Based on record review and interview, the facility failed to ensure dialysis communication forms were consistently filled out for one (#21) of one sampled resident reviewed for dialysis. The administrator reported three residents in the facility received dialysis services. Findings: A Nursing Home Dialysis Transfer Agreement, signed 01/21/14, read in part, Facility shall ensure that all appropriate medical, social, administrative, and other information accompany all designated residents at the time of transfer to center. Resident #21 had diagnoses which included end stage renal disease. A physician's order, dated 11/03/21, documented Resident #21 was to receive dialysis every Tuesday, Thursday, and Saturday. Resident #21's 2024 TARs documented they had been transported to dialysis 13 times in November and 13 times in December. Out of 26 opportunities, the resident's health record contained five dialysis communication forms. On 01/08/25 at 9:41 a.m., LPN#1 stated the nurse on duty should ensure a dialysis communication form was sent with the resident to dialysis. They stated once the resident returned from dialysis the form should be given to the business office manage to place in the resident's chart. On 01/08/25 at 10:01 a.m., the business office manager stated the forms do not always make it back from dialysis with the resident. On 01/08/25 at 11:30 a.m., the administrator stated the facility needed to ensure the communication forms made it back to the facility.

Based on record review and interview, the facility failed to ensure a resident with a diagnosis of diabetes and received routine insulin had an HgbA1C lab collected as ordered by a physician for one (#22) of five sampled residents reviewed for unnecessary medications. The DON stated 23 residents at the facility have physician routine orders for HgbA1C tests. Findings: Resident #22 had diagnoses which included type two diabetes. A physician's order, dated 08/12/19, documented Resident #22 was to have HgbA1C labs drawn each January, April, July, and October. A review of the resident's EHR revealed no documentation the resident's HgbA1C had been collected since July 2024. On 01/07/25 at 9:45 a.m., the infection preventionist stated in October 2024 the facility's QA committee had identified through their quality assurance program the HgbA1C labs for Resident #22 had not been done. They were asked since the discovery, how many times had the resident's lab been checked. The infection preventionist stated they had not been checked since identified by the QA committee. They stated the HgbA1C was important to get an accurate measurement of the resident's blood sugar levels and would they would contact the physician for an order to obtain the lab now. On 01/08/25 at 8:49 a.m., the DON stated all lab work needed to be completed as ordered so the providers could make informed decisions about care.

Based on record review and interview, the facility failed to ensure lab work identified by the QA committee as not having been done was collected once the omission was identified for one (#22) of five sampled residents reviewed for unnecessary medications. A facility document titled All Residents, dated 01/06/25, documented 38 residents resided at the facility. Findings: An active physician's order, dated 08/12/19, documented Resident #22 was to have HgbA1C labs drawn each January, April, July, and October. A review of the resident's EHR revealed no documentation the resident's HgbA1C had been collected since July 2024. On 01/07/25 at 9:45 a.m., the infection preventionist stated in October 2024 the QA committee, through their quality assurance program, had identified the previous DON had not been monitoring labs and Resident #22 HgbA1c had not been collected since July 2024. The infection preventionist was asked how many times the resident's labs had been collected since October 2024. They stated the labs had not been collected. They were asked how effective the facility quality assurance had been in that case. They stated it had not been effective for Resident #22. They stated they would contact the physician and get an order for the lab work to be collected.

Based on record review and interview, the facility failed to ensure SNF ABN forms included the required information for two (#43 and #48) of three sampled resident reviewed for skilled services beneficiary review. The DON identified 10 residents that had discharged from part A skilled services in the previous six months to the survey. Findings: 1. A SNF ABN form for Resident #43, dated 09/20/24, was reviewed and found not to have the reasons for non-coverage and estimated cost of those services documented on the form. 2. A SNF ABN form for Resident #48, dated 12/23/24, was reviewed and found not to have the reasons for non-coverage and estimated cost of those services documented on the form. On 01/08/25 at 9:59 a.m., the infection preventionist stated they had been tasked with creating the SNF ABN forms and presenting them to the residents. They stated they were unaware the section about the reason for potential non-payment and estimated cost were required to be included on the form. They stated they understood now the information was needed for the resident and their representatives to make informed decisions about future care. On 01/08/25 at 10:32 a.m., the administrator stated they did not have a policy or procedure for the completion of the SNF ABN forms. They stated the forms were important for the residents to make decisions and should have been completed fully.

Based on record review and interview, the facility failed to ensure licensed nurses were competent to perform tasks of their position by conducting a skills check and documenting the results for each licensed nurse. A facility employee list provided by the DON documented eight licensed nurses worked at the facility. Findings: A review of LPN #1's employee file did not reveal a skills review. On 01/08/25 at 8:56 a.m. the DON stated they had looked at LPN #1's records and did not find a skills check. They stated the former DON had stopped performing skill checks at some point and they would be restarting that process. They stated it was their expectation each licensed nurse would possess the skills to perform their duties. They stated their was no facility policy or procedures regarding skills checks. On 01/08/25 at 9:01 a.m., the administrator stated none of their current licensed nurses had a skills check in their file because the previous DON had not done them. On 01/08/25 at 9:06 a.m., the assistant administrator stated the nurses last skills check had occurred in 2021.

Based on observation and interview, the facility failed to: a. implement an enhanced barrier precaution policy to prevent the spread of multidrug-resistant organisms; and b. ensure a licensed practical nurse performed hand hygiene during tracheostomy care for one (#36) of one sampled resident reviewed for tracheostomy care. The administrator reported the census in the facility was 38 and one resident had a tracheostomy. Findings: 1. On 01/06/25 at 8:45 a.m., a tour of the facility was conducted. No signage was noted indicating enhanced barrier precautions were in place to protect at risk residents. On 01/07/25 at 12:42 p.m., CNA #1 stated the facility did not use EBP. On 01/07/25 at 12:45 p.m., CNA #2 stated they were not familiar with EBP. On 01/08/25 at 09:41 a.m., LPN #1 stated the facility was in the process of implementing enhanced barrier precautions. On 01/08/25 at 10:35 a.m., the infection preventionist stated they are currently not using EBP. b. A facility Trach policy, dated 11/05/24, read in part, Cleaning A Non Disposable Inner Cannula 1. Prepare supplies before cleaning inner cannula. a. Open tracheostomy care kit with supplies. b. Cleanse trach site with 15 ml of normal saline with 5 ml of hydrogen peroxide. c. May open extra splint gauze sponges. 2. DON disposable gloves 3. Remove oxygen source if one is present. 4. Gently remove inner cannula, remove gloves and discard 5. Disposable replacement inner cannula, release lock gently remove inner cannula, Replace with appropriate sized new cannula. Engage lock on inner cannula. 6. Suction outer cannula using sterile and or clean technique. 7. Replace inner cannula into outer cannula reapply oxygen source if needed. A facility Addendum to Trach Cleaning policy, read in part, Procedure: Wash your hands, Set up equipment/trach care kit onto pre cleaned area, [NAME] gloves, Place hydrogen peroxide/sterile water solution into bowl/compartment; Place sterile water into second bowl or compartment, Remove inner cannula while holding the neck plate of trach still, Place inner cannula in peroxide/sterile water solution and soak until crust or mucus plugs are softened or removed, Use the brush or pipe cleaners to clean inside, outside, and the creases of the tube, Look inside the inner cannula to make sure it is clean and clear of mucus, Rinse tube in saline or sterile water, Reinsert into trach while holding neck plate still, Turn the inner cannula until it locks into position, and Double check the locking by pulling the inner cannula forward gently. On 01/08/25 at 8:31 a.m., LPN #1 was observed performing tracheostomy care to Resident #36. LPN #1 was observed to have prepared the material necessary for the care then don gloves. They were not observed cleaning their hands prior to donning the gloves. LPN #1 was observed removing the tracheostomy tubing from the resident and placing it on a clean surface. They then prepared a cleaning solution, applied the solution to gauze, then cleaned around the ostomy site. They discarded the gauze then repeated with new gauze. They then discarded that gauze and began cleaning the tracheostomy tubing. They then placed the tubing into the resident's tracheostomy site and secured it. They then placed a bandage around the tubing on the resident's neck. LPN #1 then removed their gloves they had put on at the beginning of the care. On 01/08/25 at 8:40 a.m., LPN #1 was asked how they thought the care had gone. They stated they believed it had gone well. They were asked how many times during the care did they change their gloves. They stated they had not and should have done so between the dirty and clean steps. They stated they had been nervous. On 01/08/25 at 8:49 a.m., the DON stated they were surprised by LPN #1's performance during the tracheostomy care. They stated it was their expectation the nurses understand the importance of not passing infections and using personal protective equipment. They stated they would be having training with LPN #1 on these issues.

Based on record review and interview, the facility failed to ensure accurate staffing information for the PBJ reports was provided to CMS for the fourth quarter of 2024. A facility document titled All Residents, dated 01/06/25, documented 38 residents resided at the facility. Findings: A CMS PBJ Staffing Data Report dated 07/01/24 through 09/30/24, documented the facility had not provided the required RN coverage or licensed nurse coverage for the quarter of 2024. A review of the facility daily staffing reports for the fourth quarter of 2024 revealed the facility had been adequately staffed for RN coverage, licensed nurse coverage, and weekend staffing. On 01/08/25 at 10:14 a.m., the administrator stated the information submitted was not accurate and the person who had entered the data had erroneously submitted incorrect information at another one of their facilities on another occasion. On 01/08/25 at 10:32 a.m., the administrator stated they had not been aware the wrong information had been submitted. They stated the employee who had entered the data had recently been let go because they had done the same thing at another facility. They stated the facility did not have a policy or procedure for the entry of PBJ report data.

Based on observation, record review, and interview, the facility failed to ensure staff wore hair nets and beard guards while in the kitchen. The CDM identified 33 residents received services from the kitchen. She identified one resident who solely received nutrition and hydration through a peg tube. Findings: A Personnel Standards policy, undated, read in part, .The following standards have been adopted by the dietary department .Hair nets, covering all of the hair, must be worn at all times while on duty .Facial hair must be covered with a beard guard . On 11/14/23 at 11:22 a.m., [NAME] #1 was observed with very short hair on their head and the bottom half of their face. They were not observed to have a hair net or beard guard on. On 11/14/23 at 11:48 a.m., DA #1 was observed in the kitchen with longer facial hair observed from side burn to side burn, covering chin, and above top lip. They were not observed to wear a beard guard. On 11/14/23 at 12:00 p.m., [NAME] #1 and DA #1 were observed assisting with plating lunch and covering trays for delivery. Neither staff were observed wearing a beard guard, and cook was not observed to wear a hair net. On 11/15/23 at 3:18 p.m., DA #1 was observed in the kitchen without a hair net or beard guard. They were observed filling a resident's pitcher. DA #1 alerted CDM the surveyor was at the door. DA #1 was observed to obtain and don a hairnet. On 11/15/23 at 3:19 p.m., the CDM was asked what the policy was regarding staff and hair nets. She stated, We all wear our hair nets. She stated, We have to wear them to come in the kitchen. She was asked what the policy was for wearing beard guards. She stated, Yeah, if they have a beard they are suppose to wear one. She was asked if any of the kitchen staff had a beard. The CDM stated, No. She was asked if DA #1 had a beard. The CDM was observed to look at DA #1 and stated the DA #1 had one. DA #1 was observed to grab another hair net. The CDM stated DA #1 was putting one on.

Based on record review and interview, the facility failed to update COVID-19 Policy and Procedures at least annually. The Administrator reported there were 34 residents residing in the facility. Findings: A COVID-19 Policy and Procedure, revised 12/23/20, stated in parts, .Staff will have their temperature checked 3 times per shift .Dietary staff to wear mask while in kitchen .Nurse's to wear N95 mask while completing breathing treatments .Facility will obtain and record temperatures on all residents qshift .Residents are to be encouraged to stay in their rooms .Residents are to wear face mask anytime they come out of their room . On 11/16/23 at 9:00 a.m., the Administrator stated the above practices documented in their current COVID-19 policy and procedures were no longer in effect and acknowledged the policy had not been updated at least annually.

Based on record review, observation, and interview, the facility failed to conduct routine pressure ulcer assessments, follow physician orders for pressure ulcer treatment, and update the care plan for one (#15) of two residents sampled for pressure ulcers. The Resident Census and Conditions of Residents form documented one resident with pressure ulcers. Findings: Res #15's significant change assessment, dated 08/13/22, documented the resident's cognition was moderately impaired, required extensive assistance with ADLs, and had no pressure ulcers. A nurse note, dated 09/06/22, documented the resident had a fluid filled blister to the left heel measuring 2.0 x 4.5 cm. The note documented an order to cleanse the area with wound wash, pat dry, and spray area with skin prep BID until resolved. A physician order, dated 10/05/22, documented to discontinue skin prep and apply Allevyn dressing to left heel and leave in place for seven days. The TAR documented the skin prep treatment was continued after the physician order documented to discontinue the treatment. The TAR did not document the order for the Allevyn dressing. The resident's EHR was reviewed and there were no pressure ulcer assessments for over five weeks from the dates of 09/06/22 until 10/13/22. The wound assessment, dated 10/13/22, documented a pressure ulcer on the left heel measured 2.0 x 0.9 cm and had a Allevyn dressing in place. The wound assessment, dated 10/20/22, documented a pressure ulcer on the left heel measured 1.0 x 0.7 cm and had a Allevyn dressing in place. On 10/26/22 at 4:20 p.m., the resident was lying on an air mattress and the resident's left heel was observed to have an Allevyn dressing. The care plan had not been updated with the new pressure ulcer and interventions to included the physician orders, air bed, and heel protectors. On 10/28/22 at 9:55 a.m., LPN #1 was observed providing wound care to the resident's left heel. There was no dressing in place. The pressure ulcer was open, approximately nickel size, and had serosanguinous drainage on the gauge when the wound was cleaned. The LPN applied skin prep to the pressure ulcer and surrounding area. The LPN stated she had no knowledge of the order for the Allevyn dressing. On 10/28/22 at 3:33 p.m., the DON stated the order for the Allevyn dressing did not make it into the resident's EHR. She stated the skin assessments should have been completed weekly and the care plan should have been updated.