about antibiotic appropriateness; -The physicians start antibiotics before anyone checks to ensure they meet criteria for an infection; -She did not always track the culture and sensitivity results; -She calls the physician if stop dates for antibiotics are missing; -The facility did not map infections to look for trends.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to offer to vaccinate eligible residents the pneumococcal vaccine (a vaccine that can protect against pneumococcal disease, which is any type of infection caused by streptococcus pneumoniae bacteria) as indicated by the current Centers for Disease Control and Prevention (CDC) guidelines for five residents (Residents #13, #21, #24, #29 and #37) in a review of 14 sampled residents. The facility census was 37. Review of the facility policy titled Influenza/Pneumococcal Vaccine, last revised 11/27/16, showed the following: -The facility will provide pneumococcal vaccine to residents upon request; -All residents admitted to the facility will receive a screening as to the date of their last pneumococcal vaccine; -Residents will be offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized. As an alternative, based upon an assessment and practitioner recommendations, pneumococcal immunization may be given 5 years following the first pneumococcal immunization, unless medically contraindicated or the resident or the resident's representative refused the second immunization; -The resident or the resident's representative will be provided with education regarding the benefits and potential side effects of the pneumococcal vaccine; -The resident's clinical record will reflect that the resident or the resident's representative was provided with education regarding the benefits and potential side effects of pneumococcal immunization and whether or not the resident received the vaccine or if the vaccine was not administered due to medical contraindication or refusal; -The pneumococcal vaccine may be given at any time during the year; -Additional information regarding influenza and pneumococcal vaccination is available from the CDC. Review of the CDC website for Pneumococcal Vaccine timing, https://www.cdc.gov/vaccines/vpd/pneumo/downloads/pneumo-vaccine-timing.pdf, updated 4/1/22, showed the following: -CDC recommends pneumococcal vaccination for a. Adults [AGE] years old and older; b. Adults 19 through [AGE] years old with certain underlying medical conditions or other risk factors: 1. Alcoholism; 2. Cerebrospinal fluid leak; 3. Chronic heart/liver/lung disease; 4. Chronic renal failure; 5. Cigarette smoking; 6. Cochlear implant; 7. Congenital or acquired asplenia; 8. Congenital or acquired immunodeficiencies; 9. Diabetes; 10. Generalized malignancy; 11. HIV infection; 12. Hodgkin disease; 13. Latrogenic immunosuppression; 14. Leukemia; 15. Lymphoma; 16. Multiple myeloma; 17. Nephrotic syndrome; 18. Sickle cell disease or other hemoglobinopathies; 19. Solid organ transplants. -Pneumococcal vaccines available: PCV13: 13-valent pneumococcal conjugate vaccine (Prevnar13®) PCV15: 15-valent pneumococcal conjugate vaccine (Vaxneuvance (Trademark)) PCV20: 20-valent pneumococcal conjugate vaccine (Prevnar20®) PPSV23: 23-valent pneumococcal polysaccharide vaccine (Pneumovax®) -For those who have never received a pneumococcal vaccine or those with unknown vaccination history administer one dose of PCV15 or PCV20: a. If PCV20 is used, their pneumococcal vaccinations are complete. b. If PCV15 is used, follow with one dose of PPSV23. The recommended interval is at least 1 year. The minimum interval is 8 weeks and can be considered in adults with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak. Their pneumococcal vaccinations are complete. -For those who previously received PPSV23 but who have not received any pneumococcal conjugate vaccine (e.g., PCV13, PCV15, PCV20) You may administer one dose of PCV15 or PCV20. Regardless of which vaccine is used (PCV15 or PCV20), The minimum interval is at least 1 year. If the adult was younger than [AGE] years old when the first dose of PPSV23 was given, then administer a final dose of PPSV23 once they turn [AGE] years old and at least 5 years have passed since PPSV23 was first given. Their pneumococcal vaccinations are complete. 1. Review of Resident #21's significant change Minimum Data Set (MDS), a federally mandated assessment, dated 11/4/22, showed the following: -Resident admitted to the facility on [DATE]; -Resident was over [AGE] years of age; -Severe cognitive impairment; -Diagnosis include: coronary artery disease, high blood pressure; chronic stage three renal (kidney) insufficiency, and diabetes mellitus (inability to control blood sugar); -Did not receive the pneumococcal vaccination because he/she was not eligible; Review of the resident's immunization record in his/her hard chart (did not match the electronic health record), showed the resident received PPSV23 on 2/21/20. The resident's medical record did not include any evidence the resident was offered or declined a pneumococcal conjugate vaccine (e.g., PCV13, PCV15, PCV20) as recommended by the CDC. The medical record showed no evidence of a contraindication for the vaccination. 2. Review of Resident #13's face sheet showed he/she was over [AGE] years of age. Review of the resident's significant change MDS, dated [DATE] showed the following: -Cognitively impaired; -Diagnoses included heart disease; -The resident was up to date with his/her pneumococcal vaccinations. Review of the resident's facility electronic medical record (EMR) for immunizations showed the resident had received a pneumococcal vaccination, Prevnar 23, on 6/12/15. Review of the resident's immunization record in his/her hard chart (did not match the electronic health record), showed the following: -Received Prevnar13 on 6/12/15; -Received a vaccination on 11/4/16 but was not sure if Prevnar 13 or PPSV23. Review of the resident's electronic medical record (EMR) and hard chart showed no documentation the resident had been offered or declined a pneumococcal conjugate vaccine (e.g. PCV15, PCV20) as recommended by the CDC. The medical record showed no evidence of a contraindication for a pneumococcal vaccination. 3. Review of Resident #24's face sheet showed he/she was over [AGE] years of age. Review of the resident's admission MDS, dated [DATE] showed the resident was up to date with his/her pneumococcal vaccinations. Review of the resident's facility EMR for immunizations showed the resident had received a pneumococcal vaccination, Prevnar 23, on 10/01/05. Review of the resident's immunization record in his/her hard chart (did not match the electronic health record), showed the following: -Received Prevnar13 on 6/12/15; -Received a vaccination on 11/4/16 but was not sure if Prevnar 13 or PPSV23. Review of the resident's EMR and hard chart showed no documentation the resident had been offered or declined a pneumococcal conjugate vaccine (e.g. PCV15, PCV20) as recommended by the CDC. The medical record showed no evidence of a contraindication for a pneumococcal vaccination. 4. Review of Resident #29's face sheet showed he/she was less than [AGE] years of age. Review of the resident's annual MDS, dated [DATE] showed the following: -Diagnoses included diabetes; -Was up to date with his/her pneumococcal vaccinations. Review of the resident's facility EMR for immunizations showed no documentation the resident had received a pneumococcal vaccination. Review of the resident's immunization record in his/her hard chart showed he/she received Prevnar13 in December of 2014. Review of the resident's EMR and hard chart showed no documentation the resident had been offered or declined a pneumococcal conjugate vaccine (e.g., PPSV23, PCV15, PCV20) as recommended by the CDC. The medical record showed no evidence of a contraindication for a pneumococcal vaccination. 5. Review of Resident #37's face sheet showed he/she was over [AGE] years of age. Review of the resident's admission MDS, dated [DATE] showed the following: -Cognitively impaired; -Diagnoses included diabetes; -The resident was not up to date with his/her pneumococcal vaccinations; -A pneumococcal vaccination was not offered. Review of the resident's discharge (return anticipated) MDS, dated [DATE] showed a pneumococcal vaccination was offered and refused. Review of the resident's facility EMR for immunizations showed no documentation the resident had received a pneumococcal vaccination. Review of the resident's facility EMR showed no documentation the resident had been offered or refused a pneumococcal vaccination or that there was a contraindication for a pneumococcal vaccination. During an interview on 1/10/23 at 1:28 P.M., Registered Nurse (RN) C said the resident had no hard chart for review. During an interview on 1/26/23 at 1:00 P.M. the resident's listed contact said the following: -He/She was the resident's Power of Attorney (POA); -He/She wanted the resident to receive a pneumococcal vaccination; -The facility had never spoken to him/her about immunizations; -He/She had never declined for the resident to receive a pneumococcal vaccination and had not received education from the facility regarding pneumococcal vaccinations. During an interview on 1/12/23, at 1:03 P.M., the Infection Preventionist (IP) Licensed Practical Nurse (LPN) R said he/she does not track immunizations for the residents. During an interview on 1/18/23, at 11:10 A.M., the Director of Nursing (DON) said the following: -Staff are expected to follow CDC guidelines for influenza and pneumococcal vaccinations; -Residents should be offered the recommended vaccinations; -Several different staff have been responsible for resident vaccinations, most recently it is Registered Nurse (RN) C.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure each certified nurse assistant (CNA) had no less than 12 hours of in-service education per year based on their individual performance review, calculated by hire date. The facility identified eight CNAs employed by the facility for more than a year. Five of five CNAs (CNA D, CNA V, CNA F, CNA W and CNA E) sampled did not have the required 12 hours of in-service education. The facility census was 37. Review of the Facility Assessment, dated 1/2/23, showed the the following: -Staff training, education, and competencies: Attach or describe your facility's training program; -Include information on what training frequency of trainings (e.g. before hire and/or ongoing, which individuals or departments conducting and tracking training's, and how the process is monitored or audited; -The facility's plan is: New hire is orientating with a current employee of the facility in their perspective department. 1. Review of CNA D's employee file, showed the employee's date of hire was 5/21/15. Review of education completed from 12/1/21-1/19/23, showed the CNA attended the following: -COVID (respiratory disease caused by the SARS-CoV-2 virus) and infection control training on 1/25/22, (did not include agenda, specifics of topics covered, or time of the education); -Electronic health record training on 2/9/22 (did not include agenda, specifics of topics covered, or time of the education); -COVID vaccination policy, screening, mask and hand sanitizer on 2/14/22, (did not include time of the education); -Disaster drill, elopement, fire, suicide threat, dementia on 3/24/22 (did not include agenda, specifics of topics covered, or time of the education); -Falls, wounds, and behaviors on 4/26/22 (did not include agenda, specifics of topics covered, or time of the education); -Electronic medical record system and [NAME] training on 6/16/22 (did not include agenda, specifics of topics covered, or time of the education). The employee's education was documented on sign in sheets (with multiple employees). There was no individual tracking for each CNA. The education did not include the amount of time or depth of the subjects reviewed or if 12 hours of education was completed. 2. Review of CNA V's employee file, showed the employee's date of hire was 4/1/19. Review of education completed from 12/1/21-1/19/23, showed the CNA attended the following: -COVID vaccination policy, screening, mask and hand sanitizer on 2/14/22 (did not include time of the education); -Falls, wounds, and behaviors on 4/26/22 (did not include agenda, specifics of topics covered, or time of the education); -Electronic medical record system and [NAME] training on 6/16/22 (did not include agenda, specifics of topics covered, or time of the education). The employee's education was documented on sign in sheets (with multiple employees). There was no individual tracking for each CNA. The education did not include the amount of time or depth of the subjects reviewed or if 12 hours of education was completed. 3. Review of CNA F's employee file, showed the employee's date of hire was 2/18/21. Review of education completed from 12/1/21-1/19/23, showed the CNA attended the following: -COVID and infection control training on 1/25/22 (did not include agenda, specifics of topics covered, or time of the education); -Electronic health record training on 2/9/22 (did not include agenda, specifics of topics covered, or time of the education); -Disaster drill, elopement, fire, suicide threat, dementia on 3/24/22 (did not include agenda, specifics of topics covered, or time of the education); The employee's education was documented on sign in sheets (with multiple employees). There was no individual tracking for each CNA. The education did not include the amount of time or depth of the subjects reviewed or if 12 hours of education was completed. 4. Review of CNA W's employee file showed the employee's date of hire was 10/10/18. Review of education completed from 12/1/21-1/19/23, showed the CNA attended the following: -COVID and infection control training on 1/25/22 (did not include agenda, specifics of topics covered, or time of the education); -COVID vaccination policy, screening, mask and hand sanitizer on 2/14/22 (did not include time of the education); -Disaster drill, elopement, fire, suicide threat, dementia on 3/24/22 (did not include agenda, specifics of topics covered, or time of the education); The employee's education was documented on sign in sheets (with multiple employees). There was no individual tracking for each CNA. The education did not include the amount of time or depth of the subjects reviewed or if 12 hours of education was completed. 5. Review of CNA E's employee file, showed the employee's date of hire was 4/16/19. Review of education completed from 12/1/21-1/19/23, showed the CNA attended the following: -COVID and infection control training on 1/25/22 (did not include agenda, specifics of topics covered, or time of the education); -Electronic health record training on 2/9/22 (did not include agenda, specifics of topics covered, or time of the education); -COVID vaccination policy, screening, mask and hand sanitizer on 2/14/22, (did not include time of the education); -Disaster drill, elopement, fire, suicide threat, dementia on 3/24/22 (did not include agenda, specifics of topics covered, or time of the education); -Falls, wounds, and behaviors on 4/26/22 (did not include agenda, specifics of topics covered, or time of the education); -Electronic Medical Record system and [NAME] training on 6/16/22 (did not include agenda, specifics of topics covered, or time of the education). The employee's education was documented on sign in sheets (with multiple employees). There was no individual tracking for each CNA. The education did not include the amount of time or depth of the subjects reviewed or if 12 hours of education was completed. 6. During an interview on 1/12/23, at 1:23 P.M., the Director of Nursing (DON) said the following: -Human Resources tracks all staff certifications; -She did not know who tracked the annual 12 hours of education for the CNAs; -She thought the CNAs were responsible to track their own hours; -She heard about the new required trainings, but had not been involved with completing them; -She would probably be the one to track nursing things; -She thought the facility did abuse and neglect training a couple of times a year. During an interview on 1/12/23, at 2:00 P.M., Human Resources (HR) staff said he/she did not track the CNAs 12 hours of education. During an interview on 1/12/23, at 2:00 P.M., administrator A said the following: -The DON was responsible to track the 12 hour CNA training to be completed annually; -The DON was responsible to ensure all required topics for CNAs were completed; -The new required trainings have not been completed at this time.

Based on observation, interview and record review, the facility failed to ensure sanitary practices in the kitchen. The facility census was 37. Review of the facility policy, Floors, revised December 2009, showed floors shall be maintained in a clean, safe, and sanitary manner. 1. Observation on 1/9/23 at 10:28 A.M. showed the range hood baffle filters had a heavy buildup of dark yellow grease and dark-colored fuzzy debris. A sticker on the exterior of the range hood showed the hood had previously been cleaned on 7/20/22 and was due for professional cleaning in January 2023. During an interview on 1/9/23 at 1:30 P.M., Dietary Staff K said dietary staff was supposed to clean the range hood filters every two weeks but no one was responsible for ensuring this was done and it was not documented. A professional company came and cleaned the hood twice a year. During interview on 01/10/23 at 11:58 A.M., the maintenance supervisor said a professional company cleaned the range hood baffles every six months and no one cleaned the baffles in between the professional company cleaning. During interview on 01/10/23 at 12:27 P.M., the administrator said she expected the range hood baffles to be clean. She expected the baffles to be cleaned in between the professional company's visits. The cleaning of the range hood baffles needs to be on a cleaning list. 2. Observation on 1/9/23 at 10:28 A.M. showed the floor in the kitchen was made of concrete. The concrete had been painted gray, but the gray paint was worn off on the frequently traveled areas, exposing numerous large areas of peeling white or yellow paint or exposed concrete underneath the gray paint. 3. Observation on 1/9/23 at 10:30 A.M. in the reach-in refrigerator showed a small carton of raw eggs inside an unsealed plastic bag sat on the second shelf over an open cardboard box of raw tomatoes. 4. Observation on 1/9/23 at 10:37 A.M. inside the dry storage room showed the lids to the bulk flour and sugar containers were soiled and had a buildup of debris. A plastic container of powdered sugar sat on the storage rack and had a heavy buildup of powdered sugar on top of the lid. 5. Observation on 1/9/23 at 10:46 A.M. showed two large areas of black charred debris on the metal backsplash behind the cooktop burners, and back debris on the panel that separated the cooktop and the adjacent fryer. Observation on 1/9/23 at 1:35 P.M. showed the stove cooktop burners had a heavy buildup of black charred debris/carbon buildup on burners and around burners as well as on the metal stove backsplash. 6. Observation on 1/9/23 at 10:47 A.M. showed a heavy buildup of dark yellow grease and debris on the fryer, located above the grease below. 7. Observation on 1/9/23 at 11:10 A.M. showed Dietary Staff K did not wash his/her hands and put on gloves. He/She opened the sliced cheese container lid and removed a slice of cheese with his/her gloved hand. He/She placed the cheese slice on a piece of bread in a skillet. He/She then picked up another slice of bread with his/her gloved hands, buttered the bread, and placed it on top of the cheese slice in the skillet. He/She did not wash his/her hands or change gloves during the observation. Observation on 1/9/23 at 11:14 A.M. showed Dietary Staff K wore the same soiled gloves and scratched his/her nose with a gloved hand. He/She then touched and flipped over a grilled cheese in a pan with his/her gloved hands and a spatula. Observation on 1/9/23 at 11:23 A.M. showed Dietary Staff K wore the same soiled gloves, pushed open the kitchen door with his/her gloved hands, and left the kitchen. He/She then re-entered the kitchen by pushing open the kitchen door with the same soiled gloves. He/She did not wash his/her hands or change gloves. He/She adjusted the mask on his/her face and put it back on over his/her nose. He/She then reached his/her soiled gloves into the plastic bag and grabbed a hamburger bun and prepared a burger for a resident's tray. Observation on 1/9/23 at 11:39 A.M. showed Dietary Staff K used the same soiled hands and removed a raw whole tomato from the reach-in refrigerator. He/She did not wash the tomato and began slicing the tomato. He/She placed two slices on top of a burger on a resident's plate. He/She then removed a whole onion from the refrigerator, sliced the onion and placed slices on the resident's plate. Observation on 1/9/23 at 11:45 A.M. showed Dietary Staff K continued to use the same soiled gloves to touch ready to eat fries and buns throughout the meal service. Observation on 1/9/23 at 11:51 A.M. showed Dietary Staff K left the kitchen again by pushing the door to dining room open with same soiled gloves. He/She re-entered the kitchen by touching the door with the same soiled gloves. He/She did not change his/her gloves or wash his/her hands. He/She re-adjusted his/her mask and then left the kitchen again and went into the dining room. He/She re-entered the kitchen a second time using the same soiled gloves and grabbed a hamburger bun and began plating another tray. He/She did not change his/her gloves or wash his/her hands. Observation on 1/9/23 at 11:55 A.M. showed Dietary Staff K heard a knock at the kitchen door. He/She opened the door with the same soiled gloves. Two staff members requested staff lunch trays. He/She began plating trays with same soiled gloves (grabbing buns and fries), then continued plating resident trays with the same soiled gloves. He/She did not wash his/her hands or change gloves during this observation. 8. During an interview on 1/9/23 at 2:17 P.M., the assistant dietary manager said the following: -The day and night aides were both responsible for sweeping/mopping the floors daily; -The cooks were responsible for cleaning the cooktop and backsplash weekly; -The cooks were responsible cleaning the fryer when needed, it was supposedly cleaned not long ago; -Dietary staff should wash their hands and/or change gloves in between clean and dirty tasks, after entering the kitchen, after touching something dirty and before touching ready to eat food; -Fresh produce was not used a lot in the kitchen. Sometimes fresh produce was washed and sometimes it wasn't, but it probably should be washed prior to use; -He was unsure if there was a designated spot for eggs to be stored in the refrigerator. He didn't think there was. He was not aware eggs should be stored on the bottom shelf; -The floors in the kitchen have been painted two to three times in the last year or two. Paint never has time to fully dry and the staff have to start walking on it and it comes off. During an interview on 1/9/23 at 2:18 P.M., Dietary Staff J said the kitchen floors had been painted three or four times since he/she had worked at the facility and the paint always come back off. During an interview on 1/9/23 at 3:22 P.M., the administrator said they can't keep the paint on the kitchen floor. She's not sure if it was the cleaning products or the traffic on the paint or the kind of paint that has been used on the floor. The floor has been painted many times.

Based on interview and record review the facility failed to have quarterly Quality Assessment and Assurance (QAA) committee meetings, or have the required members present for the meeting that occurred. The facility also failed to provide evidence that the facility consistently implemented a Quality Assurance and Process Improvement (QAPI) program with measurable data, actions, and evaluations. The facility census was 37. During an interview on 1/11/23, at 4:30 P.M., administrator A said she would provide the QAA policy. The policy was not received. Emailed request on 1/23/23 to administrator B for the QAA policy. The policy was not received. Review of the facility's policy Quality Assurance and Performance Improvement (QAPI) Program, revised April 2014, showed the following: -Facility shall develop, implement, and maintain an ongoing facility-wide Quality Assurance and Performance Improvement (QAPI) program that builds on the Quality Assessment and Assurance Program to actively pursue quality of care and quality of life goals; -Primary purpose of the QAPI program is to establish data-driven facility-wide processes that improve the quality of care, quality of life, and clinical outcomes of our residents; -The program involves the full range of services and departments in the facility; -Program covers all systems of care and management practices; -Goals, targets and benchmarks are established and measured based on the best available evidence; -Input is sought from facility staff, residents, family members and individuals who are involved in the care of residents; -Members of the facility leadership are accountable for QAPI efforts; -Staff are trained in QAPI systems and culture; -Staff are encouraged to identify and report quality concerns as well as opportunities for improvement; -Systems are in place to monitor care and services; -Care processes's and outcomes are monitored using performance indicators; -Adverse events are tracked, monitored and investigated as they occur; -Action plans are implemented to prevent recurrence of adverse events; -Performance improvement projects (PIPs) are initiated when problems are identified; -Root Cause Analysis (RCA) is used to determine whether identified issues are exacerbated by the way care and services are organized or delivered and if so how; -Establishing a QAPI committee/sub-committee that works in tandem with the facility leadership and the QAA committee; -Allocating resources for QAPI initiatives; -Providing channels of communication between staff, residents, family members and leadership; -Creating task-oriented or goal-oriented teams for QAPI; -Utilizing established QAPI self-assessment tools to initiate and then periodically re-evaluate the QAPI program; -Gathering and using QAPI data in an organized and meaningful way; -Areas that may be appropriate to monitor and evaluated include: a. Clinical outcomes: pressure ulcers, infections, medication use, pain, falls, etc.; b. Complaints from residents and families; c. Re-hospitalizations; d. Staff turnover and assignments; e. Staff satisfaction; f. Care Plans; g. State surveys and deficiencies; h. Minimum Data Set (federally required assessments) assessment data; -Setting measurable goals for improvement; -Identify benchmarks of performance and comparing facility data with national and state performance benchmarks; -Recognizing patterns in systems of care that can be associated with quality problems; -Taking systemic action targeted at the root causes of identified problems. The policy did not include the director for the QAA committee, the members of the committee, how often they would meet, what areas would be covered, or any other specifics about the QAA committee. Review of the Facility Assessment, updated 1/2/23, showed the following: -The facility provides the following general care: a. Activities of Daily Living (ADL's) (showering, bathing, oral/denture care, eating, support to any impairments); b. Mobility or fall/injury prevention; c. Bowel/Bladder-incontinence care, toilet use assistance, bowel/bladder programs, and indwelling or other urinary catheter use; d. Skin integrity-prevention and care of pressure injuries, wounds, skin care and wound care; e. Behavior and mental health-identify and implement interventions to support individuals with issues such as anxiety, care of cognitive impairment, trauma/post traumatic stress disorder, other psychiatric, intellectual or developmental disabilities; f. Medication Administration and assessment; g. Pain management; h. Infection Control; i. Management of medical conditions; j. Therapies; k. Nutrition; l. Person-centered/directed care; m. Other needs: dialysis, hospice, ostomy care, and bariatric care. Review of the facility's Quality Assurance Audit of Medication Systems, dated 3/15/22, showed a medication system audit emailed to administrator A and the Director of Nursing. The medication audit included raw findings of the audit. The facility did not provide evidence of a QAA/QAPI meeting, agenda, or documentation of attendance. Review of the facility's QAPI meeting Attendance, dated July 27, 2022, showed the following staff signed that they attended: -Activity Director; -Director of Nursing; -Laundry Supervisor; -Maintenance Supervisor; -MDS Coordinator; -Housekeeping Supervisor. The facility did not provide evidence of an agenda or data reviewed at the meeting. The Medical Director or his/her designee, administrator, owner, infection preventionist or a board member or other individual in a leadership role did not sign that they had attended the meeting. Review of the untitled attendance sheet, dated October 21, 2022, showed a meeting occurred that included two Registered Nurses (RNs) and six Licensed Practical Nurses (LPNs). An agenda of the meeting was not attached, or any record of data reviewed at the meeting. The Medical Director or his/her designee; administrator, owner, a board member or other individual in a leadership role; and the Director of Nursing did not sign that they had attended the meeting. Review of the facility's QAPI meeting, dated 12/21/22, showed the following: -Attendees: Medical Director, administrator, Assistant Director of Nursing, and an unidentified person; -Agenda included: Emergency Management exercise with local fire departments, review of recent state tags, Communication from nursing staff to the physician's office, review of a specific resident code status, need for agency personnel, and tracking falls would be done with new electronic health record program; -Attached to the meeting was a Process Improvement Plan (PIP), dated 1/6/23, for Care Plans not updated or completed timely with a goal that all care plans will be current within 30 days, there were action steps listed, measures to evaluate were random DON review, and PIP to be completed 2/6/23; -Attached to the meeting was a PIP, dated 7/27/22, Identified area for improvement was clothing not being returned in timely manner or is in the wrong closets and clothing labels are not always legible; identified action steps, measures identified that all clothing will be clearly identified, 10/23/22 labeler is on order, to be completed by January 2023. Note on the bottom said clothing labeler ordered 1/3/22; -Attached to the meeting was a PIP, dated 5/11/22, showed identified area for improvement was high risk pressure ulcers on quality measures, plan to reduce in next 90 days, action steps were listed, Objective measures were listed, date to be completed was 7/2022; -Attached to the meeting was a PIP, dated 10/2022, showed identified area for improvement was high risk pressure ulcers on quality measures, plan to reduce in next 90 days, action steps were listed, Objective measures were listed, date to be completed was 1/24/23; -Attached to the meeting was a PIP, dated 10/23/22, that showed identified area for improvement was recent fall with major injury, Action steps to identify residents through fall risk assessment quarterly and as needed with falls, develop individualized care plan for high risk residents, and pharmacy review monthly; Objective measures: review all falls weekly for root cause, and review quality measures monthly, to be completed 10/2023; -Attached to the meeting was quality measures showing a fall with major injury 11/2022, no previous falls with injury for the year (The plan to reduce falls with major injury were before the facility had a fall with major injury). -The meeting attachments did not include measurable data for evaluation of any of the PIPs or notes that discussed any of the PIPs that were attached. During and interview on 1/18/23, at 11:10 A.M., administrator B said the following: -QA meetings are held at least quarterly; -The administrator, Director of Nursing, department managers, a floor staff member, the medical director, pharmacist, dietitian and the infection preventionist would attend; -Each meeting should have an agenda and attendance sheet; -Items reviewed should have measurable data, measurable goals, and should be able to measure the progress; -The facility is responsible to designate a staff member to keep track of the meeting minutes and attendance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement policies and procedures for the inspection, testing, and maintenance of the facility water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (LD). The facility failed to ensure nursing staff performed appropriate hand hygiene during wound care and peri care, including the changing of soiled gloves and proper hand washing, failed to ensure staff wore proper personal protective equipment (PPE) into COVID-19 (an infectious disease caused by severe acute respiratory syndrome Coronavirus 2/SARS-CoV-2) isolation rooms, failed to ensure proper storage of oxygen tubing when not in use, failed to change the tubing timely and failed to ensure proper Tuberculosis (TB) (a communicable disease that affects the lungs characterized by fever, cough and difficulty breathing) screening, for six residents (Resident #10, #13, #14, #18, #27 and #37) in a sample of 14 residents and two additional residents (Resident #2 and #16). The facility census was 37. 1. Review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification (S&C) letter 17-30, dated 06/02/17 and revised on 06/09/17, showed the following: -The bacterium Legionella can cause a serious type of pneumonia called LD in persons at risk. Those at risk include persons who are at least [AGE] years old, smokers, or those with underlying medical conditions such as chronic lung disease or immunosuppression. Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including hospitals and long-term care facilities. Transmission can occur via aerosols from devices such as shower heads, cooking towers, hot tubs, and decorative fountains; -Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water; -CMS expects Medicare certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. An industry standard calling for the development and implementation of water management programs in large or complex building water systems to reduce the risk of legionellosis was published in 2015 by American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE). In 2016, the CDC and its partners developed a toolkit to facilitate implementation of this ASHRAE Standard(https://www.cdc.gov/legionella/maintenance/wmp-toolkit.html). Environmental, clinical, and epidemiological considerations for healthcare facilities are described in this toolkit; -Surveyors will review policies, procedures, and reports documenting water management implementation results to verify that facilities: -Conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system; -Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens; -Specify testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained. Review of the facility's Legionella Surveillance and Detection policy, undated, show the following: -Monitor newly admitted residents with pneumonia within 48 hours of admission will be investigated for possible Legionnaire's disease; -Newly admitted resident's with pneumonia within 48 hours will be tested for the presence of legionella in their urine. -The policy did not include a facility risk assessment for water borne pathogens, a water management program, a water flow diagram, ASHRAE industry standards, or testing protocols with acceptable ranges for control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens. During an interview on, 1/10/23 at 3:44 P.M., the Maintenance Supervisor said the following: -He checks the water temperature weekly; -He does one random room on each hall and makes sure the water temperature is between 105 degrees F-120 degrees F; -The facility does not have a water management plan, a water flow diagram, or control measures for other testing of the water system that he knew of; -He does not check for sediment or biofilm, scaling on faucets, cold water temperatures, and does not know if there are any vulnerable areas of the facility's water system. During an interview on 1/11/23 at 1:13 P.M. and 1/12/23 at 1:03 P.M., the facility Infection Preventionist (IP)/Licensed Practical Nurse (LPN) R, said the following: -She did not serve on the water management committee or know of any monitoring or screening occurring to prevent Legionella growth or detect infections caused by Legionella. During an interview on, 1/10/23 at 1:44 P.M., and 1/11/23 at 8:50 P.M., administrator A said the following: -The facility ensures hot water temperatures are between 105 degrees Fahrenheit (F)-120 degrees F once a week, but do not check any other parts of the water system; -They tried to find a company to check the water system for Legionella but couldn't find anyone; -The facility has not done a risk assessment, a water management plan, or anything else she knew of; -There was no process in place to ensure there was no sediment or biofilm in the water system or appropriate chlorine levels, there was no water flow map, or a policy with corrective actions if there was an issue. 2. Review of the facility policy titled Hand Washing, effective date of 7/2019, showed the following: -POLICY: It is the policy of this home that hand hygiene is the primary means to prevent the spread of infection; 1. The use of gloves does not replace proper hand washing. The following equipment and supplies will be necessary when performing this procedure: a. Running water; b. Soap (liquid or bar, anti-microbial or non-antimicrobial); -Employees must wash their hands for at least twenty (20) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice); Before and after assisting a resident with personal care (e.g., oral care, bathing); After personal use of the toilet (hand washing with soap and water); Before and after assisting a resident with toileting (hand washing with soap and water); After contact with a resident with infectious diarrhea including, but not limited to infections caused by norovirus, salmonella, shigella and C. difficile (hand washing with soap and water); After contact with a resident's mucous membranes and body fluids or excretions; After handling soiled or used linens, dressings, bedpans, catheters and urinals; After removing gloves. Review of facility nursing policy and procedure for perineal care with or with a catheter, dated 7/2019, showed the following: -The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition; -It is the policy of this home to provide incontinent care to residents in a manner which provides privacy, promotes dignity and ensures no cross contamination; -Procedure; -1. Identify self to resident; -2. Perform hand hygiene; -3. Explain procedure to resident; -4. Prepare equipment: A. 2 clean trash bags (1 for wipes to use, and another for soiled wipes once used); B. Wipes Package already embedded with non-rinse cleanser; C. Bath towel or hand towel to pat dry resident; D. Gloves; E. Over bed table protector (bath towel or disposable chux); -5. Provide privacy; -6. Put on gloves; -7. Pull out amount of wipes needed to thoroughly clean the resident and place into one empty clean trash bag and put wipes package away. Expose only the area of the patient to be cleaned; -8. For female residents, separate the labia, take one wipe and moving from front to back, wipe the left side of the labia, and toss into empty trash bag designated for dirty wipes, get a new wipe and moving from front to back, wipe the right side of the labia, and toss into the trash bag designated for dirty wipes, get another wipe and wipe the center of the labia and in the center over the urethra and vaginal opening on each side of the labia and in the center over the urethra and vaginal opening, use one wipe for each swipe in the same front to back motion and continue wiping until all areas contaminated with urine or feces are clean, then pat dry. (Note: If the resident has an indwelling catheter, gently wipe the juncture of the tubing from the urethra down the catheter and away from the body about 3 inches, allow to air dry); -9. For male residents, take one wipe and wipe the penis from the urethral opening or tip of the penis moving back toward the body If resident is not circumcised pull back the foreskin and clean under it, with one circular motion, be sure to replace foreskin when cleaning is complete. (Note: If the resident has an indwelling catheter, gently wipe the juncture of the tubing from the urethra down the catheter and away from the body about 3 inches, allow to air dry). Wash the scrotum, pay attention to skin folds, and pat dry; -10. Turn resident to their side; -11. Take one wipe and wipe moving from front to back over the buttocks, including the areas of the hips and thighs, and continue wiping until all areas contaminated with urine or feces are clean, then pal dry; -12. Roll the wet or dirty incontinent pad or brief under the resident; -13. Stop, cover and secure resident, remove gloves and wash hands, and reapply clean gloves; -14. Place a dry incontinent pad or briefs or both underneath resident, turn the resident onto the other side, and remove the dirty incontinent supplies. Remove gloves and wash hands; -15. Reposition resident; -16. Remove gloves. Wash hands and reapply clean gloves (Note: Do not touch anything with soiled gloves after procedure i.e curtain, side rails, clean linen, call bell, wipes package, mechanical lift, residents' clothes, etc.); -17. Clean and return all equipment to its proper place, remove gloves and wash hands with soap and water; -18. Carry soiled linen to the soiled utility room and Place soiled linen/trash in proper container; -19. Wash hands. Review of the facility's policy, Infection Control - Tuberculosis (TB) Testing of Residents, effective date 05/2017, showed the following: - It is the policy of this home that all residents will be tested for tuberculosis (TB) upon admission, annually and if resident has been exposed or develops symptoms of tuberculosis (TB). - If the resident does not have a negative tuberculosis skin test (TST) within the preceding 12 months, give a second TST in one to three weeks. 3. Review of Resident #37's face sheet showed his/her diagnoses included spinal stenosis of the thoracic region (narrowing of the space that runs up the center of your spine), pressure ulcer (pressure sores) of sacral region (base of the spine), stage 3, (full thickness skin loss involving damage or necrosis (death of tissue.), type 2 diabetes mellitus, morbid obesity, Crohn's disease of both small and large intestine ( bowel disease that can cause diarrhea), urinary tract infection, diarrhea, osteomyelitis of vertebra in the lumbar region, (inflammation of bone caused by infection, generally in the legs, arms or spine), fracture of the thoracic vertebra (middle section of the spine), weakness and pain. Review of the resident's Order Summary Report (physician orders), dated 11/14/22, showed the following: -admission date 11/14/22; -TB per facility protocol, order date 11/14/22. Review of the resident's facility electronic medical record (EMR) Immunization Report, showed the following: -TB 1 step Mantoux (PPD) was consented to and administered in right forearm on 11/16/22 with a negative (0 mm) result; -No documentation to show the resident had received a previous TB test; -No documentation to show the resident received a second step TB test. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, completed 11/21/22, showed the following: -Moderately impaired cognition; -Needs extensive assistance with help from two or more staff members for personal hygiene; -Bowel incontinence. Review of the resident's undated, hand written care plan showed the following: -Needs extensive help with bathing; -Incontinent of bowel and bladder; -Pressure ulcers buttocks, stage 3 (full-thickness skin loss potentially extending into the subcutaneous tissue layer). Observation on 1/10/23 at 4:08 P.M., showed the following: -The resident lay on his/her back in bed; -The top sheet had a large brown and yellow stain in the middle of the sheet; -Both Certified Nursing Assistant (CNA) N and CNA O entered the room, performed hand washing with soap and water and put on gloves; -CNA O pulled back the top sheet to the end of the bed; -The resident lay on his/her back in bed, exposed from the waist down, with legs touching together; brown liquid fecal matter came up through his/her legs; -CNA N removed 4-5 clean wipes from a package and handed them to CNA O; -CNA O took one wipe and wiped from top to bottom of the left groin area and put the fecal covered wipe in a clear trash bag which sat on the bed behind the resident; -CNA O took one wipe and wiped from top to bottom of the right groin area and put the fecal covered wipe in the same clear trash bag; -CNA O, with the help of the resident and CNA N, repositioned the resident to his/her left side (CNA O touched the resident on his/her right hip with his/her visibly soiled gloves), used one wipe and wiped liquid brown fecal matter from the residents buttock, wiping in a downward motion several times until the wipe was visibly soiled; -CNA O put the soiled wipe in the clear trash bag, used another wipe to wipe in a downward motion until the wipe was visibly soiled; -While the resident was on his/her left side, CNA O rolled the soiled bottom sheet and pad, tucking it under resident's bottom; -CNA O took off his/her soiled gloves, used hand sanitizer and applied a new pair of gloves (CNA O did not wash hands with soap and water between glove changes); -CNA O put a clean sheet on the bed with a pad placed in the middle and tucked the clean linen under the resident; -CNA N removed the soiled bottom sheet and pad and placed them in the clear trash bag; -With soiled gloves, CNA N pulled a wipe from the package to clean the wet mattress and put the soiled top sheet in the trash bag; -With soiled gloves, CNA N pulled the clean linen under the resident and made the other half of the bed and then applied a clean top sheet over the resident. During an interview on 1/10/23 at 4:35 P.M., CNA N said the following: -Gloves should be changed when soiled, before touching clean surfaces and after resident care; -Hands should be washed before you walk out of the resident's room and when they are dirty or soiled; -He/She did not have to wash hands between glove changes. During an interview on 1/10/23 at 4:40 P.M., CNA O said the following: -Gloves should be changed as soon as they were soiled; -Gloves should be changed after cleaning the front of a resident and before cleaning the back of a resident; -He/She did not know why he/she did not change his/her gloves between cleaning the front and back of the resident. During an interview on 1/11/23 at 1:13 P.M. and 1/12/23 at 1:03 P.M., the facility IP/LPN R, said the following: -She does not track immunizations or TB testing. During interview on 1/18/23 at 12:50 P.M. and 1:05 P.M., the Director of Nursing (DON) said the following: -TB testing was to be performed on new admissions by the nurse who was admitting the resident; -Documentation of the TB testing was written on a 24 hour report sheet; -RN C was responsible for immunizations being up to date. 4. Review of facility nursing policy and procedure for infection control, prevent and control the spread of SARS-COV-2, COVID-19 dated 3/20, revised 1/21/22, showed the following: -It is the policy of this facility to protect the residents and staff from communicable diseases and infections. The facility staff will follow Missouri DHSS (Department of Health and Senior Services), CMS (Centers for Medicare and Medicaid), and the CDC (Centers for Disease Control) guidelines for residents and/or staff with suspected or confirmed infections of SARS-COV-2/COVID-19; -The facility will follow a planned approach listed below in the sections to prevent and control the transmission of COVID-19, including education for residents, resident representatives, staff, and visitors on prevention, timely identification through surveillance via screening assessments, containment, care, and treatment, and then follow up monitoring. Staff will utilize the correct transmission-based precautions, document surveillance, initiate medical supply tracking, and mitigate potential staffing shortages to the extent possible; -Place positive residents in Contact and Droplet Isolation, this will be initiated with signs being posted on the outside of the resident door to alert staff and visitors to not enter the room and to the transmission-based Precaution type in use, as well as placing the correct disposable PPE (Personal Protective Equipment) supplies needed prior to entry outside the doorway or unit. If the facility has access to obtain respirator masks/ or N95 masks they should utilize them, otherwise use gloves, gown, mask, and eye shield. Place a receptacle inside the room for removing soiled PPE and provide dedicated resident care equipment to the room. Facility documentation showed Resident #16 and Resident #13 were COVID-19 positive and placed on isolation precautions. 5. Observation of Resident #16's room on 1/10/23 at 8:08 A.M., showed the following: -A sign on the outside of the door that read - Attention all nursing, dietary, housekeeping, maintenance, administrative and activity staff; The room requires that you wear mask, gown, gloves and face shield upon entering this residents' room; -A three draw cart sat outside the resident's room with a box of blue surgical masks, gloves and hand sanitizer on top of the cart; -The first and second drawers contained gowns and in the third drawer face shields; -Registered Nurse (RN) H entered the room wearing no face shield. During an interview on 1/10/23 at 8:09 A.M. RN H said anyone entering Resident #16's room needed to be wearing all of the items listed on the sign posted on the outside of the resident's door. 6. Observation of Resident #13's room on 1/11/23 at 8:05 P.M., showed the following: -A sign on the outside of the door that read - Attention all nursing, dietary, housekeeping, maintenance, administrative and activity staff; The room requires that you wear mask, gown, gloves and face shield upon entering this resident's room; -A three draw cart sat outside of resident's room with a box of blue surgical masks, gloves, and hand sanitizer on top of cart; -The first and second drawers contained gowns and the third drawer face shields; -Certified Medication Technician (CMT) D entered the room wearing no face shield. During an interview on 1/11/23 at 8:10 P.M., CMT D said the following: -Staff could either wear the face shield or put a blue mask on over their N-95 mask; -He/She did not wear the face shield, because he/she was instructed (could not remember by who) that they did not have to wear a face shield, just a blue mask over their N-95 mask; -He/She thought the instruction was given by administrator A. During an interview on 1/11/23 at 8:50 P.M., administrator A said the following: -She would expect everyone who went into an isolation room to wear a mask, gown, gloves and face shield; -She did not tell any staff it was okay to just put a surgical mask on over an N-95 mask instead of wearing a face shield. 7. The facility did not provide a policy related to storage of oxygen tubing. Review of Resident #13's Order Summary Report (physician order sheet) with a date range of 01/01/21 - 01/31/23, showed the following: -O2 (oxygen) at 1-2L (liters) per nasal cannula (NC) (device that has two prongs that sit inside the nose and delivers oxygen directly into the nostrils); -Order date 10/26/22. Observation on 1/9/23 at 10:40 A.M., 1/10/23 at 4:03 P.M. and 1/11/23 at 7:55 P.M. showed the following: -Oxygen tubing attached to an oxygen tank in a holder on the back of a wheelchair with the tubing wound around the tank and the nasal cannula hanging freely in the air; -Oxygen tubing was attached to an oxygen concentrator by the residents' bed with the nasal cannula hanging freely from the left bed rail. 8. Review of Resident #2's physician order sheets (POS) dated 1/2023 showed the following: -Diagnoses included congestive heart failure (CHF) (heart does not pump blood as well as it should), Chronic Obstructive Pulmonary Disease (COPD) (group of lung diseases that block airflow and make it difficult to breathe); -Continuous oxygen at two liters per minute (2LPM); -Change oxygen tubing every Monday night shift (order date of 5/5/22). Review of the resident's undated care plan showed the following: -History of CHF; -Oxygen settings: 02 (oxygen) via nasal cannula at two to four/LPM. Observations showed the following for the resident: -On 1/10/23 at 6:35 A.M., the resident lay in bed and wore 02 at 2 LPM/NC; The tubing was attached to a concentrator and was dated 10/29/22; (the oxygen tubing had not been changed on 10/31/22, 11/7/22, 11/14/22, 11/21/22, 11/28/22, 12/5/22, 12/12/22, 12/19/22, 12/26/22, 1/2/23 or 1/9/23); -On 1/11/23 at 10:30 A.M., the resident sat up in the wheelchair in his/her room and wore 02 at 2LPM/NC; The tubing was attached to a concentrator and was dated 10/29/22 (the oxygen tubing had not been changed on 10/31/22, 11/7/22, 11/14/22, 11/21/22, 11/28/22, 12/5/22, 12/12/22, 12/19/22, 12/26/22, 1/2/23 or 1/9/23). During an interview on 1/11/23 at 1:13 P.M. and 1/12/23 at 1:03 P.M., the facility Infection Preventionist (IP)/Licensed Practical Nurse (LPN) R, said the following: -Oxygen tubing should be changed weekly; -The date the tubing is changed and initials of the staff doing the task should be written on the tubing; -If oxygen is not in use, the tubing should be in a plastic bag. During interview on 1/18/23 at 12:50 P.M. and 1:05 P.M., the DON said the following: -Oxygen tubing should be changed weekly; -Oxygen tubing should be labeled and dated; -Oxygen tubing should be stored in a bag when not in use. 9. Review of Resident #14's care plan dated 3/7/22 showed the following: -Bladder incontinence related to no awareness of toileting needs; -Resident will remain clean, dry and free from odor; -Provide incontinence care after each incontinent episode. Review of the resident's significant change MDS, dated [DATE], showed the following: -Extensive assist of two for bed mobility, transfers, dressing and personal hygiene; -Incontinent of bladder and bowel. Review of the resident's POS dated 1/2023 showed diagnoses included Alzheimer's disease (progressive disease that destroys memories and other important mental functions). Observation on 1/10/23 at 6:45 A.M. showed the following: -The resident lay on his/her back in the bed; -CNA F entered the room and without washing hands, applied gloves and unfastened the resident's urine soiled incontinent brief; -He/She performed incontinent care (with the same soiled gloves) on the resident, touching the resident's hip and back area as he/she assisted the resident to roll from back to side. He/She removed the urine soiled brief and placed it in the trash can; -Without changing gloves or washing his/her hands, he/she placed a clean incontinent brief under the resident, rolled the resident and taped the brief; -Wearing the same soiled gloves, he/she applied the resident's socks and pants; -He/She removed his/her gloves and washed his/her hands; -CMT D entered the room and without washing his/her hands, assisted CNA F to assist the resident to sit on the side of the bed, and then transferred the resident to the Broda chair (mobile, padded, tilting positioning chair); -CMT D then cleaned the resident's glasses, brushed his/her hair, placed a hand splint on the resident's hand, placed an N95 mask on the resident's face and pushed the resident out of the room without washing his/her hands. During interview on 1/12/23 at 1:47 P.M., CMT D said hands should be washed upon entering a resident's room, after providing cares and before exiting a room. During interview on 1/24/23 at 2:07 P.M. CNA F said the following: -Hands should be washed upon entering a room, with gloves changes and upon exiting a room; -Gloves should be changed when they become soiled. 10. Review of resident #18's quarterly MDS, dated [DATE] showed the following: -Extensive assist of one for transfer, bed mobility and personal hygiene; -Always incontinent of bladder and bowel. Review of the resident's care plan dated 10/25/22 showed: -Potential/Actual impairment to skin integrity related to urinary incontinence; -Keep skin clean and dry. Observation on 1/10/23 at 8:45 A.M. showed the following: -CNA E pushed the resident in his/her wheelchair to his/her room, washed his/her hands, applied gloves, assisted the resident to stand, pulled the resident's pants down and assisted him/her to lay in the bed; -CNA E unfastened the resident's urine soiled incontinent brief and with gloved hands, performed incontinent care to the resident's perineum in the front, rolled the resident to his/her left side, touched the resident's skin with soiled gloves, removed the soiled incontinent brief, placed it in the trash and cleaned the resident's buttocks; -CNA E removed his/her gloves and without washing hands, placed a clean incontinent brief under the resident and secured it, pulled the resident's pants up, covered the resident with the sheet and blanket, picked up the bed remote and lowered the bed; -He/She washed hands and exited the room. During interview on 1/12/23 at 1:53 P.M. CNA D said the following: -Hands should be washed upon entering a room and before and after cares; -Gloves should be changed between front and back incontinent care; -Staff should remove soiled gloves and wash hands before touching clean areas/items. 11. Review of Resident #27's face sheet showed he/she had diagnoses that included pressure ulcer stage 1, (Observable, pressure-related alteration of intact skin with non-blanchable redness of a localized area usually over a bony prominence; may include changes in skin temperature, tissue consistency and/or sensation) and urinary tract infection. Review of the resident's Significant Change MDS, completed 11/2/22, showed the following: -Severely impaired cognition; -Requires extensive assistance of at least one staff member for bed mobility, transfers, walking in room, dressing, toileting, and personal hygiene; -Requires total assistance of at least one staff member for bathing. Review of the resident's Care Plan, revised on 10/31/22, showed the following: -Assist with toileting on routine basis, on rising, before and after meals, at bedtime, and as requested; -Incontinent of bladder. Observation on 1/11/23 at 12:15 P.M. showed the following: -CMT E and Registered Nurse (RN) C assisted the resident to the toilet with a gait belt; -CMT E and RN C washed hands and applied gloves; -RN C removed the resident's wet and soiled brief while the resident sat on the toilet; -CMT E changed the resident's visibly dirty shirt and pants with food crumbs and stains; -CMT E stood the resident from the toilet touching the resident with soiled gloves while RN C used wet wipes to clean the resident's bottom and peri area; -RN C removed the glove from his/her right hand, pulled up the resident's pants with his/her bare right hand and soiled gloved left hand; he/she then removed his/her soiled glove; -RN C put on a new set of gloves (without performing hand hygiene) and assisted the resident to his/her left side in the bed; -RN C pulled the resident's pants down and measured the resident's wounds, and then pulled the resident's brief and pants up, removed his/her gloves, (did not perform hand hygiene), removed the resident's food tray that was left sitting on the beside table from earlier, turned the resident's room light off, left the resident's room and pushed the medication cart down the hallway (without performing hand hygiene). 12. Review of the Resident #10's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Requires supervision of one staff member for bed mobility; -Requires extensive physical assistance of one staff member for bed mobility, transfers, Observation on 1/9/23, at 12:20 P.M., showed the following: -CMT E followed Resident #10 into his/her room; -CMT E put on gloves, but did not clean hands; -CMT E removed the resident's soiled brief with gloved hands; feces fell from the brief onto the toilet seat and the floor; -The resident sat on the soiled toilet seat; -CMT E assisted the resident to stand, placed the soiled brief in the trash, used tissue paper to pick up feces from the floor and toilet seat, and did not clean the floor or toilet seat with soap or cleanser; -With soiled gloves, CMT E propelled the resident's wheelchair out of the bathroom touching the wheelchair handles with his/her soiled gloves; -CMT E changed gloves, but did not clean hands with soap and water and applied new gloves; -CMT E cleaned the center area of the resident's buttocks with a disposable wet wipes; -CMT E put a clean brief on the resident with his/her soiled gloves, assisted the resident to stand, touched the resident's walker and placed his/her left hand on the resident's lower back with the same soiled gloves; -CMT E walked with the resident to his/her bed and with his/her left soiled gloved hand on the resident's back and his/her right soiled gloved hand on the resident's walker; -CMT E assisted the resident to put his/her legs on the bed with soiled gloved hands and covered the resident with a clean sheet; -CMT E then removed his/her soiled gloves and washed his/her hands; -CMT E did not clean the resident's wheelchair seat or the surfaces touched with soiled gloves. During an interview on 1/12/23, at 10:42 A.M., CMT E said the following: -Staff are expected to clean their hands when entering and leaving a resident's room; -Staff are expected to change their gloves and clean their hands after touching soiled surfaces; -He/She did not change his/her gloves or clean his/her hands when he/she should have on 1/9/23 because he/she was in a hurry; there were two staff working the floor that day and they were very busy. During an interview on 1/11/23 at 3:46 P.M., RN C said staff are expected to wash hands before and after providing care, if they touch their face or any contaminated surface, between dirty and clean tasks, and when they change their gloves. During an interview on 1/11/23 at 1:13 P.M. and 1/12/23 at 1:03 P.M., the facility IP/LPN R,

Based on record review and interview the facility failed to ensure that an effective training program for all new and existing staff was in place. The facility failed to identify specific training needs in the facility assessment, and did not have a plan or schedule of how or when required training would be completed. The facility census was 37. Review of the Facility Assessment, dated 1/2/23, showed the the following: -The facility cared for 19 residents with mental, behavioral and neurodevelopmental disorders; -The facility provided care for behavior and mental health that includes identifying and implementing interventions with issues such as anxiety, care of cognitive impairment, trauma/Post Traumatic Stress Disorder (PTSD), other psychiatric, intellectual or developmental disabilities; -Staff training, education, and competencies: Attach or describe your facility's training program; -Include information on what training frequency of training's (e.g. before hire and/or ongoing, which individuals or departments conducting and tracking training's, and how the process is monitored or audited; -The facility's plan is: New hire is orientating with a current employee of the facility in their perspective department. The facility did not identify specific staff training, education, or competencies in the facility assessment. Review of the facility policy Abuse-Reportable Events, dated 5/2019, showed the following: -It is the policy of this home to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/event in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person; -Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Any act, failure to act, or incitement to act done willfully, knowingly, or recklessly through words or physical action which causes or could cause mental or physical injury or harm or death to a resident. This includes financial, verbal, sexual, mental/psychological, or physical abuse, including corporal punishment, involuntary seclusion, or any other actions within this definition; -All new employees will receive in-service training pertaining to all aspects of abuse prohibition before working a shift. All current employees will receive in-service training pertaining to all aspects of abuse prohibition at least annually. The training will include, but will not be limited to: a. Identification or potential victims of abuse or neglect; b. Appropriate interventions to deal with aggressive, stubborn resident, etc.; c. How to recognize staff indicator i.e. stress, burnout and frustration that may lead to the potential for abuse; d. How and when, including the two-hour time frame to report allegations without fear of reprisal; e. Staff and visitors are prohibited from using any equipment (cameras, smart phones, or other electronic devices) to take, keep, or distribute photographs and recordings of patients that are demeaning or humiliating or may be an invasion of privacy. This includes not connecting on any type of social media with the resident s of the facility or the employee's supervisors; f. Staff are prohibited to discuss any facility information with news media's. Staff are also prohibited to discuss residents by name, or the resident's person health information with any non-employee; g. All media advertising will be authorized in writing and under the supervision of the Administrator. During an interview on 1/12/23, at 1:23 P.M., the Director of Nursing (DON) said the following: -She does not have an education calendar or schedule for the year, a list of required trainings, or a list of trainings identified in the facility assessment to complete; -Human Resources tracks all staff certifications (CNA's); -She did not know who tracked the annual 12 hours of education for the CNA's; -She thinks the CNA's are responsible to track their own hours; -She would probably be the one to track nursing things; -She thinks the facility does abuse and neglect training a couple of times a year; -She knows the facility has trained on dementia and behaviors, but was not sure when or who all attended; -She was not sure if care of the cognitive impaired is included in the training; -She heard about all the new trainings required that went in to effect in October but the facility has not completed those training for the staff that she knows of During an interview on 1/12/23, at 2:00 P.M., Human Resources (HR) staff said she does not track the CNA's 12 hours of education or annual training, she completes the list of training in the new hire packet with new employees. During an interview on 1/12/23, at 2:00 P.M., administrator A said the following: -The DON is responsible to track the 12 hour CNA training to be completed annually; -The DON would be responsible to ensure all required topics for CNA's are completed; -Each department is responsible to ensure all required trainings are done for their department; -The new required training's that went into effect in October have not been completed at this time.

Based on interview and record review the facility failed to provide annual staff training to include abuse, neglect, exploitation, and misappropriation of resident property and the reporting and prevention of incidents of abuse, neglect, exploitation, and misappropriation of resident property to five facility staff (Certified Nurse Assistant (CNA) D, CNA E, CNA V, CNA F and CNA W) out of five employee records reviewed. The facility census was 37. Review of the facility policy Abuse-Reportable Events, dated 5/2019, showed the following: -It is the policy of this home to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/event in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person; -Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Any act, failure to act, or incitement to act done willfully, knowingly, or recklessly through words or physical action which causes or could cause mental or physical injury or harm or death to a resident. This includes financial, verbal, sexual, mental/psychological, or physical abuse, including corporal punishment, involuntary seclusion, or any other actions within this definition; -All new employees will receive in-service training pertaining to all aspects of abuse prohibition before working a shift. All current employees will receive in-service training pertaining to all aspects of abuse prohibition at least annually. The training will include, but will not be limited to: a. Identification or potential victims of abuse or neglect; b. Appropriate interventions to deal with aggressive, stubborn resident, etc.; c. How to recognize staff indicator i.e. stress, burnout and frustration that may lead to the potential for abuse; d. How and when, including the two-hour time frame to report allegations without fear of reprisal; e. Staff and visitors are prohibited from using any equipment (cameras, smart phones, or other electronic devices) to take, keep, or distribute photographs and recordings of patients that are demeaning or humiliating or may be an invasion of privacy. This includes not connecting on any type of social media with the resident s of the facility or the employee's supervisors; f. Staff are prohibited to discuss any facility information with news media's. Staff are also prohibited to discuss residents by name, or the resident's person health information with any non-employee; g. All media advertising will be authorized in writing and under the supervision of the Administrator. 1. Review of CNA D's employee file showed the employee's date of hire (DOH) as 5/21/15. Review of education completed from 12/1/21-1/19/23, showed the CNA did not attend training on identification, reporting, and prevention of incidents of abuse, neglect, exploitation, and misappropriation of resident property in the last year. 2. Review of CNA V's employee file, showed the employee's DOH as 4/1/19. Review of education completed from 12/1/21-1/19/23, showed the CNA did not attend training on identification, reporting, and prevention of incidents of abuse, neglect, exploitation, and misappropriation of resident property in the last year. 3. Review of CNA F's employee file, showed the employee's DOH as 2/18/21. Review of education completed from 12/1/21-1/19/23, showed the CNA did not attend training on identification, reporting, and prevention of incidents of abuse, neglect, exploitation, and misappropriation of resident property in the last year. 4. Review of CNA W's employee file, showed the employee's DOH as 10/10/18. Review of education completed from 12/1/21-1/19/23, showed the CNA did not attend training on identification, reporting, and prevention of incidents of abuse, neglect, exploitation, and misappropriation of resident property in the last year. 5. Review of CNA E's employee file, showed the employee's DOH 4/16/19. Review of education completed from 12/1/21-1/19/23, showed the CNA did not attend training on identification, reporting, and prevention of incidents of abuse, neglect, exploitation, and misappropriation of resident property in the last year. 6. During an interview on 1/12/23, at 1:23 P.M., the Director of Nursing (DON) said the following: -Human Resources tracks all staff certifications (CNA's); -She does not know who tracks education for the employees; -She thinks the facility does abuse and neglect training a couple of times a year. During an interview on 1/12/23, at 2:00 P.M., Human Resources (HR) staff said he/she does not track annual education, only education for new employees. During an interview on 1/12/23, at 2:00 P.M., administrator (ADM) A said supervisors track their employees education. She was not sure when the last abuse training was completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure each certified nurse aide (CNA) had no less than 12 hours of in-service education per year based on their individual performance review, calculated by hire date. The facility identified eight CNA's employed by the facility for more than a year. Five CNAs were sampled and five out of five did not have the required 12 hours of in-service education, or training for abuse. Four of the five sampled did attend an in-service that included the topic of dementia, but there was no agenda provided, depth or scope of the training. Two of the five sampled CNA's attended an in-service for behaviors, but there was no agenda, depth, or scope of the training. Five out of five did not have documented attendance for an in-service regarding care of the cognitively impaired. The facility census was 37. Review of the facility policy Abuse-Reportable Events, dated 5/2019, showed the following: -It is the policy of this home to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/event in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person; -Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Any act, failure to act, or incitement to act done willfully, knowingly, or recklessly through words or physical action which causes or could cause mental or physical injury or harm or death to a resident. This includes financial, verbal, sexual, mental/psychological, or physical abuse, including corporal punishment, involuntary seclusion, or any other actions within this definition; -All new employees will receive in-service training pertaining to all aspects of abuse prohibition before working a shift. All current employees will receive in-service training pertaining to all aspects of abuse prohibition at least annually. The training will include, but will not be limited to: a. Identification or potential victims of abuse or neglect; b. Appropriate interventions to deal with aggressive, stubborn resident, etc.; c. How to recognize staff indicator i.e. stress, burnout and frustration that may lead to the potential for abuse; d. How and when, including the two-hour time frame to report allegations without fear of reprisal; e. Staff and visitors are prohibited from using any equipment (cameras, smart phones, or other electronic devices) to take, keep, or distribute photographs and recordings of patients that are demeaning or humiliating or may be an invasion of privacy. This includes not connecting on any type of social media with the resident s of the facility or the employee's supervisors; f. Staff are prohibited to discuss any facility information with news media's. Staff are also prohibited to discuss residents by name, or the resident's person health information with any non-employee; g. All media advertising will be authorized in writing and under the supervision of the Administrator. Review of the Facility Assessment, dated 1/2/23, showed the the following: -The facility cared for 19 residents with mental, behavioral and neurodevelopmental disorders; -The facility provided care for behavior and mental health that includes identifying and implementing interventions with issues such as anxiety, care of cognitive impairment, trauma/Post Traumatic Stress Disorder (PTSD), other psychiatric, intellectual or developmental disabilities; -Staff training, education, and competencies: Attach or describe your facility's training program; -Include information on what training frequency of training's (e.g. before hire and/or ongoing, which individuals or departments conducting and tracking training's, and how the process is monitored or audited; -The facility's plan is: New hire is orientating with a current employee of the facility in their perspective department. 1. Review of Certified Nurse Assistant (CNA) D's employee file, showed the employees date of hire (DOH) as 5/21/15. Review of education completed from 12/1/21-1/19/23, showed the CNA attended the following: -COVID (respiratory disease caused by the SARS-CoV-2 virus) and infection control training on 1/25/22, (did not include agenda, specifics of topics covered, or the amount of time of the education); -Electronic health record training on 2/9/22, (did not include agenda, specifics of topics covered, or the amount of time of the education); -COVID vaccination policy, screening, mask and hand sanitizer on 2/14/22, (did not include the amount of time of the education); -Disaster drill, elopement, fire, suicide threat, dementia on 3/24/22 (did not include agenda, specifics of topics covered, or the amount of time of the education); -Falls, Wounds, and behaviors on 4/26/22 (did not include agenda, specifics of topics covered, or the amount of time of the education); -Electronic Medical Record system and [NAME] training on 6/16/22 (did not include agenda, specifics of topics covered, or the amount of time of the education). The employees' education was documented on sign sheets (with multiple employees), there was no individual tracking for each CNA. The education did not include the amount of time or depth of the subjects reviewed or if 12 hours of education was completed. Review of education completed from 12/1/21-1/19/23, showed the CNA did not attend training on identification, reporting, and prevention of incidents of abuse, neglect, exploitation, and misappropriation of resident property in the last year. The records did include training on dementia, it did not include the agenda, depth, amount of time or scope of the training. The documentation did not include if care of the cognitively impaired was covered in the education. 2. Review of CNA V's employee file, showed the employees' DOH as 4/1/19. Review of education completed from 12/1/21-1/19/23, showed the CNA attended the following: -COVID vaccination policy, screening, mask and hand sanitizer on 2/14/22, (did not include the amount of time of the education); -Falls, Wounds, and behaviors on 4/26/22 (did not include agenda, specifics of topics covered, or the amount of time of the education); -Electronic Medical Record system and [NAME] training on 6/16/22 (did not include agenda, specifics of topics covered, or the amount of time of the education). The employees education was documented on sign sheets (with multiple employees), there was no individual tracking for each CNA. The education did not include the amount of time or depth of the subjects reviewed or if 12 hours of education is completed. Review of education completed from 12/1/21-1/19/23, showed the CNA did not attend training on identification, reporting, and prevention of incidents of abuse, neglect, exploitation, and misappropriation of resident property in the last year. The records included a training on behaviors that did not include the agenda, depth, amount of time or scope of the training. The documentation did not include if dementia, or care of the cognitively impaired was covered in the education. 3. Review of CNA F's employee file, showed the employees' DOH as 2/18/21. Review of education completed from 12/1/21-1/19/23, showed the CNA attended the following: -COVID and infection control training on 1/25/22, (did not include agenda, specifics of topics covered, or the amount of time of the education); -Electronic health record training on 2/9/22, (did not include agenda, specifics of topics covered, or the amount of time of the education); -Disaster drill, elopement, fire, suicide threat, dementia on 3/24/22 (did not include agenda, specifics of topics covered, or time of the education); The employee's education was documented on sign sheets (with multiple employees), there was not an individual tracking for each CNA. The education did not include the amount of time or depth of the subjects reviewed or if 12 hours of education is completed. Review of education completed from 12/1/21-1/19/23, showed the CNA did not attend training on identification, reporting, and prevention of incidents of abuse, neglect, exploitation, and misappropriation of resident property in the last year. The records did include training on dementia, it did not include the agenda, depth, amount of time or scope of the training. The documentation did not include if care of the cognitively impaired was covered in the education. 4. Review of CNA W's employee file, showed the employees' DOH as 10/10/18. Review of education completed from 12/1/21-1/19/23, showed the CNA attended the following: -COVID and infection control training on 1/25/22, (did not include agenda, specifics of topics covered, or the amount of time of the education); -COVID vaccination policy, screening, mask and hand sanitizer on 2/14/22, (did not include the amount of time of the education); -Disaster drill, elopement, fire, suicide threat, dementia on 3/24/22 (did not include agenda, specifics of topics covered, or the amount of time of the education); The employee's education was documented on sign sheets (with multiple employees), there was not an individual tracking for each CNA. The education did not include the amount of time or depth of the subjects reviewed or if 12 hours of education is completed. Review of education completed from 12/1/21-1/19/23, showed the CNA did not attend training on identification, reporting, and prevention of incidents of abuse, neglect, exploitation, and misappropriation of resident property in the last year. The records did include training on dementia, it did not include the agenda, depth, amount of time or scope of the training. The documentation did not include if care of the cognitively impaired was covered in the education. 5. Review of CNA E's employee file, showed the employees' DOH as 4/16/19. Review of education completed from 12/1/21-1/19/23, showed the CNA attended the following: -COVID and infection control training on 1/25/22, (did not include agenda, specifics of topics covered, or the amount of time of the education); -Electronic health record training on 2/9/22, (did not include agenda, specifics of topics covered, or the amount of time of the education); -COVID vaccination policy, screening, mask and hand sanitizer on 2/14/22, (did not include the amount of time of the education); -Disaster drill, elopement, fire, suicide threat, dementia on 3/24/22 (did not include agenda, specifics of topics covered, or time of the education); -Falls, Wounds, and behaviors on 4/26/22 (did not include agenda, specifics of topics covered, or the amount of time of the education); -Electronic Medical Record system and [NAME] training on 6/16/22 (did not include agenda, specifics of topics covered, or the amount of time of the education). The employee's education was documented on sign sheets (with multiple employees), there was not an individual tracking for each CNA. The education did not include the amount of time or depth of the subjects reviewed or if 12 hours of education is completed. Review of education completed from 12/1/21-1/19/23, showed the CNA did not attend training on identification, reporting, and prevention of incidents of abuse, neglect, exploitation, and misappropriation of resident property in the last year. The records did include training on dementia, it did not include the agenda, depth, amount of time or scope of the training. The documentation did not include if care of the cognitively impaired was covered in the education. 6. During an interview on 1/12/23, at 1:23 P.M., the Director of Nursing (DON) said the following: -Human Resources tracks all staff certifications (CNA's); -She did not know who tracked the annual 12 hours of education for the CNA's; -She thinks the CNA's are responsible to track their own hours; -She heard about the new required trainings but she has not been involved with completing them; -She would probably be the one to track nursing things; -She thinks the facility does abuse and neglect training a couple of times a year; -She knows the facility has trained on dementia and behaviors, but was not sure when or who all attended; -She was not sure if care of the cognitive impaired is included in the training. During an interview on 1/12/23, at 2:00 P.M., Human Resources (HR) staff said he/she does not track the CNA's 12 hours of education or annual training. During an interview on 1/12/23, at 2:00 P.M., the administrator A said the following: -The DON is responsible to track the 12 hour CNA training to be completed annually; -The DON would be responsible to ensure all required topics for CNA's are completed; -The new required training's have not been completed at this time.