Based on observation, interview, and record review, the facility failed to ensure a wheelchair available for common use was maintained in a safe and sanitary manner. This deficient practice had the potential to affect any of the 17 residents residing on 400 hall who may have required wheelchair assistance. The facility census was 65 residents. A review of the facility policy titled Infection Prevention and Control Program, revised 10/24/22, showed: -Purpose: To ensure the Facility establishes and maintains an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection in accordance with Federal and State requirements. -Infection Control Policies and Procedures --The Facility's infection control policies and procedures are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. --Maintain a safe, sanitary, comfortable environment for personnel, residents, visitors, and the public. --Provide guidelines for the safe cleaning and reprocessing of reusable resident care equipment. 1. Observation on 3/13/25 at 5:43 P.M. of the shower room on 400 hall showed: -A wheelchair stored in an open area near the sink with other mobility devices. -The vinyl covering of one of the armrests on the wheelchair was torn. -The foam padding of the armrest was exposed. During an interview on 3/13/25 at 6:05 P.M. the Director of Nursing (DON) said: -The wheelchair was available for common use with any resident. -Because of the exposed foam padding of the armrest, the surface of the armrest could not be effectively cleaned and/or sanitized between uses by different residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to treat residents with respect and dignity during dining observations, call bell response, and during the provision of care and treatment for six sampled residents (Resident #263, #50, # 264, #12, #30, and #43) out of 29 sampled residents reviewed for dignity and respect. The facility census was 65 residents. Review of the facility's policy titled, Privacy and Dignity, dated October 24, 2022, showed: Purpose: To ensure that care and services provided by the Facility promote and/or enhance privacy, dignity, and overall quality of life. Policy: The facility promotes resident care in manner and an environment that maintains or enhances dignity and respect, full recognition of each resident's individuality. Procedure: I. Staff assists the resident in maintaining self-esteem and self-worth. II. Residents are groomed as they wish to be groomed. III. Residents are dressed appropriate to the time of day and season as well as well as individual preferences. IV. Resident clothing is labeled in a way that respect their dignity. V. The Facility promotes independence and dignity in dining. VI. The Facility respects the resident's private space and property. VII. Staff treats residents with respect including respecting their social status, speaking respectfully listening carefully. VIII. Staff focuses on residents as individual when they speak to them and address resident as individual when providing care and services.1. Review of Resident # 263's face sheet showed he/she was admitted to the facility on [DATE] and identified herself as being her own responsible party Resident #263 had diagnoses which included Spinal Stenosis, Lumbar Region without Neurogenic Claudication, Anemia, Type 2 Diabetes Mellitus without Complications, Anemia, unspecified, Obstructive Sleep Apnea (adult)(pediatric), Paraplegia, Unspecified, Essential (primary) Hypertension, Unspecified Atrial Fibrillation, Chronic Diastolic (congestive) Heart Failure, Unspecified Urinary Incontinence, Weakness. 1. Review of Resident #263's admission Minimum Data Set (MDS a federally mandated assessment tool completed by facility staff for care planning) dated 3/8/25 showed: -There was no assessment completed at the time of review or at the time of exit from the survey process. --The completion date of the MDS was 3/18/25. Review of the resident's undated Care Plan Report, showed: -He/She had an Activities of Daily Living (ADL) Self Care Performance Deficit related to limited range of motion (ROM) to Bilateral Upper Extremities (BUE) and Bilateral Lower Extremities (BLE) secondary to Rheumatoid Arthritis (RA). -He/She required two staff for assistance with transfers using the Hoyer lift. -Staff documented that the resident required one person assistance with transfer and all weight bearing ADL's, and set up assist with eating and personal hygiene. During an interview on 3/11/25 at 11:30 A.M., the resident said: -He/She put the call bell on last night at 2:00 A.M. -Staff came into the room and indicated that he/she would be back. However, around 2:28 A.M., he/she put the call bell on again and no one answered the call light until 6:40 A.M. -He/She was soiled for all that time, and no one came to help him/her. -He/She began to cry during this interview. -Being left soiled for so long made him/her feel really horrible, bad, and sad. -He/She would be looking for another facility. -His/Her bottom was burning. -This happened a lot during the night shift. -He/She felt that staff did not like him/her because sometimes it took two staff members to change him/her. -The surveyor could talk with Certified Nursing Assistant (CNA) D, this person was great and changed him/her that morning around 6:45 a.m. -He/She told CNA D that the staff during the evening shift did not like to help him/her at all. -He/She continued to cry. During an interview on 3/14/25 at 5:41 P.M. the Administrator said: -He/She expected all staff to answer call lights in a timely manner. -It was the facility's expectation that all residents were treated with respect and dignity. 2. Review of Resident #50's Face Sheet revealed he/she was initially admitted to the facility on [DATE] with diagnoses including Quadriplegia, unspecified, Muscle Weakness (generalized) their reduced mobility, Need for assistance with personal care, Adjustment Disorder, unspecified, Hypomagnesemia, Shortness of Breath, Type 2 Diabetes Mellitus without complication , Chronic Pulmonary Edema , Morbid (severe) Obesity due to excess calories, Fracture of orbital floor, right side, subsequent encounter for fracture ,Other muscle spasm ,Personal history of other venous thrombosis and embolism, Hereditary and Idiopathic Neuropathy, unspecified, Chronic Pain Syndrome, Vitamin B12 Deficiency Anemia, unspecified, Gastro-Esophageal Reflux Disease without Esophagitis, and Vitamin D Deficiency, unspecified. Review of the resident's quarterly MDS dated [DATE] showed the resident: -Was able to make his/her needs known to staff. -Was dependent on staff for all their activities of daily living. Review of resident's undated Care Plan showed the resident: -Was dependent on staff for assistance with all meals. -Would have his/her needs met with assistance of staff thru next review period as evidenced by (AEB): being clean, dry, dressed appropriately and well groomed. -Had a flat touch call light. Position it by his/her head so he/she could turn his head to turn on the call light. -Refused to sleep in bed. Slept in recliner/broda. -BED MOBILITY: Resident was dependent on staff participation to reposition and turn in recliner -BATHING: Resident was dependent on staff participation with bathing. -PERSONAL HYGIENE/ORAL CARE: Resident was dependent on staff participation with personal hygiene and oral care. -DRESSING: Resident was totally dependent on staff for dressing. -EATING: Resident required total assistance to eat. -TRANSFER: Resident required total assistance with Hoyer for transfers. During an interview on 3/12/25 at 11:31 A.M., the resident said: -He/She did not have choices of his/her care and treatment with meals. -He/She was always fed in the main dining room. -The only reason he/she was told that he/she could not eat or be fed in his/her room was because the facility did not have enough staff on the unit. -He/She was transported by staff to the dining room around 5:15 P.M. daily and had to wait to be assisted with the meal. -Nine times out of 10, he/she was the last one to be assisted with his/her meals. -He/She waited over one hour to be assisted with his/her meals, and sometimes this caused him/her to experience muscle spasms and made him/her upset. Observation on 3/12/25 in the main dining room, showed: -At 5:41 P.M., the resident was waiting to be for assisted with his/her meal. -At 6:21 P.M., staff were assisting the resident with his/her meal. During an interview on 3/12/25 at 6:30 P.M. Certified Nursing Aide (CNA) M, who was assisting the resident said: -The staff were aware of the resident's concerns of wanting to eat in his/her room, but the facility did not have enough staff for him/her to be fed in his/her room. -Due to the loud noises and other interaction with residents, this could be very upsetting to the resident and sometimes this caused him/her to have behaviors. Observation on 3/13/25 in the main dining room showed: -At 5:25 P.M., the resident was waiting to be assisted with his/her meal. During an interview on 3/14/25 at 2:14 P.M. the Administrator said: -It was the facility's expectation that residents' choices be honored. -All residents needed to be treated with respect and dignity. Observation on 3/14/25 in the main dining room showed: -At 5:46 P.M. the resident was waiting to be assisted with his/her meal. During an interview on 3/14/25 at 5:46 P.M. the resident said: -Having to wait to be fed made him/her sad and upset. -Because the facility did not have enough staff he/she had to go in the dining room every day. During an interview on 3/14/25 at 5:50 P.M. the Staff Development Manager (SDM) said: -The reason the resident could not eat or be assisted with their meals during meal time was because the facility did not have enough staff to have some residents eat in their room. -The resident was not the only resident that did not want to eat in the dining room. -He/She was aware the resident did not like to eat in the dining room all the time. During an interview on 3/14/25 at 5:51 P.M. the Infection Control Nurse said: -The resident was not able to eat his/her meals in his/her room because the facility did not have enough staff. 3. Review of Resident #264's face sheet showed he/she was admitted with diagnoses that included Postprocedural Intestinal Obstruction, unspecified as to Partial Versus Complete, Chronic Respiratory Failure with Hypoxia, unspecified Severe Protein-Calorie Malnutrition, Chronic Obstructive Disease, unspecified, need for assistance with personal care, Unsteadiness on Feet, Muscle Weakness (generalized), Influenza a Virus with other Respiratory Manifestations, Pressure Ulcer of Sacral Region, Stage 2, Chronic Kidney Disease, Stage 3B, Sarcoma of Dendritic Cells (accessory cells) Anemia, unspecified Chronic Diastolic (congestive) Heart Failure, and Weakness. Review of the resident's admission Minimum Data Set, dated [DATE] showed staff documented: -The resident was able to communicate he/she needs to the facility staff. -The resident needed moderate to maximal assistance with care and treatment. Review of the resident's undated care plan showed: -The resident was at risk Activities of Daily Living (ADL) resident required assistance with transfers. -The resident required staff assistance to turn and reposition in bed. -The resident required staff assistance for toileting. -The resident needed to be encouraged to sit on the toilet to evacuate bowels if possible. -The resident had an actual witnessed non-injury fall on 3/1/2025. During an interview on 3/11/25 at 3:09 P.M. the resident said: -He/She had been placed on the toilet and left for a long period of time without assistance from staff. -He/She would get staff to help him/her to the bathroom, and staff would leave him/her in the bathroom for long periods of time. -Staff left him/her in the bathroom this weekend. -Last night, staff would not answer his/her call light. -He/She felt bad, helpless, and sad. -He/She wished that he/she could do better for himself/herself, but the reason he/she waited was because of being afraid of falling. -He/She did not want to do something wrong and fall. -If he/she were to fall, it would be bad and horrible. During an interview on 3/13/25 at 3:15 P.M. the resident's family said: -He/She received calls weekly from the resident. -The resident told him/her that he/she had waited long times for staff to assist him/her to the bathroom, and sometimes he/she needed things during the evening that he/she was unable to reach. -The resident felt that the facility did not have enough staff to help them at night. During an interview on 3/13/2025 at 5:41 P.M. the Administrator said: -It was the expectation of the facility that all staff answered call lights in a timely manner and treated residents with respect and dignity. 4. Observation on 3/11/25 at 2:14 P.M. showed: -Resident #30 was served her/his lunch tray in her/his room. -On the tray was a red cloth napkin and a black plastic fork and spoon. 5. Observation on 3/12/25 at 5:54 P.M. showed: -Resident #43 had been served a meal tray in her/his room. -On the tray was a white paper napkin, a black plastic spoon, and a white plastic knife. -In a Styrofoam bowl containing sections of pears, was a black plastic fork. During an interview on 3/12/25 at 5:54 P.M. the resident said: -He/She sometimes received regular silverware. 6. Observation on 3/12/25 at 5:50 P.M. on the 100 hall showed: -Five trays that had a black plastic spoon and white plastic fork for the residents. The desserts, salads, and drink were in Styrofoam containers. 7. Observation on 3/12/25 at 6:10 P.M., on the 200 hall showed: -Four trays that had black plastic spoons and white plastic forks for the residents. The residents' desserts, salads, and drinks were in Styrofoam containers. 8. Observation on 3/12/25 at 6:16 P.M., on the 300 hall showed: -Seven trays, that had black plastic spoons and white plastic forks for the residents. The residents' desserts, salads, and drinks were in Styrofoam containers. 9. Observation on 3/12/25 at 6:23 P.M., on the 400 hall showed: -Five trays that had black plastic spoons and white plastic forks for the residents. The residents' desserts, salads, and drinks were in Styrofoam containers. 10. During a telephone interview, on 3/13/25 at 2:16 P.M. the Registered Dietitian (RD) said: -It was his/her expectation that residents have regular silverware except when disposable utensils would be required during an emergency/disaster. -It was a dignity issue to not be given regular silverware.

Based on observation and interview, the facility failed to close and lock the shower doors on the 200, 300 and 400 Halls to prevent high risk wandering residents from hazardous accidents for 13 wandering residents. The facility census was 65 residents. A request was made of the facility for policies and procedures addressing the storage of chemicals. No such policies or procedures were provided prior to the exit. 1. Observation on 3/12/25 at 10:00 A.M. showed: -The door to the shower room on the 200 Hall unit was opened and exposed multiple areas within the shower room. -Multiple body washes, shampoos and conditioners, anti-perspirants/deodorant, and a bottle of hair spray. -There was a four door storage cabinet. Each door was equipped with a key-lock cabinet for staff to lock all items in the shower room. Observation on 3/12/25 at 10:15 A.M. showed: -The door to the shower room on the 300 Hall unit was opened and exposed multiple areas within the shower room where hallway residents and guest walked by. -The shower room had a Betco PH7Q Disinfectant Germicidal Spray bottle on the counter which was half full of liquid. The spray bottle had a label that stated, Hazard to Humans Harmful if inhaled. -There was a four door storage cabinet. Each door was equipped with a key-lock cabinet for staff to lock all items in the shower room to keep hazardous materials from the wandering residents on this unit. Observation on 3/12/25 at 10:35 A.M. showed: -The door to the shower room on the 400 Hall was open. -Hanging from one of the safety bars in the shower stall was a spray bottle of LNZ Liquid Enzyme Deodorizer Digester Spotter. On the label of this spray bottle was CAUTION: MAY BE HARMFUL IF SWALLOWED - KEEP OUT OF REACH OF CHILDREN. -Hanging on the same safety bar was a spray bottle of BETCO pH7Q READY-TO-USE One Step Disinfectant - Germicidal - Detergent - Deodorizer. On the label of this spray bottle were warnings to KEEP OUT OF REACH OF CHILDREN and PRECAUTIONARY STATEMENTS HAZARDS TO HUMANS AND DOMESTIC ANIMALS: Harmful if inhaled. Remove contaminated clothing and wash clothing before reuse. -Standing along on the top of the safety bar were multiple bottles of personal body wash, shampoo, hair spray, conditioner, and combs for residents. Observation on 3/12/25 at 6:05 P.M. showed: -The door to the shower room on the 300 Hall unit was opened and exposed multiple areas within the shower room and the hallway where residents and guests walked by. -The shower room had a Betco PH7Q Disinfectant Germicidal Spray bottle on the counter which was half full of liquid. The spray bottle had a label that stated, Hazards to Humans .Harmful if inhaled. Observation on 3/13/25 at 5:43 P.M. showed: -The door to the shower room on 400 Hall was opened/ajar and did not have a locking mechanism on the door lever. -Hanging from one of the safety bars in the shower stall was a spray bottle of LNZ Liquid Enzyme Deodorizer Digester Spotter. On the label of this spray bottle was CAUTION: MAY BE HARMFUL IF SWALLOWED - KEEP OUT OF REACH OF CHILDREN. -Hanging the same safety bar was a spray bottle of BETCO pH7Q READY-TO-USE One Step Disinfectant - Germicidal - Detergent - Deodorizer. On the label of this spray bottle were warnings to KEEP OUT OF REACH OF CHILDREN and PRECAUTIONARY STATEMENTS HAZARDS TO HUMANS AND DOMESTIC ANIMALS: Harmful if inhaled. Remove contaminated clothing and wash clothing before reuse. -Standing along the top of the safety bar were multiple bottles of personal body wash, shampoo, conditioner. -Outside of the shower stall was a four door storage cabinet. Each door was equipped with a key lock. Three of the cabinet doors were slightly ajar. -The toilet stall adjacent to the shower stall had an access panel removed, which exposed a hole in the drywall above the safety bar next to the toilet. The hole measured approximately 16 inches square and allowed access to the plumbing serving the shower. The access panel itself was on the floor propped against the wall. During an interview on 3/13/25 at 6:05 P.M. the Director of Nursing (DON) said: -The chemicals should be behind a locked door at all times. -The chemicals should have been locked in the four door cabinet next to the shower stall. During an interview on 3/14/25 at 2:14 P.M. the Administrator said: -It was his/her expectation that all shower doors be closed and all hazardous materials be locked up.

Based on interview and record review, the facility failed to ensure that a Quality Assurance and Performance Improvement (QAPI) Plan was in place to ensure the facility's care delivery system was consistent and accurate and did not identify concerns within the facility system and ensure a plan was in place to ensure improvement. This affected all residents. The facility census was 65 residents. A review of the facility's policy and procedure titled, QAPI Program, dated 10/24/22, showed: -Purpose: To ensure that all services provided by the facility to resident meet quality standards. -The Facility implements and maintains an ongoing, Facility-wide Quality Assurance and Performance Improvement (QAA) Program designed to monitor and evaluate the quality of resident care, pursue methods to improve care quality, and resolve identified problems. -Procedure: 1. Goals: A. To provide a means to identify and resolve present and potential negative outcomes related to resident care and safety. B. To reinforce and build upon effective systems of services and positive care measures; C. To provide a structure and process to correct identified quality deficiencies; D. To establish and implement plans to correct deficiencies and to monitor the effects of these action plans on resident outcomes; E. To help departments, consultants, and ancillary services that provide direct or indirect care to residents to communicate effectively, and to delineate lines of authority, responsibility, and accountability; and F. To establish a system and process to maintain documentation relative to the QAPI Program, as a basis for demonstrating that there is an effective ongoing program .V. Feedback: A. The Facility obtains feedback from direct care staff, other staff, residents and resident representatives, as well as other sources, to identify problems that are high-risk, high-volume, and/or problem-prone, as well as opportunities for improvement. B. Systems for obtaining feedback include but are not limited to: i. Satisfaction surveys. ii. Care Planning meetings. iii. Resident Council and Family Council meetings. iv. Safety Committee meetings. v. Suggestion box. vi. Compliance Hotline. 1. Review of the facility QAPI Agendas showed: -The facility failed to ensure that all residents were treated with dignity during mealtimes. -The facility failed to ensure that all residents were provided with choices during mealtimes and were provided assistance with meals. -The facility failed to ensure that all residents, who were at risk for alterations in skin, were changed and repositioned every two hours and did not ensure that an alteration in skin occurred. -The facility failed to ensure there was a sufficient number of staff to assist residents who were at risk for alteration in skin and required to be repositioned every two hours to prevent damage to skin. -The facility failed to ensure that the kitchen was clean and sanitary, food handling practices were in place to prevent an outbreak of foodborne illness, and did not ensure that food safety was maintained to store, prepare and distribute food safely to all residents. During an interview on 3/14/25 at 12:09 P.M. the Administrator said: -A representative from the Corporate Office came into the facility in December of 2024 to conduct a mock survey of all departments within the facility. -He/She did not receive a report from the mock survey but that there were concerns identified. -The facilities QAPI program met every three months and sometimes monthly if warranted. -Not all managers within the facility provided him/her with concerns that may be within the facility. -The management team did not share everything with him/her related to problems on the floor or in the kitchen, which made it difficult for him/her to identify breaks within the system. During an interview on 3/14/25 at 2:45 P.M the Administrator said: -The Ombudsman State Representative would enter the facility monthly to talk to the residents and reported all concerns to the Social Worker, who no longer worked there. -The Social Worker had never discussed any resident concerns with him/her. -It was his/her expectation that the facility management team discuss all concerns with him/her. -The facility's management team did not effectively communicate with him/her all concerns within the facility. During an interview on 3/14/25 at 3:59 P.M. the Medical Director said: -He/She was aware of the facility having staffing shortages recently. -It was his/her expectation that residents be repositioned every two hours. -It was his/her expectation that the facility provided appropriate nursing staff to ensure all residents received appropriate care. -He/She did attend the facility's QAPI meetings monthly and also entered the facility every Thursday to review medical records.

Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infections by not ensuring staff transported residents food down each hall in a manner to prevent cross-contamination; failed to ensure supplements and disposable equipment used during the administration of enteral nutrition were labeled, dated, and/or discarded when indicated and stored in a safe and sanitary manner between uses for two sampled residents (Resident #43 and #6); out of two sampled residents who received enteral nutrition; failed ensure personal hygiene products and care equipment (e.g., roll-on deodorant, combs, etc.) stored in the 400 Hall shower room were not available for common use to the 17 residents residing on this hall. The facility census was 65 residents. A request was made for all policies and/or procedures related to the administration of enteral nutrition via gastrostomy tube. No such policies and/or procedures were provided prior to the time of exit. A request was made for any policies and/or procedures addressing the storage of personal hygiene items. No such policies or procedures were provided prior to the time of exit. Review of the facility policy titled Infection Prevention and Control Program, revised 10/24/22, showed: -Purpose: To ensure the Facility establishes and maintains an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection in accordance with Federal and State requirements -Infection Control Policies and Procedures --The Facility's infection control policies and procedures are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. --Objectives Maintain a safe, sanitary, comfortable environment for personnel, residents, visitors, and the public. --Provide guidelines for the safe cleaning and reprocessing of reusable resident care equipment. 1. Observation on 3/12/25 showed: -At 5:41 P.M. Both Certified Nursing Assistant (CNA) D and CNA M passing and picking up trays on halls 100, 200, 300 and 400. -At 5:50 P.M.,on the 100 hall, five five trays with the residents' desserts, salads and drink were not covered. -At 6:10 P.M. on the 200 hall, four trays with the residents' desserts, salads and drink were not covered. -At 6:16 P.M. on the 300 hall, seven trays with the residents' desserts, salads and drink were not covered. -At 6:23 P.M. on the 400 hall, five trays with the residents' desserts, salads and drink were not covered. During an interview on 3/12/25 at 6:35 P.M. CNA M and CNA E said: -The deserts, salads and drinks for the residents on the halls came out uncovered from the kitchen daily. -Resident desserts, salads and drinks were served in plastic bowls and coffee cups. During a phone interview on 3/13/25 at 2:04 P.M. the Registered Dietitian (RD)said he/she expected all food items to be covered while being transported down hallways to the residents in their rooms. 2. Observation on 3/11/25 at 10:42 A.M. showed: -Resident #43 was in bed with the head of the bed elevated. -Located at the head of the resident's bed was an intravenous (IV) pole on which were hanging a full 1500 milliliter (ml) bottle of Jevity 1.2 nutritional supplement and a refillable kangaroo bag filled with water; neither the bottle nor the bag was labeled or dated. -The tubing, which was connected to both the bottle and the bag and were threaded through the feeding pump, was primed with the enteral supplement but was not labeled or dated. -The end of tubing was uncapped and draped freely over the top of the pump. -The IV pole and its wheeled base were heavily soiled with an accumulation of a dried, tan-colored substance similar in color to the Jevity 1.2. -On the counter next to the sink were three piston syringes. --One purple 60 ml ENFit syringe, which was not dated, was laying directly on the counter with the plunger stored in the barrel of the syringe (not separated to air dry). ---Clear liquid was observed collected at the end of the barrel near the tip where the plunger rested. --A second undated 60 ml piston syringe, which had a legacy tip, a circular thumb control ring, and a blue Luer tip adapter stored inside the barrel, was observed stored with the plunger inside the barrel. ---The tip of this second syringe had several drops of pink-colored liquid on it and had not been effectively rinsed after use. --A third 60 ml piston syringe with a legacy tip and thumb control ring was stored tip-down in a 500 ml graduated container; the graduated container was dated 3-8-25. Observation on 3/11/25 at 2:12 P.M. showed: -Resident #43 was in bed. -The feeding pump was programmed and running at 75 ml per hour with 100 ml water flushes to be administered every six hours. -The bottle of Jevity 1.2 and the kangaroo bag for water flushes remained unlabeled with no date. -The tubing also remained undated. 3. Observation on 3/11/25 at 10:57 A.M. showed: -Resident #6 was lying in bed by the door. -A feeding pump was observed on an IV pole located at the head of the resident's bed. -Hanging from the IV pole was a bag of IsoSource enteral supplement and a refillable kangaroo bag filled with water. -Neither of the bags was labeled nor dated. -The administration tubing threaded from the bags through the feeding pump was also not labeled or dated. -The feeding pump was programmed and running at 40 ml per hour. -The wheeled base of the IV was heavily soiled with an accumulation of a dried, tan-colored substance similar in color to the IsoSource. -A 60 ml ENFit piston syringe stored in direct contact with the overbed table with no clean barrier present. --The syringe was not dated, the syringe components were not separated to air dry, and moisture was observed on the tabletop directly below the tip of the syringe. --There was a graduated collection container on the sink counter dated 3-8-25. -A second ENFit piston syringe was seen on the floor under the resident's bed. 4. During an interview on 3/12/25 at 6:12 P.M. the Director of Nursing (DON) said: -The IV poles were dirty and should have been cleaned more frequently. -The piston syringes were supposed to be changed every night. -They were supposed to be dated when changed. -They were to be rinsed after each use and allowed to air-dry before being reassembled. -They were not be stored in direct contact with the counter or assembled while wet. 5. Observation on 3/12/25 at 5:43 P.M. showed: -The counter by the sink on the 400 hall shower room had a pile of hair combs, including nit combs [fine-toothed combs used to remove lice eggs]. --The combs had hair and dander on them. -Next to the pile of combs was one bottle of Medline Shampoo and Body Wash and two bottles of roll-on deodorant. -The bottles of deodorant were not labeled with an individual resident's name and were available for common use. During an interview on 3/12/25 at 6: 05 P.M. the DON said: -The combs should not be on the counter. -They should be sanitized after every use. -Everyone should have their own combs.

Based on interview, and record review, the facility failed to have a Registered Nurse (RN) at least eight consecutive hours a day for seven days a week. This was evidenced by the facility's documentation indicating RNs were not working in the facility for 11 out of 30 days, from 2/11/25 through 3/11/25. The facility census was 65 residents. 1. Review of the staffing sheet dated 2/12/25 showed there was no RN coverage all day. -Review of the Staffing Sheet dated 2/13/25 showed there was no RN coverage all day. -Review of the Staffing Sheet dated 2/14/25 showed there was no RN coverage all day. -Review of the Staffing Sheet dated 2/16/25 showed there was no RN coverage all day. -Review of the Staffing Sheet dated 2/17/25 showed there was no RN coverage all day. -Review of the Staffing Sheet dated 2/20/25 showed there was no RN coverage all day. -Review of the Staffing Sheet dated 2/26/25 showed there was no RN coverage all day. -Review of the Staffing Sheet dated 2/28/25 showed there was no RN coverage all day. -Review of the Staffing Sheet dated 3/4/25 showed there was no RN coverage all day. -Review of the Staffing Sheet dated 3/6/25 showed there was no RN coverage all day. -Review of the Staffing Sheet dated 3/11/25 showed there was no RN coverage all day. During an interview on 3/14/25 at 11:45 A.M. the Staff Development Manager said: -The facility needed a RN for at least eight consecutive hours a day for seven days a week. -The expectation was that the facility had a RN for eight hours a day, every day. During an interview on 3/14/25 at 12:28 P.M. the Administrator said: -It was the expectation of the facility to have a RN on the schedule daily for eight hours a day.

Based on observation, interviews, and record review, the facility failed to designate a qualified person to serve as the Director of Food and Nutrition Services. The facility did not employ a qualified Dietitian or other clinically qualified nutrition professional on a full-time basis, The facility census was 65 residents. Review of information titled, Director of Food and Nutrition Services Qualifications, and posted on 2/16/24 by the Missouri Department of Health & Senior Services (https://ltc.health.mo.gov/archives/16528), found the following: -We have recently received in influx of questions related to the qualifications for director of food and nutrition services in skilled nursing facilities. The federal regulation requires one of the following qualifications (if a qualified dietician or other clinically qualified nutrition professional is not employed full-time): --A certified dietary manager. --A certified food service manager. --Has similar national certification for food service management and safety from a national certifying body. --Has an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning. --Has two or more years of experience in the position of director of food and nutrition services in a nursing facility setting and has completed a course of study in food safety and management, by no later than October 1, 2023, that includes topics integral to managing dietary operations including, but not limited to, foodborne illness, sanitation procedures, and food purchasing/receiving. -Centers for Medicare & Medicaid Services (CMS) has noted that the approved certifications and course requirements would be the equivalent of a ServSafe Food Manager certification. Additional food manager courses we have found to meet the requirements include: AAA Food Handler, Learn2Serve, and State Food Safety. 1. Observation on 3/11/25 at 11:44 A.M. showed: -He/She had facial hair and was not wearing a beard guard while in the kitchen where food was being prepared. During an interview on 3/11/25 at 11:44 A.M. the Dietary Manager (DM) said: -He/She had been in the role for about a year. -He/She was currently enrolled in a Certified Dietary Manager course. During an interview on 3/11/25 at 12:26 P.M. the DM said: -He/She was able to order beard guards. -He/She did not know he/she needed them. -He/She had always worked in setting that did not require them, like restaurants. During a telephone interview on 3/13/25 at 2:04 P.M. the Registered Dietitian (RD) said: -In January 2025, he/she took over for another RD to serve as the Consultant RD for the facility. -When he/she took over as Consultant RD for the facility, he/she tried to verify which Certified Dietary Manager or certified food service manager course that the DM was enrolled in, as it was necessary for him/her to also take over the role of the Dietary Manager's preceptor of that course. -He/She was not able to serve as the preceptor for DM E since assuming the Consultant RD duties in January. -He/she visited every other week as the Consultant RD. -He/she learned that the DM was enrolled in an out of state university course and the DM had printed off the form needed to transfer his/her (the DM) preceptorship under his/her (the RD) license. On 3/13/25 at 4:44 P.M. the surveyor requested: -Copies of licenses and/or certifications (including ServSafe certification) for the RD and the DM. -Evidence of the DM's current enrollment in an accredited course. -Evidence of routine consultation by a Registered Dietitian provided to the DM for the past 12 months or since he/she assumed the role of the DM, if it had been less than 12 months. Review of the DM's personnel file on 3/14/25 showed: -There was no position description in the DM's personnel file. -It was unclear on what date the DM formally assumed duties as the facility's Dietary Manager. -In lieu of a signed and dated position description, there was a single-page untitled document, signed by the DM as Candidate, with a handwritten date of 2/29/21. This document contained the following information: --Show competence, understanding and/or improvement in the following areas over the next 30 days. Training will be provided by members of sister facility food service team. ---Kitchen cleanliness: ----Ensure staff are completing cleaning logs every shift. ----Assist in re-organization of storage. ----All logs were completed (temp [temperature], cleaning, dishwasher etc). ----Ensure items were dated and stored in proper containers. ---Meal service: ----Ensure all residents menus are received prior to the start of meal service. ----Ensure items on always available' menu are available upon request. ----Ensure staff are using proper handling techniques. ----Ensure temps are being monitored throughout meal service and food temp log complete. ----Ensure staff are using proper portion sizes when serving. ---Meal prep/cooking: ----Create prep schedule based off menu to decrease amount of time needed to cook. ----Ensure menu is being followed and food is palatable and visually appealing. ----Ensure altered diets are correct consistency and palatable. ---Other: ----Staff schedule should be made out and available to staff at least 2 weeks in advance. Any changes that need to be made must be communicated directly with staff. ----Dietary menus/resident tickets need to be updated daily and as needed. ----Attend Care plan meetings. ----Complete User Defined Assessments (UDA) in Point Click Care (PCC an electronic health record platform). ----Attend Risk management. ----Attend daily stand up and stand down meetings. ----Monitor food costs, limit waste, over ordering/under ordering. ----Cover holes in the schedule if they can't be filled by staff. ----Staff education and in-services on a monthly basis and as needed. ----Familiar with food service regulations and health code. ----Weekly meetings with administrator on Thursday at 2:00 P.M -NOTE: The personnel file did not contain copies of any diplomas or certifications currently held by the DM as evidence that he/she was qualified to serve as a Director of Nutrition and Food Service in a long-term care facility. -There was a copy of correspondence dated 6/10/24, granting approval of tuition reimbursement for the cost of attending a course titled Nutrition and Foodservice Professional Training (NFPT) Pathway 1, which would prepare her/him for taking the Certifying Board for Dietary Managers Certified Dietary Manager (CDM) Credentialing Exam.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review the facility failed to employ sufficient staff to carry out the functions of the Food and Nutrition Service department; and failed to ensure the Dietary Department had received adequate training and/or skills competency verification to ensure they were able to prepare and serve foods to residents in accordance with planned menus and their associated recipes. This deficient practice had the potential to affect 64 of 65 residents who received oral nutrition prepared and served by the facility's dietary department. The facility census was 65 residents. Review of the facility's policy titled Dietary Department - General, revised on 10/24/22, showed: -Policy: The dietary department is responsible for establishing a program that meets the nutritional needs of the residents and accounts for cultural, religious, physical, psychological, and social needs. -Procedure: --Training Program ---The Dietary Manager and/or Dietitian are responsible for planning and providing dietary staff with in-service education It is recommended that in-services take place on a monthly basis. ii. Part-time and off-duty employees are required to participate in in-services. ---In-service topics may include: Resident rights. Infection Control/Food Safety v. Sanitation. Nutritional needs of the elderly. Physician ordered diets. ---The Dietary Manager is also responsible for the day-to-day education of dietary staff regarding topics such as sanitation, food preparation, etc. ---Records of in-service training will be maintained by the Dietary Manager. Training records should include a sign in sheet, date, time, duration, description, and a copy of the material presented (if applicable). 1. Review on 3/14/25 at 3:08 P.M. of Dietary [NAME] P's personnel file showed: -Her/his hire date was 7/21/24. -There was no signed job description in this personnel file for any position. -There was not a copy of any Food Handler's Card or any evidence of training or orientation for the [NAME] position. 2. Review on 3/14/25 at 3:12 P.M. of Dietary [NAME] I's personnel file showed: -Her/his hire date was 10/28/24. -A Dietary Sanitation Orientation Checklist, which was checked off for successful completion of all tasks effective 11/11/24. -There was no signed job description in this personnel file for any position. -There was not a copy of any Food Handler's Card. 3. Review on 3/14/25 at 3:16 P.M. of Dietary Aide V's personnel file showed: -Her/his hire date was 4/28/23. -There was no signed job description in this personnel file for any position. -There was no copy of any Food Handler's Card or any evidence of training or orientation for this position. 4. Review on 3/14/25 at 3:19 P.M. of Dietary Aide J's personnel file showed: -Her/his hire date was 2/24/24. -There was no signed job description in this personnel file for any position. -There was no copy of any Food Handler's Card or any evidence of training or orientation for this position. 5. Review on 3/14/25 at 4:02 P.M. showed: -State Food Safety Food Handlers Cards for three dietary employees. --The Dietary Manager (DM) (dated 3/13/25). --Cook I (dated 4/1/24). --Dietary Aide U (dated 6/27/24). -A screenshot of a directive from the [NAME] County Health Department, which showed the Food Safety Training Course was required to be completed by 25% of food handlers staff on duty at any given time. During an interview on 3/14/25 at 4:02 P.M. the Administrator and Regional Nurse W said: -The DM and/or [NAME] I were on duty every day. -The DM's Food Safety Food Handlers Card had expired and was renewed on 3/13/25. -He/She did not know when the DM's card had expired. -There were no orientation checklists for dietary staff other than [NAME] I, as s/he was the most recently hired dietary staff member. -The facility did not have staff members sign job descriptions. -The Regional Dietary Manager (RDM) came to the facility once a month to conduct sanitation audits and provide training to dietary staff. -The RDM did not maintain any physical records of the training. Review on 3/14/25 at 4:13 P.M. of communication from the RDM showed: -After the dietary manager completed training and competencies for the dietary staff utilizing the attached checklist, he/she reviewed and assessed the employee's comprehension. If further training was needed, it would be conducted by himself/herself or the dietary manager. -During weekly visits he/she would oversee the following items when present at the facility: --Menu extensions and recipes. ---If menu substitutions are needed. --Sanitation Walkthroughs with reports. --Monitoring the meal service while in building. ---Checking food temps. ---Quality of food. ---Timeliness. --Receiving feedback from residents.

Based on observation, interview, record review, the facility failed to ensure meals were prepared in accordance with planned menus approved by the Consultant Dietitian using the corresponding recipes for the menu items, which resulted in foods not being attractive and palatable when served. This deficient practice had the potential to affect 64 of 65 residents who received oral nutrition prepared and served by the facility's dietary department. The facility census was 65 residents. Review of the facility's policy titled Dietary Department - General, revised on 10/24/22, showed: -Policy: The dietary department is responsible for establishing a program that meets the nutritional needs of the residents and accounts for cultural, religious, physical, psychological, and social needs. -The primary objectives of the dietary department include: --Preparation and provision of nutritionally adequate, attractive, well-balanced meals that are consistent with physician orders and accommodates resident allergies, intolerances, and preferences. --Provision of effective supervision and training of food service personnel. -Organizational Structure --The Administrator is responsible for the overall operation of the Facility. The Dietary Manager reports to the Administrator. --The Dietary Manager is responsible for the oversight of the dietary department In the Dietary manager's absence, the cook on duty assumes oversight responsibility for the dietary department. --Cooks and dietary aides report to the Dietary Manager. Dietary aides are held accountable by the cooks for the implementation of meals. --The Dietitian assumes the professional and ethical responsibility of the overall nutritional care of the residents. The Dietitian may make recommendations for departmental organization, but does not have the authority to implement such recommendations. 1. Review of the Diet Spreadsheet that included 3/11/25's lunch meal showed: -Residents with a diet order for regular texture food were to receive: --Beef & Broccoli Stir Fry - #8 dip x 2 (was equivalent to one (1) cup serving size) --Vegetable Fried [NAME] - #8 dip (#8 dip was equivalent to one-half (1/2) cup serving size). --Egg Roll - 1. --Banana Pudding - #8 dip. -Residents with a diet order for mechanical soft food were to receive: --Ground Beef & Broccoli Stir Fry w/Gravy - #8 dip x 2 with Gravy. --Rice with Gravy - #8 dip. --Bread & Margarine - 1 slice/1 teaspoon. --Banana Pudding - #8 dip. -Residents with a diet order for pureed food were to receive: --Pureed Beef & Broccoli Stir Fry w/Sauce - #8 dip x 2. --Pureed Vegetable Fried [NAME] - #10 dip (three-eights (3/8) cup serving size) --Pureed Banana Pudding - #8 dip. Observation on 3/11/25 of the steamtable prior to the start of the trayline for the lunch meal showed: -At 11:53 A.M. [NAME] I began measuring hot food holding temperatures with the following results: --White rice - 177° F (degrees Fahrenheit). --Broccoli - 191° F. --Ground beef in a sauce, which [NAME] I called Teriyaki Beef - 193° F. --Egg roll - 143° F. --Brown gravy - 191° F. --Temperatures were not measured for pureed foods at that time, as these items had not yet been prepared. --The ground beef in sauce and the broccoli were prepared, hot-held, and served separately. Broccoli was plated next to the white rice, the Teriyaki Beef was spooned over the rice, and an egg roll was placed on the plate. --No Vegetable Fried [NAME] was prepared or served, although at least one bag of this frozen product was observed during a tour of the walk-in freezer at 11:07 a.m. on 3/11/25. 2. Observation on 3/11/25 at 2:14 P.M. showed Resident #30: -Was in her/his room sitting on the edge of the bed in front of a plate of food on the overbed table. -On the resident's plate was white rice, ground beef, and an egg roll cut into small pieces. During an interview on 3/11/25 at 2:14 P.M. the resident who was in his/her room said: -The meal was OK if you liked rice. 3. Review on 3/13/25 at 12:45 P.M. of the recipes for the food items served for lunch on 3/11/25 showed: -The Beef & Broccoli Stir Fry and the Vegetable Fried [NAME] menu items were not prepared and served in accordance with the recipes for this meal. -The instructions for preparing this entrée were as follows: --In a large bowl, combine cornstarch (1st listed), water, and garlic powder with wire whisk; mix well until smooth. Set aside until ready to use. --Toss beef with cornstarch mixture to coat beef evenly. --Heat oil (1st listed) in saucepan or stockpot. Add beef and stir fry until no red juice remains and desired internal temperature is reached. --Remove beef from pan with slotted spoon and place in a clean and sanitized food processor. Grind to size of fine hamburger. Add small amount of prepared beef broth to moisten and reheat to 165° F for < [greater than] 1 second. Cover and hold until ready to use. --In same saucepan or stockpot, heat oil (2nd listed) in skillet. Add thawed broccoli and onion. Stir fry until vegetables are crisp-tender; return ground beef to saucepan. --In bowl, whisk together soy sauce, brown sugar, cornstarch (2nd listed), ginger, and water (2nd listed) with wire whisk until smooth. Add to skillet with ground beef. --Cook 3-5 minutes, stirring frequently until desired internal temperature is reached. -The Regular Textured Vegetable Fried [NAME] instructions for preparing this side dish were: --Prepare Vegetable Fried [NAME] according to the package instructions. -The [NAME] with Gravy, which was to have been served to only those residents with orders for mechanical soft diets instructions for preparing the side dish were: --Place rice in pans; add salt, oil and margarine. Pour hot water over rice; stir. --Cover with foil and bake for 1 hour or steam uncovered for 40 minutes. Fluff with a fork. --Portion #8 dip cup rice onto plate; ladle 2 oz [ounce] prepared gravy over rice. -The Pureed Beef & Broccoli Stir Fry w/Sauce instructions for preparing this entrée were: --Combine water and beef base to make broth. --Place prepared beef and broccoli stir fry in a washed and sanitized food processor; gradually add broth. --Blend until smooth. --The entrée was to be plated, with the prepared sauce ladled over it. -The Pureed Vegetable Fried [NAME] instructions for preparing this side dish were: --Place prepared rice in a washed and sanitized food processor. --Mix chicken base and hot water to make broth. --Gradually add broth to mixture and blend until smooth. During an interview on 3/13/25 at 1:19 P.M. [NAME] I (who had prepared the lunch meal on 3/11/25) said: -The only meat he/she used to prepare all textures of this meal was hamburger. -He/She did not know they were supposed to prepare Vegetable Fried Rice. -He/She did not have the recipes for any of the food items on the menu for that meal. -He/She did not always have access to the recipes. 4. Observation on 3/12/25 evening meal showed: -At 5:54 P.M. Resident #43 was lying in bed with her/his overbed table within reach. -On the overbed table was a black dinner plate on which were two scoops of pasta with a stiff cream sauce (no liquid noted) and one breadstick. -On a cafeteria tray on the overbed table was a Styrofoam bowl containing four slices of pears covered with a red powder. -The meal ticket identified that the resident had a diet order for a Regular Diet, with Regular Texture, and Thin Liquids. -The menu on the meal ticket identified that the resident was to have been served: Chicken [NAME] over Pasta, Caesar Salad, Blushing Pears, Breadstick, and Milk/Beverage. During an interview on 3/12/25 at 5:54 P.M. the resident said he/she had not been served a salad with the meal. During an interview on 3/13/25 at 1:54 P.M. the DM and [NAME] P said: -Resident #43's meal ticket showed the resident was on a Regular Diet with Regular Texture, and Thin Liquids; no items were circled on the tray ticket to identify the resident's personal preferences. -The resident received two scoops of pasta mixture, a single breadstick, blushing pears, and no Caesar salad. -Resident #43 had the option to be served the following regular menu items: Chicken [NAME] over Pasta, Caesar Salad, Blushing Pears, and a Breadstick. -If the meal ticket was not filled out, we were supposed to ask, or have someone ask the resident what they wanted in order to not take away their right to choose. 5. During an interview on 3/12/25 at 5:58 P.M. Resident #17 said the pasta was dry. I don't like Caesar salad. The breadstick wasn't hard like the last time. The pears were good. 6. Observation on 3/12/25 at 6:00 P.M. showed: -Resident #30 was in her/his room as he/she was eating dinner. -He/She was served a scoop of pasta mixture (from which he/she had already consumed some the entree), a salad, and pears. 7. During an interview on 3/13/25 at 1:58 P.M. [NAME] P said: -He/She prepared plates on 3/12/25 evening meal. -The resident's who were served mechanical soft diets were the ones that had sauce poured over the noodles. -He/She had not followed the recipe he/she just mixed it all together. During a telephone interview on 3/13/25 at 2:04 P.M. the Registered Dietitian (RD) said: -He/She had assumed responsibility for the facility in January 2025 and that s/he had been watching meal service with respect to timeliness of meal service. -He/She expected staff to follow planned recipes to correspond with the planned menus for each meal. MO00249108

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and performance of test trays to evaluate the quality of foods at the point of service, the facility failed to develop and implement a process for ensuring residents received foods that were flavorful, palatable, attractive, and at a safe and appetizing temperature. The facility census was 65 residents. Review of the facility's policy titled, Dietary Department - General, revised on 10/24/22, found: -The dietary department is responsible for establishing a program that meets the nutritional needs of the residents and accounts for cultural, religious, physical, psychological, and social needs. -The primary objectives of the dietary department include: --Preparation and provision of nutritionally adequate, attractive, well-balanced meals that are consistent with physician orders and accommodates resident allergies, intolerances, and preferences. --Provision of effective supervision and training of food service personnel. --The Administrator is responsible for the overall operation of the Facility. The Dietary Manager reports to the Administrator. --The Dietary Manager is responsible for the oversight of the dietary department. In the Dietary Manager's absence, the cook on duty assumes oversight responsibility for the dietary department. --Cooks and dietary aides report to the Dietary Manager. Dietary aides are held accountable by the cooks for the implementation of meals. 1. Review of the facility's Grievance Logs for the preceding six months found multiple complaints regarding foods being cold and/or not palatable at the point of service as follows: - On 9/25/24 9:30 A.M. - Breakfast - no menu - checked nurse's station. Don't believe the tray had ever been in the heated cart. Plate was cold scrambled eggs & bacon & toast. The 'toast' was a heel, the consistency of [NAME] toast. Note two of my dislikes are scrambled eggs & white bread. I ate the cold oatmeal with a fork. Glazed ham, scraps served in a pool of glaze (sugar) ice cream scoop of broccoli mush (maybe left over from lunch yesterday & reheated?). -On 9/25/24 at 7:15 P.M. Called nurse's station. My roommate & I have not received supper trays. --At 7:20 P.M. a nurse brought vegetable soup & salad. No coffee left so made my own instant. - On 9/28/24 Hall tray brought at 9:45 A.M. Ticket for breakfast lost. Received scrambled eggs & oatmeal on plate. Scrambled eggs is on dislikes. -On 9/30/24 Supper there was no protein served, misrepresented fruit, egg & cheese casserole, mostly bread, couldn't really find egg & cheese. Fresh fruit cup was canned. -On 12/15/24 Was told by the Dietary Manager at the Culinary Meeting when we have fried chicken we can put down what meat that we request. I put down breast meat but they sent me dark meat, so the only thing I ate was the mashed potatoes. On 1/4/25 Lunch Cheesy brown potatoes' was actually instant mashed potatoes with a little cheese mixed in. Spinach not on my plate. Supper was so bad I took a picture. Garden vegetable soup 1 tablespoon (scant) of chopped bell pepper in taupe colored broth. A brownie sundae always sounds good. All it was, was a brownie, I even requested vanilla ice cream but of course didn't get it. -On 2/21/25 Our breakfast was bad. I didn't have all the items I was suppose to get. What I did get was barely warm & most of it was cold. Another unknown resident only got one thing that he/she had ordered. Most of his/her breakfast was missing. I rarely get food that is warm. This happens most of the time. Don't understand why food has to come cold. Our lunch came later & was completely cold. -On 3/4/25 Supper Patty melt, meat was half raw. French fries were cold/hard under cooked. Observation on 3/14/25 of test trays for the lunch meal showed: -The meal was to include the entrée and the vegetable in both regular and pureed textures. -The temperatures for food items on the test trays were obtained by [NAME] I in the presence of the Dietary Manager and the surveyor. -Prior to leaving the kitchen, [NAME] I measured the temperatures of all items plated on the test trays. --Regular textured foods were measured beginning at 1:29 P.M. with the following results: ---Turkey a la King over [NAME] - 148° F (degrees Fahrenheit (F)). ---Mixed Vegetables - 143° F. --Pureed textured foods were measured beginning at 1:32 P.M. with the following results: ---Turkey ala King over [NAME] - 154° F; ---Green Beans - 153° F. --Also served on each tray was bread in the form of a dinner roll on the regular tray and a pureed dinner roll on the pureed tray. --After the temperatures were measured and recorded, the test trays were loaded on the bottom of a heated cart set to 140° F. -The Dietary Manager and the surveyor accompanied the heated cart as it left the kitchen. -The heated cart arrived on the 100 Hall at 1:35 P.M. and was plugged in. -The first tray was not removed for delivery until 1:38 P.M. -Initially only two nursing staff members removed the meal trays from the heated cart, poured beverages, and delivered trays to the residents' rooms. -At 1:45 P.M. a nurse pulled one of the staff members off the floor, and another staff member came out of a room and assisted in passing trays. -Two staff members arrived at 1:49 P.M. to assist in meal distribution. --Each time a new staff member arrived to assist, they opened the door to the cart and started shuffling through the trays. -At 1:53 P.M., the heated cart was moved to the 200 Hall and was plugged in and trays were delivered. -At 1:57 P.M., the heated cart was moved to the 300 Hall and was plugged in and trays were delivered. -At 2:04 P.M., the heated cart was moved to the 400 Hall and was plugged in and trays were delivered. -The last resident meal tray was delivered at 2:09 P.M. -The Dietary Manager and the surveyor removed the test trays from the heated cart, and the Dietary Manager measured the temperatures as follows: --Pureed Turkey a la King - 115° F at 2:10 P.M. --Pureed [NAME] Beans - 117° F at 2:11 P.M. --Regular Turkey a la King - 117° F at 2:11 P.M. --Regular Mixed Vegetables - 116° F at 2:12 P.M. During an interview on 3/14/25 at 2:12 P.M. the Dietary Manager said: -All hot foods should have been at 135° F or higher at the point of service to the residents. -All the items on the test trays were well below the acceptable hot holding temperature of 135° F. Observation on 3/14/25 at 2:15 P.M. the test trays were taste tested and showed: -Regular Mixed Vegetables lacked color, flavor, and seasoning. -Regular Dinner Roll was doughy and undercooked. During an interview on 3/14/25 at 2:20 P.M. the Dietary Manager said: -The Regular Mixed Vegetables lacked seasoning. -The Regular Dinner Roll looked undercooked. MO00249108

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff working in the kitchen effectively restrained their hair, including facial hair, to prevent contamination of food during food preparation and service; failed to ensure staff performed hand hygiene and used single-use gloves appropriately for food safety; failed to prepare and serve foods under sanitary conditions; failed to store Time and Temperature Control for Safety (TCS) foods in refrigerators within the appropriate temperature range to promote safety; failed to routinely monitor and record food temperatures when held on the steam table prior to service; and failed to routinely monitor and record the concentration of the sanitizing solutions used in the low temperature dish machine and in the three-compartment pots and pans sink. The facility census was 65 residents. Review of the facility policy titled, Dietary Department - General, revised on 10/24/22, showed: -The dietary department is responsible for establishing a program that meets the nutritional needs of the residents and accounts for cultural, religious, physical, psychological, and social needs. -The primary objectives of the dietary department include: --Preparation and provision of nutritionally adequate, attractive, well-balanced meals that are consistent with physician orders and accommodates resident allergies, intolerances, and preferences. --Maintenance of standards for sanitation and safety. --Maintenance of standards for quality of food. --Provision of effective supervision and training of food service personnel. -The Administrator is responsible for the overall operation of the Facility. The Dietary Manager reports to the Administrator. -The Dietary Manager is responsible for the oversight of the dietary department. In the Dietary manager's absence, the cook on duty assumes oversight responsibility for the dietary department. -Cooks and dietary aides report to the Dietary Manager. Dietary aides are held accountable by the cooks for the implementation of meals. -Concerns with other departments should be addressed to the appropriate department manager. -The Dietitian assumes the professional and ethical responsibility of the overall nutritional care of the residents. The Dietitian may make recommendations for departmental organization, but does not have the authority to implement such recommendations. -Employee Hygiene During Food Preparation and Service. --Employees should never use bare hand contact with any foods, ready to eat or otherwise. --Food service staff must wear hairnets when cooking, preparing, or assembling food, such as stirring pots or assembling the ingredients of a salad. However, staff do not need to wear hairnets when distributing foods to residents at the dining table(s) or when assisting residents to dine. --Staff should maintain nails that are clean and neat, and wearing intact disposable gloves in good condition that are changed appropriately to reduce the spread of infection. Gloves are necessary when directly touching ready-to eat food and when serving residents who are on transmission-based precautions. staff do not need to wear gloves when distributing foods to residents at the dining table(s) or when assisting residents to dine, unless touching ready-to-eat food. Disposable gloves are a single use items and should be discarded between and after each use. Review of the facility policy titled, Hand Hygiene, revised on 10/24/22, showed: -The Facility considers hand hygiene the primary means to prevent the spread of infections. -Facility Staff are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. -Facility Staff follow the hand hygiene procedures to help prevent the spread of infections to other staff, residents, and visitors. -Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) are readily accessible and convenient for staff use to encourage compliance with hand hygiene policy. -Facility Staff, visitors, and volunteers must perform hand hygiene procedures in the following circumstances: --Wash hands with soap and water: Before and after food preparation; In between glove changes. -The use of gloves does not replace hand hygiene procedures. -Washing Hands: --The following equipment and supplies are necessary when performing this procedure: Running water Soap (anti-microbial or non-antimicrobial) Paper towels Trash can. --Dry hands thoroughly with paper towels and then turn off faucets with a clean, dry paper towel. --Discard towels into trash. Review of the facility policy titled, Cleaning Schedule, revised 10/24/22, showed: -The dietary staff will maintain a sanitary environment in the dietary department by complying with the routine cleaning schedule developed by the Dietary Manager. --The Dietary Manager will develop a cleaning schedule that includes the frequency of which equipment and areas are to be cleaned. --The cleaning schedule is posted weekly. --The cleaning schedule includes tasks assigned to specific positions with the dietary department. --Dietary staff will initial next to the assigned task once it is completed. -The Dietary Manager monitors the cleaning schedule to ensure compliance. Review of the facility policy titled Refrigerator/Freezer Temperature Records, revised on 10/24/22, showed: -The Dietary Manager or designee is to record daily all refrigerator and freezer temperatures on DS - 53 - Form A - Refrigerator/Freezer Temperature Log during A.M. and P.M. shifts. -The freezer temperature must be 0° F [degrees Fahrenheit] or below. -The refrigerator temperature must be 41° F or below. -Temperatures above these areas are to be reported to the Dietary Manager immediately. -Note on the temperature forms the plan of action taken when temperatures are not in acceptable range. -Corrective action should be taken to correct the temperature or the items should be moved to another storage area to maintain acceptable temperature. Review of the facility policy titled Food Temperatures, revised on 10/24/22, showed: -Foods prepared and served in the facility will be served at proper temperatures to ensure food safety. -Measuring Food Temperature: --It is recommended to use a thermometer with a practical range of 0° F to 220° F. --Insert the thermometer into the center of the product. --Allow time for stabilization. Wait until there is no movement for 15 seconds. Several readings may be required to determine hot and cold spots. --Record the reading on DS - 16 - Form A - Food Temperature Log at the beginning of the tray line. --Take the temperature of each pan of product before serving. --Re-sanitize the thermometer after each use. Review of the facility policy titled Dish Machine Operation and Cleaning, revised 10/24/22, showed: -The dietary staff will use the dish machine according to the manufacturer's guidelines. The dish machine will be sanitized between uses. -Routinely monitor soap, sanitizer and rinse agent to ensure adequate supply throughout operation of the dish machine. 1. Observation on 3/11/25 at 10:03 A.M. during the initial tour of the kitchen with Assistant Administrator T showed: -Dietary staff used a heavily soiled white garbage barrel with a lid that had to be lifted by hand to discard paper towels after washing their hands. -No trash receptacle was readily available near the handwashing sink that did not require manually lifting the lid with their hands before use. -Dietary Aide K, had with facial hair that appeared to be longer than 0.25 inch, was wearing a hairnet but not a beard guard. -The walls and floors of the kitchen, both behind and under wheeled/movable equipment, as under and behind stationary storage racks and appliances, were heavily soiled with dirt. -The removable grease filters in the range hood were heavily soiled, with thick build-ups of grease running down from the bottoms of the grease filters. -The top of the Vulcan convection oven, on which were stored an open box of paper sheet pan liners and several oven mitts, was visibly soiled with a coating of debris that, when tested with a fingertip, was greasy and easily removed. The box of pan liners was visibly soiled with grease/oil stains all over the box. -Two wire utility carts in the dishwashing area, which were used to hold clean dishes after they were washed, were rusted and soiled with a sticky, greasy substance on the supports; this substance was easily removed by rubbing with a fingertip. -A 3-shelf pink hard plastic cart, on which were stored hot beverage dispensers for coffee and hot chocolate, trays of clean coffee mugs, and a gray multi-section storage bin containing individually packaged items such as sugar packets, tea bags, etc., had multiple broken sections of plastic with jagged edges exposed, and all shelves were heavily soiled and stained with what appeared to be dried coffee spills. -Plastic carts parked just outside the kitchen and in the dining room, which were used to stage food trays prior to being delivered to the residents in the dining room, were heavily soiled, as was the wall behind the carts. -The walk-in refrigerator unit was not working. The walk-in refrigerator unit needed a new fan, even though it had just recently been repaired, and the facility was storing refrigerated food items in residential refrigerators in an unoccupied resident room on the 600 Hall (Assisted Living). --The walk-in freezer had food on the floor under the wire storage racks (e.g., loose frozen yellow vegetables (squash slices), bags of frozen Brussel sprouts, etc.). --Also on the floor in the walk-in freezer was a large puddle of frozen liquid, loose cardboard scraps, a single-serve cup of yogurt, and several pink and blue plastic reusable ice cubes. --On the wire storage racks were meats that were not in their original packaging, which included pieces of poultry (which were later identified as being turkey) in a large resealable baggy, two partial rolls of ground meat wrapped in plastic wrap, and a large rectangular package of beef; none of these items was labeled or dated. --One of the small rolls of meat, which was wrapped in green paper inside the plastic wrap appeared to be sausage. The other small roll of meat appeared to be ground beef, and the end of the roll was notably [NAME] in appearance than the rest of the roll. Observation on 3/11/25 of the refrigerators in the unoccupied room on 600 hall (room [ROOM NUMBER]) with Assistant Administrator T showed: -At 10:14 A.M. Refrigerator #1 had an internal thermometer that read 54° F (verified by Assistant Administrator T). The contents of the refrigerator included: --Eight bags of shelled hard-boiled eggs which were stored in the door's shelves (each contained a dozen eggs). An opened box containing trays of raw eggs, bulk containers of salad dressing, a bulk container of pimento cheese salad, and one-gallon jugs of milk. ---There was no refrigerator temperature log on or near the refrigerator. -At 10:16 A.M. Refrigerator #2 had an internal thermometer that read 44° F (verified by Assistant Administrator T). The contents of the refrigerator included: --A large package of sliced American cheese; a bag of hotdogs; loose single-serve containers of yogurt; bulk containers of pimento cheese salad, sour cream, parmesan cheese; a bulk container of orange sections; and a large piece of cardboard that was wet and had ice formed on it. ---Assistant Administrator T removed the cardboard and said that ham had been on top of the cardboard thawing. ----There was no refrigerator temperature log on or near the refrigerator. At 10:18 A.M. Refrigerator #3 had an internal thermometer that read 46° F (verified by Assistant Administrator T). The contents of the refrigerator included: --Meat slices (identified by Assistant Administrator T as being bologna) that were ineffectively wrapped with aluminum foil and not labeled or dated; American cheese slices in a small plastic container that was covered with foil and not labeled or dated; a carton of liquid eggs; a bulk container of salad dressing; and multiple one-gallon jugs of milk. --On the top shelf of the refrigerator was a tray of shell eggs with loose debris which appeared to be particles of food on the tops of the eggs; on the bottom shelf of the refrigerator were an open bag of chopped iceberg lettuce and a bag of shredded cheese, as well as an open carton of liquid eggs with the contents dripped down the front of the carton. ---There was no refrigerator temperature log on or near the refrigerator. During an interview on 3/11/25 at 10:20 A.M. Assistant Administrator T said he/she did not know if there were any temperature logs for the three different refrigerators. Observation on 3/11/25 at 11:44 A.M. showed: -The Dietary Manager had facial hair that was longer than 0.25 inches and was not wearing a beard guard with her/his hairnet. -The Dietary Manager washed her/his hands at the handwashing sink. He/She turned the faucets off with her/his bare hands, obtained a paper towel to dry their hands, then lifted the lid of the white garbage barrel to discard the paper towel. Observation and interview on 3/11/25 showed: -At 11:48 A.M. a bath blanket was on the floor under a preparation sink equipped with a garbage grinder. --At 11:48 A.M. the Dietary Manager said Maintenance was working on a leak. -At 11:49 A.M. Dietary Aide J, who had long black hair and trimmed facial hair did not have her/his hairnet on to effectively restrain all his/her hair in the back; this person was also not wearing a beard guard. -At 11:53 A.M. [NAME] I washed her/his hands and put on a pair of single-use gloves, after which he/she obtained a food thermometer and began measuring hot food holding temperatures with the following results: --Rice - 177° F (degrees Fahrenheit); Broccoli - 191° F; Teriyaki Beef - 193° F ; Egg Roll - 143° F; [NAME] Gravy - 191° F. [NAME] I did not write down any of these holding temperatures at the time he/she took them. -At 11:56 A.M. after taking the holding temperatures, [NAME] I removed the single-use glove from her/his right hand, threw the glove into the trash, applied a new glove to the right hand without performing handwashing or hand hygiene, and started plating the first plate of food. After plating a scoop of rice, [NAME] I left the trayline, used her/his gloved hand to pull open the utensil drawer, obtained a slotted spoodle, pushed the drawer closed, returned to the trayline to dip up, and plated a spoodle full of Teriyaki Beef. [NAME] I left the trayline again to obtain a solid spoodle for the beef and left the trayline again to obtain a pair of tongs to plate an eggroll, again opening and closing drawers, all while in the process of plating the first tray. -After [NAME] I plated the food, he/she passed the plate to Dietary Aide J, who placed the plate on a cafeteria tray on which he/she had already placed a red cloth napkin and a plastic spoon and plastic fork. Dietary Aide J then carried the tray to an open cart just inside the dining room for service to the resident by nursing personnel. [NAME] I and Dietary Aide J prepared three more meal trays in the same manner. -At 12:01 P.M. Dietary Aide J exited the kitchen into the dining room and returned with a heater cart, which he/she plugged in. He/She did not change her/his gloves or wash her/his hands after handling the heated cart and the power cord. Dietary Aide J then walked over to a box of plastic eating utensils, obtained a handful of eating utensils, and carried them over to her/his workstation and placed them in a storage bin. -At 12:09 P.M. the trays were wet as [NAME] I placed the paper tray tickets on the trays. --Cook I said staff sometimes allowed the trays to air dry after washing them. --The Dietary Manager said with the time we have allotted, staff put the trays together while they're still wet. -At 12:09 P.M. Dietary Aide J carried a large container of cottage cheese into the kitchen, opened it, and attempted to scoop a portion out of the container without success because the contents were frozen. --Dietary Aide J said the cottage cheese had come from the back of one of the refrigerators in room [ROOM NUMBER]. -At 12:10 P.M. the surveyor showed the Dietary Manager that the thermometer in Refrigerator #1 in room [ROOM NUMBER] was reading in the 50's while still storing raw and shelled hard-boiled eggs. --The Dietary Manager said that's running hot. I'll need to get maintenance to look at it. -At 12:13 P.M. the Dietary Manager washed her/his hands at the handwashing sink, turned off the spigots with her/his bare hands, obtain a paper towel to dry her/his hands, and lifted the lid of the white garbage barrel with her/his bare hand to throw away the paper towel. -At 12:15 P.M. the Dietary Manager was asked about the log for hot food holding temperatures. --The log dated March 2025 was on a clipboard near the steam table. and had multiple days where the food temperatures were not recorded. -At 12:16 P.M. [NAME] I, while wearing single-use gloves, touched environmental surfaces before he/she placed an egg roll on a resident's plate with tongs. With the same gloved hands, he/she held the egg roll down with her/his left hand while cutting the egg roll into smaller pieces with her/his right hand. After doing this, [NAME] I did not remove her/his gloves, wash their hands, or put on a new pair of single use gloves. -At 12:18 P.M. continuous observation of the trayline found [NAME] I obtained a baked potato from the steam table. while wearing the same single-use gloves, [NAME] I pushed down on the baked potato to spread the potato where the skin had been scored. -At 12:21 P.M. [NAME] I handled egg rolls for two more plates, holding each down with one hand while cutting the egg roll with the other hand. No glove changes or handwashing occurred. -At 12:24 P.M. [NAME] I patted down the rice and broccoli with her/his gloved hand after plating the items on a resident's plate. --At 12:26 P.M. the Dietary Manager said the noon meal food hot holding temperature had not been recorded. -At 12:28 P.M. [NAME] I said he/she had measured the temperatures but had been too busy to write them down. -At 12:30 P.M. the Dietary Manager recorded the holding temperatures using the information the surveyor had recorded while [NAME] I took the temperatures before the start of the meal service. --The Dietary Manager said the March 2025 food temperature log had gotten wet and was shredded, he/she was backfilling the information into the March log. -At 12:32 P.M. the Dietary Manager said he/she could order beard guards, he/she didn't know he/she needed them. He/She had always worked in settings that did not require them. During an interview on 3/13/25 at 1:28 P.M. [NAME] I said during the lunch service on 3/11/25, he/she should have changed gloves and washed his/her hands each time he/she contaminated the gloves. 2. Observation and interview on 3/12/25 of the kitchen with the Dietary Manager showed: -At 12:26 p.m. the Dietary Manager was still not wearing a beard guard when in the kitchen while passing by food preparation, dish washing, and food service areas of the kitchen. -At 12:27 P.M. the Dietary Manager said he/she could not locate the low temperature sanitizing solution log for the dishmachine. He/She tested the concentration of the chorine-based sanitizing solution in the dish machine, by dipping a test strip in the standing water inside the machine which resulted in 100 parts per million (ppm). -At 12:29 P.M. the Dietary Manager dipped a test strip in the sanitizer reservoir during the rinse cycle which resulted in 200 ppm. -At 12:31 p.m., the Dietary Manager tested the concentration of the quaternary ammonium sanitizing solution in the third compartment of the 3-compartment sink where pots and pans were cleaned and sanitized - which resulted in 200 ppm. Review of the Pot and Pan Sanitizer Logs dated 1/1/25 through 3/12/25 showed: -Entries recorded three times a day with entries ranging from 150 ppm to 250 ppm, and with 250 ppm being recorded 15 times in January, 33 times in February, and 16 times in March. -The log did not define what the appropriate range should be, nor what actions were to be taken if the sanitizer's concentration was not at the correct level. Observation on 3/13/25 at 3:20 P.M. of the placard on the dish machine showed: -NSF Machine Operational Requirements as manufactured by American Dish Service. --Wash Temperature: 120° F minimum. --Rinse Temperature: 120° F minimum. --Required: 50 parts per million (ppm) available chlorine rinse. Observation on 3/13/25 at 1:51 P.M. of the test strips used for measuring the concentration of the quaternary ammonium sanitizing solution in the Pot and Pan sinks showed: -The facility used Hydrion ® QT-44 Quaternary Test Paper manufactured by Micro Essential Laboratory. --Review of the Hydrion ® QT-44 specification sheet found the following directions for use: Dip a strip of paper into the solution to be test. Hold in still solution for 10-seconds; do not agitate. Remove and immediately compare to color chart. The sanitizer concentration will be associated with the closest matching color. The specification sheet further identified that Color Match Points were available for 0 ppm, 150 ppm, 200 ppm, 300 ppm, and 400 ppm. There was no Color Match Point for 250 ppm. 3. Observation on 3/12/25 at 2:49 P.M. of the walk-in freezer with the Dietary Manager and the Regional Dietary Manager showed: -New boxes of stock received on 3/11/25 had been placed directly on the floor of the freezer. -Loose yellow vegetables (yellow squash slices) and bags of Brussel sprouts were still seen under the racks on the floor in the freezer. -The repackaged meat items observed on 3/11/25 were still present in the freezer without labels or dates. -A cardboard box of hamburger patties was open on a shelf with the inner plastic liner also open, exposing patties to the air. -A cardboard box of frozen vegetables was seen open on a shelf with the inner plastic liner also open, exposing vegetables to the air. -The large puddle of frozen liquid remained on the floor of the walk-in freezer. 4. Review of the hot food holding temperature logs dated January 2025, February 2025 and March 2025 showed: -The January 2025 log had blanks spots for temperatures that should have been recorded for evening meals. -The log for February 2025 was illegible in places and the first few days of March 2025 were recorded on the February 2025 log. -There were blanks on the March 2025 log. --In total, between 1/1/25 and the noon meal on 3/12/25, there were 34 meals for which no food temperatures were recorded and one meal where food temperatures were not recorded for all diet textures served. During an interview on 3/12/25 at 12:41 P.M. the Dietary Manager said: -The food temperature logs for January 2025 and March 2025 were incomplete. -He/She could not recall a specific date but believed the walk-in refrigerator was out of service on the first of March 2025. -A new residential refrigerator had been purchased the previous evening and the repairs needed to the walk-in refrigerator had been completed. -The contents of the defective refrigerator (with temperature reading of 54° F on 3/11/25) had been moved into the new refrigerator. The Regional Dietary Manager directed the Dietary Manager to discard the eggs. 5. During an interview on 3/12/25 at 12:55 P.M. the Regional Dietary Manager said beard guards should be worn by dietary staff with facial hair. 6. During a telephone interview on 3/13/25 at 2:04 P.M. the Registered Dietitian said: -He/she had assumed responsibility for this facility in January 2025 and that he/she had been watching meal service with respect to timeliness of the meals. -He/She had been informed but he/she was not aware how long the walk-in had been out of service. -He/She hoped the food that was in the residential refrigerator that had an internal temperature in the 50° F range had been discarded. MO00249108

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to follow physician's orders for skin treatments and to document the treatments in the medical record for one sampled resident (Resident #3) out of six sampled residents. The facility census was 61 residents. On 10/15/24 the Administrator and acting Director of Nursing (DON) were notified of past non-compliance which occurred on 7/30/24. On 7/30/24 the facility Administrator was notified the Wound Nurse was not signing off treatment orders and not completing documentation as expected. Wound Nurse A was assigned a floor position, and wound duties were assigned to the Assistant Director of Nursing (ADON) on 8/8/24. No nurses were allowed to provide wound care prior to reeducation completed 7/30/24. The deficiency was corrected on 7/30/24. Review of the facility Wound Management Policy dated 10/24/22 showed: -To provide a system for the treatment and management of residents with wounds including pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction) and non-pressure ulcers (a chronic open wound that develops due to a primary cause other than pressure or shear). -A resident who had a wound would receive necessary treatment and services to promote healing, prevent infections and prevent new wounds from developing. -A licensed nurse would perform a skin assessment upon admission, readmission, weekly, and as needed for each resident. -Upon identification of a new wound the licensed nurse would: --Measure the wound (length, width, depth) in centimeters (cm). --Initiate a Wound Monitoring Record sheet. ---A Wound Monitoring record would be completed for each wound. ---The Wound Monitoring Record was optional for recording skin tears, lacerations, cuts, and abrasions. ---If the Wound Monitoring Record was not used, documentation would be recorded within the medical record which may include nursing notes, treatment records or care plans. --Implement a wound treatment per physician's order. -Per physician's order, the nursing staff would initiate treatment and utilize interventions for pressure redistribution and wound management. -The physician and Interdisciplinary Team (IDT - A group of people from different backgrounds who work together to achieve a common goal) would be notified of: --Complaints of increased pain, discomfort or decreased mobility by a resident. --Signs of wound sepsis (a blood stream infection), presence of exudates (any fluid that has been forced out of the tissue or its capillaries because of inflammation (an immune response that causes redness and swelling of an area on the body or possibly tissue) within the body or injury, odors, or necrosis (relating to localized death of living cells as from interruption of blood supply or infection), if not already noted by the physician. --Resident refusing treatment. -Licensed nurse would document effectiveness of current treatment in the resident's medical record on a weekly basis. -Document notifications following a change in the resident's skin condition. -Update the resident's care plan as necessary. --NOTE: Nothing in the policy talked about documenting each treatment on the Treatment Administration Record (TAR). 1. Review of Resident #3's admission Minimum Data Set (MDS-A federally mandated assessment tool required to be completed by facility staff for care planning) dated 4/15/24 showed the resident: -Was severely cognitively impaired. -Had no wounds or infections. -Had Coronary Artery Disease (narrowing of the coronary arteries due to buildup of plaque). -Had Peripheral Vascular Disease (inadequate flow of blood to the extremities). Review of the resident's Physician's Order sheet (POS) dated April 2024 showed: -Facility nurse to cleanse the resident's bilateral lower extremities with wound cleaner, pat dry, apply ABD (abdominal thick wound dressing) pads and wrap with Kerlix (woven gauze that is non-adhesive used to wrap wounds and burns) two times a day for edema (swelling) and weeping of his/her lower extremities, started 4/7/24 and discontinued 4/26/24. -The wound nurse was to cleanse the resident's bilateral lower extremities with wound cleaner, pat dry, apply ABD pads and wrap with Kerlix two times a day and PRN until healed, for edema and weeping, started 4/26/24 and discontinued 4/30/24. Review of the resident's TAR dated April 2024 showed: -Facility nurse to cleanse the resident's bilateral lower extremities with wound cleaner, pat dry, apply ABD pads and wrap with Kerlix two times a day for edema and weeping of lower extremities, started 4/7/24 and discontinued 4/26/24. --No documentation that the treatment was completed by facility staff 14 out of 38 opportunities. -The wound nurse was to cleanse the resident's bilateral lower extremities with wound cleaner, pat dry, apply ABD pads and wrap with Kerlix two times a day and PRN until healed, for edema and weeping, started 4/26/24 and discontinued 4/30/24. --No documentation the treatment was completed by facility staff one out of six opportunities. Review of the resident's Hospital discharge date d 4/5/24 showed: -Diagnosis of COVID (a new disease caused by a Novel (New) coronavirus), edema and syncope (fainting or sudden temporary loss of consciousness). -Follow up with physician within one to two days. Resident had edema and swelling of both legs. -Please make sure to wrap his/her legs up daily and change his/her dressings daily to prevent worsening edema. -After wrapping his/her legs with Ace bandage (a type of compression bandage that is used to provide support and reduce swelling in injured areas of the body), please place a compression stocking over his/her legs to help reduce edema (swelling). Review of the resident's Care Plan dated 4/5/24 showed the resident did not have a plan of care for his/her wounds, or skin infections. Review of the resident's Nursing Note dated 4/6/24 showed: -Resident complained of pain in his/her lower legs, -Nurse went to assess resident's legs and resident had pulled down the Ace wraps which were saturated with fluid and his/her legs were weeping and bleeding. -Nurse spoke to operator at hospital who stated that there was not an on-call physician on for their practice. -The nurse attempted to administer Tylenol (pain medication) and the resident stated, that does not work. -Nurse went to get supplies to clean the resident's legs and to look at orders for treatment. -Resident walked out in the common area and demanded to go to hospital. -911 was called to transport resident to the hospital for evaluation and treatment. -Family was notified of the transfer and report was called to the hospital. Review of the resident's Hospital discharge date d 4/7/24 showed: -Diagnosis of lymphedema (a chronic condition that causes swelling in the body due to a buildup of lymph fluid (is part of the lymph system which helps the body fight infection and disease)) and cellulitis (an infection of deep skin tissue) to his/her bilateral lower legs. -New order for Cephalexin (antibiotic for infection) 500 milligrams (mg) oral capsule, one capsule oral, every six hours for 10 days for lymphedema. Review of the resident's Weekly Skin Observation dated 4/12/24 showed bilateral lower extremities with 3 to 4 plus pitting edema, weeping serosanguinous (containing blood and watery drainage) drainage, multiple areas of skin peeling and bleeding. Treatment in place. Review of the resident's Weekly Skin Observation dated 4/16/24 showed: -Bilateral lower extremities with 3 to 4 plus pitting edema, with multiple scabbed areas. -Right lower leg with partial thickness open area 2.5 centimeters (cm) x 2 cm. Edges well defined, scant amount of serous (watery, clear, or slightly yellow/tan/pink drainage) drainage noted. Review of the resident's Weekly Skin Observation dated 4/22/24 showed bilateral lower extremities with 3 to 4 plus pitting edema, weeping, peeling skin, treatment in place. Review of the resident's medical record showed he/she was sent to the hospital on 4/29/24. Review of the resident's Hospital discharge date d 5/2/24 showed: -admitted into the hospital on 4/29/24 for local infection of wound. -Would and blood cultures obtained, positive for Staph aureus (a bacterial skin or soft tissue infection). -Intravenous (IV - injected into the veins) antibiotic started as well as inpatient wound care. -Wrap lower extremities. -Consult wound care. -New order for Cephalexin (antibiotic) 500 mg capsule, oral four times a day for five days for infection. Review of the resident's significant change MDS dated [DATE] showed the resident: -Was severely cognitively impaired. -Had other wounds and skin problems. -Had ointments/medications other than to feet. -Had Coronary Artery Disease. -Had Peripheral Vascular Disease. Review of the resident's POS dated May 2024 showed: -Cleanse the resident's open area with wound cleaner, apply Santyl nickel thick, apply calcium alginate, cover with Kerlix, change daily and PRN for wounds, started 5/3/24 and discontinued 6/12/24. --This treatment was ordered twice. -Cleanse the resident's open area with wound cleaner, apply Santyl nickel thick, apply calcium alginate, cover with Kerlix, change daily and PRN for wounds, started 5/3/24 and discontinued 6/12/24. --This was a duplicate order. -Wound nurse to cleanse the resident's bilateral lower extremities with wound cleaner, pat dry, apply ABD pads and wrap with Kerlix two times daily and PRN for edema and weeping, started 5/2/24 and discontinued 6/12/24. Review of the resident's TAR dated May 2024 showed: -Cleanse the resident's open area with wound cleaner, apply Santyl nickel thick, apply calcium alginate, cover with Kerlix, change daily and PRN for wounds. --This treatment was ordered twice. Does not say what was to be treated. -No documentation the treatment was completed by staff seven out of 15 opportunities. -Cleanse the resident's open area with wound cleaner, apply Santyl nickel thick, apply calcium alginate, cover with Kerlix, change daily and PRN for wounds. --Does not say what was to be treated. -No documentation that the treatment was completed by staff seven out of 15 opportunities. -Wound nurse to cleanse the resident's bilateral lower extremities with wound cleaner, pat dry, apply ABD pads and wrap with Kerlix two times daily and PRN for edema and weeping. -No documentation the treatment was completed by staff 13 out of 30 opportunities. Review of the resident's Weekly Skin Observation dated 5/13/24 showed: -Skin color normal. -Skin Temperature dry. -No skin issues noted. Review of the facility Performance Improvement Plan dated July 2024 showed: -Identified Area for Assessed Improvement. --Wound Nurse A not signing off treatment orders as expected. --Wound Nurse A not completing documentation as expected. -Plan. --Current Wound Nurse A assigned a floor position, wound duties assigned to the Assistant Director of Nursing (ADON) or designee while position was being filled. --Wound Nurse position posted. --New Wound Nurse hired 9/28/24. --Regional Wound Nurse support added for enhanced oversight. -Action Steps to implement plan. --The DON or designee in-serviced licensed nurses on completion of treatments and documentation of treatments in the Medication Administration Record (MAR)/TAR. --DON or designee in-serviced ADON on position expectations and documentation expectations. --Twice weekly calls initiated with the facility nurse management and regional wound support and Regional Nurse Consultant to review wound processes for compliance. -Objective Measures to Evaluate. --Regional Wound Consultant would audit wound assessments and wound reports weekly. If concerns were identified, they would be corrected by the ADON, or designee and in-service would be provided. --DON or designee would review current wounds weekly in Risk to ensure physician notification was completed, treatment orders were in place, and treatments were completed as ordered. If any issues were identified, then education would be completed by the DON or designee. --Regional Nurse Consultant would pull weekly medication/treatment reports to send to the facility for review. -Person Responsible for Oversight. --DON or designee. -To be completed in July 2024 and ongoing. During an interview on 10/8/24 at 10:47 A.M., Wound Nurse A said: -He/she completed all his/her treatments as ordered for the resident. -If busy he/she would forget to sign the TAR that the treatment was done. -He/she was educated on wound documentation and notification to family and physician if the resident refused the treatment. -He/she did not notify the physician if the resident refused a treatment occasionally. -He/she was no longer the Wound Nurse. -If the TAR was left blank it meant the treatment did not get done. During an interview on 10/8/24 at 11:01 A.M., the ADON said: -He/she had trained on wound documentation, wound reports, and wound care plans. -He/she was assisting with wound care for the residents. -He/she was auditing the MAR and TAR to make sure the nursing staff were signing when medications were given, and treatments were done. -If the MAR/TAR was not signed the process did not happen. During at interview on 10/8/24 at 2:28 P.M., the DON said: -Wound Nurse A had been educated several times about signing the TAR after a treatment was done but kept leaving blanks on the TAR. -Wound Nurse A was no longer the wound nurse. -A new wound nurse had been hired and was in training now. -He/she and the ADON were working on training the new Wound Nurse. -He/she was auditing the MARs/TARs to make sure they were being signed when medications were given, and treatments were done. This was ongoing. -Provided education to the nursing staff about documentation on wound care and notification to physician and family. -The charge nurses were completing the treatments along with him/her, the ADON and wound nurse in training, with assistance from the Regional Wound Consultant. -He/she and the ADON are doing the weekly wound assessments, measurements, and rounding with the outside wound care team. During an interview on 10/8/24 at 4:37 P.M., the Administrator said: -The facility had a new wound nurse due to Wound Nurse A no longer treating wounds and just working the floor effective 8/8/24. -The wounds were not healing like they should. -Wound Nurse A was on the floor all day doing treatments. -An audit was done in July and found that Wound Nurse A was not signing the TAR when the treatments were done. -Wound Nurse A was educated again about signing the TAR after the treatments were done and documenting if the physician had been called or if the resident refused the treatment. -In July 2024, A Performance Improvement Plan was put into place for Wound Nurse A not signing the TAR or documenting on the treatments as expected. -All nurses were educated on wounds on admission, following physician's orders, documentation on wounds, notifying the physician of refusal of treatments, ensure the MAR/TAR were signed off, wound care planning, wound reports, and wound documentation. During an interview on 10/9/24 at 10:13 A.M., the Physician said: -He/she would expect the licensed nurses to completed treatments as ordered for the residents. -He/she was not notified the resident was refusing any treatments. -He/she should be notified if a resident was refusing treatments. -There was no outcome from the treatments not being done. -The resident was very sick and was on hospice (end of life care) due to a decline in health. MO00243272

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to follow physician's orders for treatments and to document the resident's pressure ulcers, for one sampled resident (Resident # 3) out of six sampled residents. The facility census was 61 residents. On 10/15/24 the Administrator and acting Director of Nursing (DON) were notified of past non-compliance which occurred on 7/30/24. On 7/30/24 the facility Administrator was notified of the Wound Nurse was not signing off treatment orders and not completing documentation as expected. Wound Nurse A was assigned a floor position, and wound duties were assigned to the Assistant Director of Nursing (ADON) on 8/8/24. No nurses were allowed to provide wound care prior to reeducation completed 7/30/24. The deficiency was corrected on 7/30/24. Review of the facility Wound Management Policy dated 10/24/22 showed: -To provide a system for the treatment and management of residents with wounds including pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction) and non-pressure ulcers (a chronic open wound that develops due to a primary cause other than pressure or shear). -A resident who had a wound would receive necessary treatment and services to promote healing, prevent infections and prevent new pressure ulcers from developing. -A licensed nurse would perform a skin assessment upon admission, readmission, weekly, and as needed for each resident. -Upon identification of a new wound the licensed nurse would: --Measure the wound (length, width, depth) in centimeters (cm). --Initiate a Wound Monitoring Record sheet. ---A Wound Monitoring record would be completed for each wound. ---The Wound Monitoring Record was optional for recording skin tears, lacerations, cuts, and abrasions. ---If the Wound Monitoring Record was not used, documentation would be recorded within the medical record which may include nursing notes, treatment records or care plans. --Implement a wound treatment per physician's order. -Per physician's order, the nursing staff would initiate treatment and utilize interventions for pressure redistribution and wound management. -The physician and Interdisciplinary Team (IDT - A group of people from different backgrounds who work together to achieve a common goal) would be notified of: --New pressure ulcers and wounds. --Pressure ulcers or wounds that did not respond to treatment. --Pressure ulcer or wounds that worsened or increased in size. --Complaints of increased pain, discomfort or decreased mobility by a resident. --Signs of ulcer sepsis (a blood stream infection), presence of exudates (any fluid that has been forced out of the tissue or its capillaries because of inflammation (an immune response that causes redness and swelling of an area on the body or possibly tissue) within the body or injury, odors, or necrosis (relating to localized death of living cells as from interruption of blood supply or infection), if not already noted by the physician. --Resident refusing treatment. -Licensed nurse would document effectiveness of current treatment in the resident's medical record on a weekly basis. -Document notifications following a change in the resident's skin condition. -Update the resident's care plan as necessary. --NOTE: Nothing in the policy talked about documenting each treatment on the Treatment Administration Record (TAR). 1. Review of Resident #3's admission Minimum Data Set (MDS-A federally mandated assessment tool required to be completed by facility staff for care planning) dated 4/15/24 showed the resident: -Was severely cognitively impaired. -Had one Stage one (intact skin with non-blanchable (to press blood away and wait for return of blood) redness of a localized area usually over a boney prominence) pressure ulcer. -Had Coronary Artery Disease (narrowing of the coronary arteries due to buildup of plaque). -Had Peripheral Vascular Disease (inadequate flow of blood to the extremities). Review of the resident's Physician's Order sheet (POS) dated April 2024 showed: -Apply Zinc barrier cream (skin protection against urine and fecal matter, moisturizes and sooths reddened irritated skin) to his/her buttocks every shift and as needed (PRN), every morning and at bedtime for redness, started 4/7/24 and discontinued 4/17/24. -Apply Zinc barrier cream to his/her buttocks every shift and PRN, every shift for redness on buttocks, day, evening, & night, started 4/17/24 and discontinued 4/30/24. Review of the resident's TAR dated April 2024 showed: -Apply Zinc barrier cream to the resident's buttocks every shift and PRN, every morning and at bedtime for redness, started 4/7/24 and discontinued 4/17/24. --No documentation the treatment was completed by facility staff five out of 21 opportunities. -Apply Zinc barrier cream to the resident's buttocks every shift and PRN, every shift for redness on buttocks, day, evening, & night, started 4/17/24 and discontinued 4/30/24. --No documentation the treatment was completed by facility staff seven out of 36 opportunities. Review of the resident's Care Plan dated 4/5/24 showed the resident did not have a plan of care for his/her pressure ulcers. Review of the resident's Weekly Skin Observation dated 4/12/24 showed an area to his/her coccyx (tailbone), wound Stage I reddened area, treatment in place. Review of the resident's Weekly Skin Observation dated 4/16/24 showed an area to his/her coccyx wound Stage I reddened area, non-blanchable, painful. Review of the resident's Weekly Skin Observation dated 4/22/24 showed an area to his/her coccyx wound Stage I pressure ulcer, treatment in place. Review of the resident's Weekly Wound Observation Tool dated 4/29/24 showed: -His/her right buttock wound measured 2.2 centimeter (cm) x 2.3 cm x 0.2 cm, full thickness, date acquired 4/29/24, first observation, no reference, granulation (any soft pink fleshy projections that form during the healing process in a wound that does not heal by first intention) tissue present, serosanguinous drainage (a thin, watery fluid that is a combination of blood and serum, the clear, straw-colored part of blood), small amount, no odor. --Treatment was to cleanse with hypochlorous acid (fights common bacterial skin problems), apply Santyl (an ointment used for debridement (removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue) of a pressure ulcer) nickel thick to wound bed, apply calcium alginate (a gelatinous, water-insoluble substance that is used in wound dressing to absorb exudate and promote healing) to wound base, cover with bordered gauze (an absorptive dressing that consists of three layers, soft, and flexible, easy to conform to difficult wounds). Change daily and PRN (as needed). -His/her bottom of the left foot 3 cm x 2 cm, full thickness, date acquired 4/29/24, first observation, no reference, slough (nonviable yellow, tan, gray, green or brown tissue, usually moist, can be soft, stringy, and mucinous in texture) tissue present, serosanguinous drainage, moderate amount, greenish in color, no odor. --Treatment was to cleanse with hypochlorous acid, apply Santyl nickel thick to wound bed, apply calcium alginate to wound base, cover with bordered gauze. Change daily and PRN. Review of the resident's Hospital discharge date d 5/2/24 showed: -admitted into the hospital on 4/29/24 for local infection of wound. -Would and blood cultures obtained, positive for Staph aureus (a bacterial skin or soft tissue infection). -Intravenous (IV - injected into the veins) antibiotic started as well as inpatient wound care. -Consult on left heel stage III (a full thickness tissue loss, subcutaneous fat may be visible, but bone, tendons or muscle is not exposed) wound. -Consult on right buttock stage III wound. -Consult on left buttock stage II (partial thickness, loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (nonviable yellow, tan, gray, green or brown tissue, usually moist, can be soft, stringy, and mucinous in texture) wound. -Dressing changes daily and PRN if gets soiled or falls off. -Cleanse all wounds with normal saline, place Aquacel Ag (a sterile, absorbent, and antimicrobial wound dressing), cut to wound size on wound beds, cover with bordered foam (an island dressing consisting of a highly absorbent primary hydrophilic (water-loving) foam layer with a waterproof adhesive backing). -Consult wound care. -New order for Cephalexin (antibiotic) 500 milligram (mg) capsule, oral four times a day for five days for infection. Review of the resident's significant change MDS dated [DATE] showed the resident: -Was severely cognitively impaired. -Had two Stage II pressure ulcers and infections to skin. -Pressure reducing devices for the bed and chair. -Pressure ulcer care. -Had Coronary Artery Disease. -Had Peripheral Vascular Disease. Review of the resident's POS dated May 2024 showed to apply Zinc barrier cream to his/her buttocks every shift and PRN for redness, started 5/2/24 and discontinued 6/12/24. Review of the resident's TAR dated May 2024 showed: -Apply Zinc barrier cream to his/her buttocks every shift and PRN for redness, started 5/2/24 and discontinued 6/12/24. --No documentation the treatment was completed by staff eight out of 44 opportunities. -Cleanse the resident's open area with wound cleaner, apply Santyl nickel thick, apply calcium alginate, cover with Kerlix, change daily and PRN for wounds. --No documentation the treatment was completed by staff seven out of 15 opportunities. ---This treatment was ordered twice. Did not say what was to be treated. -Cleanse the resident's open area with wound cleaner, apply Santyl nickel thick, apply calcium alginate, cover with Kerlix, change daily and PRN for wounds. --No documentation the treatment was completed by staff seven out of 15 opportunities. ---Did not say what was to be treated. Review of the resident's Weekly Wound Observation Tool dated 5/8/24 showed: -Bottom of his/her left foot 2 cm x 1 cm x 0.2 cm, full thickness, date acquired 4/29/24, first observation, unchanged, slough tissue present serous drainage, small amount, and no odor. --Treatment to cleanse with hypochlorous acid, apply Santyl nickel thick to wound bed, apply calcium alginate to wound base, cover with bordered gauze. Change daily and PRN. Review of the resident's Weekly Skin Observation dated 5/13/24 showed: -Skin color normal. -Skin Temperature dry. -No Skin issues noted. Review of the facility Performance Improvement Plan dated July 2024 showed: -Identified Area for Assessed Improvement. --Wound Nurse A not signing off treatment orders as expected. --Wound Nurse A not completing documentation as expected. -Plan. --Current Wound Nurse A assigned a floor position, wound duties assigned to the Assistant Director of Nursing (ADON) or designee while position was being filled. --Wound Nurse position posted. --New Wound Nurse hired 9/28/24. --Regional Wound Nurse support added for enhanced oversight. -Action Steps to implement plan. --The DON or designee in-serviced licensed nurses on completion of treatments and documentation of treatments in the Medication Administration Record (MAR)/TAR. --DON or designee in-serviced ADON on position expectations and documentation expectations. --Twice weekly calls initiated with the facility nurse management and regional wound support and Regional Nurse Consultant to review wound processes for compliance. -Objective Measures to Evaluate. --Regional Wound Consultant would audit wound assessments and wound reports weekly. If concerns were identified, they would be corrected by the ADON, or designee and in-service would be provided. --DON or designee would review current wounds weekly in Risk to ensure physician notification was completed, treatment orders were in place, and treatments were completed as ordered. If any issues were identified, then education would be completed by the DON or designee. --Regional Nurse Consultant would pull weekly medication/treatment reports to send to the facility for review. -Person Responsible for Oversight. --DON or designee -To be completed in July 2024 and ongoing. During an interview on 10/8/24 at 10:47 A.M., Wound Nurse A said: -He/she completed all his/her treatments as ordered for the resident. -If busy he/she would forget to sign the TAR that the treatment was done. -He/she was educated on wound documentation and notification to family and physician if the resident refused the treatment. -He/she did not notify the physician if the resident refused a treatment occasionally. -He/she was no longer the Wound Nurse. -If the TAR was left blank it meant the treatment did not get done. During an interview on 10/8/24 at 11:01 A.M., the ADON said: -He/she had trained on wound documentation, wound reports, and wound care plans. -He/she was assisting with wound care for the residents. -He/she was auditing the MAR and TAR to make sure the nursing staff were signing when medications were given, and treatments were done. -If the MAR/TAR was not signed the process did not happen. During an interview on 10/8/24 at 2:28 P.M., the DON said: -Wound Nurse A had been educated several times about signing the TAR after a treatment was done but kept leaving blanks on the TAR. -Wound Nurse A was no longer the wound nurse. -A new wound nurse had been hired and was in training now. -He/she and the ADON were working on training the new Wound Nurse. -He/she was auditing the MARs/TARs to make sure they were being signed when medications were given, and treatments were done. This was ongoing. -Provided education to the nursing staff about documentation on wound care and notification to physician and family. -The charge nurses were completing the treatments along with him/her, the ADON and wound nurse in training, with assistance from the Regional Wound Consultant. -He/she and the ADON were doing the weekly wound assessments, measurements, and rounding with the outside wound care team. During an interview on 10/8/24 at 4:37 P.M., the Administrator said: -The facility had a new wound nurse due to Wound Nurse A no longer treating wounds and just working the floor effective 8/8/24. -The wounds were not healing like they should. -Wound Nurse A was on the floor all day doing treatments. -An audit was done in July and found that Wound Nurse A was not signing the TAR when the treatments were done. -Wound Nurse A was educated again about signing the TAR after the treatment were done and documenting if the physician had been called or if the resident refused the treatment. -In July 2024, A Performance Improvement Plan was put into place for Wound Nurse A not signing the TAR or documenting on the treatments as expected. -All nurses were educated on wounds on admission, following physician's orders, documentation on wounds, notifying the physician of refusal of treatments, ensure the MAR/TAR were signed off, wound care planning, wound reports, and wound documentation. During an interview on 10/9/24 at 10:13 A.M., the Physician said: -He/she would expect the licensed nurses to completed treatments as ordered for the residents. -He/she was not notified the resident was refusing treatments. -He/she should be notified if a resident was refusing treatments. -There was no outcome from the treatments not being done. -The resident was very sick and was on hospice (end of life care) due to a decline in health. MO00243272

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to have an Infection Preventionist, maintain proper use of Personal Protective Equipment (PPE) and adhere to isolation precautions during a COVID-19 (is an infectious disease caused by the SARS-CoV-2 virus) facility outbreak placing potentially all residents at risk for exposure. The facility census was 65 residents. Review of the facility COVID 19 Testing Infection Control Manual dated 5/16/23 showed: -Purpose: --To prevent COVID 19 from entering nursing homes, detect cases quickly, and stop transmission. -Policy: --The facility will test resident and facility staff, including individuals providing services under arrangement and volunteers for COVID 19 in accordance with the current guidelines required by state and federal oversight agencies. -An outbreak is defined as a new COVID 19 infection in any facility staff or any nursing home-onset COVID 19 infection in a resident. -Residents who were asymptomatic throughout their infection and are not moderate to severely immunocompromised should be isolated regardless of vaccination status until at least 10 days have passed since the date of their first positive viral test. -Upon identification of a resident, facility staff member, person providing services under arrangement or volunteer with symptoms consistent with COVID 19 or who test positive for COVID 19, the facility will take actions to prevent COVID 19. 1. During an interview on 4/2/24 at 10:40 A.M., the Administrator said the facility is currently experiencing a COVID outbreak. Observation and interview on 4/2/24 at 11:02 A.M. through 11:16 A.M. with Licensed Practical Nurse (LPN) A showed: -LPN A was wearing his/her mask with the top of the mask exposing his/her nose. -When asked about the position of his/her mask, he/she moved the mask over his/her nose for proper placement. Observation on 4/2/24 at 1:51 P.M., with Certified Medication Technician (CMT) A showed: -He. she was wearing an N95 with the top placed under his/her nose. -When asked about mask placement, CMT A moved the mask over his/her nose. -He/She stated the mask was then being worn correctly. Observation on 4/2/24 at 1:52 P.M. with Level 1 Medication Aide (L1MA) A showed: -He/she was sitting with a resident to his/her right on a couch in the common area and another resident to his/her left, neither resident was wearing a mask. -L1MA A was wearing his/her mask with the top of the mask positioned under his/her nose. -When asked about his/her mask placement, he/she repositioned the mask over his/her nose. Observation and interview on 4/2/24 at 2:56 P.M., with Certified Nursing Assistant (CNA) A showed: -He/she was walking through the common area with residents present and his/her mask was over not his/her nose and mouth -He/she adjusted his/her mask over his/her nose when asked about mask placement. -He/She said he/she was not wearing the mask correctly because he/she was not feeling well. During an interview on 4/2/24 at 2:00 P.M., the Administrator said the first positive COVID case was on 3/25/24. Observation and interview on 4/2/24 at 2:40 P.M., through 2:51 P.M. showed: -Multiple rooms (102, 108, 109, 207, 209, and 302) were posted for contact and droplet precautions with no PPE available at the entrance to the rooms. -At room [ROOM NUMBER] CNA A placed a personal drink with a straw with the clean PPE. -CNA A said he/she just returned from break and was carrying his/her drink when the resident in room [ROOM NUMBER] needed assistance. Observation on 4/2/24 at 2:54 P.M., showed: -CMT B was standing at the end of 300 hall with the top strap of his/her N95 mask tucked inside the mask. -He/She stated he/she was wearing the mask correctly. -When asked to verify if the top strap being tucked inside the mask was correct, he/she pulled the strap out of the mask and secured the mask correctly. During an interview on 4/2/24 at 3:09 P.M., the Director of Nurses (DON) said: -Staff was not supposed to have food or drinks in the resident areas. -The drink next to the clean PPE was potential for cross contamination. -He/She has educated staff on the increased risk for cross contamination related to personal drinks and food in resident areas. -Staff are to wear their N95 masks correctly. During an interview on 4/2/24 at 3:15 P.M., the Administrator said: -He/She expected staff to wear PPE correctly and wearing their mask under their noses was not appropriate. During an interview on 4/4/24 at 3:10 P.M., the Administrator said: -He/She had been performing the role of Infection Preventionist for about a week. -About a week ago the prior Infection Preventionist resigned the position immediately. -There was a plan to hire an Infection Preventionist within the next week. MO00234193

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that two sampled residents (Residents #6 and #8) out of 9 sampled residents, received their preferred items during their meals. The facility census was 62 residents. 1. Review of Resident #6's quarterly Minimum Data Set (MDS -a resident a federally mandated assessment tool completed by the facility for care planning), dated 8/23/23, showed: - The resident was cognitively intact. - A resident who was able to make himself/herself understood and understood others. - A resident who had no symptoms of swallowing disorders. During an interview on 10/30/23 at 11:08 A.M., the resident said: - He/She filled out a survey and selected his/her likes and dislikes. - He/She did not always get what they order on the ticket or what he/she selected. - On a past ticket dated 10/30/23, it was indicated that he/she had white bread as a dislike, but on that day, he/she received white toast, he/she did not get the yogurt she requested. - He/She requests yogurts daily but there are about two times in a week, he/she did not receive the yogurts. - On a past ticket dayed 10/26/23, he/she received a turkey sandwich which was made with white bread. 2. Review of Resident #8's quarterly MDS dated [DATE], showed: -The resident was moderately cognitively impaired. - The resident was able to make himself/herself understood and understood others. - The resident had no swallowing disorders. Observation on 10/30/23 at 1:15 P.M., showed the resident did not receive the lemonade which was circled on his/her ticket as an item the resident requested. During an interview on 10/30/23 at 2:23 P.M., Nurse's Aide (NA) A said it was his/her responsibility to ensure the residents receive the drinks they asked for. During an interview on 10/30/23 at 2:26 P.M., Certified Medication technician (CMT) A said sometimes residents do not get the drinks they asked for. During an interview on 10/30/23 at 2:34 P.M., the Director of Nursing (DON) said he/she expected the CNAs to follow what is on the ticket for each residents as far as those residents obtaining the drinks they asked for on those tickets. MO 00226545

Based on observation, interview and record review, the facility failed to follow the recipe for pureed (food that was made into a paste or thick liquid suspension that was usually made from cooked food that was ground finely) rice which resulted in a bland taste for the pureed rice and the facility failed to check the temperature of plates which contained pureed vegetables, pureed meat and pureed rice which were placed on the plates and the plates were not kept at a temperature of 120 ºF (degrees Fahrenheit) or greater. This practice potentially affected 4 residents who required pureed food out of 9 sampled residents. The facility census was 62 residents. 1. Review of the undated recipe for five servings of pureed rice showed: -2 ½ cups of rice. -2 Tablespoons (Tbsp) margarine. -1 ½ cups of water. -1 teaspoon (tsp) chicken base. Observation on 10/30/23 at 11:21 A.M., showed: -Dietary [NAME] (DC) A made the pureed rice with no recipe book open. -DC A poured an unmeasured amount of milk into the pureed mixture. DC A did not add margarine, or chicken bases mixed into the water to the mixture. Observation on 10/30/23 at 11:26 A.M. during a taste test showed the pureed rice tasted bland. During an interview on 10/30/23 at 11:34 A.M., after a taste test by DC A, he/she said the pureed rice did not taste good. During an interview on 10/30/23 at 1:42 P.M., DC A said: -He/she did not add chicken broth to the recipe. -He/she should have checked the menu. -He/she was used to only adding milk and margarine. -He/she would have to pay closer attention to the menu. During an interview on 10/30/23 at 1:48 P.M., the Dietary Manager (DM) said he/she absolutely expected the DCs to follow the recipe. Observation on 10/30/23 from 11:44 A.M. through 11:49 showed: - DC A placed pureed rice, pureed meat stew and pureed vegetables on divide plates for four residents. - He/she wrapped each plate with foil paper. - He/she placed the four plates in one of the wells of the steam table with two plates stacked on top of one another. Observation on 10/30/23 at 12:09 P.M. showed: -DC A was about to serve the plates of pureed food without checking the temperature. -The state surveyor asked to check the temperature of one of the pureed vegetables on one of the plates was 97 ºF. During an interview on 10/30/23 at 2:12 P.M., DC A said: -He/she was not able to place the plates of pureed food in the steam table well 20 minutes or more minutes ahead of time because the kitchen was understaffed during the lunch meal preparation. -The temperatures of the food items on the plates should have been checked before they were sent out to the residents. During an interview on 10/30/23 at 2:16 P.M., the DM said he/she absolutely expected dietary staff to check the temperature of pureed items. MO 00226545

Based on observation and interview, the facility failed to serve the lunch meal in a timely manner, according to the facility posted schedule. This practice potentially affected all residents. The facility census was 62 residents. 1. Observation on 10/30/23 at 10:46 A.M., of the posted meal times showed the lunch meal was to be served between 11:30 A.M. and 12:30 P.M. Observation on 10/30/23 during the lunch meal preparation showed: - At 11:21 A.M., Dietary [NAME] (DC) A made pureed (food that was made into a paste or thick liquid suspension that was usually made from cooked food that was ground finely) rice. - At 11:30 A.M. (the time that lunch should be served), DC A washed the food processor container to puree another item (vegetables). - At 11:50 A.M., DC A checked the temperature of the roast beef tips was 146.6 ºF (degrees Fahrenheit) and part of that dish had to go back into the oven because the rest of the roast beef dish was not at the proper temperature. - At 11:53 A.M., DC A began to serve the meals. - At 11:54 A.M., most of the roast beef tips was still in the oven, because the temperature of the roast beef tips was still between 120 ºF -140 ºF which was not hot enough according to recipe. - At 12:21 P.M., the temperature of the stew meat, was between 174 ºF-183 ºF, -At 12:29 P.M., the temperature temp of stew meat on the steam table was 170.6 ºF. During an interview on 10/30/23 at 11:52 A.M., DC A said: - The temperature the roast beef tips had to attain, was 155 ºF (degrees Fahrenheit) . - The cooking of the roast beef was running behind because the night shift on the previous day, did not place it in the refrigerator for defrosting. Observation on 10/30/23 at 12:53 P.M., showed Nurse's Aide (NA) A delivered the first tray that was delivered any resident on the 200 Hall. Observation on 10/30/23 at 1:11 P.M. showed the first tray was delivered to a resident on the 400 Hall. Review of Resident #8's quarterly Minimum Data Set (MDS -a resident a federally mandated assessment tool completed by the facility for care planning), dated 10/4/23, showed: -The resident had moderate cognitive impairment. -A resident who was able to make himself/herself understood and understood others. -A resident who had no symptoms of swallowing disorders. Observation on 10/30/23 at 1:14 P.M., showed the last room tray was delivered to the resident. During an interview on 10/30/23 at 1:16 P.M., the resident said the following: -If he/she ate in the dining room, he/she would have already receive his/her meal, he/she gets his/her meal within 30 minutes once the dining room doors open. -If he/she received a room tray, it is at least 30-45 minutes after the dining room doors open. -On that day, he/she received his/her meal 1.5 hours after the dining room doors opened. During an interview on 10/30/23 at 1:26 P.M., Licensed Practical Nurse (LPN) A said sometimes the meals come out later than that they came out on that day (10/30/23), and how late the meals are delivered from the kitchen, depended on who cooked that day. During an interview on 10/30/23 at 1:36 P.M., DC A said the food was served late because there was only one cook and the meat for the beef stew tips was not properly defrosted. During an interview on 10/30/23 at 1:47 P.M., the Dietary Manager (DM) said there were two people who did not show up for their shift on that day (10/30/23). MO 00226545

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide supporting documentation for the use of a resident monitoring system/bracelet (a bracelet securely attached to a resident that electronically notified the facility when the resident attempted to leave the ward or unit to which the resident was assigned) safety device to include changes in the resident's behavior or exit seeking behaviors for one sampled resident (Resident #35) out of 19 sampled residents. The facility census was 66 residents. Review of the facility's policy, dated October 24, 2022, titled Restraints showed: -The facility was to provide an environment that was restraint-free unless a restraint was necessary to treat a medical symptom, in which case the least restrictive measure was to be used. -A physical restraint was defined as any equipment attached or adjacent to the resident's body that the resident cannot easily remove and restricts freedom of movement. -The facility was to provide alternate methods of behavioral control and have it documented in the resident's medical record before a physical restraint was used. -Except for emergencies, a physical restraint was only to be used after the Interdisciplinary Team (IDT) had performed an assessment and attempted to alleviate all factors. -An assessment was to be completed by a licensed nurse prior to the application of any device that restricted movement and reassessed quarterly. -Before any restraint was used, a licensed nurse was to verify that informed consent had been obtained from the resident or their responsible party and that the resident or their responsible party had been educated on risks and benefits of use. -Any resident using a restraint was to have that reflected on their care plan, including the type of device, medical symptoms requiring the device, interventions that addressed the immediate medical symptom, and approaches for minimizing or eliminating the concerning behavior and restraint. -Staff were required to document in the resident's medical record a comprehensive assessment, a specific medical symptom, the rationale for the restraint, a signed consent form, a written physician's order, a plan for eliminating the restraint, and the resident's response to the application of the device. 1. Review of Resident #35's face sheet showed he/she was admitted [DATE]: -With a legal guardian/responsible party. -With a diagnoses of wandering. -With a diagnoses of unspecified Dementia (the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). Review of the resident's Wandering Risk Assessment, dated 5/3/23, showed: -The assessment was to be completed at admission, after 72 hours, one month later, and annually, and for resident's who scored at risk for wandering, the assessment was to be updated quarterly. -The resident had no history of wandering. -The resident could follow instructions. -The resident's score showed he/she was at risk for wandering. Review of the resident's admission Minimum Data Set (MDS-a federally mandated tool used for care planning) dated 5/16/23, showed staff documented: -The resident had a Brief Interview for Mental Status (BIMS) of three indicating the resident had severe cognitive impairment. -The resident had not exhibited any wandering behavior. Review of the resident's undated care plan showed: -Staff documented the resident was at risk for wandering and/or elopement (leaving the facility unsupervised when the resident is unable to adequately protect themselves). -Staff listed interventions as: assess for fall risk, redirect the resident, identify patterns of wandering, provide structured activities, and that a resident monitoring system/bracelet was placed on the resident's right lower leg and was to be checked for working order and placement daily. -No diagnoses noted as the reason for the resident monitoring system/bracelet. -No documentation regarding when the resident monitoring system/bracelet could be removed. Review of the resident's Order Summary Report, dated August 2023, showed the physician entered a one-time order for the resident monitoring system/bracelet to be placed on the resident's right leg due to wandering and exit seeking on 7/13/23. Observation on 8/6/23 at 2:15 P.M. showed the resident was wearing a resident monitoring system/bracelet. On 8/8/23 at 12:30 P.M., a written request was made to the Director of Nursing (DON) for all notes related to wandering and/or exit seeking and none were received at time of exit. During an interview on 8/9/23 at 9:05 A.M., the resident said he/she did not mind the bracelet on his/her leg. During an interview on 8/9/23 at 12:04 P.M., the Administrator said: -The facility did not have a specific policy on the use of resident monitoring system/bracelet. -Resident monitoring system/bracelets were placed on residents that were at risk of wandering and/or elopement per the Wandering Risk Assessment. -He/she expected documentation of exit seeking behaviors or wandering prior to a resident monitoring system/bracelet being placed. On 8/9/23 at 1:09 P.M., a written request was made to the Administrator for a signed consent for the resident's resident monitoring system/bracelet, elopement assessment after 5/4/23, and any notes related to wandering or exit seeking. None were received at time of exit. During an interview on 8/9/23 at 1:45 P.M., Registered Nurse (RN) A said: -He/she had never seen the resident attempt to leave the facility. -He/she was unsure why the resident had a resident monitoring system/bracelet. -He/she expected documentation in the resident's chart if the resident had displayed wandering or exit seeking behaviors. -The facility had not reassessed the resident to see if he/she still needed a resident monitoring system/bracelet. -He/she expected an assessment for wandering/exit seeking to be completed at least quarterly for any resident with a resident monitoring system/bracelet to ensure it was still necessary -He/she was unsure if the facility had received consent from the guardian prior to placing the resident monitoring system/bracelet. During an interview on 8/9/23 at 1:46 P.M., Certified Nursing Assistant (CNA) D said when the resident was first admitted , he/she would try to wheel himself/herself out of the facility. During an interview on 8/9/23 at 1:52 P.M., the resident's guardian said: -The facility placed the resident monitoring system/bracelet on the resident within the first few days of admission. -He/she believed the resident's wandering was because the resident was unsure of where his/her room was and just followed other residents around. -He/she did not believe the resident needed a resident monitoring system/bracelet. -The resident had told him/her upon admission that the facility was so big it was difficult to find the correct room. -He/she believed the facility thought the resident was exit seeking when the resident was actually just trying to find the correct room. -He/she was not notified the facility had placed a resident monitoring system/bracelet on the resident, nor did he/she give consent. -He/she had been to the facility to visit the resident when he/she saw the bracelet and asked staff what it was for and why the resident had it on. During an interview on 8/10/23 at 11:37 A.M., Agency CNA A said: -He/she was not sure why the resident had a resident monitoring system/bracelet. -He/she was not aware of any behavioral monitoring for the resident. During an interview on 8/10/23 at 12:52 P.M., Agency Certified Medication Technician (CMT) B said: -Staff had placed the resident monitoring system/bracelet on the resident because the resident was an elopement risk and was exit seeking. -He/she had never seen that behavior from the resident. -He/she knew the resident was frequently on the wrong hall looking for the correct room. -He/she believed the resident was easy to redirect. -He/she expected a note in the chart if the resident had ever shown exit seeking behavior. During an interview on 8/10/23 at 2:24 P.M., Licensed Practical Nurse (LPN) A said: -Staff were required to get a physician's order, update the care plan, notify the family, make sure the resident monitoring system/bracelet was functional, and then staff could place it on the resident. -Staff were to perform an assessment for elopement upon admission and quarterly, unless the resident had attempted to elope, in which case the facility was to perform another assessment immediately. -He/she believed staff monitored the resident for behaviors every shift. -He/she was aware the resident wandered sometimes and believed it was because he/she was confused. -He/she didn't believe the resident was exit seeking; he/she believed the resident got disoriented to which hall his/her room was in and would go up and down each hall looking for his/her room. -The resident was easy to redirect. -As the resident had a legal guardian, the guardian was required to consent to the resident monitoring system/bracelet. -He/she did not believe the resident needed a resident monitoring system/bracelet. -He/she didn't believe the resident would attempt to leave the facility and the only door that the resident monitoring system/bracelet locked was the front door. -He/she was unaware of the resident ever attempting to approach the front door. During an interview on 8/11/23 at 9:01, RN A said: -Upon admission, if a resident displayed confusion, wandering, or exit seeking, a resident monitoring system/bracelet was placed for 14 days. -After 14 days, staff were to reassess the resident to see if they had any exit seeking behaviors. -Any exit seeking or wandering behaviors were to be noted in the resident's electronic medical record. -He/she was unsure if a legal guardian was required to sign a consent. During an interview on 8/11/23 at 9:02, LPN B said the facility did not require legal guardians to sign a consent for a resident monitoring system/bracelet, they could verbally consent, but if verbal consent was given, the staff were required to put a note in the resident's chart stating such. During an interview on 8/11/23 at 11:11 A.M., the DON said: -Staff only placed resident monitoring system/bracelets on residents that were exit seeking, the facility did not place resident monitoring system/bracelet on every resident that wandered. -He/she remembered the resident trying to go out the front door but could not find any documentation of the event. -Staff were required to get consent for placement of a resident monitoring system/bracelet but he/she didn't believe the family were involved. -Staff were to ensure a consent form was signed by the family or, if a verbal consent was given, two staff members were to sign the consent to verify consent had been given over the phone. -Staff were to always ensure the family was aware and agreeable to the resident monitoring system/bracelet before it was placed. -Staff were to reassess the resident's elopement risk quarterly. -Wandering and exit seeking were not the same thing and he/she didn't believe a resident monitoring system/bracelet was necessary for wandering. -He/she believed the resident monitoring system/bracelet was appropriate for the resident because he/she had personally witnessed the resident attempt to leave out of the side doors and front door. -He/she was not sure any of the resident's behaviors had been documented.

Based on interview and record review, the facility failed to ensure the balance of resident funds were forwarded to two discharged residents (Residents #75 and #76) out of three discharged residents, reviewed for the business office processes, within five days of their discharge. The facility also failed to inform the new Business Office Manager (BOM) about the regulatory requirements which pertained to the Business Office procedures. The facility census was 66 residents. 1. Review of Resident #75's medical record showed: -The resident was discharged from the facility on 3/27/23. -The resident had $66.00 in his/her account the day he/she left the facility. During an interview on 8/7/23 at 2:36 P.M., the BOM said: -He/she took over the BOM duties in June 2023. -He/she had to close out a few accounts when he/she became the BOM. -Resident #75's account was one of the accounts he/she had to close out. -He/she sent Resident #75 the balance of his/her funds on 7/24/23 (119 days after the resident left the facility). 2. Review of Resident #76's medical record showed: -The resident was discharged to another facility on 6/22/23. -The resident had $13.00 in his/her account on the day of his/her discharge. During an interview on 8/7/23 at 2:47 P.M. the BOM said: -He/she forwarded the balance of Resident #76's funds to the resident on 7/24/23 (32 days after the resident left the facility). -He/she was unaware that the resident had a resident trust account until he/she started closing other discharged residents out. 3. During an interview on 8/7/23 at 3:21 P.M., the BOM said he/she was not aware of the five day requirement to send the remainder of the funds to discharged residents. During an interview on 8/8/23 at 9:25 A.M., about the kind of orientation, he/she received when he started as the BOM, the BOM said he/she was oriented in updating census, how to make deposits, how to withdraw money from the Resident Fund Management System (RFMS), and conducting admissions. During an interview on 8/9/23 at 2:05 P.M., the Administrator said the BOM did not receive some training in business office procedures that he/she should have received. During an interview on 8/9/23 at 2:10 P.M., the Regional Director of Clinical Services said the corporation could provide sufficient orientation by having employees train with someone within their department at another facility. During an interview on 8/10/23 at 2:27 P.M., the BOM said: -The previous BOM was the one that did the training for him/her. -He/she did not get a chance to go to another facility and train with a more experienced BOM. -No one from another facility within the corporation came to his/her facility for his/her training.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #44's face sheet showed he/she: -Had a diagnoses of Enterocolitis (inflammation of the small intestine and colon) due to Clostridium Difficile (C-diff) entered on 7/25/23. -NOTE: No diagnoses of Acinetobacter (a bacteria that can cause infection) was present. Review of the resident's hospital History and Physical, dated 7/2/23, showed the physician documented the resident had been diagnosed during his/her hospital stay with C. diff. Review of the resident's Quarterly MDS dated [DATE], showed the resident: -Had moderate cognitive impairment. -Was totally dependent on staff for transfers. -Required one person to assist with personal hygiene. -The resident was occasionally incontinent of bowel. -The resident had a MDRO (type not specified). Review of the resident's undated Care Plan showed staff documented the resident: -Required extensive assistance and/or was dependent on staff for personal hygiene. -Did not use the toilet and required extensive to total assistance with hygiene. Observation on 8/6/23 at 2:14 P.M. showed: -A sign on the resident's door indicating the resident was on EBP. -The sign indicated providers and staff were required to wear gloves and a gown when providing cares such as dressing, bathing, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, and wound care. -An isolation cart outside the door with PPE inside. -A biohazard trash bin inside the resident's door. During an interview on 8/6/23 at 2:15 P.M., RN B said: -The resident was on enhanced barrier precautions for C. diff. -The only people that needed to wear gowns or gloves were people providing cares to the resident. During an interview on 8/6/23 at 2:15 P.M., the resident said staff had not told him/her why he/she was on EBP. Observation on 8/7/23 at 1:38 P.M. showed: -Certified Nursing Assistant (CNA) L and CNA K entered the resident's room without any PPE, washed their hands, put on gloves, and transferred the resident. -CNA L, with gloved hands but no gown, removed the resident's brief that had yellow liquid stool present. -CNA L cleaned the resident's buttocks and removed the soiled brief from the resident. -CNA L then removed his/her gloves, and without hand hygiene, put on new gloves. -CNA L applied an ointment to the resident's buttocks, removed his/her gloves, sanitized his/her hands, and put on new gloves. -CNA L opened a new brief and placed it under the resident. -As CNA L rolled the resident, he/she found additional liquid stool on the resident's genitals which he/she cleaned with wipes. -CNA L removed his/her gloves, sanitized his/her hands, and put on new gloves. -CNA K applied an ointment to the resident's genitals, removed gloves, sanitized hands, and put on new gloves. -CNA L finished applying the resident's brief. -Note: All trash was placed in the resident's trash can and not the biohazard trash. -CNA K, with clean gloves, tied the trash bag, placed a new bag in the can, moved the mechanical lift, attached the sling, and transferred the resident back to his/her wheelchair. -CNA L removed the disposable pad from the resident's bed and moved the pad and trash to the doorway. -CNA K removed his/her gloves, CNA L removed his/her gloves and handed them to CNA K to place in trash, CNA L did not perform hand hygiene, and then CNA L placed the resident's wipes back into the resident's bedside table. -CNA K put on new gloves, without performing hand hygiene, and put a shirt on the resident. -CNA L, without gloves, removed the pad and trash from the resident's room. -CNA K, with gloved hands, put the resident's dirty laundry in the chair as requested by the resident. -CNA K removed his/her gloves, did not perform hand hygiene, picked up the dirty dishes in the room and grabbed the lift used to transfer the resident, and took them into the hallway. -CNA K, still without performing hand hygiene, began typing on the computer in the hallway. During an interview on 8/7/23 at 2:00 P.M., CNA K said: -He/she was not sure why the resident was on EBP. -He/she didn't think the resident was supposed to be on EBP anymore. -If the resident had still been on EBP, he/she and the other CNA would have had to wear gowns. -He/she had been told the resident was no longer on EBP. Observation on 8/7/23 at 2:19 P.M. showed the Maintenance Director and Maintenance Assistant entered the room without any PPE, removed the resident's linens from the bed, and began working on the resident's bed. During an interview on 8/7/23 at 2:24 P.M., LPN C said: -He/she believed the resident was still on EBP. -The last thing he/she was told was the resident had C. diff. -When changing a brief for a resident suspected of C. diff, staff were to wear gowns, gloves, and possibly goggles or a shield. During an interview on 8/7/23 at 2:25 P.M., the DON said: -The resident was not in isolation, he/she had been on EBP. -The resident was no longer on EBP. -The resident had C. diff a while back. -The resident was on EBP due to an infection in his/her wound. Observation on 8/9/23 at 9:10 A.M. showed: -Staff had not removed the isolation supply cart from in front of the resident's door. -Staff had not removed the sign on the door indicating the resident was on EBP. During an interview on 8/9/23 at 11:28 A.M., LPN D said: -The resident was on EBP due to his/her wound testing positive for Acinetobacter while the resident was hospitalized . -The wound had since closed so the resident no longer needed to be on EBP. -He/she was aware the resident had C. diff in the past but did not believe the resident currently had C. diff. -He/she was unsure why staff had not removed the EBP sign from the resident's door or removed the isolation cart from outside the door. During an interview on 8/9/23 at 3:28 P.M., the DON said: -The facility did not have any microbiology (the study of microorganism) results indicating the resident had a current infection. -He/she only had the discharge paperwork from the hospital which did not include any infection testing or results. During an interview on 8/10/23 at 10:52 A.M., CNA E said: -He/she knew what precautions to take with residents because he/she got a verbal report from the off-going shift at the start of his/her shift. -If there was a sign on the door that said PPE was required, all staff should wear the PPE. During an interview on 8/10/23 at 11:03 A.M., the MDS Coordinator said: -Any resident on EBP should have it in their care plan. -The care plan was to specify what type of precautions or isolation. -He/she was unaware the resident was on EBP. -He/she reviewed the resident's current and past care plans and could not find where any precautions had been listed for the resident. During an interview on 8/10/23 at 11:37 A.M., Certified Medication Technician (CMT) A said: -He/she knew the resident's needs based on the care plan. -He/she knew when a resident was on precautions or isolation because there would be a sign on the door and an isolation cart outside the door. -He/she didn't believe the resident had any sign on his/her door indicating staff were to follow enhanced barrier precautions. -He/she had asked the resident if they were on EBP and the resident didn't know. During an interview on 8/10/23 at 12:40 P.M., Agency CNA B said: -He/she knew a resident's needs based on the care plan. -He/she knew if a resident was on precautions or in isolation because there would be an isolation cart outside the door and a sign on the door. -He/she did whatever the sign specified to do and wore whatever PPE the sign said to wear. -Most of the time the CNA's didn't know why the residents were in isolation or on precautions, they just knew to be careful. During an interview on 8/10/23 at 12:52 P.M., LPN A said: -He/she believed staff only needed to know what type of precautions to take with residents in isolation or on precautions, it didn't matter if staff knew what the infectious agent was. -Staff knew what PPE to wear when caring for the residents because a sign was placed on the door of anyone on precautions. -If the sign on a resident's door said to wear a gown and gloves while changing a brief, he/she expected staff to do so. -Maintenance would be required to wear PPE also if they touched the resident's linens. -If he/she suspected a resident of having C. diff, he/she would have notified the doctor and instructed the staff to wash their hands instead of using sanitizer, and that would be documented in the resident's chart. -He/she believed the resident was on enhanced barrier precautions because of testing positive for C. diff at the hospital but he/she wasn't sure of the resident's current status. -He/she did not know why the resident was on EBP. -If an isolation cart and sign on the door were present, he/she would assume the resident was still on precautions. During an interview on 8/11/23 at 8:59 A.M., Agency CMT B said: -He/she did not know why the resident had been on precautions. -He/she did not believe the resident was still supposed to be on precautions and believed it was an error. During an interview on 8/11/23 at 9:01 A.M., RN A said: -Staff were told what residents were in isolation or on precautions through verbal report. -Staff were not told what diagnoses led to the precautions. -He/she expected staff to follow the directions on the precautions signs if one was present. -Maintenance staff were required to wear PPE if they touched the linens of a resident on EBP. -The resident was on precautions because he/she had C. diff. During an interview on 8/11/23 at 11:11, the DON said: -Staff were aware a resident was on precautions because there would be a sign on the door. -He/she knew the resident had an isolation cubby outside his/her room but did not know a precautions sign was on the door. -He/she expected staff to follow EBP for any resident that had a sign on their door, regardless if the resident was supposed to be on precautions or not. -Nurses were to know the reason for a resident being in isolation or on precautions. -Nurses knew the reason for isolation or precautions because it was in the care plan. -Maintenance workers should have worn a gown and gloves when touching the resident's linens per the sign on the door. -Care staff should have worn a gown and gloves when changing the resident's brief per the sign on the door. Based on observation, interview and record review, the facility failed to ensure wound treatment orders were complete on the physician's order sheet; to ensure the wound vacuum (wound vac a device that uses negative pressure to help heal wounds due to the negative pressure created by the wound vac pulls fluid and infection out of the wound, encouraging the wound to heal faster) was stored to prevent cross contamination; and to include care plan interventions for wound care for one sampled resident (Resident #175); and to effectively communicate and educate the reason for Enhanced Barrier Precautions (EBP-is an approach of targeted gown and glove use during high contact resident care activities, designed to reduce transmission of S. aureus and Multiple Drug Resistant Organism (MDRO) for one sampled resident (Resident #6) out of 19 sampled residents. The facility census was 66 residents. Review of the Center for Disease Control (CDC) web article, dated 7/27/22, titled Healthcare Associated Infections showed: -Enhanced barrier precautions involved wearing gloves and a gown during high contact resident cares when the resident was suspected of having a MDRO. -EBP may be applied (when Contact Precautions do not otherwise apply) to residents with any of the following: -Wounds or indwelling medical devices, regardless of MDRO colonization statu.s -Infection or colonization with an MDRO. Effective implementation of EBP requires staff training on the proper use of personal protective equipment (PPE) and the availability of PPE with hand hygiene products at the point of care -EBP were not appropriate for a resident with suspected or confirmed Clostridium difficile (C. diff-a bacteria that causes infection of the large intestine; this bacteria forms spores, which can withstand extreme conditions of starvation, acidity, temperature, and chemical disinfectants can kill the bacteria but not the spores). Review of the CDC web article, dated 10/25/22, titled C. diff showed: -Any resident suspected of C. diff was to be isolated immediately. -Staff were to wear a gown and gloves even during short visits. -Hand sanitizer did not kill C. diff. -It was important to wear gloves as handwashing alone might not be sufficient at eliminating all spores. Review of the facility's policy titled Infection Prevention and Control Program dated 10/24/23 showed: -The facility's Infection Control Preventionist (ICP) was responsible for collecting, analyzing, and providing infection data to the nursing staff and physician. -The ICP was responsible for educating and training staff on infection control practices. -The facility was to follow CDC guidelines for the type and duration of isolation. -The ICP was to recommend changes in isolation precautions as necessary. -The ICP was responsible for ensuring staff were knowledgeable about the appropriate Personal Protective Equipment (PPE) required for potentially infectious agents. -The facility was to identify individuals with possible communicable (transmitted from person to person) diseases or infections. -The charge nurse was responsible for notifying the physician of suspected infections and determining if testing or special precautions were needed. -The licensed nurse was to document the identified problem and interventions on the resident's care plan. A copy of the facility's C. diff policy was requested and not received at time of exit. 1. Review of Resident #175's Face Sheet showed he/she was admitted on [DATE], with diagnoses that include: -Local infection of the skin and subcutaneous tissue. -Anxiety disorder (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome). -Heart disease. -Morbid obesity. -Lymphedema (a build-up of lymph fluid in the fatty tissues just under your skin) and cellulitis (a common bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin). Review of the resident's Initial Wound assessment dated [DATE], showed the resident had a trauma wound to his/her left upper thigh measuring 17 centimeters (cm) length by 24 cm width by 0.1 cm depth. The wound was full thickness without exposed support, small exudate (fluid that leaks out of a wound), serous drainage (clear to yellow fluid), amber in color, with 67 to 100 percent necrotic (tissue that is dead or not viable) tissue, with adherent slough (necrotic tissue that needs to be removed so healing can take place). Review of the resident's Physician Order Sheet (POS) dated 6/6/26, showed physician's orders to cleanse his/her wound with saline, apply Santyl (collagenase) is an enzyme used to help the healing of burns, skin wounds, and skin ulcers) to wound bed, cover the wound with gauze, change daily, change as needed and/or with saturation. Start doxycycline (an antibiotic) 100 milligrams (mg) for 14 days. Review of the resident's Weekly Skin Assessments showed: -On 6/3/23, the wound measured 17 cm length by 24 cm width by 0.1cm depth. No additional description was documented. -On 6/13/23, the wound measured 15 cm length by 20 cm width by 0.1 cm depth, with small amount of exudate, serous drainage, and slough on 67 to 100 percent necrotic tissue. Review of the resident's Nursing Notes showed the resident was hospitalized on [DATE], and readmitted on [DATE]. He/She was hospitalized again on 7/30/23 and readmitted to the facility on [DATE]. Review of the resident's admission Minimum Data Set (MDS a federally mandated assessment tool to be completed by facility staff for care planning) dated 8/3/23, showed the resident: -Needed extensive to total assistance with bed mobility, transfers, bathing, toileting and was incontinent of bowel and bladder. -Had a surgical wound, received surgical wound care and the appliance of non-surgical dressings/appliances. Review of the resident's Care Plan dated 8/3/23 showed there was no documentation showing the resident was at risk for developing wounds, had a history of wound/wound treatment, had and was being treated for a current wound, skin irritations or trauma to the skin. There were no interventions showing the resident had a wound vac and how that was to be administered to the resident and monitored. Review of the resident's POS dated 8/2023, showed physician's orders for: -Wound vac to be changed every day shift every Tuesday, Friday, and Sunday (ordered on 7/28/2023). -Check that the wound vac was charging every night shift (ordered 7/28/2023). -Check that the wound vac was set at 125 every day and night shift (ordered 7/28/2023). -Weekly Skin assessment on Friday. -Arginaid Oral Packet (Nutritional Supplements) give 1 packet by mouth two times a day for wound healing dissolve in 4-6 ounces (oz) preferred liquid (ordered 7/28/2023). -NOTE: There were no orders showing the instructions for applying the wound vac to include prepping the skin or what to place on the wound before applying the wound vac. Review of the resident's Physician's Note dated 8/3/2023, showed the physician completed a physical exam of the resident and reviewed his/her medical record. He/she documented the resident was being seen as a new skilled nursing facility admission for recent hospitalization for weakness and left leg pain. The physician documented the resident had a recent hospitalization that revealed the resident had a left lower extremity infection. It showed the resident was re-admitted to the hospital due to worsening of his/her left leg wound. General surgery was consulted and the resident underwent debridement (removing dead or unhealthy tissue from a wound) and wound vacuum placement. The resident was also given antibiotics before being released to the facility for rehabilitation. The physician documented the plan was to continue wound care and antibiotic until 8/13/23. Review of the resident's Wound Note dated 8/3/23 showed the resident was readmitted to the facility. The Wound Care Nurse and Director of Nursing (DON) applied the wound vac to the resident and it was set at 125. The wound base had 75 percent new, beefy, red tissue and 25 percent slough tissue. The surrounding skin had minimal redness, was dry and intact. Observation and interview on 8/6/23 at 4:30 P.M., showed the resident was laying in his/her bed with a hospital gown on. The resident was laying on a low air loss mattress and his/her call light was within reach. The resident's wound vac was on and running and was sitting on the floor, uncovered, at the side of his/her bed but it was not within reach of the resident. It was set on 125. The resident was alert and oriented and said that the nurse was to change his/her wound vac three times weekly on Monday, Wednesday and Friday. Observation of the wound area showed the wound vac was attached to a tubing that went to the resident's upper left thigh. There was a flat green dressing on the wound with a clear adhesive over the top, that also covered and secured the tubing. The dressing was dated 8/3/23. Observation and interview on 8/7/23 at 9:19 A.M., showed the resident was laying on the low air loss mattress. His/her wound vac machine was in a black privacy bag and was sitting on the tray table beside his/her bed. The resident said that the nurse changed his/her dressing and wound vac last night. Observation of the resident's dressing showed it was covering the wound and had a clear adhesive over it that secured the dressing and wound vac tubing. The dressing was dated 8/6/23. The resident said the nurse placed the wound vac machine on the tray table inside of the privacy bag and that was where it was always placed, except yesterday when it was on the floor. Observation and interview on 8/8/23 at 3:15 P.M., showed Licensed Practical Nurse (LPN) D, also the Wound Care Nurse and the Wound Care Consultant went into the resident's room to provide wound care to the resident. The resident was sitting up in his/her bed, on a low air loss mattress. The wound vac machine was sitting on top of his/her mattress at the foot of his/her bed and was set on 125. LPN D gathered his/her supplies off of the treatment cart and brought them into the resident's room placing the bleach wipe container on the vanity and piling the supplies on top of it. He/She washed his/her hands, gloved, then wiped down the resident's tray table, took 8x8 sheets and placed them on the tray table then placed his/her supplies on top of it. The Wound Care Consultant washed his/her hands and gloved and went to look at the resident's wound vac. He/she said depending on how much slough the resident's wound showed would determine whether to place the wound vac back on. The Wound Consultant said he/she had not seen the resident's wound since the resident came back from the hospital where the wound was debrided. The following occurred: -LPN D removed his/her gloves, washed his/her hands, re-gloved then began removing the resident's adhesive and dressing using saline and a 4x4 to moisten the skin. -He/she then discarded the dressing, removed his/her gloves, washed his/her hands re-gloved then cleaned the skin around the wound with saline and a 4x4. -LPN D discarded the soiled dressing and gauze, then de-gloved, washed his/her hands, re-gloved, placed skin prep (An antimicrobial skin cleanser)on the resident's skin around the wound, de-gloved, washed his/her hands, gloved then opened a sterile testing container and swabbed the wound, placed the swab into the container and sealed it. -LPN D then discarded his/her gloves, gave a bag with the clean wound vac canister and tubing to the Wound Care Consultant, then washed his/her hands, gloved, took a bleach wipe and wiped off a pair of scissors, de-gloved, sanitized his/her hands, re-gloved then cut the adhesive and placed it on the resident's skin around the wound. -LPN D de-gloved, sanitized his/her hands, re-gloved, then cut a thick black sponge in the shape of the wound bed and placed it on the resident's wound. -The Wound Care Nurse washed his/her hands, gloved and held the sponge in place while LPN D placed adhesive over the sponge. The Wound Care Nurse then de-gloved and washed his/her hands. -LPN D removed the wound vac tubing and wound vac canister from the sterile packaging. He/she placed the tubing on top of the sponge and secured it with adhesive tape. -LPN D then connected the wound vac canister to the wound vac machine and connected the tube to the canister. He/She turned the wound vac machine on and ensured the wound vac was working properly and the seal on the wound was secure and suctioning. -LPN D then de-gloved and washed his/her hands. He/she gloved and removed all of the supplies from the resident's room then cleaned the tray table and bagged all of the discarded materials. He/she de-gloved and sanitized his/her hands before leaving the resident's room. -Observation of the wound showed beefy, red skin with only small amount of white slough. The wound size was around the size of a 4x4 picture. -The Wound Care Consultant said the resident's wound looked very good and was healing well so they could continue using the wound vac. -LPN D said the resident had gone to the hospital twice for wound debridement and the second time the resident went into the hospital, he/she was discharged to his/her home and then came back into the facility on 8/3/23. During an interview on 8/11/23 at 9:35 A.M., Registered Nurse (RN) said: -Wound care orders should be documented on the resident's POS. -The DON and the Assistant Director of Nursing (ADON) usually check the physician's orders to ensure that they are transcribed onto the POS and that they are correct and complete upon admission and readmissions. -The DON and ADON also check the orders to ensure they are correctly transcribed month to month. -The nurses would transcribe any new orders that come in during the month to the POS. -The resident had orders for the wound vac but they were not specific to show any skin treatments to his/her thigh wound other than to show the wound vac should be placed, the settings and how often it should be checked. -The wound vac should not be on the floor. It was usually sitting on the resident's tray table. During an interview on 8/11/23 at 9:50 A.M., LPN D, also the Wound Care Nurse said: -The orders for the resident's wound vac were on the POS and showed the setting, monitoring and frequency which was sufficient. -When he/she performed the resident's wound vac change, he/she put skin prep on the skin around the wound and he/she took a culture of the wound that was sent in to the wound care doctor. He/she said they only have to do this every few months, not with every change in the wound vac. During an interview on 8/11/23 at 11:24 A.M., with the DON and Corporate Regional Nurse, the DON said: -There should be physician's orders and or guidelines that include step by step instructions for providing the care for the resident's wound. It should include the type of dressing used, any skin prep that was put on the resident, and step by step instructions on the process because they had many different nurses who change the resident's wound vac on the weekend and they all need to follow the same treatment. -The Corporate Nurse said there should be an as needed (PRN) wound vac order and a prn order for what they are to do if the wound vac was not functioning with step by step instructions of what they were to do and what supplies were needed. -Both said the wound vac treatment should be documented in the resident's care plan. The DON said the resident previously was being treated for the wound before he/she received the wound vac and that should have been in the resident's care plan. -The DON said the wound vac machine should not be on the floor. It should be placed so that it does not prevent suctioning or kinking of the tubing. Because it was a closed system there was no potential for contamination. -The Corporate Nurse said that there was an infection control issue and a dignity issue with leaving the wound vac uncovered on the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to obtain wound treatment orders to the resident's heel and apply physician ordered treatment for one sampled resident (Resident #56) who was readmitted to the facility with open areas to his/her buttock out of 19 sampled residents. The facility census was 66 residents. 1. Review of Resident #56's Face Sheet showed he/she was admitted on [DATE], with diagnoses including urinary tract infection, muscle weakness, pain, heart failure, low iron, high blood pressure, arthritis, edema (fluid in the tissues), fall history, and pressure sores (areas of damage to your skin and the tissue underneath from prolonged pressure on the skin). Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 5/1/23, showed the resident: -Needed extensive assistance with bed mobility, transfers, bathing, toileting and was incontinent of bowel and bladder. -Was at risk for developing pressure sores and was admitted with an unhealed pressure sore. -Received pressure sore interventions. Review of the resident's Care Plan updated 7/19/23, showed the resident had skin integrity impairment. Interventions showed: -Staff was to encourage good nutrition and hydration in order to promote healthier skin. -Keep the resident's skin clean and dry. Use lotion on dry skin. -Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection and report to the physician. -Provide a pressure relieving cushion to protect the resident's skin while up in a chair. -Provide treatment per physician's orders. -Complete weekly treatment documentation. Review of the resident's Pressure Sore Risk assessment dated [DATE] showed the resident was at moderate risk for wound development. Review of the resident's Nursing Notes showed the resident was discharged to the hospital on 7/26/23 and was re-admitted to the facility on [DATE]. Review of the resident's Weekly Skin Observation dated 8/6/23 showed the resident was admitted on [DATE]. His/Her skin color was normal, skin temperature was dry and skin turgor (pliability) was normal as skin returned promptly. Skin issues showed the resident was admitted with: -An open area to the left buttock: 6.0 centimeter (cm) length by 6.0 cm width (no depth documented and no further description of the wound was documented). -An open area to the right buttock: 5.0 cm length by 6.0 cm width (no depth documented and no further description of the wound was documented). -Left heel: 1.5 cm length by 1.0 cm width (no depth or further description of the area was documented). Review of the resident's Physician's Order Sheet (POS) dated 8/2023 showed physician's orders for: -Nystatin ointment 10000 units, apply topically to buttocks every day shift for wound healing (ordered 8/7/23). -Health shakes twice daily at lunch and dinner two times a day for wound healing 8/7/23 -ProStat 30 milliliters (ml) two times a day for wound healing 8/7/23 -Wound care specialist to evaluate and treat as indicated 8/7/23 -Low Air Loss mattress settings at 200 pounds with alternating every 15 minutes. Monitor for mattress integrity every shift. -There was no physician's orders that addressed the treatment to the resident's left heel. Review of the resident's Medical Record did not show the facility notified the physician for treatment orders for the resident's wound on his/her heel. Observation and interview on 8/7/23 at 9:29 A.M., showed the resident was sitting in his/her wheelchair, in his/her room. He/she said he/she was in pain from sitting on his/her bottom and wanted to lay down. Certified Nursing Assistant (CNA) F and CNA A washed their hands and put on gloves. The following occurred: -CNA A and CNA F transferred the resident to his/her bed and began to complete incontinence care. -CNA F pulled several wipes from the container to begin cleaning the resident's bowel movement with one wipe one swipe. -After cleaning the resident CNA F did not apply any cream or treatment to the resident's bottom. CNA F and CNA A assisted with putting the resident's clean brief on. During an interview on 8/7/23 at 9:29 A.M.: -CNA A said that the resident had been in the hospital for over a week and he/she thought the resident had developed a wound while there. CNA A said the resident just came back to the facility yesterday. -CNA F said while cleaning the resident, he/she observed an open area on the resident's bottom that needed to be addressed by the nurse and that there was no dressing on the open area prior to them cleaning him/her. -Both CNA A and CNA F said they were not aware that the resident had any open areas on his/her bottom and did not know if the Charge Nurse or the Wound Care Nurse knew about the resident's open areas. They said they were not aware of any ordered treatments to the area. During an interview on 8/11/23 at 9:35 A.M., Registered Nurse (RN) A said: -Wound care orders should be on the resident's POS and should be followed. -The resident was re-admitted with orders for Nystatin cream to his/her buttocks. -He/She did not notice any orders for the resident's heel. -He/She saw that the resident had open areas on his/her buttocks and heel upon re-admission in the weekly skin assessment notes. -He/She had not seen the resident's buttocks or heel because usually the Wound Care Nurse assessed all wounds. During an interview on 8/11/23 at 9:50 A.M., the Wound Care Nurse said: -The resident went to the hospital and came back with wounds to his/her buttocks that were open. -He/she assessed the resident's wounds upon his/her return to the facility and documented them in his/her notes on the Weekly Skin Assessment. -The resident had an order for Nystatin cream to his/her buttocks for wounds daily and as needed. -He/she did not see a treatment order for the resident's heel. -The physician's orders were what the resident was sent back from the hospital. -To his/her knowledge, nursing staff was applying the treatment as ordered. During an interview on 8/11/23 at 11:24 A.M., the Director of Nursing (DON) said: -The resident was re-admitted with a diagnosis of moisture associated skin damage (MASD) with superficial dermal loss and the treatment order was for Nystatin cream. -He/She expected nursing staff to follow treatment orders. -The Wound Care Nurse had assessed the resident upon re-admission but he/she was not sure if the wound care consultant had seen the resident yet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #10's Face Sheet showed he/she had the following diagnoses: -Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses). -Anxiety (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus). Review of the resident's comprehensive care plan dated 9/19/2022 showed: -He/she would remain safe while in his/her wheelchair and not slip or fall out of his/her wheelchair. -He/she required assistance of two staff members with transfers and care of the resident. Observation on 8/8/23 at 3:55 P.M., of the resident's care and transfer showed: -Agency Certified Nursing Assistant (CNA) N and Agency CNA L provided the resident mechanical lift transfer after his/her care. -Agency CNA N and Agency CNA L transferred the resident to his/her specialized wheelchair, but did not secure the brakes on the resident's wheelchair prior to lowering the resident into the chair. -Agency CNA L was standing behind the wheelchair as Agency CNA N lowered the resident into his/her wheelchair. -The resident wheelchair had moved some as CNA L was holding onto the back of the wheelchair. During an interview on 8/6/23 at 5:06 P.M. Agency CNA L said: -The resident's wheelchair should be locked during the transfer for the resident. -He/she had safe transfer training through his/her staffing agency. During an interview on 8/11/23 at 8:16 A.M., CNA A said he/she had education on safe transfers to include two person transfers with lifts and to ensure the resident's wheelchair were locked prior to transfer. During an interview on 8/11/23 at 8:43 A.M., CNA C said he/she would ensure safe transfer of the resident would include the residents wheelchair was locked during the resident transfer. During an interview on 8/11/23 at 8:49 A.M., Licensed Practical Nurse (LPN) B said he/she would expect to the resident's wheelchair to be locked during resident transfer. During an interview on 8/11/23 at 11:15 A.M., DON and Regional Nurse Consultant said: -The facility administration training and skilled transfer safety check off at least yearly for the facility care staff. -He/she would expect the care staff to ensure the resident wheelchair was locked prior to transferring of the resident. Based on observation, interview and record review, the facility failed to accurately complete a comprehensive fall investigation that included root cause and preventive interventions; to accurately document the resident's fall status on the Minimum Data Set (MDS, a federally mandated assessment tool to be completed by facility staff for care planning); to update the resident's care plan to show the preventive interventions after the fall for one sampled resident (Resident #53); and to ensure a safe mechanical lift transfer by not ensuring wheelchair brakes were locked for one sampled resident (Resident #10) out of 19 sampled residents. The facility census was 66 residents. Review of the facility's Fall policy and procedure dated 10/24/22, showed: -Following each resident fall, the licensed nurse will complete an incident report and perform a post fall assessment and investigation. -Following each resident fall, the Interdisciplinary Team (IDT) Falls Committee will review the post fall assessment within 72 hours or as soon a practicable. Based on the falls assessment and investigation the IDT Committee will review fall prevention interventions and modify the plan of care as indicated. Review of the facility's Transfer policy and procedure dated 10/24/22, showed: -To promote the safe movement of a resident from one surface to another. -Prepare any equipment and the environment including locking the residents wheelchair and bed wheels. 1. Review of Resident #53's Face Sheet showed he/she was initially admitted to the facility on [DATE] with diagnoses including dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), heart disease, diabetes (a disease in which the body ' s ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), pain and incontinence. Review of the resident's admission MDS dated [DATE], showed the resident: -Had significant cognitive incapacity and memory loss. -Needed limited assistance with transfers, supervision with mobility and had no limited range of motion in his/her upper or lower extremities. -Did not have a fall history and did not have any falls since admission to the facility and used no assistive devices. Review of the resident's Fall Risk assessment dated [DATE], showed the resident was at high risk for falls due to a history of falls, inability to stand without assistance, requires hands on assistance moving from surface to surface, occasional incontinence, taking medications that predispose falls. Review of the resident's Care Plan dated 6/27/23, showed the resident was at risk for falls. Interventions showed the nursing staff would: -Anticipate and meet the resident's needs as needed. -Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. -Ensure that The resident is wearing appropriate footwear when ambulating or mobilizing in his/her wheelchair. -Ensure the resident's call light is within reach and encourage the resident to use it for assistance as needed. -Follow rehabilitation orders. -Resident used a wheelchair for mobility. Review of the resident's Nursing Notes showed on 7/20/23 showed the resident was in his/her room at 8:00 P.M., and transferred himself/herself to bed and fell from his/her wheelchair onto his/her buttocks, with no injury noted. The nurse assessed the resident and he/she had no injuries to his/her hip, arm or any other joint or bones. The resident was able to answer all questions. The nurse notified the resident's physician and family and documented his/her vital signs (blood pressure, pulse, respirations, temperature and oxygen level). Review of the resident's Fall Investigation dated 7/20/23, showed: -The resident was in his/her room and at 8:00 P.M. transferred himself/herself to the bed, fell from his/her wheelchair onto his/her buttocks with no injury noted. -The fall was unwitnessed. -The nurse assessed the resident and found no injuries. He/she documented the resident's vital signs that were within normal limits. -The nurse notified the physician and family with no new orders. -The nurse educated the resident on requesting assistance prior to trying to transfer. -The fall Investigation Report did not show how staff found the resident or whether the resident reported the fall to them, the resident's mental status at the time of his/her fall, his/her mobility and or transfer status prior to the fall, when the last time nursing staff had seen the resident prior to his/her fall, any predisposing environmental factors or situational factors that impacted the fall, any fall interventions that were in place or should have been in place prior to his/her fall or the reason the staff think the resident fell and how they were going to prevent additional falls from the resident's wheelchair. Record review of the resident's quarterly MDS dated [DATE] showed the resident: -Was alert with significant cognitive incapacity and memory loss. -Needed supervision with transfers, mobility and could walk only with staff assistance and used no assistive devices. -Had no falls prior to or since admission, and had no recent surgeries. Review of the resident's Physician's Order Sheet (POS) dated 8/2023, showed physician's orders for: -Therapy orders: Skilled physical therapy services 5 times weekly for 4 weeks to include therapeutic exercises, therapeutic activities, neuromuscular feed, group therapy and gait training (ordered 7/31/23). -Therapy orders- Skilled occupational therapy services 5 times weekly for 4 weeks for therapeutic activity (movements that are typically performed to prevent loss of range of motion), therapeutic exercise (movement prescribed to correct impairments, restore muscular and skeletal function), Activities of Daily Living (ADL), group therapy (the treatment of multiple patients at once by one or more healthcare providers), Electrical Stimulation (e-stim treatments can decrease pain and inflammation), diathermy (the production of heat in a part of the body by high-frequency electric currents, to stimulate the circulation, relieve pain) ultrasound (an imaging test that uses sound waves to make pictures of organs, tissues, and other structures inside your body), and wheelchair management (ordered 7/31/23). Review of the resident's Care Plan showed the care plan was not updated to show the resident had an actual fall on 7/20/23 while transferring from his/her wheelchair to his/her bed and there were no updated interventions showing how the facility was going to continue to prevent further falls. Record review of the resident's Physician's Note dated 8/1/23 showed the physician completed a physical exam of the resident and re viewed his/her medications, labs and medical record. The physician documented: -The resident has a past medical history of dementia, hypertension, diabetes, hyperlipidemia, edema (swelling in the tissues) who admitted to the hospital after he/she sustained a fall that she was found to have a left hip fracture. He/She underwent a hip repair and then was re-admitted to the facility on [DATE] for rehabilitation. -He/She saw the resident and upon examination, the resident's left hip incision was healing well. The resident continued to have bilateral extremity edema. -The plan was to continue rehabilitation to stabilize his/her gait, balance, transfers, maximize activities of daily living (bathing, dressing, hygiene, transfers, mobility, toileting) and minimize falls. Medications Continued. Plan of Care was discussed with the resident. Observation on 8/8/23 at 9:20 A.M., showed the resident was sitting in his/her room in his/her wheelchair, dressed for the weather. He/she had severe swelling in both of his/her legs and was wearing compression stockings with anti-slip socks over them. He/she was hard of hearing and said he/she was doing okay. He/she did not seem to remember falling on 7/20/23. Observation on 8/8/23 at 1:30 P.M., showed the resident was sitting in his/her wheelchair in the therapy room doing physical therapy exercises. He/she had just finished leg exercises and was starting to work on arm strengthening exercises. He/she was actively participating. During an interview on 8/11/23 at 9:35 A.M., Registered Nurse (RN) A said: -The nurses were responsible for documenting the fall investigations when a resident falls. -They document their assessment of the fall or how they found the resident, what happened, what the resident says happened if they are able to tell them, what the environment looked like, how they found the resident, the nurse assessment and any actions they took at the time. They also notify the physician and follow any physician's orders and notify the responsible party. He/she said all of this information should have been in the resident's nursing notes. -The nursing notes are transferred onto the investigation report. -The fall investigation report should include any contributing factors to the fall, any interventions that were in place at the time and any new interventions that were implemented. He/She also tried to document the possible cause of the fall. -The fall investigation should be comprehensive. -The resident's care plan should show the resident's fall and the interventions that were implemented afterward. During an interview on 8/11/23 at 11:24 A.M., the Director of Nursing (DON) said: -He/she expected the nurse to document in the nursing notes what occurred, who was there, what the nursing staff did, who was notified, all details of the fall should be documented. -The nursing note was transferred onto the investigation/incident report and prompts the nurse to fill in additional information regarding the incident (any precipitating factors, environmental factors). -He/she expected the nursing note and the investigation report to be comprehensive. -After the investigation was completed, the interdisciplinary team would review the fall and determine why the resident fell and what interventions they would need to implement to try to prevent further falls. -The MDS Coordinator was responsible for the resident's MDS and the care plans (comprehensive and updating). -The interdisciplinary team discussed the resident's in morning meetings and if they determined any new or additional interventions, the MDS Coordinator would update the care plan at that time. -The interventions should be updated onto the care plan. -Nursing staff was able to put in immediate interventions as the resident's health care status changed in an emergency and were generally able to update the resident's care plans. -He/she has in-serviced nurses on how to document in the nursing notes and on the fall report.

Based on observation, interview and record review, the facility failed to obtain a physician's order for self-administration of catheter (a thin, flexible catheter used especially to drain urine from the bladder by way of the urethra) care; to assess the resident's ability and capacity for self-care of his/her catheter; and to update the care plan for one sampled resident (Resident #69), out of 19 sampled residents. The facility census was 66 residents. Review of the facility's Catheter policy and procedure dated 10/24/22, showed each resident who was incontinent of urine was identified, assessed and provided appropriate treatment and services to achieve or maintain as much normal urinary function as possible; a resident with or without a catheter, received the appropriate care and services to prevent infections to the extent possible. Regarding daily care it showed: -Wash hands and glove prior to handling the catheter, drainage system or bag. -Check the perineum (the tiny patch of sensitive skin between your genitals and anus) and urinary meatus (external orifice of the urethra, from which urine is ejected during urination) for any signs of irritation, swelling or abnormal drainage. -Remove the leg strap and inspect the skin for signs and symptoms of adhesive burns, redness, tenderness, blisters or open skin areas. -Cleanse the perineum and meatus with soap and water after each bowel movement or incontinent episode. -Cleanse the perineum from front to back and cleanse the outside of the catheter wiping away from the meatus. -Remove gloves and wash hands. -Collection bag-take care to ensure the collection bag never touches the ground at any time. -Collection bags should always be kept below the bladder. -The collection bag should be emptied when it is 3/4 full using a separate, clean container. -When emptying the collection bag, the drainage spout and the non-sterile collection container should never come in contact. 1. Review of Resident #69's Face Sheet showed he/she was admitted to the facility with diagnoses that included: -Neurogenic bladder (to lack bladder control due to a brain, spinal cord or nerve problem). -Iron deficiency. -Stroke history. -Urinary tract infection (common infections that happen when bacteria, often from the skin or rectum, enter the urethra) history. -Diabetes. -Muscle weakness. Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 7/21/23, showed the resident: -Was alert and oriented with minimal confusion. -Needed supervision with bathing dressing bed mobility, transfers and needed limited assistance with toileting. -Was continent of bowel and had an indwelling catheter. Review of the resident's Care Plan dated 7/28/23, showed the resident had a catheter and interventions showed staff would: -Administer medications as ordered. -Change the resident's catheter as needed. -The resident had a 16 French (FR a measure of the outer diameter of a catheter), 30 cubic centimeter (cc) catheter. Position catheter bag and tubing below the level of the bladder and use a bag cover. -Check the catheter tubing for kinks each shift and each time the resident was repositioned. -Maintain a closed drainage system. -Apply moisture-barrier cream after incontinence care as needed. -Monitor for signs and symptoms of discomfort on urination and frequency. -Monitor the resident's skin for redness/open areas with cares and notify charge nurse when observed. -NOTE: The care plan did not show the resident had been trained to complete his/her own catheter care to include emptying the catheter bag or using proper infection control practices when completing self-catheter care. It did not show the extent to what the resident was capable of performing. Review of the resident's Physician's Order Sheet (POS) dated 8/2023, showed physician's orders for: -Catheter Diagnosis: neurogenic bladder. -Catheter 16 FR, 30 cc Balloon. Change as needed (ordered 7/14/23). -Ensure the catheter securement device was in place (ordered 7/24/23). -Change catheter bag as needed for system failure (ordered 7/14/23). -Provide catheter care every shift and as needed (ordered 7/14/23). -NOTE: There were no physician's orders showing the resident could perform self-care related to his/her catheter and the limitations to that care. Review of the resident's Medical Record showed there was no documentation showing the facility had assessed the resident's ability and capacity for providing care of his/her catheter to include cleaning the catheter tubing and emptying the catheter bag in a sanitary manner and using proper infection control procedures. Observation on 8/6/23 at 4:38 P.M., showed the resident was sitting in a wheelchair in the day area, playing a game with peers. He/She was dressed for the weather. The resident's catheter was not observed (it was covered by the resident's pants). Observation and interview on 8/8/23 at 1:35 P.M., showed the resident was sitting in his/her wheelchair in his/her room sorting clothes. Observation showed the resident's leg bag had about 300 cc's of light yellow, clear urine in the bag without any sediment. The resident said: -He/She had been living in the facility for about 6 to 7 weeks. -He/She did most of his/her own care. -He/She entered the facility with a catheter with a leg bag, but he/she was supposed to see the doctor for a follow up appointment and was going to ask if he/she could have it removed. -Currently the nursing staff just check the amount of urine in his/her leg bag, but he/she usually emptied it himself/herself. -He/She emptied his/her catheter bag at least three times daily. -He/She also cleaned the catheter tubing himself/herself. -Most of the nursing staff did not assist with his/her catheter at all but the nursing aide working did check it. -He/she would empty the catheter bag into the toilet when it was about 800 cc full. During an interview on 8/8/23 at 1:57 P.M., Certified Nursing Assistant (CNA) G said: -When he/she was working with the resident, he/she emptied the resident's leg bag, cleaned down the catheter tubing and cleaned the opening of the catheter bag after emptying it. -He/She checked the resident's leg bag periodically during his/her shift to see how full it was. -He/She did not think that other nursing staff emptied the resident's catheter bag and provided catheter care every shift. -The resident said he/she provided self-care regarding his/her catheter most of the time. -He/She did not know if there was a physician's order for the resident to empty his/her own catheter bag but the resident did empty it and has told him/her that he/she did so regularly. During an interview on 8/11/23 at 9:25 A.M., CNA A said: -He/She usually checked the resident's catheter to ensure it was not overfull during his/her shift. -He/She assisted the resident to empty the catheter bag and provided care assistance when the resident requested assistance. -The resident was very independent and normally the resident emptied his/her own catheter bag. -He/She did not know if there was a physician's order for the resident to empty his/her own catheter bag or do his/her own catheter care. During an interview on 8/11/23 at 9:38 A.M., Registered Nurse (RN) A said: -The nursing staff were supposed to empty the resident's catheter bag and complete catheter care on the resident. -The resident did not have a physician's order for self-care of his/her catheter. -To his/her knowledge, the resident did not have an assessment for his/her ability to care for his/her catheter. -The resident was very independent and he/she had heard that he/she would not allow staff to empty his/her catheter bag. -He/she was not aware that the resident was emptying his/her own catheter bag and completing his/her own catheter care. -If the resident was completing his/her own catheter care, it should be documented somewhere in the resident's medical record and care planned. During an interview on 08/11/23 at 11:24 A.M., the Director of Nursing (DON) said: -The nursing staff were supposed to empty the resident's catheter bag and clean the tubing during care. -The resident was independent with taking himself/herself to the bathroom so he/she was not surprised if the resident emptied his/her own catheter bag or completed his/her own catheter care. -They had not completed an assessment to ensure the resident was able to perform self-care of his/her catheter or use the correct infection control practices during care. -They did not have a physician's order for the resident to perform catheter self-care. -The MDS Coordinator was responsible for updating the care plans. -Care plans should be comprehensive and reflect the health status of the resident. -They go over resident information/updates during morning meeting and then he/she would notify the MDS Coordinator of any necessary changes for any of the residents and the MDS Coordinator updated the care plan accordingly. -Nursing staff was able to put in immediate interventions as the resident's health care status changed in an emergency and were generally able to update the resident's care plans.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure weight loss was reviewed, dietary recommendations were put into place, the physician was notified of weight loss, and the care plan was accurate and reflected the resident's current health status for two sampled residents (Resident #6 and #39); the facility failed to provide alternative meal menu to bed bound residents and ensure to monitor food preference for one sampled resident (Resident #39) who was at risk for weight loss and diabetic ketoacidosis coma (a serious condition that can lead to diabetic coma or even death) out of 19 sampled residents. The facility census was 66 residents. Review of the facility's policy, titled Assessment and Management of Resident Weights dated October 22, 2022, showed: -Staff were to obtain weights upon admission and readmission, weekly for four weeks, then monthly. -Staff were able to weigh residents more frequently at the discretion of the licensed nurse or Interdisciplinary Team (IDT). -Staff were to immediately reweigh any resident whose weight had changed by five pounds and have a licensed nurse verify the weight. -Staff were to review significant weight changes. -Staff were to report the weight change in the medical record, notify the physician and dietitian, and document in the nurse's notes. -The Registered Dietitian (RD) was to complete a nutritional assessment on all residents with a significant weight change, and document the assessment and weight management recommendations in the medical record. -A licensed nurse was to notify the physician of the RD's recommendations and notify the family of the weight change. -If the physician does not want to use the RD's recommendations they were to document the rationale in the medical record. -Staff were to weigh residents with a significant weight change at least weekly. -The IDT were to update the resident's care plan to reflect individualized goals and approaches for managing the weight change. 1. Review of Resident #6's face sheet showed he/she was admitted with the following diagnoses: -Morbid Obesity (100 pounds or more over ideal body weight). -Dysphagia (difficulty swallowing). -Dehydration (not enough water). Review of the resident's weight history showed his/her weights were: -178.4 pounds on 3/3/23. -155.6 pounds on 4/13/23. -170.2 pounds on 5/1/23. -160.6 pounds on 6/21/23. -151.0 pounds on 7/4/23. -146.8 pounds on 8/1/23. -A 21.5% weight loss from 3/3/23 to 8/1/23. Review of the resident's undated care plan showed: -He/she was at risk for nutritional problems. -Staff were to provide and serve dietary supplements as ordered. -The RD was to evaluate and make diet change recommendations as needed. Review of the Consultant Dietitian Report dated 4/14/23 showed the RD did not address the resident during his/her visit. Review of the RD progress note, dated 4/17/23, showed the/she recommended: -Weekly weights for four weeks or until the resident's weight had stabilized. -The resident was to start on house supplements (dietary supplement) twice a day to aid in weight stabilization. Review of the Consultant Dietitian Report dated 5/5/23 showed the RD did not address the resident during his/her visit. Review of the Consultant Dietitian Report dated 5/18/23 showed the RD did not address the resident during his/her visit. Review of the Consultant Dietitian Report dated 6/22/23 showed the RD did not address the resident during his/her visit. Review of the Consultant Dietitian Report dated 7/12/23 showed the RD did not address the resident during his/her visit. Review of the Consultant Dietitian Report dated 7/24/23 showed the RD did not address the resident during his/her visit. Review of the resident's Medication Review Report, dated 8/9/23, showed: -The physician had ordered weekly weights on 8/3/23. -The physician ordered a diet for pureed (smooth, crushed, or blended) food on 7/31/23. -There was no order for dietary supplements. During an interview on 8/9/23 at 10:09 A.M., Certified Nursing Assistant (CNA) C said: -He/she believed the resident was weighed once a month. -Staff weighed the resident in his/her wheelchair and then subtracted the wheelchair weight from the obtained weight so the weight might not always be correct. -He/she had already weighed the resident this month. During an interview on 8/9/23 at 10:47 A.M., Registered Nurse (RN) A said: -He/she was unaware of the resident ever getting a dietary supplement. -He/she was unable to find any order, current or discontinued, in the resident's chart for a dietary supplement. -He/she was not aware the resident had a significant weight loss. -He/she did not believe the resident's weight was accurate. -He/she believed the wheelchair weight was subtracted incorrectly. -If he/she was made aware of a significant weight change, he/she expected staff to reweigh the resident and call the physician. -He/she did not know who the RD was for the facility. During an interview on 8/9/23 at 12:19 P.M., the RD said: -The resident had triggered for weight loss this month but he/she had not seen the resident yet. -The resident had not triggered for weight loss last month (July 2023). -When he/she started at the facility in June, he/she had requested a report of weights and the Director of Nursing (DON) told him/her to do it themselves. -He/she never received a list of residents who had weight loss. -He/she had started pulling reports in August and had just seen the resident had weight loss. -The resident had not been on any of his/her previous reports as needing a dietary assessment. -He/she expected any resident with weight loss to be evaluated for their ability to eat, if a diet texture change needed to be made, if the resident's cognitive ability had changed, the resident's ability to feed themselves or need for feeding assistance, swallowing issues, and potential for a speech therapy evaluation. -For residents with weight loss, he/she would expect an order for protein pudding (pudding that contains additional protein) or a dietary supplement, and weekly weights. -He/she expected the RD recommendations to be followed unless the physician disagreed, which was to be noted in the resident's chart. -He/she expected the RD recommendations to be put in place within days of the recommendation being made. During an interview on 8/9/23 at 1:29 P.M., Licensed Practical Nurse (LPN) B said: -He/she was not aware of the resident's weight loss. -He/she expected the RD to make recommendations when there was weight loss. -He/she expected the RD recommendations to be implemented with a few days. During an interview on 8/9/23 at 1:32 P.M., CNA D said: -The resident was usually weighed once a month. -Staff weighed the resident three times in the month of June 2023. -The resident's order said to be weighed monthly. -He/she had noted the resident had lost weight and told the nurses and Administrator. -Staff weighed the resident in his/her wheelchair and the wheelchair had not changed so all the weights were accurate. -He/she would weigh the resident weekly if there was an order to do so. -He/she expected the RD recommendations to be implemented at least a couple weeks after the recommendations had been made. During an interview on 8/10/23 at 11:03 A.M., the Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) Coordinator said: -He/she was responsible for ensuring care plans were accurate. -Care plans were to be comprehensive and reflect he resident's current health status. -He/she updated care plans daily. -Staff were to update care plans when a new problem arose or when the current interventions were not working. During an interview on 8/10/23 at 11:37 A.M., Agency Certified Medication Technician (CMT) A said: -He/she knew the needs of each resident by reviewing the care plans. -He/she expected care plans to be accurate. During an interview on 8/10/23 at 12:40 P.M., Agency CNA B said: -He/she expected the care plan to be accurate and be up to date so staff knew the residents' needs. -He/she did not know how to access care plans at the facility so he/she worked off verbal report from the off-going shift. During an interview on 8/10/23 at 2:24 P.M., LPN A said staff were to update care plans any time there was a change to the resident or a new order had been entered. During an interview on 8/11/23 at 11:08 A.M., Nurse Practitioner (NP) A said: -He/she expected to be notified if a resident had significant weight loss. -He/she expected new interventions to be implemented on the resident's care plan and the resident placed on a dietary supplement when weight loss was noted. -He/she had started at the facility 7/4/23 and had not received any RD recommendations to date. -He/she was not aware the resident had lost weight. During an interview on 8/11/23 at 11:11 A.M., the DON said: -The MDS Coordinator was primarily responsible for updating care plans. -The IDT went over changes during their morning meeting and the MDS Coordinator was to update the care plans with that information. -He/she believed the facility should allow nurses to update the care plans also but at that time they could not. -He/she was aware Resident #6 had significant weight loss. -He/she wasn't satisfied with how weights were obtained so the facility started weighing all residents weekly in April 2023. -He/she expected weekly weights if the RD recommended it. -He/she was still working with the CNA that weighed residents to ensure accuracy of weights obtained. -Staff weighed each wheelchair separately so they knew what weight to subtract from the obtained weight. -He/she met with the CNA that weighed the residents weekly to ask if any residents had weight loss. -He/she expected the empty wheelchair to be reweighed if the resident's weight was significantly different from the previous reading, to ensure the wheelchair weight was accurate. -He/she had not received a recommendation from the RD for Resident #6 and he/she did not read the RD's notes in the computer system. -He/she expected the RD's recommendation form and RD's notes in the computer system to match. 2. Review of Resident #39's Face Sheet showed he/he/she was admitted to the facility with the following diagnoses: -Edema (swelling, extra fluid). -Cellulitis (an infection of deep skin tissue), -Type two Diabetes Mellitus (the body either doesn't produce enough insulin, or it resists insulin) with ketoacidosis coma. -Chronic Kidney Disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should). Review of the resident's Physician's Order Sheet (POS) diet order dated 3/29/23 at 4:49 P.M. showed: -The physician ordered the resident a regular diet, Regular texture, thin consistency diet. -No physician order for a specialized diet. Review of the resident's admission weight on 3/30/23 at 4:16 P.M., was 161.4 pounds (lbs). Review of the resident's admission MDS dated [DATE] showed: -The resident was able to make his/her needs known. -Had BIMS of 12 out 15 and was moderately cognitively impaired. -Weight was 161 pounds. -Required assistance of facility staff for setup of meals. Review of the resident's undated care plan showed: -The resident was on a liberalized regular diet (relaxes restrictions of therapeutic diets, allowing individuals to eat a regular diet that includes foods they enjoy). -Dietary consult to determine preferred foods on admission and reviewed quarterly. -Monitor and document the resident's food intake and fluid intake at each meal. Notify the charge nurse if changes occur. -Monitor for low and high blood sugars. Review of the resident's Dietary Profile dated 5/3/23 showed: -The resident was on a regular diet. -The resident liked almond milk. -He/she disliked broccoli, nuts, peels, seeds, and milk. -The resident had allergies to shellfish. Review of resident's weight showed: -On 6/6/23 the resident's weight was 152 pounds. -On 7/12/23 the resident's weight was 144.2 pounds. --NOTE: which was a weight loss of 5.40 % in 30 days. Review of the resident's RD Progress note dated 6/26/23 at 4:56 P.M. showed: -The RD had written a progress note related to the resident's significant intentional weight loss of 10% in 90 days. -The resident was admitted with generalized edema, cellulitis, and Type two diabetes with ketoacidosis coma. -He/she was on a regular diet and with regular textures foods. -The resident was allergic to shellfish. -The resident had a shown a good meal intake and ate more than 75% of his/her meals. -The resident's wore dentures, and had natural teeth. No issue with chewing food and no swallowing issues. -The resident's weight variance of negative weight loss of 1.5% in 30 days, a negative weight loss of 10.7% in 90 days from admission. -The resident's anticipated weight loss was due to his/her physician ordered diuretic therapy (medication used to reduce fluid build-up in the body). -The resident's medications were reviewed and included two diuretic medications. -Nutritional triggers: the resident had significant intentional weight loss in 90 days. -The resident was at risk for altered nutrition due to his/her type two diabetes, chronic constipation, and diuretic therapy. -The resident's goals included maintaining a stable weight, and maintaining a meal intake of an average of 75%, adequate hydration, safe swallowing, and controlled blood sugar levels. Review of resident's nursing note dated 6/28/23 at 12:51 P.M., showed: -The resident was offered hotdogs for lunch as he/she did not like what was being offered. -Staff took his/her hotdogs and resident said he/she did not want them. -Staff replied, Are you saying you don't want this food I brought you? Resident replied, No. not until later. -The facility staff had no offered the resident any other alternative food item or returned later with a new meal. Review of resident's Physician's Progress Note dated 7/4/23 at 2:22 P.M., showed: -The resident was seen in his/her room. The resident's appetite was stable and he/she was wheelchair-bound. -The resident's allergies include shellfish. -Plan for the resident was to place on weight loss risk monitoring and to have the resident on weekly weights and to provide a health shake. -No physician order documented for the resident health shakes. Review of the resident's Dietary Profile dated 7/7/23 showed: -The resident was on a regular diet. -He/she was on nutritional supplement prior to admission. -He/she was a diabetic and needed a no added sugars diet. -The resident ate around 50-75% of his/her meals. -He/she liked boiled eggs and had no dislikes documented. Review of the resident's Quarterly MDS dated [DATE] showed: -The resident was able to make his/her needs known. -Had BIMS of 13 out 15 and was moderately cognitively impaired. -Weight was 145 pounds. -Had no indication of weight loss documented. -Received fluid reducing medication for seven days during look back period. -Required supervision and assistance of facility staff for setup of meals. Review of the resident's care plan meeting note dated 7/26/23 at 4:01 P.M. showed: -Care plan meeting was held with resident's friend via phone -The resident weights or diet preferences were not documented as discussed during the care plan meeting. Review of the resident's POS dated 8/23 showed: -The resident had a physician's order for weekly weights dated 8/3/23. -The resident did not have a physician order for a restricted diet. -The resident did not have a physician order for a nutritional supplement or a health shake. During an interview on 8/6/23 at 4:20 P.M., the resident said: -He/she had complained the food served was tasteless. -He/she thought he/she was to be on a restricted diet of 1400 calorie, diabetic diet. -He/she ate all meals in his/her room and felt that he/she was getting smaller portions on their room trays then dining room meals trays. -He/she felt the kitchen staff were not getting the training required for providing nutritional meals. -He/she was not sure if he/she had been seen by the RD since being admitted to the facility. -He/she was not sure if had discussed his/her request for a specialized diabetic diet with dietary staff. During an interview on 8/7/23 at 9:29 A.M., the resident said: -He/she found out the RD does visit the facility monthly. -The resident had not seen or spoken with RD related to his/her diet preference or related to his/her specialized diet request. -The resident had to send his/her meal tray back to kitchen almost every meal due to not getting the food he/she could eat or had requested. Observation on 8/7/23 at 12:37 P.M., of the resident's in-room meal tray showed: -He/she had a bowl of applesauce and a bowl of cottage cheese. -He/she had requested macaroni salad with egg and did not receive. (Not listed as an alternative menu). -He/she was not allergic to the tuna patty that was the main meat for that day, but he/she felt the facility did not rinse the tuna before they made the food and would not eat the tuna at the facility. -The facility had noodles offered, but the resident said that he/she did not like that type of noodle the facility had offered, said was more of a preference of the resident. During an interview on 8/7/23 at 12:46 P.M., the Dietary Manager said: -The resident did not really have food allergies was more of food preferences and dislikes. -The resident could not explain allergic reactions, just did not like them. -The resident tended to request items that were not listed on the menu for that day or not on the Always Available menu. Review of the resident's menu meal ticket dated 8/7/23 showed: -The resident was on a regular diet, no restricted caloric intake noted. -He/she was allergic to peanuts and shellfish. Observation on 8/9/23 at 8:47 A.M., of the resident's breakfast meal tray showed: -The resident had cold cereal, milk, sausage patty, and drinks. -He/she ate about 80% of his/her meal. -The resident had syrup on the plate but said he/she did not get a pancake. -Unknown CNA had requested a pancake for the resident and dietary staff said they did not have any more pancakes. -The resident was not offered an alternative for the missing pancakes. During an interview on 8/9/23 at 9:22 A.M., Social Services Designee (SSD) said: -He/she would visit weekly with the resident to see how he/she was doing and would interact with the resident to address any social services needs including diet needs. -The resident's diet choice would change often. -The resident had been told about the alternative menu but he/she was not sure if the resident had received a copy. -He/she thought the facility administration had discussed the resident food choices. Review of the facility undated Always Available Menu on 8/9/23 at 9:40 A.M. showed: -The menu was posted on the menu board in the main dining room. -Cold cut sandwich, grilled cheese sandwich, fried egg sandwich, hotdog on a bun, hamburger on a bun, soup of the day with crackers, side salad with dressing, applesauce, cottage cheese, hard boiled eggs, potato chips, and pudding cups. During an interview on 8/9/23 at 9:45 A.M., Dietary Manager said: -The facility just revised the resident's Always Available Menu. -The Always Available Menu should be posted in the resident's room, dining rooms and on bulletin board around the resident living area. -Activities staff would be responsible for handing out or posting the Always Available Menu to those residents that were bed bound or ate in their rooms. -He/she was not aware if the resident had a copy of the old menu. -He/she had not provided an updated copy to the resident. During an interview on 8/9/23 at 10:12 A.M., the resident said: -He/she had not seen or been provided a copy of an Always Available Menu. -Observation of the resident's room did find copy of the Always Available Menu posted or at his/her bedside. During an interview on 8/9/23 at 12:40 P.M., Registered Nurse (RN) A and LPN B said: -Review if the resident's record does not have physician order and have not seen notes repeated to require for health shake. -The weight completed by RA and documented in the weights and vitals in the resident electronic record. -The resident's weight were not reviewed by the nursing staff. -RA may notified either the DON or the charge nurse any resident's weight concerns. -The resident was particular related to his/her food choices. He/she did not like the food at the facility and was not use to the Midwest diet or food. During an interview on 8/9/23 at 12:56 P.M., Agency CMT A said he/she was not aware the resident was to receive a health shake on diet sheet. During an interview on 8/11/23 at 8:16 A.M., CNA A said: -The resident liked almond milk and was to have a diabetic regular diet. -He/she would provide the resident with alternative meal choices if the resident did not like the food provided. During an interview on 8/11/23 at 11:15 A.M., DON and RN C said: -The resident was able to get foods from the resident Always Available Menu and had been seen by RD. -The resident had a history of weight loss and gain related to excess fluid. -The resident was on fluid pills to help reduce fluid build-up. -The resident was very picky with his/her food preferences. -The resident would often change his/her food preferences. -The DON was not aware of the resident having a physician order or RD recommendation for a health shake or a nutritional supplement. -The DON or Assistant Director of Nursing (ADON) would be responsible for ensuring dietary preferences and requests were addressed by the resident's physician, RD and with dietary staff. -The Dietary Manager, Medical Records staff and Housekeeping supervisor were cross covering the responsibility in completing the new resident admission dietary assessment. -The RD would fill out the recommendation and then the DON or ADON would be responsible for notifying the resident's physician of any diet changes or recommendation. -The facility had started completing weekly weights on all residents, due to inaccurate weights and number of resident's with weight loss. -The DON had been meeting with the restorative aid weekly to monitor resident's weights and discuss any weight loss or gains.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to properly store and replace the oxygen nasal cannula/tubing (used to deliver oxygen through the resident's nose) and nebulizer mask/tubing (used for aerosol breathing treatments) and humidifiers (adds water to the oxygen to prevent dryness, used for resident comfort) in a manner to prevent the spread of infection for one sampled resident (Resident #6) and two supplemental residents (Resident #34 and #63) out of 19 sampled residents and 10 supplemental residents. The facility census was 66 residents. Review of the facility's policy, titled Oxygen Administration dated 10/24/22, showed all oxygen tubing, humidifiers, masks, and nasal cannulas used to deliver oxygen: -Were to be changed weekly. -Were to be stored in a plastic bag to protect the equipment from dust and dirt when not in use. Review of the facility's policy, titled Medication Administration Nebulizers dated 1/2023, showed: -The nebulizer mask was to be rinsed and disinfected per the manufacturer's instructions. -Once the nebulizer mask was dry, it was to be stored in a plastic bag with the resident's name and date. 1. Review of Resident #6's Quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 7/7/23 showed: -The resident had severe cognitive impairment. -The resident received oxygen therapy. -The resident was totally dependent on staff for transfers and hygiene. -The resident required extensive assistance from staff for bed mobility and dressing. Review of the resident's Licensed Nurse's Medication Administration Record (MAR), dated August 2023, showed staff documented the oxygen tubing, humidifier, and plastic bag was changed on 8/5/23. Observation on 8/6/23 at 2:15 P.M. showed the resident's oxygen concentrator (a device that concentrates the oxygen from the surrounding air) had an undated humidifier and a plastic bag attached dated 6/16/23. Review of the resident's Medication Review Report, dated 8/9/23, showed the physician entered an order for oxygen via nasal cannula continuously to keep blood oxygen levels greater than 90%. Observation on 8/9/23 at 9:35 A.M. showed the resident was wearing his/her nasal cannula, which was attached to the oxygen concentrator, with an undated, empty humidifier. Observation on 8/9/23 at 9:38 A.M. showed a staff member filled the resident's undated humidifier and did not date it. Observation on 8/10/23 at 9:32 A.M. showed the humidifier on the resident's oxygen concentrator remained undated. Observation on 8/10/23 at 1:20 P.M. showed: -The resident's empty wheelchair had an oxygen tank on the back with a nasal cannula attached. -The nasal cannula was wrapped around the handle of the wheelchair was not bagged Observation on 8/11/23 at 8:52 A.M. showed the humidifier on the resident's oxygen concentrator remained undated. 2. Review of Resident #34's Annual MDS, dated [DATE], showed: -The resident had severe cognitive impairment. -The resident received oxygen therapy. -The resident required extensive assistance from staff for transfers, bed mobility, dressing, and hygiene. Review of the resident's Licensed Nurse's MAR, dated August 2023, showed staff documented the resident had received oxygen 8/1/23 to 8/9/23. Observation on 8/6/23 at 2:15 P.M. showed: -A plastic bag for storing the nasal cannula attached to the oxygen concentrator. -The nasal cannula attached to the oxygen concentrator was stuck in the handle of the concentrator (not in the bag). Observation on 8/7/23 at 8:46 A.M. showed: -An oxygen concentrator in the resident's room with a bag for storage attached dated 6/16/23. -The nasal cannula attached to the oxygen concentrator was under a pillow on the resident's chair, uncovered. Observation on 8/8/23 at 9:04 A.M. showed: -The oxygen concentrator had an undated humidifier. -A plastic bag attached to the oxygen concentrator, dated 6/16/23, contained a nasal cannula. Observation on 8/9/23 at 9:01 A.M. showed: -The nasal cannula attached to the resident's oxygen concentrator was on the floor. -The oxygen concentrator's humidifier was dated 7/21/23. -The plastic bag attached to the oxygen concentrator to store the supplies was dated 6/16/23. During an interview on 8/9/23 at 9:02 A.M., the resident said: -A Certified Nursing Assistant (CNA) had helped him/her out of bed that morning. -He/she had used oxygen the past few weeks because he/she hadn't felt well. -The CNA had made his/her bed this morning. Observation on 8/9/23 at 9:15 A.M. showed: -CNA G entered the resident's room, assisted the resident, and left the room. -The oxygen concentrator and nasal cannula had been moved closer to the resident. -The nasal cannula attached to the oxygen concentrator was lying on the resident's bedside table uncovered. Observation on 8/10/23 at 9:10 A.M. showed: -The nasal cannula, attached to the oxygen concentrator, was lying directly on the floor. -The plastic bag attached to the oxygen concentrator was dated 6/16/23. 3. Review of Resident #63's Quarterly MDS, dated [DATE], showed the resident had moderate cognitive impairment. Review of the resident's Licensed Nurse's MAR, dated August 2023, showed staff administered Formoterol Fumarate Suspension 0.5 milligrams (mg)/2 milliliters (ml) via nebulizer two times a day from 8/3/23 to 8/9/23. Observation on 8/6/23 at 2:15 P.M. showed: -The resident was resting in bed with his/her eyes closed. -A nebulizer mouthpiece was uncovered and sticking out of the resident's bedside drawer. Observation on 8/8/23 at 9:07 A.M. showed a nebulizer mouthpiece was uncovered and sticking out of the resident's bedside drawer. Observation on 8/9/23 at 9:12 A.M. showed a nebulizer mouthpiece stuck in the handle of the machine, uncovered. Observation on 8/10/23 at 9:22 A.M. showed: -A nebulizer mouthpiece stuck in the handle of the machine, uncovered. -Registered Nurse (RN) B attempted to give the resident his/her nebulizer treatment and the resident refused; he/she did not replace or cover the nebulizer mouth piece. Observation on 8/11/23 at 8:53 A.M. showed a nebulizer mouthpiece was hanging out of the resident's bedside drawer, uncovered. 4. During an interview on 8/10/23 at 11:37 A.M., Agency Certified Medication Technician (CMT) A said: -If reusable oxygen supplies were not bagged, he/she would replace it. -Humidifiers were to be dated. -If a humidifier wasn't dated, he/she wouldn't know how old the water was and it would need replaced. During an interview on 8/10/23 at 12:40 P.M., Agency CNA B said: -Reusable oxygen supplies were to be placed in a bag when not in use. -Staff were not to hang the nasal cannula on the oxygen concentrator or oxygen tank because that was not sanitary. During an interview on 8/10/23 at 2:24 P.M., Licensed Practical Nurse (LPN) A said: -Reusable oxygen supplies were to be replaced weekly. -Nasal cannulas and nebulizer mouthpieces were to be stored in a bag so they remained clean. -Staff were to replace any oxygen supplies not found in a bag to ensure the equipment was not contaminated. -Humidifiers were required to be dated and changed weekly. During an interview on 8/11/23 at 11:11 A.M., the Director of Nursing (DON said: -Any reusable oxygen equipment was to be stored in a plastic bag when not in use. -He/she expected staff to throw away any oxygen equipment they found not stored properly. -Humidifiers were to be dated and changed weekly. -A plastic bag dated 6/16 indicated that the equipment and bag had not been replaced since that date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #49's face sheet showed he/she admitted to the facility with the following diagnoses: -Unspecified Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgement, and impulses). -Bipolar Disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). -Mood Disorder due to known Psychological Condition. Review of the resident's Treatment Administration Record (TAR) dated July 2023 showed the resident exhibited anti-psychotic medication side effects at the following times: -On 7/6/23 during the day shift. -On 7/7/23 during the day shift. -On 7/13/23 during the day shift. -On 7/14/23 during the day shift. -On 7/20/23 during the day shift. -On 7/29/23 during the night shift. Review of the resident's quarterly MDS dated [DATE] showed: -The resident was severely cognitively impaired. -The resident had verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) that occurred four to six days out of the seven day look back period of the assessment. -Wandering was not an exhibited behavior. -The resident was independent when walking in his/her room and corridors. Review of the resident's Behavior Note dated 7/8/23 at 7:09 P.M. showed: -The resident had been inappropriate with a certain staff member. -The resident had grasped the staff member's buttocks and was invading his/her personal space. -The resident could always be redirected easily and gave interventions of how the resident was normally redirected. -The nurse would continue to monitor the resident's behaviors. -Social Services had been made aware of the resident's behaviors and was developing a plan. Review of the resident's Behavior Note dated 7/12/23 at 10:35 P.M. showed: -The resident was being inappropriate with the same staff member as on 7/8/23. -It seemed the behaviors were becoming more frequent with the same staff member. -The resident was invading personal space and hovering around the staff member at eye level. -The staff member's attempt to redirect the resident was unsuccessful and the nurse needed to intervene and redirected the resident into the dining room for dinner. -The resident had also stood at the [NAME] table and pulled his/her pants down past his/her upper legs. Review of the resident's Behavior Note dated 7/17/23 at 4:09 A.M. showed: -The resident had been lingering around the same staff member again and getting into his/her personal space making him/her very uncomfortable. -The nurse attempted to explain to the resident that his/her behaviors were making it difficult for the staff member to perform work tasks. -The nurse then provided the resident with a snack and some ice water and redirected the resident into the common area. -The resident had been successfully redirected to bed once the snack was consumed. Review of the resident's Behavior Note dated 7/17/23 at 7:07 P.M. showed: -The resident had been lingering around the medication carts. -The resident was redirected to the [NAME] table to wait for a [NAME] game to start. -The resident had walked back into the dining room and began hovering around the same staff member again which was preventing that staff member from performing his/her job safely. -The staff had to repeat the redirection multiple times throughout the shift with little success. Review of the resident's Behavior Note dated 7/24/23 at 6:29 P.M. showed: -The resident had been making inappropriate comments to a member staff saying I wanted to touch your butt to see if I could get you to jump and was redirected at that time. -No physical contact was made between resident and staff members. Review of the resident's Physician Order Sheet (POS) dated August 2023 showed: -An order for Lorazepam (Ativan- a medication used to treat anxiety) Oral Tablet 0.5 milligrams (mg), give one tablet by mouth every six hours as needed for agitation/anxiety ordered on 8/3/23. -An order for Remeron (Mirtazapine- a medication used to treat depression) Tablet 30 mg, give 30 mg by mouth at bedtime related to Bipolar Disorder. -An order for Zyprexa (Olanzapine- an anti-psychotic used to treat mental disorders like Bipolar Disorder), give 10 mg by mouth in the evening related to Mood Disorder due to known Psychological Condition. -An order for antipsychotic medication- monitor for dry mouth, constipation, blurred vision, disorientation/confusion, difficulty urinating, hypotension, dark urine, yellow skin, nausea/vomiting (n/v), lethargy, drooling, extrapyramidal side effects (EPS such as tremors, disturbed gait, increased agitation, restlessness, involuntary movement of mouth or tongue). -No specific order for behavioral monitoring. Review of the resident's TAR dated August 2023 showed the resident had not exhibited anti-psychotic medication side effects as of 8/11/23 during the day shift. Review of the resident's undated care plan showed: -The resident would get confused and wander throughout the facility and was unsure of where he/she needed to go at times. -The resident used psychotropic (relating to drugs that affect a person's mental state) medications related to his/her diagnoses of Bipolar Disorder and Mood Disorder. -The resident had impaired cognitive function and thought processes related to his/her diagnosis of Dementia with a goal of remaining oriented to where his/her room was located and who his/her spouse was. -No specific care area related to the resident's behaviors. Review of the resident's Behavior Note dated 8/3/23 at 7:03 P.M. showed: -The resident had been trying to get into the dining room after meal time. -When the resident was redirected by staff he/she started to yell and threaten staff. -The resident was redirected away from the door and into the day room where he/she began unbuttoning his/her pants in front of other residents. -The resident was redirected to his/her room. Review of the resident's Medication Administration Record (MAR) dated 8/3/23 at 8:04 P.M. showed the resident had received a dose of the Lorazepam 0.5 mg. During an interview on 8/6/23 at 3:36 P.M. LPN A said the resident had been having an increase in behaviors and it was getting increasingly difficult to redirect the resident. Review of the resident's Behavior Note dated 8/8/23 at 8:53 P.M. showed a Certified Medication Technician (CMT) reported to the nurse that the resident had approached him/her and stated I'm just joking with you, you know that and then rubbed the length of his/her back making him/her feel very uncomfortable. During an interview on 8/9/23 at 10:50 P.M. CNA G said: -He/She had not had the resident exhibit any behaviors towards himself/herself or any other staff members. -He/She had only heard about the resident being inappropriate with an evening shift CMT. -He/She would redirect the resident if he/she was wandering and would usually help him/her to the activity table to play dominoes. -He/She would also offer the resident a snack or would see if the resident wanted to lay down. -He/She would tell a nurse if the resident was exhibiting any inappropriate behaviors. During a phone interview on 8/10/23 at 9:28 A.M. Registered Nurse (RN) C said: -The resident did not only show behaviors during his/her shifts. -There was a specific staff member that the resident had become attached to ever since his/her spouse passed away. -He/She would encourage the resident to play dominoes and that seemed to be an effective redirection and helped the resident become less depressed. -The resident would get too close to the staff member and had touched his/her bottom and back. -Other staff members have talked with the resident and he/she thought the resident was getting better. -He/She thought the resident's behaviors were increasing due to disease progression. -When a resident with dementia exhibited behaviors he/she would look at the resident's preferences to see what redirection would work best. -He/She had also talked with staff about trying new approaches and discussing what did and did not work. -If a new intervention was successful he/she would add it to the resident's care plan and update the MDS Coordinator about it. -He/She had been educating staff on reporting behaviors to him/her. -The staff mainly try to redirect the resident when he/she exhibited behaviors. -He/She thought the resident was getting better with his/her behaviors, but had not seen the resident for around 10 days. During an interview on 8/10/23 at 10:05 A.M. the Administrator and DON said the resident's inappropriate behaviors had not been brought to their attention until 8/9/23 and that was why they were going to have an emergency care plan meeting later that day. Review of the resident's Social Service Note dated 8/10/23 at 10:21 A.M. showed the resident had been referred to a Psychiatrist for evaluation. During an interview on 8/10/23 at 11:53 A.M. CNA J said: -The resident had not exhibited behaviors towards him/her. -He/She had never seen the resident exhibit behaviors towards anyone. -If he/she were to see the resident exhibit any behaviors he/she would report them to the nurse. -He/She could look at the residents care plan on the Electronic Medical Record (EMR) for appropriate interventions related to the resident's behaviors. -The care plan should reflect the resident's current status. -He/She thought the MDS Coordinator was responsible for care plans, but that anyone could update them. During an interview on 8/10/23 at 12:04 P.M. CMT B said: -It was his/her second day at the facility, he/she had not worked with the resident. -If a resident exhibited a behavior he/she would see if they needed something and then would redirect when possible. -If a resident with dementia exhibited any behaviors he/she would report them to the nurse. -Any intervention in place for a resident with dementia should be in the care plan. -Care plans should be up to date and reflect the resident's current status. During an interview on 8/10/23 at 1:11 P.M. RN A said: -If a resident exhibited a new behavior he/she charted the behavior and notified the doctor. -If he/she saw a resident exhibit any behaviors directed towards any staff member he/she would report it to the Administrator. -The resident had not exhibited any behavior towards him/her. -The resident's care plan should be up to date and reflect the resident's current status. -The MDS Coordinator was responsible for updating care plans. -If any care plan needed to be updated he/she would tell the MDS Coordinator. -All interventions used to prevent or redirect the resident should be in his/her care plan. -CNA's had access to the kardex which would tell them how to take care of the resident. -He/She had not seen the resident exhibit any behaviors. During an interview on 8/10/23 at 2:11 P.M. LPN A said: -The resident had been having an increase in behaviors over the last few weeks. -The DON had been notified of the resident's behaviors before, but was unsure when the DON was specifically notified. -He/She thought the facility was looking into new placement for the resident. -The resident had Ativan PRN ordered recently which seemed to help. -The resident had been getting redirected when the resident was seen around the specific staff member. -The resident usually started exhibiting behaviors around meal times. -Any intervention used to redirect the resident should be on the resident's care plan. -The MDS Coordinator was responsible for updating care plans. -He/She was unsure if he/she could update care plans. -He/She thought the increase in behaviors during the evening had to do with the resident sun downing (a state of confusion occurring in the late afternoon and lasting into the evening). -The resident had been more socially inappropriate and not verbally aggressive with staff. -The resident's spouse had passed away last year and that was when the behaviors started happening. -When a resident with dementia started to exhibit behaviors he/she would start with redirection, if redirection was not working then administering any PRN medications would be the next step. -If a PRN medication was needed he/she would report it to the DON. During an interview on 8/10/23 at 2:11 P.M. CMT D said: -The resident had been directing behaviors towards him/her since February. -He/She did report the behaviors to the DON, but mostly in passing. -The behaviors had recently escalated. -The staff members on his/her shift had been attempting to redirect the resident away from him/her, but that was causing the resident to become more verbally aggressive. -There was not a way for him/her to perform his/her job away from the resident because the resident was able to walk towards him/her if the resident saw him/her. -In the previous week maybe around 8/3/23 or 8/4/23 the resident had punched him/her twice in the arm and the resident had to be given a PRN Ativan. -The resident had cussed at him/her and other staff members when attempting to redirect the resident away from him/her, which had also been escalating. -The resident liked to stroke his/her hair, touch his/her waist and bottom, take things of the medication cart, and hover around him/her. -He/She did not think all of the resident's behaviors were due to his/her diagnosis of dementia. -It seemed like at times the resident was aware of what he/she was doing. -He/She thought the resident would look for excuses to be around him/her such as asking for medication he/she had already received or asking for water to drink from his/her cart. He/She had talked with the Assistant Director of Nursing (ADON) in depth about the resident's behaviors in July and that was when the behavior notes started to be documented. Review of the resident's Care Plan Conference Note dated 8/10/23 at 2:39 P.M. showed: -The SSD, MDS Coordinator, DON, and activities had been present at the care plan meeting along with the resident's family via phone. -The resident's disease progression was discussed with the increase in behaviors. -Possible alternative arrangement/placement of the resident was also discussed. -There was not a designated decision-maker at the time of the meeting. -The family was notified of the necessity for incapacitation in order for a placement in a specialized unit. During an interview on 8/11/23 at 9:21 A.M. the ADON said: -He/She was made aware of the resident's increased behaviors within the last couple of weeks. -He/She filled out a form and discussed the behaviors in a morning meeting. -The resident had Ativan ordered recently to help the resident with the behaviors. -He/She could not remember the timeline that CMT D told him/her regarding the resident's behaviors. -The facility had been in the process of getting new placement for the resident. -He/She had not discussed creating behavioral notes for residents exhibiting behaviors with the other nurses. -He/She knew there was anti-psychotic charting that was getting completed in the resident's EMR. -He/She thought the resident had an order to see the Psychiatrist, but was unsure if the Psychiatrist had seen the resident. During an interview on 8/11/23 at 11:12 A.M. the DON said: -He/She was notified of the resident's increase in behaviors in early July. -He/She was working on the floor in February, but if CMT D had reported anything to the previous DON, something would have been done. -The facility started to redirect the resident, but realized that was not working. -The facility had also been looking at the behavioral notes to see what interventions were working. -The Psychiatrist had only been consulted yesterday and the resident had not been seen previously. -The facility was working on getting the paperwork in place to assign the resident a Guardian. -The facility was also working on finding better placement for the resident. -He/She would expect that the interventions that worked for the resident to be in his/her care plan. -The resident also wandered and it would be difficult for CMT D and the resident to be separated throughout the shift. -When the resident became physical with staff was when the Ativan was ordered. -The resident's spouse passed away last year and there had previously been a resident with Dementia that seemed to be helping the resident with his/her grief. -He/She thought that if the facility had offered grief counseling it would be an effective intervention for the resident. -He/she would expect the staff to have the following in a behavioral note. --What happened. --Who was all involved. --Any interventions that had been done. --Who was notified. -He/She would have expected the resident to have behavioral monitoring ordered and charted in the resident's EMR. Based on observation, interview and record review, the facility failed to adequately assess, monitor, reevaluate change in behaviors; and to implement and document a behavioral safety care plan in response to increased aggressive behavioral reactions for one sampled resident (Resident #57) who had a history of inappropriate behavioral actions and to ensure proper behavioral management and monitoring for one sampled resident (Resident #49) who exhibited an increase in behaviors towards staff out of 19 sampled residents. The facility census was 66 residents. Review of the facility's undated policy titled Behavior-Management showed: -The concept of behavior management was an interdisciplinary process with the key components being: --Identifying residents whose behaviors may pose a risk to self or others. --Developing individual and practical care strategies based on assessed needs. --Implementing the behavior management program. --Ongoing assessment, monitoring, and evaluation of the effectiveness of the behavior management program including the effectiveness of psychoactive drugs. -The goal of any behavior management process was to maintain function and improve quality of life. -When a resident displays adverse behavioral symptoms (e.g., crying, yelling, hitting, biting, etc.), Licensed Nursing Staff will: --Assess the behavioral symptoms to determine possible causal factors. --Contact the attending physician. --Implement non-drug interventions to alleviate the behavioral symptoms before initiating any psychotherapeutic agent(s). -The facility must provide necessary behavioral health care and services which include: --Ensuring that the necessary care and services are person-centered and reflect the resident's goals for care. -When a resident exhibits adverse behavioral symptoms, Licensed Nursing Staff will document the behaviors in the medical record, noting the time of the behavior(s) occur, antecedent events, possible casual factors and interventions attempted. -Upon observing the adverse behavioral symptoms, staff will: --Ensure the safety of the resident as well as all other residents. --Document notification of the attending physician. --Document notification of the resident's family and/or responsible party about the change in behavior and the attending physician's response. --Document the incident on the 24-hour report. -Nursing staff will continue to monitor the resident's behavior to determine what event(s), if any, precipitated the behavior and document the following information as indicated: --Date and time of behavior. --Location of the resident when the behavior occurred. --Description of the behavior. --Non-verbal cues. --What seemed to cause the behavior. --Any interventions used and their effect. 1. Review of Resident #57's admission Face Sheet showed the resident: -Was his/her own responsible party. -Had diagnoses of Vascular Parkinson (are slow movements, tremor, difficulty with walking and balance, stiffness and rigidity and are produced by one or more small strokes). - Anxiety Disorder (a psychiatric disorder causing feelings of persistent worry, fear, anxiousness) Review of the resident's Quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 4/25/23 showed the resident: -Was cognitively intact and had no short term and long term memory problems. -He/she was able to understand others and make his/her needs known. -Had no behaviors documented. Review of the resident's Psychiatric Periodic Evaluation dated 6/19/23 showed: -Nursing staff reported the resident having increased anxiety and agitation. -Buspriron (used to treat anxiety) 5 milligrams (mg) two times a day was ordered. -The resident currently benefits psychiatrically and behaviorally at current dose. -Doses reduction attempt at this time would risk decompensation of the resident. -Plan: --Continue being flexible with the patient mood and validate concerns and feeling with acknowledgement and empathy. --Continue sleep-wake cycle support, as well to prevent isolation and promote socialization and engagement in activities. (i.e., bright light/open curtain during daytime hours, out of room during daytime hours as tolerated, dark room at night/curtain drawn, no TV or other distractions at bedtime, consistent schedule routines). --Offer concise, clear, slowly stated directions to assist with and prevent confusion regarding goals, instructions nursing care, Activities of Daily Living (ADL's). etc. Encourage socialization and engagement in activity. --Monitor for changes in mood or behavior. -NOTE: There was no documentation found that the resident's plan of care was updated with behavioral health recommendations for behavioral management were implemented. Review of the resident's Nursing Notes dated 6/19/23 10:55 A.M., showed a new order from psychiatrist for Buspirone 5 mg two times a day for anxiety. Review of the resident's Anxiety Care Plan dated 6/22/23 showed: -The resident used anti-anxiety medication related to Anxiety disorder. -Monitor and record occurrence of target behavior symptoms and specify if behavior was inappropriate response, verbal communication, violence or aggression toward staff or others. -Document per facility protocol. Review of the resident's Quarterly MDS dated [DATE] showed the resident: -Had moderate cognitive impairment, but was able to make his/her needs known. -Had behaviors towards others, either verbally or physical aggressive during look back period. -Had rejected care during the lookback period. Review of the resident's facility Incident Report dated 7/8/23 at 9:27 A.M. showed: -Incident happened in dining room. -It was reported to nursing that the resident became agitated with spouse who was trying to transfer himself/herself without assistance. Further investigation showed there was no apparent injury and that when he/she touched spouse face, it was not audible. -Spouse seemed undisturbed. -The residents were separated and brought to the dining room for meal. -The nurse interviewed the resident he/she said that his/her spouse was trying to hit the resident back was turned and he/she was just trying to get his/her spouse to stop. -The nurse asked if spouse had tried to swat at him/her before. -The resident said yes, but it didn't feel like nothing but a flea bite. So it didn't really bother him/her. Spouse had dementia and did not recollect the events. -The resident felt safe around spouse. -The nurse asked the resident if he/she wanted to move to a separate room from spouse and he/he said no. -The resident was his/her own responsible person and the family member was Durable Power of Attorney (DPOA) for spouse. -Discussed a possible room change with family member and about the above concerns. -The family member said he/she would discuss with family but was generally in agreement about a room move and would talk with the resident to facilitate the move. -Family member agreed to come in and facilitate a same day move, given the resident's resistance to spouse being moved. -The physician ordered a urinalysis (a test of your urine) for the resident's spouse and enhanced monitoring for spouse. -The resident said he/she accidentally hit his/her spouse when he/she was trying to stop spouse from transferring and the spouse swatted at the resident. -Follow-up notes dated 7/10/23 showed the facility administration met with family members to discuss concerns regarding the resident's temper toward his/her spouse, and his/her spouses disease process. It was determined that it would be safer and less agitating for both residents to room separately. Discussed rooming situation with the resident and his/her spouse. The resident's family facilitated the discussion. There were to be no restrictions on visiting in the spouse's room as long as the spouse's roommate was comfortable with the resident's presence. With the first available opportunity, the resident's spouse would be moved to a room adjacent to the resident. The resident was unhappy but accepting of the plan. -Note: The resident's care plan had no documentation related to the resident's behavior toward his/her spouse and the recommended room change due to the resident's temper toward his/her spouse and there was no behavioral monitoring plan for the resident documented. Review of the resident's Nursing Note dated 7/8/23 at 1:00 P.M., showed: -The resident reported he/she inadvertently hit his/her spouse when he/she was trying to stop his/her spouse from unsafely transferring and the spouse was trying to swat at the resident. -There were no injuries found. -Family meeting set up to discuss progression of the spouse's disease process. Review of the resident's Nursing Notes dated 7/8/23 at 6:18 P.M., showed: -The resident was at the nurse's station asking where his/her spouse was as the spouse had not returned from the dining room after supper and the resident was very hostile towards staff. -This nurse explained that it was discussed with the resident family member that a break from one another would be a good thing, the family member did not want to discuss the situation that had occurred when the resident was upset with his/her spouse as he/she was tired and unable to get clothes out of the closet and became short tempered. -Family member was in agreement with the room change for either the resident or his/her spouse, the family member had spoken to staff about handling the situation, family member said that he/she was chickening out in speaking with the resident. Staff stated that the situation would be handled by staff and to not feel as if he/she was not helpful. -Staff moved the resident's spouse to another room. -The resident had agreed to allow his/her spouse to stay in the room and he/she would move if others in agreement. -The resident was hostile towards staff related to frustration in regards to miscommunication. -The resident did calm down after a moderate amount of time. Review of the resident's Psychiatric Periodic Evaluation dated 7/12/23 showed: -The resident had a diagnosis of dementia and anxiety. -The resident had episode of an altercation with his/her spouse. -One of the staff members had seen the resident push his/her spouse. -The resident said he/she would never hurt his/her spouse. (He/she had never laid a finger on his/her spouse) -Concern with spouse because his/her spouse was moved to another room and he/she was missing his/her spouse. -The resident said he/she loved his/her spouse and would not hurt his/her spouse. -Plan: continue being flexible with the patient mood and validate concerns and feeling with acknowledgement and empathy. Continue psychotropic medication as presently prescribed. --Offer concise, clear, slowly stated directions to assist with and prevent confusion regarding goals, instructions nursing care, ADL's. etc. Encourage socialization and engagement in activity. -NOTE: No documentation found that the resident's plan of care were updated with behavioral health recommendation for behavioral management was implemented. Review of the resident's Nursing Notes dated 7/15/23 at 7:16 P.M., showed: -Upon returning to floor, this nurse was informed that the resident had become physical with his/her spouse in the dining room. -Unknown Certified Nursing Assistant (CNA) had reported to another nurse that he/she saw the resident grab his/her spouse by the arms/wrist and was shaking him/her due to spouse messing with things on dining room table. The resident and his/her spouse were separated by staff. The resident's family member was notified of above. Also notified were the Director of Nursing (DON) and Administrator. -The resident was down in his/her room, but did attempt to go into his/her spouse's room. -The resident was informed he/she could not go into his/her spouse room at that time. -Note: There was no documentation noted of any behavioral monitoring or behavioral management interventions being implemented after the incident. Review of the resident's Behavior Notes dated 7/17/23 at 4:09 A.M. showed: -The resident had expressed to the nurse that he/she had given up and that he/she had nothing left. -The nurse spoke to the resident who further expressed that he/she did not want his/her Synthroid (thyroid medication) and little of other medications, also stated that he/she was going to eat and drink minimal intake again, had nothing left that's it I'm done -The resident was not suicidal but said he/she was depressed that others had labeled him/her as abusive towards his/her spouse. -The nurse explained that was not the case and the facility was there to support the resident and conferences with him/her, as well as his/her family member, will continue. -The resident said he/she felt better and was going to get some sleep. Review of the resident's Nursing Notes dated 7/18/23 at 11:30 A.M. showed: -The nurse spoke with the resident and asked how he/she was doing. -The resident said that an unknown CNA told him/her last night that he/she was going to be arrested for what he/she was accused of doing. I can't believe that people will take the word of a staff person over me. I haven't lied to them before. -The nurse asked the resident who said that to him/her and he/she wouldn't divulge the name. Review of the resident's Nursing Notes dated 7/27/23 at 1:20 P.M. showed the resident had grabbed his/her spouse's arm forcefully and pulled it back because he/she was reaching for his/her table mate's food. The resident was also yelling at his/her spouse. Review of the resident's Behavior Notes dated 7/28/23 at 3:50 P.M. showed: -The resident approached the nurse and began yelling that he/she needed an Administrator because he/she was being forced to be away from his/her spouse and that he/she was not going to stand for it. The resident said there was a meeting today and he/she was no longer allowed to be in the same room as his/her spouse. The resident said he/she would not allow spouse to be in his/her current room because there was not a TV. The resident raised voice louder and said I will call the law on all of you for imprisonment. This nurse coordinated with the Social Service Designee (SSD) who said that the care plan meeting was Wednesday and it was decided for them to remain in separate rooms for safety concerns. The resident was [NAME]

Based on interview and record review, the facility failed to keep records of receipts of transactions for three residents (Residents #22, #28 and #32) out of four residents sampled for the purpose of reviewing resident trust fund procedures. The facility census was 66 residents. 1. Review of Resident #22's resident trust fund transactions dated 4/23 to 7/23 showed a withdrawal of $17.00 on 4/14/23 for a beauty shop appointment. Review of the transaction book showed the absence of a resident signature for that withdrawal or a receipt to show that amount was withdrawn on the resident's behalf. During an interview on 8/7/23 at 2:04 P.M., the Business Office Manager (BOM) said he/she did not see a receipt for the 4/14/23 transaction. During an interview on 8/7/23 at 3:16 P.M., the BOM said he/she forgot to print the list of six residents who received beauty shop services on that day (4/14/23) which included Resident #22. 2. Review of Resident #28's transactions dated 4/23 to 7/23, showed a withdrawal of $2.00 was done on 7/10/23. During an interview on 8/7/23 at 2:17 P.M., the BOM said he/she did not find a receipt for that transaction on 7/10/23. 3. Review of Resident #32's transactions dated 4/23 to 7/23 showed: -A $17.00 transaction for beauty shop services on 4/28/23. -A $17.00 transaction for beauty shop services on 5/11/23. During an interview on 8/7/23 at 2:35 P.M., the BOM said he/she was not sure where the receipts were for the transactions on 4/28/23 and 5/11/23, because he/she was not in the position of being the BOM at that time. 4. During an interview on 8/9/23 at 2:05 P.M., the Administrator said the BOM did not receive some training in business office procedures that he/she should have received. During an interview on 8/9/23 at 2:10 P.M., the Regional Director of Clinical Services said the corporation could provide sufficient orientation by having employees train with someone within their department at another facility. During an interview on 8/10/23 at 2:27 P.M., the BOM said: -The previous BOM was the one that did the training for him/her. -He/she did not get a chance to go to another facility and train with a more experienced BOM. -No one from another facility within the corporation came to his/her facility for his/her training.

Based on interview and record review, the facility failed to follow facility policies and procedures for checking the Nurse Aide Registry (NAR) and the Criminal Background Check (CBC) as part of the background check for all newly hired employees, within a timely manner and in accordance with state requirements prior to employing four of 10 employees sampled for the criminal background screening. The facility census was 66 residents. Review of the facility's Abuse and Neglect policy and procedure updated 10/24/22, showed the facility does not knowingly employee anyone who has had disciplinary action against his/her professional license, or a finding entered into the state nurse aide registry related to abuse, neglect, mistreatment, or misappropriation, or has been convicted of abusing, neglecting or mistreating other people. The facility screened for potentially abusive employees during the pre-admission process. Review of four employee records on 8/10/23, showed: -Certified Nursing Assistant (CNA) O was hired on 11/10/22; the documentation showed the facility staff had not checked the NAR. The employee was not an active employee. -CNA P was hired on 5/23/22; documentation showed the facility staff had not checked the NAR. The employee was not an active employee. -Certified Medication Technician (CMT) D was hired on 1/12/23; documentation showed the facility checked the Employee Disqualification List (EDL) and NAR on 8/3/23, and did not request the CBC until 8/3/23. CMT D was currently an active employee. -Licensed Practical Nurse (LPN) E was hired on 2/2/22; documentation showed the facility staff checked the EDL and NAR on 8/2/23 and did not request the CBC until 8/2/23. LPN E was currently an active employee. During an interview on 8/10/23 at 1:05 P.M., the Human Resource Manager said: -He/She had just started in the position and pulled the criminal background information that was in the employee files. -He/She did not see the NAR checks in these employee records. -He/She noticed that some of the employee records did not have the CBC and EDL checks in their files so he/she began to run those background checks and place them in the employee files (he/she was aware that CMT D and LPN E background checks were completed late). -He/She did not know anywhere else the records could be.

Based on observation, interview, and record review, the facility failed to ensure the treatment carts on 300 and 400 hall, and medication cart on 200 hall remained locked when not in use and not within eyesight. The facility census was 66 residents. Review of the facility's policy, titled Medication Storage dated January 2021, showed: -The facility was to ensure medication was accessible only to licensed nursing personnel, pharmacy personnel, or staff members that were lawfully authorized to administer medicine. -Medication rooms, cabinets, and medical supplies were to remain locked when not in use unless attended by a person with authorized access. 1. Observation on 8/6/23 at 4:59 P.M. showed: -The facility's crash cart (a cart containing equipment for use in an emergency) had the lock removed and sitting inside the cart. -The crash cart contained two sterile oral suctioning tools, three sterile suction trays, and a sealed bottle of Normal Saline (a sterile mixture of sodium chloride and water; it has a number of uses in medicine including cleaning wounds, and by injection into a vein, it is used to treat dehydration). Continuous observation on 8/7/23 from 10:02 A.M. to 10:08 A.M. showed: -The treatment cart for the 400 hall was unlocked with no staff visible. -One resident went by the unlocked cart in his/her wheelchair. -The cart contained medications for multiple residents, scissors, and medicated bandages. -Three unnamed staff members walked by the cart and did not lock it. -Two additional unknown staff members walked by the unlocked cart and did not lock it. -Two additional unknown staff members walked by the unlocked cart and did not lock it or remove the scissors from the top of the cart. -Two more unknown staff members and the Director of Nursing (DON) walked by the unlocked cart and did not lock the cart. Observation on 8/10/23 at 9:35 A.M. showed: -A treatment cart with scissors on top was left unlocked in the 300 hall. -Staff could be heard talking with a resident in a room with the door closed. -Certified Medication Technician (CMT) C and Certified Nursing Assistant (CNA) J were standing approximately 20 feet from the unlocked cart, neither CMT C nor CNA J locked the treatment cart. -A visitor walked by the unlocked cart, stopped, placed his/her water on the cart, and began talking to someone while leaning on the unlocked cart. Observation on 8/10/23 at 10:43 A.M. showed: -A treatment cart with scissors on top and prescription creams and ointments inside was unlocked in the 400 hall with no staff visible. -CNA C walked by the cart and did not lock it. Observation on 8/10/23 at 11:17 A.M. showed: -A medication cart was unlocked in the 200 hall with no staff visible. -A resident passed the unlocked cart with no staff visible. -LPN B came around the corner and passed the unlocked cart. -LPN B went into a resident's room, shut the door, and the medication cart remained unlocked with no staff visible. During an interview on 8/10/23 at 11:37 A.M., Agency CMT A said staff were to ensure medication and treatment carts were locked when staff were not with them. During an interview on 8/10/23 at 12:40 P.M., Agency CNA B said: -Staff were to lock medication and treatment carts before walking away. -He/she would not lock the carts if it wasn't his/hers because it wasn't his/her stuff. -He/she didn't want to lock the keys in the cart on accident so he/she wouldn't lock a cart he/she found unlocked. During an interview on 8/10/23 at 12:52 P.M., Agency CMT B said: -Medication and treatment carts were to be locked when staff weren't with them. -Carts must be locked if staff close the door or are not within eyesight of the cart. During an interview on 8/10/23 at 2:24 P.M., LPN A said medication and treatment carts were always to be locked when staff were not able to visually monitor them. During an interview on 8/11/23 at 9:01 A.M., Registered Nurse (RN) A said medication and treatment carts were to be locked at all times. During an interview on 8/11/23 at 11:11 A.M., the DON said medication and treatment carts were to be locked at all times when staff are not with them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to assess the dietary preferences of three sampled residents (Residents #16, #17, and #71) by not doing a dietary profile and to ensure food substitutes which were consistent with ordinary food items which were provided by the facility, were available for residents who did not prefer to eat the items which were offered. The facility census was 66 residents. 1. Review of Resident #16's face sheet showed he/she admitted with the following diagnoses: -Generalized muscle weakness. -Unspecified heart failure. -Type 2 diabetes mellitus (a group of diseases that affect how the body uses blood sugar (glucose). -High blood cholesterol (when you have too much of a fatty substance called cholesterol in your blood). -Transverse myelitis (inflammation of part of the spinal cord.) Review of the residents quarterly Minimum Data Set (MDS --- a federally mandated assessment tool completed by the facility staff for care planning), dated 5/31/23, showed the resident was cognitively intact with a Brief Interview for Mental Status (BIMS-an assessment tool that shows a score between 3 of 15 which shows the resident's mental status. This tool helps determine the resident's attention, orientation and ability to register and recall new information. These items are crucial factors in care planning decisions) of 15 out of 15. Review of the Resident's Physician's Order Sheet (POS) dated 7/23/23, showed a physician's order dated 5/23/23, for the resident to have a regular diet. During an interview on 8/8/23 at 3:19 P.M. the resident said: -He/she did not like to eat a lot of simple carbohydrates (carbohydrates which were broken down quickly by the body to be used as energy). -He/she preferred to eat more complex carbohydrates (carbohydrates which are digested more slowly and release glucose into the blood stream more gradually). -There were times he/she did not receive the items, which he/she circled on his/her meal ticket -He/she had not been given the opportunity to consult with a Registered Dietitian (RD). -The facility had not called an RD in to consult with him/her. -No one had sat with him/her to evaluate his/her likes and dislikes. Review of the resident's electronic records showed a dietary profile was not present for the resident. Review of the resident's meal ticket dated 7/27/23 for dinner, showed the resident ordered a side salad, cottage cheese, and chocolate. Review of the resident's meal ticket dated 8/2/23 for lunch showed the resident ordered a side salad and cottage cheese. Review of the resident's meal ticket dated 8/3/23 for lunch showed the resident ordered and received a lettuce only salad with Caesar's dressing. Review of the resident's meal ticket dated 8/4/23 for lunch showed the resident ordered and received a lettuce only salad with Caesar's dressing with cottage cheese Review of the resident's meal ticket dated 8/7/23 for lunch showed the resident ordered and received a salad which consisted of only lettuce. During an interview on 8/9/23 at 8:48 A.M., the resident said: -He/she received an all lettuce salad on 8/2/23. -He/she wanted tomatoes, a little grated cheese and grated carrots with his/her salad. -He/she really wanted chef's salads (a salad consisting of main ingredients which include but not limited to hard-boiled eggs, meat, tomatoes, cucumbers, cheese, leaf vegetables) instead of side salads. -He/she would prefer roast beef on her chef's salad. During an interview on 8/9/23 at 9:46 A.M., the resident said: -He/she ordered items for his/her dinner meal on 7/27/23 and received none of the items. -The dietary personnel did not tell him/her anything. -The resident was very upset that day (7/27/23) on which he/she wrote a four letter expletive word on the meal ticket which he/she kept for his/her records. During an interview on 8/9/23 at 12:45 P.M., the Registered Dietitian (RD) said -He/she would speak with the Dietary Manager (DM) about the resident receiving a Chefs' Salad. -At one time, the resident used to get the chef's salad, but currently the resident was not getting the chef's salad. During an interview on 8/9/23 at 12:58 P.M., the RD said: -A nutritional assessment for the resident was not completed until 8/9/23. -It was the responsibility of the DM to ask the resident about the residents' likes or dislikes. During an interview on 8/9/23 at 2:23 P.M., the DM said: -He/she was told that he/she had to place the likes and dislikes of a resident in the Dietary profiles. -The resident said he/she would like a chef's salad for lunch. -He/she was told that if the item were not on the Always Available Menu, the request from a resident was something he/she did not have to follow through on. - He/she now knew/understood the resident requests should be provided. -He/she had not done the dietary profile for the resident. During a phone interview on 8/15/23 at 3:49 P.M., the DM said: -The chefs' salad was not on the Always Available Menu. -Chef's salad was requested by the resident before he/she started working at the facility and continued until about one or two months ago. -Eventually about seven residents started to request Chef's salad. -The dietary budget was not enough to allow for Chef's salad for approximately seven residents. -The facility also served tossed salads, but the frequency of tossed salad availability in a certain time intervals depended on the menus. -Some weeks the dietary department served tossed salads only once and some weeks they do not have it at all, -He/she started employment at the facility in April or May of 2023. -The process of conducting dietary profiles included meeting with residents within the first 72 hours of admission and at least quarterly thereafter. -He/she had been working on the dietary profiles, but did not get a chance to work on them daily. -How often he/she was able to speak with residents, depended on dietary scheduling such as dietary employee absences or what may happen as it pertained to his/her involvement in the meal service. -If he/she had the time, he/she could get to three to four resident dietary profiles done per week 2. Review of Resident #17's face sheet showed the following diagnoses: -Generalized muscle weakness. -Parkinson's disease (a brain disorder which causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). -High blood pressure. -Hypokalemia (a lower than normal potassium level in your bloodstream). -High blood cholesterol. Review of the resident's Nutritional assessment dated [DATE] showed the food likes, food dislikes and snacks/supplements preferred sections, were not completed. Review of the resident's POS dated 8/23, showed a physician's order dated 7/1/23, for the resident to have a regular diet. Review of the residents quarterly MDS dated [DATE], showed the resident had moderate cognitive impairment with a BIMS of 11 out of 15. During an interview on 8/6/23 at 2:27 P.M., the resident said: -The dietary department did not have substitutes when they did not have what a resident circled on the meal ticket prior to the meal. -They don't substitute when food was missing because they probably don't have the substitute either. -Sometimes they'll leave items off, like a salad or fruit, because the dietary department did not have it. -He/she kept food in his/her room. -His/her major complaint was related to food. During an interview on 8/8/23 at 3:12 P.M., the resident said: -His/her issue was with the taste of the food. -He/she thought the oatmeal was too thick. -The gravy for the breakfast meal was too salty. -He/she understood that every individual had their own food choices. During an interview on 8/9/23 at 11:23 A.M., the Regional Nurse Consultant said the likes and dislikes section for the resident was not filled in after he/she reviewed it in the resident's medical record. During an interview on 8/10/23 at 9:14 A.M. the resident said: -He/she liked healthy food, no food that was battered. -He/she wanted more fruits and vegetables. -If he/she had to pick, he/she would pick a healthier diet. -A family member brought him/her fruit, dried fruit and bran flakes so he/she would have something healthy to eat. -We used to get good oatmeal but currently it was too thick. -We don't get tartar sauce, bar-b-cue sauce or ketchup or something like that, as condiments for his/her hamburgers, because the hamburger was served plain. -In the past, there used to be a side dish with lettuce and tomato and onion but they don't give it to us anymore. -He/she did not know how to solve it but he/she would like more healthy options. During a phone interview on 8/15/23 at 4:01 P.M., the DM said: -The dietary department had ketchup packets, mustard packets and pickle relish. -Some residents may find the packets difficult to open. -The dietary department would find out the residents' food likes and food dislikes, which foods they prefer, and whether or not the resident lost weight. -He/she gave the residents the options to have any fruit they have as long as the dietary department did not run out of fruit that they may have to use for future meals. 3. Review of Resident #71's face sheet showed the following diagnoses: -Hemiplegia (paralysis that affects only one side of the body) on his/her left side. -Need for assistance with personal care. -Hyperlipidemia (an elevated level of lipids, such as cholesterol and triglycerides in the blood). -Gastroparesis (a disorder that slows or stops the movement of food from your stomach to your small intestine, even though there is no blockage in the stomach or intestines). -Personal history of traumatic brain injury (caused by a forceful bump, blow, or jolt to the head or body, or from an object). Review of the resident's dietary profile dated 7/8/23, showed the food likes, food dislikes and snacks/supplements preferred sections, were not completed. Review of the residents quarterly MDS dated [DATE], showed the resident had moderate cognitive impairment with a BIMS of 12 out of 15. Review of the Resident's POS dated 8/23, showed a physician's order dated 6/16/23, for the resident to have a regular diet. During an interview on 8/9/23 at 10:11 A.M., the resident said: -He/she had issues with food. -He/she did not receive the foods he/she liked. -He/she cannot have regular milk. -From time to time, the dietary department had placed regular milk on his/her tray. During an interview on 8/9/23 at 2:23 P.M., the DM said: -He/she was told the he/she had to place the food likes and food dislikes of a resident in the Dietary profiles but he/she had not completed them yet. -The resident may receive regular milk when he/she was not on duty.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure the restroom ceiling vents in resident rooms 110, 103, 101 in the 100 Hall, had negative air flow. This practice potentially affected at least 10 residents who resided in those rooms. The facility census was 66 residents. Note: Air flow was tested by holding one piece of tissue paper to the ceiling vent. If the paper was sucked up, then negative air flow was present; if the paper fell to the floor, then negative airflow was absent. 1. Observation on 8/8/23, with the Maintenance Assistant showed: -At 1:40 P.M., a tissue paper was held up to the restroom ceiling vent in resident room [ROOM NUMBER] and the tissue paper was not held and it fell to the floor. -At 1:50 P.M., a tissue paper was held up to the restroom ceiling vent in resident room [ROOM NUMBER] and the tissue paper was not held and it fell to the floor. -At 1:53 P.M., a tissue paper was held up to the restroom ceiling vent in resident room [ROOM NUMBER] and the tissue paper was not held and it fell to the floor. -At 1:56 P.M., a tissue paper was held up to the restroom ceiling vent in resident room [ROOM NUMBER] and the tissue paper was not held and it fell to the floor. During a phone interview on 8/11/23 at 10:45 A.M., the Maintenance Assistant said: -He/she and the Maintenance Director checked the attic areas on a monthly basis. -In the 100 Hall there were two tubes which fell off the pump in the attic areas, which provided suctioning. -The two tubes were not seen, because they were under insulation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain the following attic areas free of animal droppings: the front hall mechanical room access, the therapy area attic access, the 300 Hall attic access; failed to remove remnant hay from the attic area over the 400 Hall; and to ensure the area between the bed and wall in resident room [ROOM NUMBER], was free of dead insects and cobwebs. This practice potentially affected at least 40 residents who resided in those areas. The facility census was 66 residents. 1. Observation on 8/7/23, with the Maintenance Assistant showed the following: -At 9:58 A.M., there was a pile of animal droppings in one corner of the attic area over the front hall mechanical room. -At 10:22 A.M., there was a pile of animal droppings in one corner of the attic over the therapy area. -At 11:50 A.M., there was a pile of animal droppings in the attic area over 300 Hall. -At 11:59 A.M., there was a remnant amount of hay in the attic area, close to the outside wall over 400 Hall. During an interview on 8/7/23 at 10:26 A.M., the Maintenance Assistant said: -At one time in the past after he/she was hired, there were at least two raccoons which resided in the attics of the facility. -He/she expressed knowledge of one raccoon which was found by the previous Maintenance Director in February 2022. -He/she and the Maintenance Director looked for other openings on the roof and repaired those openings and since then raccoons have not been seen or heard in the attic. 2. Observation on 8/8/23 at 11:12 A.M., with the Maintenance Assistant showed numerous dead insects which were entangled in a cobweb in the space between the bed and wall in resident room [ROOM NUMBER]. During an interview on 8/8/23 at 11:13 A.M., the Maintenance Assistant said he/she would inform the housekeeping department about that area in resident room [ROOM NUMBER]. During a phone interview on 8/14/23 at 10:15 A.M., the Housekeeping Supervisor said the housekeepers did not let him/her know about the cobweb entanglement.

Based on observation, interview, and record review, the facility failed to ensure the staffing was posted and posted correctly to include the total census of the facility. The facility census was 66 residents. Review of the facility's policy titled Nursing Department-Staffing, Scheduling, and Postings dated 10/24/22 showed: -The facility will post the following information on a daily basis: --Facility name. --The current date. --The total number and actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift including Registered Nurses (RN's), Licensed Practical Nurses (LPN's), and Certified Nursing Assistants (CNA's). --Resident census. -The facility will post the nurse staffing data specified above on a daily basis at the beginning of each shift. -Data must be posted in a clear and readable format and in a prominent place readily accessible to residents and visitors. 1. Observation on 8/6/23 at 4:55 P.M. showed no staff posting could be found anywhere in the facility. Observation on 8/7/23 at 1:44 P.M. showed no staff posting could be found anywhere in the facility. Observation on 8/8/23 at 12:15 P.M. showed no staff posting could be found anywhere in the facility. Observation on 8/9/23 at 3:03 P.M. showed: -Staffing had been posted and taped to the receptionist desk. -The staffing sheet did not include the facility census. Observation on 8/10/23 at 8:31 A.M. showed: -Staffing had been posted and taped at the receptionist desk. -The staffing sheet did not include the facility census. During an interview on 8/10/23 at 11:50 A.M. CNA J said: -He/She thought the staffing was supposed to be in a binder at the nurse's station. -He/She was unsure what needed to be included on the staffing sheet. During an interview on 8/10/23 at 11:58 A.M. Certified Medication Technician (CMT) B said: -The staffing was supposed to be posted somewhere visible. -The staffing needed to include all of the licensed staff in the building and the amount of hours they worked. During an interview on 8/10/23 at 12:59 P.M. RN A said: -The staffing was usually posted on a wall around one of the hall corners, but could not determine where it specifically was located. -He/She thought the number of residents and number of staff working needed to be included on the staffing sheet. -He/She thought the staffing sheet needed to be posted in a visible location. During an interview on 8/11/23 at 8:24 A.M. the Staffing Coordinator said: -He/She was responsible for posting the staffing sheet. -The staffing was supposed to be posted at the front of the building. -He/She knew it was not being posted prior to 8/9/23. -The staffing sheet needed to include: --The date. --The facility name. --The number of residents. --The number of licensed staff. During an interview on 8/11/23 at 11:12 A.M. the Director of Nursing (DON) said: -He/She was aware the staffing sheet was not getting posted prior to 8/9/23. -He/She thought the staffing sheet needed to be posted in a visible location. -He/She was unsure of the exact requirements for what needed to be on the staffing sheet, but thought it should include: --Licensed Staff hours. --The facility census and name. --The date.

Based on observation and interview, the facility failed to place the date that a tray of ground meat rolls and a box of hamburger patties, were taken from the freezer for defrosting; to label two containers of liquids with the substance that was in those containers; to label three containers of a white powdery substance, with the actual substance that was in those containers; to ensure three cutting boards were maintained without numerous indentations and grooves; to ensure the floor under the dishwasher was free from grime and debris buildup; to thoroughly wash the food processor between using the food processor to grind different items of food; and to ensure one Dietary Aide (DA) A washed or sanitized his/her hands between handling soiled dishes and clean dishes. This practice potentially affected 65 residents who ate food from the kitchen. The facility census was 66 residents. 1. Observation on 8/6/23 from 2:24 P.M. to 5:48 P.M., showed: -The absence of a date on the box of ground meat and the box of all beef patties as to when those items were taken from the freezer for defrosting. -The absence of labels from three large containers of white powdery substances, which could be mistaken for another substance. -The absence of labels on two condiment bottles which contained a brown colored liquid. -The presence of numerous indentations on the yellow, green, and brown cutting boards, which rendered those cutting boards not easily cleanable. -The presence of debris including plastic glasses under the dish washer area. -The absence of labels on containers of liquid. -DA A handled soiled dishes then proceeded to stack clean dishes without changing his/her gloves or washing his/her hands. -DA A used the food processor to grind the creamed corn, then only rinsed the container before using the same container to grind potatoes. During an interview on 8/6/23 at 3:12 P.M., the Central Supply Coordinator (who helped out in the kitchen for a while on that day) said the liquids that were in the two condiment bottles, were syrup which should have been labeled during the breakfast shift because syrup was used during the breakfast shift. During an interview on 8/6/23 from 4:25 P.M. to 6:26 P.M., the Dietary Manager (DM) said: -He/she had been letting staff know what each of the containers with the powdery white substances contained. -The meat was taken out of the freezer three days prior to 8/6/23, and he/she would have to let dietary staff know about placing a date on the tray the meat was in. -The dietary staff has not gotten under the dishwasher area in a while to clean under that area. -He/she expected dietary staff to change gloves and wash hands between handling soiled dishes then handling clean dishes. During an interview on 8/6/23 at 5:13 P.M., DA A said he/she was just trying to hurry the process along by not running the food processor container through the dishwasher and there were other dietary staff who did the same thing he/she did.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 12. Review of Resident #2's face sheet showed he/she admitted to the facility with the following diagnoses: -Hemiplegia (paralysis of one side of the body) following unspecified cerebrovascular (related to the brain and its blood vessels) disease affecting the left non-dominant side. -Type 2 Diabetes Mellitus. Observation on 8/6/23 at 2:35 P.M. of CNA H performing a transfer with a sit-to-stand lift of the resident showed: -He/She entered the room without washing or sanitizing his/her hands. -He/She with the supervision of LPN A connected the resident to the lift sling and used the lift to stand the resident up. -He/She then wheeled the resident to the bathroom, put on gloves, lowered the resident's pants, and placed the resident on the toilet. -He/She left the bathroom, removed his/her gloves, and did not wash or sanitize his/her hands after exiting the resident's room. Observation on 8/6/23 at 2:44 P.M. of CNA H performing perineal care and transferring the resident to his/her recliner showed: -He/She entered the room without washing or sanitizing his/her hands. -He/She put on gloves, lifted the resident off the toilet, cleaned the resident's perineal area, pulled the resident's pants up, and removed his/her gloves, but did not wash or sanitize his/her hands after removing his/her gloves. -He/She then wheeled the resident back to his/her recliner, lowered the resident into the recliner, removed the sling from behind the resident, placed the sling onto the lift, and wheeled the lift out of the resident's room and into the hallway without washing or sanitizing his/her hands upon exiting or sanitizing the equipment. -He/She walked down the hall to answer a call light in room [ROOM NUMBER] and sanitized his/her hands upon entrance into the room. During an interview on 8/6/23 at 2:51 P.M. CNA H said: -He/She thought the whole process went okay. -He/She would not have done anything differently. -He/She thought he/she performed appropriate hand hygiene throughout the whole process. -He/She would normally perform hand hygiene before and after exiting a resident room and after performing any resident care. During an interview on 8/10/23 at 11:51 A.M. CNA J said: -Hand hygiene should be performed before and after resident care. -All lifts should be sanitized after each use. During an interview on 8/10/23 at 12:01 P.M. CMT B said: -Hand hygiene should be performed when entering and exiting a resident's room, when going from a dirty to a clean task, and any other time the hands could have possibly been contaminated. -Lifts should be sanitized after each use. During an interview on 8/10/23 at 1:00 P.M. RN A said: -He/She thought CNA H did not perform hand hygiene at the appropriate times. -He/She would have expected CNA H to perform hand hygiene upon entering the room, before gloves were worn, after gloves were removed, and before and after performing the perineal care. -Lifts should be sanitized after each use or between every resident. -He/She thought CNA H should have sanitized the lift before moving onto his/her next task. During an interview on 8/11/23 at 11:12 A.M. the DON said: -He/She would expect staff to wash or sanitize their hands before and after resident contact, when going from a dirty to a clean task, and when gloves were removed. -He/She would expect staff to sanitize lifts after each use. 6a. Review of Resident #72's Licensed Nurse's Medication Administration Record (MAR), dated August 2023, showed staff applied a Lidocaine (used to relieve pain) patch to the resident six days in August 2023. Observation on 8/9/23 at 11:01 A.M. showed: -LPN B sanitized his/her hands, dated and initialed the Lidocaine patch, and sanitized hands again. -LPN B observed the resident's skin to ensure no patch was currently in place, removed the backing from the patch, and attempted to place it on the resident. -LPN B had difficulty with the patch getting stuck to his/her ungloved fingers and had to unstick the patch from itself and himself/herself multiple times. -LPN B placed the patch on the resident's left shoulder and covered the resident. During an interview on 8/9/23 at 11:06 A.M., LPN B said he/she probably should have worn gloves but didn't because the sticky backing of the patch gets stuck to his/her gloves. 6b. Review of the resident's face sheet showed he/she was admitted with a diagnoses of Type 2 Diabetes Mellitus. Observation on 8/9/23 at 11:50 A.M. showed: -LPN B sat the glucometer, alcohol wipes, and needle, on the resident's dining room table without a barrier. -LPN B used the needle to obtain blood, placed the blood on the glucometer test strip to obtain a reading, removed the strip once the reading was obtained, and disposed of the strip and needle appropriately. -LPN B, without removing or changing gloves, picked up his/her writing pen and wrote down the results in his/her notebook. -LPN B, without removing or changing gloves, picked up the resident's insulin pen and moved it, used a cleaning wipe to clean the glucometer, then removed his/her gloves and performed hand hygiene. 7. Review of Resident #39's face sheet showed he/she was admitted with a diagnosis of Type 2 Diabetes Mellitus. Observation on 8/9/23 at 11:32 A.M. showed: -LPN B laid all the resident's blood testing supplies, including the glucometer and insulin pen (an injection device with a needle that contains insulin-a hormone that lowers the level of glucose in the blood), on the resident's bedding without a barrier. -LPN B placed a drop of the resident's blood on the glucometer and injected the appropriate amount of insulin via the resident's insulin pen. -LPN B, without changing gloves, picked up the resident's insulin pen and glucometer, sat them on a tray table, and moved the tray table out of the resident's room. -LPN B, still without changing gloves, laid the resident's insulin pen on a notebook where he/she was writing down the glucometer results of multiple residents. -LPN B then cleaned the glucometer while wearing the same gloves used to test the resident's blood. During an interview on 8/9/23 at 11:54 A.M., LPN B said he/she should not have placed the glucometer on the resident's bedding or dining table without a barrier when checking Resident #39's blood sugar. 8. Review of Resident #49's face sheet showed he/she was admitted with a diagnosis of Type 2 Diabetes Mellitus. Observation on 8/9/23 at 11:38 A.M. showed: -LPN B put on gloves, inserted a test strip into the glucometer, stuck the resident's finger with a needle, placed blood on the test strip, removed the bloody test strip and disposed of used supplies. -LPN B, without changing gloves, picked up another resident's insulin pen and moved it. -LPN B, without changing gloves, picked up his/her writing pen and wrote down the results from the glucometer. -LPN B then removed his/her gloves and performed hand hygiene. 9. Review of Resident #43's face sheet showed he/she was admitted with a diagnoses of Type 2 Diabetes Mellitus. Observation on 8/9/23 at 11:42 A.M. showed: -LPN B checked the resident's blood sugar using the glucometer. -LPN B, with the same gloves, picked up his/her writing pen and wrote down the results in his/her notebook. -LPN B, with the same gloves, reached into the clean supplies and removed an alcohol pad, then completed the procedure. 10. Review of Resident #12's face sheet showed he/she was admitted with a diagnosis of gastrostomy (a surgical opening into the stomach- a gastrostomy may be used for feeding, usually via a feeding tube called a gastrostomy tube). Observation on 8/9/23 at 9:45 A.M. showed: -LPN D washed his/her hands, put on gloves, and removed the split gauze (gauze specifically designed to fit around tubing such as enteral feeding tubes). -LPN D removed his/her gloves, did not perform hand hygiene, and went through the treatment cart to obtain additional gauze. -The enteral feeding tube site was pink and no drainage was noted. -LPN D washed his/her hands, put on gloves, opened the gauze, sprayed the enteral feeding tube site with wound cleanser and cleaned the site. -LPN D, without changing gloves, opened an ointment, applied it to his/her second digit of their gloved left hand, and spread it around the site. -LPN D then applied a new, clean split gauze to the site with the same gloves used to clean the exit site. During an interview on 8/9/23 at 10:14 A.M., LPN D said: -He/she should have changed his/her gloves after cleaning the enteral tube feeding site before applying any ointment or placing new, clean gauze. -He/she thought he/she had changed the gloves but was nervous and may have forgotten. 11. During an interview on 8/10/23 at 11:37 A.M., Agency Certified Medication Technician (CMT) A said hand hygiene was required after every glove removal, regardless if the gloves had been soiled. During an interview on 8/10/23 at 12:40 P.M., Agency CNA B said hand hygiene was required after every glove removal without exception. During an interview on 8/10/23 at 12:52 P.M., Agency CMT B said: -Hand hygiene was to be performed after every glove removal. -Staff were not to touch their writing pen with gloves on after obtaining a blood glucose because there could still be blood on the glove which would get transferred to the writing pen. -Glucometers could not be laid on a resident's bed or dining room table. -Glucometers were always to be placed on a barrier. During an interview on 8/10/23 at 2:24 P.M., LPN A said: -After cleaning an enteral tube feeding site, staff were required to remove gloves, perform hand hygiene, then put on new gloves before applying the new dressing or any ointments. -Staff were to perform hand hygiene after every glove removal regardless of what was done with the gloves on. -Glucometers could not be laid on a resident's bed or dining room table. -Glucometers were always to have a barrier underneath it. -Once a blood sugar was obtained with the glucometer, staff were not to use their gloved hands to use their writing pen as the writing pen would then be contaminated. During an interview on 8/11/23 at 9:01 A.M., RN A said: -After cleaning an enteral feeding tube site, staff were to remove their gloves, perform hand hygiene, and put on new gloves before applying a clean dressing. -Hand hygiene was required after every glove removal even if the staff did not touch anything dirty. -Glucometers were required to be sat on a barrier and could not be sat directly on a table or bedding. -He/she believed gloves were required when applying a transdermal patch. -It was really hard to put on a transdermal patch with gloves as the sticky portion got stuck to the gloves so he/she did not wear gloves when applying transdermal patches. During an interview on 8/11/23 at 11:11 A.M., the DON said: -Staff were to perform hand hygiene after removing gloves without exception. -After an enteral tube feeding site is cleaned, staff were to remove their gloves, perform hand hygiene, and put on new gloves before applying a new, clean dressing. -After obtaining a blood sample for glucose testing with a glucometer, staff were not to use their gloved hands to pick up a writing pen. -Glucometers could not be sat directly on bedding or dining table, it was always to be placed on a barrier. -Staff were required to wear gloves when applying a transdermal patch. 2. Review of the facility Infection Surveillance Tracking Log Binder on 8/10/23 at 10:04 A.M., showed: -The facility had a monthly Infection Control log sheet. -The information to be documented was the resident name, type of infection, when the infection started, any medication or treatment ordered, lab work, total monthly infections, total infections by unit, any identified trending and the action plan to be addressed that month to include any education provided. -Six out the nine months did not have the tracking and trending documentation and any education required completed. -Review of the Infection Control log sheets for January, February, March and June of 2023 showed the facility did not have the total number of infections, any trending or education provided. -April 2023, had total of 30 infections and broken down by units and documented no trends noted. -May 2023 had a total of 24 infections and then broken down by units. Did not have trending or action plan documented. -July 2023, total infections broke down by unit. Had documented no trends noted. -The Infection Control Preventionist (ICP) had been logging facility infections on the control log sheet but not always completing the trending and the totals of types of infections. During an interview on 8/10/23 at 12:51 P.M., ICP said: -He/she had completed the training for ICP and training on how to document tracking and trending of facility infections and started taking over in January 2023. -He/she should have completed the Infection Control log sheet that included the tracking and trending and any education provided each month. -Part of the facility process was to send the monthly Infection Control log report to the Regional Nurse Consultant for review. -He/she attended the facility's Quality Assurance (QA) meeting monthly and reported the facility's tracking and trending of infections. -The ICP completed a separate written QA infection surveillance report to present monthly at the QA meetings. Review of the facility QA infection control report dated November 2022 to July 2023 showed: -Under the infection control section the number of residents on isolation, diagnoses, type of infection, COVID-19 (a disease caused by a virus named SARS-CoV-2. It can be very contagious and spreads quickly), received antibiotics, diagnosed with UTI, and infection trending were identified. -July 2023 was only month that education was provided due to a resident at the facility and community with outbreak of Acinestobacter (bacterial infection in blood or urine), and the facility was placed on Enhanced Isolation Precaution. The ICP re-educated wound nurse on proper use infection control. -There was no education documented for November 2022 to June 2023. -The facility was not able to provide 12 months of surveillance. During an interview on 8/10/23 at 1:43 P.M. the Regional Nurse Consultant said: -He/she had been reviewing the facility surveillance and would expect the log to include tracking and trending and totals. -He/she would expect tracking of infections by units on facility mapping or some other format to ensure monitoring for trends was done and to ensure education was provided as needed. During an interview on 8/10/23 at 1:53 P.M., Administrator said: -Infection control surveillance was the responsibility of the ICP. -Audits were part of the review in the monthly QA meetings and the Regional Nurse Consultant also reviewed and completed audits of the surveillance process. -Did not actually have documentation related to the audits completed of the Infection control surveillance. 3. Review of Resident #10's admission Face Sheet showed he/she had the following diagnoses: -Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses). -Anxiety (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus). Review of the resident's comprehensive care plan dated 9/19/2022 showed: -He/she would remain safe while in his/her wheelchair and not slip or fall out of it. -He/she required assistance of two staff members with transfers and care of the resident. Observation on 8/8/23 at 3:55 P.M., of the resident's care and transfer showed: -Agency CNA N and Agency CNA L provided the resident care. -Agency CNA L provided peri-care (cleaning the private areas of a patient) and did not wash or sanitize his/her hands between glove changes and when moving from a dirty to a clean process. During an interview on 8/6/23 at 5:06 P.M. Agency CNA L said: -He/she should have sanitized or washed his/her hands after he/she removed the gloves and between glove changes. -He/she should have sanitized his/her hands when moving from a dirty to a clean process. -He/she had infection control training through his/her staffing agency. During an interview on 8/11/23 08:16 A.M., CNA A said: -He/she would perform hand hygiene before resident cares and after resident care. -He/she would perform hand hygiene when moving from a dirty to a clean process. -Hands should be sanitized between all glove changes. 4. Review of Resident #39's Face Sheet showed he/she was admitted to the facility with a dignosis of Type two Diabetes Mellitus (the body either doesn't produce enough insulin, or it resists insulin) with ketoacidosis coma (it's a serious condition that can lead to diabetic coma or even death). Review of the resident's admission MDS dated [DATE] showed the resident: -Was able to make his/her needs known. -Was moderately cognitively impaired. -Required assistance from staff for all transfers and cares. Observation 8/9/23 at 10:26 A.M., of the resident showed: -Unknown CNA and CNA E transferred the resident to a unclean shower chair. -The shower chair's cross frame bar frame had a brown substance on the frame. -Staff transferred the resident onto the shower chair using a mechanical lift sling and bath sheet underneath the resident's body. During an interview on 8/9/23 at 10:48 A.M., CNA E said: -He/she would normally spray all shower chairs and the showers with a disinfectant spray and wipe them clean after each resident use. -He/she was not aware the shower chair was dirty or he/she would have cleaned the chair again before use. -He/she acknowledged the shower chair had a brown substance on the support bar after it was brought to his/her attention. -The staff who used the shower chair last did not thoroughly clean the chair. -He/she would spray and clean the whole chair including the cross frame bar. -He/she did not check the chair for cleanliness prior to use with the resident. 5. During an interview 8/10/23 at 12:51 P.M., the ICP said: -Staff should perform hand hygiene before and after cares. -Before leaving the resident room. -When moving from a dirty to a clean process/area. -Before and after meals. -Before any contact with a resident. -He/she would expect hands to be washed or sanitized between all glove changes. During an interview on 8/11/23 at 8:49 A.M., Licensed Practical Nurse (LPN) B said: -He/she would expect staff to wash or sanitize their hands between all gloves changes and when moving from a dirty to a clean process/area. -The facility night shift was responsible for cleaning and disinfection of the shower chairs and wheelchairs. During an interview on 8/11/23 at 11:15 A.M., DON and Regional Nurse Consultant said: -Hand hygiene was expected as staff enter the resident's room, prior to and after resident cares, between all glove changes and when moving from a dirty to a clean process/area. -The CNA's would be responsible to ensure the shower chairs were cleaned between each resident, before and after each use. -If staff noticed a brown substance on a shower chair, it should been cleaned immediately. -The shower chairs were to be disinfected and deep cleaned daily after use. Based on observation, interview and record review, the facility failed to ensure handwashing was done to prevent cross contamination during incontinence care for two sampled residents (Resident #56 and #10); to ensure proper cleaning of shower chair before use for one sampled resident (Resident #39), to have an Infection Surveillance Program that included adequate documentation and monitoring for all residents infections; to ensure proper hand hygiene was completed during a transfer with a sit-to-stand lift (an assistive device used to aide a person in transfer who can still bear weight to the lower extremities) and perineal care for one supplemental resident (Resident #2); to ensure staff wore gloves while handling a medicated patch that was absorbed through the skin for one sampled resident (Resident #72); to prevent cross-contamination while using a glucometer (a device for measuring the concentration of glucose in the blood, typically using a small drop of blood placed on a disposable test strip that sits in the machine) for three sampled residents (Resident #39, #49, and #72) and one supplemental residents (Resident #43); and to perform hand hygiene during enteral feeding tube (a method of supplying nutrients directly into the gastrointestinal tract) site care for one sampled resident (Resident #12) out of 19 sampled residents and 10 supplemental residents. The facility census was 66 residents. Review of the facility's policy titled Cleaning and Disinfection of Resident Care Equipment dated 10/24/23 showed reusable items (equipment that is designated reusable by more than one resident) were to be cleaned, disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment). Review of the facility's policy titled Hand Hygiene dated 10/24/22 showed: -Facility staff, visitors, and volunteers must perform hand hygiene by washing hands with soap and water in between glove changes. -Facility staff, visitors, and volunteers must perform hand hygiene with an alcohol-based hand hygiene product: --Immediately upon entering a resident occupied area regardless of glove use. --Immediately upon exiting a resident occupied area regardless of glove use. -The use of gloves did not replace hand hygiene procedures. Review of the facility's policy titled Transdermal [a route of administration where active ingredients are delivered through the skin] Patches dated 10/24/22 showed: -A transdermal patch consisted of several layers. The layer closest to the skin contained a small amount of the drug to allow for prompt introduction of the drug into the bloodstream. -Staff were to put on gloves, remove the old patch, clean the site to remove traces of old medication, and pat dry. -Staff were then to write the date, time, and initial on the new patch and remove the clear plastic backing without touching the adhesive surface. -Staff were then to apply the new patch to clean, dry skin, then remove gloves and perform hand hygiene. Review of the facility's policy titled Blood Glucose Monitoring dated 10/24/22 showed: -Staff were to clean the glucometer after each use. -After the blood was tested and the machine had given a reading, staff were to remove the blood strip and discard, then remove gloves and perform hand hygiene. -Staff were then to put on new gloves, disinfect the glucometer, remove gloves, and perform hand hygiene again. Review of the facility's policy, titled Feeding Tube-Site Care dated 10/24/22 showed: -The policy did not address hand hygiene or the changing of gloves during care. 1. Review of Resident #56's Face Sheet showed he/she was admitted on [DATE], with diagnoses that included: -Urinary tract infection (UTI common infections that happen when bacteria, often from the skin or rectum, enter the urethra). -Muscle weakness. -Pain. -Heart failure. -Low iron. -High blood pressure, -Arthritis. -Edema (fluid in the tissues). -Fall history. -Pressure sores (areas of damage to your skin and the tissue underneath from prolonged pressure on the skin). Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 5/1/23, showed the resident needed extensive assistance with bed mobility, transfers, bathing, toileting and was incontinent of bowel and bladder. Review of the resident's Care Plan dated 7/19/23 showed the resident had a self-care performance deficit. Interventions showed: -The resident required extensive assist by staff to dress. -The resident required extensive assist by one to two staff. -The resident was totally dependent on two staff for transferring. -The resident required a mechanical lift for transfers. -The resident had urine and bowel incontinence. Observation on 8/7/23 at 9:29 A.M., showed the resident was sitting in his/her wheelchair dressed for the weather in his/her room. He/she said he/she was in pain from sitting on his/her bottom and wanted to lay down. Certified Nursing Assistant (CNA) F and CNA A washed their hands using the paper towel to turn off the faucet. They then donned gloves. The following occurred: -CNA A removed the foot pedals on the resident's wheelchair and moved the mechanical lift over to the resident while CNA F pulled the resident's privacy curtain and attached the sling to the lift. -CNA F lifted the resident while CNA A assisted with positioning the resident and moving the resident to his/her bed. -They rolled the resident to the side to remove the sling then they began to complete incontinence care. -CNA F pulled several wipes from the container to begin cleaning the resident bowel movement with one wipe one swipe. -Both CNA's then rolled the resident to the side and CNA F continued to clean the resident's bottom while CNA A held the resident on his/her side. -CNA F used the same gloved hands to reach back into the wipe container to get more wipes to continue cleaning the resident. At one point, during cleaning the resident, CNA F changed gloves and continued to clean the resident's bottom. -After cleaning the resident, and without de-gloving, washing or sanitizing his/her hands, CNA F placed a clean brief under the resident. -CNA F, without de-gloving washing or sanitizing his/her hands, assisted with rolling the resident on his/her side to finish placing the brief under the resident. -CNA A placed the soiled brief, wipes and bed pad into the trash. -CNA F bagged the trash. -Both CNA's then removed their gloves. CNA F went to the sink to wash his/her hands while CNA A without washing or sanitizing his/her hands, lowered the resident's bed, put the floor mats on the floor next to his/her bed put the call light within the resident's reach and made the resident comfortable. -CNA A then washed his/her hands, turning off the faucet with a paper towel. During an interview on 8/11/23 at 9:15 A.M., CNA G said: -They should wash their hands upon entering the resident's room, -When performing cares they wash their hands then glove and provide care. -They were supposed to wash or sanitize their hands after cleaning the resident then re-glove and put on the clean brief. -They were supposed to wash or sanitize their hands before they leave the resident's room. -If they were cleaning bowel, they should de-glove and wash their hands after cleaning the resident then re-glove and put a new brief on the resident. During an interview on 8/11/23 at 9:25 A.M., CNA A said: -They were supposed to wash their hands upon entering the resident's room and glove. -When providing incontinence care, they were to wash or sanitize their hands each time they remove their gloves. -They should de-glove and wash or sanitize their hands before putting a clean brief on the resident and doing clean tasks. -If they were cleaning bowel, they should wash their hands after removing gloves if possible, but they should otherwise sanitize their hands before starting a clean task. During an interview on 8/11/23 at 9:35 A.M., Registered Nurse (RN) A said: -Nursing staff should wash their hands upon entering the resident's room and glove before providing any resident care. -When providing incontinence care they should complete the care then de-glove and wash or sanitize their hands before starting the clean task. -After completing the care, they should wash their hands again before leaving the resident's room. During an interview on 8/11/23 at 11:24 A.M., the Director of Nursing (DON) said: -Handwashing should be completed upon entrance into the resident's room, before the procedure/care, before starting a dirty task, before starting a clean procedure, and before leaving the resident's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to keep the kitchen, dry storage room, walk-in refrigerator, and walk-in freezer floors clean; to maintain sanitary utensils and food preparation equipment; to safeguard against foreign material from possibly getting into food and/or beverages; to keep trash dumpster's and garbage receptacles lidded; to properly document food temperatures to ensure they were suitably stored to lessen the chance of bacterial contamination; to follow correct hand/hair hygiene practices; to separate damaged foodstuff; to store food within acceptable temperature parameters; and to ensure the proper labeling, refrigeration, and/or disposal of foodstuffs to prevent the harboring and/or feeding of pests, in accordance with professional standards for food service safety. These deficient practices had the potential to affect all residents, visitors, volunteers, or staff who ate food from the kitchen. The facility's census was 91 residents with a licensed capacity for 130 residents at the time of the survey. Record review of the facility Cleaning Schedule for Dietary Services Policy dated 10/24/22 showed: -Purpose: The dietary staff will maintain a sanitary environment in the dietary department by complying with the routine cleaning schedule developed by the Dietary Manager (DM). -Policy: The dietary staff will maintain a sanitary environment in the dietary department by complying with the routine cleaning schedule developed by the Dietary Manager. -Procedure: -The Dietary Manager will develop a cleaning schedule that includes the frequency of which equipment and areas are to be cleaned. --The cleaning schedule is posted weekly. --The cleaning schedule includes tasks assigned to specific positions within the dietary department. --Dietary staff will initial next to the assigned task once it is completed. -The Dietary Manager monitors the cleaning schedule to ensure compliance. Record review of the facility Cart Cleaning Dietary Services Policy dated 10/24/22 showed: -Purpose: To establish guidelines for the cleaning of carts in the dietary department. -Policy: Carts will be sanitized after each meal. -Procedure: --Sanitation after each meal: ---Wash inside (sides, top, bottom, tray glides and inside of door) with detergent solution and a clean cloth. ---Rinse the inside of the cart with clean, warm water and a clean cloth. ---Sanitize using sanitizing solution and a clean cloth. ---Allow the inside of the cart to dry. --Weekly Sanitation: ---Wash inside (sides, top, bottom, tray glides and inside of door) with detergent solution and a clean cloth. ---Rinse the inside of the cart with clean, warm water and a clean cloth. ---Wash the wheels and casters with a brush and detergent solution. ---Rinse with clean water. Remove excess water with a squeegee. ---Sanitize using sanitizing solution and a clean cloth. ---Allow the inside of the cart to dry. Record review of the Oven - Conventional (Gas) - Operation and Cleaning Policy dated 10/24/22 showed: -Purpose: -To establish guidelines for the use and cleaning of the conventional oven. -Policy: -The dietary staff will operate the conventional oven according to the manufacturer's guidelines. The conventional oven will be cleaned after each use. -Procedure: --Sanitation of Equipment: ---Remove spills, spillovers, and burned food deposits from the over as soon as practicable. Record review of the facility Food Storage Dietary Services Policy dated 10/24/22 showed: -Purpose: -To establish guidelines for storing, thawing and preparing food. -Policy: -Food items will be stored, thawed, and prepared in accordance with good sanitary practice. Record review of the facility Food Temperatures Dietary Services Policy dated 10/24/22 showed: -Purpose: -To provide the dietary department with guidelines for food preparation and service temperatures. -Policy: -Foods prepared and served in the facility will be served at proper temperatures to ensure food safety. 1. Review of the undated A.M. (morning) [NAME] duties showed: -Cleaning duties including; --Wash cooking pots and pans. --Wipe down counters and steam table on cook side. --Sweep the cook side. Review of the undated A.M. Dietary Aide duties showed: -Clean and restock drink cart. -Empty and take out trash. -Sweep the aide side of the kitchen. Review of the undated P.M. (evening) [NAME] duties showed to sweep and mop the kitchen. Review of the undated P.M. Dietary Aide duties showed to wipe down all carts. Review of the local County Community Health Services Inspection report dated 5/9/22 showed: -Violation - Non-food contact surfaces clean. -Comments: Under carriage/under shelves of food prep area and food serve area over steam table in dining room have minor accumulation of food residues. -Corrective Action: Clean non-food contact areas on a regular schedule to keep clean to sight and touch. Observations on 6/1/23 between 11:01 A.M. through 12:59 P.M. showed: -Two food service warmers just outside the kitchen. -One warmer plugged in. -Both warmers were soiled with dried food along the sides, tray glides and bottom. -All prepared desserts were set up with no covering. -Scrambled eggs, standing water and debris on the floor of the dishwashing area. -Dried food splatter on the mixer. -Residue on the food prep area around the cook books. -Burnt food/spillage in the bottom of the oven. -Dark residue around the grill. -Dried food splatter on and around the tilt skillet and the wall behind the skillet. -Trash, food and debris under the food prep table. -Food and food-like particles on the shelving under the food prep table. -Brownish/black substance on the inside of the juice machine and dispensing ports. -Employee fanny pack on the drink storage shelf. -Debris and trash on the floor in the dry storage area. -Large trash can with no lid. -Expired Dijon mustard dated 10/9/22. -Two open drinks for employee consumption on the food prep table. -Staff cellular phone and ear phones on the food prep table. -Undated/unlabeled cut onion wrapped in plastic in walk in refrigerator. -Plate with brown lettuce and boiled eggs undated and unlabeled in the walk in refrigerator. -Two plastic bags with what resembled hot dogs undated and unlabeled in the walk in refrigerator. During an interview on 6/1/23 at 11:12 A.M., [NAME] A said: -Today is the first day he/she has observed refrigerator temperatures taken. -The DM is responsible for the items in the refrigerator. During an interview on 6/1/23 at 12:28 P.M., Certified Nursing Assistant (CNA) A said: -Room trays had been disorganized lately, taking around 45 minutes to deliver the room trays to residents. -He/she had only seen one food warmer for room trays, but has always served from the open aluminum racks also. -It was not uncommon to have to return to the kitchen several times to correct the meals for the residents. During an interview on 6/1/23 at 12:43 P.M., the DM said: -He/she did not understand why the staff were serving room trays from the open racks covered with plastic bags. -He/she expected room trays to be delivered within 20 minutes. -He/she expected salads, desserts and drinks to be covered for room trays. -The last tray was observed being delivered at 12:50 P.M., which most likely was not at the acceptable serving temperature. -He/she did not know why the staff did not use the warmers for the room trays. -He/she was unable to explain why the warmer carts were not clean. -The dietary staff were responsible for cleaning the carts. -He/she agreed that both warmer carts were soiled and not clean enough for use. -When asked to review prior logs for the refrigerator and freezer temperatures, he/she said there were no temperature logs prior to 6/1/23. -He/she was responsible for checking the food in the walk in refrigerator for labels and dates. -He/she educated the staff on checking labels. -He/she could not explain why there was an expired jar of Dijon mustard in the walk in refrigerator. -He/she acknowledged brownish/black substance on the juice machine and did not know when the machine had last been serviced. -He/she acknowledged the trash under the food prep table and did not know when it had been swept and mopped last. -He/she expected staff to sweep and mop every evening. -He/she acknowledged two open drinks on the prep table belonging to employees. -He/she acknowledge the employee fanny pack on the drink shelf. -He/she expected staff to store drinks and personal items outside of the kitchen area. -He/she acknowledged the scrambled eggs, debris and water on the floor in the dishwashing area. -He/she expected the staff to sweep and mop, if needed, between each meal. -He/she acknowledged the food splatter on the mixer. -He/she expected staff to clean the mixer after each use. -He/she acknowledged the food and food-like debris on the shelving under the food prep area. -He/she expected staff to clean areas daily and as needed. -He/she acknowledged the burnt food and spillage in the bottom of the oven. -He/she expected staff to clean as needed. -He/she acknowledged the food splatter on and around the tilt skillet. -He/she expected staff to clean after each use. -He/she acknowledged the undated and unlabeled food in the walk in refrigerator. -He/she expected staff to date and label all leftover food prior to placing in the refrigerator for storing. -He/she acknowledged the trash and debris in the dry storage area. -He/she said there were no check off lists or duties to hold staff accountable. 2. Record review of Resident #1's Annual Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 4/6/23 showed the resident was cognitively intact. During an interview on 6/1/23 at 1:45 P.M., the resident said: -He/she had chosen to eat his/her room at all times. -Meal trays were often delivered up to an hour and a half late. -His/her lunch tray comes as late as 1:45 P.M. -Most of the time the food was not hot and needs to be reheated. During an interview on 6/1/23 at 1:56 P.M., Certified Medication Technician (CMT) A said room trays are usually served on the open aluminum racks. Record review of the Resident #2's admission MDS dated [DATE] showed the resident was cognitively intact. During an interview on 6/1/23 at 2:48 P.M., the resident said there are times when the food was not warm enough to eat. Review of the Resident #3's Quarterly MDS dated [DATE] showed the resident was cognitively intact. During an interview on 6/1/23 at 2:32 P.M. the resident said: -The food delivered on the room trays has been cold. -The food was cold almost every day. -Food was delivered up to three hours late. -He/she was concerned about not being able to get and to eat the food delivered due to his/her diabetes. During an interview on 6/1/23 at 3:13 P.M., the Administrator said: -There were no temperatures documented prior to 6/1/23. -The food in the walk in refrigerator should have been labeled and dated. -There should have been someone cleaning in the kitchen area. During an interview on 6/1/23 at 3:30 P.M., with Dietary Aide A said: -He/she did not see anyone check the food temperatures on the room trays. -It is the cook's responsibility to clean the kitchen. -Sometimes the aides clean in the kitchen. During an interview on 6/1/23 at 3:37 P.M., Dietary Aide B said: -He/she was not sure who is to take temperatures in the refrigerator and freezer. -Everyone was supposed to clean in the kitchen. -The dishwasher person was supposed to clean the juice machine. -He/she did not know who was supposed to clean the equipment in the kitchen. During an interview on 6/1/23 at 3:43 P.M., [NAME] B said: -Room tray temperatures were taken prior to the food being prepared for delivery and are not checked again after leaving the kitchen. -He/she expected the room trays to be delivered from the hot covered carts. -Although the Cooks were in charge of the room tray set up he/she does not pay attention to what the room trays are put in for delivery. -He/she had concerns about the area under the prep table not being cleaned. -He/she did not know who was responsible for cleaning under the prep table. -The Cooks were responsible for cleaning the equipment. - Only one person was taking temperatures in the refrigerator and freezer. -He/she looked at the temperatures but did not write anything down. -The acceptable range for the refrigerator temperature should not be above 60 degrees Fahrenheit and the freezer should not be below 30 degrees Fahrenheit. During an interview on 6/1/23 at 4:00 P.M., the DM said: -He/she just put logs in the kitchen for the refrigerator and freezer temperatures to be logged and tracked. -At that time there had been no delegation of duties for cleaning. -The local county inspection was on 5/4/23 and they revisited on 5/9/23 to clear the violations cited. During an interview on 6/1/23 at 4:20 P.M. the local county health department said: -The facility was cited deficiencies in the kitchen on 5/4/23. -A revisit was done on 5/9/23 with remaining concerns with the cleanliness of the kitchen. - The plan was for the facility to put a cleaning schedule in place for accountability. Observation on 6/6/23 between 11:13 A.M. and 11:21 A.M. showed: -One hot cart soiled with food residue on the sides, tray rails and the bottom. -Large trash can in the kitchen with no lid. -Dietary Aide C was observed eating candy with one gloved hand and one bare hand. -The floor was littered with food and debris in front of the walk in refrigerator. -Dietary Aide B was observed not washing his/her hands prior to applying gloves. -There was a waffle, a bowl, a soda bottle and other trash and debris was under the food prep table. During an interview on 6/623 at 11:40 A.M., [NAME] C said: -Cleaning under the food prep table has not been getting done but maybe once per week. -When asked who worked and was supposed to clean on the evening of 6/5/23, he/she was the [NAME] on duty and he/she did not clean under the food prep table. -The Dietary Aides were supposed to use the hot carts to send room trays. -The only reason not to use the hot carts would have been if one was broken. -He/she expects everyone to wash hands every time they take their gloves off. -The DM was the only one checking refrigerator and freezer temperatures once daily. -Room tray temperatures were only taken prior to sending out of the kitchen. Observation on 6/6/23 between 12:48 P.M. and 12:58 P.M. showed: -CNA removed room trays from the hot cart, place it on an open cart, and traveled from hall to hall delivering room trays. -The last room tray delivered was a Quesadilla, showed a temperature of 110.2 degrees Fahrenheit. - The coffee was 116.4 degrees Fahrenheit. During an interview on 6/6/23 at 1:29 P.M., CNA B said: -He/she was trained to take the trays from the hot cart and place them on an open cart to delivery to each room. -The drinks should be covered. -Coffee should be poured right before taking it into the resident room on the tray. -Food trays should be left in the hot cart until taken into the resident room to maintain the temperatures. During an interview on 6/6/23 at 1:39 P.M., the Administrator said: -He/she expected food delivery temperatures to be above 135 degrees Fahrenheit for hot food and below 40 degrees Fahrenheit for cold food. -He/she expected room trays to be left in the hot cart until delivered to the resident room. -The refrigerator and freezer temperatures were being taken in March, but when the old DM left all the logs and information was taken and had not yet been replaced. -The new DM was hired about a month ago and is currently training for the position as well as trying to train the dietary staff. -He/she expected cleaning to be done at a bare minimum. -He/she expected staff to be washing hands in the kitchen per policy. -He/she expected all trash cans to be covered with lids in the kitchen. -It was not appropriate to eat with gloves and not to wash hands after eating in the kitchen area. -Personal items of any kind should not be in the kitchen or on food prep areas in the kitchen. -All leftovers should be labeled and dated. -Equipment should be cleaned after every use. -He/she expected there should be no trash, food or other debris under the food prep table. -There should not be food on the floor of the kitchen. MO00218689

Based on interview and record review, the facility failed to ensure that for one sampled resident, (Resident #1) out of four residents who were sampled as new admissions to the facility, admission orders were activated in the facility system and sent to the pharmacy in a timely manner. This resulted in a delay in the facility receiving the resident's medications, a medication not given to the resident on 5/5/23 at bedtime (HS), and morning medications on 5/6/23 either not given or given late. Additionally, Registered Nurse (RN) A and RN B failed to follow the facility protocol when a resident's medications were unavailable. The facility census was 70 residents. Review of the facility's undated Medication Not Available Procedure policy showed: -The charge nurse should be informed if a medication is not available. -The emergency kit (e-kit) should be checked to see if the medications were available. -If the medications were not available in the e-kit, the physician should be contacted for an alternative order or an order to hold the administration. -The relevant pharmacy should be contacted to ensure the medications were ordered properly. -A nursing note should be charted that all the steps were completed. Review of the facility pharmacy's delivery information sheet dated 12/22/21 showed: -For new residents, the face sheet with billing information and new orders should be sent to the pharmacy. -The original physician's order should be sent as soon as it was written. -First doses might be available from the e-kit. -The pharmacy deliver windows were 2:30 P.M. to 5:30 P.M., with a cut off time of 11:00 A.M. and 8:30 P.M. to 11:30 P.M., with a cut off time of 5:00 P.M., Monday through Friday, and 6:30 P.M.-9:30 P.M. with a cut off time of 5:00 P.M. on Saturdays. -Emergency or stat (immediate) orders should be called and faxed directly to the pharmacy. -All emergency requests outside of scheduled delivery times should be called to the pharmacy. Review of the Insulin Detemir (Levemir) web site on 5/25/23 showed: -This medication should not be taken if a person were having an episode of low blood sugar. -Before taking this medication, a person should ask his/her provider when blood sugar levels should be checked. -This medication could cause a serious side effect of low blood sugar, including dizziness, light-headedness, sweating, confusion, headache, blurred vision, slurred speech, shakiness, fast heartbeat, anxiety, irritability, mood changes and hunger. 1. Review of Resident #1's admission Record face sheet dated 5/5/23 showed he/she admitted to the facility with the following diagnoses: -Type 2 diabetes mellitus (a chronic disorder which affects how the body regulates blood sugar), with diabetic chronic kidney disease, (a long-term condition of the kidneys that can occur in individuals with poorly controlled blood sugar). -Hypertensive chronic kidney disease (a condition where long term high blood pressure that has caused damage to the kidneys). -Peripheral vascular disease (a condition that affects the blood vessels outside the heart and brain, mainly the blood supply to the limbs). -Chronic diastolic congestive heart failure (abnormal filling of the heart when the heart muscle becomes stiff and does not relax properly). -Depression (a mental health disorder characterized by persistent feelings of sadness and loss of interest or pleasure in activities). -Acquired absence of right leg below the knee. Review of the resident's Progress Note dated 5/5/23 at 9:12 P.M. showed the resident arrived at the facility from the hospital at 5:15 P.M. Review of the facility's Order Audit Report for the resident on 5/5/23 showed License Practical Nurse (LPN) A activated the resident's orders on 5/5/23 at 9:10 P.M. Review of the resident's Order Summary Report dated 5/5/23 showed: -Insulin Aspart Injection Solution 100 units per milliliter (ml) (a rapid acting medication used to manage diabetes mellitus), 7 units should be injected subcutaneously (beneath the skin) three times a day for diabetes mellitus. This should be held if blood sugar was less than 100, and the physician notified if the blood sugar was less than 60. The start date of the order was 5/5/23. -Insulin Detemir Solution 100 units/ml (a long acting insulin designed to provide a prolonged and consistent release of insulin), 40 units should be injected at bedtime (HS) for diabetes. The start date of the order was 5/6/23. --NOTE: The orders did not include an order to monitor the resident's blood sugar, including how often to perform blood sugar testing. -Linagliptin, 5 milligrams (mg) oral tablet (a medication used to treat type 2 diabetes). One tablet should be given by mouth in the morning for diabetes mellitus. The start date of this order was 5/6/23. -Amlodipine Besylate 10 mg oral tablet (a medication used to treat high blood pressure). One tablet should be given by mouth in the morning for high blood pressure. The start date of this order was 5/6/23. -Aspirin 81 mg oral tablet (a medication used to treat pain, fever and inflammation). One tablet should be given in the morning for prophylaxis, (measure taken to prevent disease or infection). The start date of this order was 5/6/23. -Cilostazol 100 mg oral tablet (a medication used to treat peripheral vascular disease). One tablet should be given by mouth in the morning for peripheral vascular disease. The start date of this order was 5/6/23. -Citalopram Hydrobromide 40 mg oral tablet, (a medication used to treat depression). One tablet should be given by mouth in the morning for depression. The start date of this order was 5/6/23. -Clopidogrel Bisulfate oral tablet 75 mg (a medication used to reduce the risk of blood clots). One tablet should be given in the morning for peripheral vascular disease. The start date of this order was 5/6/23. -Furosemide 40 mg oral tablet (a medication to treat fluid retention). One tablet should be given twice a day for congestive heart failure. The start date of this order was 5/6/23. -Meloxicam 15 mg oral tablet (a medication used for pain and inflammation). One tablet should be given by mouth in the morning for pain. It should be given with food. The start date of this order was 5/6/23. -Metronidazole 500 mg oral tablet (a medication used to treat infections). One tablet should be given three times a day for prophylaxis for 35 days. The start date of this order was 5/6/23. -Metroprolol Succinate 25 mg extended release (a medication used to treat high blood pressure and certain heart diseases). One tablet should be given by mouth in the morning for congestive heart failure. This should be held if pulse is less than 60 or systolic blood pressure, (the first number in a blood pressure reading) is less than 100. The start date of this order was 5/6/23. -Pantoprazole Sodium, 40 mg oral tablet delayed release, (a medication used for treating some digestive conditions). One tablet should be given by mouth in the morning for reflux disease (a chronic condition in which stomach acid and sometimes stomach contents flow backward). The start date of this order was 5/6/23. -Potassium Chloride 10 milliEquivilants (mEq) extended release tablet. One tablet should be given by mouth in the morning for potassium maintenance. -Spironolactone 25 mg oral tablet (a medication to treat high blood pressure and fluid retention caused by other underlying conditions). One tablet should be given in the morning for congestive heart failure. The start date of this order was 5/6/23. -Varenicline Tartrate 1 mg oral tablet (a medication used to help people quit smoking). One tablet should be given by mouth twice a day for depression. The start date of this order was 5/6/23. Review of the resident's Licensed Nurse's May 2023 Medication Administration Record (MAR) showed: -He/she was not given 40 units Insulin Detemir Solution at bedtime. -He/she did not have his/her morning blood sugar checked. -The morning dose of Insulin Aspart 7 units was not given. -His/her blood sugar was 228 at 11:58 A.M. --NOTE: The orders did not include an order to monitor the resident's blood sugar, including how often to perform blood sugar testing. Review of the resident's May 2023 Certified Medication Technician (CMT) MAR showed: -Cilostazol, 100 mg oral tablet was not given. -Citalopram Hydrobromide, 40 mg oral tablet was not given. -Linagliptin, 5 mg oral tablet was not given. -Metronidazole, 500 mg oral tablet was not given. -Meloxicam, 15 mg oral tablet was not given. -Metroprolol Succinate, 25 mg extended release was not given. -Pantoprazole Sodium, 40 mg oral tablet, delayed release was not given. -Varenicline Tartrate 1 mg oral tablet was not given. Review of a personal log notebook kept by RN B showed on 5/6/23, he/she did not do a morning blood sugar on the resident and that the resident had a blood sugar of 228 at midday. Review of the resident's Progress Notes dated 5/6/23 at 2:07 P.M. showed at 1:45 P.M., the resident stated he/she wanted to leave the facility because he/she was not getting his/her medications. Review of the resident's Progress Notes dated 5/6/23 at 4:22 P.M. showed: -He/she had been thinking about leaving the facility against medical advice (AMA) all morning. -He/she signed out to go to dinner at 3:15 P.M. and called a short time later to state he/she was not coming back. During an interview on 5/18/23 at 11:05 A.M., RN B said: -He/she worked the day shift on 5/6/23. -When the resident arrived, his/her orders should have been activated immediately and pharmacy would get them (medications) stat(right away). -The facility had not yet received the resident's medications that morning. -He/she thought the CMT pulled some of the medications from another cart. -They were working on getting the medications, so he/she did not call the physician. -If a resident did not have medications, they possibly could have been pulled from the e-kit, so there was nothing the physician could do. -He/she got busy and missed checking the resident's blood sugar. -If the insulin order was not opened, the prompt to do that blood sugar did not come up on the computer. -He/she was aware that he/she needed to do the blood sugar and definitely did not give the insulin. During an interview on 5/18/23 at, the Assistant Director of Nursing (ADON) said: -He/she was on call and saw the resident on 5/6/23 for wound care. -The resident was seen by around noon and told him/her he/she had not had any medications, and was talking about leaving the facility AMA. -He/she got LPN A and had him/her pull as many medications as possible from the e-kit and they were given. -The ADON or the Director of Nursing (DON) would enter admission orders into the computer themselves to make sure they are correct. -The DON put the resident's admission orders in the computer, and there was possibly a miscommunication about whether the orders had been activated. -The resident was not given her HS insulin because the orders were activated around 9:00 P.M., and they had to be activated by 7:00 P.M. in order for the facility system to populate them on the MAR. -He/she watched RN B give the noon dose of insulin and instructed LPN A to get the other medications. -When the DON became aware the medications had not come, he/she called pharmacy and ordered them stat. -The main issue was that the resident's morning medications were given late, in spite of the facility's liberal medication pass schedule, or were not given at all. -If medications were not available, the nurse should call the ADON or the DON, pull medications from the emergency kit, if possible, and call the physician. -RN B did not call the physician. He/she should have followed protocol, which was to check the emergency kit, and if the needed medications were not available, should have called the pharmacy and the physician. -The physician should have been called, no matter what. -This was an issue that needed re-education with the nurse so he/she would know what should be done. -Scheduled medications were not typically given on the night shift, so the night shift nurse would have no reason to call the physician or pharmacy. -The pharmacy did not make morning deliveries. -The resident's medications came from pharmacy after the resident had already left the facility. During an interview on 5/18/23 at 12:05 P.M., LPN A said: -He/she was working the evening shift on 5/5/23 when the resident was admitted , but was not assigned to his/her hall. -He/she did make sure the resident's admission assessment had been started, and that orders had been activated. -The resident's orders had not been activated, so he/she activated them on 5/5/23 at 9:10 P.M -When activated, the orders should automatically go to pharmacy. -Usually, this was the first thing that should be done when a resident arrived at the facility and it was a manual process. -He/she called the DON and let him/her know the orders had not been activated and that he/she had done it. -He/she did not open the resident's chart since he/she was not assigned to him/her. -He/she came in to work again at 10:00 A.M. on 5/6/23 to do treatments. -He/she became aware that the resident had not been given morning medications, so he/she pulled the orders and gave the medications. -Even though the facility had not yet received the resident's medications from pharmacy, he/she got the ones that were available from the emergency kit. -He/she explained the medications to the resident and what they were for when he/she gave them. -The RN gave the insulin. During an interview on 5/18/23 at 12:30 P.M., RN A said: -He/she admitted the resident. -He/she did the resident's assessments. -Pharmacy may have come to the facility to make a delivery around midnight, which was a typical delivery time from the pharmacy. -Pharmacy did not make morning deliveries. -He/she was responsible for two halls and was very busy, so the resident's orders were delayed in getting activated. -He/she told Licensed Practical Nurse (LPN) A, and he/she activated the resident's orders for him/her. -If a medication were not available, the e-kit could be checked. -If an equivalent medication were not available, pharmacy should be called to make a stat delivery. -The physician should be called to get an equivalent order until the ordered medication arrived. -He/she would have given the HS insulin if he/she had seen it, however it had not populated on the MAR. -The DON entered the orders for that resident in the computer when he/she got the discharge information from the hospital. -They (the facility staff) don't activate the orders until the resident actually is on the facility premises. During an interview on 5/18/23 at 2:05 P.M., CMT A said: -If the medications were not available, he/she would notify the charge nurse. -The nurse could possibly get the medications from the e-kit. -Either he/she or the nurse could call the pharmacy to let them know the resident needed the medications stat. -The nurse should notify the physician if the resident could not get his/her medications. -Typically the nurse should call the DON if there was a new admission. -If a medication was not available, he/she could not just chart that it was unavailable, but would have to let the charge nurse know and call the pharmacy. During an interview on 5/18/23 at 2:15 P.M., LPN B said: -If he/she were getting a late admission, he/she would fax the resident's medication orders to the pharmacy, if after 3:00 P.M -The pharmacy should be told the medication orders should be delivered stat. -Even if someone else put the orders in the computer, the nurse admitting the resident would be responsible for checking the orders, the resident's diagnoses and admission paperwork. -If a medication was not on the medication cart, the medication room, where overflow medications were stored, should be checked. -If the medication were not in there, he/she would call the pharmacy to find out what was going on. -Medications could be pulled from the emergency kit if available. -The nurse should call the physician to notify if a medication was not available, and possibly get an alternative order. -A CMT could also call the pharmacy and should notify the nurse, who could pull the medication from the emergency kit or call the physician. During an interview on 5/18/23 at 2:30 P.M, CMT B said: -When an admission came, the charge nurse should be notified, who would notify the DON. -If a medication were unavailable, the charge nurse would be notified who could possibly pull the medication from the emergency kit, the medication room overflow medications should be checked, and the pharmacy should be called. During an interview on 5/18/23 at 2:45 P.M., the DON said: -The admitting nurse did not activate the resident's orders until around 9:00 P.M. on 5/5/23. -The resident should have had a morning blood sugar. His/her first one was done at 11:58 A.M. on 5/6/23. -Blood sugar monitoring was not included on the resident's admission orders. -Blood sugars were tied to insulin administration orders. -The policy for medications that were not available was printed and laminated and on every medication cart and at the nurses' stations. -If a medication was not available, the charge nurse should be notified. -If the charge nurse could not get the medication from the e-kit, the physician should be notified. -It was not normal to wait four hours to activate admission orders. -Late admissions require special handling. -LPN A caught that the resident's orders had not been activated and activated them. -Because of the time they were activated, the orders probably would not have shown up on the nurse's MAR. -A blood sugar was not typically done with long-acting insulin. -The charge nurse should have notified the physician that medications were not available. -The day shift CMT should have told the charge nurse the resident's medications were not available, or could have followed the facility protocol herself, except for pulling medications from the e-kit, which the nurse would do. -RN B should have seen that a blood sugar and insulin were due and could have pulled the insulin from the e-kit, because insulins are available in the e-kit. He/she should have known the process. -The day before this happened, he/she was told by a staff person at the pharmacy that if orders were activated by 10:00 P.M., they did not need any other special communication. -The next day, the same pharmacy staff person told him/her they needed to have a call for a new admission, so this was not just the fault of RN A or LPN A. -He/she was not made aware of the situation with the medications until the resident threatened to leave AMA. -On 5/6/23, the manager on duty notified him/her at 1:48 P.M. that the resident's medications had not arrived and that the resident wanted to go home. During an interview on 5/18/23 at 3:25 P.M., the Administrator said: -The admitting nurse should have activated the orders in a more timely manner, and should have called pharmacy to let them know the facility had received a late admit. -The nurse should look at the admission orders, although it could be situational. -In this case, the resident was stable, so with the system the facility had, the nurse might not immediately have read the orders. -The facility had just done education on late admission protocol in April 2023, and a pharmacy representative came out to the facility and spoke at that time. -There were signs all over the facility telling the staff how to do late admissions. -Medications were to be requested stat delivery from pharmacy so they would have at least been available the next morning. -The staff should have followed the protocol for unavailable medications. During an interview on 5/24/23 at 12:18 P.M., Physician A said: -He/she was not aware that the resident did not receive his/her insulin. Staff did not notify him/her of this. -It was his/her expectation that if medications were not available, he/she would be notified so they could be taken from the e-kit or the order modified or another order given. -It was his/her expectation that the admitting nurse would read the resident's diagnosis and admitting orders and be aware of the resident's condition. -He/she wanted to be called so orders could be implemented and the residents could get their medications. During an interview on 5/24/23 at 9:08 P.M., LPN C said: -He/she worked on 5/6/23 on the day shift. -He/she was in charge of the 200 and 400 halls, and the resident was on the 100 hall. -He/she had a CMT for his/her hallways so was not immediately aware that the other halls did not have a CMT. -RN B was in charge of the 100 and 300 hallways and was doing treatments for those halls and did not want to pass medications for his/her hallways, even though there was not a CMT. -The facility scheduler asked him/her if he/she could also pass medications for the other hallways, so he/she did, but he/she was running behind on everything. -He/she did not start passing medications for the 100 and 300 halls until 11:00 A.M. -When a nurse was passing medications as a CMT, they went into the CMT MAR, which would not show medications the nurse would be giving. -He/she never met Resident #1 because he/she had already left the facility, and he/she was told the resident was not coming back. -As a nurse, if he/she knew a resident was diabetic, he/she would look to see if a blood sugar and insulin were needed. -If a medication were not available, he/she would let the charge nurse know and call the pharmacy. -He/she had not had any formal education on a missing medication policy. MO00218071

Based on interview and record review, the facility staff failed to ensure narcotic counts were completed and signed by both the oncoming and outgoing nurses in order to verify the correct count of narcotics. The facility census was 62 residents. The Director of Nursing (DON) was notified on 2/27/23 of Past Non-Compliance which occurred on 2/16/23. On 2/15/23 the Administrator was notified by the Board of Nursing that an employee who no longer worked at the facility may of had a resident's narcotic medication in his/her possession outside of the facility and the local authorities were investigating. The Administrator started an investigation and found the oncoming and outgoing nursing staff were not counting or signing the Controlled Substance Shift Change Count Sheets. The narcotics are to be counted every time the keys changed hands and at shift change. On 2/16/23, all nurses were educated on controlled medication storage and disposal of controlled medication. The Controlled medication storage includes counting controlled medication at shift change and when the keys to the controlled medication box changes hands. The deficiency was corrected on 2/16/23. Record review of the facility's Controlled Medication Storage Policy dated 2007 showed: -Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and record keeping in the nursing care center in accordance with federal, state and other applicable laws and regulations. -The DON and the consultant pharmacist monitor for compliance with federal and state laws and regulations in the handling of controlled medications. -A controlled medication accountability record is prepared when receiving inventory of a Schedule II a medication with a higher potential of dependency and abuse) medication. -At each shift change or when keys are surrendered, a physical inventory of all Scheduled II, including refrigerated items, is conducted by two licensed nurses or per state regulation and is documented on the controlled substance accountability record or verification of controlled substances count report. -The nursing care center may elect to count all controlled medications at shift change. -Current controlled medication accountability records are kept in the Medication Administration Record (MAR) or narcotic book. -When completed, accountability records are submitted to the DON and maintained on file at the nursing care center. 1. Record review of the facility Controlled Substance Shift Change Count Sheet dated 8/9/22 to 8/29/22 showed: -On 8/9/22, start total number of sheets was 33, plus one medication sheet resident unknown, end total number of sheets was 34. -8/10/22 count 31, start total number of sheets was 34, minus one medication sheet resident unknown, end total number of sheets was 33, and Licensed Practical Nurse (LPN) B signed outgoing nurse. -8/10/22 count #2, End total number of narcotic sheet was not counted and oncoming nurse did not sign the Controlled Substance Shift Change Sheet. -On 8/11/22 count #1, start total number of sheets was 33, plus three medication sheets resident(s) unknown, were added then scratched out (error) and four medication sheets resident(s) unknown, were added to the count, end total number of sheets was 36 scratched out (error) and 37 was the end total number of sheets. -8/11/22 count #2, start total number of sheets was 37 sheets, three liquids medication sheets resident(s) unknown, were subtracted from the count, and end total number of sheets had two counts scratched out and a count of 33 with a line through it and a count of 31 sheets. -On 8/12/22 count #1, start total number of sheets was 31 with a line through it and 29 wrote in as count, minus three morphine (pain medication) destroyed resident(s) unknown, no end of shift total number sheets left blank. -8/12/22 count #2, start and end total number of sheets was 29. -On 8/14/22, only one shift count was recorded, start total number of sheets was 29, minus one medication count sheet in the add a new medication count sheet column resident unknown, end total number of sheets was 28, not signed by the oncoming nurse. -Line between 8/14/22 and 8/15/22 showed corrected count was 30 sheets and was signed by oncoming nurse and outgoing LPN B. -8/15/22 count #1, start total number of sheets was 30 and end total number of sheets was 30 signed by oncoming and outgoing nurses. -8/15/22 count #2, start total number of sheets was 30, no end total number of sheets and not signed by the oncoming nurse. -8/15/22 count #3, start total number of sheets was 30, no end total number of sheets and not signed by the oncoming nurse. -8/16/22, only one shift count was recorded, start total number of sheets was 30 and end total number of sheets was 30. -No date or start total number of sheets, minus one medication resident unknown count sheet, plus one medication resident unknown count sheet, end total number of sheets was 29. -8/17/22, only one shift count was recorded, start total number of sheets was 29, minus one medication sheet, end total number of sheets was 29. -Note: Minus a medication sheet and the count stayed the same of 29 sheets for 8/17/22. -8/18/22 count #1, start total number of sheets was 30 and end total number of sheets was 30. --Note: Count is off from 8/17/22. -8/18/22 count #2, start total number of sheets was 30, minus two medication resident(s) unknown sheets and end total number of count sheets was 28. -Only one count for 8/19/22, start total number of sheets was 28 and end total number of sheets was 28. --Note: Missing a sheet count for 8/19/22. -Only one count for 8/20/22, start total number of sheets was 27, end total number of sheets was 27, was not signed by the outgoing nurse. --Note: Missing a sheet count for 8/20/22. -8/21/22 count #1, start and end total number of sheets was 27 and was not signed by the oncoming nurse. -8/21/22 count #2, start and end total number of sheets was 27. -8/22/22 count #1 & #2, start and end total number of sheets was 27. -8/22/22 count #3, start total number of sheets was 27, no end total number of sheets and was not signed by the oncoming nurse. -Only on count for 8/23/22, start total number of sheets was blank, had minus one twice in the discontinued medication column resident(s) unknown, no end total number of sheets. -No date or start and end total number of sheets but was signed by oncoming and outgoing nurses. -8/24/22 count #1 on the first count sheet, no start or end total number of sheets and was not signed by the outgoing nurse. -8/24/22 count #2 on the first count sheet, start and end total number of sheets was 21. -8/24/22 count #3 on the first count sheet, start and end total number of sheets was 21. -8/24/22 count #1 on the second count sheet, no start or end total number of sheets and was not signed by the outgoing nurse. - 8/24/22 count #2 on the second count sheet, start and end total number of sheets was 25. -8/24/22 Count #3 on the second count sheet, start total number of sheets was 25, plus one new medication resident unknown, and end total number of sheets was 26. -Only one count for 8/25/22 on the first count sheet, start and end total number of sheets was 20 and was not signed by the oncoming nurse. --Note: Missing a count for 8/25/22 on the first count sheet and the count is off by one medication sheet. -8/25/22 count #1 on the second count sheet, start and end total number of sheets was 26, outgoing nurse did not sign the count sheet. -8/25/22 count #2 on the second count sheet, start and end total number of sheets was 26. -8/25/22 count #3 on the second count sheet, start total number of sheets was 26, no end total number of sheets and was not signed by the oncoming nurse. -Only one count for 8/26/22 on the first count sheet, start total number of sheets was 20, minus one medication sheet left a total of 19 end sheets and outgoing nurse did not sign the sheet. --Note: Missing a count for 8/26/22 on the first count sheet and the second shift count sheet was missing both counts. -8/27/22 count #1 on the first count sheet, start total number of sheets left blank, minus two medication resident(s) unknown sheet, plus one medication resident unknown sheet, end total number of sheets was 18, and was not signed by the outgoing nurse. -8/27/22 count #2 on the first count sheet, start total number of sheets was 18, minus one medication sheet resident unknown, end total number of sheets was 17. -8/27/22 count #3 on the first count sheet, start total number of sheets was 17, no end total number of sheets and was not signed by oncoming nurse. -8/27/22 count #1 on the second count sheet, start and end total number of count sheet was 26, but was not signed by the outgoing nurse. -8/27/22 count #2 on the second count sheet, start total number of sheets was 26 minus one medication sheet, plus one medication sheet resident(s) unknown, and end total number of count sheets was 26. -Only one count for 8/28/22 on the first count sheet, start total number of sheets was 17, no end total number of sheets and was not signed by the outgoing nurse. -No date, start total number of sheets and end total number of sheets was 17. -8/28/22 count #1 on the second count sheet, start and end total number of sheets was 26, was not signed by the outgoing nurse. -8/28/22 count #2, start and end total number of sheets was 26. -8/29/22 count #1 on the first count sheet, start total number of sheets was 17 and no end total number of sheets. -8/29/22 count #2 on the first count sheet, start total number of sheets was 17, no end total number of sheets and was not signed by the outgoing nurse. -Only one count for 8/29/22 on the second count sheet, start and end total number of count sheets was 23. --Note: Missing 8/28/22 was 26, three count sheets on the second count sheet and 8/29/22 was 23 sheets. -No date, start or end total number of sheets but signed by the oncoming and outgoing nurses. -Only one shift count for 8/30/22, start and end total number of sheets was 17. -8/30/22 count #1 on the second count sheet, start total number of sheets was 23, on end total number of sheets and was not signed by the outgoing nurse. -8/30/22 count #1 on the second count sheet, no start or end total number of count sheets and was no signed by the oncoming nurse. -8/31/22 count #1 on the first count sheet, start and end total number of sheets was 17. -8/31/22 count #2 on the first count sheet, start total number of sheets was 17 and no end total number of sheets. -8/31/22 count #3 on the first count sheet, start total number of sheets was 17, minus one medication sheet resident unknown, plus one medication sheet resident unknown, end total number of sheets was 17 and was not by the oncoming nurse. -Only one count for 8/31/22 on the second count sheet, start total number of sheets was 23, minus three medication sheets resident(s) unknown, end total number of sheets was 20. -Only one count for 9/1/22, start total number of sheets was 17, minus three medication sheets resident(s) unknown, plus one medication sheet resident unknown, minus one medication sheet resident unknown, end total number of sheets was 16 and was not signed by the oncoming nurse. -Only one count for 9/2/22, start total number of sheets was 13, minus one medication sheet and end total number of sheets was 12. -No date, no start or end total number of sheets, plus one medication sheet resident unknown. -9/3/22 count #1, start total number of sheets was 23 and end total number of sheets was 23. --Note: No added medication sheets noted on count sheet a difference of 11 more sheets. -9/3/22 count #2, start and end total number of sheets was 23. -9/3/22 count #3, start total number of count sheets was 23, minus five medication sheets resident(s) unknown, plus one medication sheet resident unknown, end total number of count sheets was 19. During an interview on 2/27/23 at 1:33 P.M. LPN A said: -Narcotics are to be counted at shift change and if he/she gives the keys to the narcotic box to another nurse you are to count each time. -He/she was educated in February about making sure to count narcotics and sign the count sheets each time. -The oncoming nurse and outgoing nurses are to sign after they count. -A new change was made to put the resident's name when adding or subtracting a narcotic medication from the count. -If the count is not correct he/she was to notify the DON right away and start investigating why the count was off. During an interview on 2/27/23 at 3:40 P.M., the DON said: -He/she was notified by the Administrator that an ex-employee may of possibly had a resident's narcotic pain medication at his/her home and it was being investigated by the local authorities. -An investigation was started at that time is when he/she noticed the Controlled Substance Shift Change Count Sheet was missing counts and signatures of the oncoming nurses and the outgoing nurses. -He/she educated the nurses about medication storage and disposal of medications on 2/16/23, to include shift change counting and signing of narcotic medications. During an interview on 3/7/23 at 11:26 A.M., the Administrator said: -The DON found the missing signatures on the Controlled Substance Shift Change Count Sheet while investigation another complaint. -The DON educated the nurses on narcotic medication storage, shift counts and destroying narcotic medications on 2/16/23. -Nurses are trained in orientation and throughout the year with in-service training on going. MO00214115

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure periodic education and evaluation for one sampled resident's (Resident #17) ability to self-administer insulin (injections of the hormone that regulates blood sugar levels) and Accu-Checks (blood sugar meter which measures blood sugar via inserted one-time-use strips - a lancet, i.e. a sharp device is used to prick a finger in order to allow a small amount of blood to be placed onto the strip in the monitor onto which a small amount of blood is squeezed after pricking a finger with a sharp device) out of 15 sampled residents. The facility census was 53 residents. Record review of the facility's Self-Administration policy, revised December 2016 showed: -Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. -As a part of their overall evaluation, the staff and practitioner will assess the resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. -In addition to a general evaluation of the decision-making capacity, the staff and practitioner will perform a more specific skill assessment. -The staff and practitioner will document their findings. -The staff and practitioner will periodically, for example, during quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility for care planning) reviews, reevaluate a resident's ability to continue to self-administer medications. 1. Record review of the resident's admission Record showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Type 2 Diabetes (a long-term condition that results in too much sugar circulating in the bloodstream and can require use of insulin). -Acute (sudden severe onset) transverse myelitis (swelling of the spinal cord that can cause pain, muscle weakness, paralysis, sensory problems). Record review of the resident's most recent documented Evaluation for Self-Administering Medications assessment dated [DATE] and reviewed by his/her interdisciplinary team showed he/she was approved to self-administer medication. --NOTE: No other documentation was provided by the facility to show the resident was assessed to self-administer medications. Record review of the resident's Care Plan, revised 7/2021 showed: -He/she supervise and provide all Accu-Checks and insulin per physician orders. -He/She had been educated on importance of following doctor's directions, documentation and injecting insulins including sliding scale insulin. Record review of the resident's quarterly MDS, dated [DATE] showed: -He/she was cognitively intact. -He/She received insulin injections seven out of seven days during the look-back period. Record review of the resident's Order Summary Report dated 2/15/22 showed his/her physician ordered: -Lantus Solution (insulin glargine/long acting insulin) 100 unit/milliliter (ml), inject 24 units under the skin at bedtime, unsupervised administration. -HumaLOG (long acting insulin) solution 100 units/ml inject subcutaneously before meals per sliding scale: if blood sugar is 0 to 150 = no insulin; if 151 - 200 = 1 unit; if 201 - 250 = 2 units; if 251 to 300 = 3 units; if 301 - 350 = 4 units; if 351 - 400 = 5 units and give up to 6 units and call physician, unsupervised self-administration. -Accu-Checks before meals and at bedtime; self-administrated and documented by resident and scanned to chart monthly. During an interview on 2/13/22 at 9:48 A.M. the resident said: -He/she gave himself/herself his/her insulin. -He/she had an insulin pen and an insulin vial in his/her room. Observation on 2/16/22 at 11:10 A.M. showed: -The resident was alert and in his/her bed. -He/she had a box on his/her overbed table with his/her insulin vial, insulin pen, insulin pen needles, insulin syringes, alcohol pads, lancets, cotton balls and his/her Accu-check meter. During an interview on 2/16/21 at 11:10 A.M. the resident said: -The Director of Nursing (DON) came to his/her room in mid-December, 2021 and showed him/her how to do insulin injections and told him/her to use alcohol wipes for the insulin pen before putting on the needle. -He/she kept a record of his/her blood sugars and insulin injections, including the amount of his/her sliding scale insulin he/she injected. -No one had watched him/her do his/her Accu-Check. During an interview on 2/16/21 at 10:05 A.M. agency Registered Nurse B said: -The resident self-administered his/her own scheduled insulin, sliding scale insulin, and Accu-Checks. -Before lunch on 2/16/21 a Certified Nursing Assistant gave him/her a note from the resident requesting another insulin pen and he/she took the insulin pen to the resident. During an interview on 2/16/21 at 1:05 P.M. the DON said: -The resident's most recent documented assessment for self-administration of medication was completed in 2019. -Residents who self-administer medications should have an assessment for ability to self-administer annually and with a change in condition. -He/she had done some teaching with the resident regarding his/her insulin administration but had not documented the teaching in the resident's medical record. -The resident should have had annual assessment for his/her ability to self-administer insulins with an insulin pen and with an insulin syringe as well as an annual assessment to complete his/her own Accu-checks.

Based on observation and interview, the facility failed to maintain stand up lift A without a crack in the base that a resident would stand up on and to maintain stand-up lift B without a buildup of grime and debris on the base. This practice potentially affected three residents in the facility who depend on stand-up lifts for transfers. The facility census was 53 residents. 1. Observation with the Maintenance Director on 2/14/22 at 1:25 P.M., showed a 2 inch crack that was present in the base of the stand-up lift A. During an interview on 2/14/22 a 1:26 P.M., the Maintenance Director said he/she did not know who was in charge of ordering parts for the stand-up lift. During an interview on 2/14/22 at 3:13 P.M., Certified Nursing Assistant (CNA) C said he/she used the lift earlier that day and did not notice the crack. During an interview on 2/14/22 at 3:27 P.M., the Care Plan Coordinator and the Central Supply Coordinator both said they expected employees to check the condition of the equipment before using it. During an interview on 2/15/22 at 4:15 P.M., the Maintenance Director said he/she did not know who was in charge of ordering parts for stand up lifts and other equipment, because the new ownership group is still trying to figure that out. 2. Observation on 2/14/22 at 3:21 P.M. showed a buildup of debris on the base of standup lift B. During an interview on 2/14/22 at 3:22 P.M., CNA C said the lifts should be cleaned after every use but that one was not cleaned after it was used. Observation on 2/15/22 at 8:20 A.M., showed Stand-up Lift B was in the 300 corridor with grime and debris on the base of Stand-Up Lift B. During an interview on 2/15/22 at 4:31 P.M., the Director of Nursing (DON) said: - The Stand-Up lift should be cleaned after each use with a disinfectant cloth. - Most of the staff are agency staff. - He/she expected facility staff to check the condition of the lifts before they use it. - They should check for cracks, loose screws, loose hinges etc. before they use it. During an interview on 2/15/22 at 1:03 P.M., Agency Registered Nurse Nurse (RN) B said: - He/she expected the facility staff to clean the Stand-Up lifts after each use. - He/she thought there was a cleaning schedule, but was not for sure, because he/she was an agency nurse at the time of the interview. - He/she has not worked at the facility since October 2021. During an interview on 2/15/22 at 4:39 P.M. CNA E said: - He/she has been employed at the facility for a year and a half. - He/she has been trained to look for anything that was broken, anything wrong, the presence of hair in the wheels, because the hair caused the wheels to be hard to move, they look to see if the battery is working right. - He/she has not been told to look for the cleanliness. - He/she would not have used Lift B until he/she cleaned it first. During an interview on 2/16/22 at 10:48 A.M., The DON said there was not a Stand-up Lift cleaning schedule developed at that time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #22's Face Sheet showed he/she was admitted to the facility on [DATE] and readmitted on [DATE]. Record review of the resident's MDS submissions showed: -An entry MDS was completed on 10/15/21. -An OBRA admission MDS was completed on 10/22/21. -A discharge MDS was completed on 10/28/21. -An entry MDS was completed on 11/2/21. -A significant change MDS was completed on 11/19/21. -NOTE: Hospice services, a pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) and a Foley catheter (a tube passed through the urethra into the bladder to drain urine) were not identified in any MDS. Record review of the resident's facility admission assessment note dated 11/2/21 showed the resident had a urinary catheter. Record review of the resident's undated care plan showed: -He/she had an indwelling Foley catheter related to Neuromuscular Dysfunction of the bladder, initially dated 11/3/21. -He/she had a terminal prognosis related to End Stage Senile Degeneration of the Brain. He/She received hospice services, initially dated 11/22/21. -He/she had a deep tissue pressure injury (DTI - Deep tissue injury may be characterized by a purple or maroon localized area of discolored intact skin or a blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. Presentation may be preceded by tissue that is painful, firm, mushy, boggy, and warmer or cooler as compared to adjacent tissue) to left heel, initially dated 12/6/21. Record review of the resident's facility census information (indicating his/her payor source) the resident was placed on hospice services on 11/6/21. Record review of the resident's hospice book showed that hospice services began on 11/6/21. Record review of the resident's wound-weekly observation tool dated 1/14/22 showed: -The resident had an acquired Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. It may also present as an intact or open/ruptured blister) on his/her left heel. -The resident acquired the wound on 11/11/21. Record review of the residents Physician's Order Sheet (POS) dated 2/22 showed: -Foley Catheter ordered and started on 11/2/21. -Clean left inner heel with wound cleanser and apply small piece of Xeroform (a wound dressing) over scab. Cover with Abdominal Dressing (ABD) and secure with Kling (gauze wrap) daily, ordered on 11/14/21 and started on 11/15/21. Observation on 2/13/22 at 11:59 A.M. showed that the resident had a Foley catheter. Observation on 2/15/22 at 10:35 A.M. showed the resident's left inner heel had a wound in a circle shape that was red/pink inside and approximately the size of quarter. 3. During an interview on 02/16/2022 at 10:04 A.M., Agency Registered Nurse (RN) B said: -The MDS Coordinator does all the MDS updates. -The Director of Nursing (DON) or Assistant Director of Nursing (ADON) has asked RN B to update one in the past. During an interview on 02/16/22 11:07 A.M., the MDS Coordinator said: -He/she is informed of a change in resident condition when someone tells him/her. -He/she reviews most nurses' notes in the morning and reviews the facility dashboard. -He/expects when someone is put on hospice services, a significant change MDS should be done in 14 days. -He/she checks at last twice per week to ensure MDS' are transmitted and accepted. -He/she was unsure how to check the MDS in progress since 1/22/2022. -He/she has a calendar that shows what is in progress. -He/she noticed the resident's next quarterly MDS that was due had been missed, so he/she opened the MDS dated [DATE] to try to catch up on past due MDS submissions. -He/she does not know why it is still pending. -A significant change MDS should have been completed for this resident within 14 days of his/her admission to hospice services. During an interview on 2/16/2022 at 1:05 P.M., the DON and ADON said: -They would expect the resident's MDS to be completed on time and accurate. -If a resident was started on hospice services, there should be a significant change MDS assessment completed. Based on interview and record review, the facility failed to accurately complete a significant change Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) assessment when the resident had a change in condition and was admitted to hospice services (a type of health care for end of life care) for two sampled residents (Resident #22 and Resident #24) out of 15 sampled residents. The facility census was 53 residents. Record review of the facility's policy Electronic Transmission of the MDS revised September 2010 showed: -All MDS assessments ( admission, annual, significant change, quarterly review) and discharge and reentry records will be completed and electronically encoded into our facility's MDS information system and transmitted to the Centers for Medicare and Medicaid Services (CMS) Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system in accordance with current Omnibus Budget Reconciliation Act (OBRA) regulations governing the transmission of MDS data. 1. Record review of Resident #24's Face Sheet showed he/she was readmitted to the facility on [DATE]. Record review of the resident's MDS submissions showed: -A quarterly MDS was completed on 10/18/21. The resident was not on hospice services and did not have a condition or chronic disease that may result in a life expectancy of less than six months. -A discharge MDS on 11/16/21. -An entry MDS on 11/20/21. -A quarterly MDS was completed on 1/18/22. The resident was on hospice services and did have a condition or chronic disease that may result in a life expectancy of less than six months. This MDS was still in process and had not been fully submitted to CMS at the time of exit. --NOTE: The resident was placed on hospice services on 12/17/21. A significant change MDS was not completed to reflect this change of condition. Record review of the resident's facility census information (indicating his/her payor source) the resident was placed on hospice services on 12/17/21. Record review of the resident's Care Plan dated 2/14/2022 showed the resident was admitted to hospice services on 12/17/2021 with the diagnosis of CHF (congestive heart failure, occurs when the heart muscle doesn't pump blood as well as it should).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide discharge planning including disposition of belongings and medications for one closed record resident (Resident #56) out of one closed record sampled. The facility census was 53 residents. 1. Record review of Resident #56's admission Record showed he/she was admitted to the facility on [DATE] for short-term rehabilitation services after a hospital stay for a knee replacement. Record review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff for care planning) dated 11/18/21 showed the resident: -Was admitted to the facility on [DATE] for rehabilitation services. -Was returning to his/her home in the community after his/her rehabilitation services were completed. Record review of the resident's Care Plan dated 11/22/21 showed the resident was admitted for therapy and planned to return home with his/her spouse when therapy was completed. Record review of the resident's Social Services Note dated 11/30/21 showed: -The residents medication list was reviewed and the only new medication Lovenox (a blood thinning medication). -Nursing was aware and would provide education on how to inject the Lovenox. -The resident did not need medical equipment at home. -The resident was deciding between home health therapy versus out-patient therapy services. Record review of the resident's Order Summary Report active orders as of 12/2/21 showed Norco tablet 5-325 milligrams (mg) (controlled substance-a drug or other substance that is tightly controlled by the government because it may be abused or cause addiction) administer one tablet by mouth as needed for pain. Record review of the resident's Discharge Summary Note dated 12/3/21 showed: -The resident discharged to home with his/her spouse. -The resident was given three doses of Lovenox injections to take home and was instructed how to administer this medication. -An order for home health services physical and occupational therapy was completed (but did not state which home health agency). Record review of the resident's Discharge summary dated [DATE] showed: -The resident had home health services upon discharge. --There was no information on what home health agency was used or contact information for the agency. -Medical equipment arrangements was left blank. -Medication education was left blank. -The discharge destination was left blank. -Emergency physician services was left blank including when to call the doctor if needed. -Future scheduled appointments was left blank. -There was no documentation related to the disposition of belongings or disposition of controlled substance medications. Record review of the resident's undated Inventory of Personal Effects showed: -The resident had multiple clothing items, undergarments, hearing aids and glasses. -Upon admission the form was signed by the resident. -Upon discharge the form was not signed by the resident. Record review of the resident's medical record on 2/15/22 showed there was no Controlled Substance Record to show the controlled substances were destroyed by two nurses upon discharge. During an interview on 2/15/22 at 3:37 P.M. Agency Licensed Practical Nurse (LPN) A said: -Nursing, Social Services and physical therapy were all involved with overall discharge plan. -All controlled substances were destroyed by two nurses. -Both nurses would sign the controlled substance record for destruction of these medications. During an interview on 2/15/22 at 3:47 P.M. Medical Records Staff A said: -The discharge summary was completed by the Admissions Coordinator. -The nurses completed the discharge form for the residents. -The nurses would print off the medication list and give it to the resident upon discharge. -Social services was responsible for home health discharge planning. -No medications were sent with the resident unless they were critical medications. -All medications were sent back to the pharmacy except the controlled substances. -The Assistant Director of Nursing (ADON) and Director of Nursing (DON) would destroy controlled substances and controlled medication count sheet. -There should always be two nurses' signatures on the controlled medication count sheet when the medications were destroyed. During an interview on 2/16/22 at 10:05 A.M. Agency Registered Nurse (RN) B said: -If a resident was discharging after rehabilitation therapy to go home, someone at the facility usually filled out the residents' discharge summary but was unaware who did this. -The nurses did not fill out the residents' discharge summary. -The nurses look for discharge instructions on the discharge summary report. -The admission Coordinator or the Social Services Director (SSD) would let the nurse know what home health or Durable Medical Equipment (DME-walkers, wheelchairs) was needed for the resident to obtain physician's orders for this. -The only thing the nurses completed were obtaining physician's orders for home therapy or DME. -The nurses were responsible for printing the residents' inventory sheet and having the resident or responsible party sign the form to show the resident took their belongings with them upon discharge. -When a resident discharged from the facility and had controlled substances, these needed to be destroyed by two nurses and documented on the controlled substance count sheet. -Two nurses were required to sign for the destruction of the controlled substance medication. During an interview on 2/16/22 at 10:51 A.M. the Admissions Coordinator said: -He/she opened the Discharge Summary and would enter home health information and DME needed. -The nurses were responsible for completing the rest of the Discharge Summary. -The nurses were responsible for ensuring the residents' Inventory Sheet was signed by the family upon discharge to show the disposition of the residents' belongings. During an interview on 2/16/22 at 1:04 P.M. the DON and ADON said: -Prior to discharge, the discharge planning was completed by the Admissions Coordinator. -The Admissions Coordinator was responsible for starting the Discharge Summary and the nurses were responsible for finishing it. -The SSD would document the residents' disposition of belongings and sometimes housekeeping staff would document this. -The disposition of belongings should be be documented in the residents' electronic medical record. -Any controlled substances were destroyed by two nurses and the two nurses needed to sign the controlled substance count sheet. -Medical Records staff would monitor to ensure this was getting completed. -He/she was responsible for ensuring discharge planning, disposition of belongings upon discharge, and controlled substance destruction was completed. -He/she had not been at the facility long enough to put a monitoring process in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to perform a safe transfer when the Certified Nursing Assistant (CNA) pulled a resident up by his/her pants to transfer the resident from a chair to a wheelchair for one sampled resident (Resident #24) who was at risk for falls out of 15 sampled residents. The facility census was 53 residents. Record review of the facility's Safe Lifting and Movement of Residents Policy revised December 2013 showed: -Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding safe lifting and moving of residents. -Manual lifting of resident shall be eliminated when feasible. -Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. -Safe lifting and movement of residents is part of an overall facility employee health and safety program. -Provides training on safety, ergonomics and proper use of equipment. 1. Record review of Resident #24's admission Record showed he/she was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: -Pain in right hip, right knee and left knee. -Age-related osteoporosis (a condition in which the bones become weak over time due to decreased density). -Arthropathy (a disease of the joints that causes pain and loss of movement). -Muscle weakness. -Difficulty in walking. -Weakness. -Unspecified abnormalities of gait and mobility (is the inability to walk and move safely). -Myalgia (muscle aches and pains). Record review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff used for care planning) dated 11/20/21 showed: -The resident's Brief Interview for Mental Status (BIMS) score was 13 out of 15, demonstrating the resident is cognitively intact. -The resident was assessed to need limited assistance with all mobility and extensive assistance with toileting. -The resident is unsteady, but able to stabilize without human assistance. -The resident required assistance moving from seated to standing. -The resident was unsteady, but able to stabilize with human assistance for all other functional status. -The resident was assessed to need supervision/touching assistance or partial/moderate assistance with all functional abilities. Record review of the resident's Care Plan dated 11/21/21 and revised on 2/14/22 showed: -The resident is at risk for falls. -Staff were to educate the resident to ensure that four wheeled walker (FWW) brakes are locked before transfer. -Transfer modified independent in room with FWW or wheelchair (w/c). -Chronic back and knee pain. -Impaired cognitive function/dementia or impaired thought processes related to Alzheimer's (disease is a brain disorder that slowly destroys memory and thinking skills), and Dementia (the loss of thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities). -Staff to remind resident about safety issues frequently. -Resident up with assist times one person with rolling walker (rw) or transfer to/from wheelchair Record review of the resident's Nursing Fall Risk assessment dated [DATE] showed: -The resident was unable to independently come to a standing position. -Requires hands on assistance to move from place to place. -Uses an assistive device, such as a cane or walker. Observation of the resident on 2/14/22 at 11:36 A.M. showed: -Agency Certified Nursing Assistant (CNA) D approached the resident and bent forward at the waist. -Agency CNA D grasped the resident and the resident's clothing to assist from a sitting to a standing position. -Agency CNA D pulled on the resident and the resident's clothing while rocking the resident back and forth in the chair several times. -Agency CNA D was able to exert enough force to pull the resident to a standing position. -Agency CNA D assisted the resident into the wheelchair while maintaining a grip on the resident's clothing. -Agency CNA D assisted the resident into a seated position in the wheelchair while grasping onto the resident's sides. -Agency CNA D on gave the instructions of ok, let's go to the resident before the transfer. During an interview on 2/16/22 at 9:33 A.M. Agency CNA D said: -During a transfer to stand and pivot, he/she would use a gait belt (a belt, usually made of heavy canvas with a sturdy buckle, used to help residents move). -He/she said he/she did not have his/her gait belt at this time because he/she is a float today. -He/she said residents usually have gait belts in their room. During an interview on 2/16/22 at 10:04 A.M., Agency Registered Nurse (RN) B said: -There are pre-printed sheet by the CNA Coordinator that tell if a person is a one or person assist. there was nothing else said -CNA's should use a gait belt and not the pants of the resident for transfers. -The resident is a one person assist and a two person assist as needed. -Staff should have a gait belt on them, -He/She did not know where to find a gait belt. During an interview on 2/16/22 at 1:05 P.M. ,the Director of Nursing (DON) said: -The resident should be transferred with a gait belt and whatever their functional level is. -The resident should be transferred with a gait belt. -He/she expects staff to not use the resident's clothing as it could damage the clothing and it is not safe.

Based on interview and record review, the facility failed to distribute interest (money paid regularly to depositors of money at a financial institution a particular rate) for residents who allowed the facility to manage their resident funds during the months of December 2021 and January 2022. This practice potentially affected 11 residents who allowed the facility to manage their funds. The facility census was 53 residents. 1. Record review of the facility's trust Transaction History dated December 2021 and January 2022, showed no interest was paid for residents in December 2021 and in January 2022. During an interview on 2/16/22 10:29 A.M., the Business Office Manager (BOM) said: - Without bank statements (which were not available to the BOM until February 17, 2022) it was difficult to determine what amount of interest should have been paid to residents in 12/2021 and 1/2022. - It would be easier to allocate interest to each resident with current bank statements. During a phone interview on 2/18/22 at 9:22 A.M., the Corporate Accounts Receivable Supervisor said: - The accounts for the facility were only transferred from the old bank accounts to the new bank accounts in January 2022. - The interest did not accrue in January 2022. Interest should accrue in February 2022 for January 2022. - He/she was not involved in the buyout. - Lack of communication with the right person has caused some of these records to not be transmitted in a timely manner.

Based on interview and record review, the facility failed to procure reconciled (a process that takes place when the deposits, credits and interest that are on record but were not accounted for on the final bank statement, are added to the final amount on the bank statement, then checks and charges that are on record, but were not listed on the bank account statement, are subtracted from the adjusted final amount) bank statements for the months of December 2021 and January 2022. This practice potentially affected 11 residents who allowed the facility to manage their funds in the resident trust system. The facility also failed to maintain a record of any receipt that would have been given to the entity for two deposits of $100.00 each into the account of one resident (Resident #30) on 12/8/21. The facility census was 53 residents. 1. Record review of resident fund records showed the absence of reconciled bank statements for the months of December 2021 and January 2022. During an interview on 2/16/22 at 9:48 A.M., the Admission's Coordinator (who once worked as the former Business Office Manager (BOM), said the bank the facility used, was changed, by the time he/she took over those operations on 1/3/222. The facility no longer used Bank A. During an interview on 2/16/22 at 9:52 A.M., the BOM said: - He/she has only had the position of BOM since 1/27/22. - The accountant form the former facility management company, sent over bank statements, but not reconciled bank statements for the months of December 2021 and January 2022. - In January 2022 a new system with Resident Fund Management System (RFMS) started and the facility has not received a reconciled bank statement for January 2022. During a phone interview on 2/22/22 at 1:31 P.M., the Corporate Accounts Receivable Supervisor said: - The bank statements or December 2021 and January 2022, were not available for the BOM to do the reconciliation's. - They were only available on 2/17/22 (which was after the survey exit date). - It was very difficult to obtain the December 2021 and January 2022 bank statements from the old ownership. - There was additional difficulty in obtaining the the January 2022 bank statement because the money needed to be transferred from the old bank account under prior ownership to the new bank account under new ownership. - The January 2022 bank statement that was sent to the BOM, was one that was for the new account because he/she (the Corporate Accounts Receivable Supervisor) did not know exactly what the BOM needed at first, so he/she sent both January 2022 bank statements, the one that was under the prior ownership and the one that is under new ownership. 2. Record review of Resident #30's resident trust statement dated 12/8/21, showed: - Resident #30 received a check for $100.00. - Resident #30 received a separate check for $100.00 from his/her family. - The absence of receipts to show that those checks were deposited into Resident #30's account on behalf of Resident #30. During an interview on 2/15/22 at 2:37 P.M., both the current BOM and the former BOM said they did not have receipts for the two $100.00 deposits that were made for Resident #30. During a phone interview on 2/17/22 at 1:05 P.M., Resident #30's friend who was listed on the face sheet as an emergency contact, said: -He/she brought $100.00 for Resident #30 in December 2021. -He/she gave the money to the receptionist, because the business office was closed that day. -He/she has not received a receipt for the $100.00 that he/she dropped on behalf of Resident #30.

Based on interview and record review, the facility failed to submit the new bond (an insurance agreement pledging that one entity will become legally liable for financial loss caused to another by the act or default of a third person) for approval to the Division of Regulation and Licensure (DRL). This practice potentially affected 11 residents who have allowed the facility to manage their resident funds. The facility census was 53 residents. 1. Record review of the Bond Rider dated 1/1/22, showed: - The effective date was 1/1/22. - A signed statement which stated: Bond Insurance Company A has caused this instrument to be signed by its duly authorized Attorney-in Fact (a person who is authorized to act on behalf of another person, usually to perform business or other official transactions) on 12/21/21. Record review of the Nursing Home Surety Bond dated 1/1/22 showed: - Bond Insurance Company A is authorized to transact surety business in the state of Missouri for the use and benefit of injured persons in the aggregate penalty of $35,000.00. - This bond shall be continuous until canceled. - The bond shall be effective as of the date signed. - The date of signature on the surety bond, of 1/1/22. - The absence of a bond approval letter from the DRL. During a phone interview on 2/16/22 at 9:13 A.M., DRL Accountant A said: -The facility changed from one operating company to another on 1/1/22. -The facility has not yet sent the new surety bond for $35,000.00 for approval because the paperwork was not there even as a pending approval. -The previous bond amount was $10,500.00 During an interview on 2/16/22 at 9:40 A.M., the Admission's Coordinator who once worked as the former BOM, said: - The bond paperwork was in process before he/she had the position of BOM from 1/3/22 through 1/26/22. - It is the responsibility of Corporate Office staff or the Administrator to send the bond paperwork to DRL for approval. During an interview on 2/16/22 at 9:46 A.M., the Administrator said there is someone in corporate that is supposed to handle those matters. During a phone interview on 2/22/22 at 1:12 P.M., the Director of Clinical and Reimbursement Services said they were not aware that the bond paperwork had not been sent until the survey.

Based on interview and record review, the facility failed to ensure three prospective applicants for employment (Employees # 1, #6 and #7) out of 10 sampled new employees had documented proof of a Federal Indicator Check through the Nurse Aide (NA) Registry prior to employment and to specify in their Employment Screening policy that all prospective employees, not just those applying for the position of Nurse Assistant or Certified Nursing Assistant (CNA), would require a Federal Indicator Check through the NA Registry. The facility census was 53 residents. Record review of the facility's Employment Screening policy, revised 2/20/15 showed: -In accordance with State and Federal regulations this facility will not knowingly hire, contract or retain any individual that is ineligible to work in a healthcare facility or excluded from participation in the Medicare or Medicaid program. Prior to an employment decision to hire a prospective applicant the facility will: -Initiate a reference check from all previous employers. -Obtain a background check at least two days prior to scheduled resident contact from: --Employment Disqualification List (EDL). --Family Care Safety Registry (FCSR) for registration. The facility will verify with the FCSR the completion of a Missouri State Highway Patrol Criminal Background Check (CBC). The facility will assist the employee in completing and submitting the required registration paperwork and fees. Prospective employees who have not worked in the State of Missouri and/or resided in the State at least five consecutive years prior to the date of the application must also submit to a finger based CBC. -At least two days prior to scheduled resident contact the facility will check the CNA site for verification of active certification to work as a Nurse's Aide. If the prospective employee also reports certification in another State then a check of those registries must also be documented. -The policy did not specify that all prospective employees, not just those applying for the position of Nurse Assistant or Certified Nurse Assistant, would require a Federal Indicator Check through the NA Registry. -The facility will screen print the results of each database check and the background initiation page which validates that it did search each of the required databases for disqualifying conditions and/or exclusions. -In addition to the required database checks for new employees, with each quarterly EDL update issued by the Department, the facility will compare it against its current list of employees to verify that none have been disqualified. -Individual volunteers who may have access to residents or resident information will be subject to the same background check provisions listed under this policy. 1. Record review on 2/16/22 of the background screenings for 10 employees hired since the previous annual survey of 5/14/21 showed: -Employee #6 was hired on 6/22/21 in the position of Assistant Director of Nursing (ADON). --Documentation showed a NA Registry check was conducted on 2/15/22. --The employee did not have documentation of a Federal Indicator check through the NA Registry prior to hire. -Employee #7 was hired on 6/17/21 in the position of Licensed Practical Nurse (LPN). --Documentation showed a NA Registry check was conducted on 2/15/22. --The employee did not have documentation of a Federal Indicator check through the NA Registry prior to hire. -Employee #1 was hired on 8/17/21 in the position of Assistant Administrator. --Documentation showed a NA Registry check was conducted, but the date of the check was indiscernible due to being cut off at the bottom. --The employee did not have documentation a Federal Indicator check was completed through the NA Registry prior to hire. 2. During an interview on 2/16/22 at 11:07 A.M. the Human Resources (HR) Director said: -He/she was aware that all employees need a Federal Indicator check through the NA Registry. -He/she was responsible for making sure all potential new employees have all required background screenings. He/she uses a new hire checklist to make sure all background screenings are completed and no employees have findings that would disqualify them from work prior to hire. -He/she worked as the facility's HR Director six months ago and just came back two weeks ago. -Much of the employees' information had been maintained electronically. He/she could not find documentation in the three employees' files that their Federal Indicator checks were completed prior to hire. During an interview on 2/16/22 at 2:45 P.M. the Administrator said: -All required background screenings should be completed for all potential employees prior to them working. -The facility had some problems accessing employee information electronically following recent corporate changes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #30's admission Record showed he/she was admitted on [DATE] with a the following diagnoses: -Need for assistance with personal care. -Muscle weakness. Record review of the resident's Care Plan dated 2/06/20 showed: -The resident had an Activities of Daily Living (ADL) self-care performance deficit. -The resident required assistance of one to two staff with bathing, initiated on 12/2/19. -Staff to assist with bathing the body parts the resident cannot do. Record review of the facility's resident Showers schedule updated 10/3/21 showed the resident was scheduled for a bath on Tuesday and Friday each week. Record review of the resident's bath sheets dated 1/4/22 through 2/15/22 showed: -The resident received a bath on 1/4/22, 1/7/22, 1/11/22, and 2/8/22. -The resident was offered a bath on 1/21/22, which was documented as refused. -The resident's bath sheet for 2/15/22 was documented as N/A. -The nurse signature line was left blank on all the bath sheets. --The resident received and/or was offered a bath six times out of 13 opportunities. During an interview on 2/13/22 at 10:30 A.M. the resident said he/she gets one bath a week sometimes and this causes him/her to have skin sores and irritation, nothing open at this time. During an observation on 2/15/22 at 7:40 A.M. Agency Certified Nursing Assistant (CNA) B showed: -He/She offered the resident a shower. -The resident requested the shower to be done after lunch. During an interview on 2/15/22 at 1:05 P.M. the resident said he/she put his/her call light on waiting for staff to come get him/her for her bath. During an interview on 2/16/22 at 9:49 A.M. the resident said: -He/she did not get his/her bath yesterday. -He/she was not given a reason as to why he/she did not get his/her bath. Based on observation, interview and record review, the facility failed to ensure bathing was completed per preferences to keep three sampled residents (Resident #12, #30, and #25) clean and odor free out of 15 sampled residents. The facility census was 53 residents. Record review of the facility's Shower/Tub Bath policy revised 10/2010 showed: -The purpose of this procedure was to promote cleanliness, provide comfort, and observe the residents' skin condition. -The staff should document the date and time the shower/tub bath was performed. -All assessment data of the residents' skin observed during the shower. -If the resident refused the bath and reason. -The signature and title of the person recording the data. -Notify the supervisor if the resident refused a shower/tub bath. 1. Record review of Resident #12's admission Record showed he/she was admitted to the facility on [DATE] and had the following diagnoses: -Alzheimer's disease (a slowly progressive disease of the brain that is characterized by impairment of memory and eventually by disturbances in reasoning, planning, language, and perception). -Difficulty walking. Record review of the resident's annual Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff) dated 8/11/21 showed the resident: -Was severely cognitively impaired. -Required the total assistance of staff for bathing and dressing. -Required the extensive assistance of staff for personal hygiene. Record review of the resident's care plan showed: -Updated 8/10/18: The resident was unable to complete Activities of Daily Living (ADLs-grooming, bathing, hygiene) due to severe cognitive deficits. -Updated 8/15/18: The resident would have his/her needs met by staff to be clean, dry, dressed appropriately and well groomed. Record review of the facility's resident Showers schedule updated 10/3/21 showed the resident was scheduled for a bath on Monday and Thursday each week. Record review of the resident's Documentation Survey Report for bathing showed the resident received a bath on 12/6/21, 12/20/21 and 12/23/21. -The resident received a total of three baths out of nine opportunities during the month of December 2021. Record review of the resident's Point of Care Audit Report for bathing dated 1/2/22-2/14/22 showed: -The resident received a bath on 1/20/22, 1/24/22, 1/27/22 and 1/31/21. -There were no documented baths after 1/31/22. -The resident received a total of four baths out of 13 opportunities during this time period. Record review of the resident's Bath Sheets showed the resident received a bath on 1/6/22 and 1/13/22. Observation on 2/14/22 at 10:00 A.M. showed the resident: -Was on the Covid 19 (an infectious disease caused by severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2) pandemic unit. -Was in bed in his/her room. -Had a white pajama top on with small pink flowers and brownish stains on the front chest area. -Had greasy hair and a greasy face. Observation on 2/14/22 at 11:45 A.M. showed the resident: -Was in bed in his/her room. -Had a white pajama top on with small pink flowers and brownish stains on the front chest area. -Had greasy hair and a greasy face. During an interview on 2/14/22 at 11:48 A.M., Certified Nursing Assistant (CNA) A said: -The facility had shower aides that completed baths for the residents. -The resident looked a little rough and his/her hair was greasy. -The resident usually received a bath on Mondays and Thursdays. -He/she did not give baths to the residents. Observation on 2/14/22 at 11:45 A.M. showed the resident: -Was in bed in his/her room. -Had a white pajama top on with small pink flowers and brownish stains on the front chest area. -Had greasy hair and a greasy face. -Had multiple white flakes in his/her hair. -Had a slight smell of body odor. Observations on 2/15/22 at 7:27 A.M. and at 1:45 P.M. showed the resident: -Was in bed in his/her room. -Had a white pajama top on with small pink flowers and brownish stains on the front chest area. -Had greasy hair and a greasy face. -Had multiple white flakes in his/her hair. -Had a slight smell of body odor. During an interview on 2/15/22 at 7:32 A.M., Agency CNA B said: -He/she was only here yesterday and today. -He/she was assisting with baths and other resident cares. -He/she was helping everywhere in the building but was assigned the resident baths today. -He/she had been given the residents' shower schedule and was completing baths then helping where needed. -He/she could not complete showers on the Covid 19 unit because there was no shower room inside that unit. -He/she thought the staff working on that unit were giving the residents bed baths. During an interview on 2/15/22 at 3:37 P.M., Agency Licensed Practical Nurse (LPN) A said: -He/she was not sure who was supposed to be completing baths on the Covid 19 unit. -There was not a shower room on that hall past the barrier. -He/she was not sure how the residents were getting bathed on that unit. -He/she was not sure if bed baths were being completed on the Covid 19 unit but the residents should be getting some type of bathing. During an interview on 2/15/22 at 3:47 P.M., Medical Records Staff A said: -There was not a shower room on the Covid 19 unit. -The shower aide should be giving a bed bath by the shower aides if allowed on the Covid 19 unit. -Many agency staff were not allowed to work on the Covid 19 unit. During an interview on 2/16/22 at 10:05 A.M., Agency Registered Nurse (RN) B said: -There are three or four rooms on the Covid 19 unit in rooms that have a shower in the room. -The staff could use the rooms on the back of the hall to give residents who reside on the COVID 19 unit a shower. -He/she was unsure how the staff would know there were shower rooms in resident rooms on that hall. -Agency staff did not go work on the Covid 19 unit as far as he/she knew. During an interview on 2/16/22 at 1:04 P.M., the Director of Nursing (DON) and Assistant Director of Nursing (ADON) said: -The COVID 19 unit did not have assigned bath aides prior to this week. -Some agency staff were not allowed to go onto COVID 19 units per their agency. -If a resident was on the COVID 19 unit they should at least get a bed bath. -The back of the COVID 19 unit did have shower rooms in two back resident rooms. 3. Record review of Resident #25's admission Record showed: -He/she was readmitted to the facility on [DATE]. -He/she had a diagnoses of need for assistance with personal care. Record review of the facility's resident Showers schedule updated 10/3/21 showed the resident was scheduled for a shower three times a week on Monday and Wednesday and Friday. Record review of the resident's MDS dated [DATE] showed: -He/she was cognitively intact. -He/she was totally dependent on one staff person for assistance with bathing. Record review of the resident's shower records dated 1/1/22 through 2/14/22 showed: -He/she had baths on 1/3/22, 1/5/22, 1/7/22, 1/12/22, 1/21/22, 1/24/22, 1/26/22, and 2/9/22. -He/she did not have baths on 1/10/22, 1/14/22, 1/17/22, 1/19/22, 1/28/22, 1/31/22, 2/2/22, 2/4/22, 2/7/22, 2/11/22 and 2/14/22. -He/she did not receive showers on 11 of 19 of his/her scheduled shower days. During an interview on 2/13/22 at 11:08 A.M. the resident said: -He/she was to have three showers a week on Monday, Wednesday and Friday. -The previous week he/she did not get his/her showers on Monday, Wednesday and Friday. -He/she did have a shower the previous week on Saturday. 4. During an interview on 2/15/22 at 3:37 P.M., Agency LPN A said: -The CNAs were to complete a written bath sheet when they complete a bath for a resident. -He/she was unsure if this was documented in the electronic medical record. -Each resident had a certain bath schedule each week. -The bath aide varied from day to day. During an interview on 2/15/22 at 3:47 P.M., Medical Records Staff A said: -The residents were asked their preference for showers upon admission. -He/she would put it on a task schedule in the electronic medical record for the days the resident wanted a bath. -Shower aides are responsible for residents' baths. -Shower aides were given shower schedule sheet and complete baths for the residents based on preferences. -The shower sheets were given to the ADON. -The staff fill out a shower sheet and document in the residents' electronic medical record when a shower was done. -The staff were to re-approach a resident if they refused a bath. -The residents should be getting baths at least twice a week and per their preferences. During an interview on 2/16/22 at 10:05 A.M., Agency RN B said: -The CNAs would fill out a bath sheet after a bath and give this to the ADON. -The ADON was responsible for ensuring baths were being completed for the residents. -The bath should be done per the residents' bath schedule. -The CNAs also chart the bath in the residents' electronic medical record. -If the resident refused a bath the CNA would report this to the charge nurse. -He/she would document the refusal in the nurses notes. During an interview on 2/16/22 at 12:03 P.M. Agency CNA D said: -When a resident refuses a bath/shower the resident is offered a bed bath; -If a resident doesn't get a bath the resident gets one later in the week outside of their regular bath day. During an interview on 2/16/22 at 1:04 P.M., the DON and ADON said: -Upon admission, a schedule was made on a shower schedule based on the residents' bathing preferences. -The CNAs were responsible for completing baths. -If a resident refused a bath, the CNA should re-approach the resident a few times then notify the charge nurse of the refusal. -When a nurse was notified that a resident was refusing a bath, the nurse should ask the resident if he/she wanted a bath also. -If the resident still refused, the nurse would be document this on the shower sheet. -NA on the bath sheet may mean the resident was out of the building. -The charge nurse was responsible for checking at the end of the shifts the baths which were done and signs off on the sheet. -The ADON was responsible for monitoring to ensure resident baths were being completed. -Baths should be completed for the residents' based on their bathing preferences.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to monitor a resident's pressure injury (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) by failing to complete weekly skin and/or wound assessments for three sampled residents (Residents #22, #20, and #35) out of 15 sampled residents. The facility census was 53 residents. Record review of the facility's Prevention of Pressure Injury policy dated September 2013 showed: -The facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician, and family, and addressed. -Routinely assess and document the condition of the resident's skin per Weekly Skin Integrity form for any signs and symptoms of irritation and breakdown. Record review of the facility's Wound Care policy dated September 2013 showed: -The following information should be recorded in the resident's medical record: -The type of wound care given. -The date and time the wound care was given. -The position in which the resident was placed. -The name and title of the individual performing the wound care. -Any change in the resident's condition. -All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. -How the resident tolerated the procedure. -Any problems or complaints made by the resident related to the procedure. -If the resident refused the treatment and the reason(s) why. -The signature and title of the person recording the data. -Under Reporting: -Notify the supervisor if the resident refuses the wound care. 1. Record review of Resident #22's Face Sheet showed he/she was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: -Delirium (altered state of consciousness, consisting of confusion, distractibility, disorientation, disordered thinking and memory, defective perception - illusions and hallucinations). -Cellulitis (an infection of deep skin tissue). Record review of the resident's nurse's notes dated 11/21/21 showed: -There was a pressure wound noted to his/her right heel. -The wound originated as fluid filled blister, which erupted, and black eschar (dead tissue) was noted. -There was some serous (thin watery) fluid draining. -Medical doctor, hospice and family/responsible party were notified. -No dates, times or names were provided. Record review of the resident's undated care plan showed: -He/she had a potential/actual impairment to skin integrity related to cellulitis of bilateral lower extremities. -He/she would have no complications related to an open area to his/her left heel. -Staff should follow facility protocols for treatment of injury. -Staff should monitor/document location, size and treatment of skin injury. -He/she had a deep tissue pressure injury to left heel. -Staff should assess/record/monitor his/her wound healing weekly. -Staff should measure length, width and depth where possible. -Staff should assess and document status of wound perimeter, wound bed and healing progress. -Staff should report improvements and declines to the medical doctor. Record review of the resident's skin assessments and wound-weekly observation tools showed: -He/she had a skin assessment dated [DATE] that showed a large open area that was a blister and measured 8.5 centimeters (cm) by 5.0 cm on his/her left heel. The skin assessment showed a treatment order, the name and phone number of his/her physician and the name and phone numbers of his/her responsible party. -He/she did not have any skin assessments dated between 11/14/21 and 12/11/21. -He/she had a skin assessment dated [DATE] that showed a large open area that was a blister and measured 8.5 cm by 5.0 cm on his/her left heel. The skin assessment showed a treatment order and the name and phone numbers of his/her responsible party. -He/she had a skin assessment dated [DATE] that showed a large open area that was a blister and measured 8.5 cm by 5.0 cm on his/her left heel. The skin assessment showed a treatment order and the name and phone numbers of his/her responsible party. -He/She had a skin assessment dated [DATE] that showed a large open area that was a blister and measured 6.5 cm by 4.0 cm on his/her left heel. The skin assessment showed treatment orders and the name and phone numbers of his/her responsible party. -He/she had a skin assessment dated [DATE] that showed redness noted on his/her coccyx (the very bottom portion of the spine); redness noted on his/her groin (the area where the thigh meets the abdomen); and an open area on his/her left heel with treatment in place for this area. The skin assessment showed that there were treatments in place for these areas with no treatment orders written out and the name and number of his/her responsible party. -He/she had a skin assessment dated [DATE] that showed redness noted on his/her coccyx and an open area with eschar on his/her left heel. The skin assessment showed that there were treatments in place for all places with no treatment orders written out and the name and number of his/her responsible party. -He/she had his/her first wound-weekly observation tool dated 1/14/22 that showed family and physician were notified on 1/12/22 by phone. The wound-weekly observation tool showed the pressure ulcer on his/her left heel had worsened with slough (necrotic/avascular tissue in the process of separating from the viable portions of the body & is usually light colored, soft, moist, & stringy) present and necrotic tissue present. The wound-weekly observation tool showed the pressure ulcer was moist with a foul odor and drainage and was 4 cm long and 3 cm wide. -He/she had a skin assessment dated [DATE] that showed redness noted on coccyx and an area with an open spot on his/her left heel. The skin assessment showed treatments in place with no treatment written out and the name and numbers of his/her responsible party. -He/She did not have a wound-weekly observation tool completed dated between 1/15/22 and 1/27/22. -He/she had a wound-weekly observation tool dated 1/27/22 that showed family and physician were notified by phone on 1/27/22. The wound-weekly observation tool showed the pressure ulcer on his/her left heel had improved with granulation (any soft pink fleshy projections that form during the healing process in a wound that does not heal by first intention), slough tissue and necrotic tissue present. The wound-weekly observation tool showed the pressure ulcer was moist with no odor and measured 3 cm long by 3 cm wide by 0.3 cm deep. -He/she did not have a skin assessment completed dated between 1/15/22 and 1/31/22. -He/she had a skin assessment dated [DATE] that showed treatment in place with wound care company for his/her left heel. -He/she had a wound-weekly observation tool dated 2/2/22 that showed the physician was notified on 1/27/22 by fax and the responsible party was notified on 2/4/22 by phone. The wound-weekly observation tool showed his/her pressure ulcer on his/her left heel had improved with epithelial tissue, granulation tissue and slough tissue present. The wound-weekly observation tool showed the pressure ulcer was moist with drainage and no odor and measured 3 cm long by 2.5 cm wide and 0.5 cm deep. -He/she had a skin assessment dated [DATE] that showed treatment in place with wound care company for his/her left heel. -He/she had a wound-weekly observation tool completed dated 2/9/22 that showed the physician was notified on 1/27/22 by fax and the responsible party was notified on 2/4/22 by phone. The wound-weekly observation tool showed an unstageable pressure ulcer on his/her left heel and it measured 3.7 cm long by 3.7 cm wide and 0.2 cm deep. The wound-weekly observation tool showed that the pressure ulcer had improved with granulation tissue, slough tissue and necrotic tissue present. The wound-weekly observation tool showed the pressure injury was moist with drainage and no odor present. -He/she had a skin assessment dated [DATE] that showed treatment in place with wound care company for his/her left heel. Record review of the resident's nurse's notes dated 1/12/22 showed staff measured the wound on the resident's heel, which measured 4 cm by 3 cm and then cleaned and dressed the wound with dry dressing. Record review of the resident's nurse's notes dated 1/31/22 showed: -The resident's skin color was normal and his/her skin temperature was dry -The resident's skin turgor was normal as skin returned promptly. -The resident had skin issues. -Refer to assessment for more information. -Treatment was in place. Record review of the resident's Physician's Order Sheet (POS) dated February '22 showed: -May have an outside wound care company consult to evaluate and treat dated 1/24/22. -Left heel cleanse with Hypochlorous Acid (a weak but strongly oxidizing acid produced by the reaction of chlorine and water and used as a bleaching agent, disinfectant), skin prep to peri-wound. Apply Bactroban (antibacterial used to treat skin infections) followed by Santyl (an ointment used to treat skin ulcers) nickel thick to entire wound. Cover with Calcium Alginate (a highly absorbent, biodegradable seaweed dressing) (cut to fit wound) and then ABD (a dressing used to absorb drainage from wounds). Apply bordered gauze, secure with roll gauze daily and prn (as needed) when soiled and/or missing. Every day shift for wound healing dated 1/27/22. Record review of the resident's nurse's notes dated 2/7/22 showed: -The resident's skin color was normal and his/her skin temperature was dry. -The resident's skin turgor was normal as skin returned promptly. -The resident had skin issues. -Refer to assessment for more information. -Treatment was in place. Record review of the resident's nurse's notes dated 2/14/22 showed: -The resident's skin color was normal and his/her skin temperature was dry. -The resident's skin turgor was normal as skin returned promptly. -The resident had skin issues. -Refer to assessment for more information. -Treatment was in place. Observation on 2/15/22 at 10:35 A.M. showed Agency Registered Nurse (RN) B: -Completed wound care on the resident's left heel pressure ulcer. -The resident had a red area under his/her right knee and a boggy spot on his/her inner right heel. -When asked about the resident's right heel, Agency RN B touched the resident's right heel. -His/her finger moved approximately one-half inch in when he/she pressed on the resident's right heel. During an interview on 2/15/22 at 10:45 A.M., Agency RN B said: -He/she would have liked to have had a second person to help hold the resident's leg but that's all he/she would've changed about the wound care. -The resident did not have any other wounds that he/she saw. -The resident's right heel did not feel boggy or mushy. During an interview on 2/15/22 at 3:55 P.M., Certified Nursing Assistant (CNA) E said: -Staff had care sheets for each resident. -The care sheets included each resident's information, including if they had a Do not resuscitate (DNR - an order from a doctor that resuscitation should not be attempted if a person suffers cardiac or respiratory arrest) or full code, how they transferred, if they had any special needs, if they were on hospice, if they were incontinent, etc. -He/she would tell the nurse if a resident had any additional skin issues and then document it in the system. -He/she hadn't worked on the resident's hall for a while. -If a resident had any additional skin issues and was on hospice, then hospice would notify the nurse and the nurse would inform the CNA's. -The resident had wounds on his/her heels only. -The resident did not have any wounds on any other areas. During an interview on 2/16/22 at 10:05 A.M., Agency RN B said: -Skin assessments were assigned during the day and evening shifts to the charge nurses. -If a resident had a new skin issue, the nurse who completed the skin assessment should catch it. -If a CNA saw something and told him/her, he/she would tell the physician, Durable power of Attorney (DPOA- a person previously identified to make decisions for an individual in the event of inability to make wishes known) and Assistant Director of Nursing (ADON). -If hospice saw a new skin issue, hospice would tell the nurse. -As far as he/she knows, the resident only had a pressure ulcer on his/her left heel. -He/she saw a red area under the resident's leg but it wasn't open or anything. -He/she didn't notice anything on the resident's buttocks. -If he/she saw a new wound, he/she would assess it, notify the Director of Nursing (DON), the ADON, the resident's physician, the resident's family and make a note of the wound. -Open wounds would be documented on the wound assessment. -If he/she observed a wound while caring for another wound, he/she would do the same thing. -If he/she couldn't find any other documentation, he/she would let the wound team, if involved, know; document it; and let the DON and the ADON know. -He/she believed RN A was staging wounds now since she was the wound nurse. -He/she would not stage a wound as a charge nurse but he/she would just document it. During an interview on 2/16/22 at 1:04 P.M., the DON said: -The resident did not have a stage one wound that he/she was aware of. -He/she was not aware of any other wounds on the resident. 3. Record review of Resident #35's admission Record showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Cellulitis. -Peripheral vascular disease (PVD a slow and progressive circulation disorder). -Chronic Osteomyelitis (inflammation or swelling that occurs in the bone. It can result from an infection somewhere else in the body that has spread to the bone, or it can start in the bone - often as a result of an injury.) Left Ankle and Foot. -Contracture (an abnormal usually permanent condition of a joint, characterized by flexion and fixation) of Muscle, Unspecified Lower Leg. -Type 2 Diabetes Mellitus (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin) without complications. Record review of the resident's weekly skin assessments dated July 2021 showed weekly skin assessments were not documented for the week of 7/19/21. Record review of the resident's weekly skin assessments dated August 2021 showed weekly skin assessments were not documented for the week of 8/23/21. Record review of the resident's weekly skin assessments dated September 2021 showed weekly skin assessments were not documented for the weeks of 9/6/21, 9/13/21, and 9/27/21. Record review of the resident's weekly skin assessments dated October 2021 showed weekly skin assessments were not documented for the week of 10/4/21, 10/11/21, 10/18/21, and 10/25/21. Record review of the resident's weekly skin assessments dated November 2021 showed weekly skin assessments were not documented for the weeks of 11/1/21 and 11/8/21. The resident was out of the facility from 11/17/21 thru 11/20/21. Record review of the resident's weekly skin assessments dated December 2021 showed the weekly skin assessment were not documented for the weeks 12/6/21, 12/13/21, 12/20/21 and 12/37/21. Record review of the resident's weekly skin assessments dated January 2022 showed weekly skin assessment were not documented for the weeks 1/3/22, 1/10/22, and 1/31/22. The resident was out of the facility from 1/14/22 thru 1/24/22 Record review of the resident's weekly skin assessments dated February 2022 showed weekly skin assessments were not documented for the week of 2/7/22. 4. During an interview on 2/15/22 at 11:50 A.M., agency RN B said: -Skin assessments were to be done weekly at a minimum, and documented in the computer. -The Charge Nurse was responsible for performing the assessment and documenting it in the computer. -All residents were scheduled to have weekly assessments performed. -The scheduled was posted at the nurse's station. -If a CNA discovered any new skin issues he/she informed the charge nurse of the new skin issue. -A new skin assessment was performed and documented in the computer. -A skin assessment was an unobstructed head to toe assessment of the skin that looked for wounds, sores, defects in skin, or any abnormality of the skin. During an interview on 2/15/22 at 3:32 P.M., agency CNA A said if a wound or skin issue was discovered during cares, he/she informed the charge nurse of the new skin issue. During an interview on 2/15/22 at 3:38 P.M., agency LPN A said: -The skin assessments were performed to find any abnormalities to the skin. -The nurses were responsible for this. -Skin assessments were documented in the electronic health record. -Skin assessments would be performed at a minimum weekly. -When a CNA reported any new skin issues the nurse would perform a skin assessment. -The doctor was called to get orders, and then the family was called and informed of the change in condition. During an interview on 2/16/22 at 1:04 P.M., the DON said: -There was a schedule for the charge nurse to do skin assessments. -He/She or the ADON have had to do the skin assessments on occasion. -He/She would expect any redness or additional wounds to be reported to the ADON. -Treatment of some sort should be started and someone should document newly identified wounds, preferably under wound documentation so they don't have to look through all of the progress notes. -If the outside wound company came in, they would stage the wound; otherwise, the physician or wound nurse would document it on the wound assessment. -Residents should have both a wound assessment and a skin assessment in the same week. -The ADON created a wound report so they could look at all wounds and see the staging. -Staff was reeducated about completing a wound assessment along with a skin assessment. -Skin assessments should be performed weekly. -Skin assessments should be documented in the residents chart. 2. Record review of Resident #20's Face Sheet showed he/she was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses that included non-pressure chronic ulcer of left heel and mid-foot with unspecified severity, identified 1/24/22. Record review of the resident's Significant Change Minimum Data Set (MDS - an assessment tool used for care planning), dated 11/16/21 showed the resident: -Was cognitively intact. -Was at risk for pressure ulcers. -Was receiving care for a surgical wound. -Used a pressure reducing device for his/her bed. Record review of the resident's Skin Integrity Impairment Related to Surgery of the Left Tibia (larger of the two vertical calf bones) Care Plan, dated 12/7/21 showed interventions included following protocols for treatment and monitoring of the skin. Record review of all the resident's nursing care plans showed there was no Pressure Injury or Risk for Pressure Injury Care Plan and there was no additional Wound Care Plan developed since the Skin Integrity Care Plan dated 12/7/21. Record review of the resident's Weekly Skin Observation assessment, dated 1/26/22 showed the resident had a 1 cm by 1 cm open area on his/her left heel and a treatment order was obtained. Record review of the resident's Weekly Wound Observation assessment, dated 1/26/22 showed: -The resident had a Stage II (partial thickness loss of tissue (a shallow, open wound with a reddish pink wound bed and no slough (light-colored stringy dead tissue) pressure injury (injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure and/or friction) on the left heel 1 cm (length) by 1 cm (width) by 0.2 cm (depth). The wound was not identified by a number. -The pressure injury was facility-acquired on 1/26/22. -The wound was described as beefy red and dry with no necrotic tissue, drainage, inflammation or odor. Wound edges were well-defined and the periwound (tissue surrounding a wound) tissue was normal. -Special equipment for prevention included the use of a heel riser (relieves pressure on the heel). -The treatment orders were to clean with wound cleanser. Apply calcium alginate (a highly absorbent dressing that forms a gel-like covering helping to maintain a moist wound-healing environment). Use cut out foam and wrap with gauze daily. Record review of the resident's e-chart showed: -There were no Weekly Skin Observation assessments after 1/26/22. -NOTE: These were requested, but not provided by the facility. Record review of the resident's Weekly Wound Observation assessment, dated 2/2/22 showed: -Wound #1 was facility-acquired on 1/26/22 and was located on the left heel. -The wound was described as moist with 100 percent slough in the wound bed. It measured 1.0 cm by 0.8 cm by 0.3 cm. The periwound was described as callused (thickened and/or hardened as a result of friction or pressure) with well-defined edges. -Heel riser in use. -Treatment orders for cleaning with normal saline. Apply calcium alginate, cut to fit. Cover with island dressing (an absorbent pad with adhesive backing) daily and as needed if missing or soiled. Record review of the resident's Weekly Wound Observation assessment for Wound #1, dated 2/9/22 showed: -Wound #1 was typed as an Unstageable pressure injury (full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed). It was measured at 0.6 cm by 1.0 cm by 0.2 cm. and was described as moist with 75 to 100 percent slough in the wound bed. It had a scant amount of serosanguinous drainage (discharge containing both blood and a clear to yellow liquid) and no odor or inflammation. The periwound tissue was macerated (exposed to moisture for too long, causing the skin to look soggy, feel soft and/or appear lighter than usual), and edges were well-defined. -The wound progress was deteriorated. -Heel riser in use. -New treatment orders to clean left heel with normal saline. Skin prep (a protective, film-forming application) to periwound. Santyl nickel thick to wound bed. Cover with calcium alginate cut to fit. Secure with border gauze dressing daily. Do not change corn cushion or foam cut out daily; change only when missing or soiled. Record review of the resident's Weekly Wound Observation, dated 2/9/22 for a second wound which was not identified by a number showed: -A facility-acquired left front lower leg Stage II wound identified on 2/9/22 suspected of being a spider bite. -The wound measured 0.9 cm by 1.2 cm by 0.2 cm. -The wound was described as moist with 75 to 100 percent slough with a small amount of serosanguinous fluid. -There was no odor or inflammation. The periwound was described as pink with irregular wound edges. -There were new treatment orders to clean the wound with normal saline. Apply Santyl, nickel thick. Cover with calcium alginate, cut to fit. Secure with border gauze daily and as needed if missing or soiled. Record review of the resident's physician orders dated 2/15/22 showed: -Float heels when in bed every shift starting 2/10/22. -Left heel - clean with normal saline. Skin prep to periwound. Apply corn cushion or foam cut out over wound. Apply Santyl, nickel thick to wound bed. Cover with Calcium alginate cut to fit. Secure with small border gauze dressing or Band-Aid daily. Do not change corn cushion or foam cut-out daily; only change when soiled or missing, every day shift for wound healing starting 2/10/22. -Left lower leg below the knee - clean with normal saline. Apply Santyl, nickel thick. Cover with calcium alginate, cut to fit. Secure with border gauze dressing, daily and as needed if missing or soiled, every day shift for wound healing starting 2/10/22. Observation on 2/15/22 at 10:10 A.M. of the resident's wound care showed Agency RN B: -Completed wound care on the resident's left lower leg, left heel, -The resident had a third wound on the outer left calf approximately six inches under the knee. It was pinkish red in color. Agency RN B said he/she only had orders for two wounds and did not know the cause of the third wound or when the third wound was acquired. During an interview on 2/14/22 at 12:08 P.M. Agency Licensed Practical Nurse (LPN) B said: -He/she had already completed the wound care treatment for the resident that morning. -He/she did not know what type of wound was just below the knee. It was not a typical location for a pressure injury. The wound was open and contained slough. -He/she didn't think it looked like an insect or spider bite. -If it was a pressure injury the wound would be staged. If it was an insect or spider bite or any wound other than a pressure injury it would not be staged. During an interview on 2/14/22 at 12:49 P.M. the DON said the wound below the resident's knee was caused by a brace the resident was wearing. The resident was no longer wearing the brace. During an interview on 2/14/22 at 2:32 P.M. CNA E said: -He/she knew of only one wound the resident had which was on one of his/her heels. -The resident was to float his/her heels when in bed. During an interview on 2/16/22 at 8:50 A.M. the resident said: -He/she had the third wound on his/her leg approximately two weeks. -He/she did not know how it or the wound just below the knee got there. During an interview on 2/16/22 at 9:05 A.M. Agency CNA H said: -He/she hadn't worked with the resident in over a month and didn't know if he/she had any wounds other than a surgery scar. -If he/she saw a wound he/she had never seen before he/she would ask the other CNA's if they knew about it. If they didn't he/she would report it to the nurse. During an interview on 2/16/22 at 9:11 A.M. Agency CNA J said: -He/she worked with the resident on 2/11/22 and only noticed two wounds. -He/she assisted the resident in getting up that morning and noticed a small scabbed area on his/her calf. -He/she didn't recall seeing it there before. -He/she had not reported it to the nurse. -If he/she noticed skin changes on a resident he/she notated it in the resident's electronic record. -He/she planned to notate the small scabbed area before the end of his/her shift. During an interview on 2/16/22 at 11:57 A.M. CNA G said: -He/she showered the resident the previous morning and documented he/she had a heel wound on the shower sheet. One of his/her legs was slightly dry and red. -CNA's use the shower sheet to document all skin issues they see. -The sheet was given to the charge nurse. -If a CNA sees any new skin issues they should document it on a shower sheet and give it to the charge nurse. -He/She didn't notice any other wounds on the resident. During an interview on 2/16/22 at 12:10 P.M. RN A said: -If a CNA noticed a new area on a resident's skin they should report it to the charge nurse. -The charge nurse should immediately do an assessment of the new area. -Charge nurses use a Skin Observation form to identify new skin issues. -If a nurse is not sure if a skin issue has been previously identified they can look at the physician orders to see if there are treatment orders for the area and look at the most recent Skin Observation form. -If the area has not been identified before the nurse should fill out a Skin Observation form and at minimum should write a progress note about the new wound or skin issue and notify the physician to obtain new orders. They should also notify the family. -Wounds and pressure injuries should be care planned. -Only pressure injuries should be staged. -When he/she staged what he/she thought was an insect or spider bite what he/she meant was that the wound had partial thickness tissue loss. The Weekly Wound Observation form described the stages and what they meant and he/she used the definition when calling the possible insect bite Stage II. When the form asked the type of wound he/she had indicated other, meaning it was not a pressure injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1b. Observation of the resident on 2/15/22 at 10:31 A.M. showed: -CNA F wiped down the outside of the resident's genitalia and did not cleanse or assess the catheter insertion site. -CNA F cleaned the resident's catheter tubing with wet wipes by wiping down and away without exposing insertion site and approximately half an inch of catheter tubing. -CNA F then cleansed the resident's buttocks. -CNA F removed his/her gloves and put on clean gloves without washing or sanitizing his/her hands. -CNA F applied new brief on the resident and touched resident's catheter tubing, then with the same contaminated gloved hands, he/she touched the resident's bedding and skin. During an interview on 2/15/22 at 10:45 A.M., CNA F said he/she would not have done anything differently regarding the resident's care. 2. Record review of Resident #38's Face Sheet showed he/she was admitted to the facility 3/20/20 and readmitted on [DATE] with the following diagnoses: -Benign Prostatic Hyperplasia without lower urinary tract symptoms (BPH-enlargement of the prostate gland blocks the urethra [tube that carries urine from bladder out of body] causing problem urinating). -Obstructive and Reflux Uropathy (a condition in which the urine flow is obstructed and the backward flow of urine causing kidney damage). Record review of the resident's POS, MAR, and TAR dated February 2022 showed: -No urinary catheter care orders upon the resident's on 2/11/22. -Staff entered order for catheter care on 2/13/22 which read: catheter care each shift and as needed with soap and water. Observation of the resident on 2/15/22 at 10:14 A.M. showed: -CNA G and Agency CNA A gloved without washing/sanitizing hands. -Agency CNA A did not appropriately cleanse or assess the catheter insertion site. -Agency CNA A cleaned resident's genitalia with a downward, swiping motion instead of an outward, circular motion. During an interview on 2/15/22 at 1:14 P.M., Agency CNA A said: -He/she would clean a resident's urinary catheter by starting with catheter insertion site and work downward, then clean tubing. -He/she is expected to wash his/her hands after removing gloves before putting on a new pair of gloves. -He/she usually sanitizes his/her hands before entering the resident's room and putting on gloves. -He/she usually washes or sanitizes hands after removing gloves. During an interview on 2/16/22 at 10:05 A.M., Agency RN B said: -Staff should have wiped from the center [insertion site of catheter] out in a circular motion. -Staff should have removed dirty gloves and sanitized or washed hands before applying new gloves. -Staff should never touch the resident or their bedding before removing dirty gloves. During an interview on 2/16/22 at 1:04 P.M., DON said: -Staff should have washed or sanitized hands before putting on gloves, after removing, and in between glove changes. -Staff should not have touched the resident, their bedding, or anything else with dirty gloves on. Based on observation, interview, and record review, the facility failed to complete urinary catheter (a tube passed through the urethra into the bladder to drain urine) care each shift as ordered by the resident's physician resulting in the resident with a history of Urinary Tract Infections (UTI - an infection in one or more of structures in the urinary system) developing a UTI; failed to ensure the urine graduate was clean, replaced in a timely fashion and placed on a barrier, for one sampled resident (Resident #22); failed to ensure urinary catheter care was provided according to standards of practice for two sampled residents (Residents #22 and #38), and failed to ensure one sampled resident (Resident #25) received incontinence care using hand hygiene to prevent urinary tract infection, out of 15 sampled residents. The facility census was 53 residents. Record review of the facility's Catheter Care, Urinary policy dated 10/17 showed: -The following information should be recorded in the resident's medical record: -The date and time catheter care was given. -The name and title of the individual(s) giving the catheter care. -All assessment data obtained when giving catheter care. -Character of urine such as color (straw-colored, dark or red), clarity (cloudy, solid particles or blood) and odor. -Any problems noted at the catheter-urethral junction during perineal care such as drainage, redness, bleeding, irritation, crusting or pain. -Any problems or complaints made by the resident related to the procedure. -How the resident tolerated the procedure. -If the resident refused the procedure, the reason(s) why and the intervention taken. -The signature and title of the person recording the data. -Wash and dry hands thoroughly and put on gloves. -With non-dominate hand separate the labia of the female resident or retract the foreskin of the uncircumcised male resident. Maintain the position of this hand throughout the procedure. -Assess the urethral meatus (external opening of the urinary tract). -For a female resident: Use a pre-moistened wipe to clean the labia. Use one area of the wipe for a downward, cleaning stroke. Change the position of the wipe for each downward stroke. Next, change position of the wipe and cleanse around the urethral meatus. -For a male resident: Use a pre-moistened wipe and clean around the meatus. Cleans the glans (the rounded tip of the penis) using circular strokes from the meatus outward. -Use a pre-moistened wipe to clean the catheter from insertion site to approximately four inches outward. Record review of the facility Handwashing/Hand Hygiene policy dated 8/15 showed: -Staff should complete hand hygiene to prevent the spread of infection. -Use an alcohol based rub or soap and water for the following situations: before and after direct care with residents, before and after handling invasive devices such as urinary catheters, after removing gloves and before putting on gloves. 1a. Record review of Resident #22's Face Sheet showed he/she was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnosis: -Urinary Tract Infection. -Delirium (altered state of consciousness, consisting of confusion, distractibility, disorientation, disordered thinking and memory, defective perception - illusions and hallucinations). -Neuromuscular Dysfunction of Bladder (a disorder of urinary bladder control due to damage to the spinal cord or to the nerves supplying the bladder). -Retention of Urine. Record review of the resident's Significant Change Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff used for care planning) dated 11/19/21 showed: -Resident was severely impaired with a Brief Interview for Mental Status (BIMS) of 4 out of 15. -Resident was totally dependent on staff for toileting. -Resident was always incontinent of bladder. -NOTE: The MDS did not show that the resident had a Foley catheter. Record review of the resident's undated care plan showed: -He/she had an indwelling Foley catheter related to diagnosis of Neuromuscular Dysfunction of the bladder. -He/she was to show no signs or symptoms of urinary infection. -He/she was to remain free from catheter-related trauma. -Staff were to flush his/her catheter as ordered, monitor/document for pain/discomfort due to catheter and monitor/record/report to medical doctor for signs and symptoms of UTI: cloudiness, no output, deepening of urine color, change in behavior. -He/she was on antibiotic therapy related to an infection. Record review of the resident's November 2021 Physician's Order Sheet (POS) showed: -Foley catheter care every shift and as needed, cleanse with soap and water dated 11/2/21. -Foley Catheter tubing and drainage bag (change) every night shift every 14 day(s) related to retention of urine dated 11/2/21. Record review of the resident's November 2021 Medication Administration Record (MAR)/Treatment Administration Record (TAR) showed: -Foley catheter care every shift and as needed, cleanse with soap and water dated 11/2/21. --No documentaion by facility staff catheter care was completed 23 out of 85 opportunities. -Foley Catheter tubing and drainage bag (change) every night shift every 14 day(s) related to retention of urine dated 11/2/21. --Documentation by facility staff showed the bag was changed one out of two opportunities. Record review of the resident's Administration Note dated 11/30/21 showed: -Regarding the catheter orders: Foley Catheter tubing & drainage bag (change) every night shift every 14 day(s) related to retention of urine, unspecified, there were no new bags available. Record review of the resident's December 2021 POS showed: -Foley catheter care every shift and as needed, cleanse with soap and water dated 11/2/21. -Foley Catheter tubing and drainage bag (change) every night shift every 14 day(s) related to retention of urine dated 11/2/21. Record review of the resident's December 2021 MAR/TAR showed: -Foley catheter care every shift and as needed, cleanse with soap and water dated 11/2/21. --No documentation by facility staff catheter care was completed 20 out of 93 opportunities. -Foley Catheter tubing and drainage bag (change) every night shift every 14 day(s) related to retention of urine dated 11/2/21. --Documentation by facility staff showed the bag was changed one out of two opportunities. Record review of the resident's Administration Note dated 12/27/21 showed: -Regarding the catheter orders: Foley Catheter tubing & drainage bag (change) every night shift every 14 day(s) related to retention of urine, unspecified, it was changed on 12/23/21. --NOTE: No documentation by facility staff on the resident's MAR/TAR the foley catheter drainage bag was changed on 12/23/21. Record review of the resident's January 2022 POS showed: -Foley catheter care every shift and as needed, cleanse with soap and water dated 11/2/21. -Foley Catheter tubing and drainage bag (change) every night shift every 14 day(s) related to retention of urine dated 11/2/21. Record review of the resident's January 2022 MAR/TAR showed: -Foley catheter care every shift and as needed, cleanse with soap and water dated 11/2/21. --No documentation by facility staff catheter care was completed 26 out of 93 opportunities. -Foley Catheter tubing and drainage bag (change) every night shift every 14 day(s) related to retention of urine dated 11/2/21. --Documentation by facility staff showed the bag was changed one out of two opportunities. Record review of the resident's February 2022 POS showed: -Foley catheter care every shift and as needed, cleanse with soap and water dated 11/2/21. -Obtain a urinary analysis (a urine specimen testing for UTI) for 2/15/22 lab day every shift until 2/15/22 dated 2/13/22. -Give Ciprofloxacin HCI (Cipro - an antibiotic) Tablet 500 milligrams (mg) by mouth two times a day for infection dated 2/13/22. Record review of the resident's February 2022 MAR/TAR showed: -Foley catheter care every shift and as needed, cleanse with soap and water dated 11/2/21. --No documentation by facility staff catheter care was completed eight out of 45 opportunities. -Give Ciprofloxacin HCI Tablet 500 mg by mouth two times a day for infection dated 2/13/22 administered as prescribed. Record review of the resident's Health Status Note dated 2/13/22 showed: -Resident was having large amount of thick yellowish discharge and was not draining urine. -The catheter was discontinued and a new catheter was inserted without difficulty with immediate return of thick light yellow urine. -A urine specimen was obtained for lab. Record review of the resident's Physician's Order Note dated 2/13/22 showed new order obtained to start Cipro 500 mg by mouth twice a day for seven days. Record review of the resident's urine analysis test dated 2/15/22 showed the resident was positive for a UTI. Observation of the resident's bathroom on 2/13/22 at 9:09 A.M., showed: -A urine graduate (a container used to empty urine from the foley catheter for disposal) dated 12/13 with yellow residue on the bottom. -The graduate was located on top of the resident's toilet with no barrier. Observation of the resident's bathroom on 2/14/22 at 11:51 A.M. showed a clean urine graduate dated 12/13 inside a bag that was inside a plastic tub on top of the toilet inside the resident's bathroom. Observation on of the resident's bathroom on 2/15/22 at 10:35 A.M. showed a urine graduate dated 12/13 with urine still in the bottom. The graduate was located inside a bag that was inside a plastic tub on top of the toilet inside the resident's bathroom. During an interview on 2/15/21 at 3:55 P.M., Certified Nursing Assistant (CNA) E said: -They had care sheets for each resident. -The care sheets included each resident's information, including if they had any special needs and if they were incontinent. -He/she would empty a catheter into a graduate, rinse the graduate out and store in a plastic bag or something so it's not sitting on the toilet without a barrier. -They should change everything out every week and date the graduate when it's been changed out. During an interview on 2/16/22 at 10:05 A.M., Agency Registered Nurse (RN) B said: -Urine graduates should be changed on a weekly basis. -In the past, night shift changed out the graduates, dated them, and stored them in a plastic bag. -He/she was not aware of anyone going around and checking to make sure it was done. -He/she would say it should be documented on the TAR but he/she was an agency staff so he/she really wasn't sure. -Graduates should be dumped, rinsed out and put in a bag. During an interview on 2/16/22 at 1:04 P.M., the Director of Nursing (DON) said: -Staff should have stored urine graduates in a trash bag in the bathroom. -Staff should have changed urine graduates out at least weekly. -Staff should have rinsed urine graduates after they emptied out a foley catheter into the graduate. -He/She would expect a urine graduate to have been changed out since 12/13. 3. Record review of Resident #25's significant change MDS dated [DATE] showed: -He/she was cognitively intact. -He/She required extensive staff assistance for toileting and personal hygiene. -Was always incontinent of urine and stool. Observation of the residents incontinence care on 2/15/22 at 11:10 A.M. showed: -Agency CNA K entered the resident's room and did not wash/sanitize his/her hands prior to putting on gloves and caring for the resident. -Agency CNA K lowered the residents pants and loosened the resident's brief. -Agency CNA K removed his/her gloves and put on clean gloves without first washing/sanitizing his/her hands. -Agency CNA K then used peri wipes (disposable pre-moistened personal cleansing wipes) and wiped the resident's perineal (the area from the pubic bone to the anus) twice using two separate peri wipes. -Agency CNA K then removed his/her gloves and put on clean gloves without first washing/sanitizing his/her hands. -Agency CNA K positioned the resident on his/her left side and wiped bowel movement from his/her anus and inner buttocks wiping three times using different peri wipes. -Agency CNA K then took off his/her gloves, put on new gloves without washing/sanitizing his/her hands and assisted with putting the resident's pants up and transferring the resident back to his/her recliner. -CNA K then gathered the resident's trash can liner with the disposed items, removed his/her right hand glove, opened the resident's room door and exited to the hallway without first washing/sanitizing his/her hands. During an interview on 2/15/22 at 11:25 A.M., Agency CNA K said: -Each time he/she removed his/her gloves, he/she was supposed to wash his/her hands if there was no hand sanitizer in the room. -Each time he/she changed his/her gloves, he/she was supposed to wash his/her hands to prevent cross contamination (the transfer of bacteria or other microorganisms from one area to another). -He/she did change his/her gloves but he/she did not wash his/her hands and did not use hand sanitizer during the resident's care. During an interview on 2/15/22 at 12:33 P.M., Agency CNA K said: -He/she did not carry hand sanitizer in his/her pockets. -The facility had small bottles of hand sanitizer for staff use at the nurse's station.

2. Record review of the facility's Shift Verification of Controlled Substances Count for medication carts for the past 3 months showed: -Staff were to sign the narcotic count was completed by the on-coming nurse and the off-going nurse each shift. -The log for Medication Cart 1 in the month of November 2021 was missing signatures for 4 out of 21 opportunities. -The log for Medication Cart 1 in the month of February 2022 was missing signatures for 33 out of 98 opportunities. -The log for Medication Cart 2 in the month of February 2022 was missing signatures for 14 out of 74 opportunities. -The log for Medication Cart 3 in the month of February 2022 was missing signatures for 63 out of 107 opportunities. -The log for Medication Cart 4 in the month of February 2022 was missing signatures for 64 out of 112 opportunities. During an interview on 2/15/22 at 10:05 A.M., Registered Nurse (RN) B said: -He/she counted narcotics with the previous or next shift nurse or Certified Medication Technician (CMT) each shift. -Narcotics should be counted per resident per medication by both off-going and on-coming staff. -He/she did not know who audits Controlled Substances Count to ensure completion. During an interview on 2/16/22 at 1:04 P.M., the DON said: -Staff coming in and going out counted together. -Staff were expected to name the resident and the medication, then state the number of doses that remained. -Both in-coming and out-going staff are expected to sign Controlled Substances Count when the medication count is complete. Based on interview and record review, the facility failed to obtain a Bureau of Narcotics and Dangerous Drugs license after a change of ownership. This had the potential to affect all residents who used controlled substances (a drug or other substance that is tightly controlled by the government because it may be abused or cause addiction), and to ensure the controlled medications were counted and documented at the beginning of each shift and at the end of each shift to ensure the accuracy of the distribution and use of the controlled medications. This had the potential to affect all residents who used controlled medications in the facility. The facility census was 53 residents. A policy was requested related to controlled substance license but was not received by the facility. Narcotic shift change policy requested but not received by the facility as of 2/16/22. 1. Record review of the facility's Report of Change form from the Missouri Department of Health and Senior Services (DHSS) dated 1/10/22 showed: -The facility had a change of ownership on 1/1/22. -A change of operator was effective 1/1/22. -The new operator was a limited liability company. Record review of the facility's Bureau of Narcotics and Dangerous Drugs license reviewed 2/14/22 showed: -Missouri controlled substance registration. -Registration effective date 7/2/21. -Registration expiration date 7/31/22. -This registration in not transferable. -Printed by the facility on 2/13/22. During an interview on 2/15/22 at 10:13 A.M. the Director of Nursing (DON) said: -He/she had been at the facility since 11/23/21 as the DON. -He/she was not aware if a new controlled substance license was applied for due to the new ownership change. -The corporation would assist with applying for a new controlled substance license. -He/she and the Administrator were responsible for obtaining the new controlled substance license for the change of ownership. During an interview on 2/15/22 at 10:27 A.M. the Administrator said: -He/she started at the facility about two weeks ago. -He/she thought the corporate office submitted for a new controlled substance license due to the change of ownership. -His/her understanding was the corporate office would apply for new licenses. -He/she would check with the corporate office to see if one had been applied for and obtain a copy if it had been applied for. No information was received that a new controlled substance license was applied for at the time of the change of ownership by the end of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the medication administration error rate was less than five percent (%). Two medication errors involving insulin (a hormone that helps glucose get into cells for energy) were detected out of 27 opportunities, resulting in a medication error rate of 7.41% affecting two sampled residents (Residents #25 and #42). The facility census was 53 residents. Record review of the facility's policy titled Insulin Administration dated September 2014 showed: -The type of insulin, dosage requirements, strength, and method of administration must be must be verified before administration. -The nurse shall notify the Director of Nursing (DON) Services and Attending Physician of any discrepancies. Review of medlineplus.gov shows approved subcutaneous (beneath the skin) injection sites were listed as: -Upper arm, at least 3 inches below the shoulder and 3 inches above the elbow on the back of the arm. -Outer side of upper thighs. -Belly area, below the ribs and above the hip bone, at least 2 inches away from belly button. Record review for the product insert for Novolog insulin dated October 2021 showed: -Novolog is a fast-acting insulin. Eat a meal within five to ten minutes after taking it. -Inject subcutaneously in the abdominal area, thigh, buttocks, or upper arm. 1. Record review of Resident #25's Face Sheet showed he/she was admitted to the facility on [DATE] with a diagnosis of Type 2 Diabetes Mellitus (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin). Record review of the resident's Order Summary Report showed: -Insulin Aspart (Novolog - a fast acting insulin) 6 units subcutaneously before meals and Primary Care Physician (PCP) said to give 4 units along with sliding scale. -Insulin Aspart sliding scale: blood sugar of 151-200 administer 2 units subcutaneously before meals. -Insulin Detemir (Levemir - a long acting insulin) 50 units subcutaneously at bedtime. Observation of the resident on 2/15/22 at 7:04 A.M. showed: -Agency Registered Nurse (RN) B tested the resident's blood sugar which resulted at 151. -Agency RN B administered 8 units of Levemir (brand name for Insulin Detemir). --NOTE: The resident's insulin order was for scheduled and sliding scale Aspart not Levemir before breakfast. The resident's order for Aspart was unclear if the resident should have received 6 units plus 2 units sliding scale or 4 units plus 2 units sliding scale. During an interview on 2/15/22 at 7:04 A.M., Agency RN B said he/she gave 8 units of insulin to the resident as 6 units were ordered and an additional 2 units per sliding scale. Observation of the resident on 2/15/22 from 7:04 A.M. to 8:03 A.M. showed: -The resident did not have a meal, snack, or beverage at his/her bedside at the time Agency RN B administered his/her insulin. -The resident received his/her breakfast tray at 8:03 A.M., 59 minutes after his/her insulin was administered. 2. Record review of Resident #42's Face Sheet showed he/she was admitted to the facility on [DATE] with a diagnosis of Type 2 Diabetes Mellitus. Record review of the resident's Order Summary Report showed: -Novolog: Inject as per sliding scale: if blood sugar levels 0-150=0 units, 151-200=2 units, 201-250=4 units, 251-300=6 units, 301-400=10 units subcutaneously three times a day after meals. Observation on 2/15/22 at 11:40 A.M. showed: -Agency RN B administered Novolog 8 units to the resident in the left deltoid muscle. --NOTE: The order was to be administered subcutaneously. 3. During an interview on 2/15/22 at 1:43 A.M., Agency RN B said: -Different insulin types could be given at different time frames before meals. -He/she had not noticed the note at the bottom of Resident #25's Insulin Aspart order pcp said to give 4 units along with sliding scale. -He/she needed to call the physician and pharmacy for clarification. -He/she said staff should administer the medication that is ordered and shows to be due on the resident's Medication Administration Record (MAR) and should be accurate. During an interview on 2/16/22 at 10:05 A.M., Agency RN B said: -Insulin could be administered in the abdomen, thigh or back side of arm. -Needed to be given into the fatty tissue. -Should not be administered directly in any muscle. During an interview on 2/16/22 at 1:04 P.M., Director of Nursing (DON) said: -Once insulin was given, the resident should have food within 15 minutes for fast acting insulin. -Insulin cannot be given in deltoid muscle. -Insulin Aspart (brand name is Novolog) and Insulin Detemir (brand name is Levemir) are not the same medications and one cannot be used in place of another. -Unclear medication orders should be clarified with the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a significant medication error did not occur during the administration of insulin by administering the incorrect insulin, not providing food or beverage within 15 minutes of insulin administration, and/or administering insulin through the incorrect route for two sampled residents during the medication pass (Residents #25 and #42). The facility census was 53 residents. Record review of the facility's policy titled Insulin Administration dated September 2014 showed: -The type of insulin, dosage requirements, strength, and method of administration must be must be verified before administration. -The nurse shall notify the Director of Nursing (DON) Services and Attending Physician of any discrepancies. Review of medlineplus.gov shows approved subcutaneous (beneath the skin) injection sites were listed as: -Upper arm, at least 3 inches below the shoulder and 3 inches above the elbow on the back of the arm. -Outer side of upper thighs. -Belly area, below the ribs and above the hip bone, at least 2 inches away from belly button. Record review for the product insert for Novolog insulin dated October 2021 showed: -Novolog is a fast-acting insulin. Eat a meal within five to ten minutes after taking it. -Inject subcutaneously in the abdominal area, thigh, buttocks, or upper arm. 1. Record review of Resident #25's Face Sheet showed he/she was admitted to the facility on [DATE] with a diagnosis of Type 2 Diabetes Mellitus (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin). Record review of the resident's Order Summary Report showed: -Insulin Aspart (Novolog - a rapid acting insulin) 6 units subcutaneously before meals and Primary Care Physician (PCP) said to give 4 units along with sliding scale. -Insulin Aspart sliding scale: blood sugar of 151-200 administer 2 units subcutaneously before meals. -Insulin Detemir (Levemir - a long acting insulin) 50 units subcutaneously at bedtime. Observation of the resident on 2/15/22 at 7:04 A.M. showed: -Agency Registered Nurse (RN) B tested the resident's blood sugar which resulted at 151. -Agency RN B administered 8 units of Levemir (brand name for Insulin Detemir). --NOTE: The resident's insulin order was for scheduled and sliding scale Aspart not Levemir before breakfast. The resident's order for Aspart was unclear if the resident should have received 6 units plus 2 units sliding scale or 4 units plus 2 units sliding scale During an interview on 2/15/22 at 7:04, Agency RN B said he/she gave 8 units of insulin to the resident as 6 units were ordered and an additional 2 units per sliding scale. Observation of the resident on 2/15/22 from 7:04 A.M. to 8:03 A.M. showed: -The resident did not have a meal, snack, or beverage at his/her bedside at the time Agency RN B administered his/her insulin. -The resident received his/her breakfast tray at 8:03 A.M., 59 minutes after his/her insulin was administered. 2. Record review of Resident #42's Face Sheet showed he/she was admitted to the facility on [DATE] with a diagnosis of Type 2 Diabetes Mellitus. Record review of the resident's Order Summary Report showed: -Novolog: Inject as per sliding scale: if blood sugar levels 0-150=0 units, 151-200=2 units, 201-250=4 units, 251-300=6 units, 301-400=10 units subcutaneously three times a day after meals. Observation on 2/15/22 at 11:40 A.M. showed: -Agency RN B administered Novolog 8 units to the resident in the left deltoid muscle. --NOTE: The order was to be administered subcutaneously. 3. During an interview on 2/15/22 at 1:43 A.M., Agency RN B said: -Different insulin types could be given at different time frames before meals. -He/She had not noticed the note at the bottom of Resident #25's Insulin Aspart order pcp said to give 4 units along with sliding scale. -He/she needed to call the physician and pharmacy for clarification. -Staff should administer the correct medications and administer as ordered. During an interview on 2/16/22 at 10:05 A.M., Agency RN B said: -Insulin could be administered in the abdomen, thigh or back side of arm. -Needed to be given into the fatty tissue. -Should not be administered directly in any muscle. During an interview on 2/16/22 at 1:04 P.M., Director of Nursing (DON) said: -Once insulin was given, the resident should have food within 15 minutes for fast acting insulin. -Insulin cannot be given in deltoid muscle. -Insulin Aspart (brand name is Novolog) and Insulin Detemir (brand name is Levemir) are not the same medications and one cannot be used in place of another. -Unclear medication orders should be clarified with the physician.

Based on observation, interview and record review, the facility failed to maintain the kitchen floors under the food preparation table, the ice machine and the floors in the dry goods storage are free of grime and food debris; failed to label dry food storage containers with foods that were not easily identifiable with the name of that food; failed to discard boiled eggs that had been in the walk-in refrigerator for more than seven days; failed to maintain the juice machine free of mold in the inner parts of the juice machine; failed to ensure there was an air gap (is the unobstructed vertical space between the water outlet and the flood level of a fixture) between the drainage hose from the ice machine and the floor drain underneath the ice machine to prevent accidental backflow; failed to maintain the cutting board free of numerous nicks and grooves which rendered the cutting board not easily cleanable; failed to maintain the sprinkler head above the dishwasher area and the upper walls next to the range hood, free of a buildup of dust. This practice potentially affected 53 residents who ate food from the kitchen. The facility census was 53 resident. 1. Observations of the lunch meal on 2/13/22 from 9:04 A.M. through 11:29 A.M., showed: - Buildup of debris on the floor in one corner of the dry good storage area. - Three containers not labeled with their contents which were not easily identifiable. - The presence of debris inside the utensil storage container. - A buildup of debris under the cabinets and the six burner stove on the other side of steam table. - Two drainage hoses from ice machine that was not separated by an air gap between the drainage pipe and the floor drain. - The presence of debris including napkins, foam cups, and food particles under the cabinets in the front area next to the ice machine. - The presence of mold on inner parts of the juice machine. - A green cutting board with numerous nicks and grooves which rendered the cutting board not easily cleanable. During an interview on 2/13/22 from 12:38 P.M. through 12:46 P.M., the Dietary Manager (DM) said the following: - There is a company that is hired to come in and clean the juice machine every three months and if dietary staff noticed something like mold, they are supposed to clean the juice machine. - Dietary staff are supposed to pull the ovens out monthly and they should be sweeping twice a day under the food preparation table to remove the grime and debris away. - At the end of the night shift, the dietary staff are supposed to throw away items that are not labeled. - The eggs that have been there since 2/3/22 should have been thrown away at the end of three days. - The dishwasher should be checking on the cutting boards weekly. - He/she was unaware of the lack of an air gap between ice machine drainage hoses and the drainage hole and he/she was unaware of the debris under the cabinets in the serving area. During an interview on 2/13/22 at 1:15 P.M., Dietary Aide (DA) A said: - He/she has not been trained in monitoring the cutting boards. - It was not part of his/her duties to clean under the steam tables and the prep table. During an interview on 2/13/22 at 1:19 P.M., the Maintenance Director said the dietary department had not notified him/her before 1/13/22, about the dust on the wall or about the dust on the sprinkler head. During an interview on 2/13/22 at 1:22 P.M. DA B said: - He/she did not get under the food preparation table from the side where the stoves were located because that was on the cooks' side. - He/she only got under the table from the non-cooks side. During an interview on 2/13/22 at 1:31 P.M., Dietary [NAME] (DC) A said cleaning under the tables was one of his/her chores. During an interview on 2/15/22 at 12:54 P.M., the Environmental Services Department Supervisor said: - It is the responsibility of the Environmental Services Department to clean under the cabinets in the front part that is outside the kitchen. - Some debris is hard to remove because the cabinets were not movable. -The environmental services department is supposed to clean under those cabinets two times per day. Record review of the 1999 and 2009 Food and Drug Administration (FDA) Food Code and Missouri Food Codes, showed: - In Chapter 3-602.11, FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, and label information shall include the common name of the FOOD, or absent a common name, an adequately descriptive identity statement. - In Chapter 4-501.12, Surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and SANITIZED, or discarded if they are not capable of being resurfaced. Surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and SANITIZED, or discarded if they are not capable of being resurfaced. - In Chapter 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. C) Non FOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. - In Chapter 4-602.13, nonfood-CONTACT SURFACES of EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues; - In Chapter 5-202.13 Backflow Prevention, Air Gap. An air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment, shall be at least twice the diameter of the water supply inlet and may not be less than 1 inch (in.) - In Chapter 6-501.12, paragraph A, The physical facilities shall be cleaned as often as necessary to keep them clean.

Based on interview and record review, the facility failed to update written contracts for the use of outside resources after a change of ownership occurred. The facility census was 53 residents. A policy was requested related to use of outside resources and the facility did not have a policy related to this. 1. Record review of the facility's Report of Change form from the Missouri Department of Health and Senior Services (DHSS) dated 1/10/22 showed: -The facility had a change of ownership on 1/1/22. -A change of operator was effective 1/1/22. -The new operator was a limited liability company. Record review of the Dialysis Services Agreement showed: -A contract for dialysis (dialysis (process of cleansing the blood by passing it through a special machine - necessary when the kidneys are not able to filter the blood) services. -The contract was entered into agreement on 3/9/09 with the facility. -There was no updated contract related to the change of ownership. Record review of the Laboratory Services Agreement contract showed: -A contract for laboratory services. -The contract was entered into agreement on 9/13/11 with the facility. -There was no updated contract related to the change of ownership. Record review of the Contract for Services showed: -A contract for mental health services. -The contract was entered into agreement on 5/9/13 with the facility. -There was no updated contract related to the change of ownership. Record review of the Hospice-Skilled Nursing Facility contract showed: -A contract for hospice (end of life) services. -The contract was approved on 11/14/17. -There was no updated contract related to the change of ownership. Record review of the Mobile Imaging Services Agreement showed: -A contract for mobile imaging services. -The contract was entered into agreement on 9/1/18 with the facility. -There was no updated contract related to the change of ownership. Record review of the Nursing Facility Respite Care Agreement showed: -A contract for hospice services. -The contract was entered into agreement on 4/20/20. -There was no updated contract related to the change of ownership. During an interview on 2/15/22 at 10:27 A.M. the Administrator said: -He/she started at the facility about two weeks ago. -Facility level local contracts would be re-done upon change of ownership. -Contracts that were just used by this facility would be completed by each department as needed. -No designated staff member was in place to ensure contracts were updated. -The Administrator was responsible for ensuring all contracts were updated upon change of ownership.

Based on observation, interview and record review, the facility failed to maintain the overhangs in the attic areas of over 300 and 400 Hall free of opening that could let pests in. This practice potentially affected 31 residents who resided in the 300 and 400 halls. The facility census was 53 residents. 1. Observations with the Maintenance Director on 2/14/22, showed: -At 11:04 A.M., an opening was that was 41 inches (in.) long and about 3 in. wide, present opening at the 400 Hall attic area overhang, that could potentially let pests in and two birds' nests were present in the 400 hall overhang area. -At 11:18 A.M., two openings that were 41 in. long and about 3 in. long that could lest pests in, were present at the overhang are of 300 Hall. During an interview on 2/15/22 at 4:14 P.M., the Maintenance Director said birds' nests are a very rare occurrence so maybe he/she checked for bird's nests once per year. Record review of the 2017 Food and Drug Administration (FDA) Food Code, showed the following: Chapter 6-202.15 Outer Openings, Protected. (A) Except as specified in paragraphs (B), (C), and (E) and under paragraph (D) of this section, outer openings of a Food Establishment shall be protected against the entry of insects and rodents by: (1) Filling or closing holes and other gaps along floors, walls, and ceilings; (2) Closed, tight-fitting windows; and (3) Solid, self-closing, tight-fitting doors. Chapter 6-501.111 Controlling Pests. The premises shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the premises by: A) Routinely inspecting incoming shipments of food and supplies; B) Routinely inspecting the premises for evidence of pests; C) Using methods, if pests are found, such as trapping devices or other means of pest control as specified under; and D) Eliminating harborage conditions. 6-501.112 Removing Dead or Trapped Birds, Insects, Rodents, and Other Pests. Dead or trapped birds, insects, rodents, and other pests shall be removed from control devices and the premises at a frequency that prevents their accumulation, decomposition, or the attraction of pests.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to update the facility assessment annually and as needed and to ensure COVID 19 (a new disease caused by a novel (new) coronavirus) information was included in the assessment to determine resources necessary to meet the needs of the residents. The facility census was 53 residents. A policy for the Facility Assessment was requested and not provided. 1. Record review of facilities Facility assessment dated [DATE] showed: -It had not been updated. -It did not identify the needed space, equipment, assisted technology, communication devices, or other material resources that were needed to provide the required care and services to the residents. -It did not include an evaluation of the overall number of facility staff needed to ensure a sufficient number of qualified staff were available to meet the resident's needs. -It did not address COVID-19. -It did not reflect any COVID 19 resident population. -It did not address the needed staff competencies for COVID 19. -It did not include an evaluation of needed equipment, supplies, or skills for COVID 19. -It did not include a plan of how to manage resident care for COVID 19. During an interview on 2/15/22 at 11:37 A.M., Administrator said: -The Facility Assessment should be updated annually and as needed. -He/she was responsible for updating the Facility Assessment. -The Facility Assessment was used to determine staffing needs for the facility. -The Facility Assessment should have been updated to include COVID-19 information, competencies, and needs. -The Facility Assessment was on his/her list to go over, but he/she had not gotten it updated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to use appropriate infection control procedures to prevent cross-contamination during blood glucose testing when staff did not clean the glucometer correctly, use barrier and sat glucometer on resident use items for six sampled residents (Residents #32, #8, #25, #30, #4, and #42); facility failed to use acceptable infection control measures while providing wound care when staff did not sanitize scissors, put supplies on surfaces without barriers, and did not perform hand hygiene between glove changes for two sampled residents (Resident #22 and #20) out of 15 sampled residents; failed to maintain tuberculosis (TB-a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) testing records for one employee (Employee #2) out of ten sampled new employees, and failed to provide daily resident assessments for COVID-19 (a new disease caused by a novel (new) coronavirus) in accordance with Centers for Disease Control and Prevention (CDC) guidelines for 15 sampled residents (Residents #36, #12, #38, #35, #22, #45, #46, #42, #24, #25, #20, #17, #26, #255, and #30). The facility census was 53 residents. Record review of the facility's Obtaining a Fingerstick Glucose Level Policy and Procedure, dated October 2011, showed staff were instructed to: -Clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice. -The policy did not address the use of a clean barrier. Review of manufacturer's instructions for Assure Prism Multi glucometer (small, portable machine that measures the glucose level in the blood by placing a drop of blood on a test strip which has already been inserted into the machine), dated February 2016, showed: -The glucometer should be cleaned and disinfected after each use on each patient. -Approved cleaners listed were Clorox Germicidal Wipes, Dispatch Hospital Cleaner, PDI Super Sani-Cloth Germicidal Disposable Wipe, and CaviWipes. -Two disposable wipes are needed-one wipe for cleaning and a second wipe for disinfecting. -Fluids cannot enter the machine through the test strip port, data port, or battery compartment. --NOTE: Hand sanitizing gel was not listed as an appropriate method for cleaning/sanitizing the glucometer. Record review of the facility's Handwashing/Hand Hygiene policy, dated August 2015, showed: -Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections. -Use an alcohol-based hand rub containing at least 62% alcohol, or alternatively, soap (antimicrobial or non-antimicrobial) and water before handling clean or soiled dressings, gauze pads, etc. and after removing gloves. -The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing health-care associated infections. -Perform hand hygiene before applying non-sterile gloves. -When applying, remove one glove from the dispensing box at a time, touching only the top of the cuff. 1. Record review of Resident #32's Face Sheet showed he/she was admitted to the facility on [DATE] with a diagnosis of Type 2 Diabetes Mellitus (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin). Record review of the resident's Order Summary Report, dated February 2022, showed accuchecks (a blood sugar reading obtained by a small sample of blood from the finger) were to be completed before meals and at bedtime. Observation of the resident on 2/15/22 at 6:47 A.M., showed: -Registered Nurse (RN) B placed the glucometer directly onto the resident's clothed chest without a barrier between the resident's clothing and glucometer. -After obtaining the blood sample, RN B exited the resident's room with the same gloves on. -RN B removed gloves, sanitized his/her hands, picked up contaminated glucometer with ungloved hands, and wiped it off with gel hand sanitizer and placed the glucometer on a new, clean barrier on the medication cart. -RN B did not wash or sanitize hands after contact with the glucometer. -RN B then touched the computer and reached in the medication cart. 2. Record review of Resident #8's Face Sheet showed he/she was admitted to the facility on [DATE] with a diagnosis of Type 2 Diabetes Mellitus. Record review of the resident's Order Summary Report, dated February 2022, showed accuchecks were to be completed before meals and at bedtime. Observation of the resident on 2/15/22 at 6:58 A.M., showed: -RN B placed the glucometer on the resident's bed without a barrier between resident's bedding. -He/she obtained the resident's blood sample, then placed the contaminated glucometer on the resident's bedding without a barrier. -RN B exited the resident's room with the same gloves on. -RN B removed his/her gloves, sanitized his/her hands, picked up the contaminated glucometer with ungloved hands and wiped it off with gel hand sanitizer and placed the glucometer on a new, clean barrier on the medication cart. -RN B did not wash or sanitize hands after contact with the glucometer. -RN B then touched the computer and reached in the medication cart. 3. Record review of Resident #25's Face Sheet showed he/she was admitted to the facility on [DATE] with a diagnosis of Type 2 Diabetes Mellitus. Record review of the resident's Order Summary Report, dated February 2022, showed accuchecks were to be completed before meals and at bedtime. Observation of the resident on 2/15/22 at 7:02 A.M., showed: -RN B exited the resident's room with gloved hands after obtaining the resident's blood sugar sample. -RN B removed his/her gloves, sanitized his/her hands, and with ungloved hands, picked up the contaminated glucometer, wiped it off with gel hand sanitizer, and placed the glucometer on a new, clean barrier on the medication cart. -RN B did not wash or sanitize hands after contact with the glucometer. -RN B then touched the computer and reached in medication cart with his/her contaminated hands. Observation of the resident on 2/15/22 at 11:32 A.M., showed: -RN B placed the glucometer on the resident's body without a barrier between resident's clothing and glucometer. -After obtaining the blood sample, RN B exited the resident's room with the same contaminated gloves. -RN B removed his/her gloves, sanitized his/her hands, picked up the contaminated glucometer with ungloved hands from the barrier and wiped it off with gel hand sanitizer and placed the glucometer on a new, clean barrier on the medication cart. -RN B did not wash or sanitize hands after contact with contaminated glucometer. -RN B then touched the computer and reached in medication cart. 4. Record review of Resident #30's Face Sheet showed he/she was admitted to the facility on [DATE] with a diagnosis of Type 2 Diabetes Mellitus. Record review of the resident's Order Summary Report, dated February 2022, showed accuchecks were to be completed every morning and at bedtime. Observation of the resident on 2/15/22 at 7:08 A.M., showed: -After obtaining the resident's blood sugar sample, RN B sat glucometer with the bloody test strip directly onto the resident's bedside table without a barrier. -RN B picked up the contaminated glucometer and exited the resident's room with the same gloved hands. -RN B removed his/her gloves, sanitized his/her hands, picked up contaminated glucometer with ungloved hands, wiped it off with gel hand sanitizer, and placed on a new, clean barrier on the medication cart. -RN B did not wash or sanitize hands after contact with the glucometer. -RN B then touched the computer and reached in medication cart. 5. Record review of Resident #4's Face Sheet showed he/she was admitted to the facility on [DATE] with a diagnosis of Type 2 Diabetes Mellitus. Record review of the resident's Order Summary Report, dated February 2022, showed accuchecks were to be completed every morning and at bedtime. Observation of the resident on 2/15/22 at 7:13 A.M., showed: -RN B placed the glucometer directly on the resident's bare chest without a barrier between the resident's skin and glucometer. -RN B applied blood to test strip while inserted in glucometer and placed glucometer directly on the resident's bare chest without a barrier between the resident's skin and glucometer. -After obtaining the blood sample, RN B exited the resident's room with the same gloves on. -RN B removed his/her gloves, sanitized his/her hands, picked up contaminated glucometer with ungloved hands, wiped the glucometer with gel hand sanitizer, and placed on a new, clean barrier on the medication cart. -RN B did not wash or sanitize hands after contact with the glucometer. -RN B then touched the computer and reached in medication cart. 6. Record review of Resident #42's Face Sheet showed he/she was admitted to the facility on [DATE] with a diagnosis of Type 2 Diabetes Mellitus. Record review of the resident's Order Summary Report, dated February 2022, showed accuchecks were to be completed before meals and at bedtime. Observation of the resident on 2/15/22 at 7:21 A.M., showed: -RN B placed the glucometer on the resident's bedding without a barrier between bedding and glucometer. -After obtaining the blood sample, RN B exited the resident's room with the same gloves on. -RN B removed his/her gloves, sanitized his/her hands, picked up contaminated glucometer with ungloved hands, wiped off the glucometer with gel hand sanitizer, and placed on a new, clean barrier on the medication cart. -RN B did not wash or sanitize hands after contact with the glucometer. -RN B then touched the computer and reached in the medication cart. Observation of the resident on 2/15/22 at 11:40 A.M., showed: -After obtaining the blood sample, RN B placed the contaminated glucometer on the medication cart without a barrier, removed his/her gloves, and sanitized his/her hands. -RN B picked up contaminated glucometer with ungloved hands and placed it inside the medication cart. -RN B did not clean or disinfect the glucometer prior to placing it in the medication cart. 7. During an interview on 2/15/22 at 1:43 P.M., RN B said glucometers should be cleaned with bleach wipes and put on a clean paper towel. During an interview on 2/16/22 at 10:05 A.M., RN B said: -Glucometers were to be cleaned with either bleach wipes or hand sanitizer and put on a clean barrier. -Glucometers could be placed on the resident's bed or tray table. -Glucometers should always be on a barrier if laid down, but he/she always placed it on a bare surface. During an interview on 2/16/22 at 1:04 P.M., Director of Nursing (DON) said: -Two glucometers should have been used to allow appropriate dry time between uses. -He/She thought it was ok to sanitize the glucometers with alcohol wipes between resident use. -He/she had never cleaned a glucometer with hand sanitizer, but was unsure if that was an acceptable practice. -Glucometers should always be on a barrier when laid down. -Sani-Cloth Germicidal Disposable Wipe were available in the nurse's medication cart as well as at the nurse's station. 8. Record review of the facility's Wound Care policy, dated September 2013, showed: -Use disposable cloth (paper towel is adequate) to establish a clean field on resident's over bed table. Place all items to be used during procedure on the clean field. -Wash and dry your hands thoroughly. -Place disposable cloth next to resident (under the wound) to serve as a barrier to protect the bed linen and other body sites. -Put on exam glove. Loosen tape and remove dressing. -Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. -Put on gloves. -Use no touch technique. Use sterile tongue blades and applicators to remove ointments and creams from their containers. -Pour liquid solutions directly on gauze sponges on their papers. -Dress wound. Pick up sponge with paper and apply directly to area. [NAME] tape with initials, time and date and apply to dressing. -Discard disposable items into the designated container. Wash and dry your hands thoroughly. -Reposition the bed covers. -Use clean field saturated with alcohol to wipe over bed table. -Wipe reusable supplies with alcohol as indicated (i.e., outsides of containers that were touched by unclean hands, scissor blades, etc.) Return reusable supplies to resident's drawer in treatment cart. -Wash and dry your hands thoroughly. Record review of Resident #22's Face Sheet showed he/she was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: -Delirium (altered state of consciousness, consisting of confusion, distractibility, disorientation, disordered thinking and memory, defective perception - illusions and hallucinations). -Cellulitis (an infection of deep skin tissue). Record review of the resident's undated care plan showed: -He/she had a potential/actual impairment to skin integrity related to cellulitis of bilateral lower extremities. -He/she would have no complications related to an open area to his/her left heel. -Staff should follow facility protocols for treatment of injury. -He/she had a deep tissue pressure injury to left heel. Record review of the resident's Physician's Order Sheet (POS), dated February 2022, showed: -Left heel cleanse with Hypochlorous Acid (a weak but strongly oxidizing acid produced by the reaction of chlorine and water and used as a bleaching agent, disinfectant), skin prep to peri-wound. Apply Bactroban (antibacterial used to treat skin infections) followed by Santyl (an ointment used to treat skin ulcers) nickel thick to entire wound. Cover with Calcium Alginate (a highly absorbent, biodegradable seaweed dressing) cut to fit wound, and then ABD (a dressing used to absorb drainage from wounds). Apply bordered gauze, secure with roll gauze daily and prn (as needed) when soiled and/or missing. Every day shift for wound healing, dated 1/27/22. Observation on 2/15/22 at 10:35 A.M., showed Agency RN B: -Entered the resident's room and placed all supplies on the resident's bedside table without cleaning the table and with no barrier. -Opened the ABD pad and gauze with no gloves. -Put gloves on without sanitizing or washing his/her hands and removed the gauze. -The resident's left inner heel had a wound in a circle shape that was red/pink inside and approximately the size of quarter. -RN B poured Vashe (Hypochlorous Acid) on gauze and used the gauze with the Vashe on it and cleaned the wound. -RN B did not change his/her gloves. RN B dried the wound with dry gauze that had been opened and handled without gloves. -Opened Bactroban package and then put the Bactroban on the wound with his/her finger. -RN B put Santyl that was already in an open container on the wound with his/her finger while wearing the same gloves and put the ABD pad under the resident's left foot. -Took his/her gloves off and did not sanitize or wash his/her hands. RN B put new gloves on. -He/She cut open the calcium alginate package with scissors, placed the scissors on the bed linens, and then put the calcium alginate on the resident's wound. -He/She removed the ABD pad from under the resident's left foot and placed the same ABD pad over the calcium alginate. -He/She wrapped the resident's left heel/lower leg with gauze, cut the gauze with the same scissors used to cut open the calcium alginate package and placed the scissors back on the bed linens. -Placed the Vashe on the floor, removed his/her gloves, and placed the gloves in the trashcan. -Took the trash bag out of the trashcan and replaced the trash bag. -Washed his/her hands and the scissors with soap and water. -Took the trash bag from the resident's room to the room marked clean utility. -Placed the scissors in the nurse's station. -Placed the Vashe bottle back in the treatment cart without sanitizing the bottle. 9. Record review of Resident #20's Face Sheet showed the resident was readmitted on [DATE] with diagnoses that included non-pressure chronic ulcer of left heel and mid-foot with unspecified severity, identified 1/24/22. Record review of the resident's Significant Change Minimum Data Set (MDS - an assessment tool used for care planning), dated 11/16/21, showed the resident: -Was cognitively intact. -Was at risk for pressure ulcers. -Was receiving care for a surgical wound. -Used a pressure reducing device for his/her bed. Record review of the resident's Skin Integrity Impairment Related to Surgery of the Left Tibia (larger of the two vertical calf bones) Care Plan, dated 12/7/21, showed interventions included following protocols for treatment and monitoring of the skin. Record review of the resident's physician orders, dated 2/15/22, showed: -Left heel - clean with normal saline. Skin prep to periwound. Apply corn cushion or foam cut out over wound. Apply Santyl, nickel thick to wound bed. Cover with Calcium alginate cut to fit. Secure with small border gauze dressing or Band-Aid daily. Do not change corn cushion or foam cut-out daily; only change when soiled or missing, every day shift for wound healing starting 2/10/22. -Left lower leg below the knee - clean with normal saline. Apply Santyl, nickel thick. Cover with calcium alginate, cut to fit. Secure with border gauze dressing, daily and as needed if missing or soiled, every day shift for wound healing starting 2/10/22. Observation on 2/15/22 at 10:10 A.M., of the resident's wound care showed Agency RN B: -Placed supplies needed for the resident's wound care directly onto the top of the medication cart without sanitizing the medication cart top or placing a clean barrier on the surface. With unsanitized and ungloved hands he/she removed a medication cup from the cart, opened the tube of Santyl and squeezed some into the cup. He/She opened the packages of two adhesive dressings, placed them face down and marked them with the date and his/her initials and placed them back in the open packaging. Other items placed on the medication cart without a barrier were a multiple use bottle of normal saline and calcium alginate and border gauze, both of which were unpackaged and the dressings placed directly on the unsanitized cart surface. -Obtained a pair of scissors from the nurse's station desk without sanitizing them. -Gathered all the wound care supplies in his/her gloved hands and grabbed gloves. -Placed the wound care supplies directly on the resident's bedspread without placing a clean barrier between the bedspread and the wound care supplies. The bottom gauze square, the bottle of normal saline, scissors, the adhesive dressings and gloves were directly touching the bedspread. -Removed his/her gloves and placed them on the floor without a barrier and put on another pair of gloves that had been touching the resident's bedspread without first sanitizing his/her hands. -Removed the resident's dressing located approximately two inches below his/her left knee, placed all contaminated dressings on the floor. -Without changing gloves he/she took an unused 4 inch by 4 inch gauze pad and placed it directly onto the top of the previously opened bottle of normal saline. The saline bottle was tipped upside down with the gauze square held against the bottle's top until the gauze was soaked with saline solution. -Used the saline soaked gauze square and cleaned the wound, discarding the used gauze onto the floor near the soiled dressings he/she had removed. -He/She did not change his/her gloves or sanitize his/her hands and used the scissors, without sanitizing them, to cut the calcium alginate and placed the calcium alginate on a square of gauze on the bedspread without a barrier. -Used the same gloved hands to place his/her right index finger in the medicine cup to scoop up half of the Santyl which was applied to the wound. -Removed his/her right glove and threw it on the floor. -He/She used scissors that were not sanitized to move the wound supplies a few inches closer to him/her across the bedspread. -Put on gloves which had directly touched the bedspread and applied the cut out calcium alginate and a clean adhesive dressing to the wound and removed the left glove, discarding it onto the floor. -Without placing the resident's left foot on a barrier he/she removed the dressing from the resident's left heel and discarded it on the floor near the other soiled items. -He/She picked up a new bottle of normal saline multi-use bottle and poked his/her thumb through the opening at the top where the bottle cover was still attached using the same gloved hands and tipped the bottle top directly onto a gauze square. One corner of the gauze pad touched the nurse's pants. -He/She wiped the resident's left heel. With the same gloved hands the nurse used the remainder of the calcium alginate and placed it on a non-adherent pad and then on an adhesive dressing. The dressings were placed calcium alginate and adhesive side up directly onto the bedspread. -The nurse picked up the medicine cup with the remaining Santyl and used his/her contaminated gloved right index finger to swipe out the remaining Santyl which was applied to the back of the resident's heel. -Removed his/her right glove and placed it on the floor and put his/her right ungloved thumb on the calcium alginate dressing that would directly touch the resident's wound before applying it to the resident's heel. -Picked up most of the soiled items off of the floor with a gloved hand and with a bare hand picked up the remainder of the soiled items, placing them in the trash. -Put the scissors near the sink and washed his/her hands. -Carried the scissors and bottle of normal saline down the hallway and sat the bottle of normal saline on top of the medication cart without cleaning the medication cart or bottle and did not place a barrier between the cart and bottle. -Cleaned the scissors with hand sanitizer and left them on the nurse's station counter. -Placed the multi-use bottle of normal saline into the medication cart without sanitizing the bottle. 10. During an interview on 2/16/22 at 10:05 A.M., Agency RN B said: -During wound care, he/she would gather all of the stuff; wash his/her hands; clean where he/she was putting things down; put a barrier down; put whatever body part he/she was completing wound care for on some kind of barrier; put his/her gloves on; take off the dressing and throw it away; remove his/her gloves; wash his/her hands; put on new gloves; clean the wound; if drainage or anything got on the gloves, he/she would change gloves again; if nothing got on the gloves, he/she wouldn't change gloves; put treatment on with dressing and tape (whatever the treatment called for); take gloves off; wash hands; and situate the resident. -If he/she needed to use the scissors during the wound care, he/she would clean the scissors with hand sanitizer or soap and water, both before and after use. -It was not appropriate to put supplies anywhere without a barrier. -Before putting anything back in the cart, staff should sanitize all items with hand sanitizer or bleach wipes, if accessible. During an interview on 2/16/22 at 1:04 P.M., the DON said: -Sometimes staff would bring a table with them to do wound care. -Staff should clean the cart; lay down a towel; put supplies on the towel; wash hands prior to going into a resident's room; put gloves on; remove the dressing; change gloves and wash/sanitize hands; reglove; clean the wound from center to outside; if the resident had multiple wounds, change gloves between wounds; after cleaning wound, remove gloves and sanitize/wash hands; reglove; apply treatment; and initial dressing. -He/she would expect multiple glove changes with hand sanitizing in between. 11. Record review of TB Screening, Testing and Treatment of U.S. Health Care Personnel on the Centers for Disease Control and Prevention's website showed instructions to repeat a TST within one to three weeks after an initial negative TST. Record review of the facility's Employee Infection and Vaccination Status policy, dated August, 2013, showed: -Prior to or upon an employee's duty assignment the facility will screen for tuberculosis. -Employees will be current with mandated vaccinations and TST. During an interview on 2/16/22 at 1:05 P.M., with the DON and ADON: -The DON said the TB test for new staff is given prior to the employee working on the floor. It is read 48 to 72 hours later by any nurse. The second step was started a week after the first step results are read. Results are documented in the employee TB log located at the nursing station. -The ADON said he/she was responsible for the TB tests for new hires and completed them the same day as the employee's drug test. He/She used an orientation calendar to set up the new employee TB schedule. The facility's Employee Directory Report, generated 2/13/22, showed Employee #2 as actively employed. Record review of Employee #2's employee file showed: -He/she was hired on 10/26/21. -There was no documentation of TB testing for the employee. During an interview on 2/16/22 at 11:07 A.M., the Human Resources (HR) Director said: -He/she was responsible for scheduling the new employee two-step TB with the Assistant Director of Nursing (ADON). If the ADON was not available the Director of Nursing (DON) did the Mantoux TB skin test (a tiny amount of inactive TB protein (tuberculin) is injected just below the skin to aid in the diagnosis of tuberculosis). If neither the ADON nor the DON was available a charge nurse could administer the skin test. -Any nurse can read (check for swelling) the results 48 to 72 hours later. The nurse documents the results in the TB book which was kept at the nurses' desk. -The second step was scheduled a week to 10 days after reading the first step. -He/She was unable to find Employee #2's TB records. 12. Record review of the facility Novel Coronavirus (COVID-19) Prevention and Response policy, dated 2021, showed: -The facility will respond promptly upon suspicion of illness associated with a novel coronavirus in efforts to identify, treat, and prevent the spread of the virus. -Staff shall be alert to signs of COVID-19 and notify the resident's physicians if fever, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea are evident. -Actively monitor all residents upon admission and at least daily for fever and symptoms consistent with COVID-19. -Use clinical judgement on a case-by-case basis to determine if a resident has signs and symptoms compatible with COVID-19. Review of the Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 (The virus that causes the disease COVID-19) Spread in Nursing Homes, Updated February 2, 2022 showed: -Older adults living in congregate settings are at high risk of being affected by respiratory and other pathogens, such as SARS-CoV-2. -Even as nursing homes resume normal practices, they must sustain core ICP practices and remain vigilant for SARS-CoV-2 infection among residents and HCP in order to prevent spread and protect residents and HCP from severe infections, hospitalizations and death. -Evaluate residents at least daily. -Ask residents to report if they feel feverish or have symptoms consistent with COVID-19 or an acute respiratory infection. -Actively monitor all residents at least daily for fever (temperature of 100.0 or higher degrees Fahrenheit (F) - the customary unit of temperature in the United States that defines the melting point of water as 32 degrees and the boiling point of water at 212 degrees) and symptoms consistent with COVID-19. -Ideally include an assessment of oxygen saturation via pulse oximetry (a small electronic device placed on the resident's finger to measure the blood oxygen level). -Other COVID-19 symptoms can include fatigue, muscle or body aches, headache, sore throat, loss of taste and/or smell, or new dizziness, nausea, vomiting, or diarrhea. -More than two temperatures of 99.0 degrees F might also be a sign of fever in this population. -Identification of these symptoms should prompt isolation and further evaluation for CoV-2 infection; anyone with even mild symptoms of COVID-19, regardless of vaccination status, should receive a viral test as soon as possible. Record review of Residents' #36, #12, #38, #35, #22, #45, #46, #42, #24, #25, #20, #17, #26, #255, and #30 electronic medical records showed no documentation of daily assessments for signs and symptoms of COVID-19 During an interview on 2/16/22 at 9:41 A.M. Agency RN B said: -Residents were not assessed daily for signs and symptoms of COVID-19. -Not all residents have a daily temperature taken; residents on Medicare A and residents on antibiotics have temperatures done daily. -COVID-19 screenings were not completed or documented for residents daily at the facility. During an interview on 2/16/22 at 10:02 A.M., the DON said: -Residents were not evaluated/assessed daily for signs and symptoms of COVID-19, including that daily temperatures and a review for signs and symptoms of COVID was not completed daily for each resident. -If residents were not feeling well, facility staff took the residents temperature, respiratory rate, and oxygen saturation (a small electronic device was placed on the resident's finger to measure the blood oxygen level) and then did a rapid COVID-19 test (a COVID-19 test that produces a result in minutes). -Residents' vital signs (body temperature, heart rate, rate of breathing and blood pressure) were taken monthly and as needed; for residents receiving Medicare A skilled services or antibiotics (medication for infection) a temperature was taken daily. -The new company was coming up with a COVID-19 resident screening for the software used for electronic medical records. -There had not yet been discussion regarding what will be the frequency of the resident COVID-19 screening. -He/she thought the resident COVID-19 screenings should be daily and should consist of a daily temperature and symptom checklist assessment. -He/she had worked at the facility since November 23, 2021 and since that time the facility had not been doing daily resident COVID-19 assessments.