Based on observation, interview and record review, the facility failed to ensure inventories of schedule II narcotic controlled substance medication (substances in this schedule have a high potential for abuse which may lead to severe psychological or physical dependence) and schedule IV and V narcotic controlled substance medications, were reconciled by at least two qualified staff to ensure accountability for ten residents (Resident #4, 9, 5, 7, 8, 10, 6, 11, 12 and 13) that had narcotics held in the A-hall medication cart each shift per policy. The facility census was 61. Review of the facility policy, Accountability of Controlled Substances, revised 11/27/24, showed the following: -The controlled substance count is completed at the start of each shift; the charge nurse is responsible for counting all controlled substances and for signing the narcotic sheet;-Two nurse signatures (two Licensed Practical Nurses (LPN), two Registered Nurses (RN), or one LPN and one RN, or one nurse (LPN/RN and one Certified Medication Technician (CMT) must sign off on each narcotic count sheet;-By signing these sheets, the charge nurses agree that the current narcotic count is correct not only at the beginning of the shift but also at the end of the shift. 1. Review of the facility Controlled Substance Drug Supply Shift Change Record, dated August 2025, for the A unit medication cart (which housed the narcotic box for the A hall residents) on 09/03/25 at 12:35 P.M. showed the following: -On 08/04/25, there was no documentation of a shift to shift narcotic medication count by any staff for the beginning or ending 7:00 A.M., 3:00 P.M. or 11:00 P.M. (all three shifts) shift counts; there was no documentation of a total card count;-On 08/12/25, there was no documentation of a shift to shift narcotic medication count by any staff for the beginning or ending 7:00 A.M., 3:00 P.M. or 11:00 P.M. (all three shifts) shift counts; there was no documentation of a total card count;-On 08/17/25, there was no documentation of a shift to shift narcotic medication count by any staff for the beginning or ending 7:00 A.M., 3:00 P.M. or 11:00 P.M. (all three shifts) shift counts; there was no documentation of a total card count;-On 08/20/25, there was no documentation of a shift to shift narcotic medication count by any staff for the beginning or ending 7:00 A.M., 3:00 P.M. or 11:00 P.M. (all three shifts) shift counts; there was no documentation of a total card count;-On 08/21/25, there was no documentation of a shift to shift narcotic medication count by any staff for the beginning or ending 7:00 A.M., 3:00 P.M. or 11:00 P.M. (all three shifts) shift counts; there was no documentation of a total card count;-On 08/22/25, there was no documentation of a shift to shift narcotic medication count by any staff for the beginning or ending 7:00 A.M., 3:00 P.M. or 11:00 P.M. (all three shifts) shift counts; there was no documentation of a total card count. 2. Review of the A hall narcotic card/bottle count (which listed the date, shift, beginning count, added, removed, names of cards added or removed, along with the signatures of oncoming and outgoing staff showing the items had been counted) on 09/03/25 at 12:40 P.M. showed the following:-On 8/4/25 at 7:00 A.M., 3:00 P.M. and 11:00 P.M. there were no nurse signatures documented in the boxes for oncoming and outgoing staff to show the count was completed;-On 8/12/25 at 7:00 A.M., 3:00 P.M. and 11:00 P.M. there were no nurse signatures documented in the designated boxes for oncoming and outgoing staff to show the count was completed;-On 8/17/25 at 7:00 A.M., 3:00 P.M. and 11:00 P.M. there were no nurse signatures documented in the designated boxes for oncoming and outgoing staff to show the count was completed;-On 8/20/25 at 7:00 A.M., 3:00 P.M. and 11:00 P.M. there were no nurse signatures documented in the designated boxes for oncoming and outgoing staff to show the count was completed;-On 8/21/25 at 7:00 A.M., 3:00 P.M. and 11:00 P.M. there were no nurse signatures documented in the designated boxes for oncoming and outgoing staff to show the count was completed;-On 8/22/25 at 7:00 A.M., 3:00 P.M. and 11:00 P.M. there were no nurse signatures documented in the designated boxes for oncoming and outgoing staff to show the count was completed. 3. Review of the individual resident's narcotic count sheets showed the following narcotic medications were stored in the narcotic lock box for the following residents:-Resident #4, Ativan (schedule IV narcotic controlled substance for anxiety) and morphine sulfate solution (schedule II narcotic controlled substance for pain);-Resident #9, hydrocodone (schedule II narcotic controlled substance for pain)/acetaminophen (apap);-Resident #5, Ativan, Roxanol (schedule II narcotic controlled substance for pain), hydrocodone/apap and Lyrica (schedule V narcotic controlled substance for pain); -Resident #7, Roxanol (schedule II narcotic controlled substance for pain) and Ativan;-Resident #8, Roxanol, Ativan and hydrocodone/apap;-Resident #10, tramadol (schedule IV narcotic controlled substance for pain), tramadol hydrochloride (HCL) (schedule IV narcotic controlled substance for pain) and hydrocodone/apap;-Resident #6, Ativan;-Resident #11, oxycodone instant release (IR) (schedule II narcotic controlled substance for pain) and oxycodone (schedule II narcotic controlled substance for pain);-Resident #12, tramadol hcl, Ativan and hydrocodone/apap;-Resident #13, tramadol hcl. 4. Review of the facility Controlled Substance Drug Supply Shift Change Record, dated September 2025, for the A unit medication cart on 09/03/25 at 12:35 P.M. showed on 09/02/25, there was no documentation of a shift to shift narcotic medication count by any staff for the beginning or ending 3:00 P.M. or 11:00 P.M. shift counts; there was no documentation of a total card count. 5. Observation of the A hall narcotic card/bottle count binder showed there was no log sheet for September 2025, and no documentation of a count of cards/bottles by any staff for each beginning or ending shift, 7:00 A.M., 3:00 P.M. or 11:00 P.M. (all three shifts) for 09/01/25 and 09/02/25 and no documentation of a count of cards/bottles by any staff for the beginning of the shift at 7:00 A.M. on 09/03/25. 6. During an interview on 09/03/25 at 12:12 P.M., LPN B said the following:-Two staff (nursing) are to count the narcotics together at the beginning and end of each shift;-Both staff are to sign two documents (initial one to show the count was completed each shift change) and sign their signature to the other to show the number of cards/bottles were counted, added or removed. During an interview on 09/03/25 at 12:35 P.M., LPN A said the following:-Two staff were to count the narcotics at the beginning and end of each shift. They should initial the count was completed and accurate each time;-He/She was unsure what the other document (narcotic card/bottle count) was. During an interview on 09/03/25 at 3:25 P.M., the Director of Nursing said the following:-The charge nurses were responsible for completing the narcotic counts;-She would expect nursing to complete the narcotic counts at the beginning and end of each shift, initialing each time the count was completed; -They should also document the total number of containers/cards and each of them sign the sheet;-She expected nursing to initial and sign both documents any time they are taking over the medications and turning the keys over;-The initials and signatures are verifying that they have counted the narcotics and the number of containers and that they match;-It would be easier to identify when/if a medication count was off/or a medication disappeared if the counts were completed and signed as completed as protocol;-The RN supervisor was to do a narcotic audit once weekly;-She was unaware there was no September narcotic card/bottle count sheet for the A hall until the surveyor asked to review the count sheet. During an interview on 09/03/25 at 3:40 P.M., the Administrator said she expected staff to complete the narcotic counts at every shift change. Staff should initial and sign both sheets each time where necessary. MO#2592572

Based on interview and record review, the facility failed to follow their policy on reporting allegations of abuse to the state agency immediately, but no later than two hours after the allegation was made for one resident (Resident #1), in a review of eight sampled residents. Resident #1 reported an allegation of abuse to Certified Nurse Aide (CAN) A on 06/15/25. CNA A reported the allegation to his/her charge nurse, Licensed Practical Nurse (LPN) D, who also reported the allegation to Registered Nurse (RN) B. No staff reported the allegation to the Director of Nursing (DON) or the Administrator until four days later. Additionally, when the administrator became aware of the allegation on 06/19/25 at 10:45 A.M., she did not notify the state agency of the allegation until 1:12 P.M. (greater than two hours). The facility census was 65. Review of the facility policy for Abuse, Neglect and Reporting Reasonable Suspicion of a Crime, with a revision date of 02/13/25, showed the following: -It is the policy of this facility to protect the rights of all residents to be free from mistreatment, abuse, neglect, injuries of unknown sources and misappropriation or stealing of resident property or money; -Sexual Abuse is defined as, but not limited to, sexual harassment, sexual coercion, or sexual assault; -Reporting Abuse/Neglect: c. Reporting to Department of Health and Senior Services (DHSS) following the Guidelines for Facility Self-Reporting for Certified Facilities, the Administrator, Director of Nursing (DON) or Human Resources (HR) Director will call the Department of Health and Senior Services (DHSS) and make the necessary self-report immediately, but not later than two (2) hours after the allegation is made; d. If the report is made after office hours or on a weekend to a Unit Supervisor or Charge Nurse, they must contact the Administrator, DON or HR Director at their emergency number (numbers are listed on the Emergency Telephone Numbers list located at each Nurses Desk) to immediately report the abuse; Review of the resident's rights employee orientation, dated 2025, showed residents have the right to be free from verbal, sexual, physical, financial, mental abuse, and involuntary seclusion by anyone. This includes, but isn't limited to nursing home staff, other residents, consultants, volunteers, staff from other agencies, family members or legal guardians, friends, or other individuals. If you witness or suspect abuse or neglect is happening to anyone in the facility, please contact the Human Resources Director or Director of Nursing or Administrator immediately. 1. Review of Resident #1's face sheet showed his/her diagnoses included paraplegia (a condition characterized by paralysis of the lower half of the body, typically including the legs and sometimes the torso). Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 05/20/25 showed the following: -The resident had the ability to make self-understood and able to understand others; -Brief Interview for Mental Status (BIMS-a brief, standardized assessment used to quickly screen for cognitive impairment, focusing on orientation, short-term memory, and attention, often used in long-term care facilities) with a score of 9 (moderate cognitive impairment); -No hallucinations or delusions; -No behaviors; -He/She was dependent on staff for toileting hygiene, showering, upper and lower body dressing, putting on/taking off footwear, rolling left and right, sit to lying, lying to sitting on the side of the bed, sit to stand, chair/bed to chair transfer, and tub/shower transfer. During an interview on 06/25/25 at 12:53 P.M., the resident said the following: -He/She had not been comfortable with CNA G; -Certified Nurse Aide (CNA) G stroked his/her hair and said he/she liked his/her hair; -He/She saw CNA G holding women's underwear and he/she had been stroking the underwear between his/her fingers. 2. Review of a facility abuse investigation, dated 06/25/25, showed the following: -On Thursday, June 19, 2025, CNA A reported to the administrator when he/she worked on June 15, 2025, Resident #1 confided in him/her that CNA G had done something sexually abusive to him/her but he/she wouldn't go into detail; -CNA A said he/she reported the allegation to Registered Nurse (RN) B, Licensed Practical Nurse (LPN) C, LPN D, LPN E and RN F. 3. During an interview on 06/25/25 at 12:25 P.M., CNA A said the following: -In May the resident told him/her he/she did not want CNA G in his/her room and would not tell him/her the reason; -The resident said he/she saw CNA G rubbing women's silk underwear between his/her fingers in the hallway outside of his/her room; -The resident said this was not the reason he/she did not want CNA G in his/her room, but that CNA G sexually assaulted him/her; -The resident would not tell him/her anymore and did not want him/her to report the sexual abuse allegation; -He/She told the resident he/she had to report the sexual abuse allegation; -He/She reported the sexual abuse allegation to his/her supervisor, LPN D on June 15, 2025. During an interview on 06/25/25 at 2:13 P.M., LPN D said the following: -About one to two weeks ago, CNA A reported the resident said CNA G did something sexual to him/her; -He/She immediately reported the allegation to RN B; -Two days later (on June 17th), he/she followed up with the DON and she had not received an abuse allegation report from RN B. During an interview on 06/25/25 at 3:34 P.M., LPN E said the following: -He/She and LPN D had been on orientation and working together on June 15, 2025; -LPN D had come to the nurses' station and told RN B he/she needed to have a private conversation with him/her about something disturbing that the resident had reported to CNA A; -LPN D said the resident reported CNA G had made inappropriate moves on him/her and pulled out a pair of women's silk panties from his/her pocket rubbed them. This was something that needed to be reported to the staff supervisor. The chain of command was the CNA would report to the LPN and the LPN would report to the charge nurse; -LPN D reported what CNA A reported to him/her to RN B; -LPN D said he/she would follow up and make sure the allegations had been reported to the DON. During an interview on 06/25/25 at 2:22 P.M. and 4:47 P.M., RN B said the following: -He/She was the nursing supervisor on June 15th; -LPN D told him/her the resident was supposedly sexually assaulted; -He/She tried to talk with the resident, but he/she would not talk with him/her. -He/She did not believe the resident had been sexually abused; he/she thought it was just CNA gossip and if he/she had been, there was a phone number on the door he/she was supposed to call; -Staff are supposed to call the abuse hotline if abuse allegations are reported; he/she did not call the abuse hotline; -He/She did not report the resident's allegation of abuse to the administrator. During an interview on 06/25/25 at 3:20 P.M., the Assistant Director of Nursing (ADON) said the following: -About four to five weeks ago a CNA came to her and said the resident was having problems with CNA G being in his/her room; -She interviewed the resident and asked if there was anything that needed to be addressed and the resident said, no, he/she just had not liked how CNA G took care of him/her; -She did not know the resident had reported he/she had been sexually abused; -No report of sexual abuse had been reported to her; -The staff member who received the report of abuse did not follow through with reporting the abuse allegation to the administrator. During an interview on 06/25/25 at 11:38 A.M., 2:40 P.M., 4:06 P.M. and 5:23 P.M., the DON said the following: -About five weeks ago, a CNA (did not remember who) reported to her the resident did not want CNA G in his/her room; the resident would not give a reason why he/she did not want CNA G in his/her room; -On June 17th, LPN D might have said something about the resident alleging abuse against CNA G, but she had not remembered asking him/her if RN B had informed her CNA A had reported the resident alleging sexual abuse. LPN D might have said something, but she had a lot of things going on and does not remember the conversation; -RN B had not reported an allegation of sexual abuse involving the resident to her; -She would have been responsible for telling the administrator about the reported allegation if she was made aware of it on 06/17/25; -She had not reported the resident's abuse allegations to the administrator or to the Department of Health and Senior Services on 06/17/25; -The first time she could remember being made aware of the resident's sexual abuse allegation was on June 19, 2025, when the administrator informed her about the resident's abuse allegations; -Abuse allegations should be reported to the state agency within two hours; -When abuse allegations are made, the facility is to report it to the state agency and start an investigation immediately; -The allegations of abuse should have been reported to the State immediately. During an interview on 06/25/25 at 11:00 A.M., 4:38 P.M. and 5:05 P.M., the Administrator said the following: -On 06/19/25 at 10:45 A.M., CNA A reported to her he/she had reported the sexual abuse allegation to his/her supervisor, LPN D, on June 15th; -On June 19th, she asked the DON if the allegation had been reported to her and the DON said no sexual abuse allegation had been reported to her; -She thought the DON had already completed a prior investigation regarding the resident and CNA G which had been unfounded; the prior allegation was not related to a sexual abuse; -She did not recognize this as an additional concern being reported; -She would expect her staff to contact her and report any abuse allegations immediately; -The resident's abuse allegation should have been reported to the state agency within two hours of getting the report from CNA A on June 15th. MO256136

Based on interview and record review, the facility failed to provide evidence that allegations of abuse were thoroughly investigated, per facility policy, for one resident (Resident #1), in a review of eight sampled residents. The facility census was 65. Review of the facility policy for Abuse, Neglect and Reporting Reasonable Suspicion of a Crime, with a revision date of 02/13/25, showed the following: -It is the policy of this facility to protect the rights of all residents to be free from mistreatment, abuse, neglect, injuries of unknown sources and misappropriation or stealing of resident property or money; -Sexual Abuse is defined as, but not limited to, sexual harassment, sexual coercion, or sexual assault; -Investigations of Abuse/Neglect: a. The facility will ensure that all alleged reports of mistreatment, neglect or abuse, injuries of unknown source and misappropriation of resident property are investigated; b. The Human Resources Director is responsible for investigations of alleged abuse by an employee or staff member; h. The documented contents of the investigation will include: a. specific description of the incident, people involved, date, time and location of the incident; b. relevant information from the resident's medical record; d. personal information for all staff involved in the incident; e. written, signed statements by all people involved in incident; f. documentation of interviews conducted by facility staff; h. a summary of the investigation including corrective action taken; i. any other relevant information to the incident. 1. Review of Resident #1's face sheet showed his/her diagnoses included paraplegia (a condition characterized by paralysis of the lower half of the body, typically including the legs and sometimes the torso). Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 05/20/25, showed the following: -The resident had the ability to make self-understood and able to understand others; -Brief Interview for Mental Status (BIMS-a brief, standardized assessment used to quickly screen for cognitive impairment, focusing on orientation, short-term memory, and attention, often used in long-term care facilities) with a score of 9 (moderate cognitive impairment); -No hallucinations or delusions; -No behaviors. During an interview on 06/25/25 at 12:53 P.M., the resident said the following: -He/She had not been comfortable with Certified Nurse Aide (CNA) G; -CNA G had stroked his/her hair and said he/she liked his/her hair; -He/She had seen CNA G holding women's underwear and he/she had been stroking the underwear between his/her fingers. 2. Review of the facility's abuse investigation, dated 06/25/25 and signed as completed by the administrator, showed the following: -On Thursday, June 19, 2025, CNA A reported to the administrator when he/she worked on June 15, 2025, the resident confided in him/her CNA G had done something sexually to him/her but he/she wouldn't go into detail; -CNA A said he/she reported the allegation to Registered Nurse (RN) B, Licensed Practical Nurse (LPN) C, LPN D, LPN E and RN F; -The administrator went to the resident's room and asked the resident about the incident with CNA G; -The resident refused to talk with the administrator about the incident; -The administrator called the staff members who had been reported as aware of the situation and requested statements be sent to her; -Seven statements were included in the investigation, including statements provided from Registered Nurse (RN) B, Licensed Practical Nurse (LPN) C, LPN D, LPN E, RN F and the DON; -The administrator contacted the local police department; -The administrator contacted the next of kin. 3. During an interview on 06/25/25 at 4:09 P.M., CNA G said he/she had not been contacted by the facility in reference to an abuse allegation. During an interview on 06/25/25 at 2:13 P.M., LPN D said the following: -About one to two weeks ago, CNA A reported the resident said CNA G did something sexual to him/her; -He/She immediately reported the allegation to his/her charge nurse, RN B; -He/She did not talk with the resident about the allegation, he/she thought the Director of Nursing (DON) should have spoken with the resident; -He/She had not begun a facility investigation into this allegation. During an interview on 06/25/25 at 2:22 P.M., and 4:47 P.M., RN B said the following: -On June 15th, LPN D told him/her that the resident was sexually assaulted; -He/She was the nursing supervisor during that time; -He/She had not begun a facility investigation into this allegation; -He/She tried to talk with the resident, but he/she would not talk with him/her. During an interview on 06/25/25 at 3:20 P.M., the Assistant Director of Nursing (ADON) said the following: -About four to five weeks ago, a CNA came to her and said the resident was having problems with CNA G being in his/her room. She interviewed the resident and asked if there was anything that needed looked into or anything that needed to be addressed and the resident said, no, he/she just had not liked how CNA G took care of him/her; -She did not know the resident reported an additional concern that he/she had been sexually abused; -No report of sexual abuse had been reported her. During an interview on 06/25/25 at 11:38 A.M., the DON said the following: -About five weeks ago a CNA (did not remember who) reported to her, Resident #1 did not want CNA G in his/her room; -During the previous investigation she did not talk with staff about Resident #1 not wanting CNA G in his/her room; -She did not know how the present administrator would like abuse investigations to be conducted; -The old administrator would have the Social Service director (SSD) conduct resident interviews; -She had not conducted resident interviews regarding Resident #1's abuse allegation of 06/19/25. During an interview on 06/25/25 at 4:06 P.M., the DON said the following: -She was responsible for the duties of Human Resources and had been for the past four months; -She did not remember LPN D asking her or telling her about CNA A reporting the resident's sexual abuse allegations; -She would have been responsible for telling the administrator and she did not tell the administrator about CNA A reporting Resident #1's sexual abuse allegations; -When abuse allegations are made, the facility should start an investigation immediately; -When the investigation is finished, the facility faxes it to the state agency; -During an abuse investigation, the facility should talk with the resident first and statements are gathered from anyone involved; -On Monday June 19, 2025, the administrator informed her about the resident's abuse allegations; -She had not begun a facility investigation into this allegation; -She had not interviewed any other resident's during the facility investigation of this allegation. During an interview on 06/25/25 at 11:00 A.M., 4:38 P.M., 5:05 P.M. and 07/10/25 at 8:23 A.M., the Administrator said the following: -On 06/19/25 at 10:45 A.M., CNA A reported to her the resident said he/she had been sexually assaulted by CNA G; -She thought the DON had already completed a prior investigation regarding the resident and CNA G which had been unfounded; -She did not speak with CNA G, regarding the new allegation as he/she no longer worked at the facility; -She would not have expected LPN D or RN B to have spoken to the resident because it had been an ongoing issue the DON had already investigated; -There are cameras in the hallways; -She had not viewed the camera footage for any observation of CNA G standing outside the resident room rubbing silk underwear between his/her fingers; -The resident's abuse allegation investigation, dated 06/25/25, consisted of staff statements, calling the police, talking with the resident and the next of kin; -The abuse investigation had not included any other resident interviews; -All the supervisors would be involved during an abuse investigation; -She would expect the DON to conduct resident interviews to ensure other residents were okay; -There was no resident interviews conducted during the investigation. Review of the facility investigation showed it did not contain the following documentation as directed by the facility policy: -No written, signed statement by all people involved in the incident, including the resident and CNA G; -No documentation of the resident's refusal to provide a written statement; -No documentation of interviews conducted or attempted by facility staff; -No documentation of a summary of the investigation, including corrective action taken. MO256136

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a licensed nursing home administrator was employed by the facility. The facility census was 62. Review of the most current Facility Assessment, dated [DATE], showed the following: -Licensed beds: 109; -Average daily censes: 53; -23 residents required extensive assistance of two or more staff for activities of daily living (ADLs); -Services required: assistance with ADLs, transfers, ambulation, restorative nursing, bowel and bladder training programs, incontinence prevention and care, catheter and colostomy care, pressure injury prevention and care, managing medical conditions and medication related issues, medication administration, pain assessment and management, physical, occupational, speech and respiratory therapy, management of braces and splints, nutrition, specialized diets, intravenous nutrition, tune feeding, person centered, directed care, psychosocial and spiritual support and dementia specialized care; -Administrative staff personnel required: administrator, human resource director, social services director, accounting director, clerical and medical records. Review of the facility's Administrator Job Description policy, dated [DATE], showed the following: -Must possess a current Health Facility Administrator's license from the State of Missouri; -Knowledge of long-term care management, policies, budgeting, personnel management, and census development is required. During an interview on [DATE] at 2:30 P.M., the Director of Accounting said the facility did not currently have a licensed administrator. During an interview on [DATE] at 3:35 P.M., the Board of Director's [NAME] President said the following: -The Human Resources Director took care of the day to day activities at the facility; -The Board of Directors took care of writing checks to pay bills; -She went to the facility to be involved with the issues in the facility and help as needed. During an interview on [DATE] at 9:55 A.M., the Human Resources Director said the following: -The facility did not currently have a licensed administrator; -The previous administrator resigned [DATE]; -The Human Resources Director had a temporary emergency license that expired on [DATE]; -He was taking care of the daily needs of the facility and addressed issues when brought to him. MO246378

Based on interview and record review, the facility failed to report an injury of unknown origin for one resident (Resident #1), in a review of five sampled residents. The census was 52. Review of the facility policy, Abuse/Neglect and Reporting Reasonable Suspicion of a Crime, last revised 1/5/17 showed: -It is the policy of the facility to protect the right of all residents to be free from mistreatment, abuse, neglect and injuries of unknown sources; -All allegations of mistreatment, abuse or neglect, and injuries of unknown sources will be reported and thoroughly investigated; -It is the responsibility of each covered individual who is an owner, operator, employee, manager, agent or contractor of the facility to report an incident or situation which may be considered a reasonable suspicion of a crime; -There are two specific time period limits which will be followed, depending on the seriousness of the event that leads to the reasonable suspicion report: -Serious Bodily Injury-within two hours; -All others-within 24 hours: If the events do not result in serious bodily injury to a resident, the covered individual shall report the suspicious crime no later than 24 hours after forming the suspicion. 1. Review of Resident #1's care plan, dated 10/19/23, showed the following; -Non-verbal, will occasionally answer to yes or no questions; -Staff will provide all care; -Two staff assist with full body mechanical lift for all transfers; -Receives anticoagulant therapy (medication therapy that helps prevent blood clots): monitor for signs/symptoms such as hematuria (blood in urine), bleeding gums, tarry stools (blood in stools), petechiae (tiny round, brownish- purple spots due to bleeding under the skin) etc. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument to be completed by the facility, dated 10/27/23, showed the following: -Short and long term memory problem; -No behaviors, rejection of care; -Dependent on staff for bed mobility, transfers, bathing and personal hygiene; -Incontinent of bladder and bowel; -Antiplatelet (medications that stop blood cells from sticking together and forming a blood clot) used daily for last seven days. Review of the resident's Physician Order Sheet, dated 12/2023, showed the following: -Diagnoses included dementia (group of thinking and social skills that interferes with daily functioning); -Aspirin (blood thinner) 81 milligrams (mg) by mouth daily (1/9/21); -Plavix (blood thinner) 75 mg by mouth daily (1/9/21); -Full body mechanical lift for all transfers. Review of the resident's comprehensive Certified Nurse Assistant (CNA) shower review sheet, dated 12/16/23, showed old bruises (no indication of location), nothing noticed. Review of the resident's progress notes, dated 12/18/23 at 6:42 P.M., showed Licensed Practical Nurse (LPN) B documented staff reported a bruise to the resident's chest area. Upon assessment, noted seven centimeter (cm) by seven cm raised, purple colored bruise to the left armpit area of unknown origin. Bruise not open. No warmth. Registered Nurse (RN) supervisor updated. (did not specify what RN). Review of the resident's comprehensive CNA shower review sheet, dated 12/20/23, showed left chest (to include the areola and arm) was circled and a notation bruising reported. (did not indicate to whom this was reported). Review of the resident's progress notes on 12/27/23 and authored by Licensed Practical Nurse (LPN) B, dated 12/18/23 at 6:42 P.M., showed staff reported a bruise to the resident's chest area. Upon assessment, noted seven centimeter (cm) by seven cm raised, purple colored bruise to the left armpit area of unknown origin. Bruise not open. No warmth. Registered Nurse (RN) supervisor updated (did not specify what RN). During an interview on 1/10/24 at 1:28 P.M., CNA E said the following: -He/She discovered a bruise on the resident after undressing him/her on 12/18/23; -The bruise was big (probably like baseball size) and purple, near the shoulder area; -He/She reported it to his/her charge nurse, LPN B. During an interview on 1/9/24 at 7:40 P.M., LPN B said the following: -He/She recalled CNA E reporting a noted bruise on the resident on 12/18/23; -He/She assessed and measured the area which was seven centimeters (cm) by seven cm and appeared fresh/purple in color; -The bruise was on the chest, between the aereola and the armpit; -The resident was not interviewable and did not have a roommate; -She faxed the physician and left a telephone message for the family; -He/She reported the bruise to his/her supervisor RN C. During an interview on 1/10/24 at 2:30 P.M., RN C said the following: -He/She did not recall if staff reported a bruise or if he/she reported a bruise on the resident's chest on 12/18/23; -He/She did not recall if he/she assessed the bruise, but if he/she had, he/she would have documented it in the medical record. During an interview on 1/9/24 at 2:23 P.M., the Director of Nurses said the following: -She had not reported the resident's injury of unknown origin to the state agency (SA). She first learned of the bruise on 12/27/23 after the SA had reported it to the administrator; -She would expect both she and the administrator notified of an injury of unknown origin immediately; -An injury of unknown origin should be reported to the SA as soon as it was identified. During an interview on 1/12/24 at 2:54 P.M. the Administrator said injuries of unknown origin should be reported to the administration and state agency immediately. MO229692

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to turn and reposition two residents (Resident #5 and Resident #32), who were identified as at risk for developing pressure ulcers (localized damage to the skin and underlying soft tissue, usually over a bony prominence or related to a medical or other device. It can present as intact skin or an open ulcer and may be painful. It occurs as a result of intense or prolonged pressure or pressure in combination with shear), in a review of 15 sampled residents, according to facility policy and the residents' plan of care. The facility census was 51. Review of the facility policy Resident Turning and Repositioning, last reviewed on 9/4/23, showed the following: -Those residents who are unable to address the need to turn and reposition themselves independently will be turned every two hours and as needed (PRN) by the trained nursing department; -Lay the resident on one side of the body for two hours. A foam wedge may be used behind the resident and in front of the resident to keep the resident off of their back; -Turn the resident to the opposite side for two hours at the most; -Apply heel protectors, pillow between knees and positioning wedges to ensure that the resident will not fall on their backs when positioned on their side and to always protect the knees and heels from pressure; -If residents are sleeping or drowsy, the resident will need to be properly positioned in a recliner in the resident room or geri center or laid down in good body alignment. 1. Review of Resident #5's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/16/23, showed the following: -Severe cognitive impairment; -Dependent on staff for chair/bed to chair transfers -Always incontinent of bladder and bowel; -At risk for pressure ulcers. Review of the resident's care plan, dated 8/21/23, showed the following: -The resident requires assistance with activities of daily living (ADL) task performance as follows: two assist for bed mobility and total assist for transfers with full body lift with two assist; -The resident enjoys napping either in the recliner in the commons area or in his/her room after meals; -The resident is at high risk for skin breakdown related to Braden Scale score (assessment tool that uses six areas to rate the risk for pressure ulcers: sensory perception, moisture, activity, mobility, nutrition, and friction and shear), decreased mobility, incontinence, vitamin deficiencies, and intermittent moisture associated skin redness; -The resident is incontinent of bowel requiring incontinence care. -Monitor redness or skin breakdown during wrap around (incontinence brief) change at least every two to three hours. Review of the resident's Braden scale, dated August 2023, showed the resident was at high risk for developing pressure ulcers. Observation on 11/1/23 at 6:12 A.M. in the TV area by the nurse's station showed the following: -The resident sat in his/her wheelchair with his/her eyes partially open; -The resident said he/she was tired. Observation on 11/1/23 at 7:47 A.M. in the TV area by the nurses' station showed the resident sat in his/her wheelchair with his/her eyes closed. Observation on 11/1/23 at 7:52 A.M. showed Licensed Practical Nurse (LPN) Q pushed the resident in his/her wheelchair from the TV area by the nurse's station to the dining room. Continuous observation on 11/1/23 from 8:05 A.M. to 8:38 A.M. in the dining room showed the resident sat in his/her wheelchair at the table. Continuous observation on 11/1/23 from 8:42 A.M. to 9:02 A.M. showed the following: -The resident sat in his/her wheelchair at the table in the dining room; -Registered Nurse (RN) P served the resident's breakfast tray and fed the resident. Observation on 11/1/23 at 9:20 A.M. showed the resident sat in his/her wheelchair at the table in the dining room. The resident was no longer eating. Observation on 11/1/23 at 9:22 A.M. showed the Director of Nursing (DON) pushed the resident in his/her wheelchair out of the dining room to the secured unit for activities. Observation on 11/1/23 at 9:38 A.M. showed the resident sat in his/her wheelchair in the common area in the secured unit. Observation on 11/1/23 at 10:18 A.M. showed activity staff pushed the resident in his/her wheelchair from the secured unit to the TV area by the nurses' station. Observation on 11/1/23 at 10:33 A.M. showed LPN Q pushed the resident in his/her wheelchair to his/her room. Observation on 11/1/23 at 10:38 A.M. showed the following: -The resident sat in his/her wheelchair in his/her room; -Certified Nurse Aide (CNA) J and CNA N transferred the resident with the mechanical lift to his/her bed; -The resident had a strong smell of urine; -The resident's incontinence brief was saturated with urine; -The resident's buttocks and posterior thighs had multiple creases and indentations from the lift sling. (Observation of the resident on 11/1/23 from 6:12 A.M. to 10:38 A.M. (four hours and 26 minutes) showed staff did not reposition the resident.) During an interview on 11/1/23 at 2:30 P.M., CNA J said the following: -The resident required total staff assistance for transfers and repositioning; -The resident was up in his/her chair before he/she came on duty at 7:00 A.M.; -Staff did not reposition the resident until around 10:30 A.M. 2. Review of Resident #32's care plan, dated 6/6/23, showed the following: -The resident required total assist with all ADLs; -The resident lies down after lunch daily; -Staff will provide all care; -Use full body lift for all transfers with two staff assist; -Uses Broda chair while out of bed; -The resident is at high risk for skin breakdown related to incontinence of bowel and bladder, multiple disease processes and total dependency on staff for all ADLs; -Staff will turn/position every two hours. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Short and long-term memory problems; -Dependent on staff for chair/bed to chair transfers; -Always incontinent of bladder and bowel; -At risk for pressure ulcers; -Pressure reducing device for chair; -Turning and repositioning program. Review of the resident's Braden scale, dated October 2023, showed the resident was at very high risk for developing pressure ulcers. Observation on 11/1/23 at 6:12 A.M. showed the resident sat in his/her Broda chair in the TV area by the nurse's station. The resident rocked his/her upper body back and forth. Observation on 11/1/23 at 7:47 A.M. showed the resident sat in his/her Broda chair in the TV area by the nurse's station. The resident continued to rock his/her upper body back and forth. Observation on 11/1/23 at 8:00 A.M. showed the following: -The resident sat in his/her Broda chair in the TV area by the nurses station with his/her eyes closed; -Registered Nurse (RN) P pushed the resident in his/her chair to the dining room; -The resident continued with upper body rocking movement. Observation on 11/1/23 at 8:21 A.M. showed the resident sat in his/her Broda chair in the dining room. The resident continued with upper body rocking movement. Observation on 11/1/23 at 8:32 A.M. showed the resident sat in his/her Broda chair in the dining room. The resident continued with upper body rocking movement. Continuous observation on 11/1/23 from 8:37 A.M. to 9:20 A.M. showed the resident sat in his/her Broda chair in the dining room as the MDS Coordinator fed him/her breakfast. Observation on 11/1/23 at 9:45 A.M. showed the resident sat in his/her Broda chair in the dining room. The resident's eyes were closed. Observation on 11/1/23 at 9:49 A.M. in the TV area by the nurses' station showed the following: -The resident sat in his/her Broda chair awake; -The resident had intermittent upper body rocking movement. Observation on 11/1/23 at 9:50 A.M. in the TV area by the nurses' station showed the following: -The resident sat in his/her Broda chair with his/her eyes closed; -The resident had intermittent upper body rocking movement; -Licensed Practical Nurse (LPN) Q lowered the back of the resident's chair. Continuous observation on 11/1/23 from 10:04 A.M. to 10:28 A.M. showed the resident sat in his/her Broda chair in the TV area by the nurses' station with his/her eyes closed. The resident had intermittent upper body rocking movement. Continuous observation on 11/1/23 from 10:55 A.M. to 12:00 P.M. showed the resident sat in his/her Broda chair in the TV area by the nurses' station with his/her eyes closed. Observation on 11/1/23 at 12:00 P.M. showed the resident sat in his/her Broda chair in the TV area by the nurses' station with his/her eyes closed. CNA J pushed the resident in his/her chair to the dining room. Observation on 11/1/23 at 1:47 P.M., showed the following: -The resident lay on his/her back in bed; -CNA J and CNA N rolled the resident over to his/her left side; -The resident was incontinent of urine. This incontinence brief, pants and the mechanical lift sling were wet with urine. -The resident's buttocks were dark pink with red creases from the items he/she sat on while in the wheelchair. (Observations showed staff did not reposition the resident on 11/1/23 from at least 6:12 A.M. to 1:47 P.M. (seven hours and 35 minutes)). During an interview on 11/1/23 at 2:30 P.M., CNA J said the following: -The resident required total staff assistance for transfers and repositioning; -The resident was up in his/her chair before he/she came on duty at 7:00 A.M.; -Staff did not reposition the resident until after lunch today. 3. During an interview on 11/2/23 at 2:56 P.M., the Director of Nurses (DON) said ideally, staff should turn and reposition Resident #5 and #32 every two hours, however the minimum was to reposition before meals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow professional standards of practice for one resident (Resident #8), in a review of 15 sampled residents and for two additional residents (Resident #23 and #52). Staff failed to correctly apply a splint per physician's orders for Resident #8, failed to follow medication administration guidelines for Resident #23, and failed to follow physician's orders and medication guidelines to rinse the mouth following administration of an inhaled medication for Resident #52. The facility census was 51. 1. Review of Resident #8's physician orders, dated 6/15/23, showed the resident was to have both hand splints/palm protectors on while in bed, off when the resident was out of bed, apply and monitor each shift. Review of the resident's care plan, dated 6/22/23, showed the following: -Provide gentle passive range of motion of both hands; -Put both hand splints/palm protectors on the resident while he/she was in bed, remove the resident's hand splints/palm protectors when he/she is out of bed, and monitor each shift. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/31/23, showed the following: -He/She had severe cognitive impairment; -He/She received passive range of motion exercises with restorative nursing. Review of the resident's physician orders, dated October 2023, showed the resident was to have both hand splints/palm protectors on while in bed, off when the resident was out of bed, apply and monitor each shift (original order dated 6/15/23). Review of the resident's nurse note, dated 10/26/23 at 8:17 A.M., showed the resident had contractures (muscles, tendons, joints, or other tissues tighten or shorten causing a deformity) to both hands and used bilateral hand splints while in bed. Observation on 10/30/23 at 11:40 A.M., showed the following: -The resident sat in wheelchair; -He/She had a rolled up washcloth in both hands; -He/She had contracture in both hands. Observation on 11/1/23 at 1:53 P.M., showed the resident lay in bed without a splint in either hand. During an interview on 11/1/23 at 1:53 P.M., Certified Nurse Aide (CNA) J said the resident did not like the hand splints and tried to take them off. (During the interview, CNA J was in the resident's room and did not attempt to put the splints on the resident.) Observation on 11/2/23 at 6:15 A.M., showed the following: -The resident lay in bed; -The resident did not have a splint in either hand. During an interview on 11/2/23 at 6:50 A.M., Licensed Practical Nurse (LPN) L said the following: -Staff put the hand splints on the resident when he/she went to bed; -He/She did not know why the resident did not have splints on this morning while in bed; -He/She did not remember if the resident had the splints on when he/she checked earlier in the shift. Observation on 11/2/23 at 7:12 A.M., showed the following: -The resident sat in a wheelchair in the television common area. -The resident had hand splints on both hands; -The resident's right hand had a white splint with padding and a strap that went across the wrist/hand. During an interview on 11/2/23 at 7:12 A.M., CNA K said the following: -Staff placed the splints on the resident this morning; -The splints were supposed to be off while the resident was in bed; -He/She was not notified if the order was changed to be put the splints on while the resident was in bed. 2. Review of Resident #23's face sheet, showed diagnoses of hypothyroidism (underactive thyroid) and heartburn. Review of the resident's quarterly MDS, dated [DATE], showed the resident had severe cognitive impairment. Review of the resident's care plan, last updated 10/27/23, showed the resident was at risk for weight loss related to heartburn, but the care plan did not include hypothyroidism. Review of the resident's physician orders, dated October 2023, showed the following: -Levothyroxine (thyroid medication) 50 mcg, give one tablet by oral route once daily on an empty stomach with a full glass of water at least 1 to 30 minutes before breakfast (ordered on 3/22/22); -Famotidine (a medication used to treat stomach ulcers and heartburn) 10 milligrams (mg), give one tablet by oral route once daily (ordered on 3/22/22); -Tylenol (analgesic) 500 mg, give two tablets by oral route three times a day (ordered on 10/13/22). Review of levothyroxine information on Drugs.com, last updated 10/6/23, showed the following: -Take oral levothyroxine on an empty stomach, at least 30 to 60 minutes before breakfast with a full glass of water. -If you cannot swallow a tablet whole, crush the tablet, and mix with 1 or 2 teaspoons of water; -Sometimes it is not safe to use certain medicines at the same time. Some medicines can affect the thyroid hormone levels and also make levothyroxine less effective. -The list of medications to avoid taking four hours before or after the use of levothyroxine included famotidine. Observation on 11/2/23 at 6:35 A.M., showed LPN L crushed two tablets of acetaminophen 50 mg, one tablet of famotidine 10 mg, and and levothyroxine 50 mcg, mixed them in pudding (not water), administered the medications to the resident, and provided a plastic glass of water. During an interview on 11/2/23 at 6:45 A.M., LPN L said the following he/she administered all three medications together because the resident would be angry about being awakened twice (to give medications) instead of once. 3. Review of Resident #52 diagnosis list showed he/she had a diagnosis of chronic obstructive pulmonary disease (COPD) (a group of lung diseases that block air flow and make it difficult to breathe). Review of the resident's November 2023 physician order sheet showed an order for Advair Diskus (a steroid and bronchodilator combination medicine that is used to prevent asthma attacks) 100 micrograms (mcg)-50 mcg/dose powder for inhalation. Inhale one puff by inhalation route twice daily approximately 12 hours apart. Order start date 10/5/23. Protocol: RINSE MOUTH AFTER USE. Review of www.drugs.com regarding use of Advair Diskus directed to rinse your mouth with water without swallowing after each use of the inhaler. Observation on 11/1/23 at 6:47 A.M. showed the following: -LPN O held the Advair Diskus to the resident's mouth and the resident inhaled one puff of the medication; -LPN O gave the resident a drink of water; -LPN O did not assist or encourage the resident to rinse his/her mouth after administration of the Advair Diskus. During an interview on 11/1/23 at 7:33 A.M., LPN O said the following: -He/She did not assist or encourage the resident to rinse his/her mouth after administration of the Advair Diskus; -He/She did not see the instructions to rinse the resident's mouth after use of the medication. 4. During an interview on 11/2/23 at 2:56 P.M., the Director of Nursing (DON) said the following: -The expectation was the nursing staff followed physician orders; -The nurse should administer the inhaler to the resident and give education to rinse out the resident's mouth afterwards.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to check two dependent residents (Residents #5 and #32) for incontinence according to their plan of care, and failed to provide complete incontinence care to one resident (Resident #17) in a review of 15 sampled residents,. The facility census was 51. Review of the facility policy, Perineal Care, dated 01/26/11, showed the following: -Perineal care is the washing of the genital and rectal areas of the body. Perineal care is usually called peri care; -Peri care prevents skin breakdown of the perineal area, itching, burning, odor and infections. Peri care is very important in maintaining the resident comfort. -All areas that have been touched by the attends/pad (adult protective brief or the cloth pad under the resident) must be washed; -Wash across the abdomen, be sure to lift and wipe all folds, rinse then dry; -Gently wash the inner legs and outer peri areas, rinse and pat dry; -Turn the resident to the side and wash across lower back, rinse and pat dry; -Wash each buttock, rinse and pat dry; -Wash the anal (opening of the rectum) area, rinse and pat dry, remember front to back; 1. Review of Resident #32's care plan, dated 6/6/23, showed the following: -The resident required total assist with all activities of daily living (ADLs); -Staff will provide all care; -Use full body lift for all transfers with two staff assist; -Uses Broda chair (specialized reclining wheelchair) while out of bed; -The resident is at high risk for skin breakdown related to incontinence of bowel and bladder, multiple disease processes and total dependency on staff for all ADLs; -Staff will turn/position and provide incontinence care with barrier cream afterwards every two hours. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/27/23, showed the following: -Short and long-term memory problems; -Dependent on staff to provide toileting hygiene and to transfer from chair/bed to chair; -Always incontinent of bladder and bowel Observations on 11/1/23 at 6:12 A.M. and 7:47 A.M. showed the resident sat in the TV area by the nurse's station in a Broda chair. Observation on 11/1/23 at 8:00 A.M. showed the following: -The resident sat in his/her Broda chair in the TV area by the nurse's station with his/her eyes closed; -Registered Nurse (RN) P pushed the resident in the Broda chair to the dining room. Observations on 11/1/23 at 8:21 A.M. and 8:32 A.M. showed the resident sat in his/her Broda chair in the dining room. Continuous observation on 11/1/23 from 8:37 A.M. to 9:20 A.M. showed the resident sat in his/her Broda chair in the dining room. The MDS Coordinator fed the resident breakfast. Observations on 11/1/23 at 9:45 A.M. and 9:49 A.M. showed the resident sat in his/her Broda chair in the TV area by the nurses' station. Observation on 11/1/23 at 9:50 A.M. in the TV area by the nurses' station showed the following: -The resident sat in his/her Broda chair with his/her eyes closed; -Licensed Practical Nurse (LPN) Q lowered the back of the resident's chair. Continuous observation on 11/1/23 from 10:04 A.M. to 10:28 A.M. showed the resident sat in his/her Broda chair in the TV area by the nurses station with his/her eyes closed. Continuous observation on 11/1/23 from 10:55 A.M. to 12:00 P.M. showed the resident sat in his/her Broda chair in the TV area by the nurses' station with his/her eyes closed. Observation on 11/1/23 at 12:00 P.M. showed the resident sat in his/her Broda chair in the TV area by the nurses' station with his/her eyes closed. Certified Nurse Assistant (CNA) J pushed the resident in the Broda chair to the dining room. Observation on 11/1/23 at 1:47 P.M., showed the following: -The resident lay on his/her back in bed; -CNA J and CNA N rolled the resident over to his/her left side; -The resident was incontinent of urine. This incontinence brief, pants and the mechanical lift sling were wet with urine. (Observations showed staff did not check for incontinence or provide incontinence care for the resident on 11/1/23 from at least 6:12 A.M. to 1:47 P.M. (seven hours and 35 minutes)). During an interview on 11/1/23 at 2:30 P.M., CNA J said the following: -The resident required total staff assistance for transfers and incontinence care; -Staff try to check and change the resident before meals and after meals; -The resident was up in his/her chair before he/she came on duty at 7:00 A.M.; -Sometimes staff check the resident for incontinence while he/she is up in his/her chair. His/Her chair can be tilted back and staff can check his/her brief; -Staff did not check the resident for incontinence until after lunch today. 2. Review of Resident #5's annual MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Dependent on staff to provide toileting hygiene and to transfer from chair/bed to chair; -Always incontinent of bladder and bowel. Review of the resident's care plan, dated 8/21/23, showed the following: -The resident required assistance with ADL task performance as follows: total assist for transfers with full body lift with two assist and extensive assist with grooming; -The resident is incontinent of bowel requiring incontinence care. Observation on 11/1/23 at 6:12 A.M. showed the resident sat in his/her wheelchair in the TV area by the nurse's station with his/her eyes partially open. Observation on 11/1/23 at 7:47 A.M. in the TV area by the nurses' station showed the resident sat in his/her wheelchair with his/her eyes closed. Observation on 11/1/23 at 7:52 A.M. showed Licensed Practical Nurse (LPN) Q pushed the resident in his/her wheelchair from the TV area by the nurse's station to the dining room. Continuous observation on 11/1/23 from 8:05 A.M. to 8:38 A.M. showed the resident sat in his/her wheelchair at the table in the dining room. Continuous observation on 11/1/23 from 8:42 A.M. to 9:02 A.M. in the dining room showed the following: -The resident sat in his/her wheelchair at the table; -Registered Nurse (RN) P served the resident's breakfast tray and fed the resident. Observation on 11/1/23 at 9:20 A.M. in the dining room showed the following: -The resident sat in his/her wheelchair at the table; -The resident was no longer eating. Observation on 11/1/23 at 9:22 A.M. in the dining room showed the following: -The resident sat in his/her wheelchair at the table; -The Director of Nursing (DON) pushed the resident in his/her wheelchair out of the dining room to the secured unit for activities. Observation on 11/1/23 at 9:38 A.M. showed the resident sat in his/her wheelchair in the common area in the secured unit. Observation on 11/1/23 at 10:18 A.M. showed activity staff pushed the resident in his/her wheelchair to the TV area by the nurses' station. Observation on 11/1/23 at 10:33 A.M. showed LPN Q pushed the resident in his/her wheelchair to his/her room. Observation on 11/1/23 at 10:38 A.M. showed the following: -The resident sat in his/her wheelchair in his/her room; -CNA J and CNA N entered the resident's room and transferred the resident with the mechanical lift to his/her bed; -The resident had a strong smell of urine; -The resident's incontinence brief was saturated with urine; -CNA J and CNA N provided pericare. (Observations showed staff did not check for incontinence or provide incontinence care for the resident on 11/1/23 from at least 6:12 A.M. to 10:38 A.M. (four hours and 26 minutes)). During an interview on 11/1/23 at 2:30 P.M. CNA J said the following: -The resident required total staff assistance for transfers and incontinence care; -Staff try to check and change the resident before meals and after meals; -The resident was up in his/her chair before he/she came on duty at 7:00 A.M.; -Staff did not check the resident for incontinence until around 10:30 A.M. 3. Review of Resident #17's quarterly MDS, dated [DATE], showed the following: -Cognitively impaired; -Required substantial to maximal assistance with toileting hygiene; -Always incontinent of bowel and bladder. Review of the resident's care plan, dated 07/03/23, showed the following: -The resident was at high risk for skin breakdown related to decreased mobility, incontinence, anemia or poor food consumption at times; -The resident will not experience complications related to incontinence as evidenced by no signs or symptoms of urinary tract infection (UTI), skin breakdown or rashes through the next review. Observation on 11/01/23 at 7:20 A.M. showed the following: -The resident lay in bed and was incontinent of urine; -CNA H wet a washcloth with water and brought it and a towel to the resident's bed; -CNA H wiped the resident's inner, upper thighs and perineum (the area between the genitals and the rectal opening) with the wet wash cloth, (no soap or cleaning product was used) then dried the areas with a towel; -CNA H and CNA I turned the resident to his/her right side; -CNA H pulled the soiled incontinence brief out from under the resident and tucked a new brief under the resident; -CNA H assisted CNA I to turn the resident onto his/her back and fastened his/her new incontinence brief; -Staff did not wash the resident's buttocks which were in contact with the urine soiled incontinence brief. During an interview on 11/2/23 at 9:45 A.M., CNA H said the following: -Complete incontinence care would include cleaning and drying the front (groin and perineum) and the back (buttocks) of a resident; -He/She did not wash and dry the resident's buttocks during incontinence care. 4. During an interview on 11/2/23 at 2:56 P.M., the Director of Nurses (DON) said the following: -Complete incontinence care would include cleaning a resident's bottom (buttocks) as well as the perineal area; -Staff should check dependent residents for incontinence and change them every two hours and as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to adequately document appropriate diagnoses residents or resident behaviors to justify the implementation or continued used of antipsychotic medications for three residents with a diagnosis of dementia (Residents #11, #17, and #32), in a review of 15 sampled residents. The facility census was 51. A review of the facility policy, Psychotropic Medication, dated 10/10/13, showed the following: -Policy: the facility will make every effort to comply with state and federal regulations to the monitoring and use of psychopharmacological medication, this will include regular review for the continued need, appropriate dosage, side effects, risks and/or benefit. The facility supports the appropriate use of psychopharmacological medications that are therapeutic and enabling for residents suffering from mental illness; -General statement: -No psychopharmacologic medication will be administered without a physician order that includes the diagnosis, dosage, route, and frequency; -A nurse, prior to requesting the need for this medication, will do the following: -Try to determine the underlining cause of the behavioral symptoms and take action to correct; -Document all interventions attempted prior to use or request of psychoactive medication; this includes but not limited to environmental changes, medical interventions such as pain medication and/or evaluation for a change in condition; -Evaluate/monitor the effects of the medications on the resident's behavior and keep physician informed; -Nursing staff will develop a behavioral care plan and document behaviors; -Consulting pharmacist/physician; -Monitors psychotropic drug use in the facility to ensure that medications are not used in excessive doses or for excessive duration; -Participates in the interdisciplinary quarterly review of residents on psychoactive medications; -Notifies the physician and the director of nurses (DON) if whenever a psychotropic medication is past due for review; -Attempt a gradual dose reduction (GDR) decrease or discontinuation of psychotropic medications after no more than three months unless clinically contraindicated. 1. Review of Resident #11's physician's order, dated 5/16/22, showed an order for Seroquel (an antipsychotic medication), 25 milligrams (mg) by mouth one time daily for unspecified psychosis not due to a substance or known physiological condition. Review of www.drugs.com for Seroquel showed the following: -Seroquel (quetiapine) is used to treat schizophrenia and to treat episodes of mania (frenzied, abnormally excited or irritated mood) or depression in patients with bipolar disorder (manic depressive disorder; a disease that causes episodes of depression, episodes of mania, and other abnormal moods). -Seroquel is used in combination with antidepressant medications to treat major depressive disorder in adults. -Seroquel may increase the risk of death in older adults with mental health problems related to dementia. -Potential adverse effects of Seroquel included somnolence (sleepiness), postural hypotension (a drop in the blood pressure when a person stands), motor, and sensory instability, which may lead to falls, and consequently, fractures (broken bones) or other injuries. Review of the document, Consultant Pharmacist's Medication Regimen Review, for recommendations between 05/01/23 and 06/09/23, showed the consulting pharmacist said the following: -Facility staff documented No behaviors several times in the chart in the nursing notes; -There have not been behaviors documented that justify the use of an antipsychotic medication; -The physician responded and said, The behavioral symptoms present a danger to the resident or others. Review of the document, Note to Attending Physician/Prescriber, dated 06/06/23, showed the consulting pharmacist said the following: -The resident has an order for Seroquel 25 mg every day for a diagnosis of dementia with psychosis, an off-label use; -Documentation should be in the resident's chart to justify use of an antipsychotic along with daily behavior monitoring; -There have not been behaviors documented that justify antipsychotic use; -The physician responded by checking the response: Attempted GDR would likely impair the resident's function, and GDR would cause psychiatric instability by exacerbating underlying psych disorder Review of the resident's physician orders for July 2023 and August 2023 showed an order for Seroquel 25 mg by mouth one time daily for unspecified psychosis not due to a substance or known physiological condition (original order date of 5/16/22). Review of the resident's nursing progress notes, from 07/01/23 through 8/4/23, showed no documentation of behaviors related to his/her diagnosis of unspecified psychosis. Review of the resident's physician progress notes, dated 8/4/23, showed nursing notes no problems (indicating staff reported no behaviors during thislook backk assessment). Review of the resident's nursing progress notes, from 8/4/23 through 8/9/23, showed no documentation of behaviors related to his/her diagnosis of unspecified psychosis. Review of the facility's monthly fall logs showed on 8/9/23 at 4:58 A.M., the resident fell in his/her bathroom. Review of the resident's nursing progress notes, from 8/9/23 through 9/1/23, showed no documentation of behaviors related to his/her diagnosis of unspecified psychosis. Review of the resident's physician orders for September showed an order for Seroquel 25 mg by mouth one time daily for unspecified psychosis not due to a substance or known physiological condition (original order date of 5/16/22). Review of the resident's physician progress notes, dated 9/1/23, showed nursing notes no problems (indicating the resident did not have behaviors during thislook backk assessment). Review of the resident's nursing progress notes, from 9/1/23 through 9/13/23, showed no documentation of behaviors related to his/her diagnosis of unspecified psychosis. Review of the facility's monthly fall logs showed on 9/13/23 at 4:30 A.M., the resident fell in his/her bathroom. The resident told staff he/she lost his/her balance. Review of the resident's nursing progress notes, from 9/13/23 through 10/6/23, showed no documentation of behaviors related to his/her diagnosis of unspecified psychosis. Review of the resident's October 2023 POS showed an order for Seroquel 25 mg by mouth one time daily for unspecified psychosis not due to a substance or known physiological condition (original order date of 5/16/22). Review of the resident's physician progress notes, dated 10/6/23, showed nursing notes no problems (indicating the resident did not have behaviors during thislook backk assessment). Review of the resident's nursing progress notes, from 10/6/23 through 10/13/23, showed no documentation of behaviors related to his/her diagnosis of unspecified psychosis. Review of the resident's care plan, dated 10/13/23, showed no focus, goals or interventions specific to the use of the antipsychotic medication Seroquel. Review of the resident's nursing progress notes, from 10/13/23 through 10/23/23, showed no documentation of behaviors related to his/her diagnosis of unspecified psychosis. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated 10/23/23, showed the following: -Cognitively impaired; -No behaviors related to psychosis; -Medical diagnosis of Alzheimer's disease and seizure disorder (a sudden, uncontrolled burst of electrical activity in the brain which can cause changes in behavior, movements, feelings); -One fall during thelook backk period; -Received an antipsychotic medication; -No gradual dose reduction (GDR), declined by physician. Review of the resident's nursing progress notes, from 10/23/23 through 10/30/23, showed no documentation of behaviors related to his/her diagnosis of unspecified psychosis. Observation on 10/30/23 at 11:15 A.M. showed the resident lay in his/her bed and appeared to be sleeping. Observation on 10/31/23 at 4:30 P.M. showed the resident lay in his/her bed and appeared to be sleeping. Observation on 11/2/23 at 9:35 A.M. showed the resident lay in his/her bed and appeared to be sleeping. During an interview on 11/02/23 at 1:30 P.M., Licensed Practical Nurse (LPN) F said the resident usually did not have any behaviors. 2. Review of Resident #32's physician's orders, dated 1/9/21, showed the following: -Risperidone (anti-psychotic medication), give 0.5 mg by mouth two times per day; -Risperidone give 1 mg by mouth once daily; -Diagnoses of unspecified dementia, unspecified severity with behavioral disturbance and altered mental status. Review of Drugs.com for Riperidone showed the following: -Risperidone is used to treat schizophrenia and to treat symptoms of bipolar disorder (manic depression); -Risperidone may increase the risk of death in older adults with dementia-related psychosis and is not approved for this use. -Call your physician at once if you have uncontrolled muscle movements in your face (chewing, lip smacking, frowning, tongue movement, blinking or eye movement); -Common side effects may include headache; dizziness, drowsiness, feeling tired; tremors, twitching or uncontrollable muscle movements; agitation, anxiety, restless feeling. Review of the resident's Note to Attending Physician/Prescriber, dated 3/7/23, showed the following: -This elderly dementia resident has an order for the following antipsychotic medication; -Risperidone 0.5 mg twice daily and 1 mg at bedtime (for dementia with behaviors); -NOTE: Risperidone carries a black box warning regarding the increased risk of mortality in elderly dementia residents. Documentation should be in the chart to justify use of an antipsychotic. In reviewing the behavior monitoring, the only behaviors noted are making faces, general restlessness.) These do not justify use of antipsychotics; -As you are aware, there are various CMS-related medication usage requirements related to the use of all psychoactive medications. This recommendation is a reminder to conduct an evaluation in an attempt to establish the lowest effective dose with the fewest number of medications through periodic reduction and/or discontinuation, and does not necessarily reflect his/her clinical judgment or opinion regarding the discontinuation or reduction; -Please review the resident's psychotropic medications and consider a GDR of risperidone to 0.5 mg three times daily (twice daily and at bedtime) to ensure this resident is using the lowest possible effective/optimal dose; -The physician marked: Attempted GDR would likely impair the resident's function. Continue risperidone; -Signed by the resident's physician 3/9/23. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Short and long-term memory problems; -No behaviors; -No rejection of care; -A GDR had not been attempted; -A GDR had been documented by a physician as clinically contraindicated. Review of the resident's care plan, dated 6/6/23, showed the following: -Report any behavior changes to the charge nurse: increased sleeping or restlessness; -Significant side effects of psychotropic medication therapy may include any of the following: drop in blood pressure, uncontrolled mouth movements, continual body movements, cognitive and behavioral changes. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Short and long-term memory problems; -No behaviors; -No rejection of care; -The resident received anti-psychotic medications on a routine basis; -A GDR has not been attempted; -A GDR has been documented by a physician as clinically contraindicated on 6/15/23. Review of the resident's Note to Attending Physician/Prescriber, dated 9/7/23, showed the following: -This elderly dementia resident has an order for risperidone 0.5 mg twice daily and 1 mg at bedtime (for dementia with behaviors); -NOTE: Risperidone carries a Black Box Warning regarding the increased risk of mortality in elderly dementia residents. Documentation should be in the chart to justify use of an antipsycotic along with daily behavior monitoring; -Please review the resident's psychotropic medications and consider a GDR ofRisperdall three times daily, to ensure this resident is using the lowest possible effective/optimal dose; -The physician marked, attempted GDR would likely impair the resident's function. A GDR would likely cause psychiatric instability by exacerbating underlying psych disorder. Review of the resident's nurses' notes showed the following: -On 9/11/23 at 10:07 P.M., staff documented the resident was making faces, strange movements; -On 9/25/23 at 9:39 P.M., staff documented the resident was making faces, strange movements; Review of the resident's physician's orders, dated October 2023, showed the following: -Risperidone (anti-psychotic medication), give 0.5 mg by mouth two times per day (original order dated 1/9/21); -Risperidone give 1 mg by mouth once daily (original order dated 1/9/21); -Diagnoses of unspecified dementia, unspecified severity with behavioral disturbance and altered mental status. Review of the resident's nurses' notes, dated 10/23/23 at 9:58 A.M., showed staff documented the resident was alert/oriented to person only. Very anxious/restless most of the time. Resistive with care at times. Review of the resident's MDS chart note, dated 10/23/23 at 7:29 P.M., showed the following: -The resident rarely speaks at all; -No behaviors were noted; -The resident continued to decline and become more withdrawn. Review of the resident's MDS chart note, dated 10/25/23 at 12:06 A.M., showed the resident continues to decline and exhibit more isolating behaviors. Review of the resident's nurses' notes, dated 10/27/23 at 9:07 A.M., showed staff documented the resident was very anxious/restless most of the time. The resident is resistive with cares at time. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Short and long-term memory problems; -No behaviors; -No rejection of care; -High risk medication classes: antipsychotic; indication noted: blank; -GDR documented by a physician as clinically contraindicated on 6/15/23. Review of the resident's nurses' notes dated 10/28/23 at 5:20 P.M. showed staff documented the resident was making faces, general restlessness, repetitive mannerisms, and was anxious. Observation on 11/1/23 at 6:12 A.M. showed the resident sat in his/her Broda chair in the TV area by the nurse's station. His/Her eyes were wide open and he/she rocked his/her upper body back and forth. Observation on 11/1/23 at 7:47 A.M. showed the resident sat in his/her Broda chair in the TV area by the nurse's station. His/Her eyes were closed, and he/she continued with upper body rocking movement. Observation on 11/1/23 at 9:49 A.M. showed the resident sat in his/her Broda chair in the TV area by the nurses' station. The resident was awake and had intermittent upper body rocking movement. Observation on 11/1/23 at 9:50 A.M. showed the resident sat in his/her Broda chair in the TV area by the nurses' station. His/Her eyes were closed, and he/she had intermittent upper body rocking movement. Continuous observation on 11/1/23 from 10:04 A.M. to 10:28 A.M. in the TV area by the nurses' station showed the following: -The resident sat in his/her Broda chair with his/her eyes closed; -The resident had intermittent upper body rocking movement. During an interview on 11/1/23 at 10:55 A.M., Certified Nurse Assistant (CNA) J said he/she was not sure why the resident rocked/moves his/her upper body but the resident did it all the time. During an interview on 11/2/23 at 12:35 P.M., LPN Q said the following: -The resident didn't have behaviors but was very anxious all the time; -Staff could usually tell by the look in the resident's eye if he/she was feeling anxious; -The resident's upper body rocking/movements means the resident is anxious; -If the resident seems anxious, staff just talk to him/her and let him/her know they are around; -When the resident is relaxed, he/she doesn't have the upper body rocking/movements. 3. Review of Resident #17's face sheet showed the following: -admission on [DATE]; -Vascular dementia (brain damage caused by multiple strokes), unspecified severity, with behavioral disturbance; -Generalized anxiety disorder (severe, ongoing anxiety that interferes with daily activities); -Sleep disorder (involves problems with the quality, timing, and amount of sleep, which result in daytime distress and impairment in functioning), unspecified; -Alzheimer's disease. Review of the resident's Physician's Orders for September 2023 showed an order for risperidone (a medication used in the treatment of schizophrenia, bipolar disorder, autism spectrum disorder, and helps regulate mood, behaviors, and thoughts) 0.5 mg tablet, give one tablet three times per day for diagnosis of generalized anxiety disorder (original order dated 5/23/22). Review of the document, Note to Attending Physician/Prescriber, dated 9/8/23, showed the consulting pharmacist said the following: -The resident had an order for risperidone (a medication used in the treatment of schizophrenia, bipolar disorder, autism spectrum disorder, and helps regulate mood, behaviors, and thoughts) 0.5 mg. every day for a diagnosis of anxiety and dementia with behaviors; -These are off-label indications for risperidone, and it carries a Black Box Warning regarding the increased risk of mortality in elderly dementia patients. Documentation should be in the chart to justify use of an antipsychotic along with daily behavior monitoring; -Please review this residents psychotropic medications and consider a GDR of risperidone possibly reducing morning dose to 0.25 mg, to ensure this resident is using the lowest possible effective/optimal dose; -The physician responded by checking the responses: Attempted GDR would likely impair the resident's function, and GDR would cause psychiatric instability by exacerbating underlying psych disorder; -The physician added, Continue risperidone. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Rarely understood; -No behaviors related to psychosis; -Medical diagnosis of Alzheimer's disease, dementia, and anxiety disorder; -Received an antipsychotic medication on a routine basis; -No gradual dose reduction (GDR) documented by a physician as clinically contraindicated. Review of the resident's care plan, dated 10/30/23, showed the following: -The resident exhibits physically and verbally abusive behavior towards staff and other residents; -Administer prescribed medications as ordered; -Psychotropic medication for dementia and agitation; -Monitor for adverse side effects or toxicity. Review of the resident's Physician's Orders, dated November 2023, showed an order for risperidone 0.5 mg tablet, give one tablet three times per day for diagnosis of generalized anxiety disorder (original order dated 5/23/22). 4. During an interview on 11/02/23 at 12:40 P.M., the consulting pharmacist said the following: -Alzheimer's disease, dementia with behavioral disturbance, unspecified psychosis are all off-label (unapproved indication or in an unapproved age group) diagnoses for antipsychotic use due to the black box warning (a warning for certain prescription drugs that the United States Food and Drug Administration (FDA) specifies has potential serious side effects with their use); -Some of the adverse effects of antipsychotic medications can include falls, somnolence (increased sleepiness), low blood pressure and extrapyramidal side effects (EPS), drug-induced movement disorders; -She has regularly made recommendations to the providers (physicians and nurse practitioners) to wean and discontinue the use of antipsychotic medications in residents without an appropriate supporting diagnosis because of the potential side effects unless the resident is having behaviors that would indicate the need for the medication; -Residents on antipsychotic medications should have behavior monitoring completed routinely. If there is no documentation of behaviors, then there isn't a need for the antipsychotic medication. During an interview on 11/02/23 at 2:56 P.M., the director of nurses (DON), said the following: -Some of the providers (physicians and nurse practitioners) will wait to see the consulting pharmacist's recommendations before a drug change (an antipsychotic) is made; -Facility staff should be documenting if a resident is having behaviors in the progress notes; -Dose reductions are up to the physician.

Based on observation, interview, and record review, the facility failed to ensure meals were served to meet the nutritional needs of the residents when staff failed to prepare and serve food according to the diet spreadsheet menu. Staff also failed to have recipes readily available for staff to utilize when preparing food items listed on the diet spreadsheet menu. The facility census was 51. The facility did not have a policy related to preparing and serving food according to the diet spreadsheet menu or availability of recipes. 1. Review of the Diet Orders, obtained 10/30/23, showed the following: -Thirty-four residents with a physician-ordered regular diet; -Twelve residents with a physician-ordered mechanical soft diet; -Five residents with a physician-ordered heart healthy diet; -Two residents with a physician-ordered consistent carbohydrate (CCHO) diet; -Two residents with a physician-ordered no concentrated sweets (NCS) diet; -Four residents with a physician-ordered low concentrated sweets (LCS) diet. Review of the Diet Spreadsheet, for 10/30/23 (Day 2, Monday) Lunch, showed the following: -Staff were to serve one garlic bread stick to residents with a regular diet; -Staff were to serve one slice of bread and one teaspoon of margarine to residents with a mechanical soft diet; -Staff were to serve one slice of bread to residents with a heart healthy diet; -Staff were not to serve a bread item to residents with a CCHO (LCS); -Staff were to serve baked mostaccioli to residents with a regular, mechanical soft, and CCHO (LCS) diet; -Staff were to serve lightly sauced mostaccioli with ground beef to residents with a heart healthy diet. During an interview on 10/31/23 at 9:18 A.M., the Registered Dietitian said residents with diet orders for NCS, LCS, and CCHO were considered the same, and staff should use the CCHO (LCS) column of the diet spreadsheet to determine what items to serve residents with those diet orders. Observation on 10/30/23, from 11:50 A.M. to 12:43 P.M., during the lunch meal service in the kitchen, showed [NAME] B served one garlic breadstick and baked mostaccioli to all residents with regular, heart healthy, LCS, NCS, and CCHO diets. During an interview on 10/30/23 at 1:45 P.M., [NAME] B said the following: -He/She was not familiar with the diet spreadsheet menu and had not seen it before; -He/She was not familiar with the specific diet types, such as heart healthy, NCS, LCS or CCHO, that were listed on the diet spreadsheet menu; -He/She was unaware residents with a heart healthy diet order were to be served a slice of bread and lightly sauced mostaccioli with ground beef; -He/She was unaware residents with a LCS, NCS, or CCHO diet order were not to be served a garlic bread stick; -He/She was just the cook and thought the certified nurse aides (CNAs), who brought residents their food, would take items off of a resident's plate if there was something a resident was not supposed to have. During an interview on 10/31/23 at 9:52 A.M., the Dietary Manager said she expected staff to follow the diet spreadsheet menu when serving food items to residents. During an interview on 10/31/23 at 9:18 A.M., the Registered Dietitian said staff should be familiar with and use the diet spreadsheet menu when serving food items to residents. 2. Review of the Diet Spreadsheet, for 10/30/23 (Day 2, Monday) Lunch, showed the following: -Staff were to serve chopped soft Italian blend vegetables to residents with a mechanical soft diet; -Staff were to serve lightly sauced mostaccioli with ground beef to residents with a heart healthy diet. Review of the recipe binder, located on the kitchen preparation counter, showed no recipes for chopped soft Italian blend vegetables or lightly sauced mostaccioli with ground beef. Observation on 10/30/23, from 11:50 A.M. to 12:43 P.M. during the lunch meal service in the kitchen, showed the following: -Staff served Italian blend vegetables (not chopped soft) to residents with a mechanical soft diet; -Staff served baked mostaccioli (not lightly sauced mostaccioli with ground beef) to residents with a heart healthy diet. During interview on 10/31/23 at 9:52 A.M., the Dietary Manager said not all of the recipes for the current menu cycle were in the binder because he/she had trouble with his/her printer and didn't get them all printed and placed into the recipe binder.

Based on observation, interview, and record review, the facility failed to ensure residents with a physician order for a mechanical soft diet (a texture-modified diet that restricts foods that are difficult to chew or swallow) received food items with the proper texture. The facility census was 51. Review of the facility policy, Dental Soft (Mechanical Soft) Diet, dated 2022, showed the following: -The Dental Soft (Mechanical Soft) Diet is for individuals with limited or difficulty in chewing regular consistency foods; -The diet consists of food of nearly regular textures but excludes very hard, crunchy, or hard to chew foods; -Foods should be moist and fork tender; -Dry, hard crusty breads are excluded; -Vegetables are cooked soft, moist, and fork tender with no large chunks or pieces; -All vegetables should be chopped or diced into bite-size pieces (0.5 inches or smaller). Review of the Diet Orders, obtained 10/30/23, showed 12 residents with a physician-ordered mechanical soft diet. Review of the Diet Spreadsheet, for 10/30/23 (Day 2, Monday) Lunch, showed staff was to serve chopped soft Italian blend vegetables and a slice of bread and margarine to residents on a mechanical soft diet. Observation on 10/30/23, from 11:50 A.M. to 12:43 P.M. during the lunch meal service in the kitchen, showed [NAME] B served Italian blend vegetables and a garlic breadstick to the residents with a mechanical soft diet. Observation on 10/30/23 at 12:44 P.M. of the test tray, obtained after all residents had been served during the lunch meal service, showed the following: -The Italian blend vegetables contained Italian green beans that were approximately one to three inches in size and crinkle-cut carrots that were approximately one inch wide. The crinkle-cut carrots and Italian green beans were firm when chewed and were not soft when a fork was inserted into them; -The garlic bread stick had a dense, sponge-like texture that was difficult to chew. During an interview on 10/30/23 at 1:45 P.M., [NAME] B said the following: -He/She was unaware residents with a mechanical soft diet order were to be served a slice of bread and margarine and not the garlic bread stick; -He/She did not prepare the chopped soft Italian blend vegetables and thought the Italian blend vegetables (served to residents on a regular diet) were soft enough to serve to residents with a mechanical soft diet order. During an interview on 10/31/23 at 9:52 A.M., the Dietary Manager said she expected staff to serve food items per the diet spreadsheet menu and the residents' physician orders for texture. She was unaware staff did not prepare or serve the chopped soft Italian vegetables, bread, and margarine to residents with an order for a mechanical soft diet. During an interview on 10/31/23 at 9:18 A.M., the Registered Dietitian said staff should prepare and serve foods at the appropriate texture as ordered by a resident's physician. Staff should serve the food items as listed on the diet spreadsheet menu.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure nursing staff performed appropriate hand hygiene and changed gloves during the provision of care for three residents (Residents #8, #17, and #32), in a review of 15 sampled residents. The facility census was 51. Review of the facility's undated hand hygiene policy showed to use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: -Before and after direct contact with residents; -Before donning sterile gloves; -Before moving from a contaminated body site to a clean body site during resident care; -After contact with a resident's intact skin; -After contact with blood or bodily fluids; -After handling used dressings, contaminated equipment, etc.; -After removing gloves; Review of Infection Control Guidelines for Long-Term Care Facilities emphasis on Body Substance Precautions, dated July 1999, showed the following: -Handwashing remains the single most effective means of preventing disease transmission. Wash hands often and well; -Wash hands whenever they are soiled with body substances, before performing invasive procedures and when each resident's care is completed. 1. Review of Resident #17's care plan, dated 07/03/23, showed the resident required extensive assistance with personal hygiene and total assistance from two staff for bed mobility and toileting hygiene. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated 10/15/23, showed the following: -Required substantial to maximal assistance with toileting hygiene and mobility; -Always incontinent of bowel and bladder. Observation on 11/01/23 at 7:20 A.M. showed the following: -Certified Nurse Assistant (CNA) H entered the resident's room and washed his/her hands with soap and water and donned gloves; -The resident lay in bed and was incontinent of bladder; -CNA H wiped the resident's inner, upper thighs and perineum (the area between the genitals and the rectal opening) with the wet wash cloth, then dried the areas with a towel; -CNA H did not change gloves and assisted CNA I to turn the resident to his/her right side by touching the resident on his/her left shoulder and left hip, pulled the soiled incontinence brief out from under the resident, and tucked a new incontinence brief under the resident; -CNA H, wearing the same gloves, assisted CNA I to turn the resident onto his/her back by touching the resident's left shoulder and left hip, and fastened the resident's new incontinence brief. During an interview on 11/2/23 at 9:45 A.M., CNA H said the following: -Staff should wash hands before, during and after the care of a resident; -Staff should wash hands, or at least use hand sanitizer, between changing gloves; -Staff should change gloves after providing perineal care and before putting on new gloves. 2. Review of Resident #8's quarterly MDS, dated [DATE], showed the following: -He/She was dependent on staff for toileting hygiene; -He/She required substantial/maximal assistance with rolling left and right, lying to sitting, and chair/bed-to-chair transfer; -Always incontinent of bladder and bowel. Review of the resident's care plan, updated 8/11/23, showed the following: -The resident was incontinent of bladder and bowel and required incontinence care; -The staff provided incontinence care every two hours and as needed. Observation on 11/1/23 at 1:53 P.M., showed the following: -Certified Nurse Aide (CNA) J and CNA M washed their hands and donned gloves; -The CNAs transferred the resident from the wheelchair to bed; -The resident was incontinent of urine; -CNA M washed the resident's groin, pubis, and genital area, and without removing his/her gloves and washing his/her hands, assisted the resident to turn on his/her side while touching the resident; -CNA J washed the resident's buttocks and between the resident's buttocks; -Without removing their gloves and performing hand hygiene, CNA J and CNA M put the clean incontinence brief on the resident. During an interview on 11/1/23 at 2:00 P.M., CNA J said the following: -The staff were supposed to wash hands and put on gloves before providing resident care, then take off gloves and wash hands after resident care was completed; -The staff were supposed to change gloves and wash hands when their hands become dirty; -He/She did not wash his/her hands or change gloves after providing incontinence care and before touching the clean, disposable incontinence brief; -He/She forgot since it was just a brief change and he/she was not getting the resident back up to the wheelchair. 3. Review of Resident #32's care plan, dated 6/6/23, showed the following: -The resident required total assistance with all activities of daily living (ADLs); -Staff will provide incontinence care every two hours. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Dependent on staff for toileting hygiene; -Always incontinent of bladder and bowel. Observation on 11/2/23 at 1:47 P.M., showed the following: -CNA J and CNA N washed their hands and put on gloves; -The resident lay in bed and was incontinent of bowel and bladder; -CNA J unfastened the resident's incontinence brief and tucked it under the resident; -CNA J cleaned the resident's groin, pubis, and genital area; -CNA J placed the soiled washcloths used to clean the resident directly on the bedside table without a barrier; -CNA J tucked the soiled incontinence pad, soiled incontinence brief, resident's pants, lift sling, and clean incontinence brief under the resident. (CNA J did not remove his/her gloves prior to handling the clean incontinence brief); -CNA N removed all the soiled items out from under the resident and put the linens in a bag and put the incontinence brief in trash bag; -Without removing his/her gloves and performing hand hygiene, CNA N pulled the clean incontinence brief out from under the resident, then fastened the clean incontinence brief. During an interview on 11/2/23 at 2:10 P.M., CNA N said the following: -He/She should have waited to separate the linen and soiled incontinence brief until the resident had a clean brief on and was covered up with a blanket; -He/She was focused on keeping soiled items off the bed and floor, so he/she did not think about handling the soiled linens/incontinence brief. During an interview on 11/2/23 at 2:15 P.M., CNA J said the following: -He/She did not know why he/she put soiled washcloths on the bedside table. -He/She was focused on not touching anything clean until the incontinence care was done. 4. During an interview on 11/2/23 at 2:56 P.M., the Director of Nurses (DON) said staff should wash their hands before and after putting on gloves, and before, during, and after providing personal care to a resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to complete inspections of bed frames, mattresses and bed rails as part of a regular maintenance program to identify areas of possible entrapment for four residents (Residents #3, #33, #37 and #40), in a review of 15 sampled residents, and for two additional residents (Residents #11 and #27) who used bed rails. The facility census was 51. Review of the Food and Drug Administration (FDA) document titled, Guide to Bed Safety Rails in Hospitals, Nursing Homes and Home Health Care: The Facts, revised April 2010, shows the potential risk of bed rails may include: -Strangling, suffocating, bodily injury or death when patients or part of their body are caught between rails or between the bed rails and mattress; -More serious injuries from falls when patient climb over rails; -Skin bruising, cuts and scrapes; -Inducing agitated behavior when bed rails are used as a restraint; -Feeling isolated or unnecessarily restricted; -And preventing patients, who are able to get out of bed, from performing routine activities such as going to the bathroom, or retrieving something from a closet. 1. Review of Resident #11's care plan, date 08/09/23, showed the following: -Falling star plan of care due to history of seizures, dementia, rib fractures from falling and multiple falls; -May have mobility bars on his/her bed for transfers, bed positioning/mobility and comfort. Review of the resident's medical record showed no evidence staff conducted an inspection of the resident's bed frame, mattress and mobility bars to identify areas of possible entrapment. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/23/23, showed the following: -Cognitively impaired; -Independent for mobility. Observation on 10/30/23 at 11:15 A.M. showed the resident lay in his/her bed with mobility bars (inverted, u-shaped bars attached to the bed to aid mobility) on both sides of the resident's bed. Observation on 10/31/23 at 4:30 P.M. showed the resident lay in his/her bed with mobility bars on both sides of the resident's bed. Observation on 11/01/23 at 6:35 A.M. showed the resident lay in his/her bed with mobility bars on both sides of the resident's bed. Observation on 11/2/23 at 9:35 A.M. showed the resident lay in his/her bed with mobility bars on both sides of the resident's bed. 2. Review of Resident #33's care plan, date 06/13/23, showed the following: -The resident is a high fall risk due to cognition, multiple disease processes, and frequent falls; -Mobility bars on bed to assist with transfers and bed positioning/comfort. Review of the resident's medical record showed no evidence staff conducted an inspection of the resident's bed frame, mattress and mobility bars to identify areas of possible entrapment. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively impaired; -Medical diagnosis of Alzheimer's disease; -Two or more falls during the look back period. Observation on 10/30/23 at 11:15 A.M. showed the resident lay in his/her bed with mobility bars on both sides of the resident's bed. Observation on 10/31/23 at 9:50 A.M. showed the resident lay in his/her bed with mobility bars on both sides of the resident's bed. The resident's right hand and wrist rested through and within the frame of the mobility bar. Observation on 11/01/23 at 6:30 A.M. showed the resident lay in his/her bed with mobility bars on both sides of the resident's bed. 3. Review of Resident #40's quarterly MDS, dated [DATE], showed the following: -The resident was cognitively intact; -He/She was independent with rolling left and right; -He/She required maximum assistance with sitting to lying, lying to sitting on the side of bed, sit to stand, and chair/bed-to-chair transfer; -Diagnoses included transient ischemic attack (a temporary blockage of blood flow to the brain), lumbar region spondylosis (age-related change of the bones and discs of the spine), and lumbar region spinal stenosis (narrowing of the spinal canal in the lower back). Review of the resident's care plan, dated 10/12/23, showed bilateral mobility bars on his/her bed for assist with transfers, bed positioning, and comfort. Review of the resident's medical record showed no evidence staff conducted an inspection of the resident's bed frame, mattress and mobility bars to identify areas of possible entrapment. Observations on 10/31/23 at 1:01 P.M. and on 11/2/23 at 6:10 A.M. showed the resident lay in bed with bilateral mobility devices on the bed. 4. Review of Resident #37's quarterly MDS, dated [DATE], showed the following: -The resident was cognitively intact; -He/She required maximum assistance with rolling left and right in bed. Review of the resident's care plan, dated 8/14/23, showed the following: -The resident had impaired ADL function due to paralysis (loss of muscle function in part of the body) from stroke and multiple disease processes; -Provide mobility bars on the resident's bed to assist with positioning and comfort. Observation on 11/2/23 at 6:10 A.M., showed the resident lay in bed with bilateral mobility devices on both sides of the bed. Review of the resident's medical record showed no evidence staff conducted an inspection of the resident's bed frame, mattress and mobility bars to identify areas of possible entrapment. 5. Review of Resident #27's care plan, dated 6/20/23, showed the following: -The resident is a fall risk due to multiple disease processes: right side paralysis, seizures and general muscle weakness; -Half side rails on his/her bed for position change and comfort; -He/She is transferred by full body lift with two staff. Review of the resident's annual MDS, dated [DATE], showed the following: -Cognitively intact; -Diagnosis of osteoporosis (a disease in which bones become fragile and more likely to break). Review of the resident's October and November 2023 physician's orders showed an order for half side rails on bed for bed mobility, transfers and positioning. Observations on 10/30/23 at 10:55 A.M. and on 11/2/23 at 12:36 P.M. showed mobility bars on both sides of the resident's bed. Review of the resident's medical record showed no evidence staff conducted an inspection of the resident's bed frame, mattress and mobility bars to identify areas of possible entrapment. 6. Review of Resident #3's care plan, dated 6/22/23, showed the following: -Falling Star Plan of Care due to multiple disease processes: anxiety, muscle weakness, chronic pain, poor balance and history of falls with fractures; -Left side of the bed is against the wall per his/her preference; -Half side rail on his/her bed on his/her right side for positioning, transfers, and bed mobility. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Rarely/never understood; -Short and long-term memory okay; -Diagnosis of hemiplegia (paralysis on one side of the body) or hemiparesis (one sided muscle weakness). Review of the resident's October 2023 and November 2023 physician's orders showed may have half side rail on his/her right side for bed mobility, transfers, and positioning. Observations on 10/30/23 at 10:49 A.M. and on 11/2/23 at 12:35 P.M. showed mobility bars on both sides of the resident's bed. Review of the resident's medical record showed no evidence staff conducted an inspection of the resident's bed frame, mattress and mobility bars to identify areas of possible entrapment. 7. During an interview on 11/02/23 at 12:25 P.M., the Director of Nurses (DON) said the facility did not have a policy in place for measuring the entrapment zones or a regular maintenance program to identify areas of possible entrapment. No one was responsible for the assessment of entrapment zones.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards for food service safety. Staff failed to properly thaw potentially hazardous foods in order to prevent cross contamination to other food items. Staff failed to discard food that was expired or showed visible signs of deterioration, failed to store and handle food products to maintain quality and free from potential contaminants, and failed to label and date opened food items. Staff failed to ensure foodware and drinkware was handled appropriately and protected from moisture, debris, and other contaminants and surfaces and equipment were properly cleaned and sanitized. Staff failed to ensure hygienic practices when preparing and serving food and beverages to residents and employ proper hand hygiene and surface sanitization practices. Staff failed to ensure an adequate air gap was present at the drain for three of the facility's five ice machines to prevent possible backflow contamination into the units. The facility census was 51. Review of the facility policy, Food Storage (Dry/Refrigerated/Frozen), dated 2011, showed the following: -Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety; -Discard food that has passed the expiration date, and discard food that has been prepared in the facility after seven days of storing under proper refrigeration; -Leftover contents of cans and prepared food will be stored in covered, labeled and dated containers in refrigerators and/or freezers; -Store raw animal foods such as eggs, meat, poultry, and fish separately from cooked and ready-to-eat food. If they cannot be stored separately, place raw meat, poultry, and fish items on shelves beneath cooked and ready-to-eat items; -Wrap food properly. Never leave any food item uncovered and not labeled; -Defrost freezers regularly to improve their efficiency. Review of the facility policy, Handling Leftover Foods, dated 2011, showed the following: -Leftover foods will be properly handled, cooled, and stored to ensure food safety and minimal waste; -Leftover foods stored in the refrigerator shall be wrapped, dated, labeled with a use by date that is no more than 72 hours from the time of first use; -Refrigerated leftovers stored beyond 72 hours shall be discarded; -Leftover foods stored in the freezer shall be wrapped air-tight and moisture proof, dated, and labeled; -All staff are trained in the preparation and handling of leftovers. 1. Observation on 10/30/23 at 10:43 A.M., of the walk-in cooler located in the kitchen, showed the following: -A three-tiered, rolling cart sat in the middle of the walk-in cooler; -Two large, clear bags of raw chicken sat in a tub on the top shelf of the cart. Red liquid was visible within the bags and the tops of the bags overhung the edges of the tub; -Two large packages of raw pork loins, that were semi-firm to the touch, sat on a shallow baking sheet on the second shelf of the cart; -Two unopened 6-pound packages of pre-cooked iced sheet carrot cake and a metal pan of approximately five packages of uncooked ground sausage sat next to each other on the bottom shelf of the cart. During an interview on 10/30/23 at 10:43 A.M., [NAME] A said the packages of carrot cake should not have been placed next to or under the thawing raw meat items on the cart. During an interview on 10/31/23 9:52 A.M., the Dietary Manager said raw food items should not be thawed above or beside pre-cooked and ready-to-eat items. 2. Observations on 10/30/23 at 10:14 A.M. and 1:21 P.M. and on 10/31/23 at 9:18 A.M., in the kitchen, showed the following: -An 18-ounce package of honey wheat bread, located on the shelves below the main food preparation counter, was firm to the touch and had a dry, powdery yellow- and gray-colored substance that coated the entire interior contents of the package; -An opened 24-ounce bottle of caramel topping, with a label that read For Best Quality, Refrigerate After Opening, was not refrigerated and sat on the seasoning storage shelf; -An opened 20-ounce container of grape jelly and an opened 32-ounce bottle of lemon juice, both with labels that read Refrigerate After Opening, were not refrigerated and sat on the seasoning storage shelf. Observation on 10/30/23 at 10:35 A.M., of the walk-in freezer located in the kitchen, showed the following: -An uncovered, unlabeled, and undated small black bowl, which sat on top of individually-packaged 4-ounce containers of orange cream Magic Cup desserts, contained a previously-melted and refrozen light-orange substance; -A half-full 2-gallon zipper-top bag of cooked pancakes was undated; -A 4-ounce package of strawberry ice cream had the seal partially open and previously-melted ice cream was visible on the package rim and cardboard seal; -Three 4-ounce packages of raspberry sherbet had previously-melted raspberry sherbet residue on top of the cardboard seals and package rims; -An excessive amount of ice accumulation, located on and under the fan portion of the walk-in freezer, showed frozen drips of ice and large chunks of ice on a cardboard box of food and on the metal shelves on which the box sat; -A 15-pound box of catfish nuggets, with an order date of 08/21/22 and no visible manufacturer's expiration date, had the plastic interior bag unsealed and the catfish nuggets exposed to air; During an interview on 10/30/23 at 10:43 A.M., [NAME] A said the bag of pancakes and the bowl (of orange substance) should not have been in the walk-in freezer. During an interview on 10/30/23 at 10:57 A.M., the Dietary Manager said she was aware of the unsealed catfish nuggets in the walk-in freezer and said they should have been sealed. Observation on 10/30/23 at 10:43 A.M., of the walk-in cooler located in the kitchen, showed the following: -A half-full pitcher of a light pink liquid was labeled Str. [NAME]. 10-24. The rim and underneath of the pitcher's lid had pink liquid residue surrounding it from being previously poured from the pitcher; -A half-full pitcher of a red liquid was labeled Nectar Cherry 10-25. The rim and underneath of the pitcher's lid had red liquid residue surrounding it from being previously poured from the pitcher. Observation on 10/30/23 at 11:28 A.M., of the resident activities room, showed the following: -The freezer portion of the refrigerator contained a large, full container, labeled 6-16, of an unknown reddish-colored substance and an unsealed and undated bag of four waffles with an excess amount of ice crystals; -The refrigerator contained a large, 1/8-full container, labeled 9-27, of an unknown reddish-colored substance, an unsealed and loosely wrapped ¼-full 16-ounce paper package of 55% vegetable spread, an unlabeled and undated clear container of an unknown white substance, and an unlabeled and undated foil-wrapped item that was loosely wrapped around the item; -The cabinets near the refrigerator contained an unsealed half-full 2-pound bag of powdered sugar and two 16.3-ounce jars of peanut butter with no visible manufacturer's expiration date. During an interview on 10/30/23 at 11:28 A.M., the Activities Director said she had been working on going through the unlabeled and undated food items in the activities room. Observation on 10/30/23 at 1:54 P.M., of the unlocked clean utility room that served the C and D hallways, showed the following: -A sign posted on the upper cabinet read, All food item and coffee supplies are to be stored appropriately in closed containers. Any food left open in the cabinets will be thrown away; -The upper cabinets contained two 24-count boxes of 8-ounce containers of Jevity 1.5 calorie nutritional supplement with a use by date of 07/01/21, a grocery bag of various instant oatmeal packets with no visible manufacturer's expiration date, two packages of toaster pastries with no visible manufacturer's expiration date, and an undated and unlabeled package of saltine crackers that was open and not sealed; -The refrigerator contained an open can of soda that was not labeled with the owner's identifier, an unlabeled and undated clear container of an unknown cream-colored substance, a container labeled Chicken and Noodles Meal to Go with a sell by date of 10/22/23, an unlabeled and undated zipper top bag of an unknown orange-colored substance, an unlabeled and undated clear plastic package of a red-colored substance, and a small unlabeled and undated container of a red-colored substance. Observation on 10/30/23 at 2:21 P.M., of the special care unit, showed the following: -The cabinets near the refrigerator contained a 15-ounce can of pumpkin with a best by date of April 2017, thirteen 0.28-ounce packets of hot cocoa with no visible manufacturer's expiration date, and two undated jars with non-commercial labels that read Hazel Nut Cappuccino Mix and Mocha Cinnamon Cappuccino Mix; -A sign on the refrigerator read, This refrigerator is for resident food only, we have a mini fridge for staff food. I will start throwing food away that does not have a resident's name on it and did not come from the kitchen; -The interior of the refrigerator contained a maroon-colored bowl with a lid labeled 10-21 V; a zipper top bag of sandwiches dated 10/26/23, and a 32-ounce bottle of ranch dressing with a best by date of 07/28/23; -The freezer portion of the refrigerator contained an 8.5-ounce cheese ravioli frozen dinner with a best by date of December 2022. During an interview on 10/31/23 at 9:52 A.M., 10:57 A.M., and 1:16 P.M., the Dietary Manager said the following: -She expected all food items to be labeled, dated, and sealed; -She expected expired foods to be discarded and food items to not show visible signs of deterioration; -She was unaware of the package of honey wheat bread that was coated with the yellow- and gray-colored powdery substance found below the food preparation counter and that the food item should have been discarded; -She expected the manufacturer's label directions for refrigeration to be followed; -She was unaware of the caramel topping, grape jelly, and lemon juice found on the seasoning shelf in the kitchen and the items' need for refrigeration; -She placed cereal, toaster pastries, soups, etc. in the special care unit and clean utility room cabinets for residents in case they needed something to eat between or after meals. She tried to pull out expired items from those food storage areas but employees put items there too; -It was the Activity Director's responsibility to monitor the refrigerator and cabinets in the activity room for expired, unlabeled, and undated food items. 3. Review of the facility policy, Cleaning Instructions: Kettles and Utensils, dated 2011, showed the following: -Kettles and utensils will be cleaned and sanitized regularly; -Clean interior and exterior with hot water and detergent; -Scour when necessary; -Rinse with clean water, sanitize with appropriate sanitizing solution and allow to air dry. Review of the facility policy, Cleaning Instructions: Ice Machine and Equipment, dated 2011, showed the following: -Ice machine and equipment will be kept clean and sanitized, according to the manufacturer's procedures, or according to the following guidelines: -Unplug machine and remove ice, allow machine to defrost; -Wash inside with detergent solution then rinse with clean, hot water and drain; -Sanitize inside with a cloth soaked in sanitizing solution, allow to air dry; -Wipe down exterior with detergent solution; -Rinse and allow to air dry; -Clean underneath and around the machine; -Wash and sanitize ice scoop in dishwashing machine daily; -Store the ice scoop outside the machine in a separate, sanitized container that allows the water to drain and not collect around the scoop. Observation on 10/30/23 at 10:14 A.M., in the kitchen, showed the following: -A heavy accumulation of black encrusted debris was on two cast iron skillets that hung on a pan storage rack located above the food preparation counter; -A heavy accumulation of yellow, crusty debris was located on the left metal guard at the top of the deep fryer; -A moderate accumulation of black buildup was located across the length of the left and back guards that surrounded the flat griddle; -A moderate accumulation of food crumbs and debris was in the flat griddle crumb tray and in the food frying baskets located on top of the deep fryer; -A heavy accumulation of encrusted black debris was on the front three burners of the six-burner stovetop; -Brown, dried residue was visible across 50% of the metal surface located above the oven handle on the second (when viewed left to right) of two oven doors located under the six-burner stovetop. The interior surface of this oven had a moderate accumulation of black, charred debris and the bottom metal plate was not correctly positioned within the bottom component of the stove; -A moderate accumulation of dark yellow grease speckled a 3 foot by 3 foot section of the wall above the deep fryer. A 3 foot crack and a 2 foot crack in the drywall in this area showed areas of loose and broken areas of white drywall; -Dried white splatters of debris speckled the right side of the deep fryer; -A heavy buildup of black encrusted debris was on two metal oven racks that leaned against the deep fryer. The bottom edge of each oven rack sat directly on the floor's surface; -A moderate accumulation of dust and dried brown debris coated a piece of worn foil that covered the bottom shelf of a metal storage rack located rack near the convection oven and steam table. Three steam table pan lids sat on the foil and had a moderate coating of dust and debris on their surface. The rungs of the metal storage rack showed a moderate accumulation of dust and debris on their surfaces; -A moderate accumulation of grease, food crumbs, and trash were on the floor underneath the primary food cooking area that included the six-burner stovetop, oven, griddle, and deep fryer. The wheels of the deep fryer had a moderate accumulation of dust, debris, grease, and hair visible on their surface and intertwined in the wheels' attachment to the deep fryer unit; -An approximate 6-inch by 12-inch section of missing tile, located along the back wall behind the convection oven and stove area, showed the interior portion of the wall with visible wooden studs and exposed drywall. Observation on 10/30/23 at 9:48 A.M., of the ice machine in the kitchen, showed the following: -Moist black and pink debris speckled the length of a horizontal white plastic component, which was located directly above prepared ice; -A moderate buildup of dried white debris was on the unit's gray-colored left interior side and was located next to prepared ice; -Reddish-colored residue was visible along 50% of the front portion of the unit under the ice machine door. Observation on 10/30/23 at 11:41 A.M., of the ice machine located outside of the kitchen and near the staff breakroom, showed the following: -Multiple, small spots of moist black and red residue speckled the white plastic portion of the ice dispenser discharge area. The flap of the ice dispenser was open approximately 0.5 inches with prepared ice and hanging drips of water visible on and above the black and red residue; -Multiple moist dark gray drips and dried white drips were visible on the gray textured plastic portion located around and underneath the ice dispenser discharge area. Observation on 10/30/23 at 1:28 P.M., of the utensil drawers located under the food preparation counter and seasoning storage shelf in the kitchen, showed a beige-colored cloth towel was spread out on the bottom of the third drawer (on the far right side). Various serving utensils and measuring scoops and spoons rested directly on the surface of the cloth. Underneath the cloth towel, there was an approximate 3-inch by 6-inch area of rust on the interior surface of the metal drawer. Observation on 10/30/23 at 1:54 P.M., of the unlocked clean utility room that served the C and D hallways, showed the following: -The ice machine had multiple, small spots of black residue and an area of red staining on the white plastic portion of the ice dispenser discharge area. The flap of the dispenser had a hanging drip of water that made contact with the black reside and red stained area; -Dried white and black residue was visible on the gray textured plastic portion located around and underneath the ice dispenser discharge area; -A plastic bag, trash, and bits of debris were located on the floor underneath the ice machine; -An approximate 2 foot by 3 foot area of tile floor was missing under the ice machine; -A cabinet, located just to the right of the ice machine, had an approximate 0.5 inch gap between an approximate 2-foot by 2-foot portion of veneer that had separated from the end of the cabinet; -The lower cabinet trim and covebase were swollen with water damage and were separated from the cabinet. A section of brown unknown construction material laid under and against the side of the ice machine; -A small refrigerator located in the room contained various food items; -The freezer portion of the refrigerator contained black spots on the right side and an excess of ice. A piece of white material was frozen into the ice; -The bottom portion of the refrigerator contained various brown sticky splatters of an unknown substance and bits of trash and other debris; -The refrigerator's upper door shelf contained a light brown sticky substance. An empty paper bag stuck to the substance when the bag was attempted to be moved. During an interview on 10/30/23 at 10:08 A.M. and on 10/31/23 at 9:52 A.M., the Dietary Manager said the following: -She cleaned the ice machine located in the kitchen monthly by wiping the unit's interior with sanitizer and then wiping it with a wet cloth; -She sometimes cleaned the dispenser-style ice machine located near the employee breakroom but was unaware of how to specifically clean it; -She was unaware of who cleaned the ice machines located in the special care unit and clean utility rooms; -Dietary staff were responsible for cleaning the refrigerators in the special care unit and clean utility room; -There were no established cleaning schedules or specific cleaning tasks assigned to dietary staff. Each dietary staff found an item that needed to be cleaned and worked on cleaning it each shift. During an interview on 10/31/23 at 2:41 P.M., the Director of Support Services,said was aware of the water damage to the cabinets and floor in the clean utility room near the C and D hallways. He said the leak had been fixed but he had not yet had time to repair the damage. 4. Review of the facility policy, Cleaning Instructions: Work Tables and Counters, dated 2011, showed the following: -Work tables and counters will be cleaned and sanitized on a regular basis; -Scrub top and sides with hot, soapy water and rinse with clean, hot water; -Sanitize with a clean cloth and sanitizing solution; -Allow tables and counters to air dry. Review of the facility policy, Hand Washing, dated 01/10/2012, showed the following: -Hand washing remains the single most effective means of preventing disease transmission; -Wash hands often and well; -Hands must be washed before and after removing gloves. Review of the undated facility policy, Infection Control, showed the following: -All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors; -The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Observation on 10/30/23 at 11:45 A.M., in the kitchen, showed the following: -A shallow metal pan, which contained two ice scoops and approximately 1/8 inch of water, sat on top of the ice machine; -Dietary Aide A took the two ice scoops, one in each of his/her hands, and wiped the scoops' ice contact surfaces on the sides of his/her shirt to dry them; -He/She placed plastic sleeves on the ice scoops and placed one scoop on the beverage cart, located in the kitchen, and one scoop on the beverage cart, located in the adjacent dining room; -He/She removed a label from a beverage container, lifted the lid of the trash can with his/her left hand, and placed the label in the trash can; -While placing the label in the trash can, the fingers of his/her right hand touched the interior surface of the trash can liner; -Without washing his/her hands, he/she grasped the handle of the beverage cart (located in the kitchen) with his/her dirty hands and pushed the cart out the kitchen door toward the hallway and dining room area. Continuous observation on 10/30/23 from 11:50 A.M. to 12:43 P.M., in the kitchen during the lunch meal service, showed the following: -Cook B wore gloves and used serving utensils to plate residents' meals at the steam table; -During a pause in plating residents' meals, [NAME] B removed his/her gloves and went to the three-compartment dish sink; -He/She moved a steam table cover, that was located in the second (rinse water) compartment, and dipped the cover in and out of the third (sanitizer) compartment for a total time of 10 seconds. He/She did not fully submerge or allow the cover to soak in the sanitizer solution; -A sign posted above the third sink bay read, Soak all items in sanitizer for 60 seconds; -He/She laid the steam table cover on a large, cloth towel that was spread out on the counter next to the sink. -An inverted clear food processor container with visible moisture on its interior surface, an inverted cast iron skillet, two inverted steam table pan lids, and various food serving utensils were also located on the surface of the towel; -Another large, cloth towel was spread out on a nearby counter near the clean dish storage area. Three clear bowls were inverted on this towel and moisture was visible on the interior surfaces of the bowls; -Cook B obtained new gloves, did not wash his/her hands, used his/her mouth to blow into each glove to partially inflate them prior to donning the gloves, and returned to the steam table to resume plating residents' meals; -He/She used his/her gloved hands to grasp the oven door handle, open the oven door, don oven mitts over his/her gloved hands, remove a pan of mostaccioli from the oven and place the pan on the steam table counter; -He/She removed an almost empty pan of baked mostaccioli from the steam table, placed the full pan of baked mostaccioli into the steam table, and removed the oven mitts from his/her gloved hands; -Using his/her same gloved hands, he/she used a serving utensil to transfer food from the almost empty baked mostaccioli pan to the full baked mostaccioli pan now located in the steam table; -The serving utensil, located in the nearby pan of vegetables on the steam table, slid entirely down into the pan and the handle of the utensil made contact with the vegetables and associated liquid in the pan; -Cook B used his/her same gloved hands to retrieve the utensil from the pan of vegetables and sat it back on the edge of the pan for use when serving residents' meals; -He/She carried the empty pan of baked mostaccioli to the three-compartment sink and placed the pan into the first compartment of the sink to soak; -Without washing his/her hands, he/she removed his/her gloves, donned new gloves, and continued plating residents' meals at the steam table; -He/She touched his/her face with his/her gloved hands, and without washing his/her hands or changing his/her gloves, put a bowl of a dessert item onto a resident's tray; -The serving utensil for the vegetables slid entirely into the pan three additional times during the meal service. Each time, the utensil's handle made contact with the vegetables and associated liquid and [NAME] B used his/her gloved hand to retrieve the utensil and continued serving residents' meals; -Using his/her gloved hands, he/she then obtained a small bowl and touched the rim of the bowl with his/her gloved hands; -He/She scooped green beans, located in a pan on the steam table, into the bowl to serve to a resident; -Cook A informed [NAME] B that the resident required pureed food and [NAME] B poured the green beans from the bowl back into the pan of green beans on the steam table. During an interview on 10/31/23 at 9:52 A.M., the Dietary Manager said once food items were served out of pans from the steam table, those food items should not be returned back to the pans on the steam table. Observation on 10/30/23 at 11:53 A.M., showed Activity Aide R served glasses of tea and water to residents in the memory unit dining room. He/She did not wear gloves and touched the top rims (drinking surfaces) of the drinking glasses with his/her bare hands as he/she served Resident #52 and #29. Observation on 10/30/23 at 12:12 P.M., in the kitchen during the lunch meal service, showed the following: -Dietary Aide C used a cloth to wipe up a spill from the floor located near the steam table and beverage preparation counter; -With the dirty cloth in his/her hands, he/she rested the cloth on the top surface of the beverage preparation counter prior to discarding the cloth in a soiled linen receptacle located in the kitchen; -No staff cleaned or sanitized the surface of the beverage preparation counter after it was touched with the dirty cloth. Observation on 10/30/23 at 1:34 P.M., of the clean dish area in the kitchen, showed the following: -Seven clear plastic cups were inverted on a plastic serving tray and moisture was visible on the interior surfaces of the cups. The entire surface of the cups' rims made contact with the surfaces of the serving trays and did not allow the cups to be effectively air dried; -Five clear plastic fluted bowls were inverted on a cloth towel and moisture was visible on the interior surfaces of the bowls. The entire surface of one bowl's rim made contact with the surface of the cloth towel and the remaining bowls were layered partially on each other in a row with approximately 50% of the remaining bowls' rims making contact with the surface of the cloth towel. Observation on 10/30/23 at 1:38 P.M., of a cart located in the dining room area near the kitchen, showed the following: -Twelve clear plastic cups with handles sat inverted on a serving tray and moisture was visible on the interior surfaces of the cups; -Nine semi-transparent brown and clear small cups were inverted on a serving tray and moisture was visible on the interior surfaces of the cups; -The entire surface of the cups' rims made contact with the surfaces of the serving trays and did not allow the cups to be effectively air dried. Observation on 10/30/23 at 1:36 P.M., of the clean dish area in the kitchen, showed a moist white cloth sat on the counter next to a red sanitizer bucket that was ¼ full of liquid. No staff were present in the area nor were staff using the cloth or associated liquid to sanitize surfaces. Observation on 10/30/23 at 1:31 P.M., in the kitchen, showed [NAME] B used a cloth from a red bucket of liquid to wipe the surface of the food serving counter and steam table. During an interview on 10/30/23 at 1:31 P.M., [NAME] B said the following: -The red bucket contained a solution of detergent and sanitizer; -He/She was unaware of the chemical concentration of the solution and he/she didn't test sanitizer solutions, such as with chemical test strips, to find out the chemical concentration; -He/She thought the Dietary Manager had chemical concentration log sheets in the Dietary Manager's office but he/she wasn't for sure. Observation on 10/31/23 at 9:31 A.M., in the kitchen, showed the following: -Cook A poured tomato juice from a can into a large pan of food, located on the food preparation counter; -He/She opened the lid of the trash can with his/her bare hands and discarded the empty tomato juice can into the trash can; -Without washing his/her hands, he/she put on gloves; -He/She obtained a piece of foil from a large container of foil located on the food preparation counter, and put the foil onto the large pan of food; -He/She placed the foil-covered pan onto a cart, opened the convection oven doors, then opened the oven door, and placed the pan into the oven; -He/She moved the cart to the kitchen hallway, adjusted his/her glasses, and removed his/her gloves; -He/She discarded his/her gloves in the trash can and touched the trash can lid with his/her bare hands. He/She did not wash his/her hands; -With his/her bare dirty hands, he/she touched clean dishes, located in the dish drying area, and put them away in the clean dish storage area; -He/She touched his/her nose, adjusted his/her glasses, and touched and opened the lid of the tea beverage dispenser to look inside of the dispenser; -He/She used a towel to dry moisture from a clean utensil located in the dish drying area and, while grasping the food-contact surface of the utensil with his/her bare dirty hands, hung the utensil on a rack above the food preparation area; -He/She continued using his/her bare dirty hands to move clean dishes from the dish drying area to the clean dish storage area. During an interview on 10/31/23 at 9:52 A.M. and at 1:16 P.M., the Dietary Manager said the following: -She expected staff to practice proper hand hygiene; -She expected staff to wash their hands frequently, such as after performing dirty tasks or after touching their face; -Changing gloves did not substitute the need for hand washing; -Prior to donning gloves, staff should not blow into the gloves to inflate them; -Cleaning cloths used to wipe spills from the floor should immediately be placed in the soiled linens container and not come in contact with food preparation counter surfaces; -Staff should fill the red sanitizer bucks with sanitizer solution from the sanitizer dispenser located by the three-compartment sink; -She expected sanitizing cloths to be fully submerged in the sanitizer solution in the red buckets when not in active use; -Staff did not log chemical levels of sanitizer solution in the red buckets but she expected staff to change the sanitizer solution in the red buckets every hour in order to maintain the proper temperature of the sanitizer solution; -Dishes cleaned in the three-compartment sink should be sanitized in the third compartment by submersing them for at least 60 seconds; -She expected all food and dish contact surfaces and equipment to be cleaned and sanitized appropriately; -Staff should not handle dishware and glassware by the eating and drinking surfaces of those items; -Dishware, cookware, and utensils, including ice scoops, should be air dried and not dried on the surface of staff's clothing or towel-dried; -He/She had not realized that placing dishes to dry on towels or on trays may not be effective at air drying the dishes. 5. Observation on 10/30/23 at 11:41 A.M., of the ice machine located outside of the kitchen and near the staff breakroom, showed the following: -An approximate 5-foot long, vertical section of 1-inch white pipe, located at the back side of the ice machine, connected to an approximate 3-foot long horizontal section of 1-inch pipe; -The 3-foot horizontal pipe connected to a 1-inch elbow that rested on the concrete edge of a floor drain; -The 1-inch drain pipe elbow was flush with the flood rim level of the floor drain and did not contain a sufficient air gap to prevent backflow of liquid back into the ice machine. Observation on 10/30/23 at 2:09 P.M., of the ice machine located in the unlocked clean utility room that served the A and B hallways, showed the fol

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to pull the privacy curtains and close the door leading to the hallway to allow for privacy while providing toileting, incontinence care and dressing for two of 18 sampled residents (Resident #7 and #162). The facility census was 69. Review of the facility policy Quality of Life, Dignity and Privacy dated 3/13/12 showed the following: Each resident should be cared for in a manner that promoted and enhanced quality of life, dignity, respect and individuality; 1. Residents would be treated with dignity and respect at all times; 3. Residents would be groomed as they wished as long as adequate hygiene was maintained; 9. Staff would promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. 1. Review of Resident #7's face sheet showed the following: -admission dated 9/17/18; -Diagnosis of stroke and suicidal ideations. Review of the resident's care plan dated 9/17/19 showed the following: -The resident was total assistance with all Activities of Daily Living (ADL). He/She was unable to get out of a chair or reposition on his/her own. Staff should provide AM and PM care, provide privacy and assist of one to two staff members with transfers. Staff should provide grooming and hygiene needs. He/She was able to choose what he/she wanted to wear each day; -The resident was incontinent of urine and had constipation. Staff should monitor for redness or skin breakdown during toileting/diaper change every two to four hours. Review of the resident's annual MDS dated [DATE] showed the following: -Moderately impaired cognition; -Somewhat important to choose what clothes to wear; -Required limited assistance of one staff member with bed mobility, dressing and personal hygiene; -Required extensive assistance of two staff members with transfers and toileting; -Frequently incontinent of bowel and bladder. Observation on 2/23/20 at 3:30 P.M. showed the following: -Certified Nurse Assistant (CNA) B and Nurse Assistant (NA) C entered the resident's room, closed the door and left the privacy curtain open. The resident's roommate sat in a chair directly across the room with full view of the resident lying in his/her bed. CNA B and NA C did not ask the resident's permission to leave the privacy curtain open; -CNA B removed the resident's incontinence brief and turned the resident side to side and provided incontinence care. The resident was fully exposed from the waist down to his/her roommate; -CNA B and NA C left the resident fully exposed from the waist down and obtained clean supplies and clothing from the resident's closet and sink area. The resident lay in bed fully exposed from the waist down with the privacy curtain open. The resident's roommate remained in a chair directly across the room with full view of the resident; -CNA B and NA C turned the resident side to side and dressed the resident in a clean incontinence brief and clothing; -CNA B and NA C transferred the resident from bed to a wheelchair and changed the resident's shirt. The resident remained in full view of his/her roommate with his/her chest exposed. During interview on 2/26/20 at 3:55 P.M. CNA B said he/she should provide privacy while providing resident cares. He/She should have pulled the privacy curtain and not left the resident exposed to his/her roommate while cares were provided. 2. Review of Resident #162's care plan dated April 2019 showed the resident had urinary incontinence. Monitor skin during toileting/diaper change every two to four hours. Review of the resident's quarterly MDS, dated [DATE] showed the following: -Severely impaired cognition; -Always incontinent of bladder and bowel; -Extensive assist of two staff for personal hygiene. Review of the resident's Physician Order Sheet, dated February 2020 showed the resident's diagnoses included Alzheimer's dementia (loss of memory) and incontinence. Observation on 2/25/20 at 6:45 A.M. showed the following: -The resident lay on his/her back in the bed. -CNA I and CNA J entered the room (leaving the door to the hallway open), and pulled the privacy curtain 3/4 of the way around the resident's bed, leaving the resident in bed exposed to view from anyone in the hallway; -An ambulatory resident stood in the doorway and peered into the resident's room; -CNA I and CNA J unfastened the resident's incontinent brief, rolled the resident, removed the brief, (exposing the resident's front and back perineal areas) and applied a dry brief; -Staff did not provide privacy for the resident during cares. During interview on 2/25/20 at 6:50 A.M. CNA I and CNA J said the following: -They should have pulled the privacy curtain completely around the resident's bed for privacy; -They should have closed the door to the hallway for additional privacy. During interview on 2/26/20 at 6:30 P.M. the Director of Nursing said the following: -Staff should provide residents privacy while providing personal cares; -Staff should pull the privacy curtain and close the room door. The resident should not be visible while exposed to roommates or other residents/visitors/staff in the hallway.

Based on observation, interview and record review, facility staff failed to ensure one additional resident (Resident #21) was free from significant medication errors. Staff failed to prime (remove the air) from the Humalog Kwikpen (prefilled pen of fast acting insulin injected under the skin used to treat diabetes dose dialed on the pen and injected through a new sterile needle attached to the pen prior to each administration), needle as instructed by the manufacturer prior to administration of the physician prescribed dose resulting in administration of less than the ordered dose of Humalog. The facility census was 69. Review of the facility policy Administration of Medication dated 11/19/19 directed staff to read the electronic medical record and ensure administration of the correct medication, the correct dose, by the correct route, at the correct time to the correct resident. Review of the Humalog Kwikpen package insert showed the following in part: -Humalog KwikPen was a disposable single-patient-use prefilled pen containing 300 units of Humalog insulin. Each turn (click) of the dose knob dialed one unit of insulin. You could give from one to 60 units in a single injection; -Pull the pen cap off, wipe the rubber seal with alcohol swab, check the liquid in the pen and ensure the liquid was clear. Select a new needle, remove the paper tab from the outer needle shield, push the capped needle straight onto the pen and twist the needle on until tight. Pull off the outer needle shield and remove the inner needle shield; -Prime (remove the air from the needle and cartridge). If you do not prime before each injection you may get too much or too little insulin. Turn the dose knob to select two units, hold the pen with the needle pointed up, tap the cartridge holder gently to collect air bubbles at the top, push the dose knob in until it stops and 0 is seen in the dose window. Hold the dose knob in and count to five slowly. You should see insulin at the tip of the needle. Repeat the priming procedure if you did not see insulin at the tip of the needle; -Turn the dose knob and select the number of units you need to inject and administer the medication. 1. Review of Resident #21's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/30/19 showed the following: -Cognitively intact; -Received insulin injections seven of the previous seven days. Review of the resident's Physician Order Sheet dated 2/24/20 showed the following: -Diagnosis of diabetes and kidney disease; -Humalog KwikPen Insulin 100 units/milliliter (ml) subcutaneous (tissue just below the skin) inject 10 units daily before supper with sliding scale (dose based on blood sugar level) Humalog KwikPen Insulin; -Humalog KwikPen Insulin 100 units/ml subcutaneous per sliding scale blood sugar of 201-250 administer 3 units, blood sugar of 251-300 administer 4 units, blood sugar of 301-350 administer 5 units, blood sugar greater than 351 administer 6 units every day before meals and at bedtime. Observation on 2/24/20 at 4:39 P.M. showed the following: -Licensed Practical Nurse (LPN) E obtained the resident's blood sugar level of 128 milligrams per deciliter (mg/dL) (measurement of the amount of glucose or sugar in the blood) and determined Humalog KwikPen sliding scale Insulin dose was not required; -LPN E obtained the resident's Humalog Kwikpen from the top medication cart drawer, removed the lid, cleansed the tip with an alcohol pad and attached a new sterile needle. LPN E did not prime the new sterile needle; -LPN E dialed up 10 units of Humalog insulin and administered the medication in the resident's subcutaneous tissue of the abdomen. During interview on 2/24/20 at 5:10 P.M. LPN E said the following: -He/She thought priming the insulin pen was only necessary when the package was initially opened. It was not necessary to prime the needle each time. He/She never primed the needles on the insulin pens; -He/She spoke with the Director of Nursing (DON), the DON said she did not prime the KwikPen insulin needles either; -LPN E obtained the KwikPen Humalog Insulin package insert, reviewed the instructions and said he/she would call the pharmacist; -He/She called the pharmacist and reported the pharmacist said it was necessary to prime the new needle every time before administration of KwikPen insulin. During interview on 2/26/20 at 5:15 P.M. the nurse manager/Registered Nurse (RN) D said the KwikPen insulin needle must be primed every time. During interview on 2/26/20 at 11:35 A.M. the DON said the following: -If staff did not prime the needle before insulin administration, the resident potentially did not receive the full-prescribed insulin dose; -This was a medication error in administration and the physicians should be notified of the error.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain the residents' environment clean and in good repair. The facility census was 69. Review of the facility Housekeeping Cleaning Policy dated 4/30/18 showed the following in part: -Primary purpose was to perform day-to-day activities of housekeeping and assure the facility was maintained in a clean, safe and comfortable manner; A. Follow cleaning schedule; B. Clean floors. Inspect furnishings for wear or defects and report to supervisor; C. Cleans all bathrooms in facility. Disinfect all walls, floor, fixtures; J. Curtains or drapes that were soiled need to be removed cleaned and replaced. Check for wear and defects and report to supervisor. 1. Observation on 2/24/20 at 2;40 P.M showed a section of missing tile in the hallway between rooms #114 and #113 on Walnut Lane. Observation on 2/24/20 at 2:45 P.M. showed broken tile in the door way between the hallway and room [ROOM NUMBER] on Walnut Lane. Observation of the C hall shower room on 2/25/20 at 7:50 A.M. showed the following: -A cabinet inside the door with broken top and edges, gouged surfaces and soiled appearance; -Dirt and grim under the paper towel wall dispenser down the tile wall to the floor and baseboard; -Black mildew down the tile wall beside and under the handwashing sink and along the baseboard edge; -Black and pink mold and mildew-like substances along the entire length and width of the open shower stall covering the top and bottom edge of the baseboard. Soiled floor tile throughout the shower stall; -Black dirt and grim behind the corner edge of the entrance door extending into the shower stall with a wadded up gauze dressing on the floor; -Black substance around the entire toilet base of both toilets; -Unflushed first stall toilet with a soiled glove on the floor next to the toilet; -Brown soiled mechanical lift toilet seat cushion placed in second toilet stall; -Soiled tile throughout both toilet stalls; -Open stall with two open water pipes and one pipe dripping on the floor. Black and gray substance under the dripping water pipe and along the base board surrounding the area. A wheelchair with a mechanical lift pad, a wheelchair containing two seat cushions and a shower chair placed randomly in the open stall. Two wheelchair foot rests and a hanger were on the floor; -Two large trash and dirty linen barrels in front of the toilet stalls. Observations of the C hall shower room on 2/25/20 showed staff assisted residents with toileting and showers throughout the day. Observation of room C-53 showed the following: -The window curtain hooks were torn from the center of the curtain panel and hung loosely from the curtain rod; -Soiled paper towels and soiled gloves on the floor under the room sink near the trash can. During interview on 2/25/20 at 8:00 A.M. Certified Nurse Aide (CNA)A said residents used the shower room for toileting and showers. During interview on 2/26/20 at 9:50 A.M. the Maintenance Director said the C hall shower room needed to be cleaned, it was not homelike. The clutter needed to be removed, base boards cleaned, wall and tile cleaned. Water was dripping on the floor from the open pipes and needed to be cleaned and capped off. The shower rooms should be cleaned daily and anytime when dirty. During interview on 2/26/20 at 6:30 P.M. the Director of Nursing said the following: -Staff should keep the facility clean, pleasant and homelike; -The C hall shower room should be clean and kept pleasant for resident's showers.

Based on interview and record review the facility failed to develop and implement written policies consistent with the requirements for reporting. The facility census was 53. 1. Review of the document Abuse /Neglect and Reporting Reasonable Suspicion of a Crime Policy and Procedures dated, 1/5/17 showed the following: Policy: It is the policy of the facility to protect the right of all residents to be free from mistreatment, abuse, neglect, injuries of unknown origin and misappropriation or stealing of resident property or money. Abuse/Neglect Procedures: The facility will not permit residents to be subjected to abuse or neglect by anyone, including staff members, other residents, consultants, volunteers, vendors and staff of other agencies serving the resident, family members, legal guardians, sponsors, friends or other individuals. Abuse/Neglect Definitions of Reportable Issues- To assist our facility in defining incidents of abuse and neglect, the following information is provided. All issues listed below are considered reportable issues and staff should begin the investigation and reporting process immediately. Verbal abuse, sexual abuse, physical abuse, involuntary seclusion, mental/emotional abuse, financial abuse, neglect. Reporting Abuse/Neglect: 6. a.)Who to report and when to report-Any individual, employee, resident, parent/guardian, family member or other interested party who witnesses or suspects that a case of abuse or neglect has occurred must report the alleged violation as soon as possible but no later than two hours after they witnessed the incident. b.) Reporting to Department of Health and Senior Services: Following the guidelines for facility self-reporting the Administrator, DON or Human Resource Director will call and make the necessary report. The policy did not contain direction for the staff to report abuse/neglect even when it did not result in serious bodily injury, direction for staff to report to the state agency within two hours and did not make it clear that abuse should be reported even if unwitnessed. During interview on 3/11/20 at 12:45 P.M., the administrator said the policy should say that any suspicion of abuse/neglect should be reported to the state agency within two hours. The policy should be clear that abuse does not have to be witnessed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to complete a significant change in status assessment (SCSA) Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, for three residents (Resident #27, #17 and #162) in a review of 18 sampled residents, within 14 days after the facility determined, or should have determined, there had been a significant change in the resident's physical or mental condition (improvement or decline) which had an impact on more than one area of the resident's health status and required interdisciplinary review and/or revision of the care plan. The facility census was 69. During interview on 2/26/20 at 6:30 P.M. the Director of Nursing said the facility followed the Resident Assessment Instrument (RAI) User's Manual while completing the MDS assessment. Review of the Long Term Care Facility Resident Assessment Instrument (RAI) User's Manual, version 3.0 showed a significant change is a decline or improvement in a resident's status that: -Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, is not self-limiting; -Impacts more than one area of the resident's health status -Requires interdisciplinary review and/or revision the care plan. The Manual also showed a Significant Change In Resident Status (SCSA) is appropriate if there is a consistent pattern of changes, with either two or more areas of decline, or two or more areas of improvement. This may include two changes within a particular domain (e.g., two areas of ADL decline or improvement). Guidelines for determining significant change in resident status included the following: -Any decline in an ADL physical functioning area where a resident is newly coded as 3, 4, or 8 in -Any improvement in an ADL physical functioning area where a resident is newly coded as 0, 1, or 2 since the last assessment; -Resident's decision-making changes; -Presence of a resident mood item not previously reported by the resident or staff and/or an increase in the symptom frequency. Increase in the number of areas where behavioral symptoms are coded as being present and/or the frequency of a symptom increases; -Resident's incontinence pattern changes from 0 or 1 to 2, 3, or 4 or there was placement of an indwelling catheter; -Emergence of a pressure ulcer at Stage 2 (a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed) or higher, when no pressure ulcers were previously present at Stage 2 or higher or worsening in pressure ulcer status; -Emergence of an unplanned weight loss problem (5% change in 30 days or 10% change in 180 days); -admission or discharge from hospice care; -Overall improvement or deterioration of the resident's condition. 1. Review of Resident #27's quarterly MDS completed 5/17/19 showed the following: -Severely impaired cognition; -Required extensive assistance of two staff members with bed mobility; -Required total assistance of two staff members with transfers, dressing, toileting and personal hygiene; -Always incontinent of bowel and bladder; -No hospice care provided while a resident in the facility. Review of the resident's record showed no additional assessments completed since 5/17/19's quarterly assessment. Review of the resident's Physician Order Sheet (POS) dated 1/22/20 showed admit to hospice care. Review of the resident's care plan dated 1/24/20 showed the resident had terminal illness and elected hospice services. Staff should assess for comfort and provide a calm environment, spiritual and emotional support. Review of the resident's nurses' notes showed the following: -On 1/30/20 at 10:44 A.M. staff documented the resident was totally dependent for personal hygiene and incontinence care. The resident was on hospice care; -On 2/22/20 at 10:34 A.M. staff documented the resident was on hospice. Review of the resident's record showed no significant change is status assessment completed. The resident met the criteria for significant change in status assessment. 2. Review of Resident #162's quarterly MDS, dated [DATE] showed the following: -Severely impaired cognition; -Extensive assist for two for bed mobility, dressing, toileting and personal hygiene; -Always incontinent of bladder and bowel; -No hospice care provided while resident. Review of the resident's care plan dated 10/29/19 showed the resident was on hospice care due to family election of palliative care. Staff to assess for comfort, spiritual and emotional needs. Hospice nurse visits for additional palliative care recommendations. Review of the resident's POS dated February 2020 showed the resident was admitted to hospice care on 8/29/19 with a diagnosis of progressive dementia and weight loss. Review of the resident's record showed no significant change is status assessment completed. The resident met the criteria for significant change in status assessment. 3. Review of Resident #17's quarterly MDS dated [DATE] showed the following: -Required extensive assistance of one staff member with transfers; -Required total assistance of one staff member with locomotion on and off the unit; -Frequently incontinent of bowel. Review of the resident's quarterly MDS dated [DATE] showed the following: -Required limited assistance of one staff member with transfers; -Independent locomotion on and off the unit with set up help only; -Continent of bowel. The quarterly MDS dated [DATE] showed the following when compare to the previous quarterly MDS dated [DATE]: -The resident improved from extensive assistance to limited assistance of one staff member with transfers; -The resident improved from total assistance on one staff member to independent with set up help only for locomotion on and off the unit; -The resident improved from frequently incontinent to continent of bowel; -The resident's assessment met the criteria for significant change in condition. Observation of the resident from 2/23/20 to 2/26/20 showed the resident propelled self in the hallway, dining room and room independently in a wheelchair. Staff provided limited assistance with transfers from the wheelchair to bed or toilet. During interview on 2/26/20 at 6:15 P.M. the MDS coordinator said the following: -He/She followed the RAI manual directions for guidance on completion of MDS assessments; -He/She did not know a significant change in status was required for an admission to hospice; -The facility was behind in completing resident MDS', a lot of the residents' assessments were missing. During interview on 2/26/20 at 6:30 P.M. the DON said the following: -The MDS nurse was unable to keep up with the MDS' and the facility was behind; -He/She thought they were catching up and most residents were current. He/She thought the issue was resolved; -The MDS staff should follow the RAI manual and complete MDS' as directed by the manual.

Based on interview and record review, the facility staff failed to ensure a Quarterly Minimum Data Set (MDS), a federally mandated resident assessment completed by the facility staff, was completed no less than once every three months for six of 18 sampled residents (Resident #7, #8, #11, #17, #27, and #162). The facility census was 69. During interview on 3/26/20 at 6:15 P.M. the MDS Coordinator said the facility followed the RAI 3.0 process for completion of all MDS assessments. Review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual MDS 3.0, dated 2019, showed the following: -The OBRA of 1987 provided the statutory authority for federal statute and regulations that required nursing homes to conduct initial and periodic assessments for all their residents. The assessment information is used to develop, review, and revise the resident's plans of care that will be used to provide services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; -The Quarterly Assessment is a 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; -The ARD must be within 92 days after the ARD of the previous OBRA assessment (Quarterly, Admission, SCSA, SCPA, or Annual assessment plus 92 days); -The completion date (item Z0500B) was ARD plus 14 days. 1. Review of Resident #8's MDS record showed: -MDS admission assessment ARD 9/17/19; -No quarterly assessment completed as of 2/26/20 (161 days late). 2. Review of Resident #162's MDS record showed: -MDS quarterly assessment ARD of 7/17/19; -No documentation staff completed quarterly assessments due on 10/17/19 or 1/17/19. 3. Review of Resident #27's MDS record showed the following: -MDS quarterly assessment ARD of 5/17/19 completed on 5/28/19; -No documentation staff completed additional quarterly MDS assessments on 8/17/19 or on 11/17/19. 4. Review of Resident #7's MDS record showed the following: -MDS annual assessment ARD of 9/20/19 completed on 9/23/19; -No documentation staff completed a quarterly MDS assessment due 12/20/19. 5. Review of Resident #17's MDS record showed the following: -MDS quarterly assessment ARD of 10/24/19 completed on 10/31/19; -No documentation staff completed a quarterly MDS assessment due 1/24/20. 6. Review of Resident #11's MDS record showed the following: -MDS quarterly assessment ARD of 9/26/19 completed on 10/3/19; -No documentation staff completed a quarterly MDS assessment due 12/26/19. 7. During interview on 2/26/20 at 6:15 P.M. the MDS coordinator said the following: -He/She followed the RAI manual directions for guidance on completion of MDS assessments; -Residents' quarterly MDS assessments should be completed every 92 days; -The facility was behind in completing resident MDS', a bunch of the residents' assessments were missing. During interview on 2/26/20 at 6:30 P.M. the DON said the following: -The MDS nurse was unable to keep up with the MDS' and the facility was behind; -He/She thought they were catching up and most residents were current. He/She thought the issue was resolved; -The MDS staff should follow the RAI manual and complete MDS' as directed by the manual.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure staff performed Activities of Daily Living for seven dependent residents (Resident #27, #59, #7, #36, #41, #60 and #162) of 18 sampled residents. The facility census was 69. During interview on 2/26/20 at 6:60 PM the Director of Nursing (DON) said they did not have a policy regarding staff providing residents' morning and bedtime ADL cares. Staff should follow the Certified Nurse Assistant (CNA) manual. Review of the facility policy Perineal Care dated 1/26/11 showed the following: -Perineal care is washing of the genital and rectal areas of the body. Perineal care was usually called peri care. Peri care prevented skin breakdown of the perineal area, itching, burning, odor, and infections. Pericare was very important in maintaining the resident's comfort; -Gather your equipment,necessary for completion of care. Remember to take two disposable bags, one for linen and one for trash. Wash your hands and put on gloves. Explain to the resident what you are going to do. Provide privacy, close the door and curtains to the room. Cover the resident other than area you are working on. Assist resident to back-lying or side-lying position, place pads under resident's hips. Expose only the peri area. All areas that has been touched by the attends/pad must be washed. Removed soiled briefs, be sure to clean resident if feces present, remove gloves and wash hands, apply fresh gloves; -Female: Wash across the abdomen, be sure to lift and wipe all folds, rinse, then dry. Gently wash the inner legs and outer peri area along the outside of the labia, rinse and pat dry. Wash the inner labia from front to back, rinse, pat dry. Turn resident to side and wash across lower back, rinse, pat dry. Wash each buttock, rinse and pat dry. Wash anal area, rinse, pat dry. Remember front to back. Remove bed protector if soiled and dispose of gloves and wash hands. Put on fresh gloves and provide resident with a clean brief; -Male: Wash across the abdomen, be sure to lift and wipe all folds, rinse, then dry. Using a circular motion, gently wash the penis by lifting it and cleaning from the tip downward, rinse and dry. Uncircumcised males, retract the fore skin wash, rinse and dry, then pull skin over the end of penis. Wash the scrotum rinse and pat dry, wash the outer skin areas between legs rinse and pat dry, wash each buttock rinse and pat dry, wash the anal areas rinse pat dry, remember front to back. Remove bed protector if soiled and dispose of gloves and wash hands. Put on fresh gloves and provide resident with a clean brief. Review of the Nurse Assistant in a Long-Term Care Facility, Student Reference, 2001 Revision, showed the following: -Activities of personal care section: d. shaving - evaluate the resident's need for shaving daily. Let residents shave themselves if they were able. 1. Review of Resident #27's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument, completed by facility staff, dated 5/17/19 showed the following: -Severely impaired cognition; -Required extensive assistance of two staff members with bed mobility; -Required total assistance of two staff members with dressing, toileting and personal hygiene; -Always incontinent of bowel and bladder. Review of the resident's care plan updated 10/24/19 showed the following: -Diagnosis of Alzheimer's disease, dementia, chronic kidney disease, urinary incontinence, hematuria (blood in the urine), and rash; -The resident had urinary and bowel incontinence. Staff should monitor for signs/symptoms of urinary tract infections, encourage fluid intake, monitor redness or skin breakdown during toileting/brief change every two to four hours, lubricate skin every shift and as needed. -The resident was at risk for skin breakdown. Staff should provide incontinence care as needed, prevent friction during transfers, resident care and bed mobility. Apply skin protectant/skin barrier when performing perineal care; -The resident required assistance with Activities of Daily Living (ADLs). Staff should assist with bed mobility, personal hygiene, bathing, dressing and transfers. Observation on 2/23/20 at 12:34 P.M. showed the resident sat in the dining room in a reclining wheelchair attempting to feed his/herself. He/she had white facial hair on his/her chin and nasal drainage and debris running down his/her upper lip area. Observation on 2/23/20 at 03:17 P.M. showed the resident sat in the common area near the nurse's desk. [NAME] facial hairs remained on his/her chin. His/her fingers were soiled with nasal drainage and food particles. Observation on 2/23/20 at 5:51 P.M. showed the resident sat in the dining room, white facial hair remained on the resident's chin. Observation on 2/25/20 at 6:35 A.M. showed the following: -Certified Nurse Assistant (CNA) S placed clean wash cloths in the sink, turned on the faucet, loosened the resident's urine soiled incontinence brief, obtained a clean incontinence brief from the resident's closet and wrung out the wet wash cloths from the sink; -CNA S applied shower gel from the resident's bedside table drawer on a wet wash cloth, made suds on the wash cloth, washed the resident's front perineal area, turned the resident on his/her side and removed the resident's urine saturated incontinence brief; -CNA S applied shower gel soap on a wet wash cloth, made suds on the wash cloth, reached behind the resident, and wiped the resident's buttocks area, obtained a wet wash cloth and rinsed the resident's buttocks and dried with a towel. CNA S did not rinse the shower gel soap from the resident's front perineal area; -CNA T entered the room, applied the resident's clean incontinence brief; -CNA S and CNA T dressed the resident, applied deodorant, transferred the resident to a wheelchair with a mechanical lift, applied the resident's shoes and glasses and combed the resident's hair. CNA S and CNA T did not wash the resident's face or hands and did not provide the resident oral care. [NAME] facial hair remained on the resident's chin. Review of the shower gel bottle on 2/25/20 at 6:45 A.M. showed the directions included rinse well. During interview on 2/25/20 at 7:30 A.M. CNA S said the following: -The resident did not nothing for his/herself; -Morning care included providing the resident perineal care, oral care, wash the resident's face and hands before breakfast; -He/She only provided the resident perineal care and did not provide any other cares before breakfast; -He/She used body wash for soap while providing the resident's incontinence care and he/she should rinse the body wash off the resident's skin. He/She did not rinse the resident's skin. 2. Review of Resident #162's care plan dated 4/19 showed the resident had urinary incontinence. Resident will not experience complications related to incontinence as evidenced by no signs or symptoms of urinary tract infection (UTI). Monitor skin during toileting/diaper change every two to four hours. Review of the resident's quarterly MDS dated [DATE] showed the following: -Severely impaired cognition; -Always incontinent of bladder and bowel; -Extensive assist of two staff for bed mobility and personal hygiene. Review of the resident's Physician Order Sheet (POS), dated February 2020 showed the resident's diagnoses included Alzheimer's dementia (loss of memory) and incontinence. Observation on 2/25/20 at 6:45 A.M. showed the following: -The resident lay on his/her back in the bed. -CNA I and CNA J entered the room and prepared to change the resident's soiled incontinent brief; -CNA J unfastened the resident's urine saturated incontinent brief, rolled the resident to his/her left side, tucked the incontinent pad and brief under the resident and CNA I removed the soiled items; -CNA J (without providing any perineal care) applied a clean incontinent brief and covered the resident with the blanket. During interview on 2/25/20 at 6:50 A.M. CNA I and CNA J said perineal care (including all soiled areas) should have been provided on the incontinent resident. 3. Review of Resident #36's resident's care plan dated 10/16/19 showed the following: -Extensive assistance of one for toileting; -Assist with toileting as necessary to promote continence. Review of the resident's annual MDS, dated [DATE] showed the following: -Severely impaired cognition; -Required extensive assist of two staff members with transfers and toileting; -Required extensive assist of one staff member with personal hygiene; -Always incontinent of bladder; -Frequently incontinent of bowel. Observation on 2/24/20 at 10:50 A.M. showed the following: -The resident asked to use the bathroom; -CNA V unfastened the resident's incontinence brief and turned the resident to his/her side; -CNA U removed the resident's incontinence brief. The resident was incontinent of urine and a moderate amount of feces; -CNA U wiped the resident's buttocks with the soiled incontinence brief and placed a mechanical lift pad under the resident. Without providing incontinence care CNA U and CNA V transferred the resident to the bedside commode. The resident had a large soft bowel movement and urinated in the bedside commode; -CNA U and CNA V attached the mechanical lift pad to the lift, raised the resident off the bedside commode and transferred the resident to bed. The resident's buttocks and the lift pad were soiled with feces; -CNA U and CNA V turned the resident on his/her side and rolled the feces soiled mechanical lift pad and the feces soiled washable incontinence bed pad under the resident. CNA V wiped the resident's feces soiled buttocks with wet wipes and reached in between the resident's legs and wiped the perineum; -CNA U and CNA V turned the resident on his/her side and CNA U removed the feces soiled mechanical lift pad and feces soiled washable incontinence bed pad; -CNA V and CNA U, without washing all areas of the resident's feces and urine soiled buttocks and hips, applied a clean washable incontinence bed pad under the resident and placed a clean incontinence brief under the resident; -CNA V and CNA U, without providing complete frontal incontinence care, fastened the brief. During interview on 2/26/20 at 11:15 A.M. CNA U said the following: -The resident was incontinent most of the time and did not usually use the bedside commode; -He/She did not wash all areas of the resident's skin soiled with urine and feces; -He/She did not provide the resident complete incontinence care; -He/She should wash the resident from front to back while providing incontinence care. 4. Review of Resident #41's care plan dated 7/14/17 showed the following: -Incontinent of bowel and bladder; -Provide meticulous skin care before changing incontinent pads; -Provide hygiene needs. Review of the resident's annual MDS dated [DATE] showed the following: -Diagnoses included Alzheimer's; -Severely impaired cognition; -Extensive assist of two for transfer and toileting -Extensive assist of one for personal hygiene; -Always incontinent of bladder and bowel. Observation on 2/23/20 at 11:25 A.M. showed the following: -The resident sat in his/her recliner in the common area; -CNA M and CNA O transferred the resident to the toilet; -CNA M removed the urine soiled incontinent brief and placed it in the trash and placed a clean incontinent brief around the resident's legs, and taped the sides; -CNA O and CNA M assisted the resident to stand and CNA M cleansed the resident's buttocks and anal area with three wipes and then pulled the resident's pants up; -Staff did not provide peri care to the resident's front perineum. 5. Review of Resident #60's care plan, dated 2/6/19, showed the following: -Fully dependent on staff for ADL's; -At risk for skin breakdown related to incontinence; -Resident skin will remain intact, provide incontinent care as needed. Review of the resident's annual MDS dated [DATE] showed the following: -Severely impaired cognition; -Extensive assist of two staff for transfers, toileting and personal hygiene; -Always incontinent of bladder and bowel. Observation on 2/24/20 at 4:35 P.M. showed the following: -The resident wore house shoes and sat in a recliner in the common area; -CNA B and NA L transferred the resident from his wheelchair to the toilet in the shower room; -CNA B removed a urine soiled incontinent brief and placed it in the trash; -CNA B and NA L assisted the resident to stand and CNA N cleansed the resident's buttocks; -Neither CNA provided perineal care to the resident's front peri area; -CNA B and NA L transferred the resident back to the wheelchair. During interview on 2/25/20 at 7:48 P.M., CNA N said all soiled areas should be cleaned during incontinent care. 6. Review of resident #59's face sheet showed diagnosis of urinary tract infection, skin changes, stroke, rash, and dementia. Review of the resident's care plan dated 8/2/19 showed the following: -The resident was total care with all ADLs. Staff should anticipate his/her needs and provide morning and evening care, provide meticulous skin care before changing incontinent pad, provide grooming and hygiene needs; -The resident had urinary and bowel incontinence. Staff should encourage fluid intake, monitor skin for redness or breakdown during toileting/diaper changes, lubricate skin every shift and as needed and utilize prompted voiding every one to two hours. Review of the resident's quarterly MDS dated [DATE] showed the following: -Long and short term memory problem; -Required extensive assistance of two staff members with bed mobility; -Required total assistance of one staff member with dressing and personal hygiene; -Required total assistance of two staff members with toileting; -Always incontinent of bladder; -Frequently incontinent of bowel. Observation on 2/25/20 at 1:50 P.M. showed the following: -CNA X pushed the resident in a wheelchair down the hall to his/her room and said the resident came to his/ her room to get changed and go to bed. Otherwise the resident sat in a recliner chair at the nurses' desk most of the day; -CNA X and CNA A transferred the resident to bed; -CNA X obtained wet wipes, removed the resident's pants and urine saturated incontinence brief. A strong urine odor was noted; -CNA A turned the resident on his/her side. The resident's skin was wet with urine and soiled with feces; -CNA A wiped the resident's buttocks with two swipes of a wet wipe. CNA X wiped the resident's front area with two swipes of a wet wipe; -CNA A and CNA X did not provide the resident complete incontinence care and did not wash all areas of the resident's skin soiled with urine and feces; -CNA A and CNA X applied the resident's clean incontinence brief and pants, and transferred the resident to a wheelchair. During interview on 2/25/20 at 2:00 P.M. CNA X said he/she should wipe and clean all areas of the resident's skin soiled with urine or feces. He/She wiped the resident's front area and CNA A wiped the back. 7. Review of Resident #7's care plan dated 9/17/19 showed the following: -The resident was total assistance with all ADLs. He/She was unable to get out of a chair or reposition on his/her own. Staff should provide AM and PM care, provide assist of one to two staff members with transfers. Staff should provide grooming and hygiene needs; -The resident was incontinent of urine and had constipation. Staff should monitor for redness or skin breakdown during toileting/diaper change every two to four hours. Review of the resident's annual MDS dated [DATE] showed the following: -Moderately impaired cognition; -Required limited assistance of one staff member with bed mobility, dressing and personal hygiene; -Required extensive assistance of two staff members with transfers and toileting; -Frequently incontinent of bowel and bladder. Observation on 2/23/20 at 3:20 P.M showed the following: -The resident lay in bed and CNA B said the resident was wet; -Nurse Assistant (NA) C removed and bagged the residents soiled incontinence brief; -CNA B washed the resident's front perineal area, turned the resident on his/her side, reached behind the resident and wiped his/her buttocks. CNA B said the resident was wet and to get the main areas this time. CNA B did not wash the resident's urine soiled skin folds; -CNA B dried the resident's skin and applied a clean incontinence brief. During interview on 2/26/20 at 6:30 P.M. the Director of Nursing said the following: -Staff should provide morning care for residents before breakfast. Morning cares included incontinence care as needed, oral care, face and hand washing, comb hair, apply glasses and dressing; -Staff should provide incontinence care and wash all areas soiled with urine or feces. Staff should wash residents' from front to back and wash all skin folds. There was never a time when staff should not wash all areas of the resident's skin soiled with urine or feces. Residents could develop urinary tract infections if not provided complete perineal care after each incontinent episode.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure foot pedals were in place on wheelchairs during transportation for three residents (Resident #60, #162 and #41), failed to ensure staff used proper technique during gait belt (canvas belt placed around the resident's waist to assist with ambulation, transfer, and positioning in a chair) transfers for two residents (Resident #7 and #41) and failed to consistently implement, evaluate and modify care plan interventions to prevent falls, in accordance with current standards of practice, for one resident (Resident #59) who had a history of repeated falls in a review of 18 sampled residents. The facility census was 69. Review of the facility policy Fall Prevention Program dated 7/13/12 showed the following: This is to be used as a guideline for the preventions of falls/injuries related to falls. All fall reports are routed to the combined resident committee. All new admissions are assessed for fall risks, care plans are reviewed for completion. The falls are reviewed in the weekly combined resident committee meeting to review reports, to evaluate any interventions that were in place and what interventions may be needed to be put in place to prevent further incidents. All reported falls are logged into the computer. The care plan is reviewed and updated in the computer with any new interventions if needed. The unit supervisor will be sure the information is reviewed by staff members to ensure the interventions recommended by the committee are followed. Each month the Director of Nursing (DON) will provide pharmacy consultant a list of the previous month's falls. If a fall is emergent, caused injury or we feel is directly related to medication, we will fax immediately to pharmacy consultant for recommendations. A leaf will be placed above the bed of residents on the program. This will be reviewed quarterly for continuation or discontinued. Review of the facility policy Using Gait Belts on Residents dated 2/12/09 showed the following: Residents not designated as up ad lib by physician order will be ambulated with the use of a gait belt for their safety. All employees are shown how to use the gait belt properly on residents during orientation. For most residents it is appropriate to place gait belt around the waist just above the hips and snug enough that you can get two hands under the belt. Appropriate lifting of Residents using the gait belt: Resident should be able to bear weight on at least one lower extremity to do a stand pivot transfer. If unable, should be referred to physical therapy for screening. Two person transfer- Each person should be facing resident on each side of the resident. Using inner arm, whoever performing transfer should put hand in gait belt. Instructing resident to push from arms on chair or grab arms on each person performing transfer behind the elbow. Lifting in this manner will allow the persons transferring the resident to have more control with their outside hand to help with hygiene, clothing management or to help move the wheel chair or chair closer if needed. Persons performing transfer use good body mechanics, bending at the knees and giving resident time to transfer, Never lift shoulders for any reason. 1. Review Resident #59's face sheet showed the following; -admission date 7/30/19; -Diagnosis of stroke, broken hip, sleep apnea, and dementia. Review of the resident's Fall Risk assessment dated [DATE] showed staff scored the resident 12 indicating high risk for falls. Review of the resident's care plan dated 8/2/19 showed the following: -The resident was total care with all Activities of Daily Living (ADLs). Goal was resident safe and free from accident/injury daily. Staff should anticipate his/her needs and provide morning and evening care, provide meticulous skin care before changing incontinent pad, provide grooming and hygiene needs. He/She required one to two person assist with transfers and a gait belt. He/She preferred to nap in a recliner in the common area during the day; -The resident was on the falling star plan of care. Goal was to limit and prevent falls and injuries related to falls. The resident was a high risk for falls. Staff should assist with transfers and the resident used a wheelchair for mobility. Keep call light in reach and answer promptly. Review of the resident's admission MDS dated [DATE] showed the following; -Severely impaired cognition; -Required total assistance of two staff members with bed mobility, transfers and toileting; -Required total assistance of one staff member with locomotion on and off the unit, and dressing; -Walk in room and walk in corridor did not occur; -Fell prior to admission two or more times without injury; -Fell prior to admission on e time with injury (except major injury). Review of the resident's nurses' note dated 8/9/19 at 2:57 P.M. showed staff documented the resident was alert to self only, confused to time and place. He/She was total dependence on staff for all ADLs. Transferred with extensive assistance of two staff members, used a wheelchair for locomotion propelled by staff, was incontinent of bowel and bladder. Review of the resident's nurses' note dated 8/28/19 at 2:45 P.M. showed staff documented the resident was found on the floor by his/her bed. No injuries noted, bed was in the lowest position to the floor, mats on either side of the bed. Staff would continue to monitor. Review of the resident's Accident report dated 8/28/19 showed staff documented the following: -Severity: Incident with no harm; -Outcome: no apparent injury -Accident type: fall -Corrective actions take: neuro checks done; -Measures to prevent recurrence: frequent checks on the resident. Review of the resident's care plan dated 8/28/19 showed staff documented the resident was found on the floor next to his/her bed. Fall mats on both sides of the bed, mobility bars in place on both sides of the bed. Staff should assist with toileting at 10:00 P.M. daily and provide frequent checks during the night. Review of the resident's nurses' note dated 8/30/19 at 2:19 P.M. showed staff documented the resident was found on the floor by his/her bed. It appeared he/she crawled out of bed. No injuries noted. Staff would continue to monitor. Review of the resident's Accident report dated 8/30/19 showed staff documented the following: -Severity: Incident with no harm; -Outcome: no apparent injury -Accident type: fall -Corrective actions take: resident put back to bed and cleaned up, given medication for pain; -Measures to prevent recurrence: monitor and do frequent bed checks. Review of the resident's care plan showed no documentation staff updated the resident's care plan with additional fall prevention interventions since 8/28/19. Review of the resident's nurses' note dated 9/13/19 at 8:20 A.M. showed staff documented the resident was lying on the floor mat next to his/her bed on his/her left side. The resident pulled the blanket and pillow off the bed and was asleep. The resident had bruising on his/her left shoulder from previous falls that was fading. No open or raised areas noted with skin assessment. Range of motion noted in arms and legs, the resident denied pain or discomfort with no distress noted. Review of the resident's Accident report dated 9/13/19 showed staff documented the following: -Severity: Incident resulted monitoring but no harm; -Outcome: no apparent injury -Accident type: fall -Corrective actions take: bed in low position with mats on both sides of the bed; -Measures to prevent recurrence: bed in low position with mats on both sides of the bed. Review of the resident's care plan showed no documentation staff updated the resident's care plan with additional fall prevention interventions since 8/28/19. Review of the resident's nurses' note dated 9/18/19 at 7:02 P.M. showed staff documented the resident was found at 5:15 A.M. on the floor next to his/her bed. Appeared he/she rolled out of the bed. Review of the resident's Accident report dated 9/18/19 showed staff documented the following: -Severity: Incident resulted monitoring but no harm; -Outcome: no apparent injury -Accident type: fall -Corrective actions take: Took vital signs (Temperature, heart rate, respirations and blood pressure), checked for injuries, sat him/her up and picked the resident up off the floor. Placed in wheelchair and brought to the nurses' desk; -Measures to prevent recurrence: none documented. Review of the resident's care plan showed no documentation staff updated the resident's care plan with additional fall prevention interventions since 8/28/19. Review of the resident's nurses' noted dated 9/25/19 at 10:03 P.M. showed staff documented resident crawling on the floor in the central lounge area. Staff assisted the resident to a wheelchair and to bed. The resident's bed was in the lowest position with mats on the floor. Bruising was noted to the left knee, left hip, left calf and left shoulder. He/She had an area on the left side of his/her head approximately the size of a quarter that was bleeding. The resident could move his/her arms and legs normally. Review of the resident's Accident report dated 9/25/19 showed staff documented the following: -Severity: Incident resulted in treatment and temporary harm; -Outcome: hematoma (blood or bleeding under the skin due to trauma); -Accident type: fall; -Corrective actions take: resident was very anxious and had been readjusted in her chair several times by different staff members; -Measures to prevent recurrence: monitor the resident more often. Review of the resident's care plan showed no documentation staff updated the resident's care plan with additional fall prevention interventions since 8/28/19. Review of the resident's nurses' note dated 11/30/19 showed the following: -At 9:16 A.M. staff documented the resident was found lying on the floor, face down, under the Christmas tree in the common area with the recliner tipped on top of his/her. The recliner was moved and the resident assessed. A deep laceration with hematoma was noted to the left side of his/her head, a small bruise noted to the left leg above the ankle. Transferred the resident to the hospital; -At 2:05 P.M. staff documented the resident was admitted to the hospital with urinary tract infection and a closed head injury. Review of the resident's Accident report dated 11/30/19 showed staff documented the following: -Severity: Incident resulted in hospitalization and temporary harm; -Outcome: deep laceration; -Accident type: fall -Corrective actions take: immediate assessment and first aid administered. Pressure applied to laceration. -Measures to prevent recurrence: Ensure resident was not sat by the Christmas tree and ensure environment was safe before leaving the resident unattended. Review of the resident's care plan showed no documentation staff updated the resident's care plan with additional fall prevention interventions since 8/28/19. Review of the resident's nurses' note dated 12/4/19 showed staff documented the resident returned to the unit from the hospital with three staples to the left side of his/her head from the laceration. Review of the hospital Discharge summary dated [DATE] showed diagnosis of urinary tract infection and close head injury. Review of the resident's Fall Risk assessment dated [DATE] showed staff scored the resident 16 indicating high risk for falls and scored higher risk for falls than previous assessment completed 7/30/19. Review of the resident's care plan showed no documentation staff updated the resident's care plan with additional fall prevention interventions since 8/28/19. Review of the resident's quarterly MDS dated [DATE] showed the following: -Long and short term memory problem; -Required extensive assistance of two staff members with bed mobility; -Required total assistance of one staff member with locomotion on and off the unit, dressing and personal hygiene; -Walk in room and walk in corridor did not occur; -Required total assistance of two staff members with transfer and toileting; -The resident had a fracture related to a fall in the last two to six months prior to admission. Review of the resident's nurses' note dated 2/9/20 at 1:52 P.M. showed staff documented the resident sat in a recliner with legs elevated at the nurses' desk. Staff heard a noise, turned and observed the resident land on his/her left side on the floor in front of the recliner, heard his/her head hit the floor. Small raised area noted on the left side of forehead. He/She had active range of motion to all extremities. Staff assisted the resident off the floor and into a wheelchair. Review of the resident's Accident report dated 2/9/20 showed staff documented the following: -Severity: Incident resulted in monitoring but no harm; -Outcome: hematoma; -Accident type: fall -Corrective actions take: put in wheelchair -Measures to prevent recurrence: alternate positions from wheelchair to recliner when restless and vice versa. Review of the resident's care plan showed no documentation staff updated the resident's care plan with additional fall prevention interventions since 8/28/19. Observations on 2/23/20 showed the following: -At 3:09 P.M. the resident sat in an electric recliner chair in the common area near the nurses' desk. The foot rest was up and the chair reclined. The resident's feet hung over the side of the raised foot rest as she pulled his/herself into a sitting position and scooted towards the edge of the seat with feet dangling towards the floor; -At 3:13 P .M. the resident continued to adjust his/her position in the electric recliner with one foot dangling over the edge of the foot rest and one foot and leg over the arm of the chair. The resident was turned sideways in the recliner chair. During interview on 2/25/20 at 7:30 A.M. Certified Nurse Aide (CNA) S said the resident got up early and staff put his/her in the recliner chair near the nurses' desk. The resident was a fall risk. He/She could not walk and could not do anything for him/herself. He/She moved his/her legs while in the chair. During interview on 2/25/20 at 2:30 P.M. the Registered Nurse (RN) D nurse manager said the following: -Following a resident's fall, staff should provide assessment and treatment of injuries, complete the Accident report and add the new fall intervention to the resident's care plan, chart a progress note about the fall, initiate neurological checks and notify the RN on call, physician and the resident's family of the fall; -The resident did not sleep well and became anxious when alone; -The resident was fidgety in the recliner chair and could not walk; -The resident required mechanical lift transfers; -On 11/30/19 the resident fell out of the recliner chair under the Christmas tree and lacerated his/her head. Staff moved the resident away from the Christmas tree as an intervention; -The resident fell 2/9/20; -Staff should update the resident's care plan with new fall prevention interventions after each fall. 2. Review of Resident #41's annual MDS dated [DATE] showed the following: -Diagnoses included Alzheimer's; -Severely impaired cognition; -Extensive assist of two for mobility and transfer; -Walk to dine with wheelchair five times weekly; -Wheelchair for mobility; -One non-injury fall since admission or last assessment; -Range of motion impairment of lower extremity on one side; -Not steady, only able to stabilize with human assistance. Review of the resident's care plan dated 7/14/17 showed the following: -Falling Star plan of care: Limit and prevent falls and injuries related to falls; -Ambulated very short distances with walker and assist of two staff. Observation on 2/23/20 at 11:25 A.M. showed the following: -The resident wore socks and house slippers and sat in his/her recliner in the common area; -CNA M and applied CNA O applied a gait belt around the resident and as each staff held the back of the belt, both staff hooked their arms under the resident's arms and lifted him/her out of the recliner and into the wheelchair. The gait belt rose to the resident's chest; -CNA M pushed the resident in his/her wheelchair to the shower room without foot pedals as the resident's feet drug the floor; CNA M instructed the resident to lift his/her feet, however the resident could not hold them up. When they approached the shower room doorway, CNA O bent down and lifted the resident's feet temporarily; -CNA M and CNA O transferred the resident from the wheelchair to the toilet as each placed one hand on the back of the belt and hooked their arms under the resident's arms; -Staff assisted he resident to stand using the same technique and repositioned him/her on the toilet; -After toileting, CNA M and CNA O assisted the resident to stand by lifting with one hand on the back of the gait belt and their arms hooked under the resident's arms transferring the resident back to the wheelchair; -CNA M pushed the resident in the wheelchair to the dining room while the resident's feet drug the floor. 3. Review of Resident #162's care plan dated 4/19 showed the following for the resident: -Required assist with transfers; -At risk for falls due to impaired decision making skills. Review of the resident's quarterly MDS, dated [DATE] showed the following: -Severely impaired cognition; -Limited assist of two staff for transfers; -Used a wheelchair for mobility; -Extensive assist of one for mobility; -No ROM limitations; -No falls since admission or previous assessment. Review of the resident's Physician Order Sheet, dated 2/20 showed the following: -Diagnoses included Alzheimer's dementia (loss of memory) and history of falls; -Up with assist of two staff to wheelchair; -Hospice for progressive dementia. Observation on 2/24/20 at 4:55 P.M. showed the following: -The resident sat in his/her recliner in the common room; -CNA B and CNA N raised the electric recliner and transferred the resident to the wheelchair; -There were no foot pedals on the wheelchair; -The resident had to lift his/her feet while CNA B pushed him/her to the shower room where staff toileted him/her; -CNA C pushed the resident (in the wheelchair) to the dining room while the resident lifted his/her feet during the transport. 4. Review of Resident #60's care plan, dated 2/6/19 showed the following: -Fully dependent on staff for ADL's; -Total dependence of two staff for transfers. May use sit to stand or Hoyer PRN (mechanical lift, as needed); -Falling star plan of care: Limit and prevent falls and injuries related to falls. Review of Resident #60's annual MDS dated [DATE] showed the following: -Severely impaired cognition; -Extensive assist of two staff for transfers and toileting; -Walker and wheelchair used; -One non-injury fall since admission of last assessment. Observation on 2/24/20 at 4:35 P.M. showed the following: -The resident wore house shoes and sat in a recliner in the common area; -CNA B and Nurse Aide (NA) L applied a gait belt and transferred the resident to his/her wheelchair; -CNA B pushed the resident in the wheelchair (without foot pedals) to the shower room and toileted the resident; -CNA C pulled the resident, in the wheelchair, out of the shower room and pushed him/her (without foot pedals) to the dining table as the resident's feet drug the floor. During interview on 2/26 at 9:42 A.M. CNA M said the following: -Foot pedals should be used when staff transported residents in wheel chairs if their feet drug the floor; -Staff should never hook or lift a resident under their arms. Hands should be placed on the gait belt. 5. Review of Resident #3's care plan, last revised 3/11/19 showed the following: -Falling star plan of care: Limit and prevent falls and injuries related to falls; -Assist with mobility as needed; -Transfers with assist of one; -Used wheelchair. Review of the resident's annual MDS, dated [DATE] showed the following: -Dementia without behavioral disturbances; -Severely impaired cognition; -Limited assist of one staff for transfers; -No ROM impairment; -Wheelchair used for mobility. Observation on 2/23/20 at 11:57 A.M. showed the following: -The resident sat in the recliner in the common area; -CNA O and CNA P applied a gait belt around the resident and CNA P put one hand on the gait belt and hooked her other arm (not holding the belt) under the resident's arm. Staff transferred the resident to the wheelchair. 6. Review of Resident #7's face sheet showed the following: -admission dated 9/17/18; -Diagnosis of stroke. Review of the resident's care plan dated 9/17/19 showed the following: -The resident had diagnosis of stroke with left sided weakness. Staff should assist resident with all ADL tasks, assist with position changes in bed and chair, provide range of motion to both lower extremities for contracture prevention (stiffness of joints) and range of motion to left should, elbow and wrist. -The resident was total assistance with all ADLs. He/She was unable to get out of a chair or reposition on his/her own. Staff should monitor frequently for position changes and comfort. He/She required extensive staff assistance with transfers. Review of the resident's annual MDS dated [DATE] showed the following: -Moderately impaired cognition; -Required limited assistance of one staff member with bed mobility; -Required extensive assistance of two staff members with transfers. Observation on 2/23/20 at 3:20 P.M showed the following: -CNA B applied a brace on the resident's left foot and applied the resident's shoes. He/She sat the resident on the side of the bed and applied a gait belt. The resident leaned to the left with left arm flaccid (no movement); -CNA B and NA C lifted the resident with one arm under the resident's arms and one hand behind the resident on the gait belt and transferred the resident to the wheelchair. The resident stooped forward with shoulders raised and limited movement of his/her feet during the transfer. During interview on 2/26/20 at 3:55 P.M. CNA B said he/she should transfer the resident holding the gait belt and should not lift the resident under the arms. During interview on 2/26/20 at 6:30 P.M. the Director of Nursing said the following: -Following a residents fall, staff should identify a meaningful intervention and implement the intervention immediately to prevent further falls. Interventions implemented could be modified; -Staff should include the new fall intervention in the accident report completed after each fall and share the information with staff between shifts; -Staff should include new fall prevention interventions in the residents' care plans; -Staff should apply footrests on residents' wheelchair and not drag residents' feet while pushing them down the hall; -Staff should not lift residents under the arms during a gait belt transfer. Staff should lift the resident holding onto the gait belt.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to appropriately assess, obtain informed consents, and reassess the safety and effectiveness of cane rails, one-quarter length bedrails and one-half length bedrails in use for five residents (Resident #11, #27, #36, #40, and # 55) of 18 sampled residents who had bedrails in place on their beds. The facility census was 69. Review of the facility's Bed Rail Checks, Installation and Removal policy dated 6/22/17 showed the following: -Bedrails were defined as any device that could be attached to one or both sides of a bed for the purpose of fall restraint or mobility assist; -All bedrail installations would be monitored and checked monthly by support services staff to eliminate hazards or entrapment of any kind, and review quarterly by support services supervisor and/or administrator; -Support services would be in-serviced at least annually; -A log would be maintained with a record of date of inspection, resident's last name, room/bed number and clearance measurements; -Bedrail installation and removal must be approved the Director of Nursing (DON) and/or designee; -The following protocol would take place for bedrail installation/removal; a. The decision to add or remove bed rails was at the discretion of the DON and or designee who would provide a written request to the support service supervisor; b. Once request received, provided availability of bedrail specific for the bed, support services would carry out the request as specified; c. Due to differences in make and model of beds, it might be necessary to change the bed as well; d. In the event of installation of bedrails, measurements, per Primaris bed safety checks, should be recorded and logged in notebook (Overall Bed Check) with work request attached; e. Likewise, removal of bed rails must be accompanied by a work request from the DON/designee and completion of work request logged and recorded in Overall Bed Check log. Review of the Food and Drug Administration's bed safety guidelines: A Guide to Bed Safety, Bed rails in Hospitals, Nursing Homes, and Home Health Care, dated April 2010, showed the following: -Patients who have problems with memory, sleeping, incontinence, pain, uncontrolled body movements, or who get out of bed and walk unsafely without assistance, must be carefully assessed for the best ways to keep them from harm; -Assessment by the health care team will help to determine how to best keep the patient safe; -Potential risks of bed rails may include strangulation, suffocation, bodily injury or death when patients or part of their body are caught between rails and mattresses, more serious injuries from falls when patients climb over the rails, skin bruising cuts and scrapes, and feeling isolated or unnecessarily restricted; -When bed rails are used, perform an on-going assessment of the patient's physical and mental status and closely monitor high risk patients; -Use a proper size mattress with a raised foam edge to prevent patients from being trapped between the mattress and the bed rail; -Reduce the gaps between the mattress and the rails; -A process that requires ongoing patient evaluation and monitoring will result in optimizing bed safety; -Reassess the need for using bed rails on a frequent and regular basis. 1. Review of Resident #36's Annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/7/20, showed the following: -Diagnoses included anxiety disorder and mixed obsessional thoughts and acts; -Severely impaired decision making; -Extensive assistance with bed mobility; -Two person physical assistance in bed; -Bed rails were not utilized. Review of the resident's care plan, dated 2/24/20, showed the following: -Diagnoses included dementia-impaired judgement, related to diagnosis of obsessive compulsive disorder as manifested by impaired decision making; -Resident will participate in self-care within mental and physical limitations; -Maintain safe environment. Review of the resident's medical record showed no documentation the facility obtained consent or completed an assessment to indicate the use of the cane rails on the resident's bed. Observation on 2/24/20 at 10:50 A.M. showed the resident in bed with bed canes attached to the upper portion of the bed frame on each side of the bed, an approximate one inch gap was noted between the bed cane and the mattress. Certified Nurse Aide (CNA) U and CNA V provided the resident personal cares and incontinence care. CNA U and CNA V turned the resident side to side and removed soiled clothing and incontinence brief. The resident did not utilize the bed cane and assist with bed mobility during cares. Observation on 2/24/20 at 1:54 P.M. showed the resident's bed had metal, cane rails raised on both sides of the bed. During interview on 2/26/20 at 11:15 A.M. CNA U said the resident had short bed rails on the top part of his/her bed. The resident did not use the bed rails any more. He/She used to use them while turning side to side. Observation on 2/26/20 at 3:42 P.M. showed the resident's bed had metal, cane rails were not used during cares provided by staff. 2. Review of the Resident #40's significant change MDS, dated [DATE], showed the following: -Diagnoses included multiple sclerosis (a degenerative disease affecting nerves), muscle weakness, generalized; -Cognitively intact; -Severely impaired decision making; -Extensive assistance with bed mobility; -Upper extremity, impairment to one side; -Lower extremity, impairment to one side; -Bed rails were not utilized. Review of resident's care plan, updated 2/24/20, showed the following: -Diagnoses included pain related to leg fracture and multiple sclerosis; -Half side rails to assist with self-positioning for comfort. Review of the resident's medical record showed no documentation the facility obtained consent or completed an assessment to indicate the use of a cane rail on the resident's bed. Observation on 2/24/20 at 2:30 P.M. showed the resident's bed had a cane rail on both sides which were raised. 3. Review of Resident #11's Physician Order Sheet (POS) dated 2/27/18 showed the following: -Diagnosis of dysphagia (swallowing issue), glaucoma, and chronic pain; -Mobility bars at all times for bed mobility. Review of the resident's care plan updated 3/1/18 showed the following: -The resident was at risk for skin breakdown related to decreased mobility. Staff should provide pressure reducing mattress, maintain turning and positioning schedule upon request of resident, prevent friction during transfers, resident care and bed mobility, provide one-half side rails to assist with positioning and comfort; -The resident used side rails per his/her request. Staff should ensure the rail was in position for the resident to assist with turning and re-positioning; -The resident had artificial legs since [AGE] years of age and ambulated with a wheelchair. Review of the resident's quarterly MDS dated [DATE] showed the following: -Cognitively intact; -Required extensive assistance of two staff members with bed mobility and toileting; -Required total assistance of two staff members with transfers; -Lower extremity range of motion impairment on both sides; -Bed rails not utilized in bed. Review of the resident's medical record showed no staff documentation the facility obtained consent or completed an assessment to indicate the use and safety of a one-half length bed rail on both sides of the resident's bed. Observation of the resident on 2/23/20 at 11:27 A.M. showed the resident in a wide bed with the head of bed elevated with half bed rails attached and in the raised position on the center section of the resident's bed. The top and bottom one-quarter of the mattress was open without a side rail. There was no gap between the bed rails and the mattress. 4. Review of Resident #27's face sheet showed diagnosis of Alzheimer's disease and dementia. Review of the resident's quarterly MDS dated [DATE] showed the following: -Severely impaired cognition; -Required extensive assistance of two staff members with bed mobility; -Required total assistance of two staff members with transfers, dressing and toileting; -No function limitation in upper and lower extremities range of motion; -Bed rails not utilized in bed. Review of the resident's care plan updated 10/24/19 showed the following: -The resident was at risk for skin breakdown. Staff should provide a pressure reducing mattress, prevent friction during transfers, resident care and bed mobility, reposition every two hours and keep heels off the bed at all times; -The resident required assistance with Activities of Daily Living (ADLs). Two staff members should assist with bed mobility, personal hygiene and mechanical lift transfers. -The care plan did not include use of bed rails. Review of the resident's medical record showed no staff documentation the facility obtained consent or completed an assessment to indicate the use and safety of a one-quarter length bedrail on the right side of the resident's bed. Observation on 2/25/20 at 6:35 A.M. showed the following: -The resident lay in bed with a one-quarter length metal bed rail attached to the right side of the bed in the raised position and no bed rail on the left side of the bed. No gap was noted between the bedrail and the mattress; -CNA S and CNA T provided the resident incontinence care, turned the resident side to side and dressed the resident. The resident did not assist staff with any cares and did not utilize the one-quarter length bed rail when turned by staff side to side or repositioned in bed. During interview on 2/25/20 at 6:40 A.M. CNA S said the resident was total care and did nothing for his/herself. The resident did not use the one-quarter length bed rail or hold onto the rail during cares. He/She thought at one time the resident rolled out of bed and the bed rail was attached to the bed to prevent falls. 5. Review of Resident #55's care plan dated 6/6/17 showed the following: -Resident had diagnosis of seizure disorder and will have no injuries due to seizure activity; -Use of siderails related to resident's request to help him/her move, protection due to history of seizures and family/resident request; -Will have no injuries related to side rail usage; -Maintenance will be notified of any issues per maintenance form immediately; -Staff to ensure that the rails remain in working order; -Hoyer (mechanical) lift transfer. Review of the resident's quarterly MDS dated [DATE] showed the following: -Extensive assist of two for bed mobility and transfer; -No use of side rails. Observation on 2/23/20 at 3:32 P.M. showed the resident lay in bed with raised 1/4 rails attached to the center section of the bed. Observation on 2/23/20 at 6:35 P.M showed the following: -CNA Q and Nurse Aide (NA)L transferred the resident from the wheelchair to the bed per Hoyer lift; -Staff performed perineal care and then raised 1/4 metal rails in the center of the bed; -The resident did not use the side rails for turning during cares. During interview on 2/25/20 at 2:30 P.M. Registered Nurse D/ nurse manager said the following: -Staff only completed bed rail assessments for residents who required a full set of bed rails. Assessments for safety and risk of use was not completed for bed rails smaller than full rails or for bed canes; -Staff did not obtain signed consent for bed rail use; -Staff applied bed rails if the resident requested or if physical therapy recommended for bed mobility; -There was no written communication between physical therapy and nursing regarding the request for bed rail use; -Maintenance department applied the bed rails and maintained the bed rails. If a bed rail became loose, maintenance fixed it. He/She did not know if maintenance assessed the bed rails for safety routinely; -The residents' care plans should include use of bed rails; -Staff did not complete a bed rail assessment or obtain a signed consent form prior to application of one-half bed rails for Resident #11; -Staff did not complete a bed rail assessment or obtain a signed consent form prior to application of one-quarter length bed rail for Resident #27. Staff applied the bedrail on the resident's right side of the bed for mobility. The resident was no longer able to use the bed rail and it should be removed. During interview on 2/26/20 at 9:50 A.M. the Maintenance Director said nursing staff usually told him to put the side rails on the residents' beds. He only routinely checked the residents with one-half bed rails or larger for ongoing safety issues. No positioning devices attached to residents' beds were monitored for ongoing safety and maintenance. During interview on 2/26/20 at 6:30 P.M. the Director of Nurses said the following: -Maintenance department applied residents' bed rails. Residents used bed rails for fall prevention, seizures and bed mobility; -Residents' families and physical therapy requested the use of bed rails; -Staff only routinely checked on two sets of full bed rails in the facility for safety and maintenance. All the other bed rails were smaller and did not require routine assessments for safety and maintenance; -The facility did not obtain signed consent forms for bed rails and did not complete safety and risk assessments prior to application of bed rails on the residents' beds; -The facility did not complete ongoing safety and risk assessments for the bed rail use; -If a resident was unable to utilize the bed rail for mobility assistance, the bed rail should not be on the bed; -Staff should include all bed rail use on the residents' care plans.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to ensure medications were stored/destroyed appropriately. The facility census was 69. Review of the facility policy Destruction of expired/opened and used medication (not controlled) dated [DATE] showed : All medication will be collected weekly from the units and given to the nursing office for destruction or credit. Controlled medications are destroyed on site- see policy. Destruction and Returned for Credit: 1.) Medication will be counted and logged into Omniview web portal; 2.) Record are available on web site. Boxes are kept in the nursing office and pharmacy transporter picks them up weekly. Review of the facility policy Destruction of controlled substances dated [DATE] showed the following: This is a guideline for use in the destruction of all controlled substances for our facility: 1.) All unused controlled substances will be destroyed in the nursing office by two licensed nursing staff; 2.) All medication counted and logged on controlled substance sheet; 3.) The individual resident controlled substance log is completed and sent to medical records to be scanned in the resident record; 4.) A copy of the destruction record is maintained in Omni view; 5.) The medication is removed from the packaging, placed in RX destroyer and the contained is kept in the nursing office. 1. Observation on [DATE] at 1:38 P.M. showed the following in the C/D hall medication room: -A large white bin (approximately five gallons), marked with a sticker which read for incinerator set just inside the door between the wall and the cabinet; -The bin had a blue lid which opened on each end and was not closed. The contents were visible without moving or adjusting the lid; -The bin was 90-95% full of used insulin pens, partially empty insulin vials, partially empty saline vials, paper and plastic medication cups with miscellaneous pills of various shapes, sizes and colors; -Loose pills were noted throughout the bin. During interview on [DATE] at 1:45 P.M. Registered Nurse (RN) D said the following: -The bin had been there ever since she started work at the facility; -He/She did not know why the bin was there and it should not contain pills or any medications; -Pills should be placed in the drug buster bottle. During interview on [DATE] at 2:27 P.M. RN D said the following: -The process for destruction of refused medications was to place them in the drug buster. They should not be placed in an open bin; -He/She would not expect pills or unused medications to be placed in the bin; -If a narcotic needed to be destroyed, two nurses would fill out the pink sheet and destroy the medication together, both having signed the pink sheet and marking it on the narcotic count sheet; -He/She did not know the resident names of the medications in the bin, did not know the medication names, the prescription numbers, or the strength of the medications; -There was not an accounting of what had been placed in the bin so he/she could not be sure if the bin contained narcotic medications. During interview on 2/26 at 6:30 P.M. the Director of Nurses (DON) said the following: -Medications needing destroyed should be kept in the medication room. It was the Restorative Aide (RA) Supervisor's job to send medications back to the pharmacy. He/She worked Monday through Friday; -It would be the job of the primary nurse to take medications which needed destroyed to the RA supervisor's office; -If medications were refused, it should be documented refused and the medication should be placed in the drug buster bottle; -It was inappropriate to place un-used medications in the bin, these medications should be destroyed. During interview on [DATE] at 2:21 P.M. the RA supervisor said the following: -He/She was an Licensed Practical Nurse (LPN); -He/She was inserviced several years ago regarding the white bin in the C /D medication room. It was supposed to be used to discard only glass vials/ bottles which could not be placed in the sharps containers; -He/She knew the bin was in the medication room at one time, but did not know it contained medications; -Medications should be placed in the drug buster bottle; -He/She no longer destroyed any medications. He/She is only responsible for returning medications to the pharmacy.

Based on observation, interview and record review the facility failed to ensure residents' medications were secured in a locked cart or cabinet when left unattended during a medication pass. The facility census was 69. Review of the facility policy Administration of Medication dated 11/19/19 showed the following in part: -Read the electronic medical record and ensure administration of the correct medication, the correct dose, by the correct route, at the correct time to the correct resident; -Medication carts should not be left unattended. If you needed to step away, make sure the cart was locked and the computer screen was on lock out. 1. Observations on 2/24/20 showed the following: -At 3:41 P.M. Licensed Practical Nurse (LPN) R parked the medication cart against the C-hallway wall and obtained and prepared Resident #300's medications from the medication cart for administration. The medication cart was full of resident medications and contained a locked cabinet of narcotic medications inside one of the unlocked drawers. LPN R did not lock the medication cart, walked away from the unlocked medication cart and entered the resident's room. The medication cart's unlocked drawers faced outward toward the hall with the back of the medication cart against the wall out of LPN R's line of sight. He/She applied gloves, administered eye drops, entered the resident's bathroom and washed his/her hands, returned to the resident bedside and administered the resident's oral medications. He/She faced the resident with his/her back towards the room door. Two residents and one staff member passed by the unlocked medication cart in the hallway. LPN R returned to the unlocked medication cart and pushed the cart down the hall; -At 3:48 P.M. LPN R parked the unlocked medication cart against the C-hallway wall and obtained and prepared Resident #57's medications from the medication cart for administration. LPN R did not lock the medication cart, walked away from the unlocked medication cart and entered the resident's room. The medication cart's unlocked drawers faced out toward the hall with the back of the medication cart against the wall out of LPN R's line of sight. He/She entered the resident's bathroom, washed his/her hands and applied gloves, administered the resident's oral medications followed by the eye drops. He/She removed the gloves, entered the resident's bathroom and washed his/her hands. One resident and one staff member passed by the unlocked medication cart in the hallway. LPN R returned to the unlocked medication cart and pushed the cart down the hall; -At 3:54 P.M. LPN R parked the unlocked medication cart against the C-hallway wall and obtained and prepared Resident #46's medications from the medication cart for administration. LPN R did not lock the medication cart, walked away from the unlocked medication cart and entered the resident's room. The medication cart's unlocked drawers faced out toward the hall with the back of the medication cart against the wall out of LPN R's line of sight. One staff member and two residents passed by the unlocked medication cart. He/She administered the resident's oral medications and returned to the unlocked medication cart and pushed the cart down the hall; -At 3:57 P.M. LPN R parked the unlocked medication cart against the C-hallway wall and obtained and prepared Resident #262's medications from the medication cart for administration. LPN R did not lock the medication cart, walked away from the unlocked medication cart and entered the resident's room. The medication cart's unlocked drawers faced out toward the hall with the back of the medication cart against the wall out of LPN R's line of sight. He/She administered the resident's oral medications and returned to the unlocked medication cart and pushed the cart down the hall; -At 4:00 P.M. LPN R parked the unlocked medication cart against the C-hallway wall and obtained and prepared Resident #301's medications from the medication cart for administration. LPN R did not lock the medication cart, walked away from the unlocked medication cart and entered the resident's room. The medication cart's unlocked drawers faced out toward the hall with the back of the medication cart against the wall out of LPN R's line of sight. He/She administered the resident's oral medications and returned to the unlocked medication cart; -At 4:02 P.M. LPN R prepared Resident #302's medications from the unlocked medication cart for administration. LPN R did not lock the medication cart, walked away from the unlocked medication cart and entered the resident's room. The medication cart's unlocked drawers faced out toward the hall with the back of the medication cart against the wall out of LPN R's line of sight. He/She administered the resident's oral medications and returned to the unlocked medication cart and pushed the cart down the hall; -At 4:04 P.M. LPN R parked the unlocked medication cart down C-hall and parked the cart near the nurse's desk. He/She locked the medication cart and walked down the hall. During interview on 2/24/20 at 4:20 P.M. LPN R said he/she should lock the medication cart every time he/she walked away from the cart. He/She did not lock the medication cart, one of the drawers was not completely closed and the cart would not lock. The cart should remain in his/her line of sight at all times if the cart was unlocked. The medication cart was not within his/her line of sight when he/she entered the resident's room and administered their medications. During interview on 2/26/20 at 6:30 P.M. the Director of Nursing said staff should keep the medication carts locked at all times when out of the nurses' line of sight.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure staff washed their hands and changed soiled gloves after each direct resident contact and where indicated by professional standards of practice during personal care for eight residents (Resident #41, #60, #162, #27, #59, #7, #34 and #36) in a review of 18 sampled residents. The facility census was 69. Review of the facility policy Handwashing/Hand Hygiene undated, showed the facility considers hand hygiene the primary means to prevent the spread of infection. All personnel shall be trained and regularly inserviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff use to encourage complainace with hand hygiene policies. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: when hands are visibly soiled, before eating, after personal use of the toilet or conducting your personal hygiene, After contact with a resident with infectious diarrhea including, but not limited to infections caused by norovirus, salmonellla, shigella and C.difficle. Use alcohol based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: before and after coming on duty, before and after direct contact with residents, before preparing or handling medications, before performing any non-surgical invasive procedures, before and after handling an invasive device (e.g., urinary catheters, IV access site), before donning sterile gloves, before handling clean or soiled dressings, gauze pads, etc., before moving from a contaminated body site to a clean body site during resident care, after contact with a resident's intact skin, after contact with blood or bodily fluids, after handling used dressings, contaminated equipment, etc ., after contact with objects in the immediate vicinity of the resident, after removing gloves, before and after entering isolation precaution settings, before and after eating food and assisting a resident with meals. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Single use disposable gloves should be used before aseptic procedures, when anticipating contact with blood or bodily fluids, when in contact with a resident, or the equipment of a resident, who is on contact precautions. Washing Hands: Vigorously lather hands with soap and rub them together, creating friction to all surfaces, for a minimum of 20 seconds (or longer) under a moderate stream of running water, at a comfortable temperture. Hot water is unnecessarily rough on hands. Rinse hands thoroughly under running water. Hold hands lower than wrists. Do not touch fingertips to inside of sink. Dry hands thoroughly with paper towels and then turn off faucets with a clean, dry paper towel. Discard towels into trash. Use lotions throughout the day to protect integrity of the skin. Using Alcohol- Based Hand Rubs: Apply generous amount of product to palm of hand and rub hands together. Cover all surfaces of hands and fingers until hands are dry. Follow manufacturers' directions for volume of product to use. 1.Review Resident 36's care plan dated 10/16/19 showed the following: -Extensive assistance of one for toileting; -Assist with toileting as necessary to promote continence. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument, dated 1/7/20, showed the following: -Severely impaired cognition; -Extensive assist of two for transfer and toileting; -Extensive assist of one for personal hygiene; -Always incontinent of bladder; -Frequently incontinent of bowel. Observation on 2/24/20 at 10:50 A.M. showed the following: -The resident asked to use the bathroom; -Certified Nurse Aide (CNA) U and CNA V cleaned hands with alcohol based hand rub (gel) and applied gloves. CNA V unfastened the resident's incontinence brief and rolled the resident to his/her side; -CNA U removed the resident's incontinence brief. The resident was incontinent of urine and a moderate amount of feces; -CNA U wiped the resident's buttocks with the soiled incontinence brief and placed a mechanical lift pad under the resident; -CNA V bagged the feces and urine soiled incontinence brief, removed gloves and without washing hands, pushed the mechanical lift towards the resident's bed; -CNA U with the same soiled gloves and CNA V without washing hands hooked the mechanical lift pad to the mechanical lift and transferred the resident to the bedside commode. Feces fell from the resident's buttocks onto the bedside commode seat. CNA U with the same soiled gloves, obtained a paper towel and wiped up the feces. CNA V lowered the resident onto the bedside commode toilet seat and unhooked the mechanical lift pad from the lift; -CNA U changed gloves without washing hands and bagged the soiled bed linens; -CNA V removed gloves and without washing hands left the room and returned with two clean washable incontinence bed pads. Without washing hands CNA V applied gloves; -CNA U and CNA V attached the mechanical lift pad to the lift, raised the resident off the bedside commode and transferred the resident to bed. The resident's buttocks and the lift pad were soiled with feces. The resident had a large soft bowel movement and urinated in the bedside commode; -CNA U and CNA V rolled the resident on his/her side and rolled the feces soiled mechanical lift pad and the feces soiled washable incontinence bed pad under the resident. CNA V wiped the resident's feces soiled buttocks with wet wipes and reached in between the resident's legs and wiped the perineum; -CNA U and CNA V with the same soiled gloves and without washing hands, touched the resident's leg and back and rolled the resident over and CNA U removed the feces soiled mechanical lift pad and feces soiled washable incontinence bed pad; -CNA V with the same soiled gloves and without washing hands, applied a clean washable incontinence bed pad under the resident, removed the gloves, gelled his/her hands and applied gloves; -CNA U, with the same soiled gloves and without washing hands, placed a clean incontinence brief under the resident and fastened the brief. CNA U removed his/her gloves and without washing hands left the room. CNA U returned with a clean mechanical lift pad and without washing hands and without applying gloves placed the clean mechanical lift pad under the resident; -CNA V dumped the contents of the bedside commode in a trash bag and wiped out the feces and urine soiled bedside commode bucket with wet wipes used for resident incontinence care. CNA V placed the commode bucket under the hand washing sink in the resident's room and filled the bucket partially with water from the faucet. CNA V sloshed the feces and urine soiled bucket back and forth and dumped the contents in the toilet. CNA V wiped the feces soiled bedside commode seat with wet wipes used for resident incontinence care and bagged all the trash. CNA V placed the feces and urine soiled bedside commode in the resident's bathroom, removed gloves and washed hands; -CNA U, without washing hands, applied the resident's clean pants and hooked the mechanical lift pad to the mechanical lift and CNA V raised the resident in the mechanical lift off the bed; -CNA U, without washing hands, positioned the wheelchair under the resident and CNA V lowered the resident into the wheelchair, combed the resident's hair, applied the resident's glasses, placed foot pedals on the wheelchair and pushed the resident in the wheelchair to the dining room. During interview on 2/26/20 at 11:15 A.M. CNA U said the following: -The resident was incontinent most of the time and did not usually use the bedside commode; -He/She should change gloves and wash hands anytime they were soiled; -He/She should not touch clean items with soiled hands; -He/She did not wash hands and change gloves correctly; -He/She should clean the feces and urine soiled bedside commode with disinfectant and not with wet wipes. Wet wipes did not disinfect the commode; -He/She should not empty the bedside commode contents of feces and urine in a trash bag. It should be emptied in the toilet and flushed down the toilet; -He/She should not wash out the bedside commode bucket with water from the resident's handwashing sink. He/She should take the feces and urine soiled bedside commode bucket in the dirty utility room. 2. Review of Resident #41's care plan dated 7/14/17, showed the following: -Incontinent of bowel and bladder; -Provide meticulous skin care before changing incontinent pads. Will have no skin breakdown related to urinary incontience; -Provide hygiene needs. Review of the resident's annual MDS dated [DATE], showed the following: -Diagnoses included Alzheimer's; -Severely impaired cognition; -Extensive assist of two for transfer and toileting -Extensive assist of one for personal hygiene; -Always incontinent of bladder and bowel. Observation on 2/23/20 at 11:25 A.M. showed the following: -The resident sat in his/her recliner in the common area; -CNA M and CNA O transferrred the resident to his/her wheelchair and pushed him/her into the bathroom; -CNA M and CNA O (without washing hands) donned gloves and transferred the resident to the toilet; -CNA M removed the resident's urine soiled incontinent brief, placed a clean incontinent brief around the resident's legs, and taped the sides; -CNA O and CNA M assisted the resident to stand and CNA M cleansed the resident's buttocks and anal area with three wipes and (without changing gloves or washing hands) pulled the resident's pants up, placed his/her hand on the gaitbelt and then degloved. 3. Review of Resident #27's quarterly MDS dated [DATE] showed the following: -Severely impaired cognition; -Required extensive assistance of two staff members with bed mobility; -Required total assistance of two staff members with dressing, toileting and personal hygiene; -Always incontinent of bowel and bladder. Review of the resident's care plan updated 10/24/19 showed the following: -Diagnosis of Alzheimer's disease, dementia, chronic kidney disease, urinary incontinence, hematuria (blood in the urine), and rash; -The resident had urinary and bowel incontinence; -The resident was at risk for skin breakdown. Staff should provide incontinence care as needed, prevent friction during transfers, resident care and bed mobility. Apply skin protectant/skin barrier when performing perineal care; -The resident required assistance with Activities of Daily Living (ADLs). Staff should assist with bed mobility, personal hygiene, bathing, dressing and transfers. Observation on 2/25/20 at 6:35 A.M. showed the following: -CNA S applied gloves without washing hands and placed clean wash cloths in the sink, turned on the faucet, loosened the resident's urine soiled incontinence brief, obtained a clean incontinence brief from the resident's closet and wrung out the wet wash cloths from the sink; -CNA S with the same soiled gloves and without washing hands, applied shower gel from the resident's bedside table drawer on a wet wash cloth and made suds on the wash cloth; -CNA S washed the resident's frontal perineal area, turned the resident on his/her side and removed the resident's urine saturated incontinence brief; -CNA S with the same soiled gloves and without washing hands, applied shower gel soap on a wet wash cloth, made suds on the wash cloth, reached behind the resident, and wiped the resident's buttocks area; -CNA S with the same soiled gloves and without washing hands, obtained a wet wash cloth and rinsed the resident's buttocks and dried with a towel; -CNA T entered the room, gloved without washing hands and applied the resident's clean incontinence brief. During interview on 2/25/20 at 6:45 A.M. CNA S said the following: -He/She should not touch clean items with soiled hands or soiled gloves; -He/She should change gloves and wash hands when moving from front to back and every time he/she touched something soiled. 4. Review of Resident #60's care plan, dated 2/6/19 showed the following: -Fully dependent on staff for ADL's; -Provide incontinence care as needed. Review of the resident's annual MDS dated [DATE] showed the following: -Severely impaired cognition; -Extensive assist of two staff for transfers, toileting and personal hygiene; -Always incontinent of bladder and bowel. Observation on 2/24/20 at 4:35 P.M. showed the following: -The resident sat in a recliner in the common area; -CNA B and NA L transferred the resident from his wheelchair to the toilet in the shower room; -CNA N and CNA B (without washing hands) donned gloves and transferred the resident to the toilet; -CNA B removed a urine soiled incontinent brief, placed it in the trash and then removed the resident's urine soiled pants; -CNA B and CNA N (without changing gloves and washing hands) applied clean pants and the resident's shoes; -CNA N handed a clean incontinent brief to CNA B who (with the same gloves) secured it around the resident's legs; -CNA B and NA L assisted the resident to stand and CNA N cleansed the resident's buttocks (with wet wipes) of soft feces. He/She de-gloved and (without washing hands) re-gloved and pulled the resident's incontinent brief and pants up; -CNA B and NA L transferred the resident back to the wheelchair. During interview on 2/25/20 at 7:48 P.M., CNA N said the following: -Hands should be washed before beginning cares, after cares and with glove changes; -Gloves should be changed when they become soiled. 5. Review of Resident #162's care plan dated 4/19 showed the resident had urinary incontinence. Resident will not experience complications related to incontinence as evidenced by no signs or symptoms of Urinary Tract Infection (UTI). Review of the resident's quarterly MDS, dated [DATE] showed the following: -Severely impaired cognition; -Always incontinent of bladder and bowel; -Extensive assist of two staff for bed mobility and personal hygiene. Observation on 2/25/20 at 6:45 A.M. showed the following: -The resident lay on his/her back in the bed. -CNA I and CNA J entered the room and prepared to change the resident's soiled incontinent brief; Did the CNAs wash hands or apply gloves? When? They washed their hands and donned gloves before beginning and at end. -CNA J unfastened the resident's urine satuarated incontinent brief, rolled the resident to his/her left side, tucked the incontinent pad and brief under the resident and CNA I removed the soiled items; -CNA J (without changing gloves or washing hands) applied a clean incontinent brief and covered the resident with the blanket. During interview on 2/25/20 at 6:50 A.M. CNA I and CNA J said soiled gloves should be removed and hands washed before touching clean items. 6. Review of resident #59's face sheet showed diagnosis of urinary tract infection, skin changes, stroke, rash, and dementia. Review of the resident's care plan dated 8/2/19 showed the following: -The resident was total care with all Activities of Daily Living (ADLs). Staff should anticipate his/her needs and provide morning and evening care, provide meticulous skin care before changing incontinent pad, provide grooming and hygiene needs; -The resident had urinary and bowel incontinence. Review of the resident's quarterly MDS dated [DATE] showed the following: -Long and short term memory problem; -Required extensive assistance of two staff members with bed mobility; -Required total assistance of one staff member with dressing and personal hygiene; -Required total assistance of two staff members with toileting; -Always incontinent of bladder; -Frequently incontinent of bowel. Observation on 2/25/20 at 1:50 P.M. showed the following: -CNA X pushed the resident in a wheelchair down the hall to his/her room and said the resident came to his/her room to get changed and go to bed. Otherwise the resident sat in a recliner chair at the nurses' desk most of the day; -CNA X gloved without washing hands and CNA A washed hands and applied gloves; -CNA X obtained wet wipes, removed the resident's pants and urine saturated incontinence brief. A strong urine odor was noted; -CNA A turned the resident on his/her side. The resident's skin was wet with urine and soiled with feces; -CNA A and CNA X provided the resident incontinence care and with the same soiled gloves and without washing hands, applied the resident's clean incontinence brief and pants, and transferred the resident to a wheelchair. CNA A removed his/her soiled gloves and gelled his/her hands. CNA X removed his/her soiled gloves and without washing hands pushed the resident in the wheelchair to the nurses' desk common area. During interview on 2/25/20 at 2:00 P.M. CNA X said the following: -He/She should wash hands when he/she entered and exited a resident's room and change gloves when the gloves were soiled; -He/She should not touch clean briefs with soiled hand or soiled gloves; -He/She should have washed his/her hands and changed gloves more frequently. 7. Review of Resident #7's care plan dated 9/17/19 showed the following: -The resident was total assistance with all Activities of Daily Living (ADL). He/She was unable to get out of a chair or reposition on his/her own. Staff should provide AM and PM care, provide assist of one to two staff members with transfers. Staff should provide grooming and hygiene needs; -The resident was incontinent of urine and had constipation. Staff should monitor for redness or skin breakdown during toileting/diaper change every two to four hours. Review of the resident's annual MDS dated [DATE] showed the following: -Moderately impaired cognition; -Somewhat important to choose what clothes to wear; -Required limited assistance of one staff member with bed mobility, dressing and personal hygiene; -Required extensive assistance of two staff members with transfers and toileting; -Frequently incontinent of bowel and bladder. Observation on 2/23/20 at 3:20 P.M showed the following: -CNA B wore gloves and bagged soiled linens and trash in the resident's bathroom, exited the bathroom and with the same soiled gloves, touched the resident's oxygen tubing and adjusted the nasal piece in the resident's nose; -CNA B and NA C washed hands and applied gloves. CNA B said the resident was wet and laid his/her gait belt on the top portion of the resident's bed; -NA C removed and bagged the resident's soiled incontinence brief; -CNA B washed the resident's front perineal area, turned the resident on his/her side, reached behind the resident and wiped his/her buttocks and said the resident was wet; -CNA B with the same soiled gloves and without washing hands, dried the resident's skin and applied a clean incontinence brief; -NA C with the same soiled gloves and without washing hands, obtained a Vaseline tube from the resident's bedside table drawer and applied Vaseline with a soiled gloved finger on the resident's abdomen. NA C said the resident had dry skin. 8. Review of Resident #34's care plan dated 3/7/17 showed the following: -Resident is at risk for respiratory distress due to diagnosis of COPD -Monitor for signs of infection such as increased dyspnea, fatigue, sputum production, fever, etc. Review of Resident #34's annual Minimum Data Set (MDS) an assessment instrument, dated 1/7/20 showed the following: -Diagnoses included dementia and chronic obstructive pulmonary disease (COPD) (A group of lung diseases that block airflow and make it difficult to breathe); -Cognitively intact; -Independent for bed and transfer mobility; -Limited assistance by 1 person for personal hygiene. Review of resident's progress notes dated 2/24/20 showed the resident had pneuomonia . Observation on 2/24/20 at 9:39 A.M. showed the following: -CNA V removed an incontinence brief from the resident's bathroom trash can without gloves and put it in different trash bag; -He/She closed the trash bag up and carried it down the hallway into another room. Observation on 2/25/20 at 8:28 A.M. showed the following: -RN Nurse manager entered the resident's room without washing hands or using hand sanitizer; -RN Nurse manager removed the breakfast tray from resident's room and walked towards kitchen area. Observation on 2/25/20 at 8:30 A.M. showed the following: -The RN Nurse manager applied hand sanitizer before entering the resident's room; -He/She moved items around on the bedside table and touched the resident; -He/She took nebulizer cup from the resident and placed it near the nebulizer; -He/She left the resident's room without washing hands or using hand sanitizer. Observation on 2/25/20 at 8:51 A.M. showed the following: -The RN Nurse manager entered resident's room without using hand sanitizer or washing hands; -He/She touched resident's bedside table and touched the resident; -He/She left the resident's room without washing hands or using hand sanitizer. -He/She walked towards nurse's station. During interview on 2/25/20 at 11:30 A.M., The RN Nurse Manager said the following: -Pneumonia was not contagious; -He/She should wash hands and/or wear gloves when assisting a resident with an illness. During interview on 2/26/20 at 6:30 P.M. the DON said the following: -Hands should be washed before cares, after cares and when soiled. Wash or sanitize hands with glove changes; -Hands must be cleaned with soap and water if visibly soiled; -Clean items should not be touched with soiled hands; -He/She would expect staff to use standard precautions depending on catergory; -He/She would expect bedside commode buckets to be cleaned daily and would expect contents to be dumped in the toilet; -He/She would not expect staff to get water for the commode bucket from the sink. They should use the sprayer over the toilet. -Staff should use standard percautions when a resident has pneumonia; -Hands should be washed before and after care of residents that are ill.

Based on observation, interview, and record review, the facility failed ensure the areas within the rangehood, the wall behind the range, griddle and deep fat fryer, the metal backspash for the range and griddle, and the suppression nozzle over the deep fat fryer were free from a buildup of grease and debris. The facility also failed to ensure the wall behind the range, griddle, and deep fat fryer was maintained with an easily cleanable surface. The facility census was 69. Observation on 2/24/20 at 10:08 A.M. showed the wall behind the deep fat fryer, griddle, and range had a heavy buildup of yellow grease. The wall was constructed with drywall, covered with paint. The drywall compound and paint was cracked and peeling in areas above the deep fat fryer. The metal backsplash behind the range and the griddle had a heavy buildup of grease and debris. The baffle filters within the rangehood, located over the range, griddle, and deep fat fryer, and the areas within the hood below the filters, had a buildup of clear grease. The fire suppression nozzle and piping, located over the deep fat fryer, had a buildup of grease and debris. During an interview on 2/25/20 at 1:30 P.M., the dietary supervisor said the following: -Staff last cleaned the rangehood and filters in January, 2020. The vendor was supposed to clean the rangehood in February, but did not. Staff are to clean the rangehood monthly; -Staff are to wipe down the suppression nozzles within the range hood monthly; -Staff tried cleaning the wall behind the range and deep fat fryer but have not had any luck; -She thought staff were cleaning the metal backsplash when they cleaned the ovens monthly. Review of a cleaning list posted in the kitchen showed staff were to clean the stove, hoods, ovens, fryer and grates monthly or as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to turn and reposition four residents (Resident #28, #47, #57 and #64), who were identified as moderate to high risk for developing pressure ulcers, in a review of 17 sampled residents, in accordance with facility policy and their plan of care. The facility census was 67. 1. Review of the National Pressure Ulcer Advisory Panel (NPUAP), prevention and treatment of pressure ulcers; quick reference guide, Washington DC: National Pressure Ulcer Advisory Panel: 2009 showed the following: -Ongoing assessment of the skin is necessary to detect early signs of pressure damage; -Repositioning should be considered in all at-risk individuals, repositioning should be undertaken to reduce the duration and magnitude of pressure over vulnerable areas of the body; -In order to lessen the individual's risk of pressure ulcer development, it is important to reduce the time and the amount of pressure he/she is exposed to; -When an individual is seated in a chair, the weight of the body causes the greatest exposure to pressure to occur over the ischial tuberosities. As the loaded area in such cases is relatively small, the pressure will be high, therefore, without pressure relief, a pressure ulcer will occur very quickly. Review of the facility's Braden Scale Use and Documentation Policy, revised 5/13/13, showed the following: -A Braden score of 15 to 18 indicates mild risk for pressure ulcers; -Residents identified as mild risk require frequent turning, manage moisture, nutrition, and friction/shear, use of a commercial moisture barrier, absorbent pads or depends that wick and hold moisture, offer the bedpan or urinal in conjunction with a turning schedule; -A Braden score of 13 to 14 indicates moderate risk for pressure ulcers; -Residents identified as moderate risk require a turning schedule, pressure reduction support surface, maximal remobilization to protect heels, manage moisture, nutrition, friction and shear, increase protein intake, increase calorie intake, and supplement with vitamins; -Residents at moderate risk for pressure ulcers should be turned and repositioned at a minimum of every two hours, whether in bed or up in a chair; -A Braden score of 10 to 12 indicates high risk for pressure ulcers; -Residents identified as high risk require increased frequency of turning, at a minimum of every two hours, pressure reduction support surfaces, and incontinent care including the use of designated skin care products; -If the resident scores moderate risk but has an existing pressure ulcer, including Stage I, the resident will be considered high risk. 2. Review of Resident #64's care plan, effective 1/26/18, showed the following: -At high risk for skin breakdown related to Braden Scale Score, decreased mobility, incontinence, edema, anemia, and malnourishment; -Provide incontinent care as needed; -Complete the Braden Scale and review quarterly and as needed; -Urinary incontinence related to dementia; -Utilize prompted voiding every one to two hours. (The resident's care plan did not provide staff direction for repositioning the resident or other interventions to prevent skin breakdown.) Review of the resident's Braden Risk Assessment, dated 11/4/18, showed a score of 13, indicating the resident was at moderate risk for developing pressure ulcers. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment required to be completed by facility staff, dated 11/10/18, showed the following: -Dependent on two or more staff for transfers and toileting; -Required extensive assistance of two or more staff for bed mobility; -At risk for pressure ulcers. Observation on 11/28/18 showed the following: -From 11:05 A.M. until 12:10 P.M., the resident sat in his/her wheelchair in the common area; -At 12:10 P.M., staff pushed the resident in his/her wheelchair into the dining room for lunch; -From 12:10 P.M. until 1:39 P.M., the resident sat in a wheelchair in the dining room at a table; -At 1:39 P.M., staff pushed the resident in his/her wheelchair out of the dining room to the common area; -From 1:39 P.M. until 2:00 P.M., the resident sat in a wheelchair in the common area. (The resident remained in his/her wheelchair without repositioning from 11:05 A.M. to 2:00 P.M., two hours and 55 minutes.) Observation on 11/29/18 showed the following: -From 7:40 A.M. until 8:20 A.M., the resident sat in a wheelchair in his/her room. There was a puddle of clear liquid on the floor underneath the resident. The resident was not wearing an incontinence brief; -At 8:20 A.M., the resident remained seated in the wheelchair in his/her room. The puddle of liquid remained on the floor under the resident and the resident remained without an incontinence brief. Staff delivered the resident a meal tray to his/her room. Staff did not turn or reposition the resident or check him/her for incontinence; -From 8:20 A.M. to 8:46 A.M., the resident sat in a wheelchair in his/her room. The puddle of liquid remained on the floor under the resident's chair; -At 8:46 A.M., staff entered the room and administered the resident his/her medications. Staff did not reposition the resident or check him/her for incontinence. The puddle of liquid remained underneath the resident on the floor. The resident remained without an incontinence brief; -From 8:46 A.M. until 11:05 A.M., the resident remained seated in a wheelchair in his/her room. The puddle of liquid remained underneath the resident on the floor. The resident remained without an incontinence brief; -At 11:05 A.M., staff wheeled the resident from his/her room to the shower room; -At 11:10 A.M., staff transferred the resident from the wheelchair to a shower chair. The incontinent pad under the resident was wet with urine and smeared with feces. The resident's buttocks were reddened. (The resident remained in his/her wheelchair from at least 7:40 A.M. to 11:10 A.M., three hours and 30 minutes, without staff repositioning or checking the resident for incontinence.) During an interview on 11/29/18 at 12:08 P.M., Certified Nurse Assistant (CNA) C said he/she assisted with the resident's transfer from the wheelchair to the shower chair. The pad under the resident had been wet with urine and smeared with feces. The resident was always incontinent of bowel and bladder. Staff should turn, reposition and check residents for incontinence every two hours. 3. Review of Resident #47's Braden Risk Assessment, dated 10/18/18, showed a score of 12, indicating he/she was at high risk for developing pressure ulcers. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Daily decision making was moderately impaired; -Required extensive assistance from one staff for bed mobility, dressing and toilet use; -Required total assistance from two staff for transfers; -Always incontinent of bowel and bladder; -At risk for pressure ulcers. Review of the resident's care plan, dated 11/12/18, showed the following: -At risk for skin breakdown related to Braden Scale Score, decreased mobility, incontinence and poor appetite; -Check every two hours and as needed (PRN) for incontinence; -Assist of one to two staff with turning and positioning as scheduled and PRN; -Use pressure reducing cushion when in wheelchair. Observation on 12/4/18 showed the following: -From 9:09 A.M. to 11:29 A.M., the resident sat in his/her wheelchair in his/her room; -At 11:29 A.M., staff pushed the resident in his/her wheelchair to the common area by the nursing station; -At 11:30 A.M., staff pushed the resident in his/her wheelchair to a table in the dining room; -From 11:30 A.M. to 12:02 P.M., the resident sat in his/her wheelchair at a table in the dining room. During interview on 12/4/18 at 1:08 P.M., CNA A (staff responsible for the resident's care) said the resident remained seated in his/her wheelchair from 12:02 P.M. to 12:55 P.M. Further observation on 12/4/18 showed the following: -Between 12:55 P.M. and 1:25 P.M., the resident sat in his/her wheelchair in his/her room. No staff entered the resident's room; -At 1:27 P.M., CNA A and CNA B transferred the resident to his/her bed. CNA A removed the resident's urine saturated incontinence brief. The resident was incontinent of bowel and bladder. The resident's buttocks and thighs were reddened with red creases throughout. (The resident remained in his/her wheelchair without repositioning from 9:09 A.M. to 1:27 P.M., for four hours and 18 minutes.) During interview on 12/4/18 at 1:35 P.M., CNA B said all residents should be turned and repositioned every two hours. He/she didn't know why he/she didn't turn or reposition the resident. 4. Review of Resident #28's Braden Risk Assessment, dated 9/17/18, showed a score of 13, indicating the resident was at moderate risk for developing pressure ulcers. Review of the resident's care plan, effective 9/17/18, showed the following: -At high risk for skin breakdown related to decreased mobility; -Complete the Braden Scale and review quarterly and as needed; -Maintain turning and repositioning schedule as recommended (specify frequency); -Urinary incontinence; -Utilize prompted voiding every one to two hours with positive reinforcement. Review of the resident's admission MDS, dated [DATE], showed the following: -Required extensive assistance of two or more staff for bed mobility, transfers, and toileting; -Frequently incontinent of bowel and bladder; -At risk for pressure ulcers. Observation on 11/29/18 showed the following: -At 7:45 A.M., staff wheeled the resident to the dining room in his/her wheelchair; -From 7:45 A.M. to 9:25 A.M., the resident sat in his/her wheelchair at the dining room table; -At 9:25 A.M., staff pushed the resident in his/her wheelchair from the dining room to the activity room; -From 9:25 A.M. until 10:13 A.M., the resident sat in a wheelchair in the activity room; -From 10:13 A.M. until 11:04 A.M., the resident sat in a wheelchair in the common area. (The resident remained in his/her wheelchair without repositioning from at least 7:45 A.M. to 11:04 A.M., three hours and 19 minutes.) Observation on 12/4/18 showed the following: -At 8:50 A.M., the resident sat in a wheelchair in the common area; -At 9:19 A.M., staff pushed the resident in his/her wheelchair from the common area to the activity room in his/her wheelchair; -From 9:19 A.M. until 11:50 A.M., the resident remained seated in a wheelchair in the activity room. (The resident remained seated in his/her wheelchair from at least 8:50 A.M. until 11:50 A.M. , three hours, without staff repositioning, toileting or checking the resident for incontinence.) 5. Review of Resident #57's care plan, dated 9/19/18, showed the following: -At risk for skin breakdown related to incontinence; -Maintain turning and repositioning schedule of every two hours while in bed and every hour when he/she is up in a chair. Review of the resident's Braden Risk Assessment, dated 10/18/18, showed a score of 13, indicating he/she was at moderate risk for developing pressure ulcers. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Daily decision making was severely impaired; -Required total assistance from two staff for bed mobility and transfers; -Always incontinent of bowel and bladder; -At risk for pressure ulcers; -On a turning and repositioning program. Observation on 11/28/18 showed the following: -From 11:00 A.M. to 11:59 A.M., the resident sat in his/her wheelchair in the activity room; -At 11:59 A.M., staff pushed the resident in his/her wheelchair to a table in the dining room; -From 12:14 P.M. to 12:50 P.M., the resident sat in his/her wheelchair at a table in the dining room; -At 12:50 P.M., staff pushed the resident in his/her wheelchair to his/her room and administered a breathing treatment; -At 1:02 P.M., staff pushed the resident in his/her wheelchair to the common area by the nursing station; -From 1:22 P.M. to 1:45 P.M., the resident sat in his/her wheelchair by the nursing station; -At 1:45 P.M., staff transferred the resident from his/her wheelchair to a recliner in the common area. (The resident remained in his/her wheelchair from 11:00 A.M. to 1:45 P.M., two hours and 45 minutes, without staff repositioning the resident.) During an interview on 12/4/18 at 1:35 P.M., CNA B said all residents should be turned and repositioned every two hours. He/she didn't know why he/she didn't turn or reposition the resident. During an interview on 12/4/18 at 2:30 P.M., the Director of Nurses (DON) said she expected staff to turn any resident at risk for pressure ulcer development at least every couple of hours and more often if needed or requested.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assess and vaccinate eligible residents with the pneumococcal vaccine as indicated by the current Centers for Disease Control (CDC) guidelines, unless the resident had previously received the vaccine, refused, or had a medical contraindication present for seven residents (Residents #4, #8, #15, #19, #25, #28 and #57), in a review of 17 sampled residents. The facility also failed to provide education to residents and/or resident representatives based on the current CDC guidelines for administering the pneumococcal vaccine. The facility census was 67. 1. Record review showed no evidence the facility had developed policies and procedures to ensure the following: -Before offering the pneumococcal immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization; -Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized; -The resident or the resident's representative has the opportunity to refuse immunization; and -The resident's medical record includes documentation that indicates, at a minimum, the following; -That the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and -That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal. During an interview on 11/27/18 at 9:55 A.M., the Administrator said the facility used the CDC guidelines for pneumococcal vaccination as the facility's policy. Review of the US Department of Health and Human Services CDC Pneumococcal Vaccine Time for Adults, dated 11/30/15, showed the following: -Two pneumococcal vaccines were recommended for adults: 13-valent pneumococcal conjugate vaccine (PCV13, PREVNAR 13) and 23-valent pneumococcal polysaccharide vaccine (PPSV23, Pneumovax 23): -One dose of PCV13 was recommended for adults 65 years or older who had not previously received PCV13; -One dose of PPSV23 was recommended for adults 65 years or older, regardless of previous history of vaccination with pneumococcal vaccines. Once a dose of PPSV23 was given at age [AGE] years or older, no additional doses of PPSV23 should be administered; -For those age [AGE] years or older who had not received any pneumococcal vaccines, or those with unknown vaccination history, administer one dose of PCV13. Administer one dose of PPSV23 at least one year later for most adults or at least eight weeks later for adults with immunocompromising conditions; -For those age [AGE] years or older who previously received one dose of PPSV23 and no doses of PCV13, administer one dose of PCV13 at least one year after the dose of PPSV23 for all adults regardless of medical conditions; -For residents age [AGE]-64 years, administer one dose of PPSV23 at 19 through 64 years. This includes adults with chronic heart or lung disease, diabetes mellitus, alcoholism, chronic liver disease and adults who smoke; -For residents age [AGE]-64 years, administer one dose of PCV13 then administer PPSV23 at least eight weeks apart from the PCV13 (at 19-64 years). Administer another PPSV23 at least five years after the first dose of PPSV23(at 19-64 years). Review of the facility's Immunization Consent Form, undated, showed the following: -A place on the form for the resident or guardian to sign, requesting the pneumococcal vaccine be administered; -Note: If the resident has had pneumococcal vaccine since the age of 65, the vaccine is not needed. (The facility's consent form did not include the current CDC guidelines for pneumococcal vaccination.) 2. Review of Resident #25's face sheet showed the following: -The resident was over age [AGE]; -The resident was admitted to the facility on [DATE]. Review of the resident's immunization record showed the resident refused the pneumococcal vaccine on 10/10/10. Review of the resident's medical record showed no evidence staff offered the resident the pneumococcal vaccination after 10/10/10, and no evidence staff provided the resident or his/her responsible party with education regarding CDC guidelines for pneumococcal vaccinations. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment required to be completed by facility staff, dated 9/17/18, showed the following: -The resident's pneumococcal vaccine was not up to date; -The resident was offered the pneumococcal vaccine and declined. During an interview on 12/11/18 at 4:28 P.M., the resident's responsible party said the following: -The resident has not received the pneumonia vaccine at the facility; -He/she would want the resident to receive the pneumonia vaccine. 3. Review of Resident #4's face sheet showed the following: -The resident was over age [AGE]; -The resident was admitted to the facility on [DATE]. Review of the resident's immunization record, dated 10/16/18, showed no evidence the resident had or had not received the pneumococcal vaccination. Review of the resident's medical record showed no evidence staff offered the resident the pneumococcal vaccination, and no evidence staff provided the resident or his/her responsible party with education regarding CDC guidelines for pneumococcal vaccinations. 4. Review of Resident #28's face sheet showed the following: -The resident was under age [AGE]; -The resident was admitted to the facility on [DATE]. Review of the resident's immunization record, dated 9/17/18, showed the resident had not received a pneumococcal vaccine in the past. Review of the resident's medical record showed no evidence staff offered the resident the pneumococcal vaccination, no evidence the resident declined the vaccination, and no evidence staff provided the resident or his/her responsible party with education regarding CDC guidelines for pneumococcal vaccinations. 5. Review of Resident #19's face sheet showed the following: -The resident was over age [AGE]; -The resident's original admission to the facility was on 12/8/16; -The resident's last admission to the facility was on 7/31/18. Review of the resident's immunization record, dated 10/17/18, showed no evidence the resident had or had not received the pneumococcal vaccine. Review of resident's medical record showed no evidence staff offered the resident the pneumococcal vaccination, and no evidence staff provided the resident or his/her responsible party with education regarding CDC guidelines for pneumococcal vaccinations. 6. Review of Resident #8's face sheet showed the following: -The resident was over age [AGE]; -The resident was admitted to the facility on [DATE]. Review of the resident's immunization record showed the resident received the pneumococcal vaccine on 3/3/08. The form did not specify which vaccine the resident received. Review of the resident's medical record showed no evidence staff offered the resident and additional pneumococcal vaccination, and no evidence staff provided the resident or his/her responsible party with education regarding CDC guidelines for pneumococcal vaccinations. 7. Review of Resident #57's face sheet showed the following: -The resident was over age [AGE]; -The resident was admitted to the facility on [DATE]. Review of the resident's immunization record, dated 5/13/11, showed the resident received the pneumococcal vaccine on 09/23/09 at his/her physician's office. The form did not specify which vaccine the resident received. Review of the resident's quarterly MDS, dated [DATE], showed the following: -The resident's pneumococcal vaccine was not up to date; -The resident was offered the pneumococcal vaccine and declined. Review of the resident's medical record showed no evidence staff offered the resident any additional pneumococcal vaccinations, and no evidence staff provided the resident or his/her responsible party with education regarding CDC guidelines for pneumococcal vaccinations. 8. Review of Resident #15's face sheet showed the following: -The resident was over age [AGE]; -The resident's original admission to the facility was on 5/12/14; -The resident's last admission to the facility was on 5/5/17. Review of the resident's immunization record, dated 7/13/15, showed the resident received the pneumococcal vaccine on 11/25/14 at the hospital. The records did not indicate which vaccine he/she received. Review of the resident's medical record showed no evidence staff offered the resident any additional pneumococcal vaccinations, and no evidence staff provided the resident or his/her responsible party with education regarding CDC guidelines for pneumococcal vaccinations. During an interview on 12/4/18 at 2:30 P.M., the Director of Nursing (DON) said upon admission to the facility, the admitting nurse should check to see if the resident had received a pneumococcal vaccine in the past and which type of vaccine was received. Staff should follow the current CDC guidelines for pneumococcal vaccination and contact families and physicians to determine the resident's vaccination status. Staff should document in the resident's record if the resident or guardian refused the vaccine.

Based on observation, interview, and record review, the facility failed to remove and discard expired medications from the medication carts for 13 residents (Residents #24, #4, #65, #15, #11, #23, #6, #5, #47, #49, #34, #51, #44 ). The facility census was 67. 1. Review of the facility's policy, Destruction of Expired/Opened Used Medication, Not Controlled, dated 1/10/12, showed all medication will be collected weekly from the units and given to the nursing office for destruction or credit. Controlled medication are destroyed on site. 2. Observation on 11/28/18 at 1:45 P.M., of the medication cart on D wing, showed the following: -Two cards of loperamide (antidiarrheal) 2 milligrams (mg) labeled for Resident #6. One card contained 13 tablets and showed an expiration date of 07/18. The second card contained 30 tablets and showed an expiration date of 10/31/18; -One card of clonidine HCL (sedative and antihypertensive) 0.1 mg labeled for Resident #5. The card contained 30 tablets and showed an expiration date of 7/31/18; -Two cards of loperamide 2 mg labeled for Resident #5. One card contained 30 tablets and the second card contained 18 tablets. Both medication cards showed an expiration date of 8/31/18. Observation on 11/28/18 at 3:43 P.M., of the medication cart on D wing, showed the following: -Two cards of 100 mg docusate sodium (stool softener) labeled for Resident #24. One card, containing 20 tablets, had an expiration date of 2/28/17. The second card, containing 30 tablets, had an expiration date of 5/31/18; -One card, containing 29 tablets of 100 mg docusate sodium, was labeled for Resident #4. The card had an expiration date of 10/31/18. 3. Observation on 11/28/18 at 1:00 P.M., of the special care unit medication cart, showed the following: -One card of loperamide 2 mg labeled for Resident #65. The card contained 29 tablets and showed an expiration date of 4/30/18; -One card of ondansetron ODT (medication used to prevent nausea and vomiting) 4 mg labeled for Resident #15. The card contained 30 tablets and had an expiration date of 06/18, -One card of docusate sodium 100 mg labeled for Resident #11. The card contained 30 tablets and showed an expiration date of 7/31/18; -One card of oxybutynin ER (medication used to treat overactive bladder) 5 mg labeled for Resident #23. The card contained 30 tablets and showed an expiration date of 5/30/18; -One card of loperamide 2 mg labeled for Resident #23. The card contained 29 tablets and showed an expiration date of 10/31/18; -One card of hydroxyzine HCL (antihistamine) 25 mg labeled for Resident #23. The card contained 28 tablets and showed an expiration date of 7/31/18. 4. Observation on 11/28/18 at 2:15 P.M., of the medication cart on C wing, showed the following: -One card of risperidone (antipsychotic) 1 mg labeled for Resident #47. The card contained 30 tablets and showed an expiration date of 7/31/18; -One card of acetaminophen (pain reliever) 500 mg labeled for Resident #49. The card contained 26 tablets and showed an expiration date of 11/17; -Three cards of clonidine HCL 0.1 mg labeled for Resident #34. One card contained 30 tablets and expired on 8/31/18. The second card contained eight tablets and expired on 7/31/18. The third card contained nine tablets and expired on 6/30/17. 5. Observation on 11/28/18 at 2:45 P.M., of the medication cart on A and B wing, showed the following: -Two full cards (containing 30 tablets each) of docusate sodium 100 mg labeled for Resident #51. One card expired on 6/30/17, and the second card expired on 7/31/18; -One card of bisacodyl (laxative) 5 mg labeled for Resident #51. The card contained 30 tablets and showed an expiration date of 07/18; -Four cards of Tylenol Arthritis ER 650 mg labeled for Resident #51. One card contained six tablets, one contained 10 tablets, and two cards contained 30 tablets each. All four cards showed an expiration date of 10/31/18; -A bottle of Q-Tussin DM syrup (cough medication) 10 milliliters (ml) labeled for Resident #44. The bottle showed an expiration date of 09/17. -An opened bottle of stock multi-vitamins showed an expiration date of 09/18; -An opened bottle of calcium antacid 750 mg showed an expiration date of 08/18. During an interview on 11/28/18 at 1:15 P.M., Licensed Practical Nurse (LPN) K said staff should pull expired medications from the cart and destroy them. During an interview on 11/28/18 at 1:17 P.M., Registered Nurse (RN) J said staff should pull expired medications from the medication cart and give them to the Director of Nursing (DON). The DON sends the medications back to the pharmacy for destruction. Each certified medication technician (CMT) or nurse who has access to the medication cart should monitor for expired medications. If expired medications are found, staff should remove them from the medication cart. During an interview on 11/28/18 at 2:50 P.M., Licensed Practical Nurse (LPN) L said he/she should check the medication cart for expired medications and remove them. During an interview on 12/4/18 at 2:30 P.M., the Director of Nursing (DON) said staff who administer medications should be checking the medication rooms and carts on a monthly basis and removing any expired or discontinued medications. Staff bring all the expired or discontinued medications to the DON. The unit supervisor usually assigned this task to the night shift charge nurse once a month. The unit supervisor should follow up and check the medication rooms and carts to ensure this had been done.

Based on observation, interview, and record review, the facility failed to ensure staff with facial hair wore beard restraints in the kitchen; failed to ensure the flooring in the dish machine area was free of an accumulation of black debris; failed to ensure the wall behind cooking equipment was free of grease and debris; and failed to ensure fans in the kitchen were clean and free of debris. The facility census was 67. 1. Review of the facility's policy, Code of Dress and Personal Appearance, dated 2011, showed employees will use effective hair restraints, such as hairnets, hair bonnets, and beard guards to prevent contamination of food or food contact surfaces. 2. Observation on 11/27/18 between 11:34 A.M. to 12:39 P.M., showed Dietary Staff E had a full moustache and goatee and did not wear a beard restraint. Dietary Staff E added desserts from the reach-in cooler to all prepared resident trays. He/she covered all plates of food with dome covers and then placed the trays in carts for transport to the halls. He/she carried all prepared resident trays to the serving window to be served to residents in the main dining room. He/she also plated all trays/plates for those residents with an order for a pureed diet. He/she did not wear a beard restraint during this observation. Observation on 11/27/18 at 4:06 P.M., showed Dietary Staff E placed frozen catfish fillets into the fryer basket. He/she lowered 10 fillets into hot oil, cooked the fillets, removed them from the oil, and repeated the process for another round of frying catfish. He/she did not wear a beard restraint during food preparation. Observation on 11/27/18 at 4:12 P.M., showed Dietary Staff E leaned over the steam table and measured food temperatures for the evening meal. He/she did not wear a beard restraint. Observation on 11/27/18 at 4:24 P.M., showed Dietary Staff E removed frozen fish fillets from a large cardboard box and placed the fillets in the fryer baskets. He/she did not wear a beard restraint. During an interview on 11/28/18 at 3:30 P.M., the Dietary Manager said all staff should wear hair restraints while in the kitchen. She didn't think about a beard restraint for Dietary Staff E. Normally he/she shaved his/her face and she hadn't noticed his/her facial hair. During an interview on 11/28/18 at 3:59 P.M., Dietary Staff E said he/she had a moustache and goatee for a while now and tended to keep facial hair longer in the winter. He/she was unaware a beard restraint was needed. 3. Observation on 11/27/18 at 10:49 A.M., showed a heavy buildup of black debris on the grout and on the floor tiles under the garbage disposal below the dish machine area. Observation on 11/28/18 at 9:30 A.M., showed the floor tiles in the dish machine area had a heavy buildup of black debris on the grout and on the surfaces of the tiles. During an interview on 11/28/18 at 10:55 A.M., the Dietary Manager said dietary staff mopped the floors daily and cleaned the floors weekly with the floor cleaner machine. The floor cleaner machine wasn't able to get underneath the dish machine counter and couldn't reach around the garbage disposal. He/she said the black debris would not come off the tiles and grout; she had tried to remove it in the past. Observation on 11/28/18 at 3:25 P.M., showed a heavy accumulation of black debris on the floor tiles and on the grout between the tiles under the garbage disposal. The soiled area measured approximately 2-feet wide and 2-feet long. Observation and interview on 11/28/18 at 3:25 P.M., showed the black debris easily came off of the floor and grout with a paper towel. The Dietary Manager confirmed this observation and said the flooring needed to be addressed. 4. Observation on 11/27/18 at 10:51 A.M., showed a heavy buildup of sticky yellow grease and debris visible on the blue wall in the kitchen behind the fryer and six-burner stove. Observation on 11/28/18 at 9:30 A.M., showed a heavy buildup of sticky yellow grease and debris on the blue wall behind the stove and fryer unit, with the heaviest buildup located behind the fryer. During an interview on 11/28/18 at 3:30 P.M., the Dietary Manager said dietary staff cleaned the walls in the kitchen when needed. Cleaning of the walls was not regularly scheduled. The wall behind the fryer and stove probably hadn't been cleaned in a while. Staff had recently cleaned the large equipment in this area, but the wall behind the fryer and stove had probably been missed during the recent cleaning. 5. Observation on 11/27/18 at 10:42 A.M. and on 11/28/18 at 9:30 A.M., showed a buildup of lint and debris was visible on a round black fan pointed toward the clean side of the dish machine. A second white and gray fan had a buildup of lint and debris and was pointed toward the dirty side of the dish machine. During an interview on 11/28/18 at 3:30 P.M., the Dietary Manager said fans were cleaned as needed and were not regularly scheduled for cleaning.