Camdenton Windsor Estates

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to provide an appropriate emergency discharge notice when staff discharged one resident (Resident #1) to the hospital and refused to allow the resident to return to the facility. The facility census was 54.1. Review of the facility's policies on 3/3/26, showed the facility did not have a policy for emergency discharge. 2. Review of Resident #1's face sheet, dated 3/3/26, showed the resident admitted to the facility on [DATE], and facility staff discharged him/her to the hospital 02/23/26.Review of the residents progress notes, dated 3/3/26, at 11:52 A.M., showed staff documented they spoke with the residents guardian in regard to a notice of immediate discharge because the facility can no longer meet the residents needs. Review of the resident's Immediate Discharge Notice, dated 3/3/26, showed staff documented the resident would discharge to the hospital. During an interview on 3/3/26 at 10:09 A.M., the administrator said he/she will not take the resident back due to safety concerns for the other residents. He/She said he/She is aware the facility will receive a citation because the hospital is not an acceptable discharge location. During an interview on 3/3/26 at 10:37 A.M., the care plan coordinator said he/she emailed the social worker at the hospital where the resident was discharged to alert him/her that the facility would not be accept the resident back to the facility. Incident #2786352

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, facility staff failed to ensure residents' personal information was protected when staff left the computer screen open in public areas for four residents (Resident #12, #18, #32, and #34) out of eleven sampled residents. Facility staff failed to protect residents' privacy when staff failed to provide privacy during perineal care for one resident (Resident #17) out of three sampled residents and during medication administration by feeding tube for one resident (Resident #202) out of one sampled resident. The facility's census was 46.
1. Review of the facility's policies showed staff did not provide a policy for privacy.
Review of the facility's policy titled, Resident Rights, undated, showed each resident has the right to privacy and confidentiality.
2. Observation on 04/08/25 at 8:40 A.M., showed Certified Medication Technician (CMT) A left the computer screen open and unattended with Resident #32 medication information visible in the hallway. Observation showed residents and staff walked by the cart.
Observation on 04/08/25 at 8:42 A.M., showed CMT A left the computer screen open and unattended with Resident #34 medication information visible in the hallway. Observation showed residents and staff walked by the cart.
Observation on 04/08/25 at 8:55 A.M., showed CMT A left the computer screen open and unattended with Resident #12 medication information visible in the hallway. Observation showed residents and staff walked by the cart.
Observation on 04/08/25 at 10:45 A.M., showed CMT A left the computer screen open and unattended with Resident #18 medication information visible in the hallway. Observation showed residents and staff walked by the cart.
During an interview on 04/09/25 at 10:08 A.M., CMT A said computer screens should be minimized when away from the cart. He/She said when screens are left open other staff or residents can see the information on the screen, and it is a risk for privacy. He/She said he/she just forgot to minimize the screen when he/she walked away.
During an interview on 04/10/25 at 01:26 P.M., Director of Nursing (DON) said when staff walk away from their computer the screen should be minimized. He/She said it is a violation of privacy and it is no one else business about that resident what is on the screen.
During an interview on 04/10/25 at 2:30 P.M., the administrator said when staff is away from the chart the computer screen should be minimized. He/She said no other staff or residents should see other residents' information. He/She said it is a violation of privacy.
3. Review of Resident #17's quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 01/08/25 showed staff assessed the resident as follows:
-Cognitively Intact;
-Dependent on staff for dressing and toileting hygiene;
-Substantial/maximal assistance on staff for personal hygiene.
Review of the resident's care plan, dated 03/14/25, showed staff are directed to assist the resident with transfers, dressing, toileting, and personal hygiene.
Observation on 04/09/25 at 9:20 A.M., showed Certified Nursing Assistant (CNA) C and Nursing Assistant (NA) B transferred the resident from his/her chair to bed, and provided perineal care to the resident with the resident's roommate in his/her wheelchair facing the resident. CNA C and NA B did not pull the privacy curtain between the residents to provide privacy during perineal care.
During an interview on 04/09/25 at 9:50 A.M., NA B said he/she should have pulled the curtain between the residents for privacy. He/She said he/she didn't even think about it at the time.
During an interview on 04/09/25 at 10:26 A.M., CNA C said he/she didn't even realize the roommate was in the room until he/she came on the other side of the bed afterwards. He/She said he/she should have pulled the curtain for privacy.
3. Review of Resident #202's Quarterly MDS, dated [DATE], showed staff assessed the resident as:
-Cognitively impaired;
-Required a feeding tube;
-Diagnosis of traumatic brain injury.
Observation on 04/09/25 at 11:45 A.M., showed Licensed Practical Nurse (LPN) D enter the resident's room to administer medication by feeding tube. Observation showed the LPN did not close the curtain to the outside parking lot and exposed the residents abdomen.
During an interview on 04/10/25 at 08:40 A.M., LPN D said he/she did not need to close the curtain because the window was a one way view and people could not see in from the outside
During an interview on 04/10/25 at 08:47 A.M., the Maintenance Director said he/she was not aware of any one-way windows or films used on the facility windows.
During an interview on 04/10/25 at 02:20 P.M., the administrator said he/she was not aware of any one-way window films or windows used at the facility and would expect staff to close the room curtains to provide privacy during care.
During an interview on 04/10/25 at 01:26 P.M., Director of Nursing (DON) said during care curtains should be pulled for privacy. He/She said this includes curtains by the window or in between residents.
During an interview on 04/10/25 at 2:30 P.M., the administrator said he/she would expect staff to close the door and pull the curtains for all care provided to the residents to maintain their privacy. He/She said the DON is responsible to ensure nursing staff provide privacy.

Based on interview and record review, facility staff failed to designate one or more individuals with specialized training in Infection Prevention and Control (IPC) as the Infection Preventionist (IP) for the facility's Infection Prevention and Control Program. The facility's census was 46.
1. Review of the facility's policy titled, Infection Prevention and Control Program, dated 08/2024, showed the IP is qualified to conduct IPC activities as a result of education, training and experience. He/she will complete the Centers for Disease Control and Prevention (CDC) Long Term Care Infection Preventionist module.
2. During an interview 04/09/25 at 1:53 P.M., the Director of Nursing (DON) said the facility does not currently have a qualified IP. He/She said a nurse was recently hired to be the facility's IP but the nurse is not certified, and he/she was not aware the IP needed to be certified.
During an interview on 04/10/25 at 2:36 P.M., the administrator said he/she was not aware the IP needed to be certified. He/she said a nurse was recently hired to be the facility's IP but the nurse is not certified.

Based on observation, interview and record review, the facility staff failed to serve food in accordance with the nutritionally calculated recipes and menus to three residents who received pureed diets. The facility census was 46.
1. Review of the facility's Food Preparation and Distribution policy, dated April 2011, showed recipes should be followed on each item prepared.
Review of the facility's Week 4, Day 25 lunch menu showed residents who received pureed meals were to receive a #6 (five and one third ounces) scoop of pureed ham, a #8 (four ounces) scoop of candied sweet potatoes, a #12 (two and two thirds ounces) scoop of buttered spinach and a #16 (two ounces) scoop of dinner roll.
Review of the facility's standardized recipes showed they did not contain a recipe for pureed mixed peas and carrots.
Review of the facility's standardized recipe for pureed ham showed staff were instructed to prepare five servings by processing five, 4.5 ounce servings of ham and a slurry of water and food thickener.
Observation on 04/09/25 at 12:09 P.M., showed [NAME] J added 4 slices of ham, which were not weighed, and an unmeasured amount of hot water to a food processor. Observation showed [NAME] J did not add thickener. [NAME] J pureed the ham and water and divided the ham among three plates which set on the counter.
Observation on 04/09/25 at 12:12 P.M., showed [NAME] J added two unmeasured dessert cups of mixed peas and carrots to the food processor. [NAME] J pureed the peas and carrots and divided the vegetables among three plates, which sat on the counter. Observation showed the peas and carrots were not divided evenly among the three plates. Observation showed [NAME] J did not prepare or serve pureed potatoes or bread.
During an interview on 04/09/25 at 12:21 P.M., [NAME] J said they did not have any candied sweet potatoes, so they served baked sweet potato fries as an alternative. [NAME] J said he/she could not locate a recipe for mixed peas and carrots. [NAME] J said residents who receive pureed meals cannot have bread or potato fries since they don't puree well. [NAME] J said residents who receive pureed meals can have mashed potatoes. [NAME] J said he/she never pureed bread or potato fries, and he/she tended to give extra vegetables or meat as a substitute. [NAME] J said the residents were to receive three ounces of meat and three ounces of vegetables. [NAME] J said he/she used four, three-ounce slices of ham and did not measure the amount of peas and carrots. [NAME] J said he/she believed he/she was giving the residents 25% more meat and vegetables than the menu indicated.
During an interview on 04/10/25 at 11:15 A.M., the Dietary manager (DM) said cooks have a daily menu and recipes, and they should be followed. The DM said kitchen staff were using a pureed bread mix, but it was on back order. The DM said residents receiving pureed meals should have received a starch (potato) as the menu indicated. The DM said he/she was not aware staff were not following recipes or menus. The DM said he/she is also serving as the activities director so his/her DM role is not 100%.
During an interview on 04/10/25 at 1:10 P.M., the administrator said cooks were responsible for following all menus and recipes unless approved substitutions were made. The administrator said the DM was responsible for ensuring kitchen staff followed menus and recipes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections when staff failed to implement the Enhanced Barrier Precautions (EBP) Policy when they did not properly educate or alert staff of residents who required EBP during wound care for three (Resident #8, #18, and #19) of three sampled residents, failed to properly clean and disinfect glucometer (a device for monitoring blood sugars) and provide a barrier for the glucometer and insulin supplies for six residents (Resident #16, #17, #18, #21, #37, and #203) out of six sampled residents. Staff failed to perform proper hand hygiene during blood sugar checks and insulin administration for five residents (Resident # 16, #17, #18, #21, and #37) out of six sampled residents and failed to perform appropriate hand hygiene during toilet hygiene for two residents (resident #12 and #17) of three sampled resident and tracheostomy, catheter and feeding tube care for one (Resident #202) of one sampled resident in a manner to prevent the spread of infection. The facility census was 46.
1. Review of the facility's policy titled, Enhanced Barrier Precautions to Infection Control Guidance, dated 03/2024, showed the purpose is to prevent broader transmission of multidrug-resistance organisms (MDRO) and to help protect patients with chronic wounds and indwelling devices. EBP should be implemented for the period of their stay or until wounds have resolved or indwelling medical devices have been removed. Residents with a wound, regardless of their MDRO status, residents with an indwelling medical device including urinary catheter, feeding tube, tracheostomy/ventilator regardless of their MDRO status. Use EBP when providing high-contact resident care activities such as performing wound care, caring for or using an indwelling medical device. Gloves and gown are required when conducting high-contact resident care activities listed above.
2. Review of Resident #8's Quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 03/10/25, showed staff assessed the resident as cognitively intact, and had one venous ulcer (a wound on the leg or ankle caused by abnormal or damaged veins) present.
Review of the resident's care plan, updated 04/01/25, showed:
-EBP is required to be free from infections due to a wound;
-An EBP identifier will be hung outside the resident's door to let staff know they need to utilize a gown, gloves when performing high-contact cares;
-Staff will perform hand hygiene, put on Personal Protective Equipment (PPE), enter the room and perform necessary cares, remove PPE, perform hand hygiene, and exit the room taking all trash/linens with them.
-Cleanse wound to Left outer ankle with wound cleanser and apply dry bordered dressing daily.
Observation on 04/09/25 at 1:14 P.M., showed the resident's room did not contain a sign to alert staff on the use of EBP.
Observation on 04/09/25 at 1:15 P.M., showed Licensed Practical Nurse (LPN) E provided wound care to the resident and did not wear a gown when he/she performed wound care to the resident's leg.
During an interview on 04/09/25 at 1:40 P.M., LPN E said he/she did not think the resident required EBP precautions, and did not think he/she needed to wear a gown during wound care since the resident's wound was very tiny and without drainage.
3. Review of Resident #18's Significant Change MDS, dated [DATE], showed staff assessed the resident as moderate cognitive impairment, and uses a feeding tube for nutrition.
Review of the resident's care plan, updated 04/01/25, showed:
-EBP is required to be free from infections due to an opening in the resident's abdomen from a PEG tube (feeding tube placed directly into the stomach through the abdominal wall) placement;
-An EBP identifier will be hung outside the resident's door to let staff know they need to utilize a gown, gloves when performing high-contact cares;
-Staff will perform hand hygiene, put on PPE, enter the room and perform necessary cares, remove PPE, perform hand hygiene, and exit the room taking all trash/linens with them.
-Cleanse area around PEG tube site with wound cleanser and apply split gauze dressing daily.
Observation on 04/08/25 at 02:40 P.M., showed the resident's room did not contain a sign to alert staff on the use of EBP.
Observation on 04/08/25 at 02:40 P.M., showed LPN D entered the resident room to assess and provide wound care to the residents PEG tube site on his/her abdomen. Observation showed the LPN did not wear a gown and provided the treatment.
During an interview on 04/09/25 at 1:32 P.M., LPN D said there should be a sign on the resident's door to alert staff to use EBP and since the resident has a feeding tube. He/She said he/she should have worn a gown during the wound care to the resident's PEG tube site, but he/she did not think about it at the time.
Observation on 04/09/25 at 9:15 A.M., showed the resident's room did not contain a sign to alert staff on the use of EBP.
Observation on 04/09/25 at 9:16 A.M., showed LPN E entered the residents room to provide wound care. The LPN did not wear a gown when he/she provided wound care to the resident's PEG tube site.
During an interview on 04/09/25 at 1:40 P.M., LPN E said there should be a sign on the resident's door to alert staff to use EBP since the resident has a feeding tube. LPN E said he/she should have worn gown when he/she provided wound care to the resident's PEG tube site, and he/she was not sure why he/she did not wear a gown.
4. Review of Resident #19's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact, and had one venous ulcer present.
Review of the resident's care plan, updated 03/17/25, showed:
-EBP is required to be free from infections due to a wound on the resident's left leg;
-An EBP identifier will be hung outside the resident's door to let staff know they need to utilize a gown, gloves when performing high-contact cares;
-Staff will perform hand hygiene, put on PPE, enter the room and perform necessary cares, remove PPE, perform hand hygiene, and exit the room taking all trash/linens with them.
Observation on 04/09/25 at 9:22 A.M., showed a sign on the resident's door to alert staff to use EBP.
Observation on 04/09/25 at 9:23 A.M., showed LPN E entered the residents room to provide wound care. The LPN did not wear a gown when he/she provided wound care to the resident's leg wound.
During an interview on 04/09/25 at 1:40 P.M., LPN E said he/she was not sure why he/she did not wear a gown when he/she provided wound care to the resident's leg.
5. During an interview on 04/10/25 at 1:58 P.M., the Director of Nursing (DON) said he/she educated staff on residents who require the use of EBP, to wear gown and gloves when doing wound care for those residents and he/she expects all the nurses to use EBP when they provide care to a wound or device such as a PEG tube. The DON said he/she was responsible to ensure alert signs were placed on the door for resident #8 and #18.
During an interview on 04/10/25 at 2:36 P.M., the administrator said if a resident required EBP, there should be a caution sign on the resident's door to alert staff. He/She said he/she expects staff to use EBP during wound care, the charge nurse to ensure the nurse aides use appropriate EBP, and the DON to ensure the nurses use appropriate EBP.
6. Review of the facility's Blood Glucometer Disinfecting policy, undated, showed staff were directed to:
-Wash hands;
-Put on gloves;
-Provide a clean field in which to place the glucose meter (a paper towel works well for this);
-Clean the blood glucose meter prior to using with approved wipes with 10% bleach or comparable product, place on clean field and let air dry according to manufacturer's directions.
-Removed gloves;
-Wash Hands.
Review of the facility's Blood Glucose Monitoring policy, undated, showed staff were directed to place equipment on a clean surface (such as clean towel).
7. Review of Resident #16's medical record showed the resident admitted to the facility on [DATE] with a diagnosis of diabetes.
Observation on 04/08/25 at 11:15 A.M., showed Certified Medication Technician (CMT) A did not perform hand hygiene, applied gloves, obtained a blood sample and placed the glucometer on top of the medication cart without a barrier. The CMT disposed the glucose strip, removed his/her gloves, and did not perform hand hygiene. CMT A drew up insulin from insulin vial and laid the open needle on top of medication cart without a barrier and did not perform hand hygiene. Observation showed CMT A applied gloves, administered insulin, removed gloves, cleaned glucose meter with an alcohol prep pad, and did not perform hand hygiene.
8. Review of Resident #17's medical record showed the resident admitted to the facility on [DATE] with a diagnosis of diabetes.
Observation on 04/08/25 at 10:55 A.M., showed CMT A did not perform hand hygiene, applied gloves, obtained a blood sample and placed the glucometer on resident's bedside table without a barrier, disposed of the glucose strip, removed his/her gloves, cleaned the glucose meter with an alcohol prep pad, and did not perform hand hygiene.
9.Review of Resident #18's medical record showed the resident admitted to the facility on [DATE].
Observation on 04/08/25 at 10:45 A.M., showed CMT A did not perform hand hygiene, applied gloves, obtained a blood sample and placed the glucometer on residents' blankets without a barrier. Observation showed the CMT disposed of the glucose strip, removed his/her gloves, cleaned glucose meter with an alcohol prep pad.
10. Review of Resident #21's medical record showed the resident admitted to the facility on [DATE] with a diagnosis of diabetes.
Observation on 04/08/25 at 10:58 A.M., showed CMT A did not perform hand hygiene, applied gloves, obtained blood sample and placed glucometer on the residents' blankets without a barrier. Observation showed CMT A disposed the glucose strip, removed gloves, and cleaned the glucose meter with an alcohol prep pad. CMT A drew up insulin from insulin vial and laid the open needle on top of medication cart without a barrier, did not perform hand hygiene, applied gloves, administered insulin, and removed gloves.
11.Review of Resident #37's medical record showed the resident admitted to the facility on [DATE] with a diagnosis of diabetes.
Observation on 04/08/25 at 10:52 A.M., showed CMT A did not perform hand hygiene, applied gloves, obtained a blood sample and placed the glucometer on residents blankets without a barrier. Observation showed the CMT disposed of the glucose strip, removed his/her gloves, and cleaned glucose meter with an alcohol prep pad.
12. Review of Resident #203's medical record showed the resident admitted to the facility on [DATE] with a diagnosis of diabetes.
Observation on 04/08/25 at 11:09 A.M., CMT A did not perform hand hygiene, drew up insulin from insulin vial and laid the open needle on top of medication cart without a barrier. Observation showed the CMT removed a medication pill from the container and placed into medication cup on top of medication cart. CMT A applied gloves, obtained blood sample and placed the glucometer on top of medication cart without a barrier. CMT A administered insulin, removed gloves, gave medication to resident, sanitized hands, removed glucose strip with a Kleenex and disposed of it. The CMT did not clean glucose meter.
During an interview on 04/09/25 at 10:08 A.M., CMT A said he/she should have sanitized his/her hands more in between gloves changes. He/She said he/she shouldn't lay the glucometer down anywhere with blood on the strip due to risk of contamination and said the other CMT has mentioned that using a paper plate as a barrier is a good idea, but he/she just doesn't think about it. He/She said he/she was always taught to just use an alcohol prep wipe to clean the meter between residents and was never told differently. He/She said he/she shouldn't set an open needle on top of the medication care because of risk of contamination or an accidental needle stick.
13. During an interview on 04/10/25 at 1:41 P.M., the Director of Nursing (DON) said the glucometers should be cleaned with disinfecting wipes in the bottom of the medication cart. He/She said alcohol prep wipes are not acceptable cleaning method. He/She said laying the glucometer on residents' blankets or on top of unclean medication cart is not acceptable and there should be a barrier to prevent contamination. He/She said there should never be an open needle on top of medication cart due to risk of contamination or a needle stick. He/She said staff should be sanitizing or handing hands in between gloves changes.
During an interview on 04/10/25 at 2:30 P.M., the administrator said he/she is unsure of the glucometer cleaning process. He/she said it is not acceptable to place an open needle on top of medication cart or lay the glucometer on residents blankets due to risk of blood borne pathogen and contamination.
14. Review of the facility's Handwashing policy, undated, showed the policy did not contain direction for when to perform hand hygiene.
Review of the facility's Enteral feeding tube policy, undated, showed the policy did not contain direction for when to perform hand hygiene.
Review of the facility's Perineal Care policy, undated, directed staff to perform perineal care, remove gloves, wash hands and position the resident.
Review of the facility's Catheter care policy, undated showed staff are directed to:
-Wash hands and apply gloves;
-Change the position of the washcloth with each cleansing stroke;
-Remove gloves and wash hands;
-Position the resident;
-Wash hands.
15. Review of Resident #12's Significant Change of Status (SCSA) MDS, dated [DATE], showed staff assessed the resident as:
-Cognitively impaired;
-Dependent on staff for toilet and personal hygiene;
-Required substantial or maximum assistance of staff for toilet transfers;
-Diagnosis of stroke and renal failure.
Observation on 04/09/25 at 08:50 A.M., showed Nurse Aide (NA) I and Certified Nurse Aide (CNA) H entered room to assist the resident and applied gloves. NA I and CNA H assisted the resident to the toilet. CNA H removed the soiled pants from the resident and NA I removed the soiled brief. With the same soiled gloves, CNA H placed clean pants on the resident and NA I places a clean brief on the resident. CNA H cleaned the resident's peri. With the same soiled glove NA I pulled up the residents clean brief and pants. With the same soiled gloves, CNA H handed the resident's hairbrush to NA I, NA I touched the wheelchair, the bed linens, placed a blanket on the resident's lap, and braided the residents hair.
During an interview on 04/09/25 at 9:02 A.M., CNA H said staff should always wash their hands between dirty and clean stuff. He/She said he/she should have performed hand hygiene after removing the soiled pants and putting new clean pants on and before touching the resident's hairbrush. CNA H said hand hygiene would prevent the clean items from becoming dirty and just forgot.
During an interview on 04/09/25 at 09:12 A.M., NA I said he/she has only been with the facility since January and currently in classes. He/She said that he/she didn't think about the need to change his/her gloves between touching the soiled brief and clean brief and before touching clean items in the room to include brushing the resident's hair.
16. Review of Resident #17's quarterly MDS, dated [DATE] showed staff assessed the resident as follows:
-Cognitively Intact;
-Dependent on staff for dressing and toileting hygiene;
-Substantial/maximal assistance on staff for personal hygiene.
Observation on 04/09/25 at 9:20 A.M., showed CNA C and NA B entered residents' room with gown and gloves on. CNA C removed residents soiled shorts. CNA C removed his/her gloves, did not perform hand hygiene and applied new gloves. CNA C provided peri care, removed his/her soiled gloves and applied new gloves. CNA C applied cream to buttock. With the same soiled gloves, CNA C placed a drawsheet underneath resident. NA B wiped bowel movement from residents' leg and lower back, and removed the soiled linens from the bed. With the same soiled gloves, NA B touched the residents' blankets, resident oxygen tubing and the bed remote. With the same soiled gloves, CNA C placed the resident's oxygen on. CNA C and NA B removed their gloves and gown, did not perform hand hygiene and walked out of the room.
During an interview on 04/09/25 at 9:50 A.M., NA B said he/sheshould have changed gloves more often and washed her hands before touching blankets, oxygen tubing, or bed remote and before leaving the room. He/she said not washing hands is a risk for infection and contamination.
During an interview on 04/09/25 at 10:08 A.M., CNA C said he/she should have changed his/her gloves more often and performed hand hygiene between glove changes. He/She said he/she should not have touched oxygen tubing with soiled gloves. He/She said he/she should have washed hands before leaving the room, but states that he/she knew he/she was going to the shower room afterwards. He/She said not performing hand hygiene is a risk of contamination.
17. Review of Resident #202's Quarterly MDS, dated [DATE], showed staff assessed the resident as:
-Cognitively impaired;
-Dependent on staff for all care;
-Had a tracheostomy (tube inserted into the windpipe for breathing);
-Had a feeding tube (tube inserted into the stomach for hydration and artificial nutrition administration);
-Had an indwelling catheter (tube inserted into the bladder to drain urine);
-Diagnosis of traumatic brain injury.
Observation on 04/08/25 at 02:09 P.M., showed LPN D enter the resident room to provide tracheostomy care, feeding tube care and catheter care. Observation showed the nurse set up a barrier and placed down supplies to perform tracheostomy care, applied sterile gloves, and provided tracjeostomy care. The LPN removed his/her gloves, applied clean gloves and applied a clean dressing to the tracheostomy site without performing hand hygiene. The LPN removed his/her gloves, gathered wet cloths and clean dressing for feeding tube care. The LPN did not wash his/her hands and applied gloves. The LPN used a wet cloth to wipe down the soiled feeding tube, used the same portion of the cloth over the same area of the tube multiple times and applied a clean dressing. The LPN removed his/her gloves, applied clean gloves, cleansed around the catheter site, cleansed the tubing with a warm cloth, used the same portion of the cloth over the same area multiple times, applied a clean dressing, and did not perform hand hygiene between catheter site cleaning and application of a clean dressing.
During an interview on 04/08/25 at 2:31, LPN D said he/she did not wash or sanitize between glove changed because he/she did not want to risk touching his/her gown or ruin the clean field. He/She said he/she is aware he/she used the same portion of the wipe on the difficult areas to clean off the tubing, but moved to a clean portion once the difficult areas were clean. Hand hygiene helps decrease the risk of spreading infection and bacteria.
18. During an interview on 04/10/25 at 01:13 P.M., the DON said hand hygiene should be performed before care and after care, between glove changes, and between dirty and clean tasks. He/She said gloves are not to be considered a barrier that will prevent transmission of germs. He/She said gloves should be changed between different areas of the body. The DON said he/she does spot checks on the staff and interviews residents about staff performance. He/She did not know staff were performing inadequate hand hygiene during cares.
During an interview on 04/10/25 at 02:20 P.M., the Administrator said he/she would expect staff to perform hand hygiene between glove changes, between dirty and clean tasks and when care is completed. He/She said staff are trained by electronic inservice company and monthly and tasks such as hand hygiene are monitored by the DON. He/She was not aware staff performed inappropriate hand hygiene during cares.

Based on observation, interview and record review, the facility staff failed to store food in a manner to prevent potential contamination and outdated use and failed to maintain frozen foods at a temperature to keep the food frozen solid. Facility staff failed to maintain and serve pureed food items at temperatures adequate to prevent food borne illness. Facility staff failed to perform hand hygiene as often as necessary, using approved techniques, to prevent cross-contamination. These failures have the potential to affect all residents. The facility census was 46.
1. Review of the facility's food service policies showed they did not contain policies related to food storage.
Review of the Record of Cooler and Freezer Temperatures, dated April 2025, which was mounted on the front of three-part freezer showed staff recorded the temepratures as:
-04/01 morning freezer temperature recorded as seven;
-04/02 morning freezer temperature recorded as eight;
-04/03 morning freezer temperature recorded as seven;
-04/04 morning freezer temperature recorded as five, afternoon temperature recorded as seven;
-04/05 morning freezer temperature recorded as four;
-04/08 morning freezer temperature recorded as five;
-04/09 morning freezer temperature recorded as 10;
-04/10 morning freezer temperature recorded as nine.
Observation on 04/07/25 at 9:52 A.M. showed the reach in refrigerator contained:
-One opened five-pound container of cottage cheese with a best by date of 3/30/25;
-One opened five-pound container of cottage cheeses with a best by date of 4/6/25;
-One unopened five-pound container of cottage cheese with a best by date of 3/30/25;
-One plastic container of lemon and lime wedges, undated;
-An aluminum baking sheet on the bottom shelf with saturated pieces of cardboard stuck to it.
Observation on 04/07/25 at 10:00 A.M showed the three-door freezer contained a large area of dried purple substance along the bottom shelf/base.
Observation on 04/07/25 10:04 A.M., showed the cook's refrigerator contained:
-A one gallon container of tuna salad, opened and undated;
-A one gallon container of Pasta salad with cheese, opened and undated.
Observation on 04/08/25 at 2:10 P.M., showed the milk refrigerator contained an opened container of coffee creamer with a best by date of 07/07/24.
Observation on 04/08/25 at 2:20 P.M., showed the cooks refrigerator contained:
-A plastic container labeled carrots, dated 4/4;
-A plastic container labeled Italian veggies, with a use by date of 4/6;
-A ten-pound container of hard-boiled eggs, dated 3/30 and was partially open to the air;
-A plastic container labeled Philly cheese steak, dated 4/3/25;
-A plastic container labeled peas, dated 4/4;
-A five-pound container of cottage cheese, which was opened and undated and had a best by date of 03/30/25;
-A five-pound container of pasta salad, opened and undated;
-A five-pound container of tuna salad, opened and undated;
-A plastic bag of lettuce, undated.
Observation on 04/08/25 at 2:26 P.M., showed the three-door freezer contained a digital external thermometer which indicated a temperature of nine degrees Fahrenheit (F), Observation showed a calibrated digital thermometer placed in the freezer for five minutes indicated a temperature of 13 degrees F. Observation showed a package of cinnamon rolls stored on the bottom shelf were soft to firm with pressure.
Observation on 04/09/25 at 8:14 A.M., showed the three-door freezer external thermometer indicated a temperature of 4 degrees F. Observation showed a package of cinnamon rolls stored on the bottom shelf were soft to firm with pressure.
Observation on 04/09/25 at 11:06 A.M., showed the three-door freezer external thermometer indicated a temperature of six degrees F. Observation showed the freezer contained a large bag of french fries, a package of cinnamon rolls and a plastic bag of whipped topping which were soft to firm with pressure.
Observation on 04/09/25 at 12:32 P.M., showed the external temperature of the three-door freezer indicated five degrees F.
During an interview on 04/07/25 at 9:54 A.M., [NAME] K said kitchen staff were responsible to date items when opened and refrigerated cottage cheese is good for two days after opened.
During an interview on 04/07/25 at 9:58 A.M., Dietary Aide (DA) L said he/she did not know who placed the items in the refrigerator. DA L said kitchen staff should date items before placing in the refrigerator.
During an interview on 04/07/25 at 10:02 A.M., the Dietary Manager (DM) said the purple stuff was from dragon fruit that was stored in the freezer, and must have spilled without staff noticing. The DM said he/she thought staff used the dragon fruit over the weekend. The DM said there was a weekly cleaning schedule for the larger items in the kitchen, but he/she expected staff would have cleaned the spill when they removed the dragon fruit from the freezer.
During an interview on 04/10/25 at 9:40 A.M., [NAME] J said the freezer temperature averaged seven degrees F. [NAME] J said he/she did not know what the temperature should be but the freezer tiems should be frozen solid.
During an interview on 04/10/25 at 11:15 A.M., the DM said opened food items should be labeled and dated with a three-day discard date. The DM said the freezer temperature should be between negative twenty and zero degrees F in order to keep all items frozen solid. The DM said he/she did not know the freezer temperatures were not zero or below.
2. Review of the facility's Food Preparation and Distribution policy, dated April 2011, showed recipes should be followed on each item prepared.
Review of the facility's standardized recipe for pureed ham showed staff were instructed to reheat the pureed item to a minimum temperature of 165 degrees F or higher for 15 seconds. Hold at minimum required temperature or higher for service.
Observation on 04/09/25 at 12:09 P.M., showed [NAME] J prepared pureed ham and mixed peas and carrots for three residents who receive pureed meals. Observation showed [NAME] J plated the pureed items and left the plated items on a kitchen counter. Observation at 12:28 P.M., showed [NAME] J placed a plate with pureed items in the microwave for 30 seconds. Observation showed the temperature of the pureed ham was 145 degrees F and did not reach 165 degrees F. Observation showed the pureed items were served to a resident.
During an interview on 04/09/25 at 12:28 P.M., [NAME] J said he/she placed pureed items in the microwave for 30 seconds to ensure the foods were brought up to a temperature of 140 degrees F. [NAME] J said he/she did not usually look at the reheating directions on the recipe because he/she thought 140 degrees F was the proper temperature.
During an interview 0n 04/10/25 at 11:15 A.M., the DM said all cooks should follow the standardized recipes which included reheating instructions. The DM said he/she was not aware staff were not following recipes.
3. Review of the facility's Handwashing policy, dated April 2011, showed the policy did not contain guidance on when staff should wash hands.
Review of the facility's Hand Washing Procedure, which was posted next to the kitchen hand washing sink, showed staff were to wash hands after handling soiled rags, cans, or cleaning material. Review showed the procedure did not contain guidance related to soiled kitchen wares.
Observation on 04/09/25 at 10:49 A.M., showed DA M prewashed soiled kitchen wares and loaded the wares on a dish rack. DA M ran the spoiled wares through the dish machine, removed a rack of clean wares and handled clean silverware and did not wash his/her hands. Observation showed DA M returned to soiled side of the dish machine, removed gloves, donned new gloves and did not wash hands. Observation showed DA M placed dirty silverware in a sanitizer bucket, loaded a dish rack with dirty dishes, handled soiled water pitchers with straws, cleaned a service cart and pushed a rack of soiled wares into the dish machine. Observation showed DA M then removed clean wares which were placed on a drying rack and did not wash his/her hands.
During an interview on 04/09/25 at 11:18 A.M., DA M said he/she should change gloves whenever changing from the soiled side to the clean side of the dish machine. DA M said he/she changed gloves most of the time, but he/she just forgot. DA M said he/she should wash hands when changing gloves and he/she did not know why he/she did not wash his/her hands.
During an interview on 04/10/25 at 11:15 A.M., the DM said staff should wash hands and change gloves between dirty and clean tasks. The DM said staff should wash hands and change gloves after handling soiled kitchen wares. The DM said he/she was responsible for ensuring staff washed hands before donning clean gloves. The DM said he/she was not aware DA M was not washing his/her hands when required. The DM said he/she is also serving as the activities director so he/she is only performing kitchen related duties about 75% of the time.
During an interview on 04/10/25 at 1:10 P.M., the administrator said the cooks were responsible for labeling and dating all left over food items with a three day, use by date. The administrator said the freezer temperature should be at zero degrees F or less and the cooks and DM were responsible for checking the temperature log to ensure correct temperatures were maintained. The administrator said items stored in the freezer should be frozen solid. The administrator said staff should follow the standardized recipes including portion sizes and reheating instructions. The administrator said all staff are responsible for washing hands after completing any dirty task and before donning clean gloves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to maintain a medication error rate of less than 5% out of 38 opportunities observed, two errors occurred, resulting in a 5.26% error rate, which effected two residents (Resident #12 and #32) out of eight sampled residents. The facility census was 46.
1. Review of the Facility's Medication Administration policy, undated, showed:
-Medication are given to benefit a resident's health as ordered by the physician;
-Read label three times before administering the medications:
-First when comparing the label with the medication sheet;
-Second when setting up the medication;
-Third when preparing to administer the medication to the resident.
2. Review of Resident #12's Significant Change MDS, dated [DATE], showed staff documented the resident diagnosis of Hypertension.
Review of the resident's physician's order sheets (POS), dated 02/10/25, showed an order for Diltiazem (medicine used to treat high blood pressure) 240 milligram (mg), one capsule daily.
Observation on 04/08/25 at 8:55 A.M., showed Certified Medication Technician (CMT) A administered Diltiazem 180mg to the resident.
During an interview on 04/09/25 at 10:08 A.M., CMT A said he/she was not sure how he/she did not catch the medication error until now. He/She said the resident was previously on 180mg and the order must not have gotten followed through to get that changed and the correct card put in the medication cart. He/She said there is a lot of risks if the resident is not receiving the correct dosage of medication as prescribed depending on the medication. He/She said he/she would go inform charge nurse about medication error.
3. Review of Resident #32's admission MDS, dated [DATE], showed staff documented the resident diagnosis of arthritis.
Review of the resident's physician's order sheets (POS), dated 03/12/25, showed an order for Vitamin D3 (for bone and muscle strength, immune function, and healthy skin) 1,250 micrograms (MCG), one tablet daily on Tuesday and Friday.
Observation on 04/08/25 at 08:40 A.M., showed CMT A administered Vitamin D3 50mcg to the resident.
During an interview on 04/09/25 at 10:08 A.M., CMT A said he/she noticed the incorrect dosage of Vitamin D3 was given after the observation. He/She said he/she was unsure how long the resident had been getting the incorrect dosage.
4. During an interview on 04/10/25 at 1:35 P.M., the Director of Nursing (DON) said staff should verify medication with the physician's order to ensure the correct dosage is given. He/She said there are a lot of risks to the residents regarding medication errors depending on the type of medication that was given incorrectly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to ensure residents remained free from unnecessary medications when they did not ensure a 14-day stop date for the as needed use of a psychotropic medication (a drug that affects behavior, mood, thoughts, or perception) or provide a rationale for the continued use of the medication for one resident (Resident #18), and did not implement the physician's order for a gradual dose reduction (GDR) for a psychotropic medication for one resident (Resident #19) out of four sampled residents. The facility's census was 46.
1. Review of the facility's policies showed it did not contain a policy to address Psychotropic Medication Use or the Medication Regimen Review (MRR) process.
2. Review of Resident #18's Significant Change of Status (SCSA) Minimum Data Set (MDS), a federally mandated assessment, dated 03/18/25, showed staff assessed the resident as follows:
-Mild cognitive impairment;
-Diagnoses of depression, schizoaffective disorder (symptoms such as hallucinations and delusions, and mood disorder);
-Did not receive antianxiety medications in the seven-day review period;
-Received hospice care.
Review of the resident's Physician Order Sheet (POS), dated 03/01/25 through 04/07/25, showed an order for Lorazepam (psychotropic medication used to treat anxiety) 0.5 milligram (mg), one tablet by mouth every four hours as needed for schizoaffective disorder, effective 03/26/25. The order did not contain a stop date.
Review of the resident's Medication Administration Record (MAR), dated 03/13/25 through 04/08/25, showed staff did not document the resident received the as needed Lorazepam.
During an interview on 04/10/25 at 11:38 A.M., the MDS Coordinator said as needed psychotropic medications should have a stop date of 14 days whether the resident is under the care of hospice care or not, unless the physician states otherwise. He/She said the night shift nurse should be responsible to double check the orders, but he/she was not sure anyone was assigned the responsibility. He/She said he/she was not sure why the resident's Lorazepam order did not have a stop date, other than the order just got overlooked by staff.
During an interview on 04/10/25 at 12:29 P.M., the Director of Nursing (DON) said as needed psychotropic medications should have a stop date of 14 days unless the physician documents otherwise, whether the resident is under the care of hospice or not. He/She said the nurse who received the order is responsible to ensure a stop date is obtained, and the pharmacist checks monthly as well. He/She said the resident's Lorazepam order just got missed, and it was ultimately his/her responsibility to audit and ensure as needed psychotropic orders have a stop date.
During an interview on 04/10/25 at 2:36 P.M., the administrator said as needed psychotropic medications should have a stop date of two weeks. He/She said the nurses are responsible to obtain a stop date on the order and the DON should ensure it gets done.
2. Review of Resident #19's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows:
-Cognitively intact;
-Diagnoses of anxiety disorder and depression;
-Received antidepressant medications with indication noted;
-Date of last attempted GDR not documented.
Review of the resident's care plan, updated 03/17/25, showed staff documented the resident received antidepressant medication for depression, will be prescribed the lowest effective dose of medication, and the pharmacy consultant will review the medications.
Review of the resident's POS, dated 04/01/25 through 04/09/25, showed an order for Amitriptyline (psychotropic medication used to treat depression) 25 mg tablet, three times daily for depression at 6:00 A.M.-10:00 A.M., 11:00 A.M. to 1:00 P.M., and 2:00 P.M. to 6:00 P.M, with an effective 10/01/24.
Review of the resident's monthly MRR, dated 12/27/24, showed:
-On 12/18/24, the pharmacist documented recommendation to the physician the resident's Amitriptyline 25 mg three times a day is due for review. Please consider a GDR on Amitriptyline 25 mg to at bedtime.
-01/23/25, the physician signed the recommendation and documented I accept the recommendation above. Please implement as written.
Review of the resident's monthly MRR, dated 01/29/25, showed the pharmacist documented in his/her report to the nursing staff see pharm consult regarding Amitriptyline 25 mg at bedtime per the physician.
Review of the resident's MAR, dated 01/29/25 through 01/31/25, showed staff documented they adminstered the Amitriptyline 25 mg three times daily from 01/29/25 through 01/31/25. Staff did not implement the physician's order for Amitriptyline 25 mg to be administered at bedtime.
Review of the resident's monthly MRR, dated 02/27/25, showed the pharmacist documented see pharm consult regarding Amitriptyline to 25 mg at bedtime per the physician.
Review of the resident's MAR, dated February 2025, showed staff documented they adminstered the Amitriptyline 25 mg three times daily. Staff did not implement the physician's order for Amitriptyline 25 mg to be administered at bedtime.
Review of the resident's monthly MRR, dated 03/27/25, the pharmacist documented see pharm consult regarding Amitriptyline to 25 mg at bedtime per the physician.
Review of the resident's MAR, dated March 2025, showed staff documented they adminstered the Amitriptyline 25 mg three times daily from 03/01/25 through 03/31/25. Staff did not implement the physician's order for Amitriptyline 25 mg to be administered at bedtime.
Review of the resident's MAR, dated 04/01/25 through 04/09/25, showed staff documented they adminstered the Amitriptyline 25 mg three times daily from 04/01/25 through 04/09/25. Staff did not implement the order for Amitriptyline 25mg to be administered at bedtime.
During an interview on 04/10/25 at 11:38 A.M., the MDS Coordinator said the DON was responsible to implement the order from the physician in January, and he/she did not think there was a system in place for anyone else to double check.
During an interview on 04/10/25 at 12:29 P.M., the DON said he/she is responsible to follow up on the pharmacist's recommendations to the physician and to ensure the physician's response is acted on and any orders are implemented. The DON said he/she overlooked the Amitriptyline order from the physician in January, and did not realize the pharmacist was referring to the same order in his/her report on 01/29/25, 02/27/25, and 03/27/25. The DON said depending on the resident, medications ordered to be given at bedtime are scheduled between 6:00 P.M. and 12:00 A.M.
During an interview on 04/10/25 at 2:36 P.M., the administrator said he/she was not sure about the MRR process but is aware the pharmacist does a routine review and sends a report to the DON for follow up.

Based on interview and record review, the facility failed to provide the services of a Registered Nurse (RN), for at least eight consecutive hours per day, seven days a week. The facility census was 46.
1. Review of the Facility Assessment tool, dated 12/13/24, showed the facility is to provide one RN Director of Nursing (DON) full time and one RN or Licensed Practical Nurse (LPN) for each shift. The assessment does not contain direction for use of an RN eight consecutive hours per day, seven days a week.
Review of the facility's RN staff schedule, dated December 2024, showed the facility did not have an RN, eight consecutive hours a day, in the building on Monday, December 30, 2024.
Review of the facility's RN staff schedule, dated January 2025, showed the facility did not have an RN, eight consecutive hours a day, in the building on Monday, January 13, 2025.
Review of the facility's RN staff schedule, dated February 2024, showed the facility did not have an RN, eight consecutive hours a day, in the building on Monday, February 3, 2025.
During an interview on 04/10/25 at 1:13 P.M., the DON said he/she counts him/herself as RN coverage when they are in the building. He/she said they recently hired an RN that works weekends and is the weekend RN coverage. He/She was aware there were days there was not an RN in the building, but he/she was working a lot of hours and did remain on-call 24 hours a day. The DON said if they needed a day off, they would ensure there was two LPN's in the building. He/She said the days there was no RN in the building, the residents in the building at the time did not have any needs that required RN oversight or potential interventions.
During an interview on 04/10/25 at 2:20 P.M., the Administrator said the facility should have an RN in the facility at least eight consecutive hours daily. He/She said if the facility has no RN, the DON will cover those hours. The Administrator said that the DON and him/her are responsible to ensure there is RN coverage in the building, but the DON was working a lot of hours to cover as a floor nurse and took very few days off. He/She did not know there was days without an RN in the building at least eight hours on three different days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, facility staff failed to provide appropriate respiratory care and services, when they did not ensure oxygen delivery at the prescribed flow rate for one resident (Resident #6), and did not change oxygen tubing or properly clean and maintain oxygen concentrators for five (Resident #4, #6, #17, #19, and #26) out of five sampled residents. The facility census was 46.
1. Review of the facility's Oxygen Administration policy, undated, showed staff are directed as follows:
-Set the flow meter to the rate ordered by the physician.
-At regular intervals, check and clean oxygen equipment, masks, tubing and cannula.
-Place cannula tubing in plastic bag attached to concentrator when tubing is not in use.
-Change tubing per cleaning guidelines.
2. Review of Resident #4's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 04/01/25, showed staff assessed the resident as follows:
-Mild cognitive impairment;
-Required oxygen therapy;
-Diagnosis of Chronic Obstructive Pulmonary Disease (COPD, a condition caused by damage to the airways or other parts of the lung).
Review of the resident's physician order sheet (POS), dated 02/18/25, showed staff are directed to change the oxygen tube monthly on the first day of the month.
Observation on 04/07/25 at 10:45 A.M., showed the resident in bed with oxygen via nasal cannula in place. Observation showed the oxygen tube dated 03/01/25.
Observation on 04/08/25 at 3:00 P.M., showed the resident in bed with oxygen via nasal cannula in place. Observation showed the oxygen tube dated 03/01/25.
3. Review of Resident #6 admission MDS, dated [DATE], showed staff assessed the resident as follows:
-Moderate cognitive impairment;
-Diagnosis of Emphysema (a progressive, chronic lung disease characterized by the damage and enlargement of the tiny air sacs (alveoli) in the lungs, leading to reduced lung function and shortness of breath).
Review of the resident's POS, dated 02/18/25, showed staff are directed to change the oxygen tube monthly on the first day of the month.
Review of the resident's POS, dated 02/25/25, showed an order for Oxygen two Liters (L) per minute per nasal cannula continuous
Observation on 04/07/25 at 10:00 A.M., showed the resident in bed with oxygen via nasal cannula in place. Observation showed the oxygen tube dated 03/01/25. Observation showed the resident's oxygen concentrator set at five liters per minute.
Observation on 04/08/25 at 2:05 P.M., showed the resident in bed with oxygen via nasal cannula in place. Observation showed the oxygen tube dated 03/01/25. Observation showed the resident's oxygen concentrator set at five liters per minute.
Observation on 04/09/25 at 2:00 P.M., showed the resident in bed with oxygen via nasal cannula in place. Observation showed the oxygen tube dated 03/01/25 and 04/08/25. Observation showed the resident's oxygen concentrator set at five liters per minute.
Observation on 04/10/25 at 10:00 A.M., showed the resident in bed with oxygen via nasal cannula in place. Oxygen tubing dated 03/01/25 and 04/08/25. Observation showed the resident's oxygen concentrator set at five liters per minute.
During an interview on 04/10/25 at 12:15 P.M., Licensed Practical Nurse (LPN) D said the nurse should check oxygen settings every shift. He/She said he/she was not sure why the resident's oxygen is set to five liters, and does not remember what it should be, but knows it's not to be that high. LPN D said there are many potential risks to the flow rate being too high, and it should be set for what the physician ordered.
During an interview on 04/10/25 at 1:45 P.M., the Director of Nursing (DON) said every staff who walks into a room for a resident with continuous oxygen, is responsible to check the rate on the concentrator, aides can check and tell charge nurse if there is a concern. The DON said he/she is not sure why the residents oxygen is set at five liters, but it shouldn't be. The DON said if there was ever a need for a higher amount than ordered, staff should contact the doctor and document it.
During an interview on 04/10/25 at 2:45 P.M., the administrator said the charge nurse is responsible to check the flow rate for oxygen.
4. Review of Resident #17's Annual MDS, dated [DATE], showed staff assessed the resident as:
-Cognitively intact;
-Diagnosis COPD;
-Required oxygen therapy.
Review of the resident's POS, dated 02/18/25, showed staff are directed to change the oxygen tube monthly on the first day of the month.
Observation on 04/07/25 at 10:42 A.M., showed the resident in bed with oxygen via nasal cannula in place. Observation showed the oxygen tube dated 03/01/25.
Observation on 04/08/25 at 09:21 A.M., showed the resident in bed with oxygen via nasal cannula in place. Observation showed the oxygen tube dated 03/01/25.
5. Review of Resident #19's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact, received oxygen therapy and diagnosis of dependence on supplemental oxygen.
Review of the resident's POS, dated 03/08/25 through 04/08/25, showed:
-Change the oxygen tube monthly on the first Monday of the month;
-Weekly concentrator cleaning. Special Instructions: Wipe down concentrator with disinfectant wipes allow to dry. Cleanse filter with soap and water and allow to dry.
Observation on 04/07/25 at 10:50 A.M., showed the resident in bed with oxygen via nasal cannula in place. Observation showed the oxygen tube dated 03/01/25.
Observation on 04/08/25 at 8:45 A.M., showed the resident in his/her wheelchair and received oxygen via nasal cannula from a portable oxygen tank. The oxygen tubing was undated.
Observation on 04/08/25 at 2:13 P.M., showed the resident in bed with oxygen via nasal cannula in place. The oxygen tubing was undated, and the concentrator with scattered dried debris and dried brownish/red substance behind the flow rate display.
Observation on 04/09/25 at 8:32 A.M., showed the oxygen concentrator with scattered debris and dried brownish/red substance behind the flow rate display, the black filter on the back covered with white debris and hair strands.
Observation on 04/10/25 at 8:46 A.M., showed the oxygen concentrator with scattered debris and dried brownish/red substance behind the flow rate display, the black filter on the back covered with white debris and hair strands.
During an interview on 04/09/25 at 08:36 A.M., the resident said the concentrator could use some cleaning.
During an interview on 04/10/25 at 11:23 A.M., LPN D said the night shift nurse is responsible to change the resident's oxygen tubing per the schedule on the POS. He/She said the night nurse is also responsible to clean the concentrator, but he/she was unsure of the schedule.
6. Review of Resident #26's Quarterly MDS, dated [DATE], showed staff assessed the resident as:
-Cognitively intact;
-Diagnosis COPD.
Review of the resident's POS, dated 02/18/25, showed staff are directed to change the nebulizer tube monthly on the first day of the month.
Observation on 04/07/25 at 10:44 A.M., showed nebulizer tube laid on the resident's nightstand and dated 03/01/25.
Observation on 04/08/25 at 2:15 P.M., showed nebulizer tube laid on the resident's nightstand and dated 03/01/25.
Observation on 04/09/25 at 08:30 A.M., showed nebulizer tube laid on the resident's nightstand and dated 03/01/25.
During an interview on 04/10/25 at 12:06 P.M., LPN D said the night shift nurse is in charge of changing nebulizer tubing. He/She said he/she is not sure how often it is scheduled to change. He/She said he/she will change the tubing if he/she finds it on the floor or sees that it hasn't been changed in over a month.
During an interview on 04/10/25 at 1:50 P.M., the DON said oxygen and nebulizer tubing should be changed at the beginning of the month by the night shift nurse. He/She said he/she asks the night nurse if its been done and just goes with that, but he/she said he/she should probably be checking it his/herself to ensure its being done.
During an interview on 04/10/25 at 2:30 P.M., the administrator said oxygen and nebulizer tubing should be changed on the first day of the month by the night shift nurse. He/She said it is the DON's responsibility to ensure its getting done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to ensure residents' environment remained free of accident hazards when staff failed to ensure resident's did not retain smoking materials while in the facility for six residents (Resident #10, #23, #26, #29, #34, and #40) out of six sampled residents as directed in the facility policy. The facility census was 46.
1. Review of the facility's Resident Smoking Policy, dated 12/2016, showed the policy will cover all types of smoking devices such as:
-Cigarettes, tobacco, pipes, cigars (requiring matches or fire to light);
-Electronic or vapor smoking replacement devices (require batteries that could cause resident damage);
-Chewing tobacco;
-Residents may not have or keep smoking materials in room, Smoking materials include; cigarettes, pipes, electronic or e-cigarettes, chewing tobacco, cigars, matches;
-Smoking shall not be permitted in the living/sleeping area or inside the facility.
Review of the facility's admission Packet, Resident Rules and Regulations, showed residents may not retain matches or lighters.
2. Review of Resident #10's Significant Change of Status (SCSA) Minimum Data Set (MDS), a federally mandated assessment tool, dated 03/03/25, showed staff assessed the resident as cognitively intact and used tobacco.
Observation on 04/08/25 at 11:35 A.M., showed the resident exit the facility to the designated smoke area. He/She removed a lighter from his/her walker and lit his/her cigarette.
During an interview on 04/07/25 at 10:53 A.M., the resident said he/she goes in and out to smoke whenever he/she likes to. He/She said they are supposed to turn in their lighters after each break.
3. Review of Resident #23's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact.
Observation on 4/07/25 at 11:38 A.M., showed the resident with one pack of cigarettes and lighter in coat pocket.
During an interview on 04/07/25 at 11:38 A.M., the resident said he keeps his smoking material with him. He/She said he/she can go outside at any time to smoke.
Observation on 04/09/25 at 1:16 P.M., showed the resident in his/her room with a vape (a device used for inhaling vapor containing nicotine and flavoring) in hand up by mouth. Resident covered vape and put in coat pocket.
4. Review of Resident #26's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact.
Observation on 4/07/25 at 11:00 A.M., showed the resident had one electronic vape laying in nightstand next to bed and one pack of cigarettes in three drawer organizer in his/her room.
During an interview on 04/07/25 at 11:00 A.M., resident said he/she vapes outside. He/She said he/she charges the vape when he/she comes inside from vaping. Resident said he/she charges the vape in his/her room with a charger connected to his/her laptop. He/She said from time to time he/she will smoke a cigarette, but usually vapes.
Observation on 04/08/25 at 2:15 P.M., showed one electronic vape on nightstand and one pack of cigarettes in the drawer organizer in the resident's room.
Observation on 04/09/25 at 8:38 A.M., showed one electronic vape laid on nightstand and one pack of cigarettes in the drawer organizer in the resident's room.
5. Review of Resident #29's Annual MDS, dated [DATE], showed staff assessed the resident as severe cognitive impairment and used tobacco.
Observation on 04/07/25 at 11:55 A.M., showed the resident with a pack of cigarettes inside the cup holder attached to his/her wheelchair, as he/she propelled down the hallway to the dining room.
Observation on 04/08/25 at 8:30 A.M., showed the resident in the dining room with a lighter and a pack of cigarettes inside the cup holder attached to his/her wheelchair.
Observation 04/08/25 at 2:07 P.M., showed the resident in front of the nurses' station with a lighter and a pack of cigarettes inside the cup holder attached to his/her wheelchair.
Observation on 04/09/25 at 8:23 A.M., showed the resident in the dining room with a lighter and a pack of cigarettes inside the cup holder attached to his/her wheelchair.
During an interview on 04/10/25 at 11:04 A.M., Licensed Practical Nurse (LPN) D said the resident keeps his/her smoking materials with him/her.
6. Review of Resident #34's admission MDS, dated [DATE], showed staff assessed the resident as cognitively intact and used tobacco.
Review of the resident's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact.
Observation on 04/08/25 at 11:35 A.M., showed the resident exit the facility to the smoke area. He/She removed a lighter from his/her jacket and lit his/her cigarette.
During an interview on 04/07/25 at 11:18 A.M., the resident said he/she goes outside to smoke whenever he/she wants to. He/She said he/she does not turn in his/her smoking materials to include his/her lighter.
7. Review of Resident #40's admission MDS, dated [DATE], showed staff assessed the resident as cognitively intact and current tobacco use.
Observation on 04/07/25 at 12:30 P.M., showed the resident in bed with a vape on his/her bedside table.
During an interview on 04/07/25 at 12:31 P.M., the resident said he/she does vape, but has not get out of bed since he/she admitted to the facility. The resident said they have to go outside to vape.
Observation on 04/09/25 at 9:20 A.M., showed the resident in bed with a vape on his/her bedside table.
8. During an interview on 04/10/25 at 12:16 P.M., Certified Nurse Aide (CNA) G said all residents are independent smokers. He/She said residents are supposed to give their smoking materials back at the nurses station when they come back inside from smoking. He/She said this includes lighters, cigarettes, and electronic vapes. He/She said residents should only smoke or vape outside. He/She said residents should not charge vapes in their room. He/She said it is a fire hazard for the residents to keep smoking materials on themselves.
During an interview on 04/10/25 at 12:06 P.M., LPN D said independent smokers are able to keep their smoking materials on them including their lighter and cigarettes. He/She said he/she is unaware of any residents who currently vape. He/She said he/she has not seen any chargers for vapes or has never been asked to charge a vape.
During an interivew on 04/10/25 at 1:45 P.M., the Director of Nursing (DON) said residents are supposed to give smoking material back at the nurses station when they come back in from smoking. He/She said this includes cigarettes, lighters, and vapes. He/She said he/she was not aware that residents are keeping smoking materials on them or vaping inside the facility. He/She said this is a fire hazard for resident to keep smoking materials on them or charge vapes inside of room. He/She said it is all staff's responsibility to check if residents has smoking materials on them and if they find smoking materials staff should go to the charge nurse.
During an interivew on 04/10/25 at 2:30 P.M., the administrator said smoking materials should be kept at the nurses station. He/She said this includes cigerattes, lighters, and vapes. He/She said he/she was absolutely not aware that residents are keeping smoking materials on themselves or that vapes were being charged in resident rooms. He/She said resident keeping smoking materials on themselves and charging vapes inside of rooms is a fire hazard. He/She said the residents are their own people and are aware of the policy when they were admitted and they should obey the policy. He/She said staff should monitor for smoking materials and if found they should be taken to the nurses station.

Based on interview and record review, the facility staff failed to ensure the activities program was directed by a qualified professional. The census was 46.
1. Review of the facility's Role of the Activity Recreational Services policy, dated March 2012, showed the activity program must be directed by a qualified professional (Activity Director) who is directly responsible to the Administrator.
During an interview on 04/09/25 at 9:14 A.M., the activity director said he/she was not certified and did not know he/she should be certified. He/She looked into it a while ago but the facility changed management and believes it fell through the cracks.
During an interview on 04/10/25 at 1:13 P.M., the Director of Nursing (DON) said he/she is not sure if the Activity Director is certified and tries to keep to his/her department.
During an interview on 04/10/25 at 2:20 P.M., the Administrator said the activity director is not certified and became aware he/she was not certified in August and is aware of the requirement to have them certified. He/She did not have an answer on why the Activity Director is not certified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to maintain professional standards of practice when staff failed to notify the physician and follow up with pharmacy when medications were unavailable for three (Resident #10, #12, and #201) out of three sampled residents. Facility staff failed to document the correct dose of medication for two (Resident #12 and #32) out of eight sampled residents. Staff failed to document the weight for one resident (Resident #40) weekly per physician orders. Staff failed to document weight and food intake for one resident (Resident #18) of one sampled resident with a history of significant weight loss. The facility census was 47.
1. Review of the facility's policies showed staff did not provide a policy for physicians orders.
Review of the facility's telephone order policy, undated and the medication error policy, undated, showed the policies did not contain direction or guidance for unavailable or ommited medications.
Review of the facility's condition change policy, undated, showed the policy did not contain direction or guidance for notification of the physician when medication is unavailable or omitted.
2. Review of Resident #10's Significant Change of Status Minimum Data Set (MDS), a federally mandated assessment tool, dated 03/03/25 showed the staff assessed the resident as cognitively intact.
Review of the Physician Order Sheet (POS), dated April 2025, showed:
-Fluticasone propionate (anti-inflammatory and hayfever medication) spray, 50 mircrograms (mcg) twice a day;
-The order did not contain number of sprays or to which nostril;
-The POS did not contain an order to allow the resident to self administer the medication.
Review of the resident's Medication Administration Record (MAR), dated March 2025, showed staff documented the fluticasone was unavailable on 03/26/25-03/28/25, 03/30/25 and 03/31/25.
Review of the resident's MAR, dated April 2025, showed staff documented the fluticasone was unavailable from 04/01/25 through 04/09/25.
Review of the nurse notes, dated 03/01/25 through 04/09/25 showed staff did not document contact with the physician or the pharmacy when the resident did not recieve his/her medication.
During an interview on 04/07/25 at 10:13 A.M., the resident said he/she had been out of his/her nasal spray for a long time now. He/She said that when at home he/she was taking two sprays to each nostril twice a day but at the facility they told her it was one spray to each nostril twice a day. He/She said he/she ran out of the medication and the pharmacy won't fill it because he/she ran out too soon. The resident said that the staff keep the medication in the medication cart but gives the spray to her to give it to him/herself.
During interview on 04/09/25 at 10:08 A.M., Certified Medication Techinition (CMT) A said the resident's nasal spray has been sent off for refill but insurance has not refilled it. He/She said the resident knows he/she is only supposed to use one spray each nostril, but he/she says he/she needs two sprays and that's probably why insurance hasn't refilled it because its to soon.
3. Review of Resident #12's Quarterly MDS, dated [DATE] showed the staff assessed the resident as cognitively impaired.
Review of the resident's POS, dated April 2025, showed and order for fluoxetine (an antidepressant) 10 milligrams (mg) once daily;
Review of the resident's MAR, dated April 2025, showed staff documented the fluticasone was unavailable from 04/05/25 through 04/08/25.
Review of the nurse notes, dated 03/01/25 through 04/09/25, showed staff did not document contact with the physician or the pharmacy when the resident did not recieve his/her medication.
During interview on 04/09/25 at 10:08 A.M., CMT A said the resident's Fluoxetine has been ordered, but he/she is not sure why its not here yet. He/She said when medications aren't available for a few days he/she tells the evening CMT and that CMT will call pharmacy or let the charge nurse know.
4. Review of Resident #201's admission MDS, dated [DATE], showed staff assessed the resident as cognitively intact and admitted on [DATE].
Review of the resident's POS, dated April 2025, showed a physician order on 03/21/25 for the following:
-Alendronate (used to treat weak/thin bones) 35 mg weekly on Mondays;
-Meloxicam (used to treat symptoms of arthritis) 15 mg daily;
Review of the resident's MAR, dated March 2025, showed staff documented the following:
-Alendronate as unavailable on 03/24/25 and 03/31/25;
-Meloxicam as unavailable 03/21/25 through 03/31/25.
Review of the resident's MAR, dated April 2025, showed staff documented the meloxicam as unavailable 04/01/25 through 04/08/25.
Review of the nurse notes, dated 03/01/25 through 04/09/25, showed staff did not document contact with the physician or the pharmacy when the resident did not recieve his/her medication.
5. During an interview on 04/10/25 at 1:13 P.M., the Director of Nursing (DON) said when a medication is unavailable, the CMT is to write a note and let the DON know. If it is an over the counter (OTC) medication, he/she would go to a local store and pick it up. If the medication is a prescription, then the CMT can check the emergency supply and pull from that. If the medication is not in the emergency supply, the CMT is to notify the charge nurse. The resident should not go longer than a few days without the medication. The nurse should be calling the pharmacy to follow up and notify the DON and physician. Until yesterday, the CMT's were doing their own chart audits but now the nurse will be double checking with the CMT. He/She said he/she was not aware of the medications missing. Missing medication could cause harm or potentially death of a resident if missing.
During an interview on 04/10/25 at 2:20 P.M., the Corporate Nurse said that staff should document the unavailable medication, notify the nurse, physician and DON of the medication and document any adverse effects of missing medications.
During an interview on 04/10/25 at 2:20 P.M., the Administrator said CMT's should pull medications from the emergency supply if the medication is unavailable and would need to defer to nursing for the rest of the procedure. He/She said that the physician should be notified right away of any medication is out to avoid any adverse reactions.
6. Review of Resident #12's Significant Change MDS, dated [DATE], showed staff documented the resident diagnosis of Hypertension (high blood pressure).
Review of the resident's POS, dated 02/10/25, showed an order for Diltiazem (medicine used to treat high blood pressure) 240 mg, one capsule daily.
Observation on 04/08/25 at 8:55 A.M., showed CMT A administered Diltiazem 180mg to the resident.
During an interview on 04/09/25 at 10:08 A.M., CMT A said the resident was previously on 180mg and the order must not have gotten followed through to get that changed and the correct card put in the medication cart. He/She said there is a lot of risks if the resident is not receiving the correct dosage of medication as prescribed depending on the medication.
7. Review of Resident #32's admission MDS, dated [DATE], showed staff documented the resident diagnosis of Arthritis (a condition characterized by joint inflammation, causing pain, swelling, stiffness, and limited movement).
Review of the resident's POS, dated 03/12/25, showed an order for Vitamin D3 (for bone and muscle strength, immune function, and healthy skin) 1,250 mcg, one tablet daily on Tuesday and Friday.
Observation on 04/08/25 at 08:40 A.M., showed CMT A administered Vitamin D3 50mcg to the resident.
During an interview on 04/09/25 at 10:08 A.M., CMT A said he/she noticed the incorrect dosage of Vitamin D3 was given after the observation. He/She said he/she was unsure how long the resident had been getting the incorrect dosage.
During an interview on 04/10/25 at 1:35 P.M., the DON said staff should verify medication with the physician's order to ensure the correct dosage is given. He/She said there are a lot of risks to the residents regarding medication errors depending on the type of medication that was given incorrectly.
8. Review of the facility's Weight and Height Measurement policy, dated 03/2012, showed residents are weighed on admission and monthly unless ordered by the attending physician to monitor the resident's condition.
9. Review of Resident #40's admission MDS, dated [DATE], showed staff assessed the resident as follows:
-admitted [DATE];
-Cognitively intact;
-Dependent on staff for mobility, and transfers.
Review of the resident's POS, dated 03/2025, showed an order for weekly weights times four weeks. Once A Day on Mon.
Review of the resident's care plan, reviewed/revised 03/29/25, showed weigh the resident weekly or as ordered by PCP (primary care physician).
Review of the resident's medical record, dated 03/17/25 through 04/10/25, showed the record did not contain a weight for the resident.
During an interview on 04/07/25 at 12:31 P.M., the resident said he/she has not been weighed since he/she arrived to the facility, because he/she has not got out of bed since admitted to the facility.
During an interview on 04/10/25 at 11:07 A.M., Licensed Practial Nurse (LPN) D said facility policy is that residents are weighed on admit, weekly for four weeks, then monthly on the first of the month. He/She said the nurses and CNAs are responsible to obtain resident weights, but he/she is not sure if anyone is designated to verify all the monthly weights are obtained and documented.
During an interview on 04/10/25 at 12:06 P.M., the MDS Coordinator said residents are weighed on admit, weekly for four weeks, then monthly, unless other directions such as daily. He/She said the charge nurse is responsible to tell the CNAs which residents need to be weighed, and the monthly weights should be obtained within the first five days of each month.
During an interview on 04/10/25 at 2:58 P.M., Certififed Nurse Assistant (CNA) G said the CNAs are responsible to weigh residents when directed by the charge nurse at beginning of each shift, document the weight on paper and give to the nurse to calculate the difference between the resident and the chair they were weighed in. He/She said residents are weighed at different intervals such as monthly, weekly, or daily, and the nurse usually tells the CNAs who needs to be weighed and when.
During an interview on 04/10/25 at 12:29 P.M., the DON said residents should be weighed on admit, weekly for four weeks, then monthly, and if ordered otherwise by physician.
10. Review of the facility's policy titled, Weight and Height Measurement, dated 03/2012, showed residents are weighed on admission and monthly unless ordered by the attending physician to monitor the resident's condition.
11. Review of Resident # 18's Significant Change in Status (SCSA) MDS, dated [DATE], showed staff assessed the resident as:
-Mild cognitive impairment;
-Received nutrition via tube feeding and a mechanically altered diet;
-Received hospice care.
Review of the resident's care plan, updated 3/18/25, showed the resident's goal is to maintain his/her current weight or possibly gain weight through the next assessment, and staff were directed:
-Monitor and record weights as ordered by the physician, report weights to the resident;
-Resident required nutrition through a feeding tube;
-Resident can be expected to lose weight due to his/her terminal condition;
-Resident at risk for altered nutritional status, chooses to have a pureed diet using a divided plate, follow diet recommendations as ordered.
Review of the resident's progress notes, dated 03/04/25 through 03/31/25, showed:
-On 03/14/25, the RD documented resident returned to facility on 03/12/25, received a puree diet supplemented with 90 cc Boost three times daily and enteral (tube) feeding, February 2025 weight 176 lbs, (a 1% loss in one month, and 2% loss in three months). Recommend weekly weights for four weeks to closely monitor with addition of enteral feeding, will continue to monitor and follow up as needed;
-On 03/16/25, the RD documented recommend weekly weights for four weeks to closely monitor with addition of enteral feeding.
Review of the resident's POS, dated 03/01/25 through 04/07/25, showed:
-Weigh monthly unless otherwise indicated;
-Boost 90 cc at meal pass due to weight loss/nutritional supplement with Meals, effective 11/11/24;
-Jevity 1.5 Cal liquid, give 300 ml bolus three times a day after meals if less than 50% of meal consumed, effective 3/31/25.
Review of the resident's electronic medical record (EMR), dated 04/09/25, did not contain documentation of weekly weights and did not contain documentation of the resident's daily food intake.
During an interview on 04/08/25 at 2:38 P.M., LPN D said he/she thinks the Certified Nurses Aides (CNAs) document the resident's meal intake in the electronic chart, but they just tell the nurse if the resident ate his/her meal or not.
During an interview on 04/09/25 at 12:35 P.M., CNA G said staff assist the resident with meals in the dining room and verbally tell the charge nurse how much the resident ate. He/She said the CNAs have not been instructed to document the resident's meal intake, and do not report his/her fluid intake because the resident has a feeding tube.
During an interview on 04/10/25 at 11:07 A.M., LPN D said the resident had a feeding tube placed in March and should have at least one weight documented after his/her readmission in March. He/She said facility policy is residents are weighed on admit and the nurse and CNA are responsible to weigh residents as ordered. He/She said the DON is responsible to communicate recommendations from the RD to the nurses, and he/she was not aware the RD wanted the resident weighed weekly for four weeks after tube feeding started.
During an interview on 04/10/25 at 12:06 P.M., the MDS Coordinator said charge nurse is responsible to tell the CNAs which residents need to be weighed, and the monthly weights should be obtained within the first five days of each month. He/She said the resident should have had a documented weight after admission in March. He/She said the DON follows up on recommendations from the RD. He/She said there was no system in place to document the resident's percentage of food intake.
During an interview on 04/10/25 at 12:29 P.M., the DON said he/she expected staff to weigh the resident after he/she re-admitted to the facility, and he/she probably should have been weighed weekly especially with the feeding peg tube. He/She said he/she is responsible to ensure the recommendations from the RD gets implemented, and just missed the weight recommendations on 03/14/25 and 03/16/25. He/She said there is not currently a charting system in place to document the resident's meal consumption.
During an interview on 04/10/25 at 2:36 P.M., the administrator said each resident should be weighed on admit. He/She said the resident opted to have a feeding tube placed to enhance his/her weight, and staff should have obtained the resident's weight after he/she re-admitted to the facility to monitor for any increased or decreased weight. He/She said the RD consults with residents monthly, sends his/her report to the administrator, who gives the report to the DON and dietary manager for follow up as recommended. He/She said there is not currently a charting system in place to document the resident's meal consumption, so he/she expects the CNA that assists the resident to eat to report the resident's food intake to the charge nurse after each meal.
During an interview on 04/10/25 at 2:58 P.M., CNA G said the CNAs are responsible to weigh residents when directed by the charge nurse at beginning of each shift, document the weight on paper and give to the nurse to calculate the difference between the resident and the chair they were weighed in. He/She said residents are weighed at different intervals such as monthly, weekly, or daily, and the nurse usually tells the CNAs who needs to be weighed and when.
During an interview on 04/11/25 at 9:03 A.M., the resident's physician said he/she would expect staff to weigh the resident when he/she re-admitted to the facility to have a new baseline weight after the hospitalization and would expect staff to follow the RD's recommendations for additional weights for monitoring.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to provide written information to the resident and/or the resident's representative of the bed hold policy at the time of transfer to the hospital for three residents (Resident #12, #42, and #47) out of three sampled residents. The facility's census was 47.
1. Review of the facility's Bed Hold Policy Guidelines, undated, showed the facility will notify all residents, and/or representative of the bed hold policy guidelines. This notification shall be given upon admission to the facility, at the time of transfer to the hospital or leave; at the time of non-covered therapeutic leave.
2. Review of Resident #12's medical record showed the resident discharged from the facility on 12/18/24 and readmitted to the facility on [DATE]. Review showed the resident discharged from the facility of 02/21/25 and readmitted to the facility on [DATE]. The medical record did not contain documentation staff issued a bed hold or reviewed upon discharge on [DATE] or 02/21/25.
3. Review of Resident #42's medical record showed the resident discharged from the facility on 03/16/25 and readmitted to the facility on [DATE]. The medical record did not contain documentation staff issued a bed hold or reviewed upon discharge on [DATE].
4. Review of Resident #47's medical record showed the resident discharged from the facility on 12/02/24 and readmitted to the facility on [DATE]. The medical record did not contain documentation staff issued a bed hold or reviewed upon discharge on [DATE].
5. During an interview on 04/10/25 at 08:40 A.M., Licensed Practical Nurse (LPN) D said he/she does not do anything with bed holds.
During an interview on 04/10/25 at 1:25 PM., the Director of Nursing (DON) said bed hold should be sent with the resident when they go out. The charge nurse or whoever is initiating the transfer is responsible. The DON said she believes the previous business office manager was going to up date the form, and they never got another one so it just hasn't been being done.
During an interview on 04/10/25 at 2:40 P.M., the administrator said the nurses are responsible to give upon transfer out of the facility. She said she is not sure why its not being done. The expectation is for it to be done at the time the resident is sent out for leave, and no one responsible for follow up on the process, but will be someone assigned.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to notify the Central Office Medical Review Unit (COMRU) or the state mental health authority of a change in condition Level I Preadmission Screening and Resident Review (PASRR) evaluation and determination after admission for one resident (Resident #18) of one sampled resident, when the resident was diagnosed with a new mental disorder and later experienced a significant change in his/her functional status. The facility's census was 46.
1. Review of the facility's policies showed it did not contain a policy to address the PASRR screening and referral process.
2. Review of Resident #18's electronic medical record (EMR) showed the resident admitted to the facility on [DATE] with diagnoses of Huntington's Disease and Depression (other than bipolar). He/She received a new diagnosis of schizoaffective disorder (a mental health condition with symptoms such as hallucinations and delusions, and mood disorder) on 06/10/24.
Review of the resident's Significant Change Minimum Data Set (MDS), a federally mandated assessment, dated 03/18/25, showed staff assessed the resident as follows:
-Mild cognitive impairment;
-Not evaluated by Level II PASRR and determined to have a serious mental illness and/or mental retardation or a related condition;
-Received antipsychotic medications on a routine basis only.
Review of the resident's care plan, updated 04/01/25, showed staff assessed the resident at risk for inadequately being able to meet his/her own needs due to cognitive deficits caused from Huntington's and Schizoaffective disorder. The resident received antipsychotic medications for diagnosis of Huntington's Disease, Schizoaffective disorder, and Persistent mood disorder.
Review of the resident's EMR did not contain documentation staff completed or submitted a change in status PASRR to COMRU.
During an interview on 04/08/25 at 11:24 A.M., the MDS Coordinator said he/she has been responsible for the past seven months to complete and submit PASRRs prior to a resident's admission to the facility. He/She said he/she completed a significant change MDS for the resident about a month prior and he/she was not aware of the requirement to update COMRU with a significant change PASRR.
During an interview on 04/10/25 11:38 AM the MDS Coordinator said facility staff follow federal and state policies regarding PASRR. He/She said the resident currently has a diagnosis of schizoaffective disorder which is a mental illness diagnosis, but he/she was not aware he/she needed to send an update to COMRU.
During an interview on 04/10/25 at 2:36 P.M., the administrator said he/she knew very little about the PASRR process, facility staff follows state and federal requirements for PASRR, and the MDS Coordinator is currently responsible to complete residents' PASRRs. He/She said if a significant change PASRR was required to be sent to COMRU he/she expects the MDS Coordinator to send the update as required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility staff failed to ensure services provided met professional standards of practice when staff did not complete and document neurological checks for two (Resident #1 and #2) of two sampled residents who had unwitnessed falls, as directed by the facility policy. The facility's census was 49.
1. Review of the facility's Neurological assessment form instructions, dated 01/01/25, showed staff are required to complete neurological checks for seventy-two hours post an unwitnessed fall or head injury. Staff are directed to perform neurological checks as follows:
-First hour check every fifteen minutes;
-Second hour check every thirty minutes;
-Next two hours check every hour;
-Next 72 hours check every shift.
2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 01/09/25, showed staff assessed the resident with severe cognitive impairment, one injury fall, and one non-injury fall since admission.
Review of the facility's event report, dated 12/22/24, showed the resident had an unwitnessed fall. The report did not contain documentation staff completed neurological checks.
Review of the resident's progress notes, dated 12/22/24, showed staff documented the resident fell. Review showed staff did not document neurological checks were completed.
3. Review of Resident #2's Quarterly MDS, dated [DATE], showed staff assessed the resident with a severe cognitive impairment, and one non-injury fall since admission.
Review of the facility's event report, dated 10/26/24, showed the resident had an unwitnessed fall. The report did not contain documentation staff completed neurological checks.
Review of the resident's progress notes, dated 10/26/24, showed staff documented the resident fell. Review showed staff did not document neurological checks were completed.
4. During an interview on 01/22/25 at 11:57 A.M., Licensed Practical Nurse (LPN) A said staff are directed to complete neurological checks if a resident had an unwitnessed fall or a witnessed fall with head injury. He/She said the neurological checks should be completed and documented in the resident's medical records for seventy-two hours. He/She said the neurological checks are documented in the resident's medical records.
During an interview on 01/23/25 at 3:32 P.M., MDS Coordinator said staff are directed to perform neurological checks on a resident who had witnessed fall with head injury or an unwitnessed fall. He/She said the neurological checks should be completed for seventy-two hours by the nurse and documented in the resident's medical record. He/She said he/she staff documented the neurological assessments in the resident's medical records. The MDS Coordinator said he/she did not know who was responsible to complete the neurological assessments and he/she did not know about the missing assessments.
During an interview on 01/23/25 at 3:47 P.M., administrator said staff are directed to conduct a neurological assessment on a resident who had either a witnessed fall with head injury or an unwitnessed fall. He/She said the nurse completes the assessment for up to seventy-two hours and document the findings in the resident's medical records. He/She said staff could not locate the completed neurological checks for Resident #1's fall on 12/22/24 or Resident #2's fall on 10/26/24. He/She said the Director of Nursing (DON) was responsible to ensure the neurological assessment were completed. He/She did not know about the missing neurological assessments.
During an interview on 01/23/25 at 3:48 P.M., the Director of Nursing (DON) said staff are directed to conduct a neurological assessment on a resident who had either a witnessed fall with head injury or an unwitnessed fall. He/She said the nurse completes the assessment for up to seventy-two hours and document the findings in the resident's medical records. He/She said he/she did audit to ensure the neurological assessment were completed and did notice a missed completed assessment, so he/she did educate the staff on completing the assessment. He/She thought all the other assessment's were completed. The DON said he/she did not notice the other two assessment were not completed. The DON said he/she only knew about the one assessment that was not completed and in-serviced the staff member who did not complete that assessment, but not all the staff.
MO00248346

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, facility staff failed to review and revise the comprehensive care plan for three residents (Resident #1, #2, and #3) out of three sampled residents care plans who sustained falls. The facility census was 49.
1. Review of the facility's Comprehensive Care Plan policy, undated, showed staff are directed as follows:
-An individualized comprehensive care plan includes measurable goals and time frames will be developed to meet the resident's highest practicable physical, mental, and psychosocial well-being;
-Assessment of each resident is ongoing process and the care plan will be revised as changes occur in the resident's condition;
-The interdisciplinary care plan team is responsible for the periodic review and updating of care plans when changes occur that impact the resident's care (i.e., change in diet, discontinuation of therapy, changes in care areas that do not required significant change assessment).
2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 01/09/25, showed staff assessed the resident with severe cognitive impairment, one injury fall, and one non-injury fall since admission.
Review of the facility's event report, dated 12/22/24, showed staff documented the resident had an unwitnessed fall.
Review of the resident's care plan, dated 01/18/25, showed the care plan did not contain documentation of a new fall intervention for the fall on 12/22/24.
During an interview on 01/23/25 at 3:32 P.M., the MDS Coordinator said he/she did not have an opportunity to update the resident's care plans, since he/she had been assisting staff with resident care.
During an interview on 01/23/25 at 3:47 P.M., the administrator said he/she would expect new interventions after each fall for the resident.
During an interview on 01/23/25 at 3:48 P.M., the Director of Nursing (DON) said he/she would expect new interventions after each fall for the resident.
3. Review of Resident #2's Quarterly MDS, dated [DATE], showed staff assessed the resident with severe cognitive impairment and one non-injury fall since admission.
Review of the facility's event report, dated 10/26/24, showed the resident had an unwitnessed fall.
Review of the resident's care plan, dated 12/28/24, showed it did not contain documentation of a new fall intervention for the fall on 10/26/24.
During an interview on 01/23/25 at 3:47 P.M., the administrator said he/she would expect new interventions after each fall for the resident.
During an interview on 01/23/25 at 3:48 P.M., the Director of Nursing (DON) said he/she would expect new interventions after each fall for the resident.
4. Review of Resident #3's Quarterly MDS, dated [DATE], showed staff assessed the resident as having a moderate cognitive impairment, had one non-injury fall and one injury fall since admission.
Review of the facility's event report, dated 12/05/24, showed the resident had a witnessed fall.
Review of the resident's care plan, dated 01/08/25, showed it did not contain documentation of a new fall intervention for the fall on 12/05/24.
During an interview on 01/23/25 at 3:32 P.M., the MDS Coordinator said he/she did not know the resident had a fall.
During an interview on 01/23/25 at 3:47 P.M., the administrator said he/she would not expect a new intervention after the resident's fall, since it was due to his/her coat being on the chair and he/she slid out of the wheelchair.
During an interview on 01/23/25 at 3:48 P.M., the DON said he/she would not expect a new intervention after the resident's fall, since it was due to his/her coat being on the chair and he/she slid out of the wheelchair. He/She said staff educated the resident to not place items in his/her chair.
5. During an interview on 01/22/25 at 3:28 P.M., Certified Nurse Aide (CNA) B said the purpose of the care plan is to provide guidance to staff to the type of care the resident needed. He/She said the MDS Coordinator was responsible to update the care plan. He/She said he/she would ask another CNA or a nurse if he/she had questions in the type of care the resident required.
During an interview on 01/23/25 at 3:32 P.M., the MDS Coordinator said he/she was responsible to update the care plans when there was a change in condition, including falls. He/She said the care plans should be updated with new interventions after each fall, however he/she had been working the floor and had not had a chance to update the care plans.
During an interview on 01/23/25 at 3:47 P.M., the administrator said the MDS Coordinator was responsible to update the care plans on an annual, quarterly and when a resident had a change. The Administrator said he/she would expect new interventions after each fall, depending on how the resident fell or the resident's needs. He/She said the MDS Coordinator had been assisting residents with care, so he/she had not had an opportunity to update all of the new interventions.
During an interview on 01/23/25 at 3:48 P.M., the DON said the MDS Coordinator was responsible to update the care plans on an annual, quarterly and when a resident had a change. He/She said depending on how the resident fell or his/her needs, would determine if staff implemented a new interventions after each fall. He/She said the MDS Coordinator had been assisting residents with care, so he/she had not had an opportunity to update all of the new interventions.
MO00248346

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to report an allegation of physical abuse for one resident (Resident #1) out of one sampled residents to the Department of Health and Senior Services (DHSS) within the two hour required timeframe. The facility census was 50.
1. Review of the facility's Investigation policy, undated, showed all allegations of abuse will be reported no later than two hours to the State Survey Agency and if applicable, law enforcement, and there are instances where an alleged violation of abuse, neglect, misappropriation of resident property and exploitation would be considered to be a reasonable suspicion of a crime. In these cases, the facility is obligated to report to the Administrator, to the state survey agency, and to other officials in accordance with State Law.
2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 10/24/24, showed staff assessed the resident as admitted on [DATE] with severe cognitive impairment.
Review of the facility's investigation, dated 11/15/24, showed the facility documented Certified Nurse Aide (CNA) A reported to the administrator on 11/15/24 at 4:10 P.M., Registered Nurse (RN) B hit Resident #1 and threw a sheet over his/her head at 2:30 A.M. on 11/15/24. Reviewed showed staff documented they notified DHSS on 11/15/24 at 5:04 P.M
During an interview on 11/09/24 at 9:30 A.M., the administrator said CNA A reported RN B slapped the resident and threw a fitted sheet over his/her head. He/She said it occurred around 3:30 A.M. on 11/15/24, but CNA A did not report the incident until later in the afternoon. He/She said CNA A did not know to report allegations of abuse immediately. He/She said he/she educated the CNA of his/her responsibility to notify him/her as soon as abuse was witnessed.
During an interview on 11/09/24 at 2:25 P.M., RN B said staff are directed to immediately notify upper management and the State agency within two hours of reported or observed abuse.
During an interview on 11/09/24 at 2:43 P.M., CNA A said he/she did not know he/she was supposed to report abuse within two hours to the administrator. CNA A said he/she was directed to make a report as soon as he/she was able to. CNA A said he/she did report to the administrator when he/she first had contact with him/her. CNA A said he/she was educated after the incident to report abuse immediately.
MO00245237

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to store oxygen/nebulizer masks and tubing in a manner to prevent infection-causing contaminants for six (Resident #8, #33, #38, #6, #25, and #105) out of 14 sampled residents. Staff failed to ensure two resident (Residents #25 and #105) out of a sampled residents had orders for oxygen therapy. The facility census was 44.
1. Review of the facility's policy titled Oxygen Administration, dated March 2012, showed staff were directed to check and clean oxygen equipment, masks, tubing and cannulas at regular intervals. Place oxygen tubing in plastic bag attached to concentrator when tubing is not in use.
Review of the facility's policy titled Bi-level Positive Airway Pressure (BiPAP), a non-invasive ventilation device used to keep airways open during sleep, Administration, dated March 2012, showed staff were directed to use tap water, distilled water is optional for humidifier. Refer to Continuous Positive Airway Pressure (CPAP), a non-invasive ventilation device used to keep airways open during sleep, policy for additional information.
Review of the facility's policy titled CPAP Administration, dated March 2012, showed staff were directed to do the following:
-Use wet cloth, or cleaning wipe to clean outside surface of machine;
-Remove filter from machine and clean weekly by running under warm water;
-Tubing should be cleaned weekly;
-Mask and nasal pillows can be wiped down daily with a damp cloth and a mild soap, rinse and allow to air dry;
-Clean the humidifier holding tank with a damp cloth and mild soap weekly.
2. Review of Resident #8's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 09/03/23, showed staff assessed the resident as:
-Cognitively intact;
-Did not receive oxygen;
-Did not receive BiPAP.
Review of the resident's Quarterly MDS, dated [DATE], showed staff assessed the resident as:
-Cognitively intact;
-Received oxygen;
-Did not receive BiPAP.
Review of the resident's care plan, dated 11/13/23, showed staff documented:
-Required oxygen therapy;
-Required BiPAP at night;
-Administer oxygen by nasal cannula;
-Keep tubing off floor and replace weekly labeled with dates.
Review of the resident's Physician Order Sheet (POS), dated 03/17/24, showed:
-Change oxygen tubing monthly on the first;
-Check oxygen saturation as needed and notify the physician less than 90 percent (%);
-Oxygen at 3 liters per nasal cannula continuously;
-May use BiPAP with 16 pressure in and 16 pressure out at HS;
-Ipratropium-Albuterol (medication used to prevent wheezing and difficulty breathing) solution 0.5 milligrams (mg)-3 mg/3 milliliters (ml), inhale one tube four times a day
-BiPAP cleaning once a week on Mondays, clean mask with normal saline and let dry.
Observation on 03/17/24 at 1:18 P.M., showed the resident wore oxygen from a concentrator. Observation showed the oxygen tubing did not have a date. Observation showed a BiPAP machine and mask sat on the nightstand without a bag for tubing.
Observation on 03/18/24 at 8:10 A.M., showed the resident wore oxygen from a concentrator. Observation showed the oxygen tubing did not have a date. Observation showed a BiPAP machine and mask sat on the nightstand without a bag for tubing.
Observation on 03/18/24 at 9:34 A.M., showed a nebulizer machine on the resident's dresser, the tubing and mask laid in the drawer. The tubing did not have a date or a bag for storage.
3. Review of Resident #33's Quarterly MDS, dated [DATE], showed staff assessed the resident as:
-Severe cognitive impairment;
-Did not receive oxygen.
Review of the resident's care plan, dated 10/19/22, showed staff documented:
-At risk for inadequately being able to meet own needs due to cognitive deficit;
-At risk for respiratory insufficiency due to Chronic Obstructive Pulmonary Disorder (COPD), a group of diseases that cause airflow blockage and breathing related problems;
-Administer medications for COPD as ordered.
Review of the resident's POS, dated 03/17/24, showed the POS did not contain orders for nebulizer treatments.
Observation on 03/17/24 at 1:20 P.M., showed a nebulizer mask and tubing in the resident's room not dated and not stored in a bag.
Observation on 03/18/24 at 8:00 A.M., showed a nebulizer mask and tubing in the resident's room not dated and not stored in a bag.
4. Review of Resident #38's Quarterly MDS, dated [DATE], showed staff assessed the resident as:
-Severe cognitive impairment;
-Did not receive CPAP.
Review of the resident's care plan, revised 03/11/24, showed:
-Has memory loss, staff to ensure safety of the resident;
-Required the use of oxygen as needed;
-Required the use of CPAP at bedtime and staff will ensure my device is on at HS.
Review of the resident's transfer orders, dated 06/30/23, showed:
-CPAP, fill humidifier with purified water every night;
-CPAP, clean reservoir with warm soapy water, rinse, and let dry every week;
-Oxygen with CPAP pressure setting two every night.
Review of the resident's POS, dated 03/17/24, showed:
-03/09/24: Ipratropium-Albuterol solution 0.5 mg-3 mg/3 ml amount, inhale one tube three times a day;
-Did not contain orders for CPAP or settings for the CPAP;
-Did not contain orders for cleaning the CPAP;
-Did not contain orders for tubing change of the nebulizer.
Observation on 03/17/24 at 1:26 P.M., showed a nebulizer machine, tubing, and mask on the bedside table not dated or in a bag. Observation showed a CPAP machine and mask sat on the bedside table not in a bag.
Observation on 03/18/24 at 8:00 A.M., showed a nebulizer machine, tubing, and mask on the bedside table not dated or in a bag. Observation showed a CPAP machine and mask sat on the bedside table not in a bag.
Observation on 03/18/24 at 11.00 A.M., showed a CPAP machine and mask sat on the bedside table not in a bag.
Observation on 03/19/24 at 7:45 A.M., showed a CPAP machine and mask sat on the bedside table not in a bag. Observation showed a nebulizer mask and tubing in the resident's chair not dated and not in a bag.
5. Review of Resident #6's Annual MDS, dated [DATE], showed staff assessed the resident as:
-Cognitively intact;
-Did not receive oxygen.
Observation on 03/17/24 at 1:55 P.M., showed the resident in his/her room with an oxygen concentrator next to his/her bed. The oxygen tubing and nasal cannula were laying on the floor.
During an interview on 03/17/24 at 1:55 P.M., the resident said he/she uses oxygen at night now.
Review of the resident's care plan, dated 2/28/24, showed it did not contain direction for staff in regard to the resident's oxygen use.
Review of the resident's POS, dated March 2024, showed it did not contain an order for oxygen.
During an interview on 3/22/24 at 10:08 A.M., the Director of Nursing (DON) said the resident did not have a current order for oxygen.
During an interview with the charge nurse on 3/25/24 at 9:45 A.M., Licensed Practical Nurse (LPN) I said the POS did not contain a current oxygen order.
6. Review of Resident #25's Quarterly MDS, dated [DATE], showed staff assessed the resident as:
-Cognitively intact;
-Dependent on staff for transfers;
-Required moderate assist from staff for bed mobility;
-Received oxygen;
-Did not require BiPAP;
-Wheelchair;
-Diagnoses of obesity (having to much body fat), Sleep Apnea and Acute Bronchospasm (contraction in the airways that can make it hard to catch your breath).
Review of the resident's care plan, dated 12/22/23, showed staff documented:
-Administer oxygen two liters per minute (LPM) by nasal cannulas, as needed continuously;
-Keep tubing off floor and replace tubing weekly labeled with dates
-Did not contain the resident's use of BiPAP, setting or cleaning instructions.
Review of the resident's POS, dated 03/01/2024, showed:
-May use BiPAP at bedtime;
-Did not contain settings, or cleaning instructions for BiPAP;
-Did not contain oxygen.
Review of the resident's TAR, dated 03/01/24, showed it did not contain orders for BiPAP or oxygen.
Observation on 03/17/24 at 2:09 P.M., showed the resident on side of his/her bed. Resident's oxygen concentrator on, tubing not dated. Oxygen tubing on the tile floor. Resident's BiPAP machine on bedside table. The water reservoir to the BiPAP has a thick layer of white powdery substance on the bottom of it.
Observation on 03/18/24 at 11:11 A.M., showed the resident on side of his/her bed. Resident's oxygen concentrator on, tubing not dated. Oxygen tubing on the tile floor. Resident's BiPAP machine on bedside table. The water reservoir to the BiPAP has a thick layer of white powdery substance on the bottom of it.
Observation on 03/19/24 at 8:38 AM., showed the resident's oxygen concentrator on and oxygen tubing not bagged or covered. Oxygen tubing lay directly on the floor. The tubing is not dated.
Observation on 03/19/24 at 2:10 P.M., showed resident on side of his/her bed, electric wheelchair on other side of room, out of reach of the resident. Observation showed the back of the resident's wheelchair with his/her oxygen tank with oxygen tubing and nasal cannula wrapped around the tank, not bagged, covered, or dated.
Observation on 03/20/24 at 8:44 A.M., showed Nurse Aide (NA) K assisted the resident in his/her room. Observation showed the resident's oxygen tank and oxygen tubing on the back of the wheelchair, not bagged or covered and not in use. Observation showed the resident's oxygen tubing not dated and coils of tubing on tile floor. Observation showed NA K left the room and did not bag, or cover the oxygen tubing on the back of the wheelchair. The resident's BiPAP water reservoir to have a thick layer of white powdery substance in the bottom of it.
During an interview on 03/20/24 at 8:46 A.M., NA K said he/she does not know what he/she is supposed to do with oxygen tubing when it is not in use.
During an interview on 03/20/24 at 8:48 A.M., NA F said If oxygen tubing is on the floor staff should throw it away. The NA said he/she had been in Resident #25's room three times this morning. The NA said he/she had not noticed the oxygen tubing on back of wheelchair. The NA said he/she is pretty sure it is supposed to be in a bag. The NA said he/she does not know when staff clean Resident #25's BiPAP, and he/she has not cleaned it. The NA said he/she doesn't know if there is a set day for changing oxygen tubing, and he/she only changes it when he/she notices it on the floor.
7. Review of Resident #105's admission MDS, dated [DATE], showed staff assessed the resident as:
-Cognitively intact;
-Dependent on staff for transfers;
-Required maximal assist from staff for bed mobility;
-Continuous oxygen;
-Wheelchair;
-Diagnosis of Chronic Obstructive Pulmonary Disease (COPD), constriction of the airways and difficulty, or discomfort in breathing.
Review of the resident's care plan, dated 02/13/24, showed staff documented:
-Required assistance with bed mobility and transfers;
-Continuous oxygen at two LPM by nasal cannulas;
-Tubing will be intact and in good working condition.
Review of the resident's Physician Order Sheet (POS), dated 03/01/2024, showed it did not contain an order for oxygen.
Review of the resident's TAR, dated 03/01/24, showed it did not contain oxygen.
Observation on 03/17/24 at 3:36 P.M., showed the resident's oxygen tubing and nasal cannula, not dated and under the resident's covers on a bare air mattress. Observation showed the bed made.
During an interview on 03/17/24 at 3:36 P.M., The resident said he/she is on two liters of oxygen right now. Resident said staff made his/her bed.
Observation on 03/18/24 at 8:19 A.M., Observation showed the sheets on the residents bed stripped to foot of bed and oxygen nasal cannula directly on sheets. Observation showed oxygen tubing undated.
Observation on 03/18/24 at 5:23 P.M. showed the resident wore oxygen and the oxgeb tubing not dated.
Observation on 03/19/24 at 8:36 A.M., observation showed the resident's oxygen concentrator on and oxygen tubing hung over the headboard of the bed, not covere, dated or bagged.
During an interview on 03/20/24 at 8:48 A.M., NA F said some residents have bags staff put the oxygen tubing in or it is put it in a dresser drawer. The NA said he/she does not date oxygen tubing. The NA said he/she does not know what the oxygen policy says. The NA said he/she has been in Resident #105's room this morning. The NA said he/she made the resident's bed. The NA said he/she did not bag the resident's oxygen tubing, he/she doesn't know why. The NA said he/she did not know the resident's oxygen tubing is on the floor.
During an interview on 03/20/24 at 9:34 A.M., LPN I said he/she does not know why Resident #105 doesn't have an oxygen order, because he/she uses it every night.
8. During an interview on 03/20/24 at 9:08 A.M., Certified Nurse Assistant (CNA) a said oxygen tubing, nebulizer tubing and masks, CPAP or BiPAP masks should all be stored in a bag when not in use, and never stored on the floor, dresser, or uncovered. CNA A said this is to prevent the spread of germs that lead to infections. CNA A said if tubing is on the floor, staff should change and replace it. CNA A said tubing should be dated as well. Distilled water should be used in a CPAP or BiPAP machines, not regular tap water to prevent calcium build up.
During an interview on 03/20/24 at 9:46 A.M., the MDS Coordinator said he/she is responsible for completing the MDS and care plan on all the residents. The MDS Coordinator said if a resident receives oxygen, BiPAP, or CPAP then it should be coded on the MDS in the resident's care plan.
During an interview on 03/20/24 at 10:05 A.M., CNA O said when oxygen, nebulizer, BiPAP, or CPAP are not in use they should be stored in a bag. CNA O said the tubing or mask should not be on the floor or dresser. CNA O said if staff find tubing on the floor, they should sanitize it before allowing the resident to use it.
During an interview on 03/20/24 at 10:15 A.M., LPN I said he/she would expect the care plan to address oxygen, CPAP, or BiPAP if a resident uses those things. The LPN said if a resident uses oxygen, nebulizer, BiPAP, or CPAP they should have a physician's order to direct staff on the settings. The LPN said there should be orders of when to change the tubing, and the type of water to use in the machine. LPN I said the charge nurse is responsible to obtain the orders, and the DON is responsible to oversee the charge nurses to ensure the orders are carried out. LPN I said staff should use distilled water only in the machines to prevent calcium build up. The LPN said when a nebulizer, CPAP, BiPAP, or oxygen is not in use they should be stored in a bag and dated. The LPN said tubing or masks should not be stored on the floor, on top of the dresser, or in a drawer. The LPN said if found stored not in a bag staff are expected to change the tubing, and masks. LPN I said if a CPAP or BiPAP mask is not stored in a bag staff should sanitize the mask prior to a resident using it. The LPN said this could lead to potential infections for the resident if not cleaned or stored properly.
During an interview on 03/20/24 at 10:51 A.M., Certified Medication Technician (CMT) G said when a CPAP, BiPAP, nebulizer, or oxygen are not in use they should be stored in a bag with a date on it. The CMT said if not stored properly then it should be replaced. CMT G said tubing or masks should not be stored in a dresser, in a drawer, or on the floor. The CMT said this can lead to a resident getting an infection.
During an interview on 03/20/24 at 11:15 A.M., the DON said oxygen, nebulizer, CPAP, or BiPAP tubing and masks should be stored in a bag when not in use. The DON said they should not be on the floor, laying on top of a dresser, or in a dresser drawer. The DON said if staff find them not in a bag they should change out the tubing and mask on oxygen or nebulizer, and sanitize a CPAP or BiPAP mask before the resident uses it. The DON said the tubing should be changed out monthly and should be dated when it is changed. The DON said the BiPAP or CPAP machines should have distilled water used in them only. The DON said if a machine has calcium build up then staff are expected to clean the machine. The DON said if a mask or tubing are not stored properly it can lead to resident infections. The DON said there should be orders on the resident's chart if they use oxygen, nebulizer, BiPAP, or CPAP and those orders should state the pressure setting or amount of OXYGEN needed, cleaning orders, and orders for changing out the tubing and mask. The DON said if a resident uses oxygen, CPAP, or BiPAP it should be on the resident's care plan. The DON said the care plan should also state to use distilled water in the machines, and when to clean the machine. The DON said the MDS should be coded correctly if a resident uses oxygen, BiPAP, or CPAP. He/She said if a MDS is not coded correctly, or the care plan is not accurate then staff don't know how to take care of the resident. The DON said the charge nurse is responsible to ensure the resident has the proper orders on his/her chart. The DON said the MDS Coordinator is responsible for accurately coding the MDS's and care plans.
During an interview on 03/20/24 at 2:08 P.M., the Administrator said oxygen and nebulizer tubing should be changed out weekly and dated. He/She said when oxygen, nebulizer, CPAP, or BiPAP are not in use they should be stored in a bag. The Administrator said the tubing or masks should never be on the floor, the dresser, or in a drawer. The Administrator said if the tubing or mask are not stored in a bag the staff are expected to replace or clean it prior to a resident using it. The Administrator said the DON is responsible to oversee the nursing staff and ensure all orders are followed. The Administrator said residents should have orders, be coded on the MDS, and on the care plan for oxygen, nebulizer, CPAP or BiPAP if the resident uses them. The Administrator said there should be orders for tubing and mask changes, for the oxygen setting, for the CPAP or BiPAP pressure settings, and cleaning. The Administrator said staff should date the tubing when it is changed. The Administrator said the CPAP and BiPAP reservoirs should be cleaned weekly, and staff should only use distilled water in the machines to prevent calcium build up.
During an interview on 03/28/24 at 8:30 A.M., the Medical Director said he/she is the only physician who covers the facility, and he/she sees all the residents in it. The Medical Director said he/she tubing should not be on the floor, a soiled bed, or in a bin. The Medical Director said staff are expected to change nebulizer mask and tubing, and oxygen tubing out and clean a CPAP or BiPAP mask if they were stored on a dirty surface such as the floor prior to a resident using them. The Medical Director said if staff don't it could lead to a potential infection. The Medical Director said staff should use distilled water in a CPAP or BiPAP machine to prevent calcium build up. The Medical Director said calcium build up could clog up the machine and cause it to not work properly resulting in the resident not getting the proper pressure settings as ordered. The Medical Director said if a resident uses oxygen, BiPAP, CPAP, or nebulizer he/she would expect them to have orders on their chart for those along with the settings or oxygen flow amount.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to lock the medication and treatment carts, failed to store medications and chemicals in a safe manner. The facility census was 44 out of a capacity of 82 residents.
1. Review of the facility's policy titled Storage of Medication, dated March 2012, showed staff were directed:
-All medications for residents must be stored at or near the nurse's station in a locked cabinet, a locked medication room, or locked in a medication cart;
-All medication carts must be under visual control of the staff at all times when not stored safely and securely;
-The key to the medicine cabinet, medicine room, or medication cart is the responsibility of the person authorized to handle and administer medications;
-An unattended medication cart must be locked at all times;
-All poisonous substances and other hazardous compounds must be kept in a locked container away from medications and may not be accessible to the residents.
Review of policies provided by the facility showed the policies did not contain a chemical storage policy.
2. Observation on 03/17/24 at 12:10 P.M., showed Certified Medication Technician (CMT) G left his/her medication cart unattended in the dining room with multiple residents nearby. Observation showed seven pills of Famotidine (a medication used to treat heartburn and stomach ulcers) 10 milligram (mg) on top of the medication cart.
Observation on 03/17/24 at 12:19 P.M. and 1:12 P.M., showed the treatment cart unlocked and unattended at the nurse's station. Observation showed residents sat across the hall from the cart.
During an interview on 03/20/24 at 10:15 A.M., Licensed Practical Nurse (LPN) I said medication carts, and treatment carts should be locked when not attended by staff. LPN I said staff should never leave medications laying on top of a cart for resident safety.
During an interview on 03/20/24 at 10:51 A.M., CMT G said all medication and treatment carts should be locked when left unattended, and he/she was not sure why he/she left the Famotidine laying on top of the cart. CMT G said he/she probably got busy serving meal trays and forgot it was there. CMT G said medications should not be left on top of the medication cart because the facility has residents who wander and get into things. It is a potential danger for the residents.
During an interview on 03/20/24 at 11:15 A.M., the Director of Nursing (DON) said all medication carts, treatment carts should be locked when not attended. The DON said medications should never be left on top of the medication cart. The staff assigned to those carts are responsible for the cart and keeping it locked.
During an interview on 03/20/24 at 2:08 P.M., the Administrator said all medication and treatment carts should never be left unlocked and unattended. Medications should not be left on top of the medication cart. The administrator said a resident could take the medication and be harmed.
3. Observation on 03/18/24 at 8:10 A.M., showed the housekeeping cart sat near room four unlocked and unattended with a bottle of toilet bowl cleaner on it.
Observation on 03/18/24 at 8:29 A.M., showed a different housekeeping cart sat in the hallway near the Minimum Data Set (MDS) office unlocked and unattended with a bottle of toilet bowl cleaner on it. The Housekeeping Supervisor opened the unlocked door of the cart, shut it and left it unlocked and unattended. Resident #48 wandered in the hall nearby.
Observation on 03/18/24 at 1:54 P.M., showed the Housekeeping Supervisor left his/her cart sitting next to room [ROOM NUMBER] unlocked and unattended with a bottle of toilet bowl cleaner on it.
Observation on 03/19/24 at 8:59 A.M., showed a housekeeping cart sat in the dining room unlocked and unattended with Resident #33 nearby, and had two bottles of toilet bowl cleaner on it.
Observation on 03/19/24 at 10:02 A.M., showed the housekeeping cart sat in the hall unlocked and unattended with two bottles of toilet bowl cleaner on it.
Observation on 03/20/24 at 8:00 A.M., showed Housekeeper L left his/her cart unlocked and unattended with two bottles of toilet bowl cleaner on it near room [ROOM NUMBER].
Observation on 03/20/24 at 8:00 A.M., showed the Housekeeping Supervisor left his/her cart unlocked and unattended with a bottle of toilet bowl cleaner on it in the hall near the MDS office.
Observation at 03/20/24 at 9:00 A.M., showed the Housekeeping Supervisor left his/her cart unlocked and unattended with a bottle of toilet bowl cleaner on it in the hall near the MDS office with residents nearby.
During an interview on 03/20/24 at 9:37 A.M., Housekeeper L said all chemicals should be locked up so residents can't get them. Housekeeper L said housekeeping carts should be locked when staff are not near them. Housekeeper L said the toilet bowl cleaner should be locked up when staff are not near it. The lock on his/her cart does not work and he/she reported this to the Housekeeping Supervisor last week. He/She is not sure what is being done about that.
During an interview on 03/20/24 at 10:15 A.M., LPN I said all chemicals should be locked up to prevent residents from getting to them. LPN I said if a resident got a a hold of a chemical, he/she could drink it, or get hurt by a chemical burn if spilled. LPN I said all housekeeping carts should be locked when not attended by staff.
During an interview on 03/20/24 at 10:57 A.M., the Housekeeping Supervisor said all chemicals should be locked up and kept away from the residents for their safety. The housekeeping supervisor said if a resident got a hold of a chemical that they could spill it or ingest it. The toilet bowl cleaner should be kept locked up and not left unattended. The housekeeping supervisor was aware that staff were having trouble locking their carts and he/she reported it to maintenance but was not sure if they had ordered new locks or not.
During an interview on 03/20/24 at 11:07 A.M., the Maintenance Director said all chemicals should be locked up for resident safety. The housekeeping carts needed new locks last week, but he had not looked at them yet. He/She said he/she will look at them now.
During an interview on 03/20/24 at 11:15 A.M., the DON said all housekeeping carts should be locked when not attended. All chemicals should be locked up, and toilet bowl cleaner should be locked up as it is a chemical. The staff assigned to those carts are responsible for the cart and keeping it locked.
During an interview on 03/20/24 at 2:08 P.M., the Administrator said all chemicals should be locked up for resident safety. Toilet bowl cleaner should be locked up and not left unattended.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, facility staff failed to ensure residents who were unable to complete their own activities of daily living (ADLs), received the necessary care and services to maintain good personal hygiene when staff failed to provide hair care and assist resident with facial hair for four residents (Residents #14, #24, #33, and #50) out of fourteen sampled residents. The facility census was 44.
1. Review of the facility's policy titled Activities of Daily Living (ADL), dated March 2012, the purpose is to assist resident in achieving maximum function. Review showed:
-Directed staff on how to dress residents in appropriate clothing, footwear and assistive devices;
-Did not address hair care, facial hair care, and nail care.
Review of the facility's policy titled Shampoo (Resident in Bed), undated, showed staff were directed to:
-Shampoos are usually given with the scheduled shower or tub bath;
-Directed staff on how to appropriately shampoo a resident that is bedfast.
Review of the facility's policy titled Shaving the Resident, undated, showed staff were directed to do the following:
-The purpose is to remove facial hair and improve the resident's appearance and morale;
-Directed staff on how to appropriately shave residents with a disposable safety razor or personally owned electric razor;
-Does not provide direction for frequency of shaving.
Review of the facility's policy titled Nails, Care of (Fingers and Toes), undated, showed staff were directed to do the following:
-The purpose is to provide cleanliness, comfort, prevent spread of infection;
-Directed staff on how to appropriately provide finger and toenail care and grooming;
-Does not provide direction for frequency of finger and toenail care.
2. Review of Resident #14's Quarterly MDS, dated [DATE], showed staff assessed the resident as:
-Cognitively intact;
-Did not reject care;
-Dependent on staff for eating, bed mobility, transfers, toileting, hygiene, dressing, and bathing;
Review of the resident's care plan, dated 09/24/23, showed staff were directed to:
-Provide assistance with eating, bed mobility, transfers, grooming, toileting, hygiene, dressing, and bathing;
-Did not contain direction for facial hair preference.
Review of the facility's shower documentation showed the resident received showers on the following dates:
-02/27/24 did not contain documentation of shave completed;
-03/01/24 did not contain documentation of shave completed;
-03/07/24 did not contain documentation of shave completed;
-03/10/24 did not contain documentation of shave completed;
-03/11/24 did not contain documentation of shave completed;
-03/15/24 did not contain documentation of shave completed;
Observation on 03/17/23 at 1:38 P.M., showed the resident with multiple chin hairs approximately one inch long.
Observation on 03/18/24 at 7:58 A.M., showed Certified Nurse Assistant (CNA) A fed the resident breakfast in bed and the resident had multiple chin hairs approximately one inch long.
Observation on 03/18/24 at 11:51 A.M., showed Nurse Assistant (NA) N provided care to the resident. Observation showed the resident had multiple chin hairs approximately one inch long.
Observation on 03/18/24 at 1:45 P.M., showed the resident in bed with multiple chin hairs approximately one inch long.
Observation on 03/18/24 at 2:46 P.M., showed the MDS Coordinator and Licensed Practical Nurse (LPN) I provided wound care to the resident. Observation showed the resident had multiple chin hairs approximately one inch long.
During an interview on 03/18/24 at 3:03 P.M., the resident said he/she prefers to have his/her facial hair shaved. The resident said he/she has arthritis in his/her hands and is not able to shave himself/herself. Staff must assist him/her to shave.
Observation on 03/19/24 at 7:50 A.M., showed the resident in bed with multiple chin hairs approximately one inch long.
Observation on 03/20/24 at 8:07 A.M., showed the resident in bed with multiple chin hairs approximately one inch long.
During an interview on 03/20/24 at 9:08 A.M., CNA A said he/she noticed this morning the resident had long chin hairs. The CNA said the resident is not able to shave himself/herself and he/she planned to help the resident shave today.
3. Review of Resident #24's Quarterly MDS, dated [DATE], showed staff assessed the resident as:
-Severely cognitively impaired;
-Did not reject care;
-Lower extremity impairment on one side;
-Dependent on staff for all ADL's (toileting, bathing, personal hygiene);
-Required substantial/maximum assistance for upper and lower body dressing.
Review of the resident's care plan, dated 03/13/24, showed staff were directed to:
-Facial Hair Preference - clean shaved;
-Have my wishes followed with facial hair;
-Shaved and/or cleaned up as needed or whenever asked;
-Appearance will remain clean and acceptable.
Review of the facility's shower documentation showed the resident received showers on the following dates:
-01/19/24 did not contain documentation of shave completed;
-02/22/24 did not contain documentation of shave completed;
-03/02/24 did not contain documentation of shave completed;
-03/05/24 did not contain documentation of shave completed.
Observation on 03/17/24 at 3:34 P.M. showed resident in bed with facial hair.
Observation on 03/18/24 at 8:32 A.M., 10:36 A.M., and 4:0 showed resident in his/her room with facial hair.
Observation on 03/18/24 at 10:36 A.M. showed resident in his/her room with facial hair.
Observation on 03/18/24 at 4:05 P.M. showed resident in his/her room with facial hair.
Observation on 03/19/24 at 5:19 P.M. showed resident in dining room with facial hair.
Observation on 03/20/24 at 8:03 A.M. showed resident with facial hair.
During an interview on 03/18/24 at 8:32 A.M., the resident said he/she likes to be clean shaven and sometimes staff does it in the shower but not always.
4. Review of Resident #33's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows:
-Severely cognitively impaired;
-Did not reject care;
-Required maximum assistance for personal hygiene;
-Required minimum assistance for bathing.
Review of the resident's care plan, dated 01/15/23, showed staff were directed to:
-At risk for inadequately being able to meet own needs due to cognitive deficits;
-Provide cues and assistance for tasks;
-Provide assistance for shaving, hygiene, dressing, toileting, and bathing;
-Facial hair preference - clean shaved.
Review of the facility's shower documentation showed the resident received showers on the following dates:
-02/27/24 did not contain documentation of shave completed;
-02/29/24 did not contain documentation of shave completed;
-03/05/24 did not contain documentation of shave completed;
-03/07/24 did not contain documentation of shave completed;
-03/11/24 did not contain documentation of shave completed;
-03/15/24 did not contain documentation of shave completed;
Observation on 03/17/24 at 1:20 P.M., showed the resident walked the halls and his/her hair unkept and facial hair approximately a half inch long.
Observation on 03/18/24 at 8:00 A.M., showed the resident walked the halls and his/her hair unkept and and facial hair approximately a half inch long.
Observation on 03/18/24 at 9:56 A.M., showed the resident in a chair near the nurse's station with his/her hair unkept and facial hair approximately a half inch long.
Observation on 03/18/24 at 3:11 P.M., showed the resident stood at the nurse's station with his/her hair unkept and facial hair approximately a half inch long.
Observation on 03/18/24 at 3:16 P.M., showed the resident's hair was unkept.
Observation on 03/19/24 at 8:59 A.M., showed the resident sat in the dining room with unkempt hair.
Observation on 03/19/24 at 2:29 P.M., showed the resident walked the hall with unkempt hair.
Observation on 03/20/24 at 8:04 A.M., showed the resident hair was unkept.
5. Review of Resident #50's admission MDS, dated [DATE], showed staff assessed the resident as:
-Unable to complete mental status evaluation;
-Severely impaired cognitive skills for daily decision making;
-Did not reject care;
-Dependent for all ADLs, to include oral hygiene, toileting, shower/bathe self, upper/lower body dressing, and personal hygiene;
-Lower extremity impairment on one side.
Review of the resident's care plan, dated 03/04/24, showed staff were directed:
-Facial Hair Preference: does not mind to be clean shaven or to have facial hair, preferences change;
-Have wishes followed in regard to facial hair;
-Be shaved and/or cleaned up as needed or when asked;
-Appearance will remain clean and acceptable.
Review of the facility's shower documentation showed the resident received showers on the following dates:
-03/01/24 did not contain documentation of shave completed;
-03/03/24 did not contain documentation of shave completed;
-03/05/24 did not contain documentation of shave completed;
-03/09/24 did not contain documentation of shave completed;
-03/11/24 did not contain documentation of shave completed;
-03/13/24 did not contain documentation of shave completed;
Observation on 03/17/24 at 2:29 P.M. showed the resident with greasy disheveled hair and unshaved facial hair.
Observation on 03/18/24 at 8:37 A.M. showed the resident wore the same light tan hospital gown, with greasy, disheveled hair, unshaved facial hair, and dry, chapped lips.
Observation on 03/19/24 at 9:11 A.M. showed the resident in his/her wheelchair in the therapy area with greasy hair and unshaved facial hair.
Observation on 03/19/24 at 11:51 A.M. showed the resident in his/her bed with greasy, disheveled hair and unshaved facial hair.
Observation on 03/20/24 08:07 AM showed the resident in his/her room with greasy, disheveled hair, and unshaved facial hair.
During an interview on 03/17/24 at 2:29 P.M., the resident nodded his/her head and mouthed yes when asked if he/she preferred to be clean shaven.
6. During an interview on 03/19/24 at 9:57 A.M., LPN I said the resident's do not have assigned shower days, but staff give them showers twice a week. The LPN said staff keep a log in the shower book.
During an interview on 03/20/24 at 9:08 A.M., CNA A said the aides are responsible to give the resident's showers or baths. The CNA said when a resident gets a shower or bath, staff should wash the resident's hair, provide nail care, and shave the resident's facial hair. The CNA said staff should assist residents to comb their hair as needed. If a resident refuses care from one staff member, then another staff member should attempt to help the resident.
During an interview on 03/20/24 at 9:46 A.M., the MDS Coordinator said the resident's care plan directs staff on how much assistance the resident needs for care. This includes resident's facial hair preference.
During an interview on 03/20/24 at 10:15 A.M., LPN I said all staff are responsible to ensure resident's ADLs are taken care of. The LPN said if non-nursing staff notice any resident need assistance, then that staff member should notify a nursing staff member. The LPN said all residents are to get a shower or bath twice a week. The LPN said when staff give a resident a shower or bath, they are expected to wash the resident's hair, provide nail care, and shave the resident's facial hair. LPN I said a resident should have clean clothes on daily, and staff are expected to assist the resident to change them when needed. The LPN said staff should change a resident's clothes if they become soiled. The LPN said staff should ensure a resident has their teeth brushed, their hair is combed, and faces is washed.
During an interview on 03/20/24 at 11:15 A.M., the Director of Nursing (DON) said all residents are to get a shower twice a week. The DON said if the resident refuses then he/she expects staff to document this in the resident's chart. The DON said he/she expects staff to wash a resident's body and hair, provide nail care, and shave or pluck a resident's facial hair per the resident's preference. The DON said he/she expects staff to assist a resident to change their clothes daily and as needed if they become soiled. The DON said staff should comb a resident's hair and not leave it unkept.
During an interview on 03/20/24 at 2:08 P.M., the Administrator said residents are to get a shower twice a week. The Administrator said he/she expects staff to wash the resident's body, wash the resident's hair, provide any nail care needed, apply lotion, and shave the resident's facial hair. The Administrator said if a resident prefers a beard that it should be on the care plan. The Administrator said staff are expected to ensure a resident's clothing is changed daily and if they become soiled. The Administrator said staff are expected to comb a resident's hair and not leave it unkept. The Administrator said the aides, charge nurse, and DON are responsible to ensure the resident's receive ADL care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to develop and implement a comprehensive person-centered care plan for four residents (Resident #6, #14, #21, #25, #33) out of 14 sampled residents. The facility census was 44.
1. Review of the facility's policy titled Care Plan Comprehensive, dated March 2012, showed:
-The interdisciplinary care plan team with input from the resident, family, and/or legal representative will develop and maintain a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain;
-The comprehensive care plan will be based on a thorough assessment that includes, but is not limited to, the Minimum Data Set (MDS), a federally mandated assessment tool;
-Assessment of each resident is ongoing process and the care plan will be revised as changes occur in the resident's condition;
-A well-developed care plan will be oriented to:
-Preventing avoidable declines in functioning or functional levels or otherwise clarifying why another goal takes precedence (e.g. palliative approaches in end of life situation).
-Managing risk factors to the extent possible or indicating the limits of such interventions.
-Applying current standards of practice in the care planning process.
2. Review of Resident #6's Annual MDS, dated [DATE], showed staff assessed the resident as cognitively intact.
Review of the resident's face sheet showed staff documented the resident has a diagnosis of sleep apnea (sleep disorder in which breathing repeatedly stops and starts).
Review of the resident's Physician Order Sheet (POS), dated March 2024, it did not contain an order for oxygen.
Review of the resident's care plan, dated 2/28/24, showed the care plan did not contain documentation of the resident's oxygen use.
Observation on 03/17/24 at 1:55 P.M., showed the resident in his/her room with an oxygen concentrator next to his/her bed. The oxygen tubing lay on the floor.
During an interview on 3/17/24 at 1:55 P.M., the resident said he/she has sleep apnea and uses oxygen at night.
During an interview on 3/22/24 at 10:08 A.M., the Director of Nursing (DON) said the resident refused to wear his/her Continuous Positive Airway Pressure (CPAP), a non-invasive ventilator worn during sleep to keep airways open, so he/she started oxygen. The DON said there is not a current order for oxygen .
During an interview with the charge nurse on 3/25/24 at 9:45 A.M., Licensed Practical Nurse (LPN) I said he/she was aware of the resident's sleep apnea diagnosis. LPN I said, the resident did not want to use CPAP, but preferred using oxygen at night. The LPN said oxygen is administered via nasal cannula. The LPN said the POS did not contain a current oxygen order.
3. Review of Resident #14's Quarterly MDS, dated [DATE], showed staff assessed the resident as:
-Cognitively intact;
-Did not resist care;
-Dependent on staff for all Activities of Daily Living (ADL's);
-At risk for pressure ulcers.
Review of the resident's care plan, dated 09/04/23, showed the following:
-Will need full support of staff to have needs met;
-At risk for pressure ulcers;
-Did not contain podus boot (pressure relieving boot for foot) to left lower extremity at all times.
Review of the resident's POS, dated 03/17/24, showed an order for podus boot to left lower extremity at all times, ordered on 08/21/23.
Review of the resident's Treatment Administration Record (TAR), March 2024, showed staff documented the resident wore a podus boot on his/her left lower extremity at all times.
Observation on 03/18/24 at 7:58 A.M., showed the resident in bed. Certified Nurse Assistant (CNA) A assisted the resident with his/her meal and the resident did not have a Podus boot on his/her left lower extremity.
Observation on 03/18/24 at 2:46 P.M., showed LPN I and the MDS Coordinator provided wound care to the resident. The resident did not have a podus boot on his/her left lower extremity. The LPN and MDS Coordinator left the resident's room without putting the podus boot on the resident. The MDS Coordinator and LPN I left the room and did not apply the resident's podus boot.
Observation on 03/19/24 at 8:47 A.M., showed Nurse Assistant (NA) K and CNA B provided care to the resident and repositioned him/her. The resident did not have his/her podus boot on the left lower extremity.
4. Review of Resident #21's Quarterly MDS, dated [DATE], showed staff assessed the resident as:
-Cognitively intact;
-Required set up assistance for eating;
-Unknown if the resident was at risk for weight loss.
Review of the Resident's care plan, revised 03/04/24, showed the following:
-Regular diet;
-Provide assistance with eating;
-Did not contain risk for weight loss or interventions.
Review of the resident's weights showed:
-09/01/24 admit weight of 286.0 pounds (lbs);
-10/01/24 286.1 lbs;
-11/01/24 267.6 lbs;
-01/01/24 266.0 lbs;
-02/01/24 264.4 lbs;
-03/01/24 252.6 lbs.
During an interview on 03/17/24 at 4:24 P.M., the resident said he/she eats in room most of the time.
5. Review of Resident #25's Quarterly MDS, dated [DATE], showed staff assessed the resident as the following:
-Cognitively intact;
-Did not require BiPAP;
-Diagnoses of Obesity (overweight), Sleep Apnea and Acute Bronchospasm (contraction in the airways that can make it hard to catch your breath).
Review of the resident's POS, dated 03/01/2024, showed an order dated 09/02/23 for BiPAP at bedtime.
Review of the resident's care plan, dated 12/22/23, showed teh care plan did not contain documentation for the resident's BiPAP.
Review of the resident's TAR, dated 03/01/24, showed it did not contain documentation in regard to the resident's BiPAP use.
Observation on 03/17/24 at 4:40 P.M., showed resident in bed. A BiPAP sat on the resident's bedside table.
During an interview on 03/20/24 at 9:14 A.M., Certified Nurse Aide (CNA) A said if a resident has a BiPAP, it should be on the care plan.
During an interview on 03/20/24 at 9:34 A.M., Licensed Practical Nurse (LPN) I said BiPAP, cleaning instructions and water to be used should be on care plan.
During an interview on 03/20/24 at 11:15 A.M., Director of Nursing (DON) said BiPAP should be on care plans. Frequency of change of tubing should be on care plan. Use of distilled water for Bipap should be on care plan.
During an interview on 03/20/24 at 2:09 P.M., administrator said BiPAP should be care planned.
During an interview on 03/26/24 at 3:36 P.M., the MDS Coordinator said the resident's BiPAP, settings and cleaning schedule should be on the care plan.
6. Review of Resident #33's Significant Change MDS, dated [DATE], showed staff assessed the resident as the following:
-Severe cognitive impairment;
-Did not resist care;
-Hospice.
Review of the resident's care plan, revised 12/19/23, showed it did not contain direction for staff in regard to hospice care.
Review of the resident's hospice binder showed the resident started hospice services on 12/14/23.
Review of the resident's nurses notes, dated 12/14/23, showed staff documented the resident admitted to hospice.
7. During an interview on 03/20/24 at 9:08 A.M., CNA A said he/she has access to the resident's care plan in their chart. CNA A said the care plan should be individualized and able to direct staff on how to care for the residents. CNA A said he/she would expect things like oxygen, CPAP, BiPAP, hospice, risk for weight loss on the care plan.
During an interview on 03/20/24 at 9:46 A.M., the MDS Coordinator said he/she is responsible for completing all the MDS's and care plans at the facility. The MDS Coordinator said a care plan should be updated upon admission, quarterly, annually, with any significant change, and as needed. The MDS Coordinator said he/she runs a Facility Activity report each morning to show any new orders from the previous 24 hours. The MDS Coordinator said he/she will update the care plan as needed with the new orders. The MDS Coordinator said the resident's care plan should be individualized and he/she would expect to see things on the care plan such as oxygen, how much assistance a resident needs for their ADL's, hospice, risk for weight loss, any special assist devices, and thing such as braces, heel protectors or Podus boots. The MDS Coordinator said if something is not on the care plan then staff won't know how to care for the resident.
During an interview on 03/20/24 at 10:15 A.M., LPN I said the MDS Coordinator is responsible to update the care plans. The LPN said a care plan should be individualized and he/she would expect things such as weight loss risk, hospice, oxygen, the amount of care a resident needs, oxygen, and any special equipment on the care plan. The LPN said the aides are responsible to put Podus boots on and the charge nurse is responsible to check them. The LPN said he/she noticed on 03/19/24 late in the afternoon Resident #14 did not have his/her Podus boot on and put it on him/her.
During an interview on 03/20/24 at 11:15 A.M., the DON said the MDS Coordinator is responsible to update the care plans in the facility. The DON said the care plan should be done on admission, updated with new orders as needed, quarterly, annually, and with any significant change. The DON said the care plan should be person centered and direct staff on how to care for the resident. The DON said he/she would expect to see hospice, weight loss risk, any special equipment used by the resident, and the amount of care a resident requires on the care plan.
During an interview on 03/20/24 at 2:08 P.M., the Administrator said the MDS Coordinator is responsible to update the care plans for all the residents. The Administrator said the care plan should be individualized and direct the care of the resident. The Administrator said he/she would expect the care plan to address weight loss risk, Podus boots, hospice care, the amount of care a resident needs, and any special equipment needed by the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to document a complete and accurate Minimum Data Set (MDS) assessment (a federally mandated assessment instrument) when staff did not accurately code for three residents (Residents #8, #25 and #38) who use a Bi-level Positive Airway Pressure ((BiPAP) a non-invasive ventilation machine capable of generating air pressure to ensure airways remain open) or Continuous Positive Airway Pressure ((CPAP), a non-invasive ventilation machine that uses mild air pressure to ensure airways remain open during sleep), for one resident (Resident #25) who rejected care and for anticoagulant (a medication used to inhibit coagulation of the blood) use for two residents (Residents #14 and #47) out of 14 sampled residents. The facility census was 44.
1. During an interview on 03/20/24 at 11:15 A.M., the Director of Nursing (DON) said the facility does not have a Policy for MDS. The facility uses the Resident Assessment Instrument (RAI) manual as guidance for completion MDS.
2. Review of Resident #8's Quarterly MDS, dated [DATE], showed staff assessed the resident as:
-Cognitively intact;
-Did not require a BiPAP.
Review of the resident's care plan, dated 11/13/23, showed staff documented the resident uses BiPAP at night.
Review of the resident's Physician's Order Sheet (POS), dated 03/17/24, showed a physician order may use BiPAP with 16 pressure in and 16 pressure out at night and BiPAP cleaning once a week on Monday's, cleanse mask with Normal Saline (NS) and let it dry with a start date of 08/31/23.
Observation on 03/18/24 at 8:10 A.M., showed the resident BiPAP machine on his/her dresser.
3. Review of Resident #25's Quarterly MDS, dated [DATE], showed staff assessed the resident as:
-Cognitively intact;
-Rejection of care not exhibited;
-Did not require a BiPAP.
Review of the resident's care plan, dated 12/22/23, showed staff documented if resident has physical behaviors which are potentially harmful to staff, the care may be delayed to another time. Review of the residents care plan did not contain the resident's use of BiPAP or Lymphedema pumps (device that helps move fluid out of an area of the body that has excess fluid).
Review of the resident's Physician Order Sheet (POS), dated 03/01/2024, showed the resident may use BiPAP at bedtime. Did not contain an order for lymphedema pumps.
Review of the resident's Treatment Administration Record (TAR), date 03/01/2024, showed staff documented the resident refused his/her Lymphedema Pumps on 03/04/24.
Review of the resident's nurse's notes, dated 03/01/24, showed Licensed Practical Nurse (LPN) I documented the resident refused a shower twice.
Review of the resident's nurse's notes, dated 03/02/24, showed LPN I documented the resident continues with behaviors of telling family he/she is not taken care of and sits soiled for hours. Is noncompliant with trying to assist with own Activities of Daily Living (ADL's). Refuses to transfer from bed to chair for staff during perineal care and refuses to toilet self. Refuses to use bedside commode. Resident is incontinent of bowel and bladder.
Review of the resident's nurse's notes, dated 03/03/24, showed LPN I documented the resident refuses to transfer from bed to chair for staff during perineal care and refuses to toilet self, refuses to use bedside commode. Resident is incontinent of bowel and bladder.
Review of the resident's nurse's note, dated 03/06/24, showed the DON documented the resident has been offered multiple times to toilet to help with independence, but continues to refuse. Resident refuses to use Lymphoid wraps during scheduled time. Resident refused multiple times with different staff and times to do his/her showers.
During an interview on 03/19/24 at 11:17 A.M., the DON said the resident is refusing showers with aides and his/her pumps too. The nurses have been charting this behavior from the resident. The resident will refuse and then call family. His/Her family is aware of this behavior from resident. Facility staff have started daily charting of what cares the resident is refusing and the times.
Observation on 03/17/24 at 4:40 P.M. showed resident BiPAP on the bedside table.
During an interview on 03/17/24 at 4:40 P.M., the resident said he/she uses the BiPAP at night when he/she sleeps. The resident said staff put the water in the BiPAP reservoir every night.
During an interview on 03/20/24 at 9:14 A.M., Certified Nurses Aide (CNA) A said staff clean the resident's BiPAP tank every day, or every other day. The CNA said staff put distilled water in the resident's BiPAP machine.
During an interview on 03/20/24 at 9:34 A.M., LPN I said the resident uses his/her BiPAP at night. The LPN said staff put water in the resident's BiPAP.
During an interview on 03/20/24 at 11:15 A.M., The DON said the resident had a BiPAP and staff put the water in the resident's BiPAP. The DON said the resident's BiPAP should be documented on the MDS assessment.
4. Review of Resident #38's admission MDS, dated [DATE], showed staff assessed the resident as:
-Cognitively impaired;
-Did not require CPAP.
Review of the resident's Quarterly MDS, dated [DATE], showed staff assessed the resident as:
-Severe cognitive impairment;
-Did not require CPAP.
Review of the resident's care plan, dated 03/04/24, showed staff resident requires CPAP at night. Ensure CPAP device is put on at night.
Review of the resident's Transfer admission Orders, dated 06/30/23, showed an order for oxygen with CPAP/BiPAP pressure setting two, use every night.
Review of the resident's POS, dated 03/17/24, showed it did not contain orders for CPAP.
Observation on 03/18/24 at 8:06 A.M., showed the resident in bed with his/her CPAP on.
5. Review of Resident #14's Quarterly MDS, dated [DATE], showed staff assessed the resident as:
-Cognitively intact;
-Received an anticoagulant.
Review of the resident's care plan, dated 09/24/23, showed staff documented the resident is at risk for bleeding due to anticoagulant therapy. Monitor for bruising and bleeding.
Review of the resident's POS, dated 03/17/24, showed physicain orders for aspirin 81 milligrams (mg) daily and Clopidogrel (an antiplatelet medication used to reduce the risk of heart disease and stroke) 75 mg daily with a start date of 09/05/23.
6. Review of Resident #47's Quarterly MDS, dated [DATE], showed staff assessed the resident received an anticoagulant seven out of seven days in the look back period (period of time used to assess the resident).
Review of the resident's POS, dated 03/01/24, showed Clopidogrel 75 mg once a day in the morning on 10/20/23.
During an interview on 03/20/24 at 11:15 A.M., the DON said he/she thought Clopidogrel was an anticoagulant, he/she had not been aware it isn't.
7. During an interview on 03/20/24 at 9:46 A.M., the MDS Coordinator said he/she is responsible to complete the MDS assessments and care plans. The MDS coordinator said he/she received training through the corporation's class, and with the corporate MDS person. The MDS Coordinator said he/she has a RAI manual he/she can refer to as well. The MDS Coordinator said a MDS should be coded accurately so a resident is properly cared for. The MDS coordinator said oxygen, BiPAP, CPAP, and certain medications like anticoagulants should be coded on the MDS if a resident receives them. The MDS Coordinator said he/she was not aware that Clopidogrel was not an anticoagulant.
During an interview on 03/20/23 at 11:15 A.M., the Director of Nursing (DON) said the MDS Coordinator is responsible for completing all MDS assessments and care plans. The DON said he/she expects the assessments coded accurately. The DON said if a resident receives oxygen, CPAP, BiPAP, or anticoagulant medications it should be coded on the MDS.
During an interview on 03/20/24 at 2:08 P.M., the Cooperate Quality Assurance (QA) nurse said he/she thought Clopidogrel was an anticoagulant and was not aware that Clopidogrel was not an anticoagulant but is an antiplatelet.
During an interview on 03/20/24 at 2:08 P.M., the Administrator said the MDS Coordinator is responsible for completing all MDS assessments in the facility. The administrator said the MDS assessments should be coded accurately. The administrator said oxygen, BiPAP, CPAP, and anticoagulants should be coded on the MDS if a resident receives them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to provide a clean, homelike and comfortable environment when staff failed to maintain resident rooms and common areas. The facility census was 44 out of a capacity of 82 residents.
1. Review of the facility's policy titled, Housekeeping Department, Seven Step Cleaning Procedure undated, showed staff were directed to do the following:
-Dust mop, keeping dust mop on floor; use pan and broom to pick up debris;
-Sanitize Floor, do not over wet the floor; use scraper to remove items stuck to floor, and change mop water every three rooms (or when visually soiled).
Review of the facility's policy titled, Deep Cleaning a Resident Room, undated, showed:
-Deep cleaning is the segment of housekeeping that ensure total cleanliness of the resident room;
-Floors: clean all corners, edges and baseboards; be sure to remove any buildup around closets, behind bed, furniture, and door jams; dust mop and wet mop entire room.
2. Observation on 03/17/24 at 12:08 P.M. showed the floor outside room [ROOM NUMBER] with debris visible down the length of the hallway.
Observation on 03/17/24 at 12:15 P.M. showed the floor outside rooms 31 to 36 with debris visible down the length of the hallway.
Observation on 03/17/24 at 12:20 P.M., showed resident occupied room [ROOM NUMBER] floor dirty.
Observation on 03/17/24 at 1:33 P.M., showed resident occupied room [ROOM NUMBER] with multiple stains on the floor.
Observation on 03/17/24 at 1:49 P.M., showed resident occupied room [ROOM NUMBER] with multiple black marks on the walls and floor.
During an interview on 03/20/24 at 10:57 A.M., the Housekeeping Supervisor said he/she tries to clean marks on the walls, but some need painted and maintenance does that.
3. Observation on 03/18/24 at 8:29 A.M., showed the housekeeping supervisor's cart with dark brown mop water in the bucket. Observation showed the housekeeping supervisor removed the mop from the bucket and mopped the Minimum Data Set (MDS) office.
Observation on 03/18/24 at 9:53 A.M., showed the housekeeping supervisor mob bucket contained dark brown water. Observation showed the housekeeping supervisor used the dark brown water to clean the staff bathroom, hallway, clean utility room, and resident occupied rooms #23 and #25.
Observation on 03/19/24 at 7:53 A.M., showed the housekeeping supervisor bucket water tan and mopped the clean utility room.
Observation on 03/19/24 at 10:01 A.M., showed the housekeeping supervisor bucket water dark brown and mopped resident occupied room [ROOM NUMBER].
During an interview on 03/20/24 at 9:37 A.M., Housekeeper L said staff are to mop all resident rooms daily. The housekeeper said staff should change mop water out every three to four rooms, or if it is visibly dirty. The housekeeper said staff should not mop with dirty water as it does not clean the floors and makes them dirtier. The housekeeper said this could lead to infections.
During an interview on 03/20/24 at 9:08 A.M., Certified Nurse Assistant (CNA) A said staff should never use dirty mop water to clean with. The CNA said this could spread germs and cause infections.
During an interview on 03/20/24 at 10:15 A.M., Licensed Practical Nurse (LPN) I said staff should not mop with dirty water and it should be changed out if it's dirty before cleaning anything else.
During an interview on 03/20/24 at 10:57 A.M., the Housekeeping Supervisor said all resident rooms are to be cleaned daily and as needed. The housekeeping supervisor said mop water should be changed every two to three rooms, and as needed. He/She said staff should not use dirty mop water to clean with. The housekeeping supervisor said he/she was not aware he/she had cleaned rooms with dirty water.
During an interview on 03/20/24 at 11:15 A.M., the Director of Nursing (DON) said staff should not mop with dirty mop water because it does not clean anything. The DON said this could cause germs to spread.
During an interview on 03/20/24 at 2:08 P.M., the Corporate Quality Assurance (QA) nurse said mop water should be changed every three rooms or as needed, such as cleaning up body fluids. The QA nurse said staff should not mop floors with brown or black water. He/She said this could cause germs to spread and leave floors sticky. The QA nurse said he/she noticed the housekeeper's water was dirty and meant to tell him/her to change it. He/She said he/she got busy and forgot to go back to tell him/her.
During an interview on 03/20/24 at 2:08 P.M., the administrator said all resident rooms should be cleaned daily, and mop water should be changed every three rooms, or with a big mess. The Administrator said staff should not mop with dirty water as this can lead to infections and spread germs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to document the administration of the pneumococcal (lung inflammation caused by bacteria or viral infection) vaccine for six out of eight sampled residents (Resident #8, #14, #21, #25, #33, and #38). The facility census was 44.
1. Review of the Center for Disease Control (CDC) guidelines, dated 03/15/23, showed the following:
-People age [AGE] or older who have no pneumococcal vaccines should receive 20 valent pneumococcal conjugate vaccine (PCV20) or 15 valent pneumococcal conjugate vaccine (PCV15), and then one year later pneumococcal polysaccharide vaccine (PPSV23);
-People age [AGE] through 64 who have no pneumococcal vaccines should receive PCV20 or PCV1, and then one year later PPSV23.
Review of the facility's Immunization policy, not dated, showed staff are directed to as follows:
-Adults 65 years or older who have not already received a pneumococcal conjugate vaccine should receive either:
-A single dose of PVC15 followed by a dose of PPSV23 one year later;
-A single dose of PVC20, if a PCV20 is administered a dose of PPSV23 is not required;
-Adults 19 through [AGE] years old who have not received a pneumococcal conjugate vaccine should receive either:
-A single dose of PVC15 followed by a dose of PPSV23;
-A single dose of PCV20, if PCV20 is administered a dose of PPSV23 is not indicated.
2. Review of Resident #8's medical record showed:
-Resident age [AGE];
-admitted to the facility on [DATE];
-Signed consent, dated 10/02/23, for all vaccines to be administered;
-The record did not contain documentation staff offered or administered a pneumococcal vaccine.
3. Review of Resident #14's medical record showed:
-Resident age [AGE];
-admitted to the facility on [DATE];
-Signed consent, dated 10/02/23, for all vaccines to be administered;
-The record did not contain documentation staff offered or administered a pneumococcal vaccine.
4. Review of Resident #21's medical record showed:
-Resident age [AGE];
-admitted to the facility on [DATE];
-Signed consent, dated 10/02/23, for all vaccines to be administered except the Covid (an infectious disease caused by a virus) vaccine;
-The record did not contain documentation staff offered or administered a pneumococcal vaccine.
5. Review of Resident #25's medical record showed:
-Resident age [AGE];
-admitted to the facility on [DATE];
-Signed consent, dated 10/02/23 for all vaccines to be administered except the Covid vaccine;
-The record did not contain documentation staff offered or administered a pneumococcal vaccine.
Event History showed staff documented:
-Diagnosed with chest congestion on 12/13/23;
-Diagnosed with pneumonia on 12/23/23;
Review of the Physician Order Sheet (POS) showed:
-12/13/23: Levaquin (antibiotic) 500 milligrams (mg) daily for 10 days;
-12/23/23: Doxycycline (antibiotic) 100 mg twice a day (BID) for 10 days.
6. Review of Resident #33's medical record showed:
-Resident age [AGE];
-admitted to the facility on [DATE];
-Signed consent, dated 09/26/23, for all vaccines to be administered;
-The record did not contain documentation staff offered or administered a pneumococcal vaccine.
7. Review of Resident #38's medical record showed:
-Resident age [AGE];
-admitted to the facility on [DATE];
-Signed consent, dated 10/02/23, for all vaccines to be administered except the Covid vaccine;
-The record did not contain documentation staff offered or administered a pneumococcal vaccine.
Event History showed staff documented the resident had been diagnosed with a Upper Respiratory Infection (URI) on 03/09/24.
Review of the POS showed:
-03/09/24: Levaquin 500 mg daily for URI with stop date of 03/20/24;
-03/09/24: Prednisone (steroid) 20 mg BID for URI with stop date of 3/20/24.
8. During an interview on 03/18/24 at 9:35 A.M., the Director of Nursing (DON) said he/she is the Infection Preventionist (IP) for the facility. The DON said any vaccines that have been given to the residents are recorded in the resident's chart. The DON said he/she ordered the pneumonia vaccines on 03/17/24 and they should arrive on 03/18/24. The DON said if a vaccine is not logged in the resident's chart, then it has not been given.
During an interview on 03/19/24 at 9:10 A.M., the DON said the pneumonia vaccines had not arrived to the facility. The DON said he/she called the pharmacy to find out when the vaccines would be delivered and the pharmacy said it should be 03/19/24 or 03/20/24.
During an interview on 03/20/24 at 8:00 A.M., the DON said the pharmacy emailed him/her and the pneumvaccines should be delivered on 03/21/24. The DON said there is a resident who is allergic to the vaccine, so he/she emailed the pharmacy to have them not send that dose. The DON said the pharmacy said they had just received the vaccine orders on 03/20/24 when the DON emailed about the allergy. The DON said he/she did not know why the pneumonia vaccines had not been ordered or given prior to 03/17/24.
During an interview on 03/20/24 at 10:15 A.M., Licensed Practical Nurse (LPN) I said if something is not documented then it was not done. The LPN said the Business Office Manager (BOM) is responsible for obtaining vaccine consents or declination upon admission with the admission paperwork. LPN I said vaccines are given once they arrive from the pharmacy. The LPN said he/she or the DON would give the vaccines once they arrived from the pharmacy.
During an interview on 03/20/24 at 11:05 A.M., the BOM said he/she completes the admission paperwork and obtains the vaccine consents or declinations upon admission with each resident. The BOM said he/she uploads the documents into the resident's chart.
During an interview on 03/20/24 at 11:15 A.M., the DON said if something is not documented then it is not done. The DON said the BOM is responsible for obtaining the vaccine consent or declination up a resident's admission with the admission paperwork. Once the consent is obtained then the DON said he/she orders the appropriate vaccine from either the pharmacy or medical supplier. The DON said that either the charge nurse or him/her give the vaccines once they arrive to the facility. The DON said any vaccine that is given should be documented in the resident's chart. The DON said all consents should be followed. The DON said if vaccines are not given then the resident could have a potential outcome of an infection such as pneumonia, URI, influenza, or Covid.
During an interview on 03/20/24 at 2:08 P.M., the administrator said that BOM is responsible for obtaining the vaccine consents or declinations with the resident's admission paperwork. The administrator said any vaccine not on hand is ordered from the pharmacy or medical supply company and once they arrive the charge nurse or DON is responsible for administration of the vaccine. The administrator said any vaccine given should be documented in the resident's chart and if something isn't documented then it is not done. documented in the resident's chart. The administrator said if something isn't documented then it was not done.
During an interview on 03/28/24 at 8:30 A.M., the Medical Director (MD) said he/she is the only physician who covers the facility, and he/she sees all the residents in it. The Medical Director said he/she expects staff to give any vaccine the resident or responsible party signs consent for. The MD said he/she does not have an exact timeline for when the vaccine should be given once the consent is signed as the vaccines are not always easy to get from the supply company, however he/she said within a month of the consent being signed would be adequate. The MD said if a resident is admitted for short term rehab, for a couple of weeks for example, then he/she does not expect staff to administer the vaccine. The MD said any long-term care resident should get their vaccines given timely. Residents could have a potential outcome of URI or pneumonia if the pneumoccal vaccine is not given.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review facility staff failed to ensure pureed food items were reheated to proper temperatures. Facility staff failed to follow puree recipes. Facility staff failed to ensure hot foods were held at 140 degrees Fahrenheit ºF or greater during meal service. Facility staff failed to ensure hot food on room trays for three residents (Residents #27, #25, and #105) of three sampled residents were maintained at 120 ºF at the time the food was delivered and to ensure employees who delivered food to the residents in the rooms knew what the appropriate temperature should be at the time of service. The facility census was 44.
1. Review of the facility's policy titled Food Temperatures, dated April 2011, showed staff shall ensure food is at least 120 ºF. A test meal should be sent with the hall trays when there are food temperature complaints until the temperatures are at the appropriate levels. Record on Temperature Record of Test Trays form.
2. Review of Resident #27's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated 01/04/24, showed staff assessed the resident as follows:
-Moderately impaired cognition;
-Required set up assistance from staff for eating.
Observation on 03/17/24 at 12:24 P.M., showed Nurse Aide (NA) F served the resident his/her hall tray. At time of service the resident's stuffing covered in turkey gravy temped at 118 ºF, the turkey and gravy temped at 114 ºF, and the green beans temped at 111 ºF. The NA left the room and did not offer to reheat the resident's food or get a new tray.
During an interview on 03/17/24 at 12:29 P.M., the resident said the food could be warmer but he/she gets hall trays.
3. Review of Resident #25's Quarterly MDS, dated [DATE], showed staff assessed the resident as:
-Cognitively intact;
-Required set up assistance from staff for eating.
Observation 03/18/24 at 5:17 P.M., showed NA J served the resident his/her dinner tray in the resident's room. At the time of service the ham temped at 113 ºF. The NA did not take the tray to reheat, or get the resident a new tray.
During and interview on 03/18/24 at 5:24 P.M., the NA said food is supposed to be 120 degrees when served to the resident. The NA said if the resident's food is under 120 degrees staff are supposed to ask resident if he/she wants a different tray. The NA said since it is just little under 120 degrees he/she leaves it up to the resident. The NA said the resident's food is probably cold because it is the last hall tray.
During an interview on 03/17/24 at 4:23 P.M., the resident said the food isn't great. The resident said he/she eats in his/her room and the food is sometimes cold. Cold eggs are not good.
4. Review of Resident #105's admission MDS, dated [DATE], showed staff assessed the resident as:
-Cognitively intact;
-Required set up assistance from staff for eating.
Observation on 03/19/24 at 5:16 P.M., showed Certified Nurse Aide (CNA) D served the resident his/her dinner tray in the resident's room. At time of service, the Tamale Pie with hamburger temped at 117 ºF. The NA left the room and did not reheat the resident's food.
During an interview on 03/17/24 at 3:23 P.M., the resident said sometimes the food is good and sometime it is bad. The resident said the other day he/she got his/her baked potato and it was ice cold. The resident said another time he/she got cold turkey.
During an interview on 03/20/24 at 9:14 A.M., Certified Nursing Assistant (CNA) A said he/she has never temped the meal trays. The CNA said the food should be 120 ºF for hall trays. The CNA said he/she has seen food served on the hall at less than 120 ºF but still over 100 ºF. The CNA said residents have complained about food temperatures in resident council meetings.
During an interview on 03/20/24 at 9:34 A.M., Licensed Practical Nurse (LPN) I said he/she has no idea what the temperature of food should be when served to residents. The LPN said if the food is cold staff should take it back to the kitchen and get a new plate.
During an interview on 03/20/24 at 11:15 A.M., the Director of Nursing (DON) said he/she does not know what the food temperature is supposed to be when served to residents. The DON said nursing staff deliver hall trays and they don't have thermometer. The DON said he/she is aware residents have complaints about cold food. The DON said if a resident's food is cold staff should take the tray back to the kitchen and reheat the food.
5. Review of the facility's policy titled Food Temperatures, dated April 2011, showed the Dietary Services manager or designee is responsible for seeing that all food is the proper serving temerpature(s) before trays are assembled. Review showed staff were directed to keep the temperature of hot foods no less than 140 ºF during meal service.
Review of facility Food Preparation and Distribution policy, dated May 2015 showed:
-Foods are prepared by methods that conserve nutritive value, flavor and appearance;
-Recipes should be followed on each item prepared.
Review of meatloaf and scalloped potatoes puree recipes showed cooks were directed to reheat both items to a minimum temperature of 165 ºF or higher for 15 seconds and hold at minimum temperature or higher for service.
Review of pureed meatloaf, potatoes and corn recipes showed cooks were directed to follow hot holding temperature of 135 ºF or 140 ºF based on facility policy.
Observation on 03/18/24 from 11:00 A.M. through 11:45 A.M., during lunch meal preparation, showed:
-Cook P prepared pureed corn in a food processor and placed the pureed corn on the steam table for service. Observation showed [NAME] P did not check the temperature of the corn before placing it on the steam table.
-Cook P used a spoon to remove meatloaf from the steam table and placed the meatloaf in a bowl. [NAME] P transferred the meatloaf from the bowl to a food processor and pureed the meatloaf. [NAME] P then transferred the pureed meatloaf to a pan on the steam table. Observation showed [NAME] P did not check the temperature of the meatloaf before it was placed on the steam table for service.
-Cook P removed scalloped potatoes from the steam and place the potatoes in a bowl. [NAME] P transferred the potatoes from the bowl to a food processor. [NAME] P pureed the potatoes in the food processor and transferred the potatoes to a pan on the steam table. Observation showed [NAME] P did not check the temperature of the potaotes before they were placed on the steam table for service.
Observation on 03/18/24 at 11:52 A.M., showed:
-The temperature of the pureed meatloaf on the steam table was 124 ºF.
-The temperature of the pureed scalloped potatoes was 130 ºF on the steamtable.
-The temperature of the pureed bread was 112 ºF on the steam table.
6. Review of the pureed dinner roll recipe showed cooks were directed to prepare a slurry using bread product and water or milk. Cooks were also directed to process until smooth.
Observation on 03/18/24 at 11:54 A.M., showed the pureed corn was runny in consistency and the pureed bread was thick in consistency.
During an interview at on 03/18/24 at 12:08 P.M., [NAME] P said he/she pureed food items and placed the items on the steam table. [NAME] P said he/she checked food temperatures about 10 minutes after placing the food on the steam table and the temperature should be greater than140 degrees F. [NAME] P said he/she never reheated pureed items to 165 ºF and was not aware that pureed items should be reheated. [NAME] P said he/she never looked at the puree recipe instructions that indicated reheating to 165 ºF. [NAME] P said he/she did not follow recipes when preparing pureed food items. [NAME] P said a pureed item should be moist, soft and pudding like. [NAME] P said the corn was too runny and the bread was kind of thick.
During an interview on 03/18/24 at 11:52 A.M., the Dietary Manager said the cook was responsible for ensuring all foods were prepared according to the recipes and at the correct consistencies. The dietary manger said the cook was responsible for ensuring proper food temperatures were met with cooking and holding food. The dietary manager said the corn was too runny and the pureed bread looked too thick.
During an interview on 03/20/24 at 2:09 P.M., the administrator said food should be 140 ºF when served to residents.

Based on observation, interview, and record review, facility staff failed to accurately count controlled medications for two residents (Residents #13 and #16). Facility staff failed to remove and destroy expired medications and medical supplies. The facility census was 44.
1. Review of the facility's policy titled Medications, Scheduled II-V, dated March 2012, showed staff shall have disposition records for controlled medications. All scheduled medications must be counted, comparing number of pills to disposition record at every change of shift by two Certified Medication Technicians (CMT), or one CMT and one licensed nursing staff. Both personnel must sign verification of correct count. Any time the count is incorrect, licensed nursing staff will call the Director of Nursing (DON).
Review of the facility's policy titled Narcotic Count, dated March 2012, showed staff shall reconcile by physical count the remaining narcotic supply at each shift change by the incoming and outgoing licensed nurse. After the supply is counted, the nurse records the date and his/her signature, verifying the count is correct. If the count is not accurate, the nurse going off duty is to remain on duty until the count is reconciled and the DON must be notified for further instruction.
2. Review of Resident #13's controlled medication record, dated 03/18/24 showed Licensed Practical Nurse (LPN) I documented the resident had 27 Hydrocodone APAP 5-325 (controlled medication used to relieve pain) milligrams (mg) tablets left at 6:00 A.M.
Observation on 03/18/24 at 8:34 A.M., showed 28 Hydrocodone APAP 5-325 mg tablets in the resident's bubble pack.
3. Review of Resident #16's controlled medication record, dated 03/18/24 showed LPN I documented the resident had five Hydrocodone APAP 5-325 mg tablets left at 6 A.M.
Observation on 03/18/24 at 8:34 A.M., showed six Hydrocodone APAP 5-325 mg tablets in the resident's bubble pack.
During an interview on 03/18/24 at 8:47 A.M., LPN I said he/she came on shift at 6:00 A.M. The LPN said he/she counted the cards of controlled medications but not the actual pills. The LPN he/she is supposed to count the pills in each card but he/she did not because he/she was taking short cuts due to being in a hurry.
During an interview on 03/20/24 at 11:15 A.M., the DON said staff should count controlled medications when they come on shift with the nurse going off shift. The DON said staff are supposed to count the cards and the number of pills in each card. Staff are supposed to notify him/her immediately, if the count is wrong. The DON said staff had not notified him/her of the wrong count.
During an interview on 03/20/24 at 2:09 P.M., the administrator said the on oncoming staff and the off going staff count controlled medications at shift change. Staff should count cards and pills.
4. Review the facility's policy titled Storage of Medications , dated March 2012, showed staff may not retain outdated drugs or biologicals for use. All such drugs must be returned to issuing pharmacy, or destroyed in accordance with established guidelines.
5. Observation 03/18/24 at 8:55 A.M., showed the following expired medications and supplies in the medication storage room:
-Clearlax Polyethylene Glycol 3350 Powder (laxative), 17.9 ounces (oz) with an expiration date of 01/24;
-Clearlax Polyethylene Glycol 3350 Powder with an expiration date of 02/23;
-51-25 gauge safety needles with an expiration date of 12/25/22.
During an interview on 03/18/24 at 8:55 A.M., LPN I said he/she did not know needles expired. The LPN said staff monitors the medication room and carts for expired medications weekly. The LPN said he/she did not know how the items were missed.
During an interview on 03/20/24 at 11:15 A.M., the DON said staff should check medication rooms and medication carts for expired medication. The staff are not checking the medication room.
During an interview on 03/20/24 at 2:09 P.M., the administrator said staff should check storage room for expired medications weekly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review facility staff failed to develop and implement complete policies and procedures for the inspection, testing, and maintenance of the facility's water system to inhibit the growth of waterborne pathogens and reduce the risk of outbreak of Legionnaire's Disease (a serious type of lung disease caused by Legionella bacteria) (LD). Facility staff failed to perform proper hand hygiene for two (Resident #14, and #25) of two sampled residents. The facility census was 44.
1. Review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification (S&C) letter 17-30, dated 06/02/17 and revised on 06/09/17; showed:
-The bacterium Legionella can cause a serious type of pneumonia called LD in persons at risk. Those at risk include persons who are at least [AGE] years old, smokers, or those with underlying medical conditions such as chronic lung disease or immunosuppression. Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including hospitals and long-term care facilities. Transmission can occur via aerosols from devices such as shower heads, cooking towers, hot tubs, and decorative fountains;
-Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water;
-CMS expects Medicare certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. An industry standard calling for the development and implementation of water management programs in large or complex building water systems to reduce the risk of legionellosis was published in 2015 by American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE). In 2016, the CDC and its partners developed a toolkit to facilitate implementation of this ASHRAE Standard(https://www.cdc.gov/legionella/maintenance/wmp-toolkit.html). Environmental, clinical, and epidemiological considerations for healthcare facilities are described in this toolkit;
-Surveyors will review policies, procedures, and reports documenting water management implementation results to verify that facilities:
-Conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system;
-Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens;
-Specify testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained.
Review of the facility's water management program records, provided by the maintenance director on 03/21/24, showed the records contained documentation of Developing A Legionella Water Management Program to Reduce Legionella Growth and Spread in Buildings toolkit published by the Centers for Disease Control and Prevention (CDC) which directed the staff to:
-Form a water management team;
-Describe the building water systems using text and flow diagrams;
-Identify areas where Legionella could grow and spread;
-Decide where control measures should be applied and how to monitor them;
-Establish ways to intervene when control limits are not met;
-Make sure the program is running as designed and is effective;
-Document and communicate all the activities of the water management program;
-Utilize tools provided by the CDC and the ASHRAE industry standard as guidance in development, implementation, and ongoing evaluation of program;
-Review the elements of the program at least once per year and whenever:
*Data review shows control measures are persistently outside of control limits;
*A major maintenance or water service change occurs;
*One or more cases of disease are thought to be associated with your system(s);
*Changes occur in applicable laws, regulations, standards, or guidelines.
Review of the facility's policy titled Water Management Program to Reduce Legionella Growth, undated, showed staff were directed as follows:
-The water management committee will implement a water management program that includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections and environmental testing for pathogens;
-The water management committee will specify testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained.
Review of the Water Management Program showed areas of concern included sinks, showers, bathrooms, whirpool tub, laundry and the dietary booster heater.
Review of the Water Management Program showed control measures included checking disinfectant levels in sinks, showers, bathrooms, whirpool tub, laundry and the dietary booster heater.
Review of the water management program showed the program did not include policies or procedures related to control measures or disinfectant levels.
During an interview on 03/21/24 at 8:55 A.M., the maintenance director said he/she did not know if the public water supply was treated or if the facility had any disinfectants as part of the water system. The maintenance director said he/she never checked the water for disinfectant or chlorine levels.
During an interview on 03/21/24 at 8:30 the administrator said the maintenance director was responsible for maintaining the facility's water systems. The administrator said the maintenance director checks water temperatures and periodically drains boilers and water heaters. The administrator said he/she was not aware of any disinfectant or chlorine levels being checked. The administrator said the water management program had been in place for some time and he/she was not aware of any issues so he/she never thought about it.
2. Review of the facility's policy titled Handwashing, dated March 2012, showed staff were directed to do the following:
-The purpose of hand washing is to reduce the transmission of organisms;
-Use disposable hand towel to dry hands well and turn off the faucet.
3. Observation on 03/18/24 at 11:51 A.M., showed Nurse Assistant (NA) N performed catheter care on Resident #14. The NA washed his/her hands, scratched his/her nose with his/her right hand, pulled gloves from his/her pants pocket and put them on. The NA then opened the residents nightstand drawer, grabbed supplies, put a trash bag in the trash can, and provided care. The NA removed his/her gloves, washed his/her hands and put on a pair of gloves from his/her pants pocket. The NA cleaned the resident's perineal area again, removed his/her gloves, washed his/her hands, pulled gloves from his/her pants pocket and put them on. Observation showed the NA touched the resident's blanket.
During an interview on 03/18/24 at 1:50 P.M., NA N said he/she did not know he/she touched his/her nose, the drawer, got gloves from his/her pant pocket, and then provided care. NA N said he/she doesn't know why he/she did those things. NA N said he/she should have removed those gloves, washed his/her hands, and got new gloves prior to providing care to the resident.
4. Observation on 03/18/24 at 2:46 P.M., showed Licensed Practical Nurse (LPN) I performed wound care on Resident #14. LPN I washed his/her hands, turned the faucet off with his/her elbow, and dried his/her hands with a paper towel. LPN I put gloves on, adjusted the resident in the bed, removed the soiled dressing, removed his/her gloves, washed his/her hands, turned the water off with a paper towel, and dried his/her hands with the same paper towel. LPN I put gloves on, provided wound care, removed his/her gloves, repositioned the resident, washed his/her hands, and turned the water off with his/her elbows.
During an interview on 03/20/24 at 10:15 A.M., LPN I said staff should wash their hands before and after cares, when they change their gloves, and if their hands become soiled. The LPN said the proper way to wash hands is to turn the water on, apply soap and lather, scrub all surfaces of the hands, then rinse. LPN I said staff should get a paper towel and dry their hands, then turn the water faucet off with a paper towel. LPN I said that he/she realizes that he/she turns the water off with his/her elbow and should not do that. LPN I said proper hand hygiene is important so that infection is not spread. The LPN said staff do hand washing competencies upon hire and at least annually.
5. Observation on 03/19/24 at 10:50 A.M., showed Certified Nurse Assistant (CNA) O performed perineal care on Resident #25. CNA O washed his/her hands, put gloves on and removed wipes from a package, removed his/her gloves, did not wash his/her hands and applied a new pair of gloves. CNA O removed the resident's brief, provided perineal care, and repositioned the resident with the same soiled gloves on. CNA O removed the soiled sheets from the bed, wiped the resident's buttocks, changed his/her gloves, without performing hand hygiene and bagged the dirty linens. The CNA removed his/her gloves, picked trash up off the floor, washed his/her hands, applied clean gloves, put a clean brief on the resident, removed his/her gloves, picked up the bagged linens and left the resident's room without washing his/her hands.
During an interview on 03/20/24 at 10:05 A.M., CNA O said staff should wash their hands before and after providing resident care, and if their hands are soiled. The CNA said staff should use hand sanitizer or wash their hands with gloves changes. CNA O said he/she realized he/she forgot to wash his/her hands with glove changes. CNA O said there is a potential of infection and germs spread if staff don't do proper hand hygiene.
6. During an interview on 03/20/24 at 9:08 A.M., CNA A said staff should wash their hands before and after providing resident care, before they leave a room, when their hands are soiled, and between glove changes. The CNA said staff should turn the hot water on, scrub with soap on all surfaces of their hands and arms up to the elbow, then rinse their arms and hands from the elbow down. CNA A said staff should then get paper towels and dry their hands, then use a different paper towel to turn the water off. CNA A said if staff don't wash their hands properly it can lead to the spread of infections to other residents and cross contamination.
During an interview on 03/20/24 at 11:15 A.M., the Director of Nursing (DON) said staff are expected to wash their hands prior to providing resident care, with glove changes, after providing resident care, and if they become soiled. The DON said he/she does competency checks with staff upon hire, with in-services, and also does random spot checks. The DON said the proper way to perform hand hygiene is to turn the water on, lather and scrub hands up to the elbows with soap for at least 20 seconds, rinse from the elbows to the hands, dry with a paper towel, then get a new paper towel and turn off the water. The DON said staff should not turn the water off with their elbow. The DON said proper hand hygiene is essential to not spreading germs that cause infections.
During an interview on 03/20/24 at 2:08 P.M. the Quality Assurance (QA) nurse The QA nurse said staff should also wash their hands after providing any care to a resident before they leave the room.
During an interview on 03/20/24 at 2:08 P.M., the Administrator said staff are expected to wash their hands before providing resident care, with any glove change, if they become soiled, and after providing resident care. The Administrator said the proper way to wash your hands is to turn the hot water on, apply soap and lather, scrub the hands, rinse with clean water, then use a paper towel to dry their hands. The Administrator said once they dry their hand then they should get another paper towel and turn off the water. The Administrator said staff should not turn the water off with their elbow. The Administrator said all staff are trained upon hire for proper hand hygiene. The Administrator said proper hand hygiene prevents the spread of germs that lead to infections.

Based on interview and record review, facility staff failed to provide an appropriate 30 day discharge notice for one resident (Resident #1) and failed to allow Resident #1 to return to the facility when the resident was ready for discharge from the hospital. The facility census was 49.
1. Review of the facility's Discharge/Transfer of Resident policy, undated, showed for the transfer of a resident staff are to explain the transfer and reason to the resident and/or representative and give copy of transfer or discharge notice to the resident and/or representative or person responsible for care. Review showed if it is an emergency transfer, transfer or discharge notice form may be completed later, but as soon as possible.
2. Review of Resident #1's Entry and Discharge Minimum Data Set (MDS), a federally mandated assessment tool, dated 1/17/24, showed the resident was admitted and discharged on 1/17/24.
Review of the resident's progress notes, dated 1/17/24, showed the resident admitted to the facility and received an intravenous (IV) antibiotic medication. Review showed staff documented the resident became weak and unsteady, and an order obtained to send the resident to the emergency room and to not accept the resident back to the facility.
Review of the resident's medical record showed the medical record in did not contain an emergency or 30 day discharrge notice prior to discharge and was not provided with an acceptance of admission to an alternative facility.
During an interview on 1/18/24 at 12:51 P.M., the facility's social services designee (SSD) said the resident was accepted to the facility based on the resident's diagnosis which required IV medications. The SSD said the hospital social work did not inform him/her the resident had a history of drug use, wound care and had behaviors. The SSD said facility staff decided when the resident required emergency room treatment the resident should not be re-admitted , as the facility would not be able meet the resident's needs.
During an interview on 1/18/24 at 1:01 P.M., the Administrator said the resident was accepted based on the information the hospital provided. The administrator said the hospital sent the additional information regarding the substance abuse and behaviors when arrived at the facility.
During an interview on 1/18/24 at 02:34 P.M., the Licensed Practical Nurse (LPN) said the resident was admitted to the facility based on the information the hospital provided in the admission packet which did not include the medical history of drug and alcohol use, or report that the resident was violent at the hospital and required multiple security guards to restrain the resident. The LPN said the facility could not adequately care for the resident, and with the resident requiring a transfer to the emergency room for the reaction to the antibiotic, an order was procured to not re-admit the resident.
During an interview on 1/18/24 at 03:12 P.M., the hospital social worker said the resident remained in the emergency department and placement had not yet been found for the resident. He/She said the hospital had sent inquiry to a different facility but had not heard back.
MO00230448

Based on observations and interviews the facility failed to offer internet, to the extent available to the facility, to all residents. The facility census was 49.
1. Review of the facility's policies showed the facility did not have a policy in regards to resident Internet usage.
2. Observation and Interview on 11/1/23 at 2:15 P.M., showed Nurse Assistant (NA) A using Matrix Care Software (an Internet based computer software used to maintain medical records) to document in resident medical records. NA A said the residents don't get access to internet and there is no computer set up for them to use. He/She said sometimes the staff feel bad for them and will allow them to use their hotspots to talk to their friends and family.
During an interview on 11/1/23 at 11:50 A.M., Resident #1 said he/she wanted to remain at the facility because he/she had made a lot of friends there but they do not offer internet to the residents. Resident #1 said there were a lot of younger residents in the facility like himself/herself that would benefit from internet availability. For example, he/she would like to attend college but without internet he/she was unable to do that.
During an interview on 11/1/23 at 1:15 P.M., Resident #2 said he/she would use the Internet if he/she had access to it for educational purposes as well as being able to stay in touch with family and friends.
During an interview on 11/2/23 at 1:30 P.M., Resident #3 said he/she would access the internet if it was available to watch videos and stay up with what was new in the world.
During an interview on 11/1/23 at 1:45 P.M., Resident #4 said he/she would feel more connected with friends and family if internet was accessible. He/She said, I feel completely alone and bored without internet access.
During an interview on 11/1/23 at 2:00 P.M., Resident #5 said internet access would be so helpful because then he/she would have more access to his/her loved ones, be able to subscribe to television programs, and keep them from being so bored.
During an interview on 11/1/23 at 1:45 P.M., Licensed Practical Nurse (LPN) A said the residents don't have access to internet. He/She said they have asked upper management numerous times but they just keep saying they were on the list. LPN A said they had a younger clientell and would definitely benefit from access to the internet so they could contact their loved ones easier and anything else they wanted to do.
During an interview on 11/1/23 at 2:00 P.M., the Director of Nursing (DON) said they do not have access to the internet for residents. They had asked in the past but never got it.
During an interview on 11/1/23 at 2:30 P.M., the Administrator said they do not have internet access for residents. He/She said they have asked for it in the past from corporate but they say it is too expensive. He/She knew there were a couple of residents who would like it.
MO00226551

Based on observation, interview, and record review, facility staff failed to ensure a medication error rate of less than 5%. Out of 25 opportunities observed, 5 errors occurred, resulting in a 20% error rate, which affected four residents (Resident's #4, #5, #13, and #37). The facility census was 43.
1. Review of the facility's Medication Administration Policy, undated, stated the purpose is to administer medications to benefit the resident's health, as ordered by the physician. Review of the facility's Medication Error Policy, undated, stated to report all medication errors immediately to the attending physician, Director of Nursing (DON), and the Administrator.
Review of the facility's Medication Administration Guidelines Policy, undated, showed it is the purpose of this facility that resident's receive their medications on a timely basis and in accordance with established policies and the person administering the drugs must chart the medications immediately following the administration.
2. Review of Resident #4's Physician Order Sheet (POS), dated November 2022, showed an order directed staff to administer Prednisone (steroid medication) 10 milligrams (mg) oral (by mouth) daily from between the hours of 6:00 A.M. and 10:00 A.M.
Review of the resident's Medication Administration Record (MAR), dated November 2022, showed staff documented the resident had an order for prednisone 10 mg oral twice a day (BID) from 6:00 A.M. to 10:00 A.M. and 2:00 P.M. to 6:00 P.M.
Observation on 11/29/22 at 3:03 P.M., showed Certified Medication Technician (CMT) Q administered Prednisone 10 mg to the resident.
3. Review of Resident #5's POS, dated November 2022, showed an order directed staff to apply a 50 microgram per hour (mcg/hr) fentanyl (narcotic pain medication) transdermal (to the skin) patch every 72 hours at 12:00 A.M.
Review of the resident's Controlled Drug Receipt/ Record/ Disposition Form, showed Registered Nurse (RN) O signed out a 50 mcg fentanyl patch on 11/29/22 at 12:00 A.M.
Observation on 11/30/22 at 5:40 A.M., showed RN O removed a 50 mcg fentanyl patch from the medication cart and dated the patch 11/29. Further observation, showed RN O removed a fentanyl patch from the resident's left shoulder and applied the new patch to the resident's right shoulder.
4. Review of Resident #13's POS, dated November 2022, showed an order directed staff to administer:
-Docusate sodium (stool softener) 100 mg orally daily from between the hours of 11:00 A.M. to 3:00 P.M.;
-Spironolactone (treatment for high blood pressure and fluid retention) 50 mg orally BID from between the hours of 6:00 A.M. to 2:00 P.M. and 2:00 P.M. to 10:00 P.M. with special instructions to administer with breakfast and lunch.
Review of the resident's MAR, dated November 2022, showed an entry for docusate sodium 100 mg once a day. Further review, showed a line drawn through the entry. Additional review, showed staff documented the resident had an order for spironolactone 50 mg orally BID between the hours of 6:00 A.M. to 2:00 P.M. and 2:00 P.M. to 10:00 P.M. with special instructions to administer with breakfast and lunch.
Observation on 11/29/22 at 11:26 A.M., showed CMT Q administered Spironolactone 50 mg to the resident, without food. Further observation, showed CMT Q did not administer the resident's ordered docusate sodium.
During an interview on 11/29/22 at 11:26 A.M., the resident said he/she normally received a stool softener at this time.
During an interview on 11/29/22 at 11:26 A.M., CMT Q said the resident did not have an order for a stool softener.
5. Review of Resident #37's POS, dated November 2022, showed an order directed staff to administer Nystatin suspension (antifungal medication) 15 milliliters (mL) 100,000 unit/milliliters (units/mL) orally four times a day (QID) between the hours of 6:00 A.M. to 10:00 A.M., 11:00 A.M. to 1:00 P.M., 2:00 P.M. to 6:00 P.M., and 6:00 PM to 10:00 P.M.
Review of the resident's MAR, dated November 2022, showed the resident's MAR directed staff to administer Nystatin suspension 15 mL 100,000 units/mL orally QID. Staff documented discontinued over the entry.
Observation on 11/29/22 at 11:17 A.M., showed CMT Q did not administer the Nystatin suspension to the resident.
During an interview on 12/1/22 at 4:40 P.M., the resident said he/she has not been receiving his/ her Nystatin wash. He/She said his/her cheeks are sore and rated his/her pain a 6 on a scale of 1 to 10. He/She said he/she has not been eating as much as usual because of the mouth pain.
6. During an interview on 12/2/22 at 11:23 A.M., LPN L said there are six things that contribute to medication errors, and those included wrong medication, wrong route, and wrong person. He/She said he/she couldn't remember the other three at this time. The LPN said the CMTs are expected to report all medication errors to the charge nurse, who will then assess the resident, and notify the Director of Nursing (DON) and physician. He/she said an investigation is completed and documented. He/she said he/she was not aware a medication error occurred during the survey.
During an interview on 12/2/22 at 1:06 P.M., the DON said staff receives ongoing education regarding medications. He/she said if the order says the medication is to be given with food and it's not, that is a medication error. He/she said medication errors occur with the wrong medication, wrong person, wrong dosage, wrong time and wrong route. He/she said staff is expected to report all medication errors to the DON so an investigation is completed and documented and the physician is notified. He/she said for topical patches, staff is not supposed to back date patch because it could cause an medication error. He/ she said the resident's MARs and Treatment Administration Records (TARs) should match the POS. He/ he said if there is not an order, then staff should not perform the treatment.
During an interview on 12/2/22 at 1:25 P.M., CMT P said if a medication is ordered to be given with food and it is not, it is a medication error. He/She said medications should be given at the ordered times. CMT P said is the DON and charge nurses responsibility to transcribe the orders to the Medication Administration Record (MAR).
During an interview on 12/2/22 at 1:30 P.M., LPN L said a transdermal patch is changed on the evening shift, from 6:00 P.M. to 10:00 P.M. LPN L said it is rotated on the body each time it is changed, and it should be dated and initialed each time it is placed. He/She said medications should never be back dated, the date it is placed is the date that should be written on it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to properly store open food to prevent contamination and outdated use, to maintain kitchen equipment in a clean and sanitary manner, and to perform hand hygiene as often as necessary to prevent cross-contamination. The facility staff also failed to ensure the ice machine drained through an air gap and to maintain the tools necessary to properly test the dishwashing machine sanitizing solution. This had the potential to affect all residents. The census was 43.
1. Review of the facility's Safe Food Handling policy, dated 4/2011, showed all food, including bulk items, should be tightly sealed with an identifying label and date.
Observation on 11/28/22 at 9:51 A.M., showed:
- Five pound can of spinach dented;
- Five pound can of diced peaches dented;
- Open bag of bread crumbs not labeled and undated;
- Open bag of brown sugar not labeled and undated;
- Bulk container of cereal flakes sat on the bottom shelf of the service counter with the scoop inside the container on the cereal;
- Open container of cereal not labeled and undated;
- Open container of chocolate icing undated.
Observation on 11/29/22 at 10:53 A.M., showed:
- Bulk container of cereal flakes sat on the bottom shelf of the service counter with scoop inside the container on the cereal;
- Ziploc bags with slice of bread and pat of butter sat on the bottom shelf of the service counter, undated.
Observation on 11/29/22 at 11:11 A.M., of the double door refrigerator, showed:
- Open bag of sliced meat not labeled, undated, and unprotected;
- Sealed bag of sliced meat not labeled, undated.
Observation on 11/29/22 at 11:26 A.M., of the three door freezer, showed:
- Open bag of breaded okra undated and unprotected;
- Open bag of yellow sticks not labeled and undated;
- One bag contained an opened box of veggie burgers undated;
- Open bag of pie crusts undated and unprotected;
- Open bag of cinnamon rolls undated.
Observation on 11/29/22 at 11:45 A.M., of the two door refrigerator, showed:
- Open bag of breaded patties not labeled and undated;
- Open bag of an unknown breaded food item not labeled and undated.
During an interview on 12/1/22 at 1:30 P.M., the dietary manager (DM) said opened food should be labeled, dated, and sealed before it is put into storage to prevent outdated use and contamination. She said bulk food items should be dated and sealed, and staff should store the scoop outside of the container to prevent cross contamination. The dietary manager said the facility has a policy on food storage, and staff have been trained on the policy.
During an interview on 12/2/22 at 10:21 A.M., the administrator and the quality assurance (QA) nurse said the facility has a policy on food storage, and the dietary staff are trained on the policy. They said opened food should be labeled, dated, and sealed before it is placed into storage. They said the scoop to bulk food items should be stored outside of the container in order to avoid cross contamination.
2. Review of the facility's Daily Cleaning Schedule, dated 4/2011, showed staff instructed to clean counter tops, slicer, toaster, knife rack, and can opener.
Review of the facility's Weekly Cleaning Schedule, dated 4/2011, showed staff instructed to clean microwave and ice machine.
Review of the facility's Monthly Cleaning Schedule, dated 4/2011, showed staff instructed to clean the fryer and ceiling lights.
Observation on 11/28/22 at 9:51 A.M., showed:
-Visible buildup of crumbs and debris across the pantry floor;
-Visible buildup of crumbs and debris across the counter next to the refrigerator;
-Visible buildup of grease on the left side of stove top and onto the floor.
Observation on 11/29/22 at 11:20 A.M., showed:
- Visible buildup of crumbs and debris on the four slice toaster;
- Visible buildup of crumbs and debris on the knife holder where the blades touched. Further observation showed staff used the knives to cut resident sandwiches during lunch service;
- Visible buildup of crumbs and debris on the work table with the meat slicer;
- Visible buildup of dust on the light bulbs over the service counters. Further observation showed a large bowl of banana pudding sat on the service counter, unprotected, and served during the resident's lunch service;
- Visible buildup of brown substance and crumbs in the microwave. Further observation showed a staff warmed a resident's lunch in the microwave;
- Visible buildup of brown substance on the blade of the can opener;
- Visible buildup of crumbs and brown grease on the deep fryer.
During an interview on 12/1/22 at 1:30 P.M., the DM said the kitchen has a cleaning schedule, but she does not use it. The DM said she cleans the kitchen, and some of the dietary staff help her. The DM said she stopped using the cleaning checklist in September, 2022, because staff initialed the checklist without cleaning the area or items on the list. She said the maintenance director (MD) is responsible to clean the lights in the kitchen, and the last time the MD cleaned the lights was in September, 2022.
During an interview on 12/2/22 at 10:21 A.M., the administrator and the quality assurance (QA) nurse said the dietary staff have a daily, weekly, and monthly cleaning list; and the DM reviews the list for completeness. They said the DM completes the heavy cleaning, and the dish aides assist with other areas. The maintenance director is responsible for cleaning the lights, and he inspects the lights monthly. The administrator said it is expected the staff would maintain the kitchen in a clean and sanitary manner.
3. Review of the facility's Glove Use policy, dated 4/2011, showed:
- The food code states that food items should not be handled with bare hands;
- Utensils or tongs should be used to serve or handle foods, both raw and cooked, whenever possible;
- Gloves should be worn if handling food is necessary. Extra caution should be taken when multiple tasks are being completed;
- Hands should be washed after handling dishes and any other time deemed necessary.
Observation on 11/29/22 at 11:51 A.M., showed [NAME] T took the food processor bowl and blade to the dishwashing area and rinsed them. He/she returned to the food service counter near the stove, placed parchment paper on the counter, gathered food items to prepare a sandwich, put a glove on his/her left hand, and opened a bag of chips with both his/her hands. The cook used his/her gloved hand to touch bread, jam jar, knife, and resident sandwich. He/she removed the glove from his/her left hand and put a glove on his/her right hand. He/she used his/her gloved hand to touch chips for the resident's lunch plate. [NAME] did not wash his/her hands when leaving the dishwashing area, before putting on gloves, or after removing gloves. He/she did not change gloves after touching non-food items.
Observation on 11/29/22 at 12:04 P.M., showed [NAME] T wore a glove on his/her right hand and his/her left hand bare. He/she used his/her gloved hand to touch meal tickets, scoops, plates, and his/her facemask. The cook used his/her glove hand to pick up and open hot dog buns for resident lunch service. He/she continued to use his/her gloved hand to touch nonfood items, his/her facemask, and hot dog buns. The cook did not change his/her gloves after touching nonfood items or after touching his/her facemasks and before touching the hot dog buns.
Observation on 11/29/22 at 12:20 P.M., showed dietary aide (DA) U prepared resident lunch plates. He/she touched his her facemask with his/her bare hand to the front of the mask. He/she then touched silverware, napkins, trays, and cups for the resident's lunch. The DA did not wash his/her hands after touching his/her facemask and before touching food related items.
Observation on 11/29/22 at 12:31 P.M., showed DA U prepared a bowl of banana pudding for a resident's lunch. The DA put his/her thumb in the pudding and served it to the resident. He/she wiped his/her thumb on his/her apron and continued to prepare resident lunch plates. The DA did not was his/her hand after touching the pudding and before preparing resident plates. He/she did not replace the bowl of pudding he/she touched with his/her thumb.
During an interview on 12/1/22 at 1:30 P.M., the DM said it is expected staff would wash their hands when entering the kitchen, before putting on and after taking off gloves, after touching their face or body, and when moving from a dirty task to a clean task. She said the facility has a policy on handwashing, and the dietary staff have been trained on the policy. The DM said staff should not serve any food that they touched without a glove. It is expected staff would wash their hands, discard the pudding, and prepare a new bowl for the resident. She said staff should not treat a gloved hand like an ungloved hand. It is expected staff would use the gloved hand only for food and the ungloved hand for all other items.
During an interview on 12/2/22 at 10:21 A.M., the administrator and the quality assurance (QA) nurse said the facility has a policy on handwashing, and the dietary staff have been trained on the policy. They said it is expected staff would perform hand hygiene before they put on gloves, after they remove gloves, when entering the kitchen, after touching their face or facemask, and when moving from a dirty task to a clean task. The administrator said staff should use gloves when they will come in contact with food, and they should remove the glove before they touch anything else. She said staff should not serve food that has come into contact with their hand. It is expected they would wash their hands and make a new plate for the resident.
4. Review of the facility's Dish Machine Temperature policy, dated 4/2011, showed:
- Chemically sanitized machines should be checked daily with test strip;
- Dip end of test strip into water in the reservoir, immediately after machine is completely finished with cycle;
- Compare strip to chart on test strip container;
- Document on log;
- Desire reading 50-100 ppm.
Observation on 11/29/22 at 1:00 P.M., showed DA U placed dishes in the dishwasher. The dishwasher used a chemical solution to sanitize the dishes. The DA placed a yellow test strip in the sanitizing solution as directed by the test strip instructions, but the test strip did not change colors. The DM ran the dishwasher a second time and placed a yellow test strip in the sanitizing solution as directed by the test strip instructions, but the test strip did not change colors. Observation also showed the dishwasher connected to a bucket of sodium hypochlorite to sanitize the dishes.
Review of the instructions for the dishwasher showed the sodium hypochlorite should be used at 50 parts per million (ppm).
Review of the directions for the test strip showed the test strip turned a shade of green if the solution reached 200 ppm of chemical sanitizer. The test strip did not have an indicator for ppm less than 200.
Review of the facility's dishwasher log, dated November 2022, showed staff documented the sanitizing solution as 100 ppm every weekday.
During an interview on 12/1/22 at 9:30 A.M., DA U said he/she tests the sanitation solution in the dishwasher every day to ensure it is the correct ppm. The DA said he/she documents 100 ppm, even though the test strip does not change colors. He/she said that is the way he/she was trained to do it by the other DAs. DA U said he/she does not know if the solution is at 50 ppm, because the test strip do not measure less than 200 ppm.
During an interview on 12/1/22 at 1:30 P.M., the DM said she did not have any other test strips for the dishwasher. She could not tell if the sanitizing solution reached 50 ppm, since the test strips did not measure anything under 200 ppm. The DM said the test strips came from the outside company that services the dishwasher, and she was not aware they were the wrong strips. She said staff should not document 100 ppm when the test strip did not change colors. It is expected they would inform her the test strips did not work. The DM said she reviewed the dishwasher documentation for completeness but not for accuracy.
During an interview on 12/2/22 at 10:21 A.M., the administrator and the quality assurance (QA) nurse said the dishwasher uses chemical sanitation, and staff test the ppm every shift. They said staff were trained to test and document the ppm, and it is expected they would document the ppm correctly. The administrator said dietary staff should notify the maintenance director if the testing strips were not working.
5. Observation on 11/30/22 at 9:50 A.M., showed the ice machine, located in the main dining room next to the food service window, did not drain through an air gap. The ice machine drainpipe contained a brown substance on the lower quarter inch of the pipe which hung below floor level.
During an interview on 11/30/22 at 9:53 A.M., the maintenance director said he is responsible to inspect and maintain the ice machine. He said the ice from the machine was used for resident drinks. The maintenance director said he thinks the ice machine drain used to drain through an air gap, but he was not sure why it no longer did. He said the ice machine should drain through a two inch air gap. The maintenance director did not know if the facility had a policy for the ice machine.
During an interview on 12/2/22 at 10:21 A.M., the administrator and the quality assurance (QA) nurse said the maintenance director is responsible to inspect and maintain the ice machine, and he checks it every month. They said the ice machine should drain through a two inch gap. The administrator and the QA nurse did not provide a policy for the ice machine.

Based on observation, interview, and record review, facility staff failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, when staff failed to use appropriate hand hygiene during the provision of care and failed to use appropriate infection control procedures during incontinence care for three residents (Resident's #16, #1 and #5). Additionally, staff failed to follow their facility policy to ensure six out of ten sampled employees, were screened upon hire for tuberculosis (TB), (disease caused by bacteria called Mycobacterium tuberculosis, that usually attacks the lungs). The facility census was 43.
1. Review of the facility's Perineal Care Policy, undated, showed the purpose is to prevent infection and odor. The policy did not contain direction for staff when disposable wipes are used for perineal care or when to change gloves and perform hand hygiene.
Review of the facility's Handwashing policy, dated 3/2012, showed the purpose is to reduce the transmission of organisms from resident to resident, nursing staff to resident, and resident to nursing staff. Review showed it did not provide guidance for staff in regard to washing their hands upon entering and/or exiting the residents' rooms, and from dirty to clean tasks.
Review of the facility's Glove policy, undated, showed:
-Wear gloves when it can be reasonably anticipated that hands will be in contact with mucous membranes, non-intact skin, any moist body substances (blood, urine, feces, wound drainage, oral secretions, sputum, vomitus, or items/surfaces soiled with these substances) and/or persons with a rash. Federal Occupational Safety and Health Administration (OSHA) laws require that gloves be worn when performing vascular access procedures. Gloves must be changed between residents and between contacts with different body sites of the same resident. If the glove is torn or a needle stick or other injury occurs, the gloves should be removed, discarded in the trash and a new glove used promptly as resident safety permits;
-Change gloves between contacts (as defined above) with different residents or with different body sites of the same resident.
-Review showed it did not provide guidance for staff in regard to hand hygiene with glove changes.
2. Observation on 11/30/22 at 4:42 A.M., showed Nurse Aide (NA) S and Certified Nurse Aide (CNA)/Certified Medication Technician (CMT) H entered Resident #16's room, applied clean clean gloves, without first performing hand hygiene, and provided perineal care to the resident. With the same gloves on, NA S and CNA/CMT H put a clean gown on the resident. NA S and CMT H removed their gloves, picked up trash, washed their hands and left the resident's room.
During an interview on 11/30/22 at 5:56 A.M., CNA/CMT H said staff is directed to wash their hands upon entering and exiting a resident's room, and between glove changes. The CNA/CMT said gloves should be changed when they are soiled. He/She did not say why he/she did not change his/her gloves or perform hand hygiene.
3. Observation on 11/30/22 at 6:30 A.M., showed Resident #1 incontinent of urine with urine on his/her back. Certified Nurse Aide (CNA) K entered the resident's room, performed hand hygiene, applied clean gloves, wiped the resident's urine covered back with a disposable wipe, and with the same gloves on, put a clean shirt on the resident.
During an interview on 11/30/22 at 1:23 P.M., CNA K said during perineal care staff is directed to wipe from front to back, and use a new wipe per swipe. The CNA said if their gloves become soiled they should remove them, wash their hands and apply clean gloves. The CNA did not say if they should remove their gloves and perform hand hygiene from dirty to clean tasks.
4. Observation on 11/29/22 at 8:29 A.M., showed CNA K entered Resident #5's room, performed hand hygiene, applied clean gloves, provided perineal care to resident, and with the same gloves on repositioned the resident. The CNA wore the same gloves, and wiped under the resident's stomach multiple times with the same portion of the wipe. Additional observation, showed the CNA touched multiple items in the residents drawer, with the same gloves on.
5. During an interview on 11/29/22 at 8:48 A.M., CNA J and CNA K said staff is directed to perform hand hygiene before providing care, when moving from a dirty area to a clean area, anytime gloves are changed, and when care has been completed. CNA K said he/she should have removed his/her gloves and performed hand hygiene after he/she provided care and before he/she touched the resident or the resident's things. The CNAs said staff is directed to use the same portion of the wipe if they are cleaning the same area, and should only fold the wipe if they move to a different area. They said they recently had an inservice in regard to hand hygiene and glove changes.
During an interview on 12/2/22 at 11:23 A.M., Licensed Practical Nurse (LPN) L said staff is expected to wash their hands before entering a resident's room and when they leave the room. He/She said they should then apply gloves, complete dirty tasks, remove their soiled gloves, wash their hands and apply clean gloves. The LPN said staff are expected to use one wipe for each swipe, and should wipe from front to back. He/She said staff are directed to remove their gloves when they are soiled, and wash their hands before they apply clean gloves. He/She said staff should not apply clean clothes with soiled gloves on.
During an interview on 12/2/22 at 1:06 P.M., the Director of Nursing (DON) said staff should perform hand hygiene before entering a resident's room, between procedures, and before leaving the room. He/she said staff should cleanse the resident's back first, and use a clean wipe for each swipe cleaning from front to back.
6. Review of the facility's Tuberculosis Control Policy, undated, showed:
-The following occupationally-exposed persons should be tested at least annually: all employees, attending physicians and dentists, volunteers who spend >10 hours weekly in the facility, nursing and health personnel, students, instructors and other individuals in regular attendance within long-term facilities;
-Initial examination: Provide a tuberculin skin test (TST) (Mantoux, five tuberculin units (TU) of purified protein derivative (PPD) to all employees during pre-employment procedures, unless a previous reaction >10 millimeter (mm) is documented;
-Repeat TST: It is generally recommended that employees be skin tested on an annual basis as a means of surveillance within a facility;
-All PPDs will be documented on the Employee Immunization record including new hires and annual administration. After the PPD has been administered, the results will be documented in mm.
7. Review of LPN D's personnel records, showed the LPN with a hire date of 4/11/19. Further review of the personnel records, showed it did not contain documentation that a TST, was administered, or read prior to his/her hire date.
8. Review of CNA E's personnel records, showed the CNA with a hire date of 4/24/19. Further review of the personnel records, showed it did not contain documentation that a TST, was administered, or read prior to his/her hire date.
9. Review of [NAME] A's personnel records, showed the [NAME] with a hire date of 8/8/19. Further review of the personnel records, showed it did not contain documentation that a TST, was administered, or read prior to his/her hire date.
10. Review of Registered Nurse (RN) B's personnel records, showed the RN with a hire date of 8/21/19. Further review of the personnel records, showed it did not contain documentation that a TST, was administered, or read prior to his/her hire date.
11. Review of Dietary Aide F's personnel records, showed the Dietary Aide with a hire date of 9/7/19. Further review of the personnel records, showed it did not contain documentation that a TST, was administered, or read prior to his/her hire date.
12. Review of Business Office Manager's (BOM) personnel records, showed the BOM with a hire date of 3/31/20. Further review of the personnel records, showed it did not contain documentation that a TST, was administered, or read prior to his/her hire date.
13. During an interview on 12/2/22 at 11:23 A.M., LPN L said the DON keeps employee TB testing record, but he/she is the one who administers the test most of the time. He/she said TB testing should be completed upon hire, and then a second test should be completed within 7 days. He/She said the results should be read within 48 hours. The LPN said after the initial tests, employees should be screened or retested annually.
During an interview on 12/1/22 at 2:45 P.M., the DON said he/she is responsible for tracking the employees TB testing status. He/She said he/she had the required TB testing documentation, including the testing dates and results, but he/she couldn't locate it. He/She said there was not TB testing documentation for the employees who worked at the facility prior to him/her starting.
During an interview on 12/1/22 at 3:17 P.M., the Administrator and the BOM said they were not able to locate the missing TB testing documentation. The Administrator said the DON is responsible for ensuring staff members have had their TB testing completed. The Administrator and the BOM said the BOM files the results.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to maintain resident dignity, when staff stood over one resident (Resident #17) while assisting the resident to eat, and failed to serve one resident (Resident #16) their meal while staff fed another resident at the same table. Additionally, facility staff failed to provide one cognitive, totally dependent resident (Resident #5) with a call system he/she was able to use. The facility census was 43.
1. Review of the facility's Resident Rights Policy, undated, showed each resident shall be treated with consideration, respect and a full recognition of his/her dignity.
Review of the facility's Feeding the Resident policy, undated, showed staff are directed to:
-Give the resident your complete attention;
-Sit so you are at the same level as the resident, when possible;
-Converse with the resident in an appropriate manner.
2. Review of Resident #17's Quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 8/29/22, showed staff assessed the resident as:
-Severely Impaired Cognition;
-Required extensive assistance from one staff member for eating.
Review of the resident's Care Plan, dated 10/25/22, showed:
-Resident at risk for inadequately being able to meet his/her own needs, due to cognitive deficits;
-Talk with him/her one on one about his/her past.
Observation on 11/28/22 at 12:35 P.M., showed Certified Nurse Aide (CNA) J stood over the resident as he/she fed him/her. Further observation, showed CNA J left the resident to go get drinks and meal trays for other residents, who sat at a different table. Additional observation, showed when CNA J returned to assist the resident he/she stood over the resident and fed him/her. The CNA spoke to other residents seated at the table and multiple staff members, but not to the resident he/she assisted.
Observation on 11/29/22 at 12:34 P.M., showed CNA J stood over the resident as he/she fed him/her. The CNA never spoke to the resident as he/she fed him/her.
During an interview 11/30/22 at 1:16 P.M., CNA J said he/she stood to feed the resident, because he/she had to keep an eye on the other residents in the dining room. The CNA said he/she used to sit down when he/she fed residents but the Director of Nursing (DON) told him/her that was not allowed. During this interview Nurse Aide (NA) M stopped and said if staff sit in the dining room, to assist residents, the administrative staff tell them to stand up.
During an interview on 12/2/22 at 11:23 A.M., Licensed Practical Nurse (LPN) L said staff should sit and engage with the residents while they feed them. He/she said standing over a resident could make the resident feel uncomfortable. He/she said when there is less staff helping in the dining room, they have to stand to see all the residents.
During an interview on 12/2/22 at 1:06 P.M., the DON said staff are educated to sit and interact with residents when assisting them to eat. He/she said standing over a resident could make them feel like staff are in their space. He/she said when at eye level with the residents, they are more likely to interact with you. He/she said staff should stay with a resident while feeding them.
3. Review of Resident #16's Quarterly MDS, dated [DATE], showed staff assessed the resident as:
-Severely Impaired Cognition;
-Required extensive assistance from one staff member with eating.
Observation on 11/29/22 at 12:14 P.M., showed Resident #16 sat at a dining room table with resident #17. CNA J served resident #17 his/her lunch tray, and fed the resident. Resident #16 reached across the table two times for resident #17's food. Further observation, showed resident #16 was served his/her meal tray at 12:37 P.M., 13 minutes after resident #17 had been served his/her tray. Additional observation, showed LPN L asked CNA J if resident #16 was doing well. CNA J said the resident was happy now that he/she had his/her food.
During an interview on 12/2/22 at 1:06 P.M., the DON said the facility did not have a process for ensuring residents who sat at the same table during meals were served at the same time. He/She said they are working on it.
4. Review of the facility's Call Light policy, undated, showed staff are directed to position the resident's call light conveniently for resident use, when providing care.
5. Review of Resident #5's Quarterly MDS, dated [DATE], showed staff assessed the resident as:
-Moderately Impaired Cognition;
-Totally dependent on one staff member for dressing and eating;
-Totally dependent on two staff members for bed mobility, transfers, toilet use and personal hygiene;
-Impairment in Range of Motion (ROM) to all extremities;
-Always incontinent of bowel;
-Required oxygen;
-Had diagnoses of Neurogenic Bladder (the nerves that carry messages back and forth between the bladder and spinal cord and brain don't work as they should), Urinary Tract Infection (UTI) (an infection in any part of the urinary system) in the last 30 days, Diabetes Mellitus, Multiple Sclerosis (MS) (a chronic, typically progressive disease involving damage to the sheaths of nerve cells in the brain and spinal cord), Anxiety Disorder, Depression, and Chronic Obstructive Pulmonary Disease (COPD) (condition involving constriction of the airways and difficulty or discomfort with breathing).
Review of the resident's Care Plan, revised 11/15/22, showed:
-Keep call light in reach at all times;
-Provide adaptive equipment to enhance independence;
-Will receive optimal level of comfort and dignity.
Observation on 11/28/22 at 10:57 A.M., showed the resident lay in bed, awake. The resident's oxygen tubing hung below his/her nose by his/her mouth, and the room had an odor. Further observation, showed the resident's hands were contracted and his/her call light hung over his/her headboard.
Observation on 11/28/22 at 12:18 P.M., showed the resident lay in bed, awake, with his/her call light out of reach.
During an interview on 11/28/22 at 2:22 P.M., the resident said he/she knows how to use the call light, but he/she can't use it because his/her hands are severely contracted. He/She said he/she knows when he/she needs to be changed, but is unable to call for help. The resident said he/she has waited hours for staff because he/she can't use the call light. The resident said, There is no dignity with being in here.
Observation on 11/29/22 at 8:28 A.M., showed the resident lay in bed, with his/her call light out of reach.
Observation on 11/29/22 at 10:47 A.M., showed the resident lay in bed, with his/her call light across his/her chest.
Observation on 11/30/22 at 9:29 A.M., showed the resident lay in bed, awake, with his/her call light out of reach. CNA J entered the resident's room and adjusted the resident's oxygen tubing. The CNA left the resident's room and did not place the resident's call light within his/her reach.
Observation on 11/30/22 at 4:12 A.M., showed the resident lay in bed, awake. Further observation, showed the resident's room had an odor.
During an interview on 11/30/22 at 4:12 A.M., the resident said staff had not changed him/her yet, and he/she needed to be changed.
During an interview on 12/2/22 at 11:23 A.M., LPN L said if the resident needs or wants anything he/she yells for staff. The LPN said at one time the resident had a sensor pad call light but he/she still yelled, so the resident was moved closer to the nurses' station.
During an interview on 12/2/22 at 1:06 P.M., the DON said the resident is supposed to have a sensor pad call light because he/she can not use a regular one. He/She said the resident does call out for help at times.

Based on observation, and interview, the facility failed to post notice of availability for reports with respect to any surveys, certifications and complaint investigations made during the three preceding years, and any plan of correction in effect with respect to the facility, in a manner prominent and accessible to the residents and public. The facility census was 43.
1. Observations from 11/28/22 at 10:00 A.M. to 12/2/22 at 3:15 P.M., showed the survey and/or complaint investigation results were not in a prominent and accessible area of the facility.
During a group interview on 11/29/22 3:05 P.M., ten residents said they had never seen the previous survey or complaint investigation results in the building.
During an interview on 12/02/22 10:54 A.M., Certified Nursing Assistant (CNA) CNA J said he/she did not know where the survey results were located.
During an interview on 12/2/22 at 11:23 A.M., Licensed Practical Nurse (LPN) L said the survey and complaint investigation results are located in the Administrator or Director of Nursing (DON)'s office. He/She said he/she did not know why the results were not in an area accessible to the public.
During an interview on 12/2/22 at 1:06 P.M., the DON said the survey and complaint results binder should be located on the wall by the administrator's office. He/she said he/she did not know it was not posted.
During an interview on 12/2/22 at 3:00 P.M., the Administrator said the survey and complaint results binder should be posted by the office on the wall. He/she said sometimes the residents will take it. He/She said he/she did not know it was not available.

Based on observation, interview, and record review, facility staff failed to provide a comfortable and homelike environment, when staff failed to ensure resident common areas and rooms were clean, free of odors, and maintained. The facility census was 43.
1. Review of the facility's Daily Care Needs Policy, undated, showed it directed to ensure the resident's room is clean and neat with all equipment properly stored and furniture clean.
Review of the facility's Cleaning Guideline- Bed Mattress Policy, undated, showed:
-Purpose: To ensure mattresses are clean and free of odors;
-Soiled mattresses will be cleaned on the residents' bath days by housekeeping and nursing staff;
-Mattresses are to be cleaned when soiled, on bath days, or when the room is deep cleaned.
2. Observation on 11/28/22 at 9:45 A.M., showed the lobby and 100 hallway had a lingering urine odor.
Observation on 11/28/22 at 9:50 A.M., showed the lobby and 100 hallway had a persistent foul odor.
Observation on 11/30/22 at 4:06 A.M., showed a foul urine odor lingered in the lobby and down the 100 hallway.
Observation on 11/30/22 at 4:33 A.M., showed a foul urine odor lingered down the 100 hallway.
Observation on 11/30/22 at 5:31 A.M., showed the lobby and 100 hallway had a persistent foul odor.
Observation on 11/30/22 at 6:14 A.M., showed a foul urine odor lingered down the 100 hallway.
Observation on 12/1/22 at 4:40 P.M., showed a foul urine odor lingered down the 100 hallway.
3. Observation on 11/30/22 at 1:03 P.M. showed the 200 hallway floor had a large sticky area.
Observation on 12/2/22 at 9:23 A.M., showed the 200 hallway floor continued to have a large sticky area.
4. Observation on 11/28/22 at 10:06 A.M., showed Resident #20 and #34's room had a persistent foul odor and a visible build up of debris on the floor.
Observation on 11/30/22 at 8:39 A.M., showed Resident #20 and #34's room had a persistent foul odor.
Observation on 11/30/22 at 10:01 A.M., showed Resident #20 and #34's room had a persistent foul odor. The resident's Resident #34's bed pad had a brown ring shaped stain. Further observation, showed the resident folded the bed pad in half to hide the brown ring, and then sat on the bed pad.
Observation on 11/30/22 at 11:14 A.M., showed Resident #20 and #34's room had a persistent foul odor. Further observation, showed Resident #34's stained bed pad continued to sit on the bed.
Observation on 12/1/22 at 12:00 P.M., showed Resident #20 and #34's room had a persistent foul odor. Further observation, showed Resident #34's stained bed pad continued to sit on the bed.
5. Observation on 11/30/22 at 9:08 A.M., showed Resident #27's room had a visibly soiled privacy curtain.
6. Observation on 11/30/22 at 6:57 A.M., showed Resident #1's room had a visibly soiled privacy curtain.
7. Observation on 11/30/22 at 6:14 A.M., showed Resident #25's room had a visibly soiled privacy curtain.
Observation on 11/30/22 at 9:06 A.M., showed Resident #25's room had a visibly soiled privacy curtain.
8. Observation on 11/30/22 at 9:06 A.M., showed Resident #35's room had a visibly soiled privacy curtain.
9. Observation from 11/28/22 at 11:59 A.M. through 12/1/22 at 8:30 A.M., showed Resident #40's room had black marks on the walls and doors. The privacy curtain and chair were visibly dirty and the room had a odor.
10. Observations from 11/28/22 at 10:44 A.M. through 12/1/22 at 8:32 A.M., showed Resident #7's room had black marks and chipped paint on the walls and doors. The closet door hung off the hinges and the mattress had white debris.
11. Observations from 11/28/22 at 12:00 P.M. through 12/1/22 at 9:40 A.M., showed Resident #28's room had black marks, chipped paint and gouges on the wall. The baseboard had pulled away from the wall, and the privacy curtain was visibly dirty. Further observation, showed the room had a persistent foul odor.
12. Observations from 11/28/22 at 11:11 A.M. through 12/1/22 at 9:40 A.M., showed Resident #24's room had black marks and chipped paint on the walls, and a vent cover with rust. The privacy curtain was visibly dirty.
13. Observations from 11/28/22 at 11:13 A.M. through 12/1/22 at 4:40 P.M., showed Resident #37's closet door off of the track.
14. During an interview on 11/29/22 at 12:52 P.M., the Nurse Practitioner said he/she visits the residents at the facility twice a month. He/She said he/she noticed the odor in the building, and the residents' dirty rooms.
During an interview on 12/2/22 at 11:03 A.M., Housekeeper P said the residents' rooms are cleaned daily. He/She said daily cleaning includes the sinks, toilets, hard surfaces, and the floors. He/She said staff clean the floors in the common areas daily. He/She said he/she noticed the large sticky spot on the floor at the beginning of 200 hall. He/She said he/she did not know who is responsible for cleaning the mattresses. He/She said the CNAs should wipe the mattresses with a disposable wipe if they are dirty. He/She said he/she did not know if there is a schedule to clean the mattresses. He/She Resident #7's mattress was dirty and he/she cleaned in on 11/27/22. He/She said there is one to two housekeepers a day for the whole building, and it's not enough. Furthermore, he/she said he/she had noticed the black marks, gouges, and chipped paint in the resident rooms, and the broken closet door in Resident #18's room. He/She said staff is directed to write down the issues on the maintenance logs.
During an interview on 12/2/22 at 10:09 A.M., the Minimum Data Set (MDS) Coordinator said the resident rooms are cleaned daily, but he/she did not know how often the mattresses are cleaned. He/She said it is not homelike to lay on dirty mattresses, have black marks on the walls, and for the rooms and common areas to have an odor. He/She said he/she noticed the odor, and believes it is a combination of the residents and the environment. Furthermore, he/she said staff is directed to fill out a maintenance request if there is environmental concerns. He/She said the maintenance staff is supposed to check the log daily.
During an interview on 12/2/22 at 12:39 P.M., the Maintenance Supervisor said staff is directed to fill out a maintenance checklist if there is environmental concerns. He/She said he reviews the logs daily and completes the repairs in a timely manner, based on priority. He/She said the direct care staff is in the rooms daily and he/she relies on them to report any issues. He/She said he/she did not know about the rooms in disrepair on the 200 hall. He/She said he/she is the only maintenance worker.
During an interview on 12/2/22 at 1:06 P.M., the Director of Nursing (DON) said when the walls have gouges and black marks, staff is directed to notify the maintenance staff using a repair list. He/she said if it's a housekeeping issue, then staff is directed to notify housekeeping staff. He/she said the facility is aware there are rooms that need repair. The DON said the Housekeeping supervisor is responsible for ensuring the room curtains are clean. He/she said some of the room curtains are stained.

Based on interview and record review, facility staff failed to check the Employee Disqualification List (EDL) (a list of individuals who have been determined to have abused or neglected a resident or misappropriated funds or property belonging to a resident) in accordance with their facility policy for nine out of ten sampled staff. Additionally, facility staff failed to check the Family Care Safety Registry (FCSR) or complete a Criminal Background Check (CBC) for one employee (NA C), and failed to check the Certified Nurse Aide (CNA) Registry for one employee (LPN D). The facility census was 43.
1. Review of the facility's Background Checks Policy, undated, showed:
-The FCSR or the EDL and CBC must be checked before the applicant/employee has any contact with residents. The CNA Registry must also be checked for all persons that have been chosen for hire;
-Always keep a hard copy of the EDL results for each employee. Also, always keep a hard copy of the CBC request and the results for each employee;
-In addition to the pre-employment EDL checks, a quarterly EDL check update must be completed to assure that no one employed, in any capacity has been added to the EDL since the initial EDL check. Quarterly checks should be completed in January, April, July and October.
2. Review of [NAME] A's personnel records, showed the [NAME] with a hire date of 8/8/19. Further review showed the personnel record did not contain documentation the facility had completed an EDL check since his/her hire date.
3. Review of Business Office Manager (BOM) personnel records, showed the BOM with a hire date of 3/31/20. Further review showed the personnel record did not contain documentation the facility had completed an EDL since his/her hire date.
4. Review of Registered Nurse (RN) B's personnel records, showed the RN with a hire date of 8/21/19. Further review showed the personnel record did not contain documentation the facility had completed an EDL check since his/her hire date.
5. Review of Nurse Aide (NA) C's personnel records, showed the NA with a hire date of 4/24/19. Further review showed the personnel record did not contain documentation the facility had completed a background check.
6. Review of Licensed Practical Nurse (LPN) D's personnel records, showed the LPN with a hire date of 4/11/19. Further review showed the personnel record did not contain documentation the facility had completed a CNA Registry check prior to the LPN's hire date, or an EDL check since his/her hire date.
7. Review of CNA E's personnel records, showed the CNA with a hire date of 4/24/19. Further review showed the personnel record did not contain documentation the facility had completed an EDL check since his/her hire date.
8. Review of Dietary Aide F's personnel records, showed the Dietary Aide with a hire date of 9/7/19. Further review showed the personnel record did not contain documentation the facility had completed an EDL check since his/her hire date.
9. Review of Housekeeper G's personnel records, showed the Housekeeper with a hire date of 10/17/19. Further review showed the personnel record did not contain documentation the facility had completed an EDL check since his/her hire date.
10. Review of Certified Medical Technician (CMT) H's personnel record, showed the CMT with a hire date of 4/14/21. Further review showed the personnel record did not contain documentation the facility had completed an EDL check since his/her hire date.
11. Review of the Minimum Data Set (MDS) Coordinator's personnel record, showed the MDS Coordinator with a hire date of 5/31/21. Further review showed the personnel record did not contain documentation the facility had completed an EDL check since his/her hire date.
12. During an interview on 12/1/22 at 3:34 P.M., the BOM said he/she is responsible for checking the EDL and CNA Registry, as well as obtaining the CBC or FSCR letter. He/She said he/she did not know why the documentation was not in the personnel files. He/She said he/she was still in training and did not know he/she had to check the EDL on a quarterly basis.
During an interview on 12/1/22 at 3:41 P.M., the Administrator said the BOM is responsible for checking the CNA Registry and EDL, as well as obtaining the CBC or FCSR letter. She said the BOM is supposed to use a checklist to ensure all required forms are completed. She said there was previous system in place to verify the paperwork was completed, but now she will be checking all new employee personnel files. He/She said because staff had not checked the EDL per facility policy, the facility was at risk for employing staff members who had a federal indicator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, and record review, facility staff failed to accurately identify care areas for five residents (Residents #17, #25, #33, and #36) in the resident's comprehensive care plans (CP). Additionally, facility staff failed to include the resident's and/or resident's representative in the development of the comprehensive care plan for three resident's (Resident #7, #28, and #295). The facility census was 43.
Review of the facility's Daily Care Needs Policy, undated, showed resident care plans are individualized and give specific instructions on care.
Review of the facility's Care Plan Comprehensive Policy, undated, showed:
-An individualized comprehensive care plan that includes measurable goals and time frames will be developed to meet the resident's highest practicable physical, mental, and psychosocial well-being;
-The interdisciplinary care plan team with input from the resident, family, and/or legal representative will develop and maintain a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain;
-Assessment of each resident is ongoing process and the care plan will be revised as changes occur in the resident's condition;
-A well-developed care plan will be oriented to managing risk factors to the extent possible or indicating the limits of such interventions; evaluating treatment of measurable goals, timetables and outcomes of care; respecting the resident's right to decline treatment; using an appropriate interdisciplinary approach to care plan development to improve the resident's functional abilities; involving resident, resident's family and other resident representatives as appropriate, assessing and planning for care to meet the resident's medical, nursing, mental and psychosocial needs; addressing additional care planning areas that are relevant to meeting the resident's needs in the long-term care setting;
-The resident's comprehensive care plan is developed within seven days of the completion of the resident's comprehensive assessment (MDS and CAA's);
-The interdisciplinary care plan team is responsible for the periodic review and updating care plans when a significant change in the resident's condition has occurred, at least quarterly and when changes occur that impact the resident's care (i.e., change in diet, discontinuation of therapy, changes in care areas that do not require a significant change assessment).
1. Review of #17's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 8/29/22, showed staff assessed the resident as:
-Cognitively impaired;
-Dependent on staff for personal hygiene;
-Used a wheelchair for mobility;
-Diagnosis of Stroke, Hemiplegia (loss of movement in one side of the body), and anxiety.
Review of the resident's care plan, dated 11/4/22, showed it did not contain direction for oral care or Broda chair (specialized reclining chair) use.
Observation on 11/28/22 at 10:14 A.M., showed the resident in a Broda chair with yellow stained teeth.
Observation on 11/28/22 at 12:18 A.M., showed the resident in a Broda chair with yellow stained teeth.
Observation on 11/30/22 at 8:40 A.M., showed the resident in a Broda chair with yellow stained teeth.
2. Review of Resident #25's annual MDS, dated [DATE], showed staff assessed the resident as follows:
-Cognitively impaired;
-Did not reject care;
-Required total assistance from two staff members for bed mobility, transfers, dressing, toileting, personal hygiene, and bathing;
-Incontinent of bowel and bladder;
-Diagnoses of coronary artery disease (CAD, buildup of plaque in the arteries), malnutrition and dementia;
-At risk for pressure ulcers;
-One Stage 3 unhealed pressure ulcer;
-Moisture associated skin damage (MASD);
-Received a pressure reducing device for bed, turning and repositioning program, nutrition and hydration to manage skin problems, and applications of nonsurgical dressings to areas other than feet;
-Received hospice care.
Review of the resident's care plan, dated 12/2/22, showed:
-Resident with an indwelling catheter (tube to continuously drain the bladder);
-At risk for pressure ulcers;
-Did not contain documentation that the indwelling catheter had been discontinued;
-Did not contain treatment for left palm wound.
Review of the Physician's Order Sheet (POS), dated November 2022, showed it did not contain an order for the resident's left palm wound.
Review of the Treatment Administration Record (TAR), dated November 2022, showed an order for left palm wound to be cleansed with cleanser, apply A&D ointment (protective barrier), and to apply a small roll of gauze bandage under fingers next to palm.
Observations on 11/28/22 at 2:39 P.M. to 12/2/22 at 11:01 A.M., showed the resident in bed with an indwelling catheter not in place.
3. Review of Resident #33's quarterly MDS, dated [DATE], showed staff assessed the resident as:
-Cognitively impaired;
-Required extensive assistance from two staff members for personal hygiene and bathing;
-Required extensive assistance from one staff member for eating;
-A fall with major injury;
-Diagnoses of a traumatic brain injury (brain dysfunction from an injury to the head) and a fracture;
-Rejected care one to three days.
Review of the resident's care plan, dated 11/4/22, showed:
-Staff are instructed to give short and simples directions with reminders for Activities of Daily Living (ADLs);
-Resident up ad lib (freely as desired);
-Did not contain direction for staff assistance with eating;
-Did not contain direction for staff for fall mat use, sit to stand lift, and facial hair preference or person hygiene.
Observation on 11/28/22 at 11:51 A.M., showed the resident with facial hair on his/her face.
Observation on 11/29/22 at 7:56 A.M., showed the resident with facial hair on his/her face.
Observation on 11/29/22 at 10:36 A.M., showed the resident continued to have facial hair on his/her face.
Observation on 11/30/22 at 8:35 A.M., showed the resident with facial hair on his/ her face.
Observation on 11/30/22 at 9:19 A.M., showed the resident with facial hair on his/ her face.
Observation on 12/1/22 at 4:30 P.M., showed the resident with facial hair on his/ her face.
Observation on 11/28/22 at 12:24 P.M., showed the resident sat in the dining room with his/her eyes closed and with food in front of him/her. Further observation showed the resident began to feed himself/herself. Staff did not assist the resident to eat.
Observation on 11/29/22 at 11:35 A.M. to 12:57 P.M., showed the resident fed himself/herself without staff assistance offered.
Observation on 11/29/22 at 1:32 P.M., showed Certified Nurse Aide (CNA) J and CNA K perform a sit to stand lift transfer. Further observation showed the resident with facial hair on his/her face. Staff did not assist the resident with his/her facial hair while assisting him/her.
Observation on 11/30/22 at 4:15 A.M., showed the resident asleep in bed with the fall mat not in place.
During an interview on 12/12/22 at 3:14 P.M., the MDS Coordinator said he/she does not know if the resident uses a sit to stand lift. He/She said if the resident does use a sit to stand lift then it should be on the care plan. He/ She said the resident is a two person assist and it should be included on the care plan.
During an interview on 12/12/22 at 3:34 P.M., Nurse Aide (NA) V said the resident uses a sit to stand lift because he/she is combative. He/She said the resident is a two person assist.
During an interview on 12/12/22 at 3:14 P.M., the MDS Coordinator said the resident uses a fall mat because the resident had a fall, and it should be included on the care plan.
During an interview on 12/12/22 at 3:34 P.M., NA V said the resident uses a fall mat NA V said he/she does not know what a care plan is, but he/she finds information out about resident's from communication with his/her co-workers.
4. Review of Resident #36's quarterly MDS, dated [DATE], showed staff assessed the resident as:
-Cognitively intact;
-Required extensive assistance from two staff members for personal hygiene;
-Did not reject care.
Review of the resident's care plan, revised 9/23/21, showed it did not contain direction for staff in regards to facial hair preferences or personal hygiene.
Observation on 11/28/22 at 10:59 A.M., showed the resident with facial hair on his/her chin.
Observation on 11/30/22 at 12:21 P.M., showed the resident with facial hair on his/her chin.
Observation on 12/1/22 at 8:31 A.M., showed the resident with facial hair on his/her chin.
5. During an interview on 12/1/22 at 9:21 A.M., the MDS Coordinator, Director of Nursing (DON) and Quality Assurance Registered Nurse (RN) said a baseline care plan should be completed in 48 hours and the comprehensive care plan should be done within a week.
During an interview on 12/2/22 at 10:03 A.M., the MDS Coordinator said the care plans should be updated quarterly, when there is a significant change, with a new fall intervention or antibiotic use. Additionally, he/she said the care plan should include activities of daily living, and facial hair preferences. He/She said he/she is still being trained on the components of the care plan. He/She said he/she did not feel the care plans are person-centered for the most part, but is attempting to update the care plans as he/she reviewed them.
6. Review of Resident #7's quarterly MDS, dated [DATE], showed staff assessed the resident as:
-Cognitively intact;
-admission date 6/9/22;
-Required total assistance from one staff member for bed mobility, toileting and personal hygiene;
-Required total assistance from two staff members for transfers;
-Did not reject care.
Review of the resident's care plan, revised 9/13/22, showed the care plan was updated on 9/13/22 and staff did not document the resident attended.
During an interview on 11/28/22 at 2:31 P.M., the resident said he/she did not participate in care plan process and he/she is his/her own responsible party.
7. Review of Resident #28's quarterly MDS, dated [DATE], showed staff assessed the resident as:
-Cognitively intact;
-admission date 2/18/22.
Review of the resident's care plan, revised 11/28/22, showed the care plan was updated on 11/28/22 and staff did not document the resident attended.
During an interview on 11/29/22 at 8:19 A.M., the resident said he/she only attended one care plan meeting since admission.
8. Review of Resident #295's admission MDS, dated [DATE], showed the status as validated not fully submitted or accepted. Additional review showed it did not contain a comprehensive person-centered care plan to instruct staff how to care for the resident.
During an interview on 11/28/22 02:29 P.M., the resident said he/she has not received a care plan yet.
During an interview on 12/1/22 at 9:21 A.M., the MDS Coordinator, Director of Nursing (DON) and Quality Assurance Registered Nurse (RN) said Resident #295 was admitted on [DATE] and there was not a comprehensive care plan completed due to the process being overlooked.
During an interview on 12/1/22 at 9:21 A.M., the Quality Assurance RN said the resident and/or resident representative should be included in the care plan meetings. The MDS Coordinator said he/she did not know the resident and/or resident representative needed to attend the care plan meeting.
During an interview on 12/2/22 at 11:23 A.M., LPN L said care plans are located on the wall kiosks for the aide to refer to. He/She said if they are not there, then the CNA is to go to the nurse for direction. If the nurse does not know, then they are to go to the DON or MDS nurse. He/she said they do not attend care plan meetings or have input into them but says they should be revised any time there is a change in any care for the resident.
During an interview on 12/2/22 at 1:06 P.M., the DON said care plans should be developed within 5 days of admission. He/She said there have been some changes to the care plan rules but is not up to date on them. He/She said care plans should include falls, wounds, infections, antibiotics, behavioral changes, and medications. He/She said residents should be interviewed as part of the care plan process. He/She said the MDS coordinator will be with a trainer to help educate him/her on the process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview and record review, facility staff failed to meet professional standards when staff failed to document they followed physician orders for eleven residents (Resident #1, #5, #7, #9, #13, #20, #28, #33, #36, #37 and #295). Additionally, staff failed to administer gastrostomy (g-tube) (a tube inserted directly into the stomach to provide nutrition and medications) medications for one resident (Resident #7) per facility policy, failed to obtain an order for oxygen use, document daily weights and provide compression stockings as ordered for one resident (Resident #20), and failed to complete neurological checks for one resident (Resident #27) after a fall. The facility census was 43.
Review of the facility's Medication Administration Guidelines Policy, undated, showed it is the purpose of this facility that resident's receive their medications on a timely basis and in accordance with established policies and the person administering the drugs must chart the medications immediately following the administration.
Review of the facility's Medication Administration policy, undated, showed if the resident refused medication, indicate the failure to administer medication on the medication record by circling initials and making a notation on the back of the medication record (include date, time what occurred, initials and title).
1. Review of Resident #1's annual Minimum Data Set (MDS) a federally mandated assessment tool used to plan care, dated 9/11/22, showed staff assessed the resident as:
-Severe cognitive impairment;
-Diagnosis of Dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes and impaired reasoning).
Review of the resident's Physician's Order Sheet (POS), dated November 2022, showed staff were directed to administer:
-Ocular Vitamin 113 mg-0.5 mg (vitamin to treat Macular Degeneration) one tab, once a day;
-Senokot Extra Strength 17.2 mg (laxative) one tab, BID;
-Venlafaxine 75 mg (used to treat Major Depressive Disorder) one tab, BID;
-Lorazepam 0.5 mg (used to treat Anxiety Disorder) one tab, TID;
-Lisinopril 10 mg (used to treat Hypertension) one tab, once a day;
-Eliquis 2.5 mg (used to treat Chronic embolism and thrombosis of deep veins) one tab, BID;
-Seroquel 25 mg (used to treat Persistent Mood Disorder) 1/2 tab (12.5 mg), once a day.
Review of the resident's Medication Administration Record (MAR), dated November 2022, showed staff documented:
-11/13/22: Did not administer Ocular Vitamin, one of two ordered doses of Senokot, one of two ordered doses of Venlafaxine, one of three ordered doses of Lorazepam, one ordered dose of Lisinopril;
-11/15/22: Did not administer one of two order doses of Eliquis;
-11/29/22: Did not administer one of three order doses of Lorazepam;
-11/30/22: Did not administer one of two order doses of Eliquis, one of two ordered doses of Senokot, one of two ordered doses of Venlafaxine, two of three ordered doses of Lorazepam, one ordered dose of Seroquel. Review showed staff did not document the medications were administered per physician's orders.
2. Review of Resident #5's quarterly MDS, dated [DATE], showed staff assessed the resident as:
-Moderately Impaired Cognition;
-Diagnoses of Neurogenic Bladder (the nerves that carry messages back and forth between the bladder and spinal cord and brain don't work as they should), Urinary Tract Infection (UTI) (an infection in any part of the urinary system)in the last 30 days, Diabetes Mellitus, Multiple Sclerosis (MS) (a chronic, typically progressive disease involving damage to the sheaths of nerve cells in the brain and spinal cord), Anxiety Disorder, Depression, and Chronic Obstructive Pulmonary Disease (COPD)(condition involving constriction of the airways and difficulty or discomfort with breathing).
Review of the resident's POS, dated November 2022, showed staff were directed to administer:
-Senna with Docusate Sodium 8.6-50 mg (laxative) one tab, BID;
-Fentanyl patch 72 hour, 50 mcg/hr (used to treat chronic pain) Transdermal every 72 hours;
-Oxybutynin Chloride 5 mg (used to treat overactive bladder) one tab, once a day;
-Paxil 40 mg (used to treat Major Depressive Disorder) 1 1/2 tab(60 mg), once a day;
-Protonix 40 mg (used to treat Gastro-esophageal reflux disease) one tablet, once a day;
-House Supplement (used to maintain weight) BID with meals;
-Baclofen 10 mg (used to treat chronic pain) one tab, TID;
-Midodrine 5 mg (used to treat Hypotension) one tab, TID;
-Gabapentin 300 mg (used to treat chronic pain) one tab, BID;
Review of the resident's MAR, dated November 2022, showed staff documented:
-11/2/22: Did not administer one of two ordered doses of Senna with Docusate Sodium;
-11/5/22: Did not administer one ordered dose of Fentanyl, one of two ordered doses of Senna with Docusate Sodium;
-11/10/22: Did not administer one of two ordered doses of Senna with Docusate Sodium;
-11/11/22: Did not administer one ordered dose of Fentanyl;
-11/13/22: Did not administer Oxybutynin Chloride, Paxil, Protonix, one of two ordered doses of Gabapentin, one of two ordered doses of House Supplement, one of two ordered doses of Senna with Docusate Sodium, one of three doses of Baclofen, one of three doses of Midodrine;
-11/20/22: Did not administer one ordered dose of Fentanyl;
-11/23/22: Did not administer one of two ordered doses of Senna with Docusate Sodium;
-11/30/22: Did not administer one of two ordered doses of Gabapentin, one of two ordered doses of House Supplement, two of three doses of Baclofen, two of three doses of Midodrine. Review showed staff did not document the medications were administered per physician's orders.
3. Review of Resident #7's quarterly MDS, dated [DATE], showed staff assessed the resident as:
-Cognitively intact;
-Diagnosis of anemia (a condition in which the blood doesn't have enough healthy red blood cells), hypertension (the force of the blood against the artery walls is too high), anxiety (a mental health disorder characterized by feelings of worry, or fear that are strong enough to interfere with one's daily activities), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily living), cerebral palsy (a cognitive disorder of movement, muscle tone, or posture), and Neurogenic bladder (name given to a number of urinary conditions in people who lack bladder control due to a brain, spinal cord or nerve problem).
Review of the resident's POS, dated November 2022, showed a physician order directed staff to administer:
-Melatonin (sleep aid) 3 mg /6 mg (milligrams) one time a day (QD);
-Check tube placement (a therapy where a feeding tube supplies nutrients) every shift (Q);
-Magnesium Oxide (dietary supplement) 400 mg twice a day (BID);
-Baclofen (pain reliever and certain types of spasticity) 10 mg three times a day (TID);
-Quatiapine (to treat certain mental/moods disorders) 25 mg QD;
-Sertraline (antidepressant)100 mg QD;
-Sertraline 50 mg QD;
-Carvedilol BID, ProSource (to treat heart failure) 30 milliliters (ml) BID;
-Flush peg tube (a flexible feeding tube is placed through the abdominal wall and into the stomach) with 200 ml six times a day;
-Centrum (multivitamin) 9 mg/15 ml QD;
-Ferrous Sulfate (iron supplement) 300 mg/5 QD;
-Pantoprazole (used for the treatment of stomach ulcers) 40 mg QD;
-Potassium Chloride (mineral supplement used to treat or prevent low amounts of potassium) 40 milliequivalents per liter (MEQ)/30 ml.
Review of the resident's MAR, dated November 2022, showed staff documented:
-11/1/22: Did not administer Centrum, one of the two ordered doses of Carvedilol, one of the two ordered doses of ProSource, two of the three ordered doses of Baclofen and three of the six ordered peg tube flushes;
-11/4/22: Did not administer Melatonin;
-11/5/22: Did not administer Melatonin;
-11/6/22: Did not administer Melatonin, Quetiapine, Sertraline 100 mg, Sertraline 50 mg, Carveodilol, Magnesium Oxide, Baclofen, and Centrum;
-11/7/22: Did not administer Melatonin, Quetiapine, Sertraline 100 mg, Sertraline 50 mg, Carvedilol and Magnesium Oxide, Baclofen, and Centrum;
-11/8/22: Did not administer Centrum;
-11/9/22: Did not administer Centrum;
-11/10/22: Did not administer Melatonin;
-11/11/22: Did not administer Melatonin and Centrum and two of the six ordered peg tube flushes;
-11/13/22: Did not administer Melatonin, one of the three ordered doses of Baclofen, and four of the six ordered peg tube flushes
-11/14/22: Did not administer Melatonin, one of the two ordered doses of Carvedilol, two of the three ordered doses of Baclofen, and three of the six ordered peg tube flushes
-11/17/22: Did not administer Melatonin and one of the six ordered peg tube flushes;
-11/18/22: Did not administer Centrum and three of the six ordered peg tube flushes;
-11/19/22: Did not administer Melatonin and one of the six ordered peg tube flushes;
-11/20/22: Did not administer Melatonin and one of the six ordered peg tube flushes;
-11/22/22: Did not administer Melatonin and one of the six ordered peg tube flushes;
-11/23/22: Did not administer Centrum and five of the six ordered peg tube flushes;
-11/24/22: Did not administer one of the six ordered peg tube flushes;
-11/25/22: Did not administer Melatonin;
-11/28/22: Did not administer Melatonin;
-11/29/22: Did not administer two of the six ordered peg tube flushes;
-11/30/22: Did not administer Centrum, Melatonin, and Prosource and three of the six ordered peg tube flushes.
4. Review of Resident #9's quarterly MDS, dated [DATE], showed staff assessed the resident as:
-Cognitively impaired;
-Diagnosis of anemia.
Review of the resident's POS, dated November 2022, showed staff were directed to administer:
-Cetirizine (antihistamine) 10 mg QD;
-Lisinopril (blood pressure medication) 10 mg QD;
-Cephalexin (antibiotic) 250 mg 1 capsule (cap) once a morning;
-Glipizide (diabetic medication to help blood glucose control) 10 mg 1 tab once a morning;
-Multivitamin 1 tab once a morning;
-Polyethylene Glycol 3350 (laxative) 17 grams (gm) once a morning;
-Ferrous Sulfate (iron supplement) 325 mg (65 mg iron) 1 tab BID;
-Senna with Docusate Sodium (stool softener) 8.6-50 mg 1 tab BID;
-To check a blood pressure daily and report to physician if systolic is over 170 or diastolic is over 100.
Review of the resident's MAR, dated November 2022, showed staff documented:
-11/13/22: Did not administer one of two ordered doses of Ferrous Sulfate, one of two ordered doses of Senna with Docusate Sodium, Cetirizine, Lisinopril, Cephalexin, Glipizide, Multivitamin, Polyethylene Glycol 3350, and did not document a blood pressure reading;
Review showed staff did not document the medications were administered per the physician's orders.
5. Review of Resident #13's quarterly MDS, dated [DATE], showed staff assessed the resident as:
-Cognitively intact;
-Diagnoses of anemia (lack of healthy red blood cells) and diabetes.
Review of the resident's POS, dated November 2022, showed staff were directed to administer:
-Acidophilius (probiotic) one capsule QD;
-Docusate Sodium (stool softener) 200 mg QD;
-Docusate Sodium 100 mg QD;
-Januvia (diabetic medication for glucose control) 50 mg 1 tablet (tab) QD;
-Vitamin D3 25 micrograms (mcg) 2 tabs QD;
-Cranberry 450 mg twice a day (BID);
-Spironolactone (diuretic) 50 mg 1 tab BID with special instructions to administer with breakfast and lunch;
-Xifaxan (treats diarrhea and can help loss of brain function with a damaged liver) 550 mg 1 tab BID;
-Lactulose (laxative and ammonia reducer) 45 ml three times a day (TID);
-Monitor and record blood sugar level BID.
Review of the resident's MAR, dated November 2022, showed staff documented:
-11/13/22: Did not administer one of the two ordered doses of Xifaxan, two of the three ordered doses of Lactulose, one of two ordered doses of Spironolactone, one of the two ordered doses of Cranberry, Acidophilius, Docusate Sodium 200 mg, Januvia, Vitamin D3, and did not check and record a blood sugar level for two or two checks.
-11/14/22: Did not administer one of the two ordered doses of Cranberry.
Review showed staff did not document the medications were administered per the physician's orders.
6. Review of Resident #25's annual MDS, dated [DATE], showed staff assessed the resident as:
-Cognitively impaired;
-Coronary Artery Disease (CAD, buildup of plaque in the arteries), hypertension (high blood pressure), GERD (gastrointestinal reflux), hyperlipidemia (high levels of fat particles in the blood), dementia (impaired ability to remember, think, or make decisions), malnutrition, and anxiety.
Review of the resident's POS, dated November 2022, showed staff were directed to administer:
-Sentry Senior (multivitamin) 500-300-250 micrograms (mcg) 1 tablet (tab) QD;
-Acetaminophen (pain reliever) 500 mg 1 tab twice a day (BID);
-Potassium Chloride (potassium supplement) 10 milliequivalents (mEq) BID;
-Boost VHC supplement (nutrition shake) 120 ml four times a day (QID) with med pass.
Review of the resident's MAR, dated November 2022, showed staff documented:
-11/10/22: Did not administer one of four ordered Boost VHC supplements.
-11/11/22: Did not administer one of four ordered Boost VHC supplements.
-11/13/22: Did not administer one of two ordered doses of Acetaminophen; one of two ordered doses Potassium Chloride; and two of four ordered Boost VHC supplements, and Sentry Senior.
Review showed staff did not document the medications were administered per the physician's order.
7. Review of Resident #28's quarterly MDS, dated [DATE], showed staff assessed the resident as:
-Cognitively intact;
-Diagnosis of hyperlipidemia (a condition in which there are high levels of fat particles (lipids) in the blood), diabetes mellitus (a group of diseases that result in too much sugar in the blood), and hypertension (the force of the blood against the artery wall is too high).
Review of the resident's POS, dated November 2022, showed a physician order directed staff to administer:
-Aspirin low dose (can treat pain, fever, inflammation, and reduces the risk of a heart attack) 81 mg one time a day (QD);
-Centrum Silver (multivitamin) 0.4 mg QD;
-Dulcolax (laxative) 5 mg QD;
-Gabapentin (anticonvulsant medication to treat partial seizures and neuropath pain) 300 mg QD;
-Lisinopril (to treat high blood pressure) 10 mg QD; check blood sugar AM/PM BID;
-Humulin (an intermediate acting insulin) 70/30 U-100 Insulin BID;
-Metformin (to treat type 2 diabetes) 500 mg BID.
Review of the resident's MAR, dated November 2022, showed staff documented:
-11/13/22: Did not administer Aspirin, Centrum Silver, Dulcolax, Gabapentin, Lisinopril or checked blood sugars level; one of the two ordered doses of Humulin and one of the two ordered doses of Metformin
-11/15/22: Did not administer one of the two ordered doses of Humulin and one of the two ordered doses of Metformin.
Review showed staff did not documented the medications were administered per the physician's orders.
8. Review of Resident #33's quarterly MDS, dated [DATE], showed staff assessed the resident as:
-Cognitively impaired;
-Diagnoses of traumatic brain injury and a fracture.
Review of the resident's POS, dated November 2022, showed staff were directed to administer:
-Aspirin (can treat pain, fever, inflammation, and reduces the risk of a heart attack) 81 mg QD;
-Miralax (laxative) 17 gm QD;
-Sentry Senior (multivitamin) 500-300-250 mcg 1 tab QD;
-Thiamine (vitamin to treat vitamin B1 deficiency) 100 mg QD;
-Quetiapine 50 mg BID;
-Tramadol 50 mg TID;
-Quetiapine 25 mg QD;
-Ativan 0.5 mg at bedtime (HS).
Review of the resident's MAR, dated November 2022, showed staff documented:
-11/11/22: Did not administer Ativan;
-11/13/22: Did not administer one of two ordered doses of Quetiapine 50 mg, one of three ordered doses of Tramadol, Aspirin, Miralax Sentry Senior, Thiamine, or Quetiapine 25 mg;
-11/19/22: Did not administer Ativan;
-11/20/22: Did not administer Ativan, one of two ordered doses of Quetiapine 50 mg, and one of three ordered doses of Tramadol.
-11/23/22: Did not administer Ativan, one of two ordered doses of Quetiapine 50 mg, and one of three ordered doses of Tramadol.
Review showed staff did not document the medications were administered per the physician's orders.
9. Review of Resident #36's quarterly MDS, dated [DATE], showed staff assessed the resident as:
-Cognitively intact;
-Diagnoses of hypertension, diabetes, malnutrition (lack of nutrients), depression, and bipolar (frequent mood swings).
Review of the resident's POS, dated November 2022, showed staff were directed to administer:
-Amlodipine (treats high blood pressure) 2.5 mg 1 tab QD;
-Vitamin B-12 1000 mcg 1 tab QD; Duloxetine 60 mg 1 tab QD;
-Ferrous Sulfate 325 mg (65 mg iron) 1 tab QD; Folic Acid 1 mg 1 tab QD;
-Miralax 17 gm QD;
-Metformin 500 mg;
-Gabapentin (treats seizures and nerve pain) 600 mg TID;
-To check blood sugars at A.M. and P.M. BID.
Review of the resident's MAR, dated November 2022, showed staff documented:
-11/11/22: Did not administer one of two ordered blood sugar checks.
-11/13/22: Did not administer one of two ordered blood sugar checks, one of two ordered doses of Metformin; two of three ordered doses of Gabapentin, Amlodipine, Vitamin B-12, Duloxetine, Ferrous Sulfate, Folic Acid, and Miralax.
-11/17/22: Did not administer one of two ordered blood sugar checks;
-11/21/22: Did not administer one of two ordered blood sugar checks.
Review showed staff did not document the medications were administered or the blood sugar results per the physician's orders.
10. Review of Resident #37's admission MDS, dated [DATE], showed staff assessed the resident as:
-Cognitive;
-Diagnoses of cancer, anemia, atrial fibrillation (A-fib, irregular, rapid, heart rate), hypertension (high blood pressure), and chronic lung disease.
Review of the resident's POS, dated November 2022, showed staff were directed to administer:
-Allopurinol (uric acid reducer) 100 mg 2 tab QD;
-Duloxetine (treats depression and anxiety) 60 mg QD;
-Metoprolol Tartrate (treats high blood pressure) 25 mg BID;
-B Complex Vitamin B12 1000 mg QD;
-Tramadol (treats moderate to severe pain) 100 mg four times a day (QID);
-Vitamin C 500 mg QD; and Miralax (stool softener) 17 grams 1 packet BID.
Review of the resident's MAR, dated November 2022, showed staff documented:
-11/13/22: Did not administer one of two ordered doses of Metoprolol, one of two ordered doses of Miralax, two of four ordered doses of Tramadol, Allopurinol, B Complex- Vitamin B12, Duloxetine; and Vitamin C.
-11/21/22: Did not administer one of two ordered doses of Miralax.
-11/23/22: Did not administer one of two ordered doses of Miralax and two of four ordered doses of Tramadol.
Review showed staff did not document the medications were administered per the physician's orders.
11. Review of Resident #295's admission MDS, dated [DATE], showed the status as validated not fully submitted or accepted.
Review of the resident's POS, dated November 2022, showed staff were directed to administer:
-Meloxicam (used to reduce pain, swelling, and stiffness of joints) 7.5 mg QD;
-Acidophilus (probiotic to put good bacteria into the body) 1 cap BID;
-Bupropion (treatment for depression and a smoking cessation aid) HCl 150 mg BID;
-Quetiapine (used to treat mental and mood disorders) 25 mg BID;
-Gabapentin 300 mg TID;
-Pamelor (treatment for depression and mood stabilizer) 25 mg TID.
Review of the resident's MAR, dated November 2022, showed staff documented:
-11/13/22: Did not administer one of two ordered doses of Acidophilus, one of two ordered doses of Bupropion HCl, one of two ordered doses of Quetiapine, two of three ordered doses of Gabapentin, two of three ordered doses of Pamelor, and Meloxicam.
Review showed staff did not document the medication were administered per the physician's orders.
During an interview on 12/2/22 at 10:21 A.M., the MDS coordinator said staff should document refusals of medications by placing an R in the box with a circle around it with a description on the back of the MAR with the reason. He/She said wound care and medications should be documented and no holes should be in the MAR/TARs. He/She said if its not documented, then it isn't done. He/She said the director of nursing (DON) is responsible to ensure treatments and medications are given. He/She said refusals of medications and treatments for greater than 3 doses should be reported to the physician but he/she is not aware of any missed medications or treatments.
During an interview on 12/2/22 at 1:06 P.M., the DON said staff receive ongoing education regarding medications. He/She said if there is a blank in the MAR, then another staff going behind could have the potential to give the medication again.
12. Review of Resident #7's quarterly MDS, dated [DATE], showed staff assessed the resident as:
-Cognitively intact;
-Gastronomy Tube (G-tube).
Review of the facility's Administrations of Medications by Naso-gastric Tube or Gastronomy Tube (G-tube) Policy, undated, showed staff were instructed to:
-Turn the feeding pump off;
-Check tube placement;
-Check the residual and return to stomach if the residual contents was greater than 100 mL;
-Give medications by gravity and to never force with a syringe plunger.
Review of the resident's POS, dated November 2022, showed staff were directed to administer Hydrocodone-Acetaminophen (narcotic analgesic) 7.5/325 milligrams (mg)/15 milliliters (ml) every four hours.
Observation on 11/30/22 at 9:27 A.M., showed Licensed Practical Nurse (LPN) L give the resident 15 mL Hydrocodone (narcotic pain medication) solution through the resident's G-tube. Further observation showed the G-tube feeding administering at 60 mL/hr. LPN L did not stop the G-tube feeding, check G-tube placement, or check a residual prior to administration of a medication.
During an interview on 12/2/22 at 1:06 P.M., the DON said staff are instructed to administer gastrostomy tube medications by giving the ordered flush, stopping the feeding during administration and checking placement with an air bolus prior to administering the medications.
Review of the facility's Physician Order Policy, undated, showed:
-Physicians' orders must be signed by the physician and dated when such orders was signed;
-Current lists of orders must be maintained in the clinical record of each resident to avoid confusion and errors;
-The content of oxygen orders should include the rate of flow, route, and rationale.
13. Review of Resident #20's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, showed staff assessed the resident as:
-Cognitively intact;
-Diagnosis of heart failure, dementia, and peripheral vascular disease (PVD) (reduced blood flow to the limbs)
-No oxygen use.
Review of the resident's POS, dated November 2022, showed it did not contain orders for oxygen use.
Review of the resident's care plan, dated 11/4/22, showed it did not contain direction for oxygen use including liters per minute or method of administration.
Observation on 11/28/22 at 10:06 A.M., showed the resident in bed with oxygen on via nasal cannula at 3 Liters per minute.
Observation on 12/1/22 at 10:32 A.M., showed the resident in bed with oxygen on via nasal cannula at 2.5 Liters per minute.
During an interview on 12/1/22 at 10:32 A.M., the resident said he/she wears the oxygen when in bed to help him/her rest better. He/She said he/she was recently sick and needed the oxygen.
During an interview on 12/2/22 at 10:21 A.M, the MDS coordinator said if residents are on oxygen, there should be an order for it and it should be in the care plan.
During an interview on 12/2/22 at 1:06 P.M., the DON said the resident's MAR's and TAR's should match the POS. He/ She said if there is not an order, then staff should not perform the treatment.
Review of the residents POS, dated November 2022 showed:
-On 12/15/21, the physician ordered staff to apply bilateral lower extremity (BLE) knee high TED hose in AM (morning) and remove at HS (night) for lymphedema;
-On 12/17/21, the physician ordered staff to monitor and record the resident's weight daily
Review of the treatment flowsheet dated November 2022 showed:
-An order stating to apply BLE knee high TED hose in am and remove at HS with times of 4:00 A.M. - 6:00 A.M. and 6:00 P.M. to 8:00 P.M.
-Staff applying TED hose as ordered;
-An order to monitor and record the weight daily;
-An R with a circle around it daily for the month of November for the weights.
Review of the resident's weight's from June 2022 through November 2022 showed:
-Did not obtain daily weights 7 days in June;
-Did not obtain daily weights 30 days in July;
-Did not obtain daily weights 30 days in August;
-Did not obtain daily weights 29 days in September;
-Did not obtain daily weights 30 days in October;
-Did not obtain daily weights 29 days in November.
Review of the resident's care plan, dated 11/4/22, directs staff to obtain a daily weight and to encourage to wear TED hose to BLE, on in A.M. and off at HS.
Observation on 11/28/22 at 10:06 A.M., showed the resident in bed. Additional observation showed the resident did not have his/her compression socks.
Observation on 11/29/22 at 8:03 A.M., showed the resident in the lobby without compression socks on.
Observation on 12/1/22 at 10:32 A.M., showed the resident in bed. Additional observation showed the resident did not have his/her compression socks.
During an interview on 11/28/22 at 10:06 A.M., the resident said he/she has compression stockings but the staff never put them on him/her. He/She said his/her legs get bigger when he/she sits up in a chair. He/She said the staff do not ask him/her to weigh daily.
14. Review of the facility's charting and documentation policy, undated, showed it did not contain direction for neurological exams after a fall with head involvement.
Review of Resident #27's admission MDS, dated [DATE] showed the staff assessed the resident as:
-Cognitively impaired;
-Requires physical assistance of two staff for bed mobility, transfers and toileting;
-Diagnosis of diabetes, anemia (low iron in blood) and atrial fibrillation (irregular heartbeat);
-Fall in one month prior to admission.
Review of the residents Fall Risk assessment dated [DATE], showed the staff assessed the resident as a high fall risk.
Review of the resident's care plan, dated 11/4/22, showed it did not contain any direction for fall prevention.
Review of the resident nurse notes showed:
-On 11/21/22 the resident had a witnessed fall and states hit head after slipping off the bed. A small hematoma on head. X-ray skull series ordered.
Review of the medical record showed it did not contain documentation of neurological checks following the resident's fall.
During an interview on 12/2/22 at 10:21 A.M., the MDS coordinator said when a resident falls, an assessment should be completed including neurological checks if suspected head injury or witnessed head injury occurs. He/She said the checks should be documented in the resident's record and care planned for new fall prevention interventions.
During an interview on 12/2/22 at 1:06 P.M., the DON said staff are expected to complete neurological checks on all residents who hit their head or staff suspects the head was involved and should be documented. He/She did not know the resident did not have neurological checks completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed ensure six dependent residents (Resident #1, #5, #16, #25, #33, and #34) received the necessary services to maintain good grooming and personal hygiene when staff failed to maintain the residents' facial hair, failed to ensure residents wore clean clothes, failed to provide timely incontinence care and failed to ensure residents were turned and repositioned. The facility census was 43.
1. Review of the facility's Positioning the Resident Policy, undated, showed it directs to reposition residents to relieve pressure, prevent skin breakdown and relieve pain.
Review showed the policy did not contain guidance for staff in regard how often residents should be repositioned.
Review of the facility's Shaving the Resident Policy, undated, showed it directs staff to remove resident's facial hair to improve the resident's appearance and morale.
2. Review of Resident #1's Annual Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 9/11/22, showed staff assessed the resident as:
-Severe cognitive impairment;
-Did not reject care;
-Required limited assistance from one staff member for personal hygiene and dressing;
-Required extensive assistance from one staff member for bathing;
-Totally dependent on one staff member for toileting;
-Diagnoses of Dementia (a chronic or persistent disorder the mental processes caused by brain disease or injury and marked by memory disorders, personality changes and impaired reasoning).
Review of the Care Plan, revised 9/13/22, showed staff are directed to:
-Resident at risk for inadequately being able to meet his/her own needs, due to cognitive deficits;
-Give short and simple directions with reminders for Activities of Daily Living (ADL);
-Did not contain direction for staff in regard to facial hair preferences or personal hygiene.
Observation on 11/28/22 at 12:38 PM., showed the resident had multiple hairs over an inch long on his/her chin.
Observation on 11/29/22 at 8:59 A.M., showed the resident had multiple hairs over an inch long on his/her chin, and hair on his/her upper lip.
Observation on 11/29/22 at 12:26 P.M., showed the resident had multiple hairs over an inch long on his/her chin.
Observation on 11/30/22 at 4:14 A.M., showed the resident in bed. The resident had a strong urine odor.
Observation on 11/30/22 at 4:33 A.M., showed the resident's bed sheets had a brown ring shaped stain, and the room had a foul urine odor.
Observation on 11/30/22 at 4:46 A.M., showed Nurse Aide (NA) S and Certified Nurse Aide/Certified Medication Tech (CNA/CMT) H walked into the resident's room and asked the resident if he/she would like to get up. The resident told the staff, No. The resident lay in bed with a brown ring shaped stain on his/her bed pad and sheets.
During an interview on 11/30/22 at 4:46 A.M., CNA/CMT H said the resident has the right to refuse care.
Observation on 11/30/22 at 5:03 A.M., showed a strong urine odor outside of the resident's room. Further observation, showed NA S asked the resident if they wanted to get up. The resident said No.
Observation on 11/30/22 at 5:15 A.M., showed NA S and CNA/CMT H walked by the resident's room and did not offer assistance.
Observation on 11/30/22 at 5:26 A.M., showed CNA/CMT H walked by the resident's room and did not offer assistance.
During an interview on 11/30/22 at 5:56 A.M., NA S said residents should be repositioned every two hours. CNA/CMT H said the residents are checked every hour. The CNA/CMT H said how often Resident #1 is checked depends on on how much fluid the resident drinks. The CNA/CMT said the resident is typically checked every hour and half to two hours. He/She said it is not typical for the resident to refuse care.
Observation on 11/30/22 at 6:14 A.M., showed the resident in bed with urine saturated linens. The linens had a brown ring shaped stain, and the room had a strong urine odor.
Observation on 11/30/22 at 6:27 A.M., showed the resident in bed with urine saturated linens. The linens and incontinence pad had a large brown ring shaped stain and the resident's gown was wet. The room had a strong urine odor. Further observation, showed CNA K asked the resident if they were wet, and the resident said Yes. The CNA assisted the resident out of bed and the linens, sheets, and two bed pads were saturated with urine and had a brown ring shaped stain. A large area in the middle of the mattress was wet.
During an interview on 11/30/22 at 6:27 A.M., CNA K said it saddened him/her the resident was this wet. He/she said the resident had not been checked for at least four hours. He/She said typically the resident's gown and linens would not be wet. The CNA said the resident is supposed to be toileted every two hours.
3. Review of Resident #5's Quarterly MDS, dated [DATE], showed staff assessed the resident as:
-Moderately impaired cognition;
-Totally dependent on one staff member for bathing;
-Totally dependent on two staff members for bed mobility, transfers, toilet use and personal hygiene;
-Impairment in Range of Motion (ROM) to all extremities;
-Always incontinent of bowel;
-Did not have behaviors;
-Did not refuse care;
-Diagnoses of Neurogenic Bladder (the nerves that carry messages back and forth between the bladder and spinal cord and brain don't work as they should), Urinary Tract Infection (UTI) (an infection in any part of the urinary system)in the last 30 days, Diabetes Mellitus, and Multiple Sclerosis (MS) (a chronic, typically progressive disease involving damage to the sheaths of nerve cells in the brain and spinal cord).
Review of the resident's Care Plan, revised 11/15/22, showed:
-Resident at risk for inadequately being able to meet his/her own needs, due to cognitive deficits;
-Assist with bed mobility with two staff members;
-Turn and reposition every two hours and as needed (PRN);
-Please be sure call light is with in reach;
-Assist with toileting every two hours and PRN;
-Nursing staff will use pillows between knees and bony prominences to avoid direct contact PRN;
-If incontinence has occurred prompt attention will be given;
-Encourage to get up out of the bed, this promotes circulation and reduces the chances for breakdown of skin;
-If there comes a time that to reposition, causes more pain, resident will only be repositioned when he/she has an incontinent episode.
Observation on 11/28/22 at 10:57 A.M., showed the resident in bed, without his/her call light. The resident lay on his/her back with a foam wedge by his/her feet, not in use. The resident had a strong foul odor.
During an interview on 11/28/22 at 2:26 P.M., the resident said sometimes he/she is left soiled for hours. The resident said staff are supposed to reposition him/her every two hours, but they don't. The resident said sometimes he/she goes the entire day without being repositioned.
Observation on 11/29/22 at 8:28 A.M., showed the resident lay on his/her back in bed. Further observation, showed staff did not enter the resident's room from 8:28 A.M. until 10:47 A.M., to provide care.
Observation on 11/30/22 at 4:12 A.M., showed the resident in bed, without his/her call light. The resident had a strong foul odor.
During an interview on 11/30/22 at 4:12 A.M., the resident said he/she needed to be changed, but staff had not been in the room.
Observation on 11/30/22 at 9:29 A.M., showed the resident lay on his/her back in bed, and had a strong foul odor. Further observation, showed CNA J entered the resident's room, adjusted the resident's oxygen tubing, and left the room without checking the resident for incontinence.
Observation on 11/30/22 at 10:26 A.M., showed NA M entered the resident's room, asked the resident what he/she wanted for lunch, and left the resident's room, without repositioning the resident or checking for incontinence.
Observation on 11/30/22 from 10:55 A.M. to 12:00 P.M., showed NA M entered the resident's room, and spoke to the resident's roommate. NA M left the room without repositioning the resident, or checking the resident for incontinence. Continuous observation until 12:00 P.M., showed staff did not enter the resident's room to provide care.
Observation on 12/1/22 at 9:48 A.M., showed the resident's mattress soiled with fecal incontinence. The resident's coccyx had a large red area, and the incontinence pad had small scant spots of blood.
During an interview on 12/1/22 at 9:48 A.M., CNA J said the area to the resident's coccyx comes and goes. He/She said they put cream on the area.
Observation on 12/1/22 at 3:16 P.M., showed the resident's mattress soiled with fecal matter.
During an interview on 12/1/22 at 3:26 P.M., the hospice nurse said the resident's mattress was not soiled Monday. He/she said the resident's bottom was excoriated.
4. Review of Resident #16's Quarterly MDS, dated [DATE], showed staff assessed the resident as:
-Severely impaired cognition;
-Totally dependent on two staff members for transfers and bed mobility;
-Totally dependent on one staff member for dressing, toileting, personal hygiene and bathing;
-Did not have behaviors;
-Always incontinent of bowel and bladder;
-Diagnoses of Dementia (progressive or persistent loss of intellectual function) and Stroke (damage to the brain from interruption of it's blood supply).
Review of the resident's Care Plan, dated 10/25/22, showed:
-Resident at risk for inadequately being able to meet his/her own needs, due to cognitive deficits;
-Give short and simple directions for ADL care;
-Assist with bed mobility with two staff members;
-Turn and reposition every two hours and PRN;
-Nursing staff will provide prompt protective and preventative skin care if incontinence episode occurs;
-Assist with toileting every two hours and PRN;
-Ensure call light is in reach.
Observation on 11/29/22 at 8:09 A.M., showed the resident sat in a Broda chair at the nurse's station. At 9:40 A.M., CNA J took the resident to his/her room and sat him/her in front of the television and left the room. The CNA did not check the resident for incontinence or reposition him/her. Continuous observation, showed staff did not check on the resident until 11:45 A.M.
Observation on 11/30/22 at 4:14 A.M., showed the resident in bed, without his/her call light. The resident had a strong foul odor.
Observation on 11/30/22 at 4:45 A.M., showed the resident in bed, with a strong urine odor. Further observation, showed when staff provided care the resident had a urine saturated brief, gown, and incontinence pad.
During an interview on 11/30/22 at 1:16 P.M., CNA J said staff are supposed to check dependent residents every two hours and as needed. The CNA said staff are supposed to turn and reposition residents at least every two hours. The CNA said Resident #16 should have been repositioned but he/she did not reposition him/her. When asked why the resident was not repositioned, CNA J said that was my bad.
5. Review of Resident #25's Annual MDS, dated [DATE], showed staff assessed the resident as:
-Cognitively impaired;
-Did not reject care;
-Required total assistance from two staff members for bed mobility, transfers, dressing, toileting, personal hygiene, and bathing;
-Incontinent of bowel and bladder;
-Had diagnoses of coronary artery disease (CAD, buildup of plaque in the arteries), malnutrition and dementia;
-At risk for pressure ulcers;
-Had moisture associated skin damage (MASD);
-Had a pressure reducing device for bed, turning and repositioning program, nutrition and hydration to manage skin problems, and applications of nonsurgical dressings to areas other than feet;
-Received hospice services.
Review of the resident's care plan, dated 12/2/22, showed staff were directed to:
-Provide toileting assistance every two hours and PRN;
-The nursing staff will position with pillows and/or wedge to elevate pressure points off the bed PRN;
-Turn and reposition every two hours and PRN, and if incontinence has occurred prompt attention to this will be given;
-Provide with non-medication pain relief interventions such as repositioning;
-Turn and reposition as needed to increase comfort, if there comes a time that when repositioning increases pain, only reposition when incontinent.
Review of a Weekly Skin Assessment, dated 11/29/22, showed staff documented the resident's buttocks continued to be red, cream applied.
Observation on 11/29/22 at 8:17 A.M., showed the resident lay in bed on his/her back. Further observation, showed the room had a strong urine odor.
Observation on 11/29/22 at 9:39 A.M., showed the resident lay in bed on his/her back. Further observation, showed the room had a strong urine odor.
Observation on 11/30/22 at 4:36 A.M., showed the resident lay in bed. Further observation, showed the right side of the bed sheets had a brown ring shaped stain, and the room had a foul urine odor.
During an interview on 11/30/22 at 5:36 A.M., Certified Nurse Aide (CNA)/Certified Medication Technician (CMT) H said he/she gets the independent residents up first.
Observation on 11/30/22 at 6:14 A.M., showed the resident lay in bed on his/her back. Further observation, showed the resident's bed sheets and incontinence pad had a brown ring shaped stain, and the hallway outside the resident's room had an a foul urine odor.
Observation on 11/30/22 at 7:03 A.M., showed the resident lay in bed on his/her back. Further observation, showed the resident's bed sheets and incontinence paid had a brown ring shaped stain, and the hallway outside the resident's room had a foul urine odor.
Observation on 12/1/22 at 8:06 A.M., showed the resident lay in bed on his/her back. Further observation, showed the resident's room had a foul urine odor.
Observation on 12/1/22 at 9:54 A.M., showed the resident lay in bed on his/her back with a wet gown on. Further observation, showed the resident's bed was wet through the incontinence pad and linens to the mattress and required a full linen change. Additional observation, showed the resident's room had a foul urine odor.
During an interview on 12/1/22 at 9:54 A.M., CNA J said he/she had not been able to change the resident until now. He/She said he/she did not know when the night shift changed him/her last. CNA J said staff checks the resident after breakfast.
During an interview on 12/1/22 at 10:25 A.M., LPN L said staff are supposed to provide repositioning and perineal care every two hours. He/She said staff turn the resident three times in an eight hour period. LPN L said the resident is positioned on his/her back to keep dressings in place.
Observation on 12/1/22 at 4:40 P.M., showed the resident lay in bed. Further observation, showed the bed wet, and a foul urine odor in the resident's room that continued into the hallway.
Observation on 12/2/22 at 11:01 A.M., showed the resident lay in bed on his/her back. He/She had no dressing in place to his/her buttocks, and the room had a foul urine odor.
During an interview on 12/2/22 at 11:01 A.M., the resident said his/her bottom is sore.
Observation on 11/29/22 at 8:17 A.M., showed a strong urine odor lingered in the resident's room. Further observation, showed the resident lay on his/her back in bed.
Observation on 11/29/22 at 9:39 A.M., showed a strong urine odor lingered in the resident's room. Further observation, showed the resident lay on his/her back in bed.
6. Review of Resident #33's Quarterly MDS, dated [DATE], showed staff assessed the resident as:
-Cognitively impaired;
-Rejected care one to three days out of seven days in the look back period (period of time used to completed the assessment);
-Required extensive assistance from two staff members for bed mobility, transfers, dressing, toileting, personal hygiene and bathing;
-Had frequent incontinence of bladder and always incontinent of bowel;
-Had diagnosis of traumatic brain injury (TBI, brain dysfunction from an injury to the head);
Review of the resident's care plan, dated 11/4/22, showed staff were directed to:
-Give short and simple directions with reminders for ADLs;
-Promptly assist the resident to the bathroom every two hours as needed;
-Turn and reposition the resident every two hours if he/she is unable to do so.
Review showed it did not contain direction for staff in regard to facial hair preferences or personal hygiene.
Review of the resident's Braden Scale for Predicting Pressure Sore Risk Assessment, dated 10/20/22, showed staff documented the resident scored a 12, which indicated he/she was at high risk for developing pressure ulcers.
Observation on 11/28/22 at 11:51 A.M., showed the resident sat in a wheelchair at the nurse's station. Further observation, showed the resident had facial hair to their chin and upper lip.
Observation on 11/28/22 at 12:24 A.M. through 11/28/22 at 1:00 P.M., showed the resident sat in a wheelchair in the dining room.
Observation on 11/28/22 at 1:02 P.M., showed NA N wheeled the resident in a wheelchair to the nurse's station.
Observation on 11/28/22 from 1:14 P.M. to 3:54 P.M., showed the resident sat in a wheelchair at the nurse's station with facial hair to their chin and upper lip. Further observation, showed the resident had a red substance on their face.
Observation on 11/28/22 at 3:54 P.M., showed an unidentified staff member wheeled the resident in a wheelchair to the dining room. The staff member did not offer to assist the resident with toileting or repositioning.
Observation on 11/28/22 at 4:10 P.M., showed the resident sat in a wheelchair in the dining room.
Observation on 11/29/22 at 7:56 A.M., showed the resident sat in a wheelchair at the nurse's station with facial hair to their chin and upper lip. Further observation, showed the resident wore the same clothes he/she had on 11/28/22.
Observation on 11/29/22 at 8:12 A.M., showed the resident in a wheelchair at the nurse's station. Further observation, showed the resident continued to have the same clothes on as he/she had on 11/28/22. Additional observation, showed the resident had facial hair to his/her chin and upper lip.
Observation on 11/29/22 at 8:21 A.M., showed the resident sat in a wheelchair at the nurse's station with his/her eyes closed. Further observation, showed the resident had facial hair on his/her chin and upper lip.
Observation on 11/29/22 at 8:37 A.M. to 9:27 A.M., showed the resident sat in a wheelchair at the nurse's station and wore the same clothes he/she wore on 11/28/22. Further observation, showed the resident continued to have facial hair on their chin and upper lip.
Observation on 11/29/22 at 9:30 A.M., showed the resident sat in a wheelchair at the nurse's station. Further observation, showed the resident leaned to the right.
Observation on 11/29/22 at 9:39 A.M., showed the resident in a wheelchair at the nurse's station, and leaned to the right. Further observation, showed the resident wore the same clothes he/she wore on 11/28/22 and continued to have facial hair to his/her chin and upper lip.
Observation on 11/29/22 at 10:01 A.M. to 10:24 A.M., showed the resident in a wheelchair at the nurse's station. Further observation, showed the residents eyes were closed, and he/she leaned in the wheelchair. The resident wore the same clothes he/she wore on 11/28/22, and had facial hair to his/her chin and upper lip.
Observation on 11/29/22 at 10:35 A.M., showed the Director of Nursing (DON) asked the resident they wanted to lay down. Further observation, showed the DON told an unidentified nurse and CNA to lay the resident down. The DON did not address resident's clothes, or facial hair. Additional observation, showed the resident leaned to one side of the wheelchair.
Observation on 11/29/22 at 10:44 A.M., showed the resident in a wheelchair at the nurse's station. Further observation, showed the DON walked by the resident and did not offer assistance.
Observation on 11/29/22 at 10:55 A.M., showed the resident sat in a wheelchair at the nurse's station, and wore the same clothes.
Observation on 11/29/22 at 10:58 A.M., showed the resident sat in a wheelchair at the nurse's station. Further observation, showed the resident's right arm and hand rested on the metal by the wheelchair wheel.
Observation on 11/29/22 at 11:02 A.M., showed the resident sat in a wheelchair at the nurse's station, and wore the same clothes. The resident continued to have facial hair to his/her chin and upper lip. Further observation, showed the DON and a an unidentified CNA walked by the resident and did not offer assistance.
Observation on 11/29/22 at 11:28 A.M., showed the resident sat in a wheelchair in the dining room, with the same clothes on, and with facial hair to his/her chin and upper lip.
Observation on 11/29/22 at 11:48 A.M., showed the resident sat in a wheelchair in the dining room.
Observation on 11/29/22 at 11:58 A.M. to 12:08 P.M., showed the resident sat in a wheelchair in the dining room and watched television.
Observation on 11/29/22 at 12:13 P.M. to 1:19 P.M., showed the resident in a wheelchair in the dining room and ate lunch.
Observation on 11/29/22 at 1:21 P.M., showed CNA J pushed the resident in a wheelchair from the dining to the nurse's station.
Observation on 11/29/22 at 1:30 P.M., showed CNA K took the resident from the nurse's station to his/her room.
Observation on 11/29/22 at 1:31 P.M., showed CNA K and CNA J assisted the resident to bed. The resident's brief was saturated with urine, and soiled with fecal matter. The resident's buttocks were red, and had a small circular red/purple area on the right side. Further observation, showed both of the resident's heels were purple and blanchable. Staff left the resident in bed with no brief on, and covered him/her with a sheet. CNA K and CNA J then left the room.
Observation on 11/29/22 at 1:32 P.M., showed the resident wore the same shirt, and had facial hair to his/her chin and upper lip.
Observation on 11/30/22 at 8:35 A.M., showed the resident sat in a wheelchair at the nurse's station with facial hair to chin and upper lip.
Observation on 11/30/22 at 9:19 A.M., showed the resident sat in a wheelchair at the nurse's station with facial hair to chin and upper lip.
Observation on 11/30/22 at 9:49 A.M., showed the resident in a wheelchair at the nurse's station.
Observation on 11/30/22 at 10:07 A.M., showed the resident in his/ her wheelchair at the nurse's station.
Observation on 12/1/22 at 4:30 P.M., showed the resident at the nurses station with facial hair to chin and upper lip.
During an interview on 12/12/22 at 3:34 P.M., NA V said the resident is always in bed when he/she arrives at the facility in the morning. The NA said he/she usually gets the resident dressed in the morning and provides care. He/She the resident is kept in his/her wheelchair for breakfast, lunch, and dinner, and staff have to wait until the resident is not combative to lay him/her down. He/She said the resident normally lays down around 7:30 P.M. or 8:00 P.M. The NA said he/she checks the resident or smells the resident to find out if he/she is wet. NA V said he/she does not toilet the resident because the resident is combative and wears a brief. He/She the resident is at an increased risk for skin breakdown because he/she is not regularly checked for incontinence or toileted. The NA said he/she checks the residents brief every two hours.
7. Review of Resident #34's Quarterly MDS, dated [DATE], showed staff assessed the resident as:
-Cognitively impaired;
-Has inattention behavior that fluctuates;
-Did not reject care;
-Required physical assistance from one staff member for dressing, toileting, and personal hygiene;
-Frequently incontinent of urine;
-Had diagnoses of hypertension (high blood pressure), dementia (loss of memory) and Parkinson's disease (nerve cell damage in the brain).
Review of the care plan, updated 11/18/22, showed:
-Urinary Incontinence;
-Goal to maintain current level of bladder continence;
-Provide assistance for toileting;
-Provide incontinence care after each incontinence episode;
-Remind and encourage to use the bathroom every two hours.
Observation on 11/30/22 at 8:39 A.M., showed the resident's room had a foul odor. The resident stood next to his/her bed and wore a white t-shirt that appeared wet with a yellow stain, and red shorts that appeared wet. Further observation, showed the resident got into bed and lay on a bed pad that had a dark ring shaped stain. The room had a foul odor.
Observation on 11/30/22 at 10:01 A.M., showed the resident's room had a persistent foul odor. The bed pad had a brown ring shaped stain. Further observation, showed the resident folded the bed pad in half, covering the brown ring, and then sat on the bed pad.
Observation on 11/30/22 at 11:14 A.M., showed the resident rolled up the stained brown bed pad and pushed it to the head of the bed, the sheet had brown stains and the room had a foul odor.
Observation on 12/1/22 at 10:44 A.M., showed the resident wore the same red shorts with a brown stain on the back. The bed pad had brownish yellow stains, and the room had a foul odor.
8. During an interview on 12/2/22 at 10:09 A.M., the MDS Coordinator said the residents receives showers and shaves once a week. He/She said he/she noticed the residents are dirty and appear unkempt.
During an interview on 12/2/22 at 11:38 A.M., LPN L said staff is directed to turn and reposition the residents every two hours but staff is not able to get it done. The LPN said with as many heavy care residents as the facility has the staff does the best they can.
During an interview on 12/2/22 at 1:06 P.M., the DON said he/she expects staff to shave residents during their showers. He/she if residents refuse care, staff is directed to reapproach and if they continue to refuse staff is directed to get family involved to encourage the resident. The DON said he/she expects staff to document when a resident refuses care, and this includes showers. He/she said staff is expected to turn and reposition all dependent residents every two hours to prevent skin issues. He/she said the facility has care issues because staff is tired from working additional hours.
During an interview on 12/14/22 at 12:45 P.M., Physician W said if a resident is left laying in urine for extended periods of time it could contribute to skin breakdown. The Physician said he/she expects staff to turn and reposition residents every two hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to provide activities to three dependent residents (Residents #5, #16 and #17). Additionally, staff failed to provide staff facilitated activities on the weekends. The facility census was 43.
1. Review of the facility's Activity Calendar, dated November 2022, showed staff offered the following activities:
-Bingo on 11/28/22 at 2:00 P.M.;
-Ball Toss on 11/29/22 at 10:00 A.M. and Crafts at 2:00 P.M.;
-Fun and Fit on 11/30/22 at 10:00 A.M. and Birthday Party at 2:00 P.M.
2. Review of Resident #5's Quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 9/9/22, showed staff assessed the resident as:
-Moderately Impaired Cognition;
-Totally dependent on two staff members for transfers;
-Impairment in Range of Motion (ROM) of all extremities;
-Had no behaviors;
-Locomotion on and off unit did not occur, during the seven day look back period (period of time used to complete assessment);
-Diagnoses of Anxiety Disorder, and Depression
Review of the resident's Care Plan, revised 11/15/22, showed:
-Give short and simple direction with activities;
-Provide with activity calendar and inform of activities coming up;
-Encourage to socialize during group activities;
-Provide reassurance and feelings of inclusion, due to history of abandonment or isolation.
Observation on 11/28/22 at 2:15 P.M., showed the Activity Director (AD) held a group activity in the dining room. Further observation, showed the resident did not attend the activity.
Observation on 11/29/22 at 10:10 A.M. through 10:49 A.M., showed facility staff held a group activity. Further observation, showed the resident did not attend the activity.
Observation on 11/29/22 at 2:15 P.M., showed facility staff held a holiday crafts activity in the main dining room. Further observation showed the resident did not attend the activity.
Observation on 11/30/22 at 10:00 A.M., showed the AD entered the resident's room and invited the resident's roommate to the Fun and Fitness group activity. Further observation showed the AD left the room and did not invite Resident #5 to the activity.
3. Review of Resident #16's Quarterly MDS, dated [DATE], showed staff assessed the resident as:
-Severely Impaired Cognition;
-Totally dependent on two staff members for transfers;
-Totally dependent on one staff member for locomotion on and off unit;
-Did not have behaviors;
-Diagnoses of Dementia (progressive or persistent loss of intellectual function) and Stroke (damage to the brain from interruption of it's blood supply).
Review of the resident's Care Plan, dated 10/25/22, showed:
-Resident at risk for inadequately being able to meet his/her own needs, due to cognitive deficits;
-Give short and simple directions and reminder of activities;
-Provide activity calendar and inform of activities coming up;
-Attend activities the resident enjoys with encouragement of staff;
-Provide reassurance and feelings of inclusion, due to history of abandonment or isolation.
Observation on 11/28/22 at 2:15 P.M., showed the Activity Director held a group activity in the dining room. Further observation, showed the resident did not attend the activity.
Observation on 11/29/22 at 10:10 A.M. through 10:49 A.M., showed the resident sat in his/her room. The resident did not attend the activity.
Observation on 11/29/22 at 2:15 P.M., showed facility staff held a holiday crafts activity in the main dining room. Further observation showed the resident did not attend the activity.
4. Review of Resident #17's Quarterly MDS, dated [DATE], showed staff assessed the resident as:
-Severely impaired cognition;
-Totally dependent on two staff members for transfers;
-Totally dependent on one staff member for locomotion on and off unit;
-Did not have behaviors;
-Diagnoses of Aphasia (language disorder that affects a person's ability to communicate), Hemiplegia (paralysis of one side of the body) and Stroke (damage to the brain from interruption of it's blood supply).
Review of the resident's Care Plan, dated 10/25/22, showed staff documented the resident was at risk for inadequately being able to meet his/her own needs, due to cognitive deficits.
Observation on 11/28/22 at 2:58 P.M., showed the AD held a group activity in the dining room. Further observation, showed the resident did not attend the activity.
Observation on 11/29/22 at 10:10 A.M. through 10:49 A.M., showed facility staff held group activity. Further observation, showed the resident did not attend the activity.
Observation on 11/29/22 at 2:15 P.M., showed held a holiday crafts activity in the main dining room. Further observation showed the resident did not attend the activity.
5. During an interview on 11/28/22 at 2:18 P.M., Resident #295 said staff do not encourage residents to attend activities.
During an interview on 11/30/22 at 1:16 P.M., CNA J said he/she does not pay attention to the activities. The CNA said activity staff ask the residents if they want to go to activities. The CNA said he/she did not know why the dependent residents don't go to activities. The CNA said the dependent residents would need someone to sit with them during the activity, and they don't have enough staff to do that.
During an interview on 12/1/22 at 3:25 P.M., the AD said he/she normally asks Resident #16 and #17 to attend activities. The AD said he/she should have asked them to attend. He/she said Resident #5 does not like to participate in activities and he/she did not know what his/her care plan said in regard to activities.
During an interview on 12/6/22 at 1:06 P.M., the Director of Nursing (DON) said now that the Activity Director is back, he/she is doing more things to make the residents feel better, like more crafts. He/she said the dependent residents should be invited to activities and he/she did not know they were not being invited. He/she said Resident #16 usually has an activity rug, but he/she said he/she did not know why it wasn't offered. The DON said staff is expected to invite all the residents to activities.
6. Review of the facility's Activity Calendar, dated October 2022, showed staff offered the following weekend activities:
-Leisure activity of choice on 10/1/22;
-Leisure activity of choice and coloring club (facilitated by a resident) on 10/2/22;
-Leisure activity of choice and puzzle packet on 10/8/22;
-Leisure activity of choice and coloring club on 10/9/22;
-Leisure activity of choice and puzzle packet on 10/15/22;
-Leisure activity of choice and coloring club on 10/16/22;
-Leisure activity of choice and puzzle packet on 10/22/22;
-Leisure activity of choice and coloring club on 10/23/22;
-Leisure activity of choice and puzzle packet on 10/29/22;
-Leisure activity of choice and coloring club on 10/30/22.
7. Review of the facility's Activity Calendar, dated November of 2022, showed staff offered the following weekend activities:
-Leisure activity of choice on 11/5/22;
-Leisure activity of choice and coloring club on 11/6/22;
-Leisure activity of choice and puzzle packet on 11/12/22;
-Leisure activity of choice and coloring club on 11/13/22;
-Puzzle packet and happy birthday to a resident on 11/19/22;
-Leisure activity of choice and coloring club on 11/20/22;
-Leisure activity of choice and puzzle packet on 11/26/22;
-Leisure activity of choice and coloring club on 11/27/22.
8. During an interview on 11/28/22 at 2:18 P.M., Resident #295 said staff do not provide activities on the weekends.
During a group interview on 11/29/22 at 3:05 P.M., the resident council members said staff do not provide scheduled activities on the weekends.
During an interview on at 12/02/22 10:54 A.M., CNA J said staff do not provide activities on the weekend.
During an interview on 12/1/22 at 3:25 P.M., the AD said there are no structured activities offered on the weekends, but he/she does pass out an activity packet that includes word searches, coloring pages, mazes and inspirational quotes. He/She said one resident holds a coloring group and will do pool noodle activities when he/she returns from church services. He/She said weekend activities are not offered for dependent residents.
During an interview on 12/6/22 at 1:06 P.M., the Director of Nursing (DON) said on the weekends they have ice cream socials, but it is harder to complete activities because there is less staff. He/she said the AD does not plan weekend activities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to properly propel two resident's (Resident #12 and #29) in wheelchairs in a manner to prevent accidents. Additionally, staff failed to ensure razors/sharps and hazardous chemicals were stored in a safe manner, and failed to lock an unattended medication cart. The facility census was 43.
Review of the facility's Wheelchair, Use of Policy, undated, showed:
-The purpose is to provide mobility for the non-ambulatory resident with safety and comfort and to provide mobility for residents learning to become independent in activities of daily living;
-Lower footrests and place resident's feet on footrests if used. Position feet and legs in a good body alignment;
-Assist resident to the area of the facility desired. Encourage and instruct resident in proper guidelines for safely propelling the wheelchair.
1. Review of Resident #12's Quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 10/15/22, showed staff assessed the resident as:
-Severe cognitive impairment;
-Required extensive assistance from two staff members for bed mobility and transfers;
-Required extensive assistance from one staff member for locomotion on and off unit;
-Used a wheelchair.
Observation on 11/29/22 at 7:48 A.M., showed the Social Service Designee (SSD) propelled the resident down the hallway without foot pedals. Further observation showed the resident's foot bounced on the floor.
During an interview on 11/29/22 at 7:51 A.M., the SSD said staff are directed to use foot pedals when propelling residents. He/She said he/she propelled the resident in his/her wheelchair every day without foot pedals. He/She said the resident can be injured if not properly propelled.
2. Review of Resident #29's Quarterly MDS, dated [DATE], showed staff assessed the resident as:
-Cognitively impaired;
-Required supervision from one staff member for locomotion (moving) around the unit;
-Used a wheelchair.
Observation on 11/30/22 at 5:00 A.M., showed Registered Nurse (RN) O propelled the resident to the dining room without foot pedals. Further observation showed the resident's right heel audibly dragged on the floor.
During an interview on 12/2/22 at 11:00 A.M., Certified Nurse Aide (CNA) J said staff should not propel residents in their wheelchairs without foot pedals. He/She said the resident could fall out of the wheelchair and be injured if not propelled properly.
During an interview on 12/2/22 at 1:06 P.M., the Director of Nursing (DON) said staff are directed no pedals, no push. He/she said the resident could be injure if staff do not use the foot pedals.
3. Review of facility policies provided showed no policy for chemical storage.
Observation on 11/30/22 at 4:18 A.M., showed the 100 hall spa unlocked and unattended with a hairdryer over the sink, plugged in, with the cord on the faucet. An unlocked and unattended cabinet contained:
-One open container of nail polish remover, labeled Contact Poison Control if ingested;
-Two razors;
-One open container of Microkill Wipes (disinfecting wipes), labeled Contact Poison Control if ingested;
-One open container of Wipe's Plus Disinfecting Wipes, labeled Contact Poison Control in ingested.
Observation on 11/30/22 at 4:24 A.M., showed a sign on the back of the 100 hall spa door that read Make sure shower cabinet is locked when done in the shower room.
Observation on 12/1/22 at 4:30 P.M., showed the 100 hall spa unlocked and unattended.
Further observation showed an unlocked and unattended cabinet that contained:
-One open container of nail polish remover, labeled Contact Poison Control if ingested;
-Two razors;
-One open container of Microkill Wipes (disinfecting wipes), labeled Contact Poison Control if ingested;
-One open container of Wipe's Plus Disinfecting Wipes, labeled Contact Poison Control in ingested.
Observation on 12/1/22 at 4:30 P.M., showed a confused resident wandered near the spa.
During an interview on 11/30/22 at 6:09 A.M., Nurse Aide (NA) S said the spas should be locked to keep chemicals secured and out of resident reach. He/She said the shower aide is responsible to ensure the spas are locked.
During an interview on 11/30/22 at 1:23 P.M., Certified Nurse Aide (CNA) K said the facility has a lot of residents who wander. He/She said the spa door and the cabinet in the spa should be locked when not in use or unsupervised. He/She said the NAs and CNAs are responsible to ensure they are locked.
During an interview on 12/2/22 at 11:36 A.M., Licensed Practical Nurse (LPN) L said sharps and chemicals should always be locked up when not in use.
During an interview on 12/2/22 at 1:06 P.M., the Director of Nursing (DON) said sharps and chemicals should be locked up and out of resident reach for safety. He/she said the shower rooms have a locking cabinet but the lock is lost and the maintenance supervisor plans to replace it. He/she said it is important the shower rooms are locked to keep residents from accidentally wandering in there. He/she said the facility has residents who wander.
4. Review of the facility's Medication Storage Policy, undated, showed:
-All medications for resident's must be stored at or near the nurse's station in a locked cabinet, a locked medication room, or one or more locked mobile medication carts;
-An unattended medication cart must remain locked at all times;
-The cart must be locked before leaving it, or secured in a locked medication room.
Observation on 11/29/22 showed Resident #33 yanked and pulled on the medication cart drawers. An unidentified CNA walked by, locked the medication cart, and redirected the resident.
Observation on 11/30/22 at 4:12 A.M., showed an unlocked and unattended medication cart that contained prescribed patient medications and stock medications.
Observation on 11/30/22 at 5:06 A.M., showed RN O obtained medications from the unlocked medication cart and walked away without locking the medication cart. The medication cart contained:
-Twelve resident stocked medication cards;
-One Epinephrine pen (used to treat allergic reactions);
-One bag of vials of Acetylcysteine solution 10% (helps to loosen or then mucus in the lungs);
-Seven Narcan sprays (a reversal for severe pain medications);
-One Progesterone injection (hormone injection).
Observation on 11/30/22 at 5:15 A.M., showed RN O locked the medication cart.
Observation on 11/30/22 at 8:57 A.M., showed a medication cart unlocked and unattended with three residents around it. The medication cart contained:
-Twelve resident stocked medication cards;
-One Epinephrine pen (used to treat allergic reactions);
-One bag of vials of Acetylcysteine solution 10% (helps to loosen or then mucus in the lungs);
-Seven Narcan sprays (a reversal for severe pain medications); and
-One Progesterone injection.
Observation on 11/30/22 at 9:17 A.M., showed Licensed Practical Nurse (LPN) L locked the medication cart.
During an interview on 12/2/22 at 11:36 A.M., LPN L said staff is expected to lock the medication cart when they leave it. He/she said he/she should have locked it but didn't. He/she said residents could get into the cart if left unlocked.
During an interview on 12/2/22 at 1:06 P.M., the DON said staff is expected to lock the medication cart when they leave it and the cart is out of their line of sight. He/she said the facility has residents who wander, and they would be able to get in the carts.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to ensure two dependent residents (Residents #5 and #16) were offered sufficient fluid intake to maintain proper hydration and health. The facility census was 43.
1. Review of the facility's Hydration Policy, undated, showed staff are directed to offer fluids to residents as follows:
-On arising, 120 (cc) of water;
-Breakfast, 400 (cc) of fluid;
-Mid-morning, 240 (cc) of fluid;
-Lunch, 400 (cc) of fluid;
-Mid-afternoon, 240 (cc) of fluid;
-After nap, 240 (cc) of fluid;
-Supper, 400 (cc) of fluid;
-Bedtime, 240 (cc) of fluid;
-At night offer 120 cc of fluid every two hours, if the resident is awake;
-Fresh water will be distributed each shift, pitchers and glasses are within reach of the resident and residents who are unable to pour and drink independently will be assisted by the staff.
2. Review of Resident #5's Quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 11/1/22, showed staff assessed the resident as:
-Moderately impaired cognition;
-Did not reject care;
-Totally dependent on one staff member for dressing and eating;
-Totally dependent on two staff members for bed mobility, transfers and personal hygiene;
-Impairment in Range of Motion (ROM) to all extremities;
-Had a catheter.
Review of the resident's Care Plan, revised 11/15/22, showed staff are directed to:
-Keep call light in reach at all times;
-Total assistance from staff with all Activities of Daily Living (ADL);
-The nurse will observe for signs and symptoms of Urinary Tract Infection (UTI), such as strong foul odor of urine;
-Encourage to drink fluids during activities;
-Staff will encourage to optimize his/her hydration status;
-At risk for Dehydration, nursing staff will encourage fluid intake;
-Nursing staff will ensure water is at bedside.
Observation on 11/28/22 at 10:57 A.M., showed the resident lay in bed, awake, without his/her call light. Further observation, showed the resident's hands were contracted. Additional observation, showed no water or fluids at the resident's bedside or in his/her room.
Observation on 11/28/22 at 12:18 P.M., Showed the resident lay in bed, awake, without his/her call light. Further observation, showed the Administrator stopped at the resident's door, said hi and left. The administrator did not offer the resident a drink, or ensure the resident had his/her call light.
Observation on 11/28/22 at 2:25 P.M., showed the resident lay in bed, awake, without his/her call light. Further observation, showed no water or fluids at his/her bedside.
During an interview 11/28/22 at 2:25 P.M., the resident said he/she is thirsty.
Observation on 11/29/22 at 8:28 A.M., showed the resident lay in bed, without his/her call light. Further observation, showed no water or other fluids at his/her bedside.
Observation on 11/29/22 at 9:38 A.M., showed the resident lay in bed, without his/her call light. Further observation, showed no water or other fluids at his/her bedside.
Observation on 11/30/22 at 9:29 A.M., showed Certified Nursing Assistant (CNA) J entered the resident's room to readjust the resident's oxygen tubing. CNA J left the room and did not offer the resident fluid. Further observation, showed no water or other fluids in the resident's room or at his/her bedside.
Observation on 11/30/22 at 10:00 A.M., showed the Activity Director (AD) entered the resident's room, and spoke with resident's roommate. The AD did not offer the resident fluid before he/she left the room. Further observation, showed no water or other fluids in the resident's room or at his/her bedside.
Observation on 11/30/22 at 10:26 A.M., showed Nurse Aide (NA) M entered the resident's room and asked the resident what he/she wanted for lunch. NA M did not offer the resident a drink before he/she left the room.
Observation on 11/30/22 at 10:55 A.M., Showed NA M entered the resident's room, spoke with resident's roommate, and left the room. Further observation, showed the NA did not offer the resident a drink before he/she left the room.
Observation on 11/30/22 at 11:46 A.M., showed the resident had cracks around the edges of his/her tongue, a white film in the corners of his/her mouth, and cracked lips.
During an interview on 11/30/22 at 11:46 A.M., the resident said he/she is thirsty.
Observation on 11/30/22 12:07 P.M., showed Licensed Practical Nurse (LPN) L fed the resident in his/her room. The resident's tray had three bowls of pureed food and a glass of lemonade and root beer. Further observation, showed the resident drank the entire glass of lemonade. The LPN did not offer the resident water.
3. Review of Resident #16's Quarterly MDS, dated [DATE], showed staff assessed the resident as:
-Severely impaired cognition;
-Totally dependent on one staff member for locomotion on and off unit;
-Did not have behaviors;
-Required extensive assistance from one staff member for eating;
-Utilized a wheelchair.
Review of the resident's Care Plan, dated 10/25/22, showed staff are directed to:
-Resident at risk for inadequately being able to meet his/her own needs, due to cognitive deficits;
-Sometimes has trouble making needs known;
-May use a wheelchair propelled by staff;
-Make sure call light is in reach;
-Encourage to optimize hydration
-Staff will encourage to optimize nutritional status;
Observation on 11/28/22 at 11:30 A.M., showed the resident sat in a Broda chair (reclining wheelchair) in the hallway with no fluids in reach.
Observation on 11/28/22 at 12:53 P.M., showed the resident sat in a Broda chair at a dining room table, with food and drink placed in front of him/her. Further observation, showed the resident fed himself/herself and drank fluid independently.
Observation on 11/28/22 at 2:15 P.M. showed the resident sat in a Broda chair in the hallway with no fluids in reach.
Observation on 11/29/22 at 8:09 A.M., showed the resident sat in a Broda chair in the hallway with no fluids within reach. Observation continued to 9:26 A.M. when staff assisted the resident to his/her room, and sat him/her in front of the television in his/her Broda chair. Additional observation, showed the staff member left the resident's room without offering the resident a drink or ensuring the resident had fluid within reach.
Observation on 11/29/22 at 10:49 A.M., showed the resident continued to sit in Broda chair in front of television, in his/her room. Further observation, showed the resident had no fluid within reach.
Observation on 11/29/22 at 12:14 P.M., showed the resident had been served a glass of ice water and lemonade. The resident drank both drinks.
During an interview on 11/30/22 at 1:16 P.M., CNA J said staff should offer fluid to dependent residents every 30 minutes. CNA J said he/she had not offered Resident #5 a drink. The CNA said staff did not offer fluids to the residents because they did not pass ice water. The CNA said the ice machine does not work half the time.
During an interview on 12/02/22 at 10:54 A.M., CNA J said when monitoring residents for dehydration he/she monitors the smell and color of the resident's urine, and for increased confusion. CNA J said Resident #5 has increased confusion, and his/her urine is dark with a strong odor.
During an interview on 12/2/22 at 11:23 A.M., LPN L said staff is expected to offer water or a drink every time they go into a resident's room if the resident is awake. He/she said water or a drink should be offered every time staff provide care. The LPN said staff is expected to report signs and symptoms of dehydration. He/She they should report dry mucous membranes (mouth), dry skin, lethargy, decreased urine output, and dark, thick and foul smelling urine.
During an interview on 12/2/22 at 1:06 P.M., the DON said staff is expected to offer the residents water at least every two hours, and during meals. He/She said staff should offer fluids to residents at night time if the resident is awake.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, facility staff failed to ensure licensed nursing staff had the required skills and competencies to meet the care needs for one resident (Resident #95) with a tracheostomy (an artificial opening into the trachea). Additionally, facility staff failed to ensure two Nurse Aide (NA)s completed the nurse aide training program within four months of his/her hire date. The facility census was 43.
1. Review of the facility's Tracheostomy Care policy, dated March 2012, showed an emergency tracheostomy tube and reinsertion supplies should be at the bedside and a resuscitation bag (ambu bag) should be available.
Review of the facility's Facility Assessment, dated 12/21/21, showed:
-Facility staff will assess the competency of staff as it relates to the residents' care needs and determine if any additional education should be provided, and who could provide it;
-Facility staff could provide tracheostomy care;
-Competencies to include tracheostomy care and suctioning;
-Ongoing in-servicing to ensure competency with ongoing evaluation.
Review of Registered Nurse (RN) O and Licensed Practical Nurse (LPN) L's training packets, undated, showed routine tracheostomy care (listed as changing ties, etc.) and suctioning training completed. Review showed the RN and LPN's training packets did not contain emergency tracheostomy care training.
Review of Resident #95's face sheet and physician orders, dated November 2022, showed:
-admitted [DATE];
-Had diagnoses of Hemiplegia (one-sided weakness), stroke, and atrial fibrillation (irregular heartbeat);
-Did not use mechanical ventilation or oxygen.
Review showed the resident's Physician Orders, dated 11/1/22 to 11/30/22 did not contain an order for tracheostomy type and size.
Observation on 11/29/22 at 11:07 A.M., showed the Director of Nursing (DON) provided tracheal suction for the resident. The DON said he/she was unable to locate a spare tracheostomy tube in the resident's room.
During an interview on 11/29/22 at 11:22 A.M., the DON said residents with a tracheostomy tube should have a spare tracheostomy tube at the bedside. He/she said the resident had a bag of supplies, but it did not have a spare tracheostomy tube in it.
During an interview on 11/30/22 at 4:22 A.M., RN O said residents with a tracheostomy tube do not have spare tracheostomies or ambu bags (resuscitation bag) in their rooms. He/she said he/she would not feel comfortable putting a tracheostomy tube back in or changing one. He/she said the facility had not offered him/her training in regard to tracheostomy care.
During an interview on 12/2/22 at 11:23 A.M., LPN L said if a resident's tracheostomy tube became dislodged or came out, he/she would call 911. He/She said the facility had not offered him/her education in regard to replacing a tracheostomy tube.
2. During an interview on 12/2/22 at 1:06 P.M., the Director of Nursing said the facility did not have a NA Training Policy.
3. Review of NA M's training packet showed:
-NA M had a hire date of 4/20/21;
-NA M had not completed a NA program.
The facility failed to ensure the completion of the program within four months of the NA's hire date.
4. Review of NA N's training packet showed:
-NA N had a hire date of 12/29/21;
-NA N had not completed a NA program.
The facility failed to ensure the completion of the program within four months of the NA's hire date.
5. During an interview on 12/2/22 at 1:06 P.M., the Director of Nursing (DON) said the NAs had not been able to complete a NA training program because the facility has had a lot of staffing issues causing the NAs to be pulled to the floor to work. He/she said he/she is aware the NAs are required to be certified within 4 months of their hire date.

Based on observation, interview, and record review, facility staff failed to post the required nurse staffing information, which included the total number of both licensed and unlicensed nursing staff directly responsible for resident care, per shift, and the resident census on a daily basis. The facility census was 43.
1. Review of the policies staff provided on 12/2/22 at 1:00 P.M., showed they did not have a policy for Staff Hour Posting.
Review of the facility's Daily Staff Postings from 11/17/22 to 11/27/22 showed the postings did not contain the resident census or the total number of staff, per shift, licensed or unlicensed.
Observations from 11/28/22 at 10:00 A.M. through 12/1/22 at 4:00 P.M., showed the facility staff posting did not contain the resident census or the total number of staff, per shift, licensed or unlicensed.
During an interview on 12/2/22 at 11:23 A.M., Licensed Practical Nurse (LPN) J said the nurse staff posting should contain the resident census, the title of staff members working. He/she said the night nurse is responsible for ensuring the posting is completed and posted.
During an interview on 12/2/22 at 1:06 P.M., the Director of Nursing (DON) said the nurse staff posting should include the name of the facility, the title of the staff, and the resident census. He/she said he/she had not reviewed the postings for accuracy, because he/she had recently started the DON position.