**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one resident (Resident #1), in a review of five sampled residents, remained free from misappropriation of property. Certified Nurse Aide (CNA C) took the resident's wallet containing cash and the resident's debit card without the resident's knowledge or permission and used the debit card to pay Instant Credit Auto $450.00 (loan company for car loans), Spectrum (an internet and cable provider) $378.00 and $139.29 at Five Below (a retail store). The facility census was 53. On 9/11/25 at 12:30 P.M. the administrator was notified of the past non-compliance which occurred on 9/5/25. On 9/8/25, the administrator became aware of the violation of misappropriation of the resident's debit card and cash by CNA C when the resident logged onto his/her bank account and found the money had been withdrawn from the account. CNA C was an agency aide, and the agency was notified on 9/8/25 that the aide could not return to the facility. Staff were in-serviced on 9/8/25 of the facility policy for misappropriation and of the facility policy for locking cabinets in each resident's room. Each residents' and/or the responsible parties' preference for a locking cabinet was reviewed and revised as needed. The deficiency was corrected on 9/10/25. Review of the undated facility policy for Resident Abuse, Neglect, Misappropriation of Resident Property and Alleged Crime showed the following:-The facility affirms the right of our residents to be free from misappropriation of resident property. The facility is committed to establishing a resident sensitive and secure environment;-Misappropriation of resident property is the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent. Review of Resident #1's face sheet showed the following:-admitted to the facility on [DATE] with diagnoses of injury to the head and weakness.-The resident was his/her own responsible party and decision maker. During an interview on 9/11/25 at 10:25 A.M. Resident #1 said the following:-He/She admitted to the facility on [DATE] from a local hospital to have some therapy and to return home;-He/She had brought his/her wallet with $94.00 in it and debit cards and placed the wallet in the top drawer of the nightstand;-He/She did not know who came into his/her room for the first couple of days, but on 9/8/25 when he/she felt better, he/she checked his/her bank account on the computer and noticed money was used to pay a car payment, a Spectrum bill and at 5 Below;-He/She looked for his/her wallet and the wallet was gone;-He/She told a staff member; the Social Services Director and the Director of Nurses (DON) have been in to speak with him/her;-They called the police and replaced his/her wallet and the $94.00 that was in the wallet;-The police officer came and took his/her statement and a copy of the charges that were made on his/her bank account. Review of the facility staffing sheet dated 9/5/25-9/6/25 showed CNA C was assigned to provide care for the resident from 7:00 P.M. to 11:45 P.M. During an interview on 9/11/25 at 12:15 P.M. the Social Services Director (SSD) said the following:-The charge nurse reported Resident #1 said someone took his/her wallet, cash and debit cards and made charges and a purchase with the debit card;-She informed the DON, who called the police and began an investigation;-A police officer came and took some information from the resident and a copy of the resident's bank information. During an interview on 9/11/25 at 10:00 A.M. the DON said the following:-Following the report from the SSD she immediately called the police and began an investigation;-A police officer from the local police department came to the facility and was given a copy of the resident's bank account information;-The officer took this information and found that Certified Nurse Aide (CNA)C had used the resident's bank card and paid his/her car payment for $450.00, paid $383.00 to Spectrum and spent $105.00 at 5 Below;-CNA C was an aide from an agency, the facility called the agency and reported this to them and that CNA C would not be allowed to return to the facility. During an interview on 9/12/25 at 3:50 P.M. Police Officer A said the following:-He/She responded to a call from the facility on 9/8/25. The resident confirmed he/she had a missing wallet and debit card. The resident pulled up his/her bank account information on his/her computer and showed that purchases were made at Instant Credit Auto for $450.00 on 9/7/25, Spectrum for $378.00 on 9/6/25 and $139.29 at 5 Below on 9/7/25;-He/She called Spectrum and Instant Credit Auto and verified the bank account information that was used to pay those bills and the address that was on the bills matched the address used by CNA C. During an interview on 9/11/25 at 2:00 P.M. the Administrator said the following:-He would consider this misappropriation of the resident's property;-The facility replaced the resident's wallet and the cash that was in the wallet;-The resident's bank cancelled the debit card and was replacing the money that was taken;-The agency that CNA C was employed at was told of the incident and the investigation pending by the local police department;-CNA C will not be allowed to work in the facility again. #2610932

Based on interview and record review the facility failed to ensure one resident (Resident # 1 ) in a review of eleven residents was free from verbal and mental abuse when Dietary Aide E threw a ceramic dinner plate towards the resident, hitting the wall behind the resident, shattering the plate and called the resident a fucking bitch. The facility census was 50. On 12/19/24 at 11:00 A.M. the administrator was notified of the past non-compliance which occurred on 12/15/24. On 12/15/24 the administrator identified Dietary Aide E verbally and physically abused Resident #1. Upon discovery, staff suspended Dietary Aide E, conducted an investigation and notified appropriate parties. Staff reviewed the abuse and neglect policies, and all facility staff was educated on the facility abuse and neglect policies. Dietary Aide E was terminated. The deficiency was corrected on 12/16/24. Review of the facility abuse policy, dated July 2017, showed the following: -It was the policy of the facility that all residents are to be free from abuse or neglect of a physical, emotional, verbal or sexual nature and from misappropriation of property; -Upon hiring and annually, employees will be trained on identifying resident abuse and neglect and how to go about reporting an incident; -All claims of resident neglect, abuse or misappropriation of property should be reported to the Administrator/delegate immediately; -The Administrator will promptly investigate all such claims; -The resident shall be protected throughout the investigation by removing the individual involved in the incident; -If there is evidence of any of the above, the individual involved will be immediately suspended without pay. The Administrator shall immediately notify the Department of Health and Senior Services (DHSS) and if necessary, local law enforcement. An investigation will then be conducted; -If the complaint was found to be true, the individual involved will be immediately terminated from employment; -Abuse is defined as any physical or mental injury or sexual assault inflected upon a resident other than by accidental means in a facility. Abuse was the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical, mental, emotional pain or anguish; -Verbal abuse is any use of oral, written or gestured language that includes disparaging and derogatory terms to residents or their families, or within their hearing distance to describe residents, regardless of their age, ability to comprehend, or disability; -Physical abuse is hitting, slapping, pinching, kicking, etc. It also includes controlling behavior through corporal punishment; -Mental abuse is defined as, but not limited to, humiliation, harassment, threats of punishment, or withholding of treatment or services. 1. Review of Resident #1's undated Face Sheet showed diagnoses of heart failure, arthritis, pain in shoulder and knee, diseases of the respiratory system, abnormal posture, and depression. Review of the resident's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument, completed by facility staff), dated 10/7/24, showed the following: -Cognitively intact; -No hallucinations or delusions; -No behaviors directed towards others; -Mobile with walker with staff assistance or with motorized wheelchair independently; -Required set up help with eating, transfers and personal hygiene. Review of the resident's Care Plan, revised 10/18/24, showed the following: -Required assistance with Activities of Daily Living (ADLs). Staff should allow the resident to express feelings of frustration and inadequacy, assume unhurried manner and allow ample time for tasks, encourage the resident to complete tasks as able with assist from staff only as needed to promote independence; -Alert and oriented and cognitively intact. Staff should allow the resident to make choices pertaining to care, offer reminders when meals occurred, supervise and assist with decision making as needed and talk to the resident during care and explain procedures; -Right to a dignified existence and treated with respect, dignity and freedom from abuse. Review of the resident's Nurses' Note, dated 12/15/24 at 12:03 P.M., showed the Director of Nursing (DON) documented the resident was in the dining room. Dietary staff was in the dining room and was asked by the resident not to throw away a banana peel and also some salsa. Dietary staff stated he/she needed to throw away the items or the items could cause bugs if not thrown out. The resident stated he/she did not want the items thrown out and that he/she would use those in the garden for compost. Dietary staff became angry and threw a plate at the wall causing the plate to shatter and fall to the floor. Dietary staff also went over and told the resident he/she was a fucking bitch. Review of the facility's Allegation of Abuse Summary report, dated 12/15/24, showed the following: -On 12/15/24 at approximately 9:10 A.M. dietary staff was in the dining room serving breakfast to Resident #1. Dietary Aide E went over to clear the garbage off the table which consisted of two banana peels and an individually portioned salsa container. Resident #1 requested Dietary Aide E not throw these items out so the resident could use the salsa again and the banana peels could be used in the garden compost. Dietary Aide E became upset and walked away from Resident #1 after telling the resident he/she would not be allowed to keep the banana peels. The banana peels could cause bugs in the facility and protocol stated he/she must throw the banana peels away. Dietary Aide E then stated to Resident #1 the salsa had to be thrown out because it was opened. Dietary Aide E came back out of the kitchen area and threw a plate at the wall directly behind Resident #1. Dietary Aide E went over to the resident's table and called the resident a fucking bitch and then left the floor; -On 12/16/24 Dietary Aide E was terminated. Review of Dietary Aide E's written statement, obtained by the DON, dated 12/15/24 at 11:30 A.M., showed Dietary Aide E said he/she was serving Resident #1 and was getting a little fed up, the recycling thing was getting out of hand. Resident #1 told Dietary Aide E not to throw away the salsa and Dietary Aide E got upset, and really angry and so mad that he/she threw a plate against the wall in the dining room. Dietary Aide E threw away the bananas and was upset, he/she told Resident #1 it caused flies and bugs. Dietary Aide E admitted he/she called Resident #1 a bitch. During an interview on 12/18/24 at 11:00 A.M. the DON said Registered Nurse (RN) A heard the plate hit the wall and came quickly. Two Certified Nurse Assistant (CNA) staff heard the plate hit the wall also and came to the dining room quickly. Dietary Aide E admitted he/she threw the plate and called Resident #1 a fucking bitch. During an interview on 12/18/24 at 2:17 P.M. the Human Resources Director said he/she saw the video recorded on 12/15/24 of Resident #1 in the dining room. The resident sat in a wheelchair eating. Dietary Aide E walked into view of the camera from the small kitchen area and Resident #1 sat directly in front of Dietary Aide E. Dietary Aide E picked up a ceramic plate from the serving area and threw the plate overhand, hit the wall behind the resident and the plate shattered. The video did not contain audio. The video footage was no longer available to view. During an interview on 12/19/24 at 9:01 A.M. CNA B said on 12/15/24 he/she was in the assist dining room and heard something break followed by, I can't stand you, you fucking bitch. CNA B went immediately to the main dining room and Dietary Aide E was shouting at Resident #1. The plate had shattered against the wall directly behind the resident, who sat in a wheelchair at a dining room table in the center of the room. Glass was all over the floor. Dietary Aide E had to have thrown the plate hard for it to shatter like that. The plate went directly over the resident's head. During an interview on 12/19/24 at 9:10 A.M. Registered Nurse (RN) A said on 12/15/24 at about 9:30 A.M. he/she was at the nurses' desk near the main dining room and heard a crash. RN A saw Dietary Aide E near the food serving area and he/she was angry and yelled bitch toward Resident #1 who sat in a wheelchair at the dining room table. Resident #1 was directly in front of Dietary Aide E when Dietary Aide E threw the ceramic plate over the resident's head and hit the wall behind the resident. Ceramic glass went everywhere. Dietary Aide E threw the plate hard, and it shattered and sprayed all over the dining room floor. Resident #1 said the plate flew over his/her head. RN A heard Dietary Aide E call the resident a bitch and was looking at Resident #1. Dietary Aide E abused the resident. During an interview on 12/19/24 at 9:45 A.M. CNA C said on 12/15/24 he/she was in the assist dining room and heard a crash and then heard, I hate you, you fucking bitch. CNA C went immediately to the main dining room and Dietary Aide E stood at the kitchen area and yelled at Resident #1. CNA C asked Dietary Aide E if he/she called the resident a fucking bitch and Dietary Aide E said yes. Resident #1 said Dietary Aide E threw the plate at him/her and the plate went over his/her head and missed hitting the resident. The glass plate shattered everywhere. Dietary Aide E abused the resident. During an interview on 12/18/24 at 12:25 P.M. Resident #1 said during breakfast time on 12/15/24 the resident was at the table. Dietary Aide E took his/her plate and the resident asked to keep the two banana peels for the garden compost. Dietary Aide E said no, it was rubbish and took the resident's plate. Then Dietary Aide E took the resident's small cup of salsa and was going to through it away. The resident asked Dietary Aide E to save it for the following day. Dietary Aide E said no and threw the salsa away. Resident #1 asked Dietary Aide E if he /she wanted the resident to tell his/her supervisor and Dietary Aide E then threw a plate over the resident's head and hit the wall behind the resident. The plate shattered. The plate was a ceramic dinner plate. Dietary Aide E threw the plate hard to shatter it like that. The resident did not know the plate was coming or that Dietary Aide E was angry. Dietary Aide E must have gotten angry when the resident asked if he/she should tell Dietary Aide E's supervisor about the banana peels and salsa. Resident #1 did not hear Dietary Aide E say anything. During an interview on 12/19/24 at 11:45 A.M. the Administrator said he was notified of the abuse allegation on 12/15/24. Dietary Aide E was terminated for abuse of Resident #1. Dietary Aide E's behavior was abusive. MO00246640

Based on observation, interview and record review, the facility failed to ensure residents were aware of posted resident rights in an easily accessible area for review at their leisure. The resident census was 49. Review of the facility's policy, Resident Rights, revised February 2021 showed the following: -Federal and state laws guarantee certain basic rights to all residents of the facility; -These rights include the resident's right to: -Communication with and access to people and services, both inside and outside the facility; -Be informed about his or her rights and responsibilities; -Communicate with outside agencies (e.g., local, state, or federal officials, state and federal surveyors, state long-term care ombudsman, protection or advocacy organizations, etc.) regarding any matter; -Copies of resident rights are posted throughout the facility. During group interview, on 10/23/24 at 10:02 A.M., seven of seven residents said they did not know where the resident rights were posted in the facility. Observation on 10/23/24 at 10:45 A.M., showed the resident rights posted along the wall around the corner from the nursing station, beside a portion of the wall and near the exit door to a different part of the facility. The location of the posted resident rights was not in a frequently traveled area for a resident in a wheelchair. The location of the resident rights on the second and third floor were in the same location. During an interview on 10/25/24 at 9:11 A.M., Registered Nurse (RN) A said the following: -Resident rights should be posted for all to see; -The location of the posted resident rights was not in an area the residents would frequently go past; -The resident rights would be better if they were in a different location for the residents to see; -Prior to the state agency (SA) showing him/her where the resident rights were posted, he/she could not have told anyone where they were posted as he/she did not realize the resident rights were posted where they were. During an interview on 10/25/24 at 9:30 A.M., the Assistant Director of Nursing (ADON) said the following: -Resident rights should be posted for all the residents to see and review; -Resident rights are posted on the first floor by the elevator and should also be at the nursing station; -The ADON was unable to show the SA where resident rights were posted. During an interview on 10/25/24 at 12:50 P.M., the Director of Nursing (DON) said resident rights should be readily accessible for residents to see and use. During an interview on 10/25/24 at 1:15 P.M., the Administrator said the following: -Resident rights should be readily accessible for resident to see and use; -He felt like the location of the resident rights was in a high traffic area.

Based on observation, interview and record review, the facility failed to protect the resident rights when the facility did not provide accessible information regarding the State Long Term Care Ombudsman program and the State Survey Agency in a location that was readily accessible and could be read by residents in the facility without assistance. The facility census was 49. Review of the facility's policy, Filing Grievance/Complaints, revised April 2017, showed the following: -Residents and their representatives have the right to file a grievance, either orally or in writing, to the facility staff or the agency designated to hear grievances (e.g. the State Ombudsman); -A copy of the grievance/complaint procedure is posted on the resident bulleting board. During group interview, on 10/23/24 at 10:02 A.M., seven of seven residents said the following: -They knew what the Ombudsman program was but was unaware of who their representative was or how to contact them; -They did not know how to contact the State Survey Agency if they had any concerns. Observation on 10/23/24 at 10:45 A.M., showed the following: -The resident rights poster was along the wall around the corner from the nursing station with the Ombudsman program number at the bottom of the poster; -The poster was located beside a portion of the wall and near the exit door to a different part of the facility; -The location of the posted Ombudsman number was not in a frequently traveled area for a resident in a wheelchair; -The posted State Survey Agency hotline number was located in a 8 x 10 inch picture frame, above the automated automatic defibrillator (AED) in an area and font type, that would be difficult for a resident to read, especially if the resident was seated in a wheelchair or had impaired vision; -The location of the Ombudsman information and State Survey Agency hotline contact information on second and third floors were in the same location. During an interview on 10/25/24 at 9:11 A.M., Registered Nurse (RN) A said the following: -Resident rights, the Ombudsman's number and state agency hotline number should be posted for all to see; -The location of the posted Ombudsman number and state agency hotline number was not in an area the residents frequently go past; -Prior to the state agency (SA) showing him/her where the Ombudsman number and state agency hotline number were posted, he/she did not realize the information was located where it was. During an interview on 10/25/24 at 9:30 A.M., the Assistant Director of Nursing (ADON) said the following: -The Ombudsman program number and state survey agency hotline number should be posted for all the residents to see and review; -She felt like the Ombudsman number and state agency hotline number should be posted in a higher traffic area for residents to see and where they are at could be hard for the residents to review. During an interview on 10/25/24 at 12:50 P.M., the Director of Nursing (DON) said the Ombudsman number and State Survey Agency hotline number should be readily accessible for residents to see and use. During an interview on 10/25/24 at 1:15 P.M., the Administrator said the following: -The Ombudsman number and State Survey Agency hotline number should be readily accessible for resident to see and use; -He felt like the location of the Ombudsman number and State Survey Agency hotline number was in a high traffic area.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff safely transported residents in wheelchairs for four residents (Residents #26, #27, #25, and #4), in review of 19 sampled residents, and for two additional residents (Residents #11 and #40). The census was 49. During an interview on 11/05/24 at 10:19 A.M., the Director of Nursing (DON) said the facility did not currently have a policy for transporting residents in wheelchairs or the use of wheelchair foot rests. 1. Review of Resident #26's undated face sheet showed the resident's diagnoses included difficulty in walking, unsteadiness on feet, psychoactive substance-induced sleep disorder, history of falls, major depression, anxiety disorder, and mild cognitive impairment. Review of the resident's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 09/25/24, showed the following: -Severe cognitive impairment; -Impaired range of motion to one side of the lower extremities; -Used a manual wheelchair; -Dependent on staff for transfers; -Supervision or touching assistance to wheel 50 to 150 feet once seated. Review of the resident's Care Plan, revised 10/10/24, showed the following: -Alert with periods of forgetfulness; -Diagnosis of dementia; -Required assistance with all activities of daily living (ADLs); -Limited physical mobility related to weakness and poor balance; -Impulsive at times, related to dementia; -High risk for falls, related to gait and balance problems; -Ensure appropriate footwear or non-skid socks worn, when ambulating or mobilizing in wheelchair. -Not to be left alone while up in wheelchair. Observation on 10/23/24 at 9:26 A.M. showed Certified Nurse Assistant (CNA) T pushed the resident in his/her wheelchair from the dining area to his/her room, approximately 50 feet, without foot rests on the wheelchair. The resident wore house slippers and his/her feet dragged on the carpeted floor for the duration of the transport. Observation on 10/24/24 at 1:15 P.M. showed CNA K pushed the resident in his/her wheelchair from the dining area to his/her room, approximately 50 feet, without foot rests on the wheelchair. The resident wore house slippers, and held his/her feet up approximately one inch off the floor during the transport. Observation on 10/24/24 at 1:20 P.M. showed CNA K pushed the resident in his/her wheelchair from his/her room to the dining area, approximately 50 feet, without foot rests. The resident wore house slippers, and held his/her feet up approximately one inch off the floor during the transport. 2. Review of Resident #27's admission MDS, dated [DATE], showed the following: -Supervision or touch assist with transfers; -Used a manual wheelchair; -Partial to moderate assist needed to wheel 50 to 150 feet in wheelchair once seated. Review of the resident's Care Plan, dated 08/30/24, showed the following: -Assist of one staff for transfers due to impaired mobility and balance; -Wheelchair is main mode of transportation; -Assist of one staff to propel (in wheelchair). Review of the resident's Physician Order Sheets (POS), dated October 2024, showed the following: -Diagnoses included cognitive deficit, history of falls and right femur (thigh bone) fracture; -Weight bearing as tolerated to right lower extremity. Observation on 10/24/24 at 5:19 A.M., showed Certified Medication Technician (CMT) J pushed the resident out of his/her room to the dining room without any foot rests on the wheelchair. The resident wore tennis shoes. CMT J did not instruct the resident to hold up his/her feet. The resident's toes were pointed downward and close to the floor. Observation on 10/25/24 at 12:41 P.M. showed an unidentified staff pushed the resident out of his/her room in his/her wheelchair without foot rests to the dining room. The resident's feet hovered just above the floor. Staff did not instruct the resident to raise up his/her feet. During an interview on 11/5/24 at 10:36 A.M., CMT J said staff should not push residents in their wheelchairs without foot rests because their feet could drag on the floor. 3. Review of Resident #25's quarterly MDS, dated [DATE], showed the following: -Required substantial to maximum assist with transfers; -Impaired range of motion of one lower extremity; -Used a manual wheelchair; -Wheeled self (once seated) in wheelchair independently 50-150 feet. Review of the resident's care plan, last revised 7/29/24, showed the resident required extensive assist with activities of daily living and potential for injury related to impaired mobility, balance and history of falls. Review of the resident's POS, dated October 2024, showed the resident's diagnoses included displaced fracture of the right femur. Observation on 10/24/24 at 7:25 A.M. showed CNA N pushed the resident in his/her wheelchair, from his/her room to the dining room, without foot rests on his/her wheelchair. The resident wore non-skid socks and his/her feet hovered just off the floor. The staff did not direct the resident to lift his/her feet. During an interview on 10/25/24 at 12:20 P.M., CNA N said the following: -Staff should not push residents in wheelchairs without foot rests; -Residents who propelled themselves may not have foot rests, but they should be applied if staff need to push them; -Residents who self propelled did not have foot rests and in other cases the foot rests may be lost. 4. Review of Resident #4's undated face sheet showed the resident's diagnoses included muscle weakness, unsteadiness on feet, other abnormalities of gait and mobility, cognitive communication deficit, major depression, and falls. Review of the resident's significant change MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Impaired range of motion to one side of the upper extremities; -Used a manual wheelchair; -Required substantial to maximum assistance for all mobility; -Independent to wheel 50 to 150 feet once seated. Review of the resident's Care Plan, revised 09/05/24, showed the following: -Required assistance with all ADLs relate to impaired mobility and balance; -Required assistance or escort to activity functions; -Potential for injury related to falls and impaired mobility and balance; -Educated to wait for assistance; -Ensure wears proper fitting shoes that are supportive with non-skin soles for ambulation. Observation on 10/24/24 at 1:23 P.M. showed CNA K pushed the resident from the dining room to his/her room, approximately 75 feet, without foot rests on his/her wheelchair. The resident wore house shoes and his/her feet hovered just above the carpeted floor during the transport. 5. Review of Resident #11's undated face sheet showed the resident's diagnoses included function deficit following a stroke, other abnormalities of gait and mobility, psychosis, and dementia. Review of the resident's significant change MDS, dated [DATE], showed the following: -Severe cognitive impairment; -No impairment of range of motion in upper or lower extremities; -Used a manual wheelchair; -Required substantial to maximum assistance for all mobility; -Partial to moderate assistance to wheel 50 feet and make two turns, once seated; -Dependent to wheel up to 150 feet once seated. Review of the resident's Care Plan, revised 10/03/24, showed the following: -Required assistance with ADL care; -Wheelchair was main mode of transportation; -Assistance of one staff for wheelchair locomotion; -Alert with periods of forgetfulness related to dementia; -Potential for injury related to falls -Poor safety awareness; -Ensure proper fitting shoes that are supportive with non-skid soles for ambulation; -Offer frequent reminders and cues. Observation on 10/24/24 at 1:08 P.M. showed CNA K pushed the resident from the dining room to his/her room, without foot rests on his/her wheelchair. The resident wore house shoes and his/her feet hovered just above the carpeted floor during the transport. 6. Review of Resident #40's undated face sheet showed the resident's diagnoses included fall, dementia, psychotic disturbance, mood disturbance, muscle weakness, unsteadiness on feet, and cognitive communication deficit. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Uses a manual wheelchair; -Supervision to touching assistance for all mobility; -Supervision to touching assistance to wheel 50 to 150 feet once seated. Review of the resident's care plan, revised 08/03/24, showed the following: -Assistance required for all ADLs related to impaired mobility and balance; -Alert with periods of forgetfulness; -Periods of disorganized thinking at times; -Wheelchair with one staff assistance for locomotion; -Potential for injury from falls related to impaired mobility and balance, history of falls and psychotropic drug use; -Ensure proper fitting shoes that are supportive with non-skid soles are worn for ambulation. Observation on 10/24/24 at 5:18 A.M. showed CNA Y pushed the resident in his/her wheelchair from his/her room to the dining room, without foot rests on his/her wheelchair. The resident wore house slippers and his/her feet hovered just above the carpeted floor during the transport. 7. During an interview on 10/25/24 at 9:32 A.M., CNA W said the following: -Many residents self propelled and did not like foot rests on their wheelchairs because they got in the way and they could not get close enough to the dining room tables for meals; -Residents told staff if they wanted foot rests on their wheelchairs; -Staff should not push residents in wheelchairs without foot rests. During an interview on 10/25/24 at 12:29 P.M., CNA K said if residents can hold their feet up, they don't need foot rests on their wheelchairs. During an interview on 10/25/24 at 12:06 P.M., the Education/Staffing Director said staff should not push residents in wheelchairs without foot pedals. During an interview on 10/25/24 at 1:00 P.M., the Director of Nurses said she expected staff to push residents in their wheelchairs with foot rests on the wheelchair.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure bed rails assessments were consistent with facility policy to evaluate the resident's risk for entrapment and failed to conduct ongoing assessments to ensure the proper use and safety of the bed rails for eight residents (Residents #12, #102, #24, #25, #23, #207, #4 and #45), in a review of 20 sampled residents. The facility census was 49. Review of the facility policy, Bed Safety and Bed Rails, revised on August 2022, showed the following: -Bed rails are adjustable metal or rigid plastic bars that attach to the bed. They are available in a variety of types, shapes, and sizes ranging from full to one-half, one- quarter, or one-eighth lengths. Some bed rails are not designed as part of the bed by the manufacturer and may be installed on or used along the side of a bed. For the purpose of this policy bed rails include: side rails, safety rails, and grab/assist bars; -The use of bed rails or side rails (including temporarily raising the side rails for episodic use during care) is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent; -The resident assessment to determine risk of entrapment includes, but is not limited to: -Medical diagnosis, conditions, symptoms, and/or behavioral symptoms; -Size and weight; -Sleep habits; -Medication(s); -Acute medical or surgical interventions; -Underlying medical conditions; -Existence of delirium; -Ability to toilet self safely; -Cognition; -Communication; -Mobility (in and out of bed); and -Risk of falling. Review of the Food and Drug Administration's Guide of Bed Safety, Bed Rails in Hospitals, Nursing Homes and Home Health Care: The Facts, revised April 2010, showed the following: -Residents who have problems with memory, sleeping, incontinence, pain, uncontrolled body movement, or who get out of bed and walk unsafely without assistance, must be carefully assessed for the best ways to keep them from harm, such as falling; -Assessment by the resident's health care team will help to determine how best to keep the patient safe; -Potential risks of bed rails may include strangling, suffocating, bodily injury or death when residents, or part of their body, are caught between rails or between the bed rails and mattress, more serious injuries from falls when residents climb over rails, skin bruising, cuts, and scrapes, feeling isolated or unnecessarily restricted, and preventing patients, who are able to get out of bed, from performing routine activities such as going to the bathroom or retrieving something from a closet; -When bed rails are used, perform an on-going assessment of the resident's physical and mental status and closely monitor high-risk patients; -A process that requires ongoing evaluation and monitoring will result in optimizing bed safety; -Reassess the need for using bed rails on a frequent, regular basis. 1. Review of Resident #12's undated Face Sheet showed the following: -The resident was his/her own responsible party; -Diagnoses include multiple sclerosis (a disease in which the immune system eats away at the protective covering of nerves) and weakness. Review of the resident's Bed Rail/Assist Bar Evaluation, dated 03/06/24, showed the following: -Assessment did not specify if it was an admission, readmission, quarterly, annual or significant change assessment for bilateral assist bar/bed rail; -Has the resident expressed a desire to have bed rails/assist bar while in bed for their own safety and/or comfort? Yes; -The resident does not have fluctuations in levels of consciousness or a cognitive deficit with episodes of confusion/behaviors; -Is the resident physically able to release bed rails/assist bar? No; -Is the resident able to follow directions? Retain safety information? Yes; -Is the resident able to get in bed safely without assistance? No; -Is the resident able to get out of bed safely without assistance? No; -Does the resident have a history of falls? No; -Is the resident having problems with balance or poor trunk control? No; -Will/Does the resident use the bed rails/assist bar for positioning or support? Yes; -Does the bed rail/assist bar help the resident rise safely from a supine position (lying) to a sitting/standing position? Yes; -Does the resident have a history of postural hypotension (also known as orthostatic hypotension)? No; -Is there a risk to the resident if bed rails/assist bar are used? No; -Do the bed rails/assist bar alternatives/interventions create more risk than bed rails/assist bar use? No; -Based on summary of findings: The resident has requested to have bed rails/assist bar while in bed and bed rails/assist bar are indicated and will serve as an enabler to promote resident independence; -The bed rail/assist bar evaluation did not evaluate the resident's for risk of entrapment per the facility's policy. Review of the resident's significant change MDS, dated [DATE], showed the following: -Cognitively intact; -Range of motion impairment upper and lower extremity both sides; -The resident was dependent on staff assistance for rolling left and right, sitting to lying, lying to sitting on the side of the bed, chair/bed-to-chair transfers. Review of the resident's Care Plan, revised on 10/23/24, showed the following: -He/She required assistance with activities of daily living (ADLs) related to mobility and impaired balance; -Assist him/her with repositioning every two hours and as needed with assistance of one to two; -Assist bars on bed are for mobility and transfer; -He/She required a mechanical lift with two staff for transfers. Review of the resident's October 2024 Physician Order Sheet (POS) showed an order for assist rail on both sides of the bed for positioning and to assist with mobility every day and night. Observation on 10/23/24 at 2:16 P.M., showed the resident lay in bed. The resident had 1/8th assist rails in the raised position on both sides of his/her bed. During interview on 10/23/24 at 2:16 P.M., the resident said he/she was not able to grab the assist rail as much anymore but the assist rails made him/her feel safer when staff rolled him/her back and forth in bed. Observation on 10/24/24 at 10:38 A.M., showed staff transferred the resident from bed to his/her electric wheelchair. The resident had 1/8th assist rails in the raised position on both sides of his/her bed. 2. Review of Resident #102's undated Face Sheet showed the following: -admission date of 10/21/24; -The resident was his/her own responsible party; -Diagnoses include muscle weakness, fall, sacrum (tailbone) fracture and compression fracture of L2 (lumbar vertebra). Review of the resident's October 2024 POS showed an order for assist rails on both sides of the bed for positioning and to assist with mobility every day and night. Review of the resident's Baseline Care Plan, dated 10/21/24, showed the resident required one person for bed mobility and transfers. (The resident's care plan did not address use of bed rails/assist bars.) Review of the resident's Bed Rail/Assist Bar Evaluation, dated 10/23/24, showed the following: -Assessment was an admission assessment for bilateral assist bar/bed rail; -Has the resident expressed a desire to have bed rails/assist bar while in bed for their own safety and/or comfort? Yes; -The resident does not have fluctuations in levels of consciousness or a cognitive deficit with episodes of confusion/behaviors; -Is the resident physically able to release bed rails/assist bar? Yes; -Is the resident able to follow directions? Retain safety information? Yes; -Is the resident able to get in bed safely without assistance? No; -Is the resident able to get out of bed safely without assistance? No; -Does the resident have a history of falls? Yes, mechanical fall (an external force (e.g., environmental) caused the patient to fall); -Is the resident having problems with balance or poor trunk control? Yes; -Will/does the resident use the bed rails/assist bar for positioning or support? Yes; -Does the bed rail/assist bar help the resident rise safely from a supine position (lying) to a sitting/standing position? Yes; -Does the resident have a history of postural hypotension (also known as orthostatic hypotension)? No; -Is there a risk to the resident if bed rails/assist bar are used? No; -Do the bed rails/assist bar alternatives/interventions create more risk than bed rails/assist bar use? No; -Based on summary of findings: The bilateral bed rails/assist bars are indicated and will serve as an enabler to promote resident independence; -The bed rail/assist bar evaluation did not evaluate the resident for risk of entrapment per the facility's policy. Observation on 10/22/24 at 12:21 P.M., showed the resident sat in his/her wheelchair in his/her room. The resident had 1/8th assist rails in the raised position on both sides of his/her bed. During interview on 10/23/24 at 2:31 P.M., the resident said he/she used the assist rails to help him/her turn over in bed. 3. Review of Resident #24's undated Face Sheet showed he/she had a power of attorney. Review of the resident's Bed Rail/Assist Bar Evaluation, dated 03/19/24, showed the following: -Assessment was an admission assessment for bilateral assist bar/bed rail; -The resident did not have fluctuations in levels of consciousness or a cognitive deficit with episodes of confusion/behaviors; -Is the resident physically able to release bed rails/assist bar? Yes; -Is the resident able to get in bed safely without assistance: No; -Is the resident able to get out of bed safely without assistance: No; -Is the resident able to follow directions? Retain safety information? Yes; -Does the resident have a history of falls? If yes, explain. Yes -fall leading to hospitalization; -Is the resident having problems with balance or poor trunk control? If yes, explain. Yes - no explanation noted; -Will/does the resident use the bed rails/assist bar for positioning or support? Yes; -Does the bed rail/assist bar help the resident rise safely from a supine position (lying) to a sitting/standing position? Yes; -Does the resident have a history of postural hypotension (also known as orthostatic hypotension)? No; -Is there a risk to the resident if bed rails/assist bar are used? No; -Do the bed rails/assist bar alternatives/interventions create more risk than bed rails/assist bar use? No; -Summary of findings: The resident is cognitively intact. The summary did not indicate what type of bed rail would be used, that the resident requested bed rails or that the family and physician were notified. -The bed rail/assist bar evaluation did not evaluate the resident for risk of entrapment per the facility's policy. Review of the resident's Care Plan, last revised 07/22/24, showed the following: -Assist of one to two staff for bed mobility and transfers due to impaired mobility and impaired balance; -Assist rails on both sides of bed; -Assist bars make it possible for the resident to reposition himself/herself in bed, assist the resident with transfers in and out of bed, and to be more independent. Review of the resident's POS, dated October 2024, showed the following: -Diagnoses included dementia and multiple sclerosis; -Weight bearing as tolerated with sit to stand lift. -No order for assist rails. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Dependent on staff for transfers; -Required substantial to maximum assistance with bed mobility. Observation on 10/24/25 at 2:37 P.M. showed the resident lay in his/her bed with assist rails in the raised position on both sides of the bed. The left side of the bed was up against the wall. 4. Review of Resident #25's Bed Rail/Assist Bar Evaluation, dated 04/19/24, showed the following: -Assessment was an admission assessment for bilateral assist bar/bed rail; -The resident did not have fluctuations in levels of consciousness or a cognitive deficit with episodes of confusion/behaviors; -Is the resident physically able to release bed rails/assist bar? Yes; -Is the resident able to get in bed safely without assistance: No; -Is the resident able to get out of bed safely without assistance: No; -Is the resident able to follow directions? Retain safety information? Yes; -Does the resident have a history of falls? If yes, explain. Yes -fall with a non displaced right femur fracture; -Is the resident having problems with balance or poor trunk control? If yes, explain. Yes - no explanation noted; -Will/does the resident use the bed rails/assist bar for positioning or support? Yes; -Does the bed rail/assist bar help the resident rise safely from a supine position (lying) to a sitting/standing position? Yes; -Does the resident have a history of postural hypotension (also known as orthostatic hypotension)? Not addressed either way; -Is there a risk to the resident if bed rails/assist bar are used? No; -Do the bed rails/assist bar alternatives/interventions create more risk than bed rails/assist bar use? No; -Based on summary of findings: The resident has moderately impaired cognition. The resident requested the use of bilateral assist rails to serve as an enabler to promote independence. -The bed rail/assist bar evaluation did not evaluate the resident for risk of entrapment per the facility's policy. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Supervised or touch assist with bed mobility; -Substantial to maximum assist for transfers. -Impaired ROM one lower extremity. Review of the resident's Care Plan, last revised 07/29/24, showed the following: -Assist rails on both sides of bed per resident request; -Assist rails will assist the resident with repositioning in bed and with transferring in and out of bed; -The resident was aware of the risks involved with the assist rails and signed a consent; -Therapy evaluated the resident for appropriateness for assist rails, indicating they will serve as an enabler to promote independence. Review of the resident's POS, dated 10/2024, showed the following: -Diagnoses included osteoarthritis (flexible tissue at ends of bones wears down, causing pain), periprosthetic fracture (broken bone occurring near or around an orthopedic implant) around internal prosthetic right hip joint and muscle weakness; -Order for for assist rails on both sides for positioning and to assist with mobility (original order dated 4/19/24). Observation on 10/24/24 at 7:12 A.M. showed the resident lay in his/her bed. The resident had 1/8th assist rails in the raised position on both sides of his/her bed. The right side of the bed was pushed against the wall. 5. Review of Resident #23's undated face sheet showed the following: -The resident was his/her own responsible party; -Diagnoses include hemiplegia and hemiparesis following hemorrhage affecting right dominant side (weakness or paralysis affecting the right side only after a brain bleed) and orthostatic hypotension. Review of the resident's Bed Rail/Assist Bar Evaluation, dated 09/06/24, showed the following: -Assessment was an admission and readmission assessment for bilateral assist bar/bed rail; -The resident had fluctuations in levels of consciousness or a cognitive deficit with episodes of confusion/behaviors; -Is the resident physically able to release bed rails/assist bar? Yes; -Is the resident able to follow directions? Retain safety information? Yes; -Does the resident have a history of falls? If yes, explain. Yes - no explanation noted; -Is the resident having problems with balance or poor trunk control? If yes, explain. Yes - no explanation noted; -Will/does the resident use the bed rails/assist bar for positioning or support? Yes; -Does the bed rail/assist bar help the resident rise safely from a supine position (lying) to a sitting/standing position? Yes; -Does the resident have a history of postural hypotension (also known as orthostatic hypotension)? No (Staff did not answer this questions correctly as the resident had a diagnosis of orthostatic hypotension); -Is there a risk to the resident if bed rails/assist bar are used? No; -Do the bed rails/assist bar alternatives/interventions create more risk than bed rails/assist bar use? No; -Based on summary of findings: The resident has requested to have bed rails/assist bar while in bed and bed rails/assist bar are indicated and will serve as an enabler to promote resident independence; -The bed rail/assist bar evaluation did not evaluate the resident for risk of entrapment per the facility's policy. Review of the resident's significant change MDS, dated [DATE], showed the following: -Cognitively intact; -Impairment in range of motion to the upper and lower extremities one side of his/her body; -Required partial/moderate staff assistance for rolling left and right, sitting to lying, lying to sitting on the side of the bed, sit to standing transfer, chair/bed-to-chair transfers. Review of the resident's Care Plan, revised on 09/19/24, showed the following: -He/She required assistance with activities of daily living (ADLs) related to impaired mobility and impaired balance; -Assist him/her with repositioning every two to three hours and as needed with assistance of one; -Assist rails as ordered for mobility; -He/She required assistance from one to two staff for transfers. Review of the resident's October 2024 POS showed an order for assist rails on both sides of the bed for positioning and to assist with mobility every day and night. Observation on 10/22/24 at 11:28 A.M., showed the resident lay in bed awake with 1/8th assist rails in the raised position on both sides of his/her bed. The rail was stationary and unable to be lowered. During an interview on 10/22/24 at 11:28 A.M., the resident said he/she used the assist rails to help with bed mobility and transfers. Observation on 10/24/24 at 5:10 A.M., showed the resident lay in bed sleeping with 1/8th assist rails in the raised position on both sides of his/her bed. 6. Review of Resident #207's undated face sheet showed the following: -The resident was his/her own responsible party; -Diagnoses included wedge compression fracture of T9-T10 vertebra (a break in the thoracic spine that occurs when the vertebrae collapse under pressure), dementia (a group of thinking and social symptoms that interferes with daily functioning) and anxiety disorder. Review of the resident's October 2024 POS showed an order for assist rail on both sides of the bed for positioning and to assist with mobility every day and night shift for cane rails. Review of the resident's Bed Rail/Assist Bar Evaluation, dated 10/21/24, showed the following: -Assessment was an admission assessment for bilateral assist bar/bed rail; -Is the resident physically able to release bed rails/assist bar? Yes; -Is the resident able to follow directions? Retain safety information? Yes; -Is the resident able to get in bed safely without assistance? No; -Is the resident able to get out of bed safely without assistance? No; -Does the resident have a history of falls? If yes, explain. Yes - fall (have) self-transfer; -Is the resident having problems with balance or poor trunk control? If yes, explain. Yes - no explanation noted; -Will/does the resident use the bed rails/assist bar for positioning or support? Yes; -Does the bed rail/assist bar help the resident rise safely from a supine position to a sitting/standing position? Yes; -Does the resident have a history of postural hypotension? No; -Is there a risk to the resident if bed rails/assist bar are used? No; -Do the bed rails/assist bar alternatives/interventions create more risk than bed rails/assist bar use? No; -Based on summary of findings: Assist bar/bed rails: bilateral. Bed rails/assist bar are indicated and will serve as an enabler to promote resident independence; -The bed rail/assist bar evaluation did not evaluate the resident for risk of entrapment per the facility's policy. Observation on 10/22/24 at 2:10 P.M., showed the resident's bed had 1/8th assist rails in the raised position on both sides of the bed. The rail was stationary and unable to be lowered. During an interview on 10/22/24, at 2:10 P.M., the resident said he/she used the assist rails to help with bed mobility and transfers. Review of the resident's admission MDS, dated [DATE], showed the following: -Cognitively intact; -No impairment in his/her range of motion; -Used wheelchair and walker; -Required partial/moderate staff assistance for rolling left and right, sitting to lying, lying to sitting on the side of the bed, sit to standing transfer, chair/bed-to-chair transfers; -History of falls prior to admission, fall within the last 2-6 months prior to admission, fracture related to fall in six months prior to admission; -No falls since admission. Review of the resident's Care Plan, revised on 10/23/24, showed the following: -He/She was at risk for falls related to impulsiveness and gait/balance problems; -The resident/resident's family had requested assist bars to be on the sides of his/her bed; -He/She was informed of the risks involved in having assist bars and the resident signed a consent form that he/she was aware and still wanted them; -He/She will be re-evaluated if there is a change in status; -On 10/22/24 at 3:44 P.M., staff observed the resident sitting on the floor in his/her room between the wheelchair and bed. Observation on 10/24/24 at 5:11 A.M., showed the resident lay in bed sleeping with 1/8th assist rails in the raised position on both sides of his/her bed. 7. Review of Resident #4's undated Face Sheet showed the resident's diagnoses included muscle weakness, other abnormalities of gait and mobility, and falls. Review of the resident's Bed Rail/Assist Bar evaluation, dated 03/06/24, showed the following: -Assessment was marked as an other evaluation, but did not specify the reasoning; -The assist bar/bed rail is located on bilateral sides; -Has the resident expressed a desire to have bed rails/assist bar while in bed for their own safety and/or comfort? Yes; -Does the resident have fluctuation in levels of consciousness or a cognitive deficit? No; -Is the resident physically able to release bed rails/assist bar? No; -Is the resident able to follow directions? Retain safety information? Yes; -Does the resident have any visual deficits? No; -Is the resident able to get in bed safely without assistance? Yes; -Is the resident able to get out of bed safely without assistance? Yes; -Does the resident have a history of falls? Yes, one on 02/23/24; -Is the resident having problems with balance or poor trunk control? No; -Is the resident able to voluntarily move their own body? Yes; -Will/does the resident use the bed rails/assist bar for positioning or support? Yes; -Does the bed rail/assist bar help the resident rise safely from a supine position to a sitting/standing position? Yes; -Does the resident have a history of postural hypotension? No; -Is there a possibility the resident will climb over the bed rails/assist bar? No; -Is there evidence (reason to believe) the resident has (or may have) a desire to reason to get out of bed? No; -Does the resident receive any medications that would require safety precautions? No; -Is the resident continent of bowel and/or bladder? If no, explain: No, no explanation given; -Is there a risk to the resident if bed rails/assist bar are used? No; -Do the bed rails/assist bar alternatives/interventions create more risks than bed rails/assist bar use? No; -Will/does the bed rail/assist bar obstruct the resident's view? No; -Based on the summary of findings, signed by physical therapist on 05/01/24: the resident has requested to have bed rails/assist bar while in bed and the bed rails/assist bar are indicated and will serve as an enabler to promote resident independence; -The bed rail/assist bar evaluation did not evaluate the resident for risk of entrapment per the facility's policy. Review of the resident's significant change MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Impairment in range of motion to one side of the upper extremities; -Required substantial to maximum assistance for all mobility needs. Review of the resident's Care Plan, revised 09/05/24, showed the following: -He/She required assistance with activities of daily living (ADLs) due to impaired mobility and impaired balance; -Assistance of one staff for repositioning every two or three hours and as needed; -He/She had assist rails to both sides of his/her bed; -Assist rails were to help him/her with positioning and mobility; -He/She had potential for injury related to impaired mobility; -Physical therapy evaluated if the assist rails would be a benefit for him/her; -He/She will be re-evaluated if there is a change in condition. Review of the resident's Physician's Order Sheet, dated October 2024, showed an order for assist rails on both sides for positioning and to assist with mobility every day and night. Observation on 10/24/25 at 5:10 A.M. showed the resident lay in bed. The resident had assist rails in the raised position on both sides of his/her bed. 8. Review of Resident #45's undated Face Sheet showed the following: -admission date 05/15/24; -Diagnoses of hemiplegia and hemiparesis affecting the left side, morbid obesity, and need for assistance with personal care; -The resident had a responsible party. Review of the resident's significant change MDS, dated [DATE], showed the following: -Cognitively intact; -Impairment in range of motion on one side of upper and lower extremities; -Required moderate to substantial/maximal assistance for all mobility needs. Review of the resident's Care Plan, revised on 08/29/24, showed the following: -He/She required assistance with ADLs due to impaired mobility and impaired balance; -He/She had requested assist bars to both sides of his/her bed; -He/She was able to reposition himself/herself in bed and the assist bar with getting in and out of bed; -He/She will be reevaluated as needed; -Therapy had evaluated him/her for appropriateness of assist bars and it was indicated they enable him/her to be more independent. Review of the resident's bed rail/assist bar evaluation, dated 09/10/24, showed the following: -Assessment did not specify if it was an admission, readmission, quarterly, annual, significant change, or other evaluation; -The assist bar/bed rail is located on bilateral sides; -Has resident expressed a desire to have bed rails/assist bar while in bed for their own safety and/or comfort? Yes; -Does the resident have fluctuation in levels of consciousness or a cognitive deficit? No; -Is the resident physically able to release bed rails/assist bar? Yes; -Is the resident able to follow directions? Retain safety information? Yes; -Does the resident have any visual deficits? No; -Is the resident able to get in bed safely without assistance? No; -Is the resident able to get out of bed safely without assistance? No; -Does the resident have a history of falls? No; -Is the resident having problems with balance or poor trunk? No; -Is the resident able to voluntarily move their own body? Yes; -Will/Does the resident use the bed rails/assist bar for positioning or support? Yes; -Does the bed rail/assist bar help the resident rise safely from a supine position to a sitting/standing position? Yes; -Does the resident have a history of postural hypotension? No; -Is there a possibility the resident will climb over the bed rails/assist bar? No; -Is there evidence (reason to believe) the resident has (or may have) a desire to reason to get out of bed? No; -Does the resident receive any medications that would require safety precautions? No; -Is the resident continent of bowel and/or bladder? If no, explain. No, no desire to toilet; -Is there a risk to the resident if bed rails/assist bar are used? No; -Do the bed rails/assist bar alternatives/interventions create more risks than bed rails/assist bar use? No; -Will/Does the bed rail/assist bar obstruct the resident's view? No; -No page two with the summary of findings; -The bed rail/assist bar evaluation did not evaluate the resident for risk of entrapment per the facility's policy. Review of the resident's POS, dated October 2024, showed an order for assist rail on both sides for positioning and to assist with mobility every day and night. Observation on 10/22/24 at 2:34 P.M. showed the resident lay in bed. The resident had assist rails in the raised position on both sides of his/her bed. Observation on 10/23/24 at 8:31 A.M. showed the resident lay in bed. The resident had assist rails in the raised position on both sides of his/her bed. Observation on 10/23/24 at 8:38 A.M. showed the Education/Staffing Director and Certified Nurse Assistant (CNA)/Certified Medication Technician (CMT) T repositioned the resident in bed. The resident did not utilize the assist rails as the staff worked together to move him/her up in his/her bed. Observation on 10/24/24 at 6:51 A.M. showed the resident lay in bed. The resident had assist rails in the raised position on both sides of his/her bed. Observation on 10/24/24 at 1:01 P.M. showed the resident lay in bed. The resident had assist rails in the raised position on both sides of his/her bed. 9. During an interview on 10/31/24 at 9:04 A.M., Physical Therapy R said the following: -The current therapy company took over therapy at the facility one week before the annual recertification survey began; -The physical therapist or occupational therapist completed the bed rail/assist bar evaluations for new admissions and for any resident the facility requested it to be completed on; -The therapists completed a bed rail/assist bar evaluation on all residents admitted since the therapy company began at the facility, but he/she was unsure if ongoing assessments would be completed; -Ongoing assessments would be at the direction of the facility; -The residents' risk for entrapment was not evaluated as the rails being used were assist bars and not bed rails. During an interview on 10/25/24 at 10:34 A.M., the Director of Nursing (DON) said the therapy department completed the bed rail assessments on admission and as needed. During an interview on 10/25/24 at 1:15 P.M., the Administrator said the following: -The therapy department completed the assist bar assessments when a resident was admitted ; -He did not feel like there were any rails in the facility that were classified as bed rails. The rails used were assistive devices for positioning; -He was unsure how often the therapy department completed the assessments other than on admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide care in a manner to prevent the development and transmission of diseases and infections for eight residents (Residents #24, #12, #39, #27, #102, #103, #202, and #42), in a review of 20 sampled residents. Staff failed to failed to utilize Enhanced Barrier Precautions (EBP) during personal care for three residents (Residents #24, #12, and #39) who had urinary catheters (a tube inserted into the bladder to drain urine); failed to maintain a system to ensure one resident's (Resident #24's) urinary catheter tubing and dignity bag (containing the urinary drainage bag) were kept off the floor; failed to utilize proper handwashing and gloving when providing incontinence care to one resident (Resident #27); failed to ensure nebulizer masks (mask used to administer breathing treatments) and CPAP (a method of respiratory therapy in which air is pumped into the lungs through the nose or nose and mouth during spontaneous breathing, used in the treatment of sleep apnea and other respiratory disorders) masks were covered when not in use for three residents (Residents #102, #103 and #202); and failed to ensure staff used proper technique and hand hygiene during a medication pass for one resident (Resident #42). The facility census was 49. Review of the facility's undated policy, Enhanced Barrier Precautions, showed the following: -It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms; -Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities; -Policy explanation and compliance guidelines: -All staff receive training on enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precautions; -All staff receive training on high-risk activities and common organisms that require enhanced barrier precautions; -The facility will have the discretion on how to communicate to staff which residents require the use of EBP, as long as staff are aware of which residents require the use of EBP prior to providing high-contact care activities; -Initiation of Enhanced Barrier Precautions: -The facility will have the discretion in using EBP for residents who do not have a chronic wound or indwelling medical device and are infected or colonized with an MDRO that is not currently targeted by CDC; -An order for enhanced barrier precautions will be obtained for residents with any of the following: -Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO (multi-drug resistant organism); -Infection or colonization with a CDC-targeted MDRO when contact precautions do not otherwise apply; -Implementation of Enhanced Barrier Precautions: -Make gowns and gloves available immediately near or outside of the resident's room. Note: face protection may also be needed if performing activity with risk of splash or spray (i.e. wound irrigation, tracheostomy care); -Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. Review of the facility's policy, Urinary Catheter Care, last revised August 2022, showed the following: -The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections; -Use aseptic technique when handling or manipulating the drainage system; -Be sure the catheter tubing and drainage bag are kept off the floor. 1. Review of Resident #24's Care Plan, last revised 08/08/24, showed the following: -Urinary catheter due to neurogenic bladder (urinary condition where someone does not have bladder control) and urinary retention (difficulty urinating and completely emptying the bladder); -Will remain free from infection; -Place urine collection bag in privacy bag when out of bed; -Hang urine collection bag from the side of the bed, away from the door when in bed. Review of the resident's Physician Order Sheets (POS), dated 10/2024, showed to change urinary catheter monthly. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/05/24, showed the following: -Indwelling urinary catheter; -Dependent for transfers; -Substantial to maximum assist with bed mobility and dressing; -Used a wheelchair. Observation on 10/23/24 at 8:15 AM. showed the resident sat in his/her wheelchair in the dining room where the dignity bag, which contained the urinary catheter drainage bag, hung from the back of the chair and touched the floor. Observations on 10/24/24 showed the following: -At 12:35 P.M., the resident lay in his/her bed. The resident's urinary catheter drainage bag hung from the right side of the bed and the catheter tubing (which contained yellowish urine) lay on the floor; -At 1:30 P.M., the urinary catheter tubing remained on the floor. During an interview on 10/25/24, at 12:50 P.M., the Director of Nurses (DON) said she expected staff to keep catheter bags and tubing off of the floor. Observation on 10/24/24 at 2:37 P.M. showed the following: -There was no signage to indicate the resident was on EBP outside the resident's room and no cart with PPE located outside or near the resident's room. -The resident lay in the bed and the catheter tubing (which contained yellow urine) remained on the floor; -Licensed Practical Nurse (LPN) L and Certified Medication Technician (CMT) O entered the room and performed perineal care and catheter care on the resident; -Neither staff wore a gown. During an interview on 10/25/24 at 12:15 P.M., CMT O said the following: -He/She was not sure what EBP was; -He/She thought it would be used when working with anyone with infections, contagious blood or any bodily fluids and would include gowns, gloves and a face shield or goggles. 2. Review of Resident #12's significant change in status MDS, dated [DATE], showed the following: -Urinary catheter; -Dependent on staff for hygiene and to roll right to left in bed; -Application of dressing to feet. Review of the resident's Nurses Notes, dated 10/9/24, showed the wound nurse practitioner visited on 10/8/24. Left lateral foot 0.8 centimeters (cm) by 1.0 cm by eschar (dead tissue that eventually sloughs off healthy skin after an injury). Today maintenance will add padding to wheelchair foot rests. Review of the resident's Care Plan, last revised 10/23/24, showed the following: -The resident had a suprapubic catheter related to neurogenic bladder and urinary retention; -Provide catheter care as ordered; -Cleanse the suprapubic drain site with normal saline or soapy water, pat dry, apply new dressing and secure. It is to be done daily and as needed; -The resident was at risk for impaired skin integrity due to pressure areas; -Left lateral (outside) foot 0.6 centimeters (cm) by 0.8 cm by 0.2 cm. Treatment of mupirocin 2% ointment (antibiotic ointment used for skin infections), alginate/bordered form (absorbent dressing) three times a week and as needed. (The resident's care plan did not identify the need for or use of EBP when providing care for resident.) Review of the resident's POS, dated October 2024, showed the following: -Change suprapubic catheter once monthly on the 15th; -Cleanse suprapubic drain site with normal saline or soapy water, pat dry. Apply drain dressing daily and as needed for dislodgement; -Catheter care every shift; -Obtain catheter output every shift; -Mupirocin 2% ointment to left lateral foot every day shift on Monday, Tuesday and Thursday for wound. Cleanse left lateral foot, apply mupirocin ointment 2% and alginate cover with ordered form three times per week and as needed. Review of the resident's nurses note, dated 10/22/24, showed the wound nurse practitioner documented left lateral foot 0.6 cm by 0.8 cm by 0.2 cm, 100% yellow, treatment mupirocin 2% ointment, alginate with bordered foam three times a week and as needed. Observation on 10/22/24 at 2:18 P.M., showed the resident sat in his/her wheelchair in his/her room. There was no signage to indicate the resident was on EBP outside the resident's room and no cart with personal protective equipment (PPE) located outside or near the resident's room. Observation on 10/23/24 at 2:16 P.M., showed the resident sat in his/her bed in his/her room. There was no signage outside the resident's room and no cart with PPE located outside or near the resident's room. During interview on 10/23/24 at 2:16 P.M., the resident said staff do not wear gowns when providing cares. Staff only wear gloves when providing care. Observation on 10/24/24 at 12:00 P.M., showed the following: -Registered Nurse (RN) A and the Infection Preventionist (IP) entered the resident's room; -The resident lay on his/her back in bed; -RN A and the IP washed their hands and put on gloves; -RN A removed the dressing from the wound on the resident's left foot; -There was a scant amount of yellowish drainage; -RN A removed his/her gloves, used hand sanitizer, and put on new gloves; -RN A cleansed the resident's wound with wound cleanser and 4x4 gauze; -While RN A washed his/her hands and changed his/her gloves, the IP applied mupirocin 2% ointment to the wound; -RN A applied alginate to the wound and covered the wound with a bordered bandage; -RN A and the IP washed their hands and changed gloves; -RN A cleaned around the resident's suprapubic catheter insertion site with a soapy washcloth, cleaned around the site again with another wet washcloth, dried the area with a towel and placed a split sponge around the catheter tubing and secured the dressing with tape; -RN A and the IP did not wear a gown while providing treatment to the wound on the resident's foot and when providing catheter care. During an interview on 10/25/24 at 9:11 A.M., RN A said the following: -The facility did not have any current residents on EBP; -EBP was used for things like COVID-19, diarrhea, surgical incisions, MRSA (methicillin-resistant staphylococcus aureus)/VRSA (vancomycin-resistant staphylococcus aureus), pressure wounds and any wound with a wound vac; -EBP was indicated by a sign and EBP supply cart outside the room door, as well as information passed on in report. During interview on 10/25/24 at 9:16 A.M., the IP said the following: -The facility had no residents on EBP; -The facility policy said if a resident had MRSA, ESBL (Extended Spectrum Beta-Lactamase - an enzyme produced by some bacteria that may make then resistant to some antibiotics), VRE (VRE are resistant to vancomycin, the drug often used to treat infections caused by enterococci) or C-diff (a bacterium that causes an infection of the colon) then staff would need to wear gown, gloves and mask when providing direct care and there would be signage outside the resident's room; -She was aware of the new guidance for EBP to also include chronic wounds, G-tubes (a tube inserted through the belly that brings nutrition directly to the stomach), catheters and ports (port-a-cath is used to give intravenous fluids, blood transfusions, chemotherapy, and other drugs) but this was not the facility's policy. 3. Review of Resident #39's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Urinary catheter. Review of the resident's Care Plan, revised on 09/04/24, showed the following: -The resident had a urinary catheter; -Change urinary catheter monthly. Review of the resident's Physician's Orders, dated October 2024, showed the following: -Change urinary catheter every month on the 27th; -Urinary catheter care every shift; -Obtain urinary catheter output every shift, day and night. Observation on 10/22/24 at 1:41 P.M. showed no EBP signage on or near the resident's room door and no PPE available near the resident's room. During an interview on 10/23/24 at 8:49 A.M., the resident said staff always wore gloves when providing care, but he/she never saw staff wear a gown or mask when providing care to his/her catheter. Observation on 10/24/24 at 12:42 P.M., showed the following: -CNA K washed his/her hands, donned gloves, and assisted the resident to walk from the reclining chair to the bed using a walker and gait belt; -CNA K pulled down the resident's pants and asked him/her to sit on the bed; -CNA K and CNA U removed the resident's shoes and assisted the resident to lay in bed; -CNA U provided perineal care and catheter care for the resident. CNA U did not wear a gown; -CNA K drained the urine from the urinary catheter drainage bag into a urinal. CNA K wore gloves, but did not wear a gown or face protection (as directed by facility policy when performing an activity with risk of splash or spray); -CNA U wiped the tip of the urinary catheter drain with a wipe, placed it back in the holder, removed his/her gloves, and washed his/her hands; -CNA K dumped the urinal into the toilet; -CNA U placed shoes on the resident; -CNA K helped the resident to stand using a gait belt and walker, then pulled up the resident's pants; -CNA U helped the resident walk from the bed to the recliner using a gait belt and walker. -CNA U and CNA K did not wear a gown when providing care to the resident who had a urinary catheter. During an interview on 10/25/24 at 12:29 P.M., CNA K said the following: -He/She was aware of what EBP was from a training he/she received; -Any resident with an open wound, a catheter, or certain types of infections should be on EBP; -Most EBP required a gown and gloves, and some required masking as well; -If a resident was on EBP, they would have a sign on their door stating they were on EBP and they would have a PPE cart outside of their room door; -He/She was not aware of any resident who was currently on EBP; -Resident #39 should be on EBP because of his/her urinary catheter. 4. During an interview on 10/25/24 at 12:20 P.M., CNA N said the following: -The nurse would alert staff as to when EBP should be used; -EBP would include the use of a gown, gloves and a mask and would be stored in a container outside of the room; -He/She had been educated to use EBP if a resident had a wound, a catheter, or a feeding tube; -The EBP would be worn at all times when providing cares; -There were no residents requiring the use of EBP at this time as nursing had not directed staff to use them. During an interview on 10/25/24 at 12:06 P.M., the Education/Staffing Director said the following: -The facility policy for EBP was only for qualifying infections; -Catheters and wounds in general did not qualify for EBP, unless the resident had an active infection that met the facility criteria; -If a resident was on EBP, they would have a sign on their door that showed they were on EBP and the PPE requirements, and they would have a PPE cart outside of their room. During an interview on 10/25/24 at 9:30 A.M., the Assistant Director of Nursing (ADON) said the following: -EBP was used with infections and if the physician requested it; -Staff was made aware of EBP being used by a meeting, group talk, the sign outside the door and the EBP cart outside the resident's door; -No residents were on EBP at present. During an interview on 10/25/24 at 12:50 P.M., the DON said the following: -There were currently no residents on EBP; -EBP was used if there was a catheter or wound that had a microorganism that had been identified; -If a resident had a chronic wound or catheter, that didn't not necessarily constitute EBP, it depended on the organism in the wound/urine/etc.; -She expected staff to follow the facility policy for EBP; -The facility policy did not identify each person with a catheter or wound would be on EBP; -The facility should follow the Center for Disease Control (CDC) guidelines for EBP; -She was unaware of the current CDC or Centers for Medicare and Medicaid Services (CMS) recommendations related to EBP. During an interview on 10/25/24, at 1:15 P.M., the Administrator said the following: -The only time EBP was used was if there was some type of infection that would be problematic, otherwise EBP was not used routinely; -He was aware there had been talks of changes related to EBP, but was unaware changes had been made by CDC or CMS; -The facility should follow the guidelines from CDC and CMS related to EBP; -The facility was currently following their policy related to infections. Review of the facility's policy, Handwashing/Hand Hygiene, revised August 2019, showed the following: -All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors; -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 coming on duty; before and after direct contact with residents; before preparing or handling medications; before performing any non-surgical invasive procedures; before and after handling an invasive device (e.g., urinary catheters, IV access sites); before donning sterile gloves; before handling clean or soiled dressing, 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; before and after entering isolation precaution settings; before and after eating or handling food; before and after assisting a resident with meals and after personal use of the toilet or conducting your own personal hygiene; -Hand hygiene is the final step after removing and disposing of personal protective equipment; -The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Review of the facility policy, Personal Protective Equipment - Using Gloves, revised September 1010, showed the following: -Gloves shall be used only once and discarded into the appropriate receptacle located in the room in which the procedure is being performed; -Wash your hands before and after removing gloves. (Note: Gloves do not replace handwashing.); -Remove gloves before removing the mask and gown and discard them into the designated waste receptacle inside the room. 5. Review of #27's admission MDS, dated [DATE], showed the following: -Supervision to touch assist for bed mobility, transfer and toileting; -Occasionally incontinent of bladder; -Used a wheelchair. Review of the resident's care plan, dated 08/30/24, showed the following: -Occasionally incontinent of bladder; -Assist of one staff for hygiene, toileting, dressing, bed mobility and transfers; -Used a wheelchair. Observation on 10/24/24 at 5:19 A.M. showed the following: -The resident lay on a urine soaked cloth pad and disposable pad on his/her back in the bed; -Certified Nurse Aide (CNA) J entered the room, and without washing hands, put on gloves; -He/She exited the room while wearing the gloves, returned with plastic bags and placed a bag in the trash can; -He/She put on a second pair of gloves over the first pair; -He/She rolled the resident to his/her left side by touching the resident's hip area, rolled the urine soiled pads underneath the resident, wiped the resident's urine soiled back side with incontinent wipes; -Without removing his/her gloves, CNA J placed a clean incontinence brief under the resident, rolled the resident, secured the brief, picked up the resident's pants and put them on the resident, assisted the resident to sit on the side of the bed, and put socks and shoes on the resident; -He/She removed his/her gloves, and without washing or sanitizing his/her hands, put on new gloves; -He/She took the pajama top off the resident, put a clean shirt on the resident, and then transferred the resident to the wheelchair. -CNA J then removed his/her gloves and washed his/her hands. During an interview on 11/5/24 at 10:36 A.M., CNA J said the following: -He/She should wash his/her hands before cares, after perineal care, with gloves changes and when moving from a dirty to clean task; -He/She should change his/her gloves when they become soiled, after perineal care, and after touching trash. During an interview on 10/25/24, at 12:50 P.M., the DON said the following: -She expected staff to change their gloves during resident care when they become soiled; -She expected staff to wash their hands to be washed when they enter a resident care area, when they change their gloves, and when care was completed. Staff could use hand sanitizer between changing gloves. Review of the facility's policy, Administering Medications through a Small Volume (Handheld) Nebulizer, dated 2001 and last revised October 2010, showed the following: -The purpose of this procedure is to safely and aseptically administer aerosolized particles of medications into the resident's airway; -Rinse and disinfect the nebulizer equipment according to facility protocol, or: -Wash pieces with warm soapy water; - Rinse with hot water; -Place all pieces in a bowl and cover with isopropyl (rubbing) alcohol. Soak for five minutes); -Rinse all pieces with sterile water (NOT tap, bottles or distilled); and -Allow to air dry on a paper towel; -When equipment is completely dry, store in a plastic bag with the resident's name and date on the bag. The facility did not have a policy directing staff how to store CPAP masks when not in use. 6. Review of Resident #102's POS, dated October 2024, showed the following: -admission date 10/21/24; -CPAP to be worn at bedtime per home settings; -Diagnoses included obstructive sleep apnea (episodes of a complete (apnea) or partial collapse (hypopnea) of the upper airway with an associated decrease in oxygen saturation or arousal from sleep) and cardiomyopathy (causes the heart to lose its ability to pump blood well). Review of the resident's Care Plan, dated 10/22/24, showed no evidence the resident used CPAP at bedtime. Observation on 10/23/24 at 2:31 P.M., showed the resident's CPAP mask lay uncovered on the bedside table. Observation on 10/24/24 showed the following: -At 5:15 A.M., the resident lay on his/her back in bed with his/her eyes closed. The CPAP mask was on the resident's face; -At 5:30 A.M., the resident lay in his/her bed on his/her back with his/her eyes closed. The CPAP mask lay uncovered on the bedside table; -At 9:39 A.M., the resident's CPAP mask lay uncovered in the same location on the bedside table. 7. Review of Resident #103's POS, dated October 2024, showed the following: -readmission date 10/16/24; -Continuous supplemental oxygen at 2 to 4 liters per nasal cannula; -Albuterol Sulfate inhalation 2.5 mg per milliliter (ml) 0.083%, 3 ml orally via nebulizer every six hours as needed for asthma or COPD; -Diagnoses included acute on chronic respiratory failure, dependence on supplemental oxygen, and lobar pneumonia (a type of pneumonia characterized by the infection and inflammation of one or more lobes of the lung). Review of the resident's Care Plan, dated 10/20/24, showed the following: -The resident was on oxygen therapy related to respiratory illness; -Oxygen via nasal cannula at 2 to 4 liters continuously. Observation on 10/22/24 showed the following: -At 11:23 A.M., the resident lay in bed with his/her eyes closed. A nebulizer mask lay uncovered on the bedside table; -At 12:19 P.M., the resident sat on the side of the bed for lunch with his/her oxygen on per nasal cannula. A nebulizer mask lay uncovered on the bedside table; -At 4:55 P.M., the resident lay in bed with his/her eyes closed. A nebulizer mask lay uncovered on the bedside table. Review of the resident's Significant Change MDS, dated [DATE], showed the following: -Cognitively intact; -Oxygen therapy; -Diagnoses included COPD and pneumonia. Observation on 10/23/24 showed the following: -At 8:57 A.M., the resident sat on the side of the bed for breakfast with his/her oxygen on per nasal cannula. A nebulizer mask lay uncovered on the bedside table; -At 2:26 P.M., the resident sat on the side of the bed with his/her oxygen on per nasal cannula. A nebulizer mask lay uncovered on the bedside table. Observations on 10/24/24 showed at 5:10 A.M., 7:48 A.M. and 9:39 A.M., the resident lay in bed with his/her eyes closed. A nebulizer mask lay on the bedside table uncovered. 8. Review of Resident #202's face sheet showed the following: -admitted to the facility on [DATE]; -Diagnoses included acute and chronic respiratory failure (a condition where there is not enough oxygen or too much carbon dioxide in the body that can be all at once or come on over time), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe) and obstructive sleep apnea (occurs when your breathing is interrupted during sleep, sometimes for longer than 10 seconds). Review of the resident's October 2024 POS showed an order for CPAP at bedtime every night shift. Review of the resident's Baseline Care Plan, dated 10/18/24, showed the resident used a CPAP. Observation on 10/22/24 at 1:57 P.M., showed the resident's CPAP mask lay uncovered on the resident's bed near his/her pillow. During interview on 10/22/24 at 1:57 P.M., the resident said he/she took care of his/her CPAP equipment and had not had it covered since admission. Observation on 10/23/24 at 8:45 A.M., showed the resident's CPAP mask lay uncovered on top of the resident's bed pillow. Observation on 10/24/24 at 7:36 A.M., showed the resident's CPAP mask lay uncovered on the resident's bed near his/her pillow. 9. During an interview on 10/25/24 at 9:11 A.M., RN A said oxygen supplies like nasal cannulas and CPAP masks should be covered with a clear bag when not in use. During interview on 10/25/24 at 9:16 A.M., the IP said nebulizer masks and CPAP masks should be on a towel or paper towel when not in use or in a bedside table drawer. During an interview on 10/25/24 at 12:50 P.M., the DON said she expected CPAP masks to be stored in a plastic bag when not in use. The masks should not be left sitting on the bed or bedside table. Review of the facility's policy, Administering Oral Medications, dated 2001 and last revised October 2010, showed the following: -The purpose of this procedure is to provide guidelines for the safe administration of oral medication; -Do not touch the medication with your bare hands; -If a medication falls to the floor, discard and document per facility protocol. 10. Review of Resident #42's POS, dated October 2024, showed the following: -Coreg (medication used to treat high blood pressure) 25 milligrams (mg) by mouth twice daily; -Anagrelide HCL (a medication used to decrease blood clots) 0.5 mg by mouth Monday, Tuesday, Wednesday, Thursday, Friday and Saturday. Observation on 10/23/24 at 8:24 A.M., showed the following: -CMT P sanitized his/her hands, opened the medication drawer and retrieved a prepackaged slip of medications containing both Coreg and the anagrelide; -CMT P placed the prepackaged slip of medications back into the medication drawer. As he/she laid the slip into the drawer, two white pills fell out of the package and into the medication drawer; -With his/her bare hands, CMT P picked up the two pills and lay them on top of the prepackaged slip and closed the medication cart drawer; -CMT P walked over to Resident #42 and obtained his/her blood pressure; -CMT P walked back to the medication cart, sanitized his/her hands, opened the medication cart drawer, picked up the two white pills with his/her bare hands, and placed them in a medication cup; -CMT P prepared the rest of the resident's morning medication and administered all the medications, including the two medications that lay directly in the medication cart drawer, to the resident. During interview on 10/23/24 at 2:25 P.M., CMT P said he/she shouldn't have touched the pills with his/her bare hands. He/She thought since the pills fell in the medication drawer, they were okay to give to the resident. If the pills had fallen on top of the medication cart, then he/she would have discarded them and gave the resident new pills. During an interview on 10/25/24, at 12:50 P.M., the DON said if a medication fell out of a pill packet and dropped into the medication cart, she would expect staff to discard the pill and get a new pill to administer to the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to complete inspection of bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for eight residents (Resident #12, #102, #24, #25, #23, #207, #4 and #45), in a review of 20 sampled residents. The facility census was 49. Review of the facility policy, Bed Safety and Bed Rails, revised on August 2022, showed the following: -Resident beds meet the safety specifications established by the Hospital Bed Safety Workgroup; -Bed frames, mattresses and bed rails are checked for compatibility and size prior to use; -Regardless of mattress type, width, length, and/or depth, the bed frame, bed rail and mattress will leave no gap wide enough to entrap a resident's head or body. Any gaps in the bed system are within the safety dimensions established by the FDA; -Maintenance staff routinely inspects all beds and related equipment to identify risks and problems including potential entrapment risks; -The maintenance department provides a copy of inspections to the administrator and report results to the QAPI committee for appropriate action. Copies of the inspection results and QAPI committee recommendations are maintained by the administrator and/or safety committee. Review of the Food and Drug Administration's (FDA) Guide to Bed Safety, Bed Rails in Hospitals, Nursing Homes and Home Health Care: The Facts, revised April 2010, showed the following: -Between 1985 and 01/01/09, 803 incidents of residents getting caught, trapped, entangled or strangled in beds with rails were reported to the U.S. FDA; -Of those reported, 480 died and 138 had non-fatal injuries; -Most residents were frail, elderly or confused; -Potential risks of bed rails may include strangulation, suffocation, bodily injury or death when residents, or parts of their body, are caught between rails and mattresses, more serious injury from falls when patients climb over rails, skin bruising, cuts and scrapes, feeling isolated or unnecessarily restricted, and preventing patients, who are able to get out of bed, from performing routine activities such as going to the bathroom or retrieving something from a closet. 1. Review of Resident #12's undated Face Sheet showed the following: -The resident was his/her own responsible party; -Diagnoses include multiple sclerosis (a disease in which the immune system eats away at the protective covering of nerves) and weakness. Review of the resident's Bed Rail/Assist Bar Evaluation, dated 03/06/24, showed the resident requested to have bed rails/assist bar while in bed, and bed rails/assist bar were indicated and would serve as an enabler to promote resident independence. Review of the facility provided documentation of Entrapment Assessment showed the last entrapment assessment was completed on 3/21/24. The assessment did not show measurements, only four zones and pass/fail status. All the areas indicated as passed for the room the resident was assigned to. Review of the resident's significant change Minimum Data Set (MDS), a federally mandated assessment instrument, dated 7/15/24, showed the following: -Cognitively intact; -Impairment in range of motion impairment on the upper and lower extremities on both sides of his/her body; -The resident was dependent on staff assistance for rolling left and right, sitting to lying, lying to sitting on the side of the bed, chair/bed-to-chair transfers. Review of the resident's care plan, revised on 10/23/24, showed the following: -He/She required assistance with activities of daily living (ADL's) related to mobility and impaired balance; -Assist bars are for mobility and transfer on his/her bed. Observation on 10/23/24 at 2:16 P.M., showed the resident lay in bed. The resident had 1/8th assist rails in the raised position on both sides of his/her bed. Review of the resident's medical record showed no documentation staff routinely inspected the resident's bed and bed rails to identify risks and problems including potential entrapment risks. 2. Review of Resident #102's undated Face Sheet showed his/her admission date was 10/21/24. Review of the resident's baseline care plan, dated 10/21/24, showed the following: -Required one person for bed mobility and transfers; -The care plan did not address use of side rails/assist bars. Review of the resident's Bed Rail/Assist Bar Evaluation, dated 10/23/24, showed bilateral bed rails/assist bars were indicated and would serve as an enabler to promote resident independence. Observation on 10/22/24 at 12:21 P.M., showed the resident sat in his/her wheelchair in his/her room. The resident had 1/8th assist rails in the raised position on both sides of his/her bed. Review of the resident's medical record showed no documentation staff inspected the resident's bed and bed rails to identify risks and problems including potential entrapment risks. 3. Review of Resident #24's Bed Rail/Assist Bar Evaluation, dated 03/19/24, showed staff completed an admission assessment for bilateral assist bar/bed rail. The assessment did not identify if assist bars/bed rails were indicated. Review of the resident's Care Plan, last revised 07/22/24, showed the following: -Assist of one to two staff for bed mobility and transfers due to impaired mobility and impaired balance; -Assist rails on both sides of bed; -Assist bars make it possible for the resident to reposition himself/herself in bed, assist the resident with transfers in and out of bed, and to be more independent. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Dependent on staff for transfers; -Required substantial to maximum assistance with bed mobility. Observation on 10/24/25 at 2:37 P.M. showed the resident lay in his/her bed with assist rails in the raised position on both sides of the bed. The left side of the bed was up against the wall. Review of the resident's medical record showed no documentation staff routinely inspected the resident's bed and bed rails to identify risks and problems including potential entrapment risks. 4. Review of Resident #25's Bed Rail/Assist Bar Evaluation, dated 04/19/24, showed the resident requested the use of bilateral assist rails to serve as an enabler to promote independence. Staff completed an admission assessment for the bilateral assist bar/bed rail. The assessment did not identify if assist bars/bed rails were indicated. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Supervised or touch assist with bed mobility; -Substantial to maximum assist for transfers. -Impaired ROM one lower extremity. Review of the resident's Care Plan, last revised 07/29/24, showed the following: -Assist rails on both sides of bed per resident request; -Assist rails will assist the resident with repositioning in bed and with transferring in and out of bed; -The resident was aware of the risks involved with the assist rails and signed a consent; -Therapy evaluated the resident for appropriateness for assist rails, indicating they will serve as an enabler to promote independence. Observation on 10/24/24 at 7:12 A.M. showed the resident lay in his/her bed. The resident had 1/8th assist rails in the raised position on both sides of his/her bed. The right side of the bed was pushed against the wall. Review of the resident's medical record showed no documentation staff inspected the resident's bed and bed rails to identify risks and problems including potential entrapment risks. 5. Review of Resident #23's Bed Rail/Assist Bar Evaluation, dated 09/06/24, showed he resident requested to have bed rails/assist bar while in bed and bed rails/assist bar were indicated and would serve as an enabler to promote resident independence. Review of the resident's significant change MDS, dated [DATE], showed the following: -Cognitively intact; -Impairment in range of motion to the upper and lower extremities one side of his/her body; -Required partial/moderate staff assistance for rolling left and right, sitting to lying, lying to sitting on the side of the bed, sit to standing transfer, chair/bed-to-chair transfers. Review of the resident's Care Plan, revised on 09/19/24, showed the following: -He/She required assistance with activities of daily living (ADLs) related to impaired mobility and impaired balance; -Assist rails as ordered for mobility. Observation on 10/22/24 at 11:28 A.M., showed the resident lay in bed awake with 1/8th assist rails in the raised position on both sides of his/her bed. Review of the resident's medical record showed no evidence of measurements or evaluation for entrapment zones on the resident's bed. Review of the resident's medical record showed no documentation staff inspected the resident's bed and bed rails to identify risks and problems including potential entrapment risks. 6. Review of Resident #207's Bed Rail/Assist Bar Evaluation, dated 10/21/24, showed staff completed an admission assessment for bilateral assist bar/bed rails. Bed rails/assist bar were indicated and would serve as an enabler to promote resident independence Observation on 10/22/24 at 2:10 P.M., showed the resident's bed had 1/8th assist rails in the raised position on both sides of the bed. The rail was stationary and unable to be lowered. During an interview on 10/22/24, at 2:10 P.M., the resident said he/she used the assist rails to help with bed mobility and transfers. Review of the resident's admission MDS, dated [DATE], showed the following: -Cognitively intact; -Required partial/moderate staff assistance for rolling left and right, sitting to lying, lying to sitting on the side of the bed, sit to standing transfer, chair/bed-to-chair transfers; -History of falls prior to admission, fall within the last 2-6 months prior to admission, fracture related to fall in six months prior to admission; -No falls since admission. Review of the resident's Care Plan, revised on 10/23/24, showed the following: -He/She was at risk for falls related to impulsiveness and gait/balance problems; -The resident/resident's family had requested assist bars to be on the sides of his/her bed; -He/She was informed of the risks involved in having assist bars and the resident signed a consent form that he/she was aware and still wanted them; -He/She will be re-evaluated if there is a change in status; -On 10/22/24 at 3:44 P.M., staff observed the resident sitting on the floor in his/her room between the wheelchair and bed. Observation on 10/24/24 at 5:11 A.M., showed the resident lay in bed sleeping with 1/8th assist rails in the raised position on both sides of his/her bed. Review of the resident's medical record showed no documentation staff inspected the resident's bed and bed rails to identify risks and problems including potential entrapment risks. 7. Review of Resident #4's face sheet showed the following: -admission date: 12/11/23; -Diagnoses of muscle weakness, other abnormalities of gait and mobility, and unspecified falls. Review of the resident's Bed Rail/Assist Bar evaluation, dated 03/06/24, showed the resident had requested to have bed rails/assist bar while in bed and the bed rails/assist bar were indicated and would serve as an enabler to promote resident independence. Review of the facility provided documentation of Entrapment Assessments, showed the last entrapment assessment was completed 03/21/24. The assessment does not show measurements, only four zones and pass/fail status. All areas indicated as passed for the room the resident was currently assigned to. Review of the resident's Significant Change MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Impairment in range of motion to one side of the upper extremities, no impairment in the lower extremities; -Substantial to maximum assistance for all mobility needs. Review of the resident's Care Plan, revised 09/05/24, showed the following: -He/She required assistance with activities of daily living (ADLs) due to impaired mobility and impaired balance; -Assistance of one staff for repositioning every two or three hours and as needed; -He/She had assist cane rails to both sides of their bed; -Assist rails are to help him/her with positioning and mobility; -He/She had potential for injury related to impaired mobility; -Physical Therapy evaluated if the assist rails would be a benefit for him/her; -He/She will be re-evaluated if there is a change in condition. Observation on 10/24/25 at 5:10 A.M. showed the resident lay in bed. The resident had assist rails in the raised position on both sides of his/her bed. Review of the resident's medical record showed no documentation staff routinely inspected the resident's bed and bed rails to identify risks and problems including potential entrapment risks. 8. Review of Resident #45's face sheet showed the following: -admission date 05/15/24; -Diagnoses of hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs and/or facial muscles) affecting the left side, morbid obesity, and need for assistance with personal care. Review of the facility provided documentation of Entrapment Assessments, showed the last entrapment assessment was completed 03/21/24. The assessment did not show measurements, only four zones and pass/fail status. The room the resident was currently assigned to was listed as having no bed rails. Review of the resident's significant change MDS, dated [DATE], showed the following: -Cognitively intact; -Impairment in range of motion on one side of upper and lower extremities; -Required moderate to substantial/maximal assistance for all mobility needs. Review of the resident's Care Plan, revised on 08/29/24, showed the following: -He/She required assistance with ADLs due to impaired mobility and impaired balance; -He/She had requested assist bars to both sides of his/her bed; -He/She was able to reposition himself/herself in bed and the assist bar with getting in and out of bed; -He/She will be reevaluated as needed; -Therapy had evaluated him/her for appropriateness of assist bars and it was indicated they enable him/her to be more independent. Review of the resident's bed rail/assist bar evaluation, dated 09/10/24, showed staff did not identify the type of assessment (i.e. admission, quarterly, annual, etc) and did not identify if bed rails were indicated. Observation on 10/22/24 at 2:34 P.M. showed the resident lay in bed. The resident had assist rails in the raised position on both sides of his/her bed. Review of the resident's medical record showed no documentation staff routinely inspected the resident's bed and bed rails to identify risks and problems including potential entrapment risks. 9. During an interview on 10/25/24 at 11:55 A.M., the Maintenance Director said the following: -A staff member who no longer worked at the facility completed the entrapment risk assessments on 03/21/24; -No one had completed as assessment, including measurements of the bed frame, mattresses or side rails, since 03/21/24; -There was a tool to measure the beds, but he had not used the tool to do any measurements; -He was unaware of how often staff should assess the beds for risk of entrapment. During an interview on 10/25/24 at 10:34 A.M., the Director of Nursing (DON) said maintenance staff measured the beds with bed rails for entrapment zones when therapy approved the bed rails. During an interview on 10/25/24 at 1:15 P.M., the Administrator said the following: -Maintenance staff was responsible for measuring the entrapment zones; -There had been no ongoing assessments for risk of entrapment; -The assist rails were a positioning device and not a bed rail.

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food to residents in a safe and sanitary manner when staff failed to employ proper hand hygiene and gloving practices and failed to store food in a manner that prevented potential contamination. Staff failed to ensure beverage and ice machines were clean and an air gap was present at ice machine drains. Staff failed to document and demonstrate knowledge of the use and testing parameters of the facility's dishwashing machines to ensure dishes were cleaned and sanitized properly. The facility census was 49. Review of the facility policy, Food and Nutrition Services Staff, revised November 2022, showed the following: -Food and nutrition services staff should wash their hands before serving food to residents; -Employees should wash their hands after collecting soiled plates and food waste and prior to handling food trays; -Bare hand contact with food is prohibited; -Gloves are worn when handling food directly and changed between tasks. Review of the undated facility policy, Procedures for Serving Food on Second and Third Floor, showed the following: -Wash your hands for 20 seconds, take paper towel, dry your hands, then turn off faucet, put on gloves; -After you finish tasks, take off gloves, wash hands, and with a new task comes new gloves; -Wash your hands before you serve food. 1. Observation on 10/22/24, from 4:52 P.M. to 5:05 P.M., in the third floor dining room during the dinner meal service, showed the following: -Dietary Aide I served food onto residents' plates from the steam table and counter serving area; -He/She used his/her gloved hands to grasp and move a newspaper from a resident to the nurses' station; -Without changing his/her gloves, he/she touched the inside surface of a bowl, ladeled soup into the bowl, and gave the bowl of soup to a resident; -He/She touched the handles of a resident's wheelchair, pushed the resident closer to the table, and touched the resident's arm; -He/She removed his/her gloves, did not wash his/her hands, put on new gloves, and removed soiled dishes from residents' tables to the counter; -He/She picked up a butter knife from the floor and placed it in the sink, took off one glove and put on a new glove, did not wash his/her hands, and served food onto residents' plates from the steam table; -With his/her same gloved hands, he/she turned off a faucet handle (the water was running at the sink), grabbed a piece of bread from a bag of bread, and placed the bread on a resident's plate; -He/She opened and closed the microwave door, pressed buttons on the microwave, touched resident meal cards, and continued serving residents' food during the meal service. Observation on 10/23/24, from 8:01 A.M. to 8:41 A.M., in the second floor dining room during the breakfast meal service, showed the following: -Dietary Aide H used his/her bare hands to pick up soiled dishes from residents' tables and placed the dishes into the sink; -Without washing his/her hands, he/she put a glove on his/her right hand, grabbed a piece of bread from a bag of bread, placed the bread in the toaster, and turned on the toaster using the toaster controls; -He/She rested his/her gloved hand on the top of the steam table, wiped his/her gloved hand on his/her apron, and grabbed another slice of bread and placed the bread in the toaster; -Without washing his/her hands or changing his/her gloves, he/she removed toast from the toaster and held the toast in his/her left bare hand while using a knife in his/her right gloved hand to spread butter on the toast; -He/She served the buttered toast to a resident, removed soiled dishes from residents' tables, poured a cup of coffee for a resident, and brought clean silverware to a resident; -He/She removed his/her glove, discarded the glove into the trash can, did not wash his/her hands, put on new gloves, and placed more bread in the toaster; -With his/her gloved hands, he/she ate food, drank from a cup, and used a napkin to wipe his/her mouth while standing at the food preparation counter; -He/She moved soiled dishes from the counter to the sink, removed his/her gloves, discarded the gloves in the trash can, and moved soiled dishes from residents' tables to the sink; -Without washing his/her hands, he/she used his/her bare hands to remove the lid of a resident's coffee mug and refill the mug with coffee; -He/She picked up soiled dishes from residents' tables and placed them on the counter by the sink; -He/She obtained a clean drinking glass, opened the refrigerator door, poured milk from a jug into the glass, and carried the glass with his/her bare hands touching the upper drinking-edge portion of the glass and gave the glass of milk to a resident. During an interview on 10/24/24 at 9:36 A.M., Dietary Aide D said the following: -Staff should wash their hands after performing dirty tasks, when changing gloves, and before performing clean tasks; -Staff should not eat or drink personal items in the food preparation and serving areas, such as in the second and third floor kitchenettes, and should instead consume these items in the employee breakroom; -Staff should handle dishware by the non-eating and non-drinking surfaces of those items. During an interview on 10/24/24 at 1:08 P.M., the Dietary Manager said the following: -She expected staff to serve, store and prepare food and beverages under safe and sanitary conditions; -Staff should wash their hands properly and change their gloves appropriately; -Staff should not handle ready-to-eat foods with their bare hands or soiled gloves; -Staff should wash their hands and change their gloves when changing tasks, after completing dirty tasks (such as picking items up from the floor) and prior to conducting clean tasks (such as serving food to residents); -Staff should not consume food or beverages in the food preparation area and should instead eat in the breakroom or dining room; -Staff should handle clean dishware by the non-eating and non-drinking sides of those items. Review of the facility policy, Food Receiving and Storage, revised November 2022, showed foods shall be received and stored in a manner that complies with safe food handling practices. 2. Observation on 10/22/24 at 10:55 A.M., in the kitchen dry storage room, showed the following: -The top of an open 5-pound bag of buttermilk pancake mix was loosely folded over and not securely sealed; -The dates 8/3/24 and 8/10/24 were written in marker on a zippertop bag containing approximately 10 flour tortillas. Observation on 10/23/24 at 9:05 A.M., in the kitchen dry storage room, showed the top of an open 5-pound bag of buttermilk pancake mix was loosely folded over and not securely sealed. Observation on 10/23/24 at 1:01 P.M., in the kitchen walk-in freezer, showed the following: -A bag of frozen chicken breasts was not sealed and was open to the air; -A bag of frozen chicken tenders, located in a cardboard box with flaps that were loosely closed, was not sealed and was open to the air; -A bag of frozen potatoes was not sealed and was open to the air; -A bag of frozen manicotti, located in a cardboard box with flaps that were loosely closed, was not sealed and was open to the air. During an interview on 10/24/24 at 1:08 P.M., the Dietary Manager said she expected staff to properly seal, label, and date food items. She expected staff to discard expired and past-dated food items. 3. Review of the ice machine vendor cleaning records showed the following: -The kitchen ice machine was cleaned, descaled, and sanitized on 7/22/24; -The second floor ice machine was cleaned and sanitized on 8/5/24; -The third floor ice machine was cleaned and sanitized on 8/5/24; Observation on 10/22/24 at 4:25 P.M., in the kitchen, showed the following: -The ice machine had a heavy accumulation of white and brown crusty debris on the back side of the exterior surface; -Several dried white stains were visible across the front, back, and sides of the exterior surface; -A moderate accumulation of moist black debris was on the metal horizontal surface, located above the ice holding area, on the interior portion of the ice machine; -Approximately 0.25 inches of standing water sat in a blue plastic holder (located next to the ice machine) and a metal ice scoop sat in contact with the water. There was a moderate accumulation of dried white debris on the inside surface of the plastic scoop holder. Observation on 10/22/24 at 11:01 AM, in the second floor dining beverage area, showed the following: -A heavy accumulation of white and black crusty debris was visible in and around the dispensing area of the ice and water machine; -A moderate accumulation of black debris was visible between and around the nozzles of the juice dispenser; -A moderate accumulation of dark gray debris speckled the surface around the nozzles of the coffee machine. Observation on 10/23/24 at 7:19 AM, in the third floor dining beverage area, showed the following: -An excessive accumulation of white crusty debris and black buildup was visible in and around the dispensing area of the ice and water machine; -An excess accumulation of black debris was visible between and around the nozzles of the juice dispenser; -A moderate accumulation of dark gray debris speckled the surface around the nozzles of the coffee machine. During an interview on 10/24/24 at 1:08 P.M., the Dietary Supervisor said the following: -She cleaned the nozzles of the juice dispenser weekly; -She wiped the area around the spouts and primed the coffee machine on Monday (10/21/24); -When showed the photos of the machines around the nozzles and spouts, she was unaware the machines were that dirty. During an interview on 10/24/24 at 1:08 P.M., the Dietary Manager said the following: -A company cleaned and sanitized the ice machines about once per quarter, and dietary staff cleaned the outside of the machines monthly; -Dietary staff cleaned and sanitized the kitchen ice machine scoop weekly by running it through the dishwasher. She did not realize the kitchen ice scoop holder was holding water. 4. Observation on 10/23/24 at 8:37 A.M., in the third floor dining room, showed the following: -An approximate 2-foot section of 1-inch diameter PVC pipe extended from the ice machine drain into a 4-inch flanged PVC floor drain; -The 1-inch PVC pipe extended approximately 2 inches below the flood rim level of the flanged drain and contained no air gap to prevent potential backflow from the drain back into the machine. Observation on 10/24/24 at 8:31 A.M., in the second floor dining room, showed the following: -An approximate 2-foot section of 1-inch diameter clear hose extended from the ice machine drain into a 4-inch flanged PVC floor drain; -The clear hose extended approximately 1.5 inches below the flood rim level of the flanged drain and contained no air gap to prevent potential backflow from the drain back into the machine. During an interview on 10/24/24 at 1:08 P.M., the Dietary Manager said the following: -She expected there to be an adequate air gap at the ice machine drains to prevent potential backflow into the machines; -Maintenance staff were responsible for ensuring proper air gaps at the ice machine drains. During an interview on 10/23/24 at 2:35 P.M., the Maintenance Assistant said the following: -A company came every three to four months to clean and descale the ice machines; -He cleaned the ice machine drains monthly and as issues arose; -He checked to ensure there was an air space around the second and third floor ice machine drains that went into the flanged drains but was unaware the drains did not contain an adequate air gap (above the flood rim level of the flanged drain) to prevent potential backflow into the machines. 5. Review of the manufacturer's specification sheet for the kitchen dishmachine showed the following: -Operating temperatures: -Wash (minimum): 140 degrees Fahrenheit (F); -Sanitizing rinse (minimum): 120 degrees F; -Water flow pressure (required): 15-25 PSI (pounds per square inch); -Chemical sanitizer rinse (minimum): 50 PPM (parts per million) chlorine. Observation on 10/23/24 at 1:19 P.M., of the facility log Daily Temperatures for Dishwasher, located in the kitchen dishwashing room, showed the following: -Columns on the form read: Date, A.M. Test Strip, Initials, P.M. Test Strip, Initials; -A checkmark was placed in the A.M. Test Strip column for 10/3/24 through 10/22/24; -A checkmark and/or the date was placed in the P.M. Test Strip column for 10/3/24 through 10/17/24, 10/19/24, 10/20/24, and 10/23/24; -No A.M. or P.M. test strip information was logged for 10/1/24 or 10/2/24; -No A.M. test strip information was logged for 10/23/24; -No P.M. test strip information was logged for 10/18/24, 10/21/24, or 10/22/24; -No chemical test strip parameters or values were written on the form; -No water temperature or water pressure parameters or values were written on the form. Observation on 10/23/24 from 1:13 P.M. to 1:31 P.M., in the kitchen, showed Dishwasher F operated the conveyor-style dishmachine by placing racks of soiled dishes into the entry to the machine and taking out racks of clean dishes from the exit of the machine. The following parameters were observed: -At 1:13 P.M., the rinse temperature (indicated on the machine's dial gauge) was 115 degrees F and the wash temperature was 100 degrees F; -At 1:16 P.M., the rinse temperature was 110 degrees F and the wash temperature was 100 degrees F; -At 1:19 P.M., the rinse temperature was 108 degrees F and the wash temperature was 100 degrees F; -At 1:22 P.M., the rinse temperature was 109 degrees F and the wash temperature was 100 degrees F; -At 1:26 P.M., the rinse temperature was 108 degrees F and the wash temperature was 95 degrees F. During an interview on 10/23/24 at 1:16 P.M., Dishwasher F said the following: -He/She didn't think the kitchen's dish machine got the dishes clean and didn't think the water in the machine got hot enough; -He/She knew he/she needed to keep the sanitizer filled for the machine but was unaware if he/she needed to monitor the water temperature or water pressure. During an interview on 10/24/24 at 9:41 A.M., Dishwasher Q said the following: -Staff should check the sanitizer concentration of the kitchen dishwasher at the beginning of each shift using a test strip; -The test strip should be a really dark purple (200 PPM as indicated on the test strip bottle); -The water temperature and water pressure didn't really matter for the dishwasher, it was mainly the sanitizer that was important to have at the correct level. During an interview on 10/24/24 at 11:45 A.M., the Dietary Supervisor said the dishwashing staff kept turning off the kitchen dishwasher and it took a long time to heat up the water again. 6. Review of the manufacturer's specification sheet for the second and third floor dishmachines showed the following: -Operating temperatures: -Wash (minimum): 120 degrees F; -Rinse (minimum): 120 degrees F; -Water flow pressure (required): 15-25 PSI; -Chemical sanitizer (minimum): 50 PPM chlorine. Review on 10/24/24 at 8:12 A.M., of the untitled facility log, located in the second floor kitchenette, showed the following: -Columns on the form read: Date, A.M. Test Strip 200 PPM, Initials, P.M. Test Strip 200 PPM, Initials; -A checkmark was placed in the A.M. Test Strip column for 10/1/24 to 10/5/24, 10/7/24 to 10/12/24, and 10/14/24 to 10/23/24; -A checkmark was placed in the P.M. Test Strip column for 10/1/24 to 10/2/24, 10/4/24 to 10/8/24, 10/15/24 to 10/19/24, 10/21/24 , and 10/23/24; -No A.M. or P.M. test strip information was logged for 10/13/24; -No A.M. test strip information was logged for 10/6/24 and 10/13/24; -No P.M. test strip information was logged for 10/3/24, 10/9/24 to 10/14/24, 10/20/24, and 10/22/24; -No water temperature or water pressure parameters or values were written on the form. Review on 10/24/24 at 8:12 A.M., of the untitled facility log, located in the third floor kitchenette, showed the following: -Columns on the form read: Date, A.M. Test Strip 200 PPM, Initials, P.M. Test Strip 200 PPM, Initials; -A checkmark was placed in the A.M. Test Strip column for 10/1/24, 10/6/24, 10/7/24, 10/9/24, 10/10/24, 10/13/24, 10/15/24 to 10/17/24, 10/20/24 to 10/24/24; -A checkmark was placed in the P.M. Test Strip column for 10/1/24 to 10/3/24, 10/8/24 to 10/10/24, 10/12/24, 10/13/24, 10/15/24, 10/16/24, 10/18/24, 10/20/24, 10/22/24, and 10/23/24; -No A.M. or P.M. test strip information was logged for 10/11/24 or 10/19/24; -No A.M. test strip information was logged for 10/2/24, 10/3/24, 10/8/24, 10/11/24, 10/12/24, 10/18/24, and 10/19/24; -No P.M. test strip information was logged for 10/6/24, 10/7/24, 10/11/24, 10/17/24, 10/19/24, and 10/21/24; -No water temperature or water pressure parameters or values were written on the form. Observation on 10/23/24, of the second floor kitchenette dishwasher, showed the following: -At 8:44 A.M., Dietary Aide H started a load of dishes. The wash temperature (indicated on the unit's digital display) was 119 degrees F and the rinse temperature was 87 degrees F; -At 8:45 A.M., the wash temperature was 113 degrees F and the rinse temperature was 95 degrees F; -At 8:46 A.M., the cycle ended and the wash temperature was 113 degrees F and the rinse temperature was 103 degrees F; -No water pressure gauge was visible for the dishwasher. Observation on 10/24/24, of the third floor kitchenette dishwasher, showed the following: -At 8:22 A.M., Dietary Aide D started a load of dishes. The wash temperature was 91 degrees F and the rinse temperature was 87 degrees F; -At 8:23 A.M., the wash temperature was 91 degrees F and the rinse temperature was 102 degrees F; -At 8:24 A.M., the cycle ended and the wash temperature was 91 degrees F and the rinse temperature was 102 degrees F; -No water pressure gauge was visible for the dishwasher. During an interview on 10/23/24 at 8:41 A.M., Dietary Aide H said the following: -Staff washed the dishes (other than the silverware) from the second and third floor dining rooms in the in the second and third floor kitchenette dishwashers; -He/She did not monitor the water temperature or water pressure of the dishwasher located on the second floor; -He/She tested the sanitizer chemical level for the dishwasher at the end of the day. If the test strip was black, then it had enough sanitizer. If the test strip started turning white, then he/she needed to refill the sanitizer (located below the sink). During an interview on 10/24/24 at 9:36 A.M., Dietary Aide D said the following: -He/She turned on the dishwasher, located in the third level dining room, at the beginning of his/her shift, let it run, and then tested the sanitizer level with a chemical test strip; -The test strip should show a color that was not too light and not too dark; it should be in between the colors on the test strip bottle; -He/She was unaware of a minimum operating water temperature or water pressure the dishwasher needed to reach. During interviews on 10/24/24 at 11:45 A.M. and 1:08 P.M., the Dietary Supervisor said the following: -Staff should check chemical levels for the dishwashers, located in the kitchen and second and third floor kitchenettes, using chemical test strips at the beginning of each shift; -She was unaware of minimum water temperature or water pressure levels the dishwashers needed to reach. During interviews on 10/23/24 at 1:40 P.M. and on 10/24/24 at 1:08 P.M., the Dietary Manager said the following: -All of the dishwashers were low temperature machines with chemical sanitization; -The chlorine level from the sanitizer should be at least 100 parts per million; -She was unaware of a minimum water temperature or water pressure required for the dishwashers; -She expected staff to be knowledgeable on the use of and testing parameters of the dishwashers and to follow manufacturer's instructions for the machines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a significant change in status Minimum Data Set (MDS) for one (Resident (R) 32) of one resident reviewed for hospice in a total sample of 24 residents. Findings include: Review of R32's admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed an admission date of 03/07/23 with medical diagnoses including Protein Calorie Malnutrition. Review of R32's Order Summary Report, located in the EMR under the Orders tab, revealed the following order, dated 04/07/23: Pro [NAME] hospice to begin 4/6/2023. Review of R32's EMR revealed no evidence that a significant change MDS was completed in response to the resident being admitted to hospice services. During an interview on 06/08/23 at 12:56 PM, the MDS coordinator (MDSC) verified R32 was admitted to hospice services and a significant change MDS should have been completed in response. The MDSC confirmed no significant change MDS was completed for R32.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a discharge assessment using the Minimum Data Set (MDS) process within the required timeframe for two (Resident (R) 11 and R47) discharged residents reviewed in a total sample of 24 residents. Findings include: 1. Review of R11's undated admission Record, located in the resident's electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE]. R11 was discharged on 12/24/22. Review of R11's MDS tab in the EMR revealed an admission MDS, with an Assessment Reference Date (ARD) of 12/13/22. The EMR revealed no evidence that a discharge MDS assessment was encoded or transmitted after the resident was discharged on 12/24/22. 2. Review of R47's undated admission Record, located in the resident's EMR under the Profile tab revealed the resident was admitted to the facility on [DATE]. R47 was discharged on 01/16/23. Review of MDS tab in the EMR revealed an admission MDS with an ARD of 12/31/22. The EMR revealed no evidence that a discharge MDS assessment was encoded or transmitted after the resident was discharged on 01/16/23. During an interview on 06/08/23 at 11:03 AM, the MDS Coordinator said she did not know how she had missed completing the MDS discharge assessments. The MDS Coordinator confirmed that both R11 and R47 should have had a MDS discharge assessment completed/transmitted. During an interview on 06/09/23 at 11:35 AM, the Administrator said the facility did not have a MDS policy and that the facility followed the RAI (Resident Assessment Instrument) manual. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated 10/2019, revealed, Discharge Assessment-Return Not Anticipated - Must be completed when the resident is discharged from the facility and the resident is not expected to return to the facility within 30 days; Must be completed within 14 days after the discharge date ; Must be submitted within 14 days after the MDS completion date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and policy review, the facility failed to ensure a comprehensive care plan was developed for three residents (Resident (R)1, R3, and R7) of 24 sampled residents. Findings include: Review of the Facility's Policy titled Comprehensive Assessment and the Care Delivery Process dated 12/2016, revealed, Comprehensive assessments, care planning and the care delivery process involve collecting and analyzing information, choosing and initiating interventions, and then monitoring results and adjusting interventions. 1. Review of R1's admission Record, located in the resident's electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE], with diagnoses including moderate protein calorie malnutrition, dementia, age related osteoporosis, and pathological fracture. Review of R1's Physicians Orders for the month of June located in the resident's EMR under the Orders tab revealed the resident was placed on hospice service effective 05/31/23. Review of R1's Significant Change MDS with an Assessment Reference Date (ARD) of 06/07/23 located in the resident's EMR under the MDS tab revealed the MDS was in progress due to the resident's recent admission to the hospice program. Review of R1's Care Plan with a review start date and completion date of 06/11/23 located in the resident's EMR under the Care Plan tab revealed the resident's care plan did not reflect the resident admission to the hospice program. An interview on 06/09/23 at 09:51 AM the MDS Coordinator (MDSC) revealed she develops the care plans and usually revises/updates the care plans during staff meetings. The MDSC said she thought she added hospice and interventions to the resident's facility care plan. 2. Review of R3's admission Record found in the electronic medical record (EMR) under the Profile tab, revealed R3 was admitted on [DATE] with a primary diagnosis of acute respiratory failure, venous insufficiency (chronic) (peripheral), legal blindness and hearing loss. Review of R3's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 03/20/23 revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 indicating the resident was cognitively intact. The MDS revealed the resident was feeling more tired or having little energy, had no behaviors and required limited assistance with transfers, dressing and eating. During an observation and interview of R3 on 06/06/23 at 9:30 AM, both of R3's legs were covered in compression stockings and were swollen. R3 stated my legs are so swollen. Review of Progress Notes found in the EMR under the Progress Notes tab revealed a progress note, dated 05/18/23,During peri care popped blisters were noted to inside of both thighs near her groin. Resident states she had spilled hot coffee on her lap recently and the areas were from that and uncomfortable. Dressing placed for protection to stop further rubbing from brief and thighs. A review of R3's Care Plan found under the Care Plan tab, dated 03/27/23, revealed no care plan for venous insufficiency or the blisters found on R3's thighs on 05/18/23. During an interview with the Director of Nursing (DON), on 06/09/23 at 7:08 AM, she said a care plan should be completed for all residents and should be specific and personalized for each resident. The DON said that all care plans are the responsibility of the MDSC. She said that R3 should have a care plan for edema and the burns that happened on 05/17/23 when R3 spilled the coffee on her lap. 3. Review of R3's undated admission Record, located in the resident's electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses of venous insufficiency. Review of R3's Order, located in the resident's EMR under the Orders tab revealed the following order dated 03/24/23: Lasix [a diuretic] oral tablet 40 mg (furosemide) give 1 tablet by mouth one time a day for diuretic. Review of R3's Medication Administration Report, located in the EMR under the Orders tab revealed R3 received Lasix as ordered for the months of March, April, May, and June 2023. Review of R3's Care Plan, located in the EMR under the Care Plan tab revealed the absence of a care plan for Lasix. During an interview on 06/09/23 at 10:35 AM, the DON confirmed R3 received Lasix as ordered. The DON confirmed there should be a care plan for the diuretic and staff should look for swelling and weight gain. During an interview with the MDSC, on 06/09/23 at 4:35 PM, she said she was responsible for all care plans and MDS for the facility. She said the care plan should be specific and personalized for each resident. 4. Review of R7's undated admission Record, located in the resident's EMR under the Profile tab revealed the resident was admitted to the facility on [DATE] with a diagnosis of peripheral vascular disease. Review of R7's Order, located in the resident's EMR under the Orders tab revealed the following order dated 03/28/23: Apixaban [an anticoagulant] Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth two times a day for anticoagulant. Review of R7's Medication Administration Report, located in the EMR under the Orders tab revealed R7 received Apixaban as ordered for the months of March, April, May, and June 2023. Review of R7's Care Plan, located in the EMR under the Care Plan tab revealed the absence of a care plan for Apixaban, related to observing for bruising/bleeding; monitoring lab results; hematuria, and blood in stool. During an interview on 06/09/23 at 10:42 AM, the DON confirmed R7 received Apixaban as ordered. The DON confirmed there should be a care plan for the anticoagulant and staff should look for bruising and bleeding. During an interview on 06/09/23 at 4:38 PM, the MDS Coordinator said she was responsible for all care plans, and they should accurately reflect the residents' status. The MDSC confirmed that this had not been done for R1, R3, and R7.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review, and policy review, the facility failed to ensure there were weekly skin assessments completed for one resident (Resident (R) 3) of three residents sampled for skin assessments, from a total sample of 24. Specifically, the facility failed to consistently complete weekly skin assessments for R3, specifically skin assessments after blisters were identified on 05/18/23, which increased the likelihood of R3 developing a significant skin issue. Findings include: Review of the facility's Skin Tears - Abrasions and Minor Breaks, Care of policy, dated 09/2013, revealed, The purpose of this procedure is to guide the prevention and treatment of abrasions, skin tears and minor breaks in the skin . Head-to-Toe Skin Assessment to be completed by a licensed nurse weekly and recorded in the medical record .If skin breakdown noted . skin breakdown includes: burn . Charge nurse is to contact the physician for treatment orders .report new occurrence of skin breakdown to the Director of Nursing (DON) . Assessment of skin breakdown to be noted in medical record .Resident will be monitored and treatment provided based on physician order and facility protocol .RAR (resident at risk) committee to review based on referral by any member of the Interdisciplinary Team. Review of R3's admission Record, found in the electronic medical record (EMR) under the Profile tab, revealed R3 was admitted on [DATE] with diagnoses of acute respiratory failure, venous insufficiency (chronic) (peripheral), legal blindness and hearing loss. Review of R3's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 03/20/23 revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 indicating the resident was cognitively intact. The MDS revealed the resident was feeling more tired or having little energy, had no behaviors and required limited assistance with transfers, dressing and eating. Review of Progress Notes found in the EMR under the Progress Notes tab revealed a progress note, dated 05/18/23,During peri care, blisters were noted to inside of both thighs near her groin. Resident states she had spilled hot coffee on her lap recently and the areas were from that and uncomfortable. Dressing placed for protection to stop further rubbing from brief and thighs. Review of R3's Care Plan located in the Care Plan tab, revised 06/05/23, revealed there was no skin Care Plan related to skin and/or blisters for R3. Review of the POC (point of care) Response History Located in the Care Plan tab under Tasks, revealed R3 was not Scratched, Red Area, Discoloration, Skin Tear, Open Area from 05/17/23 through 06/06/23. Review of the POC (point of care) Response History Located in the Care Plan tab under Tasks, revealed R3 did not have a New Skin Condition from 05/17/23 through 06/06/23. Review of the Skin Observation Tool - (Licensed Nurse) under the Assessment tab, dated 05/30/23, revealed no documentation related to R3's blisters. This was the only Skin Observation Tool - (Licensed Nurse) completed since the identification of the blisters on 05/18/23. Review of the Skin Monitoring: Comprehensive CNA Shower Review, dated 05/22/23, revealed blister inside of right thigh nurse aware. The document was signed by a Registered Nurse (RN) 2. The Charge Nurse Assessment was blank. The most recent Skin Monitoring: Comprehensive CNA Shower Review prior to 05/17/23 (the date the blisters were identified) was dated 05/11/23. Review of the Skin Monitoring: Comprehensive CNA Shower Review, dated 05/23/23, revealed no change. The document was signed by a Registered Nurse (RN) 2 on 05/28/23. The Charge Nurse Assessment was blank. Review of the Skin Monitoring: Comprehensive CNA Shower Review, dated 05/29/23, did not indicate any blisters. During an interview with Registered Nurse (RN) 1, on 06/07/23 at 7:46 AM, he stated residents usually receive showers twice weekly and CNAs should complete a skin check every time. RN1 stated if the CNA identifies a problem, they should notify the nurse so the nurse can assess the area. The CNA had made him aware of R3's blisters. During an interview with Certified Nurse Aide (CNA) 1, on 06/07/23 at 8:23 AM, she stated CNAs complete the Skin Monitoring: Comprehensive CNA Shower Review every time a shower was completed. CNA1 stated she would notify a nurse if she observed a concern while conducting the skin checks. She stated residents are scheduled to receive showers twice weekly. Although CNA1 identified R3's blisters initially, she failed to document them on R3's shower sheet. During an interview with CNA3, on 06/07/23 at 12:30 PM, she stated she would complete a skin check every time she gave a resident a shower. She stated she would notify the nurse if she observed a concern. CNA3 was made aware of R3's blisters during change of shift report. During an interview with the DON, on 06/09/23 at 7:08 AM, she stated skin assessments should be completed weekly by a nurse. She stated it was her responsibility to ensure the skin assessments were being completed. She stated the week that was most important for R3 (when she spilled coffee in her lap) was a week that a skin assessment was missed and confirmed this was not completed. The DON stated the CNA should complete the Skin Monitoring: Comprehensive CNA Shower Review every time the resident received a shower. She stated if a CNA observed any skin concerns, they should notify the nurse as soon as possible, so the nurse could assess, notify the physician, and provide treatment if ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the pharmacist failed to identify and report irregularities regarding inadequate indications for use of an antipsychotic medication for two (Resident (R) 3 and R22) of five residents reviewed for unnecessary medication use. Findings include: Review of the facility's policy titled, Medication Therapy, revised 04/2007, revealed, Upon or shortly after admission, and periodically thereafter, the staff and practitioner (assisted by the Consultant Pharmacist) will review an individual's current medication regimen, to identify whether: a. There is a clear indication for treating that individual with the medication. 1. Review of R3's undated admission Record, located in the resident's electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with a diagnosis of major depressive disorder. Review of R3's Order Summary Report, located in the resident's EMR under the Orders tab revealed the following order dated 03/13/23: Seroquel [an antipsychotic medication] 25 mg [milligrams] Give 1 tablet by mouth in the evening for antipsychotic. Further review of the EMR revealed no evidence of an accepted indication for the use of Seroquel. Review of R3's Medication Administration Report, located in the EMR under the Orders tab revealed R3 received Seroquel as ordered for the months of March, April, May, and June 2023. Review of R3's EMR revealed no evidence of a pharmacy recommendation that identified the irregularity related to the lack of an adequate indication for the use of Seroquel. 2. Review of R22's undated admission Record, located in the resident's EMR under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, dementia, and visual hallucinations. Review of R22's Order Summary Report, located in the resident's EMR under the Orders tab revealed the following orders dated 11/30/21: Seroquel 50 mg q [every] day for agitation and Seroquel 25 mg q day for agitation. Further review of the EMR revealed no evidence of an accepted indication for the use of Seroquel. Review of R22's Medication Administration Report, located in the EMR under the Orders tab revealed R22 received Seroquel as ordered for the months of March, April, May, and June 2023. Review of R22's EMR revealed no evidence of a pharmacy recommendation that identified the irregularity related to the lack of an adequate indication for the use of Seroquel. During an interview on 06/09/23 at 9:36 AM, the Consultant Pharmacist (CP) stated she provides the facility with recommendations regarding irregularities. The CP stated she did not have her computer with her at the time of the interview but would provide the survey team with the information on R3 and R22. Review of an email from the CP, dated 06/09/23 at 4:33 PM, revealed the following statement: She [R3] was admitted with quetiapine [Seroquel] for MDD [major depressive disorder], recurrent on 3-13-23. Further review revealed, Going forward, I will ensure that ALL medications with dx [diagnosis] listed in the POS [plan of service]/MAR [medication administration record] directions are correct and will request correction based on dx located in the dx list and SOAP [subjective, objective, assessment and plan] notes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to ensure psychotropic medication had an appropriate indication for use for two of five residents (Resident (R) 3 and R22) reviewed for unnecessary medication. The facility further failed to ensure that a PRN (as needed) psychotropic medication had a documented rationale for use beyond 14 days for one of five residents (R22) reviewed for unnecessary medication. Findings include: Review of the facility's policy titled, Antipsychotic Medication Use, revised 12/2016, indicated, Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. The facility's policy further revealed, Antipsychotic medications shall generally be used only for the following conditions/diagnoses as documented in the record, consistent with the definition(s) in the Diagnostic and Statistical Manual of Mental Disorders (current or subsequent editions): a. Schizophrenia; b. Schizo-affective disorder; c. Schizophreniform disorder; d. Delusional disorder; e. Mood disorders (e.g. bipolar disorder, depression with psychotic features, and treatment refractory major depression); f. Psychosis in the absence of dementia; g Medical illnesses with psychotic symptoms and/or treatment-related psychosis or mania (e.g., high dose steroids); h. Tourette's Disorder; i. Huntington Disease; j. Hiccups (not induced by other medications); or k. Nausea and vomiting associated with cancer or chemotherapy. 1. Review of R3's undated admission Record, located in the resident's electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with a diagnosis of major depressive disorder. Review of R3's Order Summary Report, located in the resident's EMR under the Orders tab, revealed the following order dated 03/13/23: Seroquel [an antipsychotic medication] 25 mg [milligrams] Give 1 tablet by mouth in the evening for antipsychotic. There was no indication for use listed in R3's chart other than for antipsychotic, which was a description of the medication classification, not an indication for its use. Review of R3's Behavior Monitoring, for a lookback period of 03/15/23 through 06/08/23, located in the resident's EMR under the Tasks tab revealed the following behavior noted on 04/01/23: frequent crying, yelling/screaming, wandering. The remainder of the days during this lookback period noted no additional behaviors. During an interview on 06/09/23 at 10:35 AM, the Director of Nursing (DON) stated R3 was on Seroquel when she was admitted to the facility. The DON further stated she had not seen R3 exhibit any behaviors other than confusion, and R3 once stated there was vacuum cleaner in her room. The DON stated that when a resident was on an antipsychotic medication, she expected to see a reason listed in the order for the use of the medication. During an interview on 06/09/23 at 10:56 AM, the Medical Director stated, When she (the resident) came in, she was very restless, agitated, and trying to get up without help. The Medical Director added, There should be an indication for use. Simply having 'antipsychotic' is not acceptable. That may have been an oversight by the nurses. During an interview on 06/09/23 at 9:36 AM, the Consultant Pharmacist stated, There should always be an indication for use and just having the word 'antipsychotic' is not appropriate. I have previously made these types of recommendations to the facility. 2. Review of R22's undated admission Record, located in the resident's EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, dementia, and visual hallucinations. Review of R22's Order Summary Report, located in the resident's EMR under the Orders tab, revealed the following orders dated 11/30/21: Seroquel 50 mg q [every] day for agitation and Seroquel 25 mg q day for agitation. The order for Seroquel revealed no additional indication for use other than for agitation which, per the facility policy, was not an accepted indication for the use of an antipsychotic. Review of R22's Medication Administration Report, located in the EMR under the Orders tab, revealed R22 received Seroquel as ordered for the months of March, April, May, and June 2023. During an interview on 06/09/23 at 9:36 AM, the Consultant Pharmacist stated There should be a definite diagnosis in his chart. I'm good with that if I can see a diagnosis in the chart, then I know the medication is appropriate for the resident. Seroquel for agitation is not an appropriate indication for use. We will get a more appropriate diagnosis linked. During an interview on 06/09/23 at 10:29 AM, the DON stated, I know that there are certain diagnoses for Seroquel, but I don't think agitation is one of those diagnoses. During an interview on 06/09/23 at 10:51 AM, the Medical Director stated that agitation was not an appropriate indication of use for Seroquel. 3. Review of an undated facility policy titled, Medication Orders - PRN Psychotropic Medications, indicated, Regarding PRN psychotropics, excluding antipsychotics: a. For an initial fill of a PRN psychotropic, the prescriber shall not order a supply exceeding 14 days. If the prescriber believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. Review of R22's Order Summary Report, located in the resident's EMR under the Orders tab, also revealed the following order, dated 05/10/23: Trazodone 50 mg Give 1 tablet by mouth every 8 hours as needed for sleep until 06/12/2023. Review of R22's Medication Administration Report, located in the EMR under the Orders tab, revealed R22 received the PRN Trazodone on 05/11/23, 05/21/23, and 05/30/23. Review of R22's EMR revealed the absence of a documented for rationale for the continued use of Trazodone beyond 14 days. During an interview on 06/09/23 at 9:36 AM, the Consultant Pharmacist stated that PRN psychotropic medication should have a 14-day stop date unless the physician documented a rationale to continue the medication. During an interview on 06/09/23 at 10:29 AM, the DON stated, PRN psychotropics can be longer than 14 days with a rationale. During an interview on 06/09/23 at 10:51 AM, the Medical Director stated there should be a documented rationale for PRN psychotropics beyond 14 days. The Medical Director stated, I would usually document a rationale, but I don't have it now for R22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and the facility's hospice contract, the facility failed to ensure the appropriate coordination of Hospice care by specifically failing to maintain hospice care plans, Hospice election form and Physician certification and recertification of the terminal illness specific to each patient for two (Resident (R)27, and R32) of two residents sampled for Hospice. This failure had the potential result in the interruption of the residents' coordination of care. Findings include: Review of the facility's Hospice agreement titled Nursing Facility Agreement dated 06/01/2016 reads in part Obtaining the following information from the Hospice: The most recent Hospice Plan of Care for each Hospice Patient; Hospice election form; physician certification of the terminal illness for each Hospice Patient; Names and contact information for the Hospice personnel involved in the care of each Hospice Patient; Instructions on how to access Hospice's 24 hour on call system; . Hospice medication information specific to each Hospice Patient; and Hospice physician and attending physician orders for each Hospice Patient. 1. Review of R27's admission Record, located in the resident's electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE], with diagnoses including chronic kidney disease, stage III, TIA [Transient Ischemic Attack (mini stroke)], and severe protein calorie malnutrition. Review of 27's Physicians Orders for the month of June located in the resident's EMR under the Orders tab revealed the resident was placed on Hospice effective 03/09/23. Review of R27's Significant Change MDS with an Assessment Reference Date (ARD) of 03/31/23 located in the resident's EMR under the MDS tab revealed the MDS section O the resident was receiving hospice services. Review of R27's Care Plan with a revision date of 04/05/23 located in the resident's EMR under the Care Plan tab revealed the resident was receiving hospice services. Review of R27's Hospice chart located at the nurses' station revealed the chart lacked any documentation of services the resident was to receive. There was no contact information, the services and frequency provided or a care plan with interventions. During an interview 06/09/23 at 07:30 AM with Licensed Practical Nurse (LPN) 4 revealed she was unaware of the missing documentation for the resident's hospice services. LPN 4 stated the hospice nurse will assess the resident and determine when the resident will receive the services and she assumed the hospice nurse would place the documentation in the resident's hard chart maintained at the nurses' station. During an interview on 06/09/23 at 07:44 AM with the Hospice Registered Nurse (HRN) revealed the resident was placed on hospice service 03/31/23. There should be a blue sheet in the chart that documents when the nurse, certified nursing assistant, social services and the chaplain will visit the resident. The HRN also stated the hospice staff documents their notes on the computer which goes to their office. The hospice team has a meeting to discuss the residents' care needs. The minutes/notes from these meetings are sent to the facility every two weeks. The facility is responsible for importing the notes into the resident's electronic medical records and placing a copy of the resident's hard chart. The HRN further stated she was recently assigned to this resident and discovered there was no documentation of the hospice services provided to this resident. During an interview with the Director of Nursing on 06/09/23 at 02:30 PM revealed she was unaware of the lack of hospice documentation in R27's hard chart. She stated there was no system in place to monitor that hospice services were provided and documented appropriately. 2. Review of R32's admission Record, located in the EMR under the Profile tab, revealed an admission date of 03/07/23 with medical diagnosis of protein calorie malnutrition. Review of R32's Order Summary Report, located in the EMR under the Orders revealed the following order dated 04/07/23: [hospice company name] hospice to begin 4/6/2023. Review of R32's complete medical record revealed the absence of the most recent hospice care plan, hospice election form, and physician certification of terminal illness. During an interview on 06/07/23 at 2:12 PM, Registered nurse (RN) 2 stated R32 was in hospice, but not sure why R32 was on hospice. During an interview on 06/08/23 at 10:03 AM, the Hospice RN (HRN) stated she had just taken over from the previous nurse who did not provide any updates. HRN confirmed there was no documentation provided to the facility. HRN stated, I plan to get the chart updated soon. HRN was not aware that R32's chart was not complete. During an interview on 06/08/23 at 12:42 PM, the Administrator stated he was not sure how hospice care is communicated among the staff. The Administrator agreed that documentation is an issue.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to adhere to enhanced barrier precautions for one resident (R)15 from a sample of 24 residents, and failed to properly sanitize one of two glucometers on one of the two nursing units. Findings Include: Review of the facility's policy titled Enhanced Barrier Precautions dated August 2022 read in part Enhanced barrier precautions (EBPs) employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). Personal protective equipment (PPE) is changed before caring for another resident. 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 dressing; bathing/showering; transferring; providing hygiene; changing linens; changing briefs or assisting with toileting; device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); and wound care (any skin opening requiring a dressing). 1. Review of R15's admission Record, located in the resident's electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE]. Review of R15's Diagnosis Record located in the resident's EMR under the Medical Diagnosis tab revealed the resident's admitting diagnoses included an unhealed stage IV sacral pressure ulcer, diabetes mellitus type II, and partial intestinal obstruction with a colostomy. Review of R15's Physicians Orders for the month of June located in the resident's EMR under the Orders tab revealed the resident was to have daily dressing changes to the sacral ulcers. There were no physician orders for isolation. Review of the signage posted outside R15's room revealed the resident was on contact precautions (enhanced precautions) read in part Personal protective equipment (PPE) put on in the following order: wash or sanitize hands; gown; mask (if needed); eye cover (if needed) wash or sanitize hands and gloves. Wound care observation on 06/09/23 at 09:10 AM, Licensed Practical Nurse (LPN) 4 and certified nursing assistant (CNA) preparing R15 for wound care. Both staff members were wearing gloves only. The isolation tote containing the PPE was located inside the resident's room. Both staff members performed hand hygiene and applied gloves. The CNA positioned herself at the resident's bedside to position the resident on her side for the wound care. LPN 4 with gloves on performed incontinent care on the resident. LPN 4 removed her gloves and hand hygiene and applied a new pair of gloves and proceeded to perform the resident's wound care. The two staff members did not put on gowns during the resident's wound care. During an interview on 06/09/23 at 09:40 AM with LPN 4 after R15's wound care revealed the nurse stated she knew what she did wrong during the resident's wound care. LPN 4 acknowledged that she and the CNA were not wearing gowns according to the guidelines for enhanced barrier precautions. During an interview on 06/08/23 at 02:00 PM with the Infection Control Preventionist (ICP) and the Infection Preventionist Consultant (IPC) revealed the facility had only two residents on enhanced precautions. R15 was one of the two residents. The ICP stated residents requiring wound care or catheter care were placed on enhanced barrier precautions as a precautionary measure. Staff members performing direct care for these residents were expected to wear gowns and gloves. 2. During an observation on the second floor on 06/09/23 at 7:00 AM, Certified Medication Technician (CMT) 1 performed a glucometer check on R40. Prior to the glucometer check, CMT1 used a Nuvik 75% Alcohol Wipe that was located on her medication cart, to clean the glucometer. CMT1 wiped the front and back of the glucometer and then performed the glucometer check. After performing the glucometer check, CMT1 placed the glucometer back into the glucometer basket. CMT1 did not clean the glucometer after use. During an interview on 06/09/23 at 7:05 AM, CMT1 stated she did not have any additional glucometer checks to perform. CMT1 further stated there were no additional residents that received glucometers checks on that floor. When questioned about sanitizing the glucometer CMT1 had no response. During an interview on 06/09/23 at 11:50 AM, Registered Nurse (RN)1 stated the facility uses the Nuvik 75% Alcohol Wipes to clean glucometers. RN1 further stated there were only two glucometers on the third floor and the Nuvik 75% Alcohol Wipes are used to clean these glucometers. During an interview on 06/09/23 at 11:55 AM, Licensed Practical Nurse (LPN)1 stated there was one glucometer on the second floor and the Nuvik 75% Alcohol Wipes are used to clean the glucometer. Review of the manufacturer's guidelines entitled, Maintenance: Cleaning and Disinfecting Guidelines, revealed, Cleaning and disinfecting can be completed by using a commercially available EPA registered disinfectant detergent or germicide wipe. This guideline further revealed, To wipe, remove from container, follow product label instructions to disinfect the meter. Many wipes act as a cleaner and disinfectant, though if blood is visibly present on the meter, two wipes must be used; use one wipe to clean and second wipe to disinfect. During an interview on 06/09/23 at 1:13 PM, the Administrator stated there is no policy on cleaning glucometers and the staff has not been trained on cleaning glucometers.

Based on interview, record review, and policy review, the facility failed to provide abuse prohibition training for one (Certified Nursing Assistant (CNA) 4) of five staff hired in the last six months. Findings include: Review of a facility policy titled, Resident Abuse, reviewed 07/2017, revealed Upon hiring and annually, employees will be trained on identifying resident abuse and neglect and how to go about reporting an incident. Review of an offer letter in a training file for CNA 4, provided to the survey team by Human Resources (HR), revealed a hire date of 03/11/23. Further review of CNA 4's training file revealed an abuse prohibition training dated 06/11/19. There was no evidence of any current abuse training on or after the most recent hire date of 03/11/23. During an interview on 06/09/23 at 7:58 AM, HR stated CNA 4 was a re-hire on 03/11/23. HR stated CNA 4 received abuse training on her original hire date on 06/11/19. HR stated CNA 4 stopped working at the facility on 03/08/22. HR stated CNA 4 had not received abuse training upon re-hire because she believed CNA 4 was in compliance with abuse training requirements due to receiving the training when the CNA previously worked at the facility. During an interview on 06/09/23 at 11:35 AM, the Administrator stated, The training program could be improved, and the staff need to understand better what is to be documented in the personnel file. The Administrator stated he expected all staff to have all the necessary training and updates required.

Based on record review and staff interview, the facility failed to ensure the activities program was directed by a qualified activities professional. Specifically, the current Activities Director was not a qualified activities professional who was licensed or registered by the state. Findings include: Review of the Extended Survey Book provided by the Administrator on 06/08/23, revealed the current Activities Director (AD) was not licensed or certified. During an interview with the Administrator, on 06/08/23 at 4:30 PM, he stated the current AD was not certified. The Administrator stated he was not aware the current AD was not certified or needed to be certified. During an interview with the AD, on 06/09/23 at 8:20 AM, she stated she was not aware until 06/08/23 that she needed to be certified to supervise the activities problem. She stated she would discuss with the Administrator the process of getting certified. During an interview with the Administrator, on 06/09/23 at 10:30 AM, he stated he had registered the AD for a class to become a certified activities professional.

Based on record review, observation and staff interview, the facility failed to ensure the facility was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Findings include: Review of the Facility Assessment updated 11/2021 for 2022, revealed, Quality Assurance overall has been delegated as a top oversight priority of our new DON (Director of Nursing). The Q1/A (Quality Improvement/Assurance) process, its' administration and report to the QA Committee and Administrator about progress, problem areas and trouble shooting [sic] will be an outgrowth of weekly UR/High Risk meetings, Monthly QA review and quarterly meetings. PCC OL/A Module has enabled better monthly tracking of Q/A measured data. The Administrator and DON failed to ensure coffee was not accessible to residents and was served to residents within a safe temperature. Specifically, R3 spilled coffee on her lap on 05/18/23 which caused blisters on both sides of her inner thigh and on 06/07/23 R40 spilled coffee on his lap. [Refer to F689] The DON failed to ensure R207, R27, R31, R22, R39 and R52, who had falls, had adequate supervision, a comprehensive fall investigation after each fall and remained free from injury. The Administrator and DON failed to ensure R207, R1, R31, R52 did not sustain an injury due to a lack of supervision. [Refer to F689] The Director of Nursing (DON) failed to consistently ensure weekly skin assessments were complete for resident (Resident (R) 3), specifically skin assessments after blisters were identified on 05/18/23, which increased the likelihood of R3 developing a significant skin issue. [Refer to F684] The Administrator and DON failed to ensure the current Activities Director was a qualified activities professional who was licensed or registered by the state. [Refer to F680] During an interview with the Administrator and the Director of Nursing (DON) on 06/09/23 at 11:40 AM, the Administrator and DON stated they knew they were responsible for the management of the facility and were responsible for ensuring residents were safe and their needs were met. The DON stated she stated she knew she was responsible for obtaining training and understanding all her job responsibilities. Both the DON and Administrator stated they would start a Performance Improvement Plan (PIP) but then it would slack and they would not complete the action steps they have identified or monitor their progress. Both agreed there were multiple concerns related to resident care throughout the facility. The Administrator and the DON stated they were aware that falls had gotten worse and there had been little improvement based on their lack of follow-up. The Administrator and the DON stated they were not aware the Activities Director needed to be certified in order to manage an activities program in the facility.

Based on interview and record review, the facility failed to ensure the Facility Assessment was maintained accurately. Specifically, the Facility Assessment had not been reviewed/revised annually and did not accurately reflect the current resident population. Findings include: Review of a facility policy titled, Facility Assessment, revised October 2018, revealed, Once a year, and as needed, a designated team conducts a facility-wide assessment to ensure that the resources are available to meet the specific needs of our residents. This policy further revealed, The facility assessment includes a detailed review of the resident population. This part of the assessment includes . c. factors that affect the overall acuity of the residents, such as the number and percentage of residents with . (4) cognitive or behavioral impairments. This policy further revealed, The team responsible for conducting, reviewing and updating the facility assessment includes the following: a. The administrator. The policy further revealed, The facility assessment includes a detailed review of the resident population. This part of the assessment includes: a. resident census data from the previous l2 months; b. resident capacity of the facility and its occupancy rate for the past 12 months. Review of the Abbey Senior Health Facility Assessment Summary and Priorities, provided to the survey team by the Administrator, revealed Updated 11/2021 for 2022. The Facility Assessment was originally completed in November of 2017, and has continued to evolve since that time has helped us to identify and establish areas within the organization we wish to improve upon. We have classified those improvement areas into; quality improvements, facility improvements and staffing priorities. Review of the Facility Needs Assessment, dated 11/08/17, provided to the survey team by the Administrator revealed a Facility Cover Sheet that listed the Person (names/titles) involved in completing assessment. This cover sheet failed to document the current Administrator. The remainder of the Facility Needs Assessment has facility profile, demographic, census, and resident population data from 2017. There was no recent data included. During an interview 06/09/23 at 11:35 AM, the Administrator stated the Facility Assessment was last updated November 2021. The Administrator stated the Abbey Senior Health Facility Assessment Summary and Priorities was a summary of the facility's upcoming plans. The Administrator was unable to state why the Facility Needs Assessment only had data from 2017. The Administrator was additionally unable to state why he was not listed on the Administrator although he had been employed as the Administrator since November 2021.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a facility initiated transfer for four residents (Resident #16, #23, #32, and #146) out of 18 sampled residents. The facility's census was 53. 1. Record review of the facility's undated policy titled, Transfer or Discharge Documentation, showed: - When a resident is transferred or discharged , details of the transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provider; - The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in this facility; - When a resident is transferred or discharged from the facility, the following information will be documented in the medical record: - The basis for the transfer or discharge; - The specific resident needs that cannot be met; - This facility's attempt to meet those needs; - The receiving facility's service that are available to meet those needs. 2. Record review of Resident #16's progress notes showed the resident transferred to the hospital on 9/27/19 and readmitted to the facility on [DATE]. Record review of the resident's medical record showed no documentation of a letter which notified the resident and/or resident's representative of the resident's transfer to the hospital. 3. Record review of Resident #23's progress notes showed the resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. Record review of the resident's medical record showed no documentation of a letter which notified the resident and/or resident's representative of the resident's transfer to the hospital. 4. Record review of Resident #32's progress notes showed: - The resident was transferred to the hospital on 6/19/19 and readmitted to the facility the same day; - The resident was transferred to the hospital on 7/11/19 and readmitted to the facility on [DATE]. Record review of the resident's medical record showed no documentation of a letter which notified the resident and/or representative of the resident's transfer to the hospital. 5. Record review of Resident #146's progress notes showed the resident transferred to the hospital on [DATE] and readmitted to facility on 11/8/19. Record review of the resident's medical record showed no documentation of a letter which notified the resident and/or representative of the resident's transfer to the hospital. 6. During an interview on 11/7/19 at 11:30 A.M., the Director of Nursing (DON) said the facility does not send a written transfer notice to the responsible party when a resident is sent to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to document sufficient preparation and orientation of residents to ensure safe and orderly transfer from facility to hospital in a manner that the resident can understand for four residents (Resident #16, #23, #145, and #146) out of 18 sampled residents. The facility's census was 53. 1. Record review of the facility's undated policy titled, Transfer or Discharge, Preparing a Resident for, showed: - Residents will be prepared in advance for discharge; - Obtaining orders for discharge or transfer, as well as the recommended discharge services and equipment. 2. Record review of Resident #16's Physician's Order Sheet (POS), dated 11/6/19, showed: - Resident admitted on [DATE]; - Diagnoses of multiple sclerosis (a disease in which the immune system eats away at the protective covering of nerves) and neuromuscular dysfunction of bladder (involved in the control of urination); - Resident is his/her own responsible party. Record review of the resident's progress notes showed: - On 9/27/19, resident transferred to the hospital via emergency management systems (EMS) per physician's order due to needing intravenous antibiotic orders for diagnosis of urinary tract infection; - Did not contain written documentation to show the resident was prepared and oriented for transfer out of the facility. 3. Record review of Resident #23's POS, dated 10/10/19 through 11/6/19, showed: - Resident admitted on [DATE]; - Diagnoses of weakness, chronic kidney disease with heart failure, diabetes, and other symptoms and signs involving cognitive functions and awareness; - Resident has a responsible party. Record review of the resident's progress notes showed: - On 10/7/19, resident was sent to hospital for evaluation due to low blood pressure when laying and inability to sit without passing out; - Did not contain written documentation to show the resident was prepared and oriented for transfer out of the facility. 4. Record review of Resident #145's POS, dated 10/24/19 through 11/1/19, showed: - Resident admitted on [DATE]; - Diagnoses of weakness, urgency of urination, atherosclerosis of the aorta (plaque build up inside the aorta), and poliomyelitis of the vertebrae (infection of the vertebral body in the spine); - Resident has a responsible party. Record review of the resident's progress notes showed: - On 11/4/19, resident was sent to hospital for intractable back pain per family request; - Did not contain written documentation to show resident was prepared and oriented for transfer out of the facility. 5. Record review of Resident #146's POS, dated 10/16/19 through 11/3/19, showed: - Resident admitted on [DATE]; - Diagnoses of Down's syndrome, diabetes, and transient alteration of awareness; - Resident has a responsible party. Record review of the resident's progress notes showed: - On 11/4/19, resident was sent to hospital for evaluation due to the resident not talking or interacting with staff, says, ow; - Did not contain written documentation to show resident was prepared and oriented for transfer out of the facility. 6. During an interview on 11/7/19 at 11:30 A.M., the Director of Nursing (DON) said she would expect staff to orient and prepare residents for transfer and document it was done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow infection control protocols for tuberculosis (TB; a highly contagious communicable disease that affects the lungs characterized by fever, cough, and difficulty breathing) for five residents (Resident #7, #16, #24, #29, and #32) out of 18 sampled residents. This deficient practice had the potential to affect all residents. The facility's census was 53. Record review of the Department of Health and Senior Services (DHSS) Division of Community and Public Health regulation regarding communicable diseases (19 CSR 20-20.100), showed: - Long-term care facilities shall screen their residents and staff for TB using the Mantoux method purified protein derivative (PPD) five tuberculin unit (TU) test. Each facility shall be responsible for ensuring that all test results are completed and that documentation is maintained for all residents, employees and volunteers; - Each facility shall be responsible for ensuring that all test results are completed and that documentation is maintained for all residents, employees, and volunteers; - Long-Term Care Residents. Within one (1) month prior to or one (1) week after admission, all residents new to long-term care are required to have the initial test of a Mantoux PPD two (2)-step tuberculin test. If the initial test is negative, zero to nine millimeters (0-9 mm), the second test, which can be given after admission, should be given one to three (1-3) weeks later. Documentation of chest X ray evidence ruling out tuberculosis disease within one (1) month prior to admission, along with an evaluation to rule out signs and symptoms compatible with infectious tuberculosis, may be accepted by the facility on an interim basis until the Mantoux PPD two (2)-step test is completed. - All long-term care facility residents shall have a documented annual evaluation/screening to rule out signs and symptoms of TB disease. 1. Record review of the facility's undated policy titled, admission Policy (recommend: TB Screen and Immunization Policy - Residents), showed: - All residents will be screened upon admission for history of active TB; - All residents who do not have documentation of treatment of TB infection or have a previous skin test reaction of greater than 10 mm will receive a two-step skin test; - First step will be given on second day of admit and read in 48-72 hours; - If first step is negative, then second step will be administered 2 weeks after the first. 2. Record review of Resident #7's medical record showed: - Resident admitted [DATE]; - No record of the annual TB screening for 2019. 3. Record review of Resident #16's medical record showed: - Resident admitted [DATE]; - No record of the initial TB process or annual TB screening for 2019. 4. Record review of Resident #24's medical record showed; - Resident admitted [DATE]; - No record of the annual TB screening for 2019. 5. Record review of Resident #29's medical record showed: - Resident admitted [DATE]; - No record of the annual TB screening for 2019. 6. Record review of Resident #32's medical record showed: - Resident admitted [DATE]; - No record the annual TB screening for 2019. 7. During an interview on 11/7/19 at 11:30 A.M., the Director of Nursing (DON) said she would expect the resident to have a step one and step two TB screening on admission. The DON said they do annual TB screening for residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a baseline care plan within 48 hours of admission that included the minimum healthcare information necessary to properly care for the immediate needs of eight residents (Resident #2, #8, #19, #20, #23, #145, #146 and #147) out of 18 sampled residents. The facility's census was 53. 1. Record review of the facility's undated policy titled, Care Plans- Baseline showed: - To assure the resident's immediate cares are met and maintained, a baseline care plan will be developed within 48 hours of admission; - The Interdisciplinary Team will review the healthcare practitioner's orders and implement a baseline care plan to meet the resident's immediate needs including but not limited to: initial goals, Physician orders, Dietary orders, Therapy services and Social services; - The base line care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan; - The resident and their representative will be provided a summary of the baseline care plan that includes but not limited to: the initial goals of the resident, a summary of the resident's medications and dietary instructions, any services and treatments to be administered by the facility and personnel acting on behalf of the facility, any updated information based on details of the comprehensive care plan as necessary. 2. Record review of Resident #2's Physician Order Sheet (POS), dated [DATE] through [DATE], showed: - Resident admitted [DATE]; - Diagnoses include pulmonary hypertension (a type of high blood that affects arteries in the lungs and heart), panic disorder, chronic kidney disease, unsteadiness on feet, and gastrointestinal hemorrhage (gastrointestinal bleeding); - On [DATE], an order for Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST). Record review of the resident's medical records showed the facility staff did not complete a care plan within 48 hours of the resident's admission. 3. Record review of Resident #8's POS, dated [DATE], showed: - Resident admitted [DATE]; - Diagnoses of age-related physical debility, chronic kidney disease stage 3, muscle weakness, and cognitive communication deficit; - Advance Directive Do Not Resuscitate (DNR; a written physician's order telling the health care providers not to do cardiopulmonary resuscitation (CPR) if the patient's breathing stops or if the heart stops); - Regular diet; - Elevate right arm; - Ice to right elbow as needed. Record review of the resident's medical records showed: - Baseline care plan did not address the advance directive DNR; - Baseline care plan did not address the resident's diet; - Baseline care plan did not address the care of the right arm. 4. Record review of Resident #19's POS, dated [DATE] through [DATE], showed: - Resident admitted [DATE]; - Diagnoses include Chronic Obstructive Pulmonary Disease (COPD; a nonreversible lung disease that is a combination of emphysema and chronic bronchitis), atherosclerotic heart disease (hardening and narrowing of the arteries), diabetes, and major depressive disorder; - On [DATE], an order for PT, OT, and ST; - On [DATE], an order for frozen, thickened supplement after meals. Record review of the resident's medical records showed the facility staff did not complete a care plan within 48 hours of the resident's admission. 5. Record review of Resident #20's POS, dated [DATE], showed: - Resident admitted [DATE]; - Diagnoses of muscle weakness, difficulty in walking, cognitive communication deficit, and heart failure; - Full code (written physician's order to provide CPR to the resident/patient if the breathing stops or the heart stops); - Oxygen 2 liters per nasal cannula as needed; - Regular diet. Record review of the resident's medical records showed the facility staff did not complete a care plan within 48 hours of the resident's admission. 6. Record review of Resident #23's POS, dated [DATE] through [DATE], showed: - Resident admitted [DATE]; - Diagnoses of weakness, chronic kidney disease with heart failure, diabetes, and other symptoms and signs involving cognitive functions and awareness; - On [DATE], an order for PT, OT and ST to evaluate and treat;- On [DATE], an order for mechanical soft textured meals. Record review of the resident's medical records showed the facility staff did not complete a care plan within 48 hours of the resident's admission. 7. Record review of Resident #145's POS, dated [DATE] through [DATE], showed: - Resident admitted [DATE]; - Diagnoses of weakness, urgency of urination, atherosclerosis of the aorta (plaque build up inside the aorta), and poliomyelitis of the vertebrae (infection of the vertebral body in the spine); - On [DATE], an order for continuous positive airway pressure machine (C-Pap; a respiratory machine which sends a constant flow of airway pressure to the throat to ensure the airway stays open during sleep) at bedtime; - On [DATE], an order for Ceftriaxone (antibiotic) 2000 milligrams, intravenously, once daily until [DATE]; - On [DATE], an order for a Fentanyl patch (pain patch), once daily for three days. Record review of the resident's medical records showed the facility staff did not complete a care plan within 48 hours of the resident's admission. 8. Record review of Resident #146's POS, dated [DATE] through [DATE], showed: - Resident admitted [DATE]; - Diagnoses of Down's syndrome, diabetes, and transient alteration of awareness; - On [DATE], an order for PT, OT, and ST evaluation and treatment; - On [DATE], an order for NO STRAWS!!. Record review of the resident's medical records showed the facility staff did not complete a care plan within 48 hours of the resident's admission. 9. Record review of Resident #147's POS, dated [DATE] through [DATE], showed; - Resident admitted [DATE]; - Diagnoses of nontraumatic intracerebral hemorrhage (brain bleed), atrial fibrillation (abnormal heart rhythm that reduces the ability of the heart to pump blood correctly) and dysphagia (difficulty swallowing); - On [DATE], an order for PT, OT and ST evaluation and treatment; - On [DATE], an order to check placement and clean gastrostomy tube (G-tube; a feeding tube placed surgically into the stomach to provide nutrition or medications) sites daily; - On [DATE], an order for Jevity 1.2 (nutritional supplement) tube feeding via G-tube at bedtime; - On [DATE], an order to flush G-tube with 100 milliliters of water every four hours. Record review of the resident's medical records showed the facility staff did not complete a care plan within 48 hours of the resident's admission. 10. During an interview on [DATE] at 11:30 A.M., the Director of Nursing (DON) said she would expect staff to complete a 48 hour (baseline) care plan on new admissions.