Based on interview and record review, facility staff failed to prevent the commingling of 13 residents' (Resident #10, #33, #34, #38, #42, #43, #44, #45, #46, #47, #48, #49, #50) personal funds with the facility operating funds out of 37 sampled residents. The facility census was 37. Review of the facility's policy titled Conveyance of Resident Funds, revised 05/21, showed the residents personal funds and a final accounting of funds are returned to the resident, the resident representative, or the resident's estate as applicable within 30 days from the date of the resident's discharge from the facility or death. Should a resident pay for services which then retroactively become Medicare/Medicaid eligible, the facility promptly refunds the amount charged to the resident for those services as soon as the facility receives the intermediary's payment. Inquiries concerning refunds are referred to the administrator or Business Office Manager (BOM). Review of the facility-maintained Accounts Receivable Aging report, dated 05/19/25, showed the following residents with personal funds held in the facility operating account: Resident Amount Held in Operating Account #10 $1618.00 #33 $917.00 #34 $1233.00 #38 $6400.00 #42 $60.17 #43 $571.00 #44 $70.15 #45 $368.00 #46 $1297.07 #47 $228.79 #48 $2718.65 #49 $7600.00 #50 $826.00 Total $23907.83 During an interview on 05/19/25 at 1:30 P.M., the BOM said he/she started as the BOM in November 2024. The BOM said he/she had no previous experience with this role and was supposed to be trained by the outgoing BOM before he/she left but that did not happen. The BOM said he/she reviews the A/R Aging report monthly and if credits are found he/she will submit a refund request to the Recovery Specialist and the Recovery Specialist is responsible to ensure all claims are paid and the money is refunded. The BOM said the Recovery Specialist sends the facility a copy of the refund check for the facility records and the Recovery Specialist is responsible to update the accounts receivable aging report when he/she gets a refund check. The BOM said the facility should refund a resident money within 30 days of discharge and he/she is aware this has not been done. The BOM said he/she does not know why the money has not been returned within the time frame as the Recovery Specialist is responsible for ensuring it is completed. The BOM said the facility does not having anything in writing to hold resident funds past the 30 days. During an interview on 05/20/25 at 10:30 A.M., the Recovery Specialist said when a resident refund is needed, he/she is made aware by the facility BOM. The Recovery Specialist said he/she is responsible to ensure all claims are paid. The Recovery Specialist said he/she is responsible for updating the accounts receivable aging report, mailing the check to the resident and/or responsible party, and sending a copy of the check to the facility for their records. The Recovery Specialist said he/she does not know refunds should be sent within 30 days of a resident discharge from the facility. The Recovery Specialist said he/she did not know why it takes over 30 days to get a refund issued. During an interview on 05/21/25 at 9:00 A.M., the Director of Banking Services said the Recovery Specialist is responsible for the accounts receivable aging report. The Director of Banking Services said once he/she gets a check request from the Recovery Specialist he/she cuts a check and sends it to the Recovery Specialist. The Director of Banking Services said he/she did not know a resident refund should be issued within 30 days of discharge from the facility. During an interview on 05/21/25 at 10:10 A.M., the Administrator said he/she reviews the accounts receivable aging report monthly with the BOM. The Administrator said he/she is aware there are outstanding credits that need to be refunded. The Administrator said after they review the report if they find any credits the BOM will submit a refund request to the Recovery Specialist. The Administrator said once the refund request is submitted the Recovery Specialist is responsible to ensure all the claims are paid and supply a refund check for the resident and/or responsible party. The Administrator said once the Recovery Specialist gets the refund check he/she is responsible for updating the accounts receivable report in the computer system and sending a copy of the check to the BOM for the facility records. The Administrator said resident refunds should be issued within 30 days of discharge from the facility and he/she is not sure why the Recovery Specialist is not doing this within the timeframe. The Administrator said he/she is aware the facility has credits more than 30 days old that need to be refunded and he/she said the only reason he/she knows they aren't refunded within 30 days is due to the Recovery Specialist not processing the requests timely after the facility submits them. The Administrator said the facility does not have written permission to hold the resident money after discharge. During an interview on 05/21/25 at 10:30 A.M., the Regional Director of Operations said the the facility BOM is responsible to review the accounts receivable aging report each month and submit any credits to the Recovery Specialist for a refund. Once the Recovery Specialist gets a refund request the Recovery Specialist is responsible to ensure all claims are paid, and request a check for the amount left to refund. Once the Recovery Specialist has the refund check it is his/her responsibility to update the acccounts receivable aging report, mail the check to the resident and/or responsible party, and send the facility BOM a copy of the check. Refunds are to be issued within 30 days of a resident discharge and he/she expects this to be done. It is corporate policy to pay refunds out by the 17th of each month. The Regional DOP said he/she is aware refunds were not being completely timely has determined they were not being processed timely by the recovery specialist.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to store medications in a safe manner when staff failed to ensure expired insulin vials were not stored with current resident medications, and failed to ensure medications were not loose in one medication cart out of two sampled. The facility census was 37. 1. Review of the facility's policy titled Medication Labeling and Storage, dated February 2023, showed multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. Medications and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents. 2. Observation on [DATE] at 9:30 A.M. with the Director of Nursing (DON), showed: -One opened 1/2 full vial of Humalog (insulin) 100 units/milliliter (ml) with an open date of [DATE]; -One opened 1/4 full vial of Lantus (insulin) 100 units/ml with an open date of [DATE]; -One opened 1/2 full vial of Lantus 100 units/ml with an open date of [DATE]; -One opened 1/2 full vial of Insulin Lispro 100 units/ml with an open date of [DATE]; -One opened 1/4 full vial of Insulin Glargine with an open date of [DATE]. During an interview on [DATE] at 11:26 A.M., Licensed Practical Nurse (LPN) C said the insulin is supposed to be taken off the medication cart after it has been opened for 30 days. The LPN said night shift staff are responsible for checking the dates on the insulin. The LPN said staff should check the open dates on the insulin before administering the insulin to a resident. The LPN said he/she just did not check the dates on the insulin and he/she should have. Insulin that has been open longer than 30 days should not be on the medication cart. During an interview on [DATE] at 10:48 A.M., the Assistant Director of Nursing (ADON) said insulin should only be used for 28 days after it is opened. The outdated insulin should not have been on the medication cart. It is the responsibility of the ADON and DON to make sure the nurses are checking the open dates. The concern of giving insulin over the allotted open time is that the insulin won't be as effective. During an interview on [DATE] at 11:00 A.M., the DON said staff should only keep insulin on the medication cart for 28 days. The concern of keeping it past the 28 days is it will change the effectiveness of the medication. The DON said the vials of insulin and their open dates were probably not checked by the staff. The DON said it is the ADON and the DON's responsibility to make sure the nurses are checking the insulin dates. The DON said he/she does not have a process for ensuring the nurses check the dates. During an interview on [DATE] at 11:13 A.M., the Administrator said staff should put open dates on insulin when they place it on the medication cart. The administrator said he/she does not know how long insulin can be kept once opened. The administrator said he/she expects staff to take expired or outdated insulin off the medication cart. The administrator said the nursing staff should check the dates on the open vials of insulin every shift. The administrator said it is the responsibility of the ADON and the DON to make sure the nurses are checking the dates on the insulin vials every shift. 3. Observation on [DATE] at 9:44 A.M. with Certified Medication Technician (CMT) D showed the CMT medication cart contained 21 loose tablets and capsules of medications in the bottom of medication drawers and were identified as follows: -One capsule of colace (stool softener); -One tablet of 10 milligram (mg) Buspar (anti-anxiety medication); -One tablet of 10 mg of Simvastatin (lowers cholesterol); -One tablet of 100 mg Topamax (migraine medication); -One tablet of 20 mg Celexa (anti-depressant medication); -One tablet of 25 mg Topamax; -One capsule of 0.4 mg Tamsulosin Hydrochloride (used for urine retention); -One tablet of 10 mg Ampyra (used with Multiple Sclerosis); -One capsule of 1 mg Prazosin Hydrochloride (blood pressure medication); -One tablet of 20 mg Lasix (diuretic medication); -One tablet of 50 mg Metoprolol Tartrate (blood pressure medication); -One tablet of 25 microgram (mcg) Soloxine (thyroid medication); -One tablet of 4 mg Eliquis (blood thinner); -One half tablet of Buspar; -One brown capsule, unmarked and unidentifiable; -One half tablet of 500 mg metformin (used for diabetes); -Two white, round tablet, unmarked and unidentifiable; -One tablet of 200 mg Ibuprofen (analgesic); -One tablet of 15 mg Mirtazapine (anti-depressant medication); -One pink, round tablet, unmarked and unidentifiable. During an interview on [DATE] at 10:48 A.M., the ADON said the CMT's should ensure the cart is clean and free of loose pills at the end of every shift. The ADON said it is the responsibility of the ADON and DON to ensure the CMT's are cleaning the medication carts. There should not be loose pills in the medication carts. During an interview on [DATE] at 11:00 A.M., the DON said the CMT's should ensure the cart is clean and free of loose pills at the end of very shift during their narcotic medication count. He/she did not know why staff are not doing it, he/she has told them several times to do that. The DON said it is the responsibility of the ADON and the DON to make sure the staff check and clean the carts. The DON said he/she has not consistently been checking the carts as he/she should. It is not okay to have 21 loose pills in the medication cart drawers. During an interview on [DATE] at 11:13 A.M., the administrator said the CMT's should clean and check the medication carts for loose pills every shift. The administrator said he/she did not know why the CMT's are not checking their medication carts every shift. The loose pills should not have been in the medication cart. The administrator said he/she, the ADON and DON are ultimately responsible for checking the medication carts.

Based on record review and interview, facility staff failed to prevent the misappropriation of money from one resident's, out of four sampled residents, (Resident #1) checking account when Certified Nursing Aide (CNA) A stole checks from the resident, and had a third party cash the checks, without authorization of the resident. The facility census was 34. The administrator was notified on 3/13/24 of past Non-Compliance which occurred on 2/05/24. On 2/05/24, the administrator suspected CNA A used a resident's debit card to make multiple purchases from businesses, without the authorization of the resident. Upon discovery, staff suspended CNA A on 2/05/24. The facility conducted an investigation, in-serviced all staff on the facility's abuse, neglect, and misappropriation policies on 2/5/24, and terminated CNA A on 2/7/24 for violation of facility policy. 1. Review of the facility's Abuse, Neglect, and Misappropriation Policy, undated, showed the facility will assure all residents, responsible parties, and staff understand there is zero tolerance of verbal, sexual, physical, or mental abuse, corporal punishment, involuntary seclusion, neglect, or misappropriation of resident property by an employee or any other person known or unknown to the resident. Review showed 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. 2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 12/29/23, showed staff assessed the resident with impaired cognition. Review of the facility's investigation, dated 8/01/23, showed staff documented the resident's family member notified the Social Service Director (SSD), on 08/01/23, someone was writing bad checks from the resident's checking account. Review showed the facility contacted the Department of Health and Senior Services (DHSS), the local police department, and the local sheriff's department to report the incident. Reviewed showed the SSD documented the investigation did not identify any staff member involved in the incident at that time. Facility in-serviced all staff on the facility's abuse, neglect, and misappropriation policies on 8/2/24. Review of the local county sheriff's department incident report, dated 8/9/23 and reviewed on 3/18/24, showed on 2/1/24 the investigator documented the video from the local bank had been reviewed and showed CNA A and CNA A's spouse cashed checks through the drive-thru of the bank on 7/22/23. On 2/6/24 the investigator documented he/she contacted the facility and reported the stolen checks and inquired if CNA A worked there and was informed he/she had been terminated on 2/7/24. Review showed the investigator documented, during an interview on 2/27/24, at approximately 8:28 A.M., CNA A said he/she knew the resident was missing money, but he/she, thought it was the resident's sibling or guardian who was responsible, and he/she was the connection between his/her spouse and the facility. Review showed the investigator documented CNA A's spouse said he/she and CNA A wrote checks numerous times, and CNA A was aware of the checks being cashed, he/she saw the checks and took them, and he/she needed the money because he/she was broke. Review showed the deputy interviewed CNA A and CNA's spouse on 2/27/24. Review showed the local Sheriff's Department charged CNA A with Financial Exploitation of Elderly/Disabled Person, and Fraudulent Use of Credit/Debit Device, Stealing $750.00 or more on 2/27/24. Review showed the local Sheriff's Department charged CNA A's spouse with Forgery, Financial Exploitation of Elderly/Disabled Person, Fraudulent Use of Credit/Debit Device, Identity Theft or Attempt, Stealing $750.00 or more, with the reporting person as the resident's guardian on 2/27/24. Review showed the local Sheriff's Department documented CNA A and CNA A's spouse misappropriated approximately $4,195.00 from the resident through cashed stolen/fraudulent checks. During an interview on 3/11/24 at 10:17 A.M. the administrator said he reported the arrest of CNA A and his/her spouse to DHSS on 2/28/24 in order to link the previous incident with CNA A. During an interview on 3/11/24, at 10:20 A.M., the Business Office Manager (BOM) said CNA A admitted to misappropriating the resident's funds, as well as stealing approximately $4000.00 from the facility. During an interview on 3/25/24 at 3:15 P.M., the administrator said they had not been notified by their local police and/or sheriff's department of the arrest of CNA A. He said a staff member in dietary watched the news and reported it to him. During an interview on 3/28/24 at 12:45 P.M., the Director of Nursing (DON) said the Social Services Director (SSD) had brought it to his/her attention that a resident had some checks stolen in 8/2023 but that at that time no one could be identified. He/She said when there was an allegation in February 2024 a resident had his/her debit card taken by CNA A and upon review it was found the resident had given the employee the card to use to get him/her items. After their investigation they let him/her go due to a policy violation. The maintenance supervisor who has affiliation with the local sheriff's department came in sometime after CNA A was terminated and said they had arrested CNA A and his/her spouse. During an interview on 3/28/24 at 1:06 P.M., the SSD said there was an employee from the bank who came in August, 2023 who was questioning Resident #1 about checks that had come through the bank to find out if the resident had approved them. The SSD said at that time no one had been identified and the investigation was ongoing. He/She said in February, 2024 there was a report of CNA A using a residents debit card but the resident had given him/her permission. The SSD said although he/she had permission everyone knows you don't do that and CNA A was terminated. MO00232513

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, facility staff failed to meet professional standards when staff did not document in the Medication Administration Record (MAR) they administered the physician ordered medication and treatment for four residents (Resident #1, #2, #3, and #4) out of four residents. The facility census was 33. 1. Review of the facility's Medication Administration Policy, dated April 2019, showed the Director of Nursing (DON) services supervises and directs all personnel who administer medication and /or have related functions. Review showed medications are administered in accordance with prescriber orders, including any required time frame. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. The individual who administers the medication will initial the resident's MAR on the appropriate line after they administered each medication and before they administer the next medication. As required or indicated for a medication, the individual who administer the medication, records in the resident's medical record the signature and title of the person who administered the drug. 2. Review of Resident #1's admission Minimum data set (MDS), a federally mandated assessment tool, dated 5/10/23, showed staff assessed the resident as: -Cognitively intact; -Neuromuscular dysfunction of bladder (the bladder's nerves do not work properly and the bladder may not fill and empty correctly), cerebral infarction (stroke caused by disruption of blood flow to the brain), major depressive disorder, anxiety disorder, Insomnia, Hypertension (high blood pressure), and hyperlipidemia (high cholesterol); -Indwelling urinary Foley catheter (stationary flexible catheter inserted to drain urine from the bladder). Review of the resident's Physician Order Sheet (POS), dated June 2023 through July 2023, showed the physician's orders directed staff as follows: -Aspirin (used as an anti-inflammatory and blood thinner) 81 milligrams (mg) one tablet by mouth daily; -Lisinopril (used to treat high blood pressure) five mg one and a half tablets by mouth daily; -Paroxetine (used to treat depression) 20 mg one by mouth daily; -Cephalexin (antibiotic) 500 mg one capsule by mouth four times daily for 10 days for Urinary tract infection; -Foley catheter care every shift. Review of the resident's MAR, dated June 2023, showed staff did not document they administered the resident's Cephalexin on 6/20/23, 6/21/23, and 6/22/23 as directed. Review of the resident's MAR, dated June 2023, showed staff did not document they administered the resident's Aspirin, Lisinopril, Paroxetine on 6/22/23 as directed. Review of the resident's TAR, dated June 2023 showed staff did not document they provided catheter care each shift on 6/30/23 as directed. Review of the resident's TAR, dated July 2023, showed staff did not document they provided catheter care each shift on 7/5/23 and 7/6/23 as directed. 3. Review of Resident #2's admission MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Pressure ulcer of sacral region (buttocks),Stage IV (full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures); -Indwelling urinary Foley catheter, bilateral nephrostomy tubes (stationary tubes which drain urine directly from the kidney's), colostomy (a piece of the colon is diverted to an artificial opening in the abdominal wall), and acquired absence of left foot. Review of the resident's POS, dated June 2023, showed the physician's order directed staff as follows: -Methocarbamol (used for muscle spasms and pain) 500 mg one by mouth every six hours; -Sacral Decubitius Ulcer wet to dry dressing, with normal saline twice daily; -Foley catheter care every shift; -Nephrostomy tube care every shift; -Colostomy care every shift; -Wet to dry dressing to left stump (site of amputation) twice daily. Review of the resident's MAR, dated June 2023, showed staff did not document they administered the resident's Methocarbamol on 6/7/23, 6/12/23, 6/13/23, and 6/14/23 as directed. Review of the resident's TAR, dated June 2023, showed staff did not document they provided wet to dry dressings to the resident's sacrum on 6/9/23, 6/10/23, and 6/11/23 as directed. Review of the resident's TAR, dated June 2023, showed staff did not document they provided Foley catheter care, nephrostomy care, or colostomy care on 6/7/23, 6/9/23, and 6/14/23 as directed. Review of the resident's TAR, dated June 2023, showed staff did not document they provided wet to dry dressing to the resident's left stump on 6/7/23 and 6/13/23 as directed. 4. Review of Resident #3's quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -Benign prostatic hyperplasia (BPH) (prostate enlargement causing urination difficulty), dementia, muscle wasting and atrophy (degeneration of cells), arteriosclerotic heat disease (thickening and hardening of the walls of the coronary arteries), peripheral vascular disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs causing pain), hyperlipidemia, hypertension, violent behavior, and retention of urine; -Indwelling urinary catheter. Review of the resident's POS, dated July 2023, showed the physician's orders directed staff as follows: -Lisinopril (used to treat high blood pressure) 5 mg one tablet by mouth daily; -Quetiapine (used to treat agitation and aggression) 50 mg one tablet by mouth daily; -Carvedilol (used to treat high blood pressure) 3.125 mg one tablet by mouth twice daily; -Gabapentin (used to treat nerve pain) 300 mg one capsule by mouth twice daily; -Quetiapine (used to treat schizophrenia, bipolar disorder, and depression) 75 mg one tablet by mouth at bedtime; -Memantine (used to treat dementia) 5 mg one tablet by mouth twice daily; -Atorvastin (used to treat high blood pressure) 40 mg one table at bedtime; -Donepezil (used to treat dementia) 10 mg one tablet at bedtime; -Health shakes twice daily; -Foley catheter care every shift; -Cleanse wound on left stump with wound cleanser, apply triple antibiotic ointment cover with a two by two gauze and tape. Change daily; -Cleanse wound on stump with pure and clean, apply xeroform (type of wound dressing),gauze, foam, and tape. Change daily. Review of the resident's MAR, dated June 2023, showed staff did not document they administered the resident's Gabapentin, quentiapine 75 mg, memantine, atorvastin, donepezil, and health shakes on 6/29/23 and 6/30/23 as directed. Review of the resident's MAR, dated June 2023, showed staff did not document they administered the resident's quentiapine 50 and Lisinopril on 6/30/23 as directed. Review of the resident's TAR, dated June 2023, showed staff did not document they provided Foley catheter care on 6/4/23 and 6/30/23 as directed. Review of the resident's TAR, dated June 2023, showed staff did not document they provided the resident's wound care treatment with triple antibiotic ointment on 6/4/23 as directed. Review of the resident's TAR, dated June 2023, showed staff did not document they provided the resident's wound care treatment with xeroform, gauze, and tape on 6/30/23 as directed. 5. Review of resident #4's admission MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Bilateral primary osteoarthritis of knee (wearing down of the protective tissue at the ends of bones and worsens over time) and disorder of the kidneys and ureter (duct between the kidney and bladder); -Indwelling urinary catheter. Review of the resident's POS, dated June 2023 through July 2023, showed the physician's orders directed staff as follows: -Lidocaine (used to treat pain) patch 4% apply topically daily; -Foley catheter care every shift. Review of the resident's MAR, dated June 2023, showed staff did not document they administered the resident's lidocaine on 6/12/23 as directed. Review of the resident's TAR, dated June 2023, showed staff did not document they provided Foley catheter care on 6/24/23 and 6/25/23 as directed. Review of the resident's MAR, dated July 2023 showed the staff did not document they provided the resident's lidocaine patch on 7/1/23, 7/2/23, 7/3/23, 7/4/23, 7/5/23, 7/6/23, 7/7/23, 7/8/23, 7/9/23, 7/10/23, and 7/11/23 as directed. 6. During an interview on 7/13/23 at 1:35 P.M., the Registered Nurse (RN) said a hole on the MAR or TAR means the medication was not given and the DON should be notified. He/She said the Certified Medication Aide's (CMT's) and nurses are responsible for initialing the MAR or TAR upon giving the medication or providing the treatment. He/She said the DON is responsible for making sure the MAR and TAR are completed by staff. During an interview on 7/13/23 at 1:44 P.M., the CMT said a hole in the MAR or TAR means staff forgot to sign the medication or treatment was completed. He/She said it could also mean the medication or treatment was not completed. He/She said the CMT's and nurses are responsible for completing the MAR and TAR. He/She said he/she does not know who is responsible for making sure the MAR and TAR are initialed. During an interview on 7/13/23 at 1:49 P.M., MDS said a hole on the MAR or TAR would mean staff forgot to sign out the medication because there is always staff there to pass medications and complete treatments. He/She said the nurses and CMT's are responsible for documenting in the MAR or TAR and the DON is responsible for making sure the MAR and TAR are completed by staff. During an interview on 7/13/23 at 1:58 P.M., the administrator said a hole in the MAR or TAR means the medication or treatment was not completed. He/She said the CMT's and nurses are responsible for signing the MAR and TAR. He/She expects staff to let the DON know about the hole in the MAR or TAR. He/She said it is the DON's responsibility to make sure staff are initialing the MAR and TAR. During an interview on 7/13/23 at 2:41 P.M., the DON said a hole in the MAR or TAR means staff forgot to sign off or the medication or treatment was not completed. He/She said the nurses and CMT's are responsible for making sure the MAR and TAR are completed. He/She said he/she does audits on the MAR and TAR to catch when there are holes. He/She expects staff to let him/her know if there is a hole. MO00221275

Based on record review and interview, facility staff failed to keep eight residents (Resident #6, #11, #14, #15, #17, #38, #189 and #190) from going into a negative balance, which allowed the residents to spend another resident's money without written authorization and failed to maintain written authorization to manage funds for two residents (Resident #1 and #18). The facility census was 35. 1. Review of the facility's Management of Resident's Personal Funds policy, revised in March 2021 showed: -Should the resident elect to have the facility manage his or her personal funds, it is authorized in writing by the resident or the resident's representative, and a copy of such authorization is documented in the resident's medical record; -The resident is informed in advance of any charges imposed to his or her personal funds. 2. Review of the facility's maintained Trust Account Statement for the period 01/01/21 through 12/31/22, showed Resident #6's account went into a negative balance on the following dates: -On 04/30/22 the balance was -$37.20; -On 10/31/22 the balance was -$11.55. 3. Review of the facility's maintained Trust Account Statement for the period 01/01/21 through 12/31/22, showed Resident #11's account had a negative balance of -$10.82 in all 12 months. 4. Review of the facility's maintained Trust Account Statement for the period 01/01/21 through 12/31/22, showed Resident #14's account went into a negative balance on 01/31/22 for the amount of -$1.09. 5. Review of the facility's maintained Trust Account Statement for the period 01/01/21 through 12/31/22, showed Resident #15's account went into a negative balance on 01/31/22 for the amount of -$1.52. 6. Review of the facility's maintained Trust Account Statement for the period 01/01/21 through 12/31/22, showed Resident #17's account went into a negative balance on the following dates: -On 11/30/22 the balance was -$22.67; -On 12/31/22 the balance was -$22.67; -On 01/27/23 the balance was -$22.67. 7. Review of the facility's maintained Trust Account Statement for the period 01/01/21 through 12/31/22, showed Resident #38's account went into a negative balance on 01/31/22 for the amount of -$2.96. 8. Review of the facility's maintained Trust Account Statement for the period 01/01/21 through 12/31/22, showed Resident #189's account went into a negative balance on the following dates: -On 01/31/22 the balance was -$2.73; -On 04/30/22 the balance was -$4.62. 9. Review of the facility's maintained Trust Account Statement for the period 01/01/21 through 12/31/22, showed Resident #190's account went into a negative balance on the following dates: -On 02/28/22 the balance was -$30.00; -On 03/31/22 the balance was -$30.00; -On 04/30/22 the balance was -$30.00. 10. Review of Resident #1's medical record showed the record did not contain written authorization to manage funds for the resident. 11. Review of Resident #18's medical record showed the record did not contain written authorization to manage funds for the resident. 12. During an interview on 01/27/23 at 11:15 A.M., the Business Office Manager (BOM) said he/she just started as BOM in the past few months. He/She said a resident should not have a negative trust account balance and there should be a written authorization to manage funds in the resident's records. During an interview on 01/27/23 at 3:03 P.M., the administrator said the facility should have written authorization to manage resident trust funds and a resident's trust account should never be negative. The administrator said the BOM is responsible for managing the resident trust fund.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, facility staff failed to provide a safe, clean, homelike and comfortable environment when staff failed to maintain resident rooms, common areas and the building structure clean and in good repair. The facility census was 35. 1. Review of the maintenance director's inspection checklist for residents' rooms for the month of January, 2023 showed rooms #12, ##13, #21, #15, #18, #34, #25, and #23 were checked off as not needing repairs or maintenance. Observation on 1/24/23 at 10:42 A.M., showed the floor of room [ROOM NUMBER] with food and debris on it. Further observation showed ants crawling on the sink and the sink vanity. The transition strip from the hall flooring into the room was tall and in disrepair. The wall trim was off and lay on the floor. Additionally, residents were observed to have difficulty pushing their wheelchairs over the floor strip. Observation on 1/24/23 at 11:00 A.M., showed the floor of room [ROOM NUMBER] with a black/brown sticky substance in the spaces between sections of flooring. Further observation showed the privacy curtain and bathroom door jams with several stains on them. Additional observation showed spilled food from breakfast on the bedside table and on the floor by the resident's bed. Observation on 1/24/23 at 11:05 A.M., showed room [ROOM NUMBER] the trim on the floor between the hallway and the resident room was damaged and raised higher then the flooring. Observation on 1/24/23 at 11:10 A.M., showed the floor of room [ROOM NUMBER] with tears in the flooring and food debris on the floor. Additional observation showed the walls and door trim were damaged. Observation on 1/24/23 at 11:18 A.M., showed the floor of room [ROOM NUMBER] with holes in the flooring material. Additional observation showed the trim in the bathroom between the wall and floor falling away from the wall. Further observation showed the transition strip on the floor between the hall and the room damaged and raised up from the floor. Observation on 1/24/23 at 11:30 A.M., showed the carpet in the nurse desk area and down the length of 100 hall to be worn and heavily stained with dark stains. During an interview on 1/27/23 at 10:08 A.M., the housekeeping regional director said he/she took over in August of 2022 and this was the first time his/her staff cleaned the carpets in this building. Observation on 1/24/23 at 2:14 P.M., showed the floor in room [ROOM NUMBER] was sticky. Additionally, the room had a strong urine odor and the floor under the toilet tank wet, the walls around the toilet were urine stained with a brown substance and rust around base of toilet. Further observation showed rust on the bathroom door frame and part of the baseboard missing. Observation on 1/24/23 at 3:01 P.M., showed the bathroom floor of room [ROOM NUMBER] was soiled and there was a brown substance around base of the toilet. Additional observation showed a square blue plastic lid with a brown substance and a toilet plunger in it next to the toilet. Observation on 1/25/23 at 10:00 A.M., of room [ROOM NUMBER], an unused shower room, showed a brown wet substance spread on the floor and soiled clothing on the floor. During an interview on 1/25/23 at 3:34 P.M. Registered Nurse (RN) G said the plumbing is out of service for room [ROOM NUMBER], an unused shower room, and should not be in use. Observation on 1/25/23 at 10:39 A.M., showed the transition strip from the hall to resident room [ROOM NUMBER] was missing and replaced with duct tape. Additional observation showed the duct tape was torn and soiled. Observation on 1/25/23 at 3:17 P.M., showed the vinyl flooring in room [ROOM NUMBER] was sticky and had tears inside the door and a hole next to the resident's bed. Additionally, there were brown splash stains on the room privacy curtain. Further observation showed the room's bathroom showed brown splash marks on the walls and floor around toilet, and rust on the bathroom door frame. Observation on 1/26/23 at 10:22 A.M., showed room [ROOM NUMBER]'s floor with food on it and a dried dark stain. Observation on 1/26/23 at 10:30 A.M., showed room [ROOM NUMBER] with a black/brown raised substance in the joints of the flooring material throughout the entire room. Observation on 1/26/23 at 10:40 A.M., showed room [ROOM NUMBER] with ants crawling on the sink and the sink vanity. During an interview on 1/26/23 at 11:18 A.M., Housekeeper B said the resident room floors are mopped and bathrooms are cleaned every day. He/She said there are not enough staff to keep up and they are trying to hire more people. During an interview on 1/27/23 at 8:21 A.M., the activity director said housekeeping staff are aware of the stains on the flooring and scrub it with cleaning supplies but the stains come back. During an interview on 1/27/23 at 8:34 A.M., the director of nursing (DON) said the existing flooring should be cleaned better while waiting on replacement flooring. During an interview on 1/27/23 at 9:00 A.M., the administrator said housekeeping staff have been given a cleaning direction list. He/She said the existing floors should have more being done to keep them clean. 2. Review of the facility's Construction/Renovations policy, dated 09/19/22, showed Where major renovations, alterations, or modernizations are made the most current applicable code shall be enforced. Review showed the policy did not include information related to the repair of damage areas of the building. Observation on 01/27/23 at 10:00 A.M., showed the door to the center core housekeeping storage room, which also contained a functional shower, unlocked and unattended by staff. Observation showed a large section of the ceiling missing in the area where staff stored a mechanical lift and floor care equipment. Observation showed insulation, wood beams and plumbing pipes exposed in the ceiling and water dripped from the exposed pipes. Observation also showed yellow caution tape draped across entrance to the area. During an interview on 01/27/23 at 10:10 A.M., the Infection Preventionist said the room had plumbing issues which he/she believed started in May 2022 and there was some issue with getting it fixed. The Infection Preventionist said the shower in the room is still used for residents, but the door to the room should be closed and locked when not in use. During an interview on 01/27/23 at 11:30 A.M., the maintenance director said the ceiling in the housekeeping storage room had been that way throughout the duration of his/her employment at the facility which began about one and a half years ago. The maintenance director said he/she had not done anything to repair the room because he/she wanted to remodel the hole room. The maintenance director said he/she did not know about the water dripping from the pipe. The maintenance director also said the door to the room should be locked and residents should not use the room for bathing. Observation on 01/27/23 at 12:45 P.M., showed a large hole in the soffit (the underside of an architectural structure) to the roof adjacent to the fire pump room. Observation showed the hole created by broken and rotted wood and the hole exposed the interior support beam and joists of the structure. During an interview on 01/27/23 at 12:45 P.M., the maintenance director said the soffit had been that way throughout the duration of his/her employment which began one and a half years ago. The maintenance director said he/she had not contacted anyone to repair the soffit and he/she had planned to fix the soffit damage him/herself, but had not had the time to do so due to other things in the facility taking higher priority. During an interview on 01/27/23 at 4:30 P.M., the administrator said the maintenance director is responsible to maintain the building structure and make repairs as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to ensure hazardous chemicals were stored in safe manner not accessible to residents, failed to provide safe mechanical lift transfers for two residents (Residents #11 and #12) and failed to propel two residents (Residents #27 and #8) in a wheelchair in a manner to prevent accidents. The facility census was 35. 1. Review of the facility's policies provided showed the staff did not provide a policy for the storage of chemicals. Observation on 01/24/23 at 9:35 A.M., showed the door to room [ROOM NUMBER] unlocked and unattended by staff. Observation showed the room under construction and used for the storage of toxic chemicals which included paint, floor adhesive, and disinfectant spray. Observation showed residents traversed in the hallway by the room. Observation on 1/25/23 at 10:00 A.M., showed an unused shower room was unlocked and unattended by staff. Further observation showed the room contained a open pine scented cleaning solution that was within reach of residents. Observation on 01/27/23 at 10:00 A.M., showed the door to the center core housekeeping storage room, which also contained a functional shower, unlocked and unattended by staff. Observation showed a large section of the ceiling missing in the area where staff stored a mechanical lift and floor care equipment. Observation showed insulation, wood beams and plumbing pipes exposed in the ceiling and water dripped from the exposed pipes. Observation also showed yellow caution tape draped across entrance to the area. During an interview on 01/27/23 at 10:10 A.M., the Infection Preventionist said the room had plumbing issues which he/she believed started in May 2022 and there was some issue with getting it fixed. The Infection Preventionist said the shower in the room is still used for residents, but the door to the room should be closed and locked when not in use. During an interview on 01/27/23 at 11:30 A.M., the maintenance director said the ceiling in the housekeeping storage room had been that way throughout the duration of his/her employment at the facility which began about one and a half years ago. The maintenance director said he/she had not done anything to repair the room because he/she wanted to remodel the hole room. The maintenance director said he/she did not know about the water dripping from the pipe. The maintenance director also said the door to the room should be locked and residents should not use the room for bathing. Observation on 01/27/223 at 10:33 A.M., showed a 24 ounce bottle of toilet bowl cleaner with bleach and a one quart bottle of porcelain bowl and surface cleaner stored unsecured by the toilet in the shared toilet room between the activity office and resident occupied room [ROOM NUMBER]. Observation of the product label for the porcelain cleaner showed a warning that stated the product was corrosive. Observation showed the door to the activity office unlocked and unattended by staff and the resident in room [ROOM NUMBER] in bed. Observation on 01/27/23 at 10:55 A.M., showed the door to unoccupied resident room [ROOM NUMBER] unlocked and the room unattended by staff. Observation showed a one quart bottle of porcelain bowl and surface clean unsecured in the room. Observation on 01/27/23 at 11:05 A.M., showed the door to the storage room located across from the medication cart storage room unlocked and the room unattended by staff. Observation showed a can of foam fire block penetration sealer stored unsecured in the room. Observation of the product label on the can showed warnings that the products was toxic and hazardous to humans. Observation on 01/27/23 at 11:08 A.M., showed the key to the housekeeping supply room door hung exposed on the wall beside the door which allowed public access to the room. Further observation showed multiple bottles of cleaning chemicals, which included a corrosive lime descaler, corrosive commercial porcelain bowls and surface cleaner, quaternary ammonium disinfectant , glass and multi-surface cleaner, and heavy duty antibacterial cleaner. Observation of the product labels for the chemicals showed the labels contains warnings that the chemicals were toxic, hazardous to humans and/or corrosive. During an interview on 01/27/23 at 11:30 A.M., the maintenance director said the key to the housekeeping supply room had hung by the door throughout his/her employment at the facility which began about one and a half years ago and he/she was told by management that the arrangement was acceptable to the state. The maintenance director said they key hung by the door would make the contents of the room accessible to residents and there were residents in the facility that would know how to use the key. During an interview on 01/27/23 at 1:25 P.M., the maintenance director said chemicals should not be stored accessible to residents and doors to hazardous areas should self-close, lock and latch. The maintenance director said he/she did not know about the issues with the doors. During an interview on 01/27/23 at 4:30 P.M., the administrator said he/she did not have a policy for the storage of chemicals, but chemicals should be stored behind a locked door and not accessible to residents. The administrator said all staff are responsible for the proper storage of chemicals and all staff had been trained how to properly store chemicals. 2. Review of the Invacare Reliant 600 Hoyer Lift manual showed staff were directed as follows: -The legs of the lift must be in the maximum open position and the shifter handle locked in place for optimum stability and safety. If it is necessary to close the legs of the lift to maneuver the lift under a bed close the legs of the lift only as long as it takes to position the lift over the patient and lift the patient of the surface of the bed. When the legs of the lift are no longer under the bed return the legs of the lift to the maximum position and lock the shifter handle immediately. Review of Resident #11's annual minimum data set (MDS), dated [DATE], a federally mandated assessment tool, showed staff assessed the resident as follows: -Severe cognitive impairment; -Totally dependent on two plus staff for transfers. Observation on 1/24/23 at 2:00 P.M., showed Certified Nursing Assistant (CNA) F and Nursing Assistant (NA) H used a mechanical lift to transfer the resident from his/her wheelchair to his/her bed. Observation showed CNA F did not widen the lifts legs to the maximum open position when he/she lifted the resident from a wheelchair and then turned the resident. The CNA then pushed the resident to the bed where NA H assisted lowering the resident to the bed. The mechanical lift legs remained closed during the transfer. During an interview on 1/24/23 at 2:15 P.M., NA H said the legs of the mechanical lift should have been left open during the transfer from the wheelchair to the bed while the resident was suspended by the lift. Review of Resident #12's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Totally dependent on two plus staff for transfers. Observation on 1/26/23 at 10:30 A.M., showed NA H and CNA F used a mechanical lift to transfer the resident from his/her wheelchair to his/her bed. The NA spread the legs of the lift to the maximum open position and pushed the lift under the wheelchair. The CNA and NA connected the resident's lift sling and began to lift the resident. The CNA did not lock the wheelchair and the NA did not lock the mechanical lift legs causing the resident to slide out of the wheelchair before being suspended by the lift. During an interview on 1/26/23 at 10:45 A.M., NA H said he/she should have locked the wheels on the lift, but he/she just forgot to do so. During an interview on 1/26/23 at 10:54 A.M., NA J said mechanical lift legs should be spread to the open position, and the wheels of the lift should be locked. During an interview on 1/26/23 11:17 A.M., Licensed Practical Nurse (LPN) C said mechanical lift legs should be spread apart and free from obstructions during transfers and the wheels should be locked when staff are lifting the resident. During an interview on 1/27/23 at 8:18 A.M., the activity director said mechanical lift legs should always be open and the wheels locked when lifting a resident. During an interview on 1/27/23 at 8:24 A.M., CNA F said mechanical lift should have the legs spread and the wheels locked. During an interview on 1/27/23 at 8:35 A.M., the director of nursing said mechanical lift legs should be spread wide for stability during transfers. During an interview on 1/27/23 at 8:59 A.M., the administrator said mechanical lift legs should be open for stability, and the wheels of a lift should be locked when lifting the resident. 3. Review of Resident #8's significant change MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Locomotion on unit set up only. Observation on 1/24/23 at 11:45 A.M., showed CNA F propelled the resident in a wheelchair without footrest at a rapid rate from the nurse's desk down the hall to the resident's room. The residents feet slid along the flooring during the entire move. Review of Resident #27's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Locomotion on unit set up only. Observation on 1/25/23 at 10:30 A.M., showed CNA I propelled the resident in a wheelchair without footrests from the dining area to the resident's room in a rapid manner. The resident's feet slid along the floor during this move from room to room. During an interview on 1/26/23 at 10:54 A.M., NA J said wheelchairs should have footrests locked into the chair, residents should not be pushed without footrest. During an interview on 1/26/23 11:17 A.M., Licensed Practical Nurse (LPN) C said wheelchair footrests should be placed on the wheelchair when pushing a resident also staff should go slow. During an interview on 1/27/23 at 8:18 A.M., the activity director said staff should make sure the footrests are on the wheelchair and the resident's feet are on on them. During an interview on 1/27/23 at 8:24 A.M., CNA F said residents in wheelchairs should have the footrests on if staff are pushing them, and you go slow. During an interview on 1/27/23 at 8:35 A.M., the director of nursing said residents should be pushed in a wheelchair with footrests on, they should not be moved with their feet on the floor. During an interview on 1/27/23 at 8:59 A.M., the administrator said residents should be propelled with footrests on the wheelchair when going forward.

Based on observation, interview, and record review, facility staff failed to provide oxygen as ordered by the physician for one resident (Resident #4). The facility census was 35. 1. Review of the facility's Oxygen Administration policy, revised October 2010, showed: -Verify that there is a physician's order for this procedure. Review the physician's orders for oxygen administration; -Review the resident's care plan to assess for any special needs of the resident; -Did not include usage of oxygen concentrators or BiPAP. Review of Resident #4's admission Minimum Data Set (MDS), a federally mandated resident assessment tool, dated 01/04/23, showed facility staff assessed the resident as follows: -Cognitively intact; -Diagnoses included pneumonia, chronic lung disease, obesity, atrial fibrillation (rapid beating of upper heart chambers), coronary (heart) artery disease, heart failure; -Received oxygen while a resident and while not a resident; -Used BiPAP/CPAP while a resident and while not a resident. Review of Resident #4's Physician Orders, dated January 2023 showed an order for oxygen at five liters per minute with BiPAP (Bilevel Positive Airway Pressure - machine used to support breathing and open airways) at night or when sleeping. Pressure setting 9-13 for OSA (Obstructive Sleep Apnea - airway closure when sleeping) Review of the resident's care plan dated 1/13/23, showed the staff documented problem approaches included the following: -Apply oxygen as needed; -Ensure equipment utilized appropriately; -Assist resident with BiPAP equipment each night and ensure machine is on proper settings. Observation on 1/24/23 at 10:50 A.M., showed the resident in bed with his/her BiPAP mask on. Further observation showed the oxygen concentrator was not plugged in and was not connected to the BiPAP mask. Observation on 1/26/23 at 11:26 A.M., showed the oxygen concentrator was not plugged in and did not have tubing long enough to reach the resident. Observation on 1/27/23 at 8:42 A.M., showed the oxygen concentrator was not plugged in and did not have tubing long enough to reach the resident. During an interview on 1/24/23 at 10:52 A.M., the resident said he/she had been in the facility for about one month and had not used oxygen due to bed positioning and the number of wall electrical outlets. He/She said the oxygen is supposed to be set at five liters per minute and connected to his/her BiPAP mask. He/She also said facility staff are supposed to be working on moving the bed so the oxygen concentrator could reach an electrical outlet. During an interview on 1/25/23 at 10:23 A.M., the resident said he/she did not have oxygen connected to his/her BiPAP last night. During an interview on 1/26/23 at 11:27 A.M., the resident said he/she did not have oxygen connected to his/her BiPAP last night. He/She also said facility staff were supposed to move his/her bed to be able to plug in the oxygen concentrator. During an interview on 01/27/23 at 8:43 A.M., the resident said he/she did not have oxygen connected to his/her BiPAP last night. During an interview on 1/27/23 at 8:45 A.M., LPN C said the resident had a CPAP (Continuous Positive Airway Pressure) machine and he/she thought the oxygen was with the CPAP mask. Licensed Practical Nurse (LPN) C said the resident had used oxygen with CPAP and he/she had checked and saw the oxygen connected. After observing the oxygen concentrator was not plugged in, LPN C said he/she thought it was plugged in and connected to the CPAP mask. LPN C said the nurses are responsible for making sure oxygen is set up and used as ordered. During an interview on 1/27/23 at 8:50 A.M., the Infection Preventionist (IP) said the charge nurse is responsible for proper oxygen set up and use. He/She also said facility staff are charting that oxygen is on but they are not recognizing that oxygen is not connected. The IP said the Director of Nursing (DON) is responsible for ensuring staff have been trained. During an interview on 1/27/23 at 1:14 P.M., the DON said the night shift nurse is responsible for making sure oxygen and BiPAP are used according to doctors orders. The DON also said nurses have not had formal training on BiPAP/CPAP machines.

Based on interview and record review, the facility staff failed to ensure five Nurse Aides (NA) ( NA H, NA J, NA M, NA N and NA O) completed the nurse aide training program within four months of their employment in the facility. The census was 35. 1. Review of the facility's Nurse Aide Qualifications and Training Requirements Policy, revised May 2019, showed the following: -The facility will not employ any individual as a nurse aide for more than four (4) months full-time, temporary, per diem, or otherwise; -That individual is competent to provide designated nursing care and nursing related services; -That individual has completed a training program and competency evaluation program, or a competency evaluation program approved by the state; -That individual has been deemed competent as provided in 483.150(a) and (b) of the Requirements of Participation. 2. Review of NA H's personnel file showed the following: -Date of hire as an NA was 6/22/22; -No documentation the NA had completed the nurse aide training program. 3. Review of NA J's personnel file showed the following: -Date of hire as an NA was 5/11/22; -No documentation the NA had completed the nurse aide training program. 4. Review of NA M's personnel file showed the following: -Date of hire as an NA was 12/1/21; -No documentation the NA had completed the nurse aide training program. 5. Review of NA N's personnel file showed the following: -Date of hire as an NA was 9/2/21; -No documentation the NA had completed the nurse aide training program. 6. Review of NA O's personnel file showed the following: -Date of hire as an NA was 9/28/21; -No documentation the NA had completed the nurse aide training program. During an interview on 1/27/23 at 9:22 A.M., the NA said he/she was hired on 9/28/21. He/She said he/she has been working as an NA since then and has not taken classes. He/She said he/she was waiting for classes to begin in February at the facility. 7. During an interview on 1/27/23 at 8:53 A.M., the Director of Nursing said he/she was aware there were NAs working who were not certified. He/She said on-site classes were to start in February at the facility and the NAs were enrolled. During an interview on 1/27/22 at 10:36 A.M., the Administrator said he/she was aware there were five NAs working past the four month period. He/She said he/she was dreading the conversation and knew the NAs should be certified within four months of employment as an NA. He/She said he/she applied for a training license and was approved. He/She said on-site classes will begin in February.

Based on observation, resident and staff interview, and record review facility staff failed to provide alternative meals for residents which accommodated the residents' preferences. This had the potential to affect all residents. The facility census was 35. 1. Review of the resident council minutes from 12/27/22 through 1/23/23 showed the council addressed food preferences with the facility staff. 2. Observation on 1/24/23 at 12:05 P.M., showed the menu board in the dining area to have peanut butter and jelly sandwiches posted as the only alternative to the main menu item. 3. During an interview on 1/24/23 at 10:45 A.M., Resident #12 said the facility only offers a peanut butter and jelly sandwich for an alternative meal so if he/she does not like the main menu item he/she does not eat. During an interview on 01/24/23 at 11:35 A.M., Resident #23 said sometimes the food is undercooked and cold. He/She said facility staff give him/her sausage even though he/she doesn't like it, but he/she did not know he/she could ask for something different. During an interview on 1/24/23 at 11:44 A.M., Resident #32 said he/she eats vegetables, milk and juice from the facility but other food does not agree with him/her so he/she orders food and has it delivered. The resident said he/she tried to talk to the doctor and the cook about food and they said there wasn't anything they could do. During an interview on 1/25/23 at 10:40 A.M., Resident #25 said the food is disgusting and the facility only offers a peanut butter and jelly sandwich for an alternative. During an interview on 1/25/23 at 11:00 A.M., Resident #6 said he/she does not like the food and only knows of peanut butter and jelly sandwiches being an alternative. During an interview on 01/25/23 at 4:13 P.M., Resident #17 said the food ain't right and added he/she does not like beans but they give him/her ham and beans. He/She said peanut butter is the only thing they offer as an option. During an interview on 01/26/23 at 8:47 A.M., the Activity Director (AD) said some of the residents don't like to eat certain things and he/she informs the charge nurse or dietary manager so the resident may get something different. The AD said the nurses check for resident preferences and food allergies. During an interview on 1/26/23 at 11:38 A.M., Resident #4 said staff do not offer him/her a second meal option and he/she will eat what they bring or eat food that he/she buys. He/She said during admission, facility staff told him/her there was one meal for everybody and there aren't any options. He/She was not aware of the option to ask for a sandwich. During an interview on 1/26/23 at 2:18 P.M., the resident council said the facility does not offer any other food alternatives to the main menu item other than a peanut butter sandwich. During and interview on 1/27/23 at 8:27 A.M., dietary cook K said alternatives to the main menu are offered. Residents can have leftovers or a peanut butter and jelly sandwich, or an egg sandwich. During an interview on 1/27/23 at 8:40 A.M., the dietary manager said if a resident does not like the main menu item, the are given options. He/She said residents can have soup or a leftover meal. Additionally, peanut butter and jelly sandwiches are always written on the menu board as an alternative. During an interview on 1/27/23 at 9:00 A.M., the director of nursing (DON) said there should be more than just a peanut butter and jelly sandwich offered as an alternative meal choice. During an interview on 1/27/23 at 3:03 P.M., the administrator said facility staff offer meal alternatives and they are listed on a board in the dining room. He/She said the resident council, dietary manager and dietician all address food related issues but the dietary manager is responsible and the alternative should be nutritionally balanced.

Based on observation, interview, and record review, facility staff failed to follow appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to remove soiled gloves and/or perform hand hygiene during the provision of care for two residents (Residents #12 and #16). The facility census was 35. 1. Review of the facility's Handwashing/Hand Hygiene Policy, revised August 2019, showed staff are directed to use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: -before and after direct contact with residents; -before performing any non-surgical invasive procedures; -before and after handling an invasive device (e.g., urinary catheters, IV access sites); -before handling clean or soiled dressings, gauze pads, etc.; -before moving from a contaminated body site to a clean body site during resident care; -after contact with a resident's intact skin; -after contact with blood or bodily fluids; -after handling used dressings, contaminated equipment, etc.; -after contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; -after removing gloves. 2. Observation on 1/24/22 at 3:07 P.M., showed Registered Nurse (RN) L entered Resident #16's room to provide wound care. RN L did not wash or sanitize his/her hands before he/she entered the resident's room or before he/she applied clean gloves to perform care. The RN did not wash his/her hands after he/she removed the residents soiled dressing or before he/she applied new gloves. He/She then sprayed the resident's left heel wound with cleanser, removed his/her gloves and left the room. He/She did not wash his/her hands before he/she opened/closed several drawers on the treatment cart. He/She then re-entered the resident's room and did not wash his/her hands before he/she applied new gloves. He/She removed his/her gloves, placed them on the bed and did not perform hand hygiene. He/She then applied gauze to the resident's heel without gloves, dated and initialed the tape used to hold the gauze in place. He/She picked up the dirty gloves and dressing supply trash from the resident's bed and threw the items away on the treatment cart and closed several treatment cart drawers before he/she used hand sanitizer. 3. Observation on 1/26/23 at 10:30 A.M., showed Certified Nurse Aide (CNA) F and Nurse Aide (NA) H entered Resident # 12's room to provide care and transfer the resident to bed. CNA F and NA H performed hand hygiene and applied clean gloves. CNA F lifted the resident's catheter bag out of the privacy bag. NA H emptied the urine from the catheter bag into a graduated container and emptied the graduated container into the toilet. CNA F and NA H did not change their gloves or perform hand hygiene before they continued with the transfer. CNA F and NA H touched the resident and numerous surfaces around the resident. During an interview on 1/27/23 at 2:11 P.M., CNA F said you should wash your hands any time you come in contact with a resident. You should wash hands when they are soiled. He/She said anytime you go from dirty task to clean task you should change your gloves and wash your hands. During an interview on 1/27/23 at 2:15 P.M., Licensed Practical Nurse (LPN) C said you should wash your hands often. When you enter and/or exit a resident's room, after you use the restroom or when you have touched your face. He/she said you should wash your hands before you start a procedure and put on clean gloves. He/She said when you take an old dressing off you should take your old gloves off and wash your hands and put new gloves on. During an interview on 01/27/23 02:13 P.M., the Director of Nursing said you should wash your hands before starting a procedure. He/She said you should put gloves on when you enter the room, remove the old dressing take your dirty gloves off and wash your hands. He/She said you should put on new gloves before you put on the new dressing. He/She said after you put on the new dressing you should take your gloves off and wash your hands.

Based on observation, interview and record review, the facility staff failed to store food in a manner to protect from potential contamination and out-dated use. Facility staff failed to perform hand hygiene as often as necessary using approved techniques to prevent cross-contamination. Facility staff failed to allow sanitized dishes to air dry prior to stacking in storage and use to prevent the growth of food-borne pathogens and cross-contamination. The facility staff also failed to wear hair restraints to protect food and food contact surfaces from potential contamination. The facility census was 35. 1. Review of the facility's Food Storage (Dry, Refrigerated, and Frozen) policy dated 2016, showed: -All food items will be labeled. The label must include the name of the food and date by which it should be sold, consumed, or discarded. -Discard food that has passed the expiration date, and discard food that has been prepared in the facility after seven days of storing under proper refrigeration. -Leftover contents of cans and prepared food will be stored in covered, labeled and dated containers in refrigerators and/or freezers. -Never leave any food item uncovered and not labeled. Review of the facility's Labeling and Dating Foods (Date Marking) policy dated 2016, showed: -Once opened, all ready to eat, potentially hazardous food will be re-dated with a use by date according to current safe food storage guidelines or by the manufacturer's expiration date. -Frozen food packages removed from the case will be dated with the date the item was received into the facility and will be stored using the first in-first out method of rotation. Once a package is opened, it will be re-dated with the date the items was opened and shall be used by the safe food storage guidelines or by the manufacturer's expiration date. -Prepared food or opened food items should be discarded when: *The food item does not have a specific manufacturer expiration date and has been refrigerated for seven days *The food item is leftover for more than 72 hours *The food item is older than the expiration date Observation on 01/24/23 during the kitchen tour, which began at 9:55 A.M., showed: -the reach-in freezer by the exit door contained opened and undated plastic bags of cookie dough rounds and bread roll dough and an undated plastic resealable bag of chicken breasts that were removed from their original packaging; -the chest freezer contained two opened and undated plastic bags of sausage patties opened, an undated and unlabeled bag of an unidentifiable diced meat; and an undated plastic resealable bag of boneless ham. Observation showed the ham covered with ice crystals. -the reach-in refrigerator in corner of cook's station contained: *an opened and undated five pound container of commercially prepared macaroni salad; *an opened and undated five pound container of cottage cheese; *an undated four quart plastic storage container of previously prepared peas; *an opened and undated five pound bag of shredded cheddar cheese; *an opened and undated five pound bag of salad mix; *a case of precooked bacon opened to the air and undated. During an interview on 01/24/23 at 10:05 A.M., the Dietary Manager (DM) said staff should label, date and seal all opened food items before they are put away. The DM said, while staff had been trained on how to store food properly, he/she has to tell them over and over that everything has to have a date on it. The DM said he/she is responsible to check the food every morning and afternoon to make sure it is stored appropriately. The DM said he/she checked the food storage that morning and probably saw the undated and unlabeled food items, but just did not pay that much attention to it. The DM said if he/she finds food not stored appropriately during his/her checks, he/she should fix it which would include dating or labeling it. The DM said if he/she did not know when staff opened and food item, then the food item should be thrown away. Observation on 01/24/23 at 10:25 A.M., showed the dry goods pantry contained a bulk container of flour, dated 10/22, stored on the bottom shelf of the shelving unit which also contained containers of oven cleaner, multipurpose cooktop cleaner, multipurpose antibacterial cleaner and disinfectant and foaming cleanser. During an interview on 01/27/23 at 3:27 P.M., the administrator said the DM is responsible to monitor food storage daily. The administrator said opened food items should be dated and timed and frozen food should be discarded when it shows signs of deterioration which would include an accumulation of ice crystals. The administrator said food items should be stored sealed and chemicals should not be stored near food. 2. Review of the facility's Proper Hand Washing and Glove Use policy, dated 2016, showed: the policy directed staff to wash their hands upon entering the kitchen from another location; between tasks; before and after handling foods; after they touch any part of the uniform, face, or hair; before donning gloves and after removing gloves. Review also showed the policy directed staff to change their gloves anytime handwashing would be required. Observation on 01/24/23 at 10:37 A.M., showed the DM lifted the trash can lid with his/her gloved hands to dispose of trash. Observation showed, without removing his/her gloves and performing hand hygiene, the DM continued to prepare food items for service to residents at the noon meal. Observation on 01/24/23 from 11:06 A.M. to 11:30 A.M., showed the DM washed his/her hands at the handwashing sink. Observation showed the DM turned the faucet off with his/her wet bare hands and prepared a beverage in a Styrofoam cup for service to a resident. Observation showed the DM then donned a pair of gloves and removed a pan of sweet potatoes from the oven, removed the foil and checked the internal temperature of the sweet potatoes with a thermometer. Observation showed the DM wrapped the pan with aluminum foil, put the pan back in oven, removed his/her gloves and then used his/her bare hands to lift the trash can lid to dispose of the soiled gloves. Observation showed, without performing hand hygiene, the DM used his/her cell phone, reviewed menus, adjusted his/her facemask, obtained a metal food preparation/service pan from the storage rack, got a cooking utensil, donned a pair of gloves, stirred the peas cooking on the stove, and checked the internal temperature of the peas with a thermometer. Observation showed the DM poured the cooked peas into a pan and placed the pan on the steamtable. Observation showed the DM removed his/her gloves, used his/her bare hands to lift the trash can lid to dispose of the soiled gloves, adjusted his/her facemask and, without performing hand hygiene, donned another pair of gloves and frosted the cake for service to residents at the lunch meal. Observation showed the DM removed his/her gloves, pulled up his/her pants, used his/her bare hands to lift the trash can lid to dispose of the soiled gloves, and, without performing hand hygiene, donned a pair of gloves and portioned cake into Styrofoam bowls for service to residents at the lunch meal. Observation showed the DM touched the cake with his/her gloved finger as he/she put the cake into bowls. Observation showed the DM removed his/her gloves, used his/her bare hands to lift the trash can lid to dispose of the soiled gloves, donned a new pair of gloves, and placed lids on the bowls of cake. Observation showed the DM then picked up two pieces of cake with his/her gloved fingers, put the cake into a bowl and sat the bowl down on counter by food processor. Observation showed the DM removed his/her gloves, lifted the trash can lid with his/her bare hands to dispose of the soiled gloves and, without performing hand hygiene, donned a pair of gloves, removed the pan of sweet potatoes from oven and checked the internal temperature of the sweet potatoes with a thermometer. During an interview on 01/24/23 at 11:31 A.M., the DM said staff should wash their hands in between tasks which would include after they touch a trash can lid, their clothes and facemasks and between glove changes. The DM said staff should scrub their hands with soap and water for 10 seconds when they wash their hands and then use paper towel to turn off faucet. The DM said staff should never turn the faucet off with their bare hands. The DM said he/she just got in a hurry and thought he/she had washed his/her hands when needed. Observation on 01/24/23 at 11:54 A.M., showed the DM washed his/her hands at the handwashing sink. Observation showed the DM scrubbed his/her hands with soap for five seconds, rinsed and dried his/her hands, donned a pair of gloves and then portioned prepared peas from the steamtable into a metal food preparation/service pan. Observation showed the DM used the peas to prepare pureed peas for service to resident on pureed diets at the lunch meal. Observation on 01/24/23 at 12:04 P.M., showed the DM washed the food processor at the mechanical dishwashing station with his/her gloved hands, removed his/her soiled gloves and, without performing hand hygiene, put away sanitized dishes from the clean side of the station. Observation showed the DM then washed his/her hands at the handwashing sink. Observation showed the DM scrubbed his/her hands for five seconds, rinsed and dried his/her hands and then removed the food processor from dishwasher. Observation showed the DM placed the food processor on its base, donned a pair of gloves, removed milk from the reach-in refrigerator, added prepared cake and milk to food processor to prepare pureed cake for service to residents on pureed diets at the lunch meal. Observation showed the DM washed the food processor at mechanical dishwashing station with his/her gloved hands, removed his/her soiled gloves and, without performing hand hygiene, picked up bowls of pureed cake with his/her hand placed over the top of bowls and placed the bowls on the countertop next to additional bowls of prepared cake. Observation showed the DM washed hands at handwashing sink for five seconds, dried his/her hands and then placed a lid on top of a bowl of pureed cake. Observation on 01/27/23 at 3:00 P.M., showed DA A donned a hairnet, touched his/her facemask and, without performing hand hygiene, prepared drinks in carafes for service to residents. During an interview on 01/27/23 at 3:20 P.M., the administrator said staff should wash their hands between tasks, when visibly soiled, after they touch anything dirty which would include the trash cans, and before and after glove use. The administrator said when staff wash their hands, they scrub their hands with soap for 20 seconds, rinse and dry their hands and then use another paper towel to turn off the faucet. The administrator said staff should be trained on proper handwashing procedures upon hire. 3. Review of the facility's Dishwashing: Machine Operation policy dated 2016, showed the policy directed staff to Use clean, washed hands to pull out clean racks, and allow to air dry before putting dishes away for storage. Observation on 01/24/23 at 10:20 A.M., showed a large stack of black service trays stacked together wet on the countertop by the steamtable. Observation on 01/24/23 at 12:17 P.M., showed the DM removed the food processor from the dishwasher while wet and placed the food processor on its base. Observation showed the DM then prepared pureed bread in the food processor to serve to residents on pureed diets at the lunch meal. Observation on 01/27/23 at 3:04 P.M., showed 11 insulated domed plate covers stacked together wet upside down on the storage shelf. During an interview on 01/27/23 at 3:06 P.M., the DM said after dishes are washed they should air dry before they are stored or used and all staff are trained on this requirement. The DM said he/she should have allowed the food processor to air dry before he/she used it, but he/she just did not think about it at the time. During an interview on 01/27/23 at 3:18 P.M., the administrator said staff should allow dishes to air dry after they are washed and before they are put away and used. The administrator said the DM is responsible to monitor dish washing and storage every time the dishes are washed. 4. Review of the facility's Hair Restraints policy, dated 2016, showed the policy directed all Dining Services staff to wear hair restraints in all food production, dishwashing and serving areas to prevent hair from contacting exposed food. Observation on 01/24/23 from 9:45 A.M. to 1:30 P.M., showed the DM prepared food for and served food to residents at the lunch meal without wearing a hair restraint. Observation on 01/27/23 at 2:58 P.M., showed DA A put away sanitized dishes from the clean side of the mechanical dishwashing station without wearing a hair restraint. During an interview on 01/27/23 at 3:00 P.M., the DA said he/she did not have a hair restraint on because he/she just got there. The DA said he/she had been trained to put on a hairnet as soon as he/she enters the kitchen and does any tasks. During an interview 01/27/23 at 3:07 P.M., the DM said staff are to put on a hairnet as soon as they walk in the kitchen door and do any tasks. The DM said he/she usually puts a hair restraint on the back of his/her hair and he/she and did not think about the sides of his/her hair being long and loose. The DM said he/she should have worn a hairnet when he/she prepared and served food to residents on 01/24/23. During an interview on 01/27/23 at 3:16 P.M., the administrator said kitchen staff should wear hair restraints and they should put them on when they enter the kitchen before they do any tasks. The administrator said the staff are trained on the use of hair restraints upon hire.