Every finding on record at Arrowhead Senior Living Community

Based on observation, interview, and record review, facility staff failed to follow appropriate infection control practices during perineal care for one resident (Resident #39) out of 18 sampled residents and during wound care for three residents (Resident #27, #28 and #1) of four sampled residents with wounds. Facility staff also failed to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease, a serious type of pneumonia (lung infection) caused by Legionella bacteria. This failure has the potential for the failure of staff to identify and mitigate the presence of waterborne pathogens, which places all residents of the facility at risk of exposure which could lead to illness. The facility census was 51. 1. Review of the facility policies showed facility staff did not provide a policy for when to change gloves during perineal care or wound care. Review of the facility's Competency Checklist titled Hand Hygiene and Glove use, undated, showed facility staff are to wash or sanitize hands before applying gloves and gloves should be removed when completing a task, when leaving the room, or when handling objects such as drawers, call light, etc., dispose of gloves in a waste container and sanitize hands immediately after removing gloves. Review of the facility's Competency Checklist titled Wound Care, undated, showed facility staff are to: -Cleanse hands and put on gloves; -Remove soiled dressings and dispose in trash can; -Cleanse hands and put on clean gloves; -Cleanse wound. 2. Observation on 04/08/26 at 2:02 P.M., showed the Infection Preventionist (IP) provided wound care to Resident #27's right foot. The IP put on a gown, washed hands, put on gloves, removed the resident's sock, removed the soiled dressing to the resident's right foot, and with the same gloves, cleansed the resident's wound with sterile gauze. 3. Observation on 04/09/26 at 9:12 A.M., the IP provided wound care to Resident #28's left leg. The IP put on a gown, washed hands, put on gloves, removed drainage stained tubi-grips (sleeves to provide compression) from the resident's leg, removed rolled gauze, and with the same soiled gloves cleansed multiple wounds to the resident's right leg. 4. Observation on 04/09/26 at 10:08 A.M., showed Certified Nurse Aide (CNA) A and Certified Medication Technician (CMT) G entered resident #39's room to provide perineal care. CNA A and CMT G washed hands, applied gloves, and transferred the resident to the toilet with a sit to stand lift. CNA A pulled down the resident's pants and brief, removed the resident's urine saturated brief, rolled the brief, placed the brief in the trash can and with the same soiled gloves on put a clean brief on the resident. Observation showed the CNA touched the sit to stand lift, the resident's clean pants, and the resident's shirt with the same gloves on. During an interview on 04/09/26 at 10:24 A.M., CNA A said he/she should have changed his/her gloves and washed hands after he/she touched the resident's urine saturated brief and before he/she touched the resident's clean brief, pants, lift and the resident's shirt. The CNA said he/she did not think about it at the time. During an interview on 04/10/26 at 12:36 P.M., LPN E said staff are expected to wash hands and change gloves from dirty to clean tasks. The LPN said staff should have changed gloves and washed hands between touching the resident's urine saturated brief and then touching the clean brief and other clean items. 5. Observation on 04/09/26 at 10:31 A.M., showed the IP and Licensed Practical Nurse (LPN) E provided wound care to Resident #1. Observation showed the IP put on a gown, washed hands, put on gloves, removed the soiled dressing to the resident's left heel, and with the same soiled gloves on cleansed the left heel wound, removed his/her gloves, washed hands and then performed the treatment. Observation showed the IP removed his/her gloves, washed hands, applied clean gloves, removed the soiled dressing from the resident's right heel, and with same gloves on cleansed the right heel wound. The IP removed his/her gloves, washed hands and performed the right heel treatment. Observation showed the IP removed his/her gloves, washed hands, removed the dressing to the resident's left great toe, and cleansed the wound with the same gloves on. During an interview on 04/09/26 at 11:22 P.M., the IP said he/she has been taught to remove the soiled dressing, cleanse the wound and then change gloves and wash hands. The IP said that is what he/she did. 6. During an interview on 04/10/26 at 12:36 P.M., LPN E said staff are expected to wash hands and change gloves from dirty to clean tasks. During an interview on 04/10/26 at 12:30 P.M., the Director of Nursing (DON) said staff should change gloves and wash hands after removing a soiled dressing during wound care. He/She said the reason you change gloves and wash hands is because the dressing is dirty. The DON said during perineal care staff should wash hands and change gloves from dirty to clean tasks and anytime the gloves become soiled. 7. Review of the Centers for Medicare and Medicaid Services (CMS), QSO-17-30, dated 06/02/17 and revised 07/06/18, showed CMS expects Medicare and Medicare/Medicaid 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. Facilities must have water management plans and documentation that, at a minimum, ensure each facility: -Conducts 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; -Develops and implements a water management program that considers the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) industry standard and the Centers for Disease Control and Prevention (CDC) toolkit; -Specifies testing protocols and acceptable ranges for control measures and documents the results of testing and corrective actions taken when control limits are not maintained; -Maintains compliance with other applicable Federal, State and local requirements; -Note: CMS does not require water cultures for Legionella or other opportunistic water borne pathogens. Testing protocols are at the discretion of the provider. Review of the facility's Water Management Program (WMP): Legionella, undated, showed a Water Management Team (WMT) has been established which includes the administrator, Plant Operations Director, Safety Officer, Water Treatment Contractor, Director of Nursing (DON), Medical Director and Quality Assurance Director. Review showed: -With initiation of this WMP in February 2019, samples of water will be taken and tested through a contracted vendor. This testing will be done annually through various points throughout the water system; -The WMT understands the water systems, monitors and documents program performance annually; -Control measures have been established and corrective actions will be utilized if controls are not within limits; -The Plant Operations Director will oversee control locations and limits and report outliers to the team; -WMP will be documented and all activities will be communicated in safety and quality assurance meetings quarterly -Verification of water management within building will be done by the Plant Operations Director. Review of the facility's WMP, showed the records did not contain: -A written description of the building's water system; -A facility specific risk assessment; -Control measures related to identified risk areas; -Corrective actions to take if control measures are not within specified ranges; -Complete documentation of annual water system testing. Review of the facility's inspection, testing and maintenance records showed the Plant Operations Director documented all locations were tested on [DATE] and passed using Legionella test kits. Reviewed showed the records did not contain a list of sampled locations. Observations on 04/08/26 during the Life Safety Code tour showed the facility equipped with three ice machines and multiple resident room showers throughout the facility. Observation showed the kitchen ice machine drainpipe ended below a white plastic cover on the floor drain and did not contain an air gap. Observation showed the drains on two ice machines located in resident dining areas were connected directly to sink p-traps and did not contain air gaps. Observation showed shower heads were hung in a manner which created a U in the shower hose, and many were not in regular use. During an interview on 04/10/2026 at 12:52 P.M., the Infection Preventionist (IP) said he/she monitored residents for respiratory symptoms as part of the IP program and if he/she noticed any resident trends in respiratory illness he/she would report the issue to the administrator. The IP said he/she did not do anything building related as part of the IP program. During an interview on 04/09/26 at 10:55 A.M., the Plant Operations Director said he/she and the administrator reviewed the plan in January 2026 and he/she signed off as the reviewer. The director said he/she did not know the specifics of what the plan requirements were and the plan had not changed since he/she started in November of 2020. The director said he/she did not know the plan should include control measures and corrective actions for all identified risk areas. The director said facility risk areas would include spas, water fountains, ice machines. The director said he/she monitored risk areas by testing for Legionella in water heaters and spas once a year. The director said he/she never tested ice machines or resident rooms and he/she did not know if he/she should document Legionella testing locations. The director said he/she did not know of any facility control measures beyond annual water testing. The director said the facility water system has ultraviolet (UV) devices to reduce bacteria growth and he/she checks the UV devices weekly but does not document the checks. The director said as long as the UV devices were plugged in they were working and he/she did not have any other way to ensure the devices worked correctly. The director said he/she flushed water in resident rooms and water heaters but did not document the flushes because there was no policy to document the flushes. The director said the water management team met monthly and reviewed any issues that would indicate a need for Legionella testing as a part of the facility safety meeting. The director said issues that could prompt additional testing would include issues with water heaters, spas, city water or facility water temperatures out of range. During an interview on 04/09/26 12:06 P.M. the administrator said the facility's water management plan contained a water system description and risk areas which included water heaters, ice machines, stagnant water areas and low use resident room water fixtures. The administrator said annual plan review, Legionella testing and monitoring for resident infections would be control measures. The administrator said he/she did not know control measures were required for all identified risk areas. The administrator said the director flushes water fixtures in vacant resident rooms, but he/she did not know how often, how long or if the flushes were documented. The administrator said he/she did not expect the water flushes to be documented if the director said they were done. The administrator said the director completes Legionella testing annually, but he/she did not know how many tests or locations the director completed. The administrator said he/she would expect the director to document water sample locations. The administrator said the plan should include corrective actions.

Based on observation, interview and record review, facility staff failed to ensure two residents (Resident #1 and #39) out of four sampled residents with wounds, received the necessary treatment and services in accordance with professional standards when staff failed to ensure pressure wounds were identified, assessed appropriately and provided adequate pressure relief. The facility census was 51. 1. Review of the National Pressure Injury Advisory Panels (NPIAP) definitions of staging showed: -Stage 1 Pressure Injury: Non-blanchable erythema of intact skin Intact skin with a localized area of non-blanchable erythema. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. -Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Granulation tissue, slough and eschar are not present. Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. 2. Review of the facility's policy titled Wound Assessment, Prevention and Treatment, dated 11/28/17, showed a care plan will be developed for a resident with a skin issue which details the specific wound healing interventions which have been determined appropriate. This will include an individualized turning/repositioning schedule as indicated when in bed attempt to float heels.The resident should also be assessed for risk factors that increase susceptibility to develop a pressure ulcer. Examples of these risk factors include, but are not limited to:-Impaired/decreased mobility and decreased functional ability;-Co-morbid conditions, such as end-stage renal disease, thyroid disease or diabetes mellitus.Review of the facility's Wound Care Competency Checklist, undated, showed staff are directed to cleanse hands, apply gloves, remove soiled dressings, cleanse hands, apply clean gloves, and cleanse wounds. 3. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 11/19/25, showed staff assessed the resident as: -admitted on [DATE];-Cognitively intact;-Did not reject care or evaluation;-Had four Stage 2 pressure ulcers/injuries and one Stage 3 pressure ulcer/injury;-Diagnoses of Diabetes Mellitus, Non-Alzheimer's Dementia, and kidney insufficiency. Review of the resident's Braden Scale (Scale used to determine pressure ulcer/injury risk), dated 12/03/25, showed staff scored mild risk for developing a pressure ulcer/injury. Review of the resident's Quarterly MDS, dated [DATE], showed: -Cognitive;-Did not reject care or evaluation;-Dependent on staff for upper and lower body dressing and bed mobility;-Had a pressure ulcer/injury;-At risk of developing pressure ulcers/injuries;-Had one stage 2 pressure ulcer/injury present on admission. -Diagnoses of Diabetes Mellitus and Non-Alzheimer's Dementia;-Received hospice care.Review of the resident's Physician Order Summary (POS), dated April 2026 , showed: -04/03/26: Wound Care to Right Heel: Cleanse with wound cleanser, pat dry, apply xeroform gauze (petroleum-impregnated dressing) to wound bed and secure with kerlix (rolled gauze);-04/03/26: Would Care to Left Heel: Cleanse wound bed with wound cleanser, pat dry, apply Medihoney (wound material used to draw fluid from the wound to the surface and liquify non-viable tissue) to wound bed and secure with kerlix; -04/9/26: Skin-prep to Great Right toe tip, once daily for Stage I pressure ulcer care. Review of the resident's care plan, dated 04/10/26, showed: -12/16/25: Maximum assistance required for upper and lower body dressing;-01/21/26: Apply Gaymar boots (pressure relief boots) to both feet as tolerated; may float heels with pillow if patient refuses boots;-04/03/26: Low Air Loss mattress to bed;-04/09/26: Maintain pressure reducing pad to the foot of the bed;-04/09/26: Stage 1 right great toe ulcer will resolve;-04/09/26: Skin prep to right great toe as ordered. Review of the residents' progress notes showed staff documented: -On 04/07/26- The wound nurse documented: Seen today for ongoing cares of admission toe(s) injuries. Left heel and Right heel Diabetic (DM) Ulcer development. Continues to refuse pressure reducing boots in bed but accepts heels floated onto pillows; -On 04/08/26- The wound nurse documented during wound cares noted when repositioning up toward head of bed foot touched the footboard. Pillow placed at footboard to prevent recurrence. Treatment initiated and care plan adjusted. Review of the residents' Left Heel Weekly Wound Assessments showed: -On 03/10/26, the IP/Wound Nurse documented the left heel, Date acquired 11/12/25, Stage 2, Improving. Tissues: Epithelial, granulation, necrotic and moist;-On 03/18/26, the MDS Coordinator documented the left heel, Date acquired 11/12/25, Stage 2, Improving. Tissues: Epithelial, granulation, necrotic and moist;-On 03/24/26, the IP/Wound Nurse documented the left heel, Date acquired 11/12/25, Stage 3, Worsening. Tissues: Granulation, necrotic, and moist;-On 03/31/26, the IP/Wound Nurse documented the left heel, Date acquired 11/12/25, Stage 3, Improving. Tissues: Granulation, necrotic, and moist; -On 04/07/26, the IP/Wound Nurse documented the left heel, Date acquired 11/12/25, Stage 3, Worsening. Tissues: Granulation, Necrotic, moist. Review of the resident's Right Heel Weekly Wound Assessment, dated 04/07/26, showed the IP/Wound documented wound to right heel, Date acquired 04/03/26, Type: Diabetic Ulcer (DM); First observation, no reference; Tissues: Granulation and Slough (yellow, tan, white, stringy); Moist; Measurements Length (L) 6 centimeters (cm) by Width (W) 2 cm by Depth (D) 0.2 cm. Observation on 04/07/26 at 10:21 A.M., showed the resident in bed with both heels wrapped in gauze. The resident's right and left heels rested directly on a pillow. Heel protector boot on the floor, with three other heel protector boots in a chair in the room. Observation on 04/07/26 at 3:23 P.M., showed the resident in bed with both legs propped up on a pillow. The resident's right and left heels sat directly on the air mattress. Heel protector boots in a chair in the room. Observation on 04/08/26 at 8:49 A.M., showed the resident in bed with heels dug into air mattress. Observation on 04/08/26 at 3:41 P.M., showed the resident in bed with heels dug into air mattress. Dressings to bilateral heels. Observation on 04/09/26 at 9:01 A.M., showed the resident in bed with tip of right great toe pressed directly into wooden footboard. The ball of the resident's left foot is covered in a dressing and pressed directly into the wooden footboard. Both heels are dug into the air mattress. Certified Nurse Aide (CNA) F entered the resident's room and positioned the resident in bed. The CNA did not float the resident's feet on a pillow. The resident's feet remained pressed against the footboard and his/her heels dug into the mattress. Observation on 04/09/26 at 10:31 A.M., showed the resident in bed with tip of right great toe and ball of left foot pressed directly into the wooden footboard of the bed. The Infection Preventionist (IP)/Wound Nurse and Licensed Practical Nurse (LPN) E entered the resident's room to provide wound care. The IP placed an incontinence pad under the resident's feet and when he/she lifted the resident's right foot a 3 cm dark purple indented area could be seen on the tip of the resident's right great toe. LPN E said the wound is new and the indention from the footboard is seen. The IP removed the dressing to the resident's left heel and revealed a pressure injury with granulation tissue, eschar and slough with a red peri-wound (area around the wound bed). The IP/Wound nurse with the same gloves on that he/she removed the soiled dressing with cleansed the resident's wound. The IP/Wound Nurse and LPN removed their gloves, washed hands, applied new gloves and the IP/Wound nurse completed the treatment to the resident's left heel wound. While staff performed treatment and hand hygiene the resident's right great toe remained pressed against the footboard. Observation showed the IP/Wound nurse removed the soiled dressing to the resident's right heel, cleansed a dime sized wound with beefy red granulation tissue and a purple, maroon nickel sized wound above the dime sized wound with the same gloves on. During an interview on 04/09/26 at 10:31 A.M., the Wound Nurse/IP said the resident admitted to the facility with a Stage 3 pressure ulcer/injury to his/her left heel. He/She said the left heel wound is a Stage 2 with epithelial tissue and is shallow, so it has improved. The IP/Wound nurse said the right heel wound is a diabetic ulcer, so he/she has not staged the wound. He/She said the resident cannot position himself/herself in bed at all and that is why he/she has an air mattress. The IP/Wound nurse said the tip of the right great toe is indented, and he/she would expect staff to reposition the resident if they saw his/her feet resting against the footboard. The IP/Wound Nurse said the resident has a new Stage 1 pressure ulcer/injury. During an interview on 04/10/26 at 8:01 A.M., the Director of Nursing (DON) said the resident has reduced mobility and has had a recent decline. He/She said a dark purple/maroon wound could be considered a suspected deep tissue injury. During an interview on 04/10/26 at 8:22 A.M., CNA F said he/she does not believe the resident could lift his/her legs off the bed. The CNA said if he/she saw the resident's feet resting on the footboard and his/her heels dug into the mattress he/she would get another staff member to help him/her reposition the resident. The CNA said the resident really needs a bed that fits him/her because the resident scoots his/her bottom down in the bed, and that's how his/her feet end up on the footboard and dug in the mattress. During an interview on 04/10/26 at 11:07 A.M, the IP/Wound Nurse said the wound to the resident's right heel is a diabetic ulcer because he/she does not have observations of the resident's right heel not floated or without pressure relief. He/She said the resident has a new Stage I pressure ulcer to his/her right great toe and described the wound as red with some darkness, bruised looking. He/She said if staff are not utilizing pressure relief interventions the wounds could become worse. The IP/Wound nurse said he/she stages the wound according to guidelines. During an interview on 04/15/26 at 1:15 P.M., Physician M said he/she knew about the wounds to the resident's heels. He/She said staff notified him/her of the worsening wound to the left heel, facility staff obtained an x-ray, and the x-ray showed osteomyelitis (bone infection). The physician said the wounds to both the resident's heels are from pressure as they are over bony prominences, and the resident has decreased mobility and stays in bed. He/She said staff should ensure pressure relief interventions are in place and utilized. He/She said if staff are not providing pressure relief that could make the residents wounds worse and keep the wounds from improving. He/She said staff should follow the facility policy for wound care. 4. Review of Resident #39's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows:-Intact cognition;-Required maximal assistance from a staff member for bed mobility, personal hygiene, dressing, bathing and transfers;-At-risk for developing pressure ulcers/injuries;-Application of dressings to feet;-Diagnosis of Coronary Artery Disease and Diabetes.Review of the resident's Braden Scale for predicting pressure sore risk, dated 12/09/25, showed staff assessed the resident as a moderate risk for developing pressure sores.Review of the resident's care plan, dated 03/24/26, showed staff documented the resident's right heel has a diabetic ulcer on 11/18/2025. Bilateral heel boots as resident allows. Required maximum assistance with bed mobility. Review of the resident's POS, dated April 2026, showed an ordered dated 02/02/26 to cleanse right heel would with wound cleanser, apply xeroform gauze to wound bed, cover with gauze and secure every shift. Review of the resident's right heel Weekly Wound assessments showed staff documented:-On 03/03/26: right heel, Stasis Ulcer, Tissue: Epithelial, Granulation;-On 03/10/26: right heel, Stage II, Tissue: Granulation, 1 cm L by 1.1 cm W by 0.1 cm D. Much improved with no eschar; new dermis;-On 03/18/26: right heel, Stage II, Tissue: Granulation; -On 04/07/26: right heel, Improving, Tissue: Epithelial, Granulation and Slough; Slowly resolving. Observation on 04/09/26 at 3:11 P.M., showed resident in his/her recliner. The resident's right heel pressed into the footrest of the recliner. The fabric of the footrest depressed from the resident's right heel. The resident did not have heel protector on right heel.During an interview on 04/09/26 at 3:13 P.M., the resident said his/her wound is on the heel of his/her right foot. Observation on 04/09/26 at 3:20 P.M., showed the resident in a recliner in his/her room with his/her right heel dug into the footrest of the recliner. LPN E asked the resident if he/she could lift his/her leg up so a barrier could be placed on the footrest. The resident attempted to lift his/her right leg and could not. LPN E placed a pillow under the resident's right leg. LPN E removed the dressing to the resident's right heel and revealed a dime sized wound with pink/red granulation tissue. During an interview on 04/09/26 at 3:20 P.M., LPN E said he/she thinks the wound to the resident's right heel is from pressure. He/She said the wound bed is pink and top layers of skin are not present. During an interview on 04/09/26 at 3:20 P.M., the resident said the wound to his/her right heel is from laying in bed. He/She said the wound started before he/she got booties to wear. During an interview on 04/10/26 at 11:52 A.M., the IP/Wound Nurse said the resident has a diabetic ulcer to his/her right heel, and he/she determined that by direct observations, interview and medical history. During an interview on 04/10/26 at 8:01 A.M., the DON said the IP/Wound Nurse determines if wounds are pressure injuries versus diabetic ulcers. He/She said the nurses do not stage the wounds, that is the IP/Wound Nurses responsibility, as well as all assessments and measurements. He/She said staff should follow certain criteria to describe and assess wounds. He/She said he/she expects the IP/Wound Nurse to follow guidelines including the facility protocol and reference material. During an interview on 04/10/26 at 11:07 A.M., the DON said if staff are not utilizing pressure relief interventions the wounds could become worse. He/She would expect staff to reposition residents. During an interview on 04/10/26 at 12:30 P.M., the Director of Nursing (DON) said staff should change gloves and wash hands after removing soiled dressing during wound care. He/She said the reason you change gloves and wash hands is because the dressing is dirty.

Based on observation, interview, and record review, facility staff failed to obtain physician orders for oxygen use for three residents (Resident #1, Resident #2, and Resident #3) out of three sampled residents. The facility census was 54. 1. Review of the facility's Oxygen Safety and Management policy, dated 03/22/2019, showed oxygen will be provided to residents based on their physicians' orders. Physician orders for oxygen use should include the rate of oxygen flow, the route of administration, and frequency of administration. Review of the facility's standing oxygen order showed the Medical Director is responsible to provide standing orders, and if oxygen is less than 90% staff is to administer oxygen at two to five liters per minute via nasal cannula. May titrate oxygen to maintain oxygen at greater than or equal to 90%. 2. Review of Resident #1's entry MDS, dated [DATE], showed the resident admitted to the facility 01/19/2025. Review of the resident's care plan, dated 01/22/2025, showed the care plan did not contain documentation for resident use of oxygen. Review of the resident's physician order sheet (POS), dated January 2025, showed the POS did not contain a physicians order for oxygen administration. Observation on 01/23/2025 at 10:55 A.M., showed the resident in his/her room with one liter of oxygen on per nasal annular. During an interview on 01/23/2025 at 10:55 A.M., the Director of Nursing (DON) said he/she did not know why the resident did not have oxygen orders. 3. Review of Resident #2's admission MDS, dated [DATE], showed staff assessed the resident as: -Cognitive impairment; -Does not require oxygen; -Does not experience shortness of breath; -Diagnosis of heart failure, asthma, Chronic Obstructive Pulmonary Disease (COPD)(a group of chronic lung disease that causes difficulty breathing). Review of the resident's care plan, dated, 01/14/2025, showed the care plan did not contain documentation for resident use of oxygen. Review of the resident's POS, dated January 2025, showed the POS did not contain a physician order for oxygen administration. Observation on 01/23/2025 at 10:28 A.M., showed the resident in his/her room with two liters of oxygen on per nasal cannula. During an interview on 01/23/2025 at 10:28 A.M., the resident said his/her oxygen is always on. The resident said the only time the oxygen is removed is when they are switching from the concentrator to the portable tank. 4. Review of Resident #3's admission MDS, dated [DATE] showed staff assessed the resident as: -Cognitively Intact, -Required continuous oxygen, -Diagnosis of heart failure, peripheral vascular disease, and peripheral arterial disease; -Experienced shortness of breath with exertion, when at rest, and when laying flat. Review of the resident's care plan, dated 01/15/2025, showed the care plan did not contain documentation for resident use of oxygen. Review of the resident's (POS), dated January 20205, showed the POS did not contain a physician order for oxygen administration. Observation on 01/23/2025 at 10:35 A.M., showed the resident in his/her room with oxygen on at three liters per nasal cannula. During an interview on 01/23/2025 at 10:35 A.M., the resident said he/she gets short of breath and leaves his/her oxygen on all the time. 5. During an interview on 01/23/2025 at 10:40 A.M., Certified Medication Technician (CMT) A said he/she is unaware of oxygen orders for residents. He/She said it is the nurses responsibility to get oxygen orders form the physician. During an interview on 01/23/2025 at 10:43 A.M., Registered Nurse (RN) B said he/she knows which residents require oxygen from the information passed on between the nurses in report. RN B said there should be orders for residents that receive oxygen therapy. He/She said if there are no orders for a resident who uses oxygen they would need to communicate with the therapy department and the physician to identify the residents oxygen needs. RN B said he/she was unsure on the oxygen policy or how they assure resident's have orders for oxygen. During an interview on 01/23/2025 at 10:55 A.M., DON said there should be orders for residents who use oxygen in their chart. The DON said he/she was reviewing the oxygen orders and is unsure why they are not in resident charts. During an interview on 01/23/2025 at 2:24 P.M., administrator said the facility has a standing order for oxygen. During an interview on 01/24/2025 at 1:10 P.M., the nurse practioner said the physician who signed the standing oxygen orders in the facility's was through the hospital and if the facility needs orders written for oxygen they should be reaching out to a physician for those orders. He/She said the facility can provide residents with oxygen on an emergency basis to maintain normal oxygen levels but should communicate with their providers to obtain future orders. MO00248158

Based on observation, interview, and record review, facility staff failed to reconcile narcotics at the change of shift when the medication cart changed from one staff member to another, and to ensure medications were secured. The facility census was 46. 1. Review of the facility's policy titled Controlled Medication Storage, dated 01/2021, showed the Director of Nursing (DON) and the consultant pharmacist maintain facility compliance with handling of controlled mediations.The medication nurse on duty maintains possession of the key to the controlled medication storage areas. There should be a system of medications records that enables accurate reconciliation and accounting of controlled medications. At change of custody, a physical inventory of all controlled medications is conducted and documented by two licensed staff. 2. Review of the facility's A Hall Nurse on-coming and off-going narcotic count sheets, dated 08/01/24 through 08/31/24, showed the narcotic count sheet: -On 08/02/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 08/03/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 08/07/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 08/09/24 at 7:00 P.M., did not contain two licensed staff signatures; -On 08/10/24 at 7:00 A.M., did not contain two licensed staff signatures; -On 08/12/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 08/14/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 08/16/24 at 7:00 A.M., did not contain two licensed staff signatures; -On 08/17/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 08/18/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 08/19/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 08/20/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 08/21/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 08/25/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 08/26/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 08/28/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 08/30/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures. Review of the facility's A hall Certified Medication Technician (CMT) on-coming and off-going narcotic count sheets, dated 08/01/24 through 08/31/24, showed the narcotic count sheet: -On 08/08/24 at 2:00 P.M., and 10:00 P.M., did not contain two licensed staff signatures; -On 08/09/24 at 6:00 A.M., did not contain two licensed staff signatures; -On 08/09/24 at 2:00 P.M., and 10:00 P.M., did not contain two licensed staff signatures; -On 08/10/24 at 6:00 A.M., did not contain two licensed staff signatures; -On 08/11/24 at 10:00 P.M., and 6:00 A.M., did not contain two licensed staff signatures; -On 08/12/24 at 2:00 P.M., and 10:00 P.M., did not contain two licensed staff signatures; -On 08/14/24 at 6:00 A.M., did not contain two licensed staff signatures; -On 08/15/24 at 2:00 P.M., and 10:00 P.M., did not contain two licensed staff signatures; -On 08/16/24 at 6:00 A.M., did not contain two licensed staff signatures; -On 08/18/24 at 2:00 P.M., did not contain two licensed staff signatures; -On 08/25/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 08/25/24 at 2:00 P.M., and 10:00 P.M., did not contain two licensed staff signatures; -On 08/29/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 08/29/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 08/31/24 at 10:00 P.M., did not contain two licensed staff signatures. Review of the facility's B hall nurse on-coming and off-going narcotic count sheets, dated 08/01/24 through 08/31/24, showed the narcotic count sheet: -On 08/02/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 08/03/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 08/04/24 at 7:00 P.M., did not contain two licensed staff signatures; -On 08/06/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 08/07/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 08/09/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 08/17/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 08/21/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 08/23/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures. Review of the facility B hall CMT on-coming and off-going narcotic count sheets, dated 08/01/24 through 08/31/24, showed the narcotic count sheet: -On 08/08/24 at 2:00 P.M., and 10:00 P.M., did not contain two licensed staff signatures; -On 08/09/24 at 2:00 P.M., and 10:00 P.M., did not contain two licensed staff signatures; -On 08/10/24 at 6:00 A.M., did not contain two licensed staff signatures; -On 08/11/24 at 6:00 A.M., did not contain two licensed staff signatures; -On 08/12/24 at 6:00 A.M., did not contain two licensed staff signatures; -On 08/12/24 at 2:00 P.M., and 10:00 P.M., did not contain two licensed staff signatures; -On 08/14/24 at 6:00 A.M., did not contain two licensed staff signatures; -On 08/15/24 at 2:00 P.M., and 10:00 P.M., did not contain two licensed staff signatures; -On 08/17/24 at 2:00 P.M., and 10:00 P.M., did not contain two licensed staff signatures; -On 08/25/24 at 2:00 P.M., did not contain two licensed staff signatures; -On 08/30/24 at 10:00 P.M., did not contain two licensed staff signatures; -On 08/31/24 at 10:00 P.M., and 6:00 A.M., did not contain two licensed staff signatures. Review of the facility C hall nurse on-coming and off-going narcotic count sheets, dated 08/01/24 through 08/31/24, showed the narcotic count sheet: -On 08/02/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 08/03/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 08/06/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 08/07/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 08/10/24 at 7:00 A.M., did not contain two licensed staff signatures; -On 08/11/24 at 7:00 A.M., did not contain two licensed staff signatures; -On 08/12/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 08/17/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 08/20/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 08/31/24 at 7:00 P.M., did not contain two licensed staff signatures. Review of the facility C hall CMT on-coming and off-going narcotic count sheets, dated 08/01/24 through 08/31/24, showed the narcotic count sheet: -On 08/03/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 08/04/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 08/05/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 08/06/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 08/07/24 at 2:00 P.M., and 10:00 P.M., did not contain two licensed staff signatures; -On 08/08/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 08/08/24 at 2:00 P.M., and 10:00 P.M., did not contain two licensed staff signatures; -On 08/09/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 08/09/24 at 2:00 P.M., and 10:00 P.M., did not contain two licensed staff signatures; -On 08/10/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 08/10/24 at 2:00 P.M., and 10:00 P.M., did not contain two licensed staff signatures; -On 08/11/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 08/11/24 at 2:00 P.M., and 10:00 P.M., did not contain two licensed staff signatures; -On 08/13/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 08/14/24 at 2:00 P.M., did not contain two licensed staff signatures; -On 08/15/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 08/16/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 08/17/24 at 2:00 P.M., and 10:00 P.M., did not contain two licensed staff signatures; -On 08/20/24 at 2:00 P.M., and 10:00 P.M., did not contain two licensed staff signatures; -On 08/21/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 08/23/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 08/24/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 08/24/24 at 2:00 P.M., and 10:00 P.M., did not contain two licensed staff signatures; -On 08/25/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 08/26/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 08/26/24 at 2:00 P.M., and 10:00 P.M., did not contain two licensed staff signatures; -On 08/27/24 at 2:00 P.M., and 10:00 P.M., did not contain two licensed staff signatures; -On 08/28/24 at 2:00 P.M., and 10:00 P.M., did not contain two licensed staff signatures; -On 08/29/24 at 2:00 P.M., and 10:00 P.M., did not contain two licensed staff signatures; -On 08/31/24 at 10:00 P.M., did not contain two licensed staff signatures. Review showed the narcotic count sheets did not contain documentation staff completed narcotic counts at all shift changes. 3. Review of the facility's A hall nurse on-coming and off-going narcotic count sheets, dated 09/01/24 through 09/30/24, showed the narcotic count sheet: -On 09/04/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 09/06/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 09/11/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 09/13/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 09/14/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 09/21/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 09/22/24 at 7:00 P.M., did not contain two licensed staff signatures; -On 09/23/24 at 7:00 A.M., did not contain two licensed staff signatures; -On 09/25/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 09/27/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures. Review of the facility's A hall CMT on-coming and off-going narcotic count sheets, dated 09/01/24 through 09/30/24, showed the narcotic count sheet: -On 09/02/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 09/03/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 09/05/24 at 2:00 P.M., and 10:00 P.M., did not contain two licensed staff signatures; -On 09/08/24 at 2:00 P.M., and 10:00 P.M., did not contain two licensed staff signatures; -On 09/16/24 at 2:00 P.M., and 10:00 P.M., did not contain two licensed staff signatures; -On 09/22/24 at 10:00 P.M., did not contain two licensed staff signatures; -On 09/23/24 at 6:00 A.M., did not contain two licensed staff signatures; -On 09/26/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures. Review of the facility's B hall nurse on-coming and off-going narcotic count sheets, dated 09/01/24 through 09/30/24, showed the narcotic count sheet: -On 09/03/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 09/04/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 09/06/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 09/14/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 09/21/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 09/22/24 at 7:00 P.M., did not contain two licensed staff signatures; -On 09/23/24 at 7:00 A.M., did not contain two licensed staff signatures; -On 09/24/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 09/25/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 09/26/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 09/27/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 09/30/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures. Review of the facility's B hall CMT on-coming and off-going narcotic count sheets, dated 09/01/24 through 09/30/24, showed the narcotic count sheet: -On 09/05/24 at 2:00 P.M., and 10:00 P.M., did not contain two licensed staff signatures; -On 09/08/24 at 2:00 P.M., and 10:00 P.M., did not contain two licensed staff signatures; -On 09/22/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 09/22/24 at 10:00 P.M., did not contain two licensed staff signatures; -On 09/23/24 at 6:00 A.M., did not contain two licensed staff signatures. Review of the facility's C hall nurse on-coming and off-going narcotic count sheets, dated 09/01/24 through 09/30/24, showed the narcotic count sheet: -On 09/22/24 at 7:00 P.M., did not contain two licensed staff signatures; -On 09/23/24 at 7:00 A.M., did not contain two licensed staff signatures; -On 09/30/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures. Review of the facility's C hall CMT on-coming and off-going narcotic count sheets, dated 09/01/24 through 09/30/24, showed the narcotic count sheet: -On 09/04/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 09/05/24 at 2:00 P.M., and 10:00 P.M., did not contain two licensed staff signatures; -On 09/06/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 09/06/24 at 2:00 P.M., and 10:00 P.M., did not contain two licensed staff signatures; -On 09/07/24 at 2:00 P.M., and 10:00 P.M., did not contain two licensed staff signatures; -On 09/08/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 09/08/24 at 2:00 P.M., and 10:00 P.M., did not contain two licensed staff signatures; -On 09/16/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 09/22/24 at 10:00 P.M., did not contain two licensed staff signatures; -On 09/23/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 09/24/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 09/25/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures; -On 09/27/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures. Review showed the narcotic count sheets did not contain documentation staff completed narcotic counts at all shift changes. 4. Review of the facility's A hall nurse on-coming and off-going narcotic count sheets, dated 10/01/24 through 10/08/24, showed the narcotic count sheet: -On 10/05/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 10/06/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures. Review of the facility A hall CMT on-coming and off-going narcotic count sheets, dated 10/01/24 through 10/08/24, showed on 10/08/24 at 6:00 A.M., and 2:00 P.M., did not contain two licensed staff signatures. Review of the facility C hall nurse on-coming and off-going narcotic count sheets dated 10/01/24 through 10/08/24, showed the narcotic count sheet: -On 10/04/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 10/05/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 10/06/24 at 7:00 A.M., and 7:00 P.M., did not contain two licensed staff signatures; -On 10/08/24 at 7:00 P.M., did not contain two licensed staff signatures. Review showed the narcotic count sheets did not contain documentation staff completed narcotic counts at all shift changes. 5. During an interview on 10/09/24 at 5:40 A.M., LPN J said two licensed staff are to count narcotics at the change of shift with the off-going and on-coming staff member to ensure there are no discrepancies. During an interview on 10/09/24 at 9:40 A.M., Registered Nurse (RN) N said he/she is a charge nurse at the facility. RN N said two licensed staff are to count narcotics at the change of shift with the off-going and on-coming staff member to ensure there are no discrepancies. During an interview on 10/09/24 at 9:45 A.M., LPN E said he/she is a charge nurse at the facility and works all the halls. LPN E said narcotics are to be counted by two licensed staff at the change of each shift. LPN E said the staff counting should be the off-going and on-coming staff members. LPN E said this is done to ensure the narcotic count is correct before accepting the keys to the cart. During an interview on 10/09/24 at 9:50 A.M., RN A said he/she is a charge nurse at the facility. RN A said staff are expected to count narcotics at the change of shift or anytime there is a change of staff on the medication cart. RN A said two licensed staff should count the narcotics on the medication cart and sign the narcotic count log verifying the count is correct. RN A said the two licensed staff counting need to be the off-going and on-coming staff member. During an interview on 10/09/24 at 10:00 A.M., the Minimum Data Set (MDS) Coordinator said two licensed staff should count narcotics at each change of shift to ensure the count is correct and no discrepancies are found. The MDS Coordinator said the two staff counting should be the off-going and on-coming staff member accepting the keys to the medication cart. The MDS Coordinator said after the two licensed staff count, they are responsible to sign the narcotic count log, he/she said if something is not charted it was not done. During an interview on 10/09/24 at 10:20 A.M., the DON said he/she expects two licensed staff to count the narcotics on each medication cart at the change of shift, or if the keys for the cart change staff members. The DON said it is the licensed staff members responsibility to count and sign the narcotic count log verifying the count. The DON said he/she is responsible to over see the floor staff and ensure staff are doing their jobs correctly. The DON said when two licensed staff count it should be the off-going and on-coming staff member counting. The DON said he/she has educated staff previously on counting each shift and ensuring the narcotic count log is signed at the time of the count. The DON said he/she can't verify a narcotic count had been completed on the dates the narcotic log is not signed by two licensed staff members. During an interview on 10/09/24 at 10:25 A.M., the administrator said he/she expects two licensed staff to count at the change of shift or change of cart assignment and sign the logs. The Administrator said it should be the off-going and on-coming licensed staff counting. The Administrator said staff are responsible to complete the narcotic counts. During an interview on 10/09/24 at 12:35 P.M., Certified Medication Technician (CMT) M said licensed staff are responsible to count the narcotics on a medication cart before staff change the keys from one staff member to another. CMT M said the cart should be counted by the off-going and on-coming staff member at the change of shift, or anytime the medication cart changes staff hands. CMT M said once staff count they are responsible to sign the narcotic count log to verify the count was completed. CMT M said if something is not documented there is no proof it is done. During an interview on 10/09/24 at 12:47 P.M., CMT L said licensed staff are responsible to count the narcotics on a medication cart before staff change the keys from one staff member to another. CMT L said the cart should be counted by the off-going and on-coming staff member and sign the narcotic count log to verify the count was completed. CMT L said if something is not documented there is no proof it is done.

Based on observation, interview and record review, facility staff failed to accurately complete entrapment assessments and obtain physician orders for bed rails for four residents (Resident #5, #28, #30 and #32). The facility census was 38. 1. Review of the facility's Bed Mobility Device, revised November 28, 2017, directed staff as follows: -All residents will be evaluated for the need for bed mobility devices; -The bed mobility device assessment will be completed on admission, readmission, quarterly and with a significant change in status. The assessment form will be completed prior to utilization of any such device, including: short side rails containing bed control, bed cane, transfer pole, trapeze, other adaptive equipment utilized to aid in repositioning. 2. Review of Resident #5's Admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 09/02/23, showed staff assessed the resident as: -Cognitively impaired; -Diagnoses of Dementia (loss of cognitive functioning thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), Osteoporosis (bone disease that develops when bone mineral density and bone mass decreases, or when the quality or structure of bone changes), Other fracture (a break in the bone), Malnutrition (lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things, or being unable to use the food that one does eat); -Required limited one person assistance for bed mobility; -Bed rails not used. Review of the resident's medical record showed the record did not contain documentation staff completed an entrapment assessment or obtained a physician's order for the use of the bed rails. Observation on 09/24/23 at 11:19 A.M., showed the resident in bed with the left bed rail in the upright position. Observation on 09/25/23 at 9:45 A.M., showed the resident in bed with the left bed rail in the upright position. 3. Review of Resident #28's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Required limited one person physical assistance with bed mobility, transfer, toileting, and bathing; -Diagnosis of hemiparesis (weakness or the inability to move on one side of the body), hip fracture. Review of the resident's Physician Order Sheet (POS), dated 09/2023, showed the record did not contain an order for the bed assist bars. Review of the resident's medical record showed the record did not contain a completed entrapment assessment. Observation on 09/25/23 at 1:30 P.M., showed the right assist bar rail in the upright position. Observation on 09/26/23 at 10:30 A.M., showed the right assist bar rail in the upright position. 4. Review of Resident #30's Admission MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Required extensive two plus person assistance with bed mobility, transfer, dressing, and toileting; -Diagnosis of dementia. Review of the resident's POS, dated 09/25/23, showed the record did not contain an order for bed assist bars. Review of the resident's medical record showed the record did not contain a completed entrapment assessment. Observation on 09/24/23 at 12:44 P.M., showed the resident in bed with bilateral side rails in the upright position. Observation on 09/25/23 at 10:48 A.M., showed the resident in bed with bilateral side rails in the upright position. 5. Review of Resident #32's Admission MDS, dated [DATE], showed staff assessed the resident as follows: -Severe Cognitive impairment; -Required extensive two plus person assistance with bed mobility, transfer, dressing, and toileting; -Diagnosis of dementia and Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). Review of the resident's POS, dated 09/25/23, showed the record did not contain an order for bed assist bars. Review of the resident's medical record showed the record did not contain a completed entrapment assessment. Observation on 09/24/23 at 12:10 P.M., showed the resident in bed with the right assist bar rail in the upright position. Observation 09/25/23 at 10:02 A.M., showed the resident in bed with the right assist bar rail in the upright position. 6. During an interview on 09/25/23 at 12:41 P.M., the administrator said he/she had paperwork to see what the measurements should be in each zone but did not have entrapment assessments for each individual resident quarterly because the beds had never changed and they are not full bed rails, they are cane rails. He/She said they were checking the beds weekly but no measurements were taken. During an interview on 09/26/23 at 12:01 P.M., Licensed Practical Nurse (LPN) A said the nurse was required to do initial assessment and consent upon admission but they did not do anything with measurements. He/She said there were no other interventions tried before the resident had a bed cane because every bed has at least one bed cane. They could take them off but normally don't have too. He/She said therapy might be in charge of taking measurements for the residents because their department determines if a second bed cane is needed. During an interview on 09/26/23 at 12:06 P.M., the maintenance director said their system was dictated by their corporate office and provided him/her with tasks: weekly, monthly, semi-annual and annual. At one time they had bed inspection and device rail inspection generate every week but it just said pass or fail for all. He/She would check the beds, the entire operation: wheel, head and footboard and mattresses but no actual measurements were taken. He/She said in July corporate changed the weekly task to annually, he/she said he/she knew the regulation was quarterly. He/She said there was no process to alert him/her if the residents had a significant change. Only if there was a mattress change. During an interview on 09/26/23 at 12:13 P.M., LPN B said that the facility did not use bed rails, they used bed canes. He/She said the nurses were in charge of getting consents signed and assessments but the assessments did not have measurements. He/She said he/she did not know who completed measurements for the bed canes. During an interview on 09/26/23 at 12:37 P.M., the Director of nursing (DON) said bedrails assessments are completed upon admission and quarterly. The MDS coordinator was in charge of bedrail assessments. He/She did not know why they were not done. During an interview on 09/26/23 at 1:00 P.M., the MDS coordinator said he/she was in charge of quarterly bed rail assessments but did not provide measurements. 43024 47193

Based on interview and record review, facility staff failed to follow their policy as directed to check the Certified Nurse Assistant (CNA) Registry for all staff to ensure they did not have a Federal Indicator (a marker given by the federal government to individuals who have committed abuse and/or neglect) for two of six sampled employees (Licensed Practical Nurse (LPN) C and The Infection Preventionist) as directed in their policy. The facility census was 38. 1. Review of the facility's policy, titled Abuse, Neglect, Exploitation, undated, showed staff were directed to conduct employee reference checks and perform Certified Nursing Assistant CNA and Certified Medication Aide (CMA) registry, licensing board, and state approved background checks. The state nurse aide registry or state licensure body will be contacted before staff provides direct care, if there are prohibitive findings on the registry or the professional licensing body, employment will not proceed. 2. Review of LPN C's employee file showed: -Hire date of 01/06/23; -The file did not contain documentation of the Nurse Aide registry check. 3. Review of Infection Preventionist employee file showed: -Hire date of 12/28/22; -The file did not contain documentation of the Nurse Aide registry check. During an interview 09/26/23 at 12:37 P.M., the Director of Nursing (DON) said the business office manager (BOM) was responsible for all background checks. He/She said everyone that worked in nursing needed a nurse aide registry check. During an interview on 09/26/23 1:03 P.M., the BOM said he/she did the background screenings for new hires. He/She ran the nurse aide registry check for CNAs and the Nursys for the Nurses. He/She was not aware that all employees needed the nurse aide registry check and had not run them for nurses since he/she started helping as the BOM because he/she is the full time dietary manager. During an interview on 09/26/23 at 1:50 P.M., the Administrator said the Nurse aide registry check should be run on every employee. It was the responsibility of the BOM to run all background checks and he/he did not know why it would not be done.

Based on interview and record review, the facility staff failed to document collaboration of care with hospice providers for development and implementation of a coordinated plan of care and communication between the facility and their two hospice providers for two out of three residents (Resident #27, and #31) receiving Hospice services. The facility census was 38. 1. Review of the facility's Hospice Services Agreement, undated, showed: -Plan of Care. Hospice will collaborate with Facility on a coordinated Plan of Care developed jointly between Hospice and Facility. -Resident Chart. Facility and Hospice will prepare and maintain complete medical records for Hospice Patients receiving Facility services in accordance with this Agreement and will include all treatments, progress notes, authorizations, physician orders and other pertinent information. Copies of all documents of services provided by Hospice will be filed and maintained in the Facility chart. 2. Review of Resident's #27's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 08/10/23, showed: -The resident was on Hospice; -The resident had a condition or disease that may result in a life expectancy of less than six months. Review of the facility matrix list of residents on hospice, provided by the facility on 09/27/23, showed the resident was on Hospice services. Review of the resident's Progress Notes, dated 09/2023, showed the record did not contain documentation of Hospice staff visits or coordination of care with the Hospice provider. Review of the resident's medical record, dated 02/2023, showed the record did not contain documentation of a coordinated plan of care between the facility and the Hospice provider. Review of the facility's Hospice binder, undated, showed the record did not contain documentation of communication or a coordinated plan of care between the facility and the hospice provider. 3. Review of Resident #31's Admission MDS, dated [DATE], showed staff assessed the resident as: -The resident was on Hospice; -The resident had a condition or disease that may result in a life expectancy of less than six months. Review of the facility matrix list of residents on hospice, provided by the facility on 09/27/23, showed the resident was on hospice services. Review of the resident's Progress Notes, dated 09/2023, showed the record did not contain documentation of Hospice staff visits or coordination of care with the Hospice provider. Review of the resident's medical record, dated 02/2023, showed the record did not contain documentation of a coordinated plan of care between the facility and the Hospice provider. Review of the facility's Hospice binder, undated, showed the record did not contain documentation of communication or a coordinated plan of care between the facility and the hospice provider. 4. During an interview on 09/26/23 at 12:01 P.M., Licensed Practical Nurse (LPN) A said the communication with the hospice team is verbal, there is no binder for documentation but staff sometimes charted it in point click care (electronic health records system.) During an interview on 09/26/23 at 12:13 P.M., LPN B said there [NAME] no documentation or binders for communication with hospice, or at least not that he/she fills out, maybe I should be. During an interview on 09/26/23 at 12:37 P.M., the Director of Nursing (DON) said hospice care workers and the facility staff have verbal checks and updates. He/She said the hospice communication binder for documentation was put in place before him/her and it should be completed by the nurse staff but they may need more education on it. He/She said it was imperative to document communication with the hospice team to collaborate and agree on plans and provide the resident the best care. During an interview on 09/25/23 at 1:50 P.M., the Administrator said the facility's care plan should mirror Hospice's care plan, a plan of care specifically to that resident. The administrator said communication between the facility staff and the hospice clinic was expected to be documented.

Based on interview and record review, the facility failed to ensure the arbitration agreement was explained to two residents (Resident #9, and #29) and/or to their representative in a form and manner that he/she understood. The census was 38. 1. Review of the facility's policies showed staff did not provide a policy for Arbitration Agreements. Review of the facility's Admission Agreement showed page 8 the Arbitration Agreement as a single paragraph that did not contain a place to decline, or agree to the arbitration. Further review showed there was one signature page at the end of the agreement used to sign for everything listed in the admission agreement. 2. Review of the Resident's #9's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 08/24/23 showed the resident was cognitively intact. Review of the resident's Admission Agreement, dated 03/23/20 showed the signature page was signed. During an interview on 09/26/23 at 1:10 P.M., the resident said he/she did not remember signing the arbitration agreement. He/She said they don't know if they would have signed it, because if something serious or important happened I would want my own lawyer. 3. Review of Resident #29's admission MDS, dated [DATE], showed staff assessed the resident as cognitively intact. Review of the resident's Admission Agreement, dated 06/06/23 showed the signature page was signed. During an interview on 09/26/23 at 01:21 P.M., the resident said he/she has issues with his/her vision and he/she knows he/she would not have been able to read the arbitration agreement himself/herself. He/She said he/she does not remember if he/she was read that portion or if it was explained. He/She said if he/she had to sign it today he/she would not sign it. 4. During an interview on 09/26/23 at 12:40 A.M., the Social Services Director (SSD) said she was responsible for going over the arbitration agreement with the resident and/or their representative upon admission. SSD said they have never had a resident decline signing the Admission Agreement. The SSD said there is not a separate signature page to accept or decline the arbitration agreement. During an interview on 09/26/23 at 1:50 P.M., the Administrator said there was only the one signature page at the end of the Admission Agreement. He said there was not a separate form used to agree or decline the arbitration agreement. The administrator said if the resident or their representative would not agree they would need to sign something to say they don't.

Based on observation, interview and record review, facility staff failed to accurately complete entrapment assessments and obtain physician orders for bed rails for four residents (Resident #5, #28, #30 and #32). The facility census was 38. 1. Review of the facility's Bed Mobility Device, revised November 28, 2017, directed staff as follows: -All residents will be evaluated for the need for bed mobility devices; -The bed mobility device assessment will be completed on admission, readmission, quarterly and with a significant change in status. The assessment form will be completed prior to utilization of any such device, including: short side rails containing bed control, bed cane, transfer pole, trapeze, other adaptive equipment utilized to aid in repositioning. 2. Review of Resident #5's Admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 09/02/23, showed staff assessed the resident as: -Cognitively impaired; -Diagnoses of Dementia (loss of cognitive functioning thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), Osteoporosis (bone disease that develops when bone mineral density and bone mass decreases, or when the quality or structure of bone changes), Other fracture (a break in the bone), Malnutrition (lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things, or being unable to use the food that one does eat); -Required limited one person assistance for bed mobility; -Bed rails not used. Review of the resident's medical record showed the record did not contain documentation staff completed an entrapment assessment or obtained a physician's order for the use of the bed rails. Observation on 09/24/23 at 11:19 A.M., showed the resident in bed with the left bed rail in the upright position. Observation on 09/25/23 at 9:45 A.M., showed the resident in bed with the left bed rail in the upright position. 3. Review of Resident #28's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Required limited one person physical assistance with bed mobility, transfer, toileting, and bathing; -Diagnosis of hemiparesis (weakness or the inability to move on one side of the body), hip fracture. Review of the resident's Physician Order Sheet (POS), dated 09/2023, showed the record did not contain an order for the bed assist bars. Review of the resident's medical record showed the record did not contain a completed entrapment assessment. Observation on 09/25/23 at 1:30 P.M., showed the right assist bar rail in the upright position. Observation on 09/26/23 at 10:30 A.M., showed the right assist bar rail in the upright position. 4. Review of Resident #30's Admission MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Required extensive two plus person assistance with bed mobility, transfer, dressing, and toileting; -Diagnosis of dementia. Review of the resident's POS, dated 09/25/23, showed the record did not contain an order for bed assist bars. Review of the resident's medical record showed the record did not contain a completed entrapment assessment. Observation on 09/24/23 at 12:44 P.M., showed the resident in bed with bilateral side rails in the upright position. Observation on 09/25/23 at 10:48 A.M., showed the resident in bed with bilateral side rails in the upright position. 5. Review of Resident #32's Admission MDS, dated [DATE], showed staff assessed the resident as follows: -Severe Cognitive impairment; -Required extensive two plus person assistance with bed mobility, transfer, dressing, and toileting; -Diagnosis of dementia and Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). Review of the resident's POS, dated 09/25/23, showed the record did not contain an order for bed assist bars. Review of the resident's medical record showed the record did not contain a completed entrapment assessment. Observation on 09/24/23 at 12:10 P.M., showed the resident in bed with the right assist bar rail in the upright position. Observation 09/25/23 at 10:02 A.M., showed the resident in bed with the right assist bar rail in the upright position. 6. During an interview on 09/25/23 at 12:41 P.M., the administrator said he/she had paperwork to see what the measurements should be in each zone but did not have entrapment assessments for each individual resident quarterly because the beds had never changed and they are not full bed rails, they are cane rails. He/She said they were checking the beds weekly but no measurements were taken. During an interview on 09/26/23 at 12:01 P.M., Licensed Practical Nurse (LPN) A said the nurse was required to do initial assessment and consent upon admission but they did not do anything with measurements. He/She said there were no other interventions tried before the resident had a bed cane because every bed has at least one bed cane. They could take them off but normally don't have too. He/She said therapy might be in charge of taking measurements for the residents because their department determines if a second bed cane is needed. During an interview on 09/26/23 at 12:06 P.M., the maintenance director said their system was dictated by their corporate office and provided him/her with tasks: weekly, monthly, semi-annual and annual. At one time they had bed inspection and device rail inspection generate every week but it just said pass or fail for all. He/She would check the beds, the entire operation: wheel, head and footboard and mattresses but no actual measurements were taken. He/She said in July corporate changed the weekly task to annually, he/she said he/she knew the regulation was quarterly. He/She said there was no process to alert him/her if the residents had a significant change. Only if there was a mattress change. During an interview on 09/26/23 at 12:13 P.M., LPN B said that the facility did not use bed rails, they used bed canes. He/She said the nurses were in charge of getting consents signed and assessments but the assessments did not have measurements. He/She said he/she did not know who completed measurements for the bed canes. During an interview on 09/26/23 at 12:37 P.M., the Director of nursing (DON) said bedrails assessments are completed upon admission and quarterly. The MDS coordinator was in charge of bedrail assessments. He/She did not know why they were not done. During an interview on 09/26/23 at 1:00 P.M., the MDS coordinator said he/she was in charge of quarterly bed rail assessments but did not provide measurements. 43024 47193

Based on interview and record review, facility staff failed to follow their policy as directed to check the Certified Nurse Assistant (CNA) Registry for all staff to ensure they did not have a Federal Indicator (a marker given by the federal government to individuals who have committed abuse and/or neglect) for two of six sampled employees (Licensed Practical Nurse (LPN) C and The Infection Preventionist) as directed in their policy. The facility census was 38. 1. Review of the facility's policy, titled Abuse, Neglect, Exploitation, undated, showed staff were directed to conduct employee reference checks and perform Certified Nursing Assistant CNA and Certified Medication Aide (CMA) registry, licensing board, and state approved background checks. The state nurse aide registry or state licensure body will be contacted before staff provides direct care, if there are prohibitive findings on the registry or the professional licensing body, employment will not proceed. 2. Review of LPN C's employee file showed: -Hire date of 01/06/23; -The file did not contain documentation of the Nurse Aide registry check. 3. Review of Infection Preventionist employee file showed: -Hire date of 12/28/22; -The file did not contain documentation of the Nurse Aide registry check. During an interview 09/26/23 at 12:37 P.M., the Director of Nursing (DON) said the business office manager (BOM) was responsible for all background checks. He/She said everyone that worked in nursing needed a nurse aide registry check. During an interview on 09/26/23 1:03 P.M., the BOM said he/she did the background screenings for new hires. He/She ran the nurse aide registry check for CNAs and the Nursys for the Nurses. He/She was not aware that all employees needed the nurse aide registry check and had not run them for nurses since he/she started helping as the BOM because he/she is the full time dietary manager. During an interview on 09/26/23 at 1:50 P.M., the Administrator said the Nurse aide registry check should be run on every employee. It was the responsibility of the BOM to run all background checks and he/he did not know why it would not be done.

Based on interview and record review, the facility staff failed to document collaboration of care with hospice providers for development and implementation of a coordinated plan of care and communication between the facility and their two hospice providers for two out of three residents (Resident #27, and #31) receiving Hospice services. The facility census was 38. 1. Review of the facility's Hospice Services Agreement, undated, showed: -Plan of Care. Hospice will collaborate with Facility on a coordinated Plan of Care developed jointly between Hospice and Facility. -Resident Chart. Facility and Hospice will prepare and maintain complete medical records for Hospice Patients receiving Facility services in accordance with this Agreement and will include all treatments, progress notes, authorizations, physician orders and other pertinent information. Copies of all documents of services provided by Hospice will be filed and maintained in the Facility chart. 2. Review of Resident's #27's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 08/10/23, showed: -The resident was on Hospice; -The resident had a condition or disease that may result in a life expectancy of less than six months. Review of the facility matrix list of residents on hospice, provided by the facility on 09/27/23, showed the resident was on Hospice services. Review of the resident's Progress Notes, dated 09/2023, showed the record did not contain documentation of Hospice staff visits or coordination of care with the Hospice provider. Review of the resident's medical record, dated 02/2023, showed the record did not contain documentation of a coordinated plan of care between the facility and the Hospice provider. Review of the facility's Hospice binder, undated, showed the record did not contain documentation of communication or a coordinated plan of care between the facility and the hospice provider. 3. Review of Resident #31's Admission MDS, dated [DATE], showed staff assessed the resident as: -The resident was on Hospice; -The resident had a condition or disease that may result in a life expectancy of less than six months. Review of the facility matrix list of residents on hospice, provided by the facility on 09/27/23, showed the resident was on hospice services. Review of the resident's Progress Notes, dated 09/2023, showed the record did not contain documentation of Hospice staff visits or coordination of care with the Hospice provider. Review of the resident's medical record, dated 02/2023, showed the record did not contain documentation of a coordinated plan of care between the facility and the Hospice provider. Review of the facility's Hospice binder, undated, showed the record did not contain documentation of communication or a coordinated plan of care between the facility and the hospice provider. 4. During an interview on 09/26/23 at 12:01 P.M., Licensed Practical Nurse (LPN) A said the communication with the hospice team is verbal, there is no binder for documentation but staff sometimes charted it in point click care (electronic health records system.) During an interview on 09/26/23 at 12:13 P.M., LPN B said there [NAME] no documentation or binders for communication with hospice, or at least not that he/she fills out, maybe I should be. During an interview on 09/26/23 at 12:37 P.M., the Director of Nursing (DON) said hospice care workers and the facility staff have verbal checks and updates. He/She said the hospice communication binder for documentation was put in place before him/her and it should be completed by the nurse staff but they may need more education on it. He/She said it was imperative to document communication with the hospice team to collaborate and agree on plans and provide the resident the best care. During an interview on 09/25/23 at 1:50 P.M., the Administrator said the facility's care plan should mirror Hospice's care plan, a plan of care specifically to that resident. The administrator said communication between the facility staff and the hospice clinic was expected to be documented.

Based on interview and record review, the facility failed to ensure the arbitration agreement was explained to two residents (Resident #9, and #29) and/or to their representative in a form and manner that he/she understood. The census was 38. 1. Review of the facility's policies showed staff did not provide a policy for Arbitration Agreements. Review of the facility's Admission Agreement showed page 8 the Arbitration Agreement as a single paragraph that did not contain a place to decline, or agree to the arbitration. Further review showed there was one signature page at the end of the agreement used to sign for everything listed in the admission agreement. 2. Review of the Resident's #9's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 08/24/23 showed the resident was cognitively intact. Review of the resident's Admission Agreement, dated 03/23/20 showed the signature page was signed. During an interview on 09/26/23 at 1:10 P.M., the resident said he/she did not remember signing the arbitration agreement. He/She said they don't know if they would have signed it, because if something serious or important happened I would want my own lawyer. 3. Review of Resident #29's admission MDS, dated [DATE], showed staff assessed the resident as cognitively intact. Review of the resident's Admission Agreement, dated 06/06/23 showed the signature page was signed. During an interview on 09/26/23 at 01:21 P.M., the resident said he/she has issues with his/her vision and he/she knows he/she would not have been able to read the arbitration agreement himself/herself. He/She said he/she does not remember if he/she was read that portion or if it was explained. He/She said if he/she had to sign it today he/she would not sign it. 4. During an interview on 09/26/23 at 12:40 A.M., the Social Services Director (SSD) said she was responsible for going over the arbitration agreement with the resident and/or their representative upon admission. SSD said they have never had a resident decline signing the Admission Agreement. The SSD said there is not a separate signature page to accept or decline the arbitration agreement. During an interview on 09/26/23 at 1:50 P.M., the Administrator said there was only the one signature page at the end of the Admission Agreement. He said there was not a separate form used to agree or decline the arbitration agreement. The administrator said if the resident or their representative would not agree they would need to sign something to say they don't.

Based on observation, interview and record review, the facility staff failed to use gloves and perform hand hygiene as often as necessary using approved techniques to prevent cross-contamination. Facility staff also failed to allow sanitized kitchenware to air dry prior to stacking in storage to prevent the growth of food-borne pathogens. The facility census was 34. 1. Review of the facility's Proper Hand Washing Procedure and Proper Use of Gloves policy, dated 04/06/20, showed: -All employees will use proper hand washing procedures and glove usage in accordance with State and Federal Guidelines; -All employees will wash hands upon entering the kitchen from any other location, after all breaks (including bathroom and smoking breaks), and between all tasks. Hand washing should occur at a minimum of every hour; -Employee will wash hands before and after handling foods, after touching any part of the uniform, face, or hair, and before and after working with an individual resident; -Gloves are to be used whenever direct food contact is required; -Hands are washed before putting on gloves and after removing gloves. -Gloves are changed any time hand washing would be required. This includes when leaving the kitchen for a break, or to go to another location in the building; after handling potentially hazardous raw food; or if the gloves become contaminated by touching the face, hair, uniform, or other non-food contact surface, such as door handles and equipment. -When gloves must be changed, they are removed, hand washing procedure is followed, and a new pair of gloves is applied. -The proper procedure for washing hands included direction to staff to turn the faucet off with a paper towel after they dry their hands. Observation on 06/27/22 at 11:19 A.M., showed the Certified Dietary Manager (CDM) used his/her bare hands to chop heads of lettuce During an interview on 06/27/22 at 11:20 A.M., the CDM said he/she chopped the lettuce to make the salad for the lunch meal service. The CDM said staff should wear gloves when they handle ready-to-eat food items, but he/she did not wear gloves because he/she was going to wash the lettuce after he/she cut it. Observation on 06/27/22 at 11:55 A.M., showed the CDM washed his/her hands at handwashing station. Observation showed the CDM turned the faucet off with a paper towel and then used the same paper towel to dry his/her hands. Observation on 06/27/22 at 12:39 P.M., showed Cook I washed soiled dishes in the mechanical dishwasher. Observation showed, without performing hand hygiene, the cook put away sanitized dishes from the clean side of the station. Observation on 06/27/22 at 1:27 P.M., showed the CDM wiped the dining room service station countertop with a cleaning cloth; turned the faucet on and rinsed the cleaning cloth under running water; and wiped the countertop again with the cleaning cloth all with the same gloved hands. Further observation showed the CDM removed his/her soiled gloves and, without performing hand hygiene, opened a cabinet, removed drinking glasses and set the drinking glasses on the countertop for use during the meal service. Observation showed the CDM then donned a new pair of gloves, and continued to serve food to residents at the meal. Observation on 06/27/22 at 2:24 P.M., showed the CDM loaded soiled dishes into the dishwasher and then washed his/her hands at the handwashing sink. Observation showed after he/she washed his/her hands, the CDM turned the faucet off with his/her wet, bare hands and then put away sanitized dishes from the clean side of the station. Observation on 06/27/22 at 2:42 P.M., showed Cook I pulled his/her face mask down with his/her bare hand, took a drink from a cup, and returned the mask to his/her face. Observation showed, without performing hand hygiene, the cook prepared coleslaw for service to residents at the evening meal. Observation on 06/27/22 at 2:45 P.M., showed the CDM washed his/her hands at the handwashing sink. Observation showed the CDM turned the faucet off with a paper towel, used the same paper towel to dry his/her hands, and then put away sanitized dishes from the clean side of mechanical dishwashing station. Observation on 06/27/22 at 2:59 P.M., showed Cook I used his/her gloved hands to get a cleaning cloth from a bucket of sanitizer, wiped food debris off a service cart with the cleaning cloth and then used the same gloved hands to remove frozen fish fillets from the box and place the fillets on a baking sheet. During and interview on 06/28/22 at 1:05 P.M., the Dietary Manager (DM) said staff should wash their hands after changing food items; after using cleaning products; after touching their face, face mask, or door knobs; after taking drinks; and between handling dirty and clean dishes. The DM said staff should use a paper towel, not their bare hands, to turn off the faucet after they wash their hands and staff should not use the same towel to dry their hands that they used to turn off the faucet. The DM said staff should wear gloves when handling non-packaged ready-to eat food items. The DM said staff are trained on glove use and proper handwashing procedures. During an interview on 06/29/22 at 1:41 P.M., the administrator said staff should wash their hands anytime they touch a dirty surface which would include touching their face mask, taking a drink, between handling dirty to clean dishes. The administrator said staff should wear gloves when handling non-packaged ready-to-eat food items; change their gloves when they are dirty; and perform hand hygiene before and after glove use. The administrator said staff should use a paper towel to turn the faucet off after they wash their hands and they should not dry their hands with the same paper towel they used to turn off the faucet. The administrator said all staff are trained on proper handwashing procedures and glove use upon hire and periodically. 2. Review of the facility's Dishwashing policy, dated 04/27/20, showed the policy directed staff to air dry dishes in the upside down position on a clean and sanitized surface after they are washed. Observation on 06/27/22 at 11:12 A.M., showed seven metal food preparation and service pans stacked together wet on the storage shelf in the mechanical dishwashing station. During an interview on 06/27/22 at 11:14 A.M., the CDM said dishes should be air dried before they are put away. Observation on 06/27/22 at 12:39 P.M., showed Cook I removed a wet metal food preparation pan from the clean side of the mechanical dishwashing station and stacked it on top of another pan of the storage shelf. Observation on 06/27/22 at 2:24 P.M., showed 10 metal food preparation and service pans stacked together wet on the storage shelf in the mechanical dishwashing station. Observation also showed 11 square plastic plate covers stacked together upside down on a storage cart. During an interview on 06/27/22 at 2:24 P.M., the CDM said he/she stacked the plate covers on the cart before they were dry. During an interview on 06/28/22 at 1:14 P.M., the DM said staff should allow dishes to air dry before they are put away. During an interview on 06/29/22 at 1:46 P.M., the administrator said the DM is responsible to monitor dish storage periodically to ensure they are clean and dry. The administrator said staff should allow dishes to air dry before they are put away and all staff should be trained on that requirement.

Based on observation, interview and record review, the facility staff failed to serve food in accordance with the nutritionally calculated menus to all residents. The facility census was 34. 1. Review of the facility's Diet Spreadsheets/Portion Serving Communication Tool policy, dated 04/03/20, showed Diet spreadsheets or similar meal and portion serving communication tools are available to the serving staff for reference and serving guidance. Diet spreadsheets are based on the planned menu and reflect serving portions for regular and therapeutic diet orders offered in the community. Specific portion serving information for regular and therapeutic diets may be communicated to the serving staff, in place of diet spreadsheets, during meal service, by utilizing innovative communication tools such as meal cards, computer generated meal order tickets, meal orders via computer screens, etcetera (etc.). 2. Review of the facility's lunch menus dated 06/27/22 (Week 2, Day 9), showed the menus directed staff to provide the residents on regular and mechanical soft diets with a dinner roll and one teaspoon (tsp) of margarine. Review also showed the menus directed staff to provide the residents on pureed diets with a #20 (1.6 ounce) scoop of pureed dinner roll. Observation on 06/27/22 during the lunch meal service which began at approximately 12:00 P.M., showed staff did not serve the dinner rolls and margarine as directed by the menus. Observation also showed staff did not provide the residents with a substitution for the dinner rolls and margarine at the meal. During an interview on 06/27/22 at 12:50 P.M., the Certified Dietary Manager (CDM) said staff are directed to serve the meals in accordance with the planned menus. The CDM said they did not have dinner rolls to serve the residents and the other forms of bread they did have, such as bread sticks, were all frozen so he/she did not make a substitute for the dinner rolls. The CDM said they did have sliced bread they could have used as a substitution, but he/she felt the residents would not have wanted the sliced bread. During an interview on 06/29/22 at 1:19 P.M., the Dietary Manager (DM) said staff are directed to serve meals in accordance with the menu and if staff do not have a food item for the menu, they should offer a similar substitute. The DM said the food order got messed up while he/she was on vacation and the dinner rolls were not delivered, but he/she would have expected staff to offer sliced bread as a substitution. 3. Review of the facility's lunch menus dated 06/28/22 (Week 2, Day 10), showed the menus directed staff to provide the residents on regular, low concentrated sweets (LCS)/consistent carbohydrate (CCHO), and mechanical soft diets with a #6 (5.3 ounce) scoop of Ham and Potato Au Gratin. Observation on 06/28/22 during the lunch meal service which began at approximately 12:14 P.M., showed the CDM served the residents on regular, LCS/CCHO, and mechanical soft diets a four ounce scoop of Ham and Potato Au Gratin (1.3 ounces less than directed by the menus). During an interview on 06/28/22 at 12:56 P.M., the CDM said staff should serve meals in accordance with the menus. The CDM said he/she looked at the menus before meal service but he/she did not pay attention to the portion sizes to be served and he/she should have used the portion sizes listed on the menus. During an interview on 06/28/22 at 12:56 P.M., the DM said staff are directed to serve meals in accordance with the menus unless a resident requests something else. The DM said he/she would have expected the CDM to review the menus for portion sizes before service and serve the portion sizes listed on the menus. 4. During an interview on 06/29/22 at 1:48 P.M., the administrator said staff should follow the preplanned menus and if they don't have a food item needed for the menu, staff should substitute the item with something of equal nutritional value.

Based on observation, interview and record review, facility staff failed to conduct ongoing assessments for the use of bed canes (an assistive device attached to a bed) obtain resident consents for the use of bed canes, or attempt other interventions prior to bed cane use. Additionally staff failed to obtain orders for the use of bed canes and failed to update resident care plans to include the use of bed canes for 10 of 33 residents (Resident #2, #5, #10, #12, #14, #17, #26, #28, #30, and #139). The facility census was 34. 1. The facility did not provide a Bed Cane or a Bed Rail Policy. 2. Review of Resident #2's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 3/31/22, showed staff assessed the resident as: -Cognitively impaired; -Requires physical assistance of two staff for bed mobility and transfers; -Has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Does not use bed rails. Review of the resident's medical record showed it did not contain ongoing bed cane assessments, a bed cane consent, or prior interventions attempted before the use of bed canes. Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the care plan revised 6/17/22, showed it did not contain direction for staff in regard to bed cane use for the resident. Observation on 6/28/22 at 8:25 A.M., showed resident in bed with an assist bar up on one side of the resident's bed. 3. Review of Resident #5's Admission MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Required extensive assistance on two staff members for bed mobility and transfers; -Does not use bed rails. Review of the resident's medical record showed it did not contain ongoing bed cane assessments, a bed cane consent, or prior interventions attempted before the use of bed canes. Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the care plan, revised 5/30/22, showed it not contain direction for staff in regard to bed cane use for the resident. Observation on 6/27/22 at 11:18 A.M., showed the resident in bed with assist bars on both sides. Observation on 6/28/22 at 2:15 P.M., showed the resident in bed with assist bars up on both sides. 4. Review of Resident #10's Significant Change MDS, dated [DATE], showed staff assessed the resident as: -Moderate cognitive impairment; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Required extensive two person assistance for bed mobility and transfers; -Did not use bed rails. Review of the resident's medical record showed it did not contain ongoing bed cane assessments, bed cane consents, or prior interventions attempted before the use of bed canes. Review of the resident's POS, undated, showed it did not contain a order for bed canes or assistive devices. Review of the resident's care plan, revised 5/30/22, showed it did not contain direction for staff in regard to the use of bed canes for the resident. Observation on 6/27/22 at 11:08 A.M. showed the resident in bed with bed canes up on both sides. Observation on 6/28/22 at 8:37 A.M. showed the resident in bed with bed canes up on both sides. Observation on 6/28/22 at 2:44 P.M. showed the resident in bed with bed canes up on both sides. Observation on 6/29/22 at 7:32 A.M. showed the resident in bed with bed canes up on both sides. 5. Review of Resident #12's Admission MDS, dated [DATE], showed the staff assessed the resident as: -Severely cognitively impaired; -diagnosed with dementia, anxiety and depression; -Requires physical assistance of two staff for bed mobility and transfers; -Did not use bed rails. Review of the resident's medical record showed it did not contain ongoing bed cane assessments, a bed cane consents, or prior interventions attempted prior to the use of the bed canes. Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan revised 5/9/22, showed it did not contain direction for staff in regard to bed cane use for the resident. Observation on 6/27/22 at 11:05 A.M. showed the resident in bed with a bed cane up on one side. Observation on 6/28/22 at 8:41 A.M. showed the resident in bed with a bed cane up on one side. 6. Review of Resident #14's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Required extensive assistance from two staff members for bed mobility and transfers; -Did not use bed rails. Review of the resident's medical record showed it did not contain ongoing bed cane assessments, a bed cane consent, or prior interventions attempted prior to bed cane use. Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan, revised 5/9/22, showed it did not contain direction for staff in regard to bed cane use for the resident. Observation on 6/27/22 at 11:12 A.M., showed the resident in bed with one bed cane up. Observation on 6/27/22 at 12:41 P.M., showed the resident in bed with one bed cane up. Observation on 6/28/22 at 8:38 A.M., showed the resident in bed with one bed cane up. Observation on 6/28/22 at 2:54 P.M., showed the resident in bed with one bed cane up. Observation on 6/29/22 at 7:32 A.M., showed the resident in bed with one bed cane up. 7. Review of Resident #17's Significant Change MDS, dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Requires assistance from two staff members for bed mobility and transfers; -Did not use bed rails. Review of the resident's medical record showed it did not contain ongoing bed cane assessments, a bed cane consent, or prior interventions attempted before bed cane use. Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan, revised 6/5/19, showed the resident can position while in bed with use of a bed cane. Observation on 6/27/22 at 11:17 A.M., showed the resident sat in a recliner next to his/her bed, a bed can was up on one side of the bed. Observation on 6/27/22 at 2:18 P.M. showed a bed cane was up on one side of the bed. Observation on 6/28/22 at 8:36 A.M. showed the resident sat on the side of the bed, a bed cane was up one side of the bed. 8. Review of Resident #26's Admission MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Required extensive assistance from two staff members for transfers; -Required extensive assistance from one staff member for bed mobility; -Did not use bed rails. Review of the resident's medical record showed it did not contain ongoing bed cane assessments, a bed cane consent, or prior interventions attempted prior to bed cane use. Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the resident's care plan, revised 6/24/22, showed it not contain direction for staff in regard to bed cane use for the resident. Observation on 6/27/22 at 11:15 A.M., showed the resident in bed with bed canes up on both sides. Observation on 6/28/22 at 8:40 A.M. showed the resident in bed with bed canes up on both sides. Observation on 6/28/22 at 3:09 P.M. showed the resident in bed with bed canes up on both sides. 9. Review of Resident #28's Admission MDS, dated [DATE], showed staff assessed the resident as: -Cogently intact; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Required oversight with assistance of one staff member for bed mobility; -Required oversight with set up help for transfers; -Did not use bed rails. Review of the resident's medical record showed it did not contain ongoing bed cane assessments, a bed cane consent, or prior interventions attempted prior to bed cane use. Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the care plan, dated 5/30/22, showed it not contain direction for staff in regard to bed cane use for the resident. Observation on 6/27/22 at 11:27 A.M., showed the resident in bed with a bed cane up on one side. Observation on 6/28/22 at 9:15 A.M. showed the resident in bed with a bed cane up on one side. 10. Review of Resident #30's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Required extensive assistance from one staff member for bed mobility and transfers; -Did not use bed rails. Review of the resident's medical record showed it did not contain ongoing bed cane assessments, a bed cane consent, or prior interventions attempted prior to bed cane use. Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the care plan, revised 6/17/22, showed it not contain direction for staff in regard to the resident's use of bed canes. Observation on 6/27/22 at 12:00 P.M., showed the resident in bed with a bed cane up on one side. Observation on 6/28/22 at 8:24 A.M. showed the resident in bed with a bed cane up on one side. 11. Review of Resident #139's Entry MDS, dated , 6/23/22, showed it was not completed by staff. Review of the resident's medical record showed it did not contain ongoing bed cane assessments, a bed cane consent, or prior interventions attempted before the use of bed canes. Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the baseline care plan, dated 6/23/22, showed it did not contain direction for staff in regard to bed cane use for the resident. Observation on 6/27/22 at 12:49 P.M., showed the resident in bed with a bed cane up on one side. Observation on 6/28/22 at 3:56 P.M., showed the resident in bed with a bed cane up on one side. Observation on 6/29/22 at 9:18 A.M., showed resident in bed with bed cane up on one side. During an interview on 6/30/22 at 1:54 P.M., Licensed Practical Nurse (LPN) A said nurses complete an admission assessment, but he/she did not know if it included a bed cane assessment. He/She said he/she does not know if residents are informed of the risk and benefits of having bed canes. During an interview on 6/30/22 at 3:04 P.M., the Director of Nursing (DON) said if a resident uses bed canes it should be listed on the care plan. He/she said the facility uses bed canes, and he/she would not expect to see a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . He/she said the facility does complete consent forms for the assistive devices.

Based on observation, interview, and record review, facility staff failed to ensure the residents' environment remained free of accident hazards when they failed to lock a medication/treatment cart when not in use. Additionally, staff failed to implement an intervention for one resident (Resident #17) after a fall, and failed to properly propel three residents (Resident #19, #26 and #30) in wheelchairs in a manner to prevent accidents. The facility census was 34. 1. Review of the facility's Medication Storage, Storage of Medications and Biologicals Policy, dated January 2021, showed: -Only licensed nurses, authorized pharmacy personnel, and those lawfully authorized to administer medications, such as medication technicians, are allowed to access medications; -Medication rooms, medication carts, and medication supplies are locked or attended by persons with authorized access. Observation on 6/28/22 at 10:16 A.M., showed a medication/treatment cart sat on 400 B hallway, in an alcove. The treatment cart was unlocked and unattended. It contained four bottles of [MEDICATION(S)] (medication administered for chest pain) 0.4 milligrams (mg), 125 [MEDICATION(S)] (medication used for nausea and vomiting) 4 mg tablets, 28 Hycosamine (medication used for intestinal cramps) 0.125 mg tablets, 54 [MEDICATION(S)] (cough medication) 100 mg softgels, 28 [MEDICATION(S)] (medication used to relieve stomach gas) 180 mg softgels, and an open bottle of wound cleanser. Observation on 6/28/22 at 10:21 A.M., showed Licensed Practical Nurse (LPN) G walked down the hallway past the cart. He/She then turned around and walked past the cart a second time and he/she did not lock the cart. Observation on 6/28/22 at 10:24 A.M., showed LPN G and Certified Medication Technician (CMT) D stood at the cart. LPN G did not lock the cart, and walked toward the nurse's desk. CMT D stood by the cart and did not lock the cart. He/She then walked away from the cart. During an interview on 6/28/22 at 10:32 A.M., LPN G said medication and treatment carts should be locked at all times when not in use. He/She said he/she forgot to lock the cart. He/She said some of the residents who reside on the hallway wander, and have significant memory issues. He/She said if another staff member walked by the cart, and noticed it was not locked, he/she would expect them to lock it. During an interview on 6/30/22 at 2:42 P.M., Certified Nurse Aide/Certified Medication Technician (CNA/CMT) D said staff are directed to make sure the carts are locked before they walk away from them. During an interview on 6/30/22 at 1:54 P.M., LPN A said staff should lock the medication or treatment cart if they leave it. During an interview on 6/30/22 at 3:04 P.M., the Director of Nursing (DON) said he/she expects medication and treatment carts locked when not in use. 2. Review of the Facility's Fall policy, revised, April 2018, showed: -The facility will implement systems to reduce the risk of falls based on resident assessment; -Individualized care plan interventions will be developed for residents who are identified through assessment as being at risk for falls; -Interventions will be reviewed and updated on a regular basis and if/when a fall occurs. Review of Resident #17's Significant Change Minimum Data Set (MDS), a federally mandated assessment tool, dated 5/5/22, showed staff assessed the resident as: -Cognitively impaired; -Required assistance from two staff members for bed mobility, transfers, locomotion, dressing, toileting and hygiene; -Unsteady from seated to standing and surface-to-surface transfers; -Has limited Range of Motion (ROM) (movement in joint) in one lower extremity; -Uses a wheelchair and oxygen; -Has a history of falls; -Diagnoses of [CONDITION(S)] (irregular heartbeat), [CONDITION(S)] (condition in which the blood does not have enough red blood cells or hemoglobin (assists with oxygen transport)), Arthritis, Dementia, Anxiety and Depression. Review of a nurse's note, dated 6/26/22 at 2:00 P.M., showed staff documented the resident fell . Review of the care plan, revised 6/15/22, showed it did not contain direction for staff or an intervention for the fall on 6/26/22. During an interview on 6/30/22 at 1:54 P.M., LPN A said the MDS Coordinator typically updates the care plan, but the nurses can update it as well. He/She said the resident falls all the time, and he/she would expect there to be interventions in place. He/She said if goals and interventions are not in the care plan staff would not know how to assist a resident, other than by word of mouth from other staff members. During an interview on 6/20/22 at 1:12 P.M., Certified Nurse Aide (CNA) B said the nurses update the care plans. He/She said he/she did not know how often the care plans were supposed to be updated. He/She said the resident falls quite a bit, and he/she would expect to see fall interventions on his/her care plan. During an interview on 6/30/22 at 3:04 P.M., the Director of Nursing (DON) said the nurses can update the care plan. He/She said when a resident falls he/she expects a new intervention added immediately. He/she said he/she did not know resident #17's care plan had not been updated after his/her fall. 3. Review of the facility's Wheelchair Use Policy, undated, showed: -Wheelchair pedals are available for use, but should be discouraged with residents who are able to move themselves about in their wheelchairs; -If transporting a patient without pedals, ensure there are no safety risks associated with the patient suspending their feet. 4. Review of Resident #19's Admission MDS, dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -Required assistance from one staff member for locomotion; -Uses a walker for a mobility device; -Has a diagnosis of Dementia. Review of the resident's care plan, revised 5/10/22, showed the resident requires help from staff with mobility in his/her wheelchair. Observation on 6/28/22 at 1:32 P.M., showed LPN A propelled the resident from the shower room to his/her room in his/her wheelchair, without foot pedals. When LPN A entered the room, he/she said the resident should have foot pedals on his/her wheelchair. 5. Review of Resident 26's Admission MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Diagnoses of traumatic subdural hemorrhage (brain bleed), dementia, and bilateral [CONDITION(S)] of the knee; -Required extensive assistance from two staff members for transfers; -Required extensive assistance from one staff member for locomotion off of the unit. Review of the resident's care plan, revised 6/24/22, showed staff documented the resident may be able to move around for short distances but would require help from staff to move around outside of his/her room. Observation on 06/29/22 at 7:59 A.M., showed CNA B propelled the resident from his/her room to the dining room in his/her wheelchair, without foot pedals. 7. Review of Resident 30's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Diagnoses of [CONDITION(S)] (paralysis of one side of the body) and [CONDITION(S)] (synonym for [CONDITION(S)]) affecting the left side (dominant side), visuospatial deficit and spatial neglect (ones ability to identify visual and spatial relationships among objects); -Requires extensive assistance from one staff member for transfers; Review of the resident's care plan, revised 5/25/22, showed staff documented the resident could travel short distances independently in his/her. Observation on 6/28/22 at 2:40 P.M., showed the Activity Director (AD) propelled the resident from his/her room to the dining room in his/her wheelchair, without foot pedals. During an interview on 6/30/22 at 1:12 P.M., CNA B said staff are directed to ensure the residents' arms are down, and their feet are up when they propel them in their wheelchairs, unless the resident is too weak to hold their feet up. He/She said he/she would push a resident without foot pedals, if the resident is strong enough to hold up their feet. During an interview on 6/30/22 at 1:54 P.M., LPN A said staff should use foot pedals when propelling a resident in a wheelchair. He/She said staff are directed not to push a resident in a wheelchair without foot pedals. During an interview on 6/30/22 at 3:04 P.M., the DON said staff are directed to apply foot pedals to wheelchairs before propelling residents, to make sure the resident is secured.

Based on observation, interview and record review the facility failed to follow physician orders for two residents (#6 and #35) who received [CONDITION(S)] (purification of blood, as a substitute for normal kidney function) and one resident (#32) who used oxygen, and failed to obtain a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, facility staff failed failed to administer medication per current standards of practice for one resident (Resident #31), and failed to accurately update the Treatment Administration Record (TAR) for one resident (Resident #36). The facility census was 34. 1. Review of the facility's Physician Order policy, dated 9/21/21, showed physician orders will be followed related to the care needs of individual residents. 2. Review of the facility's [CONDITION(S)] policy, dated 11/28/17, showed [CONDITION(S)] services will be provided for residents with [CONDITION(S)] ([CONDITION(S)]) (kidney function has ceased and treatment is required) and will have a physician's order. The policy did not contain direction for obtaining vital signs or weights. 3. Review of Resident #6's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 4/7/22, showed staff assessed the resident as: -Cognitively intact; -Receives [CONDITION(S)]; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's Care Plan, revised, 5/9/22, showed: -Goes to [CONDITION(S)] three times per week on Tuesdays, Thursdays, and Saturdays; -Monitor weights and vital signs before and after [CONDITION(S)]; -Weights may be done at [CONDITION(S)] sometimes; facility is to ensure communication of assessments between the [CONDITION(S)] center and the facility. Review of Physician's Orders dated 5/31/22 showed: -Receives [CONDITION(S)] on Tuesdays, Thursdays, and Saturdays; -Obtain pre-[CONDITION(S)] wet weight and vital signs; -Obtain post-[CONDITION(S)] dry weight and vital signs. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. and one out (June 11) of twelve scheduled days at 12:00 - 2:00 P.M. 4. Review of Resident #35's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively impaired; -Receives [CONDITION(S)]; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's Physician's Orders dated 4/22/22 showed: -Receives [CONDITION(S)] on Tuesdays, Thursdays, and Saturdays; -Obtain pre-[CONDITION(S)] wet weight and vital signs; -Obtain post-[CONDITION(S)] dry weight and vital signs. Review of the resident Care Plan revised, 5/9/22, showed: -Goes to [CONDITION(S)] three times per week on Tuesdays, Thursdays, and Saturdays; -Monitor weights and vital signs before and after [CONDITION(S)]; -Weights may be done at [CONDITION(S)] sometimes; facility is to ensure communication of assessments between the [CONDITION(S)] center and the facility. Review of the resident's MAR, dated June 2022, showed staff did not document the following: -Weights for two out of twelve (June 16 and 21) scheduled days at 6:00 A.M. to 10:00 A.M.; -Weights for three out (June 2, 16, and 21) of twelve scheduled days at 3:00 P.M.; -Vitals signs for one out of twelve (June 21) scheduled days at 6:00 to 10:00 A.M.; -Vital signs for two out of twelve (June 16 and 21) scheduled days at 3:00 P.M. During an interview on 6/30/22 at 1:54 P.M., Licensed Practical Nurse (LPN) A said staff check vital signs and weigh the residents before they go to [CONDITION(S)]. He/She said the nursing staff is responsible for checking vitals. He/She said he/she did not know Resident #6 and Resident # 35 did not have their vitals checked or their weight obtained prior to or after [CONDITION(S)] treatments all the time. During an interview on 6/30/22 at 3:04 P.M., the Director of Nursing (DON) said he/she expects the nurses to obtain weights and check the vital signs of residents who receive [CONDITION(S)] before and after their treatment. He/she said he/she did not know it was not completed for each treatment. 5. Review of Resident #32's Admission MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Required extensive two person assistance with bed mobility, transfers, toileting and personal hygiene; -Uses oxygen. Review of the resident's care plan, dated 6/1/22, showed it did not contain direction for staff in regard to the resident's oxygen use. Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 6/27/22 at 11:53 A.M., showed the resident wore oxygen at 3.25 Liters Per Minute (LPM). Observation on 6/28/22 at 2:50 P.M., showed the resident wore oxygen at 2.5 LPM. Observation on 6/30/22 at 11:13 A.M., showed the resident wore oxygen at 2.5 LPM. During an interview on 6/28/22 at 2:50 P.M., the resident said he/she received oxygen at 3 LPM. During an interview on 6/30/22 at 1:54 PM, LPN A said the nurses are responsible for ensuring the residents get the prescribed amount of oxygen. He/She said Resident #32 received oxygen at 2.5 LPM, and the order was for 2 to 5 LPM to keep the resident's oxygen level above 90%. During an interview on 6/30/22 at 1:12 P.M., Certified Nurse Aide (CNA) B said the nurses and aides adjust the amount of oxygen the resident receives. He/She said the aides are told how many liters are to be administered by the nurses and they verify it when they check on the resident. He/She said he/she is not sure how many liters of oxygen Resident #32 receives. During an interview on 6/30/22 at 3:04 P.M., the DON said the nurses are responsible for verifying the resident receives the physician ordered amount of oxygen. He/She said he/she expects staff to follow physician orders. 6. Review of Resident #5's Admission MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] - 5/25/22: [MEDICATION(S)] (antibiotic) Tablet 800-160 milligrams (mg) ([MEDICATION(S)]-[MEDICATION(S)]) Give 1 tablet by mouth two times a day related to urinary tract infection ([CONDITION(S)]), for five Days. Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 6/30/22 at 1:54 P.M., LPN A said the nurses, MDS Coordinator and DON update the Physician Order Sheet (POS) by the end of their shift or sooner. He/She said when staff receive an order, it is entered into the electronic medical record (EMR), and then given to the MDS Coordinator and DON for review. He/She said the process is the same for an antibiotics. He/She said he/she did not know the resident #5 did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 6/30/22 at 3:04 P.M., the DON said he/she expects the nurses to obtain orders for medications. He/she said he/she did not know resident #5's [MEDICATION(S)] was not on the POS. 7. Review of Resident #31's admission MDS, dated [DATE], showed staff assessed the resident as cognitively intact. Review of the resident's POS, undated, showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The POS did not contain an order to crush or alter medications. Observation on 6/28/22 at 9:01 A.M., showed Certified Medication Technician (CMT) C broke the resident's Potassium Chloride ER tablet in half, and administered the broken pieces to the resident. During an interview on 6/30/22 at 2:42 P.M., CMT D said CMT's are responsible for ensuring medications are administered according to directions. He/She said he/she would break a pill, if it was scored, but if it was not scored he/she said he/she would ask a nurse if he/she could. He/She said he/she would apply gloves before he/she touched a medication. He/She said if a resident requested a medication be broken in half that should not be broken he/she would educate the resident, and administer the medication as directed by the nurse. He/She said he/she would report to the nurse if a resident refused to take an ER pill without first breaking it in half. During an interview on 6/30/22 at 1:54 P.M., LPN A said staff should report if a resident requested a pill be broken in half, and it is not scored. He/She said the ER tablets should not be broken. He/She said the nurse should contact the physician if a resident has an issue with swallowing medications. During an interview on 6/30/22 at 3:04 P.M., the DON said extended release medication should not be broken. 8. Review of Resident #36's, Quarterly MDS, dated , 6/16/22, showed staff assessed the resident as: -Moderate cognitive impairment; -Required extensive two person assistance with bed mobility and transfers, dressing -Required supervision with eating -Required extensive one person assistance with toileting and personal hygiene; -Has a stage I pressure ulcer. Review of the resident's POS, showed: -12/24/21: [MEDICATION(S)] Powder (an antifungal powder) 100,000 unit/gram (GM) apply topically to the perineum once a day for redness. Review of the TAR, dated June 2022, showed staff did not document they provided the ordered [MEDICATION(S)] Power on 6/11/22, 6/15/22 or 6/21/22. During an interview on 6/30/22 at 1:54 PM LPN A said an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . He/She said whomever completes the treatment should document it was completed. He/She said the MDS Coordinator audits the TARS on a regular basis. He/She said resident #36 should have [MEDICATION(S)] Powder applied every shift. During an interview on 6/30/22 at 3:04 P.M., the DON said he/she expects nursing staff to document completion of treatments in the TAR. He/She said he/she did not know there was missing documentation on the TARs.

Based on observation, interview and record review, facility staff failed to ensure comprehensive care plans were developed, revised and updated in a timely manner for five residents (Resident #20, #28, #32, #36, and #39) out of sixteen sampled residents. The facility census was 34. 1. Review of the facility's Care Plan policy, dated 11/28/17, showed: -A care plan will be developed for each resident that includes measurable objectives to meet a resident's medical, nursing, mental and psychosocial needs and are consistent with the resident's desires and preferences; -The care plan should reflect individualized problems, goals and interventions based on the resident's preferences and wishes. 2. Review of Resident #20's Quarterly MDS, a federally mandated assessment tool, dated 5/12/22, showed staff assessed the resident as: -Cognitively Intact; -Had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Used oxygen. Review of the resident's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of care plan, dated 5/9/22, showed it did not contain direction for staff in regard to resident's oxygen use. Observation on 06/27/22 at 11:45 A.M., showed an oxygen concentrator sat at the resident's bedside. During an interview on 6/27/22 at 11:46 A.M., the resident said he/she used oxygen at night. 3. Review of Resident #28's Admission MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Uses Oxygen. Review of the resident's POS, undated, showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan, dated 5/30/22, showed it did not contain direction for staff in regard to the resident's oxygen use. Observation on 6/27/22 at 11:27 A.M., showed the resident in his/her bed, he/she wore oxygen at 3 LPM. Observation on 6/28/22 at 9:15 A.M., showed the resident in bed with his/her eyes closed, he/she wore oxygen. 4. Review of Resident #32's Admission MDS, dated , 6/7/22, showed staff assessed the resident as: -Cognitively intact; -Required extensive two person assistance with bed mobility, and transfers; -Uses oxygen. Review of the resident's POS, dated 6/4/22, showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan, dated 6/1/22, showed it did not contain direction for staff in regard to the resident's oxygen use. Observation on 6/27/22 at 11:53 A.M., showed the resident wore oxygen at 3.25 LPM. Observation on 6/28/22 at 2:50 P.M., showed the resident wore oxygen at 2.5 LPM. Observation on 6/30/22 at 11:13 A.M., showed the resident wore oxygen at 2.5 LPM. 5. Review of Resident #36's Quarterly MDS, dated , 6/16/22, showed staff assessed the resident as: -Moderate cognitive impairment; -Required extensive two person assistance with bed mobility and transfers; -Has a stage I pressure ulcer (Intact skin with non-blanchable redness of a localized area, usually over a bony prominence). Review of the progress notes, dated 6/17/22, showed staff documented the resident had a Stage I pressure ulcer to his/her heel. Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan, dated 1/2/22, showed it did not contain direction for staff in regard to the resident's Stage I pressure ulcer. 6. Review of Resident #39's, Admission MDS, dated , 4/11/22, showed staff assessed the resident as: -Cognitively intact; -Did not receive hospice services. Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Social Services progress notes, dated 5/12/2022, showed the resident was admitted to Hospice Services. Review of the care plan, dated 4/8/22, showed it did not contain direction for staff in regard to resident's hospice care. During an interview on 6/30/22 at 1:12 P.M., Certified Nurse Aide (CNA) B said the nurses update the care plans. He/She said the care plan should include oxygen use, pressure ulcers, and other resident specific information. During an interview on 6/30/22 at 1:54 P.M., Licensed Practical Nurse (LPN) A said the MDS Coordinator is responsible for care plan updates. He/She said he/she did not know how often care plans were to be updated, other then when there was a change. He/She said he/she would expect to see oxygen use, pressure ulcers, and hospice services, on the care plan. During an interview on 6/30/22 at 3:04 P.M., the Director of Nursing (DON) said care plans are updated and reviewed by the MDS Coordinator on admission, quarterly and with changes in the residents' condition. The DON said he/she expects care plans to include pressure ulcer interventions, oxygen use, and hospice care. He/she said the MDS Coordinator has been working the floor to help cover staffing shortages.

Based on observation, interview, and record review, facility staff failed to treat four residents (Resident #3, #5, #12 and #34) with dignity and respect during meal service. The facility census was 34. 1. Review of the facility's Resident Rights under Federal Law Policy, undated, showed the resident has a right to a dignified existence and to be treated with respect and dignity. 2. Review of Resident #3's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 3/31/22, showed staff assessed the resident as: -Severe Cognitive Impairment: -Required assistance from one staff member for eating; -Has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 6/28/22 at 8:19 A.M., showed an unidentified staff member stood over the resident as he/she fed them. 3. Review of Resident #5's Admission MDS, dated [DATE], showed staff assessed the resident as: -Severe Cognitive Impairment; -Has short and long term memory issues; -Never/rarely makes decisions; -Required extensive assistance from one staff member for locomotion on and off the unit. Observation on 6/29/22 at 7:30 A.M., showed the resident sat in the dining room with his/her eyes closed. Seven residents were in the dining room. Observation on 6/29/22 at 7:42 A.M., showed the resident sat in the dining room with his/her eyes closed. Eleven residents were in the dining room. Observation on 6/29/22 at 8:00 A.M., showed the resident sat in the dining room with his/her eyes closed. Other residents in the dining room talked about the resident sleeping, while he/she was in the dining room. Observation on 6/29/22 at 8:08 A.M., showed the resident sat at the dining room table with his/her eyes closed. Two residents, who sat in the dining room, commented about the resident and said he/she was asleep again. Observation on 6/29/22 at 8:20 A.M., showed the resident sat in the dining room with his/her eyes closed. Eleven residents were in the dining room. Observation on 6/29/22 at 9:00 A.M., showed residents in the dining room talked about how the resident slept at the table. Observation on 6/29/22 at 9:05 A.M. showed the resident sat in the dining room with his/her eyes closed. 4. Review of Resident #12's Admission MDS, dated [DATE], showed staff assessed the resident as: -Severe Cognitive Impairment; -Never/Rarely makes decisions; -Required assistance from one staff member for eating. Review of the resident's care plan, dated 6/17/22, showed staff were directed to provide finger foods at meals, and keep his/her dignity intact. Observation on 6/27/22 at 12:41 P.M., showed the resident sat alone at a dining room table. He/She had his/her back to the other residents. Observation on 6/27/22 at 1:00 P.M., showed the resident sat alone at a dining room table. He/She had his/her back to the other residents. Observation on 6/27/22 at 1:12 P.M., showed the resident sat alone with his/her back to other residents at a dining room table. An unidentified staff member served the resident a plate of beef pot roast with gravy on it, fresh sliced tomatoes and cake. Observation showed staff place a rolled up napkin on the table and walk away. The resident ate a piece of beef pot roast with his/her fingers, with gravy on his/her fingers, he/she took a bite of cake, and then used his/her shirt sleeve to wipe his/her fingers clean. Observation on 6/27/22 at 1:18 P.M., showed the resident pick up his/her meal ticket and wipe food debris off of his/her face. He/she then used the bottom of his/her shirt and his/her hand to wipe his/her nose, and continued to eat. His/her rolled napkin sat on the table next to the plate. Observation on 6/27/22 at 1:22 P.M., showed the resident with food on his/her fingers, as he/she ate with no assistance from staff. Observation on 6/27/22 at 1:24 P.M., showed the resident pushed his/her meal away. 5. Review of Resident #34's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Moderate Cognitive Impairment; -Has short and long term memory issues; -Required oversight with setup help for eating. Observation on 6/29/22 at 8:32 A.M. showed House Keeper F tell the resident he/she always missed his/her mouth when he/she ate, and he/she made a mess on the dining room floor. There were other residents in the dining room. During an interview on 6/30/22 at 1:12 PM, Certified Nurse Aide (CNA) B said residents should be taken out of the dining room when they are finished eating. He/She said staff are directed to wake residents up if they are sleeping at a dining room table. He/She said staff should take the resident to their room, and lay them down when they are unable to stay awake. He/She said it is not appropriate for staff to point out a resident's mess in the dining room. He/She said he/she would make sure the hands of a resident, who received a finger food diet, were cleaned frequently and they had a napkin in reach. He/She said he/she did not know why the resident was served roast with gravy on it, but he/she said the resident should have been assisted with the meal. He/She said, if a resident had food on their hands and face, staff should encourage the resident to clean it off. He/she said it's important for the resident's dignity. During an interview on 6/30/22 at 1:54 PM, Licensed Practical Nurse (LPN) A said staff should not make comments about a resident making a mess. He/She said staff should just clean it up. He/She said if a resident fell asleep at the dining room table, he/she would expect staff to take the resident to bed. He/She said Resident #5 doesn't propel himself/herself in his/her wheelchair. LPN A said if a resident has a finger food diet, staff should serve the resident finger foods only. He/She said he/she would expect staff to place a napkin within reach, as well as, provide the resident with silverware. He/She said staff should assist the resident with eating, especially if the meal is messy. He/She said he/she did not know why a staff member would not offer to clean the resident's hands. During an interview on 6/30/22 at 3:04 P.M., the Director of Nursing (DON) said he/she expects staff to be kind and treat residents with respect. He/She said if a resident makes a mess staff should not bring attention to it. He/she said dependent residents should be taken from the dining room no longer than 30 minutes after eating and should not be left in the dining room if asleep in their chair. He/she said residents that require a finger food diet should have napkins and silverware, and the napkin should be unrolled for the resident to use. He/She said he/she expected staff to sit and visit with residents when assisting them to eat, and would not expect them to stand over a resident and assist them. During an interview on 6/30/22 at 3:04 P.M., the Administrator said resident dignity is covered in the resident rights policy.

Based on observation, interview, and record review, facility staff failed to use appropriate hand hygiene in a manner to prevent the spread of infection during wound care for one resident (Resident #19). Additionally staff failed to perform appropriate hand hygiene during meal service for one resident (Resident #26). The facility census was 34. 1. Review of the facility's Hand Hygiene policy, dated November 2017, directed staff to: -Wash hands with soap and water when hands are visibly soiled; -Cleanse hands with alcohol based hand rub: -Before and after contact with the resident; -After contact with blood, bodily fluids, or visibly contaminated surfaces or other objects and surfaces in the resident's environment; -After removing personal protective equipment (PPE) (e.g., gloves, gown, facemask); -Before performing a procedure such as dressing care; Review showed the policy did not contain direction for staff in regard to hand hygiene during meal service or medication administration. 2. Review of the facility's Wound Assessment, Prevention and Treatment Policy, dated November 2017, showed it did not contain direction for staff in regard to hand hygiene before, during, or after wound care. 3. Review of Resident #19's Annual Minimum Data Set (MDS), a federally mandated assessment, dated 5/3/22, showed staff assessed the resident as: -Cognitively impaired; -Had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Had Moisture Associated Skin Damage (MASD) (inflammation or erosion of the skin due to prolonged fluid exposure). Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -Wound Care: Unna Boots to bilateral lower legs, cover loosely with ace wrap, change ace wrap every three days, or as needed (PRN), if soiled: Blisters and open areas. Observation on 6/28/22 at 1:32 P.M., showed Licensed Practical Nurse (LPN) A provide care to open areas, and blisters on the resident's legs. LPN A applied an Unna boot (compressive and wet gauze-like dressing similar to a cast) and elastic bandage to the resident's right leg. The resident's legs wept large amounts of drainage on the floor. LPN A with the same gloves on, applied an UNA boot and elastic bandage to the resident's left leg, removed his/her gloves, opened the resident's dresser, retrieved a pair of clean socks, applied the socks to the resident's feet, then left the resident's room. He/She did not perform hand hygiene between dressing changes, after he/she removed his/her gloves, or before he/she left the resident's room. During an interview on 6/28/22 at 1:40 P.M., LPN A said he/she should have washed his/her hands when removing gloves, between each leg dressing, and before leaving the room. During an interview on 6/30/22 at 3:04 P.M., the Director of Nursing (DON) said he/she expected staff to perform hand hygiene before and after wound care, when changing/or removing gloves, between body sites and before leaving the room. 4. Review of Resident #26's Admission MDS, dated [DATE], showed staff assessed the resident as: -Cognitively Intact; -Had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Required set up help with supervision for eating. Observation on 6/29/22 at 8:10 A.M., showed the DON push a cart with a bag of trash on top of it, stop, grab the resident's butter knife and toast, and apply butter to the resident's toast. The DON did not perform hand hygiene before he/she touched the resident's food with his/her bare hands. During an interview on 6/30/22 at 3:04 P.M., the DON said he/she expected staff to wash or sanitize their hands, and apply gloves before they touch resident food. He/She said staff should not touch food with their bare hands.