Based on interview and review of video from the resident's room and record review, the facility failed to provide care in a dignified and respectful manner for one resident (Resident #4), in a review of eight sampled residents. The resident presented with ALS (amyotrophic lateral sclerosis, a progressive neurological disorder that leads to muscle weakness, atrophy, and eventually paralysis. ALS does not typically affect cognitive functions like thinking, memory, or sensory perception). The resident was dependent on staff for cares and had difficulty communicating both verbally and in writing. The resident wanted a drink and Certified Nurse Aide A interaction with the resident was impatient and dismissive when the resident attempted to communicate his/her preferences. The resident became upset causing further difficulty for the resident in his/her attempts to communicate. The resident felt the aide was disrespectful and should not work with vulnerable residents. The facility census was 85. On 6/4/25 the administrator was notified of the past non-compliance that occurred on 5/28/25. The facility investigated and the DON re-educated CNA A on dignity, respect and appropriate customer service. The DON educated CNA A that Resident #4 utilized a communication board and needed time to answer staff when he/she was asked a question. On 5/30/25 all staff were educated on being courteous and respectful, and treating residents with dignity and respect during interactions. The past non-compliance was corrected on 5/30/25. Review of the facility's Right to Dignity, Respect and Freedom, revised 10/25/23, showed the following: -Residents will be treated with consideration, respect and dignity; -Residents have a right to self-determination. 1. Review of Resident #4's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/8/25, showed the following: -The resident was cognitively intact; -His/Her speech was unclear, but usually understood with ability to express ideas and wants, consider both verbal and non-verbal expression; -He/She required set up assistance with eating; -He/She was dependent on staff for transfers and mobility; -Diagnoses included amyotrophic lateral sclerosis (ALS, a progressive neurological disorder that affects motor neurons in the brain and spinal cord that are responsible for controlling voluntary muscle movement), anxiety disorder (mental health condition where excessive fear or worry interferes with daily life), depression (mood disorder characterized by a persistent feeling of sadness and loss of interest in activities). Review of the resident's Care Plan, dated 6/2/25, showed the following: -The resident had trouble communicating but was usually able to make himself/herself understood; -Allow extra time for response due to slow processing; -Ask yes or no questions; -Be patient and positive; -Adjust tone/volume as needed; -Give the resident instructions with very basic one step commands; -Repeat as needed; -Use gestures to assist the resident in understanding what was meant; -Observe the resident's body language for clues; -Repeat back to the resident what was said to make sure he/she was understood; -He/She used a dry erase board, however, there were times when the resident's writing was not clear and difficult to read; -Offer the resident choices to assist with narrowing down what it is the resident needed; -Social Services worked with the resident in developing a communication ring, with his/her preferences noted throughout the ring; -He/She had ALS; -Assist the resident with meals as needed; -He/She received house shakes (nutritional supplement) with meals three times a day; -Be calm and gentle, do not rush or hurry him/her; -If the resident became agitated during care, grooming or mealtime, stop activity and return five to ten minutes later to attempt or ask another staff member to finish assisting the resident; -Cheerful dialogue with the resident while providing care to encourage and maintain self-esteem. Review of video camera footage, recorded on 5/28/25 at 12:21 P.M. in the resident's room, and viewed by the surveyor on 5/30/25 at 7:45 A.M., showed the following: -Resident #4 sat in his/her room in a wheelchair and Certified Nurse Aide (CNA) A stood at the right side of the resident and the overbed table. A meal tray sat on the overbed table; -The resident started writing on a dry erase board in his/her lap while CNA A stood to the right side; -CNA A asked the resident, You want a vanilla shake? CNA A walked out of camera view; CNA A did not introduce his/herself and greet the resident, and used a flat tone of voice. CNA A did not give the resident time to reply; -CNA A returned to the room with a can and asked, Is this want you want, do you want anything else to drink?; -The resident looked away and CNA A said, We don't have a shake machine, is this what you want, look at it. At this point CNA A's voice became louder and the tone changed to frustration; -The resident pointed and attempted to speak, then CNA A said, Do you want a Coke or Sprite?, -The resident attempted to answer by writing on dry erase board, CNA A said, Yes or no; -The resident continued to write on the dry erase board as CNA A stood on the opposite side of the overbed table. CNA A said, ma'am, while the resident continued to write, then CNA A said, I can't even read that then turned around and said, he/she would get a Coke and moved out of camera view; - CNA A came back into the room with a dark colored drink in a clear cup and said, Here you go, that's all I got; -The resident attempted to communicate verbally to CNA A, but CNA A responded to the resident with, Eat your food and drink your Coke; -The resident was still trying to communicate verbally while CNA A turned around and walked out of the room dismissing the resident; -CNA A's tone of voice throughout the interaction was non therapeutic; -After CNA A moved out of view of the camera, the resident said, help me, help me then dropped his/her arms down and looked down; - CNA A was heard speaking to someone else in the hallway, while the resident said, I can't then paused and spoke help louder; -The resident said, help me, help me, and tried to pull a lap blanket over his/her right leg then the video ended. During an interview on 6/3/25 at 1:34 P.M., the resident communicated the following with a dry erase board; -The resident saw CNA A for the first time on the day of the incident; -CNA A brought orange juice but not coffee for breakfast, even though the resident asked for both; -He/She wrote, it was frustrating because the girl (CNA A) wouldn't give me time to write; -CNA A scared the resident because he/she was impatient, yelled, and wouldn't listen; -The resident felt CNA A was mad and loud; -Immediately after, the resident texted his/her family member to view the video footage; -The family member notified the staff of the incident; -The resident felt CNA A was disrespectful and should not be working with vulnerable residents. During an interview on 6/3/25 at 10:45 A.M., the Director of Nursing (DON) said the following: -CNA A was not assigned to Resident #4's hall and had never worked with the resident; -CNA A was serving room trays at the time of the incident, didn't know the resident was slow to respond or used the dry erase board for communication, and thought the resident was hard of hearing, so he/she spoke louder; -CNA A didn't know what a Magic Shake was or that the resident was supposed to get one; -CNA A became frustrated and left the room, but he/she asked another staff member to go in the room to assist the resident and it only took a few minutes before someone came back in the room to help the resident; -She thought the staff member needed more training on customer service and sensitivity training. During an interview on 6/3/25 at 2:50 P.M., Family Member E said he/she did not want CNA A to return to the resident's room or any other vulnerable resident's room. During an interview on 6/4/25 at 8:25 A.M., the Administrator said the following: -His expectation was all staff members treat all residents with dignity and respect; -Nursing administration should provide staff education to staff regarding dignity and respect. MO254952 MO255042

Based on interview and record review, the facility failed to provide care in a dignified and respectful manner for two dependent residents (Resident #4 and #5), in a review of six residents. Residents reported Certified Nurse Aide (CNA) C was rough while providing care. The facility census was 86. Review of the facility policy Right to Dignity, Respect and Freedom, revised 10/25/23, showed the following: -Residents will be treated with consideration, respect and dignity; -Residents have a right to self-determination. 1. Review of Resident #5's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/15/24, showed the following: -The resident had severely impaired cognition; -He/She was dependent on staff for toileting, hygiene, and transfers; -He/She was always incontinent of bladder and bowel. Review of the resident's Care Plan, dated 9/15/24, showed the following: -Be patient and positive with the resident; -The resident needed assistance with activities of daily living (ADLs); -Be calm and gentle, do not rush or hurry the resident; -He/She was incontinent of bladder and bowel; -Cheerful dialogue with the resident while providing care to encourage and maintain self-esteem; -Monitor the resident for incontinent episodes and provide peri care after each episode; -Offer assistance to toilet every two hours and as needed. During an interview on 11/1/24 at 2:30 P.M., Certified Nurse Aide (CNA) D said the resident was tearful and said CNA C was rough with moving him/her in bed and the resident did not like it. CNA C had not reported this to anyone. During an interview on 11/1/24 at 3:15 P.M., the resident said the following: -A staff member was recently rough with him/her; -The resident was in bed and the staff member rolled the resident in bed and it felt like the staff member was in a hurry and it hurt; -The resident told the staff member that it hurt and the staff member said he/she was sorry but needed to get everything done; -The resident was upset about it and was tearful; -The resident felt he/she did not deserve it and did not want to be a bother. CNA D had asked the resident why he/she was crying and he/she relayed what had happened to him/her. 2. Review of Resident #4's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument, completed by the facility), dated 10/28/24, showed the following: -The resident had moderately impaired cognition; -He/She required maximal assistance with toileting hygiene; -He/She was always incontinent of bladder and bowel. Review of the resident's Care Plan, dated 11/1/24, showed the following: -The resident needed assistance with activities of daily living (ADLs); -Be calm and gentle, do not rush or hurry the resident; -He/She needed two staff members at all times when providing care; -Cheerful dialogue with the resident while providing care to encourage and maintain self-esteem; -If the resident was tearful, the resident wanted the staff to take the time to sit and talk with him/her to find out why and then make an attempt to rectify the problem or build up his/her self-esteem; -Diagnoses of major depressive disorder (serious mood disorder that affects how a person feels, thinks, and acts), mood disorder (mental health condition that affects a person's emotional state, causing long periods of extreme sadness, excessive happiness, or both), and Alzheimer's disease (progressive, irreversible brain disorder that destroys memory and thinking skills). During an interview on 11/1/24 at 12:50 P.M., the resident said the following: -On 10/31/24, CNA C said he/she was busy and asked the resident what he/she wanted now, when the resident used the call light; -On 10/31/24, when providing incontinence care, CNA C grabbed hold of the resident's left arm while rolling the resident over in bed and it hurt; -The resident told CNA C that grabbing onto his/her forearm hurt; -The resident did not report this to anyone else; -The resident was upset and did not understand why CNA C was upset with him/her because normally the resident and CNA C did not have any problems. During an interview on 11/1/24 at 5:05 P.M., the Director of Nursing said the following: -The expectation was staff treat the residents with dignity and respect and to work fast enough to complete resident care, but not to make the residents feel rushed or be rough during the provision of care; -CNA C was the type of employee who wanted to get everything done on his/her shift, so CNA C could have been in a hurry and was unintentionally rough; -She was unaware of the residents' concerns regarding CNA C. MO244399

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to maintain the temperature at a safe and comfortable level for the residents who resided on the third floor, when the blower units for the air conditioner were no longer functioning. The facility did not monitor the air temperatures while waiting for the units to be replaced and did not move residents to an area of the facility that maintained acceptable temperatures. This affected rooms 321 through 331 on the third floor. The facility census was 80. Review of the facility policy for Extreme Temperatures dated [DATE] showed the following: -In the event of a power loss, this facility's central air conditioning and heating systems will not function as they are not on the generator. The follow guidelines should be followed to ensure resident safety during times of heat or air conditioning loss; -Air conditioning Loss: In the event that there is a loss of function in the cooling system during hot weather, the following procedures are to be implemented. When the facility temperature exceeds 81 degrees Fahrenheit and remains so for four hours, the facility should: -Move residents to other air-conditioned portions of the building; -Encourage residents to increase consumption of fluids by making water, juices, and Gatorade; -Make sure an adequate supply of ice is available in the building; -Open windows to let cooler outside air in and utilize fans to move air; -Bring in addition staff, if required to assist; -Monitor body temperatures of the residents in affected areas and notify their attending physicians if necessary; -Relocate residents, if necessary, to assisted living facilities, nursing homes, family, or hospitals in the area with which the facility has agreements if temperatures are unable to be maintained in a 71-81 degree Fahrenheit range; -Monitor environment thermometers on a 24-hour basis. Review of the Centers for Disease Control showed the following guidance: -People aged 65 or older are more prone to heat-related health concerns. Older adults can't adjust to sudden temperature changes as fast as younger people. This may happen because of certain medicines they take or chronic illnesses that affect their ability to regulate body temperature. When not treated properly, heat-related illnesses can lead to death; -There are several types of heat related illnesses with heat stroke being the most serious. Heat stroke occurs when the body can no longer control its temperature; the body's temperature rises rapidly, the sweating mechanism [NAME], and the body is unable to cool down. When heat stroke occurs,the body temperature can rise to 106 degrees Fahrenheit. Heat stroke can cause permanent disability or death if the person does not receive emergency treatment; -Heat Exhaustion is the body's response to an excessive loss of water and salt, usually through excessive sweating. Heat exhaustion is most likely to affect the elderly, people with high blood pressure and those working in a hot environment; -Symptoms of heat exhaustion include: headache, nausea, dizziness, weakness, irritability, thirst, heavy sweating, elevated body temperature and deceased urine output; -First aide for heat exhaustion are call 911 if medical care is unavailable; remove from the hot area and give liquids, remove unnecessary clothing, cool with cold compresses, encourage sips of water. 1. During an interview on [DATE] at 9:08 A.M. the Administrator said the following: -The central cooling system used blower units in certain resident's rooms. There were several rooms on the third floor that the blowers went out last Thursday. The Maintenance Director had the contracted heating and cooling company out on Thursday to look at the system, and they found that the system was working, but the blower units were not. The facility was able to purchase one blower unit locally, but the other six had to be ordered and were due to be delivered this week. There were five resident rooms affected by the blower units being bad all on the third floor. The facility put fans in the affected rooms, Rooms 325, 326, 323, 324 and 327. During an interview on [DATE] at 9:30 A.M. the Maintenance Director said the following: -Last Thursday he was made aware that rooms on the third floor were hot. He called the contracted heating and cooling company and they came out and identified that the blower units in individual rooms were not working; -There were portable air conditioning units in the hall on the third and second floor to help with cooling; -He was able to locate one blower unit locally and replaced the broken on in room [ROOM NUMBER], but had to order units for the other rooms; -He had not been monitoring the temperatures and did not know what an acceptable temperature range should be. Observation on the third floor on [DATE] from 10:00 A.M. to 10:45 A.M., showed the following: -room [ROOM NUMBER] was occupied by two residents with a fan by each resident's bed. The Maintenance Director measured the room air temperature with a digital thermometer; the temperature of the room was 84.7 degrees F.; -room [ROOM NUMBER], a room identified with no functioning blowers and occupied by two residents, had an ambient temperature of 78.8 degrees. There were two fans in the room by each resident's bed were on and blowing on the residents; -room [ROOM NUMBER] a room identified with no functioning blowers and occupied by Resident #4, had an ambient temperature at 80 degrees. There was fan by the resident's bed that was on and blowing on the resident; -room [ROOM NUMBER], a room identified as having no functioning blowers and occupied by two residents, had an an ambient temperature of 86.5 degrees. There was a fan by each resident's bed that was on and blowing on the residents; -room [ROOM NUMBER] occupied by one resident with an ambient temperature of 85.6; -room [ROOM NUMBER] occupied by one resident with an ambient temperature of 81.0 -room [ROOM NUMBER] occupied by two residents with an ambient temperature of 79 degrees; -room [ROOM NUMBER] occupied by two residents with an ambient temperature of 81.1 degrees. Review of the Centers for Disease Control showed the following guidance:: -People aged 65 or older are more prone to heat-related health concerns. Older adults can't adjust to sudden temperature changes as fast as younger people. This may happen because of certain medicines they take or chronic illnesses that affect their ability to regulate body temperature. When not treated properly, heat-related illnesses can lead to death. -There are several types of heat related illnesses with heat stroke being the most serious. Heat stroke occurs when the body can no longer control its temperature; the body's temperature rises rapidly, the sweating mechanism [NAME], and the body is unable to cool down. When heat stroke occurs,the body temperature can rise to 106 degrees Fahrenheit. Heat stroke can cause permanent disability or death if the person does not receive emergency treatment; -Heat Exhaustion is the body's response to an excessive loss of water and salt, usually through excessive sweating. Heat exhaustion is most likely to affect the elderly, people with high blood pressure and those working in a hot environment; -Symptoms of heat exhaustion include: headache, nausea, dizziness, weakness, irritability, thirst, heavy sweating, elevated body temperature and deceased urine output; -First aide for heat exhaustion are call 911 if medical care is unavailable; remove from the hot area and give liquids, remove unnecessary clothing, cool with cold compresses, encourage sips of water 2. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff dated [DATE] showed: -Able to make self understood and able to understand others, some difficulty making decisions; -Requires assistance from staff for Activities of Daily Living (ADL's), dependent upon staff for mobility; -Diagnoses in part of hypertension. During an interview and observation on [DATE] at 10:45 A.M. of Resident #1 in room [ROOM NUMBER] showed the following: -The resident lay in the bed with a sheet covering him/her and a portable fan next to the bed blew air on the resident. The resident appeared disheveled and his/her face slightly flushed: -The resident said the room was hot. His/Her family brought him/her in a fan this weekend due to the room being so hot. It was better now that he/she had a fan. 3. Review of Resident #3's comprehensive MDS dated [DATE] showed: -Able to make self understood, usually understands others. Difficulty with make appropriate decisions; -Assistance from staff with ADL's, and dependent upon staff for mobility; -Diagnosis in part of hypertension, dementia, arthritis and urinary tract infection. During an interview on [DATE] at 10:59 A.M. Resident #3's family member said the resident just moved into room [ROOM NUMBER] in the past couple of weeks. The room was very warm. There was an air conditioner but it did not seem to keep the room cool. 4. Review of Resident #5's quarterly MDS dated [DATE] showed: -Able to make self understood and able to understand others. Some difficulty with making decisions; -Assistance with ADL's and dependent upon staff for mobility; -Diagnoses of stroke with paralysis on one side of the body, heart disease, hypertension, diabetes and dementia. During an interview and observation on [DATE] at 11:00 A.M. Resident #5 said: -He/She lives in room [ROOM NUMBER]; -The resident sat in the hall way by the portable air conditioning unit and wore shorts and a shirt; -He/she lived on the third floor and it was hot in his/her room and in the hall way. During an interview on [DATE] at 11:15 P.M. the Administrator said: -He did not know if the facility had a policy regarding temperatures or what to do if the cooling system fails; -He will be assessing residents to move them to a cooler place in the facility and the staff will be providing refreshments to all residents. Nursing will be monitoring the residents closely. -He will purchase more fans and/or portable air conditioning units to cool the facility until the blower units can be repaired. During an interview on [DATE] at 1:00 P.M. the Administrator said:he found the policy for the temperatures and what to do if the heating or air conditioner fails and began implementing the policy after the survey left on [DATE]. MO237680

Based on interview and record review, the facility failed to report an injury of unknown origin as required to the state survey agency for one resident (Resident #51), in a review of 18 sampled residents. The facility census was 73. Review of the facility policy, Abuse Prevention, date (last revised 09/10/23), showed the following: -The facility is committed to protecting the residents from abuse by anyone including, but not limited to facility staff, other residents, and staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual; -Identification: -Identify events, such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse; and to determine the direction of the investigation; -The administrator and director of nurses (DON) must be promptly notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after hours, the administrator and DON must be called at home or must be paged and informed of such incident; -Investigation: -The administrator, or designee, shall report any allegations of abuse, neglect or misappropriation of resident property as well as report any reasonable suspicion of crime in accordance with Section 1150B of the Social Security Act to the Department of Health as required; -Reporting: -Alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury; -Report the results of all investigations to the administrator or designated representative and other officials in accordance with state law including State Survey Agency within 5 working days of the incident. 1. Review of Resident #51's face sheet, undated, showed the resident had a legal guardian. Review of the resident's medical diagnoses profile, undated, showed the resident had a diagnosis of unspecified psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with external reality) not due to a substance or known physiological condition. Review of the resident's clinical order sheet, undated, showed aspirin (blood thinner) oral tablet, chewable, 81 milligrams (mg) by mouth daily (08/31/23), open-ended (no stop date). Review of the resident's nursing progress notes on 03/21/24 at 11:09 P.M. showed licensed practical nurse (LPN) A documented the following: -While the aide was providing peri care (washing the genitals and anal areas) he/she notified this nurse that there was a bruise on the resident. When this nurse entered the room the resident was in bed, supine (lying flat on his/her back). Aide pulled back diaper and this nurse noticed a small bruise to the pubis of resident (one of the three main bones that make up the pelvis-the area between the trunk or main body-and the lower extremities; -No other bruising was noted. No pain. (Resident) says that there was not much feeling in his/her pubic, lower abdominal area and did not recall an incident that would have caused the bruise; -Assessed the bruise and areas around the bruise. Assessed other areas of the body for bruising. Skin was clear; -Called and spoke to resident's guardian to update on the findings. No further questions or concerns at this time. Called primary care provider (PCP) service and reported the findings to the PCP. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 04/28/24, showed the following: -Cognition severely impaired; -No behavioral symptoms; -No rejection of cares; -Dependent for toileting and mobility. Review of the resident's care plan, dated 05/19/24, showed the following: -The resident received a daily aspirin and had anemia (a condition in which the blood doesn't have enough healthy red blood cells and hemoglobin, a protein found in red blood cells, to carry oxygen all through the body); -The resident will have not unknown bruising or profuse bleeding through his/her next review; -Check the resident's skin for bruising weekly. During an interview on 06/05/24 at 10:35 A.M., LPN A said the following: -He/She assessed the resident after a Certified Nurse Aide (CNA) told him/her there was a bruise on the resident; -The bruise was pale bluish gray in color and looked older, not necessarily new; -The bruise was about the size of a dime; -There was no other bruising on the resident, the resident had not had any falls or reported injuries; -He/She called the resident's next of kin and the primary care provider, but did not notify the Director of Nurses (DON) or administrator; -He/She did not consider the bruise might be from abuse because it did not look that concerning and it was small. If it had been larger, he/she would have reported it; -He/She now thought maybe he/she should have reported the bruise because of its location on the resident's body. During an interview on 06/05/24 at 1:10 P.M., the DON said the following: -She was not aware of the bruise that was found on the resident on 03/21/24 until the state agency brought it to her attention; -LPN A should have reported the injury of unknown origin (bruise) to administration when it was discovered; -Her expectation would be that all bruises, regardless of the presumed age or size, are reported, especially if it was a bruise of unknown origin; -Any bruise, regardless of presumed age or size, could be a potential sign of abuse and should be investigated immediately and reported to the state agency within the time frame defined by the regulation. During an interview on 6/14/24 at 9:30 A.M., the administrator said the following: -He was not aware of the bruise that was found on the resident until the state agency brought it to his attention; -LPN A should have reported the injury of unknown origin (bruise) to administration when it was discovered; -A bruise on a resident, regardless of the size or presumed age, should be reported immediately; -Upon finding an injury or bruise of unknown origin, the facility staff should contact the DON and administrator so an immediate investigation could be started, this would include interviews with all staff and residents, collection of statements by all involved to help identify the source of the injury or bruise and to identify if there were any concerns for intentional abuse; -Upon notification of an injury or bruise of unknown origin on a resident, following a thorough investigation, the administrator would report this incident immediately to the state agency, within two hours if concerns are related to possible abuse or neglect.

Based on interview and record review, the facility failed to thoroughly investigate bruising of unknown origin that occurred for one resident (Resident #51), in a review of 18 sampled residents, to identify cause. The facility census was 73. Review of the facility policy, Abuse Prevention, date (last revised 09/10/23), showed the following: -The facility is committed to protecting the residents from abuse by anyone including, but not limited to facility staff, other residents, and staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual; -Identify events, such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse; and to determine the direction of the investigation; -The administrator and director of nurses (DON) must be promptly notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after hours, the administrator and DON must be called at home or must be paged and informed of such incident; -The facility will initiate at the time of any finding of potential abuse or neglect an investigation to determine cause and effect, and provide protection to any alleged victims to prevent harm during the continuance of the investigation; -Suspected or substantiated cases of resident abuse, neglect, misappropriation of property, or mistreatment shall be thoroughly investigated, documented, and reported to the physician, families, and/or representative, and as required by state guidelines. 1. Review of Resident #51's face sheet, undated, showed the resident had a legal guardian. Review of the resident's medical diagnoses profile, undated, showed the resident had a diagnosis of unspecified psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with external reality) not due to a substance or known physiological condition. Review of the resident's clinical order sheet, undated, showed aspirin (blood thinner) oral tablet, chewable, 81 milligrams (mg) by mouth daily (08/31/23), open-ended (no stop date). Review of the resident's nursing progress notes on 03/21/24 at 11:09 P.M. showed licensed practical nurse (LPN) A documented the following: While aide was providing peri care (washing the genitals and anal area) he/she notified this nurse that there was a bruise on the resident. When this nurse entered the room the resident was in bed, supine (lying flat on his/her back). Aide pulled back diaper and this nurse noticed a small bruise to the pubis of resident (one of the three main bones that make up the pelvis-the area between the trunk or main body-and the lower extremities). No other bruising was noted. No pain. (Resident) says that there's not much feeling in pubic, lower abdominal area. Does not recall an incident that would have caused the bruise. Assessed bruise and areas around the bruise. Assessed other areas of the body for bruising. Skin was clear. Called and spoke to resident's guardian to update on the findings. No further questions or concerns at this time. Called primary care provider (PCP) service and reported the findings to the PCP. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 04/28/24, showed the following: -Cognition severely impaired; -No behavioral symptoms; -No rejection of cares; -Dependent for toileting and mobility. Review of the resident's care plan, dated 05/19/24, showed the following: -Problem: The resident received a daily aspirin and had anemia (a condition in which the blood doesn't have enough healthy red blood cells and hemoglobin, a protein found in red blood cells, to carry oxygen all through the body); -Goal: the resident will have not unknown bruising or profuse bleeding through his/her next review; -Approach: check the resident's skin for bruising weekly. During an interview on 06/05/24 at 10:35 A.M., LPN A said the following: -He/She assessed the resident after a certified nurse aid told him/her there was a bruise on the resident; -The bruise was pale bluish gray in color and looked older, not necessarily new; -The bruise was about the size of a dime; -There was no other bruising on the resident, the resident had not had any falls or reported injuries; -He/She called the resident's next of kin and the primary care provider, but did not notify the director of nurses (DON) or administrator; -He/She did not consider that the bruise might be from any abuse because it did not look that concerning and it was small, if it had been larger, he/she would have reported it; -He/She now thought maybe he/she should have reported the bruise because of its location on the resident's body; -He/She had abuse and neglect training when he/she was hired by the facility and on a yearly basis, the last in-service on abuse and neglect was in the past couple of months. During an interview on 06/05/24 at 1:10 P.M., the DON said the following: -She was not aware of the bruise that was found on the resident until the state agency brought it to her attention; -LPN A should have reported the injury of unknown origin (bruise) to administration when it was discovered; -Her expectation would be that all bruises, regardless of the presumed age or size, are reported, especially if it was a bruise of unknown origin; -Any bruise, regardless of presumed age or size, could be a potential sign of abuse and should be investigated immediately. During an interview on 6/14/24 at 9:30 A.M., the administrator said the following: -He was not aware of the bruise that was found on the resident until the state agency brought it to his attention; -LPN A should have reported the injury of unknown origin (bruise) to administration when it was discovered; -A bruise on a resident, regardless of the size or presumed age, should be reported immediately; -Upon finding an injury or bruise of unknown origin, the facility staff should contact the DON and administrator so an immediate investigation could be started, this would include interviews with all staff and residents, collection of statements by all involved to help identify the source of the injury or bruise and to identify if there were any concerns for intentional abuse; -Upon notification of an injury or bruise of unknown origin on a resident, following a thorough investigation, the administrator would report this incident immediately to the state agency, within two hours if concerns are related to possible abuse or neglect.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medication was administered per policy and as ordered, for one resident, Resident #55. The resident had a feeding tube (a tube inserted through the skin and the stomach wall to access for liquid nutrition and medications). Staff administered the resident's medications and did not flush appropriately between medications, and did not follow facility policy when preparing medications for dissolved medications or flushing with administration. This resulted in a medication error rate of 23.3% with 43 opportunities observed with ten errors. The facility census was 79. Review of the facility's General Guidelines for Administering Medications via Enteral Tube (Enteral feeding tubes allow liquid food to enter your stomach or intestine through a soft, flexible tube which enters a surgically created opening in the abdominal wall) Policy, revised January 2018, showed the following: -The facility assures the safe and effective administration of enteral formulas and medications via enteral tubes. Selection of enteral formulas, routes and methods of administration, and the decision to administer medications via enteral tubes are based on nursing assessment of the resident's condition, in consultation with the physician, dietitian, and consultant pharmacist; -Procedures: -ln service training on bacteriological (related to the study of bacteria, especially those that cause disease) safety, administration, and monitoring of enteral solutions and medications via the enteral tube is provided by the facility to nursing personnel; -Enteral tubes are flushed with at least 15 milliliters (A measure of volume in the metric system) mL of purified or sterile water before administering medications, between each medication, and after all medications have been administered; -Each medication is administered separately to avoid interaction and clumping. The enteral tubing is flushed with at least 15 mLs of water between each medication to avoid physical interaction of the medications. Tablets, powders, and beads (never crushed) from opened capsules, are mixed with 15-30 mLs of water prior to administration via the tube. Review of Lippincott's Clinical Do's and Don'ts (a manual of nursing practice), Administering Medication Through a Gastrostomy Tube (GT), dated, December 2002, showed the following: -If a medication is available only in tablet form, check with the pharmacist before crushing it. Also ask about compatibility of the medication with the feeding formula; -If a tablet can be safely crushed, use a pill crusher to grind it to a fine powder and mix it with 30 to 50 mL of warm water; -Remove the GT plug and attach a 30 to 60 mL piston syringe. (Interrupt continuous tube feedings, if necessary); -Release the GT clamp. To verify tube placement and patency, aspirate for gastric contents, not the residual volume, and follow our facility's policy for reinstilling it. Clamp the GT, remove the syringe, and take out the plunger; -Reattach the syringe and unclamp the GT. Pinch the tubing to seal it and add 30 ml of water to the syringe. Release the tubing, let the water flow by gravity to flush it. Clamp the GT, remove the syringe, and take out the plunger; -Reattach the syringe and unclamp the GT. Pinch the tubing to seal it and add 30 mL of water to the syringe. Release the tubing, let the water flow by gravity to flush it, and pinch it again before the syringe empties; -Pour the diluted medication into the syringe and release the tubing to administer it. If you are giving more than one drug, flush between each dose with 15 to 30 mL of water, clap the GT, and replace the plug; -Document all liquids administered, including the flushes, on the patient's intake and output record; -Do not reclamp the tubing after administering a medication without flushing it. 1. Review of Resident #55's care plan, revised on 1/15/24, showed the following: -He/She was dependent on his/her gastrostomy tube (a tube inserted through the wall of the abdomen directly into the stomach. It allows air and fluid to leave the stomach and can be used to give drugs and liquids, including liquid nutrition to the resident); -Check his/her g-tube placement via air auscultation or aspiration of stomach contents prior to giving medications or when reconnecting the tube; -The head of bed (HOB) should be elevated 30-45 degree at all times when nutrition is infusing, the tube is being flushed, meds are being given; essentially when GT is in use; -Flush the g-tube as ordered. Review of the resident's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/02/24, showed the following: -He/She had severe cognitive impairment; -His/Her diagnoses included anemia Parkinson's disease, malnutrition, depression, and psychotic disorder; -He/She was taking high risk drug classes which included antipsychotic, antianxiety, antidepressant, antibiotic, and opioid medications; -He/She had a feeding tube. Review of the resident's Physician Order Summary, dated June 2024, showed the following: -Diagnoses included severe protein-calorie malnutrition (a condition caused by not getting enough calories or the right amount of key nutrients, such as vitamins and minerals, that are needed for health), iron deficiency anemia (a condition that develops when your blood produces a lower-than-normal amount of healthy red blood cells), psychotic disorder with hallucinations due to known physiological condition (mental illnesses that are characterized by psychotic symptoms, which can generally be described as a loss of contact with reality); major depressive disorder(a common mental disorder which involves a depressed mood or loss of pleasure or interest in activities for long periods of time), age related osteoporosis (deterioration in bone mass with increasing risk to fragility fractures) with current pathological fracture, vitamin d deficiency, thyrotoxicosis (a clinical state of inappropriately high levels of circulating thyroid hormones in the body), Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), dysphagia (difficulty swallowing foods or liquids), gastrostomy status (an artificial entrance to your stomach) , enterocolitis (inflammation of both the small intestine and the colon) due to clostridium difficile (bacterium that causes an infection of the colon) and , fistula (an abnormal opening or passage between two organs or between an organ and the surface of the body) of stomach and duodenum (the first part of the small intestine); -Crush meds and give through g-tube every shift for dysphagia, order start date 8/20/23; -Flush with 20 cc of water (H2O) before and after every pill, every shift for fluid replacement, order started 8/20/23; -Multivitamin liquid, give 5 ml via g-tube one time a day for vitamin deficiency, order started 11/17/23; -Ferrous sulfate (iron) oral tablet 325 mg, give one tablet via g-tube in the morning for anemia, order started 11/17/23; -Florastor (probiotic) oral capsule 250 mg, give 1 capsule via g-tube one time a day for C-diff, order started 12/09/23; -Ropinirole HCl (restless legs syndrome) oral tablet 0.25 mg, give 1 tablet via g-tube two times a day for Parkinson's give 0.25 mg two times a day and 0.50 mg at bedtime, order started 12/15/23; -Methimazole oral tablet, give 2.5 mg via g-tube two times a day for hyperthyroidism, order started 1/12/24. -Vancomycin (antibiotic) HCl oral suspension 250 mg, give 250 milligrams via g-tube one time a day for colitis, order started 1/19/24; -Nuplazid oral capsule 34 mg, give 1 capsule via g-tube in the morning for hallucinations related to Parkinson's disease, order started 2/16/24; -Celecoxib oral capsule 100 mg, give 1 capsule via g-tube two times a day for pain/discomfort, order started 2/16/24; -Escitalopram oxalate 5 mg oral tablet, give 5 mg via g-tube in the morning for depression, order started 2/20/24; -Enteral feed order every shift Osmolite 1.5 run at 50 milliliters per hour (mL/hr) per pump with 150 mL flush every 6 hours, order started 4/22/24; -Hydrocodone-acetaminophen oral tablet 5-325 mg, give 1 tablet via g-tube one time a day for pain, order started 5/09/24. Review of the resident's Medication Administration Record (MAR), dated 6-05-24, showed the following: -Crush meds and give through g-tube every shift for dysphagia; -Flush with 20 cc H2O before and after every pill, every shift for fluid replacement; -The administration box showed LPN B documented he/she administered the following A.M. medications: -Ferrous sulfate oral tablet 325 mg, give one tablet via g-tube in the morning for anemia; -Florastor oral capsule 250 mg, give 1 capsule via g-tube one time a day for C-diff; -Hydrocodone-acetaminophen oral tablet 5-325 mg, give 1 tablet via g-tube one time a day for pain; -Lexapro 5 mg oral tablet, give 5 mg via g-tube in the morning for depression; -Multivitamin liquid, give 5 ml via g-tube one time a day for vitamin deficiency; -Methimazole oral tablet, give 2.5 mg via g-tube two times a day for hyperthyroidism, order started 1/12/24. -Nuplazid oral capsule 34 mg, give 1 capsule via g-tube in the morning for hallucinations related to Parkinson's disease; -Vancomycin HCl oral suspension, give 250 milligrams via g-tube one time a day for colitis; -Celebrex oral capsule 100 mg, give 1 capsule via g-tube two times a day for pain/discomfort; -[NAME] oral tablet, give 2.5 mg via g-tube two times a day for hyperthyroidism; -Ropinirole HCl oral tablet 0.25 mg, give 1 tablet via g-tube two times a day for Parkinson's give 0.25 mg two times a day and 0.50 mg at bedtime. Observation on 6/05/24 at 8:48 A.M., 9:11 A.M., 9:50 A.M., and 9:54 A.M. showed Licensed Practical Nurse (LPN) B prepared the residents' medications as follows: -He/She sat out ten empty medication cups on top of the medication cart; -He/She took an empty medication cup to the medication storage room and filled it with 250 ml of the resident's bottle of vancomycin located in the refrigerator; -He/She went back to the medication cart and pulled the following medications out of the cart: -1. Ferrous sulfate oral tablet 325 mg; -2. Florastor oral capsule 250 mg; -3. Hydrocodone-Acetaminophen oral tablet 5-325 mg; -4. Escitalopram oxalate 5 mg oral tablet; -5. Multivitamin liquid 5 ml; -6. Nuplazid oral capsule 34 mg; -7. Ropinirole HCl oral tablet 0.25 mg; -8. Celecoxib oral capsule 100 mg; -9. Methimazole oral tablet 2.5 mg; -He/She placed each medication in a separate medication administration cup; -He/She emptied the contents of each capsule in a separate medication administration cup; -He/She added 5 ml of water to each medication cup to dissolve each pill/capsule; -He/She unhooked the feeding tube from the G-tube and checked residual (250 ml); -He/She attached a syringe to the g-tube and put 20 mL of water in the tube; -He/She administered two unidentified medications into the tube without flushing in between the medications; -The tube became clogged and LPN B called the alternate physician for the resident who came into the facility to evaluate the resident; -The alternate physician assessed the resident and then asked LPN B to push 20 mL of water through the tube. LPN B was able to push the water through and then flushed with another 20 mL of water; -He/She then proceeded to finish the medication pass. He/She emptied seven unidentified medications into the tube and flushed with 20 mL of water. LPN B forgot to give the resident his/her hydrocodone-acetaminophen oral tablet 5-325 mg pain medication. He/She then administered the hydrocodone-acetaminophen oral tablet 5-325 mg through the resident's tube and hooked the feeding tube back up to the pump; -He/She did not flush with 20 mL of water between each medication; -He/She did not flush with 20 mL of water after the last medication was given before he/she attached the feeding tube back up to the g-tube. During an interview on 6/05/24 at 10:03 A.M., LPN B said when he/she administers medications via g-tube, he/she will put each medication in a separate medication cup and add 5 mL of water and let all the medications dissolve completely. If medications are a capsule, he/she will empty the capsule in an empty administration cup. He/She will disconnect the feeding tubing from the g-tube and check the residual volume. He/She will flush the g-tube with 20 mL of water before administering any medication and again when all of the medications have been given, before hooking the feeding tube and pump back up. During an interview on 6/05/24 at 10:17 A.M., the resident's alternate care physician said he/she would expect physician orders to be followed when administering medications through a feeding tube. During an interview on 6/05/24 at 12:34 P.M., the Director of Nursing (DON) said she expected facility policies and physician orders to be followed. Staff should get clarification on physician orders if there is a question about medications being administered through a gastrostomy tube.

Based on observation and interview, the facility failed to maintain and repair essential food preparation equipment in the main facility kitchen. The facility census was 73. 1. Observation on 6/3/24 at 1:51 P.M., showed the meat slicer sat on a metal tray on top of the metal preparation counter and was covered with a vinyl/plastic cover. A layer of yellowish grease or liquid sat in the bottom of the tray and the base of the meat slicer sat in the liquid. During interview on 6/3/24 at 1:56 P.M. and on 6/4/24 at 2:24 P.M., the Dietary Director said the following: -She had worked at the facility for 16 years in dietary and had been the dietary director since September 2023; -The meat slicer was broken and had been broken for a couple of years. The grease in the bottom is from the meat slicer possibly leaking oil. The machine has not been in use. 2. During interview on 6/5/24 at 9:36 A.M., the Consultant Dietitian said the meat slicer had not worked since the COVID-19 pandemic and had not been used much in the last 2-3 years. During interview on 6/5/24 at 9:50 A.M. and at 1:00 P.M., the Dietary Director said the meat slicer did not work properly and was unsafe to use because the blade did not safely attach to the unit. The slicer was not being used by the dietary department. The meat slicer would be used on a daily basis if the unit was functional. The meat slicer was from the 1960's. She had tried to look for parts in the past but was unable to find replacement parts. The facility owners and administrator were aware that the meat slicer did not work properly. During interview on 6/5/24 at 2:24 P.M., the Administrator said he thought the dietary staff had used the meat slicer over the Winter. He was unaware that the slicer was not safe to use. He would like to buy the kitchen a new slicer but there had been budget restraints.

Based on observation, interview, and record review, the facility failed to maintain the ice machine to be free of an accumulation of debris, failed to ensure food and beverage items were labeled, dated, properly stored and discarded when expired, failed to ensure open cans of foods were properly maintained during food preparation; failed to ensure a scoops was not stored inside a bulk food container, and failed to ensure staff used safe food handling techniques during meal service in the dining room. The facility census was 73. 1. Review of the undated facility policy, Cleaning Instructions: Ice Machine and Equipment, showed the ice machine and equipment (scoops) will be cleaned on a regular basis to maintain a clean, sanitary condition. Observation on 6/3/24 at 12:20 P.M. and on 6/4/24 at 9:11 A.M. showed the ice machine in the main kitchen had a buildup of pink and black debris on the white plastic interior portion of the unit. A small amount of white crusty debris was in the corners near the hinges. During interview on 6/4/24 at 2:24 P.M., the Dietary Director said an outside vendor fully cleaned the ice machine once or twice a month. The machine was completely emptied, cleaned and allowed to refill. Dietary staff cleaned and areas of buildup in the ice machine every week or so. During interview on 6/5/24 at 9:36 A.M. the Consultant Dietitian said the ice machine should be clean and could harbor bacteria if not maintained properly. 2. Review of the undated facility policy, Food Storage, showed the following: -Food is stored, prepared and transported at appropriate temperatures and by methods designed to prevent contamination; -All containers must be legibly and accurately labeled; -Food should be dated as it is placed on the shelves; -Date marking to indicate the date or day by which a ready-to-eat, potentially hazardous food should be consumed, sold, or discarded will be visible on all high risk food. Observation on 6/3/24 at 12:23 P.M. of the reach-in refrigerator in the kitchen showed a clear plastic pitcher contained red liquid. The pitcher was not labeled or dated. An additional clear pitcher of orange liquid was not labeled or dated. Observation on 6/3/24 at 12:24 P.M. showed a 24-ounce bottle of chocolate syrup was mostly empty and sat on a tile ledge in the corner of the kitchen next to a metal storage rack and the four-way reach in refrigerator. The label on the syrup showed to refrigerate after opening. A 32-ounce container of lemon juice sat in the same location. The lemon juice bottle was open and mostly full. The label directed to refrigerate after opening. Observations on 6/3/24 at 12:26 P.M. and on 6/4/24 at 9:11 A.M. showed in another reach-in refrigerator, an entire pork loin, still in the packaging, was completely thawed, and dated 5/23. Four large rolls of thawed hamburger dated 5/30 and two large, thawed roasts were dated 5/30 and 5/31. Observation on 6/3/24 at 12:35 P.M. and on 6/4/24 at 9:11 A.M., of an upright home-type freezer showed an open 12-ounce box of chocolate muffins dated 12/4/23. In addition, a cup containing a frozen ice cream treat was covered and stored in the freezer door. The item was not labeled or dated. Observation on 6/3/24 at 12:38 P.M., on the opposite side of the range hood, showed another opened 32-ounce bottle of lemon juice sat below a smaller flat-top griddle on a metal shelf. The label directed to refrigerate after opening. Observation on 6/3/24 at 12:45 P.M., showed a one-quart container of buttermilk sat inside the small reach-in refrigerator below the sandwich/salad preparation area. The container was bulging and did not have a use by date printed on it, nor did the container have any date written on it. Observation on 6/3/24 at 3:40 P.M. and on 6/4/24 at 9:23 A.M., in the basement level inside the dining room area, a small refrigerator held a plastic container with a strawberry poppy chicken salad labeled with a resident's name. The salad was not dated and appeared watery and slimy inside the container. Observation on 6/4/24 at 9:11 A.M., in the reach-in refrigerator showed the following: -Red liquid was pooled on the bottom of the unit; -The bottle of lemon juice sat on the tile ledge in the corner and was not refrigerated; -The reach-in beverage refrigerator had three clear drink pitchers with no labels or dates and contained orange, yellow and purple liquids. During interview on 6/4/24 at 2:24 P.M., the Dietary Director said the following: -Prepared food/leftovers were good for three days. Items such as dressing and fruit were good for seven days. Dietary staff was responsible for cleaning out the refrigerators every other day. Staff should go by the use by date on boxes of meat to know when meat should be discarded. The date on the raw meat in the refrigerator was the date it was received in the facility. The pork loin needed to be discarded. The cooks were responsible for cleaning out the meat refrigerator every Thursday; -The spill/blood in the bottom of the meat refrigerator should have been cleaned up when discovered. The liquid was from chicken that was thawing; -Drink pitchers should be labeled and dated; -The lemon juice under the stove was used for cleaning and not for consumption. The other lemon juice in the baking area should be refrigerated according to the label. During interview on 6/5/24 at 9:36 A.M. the Consultant Dietitian said all leftovers needed to be labeled and dated. Staff should follow manufacturer's use by dates when available. Leftovers were good for seven days. The date written on the label was the date it was prepared and then placed in the refrigerator. No label would be needed if an item was clearly identifiable. Meat should be used by the best by date. All meat came into the building frozen. The date should be written on the label when meat was placed in the refrigerator to thaw. All meat should be cooked as soon as it was thawed. The pork loin should have been cooked and it had not been done, so the pork should be discarded. 3. Observation on 6/3/24 at 12:36 P.M., showed four 6-lb cans of sliced carrots sat on the preparation counter next to the food processor. The lids had been removed but had been left inside the can. The lids had sunk down into the cans and were submerged approximately 0.50 inches to 1.0-inch down inside the carrot juice. Dates had been written on the can lids with black marker. The black writing had begun to smear and become illegible inside the liquid. Observation on 6/3/24 at 12:46 P.M. showed Dietary Staff C emptied all four cans of carrots into steam table pans and covered the pans with plastic wrap (to prepare them for the evening meal). During interview on 6/4/24 at 2:24 P.M., the Dietary Director said staff write the date canned items were received on the can lid with a black sharpie marker. Staff should open cans and use them right away and not let the lids sink down into the liquid. During interview on 6/5/24 at 9:36 A.M. the Consultant Dietitian said lids on the cans of carrots should have been removed after being opened. 4. Review of the undated facility policy, Food Storage, showed scoops are not to be stored in food or ice containers, but are kept covered in a protected area near the containers. Scoops are to be washed and sanitized on a regular basis as needed. Observation on 6/3/24 at 1:43 P.M. and on 6/4/24 at 9:11 A.M. showed a clear bulk container under the spice storage shelf, was not labeled and appeared to contain cornmeal. A large clear scoop was stored inside the container. During interview on 6/4/24 at 2:24 P.M., the Dietary Director said scoops should not be stored inside food items. During interview on 6/5/24 at 9:36 A.M. the Consultant Dietitian said scoops should not be stored inside containers of stored food items. 5. Review of the undated policy, Hand Washing, showed the following: -Staff will wash hands frequently as needed throughout the day following proper hand washing procedure; -Clean hands and exposed portions of the arms immediately before engaging in food preparation including working with exposed food; -Wash hands after handling soiled equipment or utensils and during food preparations, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks. Review of the undated policy, Use of Plastic Gloves, showed the following: -Plastic gloves will be worn when handling food directly to ensure that bacteria are not transferred from the food handlers' hands to the food product being served; -If used, single use gloves shall be used for only one task (such as working with ready to eat food or with raw animal food), used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation; -Remember gloves are just like hands. They get soiled. Anytime a contaminated surface is touched, the gloves must be changed. Observation on 6/3/24 at 4:53 P.M., showed Dietary staff C bent over the dining room steam table pan of carrots. His/Her nametag on a lanyard fell into and dipped into the pan of carrots. Dietary Staff C appeared unaware that the nametag made direct contact with a food item. Observation on 6/3/24 at 4:56 P.M. showed Dietary Staff C touched the serving utensils in pans of food with his/her gloved-hands. Without changing his/her gloves, he/she handled ready to eat slices of bread by removing slices from the bread bag and placing a slice on the resident's meal plate. He/She repeated this process approximately 15 or more times during the dining room meal service. He/She did not change his/her gloves or wash hands at any point during the dining room meal service. During interview on 6/4/24 at 2:24 P.M., the Dietary Director said staff should use tongs when handling ready to eat food. Staff name tags should not be worn where they can come in contact with food. During interview on 6/5/24 at 9:36 A.M. the Consultant Dietitian said staff should serve ready to eat food with a clean gloved hand, a deli sheet or a utensil. Staff should not handle bread slices with a dirty hand. Staff name tags should not come in contact with food items.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement Enhanced Barrier Precautions (EBP) for four residents (Resident #3, #5, #2, and #1), in a review of six residents who had indwelling medical devices or open wounds. Staff failed to utilize Personal Protective Equipment (PPE) while providing high-contact care activities or wound care. The facility had six residents with indwelling urinary catheters (a sterile tube inserted into the bladder to drain the bladder of urine), one resident with a wound vac (wound management system for open draining wounds), and one resident with a tube feeding (a tube inserted into the stomach to provide nutrition, water and medications). The facility census was 89. Review of Centers for Disease Control (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent the Spread of Multidrug-Resistant Organisms (MDROs, organisms resistant to antibiotic treatment), dated 7/12/22, showed the following: -Summary of recent changes were the added additional rationale for the use of EBP in nursing homes, including the high prevalence of MDRO colonization among residents in the setting. Expanded residents for whom EBP applied to include any resident with an indwelling medical device or wound (regardless of MDRO colonization or infection status), expanded MDROs for which EBP applied and clarified that in the majority of situations, EBP were to be continued for the duration of a resident's admission; -MDRO transmission was common in nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs; -EBPs were infection control interventions designed to reduce transmission of resistant organisms that employed targeted gown and glove use during high contact resident care activities; -EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with wounds or indwelling medical devices, regardless of MDRO colonization status, infection or colonization with an MDRO; -Effective implementation of EBP required staff training on the proper use of PPE and the availability of PPE and hand hygiene supplies at the point of care; -Standard Precautions which were a group of infection prevention practices, continued to apply to the care of all residents, regardless of suspected or confirmed infection or colonization status; -EBP expanded the use of PPE and refers to the use of gown and gloves during high-contact resident care activities that provided opportunities for transfer of MDROs to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices were at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities was indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds, and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. The facility had this CDC guidance they referred to, but no written policy. 1. Review of Resident #3's admission Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 3/5/24, showed the following: -Cognitively intact; -Required an indwelling urinary catheter; -Always incontinent of bowel; -Dependent on staff for toileting and transfers; -Unhealed pressure ulcer (a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and /or friction) Stage III (a full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling)); -Required pressure ulcer care and treatment. Review of the resident's Physician Order Sheet (POS), dated 3/14/24, showed the following: -Provide indwelling urinary catheter care, monitor urine output, check urinary catheter placement every shift; -Flush indwelling urinary catheter with 30 milliliters (ml) of sterile water as needed. Review of the resident's Care Plan, revised 4/18/24, showed the following: -Diagnoses of osteomyelitis (bone infection) of the left ankle and foot, retention of urine, urinary tract infection and muscle weakness; -The resident had a Stage III pressure ulcer to the tailbone on admission and was at risk for skin breakdown related to decline in mobility and incontinence. Staff should apply wound cleaning solution to the left heel and lateral foot, apply gauze and secure; -The resident required an indwelling urinary catheter. Staff should monitor the urine output and change the urinary catheter as the physician ordered; -The resident required two staff members' assistance with Activities of Daily Living (ADLs). Review of the resident's care plan showed no direction for staff to wear EBP while caring for the resident. Review of the resident's POS dated 7/10/24 showed cleanse the left foot ulcer with wound cleanser, apply a gauze dressing and secure with tape twice daily. Observation on 8/6/24 at 1:00 P.M. showed the following: -The resident sat in a wheelchair in his/her room. A sign was posted on the door indicating Enhanced Barrier Precautions were required. A supply of personal protective equipment hung on the room door. The resident had an indwelling urinary catheter and his/her left foot was in a padded boot with a gauze dressing in place; -The Director of Nursing (DON) and Assistant Director of Nursing (ADON) washed their hands, applied gloves, and without putting on a protective gown, sat down directly on the floor in the resident's room near the resident's feet. The ADON removed the padded boot and the gauze wound dressing from the resident's left foot. The DON cleansed the open wound and applied a new gauze dressing. 2. Review of Resident #5's quarterly MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Dependent on staff for eating, toileting, bathing, personal hygiene and bed mobility; -Unhealed Stage III pressure ulcer; -Required pressure ulcer care and treatment. Review of the resident's POS, dated 7/2/24, showed the following: -Diagnoses of muscular dystrophy (genetic disease causing progressive muscle weakness and loss of muscle mass), sepsis (systemic infection), osteomyelitis cystitis (inflammation of the bladder caused by infection), and kidney failure; -Indwelling urinary catheter care every shift, monitor urine output; -Cleanse buttock pressure ulcer with wound cleanser, pack the wound bed with Iodoform packing strips (medicated gauze strip used for packing a wound bed), apply gauze and secure with a dry dressing twice daily and as needed if soiled. Review of the resident's Care Plan, dated 7/17/24, showed the following: -The resident had an indwelling urinary catheter. Staff should change the urinary catheter, monitor the urine output every shift, monitor the urine for changes in appearance, and provide care every two hours and as needed; -The resident had a Stage III pressure ulcer to the buttock and was at risk for skin breakdown related to decline in mobility. Staff should turn and reposition the resident every two hours and as needed. Review of the resident's care plan showed no direction for staff to wear EBP while caring for the resident. Observation on 8/6/24 at 1:20 P.M. showed the following: -The resident lay in bed. The resident had an indwelling urinary catheter; -No EBP signage was noted on the resident's door and no supply of PPE provided in or near the resident's room; -The DON and ADON washed their hands and applied gloves and without putting on a protective gown, turned the resident on his/her side. A soiled gauze dressing was noted on the resident's right hip/buttock area. The DON removed the soiled gauze wound dressing, cleansed the open wound, packed the wound with Iodoform gauze and applied a dry dressing. The resident was incontinent of bowel. The DON and ADON provided incontinence care and repositioned the resident in bed. 3. Review of Resident #2's undated Face Sheet showed diagnoses of enterocolitis (inflammation of the digestive tract that may be caused by various infections), gastrostomy (a surgical procedure that creates an artificial opening into the stomach to provide nutritional support or gastric decompression), noninfective gastroenteritis (an intestinal infection marked by diarrhea, cramps, nausea, vomiting, and fever) and colitis (an inflammatory reaction in the colon, often autoimmune or infectious). Review of the resident's Physician Order Sheet (POS), dated 08/20/23, showed to crush medications and give through the gastrostomy tube (GT). Review of the resident's POS, dated 09/15/23, showed to flush the GT with 20 cubic centimeters (cc) of water before and after every pill. Review of the resident's POS, dated 04/22/24, showed and enteral feed order every shift Osmolite (liquid nutritional supplement) 1.5 at 50 ml/hour per pump. Review of the resident's Care Plan, revised 06/05/24, showed the following: -Staff to apply dry dressing to GT site as ordered; -Staff to flush GT as ordered; -Staff to administer medications via GT as ordered; -Staff to provide nutrition and fluids through the resident's GT. Review of the resident's Quarterly MDS, dated [DATE], showed the following: -The resident had severely impaired cognition; -The resident had a feeding tube. Observation on 08/06/24 at 11:50 A.M. showed the following: -No EBP precaution signage or PPE available for staff in the hallway, on the resident's door or inside the resident's room; -Licensed Practical Nurse (LPN) A sanitized, his/her hands, put on gloves, but did not put on a protective gown. LPN A stopped the resident's continuous feeding tube pump, checked residual (amount of liquid remaining in the stomach obtained with a syringe attached to the feeding tube), flushed the GT with 20 cc of water, administered crushed medications via GT, flushed with 20 cc of water, disconnected the syringe, reconnected the continuous feeding tube at 50 ml/hour per pump, rinsed out the syringe, doffed gloves, and washed his/her hands before leaving the room. During an interview on 08/06/24 at 2:40 P.M., the DON said staff should have been wearing appropriate EBP (a gown and gloves) while providing direct care to the resident with the GT. 4. Review of Resident #1's undated Face Sheet showed he/she had diagnoses that included periprosthetic fracture (a broken bone that occurred around an orthopedic implant such as a hip replacement) around internal prosthetic right hip joint, and infection following a procedure, other surgical site. Review of the resident's Baseline Care Plan, dated 07/08/2024, showed the following: -The resident had received intravenous (IV) antibiotic medications while a resident; -No direction to wear PPE. Review of the resident's POS, dated 07/11/24 showed the following: -Apply Vashe wound external solution 0.033% (wound cleanser) to right hip topically every eight hours as needed for wound care, if wound vac (wound management system for open draining wounds), is off, wet to dry dressing should be done; -Wound Care wet to dry dressing change, clean right hip with Vashe wound solution, pack wound with soaked 4x4 gauze using Vashe solution, cover with 4x4 gauze, ABD pads and secure with paper tape twice daily or every eight hours as needed for wound care, if wound vac is not on please do wet to dry dressing. Review of the resident's POS, dated 07/14/24 showed if wound vac becomes dislodged or leaking from right hip, remove and apply Vashe soaked 4x4 gauze and secure with ABD and secure with paper tape every eight hours as needed for wound to right hip. Review of the resident's admission MDS, dated [DATE], showed the following: -The resident had intact cognition; -The resident had a surgical wound. Review of the resident's POS, dated 07/15/24, showed to change wound vac every Monday and Thursday. Observation on 08/06/24 at 9:25 A.M. showed the following: -The resident lay awake in bed with wound vac in place; -No EBP signage or PPE available for staff in the hallway, on the resident's door, or inside the resident's room. During an interview on 08/06/24 at 9:25 A.M., the resident said he/she had a bad infection, but with antibiotic treatment and the wound vac, was doing much better. 5. During an interview on 08/06/24 at 3:35 P.M., LPN A said the following: -There was no resident on the unit currently on EBP; -On the unit, there was one resident with a wound vac and one resident with a GT; -EBP was to be used only for residents that had a current infection or that had a MDRO present. During an interview on 8/6/24 at 2:15 P.M. the ADON said the following: -She was the facility Infection Preventionist. The facility used EBPs when providing care for residents with medical devices who had MDROs. EBP was not used for residents that were not colonized. Staff were not using EBP for all residents with medical devices such as catheters, feeding tubes, and wound care, unless the resident had a known MDRO. The facility had no current policy regarding EBP use and followed the July 2022 CDC guidelines. She was not aware EBPs were required when providing care or during high-contact resident care activities if the resident had a medical device or required wound care. The facility had developed education materials on the use of EBP, but had not implemented staff education; -The DON and ADON should not sit directly on the floor in a resident's room while providing wound care. The floor was not a clean surface; -EBP signs were posted, and PPE was available in Resident #3's room. EBP was not used while changing the resident's left foot wound dressing. The resident had an indwelling urinary catheter and an open wound with known MDRO colonization. The DON and ADON should have worn a gown in addition to gloves and should wear a mask if there was any risk of spray or splash that could occur while providing care. During an interview on 8/6/24 at 2:30 P.M. the DON said the following: -She was not aware EBP was required during cares for residents with medical devices and during wound care regardless of the resident's MDRO status; -The facility should implement and educate all staff on the use of EBP while providing resident care to all residents with indwelling medical devices, during wound care or when providing high contact resident care activities to residents who have these devices or known MDRO; -She and the ADON should have worn a gown and gloves while providing care and wound treatment for Resident #3 and Resident #5; -Staff should have PPE available for use. During an interview on 8/7/24 at 10:30 A.M. the Administrator said the facility should implement the Enhanced Barrier Precautions policy for all resident who have an indwelling medical device. All staff should wear appropriate PPE when providing high contact care for those residents regardless of the MDRO status to prevent the spread of infections in the facility. The facility needed to develop and implement an EBP policy and educate all the staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide updated pneumococcal vaccine (a vaccine that can protect against pneumococcal disease) education as indicated by the current Centers for Disease Control and Prevention (CDC) guidelines and failed to provide the option to receive the updated vaccination for four residents (Resident #318, #271, #54, and #275), who were admitted after new guidance was released, in a review of 18 sampled residents. The facility census was 73. Review of the facility policy Pneumococcal Policy dated 7/2016 showed: -All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections; -Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated; -Assessments of pneumococcal vaccination status will be conducted within five (5) working days of the resident's admission if not conducted prior to admission; -Before receiving a pneumococcal vaccine, the resident or legal representative shall receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine. (See current vaccine information statements at hnp:www.cdc.gov.vaccines1hcp.vis¹inde:-htmI for educational materials.) Provision of such education shall be documented in the resident's medical record; -Pneumococcal vaccines will be administered to residents (unless medically contraindicated, already given, or refused) per our facility's physician-approved pneumococcal vaccination protocol; -Residents/representatives have the right to refuse vaccination. If refused, appropriate entries will be documented in each resident's medical record indicating the date of the refusal of the pneumococcal vaccination; -For residents who receive the vaccines the date of vaccination, lot number, expiration date, person administering, and the site of vaccination will be documented in the resident's medical record; -Administration of the pneumococcal vaccines or revaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination. Review of the Centers for Disease Control and Prevention (CDC) Pneumococcal Vaccination: Summary of Who and When to Vaccinate, reviewed 9/22/23, showed the following: -Adults 19 through [AGE] years old with any of these conditions or risk factors: 1. Alcoholism or cigarette smoking; 2. Cerebrospinal fluid leak; 3. Chronic heart disease, including congestive heart failure and cardiomyopathies, excluding hypertension; 4. Chronic liver disease; 5. Chronic lung disease, including chronic obstructive pulmonary disease, emphysema, and asthma; 6. Cochlear implant; 7. Diabetes mellitus 8. Decreased immune function from disease or drugs (i.e., immunocompromising conditions); 9. Immunocompromising conditions include: a. Chronic renal failure or nephrotic syndrome; b. Congenital or acquired asplenia, or splenic dysfunction; c. Congenital or acquired immunodeficiency; d. Diseases or conditions treated with immunosuppressive drugs or radiation therapy; e. HIV infection; f. Sickle cell disease or other hemoglobinopathies; -Adults 19 through [AGE] years old who never received any Pneumococcal Vaccine, regardless of risk condition: 1. Give 1 dose of PCV15 or PCV20; 2. When PCV15 is used, it should be followed by a dose of PPSV23 at least one year later. The minimum interval (8 weeks) can be considered in adults with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak. Their vaccines will then be complete; 3. When PCV20 is used, it does not need to be followed by a dose of PPSV23. Their vaccines are then complete; -Adults 19 through [AGE] years old who only Received PPSV23, regardless of risk condition: 1. Give 1 dose of PCV15 or PCV20 at least 1 year after the most recent PPSV23 vaccination; 2. Regardless of vaccine given, an additional dose of PPSV23 is not recommended since they already received it. Their vaccines are then complete. -Adults 19 through [AGE] years old who only received PCV13, who have a risk condition (see above) other than an immunocompromising condition: 1. Give 1 dose of PCV20 or PPSV23; 2. The PCV20 dose should be given at least 1 year after PCV13. When PCV20 is used, their vaccines are then complete; 3. The PPSV23 dose should be given at least 8 weeks after PCV13 for those with a cochlear implant or cerebrospinal fluid leak. The PPSV23 dose should be given at least 1 year after PCV13 for any of the other chronic health conditions. When PPSV23 is used, no additional pneumococcal vaccines are recommended until at least age [AGE] years; -Adults 19 through [AGE] years old who have an immunocompromising condition: 1. Give 1 dose of PCV20 or PPSV23; 2. The PCV20 dose should be given at least 1 year after PCV13. When PCV20 is used, their vaccines are then complete; 3. The PPSV23 dose should be given at least 8 weeks after PCV13. When PPSV23 is used, they need another pneumococcal vaccine at least 5 years later. At that time, give either 1 dose of PCV20 or a second dose of PPSV23. When PCV20 is used, their vaccines will then be complete. When a second PPSV23 dose is used, no additional pneumococcal vaccines are recommended until at least age [AGE] years; -Adults 19 through [AGE] years old who have received PCV13 and 1 Dose of PPSV23 and who have an immunocompromising condition: 1. Give 1 dose of PCV20 or a second PPSV23 dose; 2. The PCV20 dose should be given at least 5 years after the last pneumococcal vaccine. Their vaccines are then complete; 3. The second dose of PPSV23 should be given at least 8 weeks after PCV13 and 5 years after PPSV23. No additional pneumococcal vaccines are recommended until at least age [AGE] years; -Adults 65 years or older who don't have an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak: 1. Give 1 dose of PCV15 or PCV20; 2. When PCV15 is used, it should be followed by a dose of PPSV23 at least one year later. Their vaccines will then be complete; 3. When PCV20 is used, it does not need to be followed by a dose of PPSV23. Their vaccines are then complete; Adults 65 years or older who have an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak: 1. Give 1 dose of PCV15 or PCV20; 2. When PCV15 is used, it should be followed by a dose of PPSV23 at least 8 weeks later. Their vaccines will then be complete; 3. When PCV20 is used, it does not need to be followed by a dose of PPSV23. Their vaccines are then complete. 1. Review of Resident #271's electronic health record showed a signed written consent from the resident's responsible party, dated January 2024, giving the authorization for the resident to receive the immunization. Review of the resident's face sheet showed the resident was over [AGE] years of age and admitted to the facility on [DATE] with acute on chronic systolic (congestive) heart failure (a type of heart failure that occurs when damage to the heart develops over time) and dementia. Review of the resident's physician order sheet (POS), dated 5/25/24, showed the resident may have pneumococcal vaccines. Review of the resident's immunization record on 6/4/24 showed no documentation the resident received the pneumococcal immunization. During an interview on 6/4/24 at 11:15 A.M., the resident's representative said that he/she thought the resident's vaccines were all up to date. 2. Review of Resident #54's face sheet showed the resident was over [AGE] years of age and admitted to the facility on [DATE] with intestinal obstruction (a gastrointestinal condition in which digested material is prevented from passing normally through the bowel). Review of the resident's physician order sheet (POS), dated 5/15/24, showed the resident may have pneumococcal vaccines. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 5/22/24, showed the pneumococcal immunizations were up to date. Review of the resident's immunization record on 6/3/24 showed the following: -PCV13 received on 10/5/15; -PPSV23 received on 3/31/22. Review of the resident's electronic health record on 6/3/24 showed no documentation that the resident had been offered the PCV20. 3. Review of Resident #275's face sheet showed the resident was over [AGE] years of age and admitted to the facility on [DATE] with infection following a procedure (surgical site) and emphysema (chronic lung condition that damages the alveoli, or air sacs, in the lungs). Review of the resident's physician order sheet, dated 5/31/24, showed the resident may have pneumococcal vaccines. Review of the resident's immunization record on 6/3/24 showed no documentation that the resident had received or had been offered or declined the pneumococcal immunizations. 4. Review of Resident #318's clinical census showed the resident was over [AGE] years of age and admitted to the facility on [DATE]. Review of the resident's POS, dated June 2024, showed the following: -The resident's diagnoses included fracture of the left tibia and fracture of shaft of left fibula (bone in the leg); -The resident may have pneumococcal vaccines. Review of the resident's admission assessment MDS, completed by facility staff, dated 3/12/24, showed the pneumococcal immunizations were up to date. Review of the resident's immunization record on 6/4/24 showed the following: -Pneumovax 23 received on 2/04/14; -Prevnar 13 received on 6/14/16. Review of the resident's electronic health record on 6/4/24 showed no documentation that the resident had been offered the PCV20. During an interview on 6/3/24 at 3:30 P.M., the resident said he/she did not recall ever being offered the pneumonia vaccine. During an interview on 6/6/24 at 10:20 A.M., the Director of Nursing (DON) said the following: -She would expect staff to educate and offer vaccines based on CDC guidelines; -She would expect staff to follow physician orders. During an interview on 6/10/24, at 4:30 P.M., the Medical Director (MD) said the following: -He would expect physician orders to be followed; -He would expect staff to at least talk to the residents and educate them on vaccines based on CDC guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to complete inspections of bed frames, mattresses, bed rails/ assist bars as part of a regular maintenance program to identify areas of possible entrapment for four residents, (Resident #1, #24, #32, and #271) in a review of 18 sampled residents who used bed rails. The facility census was 73. Review of the facility's Side Rail Assessment and Consent Policy, dated (last reviewed/revised) 11/16/2023, showed the following: -It is the policy of this facility to provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the residents. The safety of the residents, staff, and visitors are a primary concern. The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. However, some residents desire to use bed rails as assistive and/or transfer devices and are not considered restraints. Because side rails have been implicated in injury up to and including death from entrapment and strangulation, a thorough assessment and consent will be obtained prior to the routine use of side rails to be used as assistive and/or transfer devices and not as a restraint; -Procedure: -Consent will be obtained for residents desirous of using side rails as assistive devices and/or transfer devices prior to use; -The resident or resident representative may provide consent; -A side rail assessment will be completed for residents who desire to use side rails as an assistive or transfer device; -Side rails will be applied according to manufacturer's recommendations; -In the event a gap between the mattress/bed and the side rail is greater than 2.5 inches, then gap stops are required to be in place; -Side rail assessment showing the decision for use is complete, done on admission, on initial use and reviewed quarterly; -Complete a new assessment yearly and at times of a significant change; -If a decision indicates freedom of movement is restricted, a physical restraint assessment must be completed; -All potential risk problems from side rail use such as strangulation and entrapment must be care planned regardless of reason for use. Review of the Food and Drug Administration (FDA) document titled, Guide to Bed Safety Rails in Hospitals, Nursing Homes, and Home Health Care: The Facts, revised April 2010, shows the potential risk of bed rails may include: -Strangling, suffocating, bodily injury, or death when patients or part of their body are caught between rails or between the bed rails and mattress; -More serious injuries from falls when patient climb over rails; -Skin bruising, cuts, and scrapes; -Inducing agitated behavior when bed rails are used as a restraint; -Feeling isolated or unnecessarily restricted; -And preventing patients, who are able to get out of bed, from performing routine activities such as going to the bathroom or retrieving something from a closet. During an interview on 06/06/24 at 10:20 A.M., the director of nurses (DON) said the the facility did not have a bed entrapment policy and procedure. 1. Review of Resident #1's face sheet, undated, showed he/she had a legal guardian. Review of the resident's medical diagnoses sheet, undated, showed the resident's diagnoses included type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy) with diabetic neuropathy (a type of nerve damage that can occur with diabetes) and primary generalized osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time, causing joint pain and stiffness). Review of the resident's clinical physician orders sheet, dated 11/10/23, showed may use assist rail/U bars x2 to enhance self-participation in bed mobility and transfers. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 05/05/24, showed the following: -Cognitively impaired; -Lower extremity impairment on both sides; -Dependent for mobility/transfers; -Bed rails not used. Review of the resident's care plan, dated 05/07/24, showed the following: -The resident needs assist with activities of daily living (ADLs); -Goal: Staff will provide ADLs for the resident; -Approaches: May use assist rails x2 to enhance self-participation in bed mobility and transfers. Review of the resident's medical record showed no evidence of measurements or an evaluation for entrapment zones on the resident's bed. Observation on 06/04/24 at 10:05 A.M. showed the resident lay in his/her bed with mobility bars (inverted, U-shaped bars attached to the bed and fixed to a raised position, to aid mobility) on both sides of the resident's bed. During an interview on 06/04/24 at 10:05 A.M., the resident said he/she used the mobility bars to help him/her turn over in bed. Observation on 06/05/24 at 05:25 A.M. showed the resident lay in his/her bed with mobility bars on both sides of the resident's bed, both rails were slightly loose and could be moved side-to-side and back and forth, with approximately a 3-inch gap between the rail and the mattress. 2. Review of Resident #32's face sheet, undated, showed he/she was his/her own person. Review of the resident's medical diagnoses sheet showed the resident had a diagnosis of acute on chronic diastolic (congestive) heart failure (a decreased function of the heart's ability to pump that may have resulted from damage to the heart, a blockage, or an infection. Acute symptoms such as shortness of breath can occur suddenly, whereas chronic symptoms usually persist on a day-by-day basis). Review of the resident's clinical physician orders sheet, dated 11/10/23, showed may use assist rail/U bars x2 to enhance self-participation in bed mobility and transfers. Review of the resident's significant change MDS, dated [DATE], showed the following: -Cognitively intact; -Partial to moderate assistance for chair/bed-to-chair transfers; -Bed rails not used. Review of the resident's care plan, dated 04/23/24, showed the following: -The resident needs assist with activities of daily living (ADLs); -Staff will provide ADLs for the resident; -May use assist rails x2 to enhance self-participation in bed mobility and transfers. Review of the resident's medical record showed no evidence of measurements or an evaluation for entrapment zones on the resident's bed. During an interview on 06/04/24 at 8:45 A.M., the resident said the following: -He/She used the mobility bars on his/her bed to help him/her get out of and move up in bed; -His/Her rails have been loose, especially the one on the side of the bed that he/she gets out of; -He/She told staff about one month ago that the rail was loose, and he/she was told there was nothing that could be done except to take it off; -He/She had stuffed sheets or towels between the rail and the mattress to keep the rail from being so loose. Observation on 06/04/24 at 8:45 A.M. showed mobility bars (inverted, U-shaped bars attached to the bed and fixed to a raised position, to aid mobility) on both sides of the resident's bed, both rails were loose and freely movable side to side and back and forth, with approximately 5-6 inches of room between the mobility bar and the mattress. 3. Review of Resident #24's face sheet showed the following: -The resident had a power of attorney; -Diagnoses included morbid obesity, rheumatoid arthritis (an autoimmune and inflammatory disease, which means that your immune system attacks healthy cells in your body by mistake, causing inflammation (painful swelling) in the affected parts of the body, mainly attacks the joints), weakness, chronic obstructive pulmonary disease (group of lung diseases that block airflow and make it difficult to breathe), chronic kidney disease stage three (mild to moderate loss of kidney function), major depressive disorder and bipolar disorder. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severely impaired cognition; -Highly impaired vision; -Required supervision by staff for all mobility areas except rolling from left to right in bed, sit to lying and lying to sitting on side of bed; -No restraints used including bed rails. Review of the resident's care plan, dated 5/7/24, showed the following: -The resident was at risk for falls related to need for assist with toileting, walking, transfers and psychotropic medication therapy; -Walks with assist of one and a walker; -Needs assist with transfers; -Keep bed in its lowest position when occupied. The resident's care plan did not address the use of bed rails on the resident's bed. There was no documentation to show his/her bed had been assessed for entrapment risk. Observations on 6/3/24 at 1:25 P.M. and 4:41 P.M., 6/4/24 at 8:55 A.M., and 6/5/24 at 5:27 A.M. showed the resident had a 1/8 bed rail on the left hand and right hand sides of his/her bed in the raised position. Record review showed no documentation the resident's care plan addressed the use of bed rails on the resident's bed. There was no documentation to show his/her bed had been assessed for entrapment risk. 4. Review of Resident #271's face sheet, undated, showed he/she had a responsible party. Review of the resident's medical diagnoses sheet, undated, showed the resident's diagnoses included acute on chronic systolic (congestive) heart failure (a condition in which the heart doesn't pump blood as well as it should), type 2 diabetes mellitus, dementia, and repeated falls. Review of the resident's clinical physician orders sheet, dated 5/25/24, showed no order for assist rail for bed mobility and transfers. Review of the resident's care plan, dated 5/25/24, showed the following: -The resident required staff assistance for transfers; -The resident required staff assistance with activities of daily living (ADLs'). Observation on 06/03/24 at 2:10 P.M. showed the resident lay in his/her bed with mobility bar attached to the bed and fixed to a raised position, on the left side of the resident's bed. During an interview on 6/3/24 at 2:10 P.M., the resident's representative said the resident required assistance from staff for ADLs and transfers. Observation on 06/05/24 at 05:35 A.M. showed the resident lay in his/her bed with mobility bar on the left side of the resident's bed in a raised position. Review of the resident's medical record showed no evidence of measurements or an evaluation for entrapment zones on the resident's bed. During an interview on 06/06/24 at 9:30 A.M., the director of maintenance said the following: -He completes a weekly safety check of all residents' rooms to make sure mattresses fit the bed frame and the side rails are not loose, but he does not do routine assessments or measurements for entrapment zones on beds with mobility bars. During an interview on 06/06/24 at 10:20 A.M., the DON said the following: -She would expect that entrapment zones should be measured on all beds that use mobility bars; -She was not familiar with the regulation that relates to how entrapment zones should be checked or the frequency of such assessments.

Based on observation, interview and record review, the facility failed to serve the proper size entree to residents on a regular diet and mechanical soft diets, and failed to served pureed food items according to the spreadsheet menu to all residents on a pureed diet. The facility census was 73. Review of the undated facility policy, Portion Control, showed the following: -Individuals will receive the appropriate portions of food as defined by the state regulations and as planned on the menu. Control at the point of service is necessary to assure that the appropriate portion is served; -Use standardized recipes to avoid waste caused by overproduction. Recipes should be adjusted as needed and the yield and serving size specified on each recipe. The menu should list the specific portion size for each food item. Menus should be posted at the tray line so that the proper portion can be referenced for each special diet; -Serve the food with ladles, scoops, spoodles and spoons of standard sizes which match the menus. Scales should be used as needed to weigh meat portions. Scoops should be leveled off (not overflowing) for the most accurate portion size. Portions that are too small result in the individual not receiving the nutrients needed. Portions that are too large increase costs as well as providing the individual more food than needed or allowed (in the case of special diets); -Dining services staff will be in serviced by the dining services manager on proper portion sizes at regular intervals. Meal observations for quality control of portion sizes should be conducted by the dining services manager, registered dietitian (RD) or dietetic technician (DTR) on a routine basis. Review of the undated facility policy, Diet Orders and Food Preferences, showed the following: -Diet orders and food preferences will be kept on record in the kitchen and used to assure that each individual's needs and desires for food are met; -Procedure: The dining services manager obtains the correct diet order from the medical record and documents it in the dining services records; -The diet order and food preference records are used during meal service to ensure the correct diet is served and food preferences are honored; -Dining services staff are trained to carefully prepare an individual's meal using the diet order and food preference records and to serve that meal to the correct individual. 1. Review of the facility's Diet Type Report, dated 6/3/24, showed 69 residents had a physician-ordered regular diet and three residents had a physician-ordered mechanical soft diet. Review on 6/3/24 of the dietary spreadsheet menu, dated Spring/Summer 2023, Week 2, Day 9 showed staff were to prepare and serve the following menu items for the evening meal: -6 ounces (2/3 cup) of turkey tetrazzini to residents with a regular diet order; -6 ounces (2/3 cup) of tetrazzini with ground turkey to residents with a mechanical soft diet order; -4 ounces (1/2 cup) of diced carrots to residents with a mechanical soft diet order. Observation on 6/3/24 at 4:31 P.M. showed Dietary Staff C prepared mechanical soft turkey tetrazzini and added an unmeasured amount of turkey tetrazzini to a food processor and blended the mixture. The item was ground into small pieces and chunks. He/She covered the pan of ground turkey tetrazzini with plastic wrap. Observation on 6/3/24 at 4:44 P.M. showed Dietary Staff C placed pans of prepared food items into the steam table. Dietary Staff D placed utensils in pans of food. He/She did not refer to the dietary spreadsheet when selecting utensils for the pans of food. Observation on 6/3/24 at 4:51 P.M. showed the steam table pans of food and the utensils in each pan: -A 4-ounce (1/2 cup) utensil was in the regular turkey tetrazzini; -A 4-ounce utensil was in the carrots; -A 4-ounce utensil was in the mechanical soft turkey tetrazzini; -No diced carrots were on the steamtable. Observation on 6/3/24 at 4:52 P.M. showed Dietary Staff C started meal service in the main dining room. Observation on 6/3/24 at 5:12 P.M., showed Dietary Staff D began plating hall trays. Observation on 6/3/24 at 5:49 P.M. showed staff plated the last resident tray. (Staff served all residents on a regular and mechanical soft diet a 4-ounce portion of turkey tetrazzini instead of a 6-ounce portion. Staff did not serve the prepared ground turkey tetrazzini to the residents on a mechanical soft diet. Staff served these residents from the same pan as the residents with a regular diet. Staff served the residents on a mechanical soft diet a 4-ounce portion of regular carrots that were not diced.) Observation on 6/3/24 at 5:50 P.M., showed Dietary Staff D plated a sample regular diet test tray. He/She said staff choose the serving scoops/utensil according to the consistency of the food item. Vegetables got a spoon with holes to drain the liquid. He/She did not refer to anything when choosing sizes. All the serving sizes of the utensils used for lunch were 4-ounce sized utensils. Observation on 6/3/24 at 5:52 P.M., of a requested sample test tray for a regular diet, showed the pieces of carrots were large in size and were long slices cut on the diagonal. 2. Review of the facility's Diet Type Report, dated 6/3/24, showed one resident had a physician-ordered pureed diet. Review on 6/3/24 of the dietary spreadsheet menu, dated Spring/Summer 2023, Week 2, Day 9 showed staff were to prepare and serve the following menu items to residents on a pureed diet at the evening meal: -6 ounces (2/3 cup) of pureed turkey tetrazzini; -#12 scoop (1/3 cup) of pureed carrots; -#16 (1/4 cup) of pureed bread; -#12 (1/3 cup) of pureed dessert. During interview on 6/3/24 at 5:09 P.M., Dietary Staff C said the resident on pureed diet typically did not come to the dining room and was usually sent hall trays. The resident on a pureed diet was going to receive pureed pork sausage, pureed green beans and mashed potatoes/gravy for the evening meal instead of turkey tetrazzini, carrots, bread and dessert. The sausage was leftover and needed to be used. Observation on 6/3/24 at 5:30 P.M. showed Dietary Staff C could not find the pureed sausage. He/She had placed it in the microwave to reheat the item. When he/she returned to retrieve the sausage, the item was not in the microwave. Observation on 6/3/24 5:40 P.M. showed Dietary Staff C and Dietary Staff D prepared the evening meal hall tray for the resident on a pureed diet. Staff plated pureed chicken with gravy, pureed green beans and mashed potatoes/gravy. The meal tray did not contain pureed bread or pureed dessert. The resident on a pureed diet should have received 6-ounces (2/3 cup) of pureed Turkey Tetrazzini and instead received pureed chicken. The resident on a pureed diet should have also received #12 scoop (1/3 cup) of pureed carrots, but instead staff served green beans. The resident should have been served #16 scoop (1/4 cup) of pureed bread but was not served any bread. The resident should have received #12 scoop (1/3 cup) of pureed dessert, but instead did not get any pureed dessert. During interview on 6/4/24 at 12:35 P.M., Resident #64 (who had a physician-ordered pureed diet) said he/she sometimes got to choose what he/she received to eat. He/She would like to have what everyone else was eating or what was on the menu for that meal. During interview on 6/4/24 at 2:24 P.M., the Dietary Director said the following: -Staff should use the spreadsheet menu to know what scoops to use. The cooks and serving area both have a copy of the spreadsheet menu to refer to at meal time; -Residents on a pureed diet should receive the same food items as the regular menu. The facility also used some frozen pre-made purees that need to be steamed or heated. If the facility used the pre-made frozen items, they should be the same items that were on the menu or close to it. During interview on 6/5/24 at 9:36 A.M., the Consultant Dietitian said the following: -Staff should use the spreadsheet menu to ensure proper serving utensils were chosen to serve food items; -Staff should prepare and serve all items on the menu for all therapeutic diets according to the spreadsheet.

Based on observation, interview, and record review, the facility failed to transfer one resident, (Resident #1), of 3 sampled residents, after the resident repeatedly requested to be transferred to bed due to pain. The facility census was 92. The facility did not provide a policy for review regarding response to resident call lights when requested. 1. Review of Resident #1's comprehensive Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 7/27/23 showed: -The resident is able to make him/herself understood and able to understand others; -The resident is alert and oriented and able to make decisions; -Dependent upon staff all Activities of Daily Living (ADL's); -Dependent upon two staff members for transfer from bed to wheelchair and wheelchair to bed; -Diagnoses of and coronary artery disease (CAD-caused by plaque buildup in the wall of the arteries that supply blood to the heart) and peripheral vascular disease (PVD-a systemic disorder that involves the narrowing of peripheral blood vessels (vessels situated away from the heart or the brain); -Had moderate pain; -The resident has a Stage 3 (a full-thickness loss of skin that extends to the subcutaneous tissue) and Stage 4 (Full thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcers. Review of the resident's care plan for surgical wounds and pressure ulcers dated 8/9/23 showed: -The resident has a surgical wound to the left foot and a Stage 3 pressure ulcer to the coccyx (tailbone) and a Stage 4 pressure ulcer to the left heel; -Encourage and assist to turn and reposition every two hours and as needed. Review of the care plan for PHQ-9 (an assessment to determine if a person is depressed) dated 8/9/23 showed: -The resident has little interest in doing things; -Approaches in part: encourage the resident to lay down when feeling tired, assist as needed. Review of the resident's care plan for activities of daily living dated 10/20/23 showed the resident required assistance of two staff members and a mechanical lift for transfers. Review of the care plan for ADL's dated 10/20/23 showed: -Problem: the resident needs assistance with ADL's; -Goal: Staff will provide ADL support; -Approaches in part: assistance of two staff members and a mechanical lift for transfers. Anything about repositioning? During an interview on 10/30/23 at 12:30 P.M. Resident #1 said the following: -A couple of days ago, right before supper around 4:30 P.M., he/she rang his/her call light for assistance to lay down. He/she had been up for several hours and was beginning to have pain. Certified Nurse Aide (CNA) B answered the call light. When he/she asked CNA B to lay him/her down, CNA B said it was time for supper and he/she was taking other residents to the dining room, could he/she wait a few minutes. He/She told CNA B that he/she could wait a bit for help. He/She waited for a half hour, and no one came back to help him/her lay down so he/she put on his/her call light again for help. Certified Medication Technician (CMT) C answered the call light this time. When he/she asked CMT C to lay him/her down, CMT C told him/her that he/she needed help to lay him/her down and CNA B was assisting residents with their supper meal; he/she would have to wait. CMT C turned off the call light and left the room. He/She waited about another half hour and rang the call light again. By this time, he/she was in a lot of pain from the pressure ulcer on his/her bottom and foot and needed to lay down to relieve the pressure. He/She rang the call light again and CNA B answered the light. CNA B told him/her that he/she needed to get some help. About a half hour went by, he/she rang his/her call light again. CNA B and CMT C came into his/her room and helped him/her to bed. -He/She was in a lot of pain by the time staff finally transferred him/her to bed. During an interview on 10/30/23 at 4:17 P.M. CMT C said the following: -On 10/18/23, Resident #1 put his/her call light on and asked to lay down. The resident said he/she had been up for several hours and needed to lay down. This was around supper time; -The resident required two staff with a mechanical lift for transfers; -He/She told the resident he/she needed help to lay him/her down and he/she and CNA B would be back in as soon as possible to transfer the resident to bed; -CNA B was assisting other residents with their supper meal at the time; -He/She did not ask the nurse for help to transfer the resident; -He/She finished passing medications and then went to eat his/her supper; -Around 6:00 P.M., while he/she was at supper, CNA B came and asked him/her if he/she could help lay the resident down. During an interview on 10/31/23 at 8:37 A.M. CNA B said the following: -The resident was not in his/her room at 3:00 P.M. when he/she began work on 10/18/23; -He/She was the only CNA on the hall, with one CMT and a nurse; -The resident returned to his/her room around 4:30 P.M. and turned on his/her call light right as he/she was taking the residents to the dining room for supper; -He/She asked the resident if he/she could wait until after supper to lay down and the resident told him/her yes; -Around 5:30 P.M. the resident rang his/her call light again and asked again if he/she could lay him/her down; -At this time, he/she was assisting two residents with their meals, and told him/her that when he/she was finished, he/she would come back and lay him/her down; -The resident was very upset when he/she told him/her that CMT C was busy passing medication and he/she was busy helping other residents with their supper meal and would have to wait until supper was completed before he/she could help him/her; -At 6:00 P.M. he/she finished assisting the other residents with their supper meal, and asked CMT C to help him/her transfer the resident to bed. During an interview on 10/31/23 at 8:45 A.M. Licensed Practical Nurse (LPN) A said the following: -He/She worked on 10/18/23 with CNA B and CMT C; -Neither CNA B nor CMT C came and asked him/her to help put Resident #1 to bed; -He/She was unaware the resident had to wait for staff to transfer him/her to bed; -The resident usually will ring the call light as he/she has pain from the wounds on his/her body; -The resident likes to have his/her positioning changed frequently due to the discomfort. During an interview on 10/31/23 at 10:06 A.M. the Director of Nursing said the following: -She would expect staff to lay a resident down when the resident requested; -If the staff on one hall was busy, she would expect them to ask for help from another hall; -If staff was not available at the time of the resident request, she would expect staff to find some help and meet the resident's request within five to ten minutes. During an interview on 10/31/23 at 10:15 A.M. the Administrator said he would expect staff to assist the resident immediately. MO226128

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and facility policy review, the facility failed to develop a baseline care plan within 48 hours of admission to address individualized care needs for one (Resident #58) of six newly admitted residents whose records were reviewed for baseline care plans. The failed practice had the potential to affect 13 residents who were newly admitted to the facility within the last 30 days. Findings included: A copy of the facility's policy on baseline care plans was requested from the Minimum Data Set (MDS) Coordinator on 10/26/2022 at 4:34 P.M., but was not received as of the end of the survey (10/28/2022). Review of an admission Record revealed the facility admitted Resident #58 on 09/27/2022 with diagnoses that included type 2 diabetes mellitus, depression, and a history of pulmonary embolism (blood clot in the lung). Review of an admission MDS, federally mandated assessment tool, dated 10/04/2022, revealed Resident #58 had a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. According to the MDS, the resident received insulin injections, antidepressant medication, and anticoagulation (blood thinner) medication on seven days during the seven-day assessment period. Review of an Order Summary Report revealed Resident #58 was admitted on [DATE] with physician orders that included: - Apixaban (blood thinner) 5 milligrams (mg) give one table by mouth two times a day for anticoagulation. - Aspirin delayed release 81 mg give one tablet by mouth one time a day for antiplatelet (to prevent blood clots). - Bupropion (an antidepressant) 300 mg give one tablet by mouth one time a day for depression. - Humulin NPH insulin 100 units per milliliter (ml) inject 65 units subcutaneously two times a day for diabetes. Review of Resident #58's electronic health record (EHR) revealed no evidence a person-centered baseline care plan was developed for the resident, to address the resident's diagnosis of diabetes and the use of high-risk medications, including insulin, anticoagulants, and antidepressants. A copy of Resident #58's baseline care plan was requested from the facility on 10/26/2022. During an interview on 10/26/2022 at 2:15 P.M., Registered Nurse (RN) #3 stated Resident #58 did not have a baseline care plan. He/She stated the resident should have had one completed within the first 48 hours after admission. He/She stated the baseline care plan came up as one of the assessments required at admission and would stay red on the dashboard in the EHR until it was done, so he/she was unsure how it was missed for Resident #58. RN #3 stated diabetes should be addressed on the baseline and comprehensive care plans. During an interview on 10/26/2022 at 4:34 P.M., the MDS Coordinator stated the baseline care plan was to be completed by the admission nurse or the nurse on the next shift and should be completed within 48 hours after admission. She stated the baseline care plan should address diabetes. During a follow-up interview on 10/26/2022 at 4:50 P.M., RN #1, who was Resident #58's admitting nurse, stated he/she did not know he/she was responsible for completing the baseline care plans and had not completed any baseline care plans since he/she had started working at the facility in June 2022. During an interview on 10/27/2022 at 8:20 A.M., Licensed Practical Nurse (LPN) #1 stated he/she completed baseline care plans as part of the admission assessment, but the comprehensive care plan was completed and updated by the MDS nurse. During an interview on 10/27/2022 at 8:31 A.M., the Director of Nursing (DON) stated the baseline care plan was to be completed upon admission by the admitting nurse, on the shift of the admission, unless the resident was admitted during the last hour of the shift. The DON stated the baseline care plan should address all the resident's needs. During an interview on 10/27/2022 at 9:05 A.M., the Administrator stated he was not familiar with the requirements for baseline care plans, but thought the MDS Coordinator did them. He stated he expected the care plan to be completed within the appropriate timelines and to reflect the resident's needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and facility policy review, the facility failed to ensure the comprehensive care plan addressed diabetes management for one (Resident #58) of three sampled residents reviewed for insulin use. This had the potential to affect 11 residents who received insulin injections. Findings included: 1. On 10/26/2022 at 4:34 P.M., a copy of the facility's policy on care plans was requested from the MDS (Minimum Data Set) Coordinator and was not received by the end of the survey (10/28/22). Review of an admission Record revealed the facility admitted Resident #58 on 09/27/2022 with a diagnosis of type 2 diabetes mellitus. Review of an admission MDS, a federally mandated assessment tool, dated 10/04/2022, revealed Resident #58 had a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. According to the MDS, the resident received insulin injections daily. Review of an Order Summary Report revealed Resident #58 was admitted on [DATE] with physician's orders that included Humulin NPH insulin 100 units per milliliter (ml), 65 units subcutaneously two times a day for diabetes. Review of Resident #58's electronic health record (EHR) revealed the Comprehensive Care Plan did not address Resident #58's diagnosis of diabetes and pertinent person-centered interventions until 10/25/2022, during the survey. During an interview on 10/26/2022 at 2:15 P.M., Registered Nurse (RN) #3 stated diabetes should be addressed on the comprehensive care plans. During an interview on 10/26/2022 at 4:14 P.M., RN #1 stated he/she did not have anything to do with the care plans. He/She stated he/she thought the care planners were responsible for care plans. During an interview on 10/26/2022 at 4:34 P.M., the MDS Coordinator stated diabetes and appropriate related interventions should be addressed on the comprehensive care plan. She indicated Resident #58 had a diabetic care plan developed on 10/11/2022, but stated she attempted to update it on 10/25/2022 and accidentally deleted it, so had to initiate a new one. The MDS Coordinator stated this made it look like the initiation date was 10/25/2022. She was unable to provide a diabetes care plan for Resident #58 dated prior to 10/25/2022. During an interview on 10/27/2022 at 8:31 A.M., the Director of Nursing (DON) stated the comprehensive care plan was a collaborative effort between the MDS Coordinator and the nursing supervisors. She stated the facility had 21 days from admission to complete the comprehensive care plan, and it should address all the resident's needs. During an interview on 10/27/2022 at 9:05 A.M., the Administrator stated care plans were completed by the MDS Coordinator, and he/she expected the care plans to be done within the appropriate timelines and to reflect the residents' needs.

Based on interviews, record review, and facility document review, it was determined the facility failed to ensure one (Registered Nurse #1) of four licensed nursing staff reviewed received training and demonstrated competency with diabetes management. This affected one (Resident #58) of two residents receiving insulin under the care of RN #1. Findings included: On 10/28/2022 at 1:34 P.M., Registered Nurse (RN) #3, a member of the administrative nursing staff as a Minimum Data Set (MDS) Coordinator and Wound Care Nurse, stated the facility did not have a policy for staff training and competencies. During the survey conducted from 10/24/2022 through 10/28/2022, facility failures with diabetes management for Resident #58 were identified. The resident was admitted with a diagnosis of type 2 diabetes mellitus and orders for high-dose insulin, but no orders for blood glucose monitoring. Licensed nursing staff failed to identify and address the lack of blood glucose monitoring for Resident #58 and failed to consult the physician regarding the need to withhold the resident's insulin for hypoglycemic episodes. Review of Progress Notes, dated 10/11/2022 at 6:42 P.M. for Resident #58, revealed the resident had an acute onset of confusion at approximately 5:30 PM. Resident #58 was noted to be aphasic (unable to understand or express speech) and verbally unresponsive. A non-emergency ambulance was called to transport the resident to the local hospital. The note was signed by RN #1. There was no evidence to indicate RN #1 checked the resident's blood glucose level during the resident's episode of confusion and aphasia. Review of a hospital Internal Medicine History and Physical (H&P) - Hospitalist indicated Resident #58 arrived in the ED via emergency medical services (EMS) with a blood glucose level of 23 milligrams per deciliter (mg/dL). During an interview on 10/26/2022 at 4:14 P.M., RN #1 acknowledged he/she did not check Resident #58's blood sugar when the resident had a change in status on 10/11/2022. RN #1 stated nursing was a new career for him/her, and he/she had only been a nurse for a short time. He/She stated his/her only nursing experience prior to coming to the facility was at the county health department, so this was his/her first rehab/long-term care experience. He/She stated that when he/she first started working, he/she had a week of orientation then a week of floor training with different nurses. RN #1 stated he/she was trained in nursing school on how to monitor a diabetic resident, but the facility had not provided any specific training. He/She stated the facility did not do skills checks when he/she was hired. RN #1 stated he/she was the nurse who admitted Resident #58. He/She stated if the resident's blood sugar was less than 100 milligram per deciliter (mg/dl) he/she would ask staff to hold the resident's insulin. He/She indicated he/she did not notify the physician when the insulin was held but should have. Review of RN #1's In-Service Tracker 2022 revealed the tracker was initiated on 07/07/2022 (RN #1's date of hire). The 0.75 hours of diabetic teaching/glucometer cleaning training had not been completed. During an interview on 10/27/2022 at 8:31 A.M., the Director of Nursing (DON) stated new staff received on-the-floor orientation with another nurse before they were expected to work on their own. She stated it depended on the employee how long it would take, but most nurses only needed three days of training on the floor unless they were new graduates, and then she would give them three weeks. She stated there was a Resident Care Coordinator (RCC) on each floor who was responsible for each floor and its operations, and the RCCs were expected to ensure new staff were trained properly. The DON stated the RN Infection Preventionist (RN IP) would go over what skills were expected of the staff when they were hired and then reviewed it annually. She stated the facility did skills checkoffs every year in October with all staff, and this included diabetes management. The DON stated the nurse who admitted Resident #58 should have used better judgment and asked for fingerstick blood sugar checks, and the physician should have caught it as well. She stated the facility trained RN #1 for 10 shifts with different RCCs on day shift, and then the RN IP spent at least two hours a day assisting him as needed. During an interview on 10/27/2022 at 8:32 A.M., RN #3, the MDS Coordinator/Wound Nurse, stated she had recently revamped the orientation checklist to include diabetic training. She stated the RN IP completed the new hire orientation. RN #3 indicated skills checkoffs were done with all staff yearly in October, but they did not do skills checkoffs when new staff members were hired. The new orientation checklist was requested and not received prior to the end of the survey. During an interview on 10/27/2022 at 11:34 P.M., the RN IP stated training was done as a team, but she completed the new-hire orientation, which consisted of the facility's philosophy, managing residents with behaviors, nutrition/hydration issues, hand hygiene, COVID-19 protocols, peri-care, transfers, and the use of gait belts. She stated the facility did have a skills checkoff list, but they stopped using it and she was not sure why. She stated they did skills checkoffs for hand hygiene and peri-care and then as needed if they were having trouble with something specific. The RN IP stated RN #1 was oriented with multiple nurses on the rehab floor and spent a week on day shift before training on evenings. She stated she met with RN #1 daily at the beginning of his/her shift when he/she was first hired to answer any questions and help with patient assessments and documentation for about three weeks. She stated the training she did with RN #1 was informal and not documented. During an interview on 10/27/2022 at 9:05 A.M., the Administrator stated staff should be receiving training with the nurses on the floor and this should be documented.

Based on interviews, record review, document review, and facility policy review, the facility failed to ensure COVID-19 vaccination education and declinations were documented in the medical record for two (Resident #11 and Resident #58) of five sampled residents reviewed for immunization documentation. Findings included: Review of an undated facility policy titled, Resident COVID-19 Vaccination Policy, revealed, [Facility] will verbally offer the COVID-19 vaccine to all residents, including boosters. The policy also indicated, [Facility] will offer education to the residents on the COVID-19 vaccine and will educate the resident if they wish to be educated. If the resident refuses to discuss the COVID-19 vaccine and the COVID-19 pandemic, [Facility] staff will respect their wishes and the [sic] end conversation politely about COVID-19. Additionally, the policy indicated, [Facility] will provide the COVID-19 consent form to the resident and/or family if they choose to receive the vaccine. During an interview on 10/26/2022 at 12:46 PM, the Registered Nurse Infection Preventionist (RN IP) stated there were 13 unvaccinated residents residing in the facility. 1. Review of an admission Record revealed the facility admitted Resident #11 on 07/20/2022. Review of Resident #11's medical record revealed no documentation regarding education provided to the resident or responsible party regarding the COVID-19 vaccination. 2. Review of an admission Record revealed the facility readmitted Resident #58 on 10/14/2022. Review of Resident #58's medical record revealed no documentation regarding education provided to the resident or responsible party regarding the COVID-19 vaccination. During an interview on 10/27/2022 at 8:44 A.M., Certified Medication Tech (CMT) #2 stated the Director of Nursing (DON) and her assistant were responsible for documentation regarding vaccinations. During an interview on 10/27/2022 at 9:15 A.M., the RN IP stated the DON was responsible for administering COVID-19 vaccines. The RN IP indicated the DON was also responsible for the education and declination process if a resident refused. The RN IP stated the only documentation of COVID-19 vaccine refusals was in the computer, under the COVID tab as, refused. During an interview on 10/27/2022 at 10:09 A.M., the DON stated the education and declination for the COVID-19 vaccine was documented in the immunization tab of the computer by the RN IP. During an interview on 10/27/2022 at 10:21 A.M., the Administrator stated the provision of education was on the COVID-19 consent form. The Administrator stated the residents who declined the COVID-19 vaccine were verbally educated. The Administrator indicated the COVID-19 vaccine consent form was to consent to the vaccine, not to decline it. During an interview on 10/27/2022 at 10:35 A.M., the DON provided a blank COVID-19 Vaccine Consent Form and stated the form was not given to residents who declined the vaccine. A review of the blank COVID-19 Vaccine Consent Form revealed an area that documented, I have read or had explained to me the Emergency Use Authorization Fact Sheet or a Vaccine Information Statement for the COVID-19 vaccine and understand the risks and benefits. This area contained a space to consent or not consent to the vaccine.

Based on observations, interviews, product information review, and policy review, the facility failed to ensure all medications and biologicals were labeled in accordance with accepted professional principles and expired medications were removed from stock to prevent their inadvertent administration to residents who received medications from two of two medication carts. Specifically, observations revealed multi-dose medications were opened, but were not labeled with the opened date, and multi-dose medications that were dated were kept in the medication carts beyond the manufacturer's specified timeframes for use. Findings included: Review of a facility policy titled, Medication Storage and Maintenance, dated August 2018, revealed, The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. 1. Drugs and biologicals shall be stored in the packaging, containers, or dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. The policy also indicated, 3. Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. Review of a facility policy titled, Medication Storage, dated August 2018, revealed, Upon opening any medications, the container must be dated with the date it was opened (insulin, eye drops, inhaler, stock supply bottles, etc. [et cetera]). The nurse must follow the Medication Manufacturer's/Pharmacy Guideline on when the medication expires and dispose as indicated. 1. Observations on 10/25/2022 at 2:51 P.M., of the ground floor medication cart were conducted with Certified Medication Technician (CMT) #2 and revealed the following: - Three insulin glargine pens were opened with no date on the insulin pens to denote when they were opened. - One opened budesonide-formoterol fumarate inhaler was not labeled with a resident identifier or dated as to when it was opened. - One opened insulin aspart protamine and aspart suspension pen-injector (70-30) had no date to denote when it was opened. Review of an insulin glargine injection package insert, obtained from the Food and Drug Administration (FDA) website, revealed opened, in-use prefilled pens could be stored for up to 28 days at room temperature and should not be refrigerated. Review of a budesonide and formoterol (inhalation) package insert, obtained from the FDA website, revealed, The correct amount of medication in each inhalation cannot be ensured after the labeled number of inhalations from the canister have been used, even though the inhaler may not feel completely empty and may continue to operate. The inhaler should be discarded when the labeled number of inhalations have been used or within 3 months after removal from the foil pouch. During an interview on 10/25/2022 at 3:02 P.M., CMT #2 stated medications should be labeled when opened. He/She indicated he/she was unsure when a medication expired once it was opened. During an interview on 10/25/2022 at 3:10 P.M., Licensed Practical Nurse (LPN) #1 revealed medications should be dated as soon as they were opened. LPN #1 revealed inhalers came from the pharmacy in a plastic sleeve marked with a prescription label. The inhaler should be kept in the plastic sleeve and dated when it was opened. LPN #1 revealed insulin was good for 28 days once it was opened and, unless dated, there was no way to know if the insulin was expired. 2. An observation on 10/25/2022 at 3:18 P.M., of the second floor medication cart with CMT #3 revealed a NovoLog FlexPen Solution Pen-injector 100 UNIT/ML (Insulin Aspart) was dated as opened on 08/29/2022. Review of a NovoLog (insulin aspart) package insert, obtained from the Food and Drug Administration (FDA) website, revealed, Once a cartridge or NovoLog FlexPen or NovoLog FlexTouch is punctured, it should be kept at temperatures below 30 [degrees] C [Celsius] (86 [degrees] F [Fahrenheit] for up to 28 days. During an interview on 10/25/2022 at 3:31 P.M., CMT #3 revealed he/she dated and labeled all medications as soon as they were opened. CMT #3 indicated medications expired 28-30 days after they were opened. During an interview on 10/26/2022 at 8:09 A.M., Registered Nurse (RN) #2 stated medications were to be labeled with the date opened and should be discarded if no date was in place to ensure the medication had not expired. RN #2 stated insulin expired 28-30 days after opening and inhalers were good until the manufacturer's expiration date. During an interview on 10/26/2022 at 12:35 P.M., the Director of Nursing (DON) indicated it was expected for all medications to be labeled, for the medication to be dated when opened, and for expired medications to be discarded. During an interview on 10/26/2022 at 2:13 P.M., the Pharmacist revealed stickers were placed on the medications for staff to label the medications when opened. The medications should be dated when opened to determine when the medication would expire. The Pharmacist indicated insulins expired 28 days from the date opened and the budesonide-formoterol inhalers expired three months after removal from the package. During an interview on 10/26/2022 at 2:34 P.M., the Administrator indicated he expected medications to be stored appropriately and to be dated when opened. The Administrator stated he expected medications to be checked prior to administration to ensure they were dated and not expired.

Based on observations, interviews, document review, and facility policy review, the facility failed to ensure the kitchen was maintained in a sanitary condition to prevent potential food borne illness for residents who received meals from the kitchen. Specifically, the facility: - Failed to ensure leftover food items stored in the refrigerators and freezers were dated, labeled, and tightly sealed. - A scoop used in a bulk flour bin was properly stored. - Kitchen equipment, shelves, and floors were free from excessive dirt, grease, and/or debris. - Floor tiles and a handwashing sink were maintained in good repair. - Sanitizer concentration in the dish machine and three-compartment sink was regularly tested and documented. - Dietary staff washed their hands when contaminated, prior to handling food. - Sanitizer water buckets and mop buckets were kept/stored away from food preparation areas and stored food/beverages. - Stock was stored off the floor. The failed practices had the potential to affect all 66 residents who resided in the facility and received food from the kitchen. Findings included: 1. Review of a facility policy titled, Labeling, dated 07/2020, revealed, It is the policy of [facility] that labeling is completed on leftover items. The policy also indicated, 2. Markings should be '3' days for leftover items. 3. Seven (7) days can be used for refrigerator stable items such as cheese, dressing and other dairy products. Observations on 10/24/2022 at 8:39 A.M., in the kitchen and food service areas revealed the following: In the True refrigerator: - Two pitchers of a brown liquid were not dated and labeled. - An open plastic container of cranberry juice cocktail was not dated. - Two open plastic containers of thickened cranberry juice cocktail were not dated. - A half-gallon container of orange juice with approximately six ounces left was not dated. - A one-gallon plastic container of diced melons was covered with plastic wrap and not dated. - A one-gallon plastic container, approximately 1/3 full of a white creamy substance with small dark particles in it was not dated and labeled. - A plastic container of red fruit gelatin with a use by date of 10/20/2022 was on a shelf on the far left side of the refrigerator. In the walk-in refrigerator in the main kitchen area: - A large clear plastic container of approximately two gallons of beef broth was not dated. - A six-quart plastic container of a brown/green substance was not dated and labeled. - A box of three blueberry muffins on the top shelf was not closed or covered, exposing the muffins to air. In the walk-in freezer: - A box of Oven Fried Flats was open, and the food product was exposed. - A six-quart container was lying on its side and had unwrapped/exposed breaded chicken pieces in the bottom. - A clear plastic sleeve was not closed, and one patty of meat was exposed. - A box of biscuit dough was open, and the inner plastic packaging was not sealed, exposing the biscuit dough. During an interview on 10/26/2022 at 1:55 P.M., the Registered Dietitian/Licensed Dietitian (RD/LD stated food in the refrigerators and freezers should be sealed, labeled, and dated. She stated she checked the refrigerators and freezers to ensure food was sealed, labeled, and dated when she conducted a sanitation inspection, which was about every six months. The RD/LD stated it was the dietary manager's responsibility to ensure food was stored properly. She stated shift supervisors also had responsibility. During an interview on 10/26/2022 at 2:35 P.M., the Certified Dietary Manager (CDM) stated food in the refrigerators and freezers should be sealed, labeled, and dated. He stated he checked the refrigerators and freezers daily when he was working to ensure food was sealed, labeled, and dated. The CDM stated it was his responsibility to ensure food was stored properly. 2. Review of an undated facility document titled, Daily Cleaning revealed the following tasks, all of which had instructions for cleaning and a line for signatures/initials when each task was completed: stove tops, floors, service carts, drawers, R1, R2, R3, IC Fridge/Freezer, dish area walls, trash cans, under spice walls, microwave, window ledges, storage rooms, hood filter above grill, stainless polished, and galley countertops/drawers. Review of an undated facility document titled, Weekly Cleaning revealed the following tasks, all of which had instructions for cleaning and a line for signature/initials when each task was completed: storage bins, condiment container, walls, spice rack/seasoning rack, galley cabinet organization, dishwasher (DW) tile wall, speed racks, soda machine, juice machine, fan covers, window screens, mounted air conditioner (A/C) vents, ice bins, Arbors baseboard and cabinets, cooler/dry shelving, and ceilings/light fixture sides. Observations on 10/24/2022 at 8:39 A.M. in the kitchen and food service areas revealed the following: - The outside and handles of the True refrigerator had food smears and debris buildup under the handles. - On the stainless-steel preparation counter on which the food processor was stored, the underside of the five handles of the drawers had a buildup of debris, which could be felt when opening the drawers. - On the stainless-steel preparation counter across from the True refrigerator, the shelving under the counter had food debris. - A large amount of food debris was on the ledge of the stainless-steel preparation table between the ice machine and the convection oven. - The shelf under the griddle had a cookie sheet with grease/debris and a narrow spatula sitting on it. - The manual can opener cutting blade had a buildup of dried food debris on it. - Two heated tray carts had a buildup of debris and dried food spills on the outside. - The floors throughout the kitchen and food service areas had a buildup of food debris, dried food spills, and trash. - Large pieces of food debris and a white cleaning rag were under the deep fat fryer and stove. - The floor under and around the stove and deep fat fryer had a coating of grease. Observations on 10/24/2022 at 4:09 P.M., revealed the kitchen/food service area floors and equipment, including under appliances and preparation tables, continued to have large amounts of dried food spills, food debris, and trash. Observation on 10/25/2022 at 7:30 A.M., the shelf under the griddle was observed to have a cookie sheet with grease/debris visible, and a narrow metal spatula and two wider metal spatulas sitting on it. During an interview on 10/26/2022 at 1:55 P.M., the RD/LD stated food debris should be swept from the floor and from under appliances and food preparation tables at least daily. The RD/LD stated it was the dietary manager's responsibility to ensure the kitchen was clean and sanitary. She stated shift supervisors also had responsibility. During an interview on 10/26/2022 at 2:24 P.M., [NAME] #2 stated he/she had received training about kitchen sanitation. When asked if he/she knew about the weekly or monthly cleaning schedules, he/she stated, I do my own stuff. We don't really have a schedule. During an interview on 10/26/2022 at 2:29 P.M., [NAME] #1 stated he/she had received training about kitchen sanitation. [NAME] #1 stated he/she knew there were cleaning schedules for the kitchen and, because they had been short-staffed, and everyone had been chipping in. During an interview on 10/26/2022 at 2:33 P.M., Dietary Aide (DA) #2 stated he/she had received training about kitchen sanitation. DA #2 stated he/she knew about the weekly and monthly cleaning schedules and indicated they were in a folder. He/She stated everyone picked up something to do. During an interview on 10/26/2022 at 2:35 P.M., The CDM stated food debris should be swept from the floor and from under appliances and food preparation tables at least daily. The CDM stated it was his responsibility to ensure the kitchen was clean and sanitary. The CDM stated he had a cleaning schedule for staff to follow for daily, weekly, and monthly cleaning. When asked to provide documentation the cleaning schedules had been followed, he stated he had no cleaning schedule which had been completed or filled out. 3. Observation on 10/24/2022 at 8:39 A.M., revealed a scoop was stored in the flour in a bulk flour container with the handle pointed downward into the flour. During an interview on 10/27/2022 at 8:35 A.M., the CDM stated scoops were not supposed to be stored in bulk containers such as flour and stated there was no policy which indicated this. 4. Observations on 10/24/2022 at 8:39 A.M., in the kitchen and food service areas revealed the following: - A three-by-three-foot area of the floor near the three-compartment sink had the floor tiles missing. The area was black and had debris in it. - The handwashing sink near the True refrigerator had a Do Not Use sign posted above it. During an interview on 10/26/2022 at 2:35 P.M.,. The CDM stated there had never been tiles on the floor near the three-compartment sink. He stated there was no plan to repair the floor. He stated the handwashing sink near the True refrigerator had been unusable for a few months and the sink would be removed. He stated the only handwashing sinks for kitchen staff were in the drink preparation room and in the dish machine room. 5. Review of a facility policy titled, Dish Machine and Sanitation, dated 07/2020, revealed, It is the policy of [facility] that Dish machines are used according to the manufacturer's directions. Procedure The following procedures are related to dish machine 1. As stated by machine manufacturer 2. Chlorine is expected to be at 50-100 ppm [parts per million] 3. Quat [chemical sanitizer] is expected to be at least 150 ppm. Observations of the dish machine on 10/24/2022 at 9:20 A.M., revealed the wash cycle temperature was 144 degrees Fahrenheit (F), and the rinse cycle was 160 degrees F. Dietary aide (DA) #1 was asked to test the dishwasher for sanitizer. He/She used two test strips, neither of which registered the presence of any sanitizer. The DA asked the surveyor, Do these expire? When DA #1 was asked how often the dishwasher sanitizer was checked, he/she stated, I think they test at night. Review of an Equipment Temperature Log, located on a clipboard on the wall near the dish machine, revealed the last date the dish machine sanitizer testing was recorded was on the morning (AM) of 09/28 (no year indicated). On 10/24/2022 at 9:25 A.M., the CDM entered the dish machine area. During an interview at this time, the CDM stated the sanitizer test strips were used three times per day. He/She was shown the Equipment Temperature Log and acknowledged the last date the dish machine sanitizer had been tested was on 09/28 and that the year was not indicated on the form. Observation and interview on 10/24/2022 at 9:39 A.M., revealed after attempting to test the dish machine sanitizer using two test strips, the CDM stated he/she believed the container of test strips had been contaminated or left wet because they were not reading the sanitizer concentration. He/She stated the strips in the bottle were the same strips that had been used by his/her staff three times per day, but were not registering now. He/She stated the dish machine company representative had been called and would be at the facility later in the day. He/She stated in the meantime, all dishes, silverware, and pitchers would be washed in the three-compartment sink. On 10/24/2022 at 9:43 A.M., the facility document titled, Sanitation Log - 3 Sink was reviewed. The log revealed the last time the testing of the sanitizer in the three-compartment sink was recorded was on 09/28 (no year indicated) at 5:00 PM. The CDM was shown the log and acknowledged there was no documentation of testing since 09/28. The CDM stated during an interview that the sanitizer they used in the three-compartment sink was Quat. During an interview on 10/24/2022 at 9:52 A.M., the CDM again stated the sanitizer concentration for the dish machine and the three-compartment sink were supposed to be tested and documented three times per day. During an interview on 10/24/2022 at 9:58 A.M., the Director of Nursing (DON) stated there had been no cases of foodborne illness during the previous month. The CDM was interviewed on 10/24/2022 at 4:13 P.M. and stated he had found a bottle of dish machine test strips in the back of his desk drawer in his office. He stated he had tested the dish machine at 9:00 A.M. and again at 11:50 A.M., and the test strips showed the sanitizer concentration was at 100 parts per million (ppm). Although the CDM stated he had tested the dish machine at 9:00 A.M., the surveyor's observations were of the CDM entering the dish machine at 9:25 AM. An observation on 10/24/2022 at 4:18 P.M., revealed the CDM tested the dish machine sanitizer, and it showed the sanitizer was at 100 ppm. During an interview on 10/26/2022 at 2:29 P.M., [NAME] #1 stated he/she used the three-compartment sink occasionally and knew the sanitizer concentration should be tested every time the sanitizer/water was changed. He/She stated he/she did not know where the test strips were kept. During an interview on 10/26/2022 at 2:24 P.M., [NAME] #2 stated the dish machine and three-compartment sink sanitizer concentration should be tested three times per day. He/She stated he/she did not know where the test strips for the dish machine were and was unable to find test strips for the three-compartment sink. He/She stated he/she had never documented sanitizer testing. Observation on 10/26/2022 at 2:31 P.M., [NAME] #2 showed the surveyor the dish machine test strips and stated they were in the CDM's office. He/She indicated he/she did not have access to them, but the CDM had handed the strips to him/her. During an interview on 10/26/2022 at 2:33 P.M., Dietary Aide (DA)#2 stated he/she had run the dish machine and used the three-compartment sink. He/She indicated the sanitizer was to be tested daily for both. He/She stated the test strips were usually by the three sinks. During an interview on 10/26/2022 at 1:55 P.M.,. The RD/LD stated the sanitizer concentration for the dish machine should be tested three times per day, and the sanitizer for the three-compartment sink should be tested each time it was set up. She stated she did not review the documentation of the sanitizer testing during her regular consulting visits. The RD/LD stated it was the dietary manager's responsibility to ensure sanitizer was at the appropriate concentration in the dish machine and three-compartment sink. She stated shift supervisors also had responsibility. During an interview on 10/26/2022 at 2:35 P.M., the CDM stated the sanitizer concentration in the dish machine and the three-compartment sink should be tested three times per day. The CDM stated it was his/her responsibility to ensure the sanitizer was at the proper concentration in both. He/She stated the dishwasher tested the dish machine. He/She stated it was his responsibility to ensure sanitizer testing strips were available and acknowledged the test strips were kept in his office. During an interview on 10/27/2022 at 8:35 A.M., the CDM stated there were no directions for testing the sanitizer in the dish machine. He/She stated they followed the directions on the test strip bottle for the appropriate concentration of the sanitizer. He/She stated there was no facility policy for testing the sanitizer three times daily. During an interview on 10/26/2022 at 4:27 P.M., the CDM was asked for the July and August 2022 sanitizer logs for the three-compartment sink and the dish machine. After looking through folders in his/her office, he/she stated he did not have the logs for July and August 2022. When asked if he/she had logs for any month of 2022, he/she stated he/she did not. CDM stated he/she was sure the sanitizer logs for September 2022, which were posted in the dish machine room and next to the three-compartment sink, were for 2022. 6. Observation on 10/24/2022 at 8:39 A.M., revealed a mop was stored in a mop bucket that contained brown water, which was next to a storage unit of large bottles of water. Observation on 10/24/2022 at 9:33 A.M., revealed a cleaning rag had been left on top of the dish machine. During an interview at this time, the CDM stated cleaning rags were not to be stored out of a sanitizer water bucket. Observation on 10/25/2022 at 7:30 A.M., there were two sanitizer rag buckets sitting on top of the food preparation counter across from the True refrigerator. During an interview on 10/26/2022 at 1:55 P.M., The RD/LD stated buckets of sanitizing solution should not be set on the top of food preparation tables. The RD/LD stated it was the dietary manager's responsibility to ensure the kitchen was clean and sanitary. She stated shift supervisors also had responsibility. During an interview on 10/26/2022 at 2:35 P.M., the CDM stated buckets of sanitizing solution for cleaning rags should be stored on the ends of the tables. 7. Review of an undated facility document in the dietary department, titled, Handwashing, revealed, The most common mode of transmission of pathogens is via HANDS! The document did not address when handwashing was necessary. Observation on 10/25/2022 at 10:31 A.M. showed [NAME] #1 use his/her right hand to adjust his/her mask. Without washing his/her hands, he/she continued to chop roast beef to be used in preparing the residents' lunch meal. During an interview on 10/27/2022 at 8:35 A.M., the CDM stated a person's hands would be considered contaminated if they adjusted their face mask and hands should be washed after touching their face mask. 8. Observation on 10/25/2022 at 11:47 A.M., three boxes of vegetable oil containers were stored on the floor in the large dry storage room. During an interview on 10/26/2022 at 1:55 P.M., The RD/LD stated boxes should not be stored on the floor in dry storage areas. During an interview on 10/26/2022 at 2:35 P.M., the CDM stated boxes should not be stored on the floor in the dry storage areas. The CDM stated it was his responsibility to ensure food was stored properly. During an interview on 10/26/2022 at 3:00 P.M., the Administrator and the CDM after being informed of all of the above findings, the Administrator stated he expected the cleaning checklist to be filled out and maintained and food to be properly stored and dated.

Based on observation, interview and record review, the facility failed to ensure staff served food items that were palatable, conserved nutritive value, flavor and appearance and failed to ensure the foods were served at a safe and appetizing temperature. The certified census was 70 and the licensed only census 23. 1. Review of the facility policy titled, Diet Order, dated January 2019, showed: -The facility staff is expected to follow the ordering physicians or Licensed Personnel's diet order as documented in the Electronic Medical Record (EMR). These orders are to include texture and liquid consistency; -Residents diet orders may be downgraded but not upgraded for resident convenience in eating; -It is the policy of this Home to ensure all residents receive a balanced diet; -Meals should be attractive, palatable and appetizing at an appropriate temperature; -Meals shall be served in a palatable and appetizing manner. Facility Dining Service staff shall make rounds to ensure satisfaction; -Temperatures shall be taken before serving of the food. The expectation of this facility is that Hot food be served at 135 Fahrenheit or above and reach the resident at 120 degrees Fahrenheit. 2. Record review of the facility menu for 09/18/19 showed the lunch meal included bacon cheeseburger and hot green vegetable. 3. Observation on 09/18/19 at 12:45 P.M. of the noon meal test tray, taken directly from the steam table in the main dining room and received after the last resident was served, showed the following food temperatures, taken with a calibrated analog metal stem type thermometer: -The regular cheeseburger was 105 degrees Fahrenheit; -The mechanical ground meat was 80 degrees Fahrenheit; -The pureed meat was 88 degrees Fahrenheit; -The Scandinavian vegetables were 90 degrees Fahrenheit; -The pureed Scandinavian vegetables were 100 degrees Fahrenheit; All the food was cool to taste. During interview on 09/18/19 at 1:00 P.M., [NAME] B, who was plating and serving residents the noon meal from the steam table in the main dining room, said serving temperatures were to be at least 120 degrees Fahrenheit at the time of service. During an interview on 9/18/19 at 12:40 P.M., Resident #33 said the food was not the greatest and that the warm food was cold. 4. Record review of the facility menu for 09/19/19 showed the breakfast meal included baked omelet. 5. Observation on 09/19/19 at 7:45 A.M. of the rehabilitation dining room showed: -Dietary Service Aide D preparing to serve residents breakfast from the steam table; -The baked omelet in the steam table pan had an appearance of a burnt top layer, covering the entire top surface. During interview on 09/19/19 at 7:50 A.M., Dietary Service Aide D said the baked omelet looked over baked and the cheese on top had been burnt. During interview on 09/19/19 at 8:05 A.M., Resident #401 said the baked omelet had a burnt taste and he/she would not be eating it; it looked and tasted terrible. 6. Observation on 09/19/19 at 8:55 A.M. of the main dining room showed: -Resident #18 sat at the table with his/her breakfast tray in front of him/her; the tray contained the baked omelet that had a layer of burnt looking cheese on top; -Resident #63 sat at a table with his/her breakfast tray. The tray contained the baked omelet that had a layer of burnt looking cheese on top, covered with grape jelly. During interview on 09/19/19 at 9:00 A.M., Resident #18 said the baked omelet was chewy and over cooked. During interview on 09/19/19 at 9:04 A.M., Resident #63 said he/she did not care for the baked omelet; it tasted burnt; he/she had tried to cover the taste with jelly, but that did not help. 7. Observation on 09/19/19 at 8:30 A.M. of the assisted dining room showed: -Dietary Service Aide C preparing and serving residents breakfast from the steam table; -The baked omelet in the steam table had an appearance of a burnt top layer, covering most of the top surface. 8. Observation on 09/19/19 at 8:45 A.M. of the breakfast meal test tray, taken directly from the steam table in the assisted dining room and received after the last resident was served, showed the following food temperatures, taken with a calibrated analog metal stem type thermometer: -The baked omelet was 114 degrees Fahrenheit; -The texture of the baked omelet was rubbery and it was cool to taste. During interview on 09/19/19 at 8:35 A.M. and 8:50 A.M., Dietary Service Aide D said: -The baked omelet looked over baked and the cheese on top had been burnt; -He/She was trying to take servings from the middle of the pan to avoid the burnt portions as the middle pieces appeared less burnt; -He/She had not taken the food temperatures when he/she took the foods from the hot cart and placed them on the steam table; -Serving temperatures were to be at least 120 degrees Fahrenheit at the time of service. During an interview on 9/18/19 at 10:00 A.M., the Dietary Director said staff are to check and log food temperatures when foods are placed in hot carts, once delivered to respective dining rooms and placed in the steam table and lastly at the end of service. During an interview on 9/19/19 at 10:00 A.M., the Dietary Director said: -He had seen the baked omelet that was served for breakfast; -The top of the baked omelet might have appeared a little over cooked and the cheese browner than he'd liked. During an interview on 9/19/19 at 5:00 P.M., the Dietary Director said he expected staff to prepare and serve foods that conserve nutritive value, flavor and appearance that is also palatable, attractive and at appetizing and correct temperatures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that nursing staff washed their hands after each direct resident contact and when indicated by professional practices during personal care, for one resident (Resident #8) in a review of 18 residents and for two additional residents (Resident #404 and #405). The facility census was 70. 1. Review of the facility policy Handwashing dated July 2016 showed the following: -The purpose was to provide guidelines for the proper hand washing to prevent the spread of infection to other personnel, residents and visitors; -All facility personnel must wash their hands for 15 seconds under the following conditions: 1. When coming on duty; 2. Between resident contacts; 3. After handling contaminated objects; 4. When hands were obviously soiled; 5. Before performing invasive procedure; 8. Before handling clean or soiled linens; 9. Before performing resident care procedures; 12. After contact with blood, body fluids, excretions, secretions, mucous membranes or non-intact skin; 14. After assistance with personal body functions (elimination, hair grooming, smoking); 15. After removing gloves; -The use of gloves did not replace hand washing. Wash hands after removing gloves. 2. Review of the facility policy Glove Use dated October 2017 showed the following: -Objective was to prevent the spread of infection; -Wash hands after removing gloves (Gloves did not replace hand washing); -Use gloves when touching excretions, secretions, blood, body fluids, mucous membranes or non-intact skin; -Wash hands before putting on gloves and after removing gloves. 3. Review of Resident #8's quarterly Minimum Data Set, (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/5/19, showed the following: -Short and long term memory problems; -Always incontinent of urine and stool; -Totally dependent on two or more staff for toilet use; -Required extensive assist of two or more staff for personal hygiene. Review of the resident's care plan dated 9/17/19 showed the following: -Resident is alert to self and pleasantly confused. He/she needs assist with decision making and has poor memory; -He/she requires assist with ADL care; -He/she wears briefs for incontinence; -He/she is incontinent of bladder and bowel. He/she needs assist to toilet. Observation on 9/19/19 at 7:07 A.M. in the resident's room showed the following: -The resident lay in bed; -He/she was incontinent of urine and bowel; -Certified Nurse Aide (CNA) P provided rectal pericare; -Feces was visible on the washcloth; -Without changing gloves or washing his/hands, CNA P placed a clean incontinence brief under the resident's hips; -CNA P removed his/her gloves and without washing hands applied clean gloves; -With gloved hands, CNA P picked up the bottle of periwash, sprayed periwash on clean wash cloths and provided pericare to the resident's front genitalia. During interview on 9/19/19 at 7:23 A.M. CNA P said he/she should have changed gloves and washed hands after providing pericare and prior to touching clean items. 4. Review of Resident #405's POS dated 9/11/19 showed the following: -admission dated 9/11/19; -Diagnosis of weakness and chronic kidney disease. Review of the resident's baseline care plan dated 9/11/19 showed the resident required assistance of one staff member with transfers. Review of the resident's admission MDS, dated [DATE] showed the resident required limited assistance of one staff member with personal hygiene. Observation on 9/19/19 at 6:45 A.M. showed the following: -CNA H assisted Resident #404 out of bed and to the bathroom, removed his/her gloves and without washing hands left the resident's room, charted on the computer and without washing hands entered the resident's room; -CNA H without washing hands, applied gloves and rinsed the resident's dentures with water. During interview on 9/19/19 at 6:50 A.M. CNA H said the following: -He/She should wash hands before and after gloving and should wash hands before providing resident cares and before applying gloves and after removing gloves; -He/She did not wash his/her hands before providing Resident #404 assistance to the bathroom. 5. Review of Resident #404's POS dated 9/10/19 showed the following: -admission date 9/10/19; -Diagnosis of left hip fracture; -Keep surgical dressing in place until follow up physician's appointment. Review of the resident's baseline care plan dated 9/10/19 showed the resident required wound care and assistance of one staff member with transfers. Observation on 9/19/19 at 6:40 A.M. showed the following: -Certified Nurse Aide (CNA) H entered the resident's room, the resident asked to use the toilet; -CNA H left the resident's room and returned with a box of gloves; -CNA H, without washing hands, applied gloves and removed the resident's bed pillow, touched the resident's legs and sat the resident up on the side of the bed. The resident had a wound dressing on his/her left hip; -CNA H walked with the resident to the bathroom, removed his/her gloves and without washing hands left the resident's room and charted on the computer at the nurses' desk. During interview on 9/20/19 at 12:25 P.M., RN N said that staff should wash their hands upon entering a resident room, when hands become soiled, with gloves changes, when going from dirty to clean tasks, and before touching clean items/surfaces and before exiting the room. During interview on 9/20/19 at 1:15 P.M. the Director of Nursing said the following: -Staff should wash hands before and after changing from dirty to clean tasks, anytime hands were soiled, and anytime gloves were soiled; -Staff should wash hands every time gloves were changed; -Staff should not touch clean items with soiled hands.