Based on interview and record review, facility staff failed to ensure one resident (Resident #1) out of one sampled resident did not receive a chemical restraint (medications used to sedate or control behavior) as a convenience to treat behaviors. The facility census was 62. The administrator was notified on 04/04/25 of past Non-Compliance which occurred on 03/28/25. Staff immediately suspended Licensed Practical Nurse (LPN) A, assessed the resident for injuries, and notified the required parties and agencies. The administrator immediately in-serviced all staff on medication administration and abuse and neglect policies and procedures. The deficiency was corrected on 03/31/25. 1. Review of the facility's policy, Administering Medications, dated 03/07/22, showed medications ordered for a particular resident may not be administered to another resident, unless permitted by State law and facility policy, and approved by the Director Nursing Services. Review of the facility's policy, Policy on Restraints, 04/01/25, showed staff are directed as follows: -Residents have the right to be free from chemical and physical restraints; -Chemical Restraint involves using medication, including prescribed, as needed, or over-the-counter drugs, to control a patient's behavior or restrict their movement, when the medication is not a standard treatment for their condition; -In Missouri nursing homes, as part of the Nursing Home Reform Act, chemical restraints are only permissible to treat a resident's medical symptoms and not for convenience or discipline and such use of medication must be documented in the clinical record and ordered by the physician or practitioner. Review of the facility's Investigation Report, dated 03/31/25, showed LPN A admitted to administering 0.25 milliliters (ml) of Lorazepam (medication used to treat anxiety) solution on 03/28/25 to Resident #1 without a physician order or contacting the physician. Staff documented LPN A administered the medication to calm the resident. Review of LPN A's signed statement showed he/she documented the resident was yelling and keeping others awake, so he/she used his/her judgment to administer 0.25 ml of Lorazepam to calm the resident. Review of Resident #1's Five Day Scheduled Assessment Minimum Data Set (MDS), a federally mandated assessment tool, dated 03/21/25, showed staff assessed the resident as severely cognitively impaired. Review of the resident's Physician Order Summary (POS), dated 03/01/25 through 03/31/25, did not contain a physician order for Lorazepam 0.25 milligram/milliliter (mg/ml) oral concentration. During an interview on 04/01/25 at 9:51 A.M., LPN A said he/she heard Resident #1 yelling, checked on him/her, and an hour later, the resident was still yelling. LPN A said he/she administered a 0.25 dose of Lorazepam to the resident. He/She said the resident had a scheduled order for Lorazepam, but he/she gave the resident an additional dose. He/She took the medication from Resident #2. He/She said staff are directed to call the physician to get an order for a medication if a resident had behaviors. He/She did not contact the physician for an order because there was a sign in the facility, not to contact the physician after 7:00 P.M. unless it was an emergent situation. He/She took it upon himself/herself to administer the medication. He/She said nurses were not allowed to administer medications without a physician order. He/She did not document the administration of the Lorazepam in the resident's medical record. During an interview on 04/01/25 at 1:27 P.M., the Director of Nursing (DON) said staff are not allowed to administer medications due to behaviors without an order. He/She said staff were directed to contact the physician to obtain orders before administering medications to a resident without an order. He/She said it would be considered a chemical restraint to administer Lorazepam for behaviors. During an interview on 04/01/25 at 1:28 A.M., the administrator said administering medications to residents because of behaviors would be considered a chemical restraint. MO00252040

Based on observation, interview, and record review, facility staff failed to provide services to meet professional standards when staff failed to document the controlled substance administered for one resident (Resident #2) and failed to complete shiftly controlled drug counts on the memory care unit. The facility census was 62. 1. Review of the facility's policy, Narcotics Count Change of Shift Policy dated 01/04/23, showed staff are directed as follows: -Narcotics must be counted with the Nurse/Certified Medical Technician (CMT) at the change of shift. The Nurse/CMT must count the total number of cards/packages and note total on count sheet. Each card/package must be counted to ensure that the total number of narcotics is accurate and matches the total number of narcotics in the card/package. The Nurse/CMT arriving for their shift and leaving their shift must initial the change of shift count sheet; -If any discrepancies are noted at change of shift Nurse/CMT is to notify Director of Nursing (DON) or Nursing Management immediately. Review of Resident #2's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 03/02/25, showed staff assessed the resident as: -Severely cognitively impaired; -Diagnosis of anxiety; -Received an anti-anxiety medication. Review of the resident's Physician Order Sheets (POS), undated, showed a physician order for Lorazepam two milligram/milliliter (mg/ml) oral concentration administer 0.25/1 ml sublingually (underneath tongue) every four hours. Review of the resident's Lorazepam's Count form, dated 03/31/25, showed staff documented 10.50 ml Lorazepam remained. Observation on 04/01/25 at 11:16 A.M., showed the resident's Lorazepam bottle contained 8.50 ml in the bottle. Review of the facility's Controlled Substance Shift Change Form, dated 03/01/25 through 03/31/25, showed: -03/04/25-03/05/25, one staff signature for the 6:00 A.M. and 6:00 P.M. shift; -03/06/25, did not contain staff signatures for the 6:00 A.M. or 6:00 P.M. shift; -03/07/25, one staff signature for the 6:00 A.M. and 6:00 P.M. shift; -03/10/25, one staff signature for the 6:00 P.M. shift; -03/11/25, did not contain staff signatures for 6:00 A.M. shift; -03/12/25-03/14/25, did not contact staff signatures for the 6:00 A.M. or 6:00 P.M. shift; -03/15/25, one staff signature for the 6:00 A.M. and 6:00 P.M. shift; -03/16/25, did not contain staff signature for the 6:00 A.M. shift; -03/17/25, one staff signature for the 6:00 P.M. shift; -03/18/25, one staff signature for the 6:00 P.M. shift; -03/19/25, did not contain staff signatures for the 6:00 A.M. or 6:00 P.M. shift; -03/20/25, one staff signature for the 6:00 P.M. shift; -03/24/25, one staff signature for the 6:00 P.M. shift; -03/25/25, one staff signature for the 6:00 A.M. shift; -03/26/25, one staff signature for the 6:00 A.M., shift; -03/27/25 - 03/30/25, one staff signature for the 6:00 A.M. and 6:00 P.M. shift; -04/01/25, did not contain staff signatures for the 6:00 A.M. or 6:00 P.M. shift. During an interview on 04/01/25 at 10:10 A.M., CMT B said narcotic medications are counted each shift by two nurses. During an interview on 04/01/25 at 1:27 P.M., the DON said staff are directed to count narcotics at the end of the each shift or nurse change by two staff members. The DON said he/she was responsible to ensure the narcotic medications were counted and documented, but he/she had been busy with other responsibilities and was not told there was an issue. During an interview on 04/01/25 at 1:28 P.M., the administrator said two staff members should count the narcotic medications at the beginning and end of each shift and document they completed the task. MO00252040

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to develop and implement a comprehensive person-centered care plan for two residents (Resident #1 and #2) out of five sampled residents. The facility census was 64. 1. Review of facility's Care Planning Policy and Procedure policy, dated 01/17/24, showed facility staff are directed as follows: -The facility's standard is to perform quality of care that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices; -To ensure individualized completion of the care plan, and family/resident participation in the resident's plan of care with admission, quarterly, annual update, and if there is a significant change of condition; -A care plan will be developed upon admission per the Centers for Medicare and Medicaid Services (CMS) guidelines. It will be updated quarterly, and annually per CMS guidelines to ensure that there is a continuity of care, and is in accordance with the individual's needs. Care plan will also be updated with a significant change of condition; The care plan must be based upon the resident assessment, choices and advance directives, if any. As the resident's status changes, the facility, attending practitioner and the resident representative, to the extent possible, must review and/or revise care plan goals and treatment choices. 2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 01/04/25, showed staff assessed the resident as follows: -Moderate cognitive impairment; -Physical and verbal behavioral symptoms directed toward others occurred one to three days during the look back period; -Did not exhibit wandering behaviors during the look back period. Review of the resident's care plan, dated 09/18/24, showed it did not contain documentation the resident had behaviors of wandering or physical aggression towards other residents. Review of the facility's investigation report, dated 12/31/24, showed the resident wandered into another resident's room, yelled at another resident, then pulled the other resident's hair and hit him/her in the head. Review of the facility's investigation report, dated 01/22/25, showed the resident hit another resident in the arm multiple times. During an interview on 01/23/25 at 10:07 A.M., Certified Medical Technician (CMT) A said the resident had a history of wandering and aggression towards other resident's. He/She said he/she did review other resident's care plans, but did not review Resident #1's care plan yet. He/She said he/she was educated to redirect the resident. During an interview on 01/23/25 at 10:20 A.M., Certified Nurse Aide (CNA) B said the resident has a history of wandering and aggression towards other residents. He/She said staff are educated to redirect to watch a tv show or another activity. During an interview on 01/23/25 at 10:28 A.M., Licensed Practical Nurse (LPN) C said the resident did have a history of wandering and physical aggression towards others. He/She believed the interventions were listed in the resident's care plan. During an interview on 01/23/25 at 11:16 a.m., the Care Plan Coordinator said the resident did have physical aggression towards other residents and wandering. He/She said he/she did not add the interventions to the care plan, even though the resident had behaviors of wandering and physical aggression. He/She said he/she just added interventions to the resident care plan. 3. Review of Resident #2's Annual MDS, dated [DATE], showed staff assessed the resident as severely cognitively impaired and wandering behavior occurred four to six days during the look back period. Review of the resident's care plan, dated 10/16/24, showed it did not contain documentation the resident had behaviors of wandering or physical aggression towards other residents. Observation on 01/23/25 at 9:56 A.M., showed Resident #2 wandered into Resident #1's room laid in Resident #1 bed. Observation on 01/23/25 at 10:16 A.M., showed a staff member assisted Resident #2 out of Resident #1's room. During an interview on 01/23/25 at 10:20 A.M., CNA B said the resident did have a history of wandering and staff are educated to redirect the resident. During an interview on 01/23/25 at 10:07 A.M., CMT said the resident did have a history of wandering and staff were directed to redirect the resident. He/She said the purpose of the care plan was to provide care and safety measure for the resident. During an interview on 01/23/25 at 10:28 A.M., LPN C said staff are educated to redirect the resident if he/she was wandering or becoming aggressive. He/She said the resident had a history of wandering, but had not noticed the resident wandering into other resident's rooms. During an interview on 01/23/25 at 11:16 a.m., the Care Plan Coordinator said he/she did not know the resident wandered. He/She said staff meet daily to discuss resident behaviors or changes. 4. During an interview on 01/23/25 at 10:28 A.M., LPN C said he/she would expect to see behaviors of wandering or physical aggression towards others addressed in the care plan by the Care Plan Coordinator. During an interview on 01/23/25 at 11:16 a.m., the Care Plan Coordinator said he/she updated care plans quarterly, when a resident had a change and new interventions were added to the care plan. He/She said the purpose of the care plan was to provide staff with direction to they type of care the resident required. He/She said if a resident had behaviors, including wandering or aggressive behaviors towards other residents, it should be added to the care plan. During an interview on 01/29/25 at 11:27 A.M., the administrator said the Care Plan Coordinator was responsible to update the care plans. He/She said staff discuss changes in resident conditions daily during meetings. He/She said the purpose of the care plan was to provide staff with direction to meet the resident needs. He/She said if the care plans were correct, then the concern is the staff may not be able to provide person centered care. He/She said staff were conducting random audits, but not currently. He/She said behaviors of wandering and aggression towards other resident's should be addressed in the care plan. During an interview on 01/29/25 at 11:28 A.M., the Director of Nursing (DON) said the purpose of the care plan was to provide staff with direction to meet the resident needs. He/She said if the care plans were correct, then the concern is the staff may not be able to provide person-centered care. He/She said behaviors of wandering and aggression towards other resident's should be addressed in the care plan. He/She said the Care Plan Coordinator was responsible to update the care plans. He/She said staff discuss changes in resident conditions daily during meetings. He/She said staff were conducting random audits, but not currently. MO00248408

Based on interview and record review, facility staff failed to contact one resident's (Resident #4's) responsible party when the resident passed away at the facility. The facility census 67. 1. Review of the facilty's Discharge of a Resident due to death policy, undated, showed staff are instructed to notify the family or the responsible party. 2. Review of Resident #4's Entry Minimum Data Set (MDS), a federally mandated assesment tool, dated 9/21/24, showed staff assessed the resident as: -admitted to the facility 9/21/24; -Diagnosis of skin cancer of scalp and neck, liver cancer with bile duct involved, rectal cancer, and throat cancer; -Received hospice services. Review of the residents nurses notes, dated 9/26/24, showed staff documented the resident passed away at 8:02 A.M. Review showed the nurses note did not contain documentation staff contacted the next of kin or family for the resident. During an interview on 10/1/24 at 10:15 A.M., Licensed Practical Nurse (LPN) B said staff are expected to contact the resident's family, doctor, administrative staff, and the coroner when a resident passes. LPN B said he/she worked the day the resisdent passed and he/she had not contacted the family because it had slipped through the cracks. He/She later asked hospice to contact the family since he/she had not done so. During an interview on 10/1/24 at 10:23 A.M., the Director of Nursing (DON) said staff are expected to notify the family, hospice, the doctor, and coroner in the case a resident passes. During an interview on 10/1/24 at 11:40 A.M., the administrator said staff are expected to notify the doctor, the family, hospice, and furneral home of the resident's passing. During an interview on 10/3/24 at 11:00 A.M., the resident's next of kin said he/she was not not notified by the facility of his/her spouses' passing. He/She said he/she was notified by hospice hours after his/her passing. MO00242752

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to prevent the misappropriation of three resident's (Resident #1, Resident #2, and Resident #3's) narcotic medications when Licensed Practical Nurse (LPN) A took the medication without authorization of the residents or the residents' responsible parties. The facility census was 67. 1. Review of the facility's Abuse Policy and Procedures/Investigation Protocols, dated 12/14/18, showed the facility defined misappropriation as the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belonging or money without the resident's consent. 2. Review of the facility's investigation, dated 9/20/24, showed the ADON was notified LPN A displayed suspicious behavior on his/her shift. When the ADON arrived he/she observed the behaviors and issued LPN A a drug test with Human Resources (HR). The test was positive for oxycodone. The ADON notified the DON and performed a narcotic count with LPN C. During the count three narcotic log sheets with the cards could not be located on the medication cart. LPN A denied knowing what happened to the sheets or the medications. The ADON and LPN C found tops of the three medication cards and the cards in the trash with identified as Resident #1, #2, and #3. Staff called the police department. LPN A was arrested. Review showed staff were inservived on their controled drug policy and medication administration policies. Review of the police records, dated 9/20/24, showed the officer arrived to the facility at 6:12 A.M. and spoke to the ADON about the stolen narcotics. Review showed the office interviewed LPN A and LPN A said he/she used the record sheets to sign out medications for several patients but put the sheets back on the nursing station table where they belonged. LPN A said he/she did not steal any medications. Review showed the officer searched LPN A's vehicle and found several orange and white Oxycodone capsules opened, two straws with white residue, three cards with white powder residue, numerous narcotic record sheets from another nursing facility, and several medication packages for Oxycodone , Oxycotin (narcotic pain medication) and Hydrocone (narcotic pain medication). The officer placed LPN A under arrest. Review showed LPN A said he/she had the missing record sheets concealed in his/her pants. The officer retreived three missing record sheets from LPN A. LPN A told the officer he/she took five narcotic medications throughout his/her 12 hour shift the previous night. Review showed LPN A said most of the pills were Oxycodone and Hydrocodone. 4. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument, dated 7/23/24, showed staff assessed the resident as follows: -Cognitively intact; -Diagnosis unspecified pain; -Received scheduled pain management; -Received as needed pain medication; -Experienced pain frequently. Review of the resident's Physician's Order Sheet (POS), dated October 2024, showed an order for Oxycodone five milligrams (mg) take one tablet by mouth every six hours as needed for severe pain. Review of the narcotic log book showed it did not contain the narcotic log sheet for the Oxycodone. 5. Review of Resident #2's admission MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Diagnosis of arthritis in the bones of the left knee, and left knee pain; -Received scheduled pain management; -Received as needed pain medication; -Experienced pain occasionally. Review of the resident's POS, dated October 2024, showed an order for Hydrocodone 5/325 mg take one tablet by mouth every six hours as needed for pain, moderate to severe (4-10). Review of the narcotic log book showed it did not contain the narcotic log sheet for the Hydrocodone. 6. Review of Resident #3's admission MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Diagnosis of necrosis (death of body tissue) of amputation stump, right lower extremity; -Received scheduled pain management; -Received as needed pain medication; -Experienced pain almost constantly. Review of the resident's POS, dated October 2024, showed an order for Hydrocodone 5/325 mg take one tablet by mouth nightly and take one table by mouth as needed daily for dressing change. Review of the narcotic log book showed it did not contain the narcotic log sheet for the Hydrocodone. 7. During an interview on 10/1/24 at 10:23 A.M., the Director of Nursing (DON) said he/she was made aware by the ADON and Human Recourses of a possible narcotic diversion. He/She said LPN A was drug tested by the ADON and Human Resource and was found to be positive for Oxycodone. He/She did the narcotic count with the ADON upon arrival to the facility. He/She said he/she was unable to find three narcotic count sheets and and blister packs for three separate residents. He/She said they searched the trash and shred bin and found the tops of the medication cards without the blister packs. He/She said the police were called and LPN A was escorted off the property and taken to jail. During an interview on 10/1/24 at 10:36 A.M., The Human Resource employee said he/she was notified by the ADON of LPN A having odd behaviors on his/her shift. He/She said it's their policy to drug test under suspicion. He/She said LPN A tested positive for Oxycodone. The human resouce employee said he/she was a witness to the drug testing and stayed with LPN A until the police arrived. During an interview on 10/1/24 at 2:12 P.M., LPN C said he/she was orienting LPN A and was told to let him/her take the lead. He/She said LPN A was not signing narcotics out as they were given and started noticing LPN A disappearing for extended periods of time to the bathroom. His/Her eyes appeared red and glassy. LPN C said he/she notified the ADON of the suspicious behaviors between 5:00-6:00 A.M LPN C said he/she and the ADON did a narcotic count and noticed three cards missing along with the narcotic log sheets for residents #1, #2, and #3. During an interview on 10/1/24 at 2:24 P.M., the ADON said he/she was notified by LPN C around 5:00-6:00 A.M. LPN A was having suspicious behaviors. ADON said he/she arrived at the facility and watched LPN A do the last medication pass. He/She said LPN A's eyes were red, glassy and he/she was not making sense. ADON said he/she and the Human Resource employee completed a drug tested on LPN A and his/her test came back positive for Oxycodone. He/She asked LPN A if he/she had a script for the Oxycodone and he/she said no. ADON said he/she did a narcotic count with LPN C and there were three missing narcotic count sheets and three pill cards for Resident #1, #2, and #3. The ADON said LPN A could not tell him/her where the sheets or medications were at. He/She said the tops to the pill cards were later found in the shred bin and the cards were found empty in the trash. MO00242385

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to implement their Grievance Policy for two residents (Resident #7 and #25) out of 18 residents when reported missing items and failed to maintain evidence demonstrating the results of all grievances for a period of no less than three years. The facility census was 70. 1. Review of the facility's Grievance policy, dated 09/13/19, showed: -A grievance will be translated into writing, containing the name and address of the person filing it if permitted; -The administrator or his/her designee shall conduct an investigation of the complaint; -The Grievance official will complete a review of the grievance no later than 30 days after its filing. The Resident has the right to obtain a written decision regarding his/her grievance; -All written grievance decisions will include the date the grievance was received, a summary statement of the residents grievance, the steps taken to investigate the grievance, a summary of pertinent findings or conclusions regarding the resident's concerns, a statement as to whether the grievance was confirmed or not confirmed, and corrective active taken or to be taken by the facility as a results of the grievance, and the date the written decision was issued; -Maintain evidence demonstrating the result of all grievances for a period of no less than three years from the issuance of the grievance decision. Review of facility's grievance binder, showed the binder contained two grievance forms completed in 2024. 2. Review of Resident #7's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 05/19/24, showed staff assessed the resident as cognitively intact. Review of resident's medical record did not contain a inventory list for the resident's property. During an interview on 07/16/24 at 9:47 A.M., the resident said three weeks ago he/she had abluetooth ear bud set go missing from his/her room. He/She said he/she reported it to the administrator but never received an update. He/She said the facility has not replaced his/her bluetooth ear buds. During interview on 07/17/24 at 2:20 P.M., the administrator said that he did not know about the bluetooth ear bud set that was missing by the resident. 3. Review of Resident #25's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact. Review of resident's medical record did not contain a inventory list for the resdient's property. During an interview on 07/16/24 at 11:26 A.M., the resident said one month ago his/her cell phone went missing from his/her bedside table in his/her room. He/She said it was reported to the administrator and business office manager, but never received an update. He/She said the facility has not replaced his/her cell phone. During interview on 07/17/24 at 2:10 P.M., the Business Office Manager said the resident did report his/her phone missing. He/She said the facility has looked for it and it has not been found. He/She said he/she needs to talk with the administrator about what needs to be done next. During interview on 07/17/24 at 2:20 P.M., the administrator said the resident did report cell phone missing. He said the facility looked for it and the cell phone was not found. 4. During interview on 07/17/24 at 2:10 P.M., the Business Office Manager said when a resident reports something missing, he/she looks for the missing item. He/She said a grievance form is filled out and discussed with administrator what to do if unable to find missing item. He/She said he/she does not have any grievances from past years. He/She said the grievances he/she has is in the grievance binder. During an interview on 07/18/24 at 3:03 P.M., the Director of Nursing (DON) said if a resident reports something missing, a grievance form should be filled out and investigate the missing item. He/She said she expects the grievance form to be filled out within 24 hours of reporting to help keep track of grievance and to start investigating the missing item. During an interview on 07/18/24 at 3:38 P.M., the administrator said residents know to report missing items to him/herself or business office manager, a grievance form is filled out, and they investigate the missing item. He said the grievance form should be filled out as soon as possible once item is reported missing. He said if they are unable to locate missing item, they contact family to see if resident had the item or if they happened to take it with them, or if its money the facility will reimburse the resident. He said the grievance should be resolved as soon as possible. He said they try to resolve the grievance same day.

Based on observation, interview, and record review, facility staff failed to thoroughly investigate and document bruises of unknown origin for one resident (Resident #15) out of one sampled residents as directed by the facility policy. The facility census was 70. 1. Review of the facility's Abuse Policy and Procedures/Investigation Protocols, dated December 14, 2018, showed an injury of unknown source defined as not witnessed by any person and the source of the injury could not be explained by the resident, and the injury raises suspicions of possible abuse or neglect because of the extent of the injury or the location of the injury or the number of injuries observed at one particular point in time or the incidence of injuries over time. Review showed the charge nurse to complete the documentation, neurological flow sheet (if appropriate), notify the responsible party, medical directorm and clinical manager. Review showed staff are directed to: -Complete a Situation, Background, Assessment, Recommendation (SBAR) -Head to toe assessment; -Secure treatment orders if applicable/complete pain assessment; -Social Services intervention five times a week for two weeks, then reassess; -Residents on same assignment interviewed; -Staff Interviews; -72hr post incident observation; -Physical Therapy/Occupational Therapy (PT/OT) referral, if applicable; -Care plan review and revision, if applicable. 2. Review of Resident #15's Annual Minimum Data Set (MDS), a federally mandated assessment tool used by staff, dated 06/15/24, showed staff assessed the resident as follows: -Cognition intact; -Dependent on staff for toileting and lower body dressing; -Diagnoses of Hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) or Hemiparesis (one-sided muscle weakness), Stroke (Damage to the brain from interruption of its blood supply). -Uses wheelchair. Review of the resident's plan of care, dated 06/03/24, showed staff assessed the resident speech unclear, at risk for falls and has a history of falls. The resident's care plan did not contain documentaion of a fall or bruise. Review of the resident's medical record, showed the record did not contain documentation of the resident's bruises, or a facility investigation of the injury of unknown origin. Observation on 07/15/24 at 1:45 P.M., showed the resident in his/her wheelchair with a bruise on the right side of his/her forehead and on lateral right eye area. During an interview on 07/18/24 at 9:25 A.M., Certified Nursing Assistant (CNA) J said the resident had the bruises on his/her face on 07/11/24 when he/she gave him/her a shower. CNA J said we only document skin issues on shower sheets if it is new, but the nurse already knew about this bruise so he/she did not put it on the shower sheet. During an interview on 07/18/24 at 10:45 A.M., the Nurse Practitioner (NP) said he/she seen the resident last on 07/11/24 and the bruises were there and appeared fresh. The NP said he/she did not talk to staff after his/her visit and figured they already knew about the bruises as they were obvious and in plain sight. During an interview on 07/18/24 at 3:54 P.M., the Director of Nursing (DON) said he/she was not notified in a timely manner of the incident. The DON said after he/she found out about it, he/she was not sure where to go with it, so there was not a complete investigation done. The DON said he/she would expect the CNA to notify the charge nurse, who would then report to him/her. During an interview on 07/18/24 at 3:55 P.M., the Administrator said this would be considered an injury of unknown origin, and the expectation it to investigate and find out what happened. The administrator said it was not reported earlier, he just found out when he walked in on Monday. The Administrator said he would expect the CNA to report something like this to their charge nurse, then that charge nurse should tell me and DON about it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to maintain professional standards of practice when staff did not complete neurological assessments for for three residents (Resident #7, #21, and #36) out of 18 sampled residents after unwitnessed falls. The facility census was 70. 1. Review of the facility's policy titled, Neurological Assessments, undated, showed when resident has an incident with a head injury/trauma, or an unwitnessed fall, the nurse is the perform neurological assessment. Review showed the nurse is required to: -Document the results on the neurological assessment flow sheet in the resident's chart; -Complete checks-Every 15 minutes for one hour, every 30 minutes for the next two hours, and every shift until the 72 hours are completed; -Neurological checks consist of level of consciousness, pupil size, hand grasps, extremities, pain response, and vital signs; -All items above must be completed on each neurological check. 2. Review of Resident #7's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 05/19/24, showed staff assessed the resident as: -Cognitively intact; -One fall with no injury since last MDS. Review of the resident's medical record showed staff documented the resident had an unwitnessed fall on 05/06/24. Review showed the medical record did not contain neurological checks as directed in the facility policy. 3. Review of Resident #21's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -One fall with major injury since last MDS. Review of the resident's medical record showed staff documented the resident had an unwitnessed fall on 06/26/24. Review showed the medical record did not contain neurological checks as directed in the facility policy. 4. Review of Resident #36's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Moderate cognitive impairment; -One fall with no injury since last MDS -Dependent with bed-to-chair transfer and bed mobility. Review of the resident's medical record showed staff documented the resident had an unwitnessed fall on 04/24/24. Review showed the medical record did not contain neurological checks as directed in the facility policy. 5. During an interview on 07/18/24 at 2:42 P.M., Licensed Practical Nurse (LPN) A said with unwitnessed falls, the nurse should do a full skin assessment and vitals. He/She said a neurological exam should be completed for unwitnessed falls or if resident hits their head. During an interview on 07/18/24 at 3:06 P.M., the Director of Nursing (DON) said after an unwitnessed fall he/she expects neurological checks to be done for first 72 hours and an incident report to be completed. During an interview on 07/18/24 at 3:38 P.M., the administrator said for unwitnessed falls, he/she expects the nurse to complete an incident report, monitor the resident, and complete neurological checks for 72 hours.

Based on observation, interview, and record review, facility staff failed to store and label medications in a safe and effective manner when staff failed to date the open multi-dose medication bottles, and placed non-medication in medication storage room refrigerator. The facility census was 70. 1. Review of the facility's Storage of Medication policy, undated, showed facility staff are directed as follows: -The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner; -Medications require refrigeration must be store in a refrigerator located in the drug room at the nurses' station or other secured location. -Medications must be stored separately from food and must be labeled accordingly. Review of the facility's Administering Medications policy, dated 03/07/22, showed the facility staff are directed to record the open date on the container when opening a multi-dose medication container. 2. Observation on 07/15/24 at 9:30 A.M., showed the west wing medication cart contained: -One opened bottle of vegetable laxative, undated; -One opened bottle of diphenhydramine, undated and without a lid; -One opened bottle of ibuprofen, undated; -One opened bottle of calcium, undated; -One opened bottle of milk of magnesia, undated. 3. Observation on 07/15/24 at 9:50 A.M., showed the [NAME] wing medication storage room contained: -One opened bottle of dietary supplement, undated; -One opened bottle of Vitamin D3, undated. 4. Observation on 07/15/24 at 9:50 A.M., showed the medication refrigerator in [NAME] wing medication storage room contained: -One to-go container containing a cinnamon roll; -Two sandwiches; -One leftover box of pizza; -One container of butter; -One soda, -One bottle of chipotle ranch; -One bottle of lime juice; -One box of leftovers; -One cup of coffee. During an interview on 07/15/24 at 9:40 A.M., certified medication technician (CMT) C said he/she usually labels the lid of the medication bottle when he/she opens it. He/She said the CMT on the medication cart is responsible for maintaining the medication cart, labeling medications when opened, and help maintain medication storage rooms. During an interview on 07/15/24 at10:05 A.M., licensed practical nurse (LPN) A said the person on the medication cart is responsible for maintaining it for that shift. He/She expects staff to label and date bottles as they are opened. He/She said he/she is not sure what the policy is on the medication storage room refrigerator containing food in the same refrigerator as the medications. He/She said that fridge always ends up with food in it due to the staff refrigerator being full and staff not having a place to put resident food and leftovers. During an interview on 07/18/24 at 3:01 P.M., the Director of Nursing (DON) said it is the responsibility of the nurse or CMT who is on the medication cart, to maintain it. He/She said he/she also does monthly audits of the medication carts. He/She said staff should be going over the carts at change of shift and signing off that they are good. He/She said he/she expects staff to label medications with an open date when they first open the bottle. He/She was not aware staff were not labeling the medications when opening them. He/She said it is his/her expectation that food is not kept in the same refrigerator as medications. He/She was aware there was an issue. He/She said he/she has cleaned out the fridge and staff keep refilling it. He/She said he/she has been looking for a solution. During an interview on 07/18/24 at 3:36 P.M., the administrator said it is his/her expectation that charge nurses, CMT's, should maintain the medication carts and the assistant director of nursing (ADON), and the DON should oversee them to ensure it is done. He/She said the nurses and CMT's should be checking medication carts daily per shift and the DON and ADON should be checking them weekly. He/She said he/she is not sure what the policy is for labeling mediations once they are opened.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, facility staff failed to review and revise the care plan after a fall for five (Resident #13, #21, #36, #44, and #52) out of eighteen sampled residents. Facility staff failed to document and update care plans in regard to pressure ulcers for two (Resident #5 and #44) out of seven sampled residents. Staff failed to address and update behaviors for one (Resident #4) of one sampled resident. The facility census was 70. 1. Review of the facility's Miniumin Date Set (MDS) Policy, undated, showed the care plans will be updated quarterly and with changes to the resident plan of care. Changes made to the care will be communicated to the interdisciplinary team. The staff member completing the care are assessment for the specified section will also compete the comprehensive care plan on the resident. 2. Review of the Resident #13's Quarterly MDS, a federally mandated assessment tool, dated 05/02/24, showed staff assessed the resident as: -Moderate cognitive impairment; -One fall since admission with injury; -Diagnosis of Quadriplegia (paralysis affects the body from the neck down. Can result in partial or total loss of function in the arms, legs, trunk, and pelvis). Review of the resident's medical record showed staff documented the resident fell on 6/11/24 in the dining room, resident was positioned straight up from eating and slid out of chair. Review of the resident's care plan, dated 06/18/24, showed the care plan did not contain documentation of the resident's fall on 6/11/24 or updated fall interventions. 3. Review of Resident #21's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -One fall with major injury since last MDS. Review of the resident's medical record, showed staff documented the resident fell on [DATE] in his/her room while ambulating to the bathroom and fractured his/her left arm. Review of resident's care plan, dated 07/01/24, showed the care plan did not contain documentation of the resident's fall on 06/26/24 or updated fall interventions. 4. Review of Resident #36's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Moderate cognitive impairment; -One fall with no injury since last MDS -Dependent with bed-to-chair transfer and bed mobility. Review of resident's medical record showed staff documented the resident fell on [DATE] in his/her room next to his/her bed. Review of resident's care plan, dated 07/01/24, showed the care plan did not contain documentation of the resident's fall on 04/24/24 or updated fall interventions. 5. Review of the Resident #44's Significant Chanage MDS, dated [DATE], showed staff assessed the resident as: -Moderate cognitive impairment; -Documentation two falls since admission with injury; -Documentation of one stage 3 pressure ulcer, a diabetic foot ulcer, and other open lesions on foot; -Diagnosis of Alzheimer Disease, dementia, Peripheral vascular disease (is a slow and progressive disorder of the blood vessels) and Diabetes mellitus. Review of resident's medical record, showed a fall on 07/04/24 in his/her room, resulting in a hematoma to the left side of his/her face. -The resident had a stage III pressure ulcer on right ischium. Review of resident's care plan, dated 07/09/24, showed the plan did not contain the following: -Documentation of the resident's fall on 07/04/24 or updated fall interventions; -Documentation of the resident's stage III pressure ulcer on the right ischium (lower buttock) or interventions. 6. Review of Resident #52's admission MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -No falls since last MDS; -Dependent for sit to stand and bed-to-chair transfers. Review of resident's medical record, showed the resident suffered a fall on 07/06/24 out of his/her wheelchair landing on his/her face and right side. Review of resident's care plan, dated 05/31/24, showed the care plan did not contain documentation of the resident's fall on 07/06/24 or updated fall interventions. 7. Review of Resident #5's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Documentation of a stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon, or muscle) and other open lesion on foot; -Diagnosis of diabetes mellitus. Review of resident's medical record showed staff documented the resident had a Stage IV pressure ulcer on right heal. Review of resident's care plan, dated 05/31/24, showed the plan did not contain documentation of the resident's Stage IV pressure ulcer or interventions. 8. Review of the Resident #4's Annual MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -One physical behavior directed toward others; -Two verbal behaviors directed toward others; -One behavioral symptom not directed toward others; -Wandering daily; -Behaviors worse than previous review; -Diagnosis of Alzheimer's, dementia, anxiety, depression, and traumatic brain injury. Review of resident's medical record showed staff documented a resident to resident altercation on 06/22/24, in the diningroom. Review of resident's care plan, dated 06/17/24, showed the care plan did not contain documentation on how to care for the resident's behaviors. During an interview on 07/18/24 at 10:38 A.M., Certified nurse aide (CNA) H said the resident is an emotional person with behaviors daily. He/She said the resident will often swat at staff during care and is easily frustrated. He/She said he/she is not an aggressive person, that handling him/her is all in the approach. He/She said he/she rarely has issues with the resident because he/she knows how to redirect him/her. During an interview on 07/18/24 at 11:12 A.M., CNA I said did not received education after the resident altercation. He/She said the resident is easily agitated, but always easily redirected. He/She said the resident gets very emotional, at times likes to be in peoples faces and can get frustrated if others don't want to be near him/her. During an interview on 07/18/24 at 11:21 A.M., licensed practical nurse (LPN) E said he/she was not aware the resident had an altercation with another resident and did not receive education regarding interventions. He/She said the resident can be emotional, easily agitated, and often refuses to sleep. He/She said the resident is easily redirected. During an interview on 07/18/24 at 3:01 P.M., the Director of Nursing (DON) said he/she it is the Care Plan Coordinators responsibility to update the care plans as needed with interventions and resident specific care. She would expect the residents frequent behaviors to be addressed on the care plan with interventions. 9. During an interview on 07/17/24 at 3:21 P.M., LPN G said he/she is responsible for care plans. The LPN said they took over the job in May of 2024, but there had not been a care plan coordinator since 2023. The LPN said resident information is shared in morning meeting or it can be placed in their box. LPN G said the care plan should be updated as needed with interventions, change in conditions and care information as soon as possible. During an interview on 07/18/24 at 3:54 P.M., the DON said gathered information, goals, and interventions are all included in the care plan. The The DON said he/she would expect any issues, changes in condition, medication changes, behaviors, wounds and falls with interventions to be updated in the care plan as needed. During an interview on 07/18/24 at 3:55 P.M., the Administrator said the expectation is the care plan to be updated as things come up and for resident's needs. The administrator said it is the Care Plan Coordinators responsibility to update the care plans as needed, he said he is not sure how quickly care plans should be updated after a change with the resident.

Based on interview and record review, the facility staff failed to provide staff in accordance with their Facility Assessment based on the care needs of their residents. The facility census was 70. 1. Review of the Facility Assessment, dated 04/10/24, showed facility staff documented the staffing requirements needed on a 24-hour basis to meet the needs of their residents for an average census of 70-80 are as follows: -West Unit: Registered Nurse (RN) or Licensed practical nurse: 1 for each shift; -East Unit: Registered Nurse (RN) or Licensed practical nurse: 1 for each shift. 2. Review of the facility night shift staff schedule for the west and east area of the facility, dated 04/20/24 through 04/30/24, showed the facility scheduled only one LPN and did not have an addition LPN or RN to staff the west and east location from 04/06/24-04/30/24 as directed in the facility assessment. 3. Review of the facility night shift staff schedule west and east area of the facility, dated 05/01/24 through 05/31/24, showed the facility scheduled only one LPN and did not have an addition LPN or RN to staff the west and east location from 05/01/24, 05/02/24, 05/05/24- 05/09/24, 05/11/24, 05/12/24, 05/14/24- 05/31/24 as directed in the facility assessment. 4. Review of the facility night shift staff schedule the west and east area of the facility, dated 06/01/24 through 06/30/24, showed the facility scheduled only one LPN and did not have an addition LPN or RN to staff the west and east location from 06/01/24 -06/03/24, 06/06/24, 06/08/24-06/30/24 as directed in the facility assessment. 5. Review of the facility night shift staff schedule the west and east area of the facility, dated 07/01/24 through 07/18/24, showed the facility scheduled only one LPN and did not have an addition LPN or RN to staff the west and east location from 07/01/24-07/04/24 and 07/15/24-07/18/24 as directed in the facility assessment. 6. During an interview on 07/18/24 at 1:20 P.M., the Director of Nursing (DON) said the facility always has a licensed nurse scheduled at each shift but not always two. He/She said he/she questioned it when he/she first started because he/she was not sure of the guidelines. He/She said he/she was not aware the facility assessment says they should have two licensed nurses at night. During an interview on 07/18/24 at 2:18 P.M., the administrator said the facility always has a licensed nurse in the building, just not two. He was not aware the facility assessment said he/her needed two licensed nurses per unit, per shift.

Based on interview and record review, facility staff failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours per day, seven days a week. The facility census was 70. 1. Review of the facility's Resident Services Policy, dated March 27, 2017, showed the facility provides sufficiant licensed nursing and ancillary services 24 hours a day, including a registered nurse for at least 8 consecutive hours daily. 2. Review of the facility's RN staff schedule, dated June 2024, showed the facility did not have an RN in the building on: -06/01/24; -06/02/34; -06/08/24; -06/09/24; -06/15/24; -06/16/24; -06/22/24; -06/23/24; -06/29/24; -06/30/24. 3. Review of the facility's RN staff schedule, dated July 2024, showed the facility did not have an RN in the building on 07/06/24 and 07/07/24. 4. During an interview on 07/16/24 at 6:50 A.M., RN F said he/she is the certified nurse aide (CNA) instructor for the facility. RN F said, I am here every day, because I am the only RN on staff right now other then the DON, and I work Monday thru Friday. During an interview on 07/18/24 at 1:20 P.M., the Director of Nursing (DON) said the facility currently is short two RN positions. He/She said they do not have a full time RN to work weekends and their CNA instructor is working as their RN through the week. During an interview on 07/18/24 at 2:18 P.M., the administrator said he/she is trying to hire an RN. He/She said he/she currently doesn't have an RN scheduled every weekend and the DON and CNA instructor are the RN's who cover the eight hour shifts during the week.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility staff failed to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (LD- a serious type of pneumonia (lung infection) caused by Legionella bacteria. Facility staff failured to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's water systems has the potential for the failure of staff to identify and mitigate the presence of waterborne pathogens, which places all residents of the facility at risk of exposure which could lead to illness. Facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to use a barrier when performing blood sugars for three (Resident #42, #51, and #53) of four sampled residents. The facility census was 70. 1. Review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification (S&C) letter 17-30, dated 06/02/17 and revised on 06/09/17, showed: -The bacterium Legionella can cause a serious type of pneumonia called LD in persons at risk. Those at risk include persons who are at least [AGE] years old, smokers, or those with underlying medical conditions such as chronic lung disease or immunosuppression. Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including hospitals and long-term care facilities. Transmission can occur via aerosols from devices such as shower heads, cooking towers, hot tubs, and decorative fountains; -Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water; -CMS expects Medicare certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. An industry standard calling for the development and implementation of water management programs in large or complex building water systems to reduce the risk of legionellosis was published in 2015 by American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE). In 2016, the Centers for Disease Control and Prevention (CDC) and its partners developed a toolkit to facilitate implementation of this ASHRAE Standard (https://www.cdc.gov/legionella/maintenance/wmp-toolkit.html). Environmental, clinical, and epidemiological considerations for healthcare facilities are described in this toolkit; -Surveyors will review policies, procedures, and reports documenting water management implementation results to verify that facilities: -Conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system; -Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens; -Specify testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained. Review of the facility's Water Management Program - Legionella, undated, showed the members of the committee will ensure the inspections of the identified areas where Legionella could grow are completed and the results are within regulatory guidelines. Maintenance will ensure the areas where Legionella could grow in the equipment are inspected, cleaned and free of bacteria. Logs will be kept in the maintenance shed. Review showed the plan indicated the facility's water flow comes from the city. Water enters the building from the water main at the street level through the building's main line. Review showed the plan did not contain a description of the building water system using text or a flow diagram. Review of the plan showed water heaters, eye wash stations, faucets, flow restrictors, whirlpool tubs, water fountains and pipes/valves/fittings were identified as areas where Legionella could grow. Review showed the control measures for water heaters were visual inspection and maintaining proper temperatures. Review showed the plan did not include a description of the visual inspection or a temperature range. Review showed the plan did not contain control measures or interventions for the additional identified areas. Review of the plan showed maintenance logs and routine maintenance for equipment such as water heaters, ice machines, backflow preventers, etc. can be found with the maintenance director. Theses logs are kept up to date and filed in the maintenance office. Review showed the maintenance records did not contain water management program documentation. During an interview on 07/18/24 at 12:20 P.M., the maintenance director said he/she flushes the water heaters for 30 seconds every month. The maintenance director said he/she checks the eyewash station tags and performs a brief function check every month, but he/she had never deep cleaned or flushed the eye wash stations. The maintenance director said housekeeping staff cleaned the water fountains and flushed toilets and sinks. The maintenance director said the shower aides cleaned and sanitized the whirlpools. During an interview on 07/18/24 at 8:00 A.M., the administrator said he/she was not familiar with the CDC Toolkit or the requirement for a water system flow diagram, control measures or specific corrective actions to be taken if control measures were out of range. X. Review of the facility's policy titled, Blood Glucose Monitoring, revised 04/19/23, showed staff are directed to place glucometers on clean surfaces. Review of the facility's policy titled, Infection Prevention and Control Program, undated, showed equipment or items in the resident environment likely to have been contaminated with infectious fluids or other potentially infectious matter must be handled in a manner so as to prevent transmission of infectious agents (e.g. wear gloves for handling soiled equipment and properly clean and disinfect or sterilize reusable equipment before use on another resident). X. Observation on 07/17/24 at 11:47 A.M., showed Licensed Practical Nurse (LPN) D entered Resident #42's room to perform a blood sugar check on the resident. LPN D placed the glucometer on the resident's bedside table without a barrier and prepped the resident for the blood sugar test. LPN D tested the resident's blood sugar and placed the glucometer on the bedside table. LPN D removed the glucometer and placed it on the top of the medication cart without a barrier before he/she removed his/her gloves and performed hand hygiene. LPN D replaced his/her gloves and cleaned the glucometer with a wipe before placing the clean glucometer back on the medication cart without a barrier. X. Observation on 07/17/24 at 11:30 A.M., showed LPN D entered the dining room to perform a blood sugar check on Resident #51. LPN D placed the glucometer on the dining room table without a barrier as he/she prepped the resident for the blood sugar test. LPN D tested the resident's blood sugar and placed the glucometer on the dining room table. LPN D removed the glucometer and placed it on the top of the medication cart without a barrier before he/she removed his/her gloves and performed hand hygiene. LPN D replaced his/her gloves and cleaned the glucometer with a wipe before placing the clean glucometer back on the medication cart without a barrier. X. Observation on 07/17/24 at 11:38 A.M., showed LPN D performed Resident #53's blood sugar check in the East wing hallway and placed the glucometer on the medication cart without a barrier. LPN D cleaned the glucometer and then placed it back on the medication cart without a barrier. X. During an interview on 07/18/24 at 3:01 P.M., the Director of Nursing (DON) said it is his/her expectation that staff do not place glucometers on dining room tables, bedside tables, or medication carts that are not sanitized. He/She said placing used glucometers on tables presents a risk for transmitting blood born pathogens or bacteria. He/She was not aware nursing staff were placing glucometers on these surfaces without a barrier. During an interview on 07/18/24 at 3:36 P.M., the administrator said it is his/her expectation staff do not place glucometers on any surface without a barrier because it is not sanitary. He/She said he/she was not aware staff were not using a barrier. During in interview on 07/26/24 at 3:52 P.M., LPN D said staff should use a barrier before placing the glucometer on surfaces. He/She said it is an infection control concern. He/She said he/she did not use a barrier because he/she did not have one at the time.

Based on interview and record review, facility staff failed to designate one or more individuals with specialized training in Infection Prevention and Control (IPC) as the Infection Preventionist for the facility's infection prevention and control program. The facility census was 70. 1. Review of the facility policies showed staff did not provide a policy for specialized training for the Infection Preventionist. During an interview on 07/18/24 at 3:50 P.M., the administrator said the Assistant Director of Nursing (ADON) is the facility's Infection Preventionist. He said the ADON started the required classes sometime last month, but he is not sure how much longer she/he has. The administrator said he was aware the training and certification needed to be completed before given the position or title of Infection Preventionist. During an interview on 07/23/24 at 10:15 A.M., the ADON said he/she was not aware he/she was the actual Infection Preventionist (IP) yet, due to he/she is enrolled in the Centers for Disease Control and Prevention Infection Preventionist training but is not certified. He/She said they are only about halfway through the modules. The ADON said he/she was aware the certification needed to be completed before they assumed that title of Infection Preventionist.

Based on observation, interview, and record review, facility staff failed to maintain personal medical information in a manner to protect three residents' privacy (Residents #1, Resident #2, Resident #3). The facility census was 77. 1. Review of the facility's Resident Confidentiality/Health Insurance Portability and Accountability Act (HIPPA), undated, showed the care of the patient is always personal in nature, and therefore any protected health information about his/her condition, treatment or personal data is absolutely confidential and must not be discussed with anyone other than those who are directly responsible for his/her care and treatment. Information generated through contact between patient and health care provides at the facility is privileged and confidential. This privilege extends to all form and formats in which the information is maintained and stored, including, but not limited to verbal, written and/or electronic forms; Review of the facility's Administering Medications Policy, revised December 2012, showed the medication cart and/or Medication Administration Record (MAR) must be clearly visible to the personnel administering medications, and must be inaccessible to residents or others passing by. 2. Observation on 2/28/24 at 9:57 A.M., showed Certified Medication Technician (CMT) A prepared Resident #1's medication and entered his/her room to administer medication. Observation showed the resident's Electronic Health Record (EHR) open and visible to residents and visitors. 3. Observation on 2/28/24 at 10:04 A.M., showed CMT A prepared Resident #2's medication. Observation showed the CMT left the cart to retrieve a blood pressure cuff from the nurse's station. Observation showed the resident's EHR open and visible to residents and visitors. CMT A returned to the cart and retrieved the resident's medications and entered his/her room to administer the medication. Observation showed the resident's EHR open and visible to residents and visitors. 4. Observation on 2/28/24 at 10:50 A.M. and 11:08 A.M., showed the medication cart unattended at the nurses station. Observation showed Resident #3's EHR open and visible to residents and visitors. 5. During an interview on 2/28/23 at 11:10 A.M., the assistant director of nursing (ADON) said staff are supposed to close the screen or put a lock on it to cover patients' information when leaving the medication cart. He/She said it is important we follow HIPPA rules and regulations to protect resident information and to ensure staff are charting under the correct name for accuracy. He/he does not know why this would not be getting done. During an interview on 2/28/24 at 4:45 P.M., CMT A he/she has a habit of leaving EHR records up and is trying to work on it because he/she knows it is important to protect resident's information. He/She said it is an oversight on his/her part because he/she only leaves for a minute or two and will come right back. During an interview on 3/5/24 at 3:20 P.M., the administrator said staff are instructed lock browser or close screen when not physically at the medication cart because HIPPA information is not meant to be shared with everyone. He/She does not know EHR are not being locked. MO00232230

Based on interview and record review, facility staff failed to follow professional standards when they failed to destroy narcotics with two staff present according to policy for one resident (Resident #4), failed to maintain documentation of a controlled substance destruction sheet for one resident (Resident #5), and failed to remove medications as directed from the ISTAT. The facility census was 77. 1. Review of the facility's Controlled Substances policy, revised October 2014, showed staff are to document the disposal on the medication disposition record, (the medication disposition record will contain the following information: method of disposition, reason for disposition and signature of witnesses). Review showed the documentation should include the signature(s) of at least two witnesses. Review showed disposal of controlled substances must take place immediately (no longer than three days) after discontinuation of use by the resident and completed medication disposition records shall be kept on file in the facility for at least two years or as mandated by state law governing the retention and storage of such records. Review of an inservice education form, dated 8/1/2023, showed due to the number of changing orders and discontinued orders, narcotics are no longer going to be the Director of Nursing's (DON) responsibility. Review showed any non narcotic medications are to be sent back to the pharmacy for destruction. Review showed the Assistant Director of Nursing (ADON) will be in charge of monitoring and auditing the medication carts and destroying medications on the spot with a nurse or Certified Medication Technician (CMT) to witness. Review showed medications are not to be destroyed unless two nurses destroy them or a nurse and a med tech destroy them together. Review showed the DON signed the inservice education form. Review of the Controlled Substance Card tracking form, dated February 2024, showed on 2/16/24 at 6:00 P.M., one card of 30 Oxycodone for Resident #1 was signed out on behalf of the Director of Nursing (DON) for destruction. Review of Resident #4's Individual Controlled Substances record, showed staff documented on 09/05/23 teh facility received 30 Oxycodone tablets 5 milligrams (mg) with an expiration date of 9/4/24. Review showed the DON documented he/she wasted 30 tablets on 2/16/24. Review showed the record did not contain the method of disposition, the reason for disposition and failed to obtain a second signature as a witness for disposition. During an interview on 2/28/24 at 11:02 A.M., the ADON said the facility has a new policy, effective August of 2023, the DON is no longer in charge of narcotics because there were multiple complaints and concerns with the DON and his/her handling of narcotics. He/She said on 2/19/24 he/she was checking the narcotics from the weekend and saw a card of Oxycodone had been pulled from the narcotics cart and was destroyed by the DON, when he/she asked the DON for the individual controlled substances records the DON could not provide it. He/She then asked CMT C, who signed the card out on behalf of the DON if he/she helped destroy the medications and CMT C said the DON declined because he/she said it had to be two nurses, he/she said he/she came to the DON's office with the card and the drug buster to destroy them. The DON later brought the individual controlled substance record to the him/her with only his/her signature and said he/she and Registered Nurse (RN) B destroyed them together but RN B forgot to sign the sheet. He/She said the DON came in and tried to get him/her to sign the sheet because he/she was worried RN B might not remember he/she signed it. He/She said he/she called to verify with RN B and he/she said he/she never destroyed those medications and was never asked too. He/She turned the discrepancy into the administrator. During an interview on 3/5/24 at 3:39 P.M., RN B said he/she did not destroy a medication with the DON on 2/16/24. He/She said the DON never asked him/her to destroy any medications with him/her and is not sure why she told people that he/she did. He/She said there have been issues with narcotics being discontinued and destroyed without witnesses and narcotic cards found in the DON's office and purse in the past and that is when the ADON start taking over narcotics. During an interview on 3/5/24 at 3:40 CMT C said he/she was working on 2/16/24 and was conducting her evening medication pass when the DON started going through resident's narcotics. He/She said a specific card had not been used and it needed to be destroyed. He/She said he/she signed the card out on behalf of the DON because he/she asked and took the card and the drug buster to his/her office to properly destroy the medications. He/She said the DON declined to destroy the medications with him/her because he/she is not a nurse. He/She offered to grab a few other nurses but the DON declined and said he/she would just wait until 2/19/24 to destroy with the ADON. He/She said he/she knows that the DON is not allowed to handle narcotics because they had been educated on that in that past but the DON fires people who question him/her about narcotics and he/she could not afford to lose his/her job. He/She left the narcotics with the DON and before he/she could report to the ADON about the situation the ADON questioned him/her. During an interview on 3/18/24 at 11:04 P.M., the DON said the incident took place late on 2/16/24, he/she was checking the narcotic box and realized a resident hadn't used his/her narcotics in a timely manner. He/She said he/she asked CMT C to bring him/her the narcotics in his/her office, he/she said he/she did not destroy medications with the CMT because he/she thought he/she needed another nurse. He/She said he/she destroyed the narcotics with RN B and does not know why he/she said he/she did not destroy the narcotics. He/She said he/she did not notice RN B did not sign off on the medication destruction sheet until later and denies asking any other nurse to sign off on the destruction sheet, after the fact. He/She said he/she is not supposed to be involved in narcotics because of the bullshit lies and high school drama about him/her being addicted to narcotics but he/she was trying to get his/her ducks in a row before going on medical leave. 2. Review of Resident #5's Controlled Substance Card tracking form, dated June 2024, showed on 7/27/23 at 10:00 A.M., one card of Hydrocodone was signed out by the DON. Review of the Individual controlled substances record destruction book for 2023-2024, showed the book did not contain a distruction sheet for the resident's card of hydrocodone. During an interview on 2/28/24 at 1:15 P.M., Resident #2's family member said his/her parent was a resident at the facility in June 2023. He/She had spoke to the DON and wanted to decline the Hydrocodone prescribed for his/her parent unless his/her other medications were not effective. He/She said the DON said he/she would pull the card and he/she said no, he/she can have them just on a last resort basis. He/She said the next day his/her parent decided to go home and the hydrocodone's were no longer in the narcotic box and had been signed out by the DON. He/She said the hydrocodone's were no longer present because they had been discontinued. During an interview on 3/18/24 at 11:04 P.M., the DON said another nurse had reported the hydrocodone was found in his/her office but he/she wasted the narcotics and there should be a destruct sheet on them, kept on file for five years. He/She could not remember who he/she wasted the narcotics with. 3. Observation on 2/28/24 at 10:18 A.M., showed the medication cart contained two medication cups with various pills with handwritten last names on the cups. The cups did not contain names of the medication in the cups. During an interview on 2/8/24 at 10:18 A.M., CMT A said he/she got all the medications out of the ISTAT at one time he/she needed for her 12 hour shift to save him/her time and because he/she heard that it cost money every time the ISTAT is opened. During an interview on 2/28/24 at 11:02 A.M., the ADON said it is not acceptable to prepop medications for later administration because a resident could receive the wrong medication, he/she said it might be happening to save time and because they are told it cost money to open the ISTAT. During an interview on 3/5/24 at 3:20 P.M., the administrator said staff are not permitted to pre-pop medications because it leaves too much room for error. Staff should immediately gather medications and administer them right away even from the ISTAT. He/She does not know why staff would be prepopping medications. MO00232230

Based on observation, interview and record review, facility staff failed to ensure the residents' environment remained free of accident hazards when to staff failed to properly store medications. The facility census was 77. 1. Review of the facility's Administering Medications Policy, revised December 2012, showed staff are directed during administration of medications, the medication cart will be kept closed and locked when out of sight of the medication nurse or aide. 2. Observation on 2/28/24 at 9:57 A.M., showed Certified Medication Technician (CMT) A left the medication cart unlocked and unattended in the hall, with his/her keys in the lock. Observation showed CMT A returned to the medication cart and retrieved the keys but did not lock the cart. Observation on 2/28/24 at 10:04 A.M., 12:49 P.M., and 12:53 P.M., showed CMT A left the medication cart unlocked and unattended in the hall, with his/her keys in the lock. Observation on 2/28/29 at 3:33 P.M., showed the treatment cart unlocked and unattended. Observation showed 15 insulin pens in the top drawer. Observation showed an unidentified staff approach the cart, retrieve a blood pressure cuff and re-enter a resident's room and left the cart unlocked and unattended, in the hall. During an interview on 2/28/24 at 11:02 P.M., the Assistant Director of Nursing (ADON) said medication carts should be locked at all times to prevent other staff, residents or visitors access to the medications inside. He/She said he/she does not know why this is not being done except oversight. During an interview on 2/28/24 at 4:45 P.M., CMT A said he/she accidentally leaves the keys in the medication cart with it unlocked because he/she knows he/she will be right back, but has been working on fixing the issue. He/She said it is important to lock the cart for the resident's safety. During an interview on 2/28/24 at 3:20 P.M., the administrator said when medication or treatment carts are not in attendance they need to be locked without keys present so all contents are secured. He/She does not know why this is not being done. MO00232230

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to provide an ongoing program of activities designed to meet residents' interests, for four (Resident #1, #2, #3, and #4) and on the weekend. The facility census was 75. 1. Review of the facility's Activity Department Policy, dated 8/17/21, showed: -The facility will provide, based on the comprehensive assessment and care plan and the preference of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community; -Activities refers to any endeavor, other than routine Activities of Daily Living (ADL's), in which a resident participates that is intended to enhance his/her sense of well-being and to promote or enhance physical , cognitive, and emotional health. These include, but are not limited to, activities that promote self-esteem, pleasure, comfort, education, creativity, success, and independence; -Activities will provide one on one to any resident that does not want to participate in group activities or are not able to attend group activities; -The Activity Department may have outside entertainment to assist with providing services to residents at no cost to the residents; -Group activities are not limited to: Birthday parties, Holiday Celebration, bingo, church activities, nail care, moves and popcorn, and arts and crafts. Review of the Activity Calendar, dated November 2023, showed: 11/01/23: Store Shopping, 2:00 P.M. Undecorating Halloween; 11/02/23: 9:00 A.M. Passing Calendars, 10:00 A.M. Board Game, 1:00 P.M. One on One's, 2:00 P.M. Bingo; 11/03/23: 9:00 A.M. One on One's/Mail, 10:00 A.M. Resident's Choice, 1:00 P.M. Facetime Hour, 2:30 P.M. Movie/Happy Hour; 11/04/23: 2:00 P.M. Bingo; 11/05/23: No activities planned; 11/06/23: 9:00 A.M. One on One's, 10:00 A.M. Balloon Ball, 1:00 P.M. Resident's Choice, 2:00 P.M. Bible Study; 11/07/23: 9:00 A.M. Bounce Ball, 10:00 A.M. Craft, 1:00 P.M. Facetime Hour, 2:00 P.M. Bingo; 11/08/23: Store Shopping, 2:00 P.M. Resident Council- canceled; 11/09/23: 9:00 A.M. Connect 4 Game, 10:00 A.M. Jeopardy Game, 1:00 P.M. One on One's, 2:00 P.M. Bingo. Review of the facility's Resident Council notes, dated 9/13/23, showed staff documented the residents requested to go outside more, the residents would like to have a birthday celebration once a month or something on their birthday, and they would like to have fudge for the ice cream social. Review of the facility's Resident Council notes, dated 10/18/23, showed staff documented the residents requested to play the corn hole game, they would like to get a dart game, and a shuffle board table. 2. Review of Resident #1's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 7/22/23, showed staff assessed the resident as: - Cognitively intact; - Independent with ADL's; -Very important to keep up with the news, and to participate in his/her favorite activity; -Somewhat important to have books, newspapers, and magazines to read; to listen to music he/she likes; to be around animals such as pets; and to do things with groups of people. Review of the resident's care plan, dated 3/13/23, showed staff were directed to: -Encourage participation and positive feedback and praise; -Provide a schedule of events to post in his/her room; -Provide materials, equipment or supplies for preferred activity pursuits. Review of the resident's Activities Quarterly/Annually Assessment, dated 10/03/23, showed staff documented the resident's activity preferences as watching television/ movies, sitting outdoors, listening to music, socializing with others, visiting with family and friends, parties/socials, Bingo, reminiscing, and Resident Council. Review showed staff are to provide encouragement and verbal reminders, provide a schedule of programs, assistance to and from group activities, and provide reading material and music resources. Review of the resident's progress notes, under activities, dated 10/01/23 through 10/31/23, showed the resident did not participate in an activity on 10/01/23, 10/02/23, 10/08/23, 10/09/23, 10/10/23, 10/15/23, 10/16/23, 10/21/23, 10/22/23, 10/23/23, 10/27/23, or 10/29/23. Review of the resident's activtity progress notes, dated 11/01/23 through 11/08/23, showed the resident did not participate in an activity on 11/01/23, 11/02/23, 11/04/23, 11/05/23, 11/06/23, 11/07/23, or 11/08/23. During an interview on 11/09/23, at 11:30 A.M., the resident said the Activity Director provides residents with the a board game three times a month, card game once a month, and Bingo on Tuesdays and Thursdays. He/She said he/she thinks staff provide activities in the back memory care unit of the facility every day. He/She said the Activity Director provides crafts as an activity on occasion, but it is on the back memory care unit of the facility, and most residents in the front of the facility do not like to go on the unit for activities. He/She said staff do not provide activities on the weekends. He/She said on the weekends, residents can choose to play Bingo or cards, and the receptionist will call the numbers for Bingo. He/She said he/she would like to do crafts on the weekends. He/She said he/he does not know what Resident's Choice is, and staff do not provide enough activities to, keep us stimulated. 3. Review of Resident #2's Annual MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Independent with ADL's; -Very important to have books, newspapers, and magazines to read; to listen to music he/she likes; to be around animals such as pets; to keep up with the news; to participate in his/her favorite activity; to go outside to get fresh air when the weather is good; and to participate in religious services or practices; -Somewhat important to do things with groups of people. Review of the resident's care plan, dated 5/29/23, showed staff are directed to: -Encourage participation and positive feedback and praise; -Provide a schedule of events to post in his/her room. Review of the resident's Activities Quarterly/Annually Assessment, dated 10/13/23, showed staff documented the resident's activity preferences as watching television/ movies, listening to music, socializing with others, visiting with family and friends, parties /socials, Bingo, reminiscing, and Resident Council. Review showed staff are to provide encouragement and verbal reminders, provide a schedule of programs, assistance to and from group activities, and provide reading material and music resources. Review of the resident's progress notes, under activities, dated 10/01/23 through 10/31/23, showed the resident did not participate in an activity on 10/01/23, 10/02/23, 10/03/23, 10/05/23 through 10/17/23, 10/19/23 through 10/26/23, or 10/28/23, 10/29/23, 10/30/23, and 10/31/23. Review showed staff documented the activity the resident participated in on 10/27/23 as received mail. Review of the resident's activities progress notes, dated 11/01/23 through 11/08/23, showed the resident did not participate in an activity on 11/01/23, 11/02/23, or 11/04/23 though 11/08/23. During an interview on 11/09/23, at 11:32 A.M., the resident said staff do not provide activities on the weekends. He/She said the Activity Director provides residents Bingo, and church on Mondays. He/She said he/she thinks staff provide activities in the back memory care unit of the facility every day. He/She said on the weekends, residents can choose to play Bingo or cards, and the receptionist will call the numbers for Bingo. He/She said he/she would like to do crafts on the weekends. He/She said he/he does not know what Resident's Choice is. 4. Review of Resident #3's admission MDS, dated [DATE], showed staff assessed the resident as: -Cognitive impairment; -Independent or supervision only for ADL's; -Somewhat important to have books, newspapers, and magazines to read; to listen to music he/she likes; to participate in his/her favorite activity; to go outside to get fresh air when the weather is good; and to participate in religious services or practices. Review of the resident's care plan, dated 2/02/23, showed staff were directed as follows: -Encourage participation and positive feedback and praise; -Explore and obtain past interests and potential re-motivation; -Provide a schedule of events to post in his/her room; -Provide assistance to and from activities of interest. Review of the resident's Activities Quarterly/Annually Assessment, dated 10/24/23, showed staff documented the resident's activity preferences as watching television/ movies, sitting outdoors, listening to music, socializing with others, parties/socials, reminiscing, and manicures. Review showed staff are to provide encouragement and verbal reminders, assistance to and from group activities, and provide reading material and music resources. Review of the resident's progress notes, under activities, dated 10/01/23 through 10/31/23, showed the resident did not participate in an activity from 10/01/23 through 10/12/23, or 10/14/23 through 10/31/23. Review of the resident's progress notes, under activities, dated 11/01/23 through 11/08/23, showed the resident did not participate in an activity from 11/01/23 through 11/08/23. Observation on 11/09/23, at 10:55 A.M. showed the resident sitting at a table in the dining room, in the back hall memory care unit of the facility. Observation showed several residents sitting at tables or watching television. During an interview at that time, the resident said staff provide activities on the back hall memory care unit, every once in awhile. He/She said he/she would like to participate in a game like Guess The Shape. He/She said he/she would definitely participate in activities staff offer. 5. Review of Resident #4's Annual MDS, dated [DATE], showed staff assessed the resident as: -Cognitive impairment; -Independent or supervision only for ADL's; -Somewhat important to have books, newspapers, and magazines to read; to listen to music he/she likes; and to participate in his/her favorite activity; -Very important to go outside to get fresh air when the weather is good. Review of the resident's care plan, dated 5/24/23, show staff are directed as follows: -Encourage participation and positive feedback and praise; -Provide a schedule of events to post in his/her room; -Provide materials, equipment or supplies for preferred activity pursuits; -Provide verbal reminders to schedule activity preferences. Review of the resident's Activities Quarterly/Annually Assessment, dated 9/25/23, showed staff documented the resident's activity preferences as watching television/ movies, sitting outdoors, listening to music, socializing with others, parties/socials, and reminiscing. Review showed staff are to provide encouragement and verbal reminders, assistance to and from group activities, and provide music resources and writing material. Review of the resident's progress notes, under activities, dated 10/01/23 through 10/31/23, showed the resident did not participate in an activity from 10/01/23 through 10/11/23, or 10/13/23 through 10/31/23. Review of the resident's progress notes, under activities, dated 11/01/23 through 11/08/23, showed the resident did not participate in an activity from 11/01/23 through 11/08/23. Observation on 11/09/23, at 10:55 A.M. showed the resident sitting at a table in the dining room in the back hall memory care unit of the facility. During an interview at that time, the resident said staff do not provide activities, which is why I'm watching tv. He/She said he/she would participate in just about any activity staff provide. 6. During an interview on 11/09/23, at 10:59 A.M., LPN B said the Activity Director posts an activity calendar, but only occasionally provides activities for the residents in the back memory care unit of the facility. During an interview on 11/09/23, at 11:00 A.M., CMT C said staff occasionally provides activities for residents in the back memory care unit of the facility, but he/she has never seen the Activity Director provide activities in the unit. During an interview on 11/09/23 at 12:45 P.M., the Activity Director said he/she documents when a resident attends an activity, in the progress notes, under the activity tab. He/She said if an activity is not documented the resident did not participate in an activity. He/She said residents can self-direct Bingo or play board games on the weekends. He/She said One on One's are when he/she visits with residents in the back memory care unit of the facility, but he/she does not remember who he/she visited with because he/she usually visits with a resident if they come to his/her office. He/She said he/she did not provide Bounce Ball on 11/07/23 because the ball was out of air. He/She said he/she did not provide an alternate activity. He/She said he she did not provide the game on 11/09/23 because he/she forgot the game. He/She said he she did not provide an alternate activity. He/She said he/she discussed with residents the cost of a foosball table, and asked residents to suggest ideas for activities, in response to the Resident Council meetings. During an interview on 11/09/23, at 1:10 P.M., the Administrator said he had heard staff were not providing activities according to the calendar, but had not followed up with the Activity Director. MO00226460

Based on interview and record review, facility staff failed to follow-up with a written response to grievances. The facility census was 69. 1. Review of the facility's Resident Rights policy, dated January 5, 2017, showed: - Residents have the right to organize and participate in resident groups in the facility; - The facility must provide a designated staff person who is approved by the resident or family group and the facility and who is responsible for providing assistance and responding to written requests that result from group meetings; - The facility must consider the views of a resident or family group and act promptly upon the grievance and recommendations of such groups concerning issues of resident care and life in the facility. Review of the Resident Council minutes, dated January 18, 2023, showed the council had the following concerns: - Television channels do not work. Housekeeping is throwing away personal items, and some residents are missing clothing; - Medication is not correctly passed at night; - When residents turn on their call lights on the night shift it takes an hour to an hour and a half to be answered. Further review of the January Resident Council minutes showed the record did not contain a response or rationale from facility staff. Review of the Resident Council minutes, dated February 15, 2023, showed the council had the following concerns: - Some residents are getting other residents clothing; - When aides come to answer the call light they will shut it off and say they will be right back but don't come back. Further review of the February Resident Council minutes showed the record did not contain a response or rationale from facility staff. Review of the Resident Council minutes, dated March 15, 2023, showed the council had the following concerns: - Resident are getting a bad attitude from Certified Medication Technicians when they ask about their own medication; - Call lights are still taking a long time and aides are still shutting off the lights and not coming back. Further review of the March council minutes showed the record did not contain a response or rationale from facility staff. During an interview on 4/5/23 at 2:08 P.M., the resident council said they do not have a place offered where they can meet without staff present. They did not know how to file a grievance. If they do share their complaints with staff, they feel they will be treated differently or just ignored. They do not get a copy of a decision about a grievance or get told why it is not corrected. The resident council said they feel that staff who are told about a complaint do not pass it on to the appropriate person to be corrected. During an interview on 4/10/23 at 9:25 A.M., Certified Nurse Aide (CNA) D said if a resident has a concern or complaint, staff are directed to report those issues to the charge nurse. During an interview on 4/10/23 at 9:45 A.M., Licensed Practical Nurse (LPN) C said grievances and resident complaints are reported to the Director of Nursing and the Administrator for follow up. He/She said the outcome of the investigation should be reported back to the resident and/or resident council depending on what the issue is. During an interview on 4/10/23 at 10:12 A.M., LPN A and LPN B said issues brought to the CNAs are supposed to be taken to the charge nurses who will then follow up on the issue including informing the resident of the outcome. During an interview on 4/10/13 at 10:21 A.M., the activity director said resident grievances are taken to the administrator. They then respond to them verbally, and do not offer a written response or rationale. During an interview on 4/10/23 at 11:56 A.M., the director of nursing and the administrator said grievances get reported directly to the two of them. The grievance is then investigated and a form is used while doing the investigation. They then tell the resident in person about the outcome. A written copy is available if it is requested.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to provide a comfortable and homelike environment, when staff failed to ensure resident rooms were clean and free of needed repairs and the dining experience was free from odors. The facility census was 69. 1. Review of the facility's Homelike Environment policy, dated May 2017 showed: -Residents are provided with a safe, clean comfortable and homelike environment and encouraged to use their personal belongings to the extent possible; -The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting which include a clean, sanitary and orderly environment, and pleasant, neutral scents. Review of the policies provided by the facility showed they did not provide a policy or procedure to manage or report environmental repairs. 2. Observations on 4/4/23 between 10:23 A.M. and 4:47 P.M., during facility tours, showed: -Resident occupied room [ROOM NUMBER] with several wheelchair leg rests laying on the floor under the sink and three broken window blind planks; -Resident occupied room [ROOM NUMBER] with a package of briefs on the floor, a bath basin on the floor under the sink and nightstand in front of the bathroom door; -Resident occupied room [ROOM NUMBER] with several broken blind planks, several wheelchair leg rests laid on the floor under the sink and a wash basin sat on the floor; -Resident occupied room [ROOM NUMBER] with broken window blinds, which caused the resident to be visible from the facility parking lot. Further observation showed the room did not contain a privacy curtain. Observation showed wheelchair footrests stacked under the sink which made the sink inaccessible by wheelchair; -Resident occupied room [ROOM NUMBER] bathroom contained a toilet with a large black raised stain around the base of the toilet; -Resident occupied room [ROOM NUMBER] with a fall mat with a large tear down the center, on the floor next to the resident's bed; -Resident occupied room [ROOM NUMBER] did not contain a curtain on the window. Observation showed there was a fall mat with a large tear down the center, on the floor next to the resident's bed; -Resident occupied room [ROOM NUMBER] with bathroom ceiling which contained a peeled finish which had fallen off in places. Observation showed a black stain around the base of the toilet; -Resident occupied room [ROOM NUMBER] with a broken floor tile in front of the bathroom door; -Resident occupied room [ROOM NUMBER] with a dirty toilet seat and a black stain around the base of the toilet; -Resident occupied room [ROOM NUMBER] with a package of briefs on the floor under the sink. Observation showed a leg rest under the sink, which made the sink inaccessible by wheelchair. Observation on 4/5/23 at 11:30 A.M., showed: - Resident occupied room [ROOM NUMBER] with one missing tile under the window and one broken tile at the entrance to the bathroom; - Resident occupied room [ROOM NUMBER] with the baseboard not attached to the wall near the closet; - Resident occupied room [ROOM NUMBER] did not have a functioning bathroom light; - Resident occupied room [ROOM NUMBER] contained two drawers without handles; - Resident occupied room [ROOM NUMBER] with baseboard not attached to the wall at the sink; - Resident occupied room [ROOM NUMBER] contained one drawer on the nightstand without a handle; - Resident occupied room [ROOM NUMBER] contained a beside table with the trim not securely attached and one drawer without a handle; - Resident occupied room [ROOM NUMBER] did not have a call light string in the bathroom. Observation on 4/6/23 at 9:45 A.M., showed room [ROOM NUMBER] had a large gouge in the wall near the floor next to the sink and chipped paint on the doorframe. Observation on 4/6/23 at 9:50 A.M., showed room [ROOM NUMBER] had several wheelchair leg rests on the floor under the sink and three broken window blind planks. Further observation showed a package of incontinent briefs sat on the sink. Observation on 4/6/23 at 9:57 A.M., showed room [ROOM NUMBER] with chipped paint to the bathroom door, gouged corners to the wall next to the bathroom and a nightstand with chipped and peeled face panel on the second drawer. Observation on 4/6/23 at 10:05 A.M., showed the bathroom in room [ROOM NUMBER] had an accumulation of a brown substance and cracked caulking around toilet base. Observation on 4/6/23 at 10:06 A.M., showed room [ROOM NUMBER] had a wall baseboard separating from the wall between the bathroom door and sink, and had wood laminate peeling on the hinge side of the door leading to the hallway. Observation on 4/6/23 at 10:08 A.M., showed room [ROOM NUMBER] had torn drywall paper that was peeling from the walls, and had used white hook and loop anchor tape on two walls directly above the resident's bed. Observation also showed the hem at the bottom of the window curtain was torn. During an interview on 4/7/23 at 11:06 A.M., the spouse of the resident in room [ROOM NUMBER] said the walls were torn and white anchors were there when the resident moved in. He/She also said the walls did not make the room feel homelike, and neither did the hem pulled out at the bottom of curtain. Observation on 4/6/23 at 10:11 A.M., showed room [ROOM NUMBER] had a wall baseboard separating from the wall near the bathroom door and sink, and had approximately two inches of torn privacy curtain border hanging from privacy curtain hooks between the two resident beds. Observation also showed there was not a full privacy curtain in place. Observation on 4/6/23 at 10:13 A.M., showed the dementia unit dining room had chipped paint and missing drywall material on the corner across from the nurse station, and had multiple scrapes/tears in the drywall throughout the dining room. Observation also showed the vinyl floor was peeling under the tall cabinet to the right of sink. Observation on 4/6/23 at 10:16 A.M., showed room [ROOM NUMBER] had a broken wall outlet wall plate and the baseboard heating unit had paint scraped off and exposed rust. Observation on 4/6/23 at 10:19 A.M., showed room [ROOM NUMBER] had an accumulation of a brown substance around the base of toilet. Observation on 4/6/23 at 10:21 A.M., showed holes in the drop ceiling tiles in the hallway above the exit door by room [ROOM NUMBER]. Observation on 4/6/23 at 10:34 A.M., showed Resident #49 sat in the dining room during a group activity with a large wet area under his/her wheelchair and visibly wet pants. During an interview on 4/6/23 at 12:18 P.M., Resident #17 said his/her tablemate (Resident #49) does this every day. He/She said staff just throw a towel down and do not disinfect the area leaving the odor for the rest of the resident's to smell while they eat. He/She said it's unsanitary and ruins the appetite. During an interview on 4/10/23 at 9:25 A.M., Certified Nurse Aide (CNA) D said when residents have an accident in the dining room, staff should clean up the mess right away using the mop bucket with disinfectant in it, not a towel. Observation on 4/7/23 at 11:00 A.M., showed the resident's shower room contained a whirlpool tub. The resident call light cord was too short to be reached by a resident if needed. Observation on 4/10/23 at 10:00 A.M., showed room [ROOM NUMBER] had broken window blinds, no privacy curtain, and wheelchair footrests stacked under the resident's sink. 3. During an interview on 4/5/23 at 11:32 A.M., the maintenance director said it is expected staff would submit a work order for anything they see broken or missing in the facility. The staff have been trained how to submit work orders, and he checks for them daily. The maintenance director said he did not have any work orders for the tiles, baseboards, drawer handles, lights, and call strings. During an interview on 4/10/23 at 9:25 A.M., Certified Nurse Aide (CNA) D said broken items in the resident rooms are supposed to be reported to maintenance by completing a work order and turned into the maintenance box to be fixed. He/she said resident briefs should be placed into the closet or bedside nightstand and not on the counter by the sink because it is not homelike or dignified. During an interview on 4/10/23 at 9:45 A.M., Licensed Practical Nurse (LPN) C said outside the maintenance office is a bin for work orders to be placed when staff find issues with the facility such as broken tiles, chipped paint and gouges in the walls. He/She said briefs should not be placed on the counters or sink but stored in the closets because it is not homelike. During an interview on 4/10/23 at 10:12 A.M., LPN C said damage in a resident room is written up on a form that the maintenance director reviews and repairs. During an interview on 4/10/23 at 10:17 A.M., Nurses Aid (NA) F said broken items in a resident's room are brought to the attention of the charge nurse who then will pass on the information to the maintenance director. During an interview on 4/10/23 at 10:20 A.M., LPN I said we tell the maintenance director if there are broken items in a resident's room to be fixed. During an interview on 4/10/23 at 10:36 A.M., the director of nursing said damaged or broken items in a resident's room will be mentioned to the maintenance director unless it is harmful or impacts privacy and then it will be fixed immediately.

Based on interview and record review, facility staff failed to provide written information to the resident and/or resident's representative of the facility's bed hold policy at the time of transfer to the hospital for three residents (Residents #13, #26, and #64). The facility census was 69. 1. Review of the facility's Hospital Transfer and Bed Hold Policy, undated, showed a copy of the policy will be sent with other papers accompanying the resident to the hospital. The bed hold policy represents the bed hold letter. 2. Review of Resident #13's medical record showed the cognitively impaired resident was transferred to the hospital on 1/27/23 and 2/02/23. Staff did not document they notified the resident or the resident's representative of the facility's bed hold policy. During an interview on 4/05/23 at 10:48 A.M., Resident #13's spouse said the resident had been sent to the hospital two or three times since admission and staff never talked to him/her about a bed hold. 3. Review of Resident #26's medical record showed the resident was transferred to the hospital on 4/01/23. Staff did not document they notified the resident or the resident's representative of the facility's bed hold policy. During an interview on 4/06/23 at 3:37 P.M., Licensed Practical Nurse (LPN) I said the resident went to the hospital on 4/01/23 for respiratory distress. LPN I said when residents go to the hospital, staff send them with a package that includes the resident's face sheet, doctor's orders, nurse notes and treatments. LPN I said he/she has never heard of a bed hold notice. 4. Review of Resident #64's census information showed staff documented the resident was transferred to the hospital on 2/21/23. Staff did not document they notified the resident or the resident's representative of the facility's bed hold policy. 5. During an interview on 4/6/23 at 3:49 P.M., the Administrator said the facility had never given bed hold notices. The administrator also said the facility never had to give a resident a different bed so he/she never thought about it. During an interview on 4/7/23 at 8:41 A.M., the Administrator said bed holds are only completed on admission with the resident and/or family and they have not been denying any returns to the same bed. He/She said the Social Service Director (SSD) is responsible for completing the bed holds on admission. During an interview on 4/10/23 at 10:40 A.M., the SSD said bed holds are completed on admission and he/she is unaware of any other times. He/She said the facility is not refusing the return to the same bed on any resident who goes to the hospital. During an interview on 4/10/23 at 11:36 A.M., the Administrator said residents may obtain a copy of the bed hold if they request it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility staff failed to complete the required Minimum Data Set (MDS), a federally mandated resident assessment, within the required timeframe for five sampled residents (Residents #53, #58, #219, #221, and #225). The facility census was 69. 1. Review of the Resident Assessment Instrument (RAI) manual version 3.0 RAI OBRA-required Assessment Summary showed assessment time frames as follows: -Entry MDS completion date no later than the 7th calendar day from the resident's entry into the facility and submitted no later than 14 days from the date of entry into the facility; -admission (Comprehensive) MDS completion date no later than 14th calendar day of the resident's admission and submitted no later than 14 calendar days from the care plan completion date; -Discharge Assessment for a resident must be completed no later than 14 days from the date of discharge and submitted by the MDS completion date plus 14 calendar days. Review of the facility's MDS policy, dated February 2022, showed: -The Nurse Assessment Coordinator to run the MDS due report in the Electronic Health Record (EHR) for the month in which the assessments are being scheduled; -The Registered Nurse (RN) assessment coordinator will determine the type of assessment to be completed and the assessment reference date (ARD) that the assessment is to be completed, as per Chapter 2 of the RAI manual; -In the EHR system, the MDS Assessment Coordinator will schedule the assessment according to the assessment type and ARD, as per Chapter 2 of the RAI manual; -Once the assessment is completed, it must be validated and finalized prior to transmission to the Centers for Medicaid and Medicare Services (CMS) database as outlined in Chapter 5 of the RAI manual. 2. Review of Resident #53's closed medical record showed the resident admitted to the facility on [DATE] and discharged from the facility on 11/21/22. Review of the resident's MDS record, dated 10/5/22 to 11/21/22, showed the record did not contain a completed or submitted discharge assessment within the required time frame. 3. Review of Resident #58's closed medical record showed the resident admitted to the facility on [DATE] and discharged from the facility on 12/20/22. Review of the resident's MDS record, dated 11/14/22 to 12/20/22, showed the record did not contain a completed or submitted discharge assessment within the required time frame. 4. Review of Resident #219's current medical record showed the resident admitted to the facility on [DATE]. Review of the resident's MDS record, dated 3/3/23 through 4/6/23, showed the record did not contain a completed or submitted admission assessment within the required time frame. 5. Review of Resident #221's current medical record showed the resident admitted to the facility on [DATE]. Review of the resident's MDS record, dated 2/24/23 to 4/6/23, showed the record did not contain a submitted admission assessment within the required time frame. 6. Review of Resident #225's current medical record showed the resident admitted to the facility on [DATE]. Review of the resident's MDS record, dated 3/1/23 to 4/6/23, showed the record did not contain a completed or submitted admission assessment within the required time frame. 7. During an interview on 4/10/23 at 10:12 A.M., Licensed Practical Nurse (LPN) A said he/she was responsible to complete the MDS assessments. Assessments should be completed annually, quarterly, upon admission and with significant changes. He/She said there are some late assessments due to time constraints and getting pulled to the floor as a charge nurse. He/She was trained by the prior MDS coordinator and has not had any formal training. During an interview on 4/10/23 at 11:36 A.M., the Director of Nursing (DON) said MDS assessments should be completed within 14 days of admission, quarterly and with significant changes. He/She said if the assessments are late, it is because the MDS Coordinator is just not completing them but should be. He/She was not aware there were late assessments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to develop a comprehensive person-centered care plan for each resident to meet the resident's medical and nursing needs when staff failed to address catheter care for one resident (Resident #26), failed to address dressing assistance, toileting assistance, and restorative services for one resident (Resident #35), failed to address smoking, personal hygiene preferences and oxygen for one resident (Resident #220), failed to address falls, personal hygiene preferences, pain and edema (swelling of the limbs) and antidepressant use for one resident (Resident #221), failed to address advanced directives and personal hygiene preferences for one resident (Resident #222) and failed to address the use of an antipsychotic and intravenous antibiotics for one resident (Resident #227). The facility census was 69. 1. Review of the facility's MDS Policy, dated February 2022, showed: -The comprehensive care plan will be developed and entered into the Electronic Health Record (EHR) system by the RN Assessment Coordinator or other discipline as assigned. The care plan is created upon admission, updated, and revised with changes in the resident's tenure. -The care plans will be updated quarterly and with changes to the residents' plan of care. Changes made to the care plan will be communicated to the interdisciplinary team (IDT); -The staff member completing the Care Area Assessments (CAA) for the specified section will also complete the comprehensive care plan on the resident. Review of the Resident Assessment Instrument (RAI) manual version 3.0 RAI showed: -Care plan completion based on the CAA process is required for OBRA-required comprehensive assessments. It is not required for non-comprehensive assessments (Quarterly, SCQA), PPS assessments, Discharge assessments, or Tracking records. However, the resident's care plan must be reviewed after each assessment, as required by §483.20, except discharge assessments, and revised based on changing goals, preferences and needs of the resident and in response to current interventions; -The IDT must evaluate the information gained to develop a care plan that addresses those findings in the context of the resident's goals, preferences, strengths, problems, and needs; -Residents' preferences and goals may change throughout their stay, so facilities should have ongoing discussions with the resident and resident representative, if applicable, so that changes can be reflected in the comprehensive care plan; -The overall care plan should be oriented towards: -Assisting the resident in achieving his/her goals; -Individualized interventions that honor the resident's preferences; -Addressing ways to try to preserve and build upon resident strengths; -Preventing avoidable declines in functioning or functional levels or otherwise clarifying why another goal takes precedence (e.g., palliative approaches in end of life situation); -Managing risk factors to the extent possible or indicating the limits of such interventions; -Applying current standards of practice in the care planning process; -Evaluating treatment of measurable objectives, timetables and outcomes of care; -Using an interdisciplinary approach to care plan development to improve the resident's abilities; -Assessing and planning for care to meet the resident's goals, preferences, and medical, nursing, mental and psychosocial needs; -Involving direct care staff with the care planning process relating to the resident's preferences, needs, and expected outcomes. 2. Review of Resident #26's Significant Change of Status, Minimum Data Sheet (MDS), a federally mandated assessment tool, dated 3/06/23, showed facility staff assessed the resident as follows: -Severe cognitive impairment; -Totally dependent on staff for assistance with personal hygiene, toilet use did not occur; -Always incontinent of bowel and bladder; -Did not have an indwelling catheter. Review of the residents physician order sheet, dated April 2023, showed an order on 4/07/23 to change the catheter every month on the first day shift. Review of the residents Care plan, last updated 3/17/23, showed staff were instructed to: -Assist to toilet as needed; -Check resident every two hours and assist with episodes of incontinence as they occur; -Complete Bowel and Bladder assessment upon admission, then quarterly and on an acute basis; -Did not include interventions for the urinary catheter. Observation on 4/04/23 at 11:17 A.M., showed the resident had a urinary catheter in place with the catheter bag hanging from the side of his/her bed. During an interview on 4/07/23 at 2:01 P.M., Certified Medication Technician (CMT) J said he/she did not know why the resident had a catheter. CMT J said he/she assumed it would be in the care plan. During an interview on 4/07/23 at 3:03 P.M., the Director of Nursing (DON) said catheter care should be in the care plan. During an interview on 4/10/23 at 9:36 A.M., Licensed Practical Nurse (LPN) I said the catheter was placed in the emergency room on 4/01/23 when the resident was sent for breathing issues. LPN I said the catheter should be in the care plan. 3. Review of Resident #35's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Received restorative therapy seven times a week for at least 15 minutes for active and passive range of motion, bed mobility, transfers, walking, and dressing and/or grooming; -Required limited assistance of one staff member for dressing; -Required extensive assistance of one staff member for toileting and transfers. Review of the resident's care plan, dated 3/31/23, showed: -A self-care deficit; -Need for assistance with personal care; -Total assistance for transfers with a mechanical lift; -Further review showed the care plan did not contain restorative services, type of toileting assistance needed, and dressing assistance. During an interview on 4/4/23 at 11:04 A.M., the resident said he/she did not receive staff assistance for toileting or dressing and only received restorative therapy for 15 minutes a day. He/She said that he/she needed assistance for hygiene after toileting and getting his/her clothing from the closet, but gets tired of waiting for staff so he/she just does the best he/she can. 4. Review of Resident #220's Annual MDS, dated [DATE], showed facility staff assessed the resident as: -Cognitively intact; -Required set-up assistance and supervision for personal hygiene; -Had limited functional range of motion on one side of the body; -Did not use tobacco or oxygen while a resident; -Had diagnosis of cancer. Review of the resident's physician order sheet, dated 3/3/23, showed an order for Oxygen at 1 Liter as needed for Shortness of Breath to maintain saturation above 92% - remove vapes (electronic smoking devices) from room when oxygen is being used. Review of the facility's list of residents who smoked, provided on 4/4/23, showed the resident as a smoker and vape user. Review of the resident's care plan, dated 4/5/23, showed it did not contain direction for staff regarding shaving preferences or the use of oxygen. Further review showed it did not contain direction for use of tobacco or vape devices until 4/4/23. Observation on 4/4/23 at 11:08 A.M., showed the resident in bed with oxygen on via nasal cannula at 2 liters, puffed from a vape device and placed the vape device on his/her chest. Further observation showed the resident had long facial hair and long fingernails. During an interview on 4/4/23 at 2:15 P.M., the resident said he/she has been a long time smoker and occasionally went outside to smoke with the other residents. The resident said staff shaves him/her once a week, but he/she could do it by himself/herself if staff would help with set up. 5. Review of Resident #221's Entry MDS, dated [DATE], showed the resident admitted on [DATE]. Review of the current medical record showed it did not contain any further MDS assessments. Review of the Physician History and Physical, dated 3/3/23, showed a diagnosis of Parkinson Disease (disorder that affects the nervous system), Osteoarthritis of multiple joints (condition that affects the joints causing pain and reduced movement), and Parkinson Dementia with agitation (progressive dementia that develops at least two years after the diagnosis of Parkinson Disease has been made and other causes are ruled out). Review of the current physician order sheet, printed 4/7/23, showed an order for duloxetine (an antidepressant) 60 mg capsule daily. Review of the Resident Summary, dated 3/2/23, completed by licensed staff showed staff assessed the resident as: -Cognitively impaired; -Received psychotropic medication (drugs that affect the mind, emotions and behavior); -Had balance problems; -Had a history of falls; -Had tremors and decreased movement to both lower extremities; -Required assistance of one staff for bed mobility; -Required assistance of two staff for transfers; -Dependent on two staff for toileting; -Dependent on one staff for eating; -Had pain and edema (swelling of the limbs). Review of the resident's nursing notes, dated 3/20/23 at 4:54 P.M., showed a CNA observed the resident was on the floor in his/her room. Review of the resident's care plan, dated 3/21/23, showed: -It did not contain new interventions or care plan review for falls on 3/20/23; -It did not contain direction on facial hair care; -It did not contain direction or guidance for psychotropic medication use; Observation on 4/4/23 at 12:52 P.M., showed the resident in a reclining wheelchair in the dining room with long facial hair and long fingernails while he/she fed himself/herself lunch. Observation on 4/10/23 at 9:21 A.M., showed the resident in the dining room with long facial hair and long fingernails. 6. Review of Resident #222's Face Sheet, dated 4/6/23, showed the resident admitted on [DATE]. Review of the resident's current medical record showed a signed do not resuscitate order dated 3/31/23. Review of the resident's care plan, dated 3/31/23, showed: -It did not contain his/her do not resuscitate order or direction for staff regarding the resident's code status; -It did not contain direction or preferences for personal hygiene including facial hair. Observation on 4/4/23 at 10:45 A.M., showed the resident in his/her room wearing a hospital type gown, unshaven and long fingernails. Observation on 4/5/23 at 8:18 A.M., showed the resident in the dining room with long facial hair and long fingernails. During an interview on 4/4/23 at 10:45 A.M., the resident said his/her facial hair is long and would feel better if he/she could get it shaved off. He/She said he/she was tired and did not think he/she had the energy to do it and doesn't want to bother staff. During an interview on 4/10/23 at 11:58 A.M., the DON said the change in code status should have been added to the care plan when the code status was updated. He/She was not aware it was not completed. 7. Review of Resident #227's Entry tracking record, dated 3/13/23, showed it did not contain MDS assessment data. Review of the resident's Physician Order Sheet, dated April 2023, showed an order dated 3/13/23 for Zyprexa (antipsychotic) one 10 mg tablet tablet by mouth daily at bedtime for altered mental status, unspecified and an order dated 3/31/23 for Rocephin (antibiotic) 2 grams intravenously (IV) every 24 hours for sinusitis. Review of the resident's care plan, updated 3/16/23, showed: -Cognitive deficit identified as a care area on 3/13/23 with no interventions; -It did not include goals or interventions related to, antipsychotic's or intravenous antibiotics. 8. During an interview on 4/10/23 at 9:25 A.M., Certified Nurse Aide (CNA) D said staff sometimes go to care plan meetings to discuss the residents' needs, how to care for them and concerns the residents might have. He/She is not sure who updates the care plan or who is responsible. He/She usually works the secured unit and does not know about the needs of residents off the unit but would think things like hygiene preferences, medication use, oxygen use, behavioral interventions and falls should be in a care plan. During an interview on 4/10/23 at 9:45 A.M., LPN C said care plans are updated by the care plan nurse and should cover all the basics such as fall precautions, eating assistance, advanced directives, specialized equipment needs, restorative, hospice, dialysis, and hygiene preferences such as shaving. He/She said some residents want shaved every day and some do not, and if it is not in the care plan, staff would not know what the resident prefers. During an interview on 4/10/23 at 10:12 A.M., the MDS nurse and care plan nurse said the MDS assessment drives what is in the care plans along with other assessments and input from the staff and residents. The care plan nurse said they have been with the facility for one month and is trying to get all the resident care plans more personalized to their needs and preferences and it's taking time. He/She said care plans are updated at least quarterly, with significant changes, and on admission. During an interview on 4/10/23 at 11:36 A.M., the DON said care plans should be updated with change in condition such as falls, on admission and at least quarterly. The care plans should be tailored to the resident's care needs. He/She said it is the responsibility of the care plan nurse to update the care plans. He/she was not aware of the missing information. Surveyor: Shiner, [NAME]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide thorough orders, monitoring, and ongoing communication with the dialysis (the clinical purification of blood by dialysis, as a substitute for the normal function of the kidney) facility for two out of two residents (Residents #11 and #17) who received services at the dialysis facility. The census was 69. 1. Review of the facility's Dialysis policy, dated 9/2017, showed the following: -The facility will ensure that residents who require dialysis will receive such services, consistent with professional standard of practice, the comprehensive person-centered care plan, and the residents' goal and preferences; -Professional standards of practice include: ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility and ongoing communication and collaboration with the dialysis facility regarding dialysis care and services; -Ongoing communication, coordination, and collaboration between the nursing home and the dialysis staff is imperative in providing optimal care for the resident. The charge nurse is designated as the contact staff at the facility to communicate with the dialysis staff. 2. Review of Resident #11's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 1/8/23, showed facility staff assessed the resident as follows: - admission date of 3/24/21; - Cognitively intact; - Diagnosis of diabetes, anemia, and end stage renal disease (permanent kidney failure); - Received dialysis while a resident. Review of the resident's care plan, dated 4/5/23, showed: -Received hemodialysis three times a week for end stage renal disease; -Dependence on renal dialysis; -Will have no complications related to dialysis through next review date; -Assess vital signs (VS) prior to and after dialysis appointment; -Schedule dialysis site, days and time and ensure transportation is available. Review of the resident's Physician Order Sheet (POS), dated April 2022, showed the record did not contain orders regarding dialysis, care of the access point, monitoring for signs of infection or daily thrill (a buzzing feeling)/bruit (sound associated with blood flow) checks. Review of the resident's current electronic medical record showed the record did not contain documentation of communication from the facility to the dialysis center. During an interview on 4/6/23 at 2:24 P.M., the resident said he/she goes to the dialysis center on Monday, Wednesday, and Friday, and the facility does not give him/her any paperwork to take to dialysis. He/She had not received any paperwork from the dialysis center to give to the facility staff, and he/she does not believe the facility and the dialysis clinic communicate with each other. 3. Review of Resident #17's MDS, dated [DATE], showed facility staff assessed the resident as follows: -admission date of 8/1/22; -Cognitively intact; -Diagnosis of renal failure and diabetes; -Did not receive dialysis while a resident. Review of the resident's care plan, dated 3/21/23, showed: -Received hemodialysis three times weekly; -Dialysis on Tuesday, Thursday, and Saturday; -Will have no complications of dialysis through next review; -Assess the access site for swelling, bleeding or signs of infection; -Assess vital signs (VS) prior to and after dialysis appointments; -Schedule dialysis site, days and time and ensure transportation is available. Review of the resident's POS, dated April 2022, showed the record did not contain orders regarding dialysis, care of the access point, monitoring for signs of infection or daily thrill bruit check. Review of the resident's medical record showed the record did not contain documentation of the required dialysis communication forms. 4. During an interview on 4/10/23 at 9:45 A.M., Licensed Practical Nurse (LPN) C said staff do not send a written communication tool to the dialysis center. Problems or changes are communicated through phone calls or fax communications. He/She said the facility does not have orders for dialysis residents in their Electronic System that shows signs of infection to watch for, days of the week, access point assessments, or monitoring of vital signs. He/She said there are only two residents receiving dialysis. During an interview on 4/10/23 at 11:36 A.M., the Director of Nursing said he/she was not sure if residents should have an order for dialysis. He/She said the dialysis center does all of their own blood work and the facility does an assessment on the resident when returning from treatment. He/She said it was not documented and a dialysis communication form was not used.

Based on interview and record review, facility staff failed to provide the services of a Registered Nurse (RN) for at least eight (8) consecutive hours per day, seven days a week. The facility census was 69. 1. Review of the facility's Nursing Staff schedule, dated 3/27/23 through 4/6/23, showed staff did not document an RN was scheduled to work on 3/27/23 through 4/6/23. Review of the facility's RN staff time sheets, dated 3/1/23 through 4/6/23, showed the hours worked between the three facility RNs as follows: -The Director of Nursing (DON), not responsible for direct resident care, Monday through Friday, 8 hours per day, he/she did not work on Saturday or Sunday; -The RN Educator worked Monday through Wednesday, averaging at least 8 hours per day. He/She worked 7 hours on Saturday 3/4, 1 hour on Saturday 3/11, 5 hours on Saturday 3/18, and 2 hours on Saturday 3/25. He/She did not work on Sundays; -The RN Wound Nurse/Infection Preventionist, worked on Thursday and Friday of each week with an average of 8 hours per day, but did not work any Saturdays or Sunday hours. -There was not an RN for 8 hours a day on 3/4, 3/5, 3/11, 3/12, 3/18, 3/19, 3/25, 3/26, 4/1, and 4/2. During an interview on 4/10/23 at 9:45 A.M., Licensed Practical Nurse (LPN) C said most weekends do not have an RN on duty or in the building on dayshift or nightshift. He/She said the Director of Nursing was available at any time for emergencies. During an interview on 4/10/23 at 11:36 A.M., the Administrator and DON said the facility tries to staff RNs every day including the weekends and will attempt to find replacements for call-ins. He/She said the facility currently had RN want ads running and two LPNs going to nursing school. The DON said he/she was available by phone when not in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to ensure medication regimens were free from unnecessary medications when staff failed to obtain an appropriate diagnosis for the use of psychotropic medications (a chemical substance that changes brain function and results in alterations in perception, mood, consciousness or behavior) for three residents (Residents #15, #30 and #226). The facility census was 69. 1. Review of American Geriatrics Society (AGS) 2019 Updated AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults showed: -Avoid antipsychotics for behavioral problems of dementia or delirium unless nonpharmacological options (e.g., behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. Review of Seroquel (Quetiapine) product monograph (a factual, scientific document on a drug product that, devoid of promotional material, describes the properties, claims, indications and conditions of use of the drug and contains any other information that may be required for optimal, safe and effective use of the drug), revised 11/29/2021, showed: -Seroquel indications for use include schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs); -Seroquel is not indicated for the treatment of elderly patients with dementia-related psychosis (a mental disorder characterized by a disconnection from reality). Review of the prescribing information for Abilify (aripiprazole) showed: -Abilify is an atypical antipsychotic indicated for treatment of schizophrenia, Bipolar I disorder, and as an add on treatment for Major Depressive Disorder; -Elderly people with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death; -Abilify is not approved for the treatment of patients with dementia-related psychosis. Review of the prescribing information for Zyprexa (olanzapine) showed: -Zyprexa is an atypical antipsychotic indicated for treatment of schizophrenia and acute treatment of manic or mixed episodes associated with bipolar I disorder and maintenance treatment of bipolar I disorder; -Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death; -Zyprexa is not approved for the treatment of patients with dementia-related psychosis. Review of the prescribing information for Depakote (divalproex) showed it is an anti-epileptic drug indicated for the treatment of: -Manic episodes associated with bipolar disorder; -Monotherapy (single) and adjunctive (add on) therapy of complex partial seizures and simple and complex absence seizures; adjunctive therapy in patients with multiple seizure types that include absence seizures; -Prophylaxis of migraine headaches. Review of the facility's Psychotropic Medication Policy and Procedure, undated, showed: -The facility supports the goal of determining the underlying cause of behavioral symptoms so the appropriate treatment of environmental, medical and/or behavioral interventions as well as psychopharmacological medications can be utilized to meet the needs of the individual resident; -Psychotropic medications include anti-anxiety, hypnotic, and antipsychotic medications; -Physician will order psychotropic medication for the treatment of specific medical and/or psychiatric conditions or when the medication meets the needs of the resident to alleviate significant distress for the resident not met by the use of non pharmacologic approaches; -Physician will document rationale and diagnosis for medication utilization and identify target symptoms; -Nursing will review the use of the medication with the physician and the interdisciplinary team on a quarterly basis to determine the continued presence of target behaviors and/or the presence of any adverse effects of the medication use; -Nursing will monitor for the presence of target behaviors on a daily basis and chart by exception (only when behaviors are present). 2. Review of Resident #15's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 1/13/23, showed facility staff assessed the resident as follows: -Severe cognitive impairment; -No behaviors; -Diagnoses included stroke, diabetes, aphasia, right sided hemiplegia/hemiparesis, anxiety, and depression; -Medications in the last seven days included antipsychotics, antianxiety, and antidepressant. Review of the resident's care plan, dated 8/16/21, showed: -Resident will not display aggressive behaviors or cause harm to self or others through the next review date; -15 minute checks; -Analyze key times, places, circumstances, triggers, and what de-escalates behavior; -Document behavioral occurrences; -Remove from escalating situations; -Staff did not document the use of antipsychotic medications or direction for staff in regard to the resident's specific targeted behaviors. Review of the resident's Nurse Practitioner (NP) progress note, dated 2/21/23, showed NP R included Alzheimer's disease in the resident's active problem list. NP R was unable to complete the resident's review of systems due to dementia and did not address antipsychotic use. Review of the resident's physician progress note, dated 3/3/23, showed Physician S included Alzheimer's disease in the resident's active problem list and did not address the resident's antipsychotic use, including risks and benefits or why potentially lower risk medications were not tried first. Review of the resident's Physician Order Sheets (POS), dated April 2023, showed: -An order on 8/22/21 for Abilify (antipsychotic) one 5 milligram (mg) tablet by mouth once a day for anxiety disorder, unspecified; -An order on 6/23/22 for Depakote Sprinkles (anticonvulsant) two delayed release 125 mg capsules by mouth two times per day for anxiety disorder, unspecified. Review of the resident's medical record showed the record did not contain an appropriate diagnosis for the use of the psychotropic medications, attempts to implement care-planned, non-pharmacological approaches, and ongoing evaluation of the effectiveness of these interventions. 3. Review of Resident #30's Quarterly MDS, dated [DATE], showed facility staff assessed the resident as follows: -Severe cognitive impairment; -Behaviors included delusions and verbal behaviors directed toward others on one to three days during the seven day assessment period; -Diagnoses included vascular dementia - unspecified severity with behavioral disturbance, stroke, seizure disorder or epilepsy, anxiety disorder, depression, psychotic disorder other than schizophrenia; -Medications in the last seven days included antipsychotics and antidepressant. Review of the resident's care plan, updated 3/16/23, showed: -Resident uses psychoactive medications; -Diagnosis of unspecified dementia with behavioral disturbances; -Administer medication as ordered; -Ask physician to review medication for possible dose reduction every three months; -Monitor behavior every shift and document; -Further review showed the care plan did not contain direction for staff in regard to the resident's specific targeted behaviors. Review of the resident's Nurse Practitioner (NP) Annual History and Physical (H&P) note, dated 2/28/23, showed NP R included vascular dementia without behavioral disturbance in the resident's active problem list. NP R was unable to complete the resident's review of systems due to dementia and did not address antipsychotic use, including risks and benefits or why potentially lower risk medications were not tried first. Review of the resident's nurse notes, from 3/25/22 through 3/02/23, showed staff did not document any resident behaviors. Review of the resident's POS, dated April 2023, showed an order on 7/17/20 for Quetiapine (antipsychotic) one 50 mg tablet mouth upon rising for generalized anxiety disorder Review of the resident's medical record showed the record did not contain an appropriate diagnosis for the use of the psychotropic medication. 4. Review of Resident #226's medical record showed an admission date of 2/28/23 with no MDS assessment data available. Review of the resident's care plan, updated 4/03/23, showed: -Resident was taking psychotropic medications for dementia with psychosis; -Resident was at risk for behavioral changes; -Abnormal Involuntary Movement Scale will be completed quarterly and on an acute basis; -Administer medication as ordered; -Analyze key times, places, circumstances, triggers, and what de-escalates behavior; -Monitor behavior every shift and document; -The care plan did not contain direction for staff in regard to the resident's specific targeted behaviors. Review of the resident's physician note, dated 3/17/23, showed the physician documented active diagnoses included dementia in Alzheimer's disease with delusions and behavioral disturbance. Further review of the physician note, dated 3/17/23, showed the resident was evaluated due to need to evaluate Zyprexa efficacy for controlling agitation and behavioral issues. Physician S said the Zyprexa was effective, but the resident was excessively somnolent (drowsy). Physician S decreased the dose of Zyprexa and said NP R would re-evaluate the resident in four days. Review showed the medical record did not contain documentation of the NP follow-up. Review of a letter typed by Physician S, dated 4/3/23, showed the physician assessed the resident as having a Mini-Mental State Examination (a screening tool for cognitive impairment) score of 11/30 which was an indicator of severe dementia. The physician also said the resident was oriented to name only and was unable to arrive at meaningful conclusions and decisions about his/her care. Review of the resident's POS, dated April 2023, showed orders for the following antipsychotic medications: -Seroquel (quetiapine) one and one half 100 mg tablets by mouth at bedtime to equal 150 mg total for dementia in other diseases classified elsewhere, unspecified severity, with psychotic disturbance; -Zyprexa (olanzapine) one 10 mg tablet by mouth at bedtime for unspecified dementia, unspecified severity, with other behavioral disturbance; -Zyprexa one 2.5 mg tablet by mouth with breakfast for unspecified dementia, unspecified severity, with other behavioral disturbance. Review of the resident's medical record showed the record did not contain an appropriate diagnosis for the use of the psychotropic medications. 5. During an interview on 4/07/23 at 1:58 P.M., Certified Medication Technician (CMT) J said the psychiatrist sees residents and writes orders for psychotropic medications. He/She said the nurse was responsible for medication orders. During an interview on 4/10/23 at 12:02 P.M., the Director of Nursing (DON) said the ordering physician is responsible for their orders. During an interview on 4/12/23 at 10:35 A.M., the Administrator said new resident admission orders are reviewed by the admitting nurse and new doctors orders for existing residents are reviewed by the Assistant Director of Nursing (ADON). The administrator said the pharmacy also reviews orders as they are placed. The administrator also said the Care Plan and MDS coordinators review orders for appropriate diagnoses quarterly or with significant resident changes.

Based on observation, interview, and record review, facility staff failed to store and label medication in a safe and effective manner in one of two medication storage carts, and two of two medication storage rooms. The facility census was 69. 1. Review of the facility's policy Medication Storage & Labeling Policy, undated, showed staff are directed as follows: - Medication must be stored in a clean, dry environment behind a single lock; - Expiration dates must be checked prior to administration. Expired medications are removed from the area of care immediately, and disposed of according to the facility medication disposal policy, per state and federal guidelines. 2. Observation on 4/5/23 at 1:11 P.M., showed the north medication storage room contained one package of dicyclomine (used to treat irritable bowel syndrome) 10 milligram (mg) capsules located on the floor of the medication storage room. The information label and resident information was torn from the top of the packaging. The package contained five out of 30 capsules. During an interview on 4/5/23 at 1:15 P.M., Licensed Practical Nurse (LPN) C said the package of dicyclomine should not be on the floor of the medication room. He/She did not know to which resident the medication belonged. The LPN said the label with resident information should not be removed until the medication is destroyed. Medication that is to be destroyed should be located on the counter or in the pharmacy bag to be returned to the pharmacy. 3. Observation on 4/6/23 at 4:08 P.M., showed the medication storage room in the central hall contained four 45 gram Vaginal Antifungal tubes with an expiration date of 2/23. 4. Observation on 4/6/23 at 4:31 P.M., showed the Memory Care medication cart contained: - 2 loose yellow round tablets with a diamond shape; - 1 loose white tablet no marking; - 2 loose round yellow tablet marked #100; - 1 loose brown round tablet marked LL; - 1 loose white round tablet marked #24. 5. During an interview on 4/10/23 at 10:10 A.M., Certified Medication Technician (CMT) O said two staff should destroy out of date or loose medication for accountability, with one staff member being a nurse. During an interview on 4/10/23 at 10:19 A.M., LPN I said all out of date or loose medication is disposed of and removed from medication carts or the storage room. During an interview on 4/10/23 at 10:24 A.M., LPN C said out of date medications or loose medications should be returned to the pharmacy if possible or destroyed. During an interview on 4/10/23 at 10:30 A.M., the Director of Nursing said out of date medications or loose medications will be destroyed. During an interview on 4/10/23 at 11:49 A.M., the Administrator said out of date medication or loose medication should be turned in by staff to be destroyed by the Director of Nursing or the Assistant Director of Nursing. Staff should make an effort document what kind of medication it is and what resident it is prescribed to.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to change their gloves and/or perform hand hygiene during perineal care for one resident (Resident #44), and failed to sanitize or clean a mechanical lift (mechanical device used to lift and transfer residents) after use for two residents (Resident #56 and one unknown resident). The facility census was 69. 1. Review of the facility's Infection Control and Prevention Guidelines, undated, showed the following: -Wash hands before and after procedures and before and after resident contact; -Wear sterile or clean gloves when appropriate; -Maintain sterility or cleanliness of the equipment and working field as necessary; -Clean all equipment and return to appropriate storage area; -Wash hands whenever visibly soiled; -Gloves should be used as an addition to not as a substitute for hand hygiene; -Contamination is still possible with glove usage; -Essential gloves be used in combination with hand hygiene; -Wear gloves when contact with blood or other potential infectious materials are possible; -Remove gloves after caring for a resident; -Wash hands or perform hand hygiene after gloves are removed. Review of Resident #44's Quarterly Minimum Date Set (MDS), a federally mandated assessment tool, dated 2/1/23 showed staff assessed the resident as follows: -Required total, two person assistance with mobility, transfers, dressing, toileting and personal hygiene; -Bilateral lower extremity impairment; -Wheelchair use. Observation on 4/7/23 at 9:03 A.M., showed Nurse Aide (NA) F and Certified Nurse Aide (CNA) E entered the resident's room to provide perineal care. NA F did not perform hand hygiene before he/she applied gloves. The NA then washed the resident's buttocks area, removed his/her gloves, did not perform hand hygiene, applied new gloves and re-washed the resident's buttocks area. The NA removed his/her gloves and did not wash his/her hands or perform hand hygiene before he/she reapplied new gloves. CNA E and NA rolled the resident to the opposite side and CNA E wiped the resident's buttock area, assisted the resident to his/her back and did not change his/her gloves or perform hand hygiene before he/she wiped the resident's inner thighs and perineal area. NA F removed his/her gloves and did not perform hand hygiene before he/she pulled up the residents clean linens over the resident. NA F left the room to obtain more linens and did not wash his/her hands. NA F returned with clean linens and applied clean gloves, but did not wash his/her hands. Both CNA E and NA F placed clean linens and pulled the resident up into the bed. During an interview on 4/7/23 at 9:24 A.M., CNA E said NA F should have washed his/her hands between glove changes, before leaving the room, and when entering the room. He/She did not realize he/she did not wash or sanitize or change gloves between washing the bottom and front areas and should have. He/she was nervous and wanted to do a good job. During an interview on 4/7/23 at 9:34 A.M., NA F said he/she should have washed his/her hands after removing gloves and before applying new gloves, before going from back to front, and before leaving the room. He/She said they are new to the facility and still learning and was just trying to get the care finished. During an interview on 4/10/23 at 9:25 A.M., CNA D said staff are directed to perform hand hygiene when going into a room, when changing gloves and before applying new gloves, when between different areas of the body, and before leaving the room. During an interview on 4/10/23 at 9:45 A.M., Licensed Practical Nurse (LPN) C said staff should wash their hands or sanitize before starting a task, after dirty to clean tasks, when changing gloves, when dirty, and before leaving a room. He/She said if hands are not clean, infections could occur. During an interview on 4/10/23 at 11:36 A.M., the Director of Nursing (DON) said he/she expects staff to perform hand hygiene when entering and before leaving a room, between two areas of the body, before touching clean linens, and work from a clean to less clean area. He/She said if staff do not wash or sanitize it could lead to staff potentially passing bacteria and causing infections. 2. Review of the facility's undated General Equipment policy showed: -All reusable items for resident care be cleansed, sanitized, checked and properly stored in such a manner to ensure proper functioning and to prohibit infection or cross contamination; -Cleaning should be done with an approved disinfectant; -All items must be clean, dry and stored in an appropriate area; -The equipment will be cleansed at the beginning of each shift and when visibly soiled prior to continued use. 3. Review of Resident #56's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Required total, two person assistance with toileting and personal hygiene; -Bilateral lower extremity impairment; -Wheelchair use. Observation on 4/6/23 at 8:58 A.M., showed CNA G and NA H use a mechanical lift to transfer the resident from his/her bed to the wheelchair. Additionally, the staff wheeled the lift into the hallway when finished and did not sanitize or clean the lift. 4. Observation on 4/7/23 at 8:19 A.M., showed CNA G and CNA E transferred an unknown resident from his/her the wheelchair to the shower chair with a mechanical lift. Additionally, the staff pushed the lift into the hallway when finished and did not sanitize or clean the lift. 5. During an interview on 4/10/23 at 9:25 A.M., CNA D said staff should clean all equipment that is used for more than one person between uses and before using on another resident so bacteria is not spread. During an interview on 4/10/23 at 9:45 A.M., LPN C said mechanical lifts should be wiped with a bleach wipe between residents and before putting in storage. He/She said they feel it is not being done consistently and could spread infections if it is not. During an interview on 4/10/23 at 11:36 A.M., the Administrator and DON said the mechanical lift should be cleaned between and before use on another resident with a microkill wipe (disinfectant wipe) or bleach wipe or could risk spread of bacteria and infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to maintain and follow current guidance and procedures for immunizations of residents against pneumococcal (infection caused by bacteria) pneumonia in accordance with national standards of practice for five (Residents #32, #47, #56, #63 and #219) sampled residents. The facility also failed to ensure two residents (Resident #63 and #219) of five sampled were offered the flu vaccine. The facility census was 69. 1. Review of the facility's Vaccination of Residents policy, undated, showed: -All new residents shall be assessed for current vaccination status upon admission; -If vaccines are refused, the refusal shall be documented in the resident's medical record; -The pneumococcal vaccine will be offered to the residents of the facility; -The policy did not provide a timeline for offering the pneumococcal vaccine. Review of the facility's Prevention and Control of Seasonal Influenza policy, undated, showed: -The Infection Preventionist will promote and administer seasonal influenza vaccine; -Unless contraindicated, all residents and staff will be offered the vaccine. Review of the U.S. Department of Health and Human Services - CDC, pneumococcal and influenza vaccine timing for adults, dated 4/01/2022, showed the following: -Four types of pneumonia vaccines are acceptable for adults 65 years or older, PCV13: 13-valent pneumococcal conjugate vaccine (Prevnar13), PCV15: 15-valent pneumococcal conjugate vaccine (Vaxneuvanc), PCV20: 20-valent pneumococcal conjugate vaccine (Prevnar20), and PPSV23: 23-valent pneumococcal polysaccharide vaccine (Pneumovax); -For those who previously received PPSV23 but who have not received any pneumococcal conjugate vaccine (e.g., PCV13, PCV15, PCV20) you may administer one dose of PCV15 or PCV20. -Regardless of which vaccine is used (PCV15 or PCV20): - The minimum interval is at least 1 year; - Their pneumococcal vaccinations are complete. 2. Review of Resident #32's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 1/13/23, showed the resident's pneumococcal vaccination is not up to date and was not offered. Review of the resident's medical record showed: -Most recent admission date of 1/27/23; -The record did not contain documentation the resident received, refused, or was offered the current pneumococcal vaccine. 3. Review of Resident #47's Quarterly MDS, dated [DATE], showed the resident was offered and declined pneumococcal vaccine. Review of the resident's medical record showed: -Most recent admission date of 11/01/21; -The record did not contain documentation the resident received, refused, or was offered the current pneumococcal vaccine. 4. Review of Resident #56's Quarterly MDS, dated [DATE], showed the resident's pneumococcal vaccination is not up to date and was not offered. Review of the resident's medical record showed: -Most recent admission date of 11/14/22; -The record did not contain documentation the resident received, refused, or was offered the current pneumococcal vaccine. 5. Review of Resident #63's admission MDS, dated [DATE], showed: -The resident's pneumococcal vaccination is not up to date and was not offered; -The resident did not receive influenza vaccine, resident not in this facility during this year's influenza vaccination season. Review of the resident's medical record showed: -Most recent admission date of 1/27/23; -The record did not contain documentation the resident received, refused, or was offered the influenza or current pneumococcal vaccine. 6. Review of Resident #219's MDS, entry tracking record dated, dated 3/03/23 did not include immunization data. Review of the resident's medical record showed: -Most recent admission date of 3/03/23; -The record did not contain documentation the resident received, refused, or was offered the influenza or current pneumococcal vaccine. 7. During an interview on 4/06/23 at 2:09 P.M., the Infection Preventionist (IP) said when a resident is admitted , the front office staff obtains vaccine history and immunization consent forms. The IP said he/she works two days a week and the second day is used to review resident immunization data to see which residents are due for immunizations and give vaccines as needed. The IP added that pneumonia vaccines are offered if it has been five years since the last pneumonia vaccination. The IP said the resident is usually updated on vaccinations within one week of admission and the medical record is updated within two weeks of admission. The IP also said the responsibility for resident immunizations is shared with the Director of Nursing (DON). During an interview on 4/07/23 at 2:09 P.M., the DON said the IP is responsible for resident immunizations. The DON said the pneumococcal vaccine is offered on admission and every five years, based on recommendation of the facility Medical Director. The DON also said every resident should have their immunizations or declination statements in the medical record. During an interview on 4/10/23 at 12:44 P.M., the administrator said the IP and DON are responsible for resident immunizations. The administrator said facility staff check resident immunization status on admission and offer vaccines as needed. The administrator said the medical record should include the combined consent/declination form and if the immunization was given. The administrator also said medical records with no immunization data have not been checked. During an interview on 4/12/23 at 8:53 A.M., the administrator said the flu season runs from October 1 through March 30 and anyone admitted or currently residing at the facility during that time frame should be offered the vaccine.

Based on interview and record review, facility staff failed to maintain and follow current guidance and procedures for immunizations of residents against Covid-19 for five (Residents #32, #47, #56, #63 and #219) sampled residents. The facility census was 69. 1. Review of the facility's Vaccination of Residents policy, undated, showed: -All new residents shall be assessed for current vaccination status upon admission; -If vaccines are refused, the refusal shall be documented in the resident's medical record; 2. Review of Resident #32's medical record showed: -Most recent admission date of 1/27/23; -The record did not contain documentation the resident received, refused, or was offered the Covid-19 vaccine. 3. Review of Resident #47's medical record showed: -Most recent admission date of 11/01/21; -The record did not contain documentation the resident received, refused, or was offered the Covid-19 vaccine. 4. Review of Resident #56's medical record showed: -Most recent admission date of 11/14/22; -The record did not contain documentation the resident received, refused, or was offered the Covid-19 vaccine. 5. Review of Resident #63's medical record showed: -Most recent admission date of 1/27/23; -The record did not contain documentation the resident received, refused, or was offered the Covid-19 vaccine. 6. Review of Resident #219's medical record showed: -Most recent admission date of 3/03/23; -The record did not contain documentation the resident received, refused, or was offered the Covid-19 vaccine. 7. During an interview on 4/06/23 at 2:09 P.M., the Infection Preventionist (IP) said when a resident is admitted the front office staff obtains vaccine history and immunization consent forms. The IP said he/she works two days a week and the second day is used to review resident immunization data to see what residents are due and give vaccines as needed. The IP said the resident is usually updated on vaccinations within one week of admission and the medical record is updated within two weeks of admission. The IP also said the responsibility for resident immunizations is shared with the Director of Nursing (DON). During an interview on 4/07/23 at 2:09 P.M., the DON said the IP is responsible for resident immunizations. The DON also said every resident should have their immunizations or declination statement in the medical record. During an interview on 4/10/23 at 12:44 P.M., the administrator said the IP and DON are responsible for resident immunizations. The administrator said facility staff check resident immunization status on admission and offer vaccines as needed. The administrator said the medical record should include the combined consent /declination form and if the immunization was given, should have immunization information. The administrator also said medical records with no immunization data have not been checked.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to maintain thermometers in the resident room refrigerators, clean vents over resident tables in the dining room, and ensure the ice machine drained through an air gap. This failure had the potential to affect all residents. The census was 69. 1. Review of the facility's Food Storage: Refrigeration in Resident Rooms policy, undated, showed: - Internal thermometers shall be placed in the front section of each unit and shall be large enough for easy visibility; - Refrigeration temperatures shall be maintained below 40 degrees, with a preferred temperature of 36-38 degrees for maximum chilling; - Refrigerator temperatures in residents' rooms shall be monitored daily to ensure the temperature is within the specified range; - The policy did not address documenting refrigerator temperatures; - The policy did not address which staff was responsible to maintain and monitor the refrigerator thermometers. Observation on 4/5/23 at 11:25 A.M., showed: - A refrigerator with food located in resident room [ROOM NUMBER] did not contain a thermometer; - A refrigerator with food located in resident room [ROOM NUMBER] did not contain a thermometer and ice was built up in the freezer which prevented the freezer door from closing; - A refrigerator with food located in resident room [ROOM NUMBER] did not contain a thermometer; - A refrigerator with food located in resident room [ROOM NUMBER] did not contain a thermometer and contained gnats inside the refrigerator; - A refrigerator with food located in resident room [ROOM NUMBER] did not contain a thermometer; - A refrigerator with food located in resident room [ROOM NUMBER] did not contain a thermometer; - A refrigerator with food located in resident room [ROOM NUMBER] did not contain a thermometer. During an interview on 4/5/23 at 11:30 A.M., the maintenance director said resident room refrigerators should contain a thermometer to ensure resident food items are maintained at an appropriate temperature. He did not know who was responsible to ensure the temperature was monitored or if the staff should document the temperatures. The maintenance director said staff should discard spoiled food, but sometimes a resident will not let them. The maintenance director said refrigerators with ice build-up need to be defrosted. He did not have any work orders to defrost refrigerators, and he checks for work orders every day. During an interview on 4/7/23 at 2:00 P.M., the dietary manager said the nursing staff are responsible to monitor and maintain the thermometers in resident room refrigerators. Staff should ensure each refrigerator has a thermometer. If the thermometer is missing then the staff should let her know. She can order thermometers for the refrigerators, but no one told her the resident room refrigerators did not have them. During an interview on 4/7/23 at 4:09 P.M., the administrator said resident room refrigerators should contain a thermometer to ensure the food is maintained at a safe temperature. He said housekeeping staff are responsible to check the refrigerators and discard any spoiled food. The housekeeping staff do not document the temperature of the refrigerators. He said it is expected the staff would defrost refrigerators that have excessive ice build-up. The administrator said the facility has a policy regarding resident room refrigerators, and the facility staff are trained on the policy. 2. Review of the facility's policies and procedures showed the facility did not have a policy regarding the vents. Observation on 4/5/23 at 12:33 P.M., showed two dirty vents in the main dining room. Observation also showed residents ate lunch at tables located under the dirty vents. During an interview on 4/7/23 at 2:28 P.M., the maintenance director said he was responsible to ensure vents throughout the facility are clean and free of dust build-up. He checks the vents monthly, but he overlooked the return vents in the dining room. He said it was expected the residents would not eat meals under dusty vents. During an interview on 4/7/23 at 4:09 P.M., the administrator said the maintenance director was responsible to ensure the vents throughout the facility are maintained free of dust build-up. He was not sure if the facility had a policy for the inspection and maintenance of vents, but the maintenance director checks them weekly. He said it was expected staff would not sit residents under dirty vents during meals. 3. Review of the Ice Machine Cleaning policy, showed the policy did not address the air gap. Observation on 4/5/23 at 1:20 P.M., showed the ice machine did not drain through an air gap. Further observation showed the bottom 1/4 inch of the drain pipe with a white substance, and the drain with a black substance where the ice machine drain pipe touched it. During an interview on 4/5/23 at 1:22 P.M., the maintenance director said the ice machine used to drain through an air gap, but he had to adjust the drain pipe. The water would miss the drain and make a big puddle on the floor. During an interview on 4/7/23 at 4:09 P.M., the administrator said the maintenance director is responsible to ensure the ice machine drains through an air gap. The maintenance director checks the ice machine monthly, and he was trained on the policy. The administrator said it is expected the ice machine would be maintained according to regulations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to prevent the misappropriation of three resident's (Resident #1, Resident #2, and Resident #3's) narcotic medications when Certified Medication Technician (CMT) A took the medication without authorization of the residents or the residents' responsible parties. The facility census was 74. 1. Review of the facility's Abuse Prohibition Policy, dated 12/14/2018, showed the policy defined misappropriation of resident's property as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. 2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated 12/29/2022, showed staff assessed the resident as follows: -Moderately impaired cognition; -Diagnosis of Diabetes Mellitus (DM) (a group of diseases that result in too much sugar in the blood, Cerebral Vascular Accident (CVA) (an obstruction or bleed from a blood vessel of the brain that causes damage to the brain), and hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles; -Received scheduled pain management; -Received as needed pain medication; -Experienced pain frequently. Review of the resident's Physician's Order Sheets (POSs), dated February 2023, showed an order for Hydrocodone/Acetaminophen (narcotic pain medication) 5/325 milligrams (mg) take one tablet by mouth every six hours, and take one to two tablets every four hours as needed for breakthrough pain. Review of the resident's Narcotic Log Sheet, dated 1/31/23, showed the count showed 39 pills left. Review showed 37 pills in the medication bubble pack. Review showed two of the medication not signed out by CMT A. 3. Review of Resident #2's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Diagnosis of DM, heart failure (a chronic condition when blood does not pump blood as well as it should), and Peripheral Vascular Disease (PVD) (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs); -Received as needed pain medication. Review of the resident's POSs, dated February 2023, showed an order for Oxycodone (narcotic pain medication) /APAP (tylenol) 5/325 mg take one tablet by mouth every six hours as needed for severe pain. Review of the resident's Narcotic Log Sheet, dated 1/31/23, showed the narcotic count for the Oxycodone/APAP 5/325 mg with six pills left. Review showed CMT A signed out one pill at 6:00 A.M., and a second one at 12:00 P.M. and he/she had signed the medication as given in the Medication Administration Record (MAR). 4. Review of Resident #3's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Diagnosis of DM, depression, and seizure disorder (a disorder in which nerve cell activity in the brain is disturbed, causing seizures); -Pain present occasionally; and -Receives prn pain medication. Review of the resident's POS, dated February 2023, showed an order for Oxycodone 5 mg take one tablet by mouth every four hours as needed for severe pain. Review of the resident's Narcotic Log Sheet, dated 1/31/23, showed the narcotic count for the Oxycodone 5 mg with 26 pills left. Review showed CMT A had signed out two pills one at 7:00 A.M., and a second one at 12:40 P.M. and he/she had signed them as given in the MAR. 5. During an interview on 2/14/23 at 10:30 A.M., the DON said that CMT A was arrested on 1/31/23 for possession of a controlled substance without a prescription. He/She said the narcotics recovered from the employee were identified as narcotics for three residents who were either signed out by her or the count was missing those narcotics. During an interview on 2/15/23 at 11:45 A.M., the officer said he/she was dispatched to the facility on 1/31/23 at approximately 1:30 P.M., for another issue and he/she said while interviewing the CMT A, he/she noticed him/her fidgeting. He/She said he/she searched the CMT and found controlled narcotics on his/her person and he/she did not have a prescription for them so he/she was arrested. During an interview on 2/15/23 at 11:30 A.M., CMT A said when he/she came on duty in the morning he/she was late and did not count with the nurse so around noon he/she did a count and noticed the count was off so he/she popped out the ones that were off and placed the pills in his/her pocket. The CMT said, I know that was my bad, I shouldn't have put them in my pocket, I should have left them in the top of the cart. He/She said, I am also guilty of signing out all my medications for the day but not popping them out. He/She said he/she has worked with the residents and you get to know when a resident will request pain pills. He/She said he/she did not count with anyone else but said he/she told Licensed Practical Nurse (LPN) C that the count had been wrong and they needed to destroy the medications later. He/She said that was not the typical way to handle a count being off and said if a cart count is off it should be counted with a second person. He/She said he/she could not explain why the count sheets were correct with the pills that were found on him/her and that he/she had signed them out to the residents as given for two residents and one residents count were not signed out but found on him/her. The CMT said he/she did not have information about the missing money. He/She said the DON has been after him/her for a while so it had to just all be a set up. During an interview on 2/17/23 at 9:00 A.M., LPN C said he/she did not count the medication cart with CMT A the day of 1/31/23 because he/she was late that morning and by the time the CMT got there he/she was already down the hall busy with resident care. LPN C said typically a cart should always be counted with two staff and if a count is wrong then it should be counted and the discrepancy should be reported to the DON. LPN C said CMT A had never come to him/her to report the count being off and the only time he/she was aware the count was off is when CMT A had been arrested and the MDS Coordinator and DON counted the cart and found missing narcotics. MO00213384

Based on observation, interview and record review, facility staff failed to serve food items to one out of one residents (Resident #19) with a pureed diet order in accordance with the nutritionally calculated menus. The census was 57. Review of the facility's Food Preparation and Service policy, dated July 2014, showed the policy did not address the use of recipes for meal preparation. Review of the facility's Menu Guidelines, no date, showed staff were directed as follows: - Do not change the menu unless it is approved by the Dietician; - When corn is on the menu, the pureed diets should receive pureed corn (not creamed corn). 1. Review of the Resident #19's medical record, showed: - admission date of 8/2/19; - Diagnosis of Alzheimer's and dysphagia (difficulty or discomfort in swallowing, as a symptom of disease); - A physician's order dated, 9/15/20, for pureed diet. Review of the pureed chicken fajita recipe showed staff were directed to blend five #6 scoops of fajita chicken, one cup of water, and one teaspoon of chicken base together in a food processor and blend until smooth, to make five servings. Staff may gradually add a commercial or natural food thickener to achieve a smooth pudding or soft mashed potato consistency. Observation on 2/3/21 at 11:45 A.M., showed [NAME] N prepared pureed chicken fajitas for lunch service. [NAME] N placed one #6 scoop (2/3 cup) of chicken fajita and one cup of hot water into the food processor and blended to a smooth consistency. [NAME] N added an unmeasured amount of commercial thickener to the mixture. [NAME] N said he/she added approximately one and a half teaspoons of commercial thickener. Further observation showed the pureed chicken did not have the consistency of pudding or mashed potatoes when poured into a service container. Review of the recipe showed staff were directed to blend two and a half cups of creamed corn and two tablespoons of melted butter together in a food processor and blend until smooth, to make five servings. Staff may gradually add a commercial or natural food thickener to achieve a smooth, pudding or soft mashed potato consistency. Observation on 2/3/21 at 11:50 A.M., showed [NAME] N prepared pureed corn for lunch service. [NAME] N placed two cups of creamed corn and 2 tablespoons of melted butter into the food processor and blended to a smooth consistency. Further observation showed the pureed cream corn did not have the consistency of pudding or mashed potatoes when poured into a service container. Review of the recipe showed staff were directed to serve tomato juice to residents with a pureed diet order. Further review of the pureed diced tomato salad recipe, showed staff were directed to use salad portions needed from regular prepared recipe, drain, and blend in a food processor until smooth. Staff may add salad dressing or a food thickener to achieve a smooth consistency. Observation on 2/3/21 at 12:40 P.M., showed Dietary Aide (DA) Q prepared pureed diced tomato salad for lunch service. DA Q placed one 4 ounce (oz) scoop of diced tomato salad and poured water into the mixture. Observation showed DA Q used approximately 1/3 cup of water in the diced tomato salad puree. Further observation showed the pureed diced tomato salad did not have the consistency of pudding or mashed potatoes when poured into a service container. Observation on 2/3/21 at 1:15 P.M., of a taste sample of the pureed chicken, showed the pureed chicken fajitas were bland and without any flavor. The pureed chicken and the pureed cream corn did not have the consistency of pudding or mashed potatoes when poured into a service container. During an interview on 2/4/21 at 9:45 A.M., [NAME] N said he/she did not serve tomato juice to the resident with a pureed diet, because the facility does not have it in stock. He/She said they do not keep tomato juice in stock, because none of the residents at the facility will drink it. He/she said he/she did not taste the pureed diced tomato salad with water, because he/she does not like tomatoes. [NAME] N said he/she imagines it tasted the same as tomato juice. Review of the recipe showed staff were directed to place two and a half cups prepared stroganoff and two and a half cups buttered pasta into a food processor and blend until smooth, to make five servings. Staff may add prepared beef broth or a thickener to achieve a smooth, pudding or soft mashed potato consistency. Observation on 2/4/21 at 11:57 P.M., showed [NAME] N prepared pureed stroganoff with noodles for lunch service. [NAME] N placed one #8 scoop (1/2 cup) of mechanically prepared stroganoff with noodles into the food processor. [NAME] N poured broth into the mixture to thin the puree. [NAME] N said the puree should be the consistency of pudding or mashed potatoes. Further observation showed the pureed stroganoff with noodles did not have the consistency of pudding or mashed potatoes when poured into a service container. During an interview on 2/4/21 at 12:55 P.M., the dietary manager (DM) said the cooks should follow the recipes as much as possible. The cooks can make some substitutions in menu items as long as it is similar in nutritive value. The recipes are designed for multiple servings, but the facility has one resident with a puree diet order. The DM said he/she would expect the cooks to make the calculations to adjust the recipe for one resident. Pureed food should be the consistency of pudding or mashed potatoes. The puree should not be a liquid or runny consistency. The dietary staff did not serve tomato juice for the pureed diet order, because the facility did not have any tomato juice. The DM said she orders food in bulk so an entire case would have been wasted for one glass of tomato juice. The DM said if the cook substituted diced tomato salad for the tomato juice then he should have followed the recipe. The DM said he/she believes the diced tomato salad and water puree probably tasted the same as tomato juice, but she did not taste the puree to find out. During an interview on 2/4/21 at 1:51 P.M., the administrator said the food items on the facility menu have a recipe. He said he would expect the cooks to follow the recipe for all diet orders.

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program to provide a safe and sanitary environment to help prevent potential spread of COVID-19 (an acute respiratory illness in humans caused by the coronavirus, SARS-CoV-2), when the staff failed to utilize and apply facemasks appropriately, failed to wash or sanitize their hands after touching their facemask, and failed to store their facemasks in a sanitary manner between uses. The facility census was 57. 1. Review of the Center for Disease Control (CDC) Preparing for Covid-19 in Nursing Homes, updated 11/20/20, showed: Implement Source Control Measures. -Healthcare Personnel (HCP) should wear a facemask at all times while they are in the facility. --When available, facemasks are generally preferred over cloth face coverings for HCP as facemasks offer both source control and protection for the wearer against exposure to splashes and sprays of infectious material from others. Cloth face coverings should NOT be worn by HCP instead of a respirator or facemask if personal protective equipment (PPE) is required. Provide Supplies Necessary to Adhere to Recommended Infection Prevention and Control Practices. Personal Protective Equipment (PPE) -Care must be taken to avoid touching the respirator, facemask, or eye protection. If this must occur (e.g., to adjust or reposition PPE), HCP should perform hand hygiene immediately after touching PPE to prevent contaminating themselves or others. -HCP include, but are not limited to, emergency medical service personnel, nurses, nursing assistants, physicians, technicians, therapists, phlebotomists, pharmacists, students and trainees, contractual staff not employed by the healthcare facility, and persons not directly involved in patient care, but who could be exposed to infectious agents that can be transmitted in the healthcare setting (e.g., clerical, dietary, environmental services, laundry, security, engineering and facilities management, administrative, billing, and volunteer personnel). -Source Control: Use of a cloth face covering or facemask to cover a person's mouth and nose to prevent spread of respiratory secretions when they are talking, sneezing, or coughing. Review of the CDC's Facemask Do's and Don'ts, dated 6/2/20, showed staff are not to touch or adjust their facemask without cleaning their hands before and after they touch it. Review of the CDC's How to Wear Face Coverings Correctly, dated 5/22/20, showed staff are to place it over their nose and mouth and secure it under their chin. Review of the CDC's Strategies for Optimizing the Supply of Facemasks, dated 3/17/20, showed facemasks should be carefully folded so that the outer surface is held inward and against itself to reduce contact with the outer surface during storage. The folded mask can be stored between uses in a clean, sealable paper bag or breathable container. Review of the facility's Pandemic Covid-19 policy, dated 6/18/20, showed: - Multidisciplinary Planning Committee: Cedar Pointe has a planning team that is assigned the responsibility to address Covid-19 preparedness planning. This team includes the Dietary (Food) Services Director; - Staff Training -Covid-19: Staff are trained on how to prevent transmission of Covid-19; - Response Plan to Minimize the Spread of Covid-19: Cedar Pointe will follow the recommendations of the local health department, Department of Health & Senior Services (DHSS), CDC, and Centers for Medicare and Medicaid Services (CMS) to minimize the spread of Covid-19. This plan is implemented by the Administrator and can include, but is not limited to, emphasizing hand and respiratory hygiene; - Response Plan to Minimize the Spread of Covid-19: What staff can do to protect themselves from getting sick is to wash hands often with soap and water and wear PPE as recommended. Observation on 2/3/21 at 8:30 A.M., showed the Dietary Manager (DM), [NAME] N, and [NAME] O stood in the kitchen and did not wear a facemask. Further observations, showed two facemasks lay on top of the paper towel dispenser at the hand washing sink. The DM washed his/her hands, donned (put on) a facemask from the top of the paper towel dispenser, pushed the kitchen door open, and exited the kitchen. The DM did not wash her hands after donning his/her facemask and before touching the kitchen door. Observation on 2/3//21 at 8:40 A.M., showed the DM entered the kitchen, washed his/her hands, removed his/her facemask and laid it on the food preparation table. The DM did not perform hand hygiene after removing his/her facemask. Observation on 2/3/21 at 8:50 A.M., showed [NAME] N and [NAME] O donned facemasks and took the trash outside to the dumpster. [NAME] O exited the building and removed his/her facemask. [NAME] O stood less than six feet away from [NAME] N. Further observation at 8:54 A.M., showed [NAME] N entered the facility, walked through the service hallway and into the kitchen. [NAME] N did not don a facemask when he/she entered the building. Observation on 2/3/21 at 9:07 A.M., showed [NAME] O entered the kitchen, removed his/her facemask, and lay it on the food preparation table. Observation on 2/3/21 at 9:18 A.M., showed the DM entered the kitchen and washed his/her hands. The DM removed the ear loop of his/her facemask from one ear, donned gloves and touched his/her facemask, slices of bread, the refrigerator door, a gallon of milk, a plate and plate cover, a cup, a pitcher of drink, and face mask. The DM did not change his/her gloves or perform hand hygiene after touching his/her facemask. Observation on 2/3/21 at 9:23 A.M., showed [NAME] O entered the kitchen, removed his/her facemask and laid it on the food preparation table. Observation on 2/3/21 at 9:47 A.M., showed the DM entered the kitchen and removed his/her facemask from over his/her nose and mouth. Observation on 2/3/21 at 9:52 A.M., showed [NAME] O donned his/her facemask, touched the kitchen door, and exited the kitchen. [NAME] O did not wash his/her hands after donning his/her facemask and before touching the kitchen door. Observation on 2/3/21 at 10:05 A.M., showed Licensed Practical Nurse (LPN) J and Receptionist R walked across the parking lot near the smoking area. LPN J and Receptionist R did not wear a facemask and stood less than six feet apart. Observation on 2/3/21 at 10:09 A.M., showed [NAME] N and [NAME] O stood at the handwashing sink in the kitchen. [NAME] O did not wear a facemask and stood less than six feet away from [NAME] N. Further observations, showed [NAME] O donned his/her facemask, touched the kitchen door, and exited the kitchen. [NAME] O did not wash his/her hands after donning his/her facemask and before touching the kitchen door. Observation on 2/3/21 at 10:12 A.M., showed [NAME] O entered the kitchen, removed his/her facemask, and laid it on the counter. [NAME] O prepared food for lunch service, and he/she did not wear a facemask. Observation on 2/3/21 at 10:28 A.M., showed a visitor and the Minimum Data Set (MDS) Coordinator sat in the outside smoking area. The visitor and the MDS Coordinator did not wear a facemask and sat less than six feet apart from each other. Observation on 2/3/21 at 10:38 A.M., showed [NAME] P prepared a cake for a meal service. [NAME] P did not wear a facemask. Additional observations, showed [NAME] N, [NAME] O, and the DM stood outside in the parking lot talking to an individual in a truck. [NAME] N, [NAME] O, the DM, and the individual in the truck did not wear a facemask and were less than six feet apart from each other. Observation on 2/3/21 at 10:52 A.M., showed the DM entered the kitchen, removed his/her facemask, laid it on top of the paper towel dispenser, donned his/her facemask, touched the kitchen door, and exited the kitchen. The DM did not wash his/her hands after donning her facemask and before touching the kitchen door. Further observation, showed [NAME] O entered the facility, and he/she did not wear a facemask. [NAME] O entered the kitchen, washed his/her hands, donned his/her facemask, touched the kitchen door, and exited the kitchen. [NAME] O did not wash his/her hands after donning his/her facemask and before touching the kitchen door. Observation on 2/3/21 at 11:25 A.M., showed [NAME] N and [NAME] O stood at the counter and looked at the recipe book. [NAME] O did not wear a facemask and stood less than six feet from [NAME] N. Observation on 2/3/21 at 11:33 A.M., showed [NAME] O entered the kitchen, removed his/her facemask, and laid it on the steam table. Further observation at 12:07 P.M., showed [NAME] O donned the facemask from the steam table and pushed the steam table out the door for lunch service. [NAME] O did not wash his/her hands after donning his/her face mask. Observation on 2/4/21 at 9:35 A.M., showed [NAME] N and [NAME] O in the kitchen, and [NAME] O did not wear a facemask. During an interview on 2/4/21 at 9:40 A.M., [NAME] N and [NAME] O said they have received training on Covid-19, facemasks, social distancing, and hand hygiene. They receive trainings and updates on CDC recommendations monthly. [NAME] N and [NAME] O said they store their facemasks in the kitchen. They are supposed to store their facemasks in a zip lock bag, but [NAME] O said he/she forgets to do that sometimes. [NAME] N and [NAME] O said the facility staff should wear their facemask everywhere in the facility, but they can take it off in the kitchen as long as they remain six feet apart. [NAME] N and [NAME] O said they did not know if the facility has a policy for wearing facemasks in the kitchen. [NAME] N and [NAME] O said staff should perform hand washing when they don and doff (take off) their facemask and whenever they touch or adjust their facemask. During an interview on 2/4/21 at 12:55 P.M., the DM said the facility has a facemask policy. The dietary staff may remove their facemask in the kitchen as long as they remain six feet apart, they are in an enclosed area, and the kitchen doors are closed. The DM said she does not know the facemask storage policy, but facemasks should not be set on the food preparation tables. The DM said staff are expected to wash their hands anytime they touch their facemask. During an interview on 2/4/21 at 12:55 P.M., the administrator said all staff are expected to wear a facemask at all times when in the facility, and this includes the dietary staff. The facility staff may remove their facemasks when they go outside, but they are expected to remain six feet apart.

Based on observation, interview, and record review, the facility failed to serve food under sanitary conditions by not ensuring food was thawed in a safe manner in order to prevent the growth of bacteria, maintaining the separation of food preparation areas from dish washing and handwashing areas to prevent cross contamination, storing rags used for cleaning in a bucket of sanitation solution to prevent the growth of bacteria, and ensuring the ice storage bin is drained through an air gap. The census was 57. 1. Review of the facility's Food Preparation and Service policy, dated July 2014, showed thawing frozen food procedures include submerging the item in cold, running water. Observation on 2/3/21 at 10:15 A.M. showed two bags of frozen liquid eggs and six bags of frozen corn kernels sat in a shallow pan in the food preparation sink under cold water. The bags were not submerged in the water. [NAME] N removed four bags of frozen corn kernels from the shallow pan, opened and poured them into a strainer in the three compartment sink, and turned on the cold water. The frozen corn kernels were not submerged in cold water. Observation on 2/3/21 at 10:38 A.M., showed the two bags of frozen liquid eggs and two bags of frozen corn kernels sat in the shallow pan in the food preparation sink under cold running water. Four opened bags of corn kernels sat in the strainer in the three compartment sink under cold running water. The corn kernels were not submerged in the cold water. Observation on 2/3/21 at 12:07 P.M., showed two bags of partially frozen liquid eggs sat in a shallow pan under cold running water. One bag floated on its side, and one bag stood on its side, partially submerged in water. Observation on 2/3/21 at 1:57 P.M., showed two bags of thawed liquid eggs and one bag of a frozen meat product sat in the shallow pan in the food preparation sink under hot running water. During an interview on 2/4/21 at 10:00 A.M., [NAME] N said food should be thawed in the food preparation sink under cold, running water. The food should be submerged in the cold running water as much as possible. Dietary staff should remove the items when they are thawed. The items should be cooked or refrigerated. He/she used the liquid eggs that were thawed in the sink to make French toast for breakfast this morning. During an interview on 2/4/21 at 11:34 A.M., [NAME] P said he/she place the frozen ham in the sink to thaw yesterday, and it will be used in ham and au gratin potatoes for dinner. [NAME] P said he/she placed the eggs and ham in the refrigerator around 6:15 P.M. after the ham thawed. Food items should be thawed under cold, running water. [NAME] P said he/she did not know how the hot water was running over the food items. 2. Review of the facility's Food Preparation and Service policy, dated July 2014, showed areas for cleaning dishes and utensils are located in a separate area from the food service line to assure that a sanitary environment is maintained. Observation on 2/3/21 at 10:15 A.M., showed [NAME] N thawed four bags of frozen corn kernels in the three compartment sink. The three compartment sink was used for washing large pots and pans and had a chemical sanitation solution dispenser. Staff used the sink to hold buckets of sanitation solution and dirty dishes and utensils. During an interview on 2/4/21 at 10:00 A.M., [NAME] N said staff should not use the three compartment sink for food preparation, because it is used for washing pots and pans. Observation on 2/4/21 at 10:42 A.M., showed [NAME] P prepared a filling for a pie in the stand-up mixer. [NAME] P turned on the faucet of the handwashing sink, measured water in a measuring cup, and poured it into the filling in the stand-up mixer. [NAME] P repeated two more times. 3. Review of the facility's Food Preparation and Service policy, dated July 2014, showed the policy did not address the storage of cleaning rags in the bucket of sanitation solution. Observation on 2/3/21 at 10:52 showed a wet rag from the bucket of sanitation solution laid on the food preparation counter. [NAME] P prepared a Texas sheet cake, used the wet rag to wipe the counter and did not return it to the bucket of sanitation solution. Observation on 2/3/21 at 10:58 A.M., showed [NAME] P mixed cake batter in the stand mixer, wiped his/her gloved hand with the rag on the counter and did not return the rag to the bucket of sanitation solution. Observation on 2/3/21 at 11:05 A.M., [NAME] P opened a stick of butter with the same gloved hands, placed it in a pan on the stove, wiped his/her gloved hand with the rag on the counter and did not return it to the bucket of sanitation solution. Observation on 2/3/21 at 11:08 A.M., [NAME] P took a knife to the dishwasher, sealed a bag of cake mix, picked up a measuring cup, wiped his/her hand on the rag on the counter and did not return it to the bucket of sanitation solution. During an interview on 2/4/21 at 9:40 A.M., [NAME] N and [NAME] O said rags should be stored in the bucket of solution when not in use. The rags should not be left on the counter due to contamination. 4. Review of the facility's Disinfecting Ice Chest and Ice Scope policy, not dated, did not address the air gap for the ice machine drain. During an interview on 2/3/21 at 11:38 A.M., [NAME] P said the facility's ice machine is located in the main dining room. The facility staff use the ice machine for resident drinks and other food related needs. Observation at 12:50 P.M., showed the ice machine located in the main dining room did not have an air gap between the ice machine drain and the floor drain. During an interview on 2/4/21 at 12:38 P.M., the Maintenance Director (MD) said he was aware the ice machine needed a gap between the machine drain and the floor drain. The MD said the facility had one ice machine. 5. Review of the facility's Sanitation-Warewashing policy, dated 1/2019, showed all dinnerware, utensils, preparation, and service supplies shall be washed and sanitized in the pot sink and/or through use of a commercially approved dish machine, and shall be air dried prior to storage. Observation on 2/3/21 at 9:50 A.M., showed [NAME] O unloaded cups and lids from the dishwasher, placed them in a gray bin on a cart, and pushed the cart into the service hallway. The cups and lids were visibly wet. Further observation at 1:57 P.M., showed some of the cups and lids remained in the gray bin in the service hallway. During an interview, nursing staff said the staff use the cups and lids to give the residents water to drink. Observation on 2/3/21 at 11:00 A.M., showed Dietary Aide Q prepared cups of drinks for the residents' lunch. [NAME] O put dishes from the dishwasher away and placed plastic cups from the dishwasher on the tray of cups Dietary Aide Q used for drinks. The cups were visibly wet. During an interview on 2/4/21 at 12:55 P.M., the dietary manager (DM) said food should be thawed under cold, running water. The DM said food should be removed from the water once they are thawed in order to keep the food items out of the danger zone. The DM said she placed the eggs in the sink to thaw, and she turned on cold, running water. She was not aware that the hot, running water was turned on in the afternoon. The DM said one of the bags of liquid eggs was thrown away, because it had a hole in it. The other bag of eggs was used for breakfast. The DM said it was okay to thaw corn kernels in a strainer. It has been done that way for years. The DM said she was not sure what the policy said about thawing food in a strainer, and she was not sure if it was necessary to submerge the food in cold, running water. The DM said the three compartment sink and the handwashing sink should not be used for food preparation because these sinks are considered dirty. The DM said dishes should be completely air dried before they are used for food service. During an interview on 2/4/21 at 1:57 P.M., the administrator said food should be thawed in the refrigerator the day before it is used. Staff can thaw food under cold, running water, but hot water should not be used. Staff should not thaw food in a strainer, because the food item needs to be submerged under cold, running water. Staff should remove the items from the water once they are thawed. The items should be refrigerated or cooked. The eggs that were thawed in the sink yesterday should not have been used. The administrator said kitchen staff should not use the three compartment sink or the handwashing sink for food preparation due to possibility of contaminating the food. The administrator said he and the DM are responsible for ensuring the kitchen staff follow the sanitation guidelines. The administrator said the MD is responsible for ensuring the ice machine is in compliance with regulations. The administrator said there should be an air gap between the ice machine drain and the floor drain. The administrator said dishes and utensils should be completely air dried before staff use them for food service.