Based on interview and record review, facility staff failed to prevent the misappropriation of one resident's (Resident #4) debit card which was used without authorization of the resident. The debit card was used between the dates of 05/06/24 and 06/26/24 with total charges to the card of $755.00. The facility census was 46. The Administrator was notified on 08/09/24 of Past Non-Compliance which occurred on 07/09/24. On 07/09/24, the Administrator identified Certified Nurse Aid (CNA) M misappropriated resident funds. Upon discovery staff suspended the employee, conducted an investigation, notified appropriate parities, educated staff and terminated the CNA. Staff corrected the deficient practice on 07/15/24. 1. Review of the facility's policy Abuse, Prevention and Prohibition Policy, dated 11/2018, showed staff were directed as follows: -Social Services will educated the resident on how to report suspected occurrences, explaining how to report, the need to report, and the facilities response to the allegations; -Should a specific employee be suspected of or have allegations made of misappropriation, the facility will follow the investigative protocol set for in this policy; -The facility will educate staff on the policy and procedure for prevention of misappropriation of resident property and of investigation reporting and staff responsibility. 2. Review of Resident #4's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 06/26/24, showed facility staff assessed the resident as follows: -Cognitively intact; -Diagnosis of cancer Renal failure, Stroke, Urinary Trach Infection, and Manic Depression. Review of the facility's investigation, dated 07/09/24, showed facility staff were informed by the resident of several withdrawals were made from the resident's bank account in the name of CNA M. The resident did not authorize the transactions. Review showed the facility attempted to contact CNA M. The police department notified and a report of the misappropriation filed. The investigating officer issued a warrant for arrest. CNA M was suspended pending the results of the investigation and terminated by the facility on 07/15/24. All responsible parties were notified. Facility staff in-serviced on 07/08/24 related to misappropriation of resident property. Review of the resident's bank statement, from 04/01/24 through 07/15/24, showed the money transfers from the residents bank account to CNA M's finacial service application on: -05/06/24, $25.00; -05/08/24, $30.00; -05/21/24, $50.00; -05/24/24, $50.00; -05/26/24, $50.00; -05/29/24, $25.00; -06/05/24, $50.00; -06/07/24, $50.00; -06/08/24, $50.00; -06/11/24, $50.00; -06/11/24, $25.00; -06/13/24, $50.00; -06/14/24, $50.00; -06/23/24, $50.00; -06/24/24, $25.00; -06/25/24, $50.00; -06/25/24, $50.00; Total amount withdrawn $755.00 During an interview on 08/07/24 at 10:37 A.M., Registered Nurse (RN) N said he/she was not aware of the misuse of the resident's debit card until after it occurred. He/She said they were in serviced about not using resident debit or credit cards and how to avoid this happening again. During an interview on 08/07/24 at 10:45 A.M., CNA E said he/she did not witness the theft or hear about it until after staff were in-serviced regarding the theft. During an interview on 08/07/24 11:00 A.M., the resident said when they learned their balance was dropping they became suspicious but trusted the staff. He/She confronted CNA M, but the staff would not talk to them. He/She then told administration who immediately took action to help. During an interview on 08/08/24 at 9:00 A.M., CNA O said he/she has been educated what to do if a resident reports theft or missing property and did not know about the incident until after the in-service about using resident debit or credit cards. During an interview on 08/08/24 9:20 A.M., Certified Medication Technician (CMT) P said they had received an in-service about taking resident money or cards. Staff are to have two witnesses and a signed agreement if they purchase something for the resident now using the resident's money. During an interview on 08/09/24 at 10:11 A.M., the Director of Nursing (DON) said he/she became aware of the theft when the administrator did. The resident's bank account was reviewed and they were able to determine CNA M had misappropriated the residents debit card. The DON said they attempted multiple time to contact CNA M and when they reached CNA M, he/she would not come in to talk with us, but denied taking the money. During an interview on 08/09/24 at 11:08 A.M., the administrator said he/she became aware of the theft when another staff member told them. The resident's bank statement was reviewed and the identified staff CNA M. The administrator said CNA M was terminated. He/She said the local police department was also made aware and are investigating. All facility staff were in-serviced regarding using resident's debit cards. MO00238732

Based on interview and record review, facility staff failed to electronically submit to Centers for Medicare and Medicaid Services (CMS), a complete and accurate direct care staffing information to the Payroll Based Journal (PBJ) data from January 1, 2024 through March 31, 2024. The facility census was 46. 1. Review of the facility's policies showed the facility did not provide a PBJ policy. 2. Review of the CMS PBJ Staffing Data Report, dated 08/01/24, showed the report did not contain a report for the period of January 1, 2024 through March 31, 2024. During an interview on 08/09/24 at 11:14 A.M., the Administrator said it is the responsibility of the corporate office to submit PBJ data. He/She said the office staff did not report even when informed of the need. During an interview on 08/12/24 at 11:03 A.M., the Corporate PBJ staff said he/she was under the impression that since the facility was not Medicare Certified during that reporting period that submission was not required. He/She said there was some miscommunication between the facility and the corporate staff on the need to submit the data. The submission of the PBJ data is currently the responsibility of the corporate office.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to provide a clean and homelike environment when staff failed to provide housekeeping and maintenance services to maintain a sanitary, orderly and comfortable environment. The facility census is 46. 1. Review of the facility's Environment/Homelike policy, undated, showed: -The facility will remain clean and sanitary; -The facility will maintain clutter and remove it if it poses a hazard; -Equipment will be in good repair; -The safety of the residents and staff will take precedence over resident choice. Review of the facility's Work Orders/Repairs policy, undated, showed: -To prioritize repairs, work orders are to be completed and forwarded to the maintenance director; -The maintenance director will review and address all work order concerns; -Any concerns the maintenance director cannot address will be brought to the administrator's attention immediately; -Repairs will be addressed in order of priority and emergency repairs will be given priority over another request. 2. Observation on 08/06/24 at 11:38 A.M., showed Resident #39's oxygen concentrator with dirt and food debris on top. The resident's light over his/her bed did not work, did not have a string attached and the night light did not work. The toilet leaked water and had a blanket around the base. The wall above and around the sink with extra plaster and scuffed in other places, and the corners of the bathroom black with debris. During an interview on 08/06/24 at 11:38 A.M., the resident said he/she told the staff about the lights and curtain three months ago and nothing has been done yet. He/She said he/she and his/her roommate would like the lights fixed. 3. Observation 08/06/24 at 11:38 A.M., showed Resident #13's privacy curtain with stains on the lower half. 4. Observation on 08/07/24 at 8:47 A.M., showed Resident #200's oxygen concentrator with dirt and debris on top of it. 5. Observation on 08/07/24 at 8:57 A.M. showed Resident #15's electric wheelchair foot pedals stained and the seat with a white stain. Observation showed the electronic lift base with dust, dirt and hair on it. During an interview on 08/08/24 at 02:50 P.M., the infection preventionist said equipment such as electronic lifts should be cleaned between residents by the nursing staff to decrease the spread of germs. 6. Observation on 08/06/24 at 11:06 A.M., showed the shower room on the 300-hall contained a large cart unlocked with drawers at various degrees of open exposing contents, a white plastic tote sat on the floor next to the cart with a hanger and personal care supplies, three pair of personal shoes, the trash can full of trash, two hangers hung from the shower knobs behind the large cart, the wall behind the scale stained with a red color, a pair of shoes sat on the floor under the portable cart, a plastic grey, bed side commode pan sat on the floor next to the shower area, a blue medical glove covered a pipe on the floor in front of the large cart, an empty wash basin on the floor next to the scale. Observation on 08/07/24 at 08:32 A.M., showed the shower room on the 300-hall contained a large cart unlocked with drawers at various degrees of open exposing contents, a white plastic tote sat on the floor next to the cart with a hanger and personal care supplies, three pair of personal shoes, two hangers hung from the shower knobs behind the large cart, the wall behind the scale stained with a red color, a plastic grey, bed side commode pan sat on the floor next to the shower area and an empty wash basin sat on the floor next to the scale. Observation on 08/08/24 at 08:36 A.M., showed the shower room on the 300-hall contained a large cart unlocked with drawers at various degrees of open exposing contents, a white plastic tote sat on the floor next to the cart with a hanger and personal care supplies, three pair of personal shoes, two hangers hung from the shower knobs behind the large cart, the wall behind the scale stained with a red color, a plastic grey, bed side commode pan sat on the floor next to the shower area and an empty wash basin sat on the floor next to the scale. During an interview on 08/08/24 at 09:52 A.M., Certified Nurse Aide (CNA) L said he/she is not sure who is responsible to clean the shower rooms but would not take a shower in the room as it is. He/She said the floors are dirty and only get mopped once per day. 7. Observation on 08/06/24 at 10:21 A.M., showed Resident #12's motorized wheelchair parked in the hallway next to room [ROOM NUMBER]. The wheelchair base contained dirt and debris. 8. Observation on 08/06/24 at 10:26 A.M., showed Resident #43's bathroom with a red stain to the floor behind the toilet and an oxygen machine contained dust and debris. 9. Observation on 08/06/24 at 10:51 A.M., showed occupied room [ROOM NUMBER] window curtain partially torn. 10. Observation on 08/06/24 at 11:18 A.M., showed an air conditioner in the dining room with towels and bath blankets stacked under the unit. The baseboard peeled from the wall at the unit. Two ceiling lights did not contain a cover and 16 lights unlit. Observation on 08/07/24 at 11:55 A.M., showed an air conditioner in dining room with towels and bath blankets stacked under the unit. The baseboard peeled from the wall at the unit. Two ceiling lights did not contain a cover and 16 lights unlit. During an interview on 08/06/24 at 11:35 A.M., an unknown family member said the condition of the dining room air conditioner has not changed over the last year. He/She said the facility has a lot of maintenance type things that need addressed making it not the best looking place. 11. Observation on 08/06/24 at 11:24 A.M., showed the armrests on Resident #34's wheelchair torn and exposed foam. 12. Observation on 08/06/24 at 09:39 A.M., showed the entrance door glass panel with broken glass and two patio chairs with torn and bare cloth seats. Observation on 08/07/24 at 11:39 A.M., showed the entrance door glass panel with broken glass and two patio chairs with torn and bare cloth seats. Observation on 08/08/24 at 02:01 P.M., showed the entrance door glass panel with broken glass and two patio chairs with torn and bare cloth seats. 13. Observation on 08/08/24 at 08:28 A.M., showed a fly strip hung over Resident #12's bed contained flies. During an interview on 08/08/24 at 08:28 A.M., the resident said it was better to have the strip than to have the flies landing on him. 14. During an interview on 08/09/24 at 08:39 A.M., the Maintenance Supervisor said fly strips are not used in resident rooms and is not sure who hung it up. There is an outside company that routinely cleans the oxygen machines but should be wiped down by housekeeping between those visits. He/She said anything that needs addressed in the facility that is mechanical would be maintenance responsibility and anything regarding cleaning would be the housekeeping staff. Currently there is not a housekeeping supervisor so the housekeepers are managed by the administrator. Staff are expected to complete work orders for things such as loose brakes, torn armrests etc. He/She said there is not a schedule to check wheelchairs for needed repairs or issues but if informed would need to order parts to replace them. In the mean-time staff would use bandage tape until the parts come in. He/She said that hoyer lifts are cleaned by the nursing staff unless the machine would need to come to maintenance for hair build up on the wheels or other maintenance issues. The issues with the building such as paint needs, floor repairs, door window repairs, stuck doors, and the dining room air conditioner are in a plan to correct but he/she has been trying to help two other facilities as well as this one. During an interview on 08/09/24 at 10:11 A.M., the Director of Nursing (DON) said staff are expected to complete work orders when they notice that something needs repaired or potentially unsafe and give to the maintenance or place in his/her box. Oxygen concentrators can be wiped down by the nursing staff if noticed to be dirty or removed if issues with functioning and complete a work order. There is a wheelchair cleaning schedule for the nightshift to use to ensure wheelchairs are kept clean as part of their assignments, but floor staff can wipe down a wheelchair if needed and mechanical lifts should be cleaned by the aids between each resident to prevent cross contamination (spread of germs) and infection control. The DON said he/she is not involved in the cleaning of the shower rooms but would expect staff to keep it clean when finished using it. He/She said he/she believes the nursing staff have a time management issue and does not feel things are getting done as they should. During an interview on 08/09/24 at 10:46 A.M., the administrator said environmental cleaning includes daily pulling trash and spot cleaning. He/She said that deep cleaning is completed on a rotation quarterly by housekeeping staff. Currently the facility does not have a housekeeping supervisor and is being overseen by the social service director. Fly strips should not be used in a resident room and was not aware it was being used or where it came from. Anything needing repairs such as curtains, leaky faucets, light bulbs, door issues would be put on a work order for maintenance to address and prioritize. He/She said anything that would potentially cost more would need sent to the home office for approval before can begin. The Administrator said there is not a formal plan to improve the facility and fix up issues but would like to go room-to-room and update it before moving to another area.

Based on observation, interview and record review, facility staff failed to keep the environment free of accident hazards when staff failed to keep chemicals and razors behind locked doors and inaccessible to residents. The facility census was 46. 1. Review of the facility's hazardous storage policy, undated, showed hazardous items must be stored behind locked doors. Items include but not limited to razors, scissors, cleaning chemicals, toe-nail clippers, and etc. 2. Observation on 08/06/24 at 11:06 A.M. and 2:53 P.M., showed the 300 hall shower room unlocked and unattended. Observation showed a large, unlocked cart and a large grey unlocked cabinet contained loose razors and a bag of ice melt chemical on the floor. Observation showed multiple unlabeled bottles, cans and tubes of shampoo, deodorant and soap sat on the top of the unlocked cart, the sink and the handrail in the shower stall. Observation showeeds several staff and resident's passed by the shower room. Observation on 08/07/24 at 08:32 A.M., showed the 300 hall shower room unlocked and unattended. Observation showed a large, unlocked cart and a large grey unlocked cabinet contained loose razors and a bag of ice melt chemical on the floor. Observation showed multiple unlabeled bottles, cans and tubes of shampoo, deodorant and soap sat on the top of the unlocked cart, the sink and the handrail in the shower stall. Observation showeeds several staff and resident's passed by the shower room. Observation on 08/08/24 at 08:36 A.M., showed the 300 hall shower room unlocked and unattended. Observation showed a large, unlocked cart and a large grey unlocked cabinet contained loose razors and a bag of ice melt chemical on the floor. Observation showed multiple unlabeled bottles, cans and tubes of shampoo, deodorant and soap sat on the top of the unlocked cart, the sink and the handrail in the shower stall. Observation showeeds several staff and resident's passed by the shower room. 3. Observation on 08/07/24 at 08:09 A.M. 02:33 P.M., showed the 300 hall beauty shop/shower room unlocked and unattended. Observation showed a purple top container of disinfectant chemical wipes sat on a wheelchair accessible shelf. Staff and resident's passed by the room. 4. During an interview on 08/08/24 at 09:52 A.M., Certified Nurse Aide (CNA) L said razors and chemicals should not be stored in the shower room because a resident could wander in here and get hurt. He/She said there are residents at the facility that wander and could go in the shower rooms and get hurt if the chemicals and razors are stored in there. He/She said he/she is not usually the one that gives showers so he/she is not sure why the items were in the room or who is responsible to keep them locked up. CNA L does not know if there are locks for the cabinets and carts kept in the shower rooms. During an interview on 08/09/24 at 08:39 A.M., the Maintenance Director said the ice melt was kept in the shower room because it was being used to calibrate the scale (stored in the shower room). He/She said there are residents that wander and could go in there and get hurt but didn't really think about it. Nursing and housekeeping would take care of the other items. The department Heads do quality assurance rounds daily to assess rooms for cleanliness, needed repairs and overall room and resident needs. During an interview on 08/09/24 at 10:11 A.M., the Director of Nursing (DON) said he/she is not involved in the cleaning of the shower rooms but feels there should not be chemicals, sharps or anything that could hurt a resident stored in there. He/She was not aware the storage cart and the cabinet did not lock. The DON said the ice melt bag was kept in the shower room to calibrate the scale but probably should have been locked up. During an interview on 08/09/24 at 10:46 A.M., the administrator said hazardous chemicals, sharp items, incontinence products and extra linens should not be stored in the shower rooms unless in the locked cabinet. He/She was not aware the locks were missing from the cabinet and said have replaced them on multiple occasions. The administrator said the ice melt is considered a hazardous chemical and should be locked up and out of resident access and did not know it was in the shower room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to destroy medications in a timely manner for ten current residents (Resident #1, #2, #12, #16, #20, #34, #35, #39, 43, and #44) and discharged residents (Resident #300, #301, #302, and #303). Staff failed to discard expired medications from one of one over the counter medication storage cabinet and two of two medication carts. The facility census was 46. 1. Review of the facility's Medication and Storage policy, revised November 2013, showed: -No discontinued, outdated, or deteriorated medications should be available for use in the facility. All medications are destroyed per policy; -Expired medications are to be removed from areas medication carts prior to or at the time of expiration; -Medications will be stored in accordance with manufacturer guidance and not to exceed expiration dates unless a shortened shelf-life once opened. Review of the facility's Destruction and Disposal of Medications policy, revised November 2013, showed non-unit dose drugs not qualifying for return to the issuing pharmacy and drugs left by residents discharged form the facility shall be destroyed. 2. Observation on 08/06/24 at 9:47 A.M., showed Certified Medication technician (CMT) Q stood in the medication storage room holding a large black trash bag of medications. Interview on 08/06/24 at 9:48 A.M., CMT Q said he/she was removing medications he/she found under the cabinet to take to the DON's office to be destroyed. He/She said there are more medications under the cabinet that needed to also be destroyed. He/She said they are either discharged residents or discontinued medications. 3. Observation on 08/06/24 at 10:15 A.M., showed the large black trash bag contained the following discontinued medications: -Five tablets of Potassium chloride extended release (Supplement) 20 milliequivalents (mEq) with an order date of 02/24/24 for Resident #2; -Two capsules of Omeprazole (Antacid) 20 milligrams (mg) with an order date of 12/11/23 for Resident #12; -Two tablets of furosemide (Lasix) 40 mg with an order date of 04/07/24 for Resident #20; -Two Capsules of hydroxyzine (Antihistamine) 25 mg with an order date of 04/26/23 for Resident #34; -Nine tablets of metformin (anti-diabetic) 1000 mg with an order date of 12/28/23 for Resident #35; -Seven capsules of duloxetine (anti-depressant) 60 mg with an order date of 11/16/23 for Resident #39; -21 tablets of simvastatin (high cholesterol) 80 mg with an order date of 11/27/23 for Resident #43; -Two tablets of metoprolol (high cholesterol) 100 mg with an order date of 02/23/24 for Resident #44; -15 tablets of buspirone (anti-anxiety) 1000 mg with an order date of 02/05/24 for Resident #300; -Three tablets of potassium chloride 28 [NAME] with an order date of 01/27/24 for Resident #301; -25 tablets of furosemide 20 mg with an order date of 02/20/24 for Resident #302. 4. Observation on 08/06/24 at 10:25 A.M., showed a large brown box contained various discontinued and discharged resident medications, including medication cards, and rolled clear prefilled medication pill packs. Observation on 08/06/24 at 10:25 A.M., showed a large brown box contained a medication card with three capsules of gabapentin (Anticonvulsant and Nerve pain medication) 100 mg with an order date of 11/27/23 for Resident #1. Observation on 08/06/24 at 10:25 A.M., showed a large brown box contained a medication card with fifteen capsules of hydroxyurea (Chemotherapy) 500 mg with an order date of 02/20/24 for Resident #302. The box contained a yellow sticker that said, Hazardous Drug Warning. 5. Observation on 08/06/24 at 10:35 A.M., showed the storage cabinet contained a folded medication card with five tablets of midodrine (anti-diarrhea) 2 (mg) with an order date of 04/26/23 for Resident #16. Observation on 08/06/24 at 10:35 A.M., showed the storage cabinet contained a folded medication card with 16 tablets of midodrine (for low blood pressure) 5 mg with an order date of 09/19/23 for Resident #303. 6. During an interview on 08/06/24 at 11:05 A.M., CMT Q said the medication room is maintained by all CMT's and nursing staff. He/She said there is not a specific staff member in charge. He/She said he/she is not sure what policy says about discarding medications. He/She said he/she has been placing all discontinued medications or discharged resident medications in the cabinet in the medication room. He/She said whoever has time is supposed to dispose of the medications. He/She said he/she believes they have had a major issue with keeping up with disposing of medications ever since the facility switched over to prefilled sealed pill packs. He/She said staff have not had time to dispose of medications on a regular basis. During an interview on 08/08/24 at 1:25 P.M., Registered nurse (RN) N said it is his/her expectation that nursing staff and CMT's discard medications the same day that medications are discontinued or residents are discharged . He/She said it is the responsibility of whoever is on the cart at the time. He/She said he/she knew there were medications that needed to be discarded but he/she was not sure why there were so many. During an interview on 08/08/24 at 1:28 P.M., Licensed practical nurse (LPN) R said the medications in the medication storage room were the medications of the residents who discharged or medications that were discontinued. He/She said they did not have a process in place before. He/She said medications should be discarded the same day that they are discontinued or residents are discharged . He/She said moving forward nursing staff plan to dispose of medications as they are discontinued or the resident is discharged . During an interview on 08/09/24 at 8:15 A.M., the Director of Nursing said the medications found in the medication storage room were discharged residents, discontinued medications or medications received during admission. He/She said it is his/her expectation that her CMT's or nurses dispose of discontinued or discharged resident medications right away. He/She said was unaware that it was backed up and he/she is not sure how or why it happened. He/She said he/she is responsible for auditing the medication storage room the nurse and CMT's are responsible for maintain them. During an interview on 08/09/24 at 8:32 A.M., the Administrator said it is his/her expectation that nurses are destroying discontinued and discharged resident medications as soon as possible. He/She said the DON is responsible for maintaining the medication room. He/She said he/she expects the DON to monitor the medication storage room at least once weekly if not more. He/She said he/she was not aware that staff were not destroying medications in a timely manner and said he/she is not sure why they were storing discontinued and discharged resident medications in the medication room. 7. Observation on 08/06/24 at 9:55 A.M., showed cabinet in the medication storage room contained the following: -One bottle of travel ease meclizine (Antihistamine) 25 mg with an expiration date of 6/24; -One bottle of oyster shell calcium (supplement) 500 mg with an expiration date of 7/24; -Two bottles of Thera-m high potency multi-vit (dietary supplement) with an expiration date of 4/24; -One bottle of thiamine vit b-1 (dietary supplement) 100 mg with an expiration date of 7/24. 8. Observation on 08/06/24 at 10:42 A.M., showed the 100/200 hall medication cart contained: -One bottle of ferrous gluconate 240 mg with an expiration date of 3/24; -One bottle of oyster shell calcium 500 mg with an expiration date of 7/24. 9. Observation on 08/06/24 at 11:01 A.M., showed the 300-hall medication cart contained: -One bottle of ferrous gluconate 240 mg with an expiration date of 3/24; -One bottle of thiamin vit b-1 100 mg with an expiration date of 5/24; -Two bottle of oyster shell calcium 500 mg with an expiration date of 7/24; -One bottle of meclizine 25 mg with an expiration date of 6/24; -One bottle of thiamin vit b-1 100 mg with an expiration date of 7/24. 10. During an interview on 08/06/24 at 11:05 A.M., CMT Q said the facility buys large bottles of over the counter (OTC) medications and they use them to refill the smaller bottles in the medication carts. He/She said he/she believes some of the medications bottle do not have accurate expiration dates on them due to the bottles being refilled. He/She said he/she is not sure how they could accurately keep track of when the refilled bottles would be expired. He/She said expired medications should not being given because they may not be effective. He/She said whoever is passing medications on the cart is responsible for the cart and making sure there are not expired medications. During an interview on 08/08/24 at 1:25 P.M., RN N said it is the responsibility of the nurse or CMT on the medication cart to check the cart for expired medications. He/She said it should be done daily on their shift. He/She said expired medications should not be given to residents because the medication may not be effective. He/She said it is the nurses responsibility to check the medication room for expired medications. He/She said the medication room should be checked at the beginning of every month. During an interview on 08/08/24 at 1:28 P.M., LPN R said it is the responsibility of the CMT's to check the expiration dates of all OTC medications in their cart daily on their shift. He/She said CMT's should be checking expiration dates as they pass them and any time they restock their cart. He/She said it is his/her expectation that the OTC medications in the medication storage room are check weekly with restocking and also once monthly. During an interview on 08/09/24 at 8:15 A.M., the Director of Nursing said it is the responsibility of the nurses and CMT's to maintain medication carts and the medication storage room, including disposing of expired medications. He/She expects CMT's and nurses to check the medication carts daily on their shift as well as checking them during their weekly changeover. He/She said changeover occurs weekly usually in the evenings on Thursdays when pharmacy brings the new medication pill packs. He/She expects staff to look over OTC medications at that time and pull and destroy any expired medications. He/She was not aware there were expired medications in the medication storage room or in medication carts. He/She said he/she is responsible for auditing the medication storage room and medication carts and the nurse and CMT's are responsible for maintain them. During an interview on 08/09/24 at 8:32 A.M., the Administrator said the DON is responsible for maintaining the medication room and medication carts. He/She said he/she expects the DON to monitor the medication storage room and carts for expired medications at least once weekly if not more. He/She said he/she was not aware that there were expired medications in the medication storage room or medication carts.

Based on observation, interview and record review, facility staff failed to serve pureed food in accordance with the nutritionally calculated recipes and menus. Facility staff failed to ensure meal substitutions were reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy. The census was 46. 1. Review of The facility's Pureed Foods instructions, dated November 2005, which were posted on the wall in the food prep area showed staff were instructed to puree: -Three ounces of cooked entrees with 1/2 slice of bread and broth, beginning with 1/2 cup of liquid and adding liquid until product is correct consistency; -One half cup of side dishes of potato, rice and noodles with milk or melted margarine and adding liquid until product is correct consistency; -One regular diet serving of pastries such as cakes or pies with fruit juice or milk, beginning with 1/2 cup of liquid and adding liquid until product is correct consistency. Review showed the instructions did not include instruction on how to puree bread. Review of the facility's Pureed Food Preparation policy, undated, showed: -Each menu cycle will be reviewed to ensure there is a pureed recipe for each item to be served; -Standardized recipes will be used to prepare all pureed foods; -Recipes will not use water to thin pureed foods. Observation on 08/06/24 at 11:23 A.M., showed [NAME] C added four slices of bread, an unmeasured amount of water and two, four ounce scoops of gumbo to a food prcessor. [NAME] C pureed the items, poured the pureed items in a pan and placed the pan on the steam table. Observation on 08/06/24 at 11:30 A.M., showed [NAME] C added 2 #8 scoops (four ounces) of white rice, four slices of bread and an unmeasured amount of water to a food processor bowl. [NAME] C pureed the items, poured the pureed items in a pan and placed the pan on the steam table. Observation on 08/06/24 at 11:37 A.M., showed [NAME] C removed two pieces of garlic bread from the serving line. [NAME] C added the garlic bread, four slices of bread and an unmeasured amount of water to a food processor bowl. [NAME] C pureed the items, poured the pureed items in a pan and placed the pan on the steam table. Observation on 08/06/24 at 11:45 A.M., showed [NAME] C added two #8 scoops of peach cobbler, an unmeasured amount of milk and three slices of bread to a food prcessor bowl. [NAME] C pureed the items, poured the items into two dessert cups, covered the cups with plastic and placed them in the refrigerator. Observation on 08/06/24 at 12:42 P.M., showed [NAME] C served pureed rice, gumbo and bread to a resident. During an interview on 08/06/24 at 11:50 A.M., [NAME] C said he/she used bread and water when making purees because there was not a recipe. [NAME] C said he/she used the size of the dessert cup and did not measure the dessert serving size but he/she guessed the dessert serving was a hair over a half cup. During an interview on 08/06/24 at 12:08 P.M., the DM said kitchen staff did not have recipes for the meal of the month. The DM said kitchen staff puree everything with bread or thickener or milk. The DM said staff should use the puree guidance that was posted on the wall if there was not a standarized puree recipe. During an interview on 08/08/24 at 1:35 P.M., the administrator said the DM was responsible for ensuring kitchen staff prepared meals according to recipes. The administrator said bread should not be added to every puree item. 2. Review of the facility's Registered Dietician policy, undated showed the Registered Dietician (RD) will: -Assist in the development and planning of regular and therapeutic diets; -Assist the diet department in reviewing and maintaining the appropriate quality of meal preparation and menus. Review of the facility's Week At a Glance menu for Week 4, Day 24 showed staff were instructed to serve three ounces of garlic herbed pork loin, four ounces of candied yams, eight ounces of tossed salad, a #6 (5.33 ounces) dip of blueberry cobbler and eight ounces of beverage. Observation on 08/06/24 during the noon meal showed staff served four ounces of gumbo, which consisted of sausage and onion, four ounces of white rice, one slice of garlic bread, four ounces of peach cobbler and eight ounces of beverage. Observation showed the residents were overserved the entree by one ounce, underserved the dessert by one and one third ounces and did not receive a salad. During an interview on 08/06/24 at 12:02 P.M., [NAME] S said the noon meal was the resident's meal of the month so there were not standardized recipes or portions in the book. During an interview on 08/06/24 at 12:08 P.M., the DM said kitchen staff did not have recipes for meal of the month. The DM said the RD did not approve the noon meal and the RD did not know what residents get for meal of the month since he/she did not have a substitution log. The DM said when serving meal of the month kitchen staff use portion sizes for similar recipe items. The DM said he/she directed the four ounce portion sizes and did not think about the salad. During an interview on 08/07/24 at 11:39 A.M., the Dietary Manager said kitchen staff did not have a substitution log. The DM said the RD did not review the resident Meal of the Month menus. The DM said During an interview on 08/07/24 at 12:43 P.M., the RD said he/she had not watched kitchen staff prepare pureed items. The RD said he/she did not the resident choice meal prior to the meal and he/she would expect gumbo to have vegetables. The RD said he/she would not consider sausage and onion an acceptable gumbo. The RD said he/she usually reviewed substitutions if they were written down and if they were not written he/she assumed staff were serving the menu as displayed. During an interview on 08/08/24 at 1:35 P.M., the administrator said the DM was responsible for making sure the RD had reviewed substitutions. The administrator said he/she did not know residents were served meals that had not been review by the RD.

Based on observation, interview and record review, facility staff failed sanitize kitchen wares in a manner to prevent contamination. Facility staff failed to ensure the dish machine was operating according to manufacturer's instructions in a manner adequate to prevent cross contamination of kitchen wares. The facility census was 46. 1. Review of the facility's Steps to Clean and Sanitize in a 3-Compartment Sink policy, undated, showed staff were directed to: -Clean items in the first sink; -Rinse items in the second sink; -Sanitize items in the third sink. Read the label for time and temperature requirements for the sanitizer you are using. Review of the sanitizer directions for use showed: -Thoroughly wash equipment and utensils in hot detergent solution; -Rinse utensils and equipment thoroughly with potable water; -Sanitize equipment and utensils by immersion in a use solution of one ounce of this product per four gallons of water (200-400 parts per million (ppm) active solution) for at least 60 seconds at a temperature of 75 degrees Fahrenheit (F); -For equipment and utensils too large to sanitize by immersion use a soultion of 200-400 ppm by rinsing, spraying or swabbing until visibly wet. Observation on 08/06/24 at 10:36 A.M., showed a signed posted above the sanitizer sink which instructed staff to soak items in sanitizer for 30 seconds. Observation on 08/06/24 at 10:30 A.M., showed [NAME] C washed a large pan and a food processor blade and bowl. Observation showed [NAME] C dipped the items in sanitizer, rinsed the items under running water and placed them on the drain board. [NAME] C then washed a measuring cup, a metal pitcher and a large plastic pitcher. [NAME] C dipped the items in sanitizer, rinsed the items under running water and placed them on the drain board. Observation showed [NAME] C washed and rinsed a large pot and placed the pot in the sanitizer. Observation showed the pot was not fully immersed in the sanitizer. [NAME] C removed the pot from the sanitizer, rinsed the pot under running water and placed the pot on the drain board. Observation on 08/06/24 at 10:40 A.M., showed [NAME] C tested the sanitizer using a paper test strip. Observation showed the test strip indicated the sanitizer concentration was 100 ppm. Observation on 08/06/24 at 11:32 A.M., showed [NAME] C hand washed a food processor bowl, lid and blade. [NAME] C rinsed the items and placed them in the sanitizer sink. [NAME] C washed and rinsed a large metal pot by hand and placed the pot in the sanitizer sink. [NAME] C then removed the food processor parts and rinsed them under running water. Observation showed the large pot was not fully submerged in the sanitizer. Observation on 08/06/24 at 11:40 A.M., showed [NAME] C swirled a large metal pot around in the sanitizer sink. [NAME] C removed the pot, rinsed it under running water and placed it on the drain board. [NAME] C then washed and a food processor blade, bowl and lid and placed the parts in the sanitizer sink. [NAME] C washed a spatula and knife and placed them in the sanitizer sink. [NAME] C then rinsed the food processor parts, the spatula and the knife under running water. [NAME] C place the items on the drain board. During an interview on 08/06/24 at 10:40 A.M., [NAME] C said the test strip should indicate at least 200 ppm. [NAME] C said the sanitizer was at 200 ppm about 90 minutes prior. [NAME] C said he/she washes and rinses kitchen wares before soaking in sanitizer for 30 seconds. [NAME] C said he/she always rinses items when they are removed from sanitizer. [NAME] C said items should be fully covered with sanitizer solution. During an interview on 08/06/24 at 10:15 A.M., the Dietary Manager (DM) said staff should follow the sanitizer label instructions when sanitizing kitchen items. The DM said he/she was not sure of the required soak time for the sanitizer. During an interview on 08/08/24 at 1:35 P.M., the administrator said the DM was responsible for making sure staff used the sanitizer correctly. The administrator said he/she did not know the sanitizer soak time so he/she would look at the sign above the sink. The administrator said he/she did not know if items should be rinsed when removed from sanitizer. 2. Review of the dish machine low temperature sanitizer directions for use showed: -A solution of 100 ppm available chlorine may be used in the sanitizing solution if a chlorine test kit is available; -Solutions containing an initial concentration of 100 ppm available chlorine must be tested and adjusted periodically to ensure that the available chlorine does not drop below 50 ppm. Review of the dish machine instruction label showed wash and rinse temperatures should be greater than 130 degrees Fahrenheit (F). Review of the dishwasher 180 degree F temperature test strip instructions showed if the color bar has turned bright orange, the dishwasher is maintaining the proper temperature. Review of the facility's August 2024 Dishwasher Temperature Log showed staff directly involved in the dishwasher process were instructed to log dishwasher temperatures. Review showed four different staff members made entries on the log. Review showed all staff members entered zero for wash temperature, 100 for rinse temperature and 100 for test strip. Observation on 08/06/24 at 10:10 A.M., showed Dietary Aide (DA) D removed a rack of clean kitchen wares from the dish machine. Observation on 08/06/24 at 10:12 A.M., showed DA D placed a load of soiled kitchen wares in the dish machine. DA D used a 180-degree F indicator test strip to verify the low temperature dish machine function. Observation showed the test strip did not turn orange, which indicated the water temperature did not reach 180 degrees F. Observation on 08/06/24 at 10:14 A.M., showed the DM used a 180-degree F indicator test strip to verify dish machine function. Observation showed the test strip did not turn orange. Observation showed there were quaternary solution test strips available at the dish machine but there were not chlorine test strips available. During an interview on 08/06/24 at 10:15 A.M., DA D said the dish machine should run about 160 degrees F. DA D said he documented 100 on the temperature log but he/she did not know why. DA D said he/she never told the DM the temperature test strips did not work. During an interview on 08/06/24 at 10:20 A.M., the DM said the test strip should turn orange but he/she did no know why it did not. The DM said kitchen staff had been using the temperature test strips for about two months. The DM said the facility's vendor told him/her they no longer carried chlorine test strips. The DM said the dish machine temperature should be between 130 and 160 degrees F. The DM said he/she did not know what staff was recording on the temperature log sheet and the temperatures were probably not correct. During an interview on 08/08/24 at 1:35 P.M., the administrator said the DM was responsible for making sure staff used the dish machine correctly. The administrator said he/she did not know kitchen staff were not using the correct test strips for the dish machine.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to develop, implement and educate on an enhanced barrier precautions (EBP) system for four (Resident #12, #17, #38, and #200) of four sampled residents when facility staff failed to post signage or other system to alert staff of resident's who required EBP and place appropriate personal protective equipment (PPE) in close proximity. The facility census was 46. 1. Review of the facility's policies showed staff did not provide a policy for EBP. Review of the Centers for Disease Control (CDC) website https://www.cdc.gov/hicpac/workgroup/EnhancedBarrierPrecautions.html article, Consideration for Use of Enhanced Barrier Precautions in Skilled Nursing Facilities, dated June 2021, showed: -Facilities should develop a method to identify residents with wounds or indwelling medical devices, and post clear signage outside of resident rooms indicating the type of PPE required and defining high risk resident care activities; -Gowns and gloves should be available outside of each resident room, and alcohol-based hand rub should be available for every resident room (ideally both inside and outside of the room). 2. Review of Resident #12's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 06/19/24, showed staff assessed the resident as: -Cognitively intact; -Always incontinent of bowel and bladder with an external urinary catheter in use; -One unhealed unhealed stage IV pressure (loss of skin and tissue exposing bone, cartilage, and/or tendon) wound present on admission; -Received pressure ulcer care included non-surgical dressing and ointment or medications other than to feet; -Diagnosis of diabetes and quadriplegia. Observation on 08/06/24 at 10:21 A.M., showed the resident room did not contain a EBP sign or PPE located outside the resident room. Observation on 08/07/24 at 09:29 A.M., showed the resident room did not contain a EBP sign or PPE located outside the resident room. Observation on 08/07/24 at 1:52 P.M., showed Registered Nurse (RN) H provided wound care to the resident and did not wear a gown. The door to the room did not contain a EBP sign or PPE located outside the resident room. Observation on 08/08/24 at 08:28 A.M., showed the resident room did not contain a EBP sign or PPE located outside the resident room. During an interview on 08/08/24 at 08:28 A.M., the resident said staff do not wear a gown when providing wound care, transfers or toileting assistance. Observation on 08/08/24 at 11:05 A.M., showed Certified Nurse Aide (CNA) E and CNA F provided incontinent care and transferred the resident and did not wear a gown. the resident room did not contain a EBP sign or PPE located outside the resident room. During an interview on 08/08/24 at 11:22 A.M., CNA E said he/she has not had any education regarding EBP or told of any residents who may need EBP. He/She did not wear a gown because the resident is not contagious. During an interview on 08/09/24 at 09:59 A.M., RN H said staff only wear a gown during treatments and care when the resident has an infection. He/She said he/she is not aware of any curent residents who would need the extra precautions because none of them have been swabbed to rule out an infection. RN said he/she has not been trained on EBP. 3. Review of Resident #17's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Open lesion other than ulcer, rash or cut with application of ointment other than to feet; -Diagnosis of diabetes, stroke and low iron. Observation on 08/06/24 at 10:41 A.M., showed the resident room did not contain a EBP sign or PPE located outside the resident room. A bandage covered the resident's left foot, ankle and lower leg. Observation on 08/07/24 at 03:25 P.M., showed the resident room did not contain a EBP sign or PPE located outside the resident room. A bandage covered the resident's left foot, ankle and lower leg. Observation on 08/07/24 at 03:28 P.M., showed CNA G and CNA J transfered the resident to bed and provide incontinence care without a gown on. Observation showed a bandage covered the resident's left foot, ankle and lower leg. The resident room did not contain a EBP sign or PPE located outside the resident room. During an interview on 08/07/24 at 03:38 P.M., CNA J said he/she was not informed of any issues with the resident that would require him/her to wear a gown. He/She is not aware of any current resident that requires extra PPE and has not been educated on EBP and is unsure what EBP means. Observation on 08/08/24 at 08:16 A.M., showed the resident left foot, ankle and lower leg with a bandage. The resident room did not contain a EBP sign or PPE located outside the resident room. During an interview on 08/08/24 at 08:16 A.M., the resident said staff do not wear a gown when providing wound care, transfers or toileting assistance. 4. Review of Resident #38's Significant Change of Status MDS, dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -Use of a feeding tube (tube surgically placed into the stomach to deliver fluid and nutrition); -On hospice; -Diagnosis of cancer. Observation on 08/06/24 at 10:36 A.M., showed the resident's room with a feed pump. Observation showed the room did not contain a EBP sign or PPE located outside the resident room. Observation on 08/06/24 at 02:55 P.M., showed the resident's room with a feed pump. Observation showed the room did not contain a EBP sign or PPE located outside the resident room. During an interview on 08/07/24 at 9:06 A.M., CNA K said he/she did not know the resident needed special PPE during care to include transfers, showers and incontinent care. He/She said he/she has not received any EBP training and was not sure what it was. 5. Review of Resident #200's admission MDS dated [DATE] showed staff assessed the resident as: -Cognitively impaired; -Used an indwelling catheter (tube inserted into the bladder to drain urine); -Diagnosis of hemiplegia (paralysis of one side of the body). Observation on 08/07/24 at 07:52 A.M., showed CNA E position the resident's indwelling catheter on the bed and did not wear a gown. The resident room did not contain a EBP sign or PPE located outside the resident room. During an interview on 08/07/24 at 08:00 A.M., CNA E said he/she was not aware the resident required any extra precautions and was not sure what EBP was. 6. During an interview on 08/07/24 at 02:00 P.M., RN N said he/she did not know anything about enhanced barrier precautions. He/She said he/she does not know what it is and does not have any information about it. During an interview on 08/07/24 at 04:15 P.M., the administrator said the facility did not have a system in place or policy for EBP. He/She said he/she recieved an email a little while ago stating EBP were recommendations and did not know the recommendation were a regulation until questioned. During an interview on 08/08/24 at 02:50 P.M., the infection prevention nurse said he/she heard the EBP were a suggestion and did not do anything regarding it. He/She said he/she and the Director of Nursing (DON) are responsible to review policies and begin training when new regulations come out. He/She said the facility does not currently have a policy or had any training regarding EBP. During an interview on 08/09/25 at 10:11 A.M., the DON said he/she recieved an email a week or two ago regarding the EBP and notified the administrator. He/She said the administrator said it was only recommendations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility staff failed to maintain professional standards of documentation for falls and neurological checks of two residents (Resident #11, and 13), and smoking assessments of one resident (Resident #13). The facility census was 40. 1. Review of the facility's policy titled, Neurological Assessment, revised October 2010, showed staff were directed to do the following: -Neurological assessments will be completed upon physician's order, following an unwitnessed fall, following a fall or other accident/injury involving head trauma, or when indicated by resident's condition; -Neurological assessment (neuro checks) will be done every 15 minutes for the first hours, then every 30 min X2, every hour X6, every 4 hours X2, every 8 hours X7 for a total of 72 hours; -If a schedule should be interrupted due to transfer to the hospital, the schedule will be resumed upon return from the hospital; -Any changes in vital signs or neurological status in a previously stable resident should be report to the medical practitioner immediately. Review of the facility's policy titled, Smoking Policy -Resident, revised January 2017, showed staff were directed to do the following: -Any resident who expressed interest to smoke will be assessed at the time of admission and at least quarterly or with any significant change to determine the level of supervision that will be needed to ensure the resident's safety; -Based on the assessment findings the resident's care plan will be revised to reflect the level of assistance, supervision, and any assistive devices that will be needed by the resident to enable them to smoke safely; -Residents smoking materials will be kept at the nurse's station when not in use. 2. Review of Resident #11's Quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 06/28/23, showed staff assessed the resident as follows: -Severe cognitive impairment; -Independent with bed mobility, transfers, and walking; -Requires limited assistance of one staff for dressing, toileting, and bathing; -A fall risk. Review of the resident's care plan, revised 09/16/23, showed staff were directed to do the following: -Be sure call light is within reach; -Educate resident to make sure his/her walker is in front of him/her and that he/she has a clear pathway when standing up; -Ensure personal items are within reach; -Ensure the resident is wearing appropriate footwear, shoes, or gripper socks when ambulating; -Non-skid pad in the resident's recliner on top of cushion; -Educate resident to ask for help when moving from sitting to standing; -Resident uses a walker for ambulation. Review of the resident's incident log record showed the resident had falls on 05/29/23, 07/02/23, 07/25/23, 08/07/23, and 09/16/23. Review of the resident's nurse notes showed the following: -Did not contain documentation of a fall on 05/29/23, 07/02/23, 09/16/23. Further review of the record showed it did not contain documentation of neurological checks, notification of the physician, notification of the responsible party, or completed 72 hours of post fall charting; -Did not contain documentation if the 07/25/23 fall was witnessed or unwitnessed, if the resident hit his/her head, neurological checks, notification of the physician, or completed 72 hours of post fall charting; -Did not contain documentation staff notified the physician or responsible party for the fall on 08/07/23. 3. Review of Resident #13's Annual MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Required limited assistance of one staff for transfers, toileting, and personal hygiene; -A smoker; -A fall risk. Review of the resident's care plan, revised 07/11/23, showed staff were directed to do the following: -Resident is to be supervised while smoking; -Smoking materials are kept secured by staff; -Smoking per facility protocol; -Anti-roll backs on resident's wheelchair; -Be sure call light is in reach; -Dycem (non-slip mat) between pad and wheelchair cushion; -Ensure personal items are within reach; -Remind resident to lock brakes on his/her wheelchair prior to transferring self. Review of the resident's incident log record showed the resident had a fall on 06/28/23. Review of the resident's nurse's notes showed the resident had an unwitnessed fall on 06/28/23. Further review of the record showed that the record did not contain documentation of neurological checks, notification of the physician, or completed 72 hours post fall charting. Review of the resident's smoking assessments dated 04/01/23, 06/30/23, and 09/30/23 showed the MDS Coordinator assessed the resident has having ashes or burn holes in his/her clothing. Further review of the three smoking assessments indicated that the resident should wear a smoke apron due to being coded with ashes or burn holes in their clothing. Observation on 10/02/23 at 1:11 P.M., showed the resident outside smoking with staff present and no smoke apron on. Observation on 10/03/23 at 9:05 A.M., showed the resident outside smoking with staff present and no smoke apron on. Observation on 10/03/23 at 1:10 P.M., showed the resident outside smoking with staff present and no smoke apron on. Observation on 10/04/23 at 1:21 P.M., showed the resident outside smoking with staff present and no smoke apron on. 4. During an interview on 10/04/23 at 1:35 P.M., Registered Nurse (RN) E and RN F said they completed smoke assessments upon admission and quarterly. They also said that if a resident had a change they were to complete a new smoke assessment at that time as well. They both said that all residents' cigarettes and lighters are to be locked up at the nurse's station and staff are to always supervise all residents when smoking. RN E said that falls should be documented in the nurse's notes and under risk management. He/She said that if a fall was unwitnessed or if the resident hit their head then staff are to also do neurological assessments and document those in the resident's chart. RN E looked in Resident #13's chart on 06/28/23 and agreed that the fall was not documented correctly in the nurse's notes, and that neurological assessments were not completed. During an interview on 10/04/23 at 1:57 P.M., Certified Nurse Assistant (CNA) C said that all residents were supposed to be supervised while smoking. He/She said that if a resident was supposed to wear a protective smoke apron that it should be documented in the care plan. During an interview on 10/05/23 at 8:31 A.M., the MDS Coordinator said that he/she did complete Resident #13's smoking assessments on 04/01/23, 06/30/23, and 09/30/23. He/She said that he/she marked that the resident had ashes or burn holes in his clothes by mistake on all three assessments which indicated the resident needed to wear a smoke apron while smoking. He/She said that he/she will re-evaluate the resident today by observing him and correct the smoking assessment to reflect that the resident handles his/her cigarettes appropriately and does not require a smoke apron. During an interview on 10/05/23 at 10:18 A.M., the Administrator and DON said that the both expect for documentation to be accurate. Both said that smoking assessments were to be completed upon admission and quarterly. The DON said that all falls should be documented on for 72 hours regardless of the fall. The DON said documentation should be in the nurse's notes and explain what happened, who was contacted, and the care given. He/She said that if the fall was unwitnessed, or if the resident hit their head then the staff are expected to do neurological assessments along with rendering first aide, calling the physician, contacting the responsible party, and contacting the DON and Administrator. He/She said if the fall was witnessed and the resident did not hit their head staff were not expected to do a neurological assessment. He/She said that staff reviewed the falls in the facility morning meeting the next day and put an intervention in place. He/She expected that intervention to be documented in the care plan.

Based on interview and record review, the facility failed to deposit funds in excess of $100 in an interest bearing account and credit all interest earned on resident's funds to that account from February 2023 through August 2023. The deficient practice affected 22 residents. The facility census was 40. 1. Review of the facility's Resident Trust Fund policy, undated showed: -Upon written authorization of a resident, the facility will hold, safeguard, manage, and account for the personal funds of the resident deposited with the facility; -Funds in excess of fifty dollars will be deposited in an interest bearing account, which will remain separate from any facility operating accounts; -All interest earned on the account will be credited to the individual resident account; -If the funds are maintained in in a pooled account, a separate accounting for each residents' share will be maintained. Review of the facility's bank statements from February 2023 through August 2023 showed the account did not contain accrued interest on resident funds in excess of one hundred dollars. During an interview on 10/04/23 at 2:27 P.M., the Business Office Manager (BOM) said when the facility changed management in February, the resident fund account was changed from an interest baring account to a non-interest account but did not know why. During an interview on 10/05/23 at 10:18 A.M., the Administrator said the facility changed management companies in February and the account was changed from an interest account. He/She said anytime there is funds in excess of $50.00 deposited for a resident, interest should be applied. He/She said the management company was in the process of correcting the account.

Based on interview and record review, the facility staff failed to establish and maintain a process to follow generally accepted accounting principles to reconcile the Resident Trust Fund Account monthly. The deficient practice affected 22 residents. The facility census was 40. 1. Review of the facility's Resident Trust Fund policy, undated showed it did not contain direction on when or how to reconcile the trust fund accounts. Review of the Resident Trust Fund (RTF) documentation, showed the reconciliation sheets do not match the adjusted bank balance for the months of February 2023 and May 2023 through July 2023. During an interview on 10/04/23 at 2:27 P.M., the Business Office Manager said he/she is responsible to reconcile the bank statement's monthly. He/She said when the new management took over there was some issues with the calculations and the changeover of money into a new account. He/She was not aware the numbers did not match on the reconciliation spreadsheet with the bank statements after adjusting for outstanding credits and debits. During an interview on 10/4/23 at 10:18 A.M., the Administrator said the Business Office Manager is responsible to reconcile bank statements monthly with the RTF balances and the corporate office/governing body staff review it monthly for accuracy. He/She was not aware there was missing and/or incorrect reconciliations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility staff failed to provide a clean, homelike and comfortable environment when staff failed to maintain the facility's exterior, resident rooms and common areas clean and in good repair. The facility census was 40. 1. Review of facility policies showed staff did not provide an environmental policy. 2. Observation on 10/02/23 at 10:49 A.M., showed the shared bathroom between room [ROOM NUMBER] and 302 contained bathroom tile that was covered with a black raised substance around the toilet. The toilet bowl base caulking sealant was covered with a black substance. The toilet seat was cracked in two and taped together with clear tape. Observation on 10/02/23 at 11:00 A.M., showed room [ROOM NUMBER] had a urine smell. The flooring in the room had damaged tiles. Observation on 10/02/23 at 11:15 A.M., showed the bathroom between 305 and 307 had a leak in the faucet and sink drain. The sink drain had a plastic bucket under it to catch the water from the drain. The floor tile around the toilet base was covered in a black raised substance and toilet base caulking was covered in a black substance. Observation on 10/02/23 at 1:27 P.M., showed a large commercial shred bin sat across from the nurse station next to three residents. Observation on 10/02/23 at 2:16 P.M., showed a vent on the 300 hallway wall near the nurse station with large amount of debris on it. Observation on 10/03/23 during the Life Safety Code Tour showed: -Missing floor tiles around the toilet base in resident room [ROOM NUMBER]; -Brown stains on ceiling tile above the bed in resident room [ROOM NUMBER]; -Cracked floor tiles and a gap at the baseboard in the bathroom of resident room [ROOM NUMBER]; -A hole in the bathroom door of resident room [ROOM NUMBER]; -Brown stains on ceiling tile in resident room [ROOM NUMBER]; -Large accumulation of dust on 300 hall air duct across from nurse station; -Veneer torn from from door to personal care room two on 300 hall; -300 hall personal care room one had a large hole in the wall, exposing the plumbing and interior wall cavity; -Exterior soffit and fascia water damage and wood rot at the facility entrance and dining room; -Damage to the the exterior soffit, fascia and gutters on the 200 hall. Observation on 10/04/23 at 01:19 P.M., showed a commercial shred bin sat next to a resident across from the nurse station. 3. During an interview on 10/03/23 at 10:10 A.M., the maintenance director said the sprinkler system had leaked in the past, causing the brown ceiling stains. The maintenance director also said he/she is responsible for completing facility repairs but has had a hard time keeping up with the work. He/She also said facility owners are working to get the roof replaced. During an interview on 10/03/23 at 11:20 A.M., the maintenance director said he/she started repairs last week and has not been able to finish it During an interview on 10/04/23 at 1:33 P.M., Certified Nurse Aid (CNA) A said staff tell maintenance about damage items in a residents' room or housekeeping if it is a cleaning matter. The aid said they were not aware of the discolored flooring in the shared resident bathroom. During an interview on 10/04/23 at 1:40 P.M., CNA B said we tell maintenance about broken items in resident rooms or anywhere in the facility directly. During an interview on 10/04/23 at 2:11 P.M., CNA C said broken items are written up in a maintenance report. Housekeeping is told directly about dirty floors or we clean them ourselves. During an interview on 10/04/23 at 3:40 P.M., CNA D said broken or damaged items are put in a maintenance report and the maintenance director is told directly in person. During an interview on 10/05/23 at 9:15 A.M., the housekeeping supervisor said rooms are cleaned daily. The toilet, sink, and flooring in the bathroom is cleaned daily. They have tried to clean the black stains but it will not come up. During an interview on 10/05/23 at 9:22 A.M., the maintenance director said staff tell him/her what items need repair and there is now a book repair request can be put into. He/She was aware of the damaged bathroom flooring. It will need to be replaced. During an interview on 10/05/23 at 10:25 A.M., the Administrator said repair requests go to the maintenance director in a logbook. Housekeeping may also be involved. The flooring in the residents bathroom needs to be replaced. The facility owners are looking into replacing the roof. He/She also said he/she did not know about the soffit and fascia damage at the entrance/dining room.

Based on interview and record review facility staff failed to check the Federal Care Safety Registry (FCSR) (a registry established by law to promote family and community safety) for one employee (Minimum Data Set (MDS) Coordinator), the Employee Disqualification List (EDL) (a list of individuals who have been determined to have abused or neglected a resident or misappropriated funds or property belonging to a resident) for two employees (Certified Nurse Aide (CNA) J and CNA H), and the CNA Registry for one employee (Licensed Practical Nurse (LPN) I in accordance with the facility's policy. There were seven employees sampled. The facility's census was 40. 1. Review of the facility's policy titled Pre-Employment Screening, revised 07/10/23, showed staff were directed to do the following: -To ensure all personnel who have contact with the individuals served are qualified and capable of employment within a care facility all potential new hires will have the following screenings completed prior to employment: -A potential employee must register with the FCSR; -A criminal background check will be conducted through the FCSR and or highway patrol if needed; -Potential employee check will be conducted through the EDL; -Potential employees will be checked through Test Master University (TMU); -Potential employee's license will be verified if applicable. 2. Review of the MDS Coordinator's personnel record showed a date of hire of 02/13/23. Further review showed the personnel record did not contain documentation the facility had completed a FCSR prior to his/her hire date. Further review showed the personnel record contained a FCSR letter that was dated 10/03/23. 3. Review of CNA J's personnel record showed a hire date of 03/23/23. Further review showed the personnel record did not contain documentation the facility had completed an EDL check. 4. Review of CNA H's personnel record showed a date of hire of 06/01/23. Further review showed the personnel record did not contain documentation the facility had completed an EDL check. 5. Review of LPN I's personnel record showed a date of hire of 08/01/23. Further review showed the personnel record did not contain documentation the facility had completed a CNA Registry check. 6. During an interview on 10/03/23 at 2:23 P.M., the Business Office Manager/Human Resource Director (BOM/HR) said that he/she took over this position a month ago and that he/she is unable to find the missing information from the employee files. During an interview on 10/04/23 at 2:25 P.M., the BOM/HR manager said that the department head will interview a potential hire and then brings him/her the application if they chose to hire. He/She said that he/she makes sure the applicant has their first step Tuberculosis (TB) test administered at that time. He/She said that he/she will run the potential employee's background checks and once those come back he/she reviews them with the Administrator before he/she calls the new hire to set up orientation. He/She said that nobody should be working without having their EDL, FCSR, and CNA registry check done. He/She said the MDS Coordinator was previously working at the sister facility and he/she is not sure why the FCSR was not run there. He/She said that when he/she realized it was not done that he/she ran it at that time on 10/03/23. During an interview on 10/05/23 at 10:18 A.M., the Administrator said that the BOM/HR is responsible for conduction the pre-employment background screening. He/She said that all new hires should have a completed FCSR, EDL, CNA registry and TB test prior to beginning work at the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to develop a comprehensive person-centered care plan for each resident to meet the resident's medical and nursing needs when staff failed to include direction to check a catheter (tube to drain the bladder) anchor and placement for one resident (Resident #31), behaviors for one resident (Resident #2); blood thinners, code status and anti-anxiety medications for one resident (Resident #8), psychotropic medications for one resident (Resident #11), and anti-depressants and activity interests for one resident (Resident #27). The facility census was 40. 1. Review of the facility's Comprehensive Care Plan policy, dated 08/15/23 showed: - Each resident will have a comprehensive care plan developed within (7) days of completion of the comprehensive Minimum Data Set (MDS - a federally mandated assessment tool) resident assessment; - The MDS Coordinator or designee shall act in a case management role by: a. Knowledge of ongoing care needs; b. Brief audit of medical record to ensure: i. psychotropic medication review - diagnosis, reduction ii. wound documentation completed weekly - skin sweeps, unavoidable letter completed if appropriate, weekly measurements, treatment appropriate iii. Medications have diagnosis, appropriate orders, administered timely and as ordered. 2. Review of Resident #31's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Diagnosis of peripheral vascular disease, diabetes mellitus, hemiplegia, urinary tract infection. Review of the resident's Physician Order Sheet (POS), dated 05/20/23, showed staff were directed to change the catheter as need for catheter care, check catheter drainage and anchor every night shift and every Sunday, check catheter output every shift for catheter care. Review of the resident's care plan, dated 9/29/23, showed the plan did not contain direction for staff to check catheter anchor and catheter placement. During an interview on 10/03/23 at 8:59 A.M., the resident said he/she has a urinary tract infection and his/her catheter bag got change once monthly. During an interview on 10/04/23 at 1:52 P.M., Certified Nurse Aid (CNA) B said they report that was given between shifts to know what care to provide a resident. They do not have access to care plans. He/She did not change catheter tubing. During an interview on 10/04/23 at 3:37 P.M., CNA D said they go a report from the nurse on what care they are to do with each resident. Only nurses do catheter work. During an interview on 10/05/23 at 8:19 A.M., Registered Nurse (RN) K said the care plan should contain direction on catheter maintenance. 3. Review of Resident #2's Quarterly MDS, dated [DATE] showed staff assessed the resident as: -Cognitively intact; -Had no behaviors or rejection of care; -Diagnosis included Schizophrenia, Bipolar depression, and anxiety. Review of the nurse notes dated 09/01/23 through 10/05/23 showed: -09/08/23 at 07:37 A.M., can be verbally demanding and rude to staff at times; -09/09/23 at 08:31 P.M., refused to let staff check and change him/her on rounds; -09/09/23 at 09:20 P.M., verbally aggressive towards staff at this time, refusing to let staff change him/her; -09/09/23 at 10:00 P.M., continues to be verbally aggressive toward staff; -09/09/23 at 10:27 P.M., throwing things across room at this time becoming increasingly combative with staff, pulling the call light out of the wall; -09/10/23 at 05:45 A.M., refusing to let staff assist him/her with dressing this morning; -09/10/23 at 09:17 A.M., continues to refuse care from staff, cursing and threatening to hit or throw things at staff, made a comment about breaking the window and throwing his/her stuff and him/herself out the window and leaving the facility; -09/16/23 at 11:56 P.M., being verbally aggressive toward staff, using foul language and yelling at staff; -09/19/23 at 03:27 P.M., yelling at Certified Medication Technician (CMT) and refused medication. Review of the resident's care plan dated 10/01/23 showed the plan did not contain direction for behavior management or history of behaviors. 4. Review of Resident #8's Significant Change MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Received an anticoagulant medications. Review of the resident's POS, dated 10/04/23, showed the resident had orders for the following: -Do Not Resuscitate (DNR); -Lorazepam (a medication used to treat anxiety) tablet 0.5 milligram (mg), give one tablet by mouth every six hours as needed (prn) for anxiety; -Xarelto (a medication used as a blood thinner) tablet 10 mg, give one tablet by mouth daily. Review of the resident's care plan, revised 08/24/23, showed the plan did not contain direction for code status, Lorazepam, or for Xarelto. 5. Review of Resident #11's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Independent with bed mobility, transfers, and walking; -At risk for pressure ulcers; -Received antipsychotic and antidepressant medications. Review of the resident's POS, dated 10/03/23, showed the resident had orders for the following: -All Cotton Elastic (ACE) wraps to bilateral lower extremities (BLE) due to swelling, on in the morning (AM) off in the evening (PM); -Lexapro (a medication used to treat depression) tablet 10 mg, give one tablet by mouth daily for depression; -Melatonin (a medication used to treat insomnia) tablet 5 mg, give 10 mg by mouth at bedtime for insomnia; -Seroquel (a antipsychotic mediation) tablet 100 mg, give one tablet by mouth at bedtime for hallucinations. Review of the resident's care plan, revised on 09/28/23, showed the following: -Did not contain direction for ACE wraps; -Did not contain direction for the use of Melatonin; -Did not contain interventions for the use of antidepressant or antipsychotic medication. 6. Review of Resident #27's admission MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Able to make his/her activity preference known; -Independent with bed mobility; -Requires limited assistance of one staff for transfers, toileting, and bathing. Review of the resident's POS, dated 10/03/23, showed the resident had and order for Lexapro 20 mg, give one tablet by mouth daily for depression. Review of the resident's care plan, revised on 09/05/23, showed the plan did not contain direction for antidepressant medication use. Further review showed the activity care plan did not address the resident's interests such as video games and lap top use. Observation on 10/02/23 at 1:35 P.M., showed the resident lay in his/her bed playing video games on his/her laptop. Observation on 10/02/23 at 2:26 P.M., showed the resident lay in his/her bed watching videos on his/her laptop. Observation on 10/04/23 at 1:23 P.M., showed the resident lay in his/her playing video games on his/her laptop. 7. During an interview on 10/04/23 at 10:30 A.M., the MDS Coordinator said that he/she started in April 2023 and the care plans were behind at that time. He/She said that he/she has been working to get them caught up, and that updating care plans is an ongoing process. He/She said that the care plans should be individualized for each resident, that they should reflect the resident's physician's orders, and match those orders. He/She said that he/she updates the care plans quarterly and as he/she needs to. He/She said that the floor nurse's update them as well. He/She said that any changes are conveyed to him/her in the facility's morning meeting and he/she updates the care plans after that. He/She said that the facility has care plan meetings quarterly and he/she will update any changes from those meetings at that time. He/She said he/she makes a care plan for each resident, then he/she assigns the appropriate department/staff to carry out that care plan (ie. Nurse, CNA, Dietary, etc). He/She said that he/she can then filter this down and print just the CNA portion of it which is what is in the binders at the desk for the aides to refer to. During an interview on 10/04/23 at 1:57 P.M., Certified Nursing Assistant (CNA) C said that the aides use the care plans to know how to take care of each resident. He/She said that the care plan should be individualized to each resident. He/She said that the aides have a binder at the desk which contains their portion of each resident's care plan in them. During an interview on 10/05/23 at 10:18 A.M., the Administrator and Director of Nursing (DON) said that the MDS Coordinator was responsible for updating the care plans. They said that the care plans should be updated quarterly and as needed. The DON said he/she expected the care plan to be individualized for each resident, and that the care plan and physicians orders should match. The DON said that anyone could update the care plan as long as a nurse reviewed it and signed off on the update. The DON and Administrator said that all staff had access to the care plans, and that all the nurses had been trained on how to update them as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review facility staff failed to provide safe mechanical lift transfer for two residents (Residents #1, and#8), failed to lock unattended treatment carts, failed to safely propel three residents (Resident #12, #9, and #3) in wheelchairs, and safely store razors and hazardous chemicals in resident showers. The facility census was 40. 1. Review of the facility's Mechanical Lift (Hoyer) policy, undated showed staff were directed to: -Place the lift pad under the resident's buttocks and thighs, so that the lower edge of seat was under the knees; -Move lift to bedside with base under the bed. Be sure to widen the base. Attach the sling to the lift; -Position wheelchair and lock brakes. Swing resident's feet off the bed. When resident has been lifted clear of the bed, grasp and move the Hoyer to the chair; -When transferring a resident keep base in widest position; -To return to bed, use same procedure in reverse; -Return lift to designated area when not in use. 2. Review of Resident #1's Quarterly Minimum Data Set (MDS) a federally mandated assessment tool, dated 07/16/23, showed staff assessed the resident as: -Cognitively intact; -Independent with transfers with set up assistance from staff; -Diagnosis of Cerebral Palsy (condition affecting movement, muscle tone or posture). Observation on 10/03/23 at 08:25 A.M., showed Certified Nurse Aid (CNA) M and CNA C entered the resident's room to transfer resident from the bed to a motorized wheelchair. The sling was positioned and hooked to the Hoyer lift. When CNA C raised the resident from the bed, CNA M left the resident suspended in the air unattended and went to position the wheelchair. Additionally, the lift base was not widened and CNA C had to move a bed control cord and a fan cord when the lift got stuck on them during the transfer. As the lift approached the wheelchair, CNA C grabbed the resident and CNA M took control of the lift, widened the base to push over the wheelchair and lowered the resident. 3. Review of Resident #8's Significant Change MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Totally dependent of two staff for bed mobility, transfers, dressing, toileting, and hygiene. Observation on 10/02/23 at 3:36 P.M., showed CNA A and CNA C entered the resident's room to transfer him/her from the bed to Broda chair. The sling was positioned under him/her and attached to the Hoyer lift. CNA A raised the resident in the Hoyer lift without fully opening the leg base on the lift while CNA C positioned the Broda chair leaving the resident hanging in the Hoyer lift sling unattended. The resident was then moved from the bed to the Broda chair, once over the Broda chair CNA A then opened the leg base fully and lowered the resident to the chair while CNA C guided the resident into the chair. During an interview on 10/05/23 at 8:12 A.M., Licensed Practical Nurse (LPN) L said there should be two staff with all Hoyer transfers, one holding to the lift and the other to guide the resident. He/She said staff should never leave the resident suspended without hand hold and always open the base of the lift during the transfer for safety reasons. During an interview on 10/05/23 at 10:18 A.M., the Administrator and Director of Nursing said Hoyer transfers should have two people for safety. The legs of the lift should be open before moving the resident, one staff should guide the lift and the other to guide the resident. The administrator said the sling should be positioned behind the resident as if the the resident is in a sitting position. The Director of Nursing said widening the base makes the lift more stable and holding onto the resident keeps them from toppling out. 4. Review of the facility's Medication Storage/Expired Medications Policy, revised 08/27/19, showed staff were directed to do the following: -The medication cart should always be locked unless in direct line of sight of the nurse or Certified Medication Tech (CMT); -No medications are to be left unattended. Observation on 10/02/23 at 1:24 P.M., showed an unlocked unattended treatment cart outside of resident room [ROOM NUMBER]. The cart contained topical prescription creams and ointments, two pair of scissors and syringes with needles. Observation on 10/02/23 at 1:42 P.M., showed the treatment cart sat unlocked and unattended near the nurse's station. Observation on 10/04/23 at 7:07 A.M., showed the treatment cart sat unlocked and unattended at the nurse's station. Observation on 10/04/23 at 11:41 A.M., showed the treatment cart sat unlocked and unattended near the nurse's station. Observation on 10/05/23 at 8:11 A.M., showed the treatment cart sat unlocked and unattended near the nurse's station. During an interview on 10/04/23 at 8:00 A.M., LPN G said that medication or treatment carts should never be left unlocked and unattended. During an interview on 10/04/23 at 1:35 P.M., Registered Nurse (RN) E and RN F said that medication and treatment carts should not be left unlocked or unattended. RN E said that this was for residents' safety. During an interview on 10/05/23 at 8:12 A.M., LPN L said treatment and medication carts should be locked when out of sight for safe keeping. During an interview on 10/05/23 at 10:18 A.M., the Administrator and Director of Nursing said treatment and medication carts should be locked when unattended for safety of other residents and protect the medications. 5. Review of facility's policies showed the facility did not provide a Wheelchair safety policy. Observation on 10/02/23 at 11:45 A.M., showed CNA C propelled Resident #12 in his/her wheelchair without foot pedals while his/her feet dragged the floor. Observation on 10/02/23 at 11:48 A.M., showed CNA C propelled Resident #9 in his/her wheelchair without foot pedals and his/her foot dragged the floor. Observation on 10/04/23 at 01:28 P.M., showed medical records propelled Resident #3 from the designated smoke area to his/her room without foot pedals on the chair. Additionally, the resident was leaning forward and the toes of his/her foot slid on the floor. During an interview on 10/04/23 at 01:32 P.M., medical records staff said residents should use leg pedals on the wheelchairs so they don't face plant. He/She said that Resident #3 normally leans forward like that and only has one foot and didn't think about putting it up on a pedal. During an interview on 10/05/23 at 08:12 A.M., LPN L said staff were directed to apply pedals on wheelchairs to keep the resident from dragging their feet or falling from the chair. During an interview on 10/05/23 at 10:18 A.M., the Administrator and Director of Nursing said pedals should be on wheelchairs before propelling a resident for safety. During an interview on 10/04/23 at 1:35 P.M., RN E and RN F said that staff should not push resident's in their wheelchairs without foot pedals. Both said that this could cause resident harm such as breaking an ankle for example. During an interview on 10/04/23 at 1:57 P.M., CNA C said that staff should not push resident's in wheelchairs without foot pedals. He/She said that if a resident does not have foot pedals on their wheelchair then the resident should propel themselves to prevent them from getting hurt. During an interview on 10/05/23 at 10:18 A.M., the DON said that staff should not push a wheelchair without foot pedals. He/She said this can cause a risk to the resident such as tipping over or injury. 6. Review of facility' Hazardous Storage Policy, undated, showed the policy did not contain direction for the safe storage of hazardous chemicals and razors in resident showers. Observation on 10/02/23 at 11:00 A.M., showed the 300 hall shower door was open and not in use with no staff present. Further observation showed unlocked cabinets that contained shaving razors and bottles of chemicals. Observation on 10/02/23 at 12:12 P.M., showed the 300 hall shower door was open and unattended. The room contained two unlocked, unattended cabinets that contained disposable shaving razors and chemicals. Observation on 10/02/23 at 3:09 P.M., showed the 300 hall shower door open with no staff present. Further the shower room contained unlocked cabinets with chemicals and shaving razors stored inside. During an interview on 10/04/23 at 1:54 P.M., CNA A said shower doors were normally closed but can not be locked. CNA A said they stored razors in the cabinets in the shower room but it also could not be locked. During an interview on 10/04/23 at 2:10 P.M., CNA C said shower doors should be locked and no chemicals or razors stored inside the same room. During an interview on 10/05/23 at 8:22 A.M., RN K said showers should not contain chemicals or razors in unlocked cabinets. During an interview on 10/05/23 at 10:18 A.M., the Director of Nursing and the Administrator said storage of chemicals and razors should not be stored in unlocked cabinets or rooms because they are a risk to the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to have a complete facility-wide assessment to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies. The facility census was 40. 1. Review of the facility's Facility Assessment policy, dated April 2019 showed: -The team responsible for conduction reviewing and updating the facility assessment includes: the administrator, representative of the governing body, the medical director, the director of nursing, the director of maintenance, director of dietary, social services, activities and rehabilitation; -The facility assessment will include a detailed review of the resident population to include religious, ethnic or cultural factors that affect the delivery of care and services, such as food and nutrition, decision making and end of life care, activities and language translation; -A breakdown of the training, licensure, education, skill level and measures of the competency for all personnel; -The facility assessment will include all personnel including directors, managers, regular full and part time employees, contracted staff full and part time, and volunteers. Review of the Facility assessment dated [DATE], showed the following: -The Administrator, Director of Nursing (DON), and Medical Director (MD) were listed as involved in completing the assessment; -The number of residents that use oxygen therapy was blank; -The age range of residents was blank; -The race/ethnicity of residents was blank; -The religious preferences of residents was blank; -The budgeted staffing plan hours for Administration, Nursing Administration, Licensed Practical Nurses (LPN) Certified Nurse Aides (CNA) was blank; -The individual staff assignments was blank; -The staff education section was blank. During an interview on 10/05/23 at 10:18 A.M., the Administrator said the facility assessment was completed when he/she took the position earlier in the year. He/She said that the administrator, director of nurses and quality assurance team review it and update it yearly but the home office (corporate/governing body) does not have input. The facility assessment should include the type of residents, type of assistance needed, types of devices, needed, and everything should be filled out without blanks. The Administrator said that the staffing needs should include the number of staff in proportion to the facility needs. He/She believed the facility assessment was completed without blanks.

Based on interview and record review, the facility failed to electronically submit to Centers for Medicare and Medicaid Services (CMS) a complete and accurate direct care staffing information to the Payroll Based Journal (PBJ) data from April 1, 2023 through June 30, 2023. The facility census was 40. 1. Review of the facility's policies showed the facility did not provided a PBJ policy. Review of the CMS PBJ Staffing Data Report, dated 09/27/23 showed the report did not contain a report for the period of April 1, 2023 through June 30, 2023. During and interview on 10/05/23 at 10:18 A.M., the Administrator and the Director of Nursing said the facility's corporate offices did not submit PBJ data during the quarter shown on the report. Corporate staff told them it was not necessary due to the facility's structure of payment. Facility staff do not self report the PBJ data themselves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to document the administration or refusal of the pneumococcal (lung inflammation caused by bacterial or viral infection) vaccine for five of seven sampled residents. (Resident #1, #2, #31, #35, and #341). The facility census was 40 residents. 1. Review of the facility's Pneumococcal Vaccine Policy, dated 2019, showed: -The pneumococcal guidelines are as recommended by the Center for Disease Control (CDC-the nation's health protection agency responsible for controlling the introduction and spread of infectious diseases); -The primary care physician will be asked that all new admissions be screened and given both pneumococcal vaccines according to Advisory Committee on Immunization Practices (ACIP) recommended schedule, unless specifically ordered otherwise by the Primary physician on admission orders; -Nursing staff will contact the primary care physician if they have questions or concerns that cannot be answered by the resident or their medical decision maker about the criteria listed in the Standing Protocol for the Pneumococcal vaccine (e.g. disease or allergy history, history of prior receipt of the vaccine); -Every admission is screened using the criteria contained within the standing protocol and given the vaccine if indicated after receiving education regarding the vaccine; -Licensed nursing staff performs the screening and vaccine administration; -A record of vaccination will be placed in the resident's medical record and in their vaccination record; -If immunization is refused, document education and refusal in the medical record. Review of the CDC guidelines for the pneumococcal vaccine, dated 9/11/23, showed people age [AGE] or older who previously received the pneumococcal polysaccharide vaccine (PPV23) should receive one dose of PPV23 at least 1 year after the PPV23 dose. 2. Review of Resident #1's medical record showed: -The resident was age [AGE]; -admitted to facility on 9/30/22; -The record did not contain documentation the resident received or refused the pneumococcal vaccine. 3. Review of Resident #2's medical record showed: -The resident was over age [AGE]; -admitted to facility on 10/08/20; -The record did not contain documentation the resident received or refused the pneumococcal vaccine. 4. Review of resident #31's Quarterly MDS dated [DATE] showed staff assessed the resident as: -Over age [AGE]; -admitted on [DATE]; -The record did not contain documentation the resident received or refused the pneumococcal vaccine. 5. Review of resident #35's Quarterly MDS dated [DATE], showed staff assessed the resident as: -Over age [AGE]; -admitted on [DATE]; -The record did not contain documentation the resident received or refused the pneumococcal vaccine. 6. Review of Resident #341's admission MDS, dated [DATE], showed staff assessed the resident as: -Over age [AGE]; -admitted on [DATE]; -The record did not contain documentation the resident received or refused the pneumococcal vaccine. 7. During an interview on 10/03/23 at 3:00 P.M., the Director of Nursing (DON) said he/she is working with the local health department to get the pneumococcal immunizations to the residents. He/She said it is the DON's responsibility to ensure residents were reviewed on admission regarding their vaccine status, and that it was up to date. During an interview on 10/04/23 at 2:54 P.M., the DON said consents and declinations should be in the medical record but may or may not be imported yet since the change of ownership in February. Once the information on need was obtained, the facility tried to get the pneumonia vaccine through the health department. The facility cannot bill for Medicare Part B vaccines so the facility tried to use other vendors to get them administered. He/She did not have a timeline for completion. During an interview on 10/05/23 at 10:18 A.M., the Administrator said the DON was working with the local health department to obtain the pneumococcal vaccines for the residents. He/She said nursing staff obtained consents on admission. If the resident had insurance to cover the vaccine, then the residents would be sent to an outside vendor, otherwise would receive it from the health department. The Administrator did not have a timeline for completion of the vaccine after admission. He/she said documentation of the vaccine may be an issue due to changing of ownership in February and getting everything uploaded into the system.

Based on interview and record review, facility staff failed to document, maintain and follow current guidance and procedures for immunizations of residents against COVID-19 for five (Residents #1, #31, #35, #340, and #341) of seven sampled residents. The facility census was 40. 1. Review of the Centers for Disease Control (CDC) COVID-19 Long-Term Care (LTC) Residents guidance, dated 9/25/23, showed: -CDC recommends everyone aged five years and older including people who live in long term care settings, get 1 updated COVID-19 vaccine; -People who are moderately or severely immunocompromised can get additional COVID-19 vaccines; -People who live in LTC settings must give consent, or agree to a COVID-19 vaccine. Review of the facility's COVID vaccination policy, undated, showed: -Facility residents will be provided education regarding the current recommendations for COVID-19 vaccinations upon admission, annually and as needed; -Residents will be provided a declination form to complete if they decline the vaccine; -If a resident requests the vaccine, they will complete a consent from, and arrangements will be made with County Health Department, or a local pharmacy to acquire and provide the current recommended COVID-19 vaccine; -Further review showed the policy did not contain a timeline for completion of the vaccine. 2. Review of Resident #1's medical record showed: -Most recent admission date of 09/30/22; -The record did not contain documentation the resident received, refused, or was offered the COVID-19 vaccine. 3. Review of Resident #31's medical record showed: -Most recent admission date of 05/19/23; -The record did not contain documentation the resident received, refused, or was offered the COVID-19 vaccine. 4. Review of Resident #35's medical record showed: -Most recent admission date of 04/22/23; -The record did not contain documentation the resident received, refused, or was offered the COVID-19 vaccine. 5. Review of Resident #340's medical record on 10/04/23 at 10:03 A.M., showed: -Most recent admission date of 09/26/23; -The record did not contain documentation the resident received, refused or was offered the COVID-19 vaccine. 6. Review of Resident #341's medical record showed: -Most recent admission date of 09/21/23; -The record did not contain documentation the resident received, refused or was offered the COVID-19 vaccine. 7. During an interview on 10/03/23 at 3:00 P.M., the Director of Nursing (DON) said the administrator was working with the pharmacy to get the COVID immunizations to the residents. He/She said it is the DON's responsibility to ensure residents are reviewed on admission regarding their vaccine status, and that it is up to date. During an interview on 10/05/23 at 10:18 A.M., the Administrator said he/she was working with the pharmacy to obtain the COVID vaccines for the residents. He/She said nursing staff obtained consents and contacted the physician for an order. If only one or two residents needed the vaccine, then they would send the residents to an outside vendor. If a larger group needed the vaccine, a clinic would be set up at the facility. The Administrator did not have a timeline for completion of the vaccine after admission. He/she said documentation of the vaccine may be an issue due to changing of ownership in February and getting everything uploaded into the system.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility water systems to inhibit growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (LD). The facility staff also failed to use appropriate hand hygiene to prevent the spread of bacteria during incontinent care and failed to properly clean a mechanical lift between residents for three (Resident #1, #2, and #8) of four sampled residents, failed to change gloves between cares, failed to ensure sanitary conditions for a catheter bag (a container to hold urine) by keeping the catheter off the floor and a trash can, failed to properly store a Continuous Positive Airway Pressure (CPAP - machine used to keep airways open) mask for one resident (Residents #31), and failed to properly administer and document three employees (Certified Nurse Assistants (CNA) J, CNA B and the Medical Records (MR) N) two step Tuberculin (TB) skin test upon hire. The facility census was 40. 1. Review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification (S&C) letter 17-30, dated 06/02/17 and revised on 06/09/17; showed: -The bacterium Legionella can cause a serious type of pneumonia called LD in persons at risk. Those at risk include persons who are at least [AGE] years old, smokers, or those with underlying medical conditions such as chronic lung disease or immunosuppression. Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including hospitals and long-term care facilities. Transmission can occur via aerosols from devices such as shower heads, cooking towers, hot tubs, and decorative fountains; -Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water; -CMS expects Medicare certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. An industry standard calling for the development and implementation of water management programs in large or complex building water systems to reduce the risk of legionellosis was published in 2015 by American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE). In 2016, the CDC and its partners developed a toolkit to facilitate implementation of this ASHRAE Standard(https://www.cdc.gov/legionella/maintenance/wmp-toolkit.html). Environmental, clinical, and epidemiological considerations for healthcare facilities are described in this toolkit; -Surveyors will review policies, procedures, and reports documenting water management implementation results to verify that facilities: -Conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system; -Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens; -Specify testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained. Review of the facility's Legionella Water Management Program, provided by the administrator on 10/03/23, showed the records contained documentation of a water management team and guidelines for the creation of a facility specific water management program. Review showed the records did not contain documentation of a facility specific risk assessment, a description of the facility's water systems, and developed procedures to monitor and inhibit the growth of Legionella and other waterborne pathogen that included identification of situations than could lead to legionella growth, control measures, testing protocols, acceptable ranges for control measures and what corrective actions are to be taken when control limits are not maintained. During an interview on 10/03/23 at 3:08 P.M., P.M., the maintenance director said he/she did not have any additional documentation related to the facility's water management program. The maintenance director said he/she checks the water temperatures in the facility monthly to ensure they are not too hot or too cold and did not have any other requirements for monitoring the facility water systems. During an interview on 10/04/23 at 10:00 A.M., the administrator said the maintenance director is responsible for the facility's water management program and if the maintenance director did not have any additional records to provide related to the facility's water management program then he/she did not have any additional documentation to provide. The administrator said he/she did not become the administrator until the end of June 2023 and he/she did not know the water management program did not contain all required information. 2. Review of the facility's Hand Hygiene policy, dated 2019, showed: -Hand hygiene continues to be the primary means of preventing the transmission of infection; -Hand hygiene (handwashing and/or Alcohol Base Hand Rub (ABHR)) consistent with accepted standards of practice such as the use of ABHR instead of soap and water in all clinical situations except when: hands are visibly soiled, before eating and after using the restroom; -Alcohol antiseptic hand rub is appropriate for routine hand hygiene in most clinical situations: -Wash hands with plain or antimicrobial soap and water when hands are visibly dirty or contaminated with blood or bodily fluids; -Wash hands with soap and water after use of hand rub/hand sanitizer agent when hands start to feel a build-up of a product or visibly soiled. Review of the facility's Use of Gloves Policy, revised November 2013, showed once gloves are removed, the next step should be hand hygiene. Review of the facility's Handwashing Policy, revised January 2022, showed staff are directed to do the following: -Staff shall clean their hands and wrist area for at least 20 seconds in a handwashing sink that is equipped with warm water, handwashing soap, paper towels, and a trash can; -Employees shall wash their hands after touching human body parts, after using the restroom, after handling soiled equipment/linen, when changing tasks, before donning (applying) gloves, and after engaging in any activity or task which contaminates hands. Review of the facility's Perineal Care policy, dated October 2010, directed staff to: -Wash and dry hands; -Position the resident and apply gloves; -Cleanse the resident using a front to back, inside to outside technique; -Gently rinse and dry resident; -Remove gloves and wash/dry hands; -Position the resident and gather/clean used supplies; -Wash and dry hands before leaving the room. Review of the facility's Mechanical Lift (Hoyer) policy, undated showed the policy did not contain direction for when to cleanse the Hoyer. 3. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 07/16/23, showed staff assessed the resident as: -Cognitively intact; -Dependent on two staff for toileting; -Dependent on one staff for dressing; -Frequently incontinent of bowel and bladder; -Diagnosis of Cerebral Palsy (congenital disorder affecting movement and tone) and hemiplegia (loss of function on one side). Observation on 10/03/23 at 8:25 A.M., showed Certified Nurse Aide (CNA) M and CNA C entered Resident #1's room to perform incontinent care. CNA C applied gloves without washing his/her hands. CNA C did not change his/her gloves after he/she provided perineal care or before he/she assisted the resident to dress. CNA M left the room to obtain a mechanical lift (Hoyer) and returned to the room without performing hand hygiene. The resident was transferred to the wheelchair from the bed using the mechanical lift. CNA M left the room with the lift and parked it outside the room without washing his/her hands or cleansing the lift. CNA M returned to the room, applied gloves, and removed the linens from the bed without performing hand hygiene. CNA C gathered the trash and left the room without performing hand hygiene. Staff left the lift outside the resident's room without cleansing the lift. 4. Review of Resident #2's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Required two staff physical assistance for dressing; -Dependent on two staff for toileting; -Incontinent of bowel and bladder. Observation on 10/03/23 at 8:52 A.M., showed CNA C, CNA A, and CNA D entered the room to provide incontinent care for the resident. CNA A and CNA C cleansed the front of the resident then rolled the resident to the side. With the same visibly soiled gloves, CNA C cleansed the resident's buttocks. CNA C left the room and returned with the same mechanical lift used for Resident #1. He/she did not perform hand hygiene when leaving or returning to the room and did not cleanse the mechanical lift. CNA D gathered the trash and left the room without performing hand hygiene. 5. Review of Resident #8's Significant Change of Status MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Totally dependent of two staff for bed mobility, transfers, dressing, toileting, and hygiene. Review of the resident's care plan, revised on 07/19/23, showed the resident: -Required assistance of one or two staff to reposition in bed; -Required assistance for personal hygiene; -May use a mechanical lift and assistance of two staff for transfers. Observation on 10/02/23 at 3:36 P.M., showed CNA A and CNA C provided incontinence care and transfer assistance to the resident. CNA A and CNA C did not wash their hands prior to putting on gloves to provide resident care. CNA C provided incontinence care while CNA A held the resident. CNA C did not wash his/her hands after he/she removed the gloves or before he/she assisted CNA A with the mechanical lift transfer. CNA A did not change his/her gloves after he/she assisted with incontinence care or before he/she assisted with the mechanical lift transfer. Neither CNA washed their hands after they provided care and transfer assistance. CNA A or CNA C did not sanitize the mechanical lift before or after resident transfer. During an interview on 10/04/23 at 1:57 P.M., CNA C said staff should wash their hands before and after resident care, and anytime they change their gloves. During an interview on 10/05/23 at 10:18 A.M., the Director of Nursing (DON) said that he/she expected staff to wash or sanitize their hands with any glove change, before and after resident care, and before staff left a resident's room. He/She said staff should use Universal Precautions. He/She said that he/she would expect staff to sanitize the mechanical lift before and after resident use as well. 6. Review of the facility's Catheter Care policy, dated 11/01/13, showed the policy did not contain direction for catheter bag positioning to decrease risk of infection. Review of the facility's CPAP policy, dated January 2017 showed the policy did not contain direction for storage of mask when not in use to protect from spread of infection. 7. Review of Resident #31's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Required one staff physical assistance for dressing and toileting; -Used Oxygen; -Did not use a CPAP; -Had a catheter; -On Hospice; -Diagnosis of heart failure, respiratory failure, hemiplegia, and diabetes. Review of the resident's physician order sheet (POS), dated 10/04/23, showed an order dated 09/29/23 for Bactrim DS (an antibiotic) 800-160 milligram (mg) twice a day for ten days for a urinary tract infection. Observation on 10/03/23 at 9:46 A.M., showed CNA C performed catheter care on the resident and assisted CNA B to pivot transfer resident to the wheelchair. CNA C did not perform hand hygiene between the catheter care and transfer. The resident's catheter bag was attached to the side of the bed frame and contained dark urine with sediment in the tubing. Additionally, the bottom of the bag rested on the floor. The resident's CPAP mask sat on the nightstand not in a bag. Observation on 10/04/23 at 1:54 P.M., showed the resident in bed with his/her catheter bag attached to the side of the trash can and the bottom of the bag rested on the floor. Additionally, the catheter bag contained a large amount of dark amber urine with sediment in the tubing. The resident's CPAP mask sat on the nightstand not in a bag. During an interview on 10/03/23 at 10:00 A.M., the resident said he/she was currently taking antibiotics for a urinary infection. He/She said he/she needed staff to apply and remove his/her CPAP mask. During an interview on 10/05/23 at 8:12 A.M., Licensed Practical Nurse (LPN) L said catheters should never be hung where they touch the floor or on a trash can or could risk the resident getting an infection or pull on the tubing. He/She said CPAP masks should be kept in a plastic bag after they are cleaned and when not in use to keep the risk of infection down. During an interview on 10/05/23 at 10:18 A.M., the DON and Administrator said catheters should not be touching the floor or attached to a trash can due to the risk of infection. The DON said CPAP masks should be kept in a plastic bag when not in use to decrease risk of bacteria collecting on the mask. 8. Review of the facility's policy titled, Tuberculosis Screening - Administration and Interpretation of Tuberculin Skin Test, revised June 2010, showed the facility will administer and interpret tuberculin skin test (TST) in accordance with recognized guidelines and pertinent regulations as follows: -A qualified nurse or healthcare practitioner will administer the first step after receiving a physician's order; -If the first step was less than 10 millimeters (mm), the qualified nurse or healthcare practitioner will administer the second step one to two weeks after the initial TST; -A qualified nurse or healthcare practitioner will interpret the TST forty-eight (48) to seventy-two (72) hours after administration; -A positive reaction will be considered to be an areas of induration (palpable hardness) around the injection site. 9. Review of CNA J's personnel record showed the following: -Hire date of 03/23/23; -First step TB skin test was administered on 03/21/23; -Did not contain documentation the facility had completed a second step TB test until 05/02/23. 10. Review of CNA B's personnel record showed the following: -Hire date of 08/03/23; -First step TB skin test was administered on 08/02/23, but did not contain any results. -Did not contain documentation the facility had completed a second step TB test. 11. Review of the MR N personnel record showed the following: -Hire date of 07/07/23; -First step TB test was not administered until 07/27/23 after the date of hire. During an interview on 10/03/23 at 2:23 P.M., the Business Office Manager/Human Resource Director (BOM/HR) said he/she took over this position a month ago and that he/she was unable to find the missing information from the employee files. He/She said the nursing leadership had changed and during that time some of the TB tests got missed. He/She said that he/she was aware that the first step TB test should be administered prior to the employee's date of hire. During an interview on 10/04/23 at 2:25 P.M., the BOM/HR manager said the department head would interview a potential hire and then brought him/her the application if they chose to hire. He/She said that he/she made sure the applicant had their first step Tuberculosis (TB) test administered at that time. He/She said that nobody should be working without having their first TB test done. During an interview on 10/05/23 at 10:18 A.M., the DON said that any nurse can administer the TB test. He/She said he/she was responsible for following up to ensure that the new hire staff completed their first and second step TB test. During an interview on 10/05/23 at 10:18 A.M., the Administrator said that all new hires should have a completed TB test prior to beginning work at the facility.