**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to ensure two residents (Resident #18 and #37) had orders for oxygen and failed to ensure oxygen tubing was dated per facility policy. The facility census was 40. 1. Review of the facility's policy titled, Oxygen Therapy, March 2019, showed staff are directed to: -Verify the physician's order; -Adjust the delivery rate per the physician's order; -Change oxygen tubing/mask/cannuala and/or tracheostomy mask weekly; -Date tubing changes. 2. Review of Resident #18's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 04/18/25, showed staff assessed the resident as: -admitted on [DATE]; -Cognitively intact; -Dependent on staff for upper body dressing and personal hygiene; -Required oxygen. Review of the resident's Care Plan, dated 04/14/25, showed the plan did not contain direction for staff in regard to the resident's oxygen use. Review of the resident's Nursing admission Assessment, dated 04/07/25, showed staff assessed the resident used oxygen at two Liters Per Minute (LPM) via nasal cannual at night. Review of the resident's Physician's Order Sheet (POS), dated May 2025, showed the record did not contain orders for oxygen or oxygen tubing maintenance. Observation on 05/12/25 at 12:35 P.M., showed the resident's oxygen tubing in the resident's room undated. Observation on 05/13/25 at 11:20 A.M., showed the resident's oxygen tubing in the resident's room undated. Observation on 05/15/25 at 1:41 P.M., showed the resident's oxygen tubing in the resident's room undated. During an interview on 05/15/25 at 1:41 P.M., the resident said he/she uses oxygen every night. The resident said he/she could not recall if staff had changed his/her oxygen tubing since he/she was admitted . 3. Review of resident #37's Quarterly MDS, dated [DATE], showed staff assessed the resident required oxygen. Review of the resident's care plan, dated 05/14/25, showed oxygen at two liters via nasal cannula. Review of the resident's POS, dated May 2025, showed the order did not specifify the oxygen flow rate. Observation on 05/14/25 at 09:00 A.M. showed the resident wore oxygen at two LPM. During an interview on 05/12/25 at 11:45 A.M. the resident said he/she uses oxygen continuously, but the nasal cannula falls off while he/she sleeps. He/She did not know the oxygen flow rate. During an interview on 05/13/25 at 11:30 A.M., Licensed Practical Nurse (LPN) G said he/she did not realize the resident's oxygen order did not include the flow rate. He/She said it is the responsibility of the nurse's to make sure orders are correct. During an interview on 05/14/25 at 3:10 P.M., the Director of Nursing (DON) said all oxygen orders should include the flow rate, and did not know how it was missed on this resident. During an interview on 05/14/25 at 3:30 P.M the administrator said oxygen orders should include the flow rate. It is the nurse's responsibility to ensure orders are transcribed correctly. If something is missing, the physician should be contacted for clarification.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility staff failed to document collaboration of care with hospice providers for development and implementation of a coordinated plan of care, communication between the facility and hospice providers and did not have physician orders for hospice for two residents (Resident #27 and #36) of three residents. The facility census was 40. 1. Review of facility Hospice Services policy, undated, showed the facility provides continuity of care to provide residents who are terminally ill with the opportunity to receive comprehensive, interdiscipinary care that recognizes the spirtiual needs, and to assist residents, family members and friends to live as fully and completely as possible with meaing and diginity. An interdisciplinary care plan which integrates the care and services provided by the faciity and the hospice provider including. Communication and/or coordination of participants and agencies providing aspects of palliative care. Hospice providers and this facility exchange information from the respective care plan, assessment updates, and resident and family conferences to asssure provision of changing necessary care and services. The facility will coordinate care planning with the hospice provider including all services and supplies provided by the hospice provider including nursing and nursing aid services, social services, chapaincy services, durable medical equipment, medictions and grief support to family members. Facility will observe, record and report to appropriate Hospice personnel, the patient's response to treatment and any changes in the patient's conditon, which migh require modificaton of the Plan of Care Review of the facility's hospice agreement, dated 04/28/20, showed the facility will observe, record and report to appropriate hospice personnel the patient's response to treatment and will immediately notify hospice if a significant change in the patient's physical status occurs. Facility records shall specifically include a record of all hospice care to the hospice patient by the faciilty and all events regarding care of the Hospice patient that occurred at the facility. 2. Review of Resident's #27's Significant Change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 03/01/24, showed the resident on hospice and has a condition or disease that may result in a life expectancy of less than six months. Review of the facility matrix list of residents on hospice, provided by the facility on 05/13/25, showed the resident listed received hospice services. Review of the resident's Physician Order Sheet (POS), dated May 2025 showed the POS did not contain a physician order for hospice care. Review of the resident's progress notes, dated March 2025, showed an MDS note the resident to receive hospice services. The record did not contain documentation of hospice staff visits. Review of the resident's progress notes, from April 2025-May 2025, showed the record did not contain documentation of hospice staff visits. Review of the resident's medical record, dated May 2025, showed the record did not contain documentation hospice staff visits. 3. Review of Resident's #36's Quarterly MDS, dated [DATE], showed staff documented the resident received hospice and has a condition or disease that may result in a life expectancy of less than six months. Review of the resident's Physician Order Sheet (POS), dated May 2025, showed the POS did not have a physician order for hospice care. 4. During an interview on 05/14/25 at 09:46 A.M., LPN G said he/she was unable to locate an order for hospice. He/She stated hospice does not document progress notes after visits with residents. A verbal report is recieved. Nurses don't usually document the verbal report. He/She said hospice is notified when the resident has a change of status or significant event. During an interview on 5/14/25 at 11:10 A.M., the DON said hospice service providers do not provide notes of care or assessments during their visit. The nurses receive a verbal report when there is something relevant to report. To his/her knowledge, those conversations are not documented. He/She said there should be an order when hospice services are being provided. During an interview on 5/15/25 at 3:30 P.M., the Adminstrator said an order is expected for residents on hospice care; and service should be communicated between facility and hospice provider.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, facility staff failed to maintain a clean, comfortable, homelike environment when staff failed to maintain the interior of building. Facility staff failed to remove trash from the exterior and maintain the exterior of the premises. The facility census was 40. 1. Observation on 05/12/25 between 12:00 P.M and 12:45 P.M., showed: -The bathroom door in resident room [ROOM NUMBER] contained a dark brown patch on the lighter stained door, and a marred area at the top with a layer of plywood dug out; -The bathroom door in resident room [ROOM NUMBER] patched with a dark brown patch in the middle of the lighter stained door; -The bathroom door in resident room [ROOM NUMBER] had a hole near the middle of the door; -The hallway ceiling tile near resident rooms #23 and #26 had yellow-brown stains; -The bathroom door frame in resident room [ROOM NUMBER] was marred near the floor; -The bathroom door frame in resident room [ROOM NUMBER] was marred, near the floor, and the door had a layer of plywood missing near the top of the door; -The door to resident room [ROOM NUMBER] contained portions of the door with a bleached-out appearance, and the bathroom door had a marred area under the door handle. Observations on 05/13/25 during the Life Safety Code tour, showed: -The hall one shower room contained square openings in the tile around both water faucets and the water outlet where the shower hose was attached. Observation showed the wall cavity was visible around the faucets and the shower hose attachment; -The floor drain in the hall one shower room had a missing tile and the drain was depressed below the tile surface which created a sharp edge. The black non-slip floor surface material was torn and in disrepair; -The floor of the hall one shower room was missing three tiles where the assist bars were installed near the commode; -The area near the floor drain in the hall two shower was missing a piece of tile; -The lower wall of the hall two shower was missing two tiles; -The hall two shower was missing two baseboard tiles and one tile was not attached and leaned against the shower wall; -The hall two shower wall was missing a tile near the hot water faucet. The wall cavity was visible where the tile was missing; -The floor in front of the commode in the hall two shower room contained two round holes which contained an accumulation of dirt and debris. There was one floor tile missing behind the commode; -A hole in the bathroom door of resident room [ROOM NUMBER]. During an interview on 05/15/25 at 1:41 P.M., the resident of room [ROOM NUMBER] said he/she wished the facility was kept up as well as the other facility where he/she lived. During an interview on 05/14/25 at 11:10 A.M., the maintenance director said he/she was responsible for facility repairs and facility grounds. The maintenance director said he/she was aware the building still had work to be done. The maintenance director said he/she tried to make repairs as issues were identified but the building was old and required a lot of work. The maintenance director said he/she was aware of the shower room issues but had not had time to make the repairs. 2. Observation on 05/13/25 at 12:50 P.M., showed the area outside the basement garage door contained more than 20 wood pallets, two mattresses, three tires, a charcoal grill, a garden hose and a soda vending machine. During an interview on 05/14/25 at 11:10 A.M., the maintenance director said the soda machine was removed from the building because it took up too much space. The maintenance director said the pallets were used to deliver facility supplies and he/she was not sure where some of the other items came from. The maintenance director said he/she thought the administrator was working on getting a dumpster to clear the area. 3. Observation on 05/13/25 at 1:15 P.M., showed multiple sections of the wood exterior of the facility at the end of resident hall two were rotted, broken and warped which exposed the wooden framework beneath to the elements. During an interview on 05/14/25 at 11:10 A.M., the maintenance director said some of the wood exterior was repaired last year but he/she did not realize the end of hall two also needed work. During an interview on 05/14/25 at 2:15 P.M., the administrator said maintenance was responsible for repairs in the building as well as the grounds around the building. The administrator said maintenance staff were making repairs but had not been able to get all repairs completed. The administrator said he/she did not know how long the pallets and other materials were outside the facility. The administrator said he/she was working to get a dumpster to remove the materials, but facility management changed on the first of March, which set things back. The administrator said the exterior of the building was repaired last year and he/she thought everything was taken care of.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to change and store oxygen tubing for one resident (Resident #18 ) of two sampled residents; failed to to use appropriate hand hygiene infection control practices during perineal and catheter care, for four residents (Resident's #12, #14, #24, and #37) of five sampled residents; failed to follow Enhanced Barrier Precautions (EBP), (the wearing of gown and gloves during high contact patient care activities to prevent the spread of multi-resistant organisms), for two residents (Resident #12 and #24) of five sampled residents. The facility census was 40. 1. Review of the facility's Hand Hygiene policy, revised 12/07/18, showed staff are directed to wash hands, as hand washing promptly and thoroughly after resident contact and after contact with blood, body fluids, secretions, excretions, and equipment or articles contaminated by them is an important component of the infection control and isolation precautions. If soap and water are not available, use alcohol gel/rub to clean hands. Review of the facility's Catheter Care policy, reviewed 03/15/23, showed staff are directed to remove gloves and wash hands after cleaning the perineal area and catheter tubing, and before repositioning the resident. Review of the facility's EBP policy, revised 07/13/23, showed EBP should be used when contact precautions do not apply for residents with open wounds that require a dressing change and indwelling medical devices. EBP requires the use of a gown and gloves during high contact resident care activities that provide opportunities for the transfer of multi-resistant drug organisms (MDRO's). High contact care activities include transfers, hygiene, changing briefs or toileting, caring for medical devices (i.e. urinary catheters, tracheostomies). Review of facility Dressing Change policy, revised 07/2007, instructs staff to discard all equipment in appropriate container after dressing change, then wash hands. 2. Review of resident #12's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 02/20/25, showed staff assessed the resident with an indwelling urinary catheter and always incontinent of bowel. Review of residents Care plan, dated 11/12/24, showed it did not contain documentation of the resident having a catheter. Review of residents hospice care plan, revised 5/12/25, showed the resident had a catheter. Review of residents Physician Order Sheets (POS) on 05/14/25 at 11:28 A.M. showed an order for Urinary Catheter. Observation on 05/13/25 at 03:16 P.M. showed an EBP sign on the door of the resident's room. Certified Nurse Assistant (CNA) F and Licensed Practical nurse (LPN) G entered the resident's room and provided perineal care without a gown. Observation on 05/13/25 at 03:25 P.M. showed CNA F and LPN G performed catheter care. CNA F washed his/her hands and put on gloves. He/She cleaned the resident's labia and catheter tubing he/she wiped top to bottom and replaced the resident's briefs. CNA F did not remove his/her soiled gloves or sanitize hands before he/she touched the clean brief. Observation on 05/13/25 at 03:40 P.M. showed CNA F and LPN G did not wash their hands before they exited the resident's room. During an interview on 05/13/25 at 03:50 P.M., CNA F and LPN G said they forgot to wear a gown during care. LPN G said the purpose of EBP is to prevent the spread of infection. During an interview on 5/15/25 at 03:30 P.M. Infection Preventionist (IP) said gown and gloves should be worn when staff perform care on residents with EBP. Staff received training on these precautions. 4. Review of Resident #14's admission MDS, dated 02/06025 showed staff assessed the resident as follows: -Cognitively Intact; -Dependent on staff for toileting; -Required partial to moderate assist for bed mobility; -Frequently incontinent of bowel and bladder. During an observation on 05/14/25 at 10:13 A.M. CNA D and CNA E provided incontinence care to the resident then removed and discarded PPE and did not wash their hands before exiting the resident's room. During an interview on 05/14/25 at 11:00 A.M. CNA D said hands should be washed before leaving a resident's room and he/she did not realize it was not done after cleaning up this resident. During an interview on 5/15/25 at 03:30 P.M., IP said hand hygiene should be done before exiting a resident's room if staff have provided care to the resident. Staff have received training on hand hygiene. 6. Review of Resident #24's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Dependent on staff for bed mobility, transfers, and toileting hygiene; -Always incontinent of bowel and bowel. Observation on 05/12/25 3:20 P.M., showed CMT B wiped resident's perineal area, CNA C placed a clean brief under the resident's left side, and CMT B continued to wear the same soiled gloves and pulled the clean brief under resident's right side. CMT B and CNA C used the mechanical lift to move the resident from the bed to the chair, adjusted the resident, and exited the room. CMT B and CNA C did not wash their hands before exiting the resident's room. Observation on 05/12/25 at 2:25 P.M., showed CMT B and CNA C entered the resident's room with a sign to direct staff for EBP prior to performing peri-care. CMT B and CNA C did not put on gowns before performing the peri-care. During an interview on 05/12/25 at 3:40 P.M., CNA C said he/she thought the EBP sign on the door was outdated. CNA C said he/she would have to ask the charge nurse or the DON if it was outdated to be sure. 8. Review of resident #37's admission MDS, dated [DATE], showed staff assessed the resident as follows: -cognitively intact; -Frequently incontinent of bowel and bladder; -Diagnosis of Stage 3 pressure ulcer (severe wounds that cause damage to the deeper layers of the skin). Review of care plan, revised 05/14/25, showed staff assessed the resident as follows: -Dependent on staff for all care; -Incontinent of bowel and bladder; -Has pressure ulcers, Stage 3. Observation on 05/14/25 at 10:12 A.M. showed the resident's room had an EBP sign. CNA D and CNA E performed perineal care for the resident and left the room without washing their hands. During an Interview on 05/14/25 at 10:13 A.M., CNA E said he/she should have washed his/her hands before he/she left the resident's room to prevent cross contamination. During an Interview on 05/14/25 at 10:15 A.M. LPN G said hand hygiene should be performed when leaving a resident's room. During an interview on 05/14/25 at 11:00 A.M. CNA D said he/she did not realize he/she did not wash his/her hands before he/she left the resident's room. During an interview on 5/15/25 at 03:30 P.M., the IP said hand hygiene should be performed after providing care and before leaving a resident's room. Staff have received training on hand hygiene.

Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to meet professional standards when staff failed to document they administered medications and failed to document the reason they did not administer the medications for two residents (Resident #1 and #2) out of four sampled residents. The facility census was 43. 1. Review of the facility's Medication Administration policy, revised 11/18/17, showed: -Drug administration shall be defined as an act in which a single dose of a prescribed drug or biological is given to a resident by an authorized person in accordance with all laws and regulations governing such acts; -The complete act of administration entails removing an individual dose from a previously dispensed, properly labeled container, verifying it with the physician's orders, giving the individual dose to the proper resident, and promptly recording the time and dose given; -After a drug is given, record the date, time, name of drug, dose and route on the residents individual medication administration record (MAR); -Document any medications not administered for any reason by circling initials and documenting on the back of the MAR the date, time, medication, dosage, reason for omission and initials. 2. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 04/26/24, showed staff assessed the resident with severe cognitive impairment and short and long term memory problems. Review of the resident's Physician Order Sheets (POS), dated 05/01/24 to 05/31/24, showed the resident's physician directed staff to provide the resident with: -Furosemide (a diuretic used to treat fluid retention) 40 milligrams (mg) of twice a day; -Quetiapine (an antipsychotic used to treat schizophrenia and major depressive disorder) 25 mg twice a day; -Tramadol (an opioid pain reliever) 50 mg three times a day; -Melatonin five mg at hours of sleep. Review of the resident's MAR, dated 05/08/23, showed staff did not document they administered the resident's furosemide, tramadol, quetiapine and melatonin as directed by his/her physician. Review showed staff did not document why they did not administer the medications. 3. Review of the resident 2's quarterly MDS dated [DATE], showed staff assessed the resident as follows: -Intact cognition; -Diagnoses of cerebral palsy, quadriplegia, depression, major depressive disorder, low back pain, epilepsy, nightmare disorder, and muscle spasm of the back; -had a scheduled pain medication regimen and frequent pain; -took antidepressant and opioid medications. Review of the resident's POS, dated 06/01/24 through 06/30/24, showed the resident's physician directed staff to provide the resident with: -Melatonin 10 mg daily; -Baclofen (a muscle relaxer) 20 mg four times a day; -Hydrocodone/acetaminophen (a narcotic pain reliever) 10/325 mg four times a day. Review of the resident's MAR, dated 06/01/24, showed staff did not document they administered the resident's scheduled melatonin, hydrocodone/acetaminophen and baclofen as directed by the physician. Review showed staff did not document why they did not administer the medications. During an interview on 06/04/24 at 4:45 P.M., Resident #2 said on the night of 06/01/24, Certified Medication Technician (CMT) A administered his/her medications very late and he/she did not believe the CMT gave him/her all of his/her medications. The resident said he/she had less pills in the cup than usual and knew that the CMT did not include his/her baclofen. The resident said the CMT also did not administer his/her P.M. dose of baclofen earlier that day which caused him/her to be in a lot of pain from his/her muscle spasms that night. The resident said he/she told the CMT that he/she did not get all of his/her medications and the CMT did not believe him/her and said that he/she gave him/her all the medications he/she had ordered. During an interview on 06/10/24 at 1:52 P.M., CMT A said he/she worked the evening shift on 06/01/24 and administered medications during his/her shift. The CMT said he/she worked at the facility through a staffing agency and that was his/her first night passing medications at the facility. The CMT said he/she had to pass medications to more residents than he/she was used to and while he/she did run late with the medication pass, he/she made sure that all residents had their medications as ordered. The CMT said medications should be documented as administered on the MAR at the time they are administered and if they are not documented it is considered an error. The CMT said he/she did not realize that he/she did not document that he/she administered all of Resident #2's medications. 4. During an interview on 06/10/24 at 2:44 P.M., the Director of Nursing (DON) said staff should document all medications administered on the MAR at the time of administration. The DON said failure to documented the administration of medication is a medication error and he/she did not know about the medications that were not documented as administered for Residents #1 and #2. During an interview on 06/10/24 at 3:12 P.M., the administrator said staff should document all medications administered on the MAR at the time of administration and staff are trained on this requirement. The administrator said failure to document the administration of medication is a medication error he/she did not know about the medications that were not documented as administered for Residents #1 and #2. MO00237011

Based on record review and interviews, facility staff failed to ensure residents were allowed to make choices about aspects of their lives while in the facility, when facility staff failed to allow one resident (Resident #24) to sign out of the facility as a consequence for his/her behavior and is his/her own responsible person. The facility census was 45. 1. Review of the facility's policies showed the facility did not provide a policy for Resident Rights. Review of the Resident #24's Quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 11/29/23, showed the staff assessed the resident as follows: -Cognitively intact; -No behaviors exhibited by the resident. Review of the resident's care plan, dated 3/24/23, showed the record did not contain direction on the residents ability to leave the facility. Review of the resident's physician order sheet (POS), dated 12/01/23-02/29/24, showed the resident may leave premise with responsible party. Review of the social service director note, dated 12/11/23, showed staff documented for the resident's safety, the resident is not to sign out after dark and if signed out needs to be back in facility before it gets dark. Will continue to monitor at this time. Review of the resident's face sheet, showed the resident is his/her own person. During an interview on 02/26/24 at 4:06 P.M., the resident said he/she is no longer allowed to sign himself/herself out. He/She said he/she is his/her own person. He/She said about a month ago he/she had an incident while on leave. He/She said ever since he/she has not been allowing him/her out. He/She said the facility told him/her that the state would not allow him/her to sign himself/herself out until he was re-evaluated as being safe to do so. He/She said no one has re-evaluated him/her or explained when the evaluation would be. He/She said he/she feels like they took it away without giving him/her a choice. During an interview on 02/27/24 at 4:10 P.M., the Director of Nursing (DON) said he/she was told by the administrator that social services filled out an assessment form on the resident and he/she was no longer allowed to sign himself/herself out unless he/she was to sign out against medical advice (AMA). During an interview on 02/27/24 at 4:30 P.M., Licensed Practical Nurse (LPN) A said the resident had an accident while out. He/She was told the residents sibling and administration spoke and decided he/she was not allowed to go out alone or sign himself/herself out anymore. He/She said the resident is his/her own person and he/she knows that by looking in the resident's medical record. During an interview on 02/28/24 at 10:07 A.M., the social services director said his/her note was put in the chart prior to the administrator putting the new interventions into place. He/She said the resident is his/her own person but was no longer able to sign out of the facility on his/her own until he/she was re-evaluated as being safe. He/She said the residents sibling or in-law comes to the facility to escort him/her on walks and to the store. He/She said even though he/she is his/her own person, he/she feels it is okay to take away his/her ability to sign himself/herself out because it is more for the resident's safety. He/She said the resident will be re-evaluated at his/her care plan meeting next month. He/She said there should have been a note from the administrator explaining the new interventions and the resident's evaluation, but he/she did not see it. During an interview on 02/29/24 at 1:50 P.M., the administrator said the social services director and himself/herself met with the resident after the incident. He/She said at that time they spoke with the resident and educated him/her on safety and not going out at night. He/She said then after the facility had another incident with a different resident, he/she decided to do a Community Survival Skills Assessment on the resident to see if he/she was safe to go out on his/her own. He/She said even though the resident was his/her own person, passed the questions on being capable of being safe, being alert and oriented, and capable of paying attention while out, he/she felt the resident still made the choice not to be safe when he/she was out. He/She said at that time he/she decided the resident was not to go out without someone signing for him/her. He/She said he/she does not have any documentation of the meeting with the resident. He/She said he/she spoke to the resident's sibling, who also expressed concern, and they agreed to not allow him/her to sign out on his/her own. He/She said that is when he/she placed the note on the front of the chart and educated staff on the new intervention. He/She said it is his/her expectation that the residents care plan and orders were also updated at that time. He/She said the resident will be re-evaluated at his/her next care plan conference. During an interview on 02/29/24 at 2:09 P.M., the administrator said he/she spoke to the social services director, and he/she did not fill out the Community Survival Skills Assessment like they had thought.

Based on interview and record review, facility staff failed to ensure one (Resident #39) received care and services for the provision of hemodialysis (the clinical purification of blood by dialysis, as a substitute for the normal function of the kidney) consistent with professional standards of practice when staff failed to provide orders, ongoing assessments of the resident's condition, and monitoring for complications after dialysis treatments. The facility census was 45. 1. Review of the facility's Long Term Care Facility Dialysis Services Agreement between the facility and the dialysis clinic , dated 09/19/05, showed the: Responsibilities of the dialysis clinic: -Dialysis Clinic (DC) shall provide relevant information regarding the patient's(s') dialysis treatment which may require follow-up care or observation by the long-term care facility (LTCF) staff; -DC shall provide instruction to certain designated employees of the facility: -About the proper care and treatment of the patient's vascular access (used in the dialysis treatment); -About the care and treatment and monitoring of a patient with end stage renal disease (including nutritional needs and fluid restrictions, and psycho-social needs); -Information about how care should be rendered to a patient in emergency and non-emergency situations; Responsibilities of the facility: -Facility shall provide information to the DC, in a timely manner, regarding the condition and needs of the LTCF patient during the dialysis treatment; -The facility shall provide to DC: -Information which may be utilized in the development and maintenance of outpatient dialysis care plans; -Information about how care should be rendered to a patient in emergency and non-emergency situations; -The appropriate healthcare staff at the facility will make an assessment of the patient's physical condition and determine whether the patient is stable enough to be dialyzed on an outpatient basis. 2. Review of the facility's policies showed the facility did not provide a policy for hemodialysis. 3. Review of Resident #39's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 12/12/23, showed facility staff assessed the resident as: -Cognitively intact; -Diagnoses of End Stage Renal Disease (longstanding disease of the kidneys leading to renal failure), Type 2 Diabetes Mellitus (a chronic condition that affects the way the body processes blood sugar) and Congestive Heart Failure (a weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues); -Receives dialysis. Review of the resident's care plan, dated 06/13/23, showed staff assessed the resident with a dialysis shunt (aids the connection from a hemodialysis access point to a major artery) placed on 06/13/23. Review showed the resident will not have signs or symptoms of infection. Review showed staff will check for thrill (An abnormal vibration that is felt on the skin overlying an arteriovenous fistula) over shunt every shift. Review showed the plan of care did not direct staff to: -Monitor vital signs, weights, nutritional, and fluid needs or restrictions; -Location of dialysis services or transportation needs; -Interventions or goals for the type of dialysis received; -Which arm to assess for thrill or blood pressure; -Monitor for risk factors or managing complications such as hemorrhage, access site infection, hypotension, and to whom to report concerns. Review of the resident's physician's order sheet (POS), dated February 2024, showed the POS did not contain an order for dialysis. Review of the resident's medical record, showed the record it did not contain documentation staff assessed the resident prior to or upon return from dialysis appointments, monitored daily vital signs, monitored risk for infection, monitored the resident's shunt patency, monitored intake and output, monitored daily weights, and the record did not contain completed communication forms. During an interview on 02/28/24 at 9:58 A.M., Licensed Practical Nurse (LPN) A said the resident goes to dialysis Monday, Wednesday, and Friday. He/She said nursing staff are not required to do any assessments before or after dialysis. He/She said the only assessment they do is to check for a thrill of his/her shunt every shift. He/She said he/she will sometimes check his/her blood pressure because the resident can sometimes feels his/her blood pressure drops after dialysis. He/She said weights are only required to be monitored monthly. He/She said the resident is usually pretty stable, so he/she doesn't think there is a concern that vitals and assessments are not done before and after dialysis. During an interview on 02/29/24 at 4:46 P.M., the Director of Nursing (DON) said he/she was not aware there needed to be any assessments done before or after dialysis. He/She said he/she does not require staff to do the assessments so he/she would not have done them either. He/She said he/she understands why assessments would be important since there is a major change in status of fluid during dialysis, but they do not currently require the assessments. He/She said they only require monthly weight checks on their dialysis residents. He/She said they do not keep on going communication with the dialysis clinic and did not know that was in their agreement. He/She said they would know if the resident was having complications from dialysis because he/she is verbal and could tell them and that they would notice him/her missing from smoke breaks and meals. He/She said he/she they do not have an emergency plan of care for dialysis residents. He/She said he/she would expect there to be an order in the chart, but he/she does not think there is one. He/She said he/she would expect the care plan to state if he/she was on dialysis and when. During an interview on 02/29/24 at 4:45 P.M., the administrator said staff did not complete assessments before after the resident dialysis appointments. He/She said he/she did not realize the assessments needed to be completed, but would have expected staff to at least check weights. He/She said there is no communication process in place, but the facility or clinic would call if there were questions. He/She said he/she did not know it was a regulation to have a communication process in place. He/She said he/she did not know if the resident was having a reaction after returning from dialysis if staff did not evaluate the resident, except if the resident verbalized issues or when he/she attended meals in the dining room. He/She said there was not and emergency plan in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to ensure three residents (Resident #14, #15 and #19) had appropriate access to their trust fund account which included evenings and weekends. The facility census was 45. 1. Review of the facility's policies showed the facility did not provide a policy for availability of funds. 2. Review of Resident #14's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 10/18/23, showed staff assessed the resident as cognitively intact. During an interview on 02/26/24 at 3:30 P.M., the resident said we cannot get money on the weekends, you have to get it on Fridays if we want it for the weekend, or your're just out of luck and have to wait. 3. Review of Resident #15's Quarterly MDS, dated [DATE], showed staff assessed the resident as mildly cognitive impaired. During an interview on 02/26/24 at 10:28 A.M., the resident said he/she did not have access to his/her funds on the weekends 4. Review of Resident #19's Annual MDS, dated [DATE], showed staff assessed the resident as mildly cognitive impaired. During an interview on 02/29/24 at 11:06 A.M., the resident said we can't have money in the evenings or on the weekends. There is only one person who can get us money, we have to ask for it by 10:30 A.M. on Friday if we want it for the weekends. The resident said, It sucks not to be able to have money on weekends because what if I wanted to order a pizza, because I like to do that sometimes, or go to the store I just can't. 5. During an interview on 02/29/24 at 3:51 P.M., the Business Office Manager (BOM) said they do not keep petty cash at the facility. He/She said he/she or the administrator go to the bank to get money when requested by the resident. The BOM said there is no one in office in the evening or on weekends to get money for the residents. The BOM said he/she was not aware what the regulation says about residents' access to money. During an interview on 02/29/24 at 5:50 P.M., the administrator said she was not aware petty cash needed to be available for residents during non-banking hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to document two residents (Resident #7 and #8) code status as Do Not Resuscitate (DNR) or Full Code (Resuscitate refers to cardiopulmonary resuscitation-CPR). The facility census was 45. 1. Review of the facility's policy titled, Advanced Directive, dated [DATE], showed each resident has the right to make their own decisions, and to formulate advance directives to serve as decisions when the individual is incapacitated. It is the policy of this facility to honor resident's wishes as expressed in advanced directives regarding medically indicated treatments whenever possible. Review showed the facility shall take all steps necessary to comply with state and federal legislation relating to advanced directives. Review showed any decision made by the resident shall be indicated in the chart in the manner easily understood by all staff. Review showed it is the intent to implement the terms of the advanced directive placed in the resident's medical record in accord with appropriate direction of the Power of Attorney and resident's physician. If a resident communicates a revocation of an advance directive to an employee of this facility, that communication, constituting revocation, shall be noted in the resident's medical record and placed in a central file to avoid any misunderstanding. 2. Review of Resident #7's Physician Order Sheet (POS), dated February 2024, showed staff documented the resident as a Full Code status. Review of the resident's care plan, dated [DATE], showed a code status of DNR. Review of the resident's Care Conference Sheet, dated [DATE], showed a code status of Full Code. Review of the resident's medical record face sheet showed a code status of DNR. Review of the resident's annual social service review form , signed [DATE], with a code staus of DNR. 3. Review of Resident #8's POS, dated February 2024, showed staff documented the resident as a Full Code status. Review of the resident's medical record face sheet showed a code status of DNR. Review of the resident's transportable Physician Orders for Patient Preferences, dated [DATE], showed a code status of DNR. 4. During an interview on [DATE] at 1:28 P.M., Licensed Practical Nurse (LPN) Q said the code status should be the same on all forms. He/She said if the information was document differently in the resident's medical record. He/She would not know which code status is correct. During an interview on [DATE] at 9:41 A.M., the Administrator said he/she would expect the residents code status to be documented in the resident's charts. He/She said the information to should be the same would be the same in all areas of the medical record to avoid confusion and prevent the wrong directives. During an interview on [DATE] at 9:45 A.M., the Director of Nursing said staff were directed to have the resident and/or representative to complete a form with the resident's code status wishes and it would be signed off by the physician. He/She said the information was documented in the resident's medical chart by the nurse. He/She said the information should be the same in each area of the resident's medical records to ensure the resident's advance directive were followed. He/She said he/she would expect staff to follow physician orders. He/She said he/she checked the Physician Order Summary monthly to verify orders are correct in the resident's medical chart. He/She said the Minimum Data Set (MDS) Coordinator was responsible to verify the care plan reflect the information in the resident's medical chart. He/She said the MDS Coordinator has been on leave for a couple of weeks.

Based on interview and record review, facility staff failed to give appropriate Center for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advance Beneficiary Notices (SNFABN) for two resident (Resident # 12 and #45) of three sampled residents the facility initiated discharge from Medicare Part A Services when benefit days were not exhausted. The facility census was 45. 1. Review of the facility's policies showed staff did not provide a policy on SNFABN Notices. 2. Review of Resident #12's Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form showed staff documented: -Medicare Part A Skilled Services started on 12/19/23; -Last covered day of Medicare Part A Skilled Services on 01/06/24; -The resident wanted to go home. Review of the resident's medical record showed the resident remained in the facility after the facility initiated his/her discharge from Medicare Part A services. Review showed the medical record did not contain documentation staff provided the resident or his/her legal representative the SNFABN. 3. Review of Resident #45 SNF Beneficiary Protection Notification Review form showed staff documented: -Medicare Part A Skilled Services started on 12/19/23; -Last covered day Medicare Part A Skilled Services on 12/31/23; -The replacement policy was terminated. Review of the resident's medical record showed the resident remained in the facility after the facility initiated his/her discharge from Medicare Part A Services. Review showed the medical record did not contain documentation staff provided the resident or his/her legal representative the SNFABN. 4. During an interview on 02/29/24 at 2:59 P.M., the Business Office Manager (BOM) said he/she did not complete the forms because he/she believed the insurance companies sent all the forms required to be in compliance with State and Federal regulations. During an interview on 02/29/24 at 4:45 P.M., the administrator said the BOM was responsible to complete the beneficiary notices. He/She said there was no system in place to audit to ensure the notices were given to the resident and/or their representative. He/She said he/she did not know the BOM was not completing all the necessary forms. During the interview on 02/29/24 at 4:46 PM., the Director of Nursing said he/she did not know the process for the beneficiary notices.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility staff failed to provide a clean, homelike and comfortable environment when staff failed maintain resident rooms, common areas, medical device equipment and the exterior of the building clean and in good repair. Facility census was 45. 1. Review of the facility's policy titled, Physical Plant and Environmental Policy and Guidelines, undated, showed staff were directed to do the following: -It is of the utmost importance to provide a safe, hospitable, clean and organized facility and grounds to ensure an environment that is conducive to providing the best care, comfort and home-like surroundings for residents; -A well maintained building and environment is also important for creating safe work surrounds across all departmental staffing and their ability to effectively, and efficiently provide care and great living environment to all residents and all necessary resources to do so; -The building and grounds must be maintained in the best presentable state and must be done through routine maintenance and upkeep, housekeeping, and ensuring compliance with current federal, state, local and National Fire Protection Association (NFPA) codes; -Maintenance/Approved contractors are responsible for: *Routine care and repairs to interior finishings, which includes ceilings, walls, floors and windows; *Resident care equipment; *Wheelchair and bed maintenance; *Maintain essential supplies and parts; -The facility Administrator must ensure that the overall scope and effective procedures are followed by each departments supervisors and staff or request of approved contractors for creating and maintaining a safe and comfortable environment for the residents, visitors and staff. 2. Observation on 02/25/24 at 11:48 A.M., showed the resident occupied room [ROOM NUMBER] with missing trim by the entrance door and the bathroom door with a small gouge. Observation showed the walls with black marks, nail holes, exposed screws and the corner of the outer closet with missing and chipped paint. Observation on 02/27/24 at 10:07 A.M., showed the resident occupied room [ROOM NUMBER] with missing trim by the entrance door and the bathroom door with a small gouge. Observation showed the walls with black marks, nail holes, exposed screws and the corner of the outer closet with missing and chipped paint. Observation on 02/28/24 at 10:53 A.M., showed the resident occupied room [ROOM NUMBER] with missing trim by the entrance door and the bathroom door with a small gouge. Observation showed the walls with black marks, nail holes, exposed screws and the corner of the outer closet with missing and chipped paint. Observation on 02/29/24 at 1:02 PM., showed the resident occupied room [ROOM NUMBER] with missing trim by the entrance door and the bathroom door with a small gouge. Observation showed the walls with black marks, nail holes, exposed screws and the corner of the outer closet with missing and chipped paint. 3. Observation on 02/25/24 at 12:58 P.M., showed the resident occupied room [ROOM NUMBER] did not have decor on the wall, exposed nails, and nail holes. The walls had missing and chipped paint. Observation on 02/27/24 at 10:12 A.M., showed the resident occupied room [ROOM NUMBER] did not have decor on the wall, exposed nails, and nail holes. The walls had missing and chipped paint. Observation on 02/28/24 at 10:56 A.M., showed the resident occupied room [ROOM NUMBER] did not have decor on the wall, exposed nails, and nail holes. The walls had missing and chipped paint. Observation on 02/29/24 at 1:02 P.M., showed the resident occupied room [ROOM NUMBER] did not have decor on the wall, exposed nails, and nail holes. The walls had missing and chipped paint. During an interview on 02/29/24 at 1:28 P.M., Licensed Practical Nurse (LPN) Q said residents are allowed to have personal items in their room. He/She said the resident in the occupied room [ROOM NUMBER], had a habit of removing items from the walls. During an interview on 02/29/24 at 4:45 P.M., the Administrator said the resident who occupied room [ROOM NUMBER], was a newer resident and he/she had not been down to the resident's room, so he/she did not know the resident did not have any decor on the walls. He/She said he/she did not feel like it was homelike if there was nothing on the walls. During an interview on 02/29/24 at 4:46 P.M., the Director of Nursing (DON) said he/she just noticed room [ROOM NUMBER] with nothing on the walls when he/she went down the hall looking for hazardous items. 4. Observation on 02/26/24 at 10:02 A.M., showed the resident occupied room [ROOM NUMBER] with gouges in the walls, wood wall trim and by the out corner of the closet. Observation showed the walls with black marks along the bottom, nail holes, exposed nails and missing and chipped paint. Observation showed missing and chipped paint on the entrance door. Observation on 02/27/24 at 9:57 A.M., showed the resident occupied room [ROOM NUMBER] with gouges in the walls, wood wall trim and by the out corner of the closet. Observation showed the walls with black marks along the bottom, nail holes, exposed nails and missing and chipped paint. Observation showed missing and chipped paint on the entrance door. Observation on 02/29/24 at 12:56 P.M., showed the resident occupied room [ROOM NUMBER] with gouges in the walls, wood wall trim and by the out corner of the closet. Observation showed the walls with black marks along the bottom, nail holes, exposed nails and missing and chipped paint. Observation showed missing and chipped paint on the entrance door. 5. During an interview on 02/29/24 at 11:49 A.M., Certified Nurse Aid (CNA) H said staff are directed to report environmental concerns to the Director of Nursing (DON). He/She said he/she had noticed the resident rooms and common areas in disrepair and had reported it to staff. During an interview on 02/29/24 at 1:07 P.M., the Maintenance Director said staff are directed to complete a maintenance form if they observe environmental issues. He/She said he/she did not always check the book and he/she did not have a reason he/she did not check. He/She said he/she did audit the rooms at least weekly. He/She said he/she did not always have the funding to make the repairs. During an interview on 02/29/24 at 1:28 P.M., LPN Q said staff are directed to report environmental or medical equipment concerns to the charge nurse, document in the maintenance book or verbally tell the maintenance department. He/She had not noticed concerns with resident rooms or medical equipment. During an interview on 02/29/24 at 4:45 P.M., the administrator said staff are directed to report maintenance issues to the charge nurse, maintenance department or DON or document in the maintenance log. He/She said the maintenance log was Monday through Friday. He/She said he/she did notice the resident rooms in disrepair. During an interview on 02/29/24 at 4:46 P.M., the DON said staff were directed document environmental concerns in the maintenance book or report directly to the maintenance department. He/She said the maintenance department checked the book Monday through Friday. 6. Observation on 02/25/24 at 1:02 P.M., showed hall two with a missing hand rails between room [ROOM NUMBER] and the electrical room and between room [ROOM NUMBER] and room [ROOM NUMBER]. Observation on 02/27/24 at 10:02 A.M., showed hall two with a missing hand rails between room [ROOM NUMBER] and the electrical room and between room [ROOM NUMBER] and room [ROOM NUMBER]. Observation on 02/28/24 at 8:51 A.M., showed hall two with a missing hand rails between room [ROOM NUMBER] and the electrical room and between room [ROOM NUMBER] and room [ROOM NUMBER]. During an interview on 02/28/24 at 8:51 A.M., the maintenance director said the hand rails were downstairs in the basement. The maintenance director said the hand rail by room [ROOM NUMBER] came off the previous week and the other hand rail came off about two weeks ago. The maintenance director said he/she had not reattached the hand rails because he/she did not have the brackets to secure them to the wall. The maintenance director said he/she thought he/she told the Business Office Manager (BOM) about the hand rails the previous week and the administrator the week before that. The maintenance director said he/she does not have the ability to purchase items needed to make repairs him/herself and those purchases have to be made by the administrator or corporate environmental director. The maintenance director said he/she did not know if anyone had ordered the part needed to restore the hand rails. During an interview on 02/28/24 at 2:00 P.M., the BOM, who was the acting administrator, said the maintenance director is responsible to maintain the facility hand rails and if they are not present, it has the potential for a resident to fall. The BOM said if anything in the facility needs repaired, he/she would expect the maintenance director to make repairs as soon as possible and if he/she needs things purchased to make repairs he/she is to notify the administrator and/or the corporate environmental director about what is needed. The BOM said he/she did not notice the missing hand rails on hall 2 and they had experienced problems with the corporate environmental director providing assistance as needed, so he/she did not know if the director or anyone else had done anything about the parts needed to restore the hand rails. 7. Review of the facility's policy titled, Wheelchair Skills, undated, showed staff were directed to do the following: -To provide skills needed for ambulation about facility per wheelchair in safe efficient manner; -Safety Precautions include wheelchair in proper working order; -Did not provide direction for staff of the protocol for a wheelchair found in disrepair. Observation on 02/25/24 at 11:48 A.M., showed Resident #31 the vinyl of the right armrest of his/her wheelchair was worn with cracks. Observation on 02/27/24 at 10:07 A.M., showed Resident #31 the vinyl of the right armrest of his/her wheelchair was worn with cracks. Observation on 02/29/24 at 1:02 PM., showed Resident #31 the vinyl of the right armrest of his/her wheelchair was worn with cracks. During an interview on 02/29/24 at 11:49 A.M., CNA H said he/she are directed to report wheelchairs in disrepair to the maintenance depart. He/She said he/she had noticed several wheelchairs with concerns and have reported to staff. He/She said if a wheelchair armrest is in poor condition, it could cause skin tears and wounds to the resident. During an interview on 02/29/24 at 1:28 P.M., LPN Q said staff are directed to report medical equipment concerns to the charge nurse, document in the maintenance book or verbally tell the maintenance department. He/She had not noticed concerns with resident rooms or medical equipment. He/She said there a concern of a resident sustaining a skin tear if the wheelchair armrest is in disrepair. During an interview on 02/29/24 at 4:45 P.M., the Administrator said staff are directed to report medical equipment to the charge nurse, maintenance department and DON or document in the maintenance log. He/She said the maintenance log was checked daily. He/She said staff should remove medical equipment in disrepair out of resident use. He/She said if a resident continued to use a wheelchair with a torn and/or worn armrest, there is the potential for skin tears and/or breakdown, or the spread of germs. During an interview on 02/29/24 at 4:46 P.M., the DON said staff were directed document environmental concerns in the maintenance book or report directly to the maintenance department. He/She said the maintenance department checked the book Monday through Friday. He/She said staff were directed to remove mechanical devices in disrepair and to put sheep's wool over it. He/She said if the wheelchair armrest were worn and/or torn, there was a concern for skin breakdown. 8. Reivew of the facility maintained window inspection records, dated January 2023 through January 2024, showed documentation of a window and screen inspection dated 10/17/23. Review showed the maintenance director documented the results of his/her inspection, but did not document the actions taken to repair the failed windows. Review showed the maintenance director documented.the windows in Resident #19's room and resident rooms [ROOM NUMBERS] failed the inspection due to the frame and window screen. Review of the window inspections, showed the records did not contain documentation of another inspection after 10/17/23. Observations on 02/27/24 during the Life Safety Code tour, showed: -The windows in resident rooms [ROOM NUMBER] did not contain window screens; -The window screen to the window in resident room [ROOM NUMBER] bowed out of the frame which created an opening between the screen and the window; -The window in resident occupied room [ROOM NUMBER] with an accumulation of dirt and debris; -The window in Resident #19's with an excessive accumulation of dirt and debris and the window did not contain a window screen. During an interview on 02/27/24 at 9:20 A.M., Resident #19 said he/she likes to look out his/her window, but he/she did not like to look out it now because it was so dirty. The resident said he/she had a bird feeder that he/she wanted to have put outside his/her window, but has not asked staff to put it up because he/she would not be able to see it through the window. During an interview on 02/28/24 at 12:25 P.M., the maintenance director said he/she is responsible to inspect the windows every few months to ensure they are clean and in good repair and have screens. The maintenance director said he/she spoke to the corporate environmental director about the missing window screen a while ago and a guy came out and gave a bid to fix them and the bid was approved, but nothing every happened after that. The maintenance director said he/she had not follow-up with anyone on the screens because that was all handled at the corporate level and now the facility recently underwent a management change, so he/she did not know how to follow-up on it now. The maintenance director said he/she is responsible to clean the outside of the windows and he/she just had not done so for a while. During an interview on 02/28/24 at 2:00 P.M., the BOM, who was the acting administrator said the maintenance director is responsible for the maintenance of the windows and to clean the windows from the outside, while housekeepers are responsible to clean the inside of the windows every three months. the BOM said the maintenance director told him/her that the corporate environmental director had approved the purchase and installation of new window screens, but no one ever came to do it or called to schedule for it to be done and now the facility is under new management. The BOM said he/she did not know about the dirty windows and there is a resident that enjoys looking out of the window while in their room, then staff should definitely ensure that resident's window is clean and in good repair. 9. Observations on 02/27/24 during the Life Safety Code tour, showed the multiple sections of the fascia board (material used to cover the joints between the top of a wall and projecting eaves) on the exterior of the facility rotted, broken and warped which expose the wooden framework beneath to the elements. During an interview on 02/27/24 at 12:00 P.M., the maintenance director said he/she was responsible for the maintenance of the facility and he/she knew about the issues with the fascia. The maintenance director said he/she does not have the ability to purchase items needed to make repairs him/herself and those purchases have to be made by the administrator or corporate environmental director. The maintenance director said he/she contacted the corporate environmental director who said he/she would handle it, but nothing ever came of it and now the facility had new management so he/she did not know what to do about getting it fixed. During an interview on 02/28/24 at 2:00 P.M., the BOM, who was the acting administrator, said the maintenance director is responsible to maintain the exterior of the facility. The BOM said if anything in the facility needs repaired, he/she would expect the maintenance director to make repairs as soon as possible and if he/she needs things purchased to make repairs he/she is to notify the administrator and/or the corporate environmental director about what is needed. The BOM said he/she did not know about the issues with the fascia and he/she did not know if the maintenance director had contacted the corporate environmental director to have it repaired and the facility now has new management.

Based on interview and record review, facility staff failed to screen six new employee (Dietary E, Dietary F, Dietary G, Certified nurse aide (CNA) H, Licensed Practical Nurse (LPN) I, and housekeeping J) out of ten new employees prior to employment to determine if any employees had a federal indicator with the Employee Disqualification List (EDL) and/or the Family Care Safety Registry (FCSR). Facility staff failed to develop a written policy to notify the Department of Health and Senior Services (DHSS) of any allegation of abuse within the required two hour timeframe. The facility census was 45. 1. Review of the Facility's Abuse Prevention Program Facility Policy, not dated, showed the purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect or abuse of our residents. This will be done by conducting pre-employment screening of employees. Review showed: -The facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. This facility therefore prohibits mistreatment, neglect, or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. -This facility will not knowingly employ any staff convicted of any crimes listed in the Missouri Healthcare Worker Background Check Act (unless waivered under the provision of the Act), or with findings of abuse listed on the Missouri Nurse Aide Registry. Prior to a new employee starting a work schedule, this facility will file a Missouri State Police Healthcare Worker Background Check application on any individual being hired for a position. The facility policy and procedures for conducting a Healthcare Worker Background Check will be followed. 2. Review of Dietary E's personnel record showed: -Hire date of 7/12/23; -Did not contain documentation staff completed an EDL or FCSR check prior to his/her hire date. 3. Review of Dietary F's personnel record showed: -Hire date of 12/20/23; -Did not contain documentation staff completed an EDL or FCSR check prior to his/her hire date. 4. Review of Dietary G's personnel record showed: -Hire date of 11/24/23; -Did not contain documentation staff completed an EDL or FCSR check prior to his/her hire date. 5. Review of CNA H's personnel record showed: -Hire date of 12/12/23; -Did not contain documentation staff completed an EDL or FCSR check prior to his/her hire date. 6. Review of LPN I's personnel record showed: -Hire date of 8/09/23; -Did not contain documentation staff completed an EDL or FCSR check prior to his/her hire date. 7. Review of Housekeeping J's personnel record showed: -Hire date of 10/11/23; -Did not contain documentation the facility had completed an EDL or FCSR check prior his/her hire date. 8. During an interview on 02/29/24 at 3:00 P.M., the Business Office Manager (BOM) said he/she is responsible for making sure the EDLs are completed. He/She said they frequently have people not show up after they are hired. He/She said since they pay for the EDL's themselves and do not get reimburse when people do not show up for work, he/she has not been running them until they have already started. He/She said he/she lets them work the floor while they wait to come back. He/She said if it came back that they had abuse or neglect on their record he/she would then let them go. During an interview on 02/29/24 on 4:45 P.M., the Administrator said staff were directed to check the EDL prior to the start date. He/She said staff receive the EDL information immediately. He/She did not know the EDL's was not received in a timely manner. 9. Review of the facility's Abuse Prevention Program Facility Policy, updated, showed if, during the course of an incident investigation, the administrator or designee has determined that there is a reasonable cause to suspect mistreatment has occurred, the resident's representative and the department of public health shall be informed. Public Health shall be informed that an occurrence of potential mistreatment has been reported and is being investigated. Review showed the facility's Abuse Prevention Program Facility Policy did not include the requirement to notify DHSS of any allegation of abuse within two hours. During an interview on 02/29/24 at 5:50 P.M., the administrator said she was not aware the facility policy did not have the required time frame for reporting to DHSS.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to notify the Ombudsman (a resident advocate who provides support and assistance with problems and/or complaints regarding the facility) of resident transfers to the hospital for five sampled residents (Resident #14, #19, #24, #49, and #50). The facility census was 45. 1. Review of the facility's Transfer and Discharge Policy and Procedure, undated , showed the policy did not include direction for staff to notify the ombudsman of resident discharge or transfer. 2. Review of an email from the Regional Ombudsman Program Director, dated 02/22/24 at 1:42 P.M., showed did not send the Ombudsamn Director the monthly notifications of discharged or transferred residents. 3. Review of Resident #14's medical record, showed the resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. The medical record did not contain documentation staff notified the Ombudsman of the resident's transfer to the hospital. 4. Review of Resident #19's medical record, showed the resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. The medical record did not contain documentation staff notified the Ombudsman of the resident's transfer to the hospital. 5. Review of Resident #24's medical record showed the resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. The medical record did not contain documentation staff notified the Ombudsman of the resident's transfer to the hospital. 6. Review of Resident #49's medical record showed the resident discharged to home on [DATE]. The medical record did not contain documentation staff notified the Ombudsman of the resident's discharge. 7. Review of Resident #50's medical record showed the resident transferred to the hospital on [DATE] and did not readmit to the facility. The medical record did not contain documentation staff notified the Ombudsman of the resident's discharge. 8. During an interview on 02/27/24 at 12:13 P.M., the Social Services Director (SSD) said he/she has not been sending the transfer or discharge information to the Ombudsman, as she was not aware this need to be done. During an interview on 02//29 at 5:50 P.M., the administrator said she was not aware tranfer and discharge information needed to be sent to the Ombudsman.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to provide written information to the resident and/or the resident's representative of the bed hold policy at the time of transfer to the hospital for three (Resident #14, #19, and #24) out of three sampled residents. The facility's census was 45. 1. Review of the facility's Bed Hold Guarantee Policy, revised 08/01/17, showed, the resident, resident family or legal representative will be given the appropriate Notice of Bed Hold Policy at the time of discharge or therapeutic leave, if possible, but notice will be given no longer than 24 hours after discharge or initiation of leave. 2. Review of Resident's #14's Quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 10/18/23, showed staff assessed the resident as cognitively intact. Review of the resident's medical record showed : -discharged from the facility on 12/24/23 and readmitted to the facility on [DATE]; -Did not contain written documentation staff notified the resident or the resident's responsible party of the facility's bed-hold policy. 3.Review of Resident's #19's Quarterly MDS, dated [DATE], showed staff assessed the resident as moderate cognitively impaired. Review of the resident's medical record showed the following: -discharged from the facility on 01/13/24 and readmitted to the facility on [DATE]; -Did not contain written documentation staff notified the resident or the resident's responsible party of the facility's bed-hold policy. 4. Review of Resident's #24's Quarter MDS, dated [DATE], showed staff assessed the resident as cognitively intact. Review of the resident's medical record showed the following: -discharged from the facility on 01/01/24 and readmitted to the facility on [DATE]; -Did not contain written documentation staff notified the resident or the resident's responsible party of the facility's bed-hold policy. 5. During an interview on 02/27/24 at 12:13 P.M., the Social Services Director (SSD) said she is responsible for this process, but the only bed hold policy gone over is at admission. The SSD said I was not aware that needed to be done and sent with the resident at discharge, so I have not been doing it. During an interview on 02/29/24 at 5:50 P.M., the Administrator said she was not aware the bed hold policy needed to be sent out with the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, facility staff failed to ensure they assessed residents using the quarterly Minimum Data Set (MDS), a federally mandated assessment completed by staff, no less frequently than once every 92 days as directed by the Resident Assessment Instrument (RAI) manual for six residents (Resident #10, #16, #22, #37, #38, #46). The facility census was 45. 1. Review of the Resident Assessment Manual (RAI), dated 10/1/17, showed the Quarterly assessment is an Omnibus Budget Reconciliation Act of 1987 (OBRA) non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored. As such, not all MDS items appear on the Quarterly assessment. The Assessment Reference Date (ARD) must be not more than 92 days after the ARD of the most recent OBRA assessment of any type. 2. Review of Resident #10's MDS assessments showed a quarterly MDS dated [DATE]. Review showed the resident did not have a quarterly MDS in January 2024. 3. Review of Resident #16's MDS assessments showed a annual MDS dated [DATE]. Review showed the resident did not have a quarterly MDS in January 2024. 4. Review of Resident #22's MDS assessments showed a quarterly MDS dated [DATE]. Review showed the resident did not have a quarterly MDS in January 2024. 5. Review of Resident #37's MDS assessments showed a quarterly MDS dated [DATE]. Review showed the resident did not have a quarterly MDS in January 2024. 6. Review of Resident #38's MDS assessments showed a quarterly MDS dated [DATE]. Review showed the resident did not have a quarterly MDS in January 2024. 7. Review of Resident #46's MDS assessments showed a admission MDS dated [DATE]. Review showed the resident did not have a quarterly MDS in January 2024. 8. During an interview on 02/29/24 at 4:46 P.M., the Director of Nursing (DON) said he/she does not know why MDS's are not up to date. He/She said it is his/her expectation they are done timely. He/She said in the past corporate would watch MDS's closely and email to check up on and remind the facility if MDS's were behind. He/She said corporate never reached out so they were not aware there were issues. During an interview on 01/29/24 at 4:45 P.M., the administrator said the MDS Coordinator was responsible to complete the MDS Assessment, but had been gone for a couple of weeks. The administrator said he/she did not know the MDS Assessments were not up to date, but expected the assessments should be completed in a timely manner. He/She said the corporate office audited the MDS Assessments and recently reached out to him/her in regard to issues.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, facility staff failed to provide person-centered, measurable time frames to meet the residents' individual needs and goals identified in the comprehensive care plans for four (Resident #3, #7, #20, and #31) sampled residents. The facility census was 45. 1. Review of the Facility's Comprehensive Care Planning Policy, revised 11/01/17, showed it is the policy of the facility to comprehensively assess and periodically reassess each resident admitted to this facility. The results of this resident assessment shall serve as the basis for determining each resident's strengths, needs, goals, life history and preferences to develop a person-centered comprehensive plan of care for each resident that will describe the services that are to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being. The Comprehensive Care Plan (CCP) shall be developed within seven days of the completion of the Resident Assessment Instrument (RAI). The CCP shall be reviewed after each Annual, Significant Change and Quarterly Minimum Data Set (MDS) and revised as necessary to reflect the resident's current medical, nursing, and mental and psychosocial needs as identified by the Interdisciplinary team (IDT). 2. Review of Resident #3's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 11/03/23, showed the staff assessed the resident as follows: -Cognitive intact; -Used oxygen therapy; -Received antidepressants, antianxiety, antipsychotic, anticoagulant, diuretic, opioid, and hypoglycemic; -Diagnoses of adult failure to thrive, depression, anxiety, panic disorder, peripheral vascular disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), Heart failure, kidney failure, and venous hypertension (idiopathic) with ulcer of bilateral lower extremity (failure of proper venous valve function resulting in an ulcer). Review of the resident's comprehensive care plan, undated, showed the record did not contain time frames to address the residents' individual care area problems, goals and/or intervention for staff to assist the resident to meet the goals. 3. Review of Resident #7's annual MDS, dated [DATE], showed the staff assessed the resident as follows: -Severe cognitive impairment; -Required dependence on staff for personal hygiene; -Used oxygen. Review of the resident's Physician Order Summary (POS), dated 2/01/24 through 2/29/24, showed: -Oxygen delivered at four liters per minute (LPN) to maintain oxygen saturation level at 90%; -Did not provide direction for staff in regard to the duration of oxygen treatment. Review of the resident's care plan, dated 10/17/22, showed the care plan did not contain documentation for the use of oxygen or personal hygiene assistance by staff. Review showed staff did not update the care plan on a quarterly basis as per their policy or clarify the order for oxygen to address the resident's needs. During an interview on 02/28/24 at 4:55 P.M., Certified Nurse Aide (CNA) R said the resident used to wear oxygen on a continuous basis, but no longer required the use of oxygen. During an interview on 02/28/24 at 4:59 P.M., Registered Nurse (RN) S said the resident wore oxygen on an as needed basis (PRN). During an interview on 02/29/24 at 1:11 P.M., the Director of Nursing (DON) said the resident used to rely on oxygen on a continuous basis, but now only requires oxygen use PRN when levels are below 90%. Additionally, the DON said staff should clarify oxygen orders with the resident's physician when staff are unsure of the order. The DON said she expects oxygen use to be addressed in the care plan. 4. Review of Resident #20's annual MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment; -Hospice; -Used insulin; -Diagnoses of renal failure, viral hepatitis, diabetes mellitus (a disease of inadequate control of blood levels of glucose), anxiety, depression, and bipolar disorder(is a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration). Review of the resident's comprehensive care plan, dated 3/29/23, showed it did not contain measurable time frames to address the residents' individual care area problems, goals and/or how staff are to assist the resident to meet the goals. 5. Review of Resident #31's quarterly MDS, dated [DATE], showed the staff assessed the resident as follows: -Severe cognitive impairment; -Impairment of both lower extremities. Review of the resident's care plan, dated 01/06/24, showed the care plan did not contain direction for staff on how to care for the resident's contractures. Observation on all days of the survey showed the resident with contactured legs. During an interview on 02/28/24 at 9:36 A.M., CNA O said he/she began his/her position in September 2023 and the resident's legs have always been contracted. During an interview on 02/28/24 at 9:48 A.M., RN S said he/she has worked at the facility since the resident was admitted . He/She said the resident's legs have gradually become more contracted however, he/she did not know how long staff have used the pillow and he/she thinks the pillow is used for skin issues. During an interview on 02/28/24 at 10:15 A.M., the DON said the resident has had contractures as long as he/she had known the resident. He/She said the resident's contracted legs sometimes were worse than others. He/She said staff are directed to use a pillow in between the resident's legs for his/her contracted legs. He/She reviewed the care plan and said he/she did not see the resident's contracted legs on the care plan. He/She said he/she would expect it to be addressed on the care plan. 5. During an interview on 02/29/24 at 4:46 P.M., the DON said any nurse can update care plans as needed but it is the MDS coordinator's responsibility for maintaining care plans. He/She said care plans should be done on admission and updated quarterly or with significant changes. He/She expects staff to update care plans after falls or changes in care with updated interventions and time frames. He/She said he/she was not aware they were not being updated with the MDS assessments. He/She said he/she noticed there are several care plans he/she noticed are missing things he/she would find important to be listed. During an interview on 02/29/24 at 4:45 P.M., the administrator said care plans should be patient centered and provide staff guidance for care. He/She said staff are directed to update care plans when the resident has a change, including a new fall with an updated intervention, and on a quarterly basis. He/She said the care plan should include oxygen, rejection of care, and advanced directives. He/She said he/she expects staff to review all areas of care in the care plan and make sure it is accurate. He/She said there are care plan meetings scheduled four days a week and he/she did not know why the care plans had not been updated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility staff, failed to review and revise care plan after falls for two residents (#8 and #47). Staff failed to hold care conference for three residents (#14, #15, and #24). The facility census was 45. 1. Review of the facility's Comprehensive Care Planning Policy, revised 11/01/17, showed: Components of the CPC may include: -Care Plan- Plan of care describing a need/problem, and indicating approaches/interventions to be instituted to assist the Resident in maintaining/receiving care in relation to the need/problem; -The following procedures shall be utilized in the development and maintenance of care plans: Participants of the Interdisciplinary Team in the development/revision of the CCP should include: the attending physician (or appointee), Registered Nurse (RN) with responsibility for the resident, Certified Nurse Aid (CNA) with responsibility for the resident, member of the food service team and the resident and/or resident representative as possible/appropriate; a. Other appropriate staff or professional's participation in the IDT shall be based on resident care, services and needs. -The Care Plan Conference shall be held as necessary to communicate major revisions to the Comprehensive Care Plan and minimally with every Comprehensive Minimum Date Set (MDS) completed. The facility shall make effort that the conference: a. Be attended by a representative from each discipline involved in the Resident's care as possible. b. Be attended by the Resident, unless the Resident is incapable of understanding the proceedings or chooses not to attend. c. Be attended by a representative of the Resident's choice, if that person so chooses to attend. d. Serve as a means of communication among disciplines and resident/representative. e. Provide a setting in which to discuss the Resident's condition, medications, progress, lack of progress, and changes in or continuance of care plans and programs plans. f. Care information be communicated to the Resident and/or representative of Resident's choice if unable to attend and document such relay of information in the Resident's record. g. Records event by creating attendance record that states the date, persons in attendance- via the Care Plan Summary/Participation Record. 2. Review of the Resident #8's Quarterly MDS, a federally mandated assessment tool, dated 11/06/23, showed staff assessed the resident as: -Moderate cognitive impairment; -Did not contain documentation of a fall since admission. Review of the resident's medical records, dated 02/12/24, showed the resident suffered a fall with a laceration to his/her forehead and was sent to the emergency room. Review of the resident's care plan, dated 02/13/24, showed the plan did not contain documentation of the resident's fall on 2/12/24 or new fall interventions. 3. Review of the Resident #47's admission MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Did not contain documentation of a fall prior to admission. Review of the resident's medical record, dated 01/26/24, showed the resident sustained a fall. Review of the resident's care plan, dated 12/13/23, showed the plan did not contain documentation of a fall on 01/06/24 or new fall interventions. During an interview on 02/29/24 at 4:45 P.M., the Administrator said care plans should be patient centered and provided staff guidance for care. He/She said staff were directed to update care plans when the resident had a change, including a new fall with an updated intervention, and on a quarterly basis. 4. Review of Resident #14's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Insulin injections taken the last seven out of seven days; -Diagnosis of diagnosis of Diabetes (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), Psychotic disorder. Review of the resisent's medical record, showed staff did not document they completed a care plan conference after 05/02/23. During an interview on 02/26/24 at 3:25 P.M., the resident said I do know what a care plan meeting is and have gone to one, but I haven't had one for a while, maybe last year. 5. Review of the Resident #15's Quarterly MDS, dated [DATE], showed staff assessed the resident as moderately cognitively impaired. Review of the resisent's medical record, showed staff did not document they completed a care plan conference after 10/05/23. During an interview on 02/26/24 at 10:28 A.M., the resident said he/she did not attend care plan meeting. 6. Review of the Resident #24's Quarterly MDS, dated [DATE], showed the staff assessed the resident as follows: -Cognitively intact; -Diagnosis of paraplegia (the inability to voluntarily move the lower parts of the body), anxiety, depression, and bipolar disorder (Mental illness that causes unusual shifts in a person's mood, energy, activity level, and concentration). Review of the resisent's medical record, showed staff did not document they completed a care plan conference after 03/24/23. During an interview on 02/26/24 at 3:51 P.M., the resident said it has been a long time since he/she has been invited to a care plan meeting. He/She said he/she had been going to them on a regular basis before. 7. During an interview on 02/29/24 at 4:46 P.M., the Director of Nursing (DON) said it is the MDS coordinators responsibility for setting up and conducting care plan meetings and maintaining care plans. He/She said care plans should be done on admission and updated quarterly or with significant changes. He/She said he/she was not aware meetings were not done or dates were not being updated. He/She said he/she was told the MDS coordinator had scheduled meetings. During an interview on 02/29/24 at 4:45 P.M., the Administrator said care plans should be patient centered and provided staff guidance for care. He/She said staff were directed to update care plans when the resident had a change, including a new fall with an updated intervention, and on a quarterly basis. He/She said the care plan should include, oxygen, rejection of care, and advanced directives. He/She said he/she would expect staff to review all areas of care in the care plan and make sure it is accurate. He/She said there were care plan meetings scheduled four days a week and he/she did not know why the care plans had not been updated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, staff failed to maintain a professional standard of care for two residents (Resident #3 and 16) when staff did document they completed weekly skin assessments. Staff failed to get one resident (Resident #14) physician order to to self-administer insulin. The facility census was 45. 1. Review of the facility's policies showed staff did not provide a policy for following physician treatment orders. 2. Review of the Resident #3's Quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 11/03/23, showed staff assessed the resident as follows: -Cognitively intact; -Risk of pressure ulcers; -One venous and arterial ulcer present; -Diagnosis of peripheral vascular disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs) and venous hypertension (idiopathic) with ulcer of bilateral lower extremity (failure of proper venous valve function resulting in an ulcer). Review of the resident's physician order sheet (POS), dated 08/02/23 through 02/29/24, showed an order for weekly skin assessments. Review of the resident's treatment administration record (TAR), dated December 2023, showed the record did not contain documentation staff completed the weekly skin assessments. Review of the resident's TAR, dated January 2024, showed the record did not contain documentation staff completed the weekly skin assessments. Review of the resident's TAR, dated February 2024, showed the record did not conatin documentation staff completed the weekly skin assessments. 3. Review of the resident #16's Quarterly MDS, dated [DATE], showed the staff assessed the resident as follows: -Cognitively intact; -Risk of pressure ulcers; -Diagnosis of peripheral vascular disease and Hemiplegia (a condition caused by brain damage or spinal cord injury that leads to paralysis on one side of the body). Review of the resident's POS, dated 07/17/23 through 02/29/24, showed an order for weekly skin assessments. Review of the resident's TAR, dated December 2023, showed the record did not contain documentation staff completed the weekly skin assessments for the month of December. Review of the resident's TAR, dated January 2024 , showed the record did not contain documentation staff completed a skin assessment between 01/23/24 and 01/30/24. Review of the resident's TAR, dated February 2024, showed the record did not contain documentation staff completed a skin assessment on 02/06/24. During an interview on 02/28/24 at 11:35 A.M., Licensed practical nurse (LPN) A said it is the job of the charge nurse to fill out and complete the TAR's. He/She said the holes in the tar where the orders are not signed off mean it was not done. He/She does not know why they were not done. 5. Review of the facility's policies showed staff did not provide a policy for the self-administration of insulin. 6. Review of Resident #14's Quarterly MDS, dated [DATE], showed the staff assessed the resident as follows: -Cognitively intact; -Diagnosis of diagnosis of Diabetes (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine). Review of the resident's care plan, dated 05/23/23, showed the record did not contain direction on the self-administration of insulin. Review of the resident's POS, dated February 2024, showed the record did not contain an order for self-administration. Observation on 02/26/24 at 11:43 A.M., showed LPN A gave the resident the insulin pen and the resident administered the insulin in his/her abdomen. 7. During an interview on 02/29/24 at 4:46 P.M., the Director of Nursing (DON) said he/she is not sure why there are holes in the TAR's. He/She is not sure why they are not complete. He/She said it is the responsibility of the nurse who is working the shift the orders are due, to complete them and initial the TAR when done. During an interview on 02/29/24 at 4:45 P.M., the Administrator said the physician orders are entered by the nurse or the DON. He/She expected staff to follow physician orders. He/She said staff should initial the MARS after administering medications or providing treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to provide assistance with grooming and bathing for four sampled residents (Resident #15, #29, #45, and #47). The facility census was 45. 1. Review of the facility's Bath/Shower policy, undated, directs staff to ensure adequate hygiene needs are met. Review showed a bath/shower is scheduled for all residents in the facility at least weekly. 2. Review of Resident #15's quarterly Minimum Data Set (MDS), a federally mandated assessment tool used to plan care, dated 12/05/23, showed facility staff assessed the resident as: -Moderate cognitive impairment; -Rejected care four out of the six days during the look back period; -Required substantial assistance from staff for personal hygiene. Review of the resident's care plan, dated, showed 10/05/23, showed: -Resident is self care deficient and needs supervision and/or assistance to complete quality care and/or poorly motivated to complete activity of daily living (ADL). -Has minimal movement of right arm; -Assist with ADL's as necessary with assistance from one staff; -Received fingernail care on shower day and as needed; -History of resisting care and services. Review of the resident's shower sheets, dated 02/17/24 and 02/24/24, showed staff documented the resident received a bath/shower, but did not document a refusal or offering of fingernails cleaning and trimming. Observation on 02/26/24 at 10:04 A.M., showed the resident with jagged and dirty nails. Observation on 02/29/24 at 12:57 P.M., showed the resident with jagged and dirty nails. Observation showed resident told a staff member he/she wanted his/her nails trimmed and the staff told the resident they would find someone to help him/her. During an interview on 02/27/24 at 2:45 P.M., Licensed Practical Nurse (LPN) A said the resident did not refuse care and he/she has cut the resident's nails before without issues. He/She said he/she has not seen the resident's nails in a couple of months. During an interview on 02/29/24 at 11:49 A.M., Certified Nurse Aide (CNA) H said the resident did not reject care. He/She said he/she noticed the resident's long nails before and had offered to cut them. He/She said he/she had told the shower aide to trim the resident's nails, but noticed the resident's nails were not trimmed. During an interview on 02/29/24 at 12:53 P.M., the resident said it bothered him/her to have nails of different lengths and debris under his/her nails. He/She said staff did not trim his/her nails on shower days or clean his/her nails. He/She said he/she told staff he/she wanted his/her nails trimmed, but did not remember when. During an interview on 02/29/24 at 4:46 P.M., the Director of Nursing (DON) said the resident gets his/her nails done every time staff offers. He/She said sometimes the resident refuses care depending on his/her mood. 3. Review of Resident #29's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment; -Partial/Moderate assistance by staff for personal hygiene and dressing; -Maximal staff for shower/bathe; -No behaviors; -Rejects care 4 to 6 days but less then daily; -Occasionally incontinent of urine and bowel. Review of the resident's care plan, dated 02/03/23, showed the resident received a shower two times per week. Staff are to provide baths, hygiene, dressing and grooming per resident's preference as able. Review of the resident's Physician Order Sheet (POS), dated February 2024, showed an order for a shower two times weekly and as needed. Review of the resident's shower record, dated December 2023, showed staff documented the resident received a shower on 12/02/23. Review of the resident's shower record, dated January 2024, showed staff documented the resident received a shower on 01/09/24 and 01/26/24. Review of the resident's shower record, dated February 2024, showed staff documented the resident received a shower on 02/02/24, 02/13/24, and 02/16/24. Observation on 02/25/24 at 10:50 A.M., showed the resident in his/her wheelchair in the common area of the facility with unkempt hair, gray pants, a black vest with a green long sleeve shirt underneath. Staff did not assist the resident to change his/her clothes after they became soiled with what appeared to be food debris. Observation on 02/26/24 at 1:30 P.M., showed the resident in his/her wheelchair in the hallway with unkempt hair and dried substance around his/her mouth. The resident wore the same gray pants with debris on them, a black vest with a green long sleeve shirt underneath. Observation on 02/27/24 at 4:15 P.M., showed the resident in his/her wheelchair in his/her room with unkempt hair, and gray pants with debris on them, a black vest with dried debris on the front with a green long sleeve shirt underneath. Observation on 02/28/24 at 5:45 P.M., showed the resident in his/her wheelchair in the common area with unkempt hair, and gray pants with debris on them, a black vest with dried debris on the front with a green long sleeve shirt underneath. 4. Review of Resident #45's admission MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment; -Partial/Moderate assistance by staff for shower/bathe and dressing; -No behaviors; -Does not reject care. Review of the residents care plan, dated 12/26/23, the resident will receive shower two times a week. Review showed staff are to provide bathing, hygiene, dressing and grooming per residents preference as able. Review of the resident's POS, dated February 2024, showed an order for the resident to receive showers two times weekly and as needed. Review of the resident's shower record, dated December 2023, showed staff documented the resident received a shower on 12/26/23. Review of the resident's shower record, dated January 2024, showed staff documented the resident received a shower on 01/26/24. Review of the resident's shower record, dated February 2024, showed staff documented the resident received a shower on 02/09/24, 02/14/24, and 02/23/24. Observation on 02/26/24 at 1:50 P.M., showed the resident in a recliner in the common area with a teal top and blue jeans on. Observation showed the resident with a black substance under his/her nails and long chin hair. Observation on 02/27/24 at 11:30 A.M., showed the resident in a recliner in the common area with the same teal top and blue jeans on. Observation showed the resident with a black substance under his/her fingernails and long chin hair. Observation on 02/28/24 at 3:30 P.M., showed the resident in a chair by the nurses station. Observation showed a black substance under his/her fingernails and long chin hair. 5. Review of Resident #47's admission Assessment MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Did not reject care; -Required supervision from staff for personal hygiene and upper and lower dressing. Review of the resident's care plan, dated 12/13/23, showed staff assessed the resident is physically able to perform ADL's independently, but has cognitive impairment and may require cueing or reminders. Review showed staff documented with disease progression, may require assistance with sequencing during ADL's or for ADL completion. Review showed the resident is capable of completing ADLs safely and efficiently with supervision/oversight and assist to schedule beauty/barber shop to keep hair at desired length. Insure hair in placed before meals. Keep facial hair at desired length/shaved per resident's usual style. Fingernail care on shower day and as needed. Trim toe nails if in good repair and no diagnosis of diabetes. Resident is independent in dressing with set up. Gather and place items to allow resident dressing as appropriate and as independent as possible. Assist the resident to choose simple comfortable clothing that enhances the resident's ability to dress self. Review showed the care plan did not contain documentation of rejection of care. Review of the resident's shower sheet, dated 02/19/24, showed staff documented the resident's finger and toe nails cleaned, but did not documentation staff trimmed the resident's nails. Review of the resident's shower sheet, dated 02/24/24, showed the shower sheet did not contain documentation staff offered or the resident refused nail trimming. Observation on 02/26/24 at 8:15 A.M., showed the resident wore the same shirt as he/she did on 02/25/24. Observation showed the resident with jagged and dirty nails. Observation on 02/26/24 at 2:03 P.M., showed the resident wore the same shirt as he/she did on 02/25/24. Observation showed the resident with jagged and dirty nails, uncovered feet with his/her toe nails long. Observation on 02/28/24 at 10:56 A.M., showed the resident continued to have jagged and dirty nails. During an interview on 02/29/24 at 11:49 A.M., CNA H said he/she noticed the resident's toe nails, but the resident hits staff when they attempt to trim his/her nails. 6. During an interview on 02/29/24 at 11:49 A.M., CNA H said resident's hair should be brushed daily when out of bed or as need. He/She said staff are directed to check residents' nails any time interacting with a resident and to clean and trim as needed. He/She said staff provide shaves every other day, shower days and when asked. He/She said residents' clothing should be changed daily and as needed. He/She said if a resident refuses care, he/she report it to the charge nurse. During an interview on 02/29/24 at 1:28 P.M., LPN Q said all staff are responsible to provide nail care and facial hair shaving when noticed. He/She said he/she has not recently noticed any resident with long facial hair or unkempt nails. He/She said if a resident refuses care, then staff should reapproach. During an interview on 02/29/24 at 4:45 P.M., the administrator said nursing staff provide nail care and facial hair shaving. He/She said the Activity Director did provide nail care as an activity. He/She said facial hair shaving and nail care should be completed on shower days and as needed. He/She said clothing should be changed daily and as needed. He/She said if a resident refuses care, staff are directed to re-approach, report to the charge nurse and document in the resident's medical records. During an interview on 02/29/24 at 4:46 P.M., the DON said the aides are responsible to provide nail care and shaving of facial hair, except for resident who see a podiatrist. He/She said staff are directed to follow the list on the shower sheets, which is a minimum of twice a week. He/She said staff are directed to change clothing daily and when soiled. He/She said if the resident refuses care, staff are to document on the shower sheet and report to nursing staff and document in the resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to provide an ongoing program of activities designed to meet the residents' interest on the weekends and when the Activity Director (AD) was not in the facility for four residents' (#7, #15, #20 and #31). The facility census was 45. 1. Review of the facility's policy titled, Activity Program, dated 07/11/06, showed the facility will provide a program of activities which includes a combination of large and small group, one-to-one and self-directed activities; and a system that supports the development, implementation, and evaluation of the activities provided to the residents in the facility. Review showed: -All residents shall be offered the opportunity, and encouraged to participate in activities, but shall not be required to participate; -It is the philosophy of the facility to meet each individuals needs and to evaluate, acknowledge, develop, implement and assess each resident's outcome in order to provide or maintain the resident's highest practicable leel of well-being. Review of the facility's Activity Calendar, dated February 2024, showed: -Saturday, 02/03/24; 10:00 A.M., Coffee Chats and 2:00 P.M. Puzzles; -Sunday, 02/04/24; 10:00 A.M., Bible Hymns, 2:00 P.M., Object Find; -Saturday, 02/10/24; 10:00 A.M., Story Time with Coffee, 2:00 P.M., Puzzles; -Sunday, 02/11/24; 10:00 A.M., Bible Versus, 2:00 A.M., Crosswords; -Saturday, 02/17/24; 10:00 A.M., Front Porch Chats, 2:00 P.M., Sudoku; -Sunday, 02/18/24; 10:00 A.M., Bible Versus, 2:00 P.M., Book Reading; -Saturday, 02/24/24; 10:00 A.M., Coffee Chats, 2:00 P.M., Word Searches; -Sunday, 02/25/24; 10:00 A.M., Bible Hymns, 2:00 P.M., Coloring Pages; -Monday 02/26/24; 8:00 A.M., News, 8:30 A.M., Exercise, 10:00 A.M., Nails, 2:00 P.M., Bingo. 2. Observation on 02/25/24 at 2:33 P.M., showed the common area, activity room, or dining room did not have staff led activities. 3. Observation on 02/26/24 at 10:52 A.M., showed the common area, activity room, or dining room did not have staff led activities. 4. Observation on 02/26/24 at 2:10 P.M., showed the common area, activity room, or dining room did not have staff led activities. 5. Observation on 02/26/24 02:32 P.M., showed no staff led activities in the common area, activity room, or dining room. 6. Observation on 02/27/24 at 10:16 A.M., showed the AD told a resident he/she was going to find other residents to attend the scheduled activity, He/She walked past three resident's sitting by the nurse station, but did not ask the resident's if they would like to attend the activity. Observation on 02/27/24 at 10:19 A.M., showed the AD entered room [ROOM NUMBER], but did not enter any other resident's room on the 2 hall before heading back to the activity room. During an interview on 02/29/24 at 1:23 P.M., the AD said he/she did not invite every resident, every time there was a scheduled activity, but did announce the activity over the intercom. 7. Review of Resident #7's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 11/08/23, showed staff assessed the resident as follows: -Severe cognitive impairment; -Somewhat important to have books, newspapers and magazines to read and keep up with the news, do favorite activities, participate in religious services or practices; -Not very important to listen to music, be around animals or do things with groups of people or go outside to get fresh air. Review of the resident's care plan, dated 07/19/22, showed staff documented the resident will attend activities five times a week with active/passive participation in the next 90 days. Review showed staff are directed to invite, remind and escort to and from activity of choose and praise involvement. Observation on 02/25/24 at 2:40 P.M., showed the resident in his/her bed. Observation on 02/26/24 at 2:12 P.M., showed the resident in his/her bed. During an interview on 02/29/24 at 1:23 P.M., the AD said he/she did not invite every resident, every time there was a scheduled activity, but did announce the activity over the intercom. 8. Review of Resident #15's Annual MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment; -Somewhat important to have books, newspapers and magazines to read; -Very important to listen to music, be around animals such as pets, to do things in a group, do favorite activities, and go outside to get fresh air; -Not very important to keep up with the news or participate in religions services or practices. Review of the care plan, dated 01/06/23, showed staff aree directed to invite, remind and escort to and from activity of choice and praise involvement. Review showed to provide leisure activity materials as requested by resident. Resident enjoys puzzles. Observation on 02/25/24 at 2:41 P.M., showed the resident in his/her wheelchair in his/her room Observation on 02/26/24 at 10:28 A.M., showed the resident sat by the nurse station. Observation on 02/26/24 at 2:12 P.M., showed the resident in his/her room. During an interview on 02/26/24 at 2:15 P.M., the resident said the AD was not in the building today, so he/she did not know what activities were scheduled. He/She said he/she did not know if staff provided activities on the weekends. He/She said he/she did attend activities when provided. 9. Review of Resident #20's admission MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Somewhat important to do things in a group and do favorite activities; -Very important to listen to music, participate in religious services, and go outside to get fresh air; -Not very important to be around animals such as pets, keep up with the news, and to have books, newspapers and magazines to read. During an interview on 02/26/24 at 8:17 A.M., the resident said there are no organized activities offered on the weekends. He/She said most weekends the residents and himself/herself just lay in bed and watch tv because there isn't much to do. He/She said he/She would like to have activities on the weekends. 10. Review of Resident #31's Annual MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Did not contain documentation of Customary Routine and Activities. Review of the resident's care plan, dated 01/06/23, showed: -Invite, remind and escort to and from activities of choise; -Encourage out of room socialization with peers/staff; -Encourage radio and TV for added stimulation; -Advice resident of all activities available and inform of act that will not be affected by residents limitations. Observation on 02/25/24 at 2:42 PM., showed the resident in his/her bed. Observation on 02/26/24 at 2:13 P.M., showed the resident in his/her bed. 11. During an interview on 02/29/24 at 11:49 A.M., Certified Nurse Aide (CNA) H said there are no weekend activities, except for on occasion when an aide would give residents a snack and put on a movie. During an interview on 02/29/24 at 1:23 P.M., the AD said there are no staff led activities on the weekends. He/She said he/she placed paper activities on the walls, but the resident's took them down. He/She said he/she did not think there was not enough staff for the weekend activities. He/She said occasionally other staff would fill in for him/her when he/she was not able to work. He/She said he/she did not invite every resident, every time there was a scheduled activity, but did announce the activity over the intercom. During an interview on 02/29/24 at 1:28 P.M., Licensed Practical Nurse (LPN) Q said he/she did not know if there are staff led weekend activities. During an interview on 02/29/24 at 4:46 P.M., the Director of Nursing (DON) said staff provided resident's with color sheets, puzzles and other paper related activities and a person from the church comes to the facility. He/She said during football season, resident's gather and watch football. He/She said the department heads assist with the AD is not in the building. He/She said sometimes the AD announced over the intercom the daily activites. He/She said staff should invite all residents to each activity. During an interview on 02/29/24 at 4:45 P.M., the Administrator said there are weekend activities, but they are self-directed unless a resident asked staff to initiate an activity. He/She said he/she would expect other staff to assist with activities when the AD is not in the building. He/She said he/she expected staff to invite all residents to all scheduled activities. He/She said he/she can see how it would be an issue for residents when there is not staff led weekend activities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to ensure the resident environment remained as free of accident hazards as is possible, when staff failed to provide safe mechanical lift transfers for two residents (Residents #31 and #37), failed to properly propel four resident's (unidentifed resident, #31, #6 and #15) in a manner to prevent accidents, failed to store sharps and toxic chemicals in a manner not accessible to residents, and failed to maintain the hot water temperature of plumbing fixtures accessible to residents on Hall two. The facility census was 45. 1. Review of the facility's policy titled, Limited Lift Resident Handling- Policy and Procedures, undated, showed staff were directed to do the following: -This policy describes ways to ensure that employees use safe resident handling and movement techniques at [NAME] Health Care facilities for tasks that are designated as high-risk for safe resident handling and movement injuries; -[NAME] Health Care wants to ensure that its residents are cared for safely, while maintaining a safe work environment for employees. This infrastructure includes resident handling and movement equipment, employee training, and a Culture of Safety approach to safety in the work environment; -Goals are to reduce the injury potential for both the resident and caregiver -It is the duty of employees to take reasonable care of their own health and safety, as well as that of their co-workers and their residents during resident handling activities by following this. Non-compliance will indicate a need for retraining and disciplinary action; -Staff will complete and document safe resident handling and movement equipment raining initially, annually, and as required to correct improper use/understanding of safe resident handling and movement; -Use proper techniques, mechanical lifting devices, and other approved equipment/aids during performance of high-risk resident handling tasks; -Did not contain direction for staff in regard to the procedure of safely transferring a resident using a mechanical lift. 2. Review of Resident #31's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 12/11/23, showed facility staff assessed the resident as: -Severe cognitive impairment; -Dependent on staff to transfer to and from a bed to a chair (or wheelchair). Review of the resident's care plan, dated 01/06/23, showed the resident required two staff member for transferring using a mechanical lift. Observation on 02/25/24 at 11:48 A.M., Certified Nurse Aide (CNA) O and CNA H entered the resident's room to provide perineal care. CNA O operated the lift while CNA H guided the resident from his/her bed to his/her wheelchair. CNA O did not open the base of the lift until he/she transferred the resident to his/her wheelchair. During an interview on 02/28/24 at 9:40 A.M., CNA O said the base of the lift should be opened for stability. He/She said he/she realized he/she should have opened the base, but it was hard to maneuver around the room when they were opened. 2. Review of Resident #37's Quarterly MDS, dated [DATE], showed facility staff assessed the resident as: -Cognitively intact; -Dependent on staff to transfer to and from a bed to a chair (or wheelchair). Observation on 02/26/24 at 2:53 P.M. showed CNA U and CNA V entered the resident's room to provide care. CNA V operated the lift to transfer the resident from the bed to the chair. CNA V did not open the base of the lift until he/she transferred the resident to the shower chair. During an interview on 03/13/24 at 1:43 P.M., CNA V said the mechanical lift legs should be opened to safely transfer a resident. He/She said the purpose of opening the legs is to provide balance for the lift and prevent it from potentially tipping over. He/She said he/she normally opened the legs and he/she did not recall not opening the legs. He/She said it was possible he/she missed an opportunity to safely transfer the resident because he/she was nervous. 3. During an interview on 02/29/24 at 1:38 P.M., LPN A said staff were directed to open the mechanical lift legs to balance the weight and prevent the lift from falling over. During an interview on 02/29/24 at 4:43 P.M., the Director of Nursing (DON) said staff were directed to open the mechanical lift legs for stability when transferring a resident, but it depended on the space of the resident's room. He/she said there was recently an in-service on safely transferring a resident using a mechanical lift. During an interview on 02/29/24 at 4:45 P.M., the Administrator said staff were directed to spread the base of the lift when transferring a resident. He/She said it depended on the room and the space if staff would open the base once transferred over to the wheelchair. He/She said opening the base of the mechanical lift provided stability. He/She said staff just received an in-service on the proper way to transfer a resident using a lift and staff were directed staff to keep the legs open when transferring the resident to prevent potential harm. 4. Review of the facility's policy titled, Wheelchair Skills, undated, showed staff were directed to do the following: -To provide skills needed for ambulation about facility per wheelchair in safe, efficient manner; -Did not contain direction for staff to the use of foot pedals or ensuring the resident's feet were placed on the foot pedals. 5. Observation on 02/28/24 at 1:19 P.M. showed Registered Nurse (RN) S propelled an unidentified resident in his/her wheelchair with one foot dragging on the floor. During an interview on 03/13/24 at 1:33 P.M., Registered Nurse (RN) S said staff were directed to use foot pedals and make sure the resident's feet were on the foot pedals before propelling a resident in a wheelchair. He/She said if staff did not ensure the resident's feet were planted on the foot pedal, there was a potential the resident could hurt their feet or flip forward out of their wheelchair. He/She said he/she may have missed an opportunity to safely propel a resident in a wheelchair, since there are some resident's who are able to propel themselves, even with one foot pedal, but ask staff to push them when they need assistance. 6. Review of Resident #31's Quarterly MDS, dated [DATE], showed facility staff assessed the resident as: -Severe cognitive impairment; -Uses a wheelchair; -Dependent on staff to wheel 150 feet. Observation on 02/28/24 at 1:20 P.M., showed Licensed Practical Nurse (LPN) A propelled the resident by the dining room to the common area with one of his/her feet off of the foot pedal, while his/her pressure relieving boot could be seen and heard dragging on the floor. During an interview on 02/29/24 at 1:38 P.M., LPN A said staff were directed to ensure resident's feet on the foot pedals prior to propelling a resident in a wheelchair. He/She said if staff did not make sure the resident's foot on the foot pedal, there was a potential the resident's feet could get stuck under the foot pedals and potentially break their ankle or the resident could flip out of the chair. He/She said he/she did not realize the resident's feet were not on the foot pedals. 7. Review of Resident #6's Quarterly MDS, dated [DATE], showed facility staff assessed the resident as: -Did not contain documentation of a Brief Interview for Mental Status (BIMS) score; -Uses a wheelchair; -Required substantial/maximal assistance from staff to wheel 150 feet. Observation on 02/29/24 at 1:17 P.M., showed CNA T propelled the resident in his/her wheelchair down the hallway. The resident's foot was under the foot pedals and not placed on the foot pedals. During an interview on 02/29/24 at 1:17 P.M., CNA T said staff were directed to make sure the resident's feet were placed on the foot pedals before propelling a resident in a wheelchair. He/She said staff should make sure the resident's feet are placed on the foot pedals while being propelled to prevent the resident from tipping forward or sustain injury. He/She said he/she did not see the residents other foot under the other foot pedals. He/She said the the resident will not use both foot pedals. 8. Review of Resident #15's Quarterly MDS, dated [DATE], showed facility staff assessed the resident as: -Moderate cognitive impairment; -Uses a wheelchair; -Required no assistance from staff to wheel 50 feet with two turns. Observation on 02/29/24 at 1:36 P.M., showed CNA H propelled the resident down the hallway without foot pedals. During an interview on 02/29/24 at 2:30 P.M., CNA H said the resident did not like to use both foot pedals. He/She said he/she asked a nurse when first employed in regard to the use of one foot petal and was told it was okay to propel the resident without both foot pedals, even though his/her training directed him/her to always use both foot pedals. 9. During an interview on 02/29/24 at 11:49 A.M., CNA H said staff were directed to use foot pedals and ensure the resident's feet were on the pedals prior to propelling a resident in a wheelchair. He/She said the resident's feet can get hung up, the resident could fly out of the chair and cause injury. During an interview on 02/29/24 at 1:28 P.M., LPN Q said foot pedals should be used when propelling the resident in a wheelchair to prevent injury to a resident. During an interview on 02/29/24 at 4:43 P.M., the DON said he/she expected staff to use foot pedals when propelling a resident in a wheelchair to prevent injury. During an interview on 02/29/24 at 4:45 P.M., the Administrator said staff were directed to use foot pedals and ensure the resident's feet are planted on the foot pedals before before propelling a resident in his/her wheelchair to prevent skins tears or the resident falling out of the chair. 10. Review of the facility's policy titled, Physical Plant and Environmental Policy and Guidelines, undated, showed: -It is of the utmost importance to provide a safe, hospitable, clean and organized facility and grounds to ensure an environment that is conducive to providing the best care, comfort and home-like surroundings for residents; -A well maintained building and environment is also important for creating safe work surrounds across all departmental staffing and their ability to effectively, and efficiently provide care and great living environment to all residents and all necessary resources to do so; -The building and grounds must be maintained in the best presentable state and must be done through routine maintenance and upkeep, housekeeping, and ensuring compliance with current federal, state, local and NFPA codes; -Maintenance/Approved contractors are responsible for preventative maintenance schedules fo [NAME] mechanicals, which incuded boilers and water heaters, and to ensure proper water temperatures of 100 to 110 are maintained in resident areas; -The facility Administrator must ensure that the overall scope and effective procedures are followed by each departments supervisors and staff or request of approved contractors for creating and maintaining a safe and comfortable environment for the residents, visitors and staff. Review of the facility's Water Management Policies and Procedures, updated 02/09/23, showed staff are to maintain the water heaters to ensure the temperatures within the tanks were above 113 degrees Fahrenheit (dF). 11. Observations on 2/26/24 during the Life Safety Code tour, showed the temperature of hot water in the sinks of resident rooms on Hall two in excess of 120 dF, when tested with a calibrated metal stem-type thermometer for a minimum of two minutes, as follows: -Resident occupied room [ROOM NUMBER] measured 124.3 dF; -Resident occupied room [ROOM NUMBER] measured 123.4 dF; -Resident occupied room [ROOM NUMBER] measured 123.2 dF; -Unoccupied, unlocked and unattended resident room [ROOM NUMBER] measured 130.5 dF; -Resident occupied room [ROOM NUMBER] measured 123.8 dF; -Resident occupied room [ROOM NUMBER] measured 123.5 dF. Review of the facility's Water Temperaure Log, dated 10/03/23 through 02/23/24, showed staff documented water temperature results of less than 120 dF weekly. Review showed the range of water tempeatures measured from 101 to 118. During an interview on 02/26/24 at 2:35 P.M., the maintenance director said he/she gets a thermometer from the kitchen and checks the water temperatures in four areas on each hall weekly. The maintenance director said he/she had not noticed any issues with the water being too hot and the temperatures usually measured between 108 dF and 110 dF. The maintenance director said the highest temperature allowed for resident accessible water fixtures is 115 dF. The maintenance director said he/she did not know if the theremometer from the kitchen had been calibrated and he/she did not know how to check the accuracy of the thermometers he/she used to check the water temperatures. The maintenance director said he/she replaced a pump in one of the water heaters two days ago and when he/she did that, he/she turned up the temperature on the water heater to reheat the water and he/she forgot to turn the temperature on the water heater back down. The maintenance director said he/she did not monitor the hot water temperature in the resident accessible water fixtures after he/she replaced the pump and turned the temperature of the water heater up to reheat the water. Observation on 02/26/24 at 2:45 P.M., showed the temperature gauge of the water heater, identified the maintenance director as the water heater he/she replaced the pump in, showed the water heater set at 132 dF and the internal tank temperature gauge showed the temperature of the water inside the tank measured 128 dF. During an interview on 02/26/24 at 2:57 P.M., the administrator said he/she is responsible for the maintenance of the facility water systems, but he/she delegates that task to the maintenance director. The administrator said the maintenance director is responsible to check the water temperatures weekly to ensure they are safe and not above 120 dF in resident accessible areas. The administrator said he/the would expect the maintenance director to monitor the water temperature of resident accessible water fixtures regularly if he/she makes repairs to water heater. The administrator said he/she knew the maintenance director had made a repair to the water heater, but he/she did not know that the maintenance director turned up the temperature on the water heater and did not turn it back it down.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to remove soiled gloves and/or properly wash hands and provide an environment to prevent the spread of bacteria and other infection causing contaminants during the provision of wound care for one resident (Residents #31). Staff failed to remove soiled gloves and/or properly wash hands during incontinence care for two resident's (Resident #7 and #8). The facility census was 45. 1. Review of the facility's policy titled, Aseptic Wound and Skin Treatment Procedure, revised 01/2018, showed staff were directed to -Establish clean and dirty fields. Remember the dirty field should be the farthest away from your clean field. (Place the plastic bag at the end or foot of the bed to receive soiled dressings). -Wash your hands; -Put on clean gloves; -Clean the wound as ordered. Clean from center outward, never going back over area, which has been cleaned. (If two (2) wounds, treat each wound as separate wounds). -Place soiled sponges used for cleaning wound in the plastic bag; -Remove gloves and place in plastic bag; -Wash your hands. 2. Review of the resident #31's Quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 12/11/23, showed the staff assessed the resident as follows: -Severe cognitive impairment; -Risk for pressure ulcers; -Diagnosis of pressure ulcer (Injury to skin and underlying tissue resulting from prolonged pressure on the skin.) to the right heel, peripheral vascular disease (A circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), dementia (the loss of the ability of thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). Observation on 02/26/24 at 9:55 A.M., showed Licensed Practical Nurse (LPN) A entered the resident's room to perform wound care. LPN A did not perform hand hygiene before he/she applied gloves. LPN A cleaned the resident's open knee wound with a gauze pad and then discarded the guaze pad on the resident's bed sheet. LPN A continued to wear the same gloves, cleaned the resident's hip and discarded the gauze on the resident's bed sheet. During an interview on 02/26/24 at 10:15 A.M. LPN A said he/she chose to clean the wound and discard the gauze the way he/she did because the resident just came from the shower. He/She said he/she would not have done it that way if he/she had not come from the shower because of the risk of spreading of infection. During an interview on 02/29/24 at 11:09 A.M., the Director of Nursing (DON) said staff are directed to perform hand hygiene and glove change when going from a dirty to a clean task. He/She said there was an infection control concern if staff did not perform hand hygiene and glove change between task. He/She said he/she expected staff to change gloves and perform hand hygiene between treatments on different wounds. He/She said staff should place used wound care supplies in the trash and not on the resident's bed. 3. Review of the facility's policy titled, Hand Hygiene, dated 12/07/18, showed all staff will wash hands, as washing hands as promptly and thoroughly as possible after resident contact and after contact with blood, body fluids, secretions, excretions, and equipment or articles contaminated by them is an important component of the infection control and isolation precautions. Review of the facility's policy titled, Perineal Cleansing, dated 12/2017, showed staff were directed to: -Wash peri-[NAME] area thoroughly with each stroke beginning at the base of the genitals and extending up over the buttocks; -Did not provide direction for staff to perform hand hygiene or glove change prior to drying the area; -Remove gloves and wash hands with soap and water and cleansing gel; -Apply new incontinent product, clothes or reposition comfortably; -Wash hands with soap and water or cleansing gel. Review of the facility's policy titled, Removing Gloves, dated 12/07/18, showed disposable gloves act as a barrier between the resident and another. Review showed to protect employee from pathogens in the resident's blood, body fluids, and body substances. Review showed protection for the resident from microorganisms the employee may have on their hands. Discard the gloves in the appropriate container and wash your hands 4. Review of Resident #7's Annual MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Required dependence on staff for toileting hygiene; Observation on 02/25/24 at 12:02 P.M., showed Certified Nurse Aide (CNA) O and CNA H entered the resident's room to provide perineal care. CNA O provided perineal care to the genital area, with the same soiled gloves, CNA O tucked the soiled brief under the resident, then repositioned the resident. CNA H removed the soiled brief, provided perineal care to the buttocks area, removed his/her gloves and applied clean gloves with washing his/her hands and put the clean brief partially under the resident. CNA H moved the trash off the bed, then repositioned the resident with the same soiled gloves. CNA O finished pulling the clean brief under the resident with the same soiled gloved. Both CNA's pulled up the clean brief with the same soiled gloves. Observations showed the CNA's removed their gloves, touched the resident, the resident's clothing and applied gloves and dressed the resident. Observation showed the CNA's placed the mechanical lift sling under the resident and before they repositioned the resident. During an interview 02/25/24 at 12:02 P.M., CNA H said they normally would use hand sanitizer between glove changes, but he/she said they did not have hand sanitizer available. During an interview on 02/28/24 at 9:40 A.M. CNA O said staff were educated to perform hand hygiene when entering and exiting a resident's room, between glove change, when moving to different areas of the body, or moving from a dirty to a clean area. He/She said he/she should have performed hand hygiene between glove changes and realized he/she missed hand hygiene opportunities when repositioning the resident and moving on to other task. He/She did not have any hand sanitizer on hand, so he/she didn't use it. He/She said he/she could have used the sink to perform hand hygiene, but had other things on his/her mind and did not remember. During an interview on 02/29/24 at 11:49 A.M., CNA H said staff were educated to use hand hygiene after contact with a resident, between glove changes, and when entering and exiting the room. He/She said the purpose of hand hygiene and glove change when providing care was to prevent the spread of bacteria. He/She said he/she received an in-service approximately every meeting on paycheck days. He/She said he/she did not have hand sanitizer, so he/she did not use hand hygiene between glove changes or before moving on to another task. He/She did not think about using soap and water. He/She said he/she was nervous when being watched while providing care. 5. Review of Resident #8's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment; -Required substantial/maximal assistance from staff with toileting hygiene. Observation on 02/26/24 at 8:21 A.M., showed CNA P entered the resident's room to provide perineal care. Observation showed the CNA provided perineal care, with the same soiled gloves, the CNA fastened the clean brief, repositioned the resident, touch the resident's pillow and blanket. During an interview on 02/27/24 at 2:28 P.M., CNA P said staff were directed to wash hands when entering and exiting a resident's room, before and after providing care, any time during glove changes and when gloves are visibly soiled. He/She said he/she did realize he/she missed a hand hygiene and glove change opportunity when going from a dirty to a clean task. He/She said he/she was nervous and knew it would be an infection control issue. He/She said he/she had an in-service on performing hand hygiene and glove change a few months ago. 6. During an interview on 02/29/24 at 11:09 A.M., the DON said staff received an in-service on glove change and hand hygiene within the last six months. He/She said staff were directed to wash hands when entering a resident's room, when moving from a dirty to clean area and before exiting the resident's room. He/She said there was an infection control concern if staff did not perform hand hygiene and glove change. During an interview on 03/07/24 at 9:41 A.M., the administrator said staff were directed to use hand hygiene when going from a dirty to clean task, upon entering and exiting the room and between wounds. He/She said if the staff did not follow protocol, there was an infection control concern. He/She said the last in-service was approximately within the past six months.

Based on interview and record review, facility staff failed to provide the services of a Registered Nurse (RN), for at least eight consecutive hours per day, seven days a week. The facility census was 45. 1. Review of the facility's policies showed the facility did not provide a policy for RN coverage. 2. Review of the facility's RN staff schedule, dated July 2023, showed the facility did not have an RN in the building the following dates: -Tuesday 07/01/23; -Thursday 07/13/23; -Thursday 07/20/23; -Monday 07/24/23; -Thursday 07/27/23; -Saturday 07/28/23. 3. Review of the facility's RN staff schedule, dated August 2023, showed the facility did not have an RN in the building the following dates: -Tuesday 08/01/23; -Thursday 08/03/23; -Saturday 08/05/23; -Tuesday 08/08/23; -Saturday 08/12/23; -Tuesday 08/15/23; -Thursday 08/17/23; -Saturday 08/19/23; -Tuesday 08/22/23; -Thursday 08/24/23; -Saturday 08/26/23; -Tuesday 08/29/23. 4. Review of the facility's RN staff schedule, dated September 2023, showed the facility did not have an RN in the building the following dates: -Saturday 09/02/23; -Tuesday 09/05/23; -Thursday 09/07/23; -Sunday 09/10/23; -Thursday 09/14/23; -Monday 09/18/23; -Tuesday 09/23/23; -Tuesday 09/26/23; -Thursday 09/28/23; -Saturday 09/30/23. 5. Review of the facility's RN staff schedule, dated October 2023, showed the facility did not have an RN in the building the following dates: -Sunday 10/01/23; -Monday 10/02/23; -Tuesday 10/03/23; -Thursday 10/05/23; -Saturday 10/07/23; -Sunday 10/08/23; -Monday 10/09/23; -Tuesday 10/10/23; -Saturday 10/14/23; -Tuesday 10/17/23; -Saturday 10/21/23; -Sunday 10/22/23; -Monday 10/23/23; -Tuesday 10/24/23; -Monday 10/30/23; -Tuesday 10/31/23. 6. Review of the facility's RN staff schedule, dated November 2023, showed the facility did not have an RN in the building the following dates: -Sunday 11/05/23; -Thursday 11/08/23; -Saturday 11/11/23; -Monday 11/13/23; -Thursday 11/16/23; -Sunday 11/19/23; -Monday 11/20/23; -Tuesday 11/21/23; -Thursday 11/23/23; -Monday 11/27/23; -Thursday 11/30/23; 7. Review of the facility's RN staff schedule, dated December 2023, showed the facility did not have an RN in the building the following dates: -Saturday 12/02/23; -Monday 12/04/23; -Tuesday 12/05/23; -Thursday 12/07/23; -Saturday 12/09/23; -Saturday 12/16/23; -Sunday 12/17/23; -Saturday 12/23/23; -Saturday 12/30/23; -Sunday 12/31/23. 8. Review of the facility's RN staff schedule, dated January 2024, showed the facility did not have an RN in the building the following dates: -Monday 01/01/24; -Saturday 01/13/24; -Monday 01/15/24; -Sunday 01/21/24; -Saturday 01/27/24; -Monday 01/29/24; -Tuesday 01/20/24. 9. Review of the facility's RN staff schedule, dated February 2023 showed the facility did not have an RN in the building the following dates: -Thursday 02/01/24; -Saturday 02/03/24; -Sunday 02/04/24; -Monday 02/05/24; -Tuesday 02/06/24; -Thursday 02/08/24; -Saturday 02/10/24; - Sunday 02/11/24; -Monday 02/12/24; -Tuesday 02/13/24; -Saturday 02/17/24; -Sunday 02/18/24; -Monday 02/19/24; -Tuesday 02/20/24. 10. During an interview on 02/28/24 at 11:13 A.M., the Director of Nursing (DON) said there might be a day without RN coverage, I wont lie but I try hard to make sure there is not a day without RN coverage, I work 7 days a week sometimes. The DON said they have ads out but have not been able to hire RN's, she said it's just her and two other RN's that each work only one or two days a week because they have other jobs. The DON said, I just don't have the RN staff for the coverage. During an interview on 02/29/24 at 5:51 P.M., the administrator said she was not aware the facility was not meeting the RN coverage expectation.

Based on interview and record review, the facility staff failed to ensure three Nurse Aide's ((NA) NA L, NA M and NA N) completed the nurse aide training program within four months of his/her employment in the facility. The census was 45. 1. Review of the facility's policies showed the facility did not provide a policy for NA qualifications. 2. Review of Certified Nurse Aide (CNA) training report showed NA L's hire date as 11/24/23. Review showed the NA's file did not contain documentation the NA completed a nurse aide training program. During an interview on 2/29/24 at 11:56 A.M., the Director on Nursing (DON) said NA L has not started the nurse aide training program yet. 3. Review of the CNA training report showed NA M's hire date as 1/16/23. Review showed the NA's file did not contain documentation the NA completed a nurse aide training program. During an interview on 2/29/24 at 11:56 A.M., the DON said he/she is not sure if NA M has started the nurse aide program yet. 4. Review of the CNA training report showed NA N's hire date as 6/27/23Review showed the NA's file did not contain documentation the NA completed a nurse aide training program. During an interview on 2/29/24 at 11:56 A.M., the DON said NA N has done the program but has not passed the test to become a certified nurse aide. 5. During an interview on 02/28/24 10:43 A.M., the DON said there has been a lag in gettting the NA Certification completed, he/she said he/she is aware this needed to be completed within the four months, but with COVID changes and waivers offered, I just haven't kept up on the changes. During an interview on 02/29/24 at 4:45 P.M., the Administrator said NA's were required to be certified after four months. He/She said there were issues attempting to get the NA's certified, including issues with payment and class times, which is why they were not certified in the time frame. He/She said they are working on resolving the issue.

Based on interview and record review, the facility staff failed to designate a person to serve as the Director of Food and Nutrition Services with the appropriate qualifications, when the facility did not employ a qualified dietitian or other clinically qualified nutrition professional full-time. The census was 45. 1. Review of facility's In-service Training policy, dated 06/06, showed the Food Service Manager or Registered Dietician plans and/or conducts regularly scheduled in-service training and education to develop the skills and knowledge required for satisfactory job performance. The policy did not contain guidance related to the qualifications of the dietary manager. Review of the dietary manager's (DM) personnel record showed he/she hired to the DM position on 09/01/22. Review showed the record did not contain documentation of prior dietary experience or related education. Documentation showed a Certified Dietary Manager course enrollment on 10/27/22 but did not include documentation of progress or completion. During an interview on 02/26/24 at 1:29 P.M., the administrator said the dietary manager was on leave since 01/22/24. The administrator said the DM was not certified and he/she did not think the facility had a Certified Dietary Manager (CDM) on staff. The administrator said the dietary manager may have received kitchen related training, but he/she did not have any documentation of training. The administrator said he/she was responsible for ensuring the dietary manager was qualified. During an interview on 02/27/24 at 9:48 A.M., the activities director said he/she used to be the kitchen manager and he/she helped the kitchen staff by doing dietary orders and answering questions in the DM's absence. The activity director said he/she was not a CDM. The activity director said he/she had food safety training about three years ago but he/she did not know the level of training. The activity director said the DM was responsible for the kitchen and he/she did not know who was responsible in the DM's absence. During an interview on 02/27/24 at 2:43 P.M., the business office manager/acting administrator said the activities director used to be the facility's DM and he/she was unaware of other qualified staff.

Based on observation, interview, and record review, facility staff failed to ensure dietary staff had the appropriate competencies and skills to safely and effectively carry out the functions of food and nutrition services. Facility staff failed to provide effective training to dietary staff related to handwashing. Facility staff also failed to provide effective training to dietary staff related to kitchen ware washing/sanitation. The facility census was 45. 1. Review of facility's In-service Training policy, dated 6/06, showed the Food Service Manager or Registered Dietician plans and/or conducts regularly scheduled in-service training and education to develop the skills and knowledge required for satisfactory job performance. Review of the facility's Hand Washing policy, revised 10/09, showed hand washing is to be done using soap and water for at least 20 seconds: -When hands are visibly soiled; -After contact with soiled or contaminated articles; -Before and after eating, drinking or handlind food; -After handling soiled equipment or utensils. Review showed the hand washing policy also directed food service employees to wash hands in a hand washing sink. They may not wash hands in a sink used for food preparation, ware washing or in a service sink used for disposing mop water or liquid waste. Review of Dishwasher W's training record showed a hire date of 11/08/23, as maintenance staff. Review showed the record did not contain documentation of training related to handwashing or operation and testing of the dish washing machine. Observation on 02/26/24 at 9:19 A.M., showed Dishwasher W precleaned soiled dishes with his/her bare hands, pulled a clean rack of wares out of the dish machine and did not wash his/her hands. Observation showed Dishwasher W completed the same sequence two additional times and did not wash his/her hands. Observation on 02/26/24 at 9:33 A.M., showed Dishwasher W precleaned soiled dishes, removed a clean rack of bowls from the dish machine and lifted each bowl to check for cleanliness. Dishwasher W did not wash his/her hands before touching the clean bowls. Observation on 02/26/24 at 9:38 A.M., showed Dishwasher W entered the kitchen and distributed clean wash cloths and oven mitts in the kitchen. Observation showed one clean wash cloth was set on a shelf directly above soiled dishes on the dirty side of the dish machine. Dishwasher W picked up soiled food processor parts, placed the parts on the dirty side of the dish machine, rinsed his/her hands in the three-part sink for five seconds and dried his/her hands with a cloth which set above dirty dishes. Dishwasher W removed clean plates from racks and placed the clean plates on a cart and did not wash his/her hands. Dishwasher W precleaned additional dirty dishes, advanced another clean rack from machine then lifted and inspected each bowl. Dishwasher W did not wash his/her hands before handling the clean bowls. During an interview on 02/26/24 at 9:48 A.M., Dishwasher W said he/she was hired as maintenance staff but was filling in as a dishwasher. Dishwasher W said he started working at the facility in November of 2023 and had worked in the kitchen for three or four days. Dishwasher W said he/she washed dishes and fixed resident drinks. Dishwasher W said he/she used the three part sink to rinse his/her hands for a few seconds and then dried his/her hands with a cloth. Dishwasher W said proper handwashing is when you use soap for about a minute. The Dishwasher said rinsing was not proper handwashing. Dishwasher W said he/she did not wash his/her hands because they did not appear dirty. Dishwasher W said the acting administrator trained him/her the first day but never talked about handwashing. During an interview on 02/26/24 at 1:29 P.M., the administrator said the dietary manager (DM) was responsible for training kitchen staff. The administrator said Dishwasher W just started picking up shifts in the kitchen and he/she did not know if Dishwasher W was trained on handwashing. 2. Review of the dish machine operational requirements label on the front of the dish machine showed the wash and rinse temperature: 120 degrees Fahrenheit (F) minimum. Observation on 02/26/24 at 9:36 A.M., showed the dish machine temperature at 106 degrees F during the wash cycle. Observation on 02/26/24 at 9:57 A.M., showed the dish machine reached a maximum temperature of 106 degrees F during a complete wash and rinse cycle. During an interview on 02/26/24 at 1:12 P.M., Dishwasher W said he/she had not told anyone about the dish machine not reaching the correct temperature because he/she did not have time yet. Dishwasher W said he/she never received training on proper operation and testing of the dish machine. Dishwasher W said the acting administrator trained him/her the first day but never talked about checking the dish machine chemical concentrations or operating temperatures. During an interview on 02/26/24 at 1:29 P.M., the administrator said the dietary manager (DM) was responsible for training kitchen staff. The administrator said Dishwasher W just started picking up shifts in the kitchen and he/she did not know if Dishwasher W was trained on the operation and testing of the dish machine. During an interview on 02/27/24 at 12:02 P.M., the acting administrator said Dishwasher W was filling in on a temporary basis and did not receive any training related to handwashing or the dish machine. The acting administrator said he/she decided to have Dishwasher W wash dishes because the facility was short staffed and needed somebody. The acting administrator said he/she gave Dishwasher W a crash course on drinks and diets but did not cover handwashing or dishwashing.

Based on observation, interview and record review, the facility staff failed to store food in a manner to prevent potential contamination and outdated use. The facility staff failed to maintain the kitchen floors and appliances in a clean manner to prevent the growth and harborage of bacteria. Facility staff failed to properly sanitize kitchen wares, food preparation surfaces and resident dining tables to prevent potential cross contamination. The facility staff failed to maintain the dining room ice machine in a clean and sanitary manner to prevent cross contamination and inhibit the growth water-borne pathogens. The facility census was 45. 1. Review of the facility policy Storage, Revised 6/06, showed kitchen staff are directed to: -Date items upon receipt; -Store left overs in covered, labeled and dated containers under refrigeration or frozen; -Clean up all debris dropped on the floor immediately; -Set aside dented cans and cans without labels in a designated area. These are not to be used. Review of the facility's Refrigerator and Freezer Storage policy, Revised 10/09, showed: -A designated dietary employee is to check, pull and throw away any potentially hazardous foods that have been in the refrigerator for seven days and staff are directed to; -Mark containers with the name of the item and the date the container was opened or the date of preparation; -Label refrigerated, potentially hazardous food prepared and held for more than 24 with the day/date by which the food shall be consumed or discarded. Observation on 02/25/24 at 9:50 A.M., showed the shelf by the entrance door contained: -An opened and undated bag of corn flakes; -A undated plastic container of crisped rice cereal; -A undated plastic container of corn flakes. Observation on 02/25/24 at 9:55 A.M., showed the dry goods pantry contained: -Three undated 16 ounce (oz) bags of whipped topping mix; -Three undated 16 oz bags of alfredo sauce mix; -An opened and undated bag of chocolate sandwich cookies; -An opened and undated bag of macaroni; -A dented 6 pound (lb) 9 oz can of sweet potatoes; -A dented 50 oz can of chicken noodle soup; -A dented 6 lb 6 oz can of tomatoes; -An undated box of individual saltine crackers; -An undated box with six packages of graham crackers; -Six undated 2.25 lb boxes of iodized salt; -Three undated 18 oz bags of lemonade soft drink mix; -Nine undated 18 oz bags of strawberry lemonade soft drink mix. Observation on 02/25/24 at 10:10 A.M., showed the freezer contained: -Two undated packages of rolls/hot dog buns; -An undated bag of meatballs; -A box of meat sat on top of a container of ice cream. Observation on 02/25/24 at 10:54 A.M., showed the refrigerator contained: -An undated plate of salad; -Two opened, unsealed and undated bags of cheddar cheese; -A bag of lettuce touched the side of the egg container; -An egg container sat on the second shelf with deli meats on the shelf below; -Several undated packages of deli meats. Observation on 02/26/24 8:51 A.M., showed the shelf by the entrance door contained; -An undated container of crisped rice cereal; -A bin of corn flakes dated 9-30; -An opened and undated bag of corn flakes; -An opened and undated bag of chex cereal. Observation on 02/26/24 at 8:56 A.M., showed the dry goods pantry contained: -Five dented cans of cream of chicken soup; -One dented can of diced tomatoes -One dented can of chicken noodle soup; -An opened and undated bag of crispy onions; -An opened, undated and unlabeled plastic zipper bag of white flakes; Observation on 02/26/24 at 9:03 A.M., showed the reach in freezer contained two opened and undated packs of hot dog buns and a bag of meatballs. During an interview on 02/25/24 at 11:01 A.M., [NAME] K said the kitchen supervisor is currently on medical leave and the Activity Director (AD) was filling in during the interim. He/She said the AD was responsible for dating items as soon as they are received and is responsible to remove dented cans and expired items from the inventory. He/She said if he/she found items without a date received, he/she would check the inventory sheet to see if it was ok to use, or needed to be discarded. He/She said the dented cans should be removed from inventory and sent back to the distributor. He/She said the staff who opened a food item, were responsible to seal and date the item. He/She said the eggs should not be stored above the deli meat and other items. During an interview on 02/26/24 at 10:10 A.M., [NAME] X said whoever worked on truck day put delivered food away. [NAME] X said dented cans should not be on shelves and he/she was not aware of any dented cans. [NAME] X said opened food items should be labeled and dated. 2. Review of the facility's policies showed facility staff did not provide policies in regards to kitchen cleanliness. Observation on 02/25/24 at 10:17 A.M., showed: -The front of the stove was covered with food splatters; -The floor by the stove and standing oven had a black and brown substance; -The front of the standing oven was covered with debris/food splatters; -The wall by the standing oven had large spatters of food; -The floor was dirty with debris and trash; -The trashcan by the back door did not contain a lid. During an interview on 02/25/24 at 11:01 A.M., [NAME] K said the floors and kitchen equipment should be cleaned daily. He/She did not know the last time the kitchen equipment was cleaned, but the floors were cleaned a couple of days ago. He/She said he/she did not know who was responsible to clean the kitchen walls. He/She said there was not enough staff to complete all the responsibilities in the kitchen. Observations of the kitchen on 02/26/24 from 8:50 A.M. through 10:00 A.M., showed: -The wall laminate near the hand washing sink was worn and exposed the wood substrate in multiple locations; -An accumulation of food particles on the front of the stove and oven; -An accumulation of dust and crumbs on a tray which set near the kitchen window and contained sixteen containers of food seasonings; -An accumulation of dust and grease on the wall and gas line next to the oven; -The wall next to the oven contained a broken light switch cover which exposed the light switch; -The wall next to the oven contained a wire shelf, which contained food colorings and extracts, which had an accumulation of dust and grease; -The area under the oven and stove littered with dirt and food debris; -The wall panels behind the dish washing machine contained multiple holes; -An accumulation of dust and grease on the ceiling in the dish washing area; -The ceiling in front of the oven contained flaking paint and a 32 inch long separation of plaster board panels. One panel drooped one inch below the other and exposed blown in insulation in the attic space; -The trash dumpster, which was located outside the kitchen exit, was not covered and was overflowing with trash which had spilled onto the surrounding ground. Observation on 02/26/24 at 9:31 A.M., showed the trash can near the rear door was not covered and was not in use. Observation on 02/26/24 at 10:56 A.M., showed the trash can near the rear door was not covered and was not in use. Observation on 02/26/24 at 1:21 P.M., showed the trash can near the rear door was not covered and was not in use. During an interview on 02/26/24 at 10:10 A.M., [NAME] X said all staff were responsible for kitchen cleaning. [NAME] X said the facility had cleaning lists but he/she was not sure where the lists were. During an interview on 02/26/24 at 1:24 P.M., [NAME] X said all kitchen staff were responsible for making sure trash cans were covered when not in use. 3. Review of the facility's policies showed facility staff did not provide policies in regards to kitchen equipment sanitiziation or maintenance. Observation on 02/26/24 at 10:58 A.M., showed a sign on the door between the dishwashing area and resident dining room which read Wash the tables with pots and pan detergent. Review of the pot and pan detergent instructions for use showed: -Scrap and pre-rinse surface food soils; -Sink #1 - wash in a solution of one ounce of detergent to four gallons of hot water; -Sink #2 - rinse with clean water -Sink #3 - sanitize with an approved sanitizer. Observation on 02/26/24 at 11:00 A.M., showed the three part sink did not contain kitchen wares sanitizer. Observation on 02/26/24 at 11:17 A.M., showed [NAME] X wiped a food preparation counter with a damp cloth which was in a sanitizer bucket. Observation showed [NAME] X refilled the sanitizer bucket with pot and pan detergent from the three part sink when he/she finished wiping the counter. Observation on 02/26/24 at 12:02 P.M., showed [NAME] X wiped a food preparation counter with a cloth from a sanitizer bucket which contained diluted pot and pan detergent. During an interview on 02/26/24 at 11:22 A.M., [NAME] X said he/she used pot and pan detergent to clean the prep counter and the resident dining tables. [NAME] X said the surfaces were not sanitized correctly by pot and pan detergent. [NAME] X said the only sanitizer available in the kitchen was connected to the dish washing machine. [NAME] X said he/she told the DM about the broken sanitizer dispenser in the three part sink. 4. Review of the facility's Ware-Washing - Dishmachine policy, dated October 2009, showed the wash temperature for low temperature dishmachines shall not be less than 120 degrees Fahrenheit (F) and the policy directed staff to record the temperatures on th Dischmachine Temperature/Sanitizer Log. Review of the dish machine operational requirements label on the front of the dish machine showed wash and rinse temperature: 120 degrees F minimum. Review of a General Operating Instructions sign, which was posted at eye level on the soiled side of the dish machine, showed the sign read, in part, Report to your supervisor if water temperature is less than 120 degrees or higher than 160 degrees. Observation on 02/26/24 at 9:36 A.M., showed the dish machine temperature at 106 degrees F during the wash cycle. Observation on 02/26/24 at 9:57 A.M., showed the dish machine reached a maximum temperature of 106 degrees F during a complete wash and rinse cycle. During an interview on 02/26/24 at 1:12 P.M., Dishwasher W said he/she never received training on proper operation and testing of the dish machine. Dishwasher W said the acting administrator trained him/her the first day but never talked about checking dish machine chemical concentrations or operating temperatures. Dishwasher W said he/she had not told anyone about the dish machine not reaching the correct temperature because he/she did not have time yet. 5. Review of the facility's Ice Machine Cleaning and Sanitizing Procedures policy, undated, showed the policy directed staff to clean the ice machines and bins with the specified cleaning solution and to change the water filters every six months. Review of the facility's Water Management Policy and Procedures, dated 09/25/12, showed Water systems and devices are to be inspected, cleaned, and maintained to reduce any risks of possible waterborne pathogens. Review showed the policy and procedures directed staff to inspect ice machines monthly and to clean and replace filters per manufacturers guidelines. Observation on 02/27/24 at 10:30 A.M., showed an excess build-up of white, brown and black debris on the exterior of the ice machine in the dining room and the ice machine's drain and water filtration cartridge. Observation showed the water filtration cartridge for the ice machine dated 10/01/18 and the cartridge's product label showed direction to change the cartridge every 12 months. Observation on 02/27/24 at 11:00 A.M., showed the dietary staff used the ice from the ice machine to prepare drinks for service to the residents at the lunch meal. During an interview on 02/27/24 at 11:02 A.M., the maintenance director said he/she was responsible for cleaning the ice machine filter. The maintenance director said he/she cleaned the filter last month by hosing it off and scrubbing the exterior with a green scouring pad. The maintenance director said he/she never changed the ice machine filter because he/she thought an outside vendor took care of the filter change. The maintenance director said he/she did not know which vendor changed the filter or when the filter was last changed. 6. During an interview on 02/26/24 at 1:29 P.M., the administrator said he/she was responsible for the kitchen in the absence of the DM. The administrator said the DM was responsible for kitchen cleanliness and ensuring sure staff have proper tools for jobs. The administrator said he/she was not aware of kitchen staff missing anything. The administrator said sanitizer from the three part sink dispenser should be used to wipe food prep counters and resident tables. The administrator said he/she was not aware kitchen staff used pot and pan detergent to wipe down surfaces because there was not sanitizer available. The administrator said maintenance staff were responsible for the area around the dumpster. The administrator said facility staff had a hard time getting the dumpster emptied by the trash vendor but he/she did not know why. During an interview on 02/27/24 at 9:48 A.M., the activities director (AD) said he/she started helping kitchen staff when the DM left for a temporary absence. The AD said he/she helped with diet orders and answered questions as needed. The AD said the DM was responsible for kitchen staff training, food prep and overall kitchen cleanliness and maintenance. The AD said he/she was not sure who was in charge of the kitchen in the DM's absence. The AD said more could be done to keep the kitchen clean. The AD said the hole in the ceiling had been there a while and he/she told the administrator about the hole. The AD said he/she told the DM and administrator about the broken sanitizer dispenser and missing sanitizer over a month ago. The AD said staff used the pot and pan detergent for wiping surfaces because it is all they had available. During an interview on 02/27/24 at 11:13 A.M., the maintenance director said he/she had been aware of the kitchen ceiling for a few weeks but did not know why he/she had not repaired the ceiling. The maintenance director said kitchen staff had not told him/her about the broken sanitizer dispenser. The maintenance director said he/she checked the dish machine temperatures and the temperatures varied from 100 to 120 degrees F. He/She said staff should not use the machine if the temperature is less than 120 degrees F. The maintenance director said he/she had not taken any action to correct the dish machine temperatures because he/she felt it was a given that staff would know not to use the machine. During an interview on 02/27/24 at 12:00 P.M., the acting administrator said he/she was not familiar with the kitchen ceiling in need of repairs or the dish machine not reaching the correct temperatures.

Based on interview and record review, the facility staff failed to designate one or more individuals with specialized training in Infection Prevention and Control (IPC) as the Infection Preventionist (IP) for the facility's infection prevention and control program. The census was 45. 1. Review of he facility's policies showed staff did not provide a policy in regard to the qualifications of the Infection Preventionist. During an interview on 02/28/24 at 2:15 P.M., the Director of Nursing (DON) said he/she had mistaken a different Center for Medicare and Medicaid Services (CMS) course with the Infection Preventionist (IP) Course, so he/she was not certified as an IP. During an interview on 02/29/24 at 8:41 A.M., the Administrator said he/she was the Certified Infection Preventionist (IP) and the Director of Nursing (DON) and Minimum Data Set (MDS) Coordinator are his/her backup when he/she was on leave. He/She said the DON and MDS Coordinator were not certified IP's, even though they were directed to obtain their certification. He/She said he/she did not know they were not certified as IP's. He/She said he/she was not a nurse and did not have any medical or laboratory experience or degree, but did have a master degree in Health Care Management. He/She said he/she did not know the IP qualifications required certain types of degrees or diplomas to be qualified as an IP.

Based on interview and record review, facility staff failed to ensure three Nurse Aides (NAs) (NA A, NA B, and NA C) completed the nurse aide training program within four months of employment in the facility. The facility census was 48. Review of the facility's Certified Nurse's Aide Policy, undated, showed staff are directed that completion of the Certified Nurses Aide course or be enrolled in a Competency Training Program leading to certification in less than 120 days from the date of employment. 1. Review of NA A's personnel file showed a hire date of 05/01/22. The NA's file did not contain documentation the NA completed a nurse aide training program. During an interview on 12/22/23 at 3:00 P.M., NA A said it had been a struggle with the facility to get into the classes to get certified. He/She said the corporate office sent the check and then somehow it got lost and they have requested a new one apparently, but he/she was still not enrolled. NA A said he/she asked periodically about it, but no one ever knows anything. NA A confirmed he/she was still working as a NA on the floor and provides direct patient care. 2. Review of NA B's personnel file showed a hire date of 06/27/23. The NA's file did not contain documentation the NA completed a nurse aide training program. During an interview on 12/22/23 at 1:45 P.M., NA B said he/she had not started classes yet to become certified, because he/she was told they had to wait for the payment from the corporate office by the administrator and as of yet they still haven't received it. 3. Review of NA C's personnel file showed a hire date of 08/04/23. The NA's file did not contain documentation the NA completed a nurse aide training program. 4. During an interview on 12/15/23 at 1:17 P.M., the administrator said NAs should complete classes and be certified within four months of their hire date, but he/she is having a hard time getting the funds from the corporate office so he/she can get them enrolled in the courses. The administrator said as far as NA A the corporate office sent the funds, but they weren't received or something, so now they are waiting on the corporate office to send the funds again so he/she can get him/her enrolled. NA B and NA C have not been enrolled, because they are still waiting for the funds to be able to enroll them. MO00228703

Based on observation, interview and record review, the facility staff failed to store food in a manner to protect from potential contamination and out-dated use. Facility staff failed to perform hand hygiene as often as necessary using approved techniques to prevent cross-contamination. Facility staff failed to allow sanitized dishes to air dry prior to stacking in storage, to prevent the growth of food-borne pathogens. Facility staff failed to touch resident-use utensils only by the handles to prevent cross-contamination. Facility staff failed to ensure the bulbs for two kitchen light fixtures were covered to prevent the potential for physical contamination by broken glass. The facility census was 46. 1. Review of the facility's Food From Outside Sources/Personal Food Storage policy, dated 04/17, showed Food and beverages brought in from outside sources, that are to be stored in the facility refrigerators and freezers, will be checked by a dietary staff member. Food and beverages will be labeled with the resident's name, food item and date. These foods and/or beverages will be placed on a designated tray/shelf. Facility storage procedures apply. Review of the facility's Refrigerator and Freezer Storage policy, dated 10/14, showed the policy directed staff to cover, label and date any item to be placed in the refrigerators and freezers. Review also showed the policy directed staff to: -Place any item to be stored in correct sized container and cover all containers; -Mark container with name of item. [NAME] the date that the original container is opened or date of preparation; -Designated dietary employee is to check, pull and throw away any potentially hazardous foods that have been in the refrigerator for seven days; -Use or discard food according to the manufacturer's use-by-date. Review of the facility's Storage policy, dated 10/20, showed: -Food shall be stored at the proper temperature and for appropriate lengths of time to protect quality of food and food cost; -Store leftovers in covered, labeled and dated containers under refrigeration or frozen; -When using only part of a product, the remaining product should be in the original package or air tight container and labeled and dated; -Store chemical and poisonous materials in a separate area that can be locked. Observation on 11/15/22 during the initial tour which began at 9:29 A.M., showed: -an opened, undated and unlabeled 22 ounce (oz.) box of egg rolls and an opened, undated and unlabeled 19.2 oz. box of chicken taquitos in the freezer of the stacked freezer/refrigerator unit; -an undated bag of chocolate chips opened to the air stored on top of three rolls of raw ground turkey on the bottom shelf in the reach-in freezer. Observation showed an opened and undated bag of chocolate chip cookie dough and an unidentifiable and unlabeled package of meat stored on top of a box of cinnamon rolls on the top shelf in the freezer; -the reach-in refrigerator contained: *an undated package of Canadian bacon opened to the air; *a large undated bag of shredded cheese opened to the air *an undated plastic food storage container of pears; *an undated plastic food storage container of sliced bananas in an unidentified red sauce; *an undated box of sliced bacon opened to the air; *an opened and undated roll of raw sausage; *an undated plastic food storage container of fruit salad; *an opened and undated bag of rolls; *an opened and undated bag of breadsticks. Observation on 11/16/22 at 9:50 A.M., showed the freezer of the stacked freezer/refrigerator unit contained an undated and unlabeled 22 oz. box of egg rolls opened to the air, an opened, undated and unlabeled 19.2 oz. box of chicken taquitos, and a small undated and unlabeled prepackaged container of macaroni and cheese. Further observation showed the food items stored with a case of chocolate ice cream cups without separation. During an interview on 11/16/22 at 9:50 A.M., Dietary Aide (DA) L said the egg rolls, taquitos, and macaroni and cheese belonged to residents and had been in the freezer for about a week. The DA said he/she did not know when the egg rolls and taquitos were opened, but they all should have the resident's name and opened date on the box if opened. The DA said the ice cream cups belonged to the facility for use by all residents. Observation on 11/16/22 at 10:25 A.M., showed the reach-in freezer in the cook's station contained opened and undated plastic bags of bread sticks, cookie dough, egg rolls and hashbrown patties removed from their original packages. Observation showed an opened and undated five pound bag of dry nonfat milk on the ledge of the cook's station. Observation 11/16/22 at 10:42 A.M., showed a large plastic container of fruit whirls cereal labeled Cornflakes 9/22 and a large undated plastic container of cornflakes covered with aluminum foil that had a hole in the top which exposed the contents to the air on the shelf in the service station. Observation during LSC tour on 11/17/22 at 10:00 A.M. and on 11/18/22 at 9:50 A.M., showed multiple cases of food items stored with cleaning chemicals and a variety of office, medical and activity supplies in the unlocked storage room at the end of the therapy hall. During an interview on 11/18/22 at 12:00 P.M., the Dietary Manger (DM) said opened food items should be stored in closed containers labeled with an opened date, discard date and the name of the item. The DM said food brought in for residents should be stored separately from main food supply and staff should seal, label and date those items just like all other foods. The DM said he/she did not know about the resident foods stored in the freezer with the ice cream cups. The DM also said food should be stored securely to protect it from being mishandled and should not be stored with chemicals or other items. The DM said he/she did not know about the food items stored in the unsecured storage closet on the therapy hall. The DM said the cook usually looks to see if food items are stored correctly, but he/she also looks multiple times a week. During an interview on 11/18/22 12:19 P.M., the administrator said staff should seal opened food items and label them with the date they are opened, what it is, and how long to keep it. The administrator said resident foods stored in the kitchen should be stored away from the main food supply and labeled with the resident's name, date received, and the opened date if opened. The administrator said food should not be stored accessible to anyone and should not be stored with other things. The administrator said the storage room at the end of the therapy hall had been designated for food overflow storage, but during the pandemic they had to use it for other things and he/she just gave it back to dietary. The administrator said he/she did not know other things were still being stored in room and the door should be locked. 2. Review of the facility's Hand Washing policy, dated 10/09/22, showed the policy directed staff to wash their hands: -When hands are visibly soiled; -After contact with soiled or contaminated articles, such as waste removal and articles that are contaminated with bodily fluids; -Before and after eating, drinking or handling food; -Before putting on gloves; -After removal of gloves; -After handling soiled equipment or utensils; -During food preparation, as often as necessary to remove soil and contamination and to prevent cross-contamination when changing tasks. Review also showed the policy directed staff to turn the water off with a paper towel after they washed their hands. Review of the facility's Glove Usage Policy, dated 10/17, showed: -Employees will wash their hands thoroughly before and after wearing or changing gloves; -Disposable gloves should be changed between task and not worn continuously; -Gloves should be changed if ripped or soiled. Observation on 11/16/22 at 9:20 A.M., showed, on multiple occasions, the DM touched his/her facemask and, without performing hand hygiene, stocked food items in the dry goods pantry. Observation on 11/16/22 at 9:38 A.M., showed DA L left the kitchen, to take a barrel of trash to the dumpster, returned to the kitchen and washed his/her hands at handwashing sink. Observation showed the DA turned the faucet off with his/her wet bare hands, touched his/her facemask and, without performing hand hygiene, continued to conduct kitchen tasks. Observation on 11/16/22 at 9:42 A.M., showed the DM washed his/her hands at the handwashing sink. Observation showed DM turned the faucet off with his/her wet bare hands and then returned to putting away food items in the dry goods pantry. Observation on 11/16/22 at 10:45 A.M., showed DA L washed soiled dishes at the mechanical dishwashing station with gloved hands. Observation showed, on multiple occasions, the DA removed his/her soiled gloves and, without performing hand hygiene, donned another pair of gloves to put away dishes from the clean side of the station. During an interview on 11/18/22 at 11:55 A.M., the DM said staff should wash their hands between task, before and after glove use, after they touch their facemask or body, and between handling dirty and clean dishes. The DM said when staff wash their hands, they should turn off faucet with a paper towel and not use their bare hands. The DM said he/she just got busy and did not realize he/she did not wash his/her hands when and as needed. During an interview on 11/18/22 at 12:13 P.M., the administrator said staff should wash their hands between task, between going from the dirty to the clean side of the dishwashing station, after they touch their facemask or other parts of body and when they remove gloves. The administrator said when staff wash their hands, they turn off the faucet with a towel and not their bare hands. 3. Review of the facility's Dish and Utensil Handling policy, dated 10/16, showed the policy directed that all equipment, tableware and utensils shall be air-dried prior to storing. Observation on 11/16/22 at 10:45 A.M., showed DA L removed wet insulated dome plate covers from the clean side of the mechanical dishwashing station, stacked them together and placed them upside down on the countertop by steamtable During an interview on 11/16/22 at 10:53 A.M., the DA confirmed the plate covers were still wet and said dishes should be dry before they are put away, but he/she thought it would be okay since they were only a little wet. Observation on 11/16/22 at 12:00 P.M., showed [NAME] K used the visibly wet stacked plate covers to cover plates of food for service to residents at the noon meal. During an interview on 11/18/22 at 12:06 P.M., the DM said dishes should be air dried after they are washed and before they are put away or used. The DM said staff should not use wet stacked dishes if they see they are wet. During an interview on 11/18/22 at 12:27 P.M., the administrator said staff should allow dishes to air dry before they are put away and staff should not use items that are stacked visibly wet. 4. Review of the facility's Dish and Utensil Handling policy, dated 10/16, showed the policy directed that cleaned and sanitized equipment and utensils shall be handled in a way that protects them from contamination and spoons, knives and forks shall be touched only by their handles. Observation 11/16/22 during the lunch meal service which began at 12:00 P.M. showed the DM touched the mouth end of the forks and spoons with his/her bare hands as he/she wrapped the utensils in napkins and placed them on resident meal trays. During an interview on 11/18/22 at 12:06 P.M., the DM said silverware should be pursed to residents without touching the mouth end and he/she got in a hurry and just did not think about what he/she was doing. During an interview on 11/18/22 at 12:27 P.M., the administrator said when staff prepare silverware for meal trays, they should not touch any part but the handle and he/she thought staff knew that. 5. Review of the facility's Maintenance and Environmental policy, undated, showed: -The facility Administrator must ensure that the overall scope and effective procedures are followed by each department's supervisors and staff or request of approved contractors for creating and maintaining a safe and comfortable environment for residents, visitors and staff; -maintenance/approved contractors are responsible for routine care and repairs to interior finishings and general electrical which included proper lighting. Observation on 11/16/22 at 10:30 A.M., showed the light fixture above the reach-in freezer in the cook's station and the light fixture between the steamtable and dry goods pantry did not contain covers which exposed the fixtures' glass florescent light bulbs. During an interview on 11/16/22 at 10:37 A.M., the DM said the light fixtures had not had covers on them during his/her employment in the last two months and he/she did not know the light fixtures needed covers. The DM said he/she had not discussed the missing light fixture covers with maintenance. During an interview on 11/18/22 at 12:34 P.M., the administrator said kitchen light fixtures should have covers and staff should notify maintenance if one is missing. The administrator said he/she knew the fixture by the steamtable did not have a cover because maintenance had to replace it because of an electrical issue, but he/she did not know about the other missing cover.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility staff failed to develop and implement policies and procedures for the inspection, testing, and maintenance of the facility water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (LD). The facility census was 46. 1. Review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification (S&C) letter 17-30, dated 06/02/17 and revised on 06/09/17; showed: -The bacterium Legionella can cause a serious type of pneumonia called LD in persons at risk. Those at risk include persons who are at least [AGE] years old, smokers, or those with underlying medical conditions such as chronic lung disease or immunosuppression. Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including hospitals and long-term care facilities. Transmission can occur via aerosols from devices such as shower heads, cooking towers, hot tubs, and decorative fountains; -Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water; -CMS expects Medicare certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. An industry standard calling for the development and implementation of water management programs in large or complex building water systems to reduce the risk of legionellosis was published in 2015 by American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE). In 2016, the CDC and its partners developed a toolkit to facilitate implementation of this ASHRAE Standard(https://www.cdc.gov/legionella/maintenance/wmp-toolkit.html). Environmental, clinical, and epidemiological considerations for healthcare facilities are described in this toolkit; -Surveyors will review policies, procedures, and reports documenting water management implementation results to verify that facilities: -Conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system; -Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens; -Specify testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained. Review of the facility's emergency preparedness plan, showed the records contained a Legionella Policy and Procedure, dated 03/23/22, which included information that described Legionella and measures that may be initiated to minimize and control the risk should there be an identified concern of an active Legionella infection. Review showed the records contained an Environmental Assessment of Water Systems, dated 03/23/22. Review showed the records did not contain documentation of a complete water management program to monitor the facility's water systems for the growth of waterborne pathogens and prevent LD. Review showed the records did not contain documentation of a water management team, a description of the buildings water flow, developed procedures to monitor and inhibit the growth of Legionella and other waterborne pathogens that included identification of situations than could lead to legionella growth, control measures, testing protocols, acceptable ranges for control measures and what corrective actions are to be taken when control limits are not maintained. During an interview on 11/18/22 at 1:50 P.M., the administrator said he/she did not have any other information for the water management program beyond the policy and assessment. The administrator said he/she is responsible for the development and implementation of the water management program and he/she did not know it did not contain all required documentation.