**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow physician's orders for one resident (Resident #1) out of five sampled residents by not administering the resident his/her medications in a timely manner. The facility census was 55. The administration was notified on 09/09/25 of the Past Non-Compliance which occurred on 08/17/25. On 08/31/25, upon notification, the facility administration started an investigation and completed a medication error report. In-serviced staff on Medication Administration Compliance. The non-compliance was corrected on 09/02/25, as the facility in-serviced the nursing staff responsible for medication administration on the facility's policy and procedures for Medication Administration Compliance. The facility policy titled, Physician/Practitioner Orders, undated, showed:- For all physician/practitioner orders received via telephone, the nurse will:a. Document the order notating the time, date, name and title of the person providing the order, and the signature and title of the person receiving the order;b. Follow facility procedures for verbal or telephone orders including, noting the order, submitting to pharmacy and transcribing to medication or treatment administration record.The facility policy titled, Medication Administration, undated, showed:- Review Medication Administration Record (MAR) to identify medications to be administered;- If any discrepancies noted, report to nurse manager. 1. Review of Resident #1's medical record showed:- Date of admission [DATE];- Diagnoses of dementia (a progressive mental deterioration) disease, schizoaffective (a condition characterized by abnormal thought processes and deregulated emotions) disorder, anxiety (worry and fear about everyday situations), depression, and persistent mood disorder (a chronic form of depression characterized by persistent low mood and other symptoms that last for at least two years).Review of the resident's September 2025 Physician Order Sheet (POS) showed:- An order for Invega Sustenna (an antipsychotic (a medication that alters thoughts and perceptions) medication) intramuscular (IM - an injection into the muscle) suspension 78 milligram (mg)/0.5 milliliter (ml) starting and ending on the 17th of every month for bipolar (a mental health condition that causes extreme mood swings), dated 08/01/25, and discontinued on 08/31/25;- An order for Invega Sustenna 78mg/0.5ml IM one time a day starting on the 1st of every month for bipolar, dated 08/31/25.Review of the resident's August 2025 Treatment Administration Record (TAR) showed:- Documentation to see the resident's progress note dated 08/17/25. Review of the resident's Progress Notes, dated 08/17/25, showed:- No documentation of the administration of the Invega injection or the reporting to the charge nurse of the medication not being administered as ordered. During an interview on 09/09/25 at 11:00 A.M., Licensed Practical Nurse (LPN) A said the Invega order had been changed due to a recent gradual dose reduction on 08/01/25. When the new order was put into the medical record, the Invega injection was populated on the Certified Medication Technician (CMT) MAR. When the injection populated on the CMT MAR, the CMT documented not given on the resident's MAR and did not report the medication wasn't given to the charge nurse. A CMT would not administer an Invega injection. The CMT should have notified the charge nurse the medication wasn't given so the charge nurse could administer it and document on it. During an interview on 09/09/25 at 11:03 A.M., LPN B said he/she was the charge nurse on 08/17/25, and the CMT never reported the medication was not given. During an interview on 09/09/25 at 11:47 A.M., the Director of Nursing (DON) said there was only one resident on Invega. On 08/01/25, the order was put into the medical record, and was due on 08/17/25. When a new order was put in the medical record, there were choices as to where it populated on a CMT MAR, CMT TAR, or the Licensed MAR. The medication populated on the CMT MAR. When the medication came due, the CMT did not pass onto the nurse that the medication was not given. She was not aware the Invega wasn't given until 08/31/25, when the resident's family called the facility regarding the injection. The facility worked with the corporate pharmacy to get the medication promptly. The psychiatric provider was notified immediately and gave an order to administer the medication on 09/01/25. During an interview on 09/09/25 at 12: 30 P.M., the Administrator said she expects staff to follow physician orders. Complaint #2609996

Based on observation, interview, and record review, the facility failed to assess the use of a merry walker (an enclosed framed wheeled walker with a seat) to determine if it was a restraint, and failed to document an ongoing re-evaluation for the use of the merry walker for one resident (Resident #12) out of one sampled resident with a restraint. The facility census was 47. Review of the facility's policy titled, Use of Restraints, undated, showed: - Purpose is to ensure that physical and/or chemical restraints are used only when needed to treat the resident's medical symptoms and then, only use the least restrictive alternative for the least amount of time; - The resident's record includes ongoing re-evaluation for the need for a restraint and is effective in treating the medical symptom; - The resident's comprehensive care plan will reflect the resident's goals and the interventions/services needed for the safe use of a restraint as long as it is medically necessary. The facility did not provide a policy regarding merry walkers. 1 Review of Resident #12's April 2024 Physician's Order Sheet (POS), showed: - Diagnoses of intellectual disability (a chronic condition that affects a person's ability to learn and function in daily life), mood disorder (a mental health problem that primarily affects a person's emotional state), restlessness and agitation, anxiety (persistent worry and fear about everyday situations), conduct disorder (a mental health condition that involves a pattern of aggressive and antisocial behaviors), and aphasia (loss of ability to understand or express speech caused by brain damage); - Requires merry walker due to unsteady gait and inability to understand that he/she is unable to ambulate independently. Maintain 100 pounds to the merry walker as ordered, dated 11/26/24, with the original order date of 12/31/19. Review of the resident's quarterly Minimum Data Sets (MDS - a federally mandated assessment instrument completed by the facility staff), dated 07/26/24 and 10/25/24, showed: - Severe cognitive impairment; - Impairment on both sides of the upper and lower extremities; - Dependent with full assist for sit to stand and transfers; - No restraint use. Review of the resident's medical record showed: - No assessment for the merry walker to determine if used as a restraint for 01/01/24 - 12/31/24, and 01/01/25-01/09/25; - No documentation of alternatives tried prior to the merry walker use; - No documentation of the least restrictive use for the merry walker; - No documentation of ongoing re-evaluations for the use of the merry walker tray; - No documentation of consent for the restraint use. Review of the resident's Physical Therapy Evaluation Summary, dated 05/11/22, showed: - Resident referred to physical therapy due to a merry walker re-assessment needed to continue the use in the facility and to determine the resident was still safe; - Resident was a fall risk; - Resident used the merry walker for all ambulation tasks and was independent throughout the facility; - Resident wanted to walk, had appropriate hand placement, appropriate sit to stand technique, was able to maneuver around objects, and didn't ambulate at a fast pace; - Resident continued to independently perform sit to stand transfers and ambulation tasks with the merry walker. Resident was able to move around objects. Resident was able to maintain proper position and balance in sitting/standing when using the merry walker. The device continued to be very appropriate and safe for the resident at this time. The merry walker allowed for the highest level of functioning without restrictions. This device was the correct size and weight for the resident. Review of the resident's care plan, revised on 10/27/24, showed: - Resident was a fall risk; - Resident had behavioral symptoms and would use the merry walker to bump up against other residents; - Resident had physical restraints and used a merry walker restraint when out of bed for increased mobility and independence. It was used due to an unsteady gait and inability to understand the resident couldn't ambulate independently due to a medical diagnosis of mental retardation (a condition that affects a person's ability to think, learn, and adapt to their environment.). The merry walker enabled the resident to safely stand and walk short distances and didn't have a restraining effect. The resident was not able to use a traditional wheelchair or geri chair (supportive recliners and medical recliners provide more substantial support and comfort than conventional wheelchairs) due to constantly attempting to get up and down from it risking injury. Encourage participation of therapy in assessing, re-assessing, and determining the least restrictive restraint to use. Maintain 100 pound weights to the merry walker. Observations of the resident showed: - On 01/07/25 at 9:20 A.M., and 1:30 P.M., and on 01/08/25 at 1:30 P.M., the resident sat in the merry walker in the tv room; - On 01/07/25 at 11:45 A.M., the resident sat in the merry walker and pushed by staff into the dining room; - On 01/08/25 at 8:00 A.M., and on 01/09/25 at 7:50 A.M., the resident sat in the merry walker in the dining room and assisted to eat by staff; - On 01/08/25 at 10:30 A.M., the resident sat in the merry walker in the tv room and ran it into another resident in a wheelchair; - On 01/08/25 at 10:45 A.M., the resident sat in the merry walker in the tv room and ran it into an empty couch numerous times; - On 01/08/25 at 11:55 A.M., the resident sat in the merry walker in the dining room and ran into the piano numerous times; - On 01/08/25 at 2:48 P.M., Certified Nursing Assistant (CNA) B unlatched the closure of the merry walker and transferred the resident from the merry walker to the bed. During a telephone interview on 01/08/25 at 4:30 P.M., Certified Occupational Therapy Assistant (COTA) D said therapy had completed an evaluation a few years back on the resident for the merry walker. There had not been a recent one done that he/she was aware of. The resident had a history of falls and the merry walker kept that from happening. The resident also stood and walked on his/her tip toes. During an interview on 01/09/25 at 1:30 P.M., the Director of Nursing (DON) said a merry walker should be assessed quarterly as a restraint device to ensure it was still appropriate for the resident. During an interview on 01/09/25 at 2:00 P.M., the Administrator said she would expect the resident to have quarterly assessments and documentation regarding the merry walker and restraint assessment. The documentation should include all the required information to show the merry walker was the correct device for the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide scheduled showers for three residents (Residents #5, #24 and #32) out of four sampled residents for activities of daily living (ADLs). The facility census was 47. Review of the facility's policy titled, Necessary Care and Services, dated 01/20/24, showed: - The facility will ensure that a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, personal and oral hygiene. 1. Review of Resident #5's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by the facility), dated 10/08/24, showed: - Dependent for personal hygiene and showers. Review of the resident's care plan, revised 10/13/24, showed: - Did not address showers/bathing frequency; - Did not address assistance required for showers/bathing. Review of the shower schedule, dated 12/01/24 - 01/07/25, showed the resident's showers were scheduled for Monday and Thursday night shifts. Review of the resident's shower sheets, dated 12/01/24 - 01/07/25, showed: - No documentation of completion for scheduled showers on 12/02/24, 12/05/24, 12/12/24, 12/19/24, 12/23/24, 12/26/24, 12/30/24, 01/02/25, and 01/06/25; - A bed bath documented with hair not washed and face not shaved on 12/09/24; - Nine opportunities missed out of 11 opportunities for scheduled showers; - 10 opportunities missed out of 11 opportunities for scheduled facial shaving and hair washing; - The facility failed to provide showers two times per week as scheduled. Observation of the resident on 01/07/25 at 10:20 A.M., and on 01/08/25 at 9:04 A.M., showed: - On 01/07/25 at 10:20 A.M., the resident with unkempt, unshaven facial hair approximately 1/4 inch long, with dry flakes of skin in/on his/her hair, face, and facial hair; - The resident with dry skin flakes on his/her shirt. During an interview on 01/07/25 at 10:20 A.M., Resident #5 said he/she did not like the facial hair and would like to be shaved. During an interview on 01/08/25 at 9:04 A.M., Resident #5 said he/she would like a shower and shave today and if it would happen. During an interview on 01/08/25 at 9:00 A.M., the Administrator said Resident #5 should be showered and shaved as scheduled and as needed/wanted. 2. Review of Resident #24's quarterly MDS, dated [DATE], showed: - Dependent for personal hygiene and showers. Review of the resident's care plan, revised 11/08/24, showed: - Did not address showers/bathing frequency; - Did not address assistance required for showers/bathing. Review of the resident's shower schedule, dated 12/01/24 - 01/07/25, showed the resident's showers were scheduled for Tuesday and Friday. Review of the resident's shower sheets, dated 12/01/24 - 01/06/25, showed: - No documentation of completion for scheduled showers on 12/03/24, 12/17/24, 12/27/24, 12/31/24, 01/03/25 and 01/06/24; - Six opportunities missed out of 11 opportunities for scheduled showers; - The facility failed to provide showers two times per week as scheduled. 3. Review of Resident #32's significant change MDS, dated [DATE], showed: - Substantial/maximal assist for personal hygiene; - Dependent for showers. Review of the resident's care plan, revised 08/21/24, showed: - Did not address showers/bathing frequency; - Did not address assistance required for showers/bathing. Review of the resident's shower schedule, dated 12/01/24 - 01/06/25, showed the resident's showers were scheduled for Mondays and Thursdays. Review of the resident's shower sheets, dated 12/01/24 - 01/06/25, showed: - No documentation for completion of scheduled showers on 12/02/24, 12/12/24, 12/16/24, 12/26/24, 12/30/24 and 01/06/24; - Six opportunities missed out of 11 opportunities for scheduled showers; - The facility failed to provide showers two times per week as scheduled. During an interview on 01/08/24 at 1:41 P.M., Resident #32 said showers were not being given two times a week as scheduled. It was more like once a week. During an interview on 01/08/25 at 3:25 P.M., the Administrator said she was aware the facility was having issues with showers being completed and they were trying to come up with a remedy for that. She would hope the residents were at least getting one shower a week if not the two that were scheduled. During an interview on 01/09/25 at 09:18 A.M., Certified Nursing Assistant (CNA) B said the showers were probably not always being completed two times a week. During an interview on 01/09/25 at 11:34 A.M., the Director of Nursing said showers were an issue and they were working to try and find a solution to fix it.

Based on interview and record review, the facility failed to ensure staff utilized safe transfer techniques for one resident (Resident #29) when staff failed to transfer the resident with assist of a gait belt (a device used to aid in the safe movement of a person from one place to another) of one sampled resident. The facility census was 47. Review of the facility's policy titled, Policy on the Use of Gait Belts in Long-Term Care Facilities, dated 01/30/24, showed: - Purpose is to ensure the safe and effective use of gait belts in assisting residents with mobility and transfers, thereby reducing the risk of injury to both residents and staff in long-term care facilities; - Gait belts must be used when assisting residents who require help with walking, standing, or transferring; - Gait belts should be used for residents with unsteady gait, those at risk of falls, or those who need support during mobility activities; - Residents who refuse the use of a gait belt must be accommodated with alternative methods of assistance. 1. Review of Resident #29's medical record showed: - An admission date of 03/04/24; - Diagnoses of spinal stenosis (a narrowing of the spinal canal that occurs when the spaces in the spine narrow, putting pressure on the spinal cord and nerve roots), moderate protein-calorie malnutrition, anxiety (persistent worry and fear about everyday situations), muscle weakness, contracture (damage to muscle tissue or joint that prevents normal mobility) of the left hand, and a history of wedge compression fracture (a type of spinal compression fracture that occurs when the front of a vertebra collapses, giving the bone a wedge shape) of the fourth lumbar (refers to the lower back, or the five vertebrae (L1-L5) in that region of the spine) vertebra. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility staff, dated 10/09/24, showed: - Moderately cognitively impaired; - Total dependence of staff for bed mobility, dressing, personal hygiene, and bathing; - Total dependence of staff for transfers and toilet use; - Always incontinent of bowel and bladder. Review of the resident's Care Plan, dated 10/13/24, showed: - Resident experienced severe pain in the neck, left arm and right hip; - Resident required activities of daily living (ADL) assistance regarding bowel irregularity; - Resident at risk of pressure ulcer/injury due to need of assistance with bed mobility; - The resident's transfer and mobility needs were not addressed. Observation on 01/08/25 at 3:00 P.M., of the resident's transfer from the wheelchair to the bed showed: - Certified Nursing Assistant (CNA) B attempted to a place gait on the resident but the resident expressed significant pain; - CNA B said he/she was going to do what he/she normally did; - CNA B put one of his/her legs between the resident's legs, one of his/her arm's under the resident's right arm, and one of his/her arm's around the resident's left upper arm/shoulder; - CNA B lifted the resident from the wheelchair and transferred him/her to the bed; - The resident's right foot made partial contact with the floor, the left foot didn't make contact with the floor for half of the transfer, and the resident did not bear any weight during the transfer. During an interview on 01/08/25 at 3:10 P.M., CNA B said the resident's left arm was contracted and caused so much pain. The way CNA B transferred the resident was the only way to do it without causing extreme pain. During an interview on 01/08/25 at 3:30 P.M., Certified Occupational Therapy Assistant (COTA) E said if a gait belt couldn't be used on a resident, then they should be transferred by a Hoyer (a mechanical device used to move or transfer a person) lift. A gait belt should be used in all physical transfers. Residents should not be lifted under the arms as it could cause damage to the shoulder. During an interview on 01/09/25 at 2:30 P.M., the Director of Nursing (DON) said staff should always use a gait belt during transfers. If a gait belt couldn't be used, then they should use a hoyer lift. During an interview on 01/09/25 at 2:45 P.M., the Administrator said staff should use a gait belt during all transfers. If a gait belt couldn't be used due to pain or unable to bear weight, then a Hoyer lift should be used instead.

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #12) out of five sampled residents who were incontinent of bowel and bladder, received appropriate treatment and services after an incontinent episode. Resident #12 was left without personal care for over six hours, resulting in the resident's brief soaked with dark urine and a strong urine odor. The census was 47. Review of the facility's policy titled, Necessary Care and Services, dated, 01/20/24, showed: - The facility will ensure that a resident who is unable to carry out activities of daily living (ADLs) receives the necessary services to maintain good nutrition, grooming, personal and oral hygiene. 1. Review of Resident #12's quarterly Minimum Data Sets (MDS - a federally mandated assessment instrument completed by the facility staff), dated 07/26/24 and 10/25/24, showed: - Severe cognitive impairment; - Impairment on both sides of the upper and lower extremities; - Dependent, full assist for sit to stand and transfers; - Totally dependent for personal hygiene; - Totally incontinent of bowel and bladder. Review of the resident's care plan, revised 10/27/24, showed: - Resident required extensive assist with ADLs; - Incontinent care was not addressed. Review of the resident's medical record showed: - Diagnoses of intellectual disability (a chronic condition that affects a person's ability to learn and function in daily life), mood disorder (a mental health problem that primarily affects a person's emotional state), restlessness and agitation, anxiety (persistent worry and fear about everyday situations), conduct disorder (a mental health condition that involves a pattern of aggressive and antisocial behaviors), and aphasia (loss of ability to understand or express speech caused by brain damage); Review of the facility assignment sheet for 01/08/25 day shift showed: - Certified Nursing Assistant (CNA) B was the only assigned staff for the hall where Resident #12 resided. Observations of the resident on 01/08/25 showed: - At 8:00 A.M., the resident sat in the merry walker in the dining room and assisted to eat by staff; - At 10:30 A.M., the resident sat in the merry walker in the tv room and ran it into another resident in a wheelchair; - On 01/08/25 at 10:45 A.M., the resident sat in the merry walker in the tv room and ran it into an empty couch numerous times; - On 01/08/25 at 11:55 A.M., the resident sat in the merry walker in the dining room and ran into the piano numerous times; - On 01/08/25 at 1:30 P.M., the resident sat in the merry walker in the tv room; - On 01/08/25 at 2:48 P.M., CNA B pushed the resident in the merry walker to his/her room. CNA B transferred the resident from the merry walker to the bed. CNA B performed incontinent care. The resident's brief was soaked with dark urine and a strong urine odor. During an interview on 01/08/25 at 3:00 P.M., CNA B said the resident got up in the morning around 6:45 A.M., went to the dining room for breakfast, to the tv room, to the dining room for lunch, and then went to bed afterwards. The resident was put to bed today at 2:48 P.M. The resident was changed then when he/she was put to bed. The resident was checked for incontinence before getting up for supper and again at bedtime. The resident really should be checked for incontinence more often between breakfast and after lunch. During an interview on 01/08/25 at 4:35 P.M. the Administrator said all residents, including Resident #12, should be checked every two hours or at least once in between meals during the day for incontinence. Resident #12 should not have gone eight hours between being checked for incontinence and changed. During an interview on 01/09/25 at 2:00 P.M., the Director of Nursing (DON) said residents should be checked every two hours if they were incontinent and changed if they were soiled.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow standards of practice when licensed staff didn't assess one resident's (Resident #12) gastrostomy tube (G-tube) (a small tube that's surgically inserted into the stomach through the abdomen) out of one sampled resident upon readmission to the facility from the emergency room (ER) when the G-tube was replaced after the resident pulled it out at the facility. This resulted in the facility holding the resident's feedings without a physician order for 11 days. The facility also failed to follow physician orders in obtaining weekly weights. The facility census was 47. Review of the facility's policy titled, Enteral Nutrition, dated 01/20/24, showed: - Responsibility of licensed nurse; - Assessment guidelines include; condition of mouth and gums, consistency of feces, condition of skin around feeding tube, weight, nutritional status, hydration, ability to chew and swallow, obstruction of esophagus; - Documentation guidelines: reason feeding was held if applicable, physician notification as necessary. 1. Review of Resident #12's Physician's Order Sheet (POS), dated December 2024, showed: - An order for enteral (any method of feeding that uses the gastrointestinal tract to deliver nutrition) feed every day and night shift, start date 12/02/24, hold dates 12/13/24 - 12/18/24; - An order to check the G-tube placement before initiation of formula, medication administration and flushing the G-tube or at least every eight hours, start date 12/02/24, hold date 12/13/24 - 12/18/24; - An order to flush the G-tube with 60 milliliters (ml) of water after each bolus feed, every night shift, start date 12/02/24, hold date 12/13/24 - 12/18/24; - An order for Jevity 1.5 cal (oral liquid nutritional supplement) 200 ml via G-tube every night shift related to abnormal weight loss. Administer at 8 P.M. and 2 A.M., start date 12/01/24; - Weekly weights every Monday, dated 02/26/24; - No physician orders to hold the G-tube feedings and the water flushes from 12/02/24 - 12/13/24. Review of the resident's Treatment Administration Record (TAR), dated December 2024, showed: - Check the G-tube placement before initiation of formula, medication administration and flushing the G-tube or at least every eight hours, start date 12/02/24, hold date 12/13/24 - 12/18/24, with 19 opportunities missed out of 22 opportunities for 12/02/24 - 12/13/24; - Flush G-tube with 60 milliliters (ml) of water after each bolus feed, every night shift, start date 12/02/24, hold date 12/13/24 - 12/18/24, with nine opportunities missed out of 12 opportunities for 12/02/24 - 12/13/24; - Jevity 1.5 cal 200 ml via G-tube every night shift related to abnormal weight loss. Administer at 8 P.M. and 2 A.M., start date 12/01/24, with nine opportunities missed out of 12 opportunities for 12/02/24 - 12/13/24. - Weigh weekly every day shift every Monday, dated 02/26/24. No documentation of weights on 12/02/24, 12/09/24, 12/16/24, 12/23/24, and 12/30/24, with five opportunities missed out of five opportunities; - The facility held the order for flushing and enteral feeding from 12/02/24 to 12/13/24 without an order. Review of the resident's emergency room Discharge paperwork, dated 12/01/24, showed: - Resident discharged from the ER on [DATE]; - Reason for the ER visit was a G-tube replacement; - Received abdomen x-ray, kidney, ureter, and bladder (KUB - abdominal x-ray) for tube placement. Review of the resident's emergency room paperwork, dated 12/01/24, showed: - Resident admitted to the hospital emergency outpatient on 12/01/24 at 7:14 P.M., and discharged to the facility on [DATE] at 9:37 P.M.; - Resident admitted due to having pulled out G-tube; - History of illness: Resident presented after pulling G-tube out. Patient reportedly pulled out an 18 French G-tube this afternoon, unsure of exact time; - Abdomen was normal, soft, nondistended, and nontender with skin turgor good; - At 8:12 P.M., front view of the abdomen showed the G-tube was in satisfactory position; - At 8:41 P.M., the G-tube was replaced, KUB done showing proper placement. Resident will be discharged back to nursing home to follow up with primary care physician. Review of the resident's progress notes showed: - On 12/01/22 at 6:55 P.M., while certified nursing assistant (CNA) got the resident into bed, the resident grabbed his/her G-tube and pulled it out with the bulb intact. Placed a dry dressing on the site after cleaning the area. Sent the resident to the ER via an ambulance; - On 12/02/22 at 2:22 A.M., the resident came back to the facility after having a new G-tube placed in the ER. The ER called said they had replaced the G-tube using a catheter (a flexible tube inserted into the bladder to drain urine) for the new G-tube and the facility would need to let his/her primary care provider know about this in the morning. The resident came back on 12/1/24 at around 10:00 P.M., was awake and in good spirits upon returning. The resident slept well throughout the night so far. Faxed the physician to let him/her know; - On 12/04/24, Jevity and flush not administered as resident did not have a G-tube at this time, waiting for appointment with physician; - On 12/05/24, Jevity and flush not administered as unable to give at this time. Physician was aware; - On 12/06/24, an appointment with general surgery obtained for 12/13/24 at 1:30 P.M., for consult regarding G-tube replacement; - On 12/07/24, unable to access G-tube to check for placement; - On 12/08/24, unable to access G-tube; - On 12/09/24, no feedings during this shift, not able to give feeding due to not having the correct G-tube; - On 12/10/24, unable to check placement due to having urinary catheter from ER, resident had wrong type of G-tube. Director of Nursing (DON) was aware; - On 12/11/24, primary care physician was rounding on residents and unable to provide check, flush or feeding due to a catheter in place. Appointment for replacement already scheduled; - On 12/12/24, no changes see prior notes; - On 12/13/24, new order from physician to hold bolus feedings and flushes. Review of the resident's medical record showed: - No assessment of the G-tube site after the readmission from the ER on [DATE]; - No skin assessment completed after the resident returned from the ER on [DATE]. Review of the resident's weights, dated 11/4/24 - 01/08/25, showed: - On 11/04/24, a weight of 119.8 pounds; - On 11/12/24, a weight of 120.2 pounds; - On 11/26/24, a weight of 116.0 pounds; - On 12/06/24, a weight 117.2 pounds; - On 12/24/24, a weight of 118 pounds; - On 01/03/25, a weight of 116.2 pounds; - On 01/09/25, a weight of 118.2 pounds. Review of the resident's General Surgeon paperwork, dated 12/17/24, showed: - Physical exam showed G-tube in place, migrated in all the way, with an over inflated balloon; - Plan: G-tube adjusted at bedside, balloon was emptied and 10 ml of sterile water placed in; - The G-tube balloon was over inflated and migrated all the way in, it was believed this was obstructing the duodenum (first part of the small intestine). During an interview on 12/31/24 at 2:04 P.M., the DON said Resident #12 pulled out his/her G-tube on 12/01/24, and was sent to the ER. She received report from two different ER nurses when the resident returned from the ER. Both ER nurses told her they were not able to replace the resident's G-tube and the resident had a catheter in the opening to hold it open until it could be replaced. Based on the information she received from the ER, she made the resident an appointment as soon as possible to have the G-tube replaced. The resident did take in food orally and she discussed with the Registered Dietician (RD) to see if the G-tube could be discontinued, but the RD felt the resident was not ready for that yet. The RD did recommend the resident's feeding be reduced from twice a day to once a day. The DON said she was told by another facility nurse the physician had been notified about the resident not receiving the feedings and flushes. She did not have documentation of the physician notification before 12/13/24, when the physician ordered to hold the G-tube feedings until the resident's appointment with the surgeon. During an interview on 01/08/24 at 3:00 P.M., CNA D said he/she returned to work a day or two after Resident #12 returned from the ER with the new G-tube. The resident had the same G-tube that was there now, with purple caps on the end, the whole time. During an interview on 01/09/24 at 7:45 A.M., the Physician said he/she had not been notified of the facility holding Resident #12's G-tube feedings until 01/13/24. Thankfully, this resident also ate orally so there wasn't a bad outcome, but there was the potential. Based on the ER paperwork, the ER replaced the G-tube and the feedings and flushes shouldn't have been held to begin with. He/She did not assess the resident's G-tube on 01/13/24, and gave orders to hold the feedings and flushes from the nurse's report. It was the nurse's responsibility to assess the resident before contacting him/her. The resident's meals should have been documented and all weights completed, especially during that time frame. The resident should have been assessed after the resident returned from the ER to verify what tube the resident received. During an interview on 01/09/24 at 2:40 P.M., the DON said she could not remember which nurse told her the physician had been contacted prior to 12/13/24. She never looked at the resident's abdomen or tube to confirm it was a catheter and not a G-tube. She just went off the report from the ER. She didn't look at the ER discharge paperwork and no other nurses ever said anything different. It was the nurse's responsibility that accepted the resident from the ER to do a full assessment, look at the ER discharge paperwork, and ensure everything was correct. It was the DON's responsibility to ensure that happened. The DON said she should have assessed the resident's abdomen and viewed the tube. If she had done that, she would have known it was a G-tube. During an interview on 01/09/24 at 2:55 P.M., the Administrator said the resident should have been assessed and the tube looked at upon readmission. The discharge paperwork should have been looked at as well. The DON was in charge of ensuring the nurse on duty during readmission did that. A physician order to hold the feeding should have been received as well.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide documentation of on-going assessments and monitoring after dialysis (a process for removing waste and excess water from the blood) center for one resident (Resident #36) out of one sampled resident. The facility's census was 47. Review of the facility's policy, Dialysis, undated showed: - This facility will ensure that residents who require dialysis receive such services consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goals and preferences; - The facility will ensure appropriate monitoring of the dialysis resident's status before, during, and after the treatments; - If this facility does not employ a qualified professional person to furnish dialysis treatments, the facility will enter into an agreement with a person or agency outside of the facility. This agreement constructs a connection between both entities and fosters accountability that is vital to the health of each resident and the success of their plan of care. Each end-stage renal disease (ESRD - a medical condition where the kidneys can no longer function to filter wastes or excess fluids from the blood) facility is responsible for ensuring the dialysis resident's needs and goals are addressed. The care plan will specify shared responsibilities divided between the nursing home and the ESRD facility, e.g., adhering to certain renal dietary restrictions based on the resident's fluid status. 1. Review of Resident #36's Physician's Order Sheet (POS), dated January 2025, showed: - admitted on [DATE]; - Diagnosis of ESRD; - No order for dialysis. - No order to assess the dialysis site and/or dressing before and after dialysis; - No order for vital signs and weights before and after dialysis. Review of the resident's quarterly Minimum Data Set (MDS - part of a federally mandated process for clinical assessment of all residents in certified nursing homes), dated 11/25/24, showed: - The resident received dialysis. Review of the resdient's Care Plan, dated 08/27/24, showed: - Problem of dehydration and fluid maintenance with interventions to assess the resident's weight and vital signs before and after dialysis appointments, report concerns to the physician, and the resident received dialysis three times a week on Monday, Wednesday and Friday; - Did not address monitoring the resident's dialysis port (an implanted venous access device) dressing/site. Review of the resident's Dialysis Communication Reports, dated 12/09/24 - 01/08/25, showed: - Eight out of 14 opportunities missed for the vital signs and weights after dialysis; - Four out of 14 opportunities missed for the assessment of the dialysis site/dressing before dialysis; - Nine out of 14 opportunities missed for the assessment of the dialysis site/dressing after dialysis. During an interview on 01/07/25 at 9:45 A.M., Resident #36 said he/she went to dialysis on Mondays, Wednesdays, and Fridays. Staff did not observe his/her dialysis port every time but did sometimes. Staff sometimes took his/her vitals upon returning to the facility after dialysis, but not all of the time. During an interview on 01/09/25 at 2:40 P.M., Licensed Practical Nurse (LPN) D said the facility used a Dialysis Communication form that was filled out with the resident's vital signs, weight, and any changes the dialysis center should know prior to the resident leaving the facility for dialysis. The dialysis center filled out the second portion with the resident's vital signs and any changes the facility should know about prior to the resident leaving dialysis and returning to the facility. Upon the resident's return, staff should get a weight, vital signs, and look at the dressing covering the dialysis port since the site can't be seen. The form had another area at the bottom for the resident's return information. The receiving nurse was responsible for obtaining that information and documenting it. During an interview on 01/09/25 at 2:45 P.M., the Director of Nursing (DON) said the facility used a Dialysis Communication form that was filled out by the facility and the dialysis center to communicate back and forth. There was a final portion of the form at the bottom that should be filled out when the resident returned from dialysis. The last portion contained a weight, vital signs, and an assessment of the dialysis port dressing/site. A lot of of the time, she received the resident back after dialysis, but if not, then the nurse receiving the resident back into the facility should complete the information. It was the DON's responsibility to ensure the form was completed. During an interview on 01/09/25 at 2:50 P.M., the Administrator said the facility used a Dialysis Communication form to communicate back and forth with the dialysis center. When the resident returned, the receiving nurse should fill out the bottom part of the form and assess the dialysis port dressing/site. It was the DON's responsibility to ensure the nurses were completing the form.

Based on interview and record review, the facility failed to limit the use of an as needed (PRN) order for psychotropic (medications that affect how the brain works and causes changes in mood, awareness, thoughts, feelings, or behaviors) medications to 14 days for three residents (Residents #17 and #30) out of two sampled residents and Resident #9 outside of the sample. The facility census was 47. The facility failed to provide a policy for the 14 day stop date on PRN psychotropic medications. 1. Review of Resident #9's January 2025 Physician's Order Sheet (POS) showed: - Diagnosis of restlessness, agitation, and insomnia (difficulty sleeping); - An order for lorazepam (an anti-anxiety medication) 2 milligram (mg)/ milliliter (ml) 0.5 ml sublingually (under the tongue) every two hours PRN for restlessness, dated 11/18/24; - An order for lorazepam 0.5 mg tablet by mouth every four hours PRN for anxiety (persistent worry and fear about everyday situations), dated 11/27/24; - The facility did not provide a 14 day stop date order for the PRN lorazepam order. Review of the resident's medical record showed: - The resident's pharmacy Medication Record Reviews (MRR), dated 11/22/24 and 12/01/24, showed the resident had an order for lorazepam 2 mg/ml 0.5 mg every two hours PRN for restlessness and the pharmacist requested a 14 day stop date; - The physician did not address the need for the 14 day stop date of the PRN lorazepam order. 2. Review of Resident #17's January 2025 POS showed: - Diagnoses of chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs), major depressive disorder (long-term loss of pleasure or interest in life), and anxiety disorder; - An order for lorazepam 2 mg/ml 0.5 ml by mouth every two hours PRN for anxiety, dated 11/09/24; - The facility did not provide a 14 day stop date order for the PRN lorazepam order. Review of the resident's medical record showed: - The resident's pharmacy MRR, dated 11/22/24 and 12/01/24, showed the resident had an order for lorazepam 2 mg/ml 0.5 mg every two hours PRN, and the pharmacist requested a 14 day stop date unless there was a documented rationale and anticipated duration of therapy; - The physician did not address the need for the 14 day stop date of the PRN lorazepam order. 3. Review of Resident #30's January 2025 POS showed: - Diagnosis of anxiety disorder; - An order for hydroxyzine (an antihistamine used to treat anxiety) 25 mg by mouth every 12 hours PRN for anxiety related to anxiety disorder, dated 04/11/24; - The facility did not provide a 14 day stop date order for the PRN hydroxyzine order. Review of the resident's medical record showed: - The resident's pharmacy Gradual Dose Reduction (GDR) request, dated 10/18/24, showed the PRN hydroxyzine order must have a stop date if ordered for anxiety; - The physician did not address the need for the 14 day stop date of the PRN hydroxyzine order. During an interview on 01/09/25 at 12:03 P.M., the Director of Nursing (DON) said she was responsible for GDRs and MRRs. She tried to get the MRRs faxed to the physicians within two weeks of receiving the email from the pharmacist. She had not done November's or December's due to working the floor so often.

Based on observation, interview, and record review, the facility failed to label and store medications in a safe and effective manner when opened insulin was found undated in the medication cart and failed to ensure the medication cart was locked while unattended. This had the potential to affect all residents. The facility census was 47. Review of the facility policy titled, Storage of Medication, dated 01/20/24, showed: - Compartments containing medications are locked when not in use and should not be left unattended; - Narcotics should be double locked at all times. The facility failed to provide a policy regarding dating insulin pens. Review of the manufacturer's recommendations for Lantus (a long-acting type of insulin), dated June 2023, showed: - Discard the medication 28 days after opening. Review of the manufacturer's recommendations for lispro insulin pen (a fast acting type of insulin), dated 2023, showed: - Discard the medication 28 days after opening. Review of the manufacturer's recommendations for Admelog insulin pen (a fast acting type of insulin), dated August 2023, showed: - Discard the medication 28 days after opening. 1. Observation on 01/08/25 at 11:14 A.M. - 11:19 A.M., of the Certified Medication Technician (CMT) medication cart showed: - The medication cart sat against the wall to the left of the medication prep room facing the hallway and unlocked. 2. Observation on 01/08/25 at 11:27 A.M. - 11:30 A.M., of the CMT medication cart showed: - The medication cart sat against the wall to the left of the medication prep room facing the hallway and unlocked. 3. Observation on 01/08/25 at 11:49 A.M., - 11:50 A.M., of the CMT medication cart showed: - The medication cart sat against the wall to the left of the medication prep room facing the hallway and unlocked; - The CMT left the cart unlocked, walked to the medication prep room, then toward the front door, and returned to the cart. 4. Observation on 01/09/25 at 9:46 A.M. - 10:25 A.M., of the nurse medication cart showed: - The medication cart sat in the hallway against the window of the medication prep room, facing the hallway, unlocked. 5. Observation on 01/09/25 at 1:15 P.M., of the CMT medication cart showed: - Two labeled and opened lispro insulin pens, not dated; - Two labeled and opened Lantus insulin pens, not dated; - One labeled and opened Admelog insulin pen, dated 12/06/24, six days past the 28 day shelf life once opened. During an interview on 01/09/25 at 10:26 A.M., Licensed Practical Nurse (LPN) E said the cart should always be locked when left unattended. The narcotics should be double locked by ensuring the cart itself was locked. During an interview on 01/09/25 at 2:30 P.M., the Director of Nursing (DON) said insulin pens should be dated when opened. Medication carts should always be locked when left unattended. During an interview on 01/09/25 at 2:45 P.M., the Administrator said medication carts should always be locked when left unattended. Insulin pens and vials should be dated when opened and discarded in 28 days unless the manufacturer information was different than 28 days.

Based on interview and record review, the facility failed to update the facility assessment (an assessment to determine what resources were necessary to care for residents competently during both day-to-day operations and emergencies) at least annually. The facility census was 47. Review of the facility's policy titled, The Purpose and Importance of a Facility Assessment, dated 08/07/24, showed: - Resident profile - the number of current residents and which of their needs have been identified, including physical, medical, ethic, cultural, or religious needs; - Care provided - what care and services are currently provided or offered to residents at the facility; - Resources needed - based on the needs identified in the resident profile, what the facility's staffing, equipment, and supplies are needed to properly care for the residents; - The assessment must be conducted, at a minimum, annually and updated as necessary. The facility must also review and update this assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment. Review of the facility's Matrix (a tool used to identify care categories for residents in a long term care facility), dated 01/08/25, showed: - One resident with a feeding tube (a small tube that's surgically inserted into the stomach through the abdomen). Review of the facility assessment, dated 08/07/24, showed: - The number of residents with intellectual and/or developmental disability not accurate per the facility census; - The assessment showed no residents with a feeding tube; - The assessment based on an average number of 40 residents; - Activities of Daily Living (ADLs) required assistance based on an average of 20 residents; - The competencies required by the facility did not include the resident with a feeding tube. During an interview on 01/09/24 at 2:45 P.M., the Administrator said said residents with feeding tubes should be included in the facility assessment. The facility had a resident with a feeding tube for multiple years. The average care required for ADLs should have been based off of a census of 40 residents instead of 20 residents. The information in the facility assessment should reflect what care was required in the facility and what staff competencies were required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain proper infection control practices during the hall tray meal pass, during incontinent care for two residents (Residents #24 and #40) out of four sampled residents, and during the medication pass for two residents (Residents #24 and #44) out of two sampled residents. The facility also failed to correctly screen five residents (Residents #4, #12, #20, #28, and #97) for tuberculosis (TB - an infectious disease characterized by the growth of nodules in the tissues, especially the lungs) out of five sampled residents required by state regulation 19 CSR 20-20.100. The facility census was 47. Review of the facility's policy titled, Hand Hygiene, dated 01/20/24, showed: - Handwashing will be regarded by this facility as the single most important means preventing the spread of infection; - Staff will follow the facility's established hand hygiene procedures to prevent the spread of infections and diseases to other staff, residents, and visitors: when coming on duty; whenever hands are visibly dirty; before having direct contact with a resident; after having direct contact with a resident; before preparing or handling medications; before handling clean or soiled dressings, gauze pads, etc; after handling used dressings, contaminated equipment, etc; after contact with blood, body fluids, excretions, secretions, mucous membranes, or non-intact skin; after handling items potentially contaminated with blood, body fluids, excretions, or secretions; before putting on gloves; after removing gloves. The facility did not provide a policy regarding hand hygiene during medication administration. Review of the facility's policy titled, Residents Tuberculosis Screening, dated 01/30/24, showed: - Residents will be screened for TB infections upon their admission to the facility and at intervals appropriate for the regional prevalence of TB, with screening performed at least annually; - Upon admission to the facility, the resident will be screened for TB; - If the PPD status is unknown or is known to have been negative in the past, the two-step TB skin test (TST) will be administered. 1. Observation of the 200 Hall meal pass on 01/07/25 at 12:28 P.M. to 12:36 P.M., showed: - CNA B did not wear gloves, did not perform hand hygiene, carried a meal tray into room [ROOM NUMBER], uncovered the plate, touched the resident's bed side commode, moved the bedside table to the resident, picked up a cup of milk from the nightstand, touched his/her own face, did not perform hand hygiene, and exited the room; - CNA B did not wear gloves, did not perform hand hygiene, retrieved a meal tray from the meal cart, uncovered the plate, entered room [ROOM NUMBER] with the tray, exited the room, and did not perform hand hygiene; - CNA B pushed the meal cart down the hall, did not wear gloves, did not perform hand hygiene, took a meal tray into room [ROOM NUMBER], uncovered the plate, uncovered the resident, touched the resident's shoes, assisted the resident to sit on the side of the bed, moved the bed side table, touched the napkin and utensils on the tray, touched the cup of fruit, did not perform hand hygiene, and exited the room; - CNA B did not wear gloves, did not perform hand hygiene, retrieved a meal tray from the cart and carried it into room [ROOM NUMBER], uncovered the plate, touched the resident's rollator (a walking frame equipped with wheels), assisted the resident to sit up in bed, touched the bedside table, touched a lantern light (a battery operated light), touched the fruit cup, did not perform hand hygiene and exited the room; - CNA B pushed the meal cart down the hallway, did not wear gloves, did not perform hand hygiene, took a meal tray into room [ROOM NUMBER], uncovered the plate, touched the bedside table, did not perform hand hygiene, and exited the room; - CNA B did not wear gloves, did not perform hand hygiene, retrieved a meal tray from the meal cart, uncovered the plate, took the meal tray into room [ROOM NUMBER], did not perform hand hygiene, and exited the room; - CNA B did not wear gloves, did not perform hand hygiene, retrieved a meal tray from the meal cart, took it into room [ROOM NUMBER], uncovered the plate and placed the tray on the resident's lap, touched the napkin, picked up two cups of chocolate shakes from another table, set them on the meal tray, touched the fruit cup, did not perform hand hygiene, and exited the room. During an interview on 01/09/25 at 2:45 P.M., the Director of Nursing (DON) and the Administrator said staff should sanitize hands between passing trays to each resident. 2. Observation of Resident #24's incontinent care on 01/08/25 at 11:38 A.M., showed: - Resident #24 lay in bed; - Certified Nursing Assistant (CNA) C performed hand hygiene, put on gloves, unfastened and lowered the resident's brief soiled with urine and fecal matter between his/her legs, performed incontinent care but did not clean under the resident's scrotum, penis, or pull back the foreskin of the penis; - CNA C did not change gloves, did not perform hand hygiene, touched the television remote on the bed, rolled the resident to the right side, removed the glove from the left hand, did not perform hand hygiene, retrieved a trash bag and a glove from his/her pocket, put a glove on the left hand, cleaned fecal matter from the resident's buttocks with a wipe, folded the incontinent pad soiled with fecal matter under the resident, rolled the resident to the left side, removed the soiled incontinent pad, and placed in a trash bag; - CNA C did not change gloves, did not perform hand hygiene, placed and secured a clean brief on the resident, put pants and shoes on the resident, and removed the gloves; - CNA C did not perform hand hygiene, did not put on clean gloves, assisted the resident to sit on the bedside while touching the resident's hands and back, put on the resident's shirt, touched the resident's left armrest and the brake handles of the wheelchair, placed a gait belt around the resident's waist, transferred the resident to the wheelchair, removed the gait belt, placed the resident's hat on the resident, and placed a green wedge under the resident's left arm; - CNA C did not perform hand hygiene, removed clean gloves from his/her pocket, put on the gloves, removed the trash from the trash can, picked up the trash bag with soiled linen, touched the inside of the room doorknob, took the bags to soiled utility room, placed the trash in the trash barrel with a lid, opened the soiled linen bag and rinsed the soiled incontinent pad and placed in a barrel with a lid, removed gloves and performed hand hygiene. 3. Observation of Resident #40's incontinent care on 01/08/25 at 3:15 P.M., showed: - Resident #40 lay in bed; - CNA A performed hand hygiene and put on gloves; - CNA A unfastened and lowered the resident's urine soiled brief: - CNA A cleaned the resident's front peri area; - CNA A did not perform hand hygiene, did not change gloves, assisted the resident to turn to the left, cleaned fecal matter from the rectal area, and cleaned the buttocks and hips; - CNA A did not perform hand hygiene, did not change gloves, removed the brief from under the resident and placed a clean brief under the resident; - CNA A removed the gloves, did not perform hand hygiene, put on gloves, and assisted the resident to his/her back and fastened the brief, positioned the resident, covered the resident with the blanket, and placed the call light in reach of the resident. During an interview on 01/09/25 at 12:28 P.M., CNA A said hands should be sanitized/washed and gloves changed between dirty and clean care and when going from one area to another. During an interview on 01/09/25 at 12:35 P.M., CNA C said hands should be washed when walking into the resident's room and put on gloves, perform incontinent care front to back using a new wipe each time, get dirty items out and put into a bag, change gloves wash hands, put clean brief and clothing on the resident, and transfer using a gait belt if needed. If a male resident allowed, should pull back the skin of the uncircumcised penis, clean it, and put the skin back. If the resident didn't allow it, then it was done during a shower. During an interview 01/09/25 at 12:40 AM the DON said she would expect staff to wash/sanitize hands before and after care, when going from dirty to clean care, and to different areas. Hand hygiene should be done before putting on clean gloves. 4. Observation on 01/09/25 at 7:22 A.M., of Resident #44's medication administration showed: - Certified Medication Technician (CMT) I removed the resident's 13 medications from the bubble pack into his/her bare hand, and placed the medications into the medication cup; - CMT I poured four medications into the bottle lids, emptied the four medications from the bottle lids into his/her bare hand, and placed them into the medication cup; - CMT I administered the medication in the medication cup to the resident. 5. Observation on 01/09/25 at 7:27 A.M., of Resident #24's medication administration showed: - CMT I removed the resident's 14 medications from the bubble pack into his/her bare hand and placed the medications into the medication cup; - CMT I poured two medications into the medication bottle lids, emptied the two medications from the bottle lids into his/her bare hand, and placed them into the medication cup; - CMT I administered the medications in the medication cup to the resident. During an interview on 01/09/25 at 2:45 P.M., the DON and the Administrator said staff should never touch medications with their bare hands. 6. Review of Resident #5's medical record showed: - admit date of 07/17/20; - Annual TB screen, dated 12/15/23; - No annual TST or screening completed for 2024. 7. Review of Resident #12's medical record showed: - admit date of 07/20/12; - Annual TB screen, dated 12/12/23; - No annual TST or screening completed for 2024. 8. Review of Resident #20's medical record showed: - admit date of 06/30/23; - First step TST administered on 12/11/23, and read on 12/14/23; - Second step TST administered on 12/19/23, and read 12/22/23; - No annual TST or screening completed for 2024. 7. Review of Resident #28's medical record showed: - admit date of 09/15/23; - First step TST administered on 12/11/23, and read on 12/14/23; - Second step TST administered on 12/19/23, and read on 12/22/23; - No annul TST or screening completed for 2024. 8. Review of Resident #97's medical record showed: - admit date of 12/02/24; - No TST or screening record of initial two step TST since admission. During an interview on 01/09/25 at 2:45 P.M., the Administrator and Director of Nursing (DON) said it was expected that residents receive a two step TST upon admission and then an annual sign and symptom screening thereafter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a facility-initiated transfer when two residents (Resident #17 and #41) out of 14 sampled residents transferred to the hospital. The facility's census was 42. Review of the facility's policy titled Discharge/Transfer of Resident, undated showed: - Purpose is to provide safe departure from the facility and to provide sufficient information for aftercare of the resident; - Notice of transfer or discharge to be provided as necessary; - Bed hold forms to be provided as necessary. 1. Review of Resident #17's medical record showed: - Resident transferred to the hospital for medical evaluation on 09/07/23 and readmitted to the facility on [DATE]; - No documentation of written notification to the resident and/or the resident's representative of the resident's transfer to the hospital on [DATE]. 2. Review of Resident # 41's medical record showed: - Resident transferred to the hospital for medical evaluation on 10/20/23 and readmitted to the facility on [DATE]; - No documentation of written notification to the resident and/or the resident's representative of the resident's transfer to the hospital on [DATE]. During an interview on 11/30/23 at 9:26 A.M., the Business Office Administrator said the written transfer/discharge notice is supposed to be given to each resident or their representative at the time of transfer to the hospital and that the nurse who gives the transfer/discharge notice is expected to document in the resident's progress notes that the notice was given. During an interview on 12/01/23 at 10:40 A.M., the Administrator said she would expect notice of a resident's transfer or discharge to the hospital to be given to the resident and/or the resident's representative in writing. She also said that she would expect it to be documented in the resident's medical record that the notice was given to the resident or their representative.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide written notification of their bed-hold policy to residents and/or their representatives at the time of transfer for two residents (Resident #17 and #41) out of 14 sampled residents. The facility's census was 42. Review of the facility's Bed Hold Guidelines policy, undated, showed: - This facility will notify all residents and/or their representatives of the bed hold guidelines. This notification shall be given on admission to the facility, at the time of transfer to the hospital and at the time of non-covered therapeutic leave. Review of the facility's policy titled Discharge/Transfer of Resident, undated showed: - Purpose is to provide safe departure from the facility and to provide sufficient information for aftercare of the resident; - Notice of transfer or discharge to be provided as necessary; - Bed hold forms to be provided as necessary. 1. Review of Resident #17's medical record showed: - Transferred and admitted to the hospital on [DATE] and readmitted to the facility on [DATE]; - No documentation that the resident's representative was informed in writing of the facility's bed hold policy at the time of transfer. 2. Review of Resident #41's medical record showed: - The resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]; - No documentation of the bed hold policy provided to the resident or the resident's representative at the time of transfer. During an interview on 11/30/23 at 9:26 A.M., the Business Office Administrator said that a bed hold notice is supposed to be given to each resident or their representative at the time of transfer to the hospital and that the nurse who gives the bed hold notice is expected to document in the resident's progress notes that the notice was given. During an interview on 12/1/23 at 10:40 A.M., the Administrator said she would expect a notice of the bed hold policy to be given to the resident or family when discharged or transferred.

Based on interview and record review, the facility failed to implement a baseline care plan (the minimum healthcare information necessary to properly care for a resident) upon admission with specific interventions for two residents (Resident #12 and #144) out of two sampled residents. The facility census was 42. Review of the facility's policy titled, Care Plan - Preliminary, dated December 2016, showed: - To assure the resident's immediate care needs are met and maintained, a hand written temporary care plan will implemented for the resident following the admission assessments and interviews with the resident, this handwritten care plan will be started by the admission nurse and updated by nurses of each shift for the first 24 hours; - The Interdisciplinary care plan team (members from different disciplines working together for a common purpose) and/or admitting nurse will review the physician orders and implement a nursing care plan to meet the immediate care needs of the resident; - The temporary care plan will be used until the comprehensive assessment has been completed and an interdisciplinary care plan has been developed according to the Resident Assessment Instrument (RAI) process. 1. Review of Resident #12's medical record showed: - An admission date of 07/17/23; - Diagnoses of major depressive disorder severe with psychotic symptoms (long-term loss of pleasure or interest in life with a collection of symptoms that affect the mind, where there has been some loss of contact with reality), anxiety disorder (persistent worry and fear about everyday situations), acute kidney failure, and chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs); - No documentation of a baseline care plan; - No documentation the resident and/or the representative received a written summary of the baseline care plan. 2. Review of Resident #144's medical record showed: - An admission date of 11/06/23; - Diagnoses of Alzheimer's disease (progressive mental deterioration), dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning), COPD, and urinary tract infection (an infection in any part of the urinary system); - No documentation of a baseline care plan; - No documentation the resident and/or the representative received a written summary of the baseline care plan. During an interview on 11/30/23 at 12:30 P.M., Licensed Practical Nurse (LPN) B said the baseline care plans were probably created but were not signed by Resident #12 and Resident #144. The baseline care plans were unavailable. During an interview on 12/01/23 at 11:45 A.M., Resident #144 and his/her power of attorney (POA, the authority to act for another person in specified or all legal or financial matters) representative said the resident was new to the facility. The resident may have been given a baseline care plan but it was unknown for sure. It would have been part of a large amount of paperwork that had been stored away at home. It would be helpful to be included in care plan meetings in the future. During an interview on 12/01/23 at 2:35 P.M., the Director of Nursing (DON) said nursing staff was responsible for the care plan and she would expect an interim care plan to be completed within 48 hours of the resident's admission. During an interview on 12/01/2023 at 2:37 P.M., the Administrator said she would expect the baseline care plans to be completed within 48 hours of the resident's admission. The baseline care plans should be signed by the resident and available for review for all new admissions.

Based on observation, interview and record review, the facility failed to implement a care plan with specific interventions to meet individual needs for two residents (Resident #20 and #31) out of 14 sampled residents. The facility census was 42. Review of the facility's policy titled, Care Plan Temporary, dated March 2015, showed: - The temporary/handwritten care plan will include, but not limited to quality of care problems, quality of life problems, diagnosis, medications and treatments ordered; - The care plans will include problems, goals, time frames, and interventions related to the immediate care needs. 1. Review of Resident #20's medical record showed: - An admission date of 11/16/22; - Diagnoses of chronic obstructive pulmonary disease (COPD, a lung disease that blocks airflow and makes it difficult to breathe) and generalized muscle weakness; - No documentation of the evaluation for bed rails; - No documentation of signed consent by the resident or the resident's representative for bed rails; - Fall risk assessment, dated 11/09/23, showed the resident as a moderate fall risk. Review of the resident's care plan, dated 11/23/23, showed bed rails with interventions not addressed. Observations of Resident #20 showed on 11/30/23 at 9:50 A.M., and on 12/01/23 at 10:10 A.M., the resident lay in bed asleep with the right side quarter-rail up. During an interview on 11/29/23 at 10:37 A.M., Resident #20 said he/she had the bed rail up so he/she didn't fall out of the bed. 2. Review of Resident #31's medical record showed: - admission date of 09/15/23; - Diagnoses of COPD, urinary tract infection (an infection in any part of bladder, kidneys, ureters, and urethra) and dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning); - No documentation of a smoking assessment. Review of the resident's admission Minimum Data Set (MDS, a federally mandated assessment instrument completed by the facility staff), dated 09/18/23, showed: - The resident used tobacco; - Diagnoses of UTI and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions); - A fall risk with a fall in the last 30 days; - Altered skin integrity. Review of the resident's care plan, last reviewed 11/02/23, showed: - Did not address the resident's smoking status with specific interventions; - Did not address infections with specific interventions; - Did not address falls with specific interventions; - Did not address altered skin integrity with specific interventions. During an interview on 11/30/23 at 9:33 A.M., Certified Nurse Assistant (CNA) H said Resident #31 was not independent with smoking. He/she did not smoke by his/herself and staff had to light the cigarette for the resident. Observation on 11/30/23 at 4:00 P.M., showed : - CNA J pushed Resident #31 in a wheelchair to a designated smoke room in the facility; - CNA J gave one cigarette to the resident and lit the cigarette for the resident. During an interview on 11/30/23 at 4:17 P.M., Licensed Practical Nurse (LPN) B said he/she would expect every resident that smokes to have a smoking assessment completed and for it to be on the care plan. He/she said the smoking assessment was completed to determine if a resident was independent or a supervised smoker. The smoking assessment addressed if a smoking apron was required. During an interview on 12/01/23 at 2:35 P.M., the Director of Nursing (DON) and the Administrator said the bed side rails, residents that smoke, and residents that were at risk for falls should be included in the comprehensive care plans.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assess residents for the use of bed rails prior to installation or use nor did they obtain informed consent from the resident or if applicable, the resident representative for two residents (Resident #11 and #20) out of 14 sampled residents and one resident (Resident #2) outside the sample with bed rails in use. The facility's census was 42. Review of the facility's policy titled, Restraints, Physical, dated March 2015, showed the following: - If side rails are used, there shall be an interdisciplinary assessment of the resident, consultation with the attending physician, and input from the resident and/or legal representative; - The staff shall obtain consent for the use of side rails from the resident or the resident's legal representative prior to their use; - Side rails may be used if assessment and consultation with the attending physician has determined that they are needed to help manage a medical symptom or condition, or to help the resident reposition or move in bed and transfer, and no other reasonable alternatives can be identified; - Before using side rails for any reason, the staff shall inform the resident and family about the benefits and potential hazards associated with side rails; - When using side rails for any reason, the staff shall take measures to reduce related risks. 1. Observations of Resident #11 showed: - On 11/28/23 at 11:01 A.M., resident in bed with quarter side rail up on left side of bed; - On 11/29/23 at 8:57 A.M., resident in bed with quarter side rail up on left side of bed; - On 11/30/23 at 12:55 P.M., resident in bed eating lunch with quarter side rail up on left side of bed. He/she used the side rail to pull himself/herself up in bed with his/her left hand; - On 12/01/23 at 10:01 A.M., resident in bed with quarter side rail up on left side of bed. Review of Resident #11's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by the facility), dated 11/04/23, showed: - Moderate cognitive impairment; - Impairment on one side of upper and lower extremity; - Diagnoses of stroke (damage to the brain from interrupted blood supply), aphasia (loss of ability to understand or express speech caused by brain damage), dementia (the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), hemiplegia (paralysis of one side of the body), and seizure (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements like stiffness, twitching or limpness, behaviors, sensations, or states of awareness) disorder. Review of the resident's medical record showed: - No documentation of bed rail assessment; - No documentation of informed consent for the use of the bed rails. 2. Observations of Resident #2 showed: -On 11/28/23 at 10:45 A.M., CNA (Certified Nurses Aid) providing care with resident in bed and quarter rails up on both sides of bed; -On 11/29/23 at 10:09 A.M., resident resting in bed on left side with quarter rails on both sides of bed in up position; -On 11/30/23 at 4:40 P.M., resident sleeping in bed in supine position with quarter bed rails on both side of the bed in the upright position. Review of Resident #2's admission Minimum Data Set (MDS, a federally mandated assessment completed by the facility), dated 09/18/23 showed: - Cognition to be modified independent; - Substantial-maximal assistance with bed mobility; - Completely dependent with bed to chair transfers; - Diagnoses of age-related osteoporosis (a gradual or progressive decline in bone density loss), polymyalgia rheumatic (inflammatory disorder causing muscle pain and stiffness around the shoulders and hips), anemia (a condition in which the blood doesn't have enough healthy red blood cells), pressure ulcer of sacral region (skin injury that occurs near the lower back and spine) and history of falling. Review of the resident's care plan, last reviewed 11/28/23, did not address the resident's use of the bed rails. Review of the resident's medical record showed: -No documentation of bed rail assessment; -No documentation of informed consent for the use of the bed rails. During an interview on 11/29/23 at 10:37 A.M., Resident #2 said he/she has the bed rails so he/she doesn't fall out of the bed. 3. Observations of Resident #20 showed: - On 11/30/23 at 9:50 A.M., the resident lay in bed asleep with right side quarter-rail up; - On 12/01/23 at 10:10 A.M. the resident lay in bed asleep with right side quarter-rail up. Review of Resident #20's MDS, dated [DATE] showed: - Diagnoses of chronic obstructive pulmonary disease (COPD, a lung disease that blocks airflow and makes it difficult to breathe) and muscle weakness, generalized. Review of the resident's care plan dated 11/23/23 did not address the resident's use of bed rails. Review of Resident #20's medical record showed: - No documentation of bed rail assessment; - No documentation of informed consent for the use of the bed rails. - Fall risk assessment dated [DATE] showed resident as moderate fall risk. During an interview on 11/30/23 at 4:19 P.M., Licensed Practical Nurse (LPN) B said that Bed Rail Assessments should be in the Electronic Medical Record (EMR) if it was completed. During an interview on 12/01/23 at 10:15 A.M., the Administrator, said he/she expected for side rail assessment and consents to be under the observation tab of the EMR but could also be found in the documents tab of the EMR. During an interview on 12/01/23 at 2:35 P.M., the Director of Nursing (DON) said residents' bed/side rails use should be included in the comprehensive care plans.

Based on observation, interview, and record review, the facility failed to ensure two residents (Resident #32 and #36) outside of the sample were free of significant medication errors when staff failed to prime an insulin (medication used to lower blood sugar) pen and hold for a count of six seconds at the site of administration as recommended by the manufacturer to ensure the residents received the full and correct dose of insulin. The facility's census was 42. Review of the facility's policy titled, Medication, Administration Guidelines, dated March 2015, showed: - It is the purpose of the facility that residents receive their medications on a timely basis and in accordance with established policies; - The complete act of administration entails removing an individual dose from a previously dispensed, properly labeled container, verifying it with the physicians' orders, giving the individual dose to the proper resident and promptly recording the information. Review of the Novolog (insulin) Kwik Pen manufacturer instruction manual showed: - The pen must be primed before use; - To prime the pen, turn the dose selector to select two units, hold the pen with the needle pointing up, tap the top of the pen gently a few times to let any air bubbles rise to the top, hold the pen with the needle pointing up, press and hold in the dose button until the dose counter shows 0, and a drop of insulin should be seen at the needle tip; - To administer the insulin, keep the needle in the skin after the dose counter has returned to show 0. When the dose counter returns to 0, the full dose will not be received until six seconds after the counter returns to 0. If the needle is removed before counting to six seconds, a stream of insulin may be seen coming from the pen needle and will not receive the full dose. 1. Review of Resident #32's Physician's Order Sheet (POS), dated 11/30/23, showed: - Diagnoses of dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), urinary tract infection (infection occurring in the bladder, kidney, urethra or ureters), and syncope (fainting); - An order, dated 7/5/2023 for Novolog FlexPen per sliding scale: - If Blood Sugar is 150 to 200, give 3 units; - If Blood Sugar is 201 to 250, give 5 units; - If Blood Sugar is 251 to 300, give 7 units; - If Blood Sugar is 301 to 350, give 9 units; - If Blood Sugar is 351 to 400, give 11 units; - If Blood Sugar is greater than 400, give 13 units; - Give before meals and at bedtime at 6:30 A.M., 11:30 A.M., 4:30 P.M., and 7:00 P.M. Observation on 12/01/23 at 11:54 A.M., showed Certified Medication Technician (CMT) A administered Novolog insulin five unites per the FlexPen to Resident #32 and failed to prime the insulin pen prior to administering of insulin. 2. Review of Resident #36's POS, dated 11/30/23, showed: - Diagnoses of Gullian-Barre Syndrome (a condition in which the immune system attacks the nerves), dysphagia (difficulty swallowing foods or liquids), type 2 diabetes mellitus, urinary tract infection; - An order, dated 1/19/23, for Novolog FlexPen per sliding scale: - If Blood Sugar is 150 to 200, give 3 units; - If Blood Sugar is 201 to 250, give 5 units; - If Blood Sugar is 251 to 300, give 7 units; - If Blood Sugar is 301 to 350, give 9 units; - If Blood Sugar is 351 to 400, give 11 units; - If Blood Sugar is greater than 400, give 13 units; - Give before meals and at bedtime at 6:30 A.M., 11:30 A.M., 4:30 P.M., and 7:00 P.M. Observation on 12/01/23 at 11:41 A.M., showed CMT A administered Novolog insulin five units per the FlexPen to Resident #36 and failed to prime the insulin pen prior to administering the insulin. During an interview on 12/01/23 at 12:05 P.M., CMT A said he/she always gave one more unit of insulin than what was ordered to ensure the resident got the full dose of medication because he/she didn't prime the insulin pen. During an interview on 12/01/23 at 1:40 P.M., the Administrator said he/she was not sure about priming the insulin pen. During an interview on 12/01/23 at 1:44 P.M., Licensed Practical Nurse (LPN) E said he/she didn't think the insulin pens had to be primed by wasting two units of insulin. He/She never primed an insulin pen prior to administering insulin.

Based on observation and interview, the facility failed to ensure the dumpster was maintained to keep pests out and/or to keep the garbage contained in the dumpster. This failure had the potential to affect all residents. The facility census was 42. Review of the facility's Waste Disposal policy, dated April, 2011, showed: - Dumpster lids are to be closed at all times; - Dumpster and dumpster area are to be kept clean and free of debris. 1. Observation on 11/28/23 at 9:49 A.M., and 12:52 P.M., 11/29/23 at 3:06 P.M., 11/30/23 at 4:05 P.M., and 12/01/23 at 8:00 A.M., and 10:32 A.M., of the outside trash dumpster located near the kitchen entrance showed: - One 8 yard (yd.) dumpster partially filled with one plastic lid completely opened; - Twelve soiled disposable exam gloves, scattered debris, 1 broken porcelain toilet lid, and two damaged wheel chairs lay on the ground beside the dumpster; - Oily grime build-up along the front concrete edge of dumpster area. During an interview on 12/01/23 at 11:03 A.M., the Maintenance Director said the trash dumpster should be closed when it was unattended. The lids are open on the trash dumpsters for convenience, there is a pole out there to help open or close the dumpster but the staff are not trained to use the pole. It is unknown if anyone is designated to clean up around the dumpster but there was a system at one time. Staff are available to help with maintaining the dumpster area, the dumpster area should be cleaned up and the junk items could be taken to the scrap yard. There should not be grime build up on the concrete below the dumpster. During an interview on 12/01/23 at 1:41 P.M., the Dietary Manager said facility staff were expected to close the dumpster lid when finished with taking out the trash. Staff should ensure the area around the dumpster was clean. The dumpster and trash cans in the kitchen should remain closed when they are not being filled. Reaching the dumpster lid is a challenge for some of the staff due to their height so it is often times left open. During an interview on 12/01/23 at 2:35 P.M., the Administrator said the dumpster area should be kept in order and the lid should be closed when it was not being filled. The area around the dumpster should be clean.

Based on observation, interview, and record review, the facility failed to maintain adequate infection control practices to prevent the transmission of infection when staff demonstrated poor hand hygiene for two residents (Resident #4, and #33) out of two sampled residents. The facility also failed to ensure the prevention of communicable disease in regards to Tuberculosis (TB) (a communicable disease that affects the lungs characterized by fever, cough and difficulty breathing) by not completing the admission TB screening and/or a yearly risk assessment for symptoms for five residents (Resident #1, #8, #18, #19, and #24) out of five sampled residents. The facility census was 42. Review of the facility's policy titled, Perineal Care, dated March 2015, showed: - To cleanse the perineum; - To prevent infection and odor; - Put on disposable gloves; - Wet washcloth and make a mitt with it. Apply soap lightly; - Use one gloved hand to stabilize and separate the labia, with the other hand, wash from front to back; - Rinse and pat dry; - Use a new washcloth and wash around the anus. Rinse and dry. 1. Observation of pericare provided for Resident #4 on 11/29/23 at 2:23 P.M. showed: - Certified Nurse Aide (CNA) J sanitized hands and donned gloves; - CNA H failed to perform hand hygiene and donned gloves; - CNA J assisted resident to stand and hold grab bar in shower stall, and pulled down resident's pants; - CNA H removed resident's urine soaked brief, strong urine odor noted, and with the same soiled gloves, touched his/her scrub pocket to retrieve trash bag for brief, placed brief in bag and set aside; - With resident standing toward wall, CNA J used one of two prepared wet washcloths, applied periwash, wiped between resident's legs front to back one time, removed gloves, sanitized hands, donned new gloves, opened a clean brief between resident's legs, and failed to clean front peri area; - Clean brief fell into CNA J's hands, Resident sat self in wheelchair, without clothing or brief, on incontinence bed pad; - With the same soiled gloves, CNA H and CNA J assisted resident to standing position; - With the same soiled gloves CNA H applied skin protectant to resident's buttock area, assisted CNA J to apply brief, pulled resident's pants up, and sat resident into wheelchair seat, on the same soiled incontinence bed pad. Both CNAs removed gloves and washed hands. 2. Observation of pericare provided for Resident #33 on 11/30/23 at 11:41 A.M. showed: - Resident sat on side of bed with fitted sheet and two incontinent bed pads saturated with urine, wearing a urine soaked gown and brief. CNA J sanitized hands and donned gloves; - CNA I failed to perform hand hygiene and donned gloves; - CNA J applied gait belt around the resident's wet gown, assisted resident up to walker, and walked resident to bathroom; - CNA J loosened gait belt, removed brief, assisted resident to sit on toilet, and removed gown; - CNA I stripped bed of urine saturated incontinent bed pads and fitted sheet, and with the same soiled gloves, retrieved a clean brief; - With the same soiled gloves, CNA J wet clean cloth, applied periwash, wiped resident's back, removed gloves, failed to perform hand hygiene, touched closet doorknob, moved hanging clothes to side, retrieved clean gown, washed hands, and donned gloves; - With the same soiled gloves, CNA I removed gait belt from resident, and opened clean brief; - CNA J placed clean brief between resident's legs; - With the same soiled gloves, CNA I assisted fastening sides of brief; - CNA J wet washcloth, applied periwash to washcloth, handed washcloth to CNA I; - With the same soiled gloves, CNA I wiped buttock area, folded cloth to clean area, cleaned front peri area, assisted CNA J to pull clean brief up into place, and assisted resident to put on clean gown; - CNA J applied the same soiled gait belt, assisted resident with walker to wheelchair in room; - CNA I removed gloves and washed hands; - CNA J removed gait belt from resident, placed it around his/her own neck, picked up dirty linens from floor, placed in bag, removed gloves, failed to perform hand hygiene, retrieved resident's hairbrush from bathroom, brushed resident's hair, placed brush back in bathroom; propelled resident in wheelchair to nurses station, and sanitized hands with hall dispenser; - CNA I retrieved bags with soiled brief and wet gown from bathroom with bare hands, failed to perform hand hygiene, donned gloves, touched bed cover folded down at end of bed, picked up bag with soiled linens and took to soiled utility with gloves on, came out without gloves on, and sanitized hands in hall with dispenser; - Both CNAs retrieved clean linens from hall linen cart, made resident's bed, and failed to clean soiled mattress prior to making bed. During an interview on 12/1/23 at 12:30 P.M., Licensed Practical Nurse (LPN) D said he/she would gather supplies, explain task to resident, ensure privacy, wash hands, prepare basin of water and washcloths or wipes, don gloves, cover resident to not expose, start in the front, wipe down to back, use new wipe or wash cloth each wipe, move to back side, wipe bottom to top, use new area of cloth or new wipe each wipe. Anytime gloves are visibly soiled, dispose of gloves, wash hands, don new gloves, and after peri care is complete, remove gloves and wash hands. During an interview on 12/01/23 at 12:45 P.M., Registered Nurse (RN) K said incontinence pad should be replaced with clean incontinence pad in chair before seating resident back in chair or wheelchair. During an interview on 12/01/23 at 2:30 P.M., the Director of Nursing (DON) said he would expect a bed to be wiped down with disinfecting wipes if soiled, before remaking the bed with clean linens. He would expect a soiled incontinence pad in a wheelchair to be changed before sitting a resident back into the wheelchair, and would expect hand hygiene to be performed when moving from dirty to clean during peri care. During a phone interview on 12/07/23 at 8:25 A.M., CNA H said he/she would gather supplies, wash hands, put on gloves, wipe front peri area inside to outside, front to back, using either the wipe and fold method for the wash cloth, or use a new wash cloth each wipe. He/she would then use a new wash cloth to clean the back peri area and buttocks, going front to back, folding cloth or using new cloth each wipe. He/she would remove gloves after finished with peri care, and wash hands, put on new gloves, and finish with care. He/she would also change gloves if visibly soiled during peri care. During a phone interview on 12/07/23 at 10:28 A.M., CNA J said he/she would gather supplies, knock, explain care to be given, wash hands, don gloves, remove brief, place it in the trash can, remove gloves, sanitize, don new gloves, always wipe front to back, fold washcloth to clean area or get a new one, use a new washcloth to do backside, use a new wash cloth to wipe down legs, place a new brief, replace clothes, remove gloves and wash hands, assist the resident to wash hands if they wanted to. He/she said if going from dirty to clean, wash hands. He/she said incontinent pad would need to be changed in chair if soiled. 3. Review of the facility's Guidelines for Screening for Tuberculosis in Long Term Care Facilities policy, dated May 2015, showed: - All residents new to long-term care who do not have documentation of a previous skin test reaction >10 mm or a history of adequate treatment of tuberculosis infection or disease, shall have the initial test of Mantoux PPD two step skin test to rule out tuberculosis within one month prior to or one week after admission as required by Department of Health Rule 19 CSR 20-20.100; - Annual skin test for residents with documented results <10 mm are not required; - Residents are to be evaluated, at least annually, to assure absence of signs and symptoms for tuberculosis disease. Record review of Resident #1's medical record showed: - An admission date of 12/31/03; - TB Annual Symptom Screen form completed on 10/14/21; - No documentation of a tuberculin skin test (TST) or screen for 2023. Review of Resident #8's medical record showed: - An admission date of 04/29/22; - No documentation of TST or screen since admission. Review of Resident #18's medical record showed: - An admission date of 11/14/19; - No documentation of a TST or screen since admission. Review of Resident #19's medical record showed: - An admission date of 06/02/16; - A TB Annual Symptom Screen form completed on 07/31/19; - No documentation of a TST or screen for 2023. Review of Resident #24's medical record showed: - An admission date of 09/16/22; - No documentation of a TST or screen since admission. During an interview on 12/01/23 at 9:00 A.M., the Infection Preventionist said the facility conducts a 2 step TST at the time of a resident's admission and then an annual screening form thereafter. He said he would expect the screenings to be completed annually and be documented in the medical record. During an interview on 12/01/23 at 11:20 A.M., the DON said we do not have any current tuberculosis questionnaires for the listed residents. Obviously we are behind on these. During an interview on 12/01/23 at 2:30 P.M., the Administrator said she would expect tuberculosis testing or screening to be completed for residents annually.

Based on interview and record review the facility failed to designate one or more individuals with the required primary professional training as the Infection Preventionist (IP) for the facility's infection prevention control program. The facility census was 42. The facility did not provide a policy regarding required primary professional training for the Infection Preventionist. During an interview on 12/01/23 at 9:30 A.M., the Infection Preventionist said that he/she is not a nurse nor is he/she trained in any other related field. The IP said that he/she is a licensed nursing home administrator and has successfully completed the nursing home infection preventionist training course. The IP said that he/she thought the regulation had changed and that anyone who completes the nursing home infection preventionist training could be the IP. During an interview on 12/01/23 at 10:40 A.M., the Administrator said that she was told that the Infection Preventionist could be anyone who had completed the nursing home infection preventionist training course.

Based on observation, interview, and record review, facility staff failed to conduct regular inspections of all bed frames and rails as part of a regular maintenance program for two resident's (Resident #11 and #20) out of 14 sampled residents with bed rails in use. The facility's census was 42. Review of the facility's policy titled, Restraints, Physical, dated March 2015, showed the following: - Inspect by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks; - The maintenance department shall provide a copy of inspections to the administrator and report results to the QA committee for appropriate action. Copies of the inspection results and QA committee recommendations shall be maintained by the administrator and/or safety committee. 1. Observations of Resident #11 showed: - On 11/28/23 at 11:01 A.M., resident in bed with quarter side rail up on left side of bed; - On 11/29/23 at 8:57 A.M., resident in bed with quarter side rail up on left side of bed; - On 11/30/23 at 12:55 P.M., resident in bed eating lunch with quarter side rail up on left side of bed; - On 12/01/23 at 10:01 A.M., resident in bed with quarter side rail up on left side of bed. During an interview on 11/30/23 at 12:55 P.M., Resident #11 said he/she used the side rail to pull himself/herself up in bed. Review of Resident #11's medical record showed no maintenance inspection for bed rails. 2. Observations of Resident #20 showed: - On 11/30/23 at 9:45 A.M., resident in bed with quarter side rail up on right side of bed; - On 12/01/23 at 10:01 A.M., resident in bed with quarter side rail up on right side of bed. Review of Resident #20's medical record showed no maintenance inspection for bed rails. During an interview on 12/01/23 at 11:00 A.M., the Maintenance supervisor said he is expected to add assist rails on the beds if there is a doctors order. He has done about six installations recently in the last two to three months, routine inspections are not being completed as part of a maintenance program, but if there are problems with the bed rails they get fixed. During an interview on 12/01/23 at 2:35 P.M., the Administrator said she would expect there to be routine inspection reports available for resident beds or bed rails but there are none available.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain a safe, clean, comfortable, homelike environment. The deficient practice had the potential to affect all residents and staff in the facility. The facility census was 42. The facility did not provide a policy. 1. Observation on 11/28/23 at 10:38 A.M. of room [ROOM NUMBER], showed: - One, 9 inch (in.) x 11 in. picture frame and two, 5 in. x 7 in. picture frames on top of the light fixture above the bed and one five foot long foil [NAME] draped over the light fixture above the head of the bed by the door. 2. Observation on 11/28/23 at 10:56 A.M., of room [ROOM NUMBER], showed: - One, 8 in x 11 in. canvas painting on top of a light fixture above the bed by the door; - Two, 2 foot areas of dry wall damage at head of bed, one tube of cream on top of a light fixture above bed, and a wooden board covered in plexiglass attached to the wall on the left side of the bed closest to the window had damage along the top edge with pieces of wood peeling off. The plexiglass was cracked with sharp points exposed. 3. Observation on 11/28/23 at 10:57 A.M., of room [ROOM NUMBER], showed: - A 5 in. x 7 in. picture frame, a small trophy, two small wooden birdhouses, a wooden nutcracker figurine, a small wooden airplane, a hangable paper craft, and an 8 in. x 11 in. canvas painting on top of the light fixture above the head of the bed closest to the door; - A 4 in. x 6 in. paper card with an artificial poppy flower attached to the card displayed on top of a light fixture above the bed located by the window. 4. Observation on 11/28/23 at 11:11 A.M., of room [ROOM NUMBER], showed an 8 in. stuffed animal, a 16 in. felt rose, and a small plastic ball cap on top of the light fixture above the bed. 5. Observation on 11/28/23 at 3:23 P.M., of room [ROOM NUMBER], showed: - A 4 in. wooden butterfly displayed on top of the light fixture located above the head of the bed by the window; - A brown substance around bottom of toilet and around the hinges of the toilet seat; - The toilet seat with areas of peeling on the top and underneath. 6. Observation on 11/28/23 at 11:38 A.M., of room [ROOM NUMBER] showed an antique vehicle replica video tape re-winder (novelty electronic) and a 5 in. x 7 in. framed portrait on top of the light fixture above the bed. 7. Observation on 11/28/23 at 11:40 A.M., of room [ROOM NUMBER] showed two poster sized portraits on top of the light fixture above the bed. 8. Observation on 11/28/23 at 11:45 A.M., of room [ROOM NUMBER] showed two small glass statues on top of the light fixture above the bed. 9. Observation on 11/29/23 at 1:44 P.M., of room [ROOM NUMBER] showed an 8 in. x 11 in. canvas painting and a 10 in. x 10 in. wooden star on top of the light fixture above the bed by the door. 10. Observation on 12/01/23 at 10:55 A.M., of 600 hall, showed: - The ceiling outside room [ROOM NUMBER] and 608 had an area stained brown; - The ceiling outside room [ROOM NUMBER] and 612, had a 14 in. area that bowed toward the ground with a 16 in. X 8 in. area of peeling spackling. Observation on 12/01/23 at 11:00 A.M., showed a clip board hanging at the nurse's station with maintenance request sheets. Record review of those request sheets showed spaces for staff to fill in the date, time, location, problem, requested by and then an area to mark the work had been completed. Review of the Maintenance Request sheets provided by the maintenance supervisor, dated 03/15/23 through 11/27/23, showed no current request for area of concern documented. During an interview on 12/01/23 at 10:45 A.M., Nursing Assistant (NA) E said there is a maintenance form up at the nurses station to fill out for things that need repaired. He/She said if it was something like glass that was broke, or something that could injure the resident, he/she would put it in a biohazard bag and take it to the nurses station. During an interview on 12/01/23 at 11:02 A.M., the Business Administrator said the maintenance Supervisor takes the request sheets from the clip board hanging at the nurse's station. Then he makes the repairs and keeps the records. During an interview on 12/01/23 at 11:10 A.M., the Maintenance Supervisor said he has a clip board at the nurse's station for Maintenance requests. Staff also come out and tell him about repairs needed. He said if he is real busy he will tell them to go write it down. He said each request sheet is set up to show up to three repair requests per sheet. When the requests have been completed, he takes them to his office and files it. He would expect to be told or a sheet to be filled out if there was damage or issues that need addressed or repaired. He would expect to be told or a sheet made about damage to drywall, because he isn't in rooms daily like nursing staff are. He said that a room had a hole in the wall that he had to cover it with a large sheet of wood, and then put plexiglass on it; he would expect the sheet of wood, and the plexiglass to be in good repair and not broke, and expect to be told if it wasn't. He said he knows that some residents have objects, crafts, or knickknacks on their light fixtures in the rooms, he doesn't like them up there, because they could fall on their head. He said most are placed there by the residents or their family members. He did not know they couldn't have them up there, but did not feel like it was his place to tell them they cant put things there. During an interview on 12/01/23 at 12:35 P.M., the Administrator said crafts, pictures, paintings, or other objects should not be on top of light fixtures in resident's rooms. She would expect staff to inform maintenance of the issue using the forms on the clip board at the nurse's station. During an interview on 12/01/23 at 12:50 P.M., the DON, said he would expect staff to fill out a maintenance request form kept at the nurse's station if they saw something in need of repair. He said staff should know displaying items on a resident's light fixture above their bed is a safety hazard.

Based on interview and record review, the facility failed to conduct at least twelve hours of nurse aide in-service education per year and failed to provide the required annual competencies of abuse prevention and dementia care for two out of two nurse aides sampled. The facility census was 42. The facility did not provide a policy. 1. Record review of the facility's 2023 in-service records showed: - Certified Nursing Assistant (CNA) C with a hire date of 12/07/20; - CNA C attended a total of one hour of in-services; - CNA C did not attend an annual competency in-service on abuse prevention; - CNA C did not attend an annual competency in-service on dementia care. 2. Record review of the facility's 2023 in-service records showed: - CNA F with a hire date of 09/17/15; - CNA F attended a total of one hour of in-services; - CNA F did not attend an annual competency in-service on abuse prevention; - CNA F did not attend an annual competency in-service on dementia care. During an interview on 11/30/23 at 8:30 A.M., the Infection Preventionist said training is provided during staff meetings, but that the facility had not been keeping up with the training records. He was aware that training on abuse prevention and dementia care were required annual training. During an interview on 12/01/23 at 10:40 a.m., the Administrator said that she would expect all CNAs to have 12 hours of continuing training each year and for the training to include abuse, neglect and dementia care training.

Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This has the potential to affect all residents. The facility census was 42. The facility failed to provide a policy. 1. Observation on 11/28/23 at 9:29 A.M., of the kitchen showed: - Scrap food items floated in the clogged garbage disposal sink; - The commercial range with brown grime build-up around the control knobs; - Food debris, oily film build-up, two drinking cups, one egg roll on the floor beneath the range; - Microwave oven interior with splattered food debris on all surfaces; - Storage below microwave with splattered grease and food debris on metal bowls and shelf surface; - Storage below steam table with four- twenty quart (qt.) pots with a brown substance on interior surfaces; - Spray bottle with bleach cleaner sat on the window shelf above sink with black grime and scattered debris; - Cabinet drawers contained cooking utensils and scattered debris on the bottom surface; - 1 inch (in.) ice machine floor drain with black grime debris on exterior surface; - Ice machine exterior surface near dispensing area with white grime build-up; - Reach-in freezer interior with scattered debris and brown grime build-up and no separate thermometer; - Floor below reach-in freezer with scattered debris; - The commercial dishwasher with white grime build up on the exterior surfaces; - The dishwasher vent hood with a brown substance inside; - Black grime build-up on the drain pipes below the dishwashing counter; - Three 16 in. x 24 in. x 1 in. deep baking pans and one muffin pan with a sticky film, black grime build-up in the inside corners, on the cooking surface and outer surfaces; - Ceiling lights over food preparation areas with four broken fluorescent light fixture covers. 2. Observation on 11/28/23 at 9:35 A.M., of the dry food storage room, showed: - One 6 pound (lb.) 8 ounce (oz.) dented can with sauerkraut on the canned food rack; - Scattered debris below the food storage shelves; - One step ladder, two desk chairs and a steam table guard sat in the floor below food storage shelves. 3. Observation on 11/30/23 at 10:45 A.M., of the walk-in refrigerator, showed: - No light or separate thermometer; - Red liquid, a sticky film and debris on the floor below the food shelves; - Dust and grime build-up between the ventilation louvers. 4. Observation on 11/30/23 at 10:50 A.M., of the walk-in freezer showed: - Separate Thermometer was not available; - 8 in. frost formations surrounded doorway opening; - Freezer door opened with 1 in. air gap; - Light fixture separated from wall surface with exposed electrical wires; - A sticky film and debris on the floor below the food shelves. During an interview on 11/28/23 at 12:28 P.M., the Environmental Consultant said an outside contractor had been contacted about the walk in freezer. The freezer should not have frost build up and the door latch should operate and allow the door to close completely. The latch will need fixed and the seal will need to be replaced. The freezer has been a problem for at least two weeks. During an interview on 11/30/23 at 9:47 A.M., the Maintenance Director said an outside service contractor was contacted to make repairs on the garbage disposal in the kitchen. A resident's teeth were accidentally placed down the disposal and it has not worked properly for several days. A plumber has been called but never visited the facility. Items like appliance guards and chairs should not be stored in the dry food storage. The freezer door and garbage disposal will be repaired by outside service contractor. During an interview on 11/30/23 at 11:40 A.M., the Administrator said the freezer and refrigerators should be clean. All appliances, counter tops floors and vents should be clean and work properly. The refrigerators should have working lights and thermometers. They should be clean and not have build-up, debris or standing liquid. All issues are a concern and should and will be fixed. During an interview on 12/01/23 at 10:52 P.M., Dietary Aide (G) said Dietary aides are expected to keep the floors, stove, toaster the counters, dishwasher, walk-in freezer and refrigerator clean. We should also clean under appliances and behind. Cleaning should be done at least three times a week. During an interview on 12/01/23 at 1:41 P.M., the Dietary Manager said the walk-in freezer had a problem with ice build-up. The freezer door should be working properly but wasn't. The Maintenance Director had been notified about the concern. The walk-refrigerator should be clean but thawing meat may have caused the red liquid to collect in the floor. Sweeping under the appliances is expected but was not always done correctly. The dishwasher should be clean inside and out along with the other appliances. The dishwasher, appliances and floor surfaces should be cleaned. The floors in the walk-in freezer and refrigerator should be cleaned and mopped. The baking sheets should be clean with no sticky film or carbon build-up and will be removed from the kitchen. The garbage disposal has been an issue for several days and a service company should be contacted. All concerns with the kitchen will be addressed and there is work to be done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain a physician's order for a code status (the type of treatment a person would or would not receive if their heart or breathing were to stop) for one resident (Resident #36) out of 12 sampled residents. The facility census was 35. Record review of the facility's Advance Directive (a written legal statement of a person's wishes in regards to medical treatment) policy, dated [DATE], showed: - Information about whether or not the resident executed an advance directive, shall be displayed prominently in the medical record. 1. Record review of Resident #36's medical record showed: - An admission face sheet with an admission date of [DATE], and no code status documented; - The Physician Order Sheet (POS), dated [DATE], with no order for the resident's code status; - No documentation of the resident's wishes in regards to if his/her heart stopped beating; - The resident requested cardiopulmonary resuscitation (CPR) (a lifesaving technique used when someone's breathing or heart stopped) on the care plan, dated [DATE]. During an interview on [DATE] at 10:42 A.M., Certified Nursing Assistant (CNA) E said if he/she needed to know a resident's code status, he/she would look in the resident's paper chart and there should be a paper on top. He/she thought the code status was also in the resident's electronic record, but he/she wasn't sure. During an interview on [DATE] at 10:48 A.M., Licensed Practical Nurse (LPN) B said a resident's code status should be on the main screen on the resident's electronic medical record. The nurses put the order in the electronic record and it populates the code status on the main screen. He/she believes the social service designee (SSD) and the business office manager (BOM) ensure the code statuses are up to date. During an interview on [DATE] at 4:08 P.M., the interim Director of Nursing (DON) said the BOM and/or the SSD creates the resident's face sheet, which includes their code status, for every resident on admission. Every resident is considered a full code, by default, when they are admitted to the facility until a signed Do Not Resuscitate (DNR) order (an order which indicated a person should not receive CPR if the heart stops beating) is obtained from the physician and then the chart will be updated to reflect that. The SSD will reach out to the nurse to write the DNR order in the chart when the DNR is obtained, and the nurse also takes care of writing the order for full code residents as well.

Based on observation, interview and record review, the facility failed to provide thorough assessments, orders and monitoring for residents that received dialysis (process for removal of waste and excess water from the blood due to kidney failure) treatments and failed to ensure a signed dialysis contract was completed between the dialysis center and the facility. In addition, the facility failed to ensure staff had a system in place to monitor a fluid restriction (limited amount of daily fluids) as ordered for one resident (Resident #24) out of a sample of two residents that received dialysis treatments. The facility census was 35. Record review of the facility's Care of the Resident Receiving Dialysis and Fluid Restriction policy and procedure, dated March 2015, showed: - Care for a dialysis resident should include care of the femoral (thigh) vein catheter (tube inserted into a large vein) with a treatment order from the physician for cleaning, the treatment to be changed daily, and the nurses to maintain the dressing to the access site at all times, and the site to be checked every shift and the dressing re-applied or re-enforced as needed (PRN); - Monitor for signs of infection; - Check for a thrill (a vibration over the dialysis access site heard with a stethoscope); - Nurses will check the thrill daily and document daily. This will be documented on the resident's treatment administration record (TAR); - Residents with a fluid restriction due to dialysis will have an order for the fluid restriction, and the nurse along with the dietary manager, will calculate the amount of fluid to be sent with each meal and the amount the nursing department will give with medications; - A resident on a fluid restriction will not have a water pitcher in their room, will be placed on intake & output (I&O) to monitor the resident's fluid intake and output, the resident will be instructed on the amount of fluids ordered by the physician and the need to comply with the restriction, the resident will be informed of the risk and benefits of the fluid restriction, and the physician will be notified of any non-compliance of the fluid restriction. 1. Record review of Resident #24's medical record, showed: -An admission date of 8/1/20; -Diagnoses included End Stage Renal (kidney) Disease (ESRD) (an irreversible kidney function); -The resident received dialysis treatments prior to admission to the facility. Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/6/22, showed: - Moderately impaired cognition; - Diagnosis of ESRD; - Received dialysis. Record review of the resident's Physician's Order Sheet (POS), dated June 2022, showed: - An order for 1 liter (1,000 cubic centimeter (cc) equals 1 liter of fluid) fluid restriction daily, dated 4/18/22; - No order for the frequency of the resident's dialysis treatments; - No order for the resident's dialysis company and/or location of the dialysis center; - No order to assess the resident's dialysis access site for signs/symptoms of infection, swelling and/or bleeding; - No order to assess the resident's condition before and after dialysis; - An order for 60 cc of fluid to be administered with each medication pass, dated 6/16/22; - An order to discontinue the 1 liter of fluid restriction, dated 6/17/22. Record review of the resident's medication administration record (MAR) and treatment administration record (TAR), dated June 2022, showed: - No documented amount of fluids consumed with each meal (to monitor for restriction) for dates 6/1/22- 6/17/22; - No documented total amount of fluids consumed in a 24 hour period; - No documented assessments of the resident's condition before and after dialysis treatments; - No documented assessments of the resident's dialysis access site for signs/symptoms of infection, swelling and/or bleeding daily. Record review of the resident's progress notes, dated 5/1/22 through 6/16/22, showed: - No on-going, thorough assessments and/or monitoring of the resident's condition before and after dialysis treatments; - No documentation of assessments for the resident's dialysis access site for signs/symptoms of infections, swelling and/or bleeding; - No documentation of the amount of fluids provided with each meal, medication administration, and/or total of amount of fluids consumed in a 24 hour period. Observations of the resident showed: - On 6/14/22 at 10:00 A.M., the resident sat in his/her wheelchair in his/her room with a clear water pitcher with approximately 400 cc of fluid within reach of the resident; - On 6/15/22 at 8:35 A.M., the resident attended a dialysis treatment outside the facility; - On 6/16/22 at 8:34 A.M., the resident sat in the recliner in his/her room with his/her breakfast tray and a clear water pitcher with approximately 450 cc of water on the bedside table within reach of the resident. The resident's breakfast tray contained 120 cc of apple juice, approximately 100 cc of coffee, and approximately 90 cc of a nutritional supplement drink; - On 6/16/22 at 1:06 P.M., the resident sat in the recliner in his/her room with approximately 60 cc of a nutritional supplement drink, 120 cc of tea, and a clear colored water pitcher with approximately 400 cc of water within reach of the resident; - On 6/17/22 at 1:04 P.M., the resident sat in the recliner in his/her room with a a double lumen (a hollow tube) right femoral catheter covered with a dry dressing. Record review of the resident's dietary card (special instructions regarding the resident's diet and/or fluids) showed: - No fluid restriction and no amount of fluids to be served with each meal. During an interview on 6/14/22 at 10:00 A.M., the resident said he/she goes to dialysis three times a week on Mondays, Wednesdays and Fridays outside the facility. His/her dialysis access site is located in his/her right upper groin (the area between the abdomen and the thigh on either side of the body) area. The nursing staff do not assess the dialysis access site and/or his/her condition before and after the dialysis treatments. He/she is on a daily fluid restriction, but not sure how much fluid was to be restricted in a 24 hour period. During an interview on 6/14/22 at 1:00 P.M., Licensed Practical Nurse (LPN) A said the resident was currently on a daily fluid restriction, but would have to review the resident's physician's orders to see how much of a fluid restriction the resident should be on. During an interview on 6/14/22 at 1:15 P.M., LPN B said the resident is currently on a daily 1 liter fluid restriction. The resident should not have a water pitcher in his/her room. Nursing staff should serve the resident's fluids when the resident's meals were served in his/her room. Staff should be documenting the amount of fluids the resident consumed with each meal and should document the amount of fluids administered with the resident's medications. Generally, staff just know about how much fluids to administer to the resident, but actually did not have a system in place to ensure the resident was receiving the correct amount of the daily fluid restriction. The resident did not have an intake and output sheet for staff to document the amount of fluids he/she received daily. The facility did not provide a signed dialysis contract for the dialysis center where the resident received his/her dialysis treatments. During an interview on 6/16/22 at 3:00 P.M., the Business Office Manager said the facility did not have a signed dialysis contract with the resident's dialysis center. During an interview on 6/17/22 at 10:57 A.M., the facility's Registered Dietician (RD) said he/she came to the facility at least once a month. He/she would expect the dietary manager to ensure the resident's amount of the daily fluid restriction and the amount of fluids to be provided with each meal, was on the resident's dietary card to ensure the dialysis resident received the total amount of the ordered daily fluid restriction. During an interview on 6/17/22 at 11:00 A.M., the Dietary Manager said he/she wasn't aware it was his/her responsibility to ensure the resident's amount of the daily fluid restriction and amount of fluids to be provided with each meal should be documented on the resident's dietary card. The RD never instructed him/her regarding the daily fluid restrictions, and he/she never received an in-service from the RD regarding how to calculate the amount of fluids for each meal. During an interview on 6/17/22 at 11:50 P.M., the resident's attending physician said the order for the resident's daily 1 liter fluid restriction originally was ordered by the resident's kidney specialist. The attending physician said he/she would expect the nursing staff to have a system in place to ensure the resident received the daily 1 liter fluid restriction. He/she should have discontinued the fluid restriction order during last month's rounds since the resident was non-complaint with the fluid restriction. He/she was not aware the facility did not have a signed dialysis contract between the facility and the resident's dialysis center, and was not aware the facility needed a signed dialysis contract. The resident's dialysis access site was being assessed at the dialysis center, but nursing staff at the facility should be assessing the resident's condition before and after dialysis treatments and should assess the resident's access site for signs/symptoms of infection. During an interview on 6/17/22 at 12:59 P.M., LPN A said nursing staff should be assessing and monitoring the resident's condition before and after dialysis treatments, and should be assessing and monitoring the resident's dialysis access site for signs/symptoms of infection and bleeding. Nursing staff should document the assessments on the resident's TAR and/or progress notes. During an interview on 6/17/22 at 1:30 P.M., the Administrator said he would expect the facility to have a signed dialysis contract with every dialysis center the residents choose to use for continuity of on-going care being provided between the dialysis center and the facility. He would expect nursing staff to have contacted the resident's attending physician, obtained orders for dialysis treatments, and should have a system in place to ensure the resident received the daily 1 liter fluid restriction. He would expect the nursing staff to have contacted the resident's attending physician to notify him/her of the resident's non-compliance with the daily fluid restriction. He also would expect the nursing staff to follow the facility's policy and procedure regarding dialysis treatments and fluid restrictions. During an interview on 6/17/22 at 2:19 P.M., the interim Director of Nurses (DON) said she would expect the charge nurses to have contacted the resident's attending physician and obtained complete dialysis orders, which included frequency of the dialysis treatments, location of the dialysis center, assessment of the resident's condition before and after dialysis treatments, and assessment of the resident's dialysis access site for signs/symptoms of infection and bleeding. She would expect the nursing staff to have documented the assessments of the resident's condition and dialysis access site on the resident's TAR and/or progress notes. She said the resident's current POS did not contain any dialysis orders and the resident's TAR/progress notes did not contain thorough, on-going assessments of the resident's condition before and after dialysis treatments, and assessments of the resident's dialysis access site. She would expect a system to be in place for monitoring and tracking of how much fluids the resident consumed in a 24 hour period to ensure he/she received the daily 1 liter fluid restriction. The dietary manager should have documented on the resident's dietary card the total amount of the fluid restriction and the amount of fluids to be served with each meal. The nursing staff should follow the facility's dialysis and fluid restriction policies and procedures.

Based on observation, interview, and record review, the facility failed to ensure residents diagnosed with dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities) had a personalized plan of care to ensure appropriate services to promote the resident's highest level of functioning and psychosocial needs were provided for one resident (Residents #138) out of three sampled residents. The facility census was 35. 1. Record review of Resident #138's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 6/2/22, showed: - Severely impaired cognitive skills; - Able to understand others and to be understood; - Diagnoses of depression and anxiety. Record review of the resident's Physician Order Sheet, (POS), dated 6/1/22 - 6/30/22, showed: - Diagnosis of Alzheimer's (a type of dementia that affects memory, thinking and behavior) disease. Record review of the resident's admission care plan, reviewed on 6/13/22, showed: - Did not address specific interventions for dementia care; - Did not address specific interventions for activities for a resident diagnosed with dementia. Observations of the resident on 6/14/22, showed: - At 10:49 A.M. and 11:36 A.M., the resident sat quietly in the day room with the television on; - At 3:30 P.M., the resident sat quietly in his/her wheelchair in the day room. Observations of the resident on 6/15/22, showed: - At 8:40 A.M., the resident sat quietly in his/her wheelchair at the Nurses' Station; - 3:30 P.M., the resident sat quietly in his/her wheelchair in his/her room. Observations of the resident on 6/16/22, showed: - At 9:30 A.M., the resident lay quietly in bed in his/her room; - At 12:30 P.M., the resident sat quietly in his/her wheelchair in the hallway. During an interview on 6/17/22 at 11:30 A.M., the MDS coordinator/Interim Director of Nursing (DON) said she did not realize residents with Alzheimer's dementia needed to have the diagnosis of Alzheimer's and dementia as problems with specific interventions. In the past, they have used the problems and related it back to the Alzheimer's and dementia on the care plan. The facility did not provide a policy in regards to Dementia Care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a proper diagnosis for an antipsychotic (a major tranquilizer) medication for one resident (Resident #138) out of five sampled residents. The facility census was 35. Record review of Mosby's 2019 Nursing Drug Reference for quetiapine (an antipsychotic medication), showed: - Drug not indicated for use in elderly patients with dementia-related psychosis; - Watch for extrapyramidal (nerves associated with motor activity) effects; - May have a drug-to-drug interaction with the QT interval (a measurement used to assess some of the electrical properties of the heart) prolonging medications. Record review of the facility's Antipsychotic Medication Use policy, dated 3/2015, showed: - Residents will only receive antipsychotic mediations, when necessary, to treat specific conditions when indicated and effective; - The attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, symptoms and risks; - Nursing staff will document, in detail, an individual's target symptom(s); - Based on assessing the resident's symptoms and overall situation, the physician will determine whether to continue, adjust or stop the existing antipsychotic medication; - Antipsychotic medications shall only be used for the following conditions/diagnoses as documented in the record, consistent with definitions in the Diagnostic and Statistical [NAME] of Mental Disorders (conditions that affect a person's thinking, feeling, mood, and behavior); - An antipsychotic medication will not be used if only symptoms should be one or more of the following: Wandering, poor self-care, restlessness, impaired memory, mild anxiety, insomnia, unsociability, inattention to surroundings, fidgeting, uncooperativeness or verbal expressions or behaviors not due to conditions listed under the indications and do not represent a danger to the resident or others. 1. Record review of Resident #138's Physician Order Sheet (POS), dated 6/1/22 - 6/30/22, showed: - An admit date of 5/27/22; - age [AGE]; - An order for quetiapine 25 milligrams (mg) one tablet by mouth at bedtime related to anxiety disorder, dated 5/28/22. Record review of the resident's medical record showed: - No documentation of specific, targeted behaviors; - No documentation by the physician as to why the resident received quetiapine with an appropriate diagnosis. Record review of the resident's admission care plan, updated 6/13/22, showed: - No antipsychotic medication use with interventions; - No identification of specific, targeted behaviors with interventions. Observations of the resident from 6/14/22 - 6/17/22, showed: - The resident sat quietly in his/her wheelchair in the day room by the nurses' station; - The resident sat quietly in the dining room during meals; - The resident lay quietly in bed in his/her room. During an interview on 6/17/22 at 10:15 A.M., Licensed Practical Nurse (LPN) B said he/she called the resident's physician when the resident had been admitted . The resident's physician verified the order for the quetiapine 25 mg one tablet by mouth at bedtime and the diagnosis for the medication was anxiety. During an interview on 6/17/22 at 10:30 A.M., the Interim Director of Nursing (DON) said the staff knows an antipsychotic medication needs an appropriate diagnosis and anxiety is not an appropriate diagnosis for this medication.

Based on interview and record review, the facility failed to ensure the Quality Assessment and Assurance (QAA) committee consisted of the minimum required number of members when the committee met. This had the potential to affect all residents in the facility. The facility census was 35. Record review of the facility's QAA committee information, showed: - The committee will meet monthly; - The members of the committee to be the administrator, the Director of Nursing (DON), the medical director, the Minimum Data Set (MDS) (a federally mandated assessment instrument completed by facility staff) Coordinator, staff from the rehabilitation department, the Social Service Director, (SSD)/Admissions, the activity director and a secretary. Record review of the facility's monthly QAA meeting roster for 1/1/22 - 6/2/22, showed: - The 1/11/22 meeting consisted of the secretary and the medical director; - The 2/9/22 meeting consisted of the secretary and the medical director; - The 3/9/22 meeting consisted of the secretary and the medical director; - The 4/13/22 meeting consisted of the DON, the medical director and the secretary; - The 5/11/22 meeting consisted of the secretary and the medical director; - The 6/8/22 meeting consisted of the secretary and the medical director. During an interview on 6/17/22 at 11:00 A.M., the MDS Coordinator said he/she was not aware his/her name was on the list of the QAA members and did not realize he/she should attend the QAA meetings. The MDS Coordinator was now the interim DON and was not aware as the interim DON, he/she needed to attend the QAA meetings. During an interview on 6/17/22 at 11:30 A.M., the Business Office Manager, (BOM) said the QAA meeting was usually held when the medical director came in for rounds. The DON concerns/report was usually gone over with him/her at that time. During an interview on 6/17/22 at 2:00 P.M., the Administrator said he had only been at this facility since March 2022. He knew the QAA committee met monthly, but did not realize he was to be in attendance at these meeting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain a safe, clean, comfortable and homelike environment. This deficient practice had the potential to affect every resident at the facility. The facility's census was 35. 1. Observation on 6/14/22 at 10:22 A.M., of room [ROOM NUMBER] showed: - No toilet paper or paper towels; - Strong odor in the room; - Floor covered with a sticky substance; - Two Styrofoam cups on the counter by the sink with one turned upside down. During an interview on 6/14/22 at 10:22 A.M., Resident #11 said staff did not bring ice water, so he/she just drinks tap water. 2. Observation on 6/15/22 at 8:35 A.M., of room [ROOM NUMBER] showed: - No toilet paper or paper towels; - Strong odor in the room; - Floor covered with a sticky substance; - Blanket with a brown substance smeared on it lay on the floor; - Towel with a brown substance smeared on it lay on the hand rail in the bathroom. 3. Observation on 6/15/22 at 10:16 A.M., of room [ROOM NUMBER] showed: - No toilet paper or paper towels in the room; - Strong odor in the room; - A pile of linens by the door and another pile of linens by the window; - Uncovered mattress with multiple brown areas on it. 4. Observation on 6/16/22 at 8:26 A.M., of room [ROOM NUMBER] showed: - Multiple black scuff marks, measured approximately 12 inches (in.) on the wall next to the closet; - Multiple areas of peeled paint, measured approximately 6 to 12 in. on the wall next to the closet; - Multiple areas of peeled paint, measured approximately 6 to 12 in. on the bathroom door frame with exposed metal; - Bathroom floor dirty and sticky; - Toilet bolts exposed, measured approximately 1 to 1 1/2 in. 5. Observation on 6/16/22 at 8:31 A.M., of room [ROOM NUMBER] showed: - Multiple black scuff marks, measured approximately 12 to 24 in. on the walls next to the closet, window and bathroom door; - Bathroom floor dirty and sticky; - No plate cover over the electrical outlet under the call light. 6. Observation on 6/16/22 at 8:34 A.M., of room [ROOM NUMBER] showed: - Multiple black scuff marks, measured approximately 12 to 24 in. on the walls next the bathroom door and left side of the bed; - Bathroom floor dirty and sticky; - Multiple areas of peeled paint, measured approximately 4 inches on the wall next to the bathroom toilet; - No caulking around the edges of the toilet; - Toilet bolts exposed, measured approximately 1 inch to 1 1/2 in. 7. Observation on 6/16/22 at 8:40 A.M., of room [ROOM NUMBER] showed: - A strong odor of urine in the room; - An 18 inch by 24 in. oval shaped dark brown stain in the middle of the floor. During an interview on 6/17/22 at 7:38 A.M., Housekeeper C said housekeeping staff clean the residents' rooms and bathrooms daily, which included dusting all furniture and walls. The housekeeping staff damp mops the floors in the residents' rooms and bathrooms, including damp mopping around the base boards daily. There are three housekeeping staff on the day shift and one housekeeping staff comes into work at 1:00 P.M., during the week. During an interview on 6/17/22 at 7:56 A.M., Licensed Practical Nurse (LPN) A said the facility has a maintenance work order form available at the nurses' station for all staff to complete when any areas of the facility and/or residents' rooms/bathrooms needed to be repaired. The Maintenance Director checks the work order forms at least daily and sometimes more frequently throughout the day. During an interview on 6/17/22 at 8:00 A.M., the Maintenance Director said the facility has a maintenance work order form that is maintained at the nurses' station for all staff to complete for any environmental issues or problems to be repaired. He/she checks the work order forms daily and sometimes several times a day. He/she makes walking rounds daily and sometimes more frequently throughout the inside of the entire facility and outside of the facility to check on any environmental issues and/or problems that need to be repaired. If the environmental issue or problem is serious, then it is repaired immediately. Generally, the work orders are completed within the same day and/or within the week, depending on the environmental issue and/or problem. There is one other maintenance staff person that assists with any maintenance work, and one staff person that is a floor technician. During an interview on 6/17/22 at 1:30 P.M., the Administrator said he would expect the facility staff to complete the maintenance work order forms maintained at the nurses' station and would expect the Maintenance Director to check the work order forms daily and/or more frequently for any environmental issues and/or problems that needed to be repaired. He would expect the housekeeping staff to clean and damp mop all residents' rooms and bathrooms daily. The housekeeping staff do have a cleaning schedule and should follow the cleaning schedule. He does walking rounds daily throughout the facility to check on the environmental issues. Record review of the Housekeeping staff 100 Hall daily cleaning schedule showed: - Clean resident rooms/bathrooms, dust and sweep/mop all resident room/bathroom floors for rooms 101 through 114.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that a staff member certified in cardiopulmonary resuscitation (CPR) (a lifesaving technique used when someone's breathing or heart stopped) was scheduled for each shift. This deficient practice had the potential to affect all 17 residents with a full code (requested CPR) status. The facility's census was 35. Record review of the facility's CPR policy, dated [DATE], showed: - The facility must maintain and document a minimum of one CPR certified staff member per shift on duty, not including any staff members needed to provide transport services; - Staff members with CPR certification will provide documentation to the facility's Director of Nurses (DON) and/or designee, and annually thereafter; - Records of the staff's CPR certification will be maintained and available for surveyor review; - The administrator will monitor for compliance; - CPR certification must be designed for healthcare providers to be acceptable (must include mouth breathing training). Record review of the facility's nursing schedule for [DATE] - [DATE], and record review of the facility's current CPR certified staff, showed: - No staff member certified in CPR scheduled for the night shift of 6:00 P.M. through 6:00 A.M., on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. During an interview on [DATE] at 11:24 A.M., the interim DON said the facility did not have a licensed and/or non-licensed staff who were CPR certified that worked the night shift from [DATE], [DATE] through [DATE], and [DATE] through [DATE]. During an interview on [DATE] at 1:30 P.M., the Administrator said he would expect the licensed and non-licensed nursing staff who worked, to be up to date on their CPR certification. Normally, it would be the DON's responsibility to ensure licensed and non-licensed nursing staff scheduled to work have a current and valid CPR certification.

Based on observation, interview, and record review, the facility failed to maintain an error rate of less than five percent (%) when medications were given. There were 30 opportunities with five errors made, for an error rate of 16.67%. This affected four residents (Residents #5, #10, #11, and #17) out of 17 residents. The facility census was 35. Record review of the facility's Preparation and General Guidelines - Medication Administration policy, dated July 2021, showed: - Five rights of medication administration included to verify the right resident, the right drug, the right dose, the right route and the right time applied for each medication administered; - A triple check of these five rights would be recommended in the process of the preparation of a medication for administration; - Crushing tablets may require a physician's order, per the facility policy. If safe to do so, medication tablets may be crushed or capsules emptied out when needed; - Orders to crush medications should not be applied to medications which, if crushed, present a risk to the resident; - The instructions for crushing medications should be included on the resident's orders and the medication administration record (MAR) so that all personnel administering medications will be aware of this need; - Please consult with the product literature or Do Not Crush lists which the facility may have, or with the pharmacist, if a question about crushing medications . Record review of the of the facility's Oral Dosage Forms That Should Not Be Crushed list, dated February 21, 2020, showed: - Depakote and Depakote extended release (ER) (divalproex), a medication used to treat seizure disorders, certain psychiatric conditions, and to prevent migraine headaches, not to be crushed. 1. Record review of Resident #5's Physician Order Sheet (POS), dated June 2022, showed: - An order for divalproex delayed release sprinkle capsule, 125 milligrams (mg) by mouth three times a day, dated 4/13/22. Observation on 6/16/22 at 12:15 P.M., showed: - Certified Medication Technician (CMT) D crushed a divalproex 125 mg tablet; - CMT D placed the crushed medication in pudding and administered it to Resident #5; - CMT D failed to administer the correct form of the medication and crushed a medication not approved to be crushed. 2. Record review of Resident #10's POS, dated June 2022, showed: - An order for Tylenol Extra Strength, (medication used to relieve mild to moderate pain and to reduce fever) 500 mg, one tablet by mouth four times a day, dated 5/31/22. Observation on 6/16/22 at 12:35 P.M., showed: - CMT D administered Tylenol Extra Strength 500 mg, two tablets to Resident #10; - CMT D failed to administer the ordered medication dosage to Resident #10. 3. Record review of Resident #11's POS, dated June 2022, showed: -An order for Tylenol Extra Strength, 500 mg, one tablet by mouth four times a day, dated 11/5/20. Observation on 6/16/22 at 12:40 P.M., showed: - CMT D administered Tylenol Extra Strength 500 mg, two tablets, by mouth to Resident #11; - CMT D failed to administer the ordered medication dosage to Resident #11. 4. Record review of Resident #17's POS, dated June 2022, showed: - An order for Hydroxyzine, a medication used to relieve itching caused by allergic skin reactions and to relieve anxiety and tension, 10 mg, two tablets three times a day, dated 6/25/20. Observation on 6/16/22 at 12:48 P.M., showed: - CMT D administered a crushed Hydroxyzine 10 mg, one tablet given in pudding to Resident #17; - CMT D failed to administer the ordered medication dosage to Resident #17. During an interview on 6/16/22 at 12:15 P.M., CMT D said he/she has been working at this facility for 25 years, so he/she knows the residents and the facility well. During an interview on 6/17/22 at 3:03 P.M., the interim Director of Nursing (DON) said she has seasoned med techs and wouldn't expect to see medication errors.

Based on observation, interview, and record review, the facility failed to label and store medications in a safe and effective manner. This had the potential to affect all residents. The facility census was 35. Record review of the facility's Medication Storage policy, dated July 2021, showed: - Outdated, contaminated, or deteriorated medications and those in containers with cracks, soiled, or without secure closures will be immediately removed from the inventory, disposed of according to the procedures of the medication disposal, and reordered from the pharmacy if a current order exists; - Refrigerated medications will be kept in closed and labeled containers, with internal and external medications separated and separate from fruit juices, applesauce, and other foods used in administering medications; - Medications requiring refrigeration will be kept in a refrigerator at temperatures between 36 to 46 degrees Fahrenheit with a thermometer to allow temperature monitoring; - The facility should maintain a temperature log in the storage area to record temperatures at least once a day; - The facility should check the refrigerator or freezer in which vaccines are stored, at least two times a day, per the Center for Disease Control and Prevention (CDC) guidelines. Observation on 6/17/22 at 12:37 P.M., of the medication room refrigerator showed: - Eleven vials of Seqirus Afluria influenza vaccine with an expiration date of 5/26/22, which included one vial with an opened date of 10/24/21; - One opened vial of Aplisol (a solution used during a tuberculosis test) not labeled with an opened date; - An undated and unlabeled bowl of food covered with plastic wrap; - No documentation of the medication refrigerator temperatures located in the medication room. Record review of the manufacturer's recommendations for the Seqirus Afluria influenza vaccine showed: - The medication to be discarded 28 days after opened. Record review of the manufacturer's recommendations for the Aplisol showed: - The medication to be discarded 30 days after opened. During an interview on 6/17/22 at 12:37 P.M., Certified Medication Technician (CMT) D said there used to be a temperature log for the refrigerator, but it disappeared last week and he/she doesn't know where it went. During an interview on 6/17/22 at 12:30 P.M., Licensed Practical Nurse (LPN) A said the night nurse usually checks the expiration dates for medications. During an interview on 6/17/22 at 12:44 P.M., the interim Director of Nursing (DON) said she would expect there to be a refrigerator temperature log for each refrigerator in each medication room. During an interview on 6/21/22 at 4:08 P.M., the interim DON said she would expect the staff to check the expiration date before administering a medication.

Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These practices affected all residents. The facility census was 35. Record review of the facility's Food Temperature policy, dated 4/2006, showed: - To keep the temperature of hot foods no less than 140 degrees Fahrenheit (F) during tray assembly; - Hot foods should be at least 120 degrees F when served to the resident; - Take and record the temperatures for all items at all meals except for bacon, toast, pancakes, French toast, waffles and non-potential hazardous cold food items; - Do not cook or heat food in the steam table; - Heat food to the proper temperature by direct heat and then transfer to the steam table no more than 30 minutes before the meal service; - Place cold menu items, such as ham salad and egg salad, in the steam table over an ice bath with the well of the steam table turned off. Observations of the kitchen on 6/14/22 at 9:44 A.M. and 6/15/22 at 3:53 P.M., showed: - No 1/2 inch (in.) or greater air gap between the ice machine drain and the floor drain; - A buildup of black carbon material on the griddle portion of the stove; - The stock pots under the preparation table and steam table with grease buildup on them; - Seven large 15 x 18 x 1 inch in. sheet pans with a black buildup on the inside and outside corners; - The cold air return vent over the Traulsen refrigerator with a build up of grease and dirt; - The door to the walk-in freezer coated with ice approximately 1/2 to 3/4 in. thick; - The door to the walk-in freezer not able to close due to the ice buildup; - The floor in front of the True refrigerator with a sticky substance on it; - The floor of the dry storage area with dirt and food debris on it; - One 25 pound bag each of flour and sugar in a large bin, without a date when opened; - The large trash can with food and paper waste, by the dishwasher, remained uncovered; - A 4 x 16 in. area under the dishwasher preparation area without sheet rock or tile, exposing the outside wall; - A 4 x 4 in. area at the corner of the three compartment sink, next to the floor, without tile or sheet rock. Observation of the kitchen on 6/16/22 at 11:30 A.M., showed: - The air temperature in the kitchen to be 84 degrees; - The Dietary Manager grilled hamburgers outside on the grill and brought them into the kitchen; - [NAME] G took the temperature of the grilled hamburgers with the temperature of 140 degrees; - [NAME] G pureed nine hamburgers for the residents on a pureed diet; - The pureed hamburgers sat on the preparation counter until placed on the steam table at 11:38 A.M.; - At 11:39 A.M., [NAME] G removed an eight in. tall container of potato salad from the refrigerator and placed it in a three in. tall pan; - [NAME] G touched the hamburger buns with his/her bare hands as he/she placed the bread on the residents' plates; - [NAME] G touched his/her clothes with his/her bare hands and touched his/her face with the back of his/her hand; - At 12:12 P.M., [NAME] G made the first pureed plate for a resident; - [NAME] G did not take the temperature of the pureed hamburger to see if at the proper serving temperature before being served; - [NAME] G did not make sure all of the sides of the potato salad were in ice before serving the potato salad. During an interview on 6/16/22 at 11:15 A.M., the Dietary Manager (DM) said she did not check the temperature of the grilled hamburgers before she took them off of the grill. She had just cut into the patty to make sure there was no red meat and that the juices ran clear. She said she should have taken a thermometer outside and checked the temperature of the hamburgers before she took them off of the grill. During an interview on 6/17/22 at 11:45 A.M., the DM said staff should take the temperature of food on the steam table before the residents were served. Staff are not supposed to use their bare hands to handle/touch raw food. The staff should be using tongs to pick up raw food. During a telephone interview on 6/21/22 at 9:40 A.M., the DM said the ice machine should have a proper air gap between the ice machine drainage pipe and the floor drain. They have had trouble getting the walk-in freezer not to have ice build up on it and the door should close properly to maintain the proper temperature.

Based on observation, interview, and record review, the facility failed to maintain infection control practices for four sampled residents (Resident #24, #26, #36, and #138) and seven residents (Resident #3, #5, #9, #10, #17, #27, and #33) outside of the sample during medication administration when facility staff did not wash or sanitize their hands during the medication administration. The facility staff also failed to follow appropriate infection control practices when staff administered a medication to a resident (Resident #36) that fell on the floor. The facility's census was 35. Record review of the facility's Medication Administration policy, dated 7/2021, showed: - The person administering medications adheres to good hand hygiene, which includes washing hands thoroughly; - Hands should be washed before beginning a medication pass, prior to handling any medication, and after coming into direct contact with a resident; - Hand sanitization will be done with an approved sanitizer between hand washings, when returning to the medication cart or preparation area (assuming hands did not touch a resident or a potentially contaminated surface), and at regular intervals during the medication pass such as after each room, again assuming handwashing not indicated. 1. Observation on 6/16/22 between 12:13 P.M. and 1:02 P.M., showed: - Certified Medication Technician (CMT) D administered medications to Residents #3, #5, #9, #10, #17, #24, #26, #27, #33, #36, and #138; - CMT D did not wash or use hand sanitizer before or after the medication administration to each resident. 2. Observation on 6/16/22 at 12:49 P.M., showed: - CMT D administered Resident #36's medications to him/her; - CMT D handed the medication cup to the resident and the resident dropped a pill on the floor; - CMT D picked the pill up off of the floor and handed it to Resident #36, who swallowed the pill. During an interview on 6/16/22 at 12:15 P.M., CMT D said he/she has been working at this facility for 25 years, so he/she knows the residents and the facility well. During an interview on 6/17/22 at 8:10 A.M., Resident #36 said he/she dropped a pill, and CMT D picked it up and gave it to him/her and he/she swallowed it. Resident #36 said he/she was not afraid of a little dirt. During an interview on 6/17/22 at 3:06 P.M., the interim Director of Nursing (DON), said she would expect the CMT to dispose of a pill that was dropped on the floor and obtain a new one for the resident to take, even if the resident was ok with taking the pill that was dropped on the floor. She would also expect staff to perform hand hygiene prior to beginning and in between residents during the med pass.

Based on interview and record review, the facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day, seven days a week, and the facility failed to designate a RN to serve as the Director of Nursing (DON) on a full-time basis. This deficient practice had the potential to affect all residents residing in the facility. The facility census was 40. Record review of the nursing schedules, dated 6/1/22 through 6/6/22 and 6/9/22, showed: - No RN scheduled for eight consecutive hours for 6/2/22 through 6/6/22 and 6/9/22. During an interview on 6/15/22 at 2:39 P.M., the interim DON, a Licensed Practical Nurse (LPN), said the facility did not have a RN in the facility for eight consecutive hours on 6/2/22 through 6/6/22 and 6/9/22. She was aware the facility had to have a RN for eight consecutive hours, seven days a week. The Administrator, the Quality Assurance Nurse and the Corporate Nurse were aware the facility did not have a RN for eight consecutive hours. During an interview on 6/17/22 at 1:30 P.M., the Administrator said he was made aware of the facility not having a RN scheduled to work for eight consecutive hours at the beginning of June 2022. He contacted the corporate office regarding not having a RN in the facility. The previous DON, a RN, had resigned and walked out of the facility on 6/2/22. The facility did not provide a RN coverage or DON policy. Based on interview and record review, the facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day, seven days a week, and the facility failed to designate a RN to serve as the Director of Nursing (DON) on a full-time basis. This deficient practice had the potential to affect all residents residing in the facility. The facility census was 40. Record review of the nursing schedules, dated 6/18/22 through 8/12/22, showed: - No RN scheduled for eight consecutive hours for 6/20/22, 7/2/22,7/3/22, 7/7/22, 7/8/22, 7/10/22, 7/14/22, 7/16/22, 7/17/22, 8/1/22, 8/4/22, 8/5/22, 8/6/22, 8/7/22, 8/8/22, 8/11/22, and 8/12/22. During an interview on 8/12/22 at 12:00 P.M., the Administrator and the Bookkeeper said the facility did not have a RN in the facility for eight consecutive hours on 6/20/22, 7/2/22,7/3/22, 7/7/22, 7/8/22, 7/10/22, 7/14/22, 7/16/22, 7/17/22, 8/1/22, 8/4/22, 8/5/22, 8/6/22, 8/7/22, 8/8/22, 8/11/22, and 8/12/22. They were aware the facility had to have a RN for eight consecutive hours, seven days a week. The Quality Assurance (QA) Nurse and corporate were aware the facility did not have a RN for eight consecutive hours. They did have a Director of Nursing hired on 7/11/22, but she had already quit. Her last worked day was on 7/19/22. During an interview on 6/17/22 at 12:30 P.M., the Administrator said he contacted his Director of Operations and a RN was coming in to work today at 1:00 P.M., and would work the eight consecutive hours that was required. The QA nurse would be here on the on 8/13/22 and 8/14/22 to work the required eight hours. The RN coming in this afternoon, will start working eight hours a day, five days a week on 8/15/22. They will continue to pursue hiring a DON and additional RN's. The facility did not provide a RN coverage or DON policy.