Every finding on record at Baisch Nursing Center

Based on observation, interview and record review the facility failed to maintain the HVAC (heating, ventililation, and air conditioning) system in working order to provide comfortable and safe temperatures for residents residing on the 100 hallway. During an Extreme Heat Warning, multiple resident rooms exceeded the acceptable indoor temperature range, resulting in residents being unable to consistemtly maintain a comfortable living environment. This deficient practice had the potential to affect all 15 residents who live on the 100 hall. The facility census was 51.Review of the facility's Extreme Heat Policy, revised 11/01/13, showed staff were to monitor temperatures and humidity between 1:00 p.m. and 7:00 p.m.; obtain temperatures in resident rooms and common areas; relocate residents when individual rooms exceeded 80 degrees; contact maintenance to repair the HVAC system; and implement emergency relocation measures when multiple rooms or wings were affected.Review of National Weather Service information showed an Extreme Heat Warning was issued for the area on 06/28/26 at 7:00 A.M,. The warning indicated dangerous heat conditions were expected to continue for five to seven days, with heat index values up to 110 degrees.Observation on 06/29/26 at 4:30 P.M. showed:room [ROOM NUMBER] at 79 degrees with a fan in use;room [ROOM NUMBER] at 82 degrees with a fan in use;room [ROOM NUMBER] at 80 degrees with a fan in use;room [ROOM NUMBER] at 82 degrees with a fan in use;room [ROOM NUMBER] at 82 degrees with a fan in use;Observation on 06/29/26 at 4:45 P.M. showed fans in use in the dining room where several residents sat. Observation on 6/29/26 at 7:45 p.m. showed:room [ROOM NUMBER] at 80 degrees with a fan in use;room [ROOM NUMBER] at 82 degrees with a fan in use;room [ROOM NUMBER] at 78degrees with a fan in use;room [ROOM NUMBER] at 86 degrees with a fan in use;room [ROOM NUMBER] at 82 degrees with a fan in use;room [ROOM NUMBER] at 88 degrees with a fan in use.During an interview on 06/29/26 at 5:00 P.M., Resident #1 said he/she was too warm in the dining room and in his/her room. During an interview on 06/29/26 at 5:05 P.M., Resident #2 said he/she was too warm in the dining room and in his/her room. During an interview on 06/29/26 at 4:45 P.M., the Assistant Director of Nursing (ADON) said staff had been providing residents with cold drinks throughout the day because the 100 Hall becomes too warm. The ADON acknowledged the area was uncomfortable for both residents and staff.During an interview on 06/29/26 at 5:15 P.M , the Maintenance Supervisor (MS) said, This is the same thing that happens each year. The Maintenance Supervisor said residents are typically relocated to other rooms or the dining room with curtains used for privacy when temperatures become excessive. The MS said the facility rented portable air conditioning units during the previous summer, but had returned them at the end of the season. The MS said he had not been scheduled to work this date and no one had contacted him until the Department arrived onsite. The MS said he planned to purchase portable units immediately for use because multiple resident rooms had become too warm. The MS said no changes had been made to the HVAC unit or the resident rooms since the previous year. The MS was aware of the heat warnings for the region, but had not prepared prior to it being issued. During an interview on 06/30/26 at 9:20 a.m., the Administrator said she had not been aware of the previous issues with the HVAC unit on the 100 hall until 06/29/26. The staff informed her the rooms were getting warm and had given the resident's fans. On 06/29/26, she called the MS in to oversee the issue when the Department came onsite. The Administrator said the facility planned to install equipment to improve airflow to the affected resident rooms and acknowledged a long-term repair to the HVAC system was needed so the problem would not occur again next year. During an interview on 06/30/26 at 9:30 a.m., the Maintenance Supervisor said duct booster fans would be installed in each room to increase airflow through the vents because the unit was producing cool air. The Maintenance Supervisor said the existing HVAC unit needed to be updated but has not been and is not scheduled to be at this time. MO3064269

Based on interview and record review, the facility failed to allow residents access to resident funds on an ongoing basis for one resident (Resident #34) out of 13 sampled residents and two residents (Residents #7 and #39) outside the sample. This had the potential to affect all residents for whom the facility managed funds. The facility census was 51. Review of the facility policy titled, Management/Protection of Resident Funds, undated, showed:- The facility shall furnish the resident with a written receipt for all expenditures and deposits regarding any of the resident's funds deposited with the facility;- A record of all transactions regarding the resident's funds shall be maintained by the facility in accordance with the generally accepted accounting principles;- The resident shall have reasonable access, upon request, to the above records and shall receive an itemized quarterly statement of his/her account;- The facility will have posted structured banking times; however, a resident's personal funds will be made available to them as follows: if a resident is requesting a withdrawal amount of $100.00 ($50.00 for Medicaid residents) or less, the funds will be available to them no later than the same day;- Residents should direct personal fund withdrawal requests to the Business Office Manager during regular business hours Monday-Friday or the Administrator in the absence of the Business Office Manager.Observation on 06/03/26 at 11:48 A.M., of the Business Office showed two signs which read:- Attention Staff and Residents, Effective 02/16/26, the business office will be closed from 10:00 A.M. to 12:00 P.M. daily for non-emergent issues; - New Bank Hours. After resident feedback, new banking hours will only be in the afternoon from 1:00 P.M. to 3:00 P.M. This will take effect February 1, 2026. Monday 1 P.M. - 3 P.M., Tuesday 1 P.M. - 3 P.M., Wednesday 1 P.M. - 3 P.M., Thursday 1 P.M. - 3 P.M., and Friday 1 P.M. - 3 P.M. During an interview on 06/03/26 at 11:49 A.M., the Business Office Manager said the business office was closed from 10:00 A.M. to 12:00 P.M. each day. The corporate office established that time for business office staff at multiple facilities to complete work without interruptions. He/She would answer the door and attempt to address concerns if someone came to the office during the closed hours. Resident banking hours had also been limited to a two-hour window Monday through Friday 1:00 P.M. to 3:00 P.M., due to interruptions to the business office staff. This practice was implemented prior to his/her employment as the Business Office Manager, and his/her understanding was the limited hours were established because of interruptions to the office operations. When asked how residents could obtain personal funds on weekends or during his/her days off, the Business Office Manager said there was not a designated individual assigned to provide residents with access to funds during those times.During an interview on 06/03/26 at 9:15 A.M., Resident #34 said he/she got his/her money at the end of the month. The bank was only open from 1:00 P.M. to 3:00 P.M., during the week and it was not open on the weekends, so he/she couldn't get any money on the weekends. It would be nice to have more bank hours, especially on the weekends.During an interview on 06/03/26 at 1:30 P.M., Resident #7 said he/she did not understand why residents could not access their personal funds anytime they wanted. Residents should be able to access their money every day, and he/she expressed dissatisfaction with the facility's limitation of banking hours to a two-hour window. Residents sometimes missed the opportunity to obtain funds because of facility activities, appointments, or afternoon naps that occurred during the designated banking hours.During an interview on 06/03/26 at 1:30 P.M., Resident #39 said residents previously could obtain personal funds at any time, but the facility changed the process to a two-hour banking window because the business office staff was being interrupted too frequently. Residents were unable to obtain funds during evenings, weekends, or when banking hours had ended. He/She had suggested the facility maintain change, including one-dollar bills, at the nurses' station for residents use during nights and weekends. The inability to access personal funds outside the designated banking hours limited resident access to their money and he/she expressed a preference to have access available whenever needed.During an interview on 06/04/26 at 11:04 A.M., the Administrator, Director of Nursing, and Assistant Director of Nursing said they would expect residents who had their funds managed by the facility to have ongoing access to their funds.

Based on observation, interview, and record review, the facility failed to maintain the environment in a safe and well-maintained condition by failing to repair damaged flooring, tiles, handrails, corridors, door frames, grout, showers and faucets, and failing to maintain a functioning door closer on the exterior door. The deficient practice had the potential to affect all residents. The facility census was 51. Review of the facility policy titled, Policy and Procedure Environment/Homelike, dated 01/01/26, showed:- The facility will remain clean and sanitary;- Equipment will be kept in good repair.Observation on 06/02/26 at 7:41 P.M., of the men's shower room on [NAME] Wing 2 showed:- Water leaked from the left shower faucet in the back shower when the water was turned on;- Water leaked from the top of the faucet and down the shower hose when water was turned on.Observation on 06/04/26 at 9:46 A.M., of the exit to the resident smoke break area from the dining room showed:-The flooring at the door threshold was chipped and deteriorated, creating an uneven surface with gaps that could present a trip hazard; -The hydraulic door closer above the doorway was damaged, causing the door to close abruptly rather than in a controlled manner.Observation on 06/04/26 at 9:51 A.M., of the hallway along [NAME] Wing 2 showed:- A damaged corridor wall guard at the corner of the hall near the nurses' station with exposed interior components;- A cracked door frame around the nurses' station door;- A missing end cap on the handrail near the women's restroom.Observation on 06/04/26 at 9:53 A.M., of the [NAME] Wing 2 women's bathroom showed:- Damaged wall tiles between the showers;- Cracked wall tiles beneath a sink;- Deteriorated grout/sealant with stains around the sink area;- Damaged restroom partition bases.During an interview on 06/02/26 at 7:45 P.M., the resident in room [ROOM NUMBER] said he/she did not like that water leaked from the shower faucet and hose in the men's restroom because it affected the water pressure. The door to the smoke break area was a major issue because people got their walkers and wheelchairs caught on the broken tile at the threshold and, with the broken door closer, it slammed back into people and would cause them to almost fall. The broken tiles and damaged places in the hallway bothered him/her and he/she wished maintenance would fix them. During an interview on 06/04/26 at 10:52 A.M., the Maintenance Director said the process for repairs was that staff would complete a work order form, which they kept at the nurses' desk. Once they filled out the order, he would process them as soon as possible. Often staff or residents would also stop him when they saw him out around the facility and asked him or told him about repairs needed. He got smaller stuff right away, while bigger projects took a while for approval from regional or when he needed to order special supplies or parts. He was not aware of any current issues that had not been addressed regarding tile, bathrooms, rails, or doors.During an interview on 06/04/26 at11:00 A.M., the Administrator, Director of Nursing, and Assistant Director of Nursing said they would expect all hydraulic door closers to be in working order and all tiles, door frames, wall corners, and handrails to be in good repair.

Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer or discharge to the hospital, including the statement of appeal rights, and the name, address, or telephone number of the Office of the State Long Term Care Ombudsman (advocates for the residents in nursing facilities) within the transfer and discharge notices, and failed to notify the ombudsman of the transfer or discharge for two residents (Residents #2 and #34) out of 13 sampled residents. The facility's census was 51. Review of the facility's policy titled, Written Notice Before Transfer/Discharge, dated 02/01/26, showed: - The facility will notify the resident and/or resident representative of transfer in writing before transfer or discharge; - Notice will be sent to the Office of the Long-Term Care Ombudsman; - The nurse on duty will record the reason for transfer in the medical record along with a copy of the notice given; - The approved notice of transfer form will be used when notifying the resident and/or resident's representative and must include the reason of the transfer in a language/manner the resident or representative understands, date of transfer, time notice was given, location in which resident is being transferred, the name, address and telephone number of the state long-term care ombudsman, Appeals Unit and the Missouri Protection and Advocacy Agency; - A copy of the bed hold policy will be given along with a transfer notice. 1. Review of Resident #2's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE], and returned to the facility the same day; - The resident transferred to the hospital on [DATE], and returned to the facility the same day; - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - No documentation that written notification was provided to the resident and/or the resident's representative for the resident's transfers to the hospital; - No documentation that a notice was provided to the Ombudsman. 2. Review of Resident #34's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE], and returned to the facility the same day; - No documentation that the written notification was provided to the resident and/or the resident's representative for the resident's transfer to the hospital; - No documentation that a notice was provided to the Ombudsman. During an interview on 05/29/26 at 11:55 A.M., the Ombudsman said he/she was not receiving transfers/discharges from the facility. During an interview on 06/02/26 at 7:52 P.M., the Social Services Designee (SSD) said she talked to someone in the ombudsman office in March and began sending notification of transfers and discharges going back to November when she started the SSD position. She was only doing them for residents who were out over 24 hours. She was going to save a tip sheet she found online and would be doing them anytime someone got a bed hold. During an interview on 06/04/26 at 11:00 A.M., the Administrator, Director of Nursing, and Assistant Director of Nursing said they would expect the facility to notify the resident and/or resident's representative in writing of transfers/discharges and information to be sent to the Ombudsman.

Based on observation, interview, and record review, the facility failed to document a complete and accurate Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility) for two residents (Residents #18 and #26) out of 13 sampled residents. The facility's census was 51. Review of the facility's policy, MDS Resident Assessment, dated 01/01/26, showed: - The purpose is to provide guidance to conduct initially and periodically a comprehensive, accurate and standardized reproducible assessment of each resident's functional capacity; - The Interdisciplinary Team (IDT) is expected to complete an assessment, coordinated by a Registered Nurse (RN), using the Resident Assessment Instrument (RAI) specified by the state in compliance with the RAI guidelines; - Each individual who completed a portion of the assessment must sign and certify the accuracy of the portion of the assessment he/she completed. Review of the RAI Manual, dated October 2025, showed to enter in Item N0350A, the number of days during the seven-day look-back period (or since admission/entry or reentry if less than seven days) that insulin (a hormone that lowers blood sugar) injections were received. 1. Review of Resident #18's medical record showed: - admitted on [DATE]; - Diagnoses of type II diabetes mellitus (a chronic condition where the body cannot use insulin correctly and sugar builds up in the blood), vitamin deficiency, and morbid obesity (a chronic disease diagnosed when a person's weight significantly impacts their health, causing life-threatening complications or disability). Review of the resident's physician order sheet (POS), dated 06/03/26, showed: - An order for Ozempic (0.25 or 0.5 mg/dose) subcutaneous solution Pen-Injector two mg/three milliliters (ml), inject 0.25 mg subcutaneously in the afternoon every Wednesday, related to type II diabetes mellitus, dated 10/28/25 and discontinued 12/09/25; - An order for Ozempic (0.25 or 0.5 mg/dose) subcutaneous solution pen-injector two mg/three milliliters (ml), inject 0.5 mg subcutaneously in the afternoon every Wednesday, related to type II diabetes mellitus, dated 12/09/25 and discontinued 02/25/26; - An order for Ozempic (one mg/dose) subcutaneous solution pen-injector four mg/three ml, inject one mg subcutaneously every day shift every Wednesday related to type II diabetes mellitus, dated 02/19/26; - An order for Trulicity (medication for type II diabetes, which can help manage blood sugar levels) subcutaneous solution auto-injector 0.75 mg/0.5ml, inject 0.75 mg subcutaneously every day shift every Wednesday related to type II diabetes mellitus, dated 02/04/25 and discontinued 10/15/25; - An order for Trulicity subcutaneous solution auto-injector 0.75 mg/0.5ml, inject 0.75 mg subcutaneously every day shift every Wednesday related to type II diabetes mellitus, dated 10/29/25 and discontinued 10/29/25; - No current or discontinued order for insulin. Review of the resident's MDS assessments showed: - A quarterly MDS assessment, dated 02/26/26 with N0350 coded one for the number of days that insulin injections were received during the last seven days; - A quarterly MDS assessment, dated 12/03/25, with N0350 coded one for the number of days that insulin injections were received during the last seven days; - A quarterly MDS assessment, dated 09/11/25, with N0350 coded one for the number of days that insulin injections were received during the last seven days; - An annual MDS assessment, dated 06/19/25, with N0350 coded one for the number of days that insulin injections were received during the last seven days; - The facility failed to properly code the MDS assessment when they coded a non-insulin medication as insulin. 2. Review of Resident #26's medical record showed: - admitted on [DATE]; - Diagnoses of type II diabetes mellitus, vitamin deficiency, and morbid obesity. Review of the resident's POS, dated 06/02/26, showed: - An order for Trulicity, subcutaneous solution auto-injector 1.5 mg/0.5ml, inject 1.5 mg subcutaneously one time a day, every Monday related to type II diabetes mellitus, ordered 04/15/25, start date of 04/21/25; - No current or discontinued order for insulin. Review of the resident's MDS assessments showed: - An annual MDS assessment, dated 03/12/26, with N0350 coded one for the number of days that insulin injections were received during the last seven days; - A quarterly MDS assessment, dated 12/11/25, with N0350 coded one for the number of days that insulin injections were received during the last seven days; - A quarterly MDS assessment, dated 09/17/25, with N0350 coded one for the number of days that insulin injections were received during the last seven days; - A quarterly MDS assessment, dated 06/19/25, with N0350 coded one for the number of days that insulin injections were received during the last seven days; - The facility failed to properly code the MDS assessment when they coded a non-insulin medication as insulin. During an interview on 06/04/26 at 8:45 A.M., the MDS Coordinator said she has only been in her position for a month. The previous Administrator completed the MDS assessments. Trulicity, Ozempic, and all other GLP-1 (glucagon-like peptide-1 antagonists- a class of prescription drugs that mimic a natural gut hormone to regulate blood sugar, slow digestion, and increase feelings of fullness) mediations should not be coded as insulin on the MDS. During an interview on 06/04/26 at 11:00 A.M., the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) said they would expect medications to be coded accurately on MDS assessments.

Based on observation, interview, and record review, the facility failed to provide and document a treatment as ordered for one resident (Resident #13) and failed to obtain a physician order for one resident (Resident #18) out of 13 sampled residents. The facility's census was 51. Review of the facility's policy titled, Physician Orders, dated 01/01/26, showed: - The purpose is to provide guidance to ensure physician orders are transcribed and implemented in accordance with professional standards; - A physician's order must be documented clearly in the medical record including the required components of a complete order: date and time of receipt of order; name of practitioner providing the order; name and strength of product; quantity or specific duration; dosage and frequency of administration; route of administration; indication/diagnosis for which the product is given; and stop date for short-term therapy, if applicable; - New orders will be reviewed weekly by the Interdisciplinary Team (IDT) as a part of routine clinical review; - A monthly review of physician orders will be completed to assure appropriateness, accuracy, and completeness; - Adherence to following physician orders will be reviewed quarterly by the Quality Assurance Committee for recommendations for sustaining professional standards. Review of the facility's policy titled, Medication and Treatment Orders, dated 01/01/26, showed: - The purpose is to establish uniform guidelines for consistency with principles of safe and effective orders receiving and recording of medication(s) and treatment(s); - A current list of orders will be maintained in the clinical record of each resident. 1. Review of Resident #13's medical record showed: - admitted on [DATE]; - A diagnosis of morbid obesity (a chronic disease diagnosed when a person's weight significantly impacts their health, causing life-threatening complications or disability). Review of the resident's annual Minimum Data Set (MDS – a mandatory assessment instrument completed by the facility) assessment, dated 05/13/26, showed the resident received application of ointments and/or medications other than to the feet. Review of the resident's physician order sheet (POS), dated 06/03/26, showed an order for nystatin (antifungal medication) external powder, apply to under the breast and abdominal folds topically every 12 hours as needed (PRN) for redness, dated 12/02/25. Review of the resident's treatment administration record (TAR), dated May 2026 through June 2026, showed no documented application of the nystatin powder. Review of the resident's weekly skin assessments, dated 05/04/26, 05/11/26, 05/18/26, and 05/25/26, showed no skin issues under the resident's breast. Observation on 06/01/26 at 11:17 A.M., of the resident showed redness and weeping skin beneath the breast folds. During an interview on 06/01/26 at 11:17 A.M., Resident #13 said he/she had redness under the breasts. The redness was sore and painful. He/She had requested staff to apply the prescribed topical treatment and nystatin powder, but staff refused to provide the treatment. He/She wanted the area treated, and staff were not applying the medication. During an interview on 06/04/26 at 8:48 A.M., Certified Nursing Assistant (CNA)/Certified Medication Technician (CMT) A said Resident #13 frequently complained about redness to the abdominal folds and beneath the breasts. CNA/CMT A said nursing assistants could not view physician orders, but nurses informed them of treatments and products that could be applied when needed. During an interview on 06/04/26 at 8:50 A.M., Licensed Practical Nurse (LPN) B said Resident #13 had redness beneath the breasts and within the abdominal folds. The resident often did not notify staff until the redness became severe and bothersome. The resident had been prescribed various creams and treatments in the past and continued to experience recurrent skin issues. Staff had attempted to educate the resident regarding skin care and preventative measures, but the resident was not always compliant. When the treatment was applied, it should be marked on the resident's TAR. 2. Review of Resident #18's medical record showed: - admitted on [DATE]; - Diagnoses of morbid obesity and hemiplegia and hemiparesis following stroke (a limitation of functions of one half of the body or of a body part); - No current or discontinued order for restorative therapy. Review of the resident's restorative program progress notes, dated 03/26/25 through 03/27/26, showed the resident received restorative therapy on 03/26/25, 03/28/25, 03/31/25, 04/02/25, 04/04/25, 04/09/25, 04/25/25, 04/28/25, 04/30/25, 05/02/25, 05/05/25, 05/07/25, 05/09/25, 05/12/25, 05/12/25, 05/14/25, 05/15/25, 05/16/25, 05/19/25, 05/21/25, 05/28/25, 05/29/25, 05/30/25, 12/15/25, and 03/27/26. During an interview on 06/03/26 at 2:10 P.M., the Assistant Director of Nursing (ADON) said she was unable to find an order for restorative therapy, but she was going to work on finding it. Restorative staff had more documentation in the therapy room. During an interview on 06/04/26 at 11:00 A.M., the Administrator, Director of Nursing, and ADON said the TAR should be marked when PRN medications were administered and for PRN medications and treatments to be provided as needed for the residents. They would also expect a resident who was receiving restorative services to have an order for restorative therapy.

Based on observation, interview, and record review, the facility failed to assess residents for the risk of entrapment and review possible risks and benefits of bed rails prior to installation or use. The facility also failed to obtain informed consent from the resident and/or the resident's representative for two residents (Residents #9 and #18) out of 13 sampled residents. The facility census was 51. Review of the facility's policy titled, Bed Rails – Intended Purpose and Potential Risks, dated 05/08/12, showed: - Intended Purpose of Bed Rails: One of several methods utilized to prevent resident from falling out of bed, reminds resident not to get out of bed when medically contraindicated and/or medical equipment is attached to the resident, defines the bed edge, helps to protect resident from falling out of bed during transport, and may assist resident with movement within the bed and getting in and out of bed; - Potential Risks of Bed Rails: Create a source of known morbidity and mortality such as strangling, suffocation, serious bodily injury (may include head trauma, bruising, contusions, and/or skin lacerations and fractures and/or dislocations), or death when residents or parts of their bodies are caught between rails, the openings of the rails, or between the bed rails and mattress; impede residents from safely getting out of bed - residents crawl over rails and fall from greater heights increasing the risk for serious injury and residents attempt to get out of bed over the footboard; restrain residents in many circumstances – hinder residents from independently getting out of bed thereby confining them to their beds and create a barrier to performing routine activities such as going to the bathroom; - The potential risks can be exacerbated by improper match of the bed rail to bed frame, improper installation, and objects such as holders or supports that remain when the bed rail is removed. Review of the Resident Bed Rail Consent Form, undated, showed: - I am responsible for the medical treatment decision of the above-named resident. I have been advised that I may request that bed rails be installed on the resident's bed. The risk and alternatives to using bed rails, as they apply to this resident's particular condition and circumstances, have been clearly explained to me; - I understand that, in addition to this signed consent form authorizing the use of bed rails for this resident, a written order from the resident's physician, specifying the medical rationale and circumstances for use, must be obtained prior to the installation of this medical treatment device; - It is also my understanding that the facility will periodically review and re-evaluate the resident's need for bed rails and that the resident, responsible party and attending physician will be consulted in this matter; - With all of the above information in mind, I consent to the installation and utilization of bed rails for the care of the above-named resident, consistent with the written orders of the attending physician. I understand that this authorization is revocable, except to the extent of those actions already taken. 1. Review of Resident #9's medical record showed: - admitted on [DATE]; - Diagnoses of osteoarthritis (degenerative joint disease causing the cartilage covering on end of bones to gradually wear away, resulting in pain), bipolar disorder (a mental health disorder that causes intense mood swings) and obstructive uropathy (a type of blockage that restricts the flow of urine); - An order which read may have bed cane for positioning, dated 11/01/24; - No documentation of a side rail assessment, entrapment risk assessment, or informed consent for use of side rails that included risks and benefits. Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility), dated 03/24/26, showed: - Moderate cognitive impairment; - Moderate assistance from staff for bed mobility. Observation of the resident showed: - On 06/03/26 at 2:41 P.M., the quarter rail up on the right side of the bed while the resident sat in a wheelchair and watched TV. The resident said he/she used the rail to get out of bed; - On 06/04/26 at 10:03 A.M., the resident lay in bed with eyes closed, the quarter rail up on the right side. 2. Review of Resident #18's medical record showed: - admitted on [DATE]; - Diagnoses of morbid obesity (a chronic disease diagnosed when a person's weight significantly impacts their health, causing life-threatening complications or disability) and hemiplegia and hemiparesis following stroke (a limitation of functions of one half of the body or of a body part); - No documentation of a side rail assessment, entrapment risk assessment, or informed consent for use of side rails that included risks and benefits; - No physician order for bed rails; Review of the resident's annual MDS assessment, dated 05/29/26, showed: - No cognitive impairment; - Impairment on one side for upper and lower extremity; - Dependent for bed mobility. Review of the resident's care plan, reviewed 07/09/25, showed it did not address bed mobility or bed rails. Observation of the resident showed: - On 06/01/26 at 10:55 A.M., the resident sat in his/her wheelchair at a tray table in the room with a quarter rail up on the right side of the bed; - On 06/01/26 at 3:10 P.M., the resident sat in his/her wheelchair with a quarter rail up on the right side of the bed; - On 06/02/26 at 12:55 P.M., the resident sat in his/her room eating lunch on his/her tray table with a quarter rail up on the right the side of the bed; - On 06/03/26 at 11:38 A.M., the resident sat in his/her wheelchair at his/her tray table with no quarter rail on the bed. During an interview on 06/03/26 at 11:38 A.M., the resident said they took the side rail off his/her bed last night because of you guys. He/She needed that bed rail and used it to turn. It takes two people to get him/her in bed. During an interview on 06/03/26 at 2:10 P.M., the Assistant Director of Nursing (ADON) said if someone had a bed rail, they should have an order. Then they let whoever was doing the evaluation know, whether it was restorative or therapy. It should also be on the care plan, and they talked to family about the bed rail. The MDS Coordinator said there was no order for the bed rail, so Resident #18 couldn't have it. The Maintenance Director took it off. They weren't sure when the bed rail was put on and she was not sure what maintenance did or if he did anything periodically with the bed rails. During an interview on 06/03/26 at 2:17 P.M., the MDS Coordinator said she had been here a month. She saw the bed rail yesterday afternoon on Resident #18's bed, and saw there was no order, no consent, no maintenance, and that's against state regulations. No one here knew who did the assessments. They didn't have a plan in place, and they were going to have to make up a protocol. They took the bed rail off because the resident did not have an order or assessment. During an interview on 06/03/26 at 3:45 P.M., the ADON said they had just gotten an order for the bed rail and the therapy department did an evaluation for Resident #18. Review on 06/03/26 at 3:45 P.M. of the documentation provided by the ADON showed: - An order for therapy evaluation for a bed cane for positioning, dated 06/03/26 at 3:01 P.M.; - An Interdisciplinary Resident Screen documented physical therapy/occupational therapy (PT/OT) recommended a bed cane to optimize the patient's independence with activities of daily living (ADLs) and mobility safely, dated 06/03/26; - No entrapment risk assessment or informed consent obtained. During an interview on 06/03/26 at 3:54 P.M., the Maintenance Director said when they put a bed rail on, the nurses go with him, and he just put it on and ensured it was tight. He knew there were certain measurements and had seen them before but didn't have anything like that. As far as placement, he didn't know measurements, but it was usually about an arm's length, so the resident could grab it. As far as gaps, generally it was right up against the mattress. The mattresses covered the whole thing, so there was not a gap. He didn't have any documentation for that. If he did that, he'd never get anything done. Observation on 06/04/26 at 9:58 A.M. showed the resident with no bed rail. During an interview on 06/04/26 at 9:58 A.M., the resident said the old man started to put the bed rail on, but he needed help. During an interview on 06/04/26 at 11:00 A.M., the Administrator, Director of Nursing, and ADON said they would expect safety/risk assessments and informed consents to be completed for residents with bed rails. They would also expect bed rails to be included in the care plan and for the residents to have an order for a bed rail.

Based on observation, interview, and record review, the facility failed to maintain proper infection control practices to prevent the development and transmission of infection during blood glucose monitoring for two residents (Residents #30 and #42) and during insulin and medication administration for three residents (Residents #28, #30, and #45) out of six sampled residents. The facility census was 51. Review of the facility's policy titled, Policy and Procedure-Use of Gloves, dated 04/01/19, showed:- Non-sterile gloves should be used primarily to prevent the contamination of the employee's hands when providing treatment and services to the resident and when cleaning contaminated surfaces;- Gloves should only be used once and discarded in an approved container located in the room in which the procedure is performed;- Once gloves are removed, the next step should be hand hygiene.Review of the facility's policy titled, Infection Prevention and Control Program, dated 04/10/19, showed:- The objectives of our infection control policies and procedures are to prevent, detect, investigate, and control infections in the facility;- Maintain a safe, sanitary, and comfortable environment to help prevent and manage the transmission of diseases and infections for all personnel, consultants, contractors, residents, visitors and the general public.1. Observation on 06/02/26 at 4:25 P.M., of Resident #30's fingerstick blood sugar (FSBS) using a glucometer (medical device used to measure the sugar concentration in blood) showed:- Licensed Practical Nurse (LPN) C placed two glucometers wrapped in Microdot bleach wipes (disinfectant wipes) on top of a barrier on top of the cart;- LPN C did not perform hand hygiene, put on clean gloves and obtained a glucometer from the top of the cart and an alcohol wipe, lancet, and test strip from the drawer of the cart;;- LPN C entered Resident #30's room, obtained the resident's FSBS and exited the room;- With the same gloves, LPN C typed on the computer and wrapped the soiled glucometer with a Microdot bleach wipe;- LPN C removed his/her gloves and performed hand hygiene.2. Observation on 06/02/26 at 4:36 P.M., of Resident #42's FSBS showed:- LPN C performed hand hygiene, put on clean gloves and obtained a glucometer from the top of the cart, and an alcohol wipe, lancet, and test strip from the drawer of the cart;- LPN C entered the resident's room, obtained the resident's FSBS and exited the room;- With the same gloves, LPN C typed on the computer and wrapped the soiled glucometer with a Microdot bleach wipe;- LPN C removed his/her gloves and did not perform hand hygiene.3. Observation on 06/02/26 at 4:42 P.M., of Resident #28's FSBS and insulin administration showed:- LPN C did not perform hand hygiene and put on clean gloves;- LPN C obtained a wrapped glucometer from top of the nurse cart, and an alcohol wipe, lancet and test strip from the drawer of the cart;- LPN C entered the resident's room, obtained the resident's FSBS and exited the room;- With the same gloves, LPN C typed on the computer and wrapped the soiled glucometer with a Microdot bleach wipe;- With the same gloves, LPN C obtained the resident's insulin pen (insulin- an essential hormone that helps regulate blood sugars in a pen-like device) from the nurse cart, and primed the pen with two units of insulin;- With the same gloves, LPN C administered the ordered amount of insulin to the resident;- LPN C exited the resident's room, removed gloves and did not perform hand hygiene.4. Observation on 06/02/26 at 4:50 P.M., of Resident #30's insulin administration showed:- LPN C did not perform hand hygiene and put on clean gloves;- LPN C obtained the resident's insulin pen from the cart and primed the pen with two units of insulin;- LPN C entered the resident's room, administered the ordered amount of insulin to the resident, and exited the room;- With the same gloves, LPN C typed on the computer;- LPN C removed his/her gloves and did not perform hand hygiene.During an interview on 06/03/26 at 11:03 A.M., LPN C said he/she sanitized his/her hands between every second or third resident and changed gloves in between residents. He/She should remove his/her gloves before touching clean items.5. Observation on 06/03/26 at 8:47 A.M., of Resident #45's medication administration showed:- Certified Medication Technician (CMT) D sanitized his/her hands;- CMT D obtained several plastic packages containing medications from the medication cart and placed them on top of the cart;- CMT D opened a package and poured some of the pills out of the package into a medication cup, and three of the pills fell onto the top of the cart;- CMT D picked up the three pills on top of the cart with his/her bare hand and placed them into the pill cup with the other medications;- CMT D obtained the ordered eye drops from the medication cart;- CMT D entered the resident's room and administered 17 medications to the resident;- CMT D did not perform hand hygiene and put on clean gloves;- CMT D placed the eye drops in the resident's right eye and then in the resident's left eye;- CMT D obtained a facial tissue and blotted both eyes with the same tissue;- CMT D exited the resident's room, removed gloves, and performed hand hygiene.During an interview on 06/03/26 at 9:00 A.M., CMT D said he/she should not pick up pills with a bare hand, and he/she should not use the same tissue to blot both eyes when administering eye drops.During an interview on 06/04/26 at 11:00 A.M., the Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON) said staff should not pick up pills with their bare hands and administer those pills to a resident. They would expect a separate tissue to be used when administering eye drops to both eyes, for staff to wash/sanitize their hands prior to and after performing fasting blood sugar checks and insulin administration and for staff to remove soiled gloves before touching clean items/surfaces.

Based on observation, interview, and record review, the facility staff failed to conduct regular inspections of all bed frames, mattresses, and side rails as part of a regular maintenance program for two residents (Residents #9 and #18) out of 13 sampled residents. The facility census was 51. Review of the facility's policy titled, Bed Rails – Intended Purpose and Potential Risks, dated 05/08/12, showed: - Intended Purpose of Bed Rails: One of several methods utilized to prevent resident from falling out of bed, reminds resident not to get out of bed when medically contraindicated and/or medical equipment is attached to the resident, defines the bed edge, helps to protect resident from falling out of bed during transport, and may assist resident with movement within the bed and getting in and out of bed; - Potential Risks of Bed Rails: Create a source of known morbidity and mortality such as strangling, suffocation, serious bodily injury (may include head trauma, bruising, contusions, and/ or skin lacerations and fractures and/ or dislocations), or death when residents or parts of their bodies are caught between rails, the openings of the rails, or between the bed rails and mattress; impede residents from safely getting out of bed - residents crawl over rails and fall from greater heights increasing the risk for serious injury and residents attempt to get out of bed over the footboard; restrain residents in many circumstances – hinder residents from independently getting out of bed thereby confining them to their beds and create a barrier to performing routine activities such as going to the bathroom; - The potential risks can be exacerbated by improper match of the bed rail to bed frame, improper installation, and objects such as holders or supports that remain when the bed rail is removed. Review of the facility's Regulatory Tasks List showed Tasks Due This Month, dated June 2025 through May 2026, with a checkmark beside Beds and Mattresses: Inspect bed rails that are in use for each month. 1. Review of Resident #9's medical record showed: - admitted on [DATE]; - Diagnoses of osteoarthritis (degenerative joint disease causing the cartilage covering on end of bones to gradually wear away, resulting in pain), bipolar disorder (a mental health disorder that causes intense mood swings) and obstructive uropathy (a type of blockage that restricts the flow of urine); - No maintenance assessments for side rails. Observation of the resident showed: - On 06/03/26 at 2:41 P.M., quarter rail up on the right side of the bed while the resident sat in a wheelchair and watched TV. The resident said he/she used the rail to get out of bed; - On 06/04/26 at 10:03 A.M., the resident lay in bed with eyes closed, the quarter rail up on the right side. 2. Review of Resident #18's medical record showed: - admitted on [DATE]; - Diagnoses of morbid obesity (a chronic disease diagnosed when a person's weight significantly impacts their health, causing life-threatening complications or disability) and hemiplegia and hemiparesis following stroke (a limitation of functions of one half of the body or of a body part); - No maintenance assessments for side rails. Observation of the resident showed: - On 06/01/26 at 10:55 A.M., the resident sat in his/her wheelchair in the room with a quarter rail up on the right side of the bed; - On 06/01/26 at 3:10 P.M., the resident sat in his/her wheelchair with a quarter rail up on the right side of the bed; - On 06/02/26 at 12:55 P.M., the resident sat in his/her room eating lunch on his/her tray table with a quarter rail up on the right side of the bed. During an interview on 06/03/26 at 3:54 P.M., the Maintenance Director said when they put a bed rail on, the nurses went with him, and he just put it on and ensured it was tight. He knew there were certain measurements and had seen them before but didn't have anything like that. As far as placement, he didn't know measurements, but it was usually about an arm's length, so the resident could grab it. As far as gaps go, generally it was right up against the mattress. The mattresses cover the whole thing, so there was not a gap. He didn't have any documentation for that. If he did that, he'd never get anything done. He did not have a set schedule or form for checking bed rails but tightens them if the residents or staff said they needed tightened. He did not know how many residents had bed rails. During an interview on 06/04/26 at 11:00 A.M., the Administrator, Director of Nursing, and Assistant Director of Nursing said they would expect maintenance assessments to be completed for residents with side rails.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment. This had the potential to affect all residents in the facility. The facility's census was 48. Review of the facility's policy, Environment/Homelike, undated, showed: - It is the policy of this facility to provide a safe, clean, comfortable and homelike environment. Including allowing residents to use personal belongings to the extent possible; - The facility will remain clean and sanitary; - The facility will be odor free; - The facility will maintain clutter and remove it if it poses a hazard; - Equipment will be kept in good repair; - The safety of the residents and staff will take precedence over resident choice. 1. Observation on 02/25/25 at 9:05 A.M. of the hallway near the front nurses' station showed a strong urine smell. 2. Observation of [NAME] Wing 2 on 02/28/25 at 12:40 P.M. showed: - room [ROOM NUMBER] with door casing bent, cracked near the floor, and pulling away from the door; - room [ROOM NUMBER] with door casing missing, exposing an old brown glue-like substance from the floor to approximately three feet up the door frame; - room [ROOM NUMBER] with door casing pulling away from the door; - Six ceiling tiles between room [ROOM NUMBER] and 127 with various sizes of round brown stains, and a ceiling tile missing and exposing ductwork; - Two ceiling tiles between room [ROOM NUMBER] and 122 with brown stains; - One ceiling tile near the shower room on [NAME] Wing 2 with a brown stain. 3. Observation of the facility on 02/28/25 at 4:00 P.M. showed: - room [ROOM NUMBER] with a large gray stain with red/brown edges covering approximately 80% of a ceiling tile, a ceiling tile with an approximate eight inch by eight inch brown stain and a six inch by six inch brown stain; - room [ROOM NUMBER] with three ceiling tiles with brown stains, one ceiling tile with an approximate three inch by two inch hole, a ceiling tile with an approximate four inch by five inch hole and another ceiling tile with an approximate 12 inch corner cracked; - Hallway outside of the Social Services office with a ceiling tile with an approximate four inch by three inch hole and crack; - Hallway by nurses' station with a ceiling tile with an approximate eight inch by three inch broken section and an approximate 12 inch crack; - 100 Hallway outside of the women's restroom across from the fire extinguisher with a ceiling tile with an approximate four inch by three inch hole; - Hallway outside of room [ROOM NUMBER] with a ceiling tile with an approximate two inch by three inch hole. During an interview on 02/27/25 at 12:45 P.M., the Maintenance Supervisor said he/she does a walk through of the facility twice a day, almost every day. For big jobs, residents or staff will write work orders and place at the nurses's station and he/she picks them up and takes to the shop and places them in a file in a drawer after completed. Sometimes residents will stop him/her and if he/she has time, the issue will be fixed then, and there is no log of those issues. He/She tries to address all issues pretty quickly. Stained, cracked ceiling tiles and tiles with holes should be replaced. Right now there are no extra tiles on hand and an order has been placed. During an interview on 02/28/25 at 4:45 P.M., the Administrator said she would expect ceiling tiles to be free from stains/holes and cracks, and to be repaired in a timely manner. Missing tiles are expected to be replaced, and door casings are to be in good repair and not be cracked, bent or missing. 49754

Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer or discharge to a hospital, including the reasons for transfer for six residents (Resident #11, #21, #22, #33, #37, and #202) out of 12 sampled residents. The facility's census was 48. Review of the facility's Discharge/Transfer Policy, revised 06/25/20, showed: - Explain transfer and reason to resident and/or representative, give copy of signed transfer or discharge notice to resident and/or representative. If an emergency, the transfer or discharge notice should be given to ambulance personnel; - Explain and give copy of bed hold form to the resident and/or representative. If an emergency transfer, may be completed later, but as soon as possible; - Complete transfer form, copy any portion of the medical record necessary for care of the resident; - Send original transfer form and portions of medical records that was copied with the resident and place copy of transfer form in medical record; - Notify business office, social service, dietary and administration of transfer. 1. Review of Resident #11's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; -The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; -The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - No documentation that the resident or resident's representative was informed in writing of the transfer/discharge to a hospital at the time of transfer. 2. Review of Resident #21's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility 01/08/25; - No documentation that the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of transfer. 3. Review of Resident #22's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility 04/01/24; - The resident transferred to the hospital on [DATE] and returned to the facility 04/15/24; - The resident transferred to the hospital on [DATE] and returned to the facility 12/13/24; - The resident transferred to the hospital on [DATE] and returned to the facility 01/28/25; - No documentation that the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of transfer. 4. Review of Resident #33's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - No documentation that the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of transfer. 5. Review of Resident #37's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility 02/22/24; - No documentation that the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of transfer. 6. Review of Resident #202's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; -The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; -The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - No documentation that the resident or resident's representative was informed in writing of the transfer/discharge to a hospital at the time of transfer. During an interview on 02/28/25 at 10:40 A.M., the Director of Nursing (DON) said he/she could not find transfer notifications. During an interview on 02/28/25 at 10:48 A.M., the Assistant Director of Nursing (ADON) said the floor nurses send a copy of the transfer sheet to the hospital at the time of transfer. The families are notified by phone to let them know. We have never sent anything in writing; we just call. During an interview on 02/28/25 at 4:45 P.M., the Administrator said he/she would expect written transfer notifications to be given to residents or their representatives.

Based on interview and record review, the facility failed to provide written information to the resident and/or the resident's representative of the facility's bed hold policy at the time of transfer to the hospital for six residents (Resident #11, #21, #22, #33, #37 and #202) out of 12 sampled residents. The facility's census was 48. Review of the facility's Bed Hold Policy Notice, undated, showed: - It is the facility's policy to notify all residents and/or residents' representatives of the facility bed hold policy; - If the resident discharges to the hospital, the bed may be held by paying the room rate that is in effect at the time the reservation is made; - If the resident and/or representative wants to hold bed, a signed authorization must be obtained with each discharge; - Upon discharge, the nursing supervisor will re-inform the resident and/or representative of the bed hold policy. This requirement will be considered met if the resident's copy of the notice is sent with other papers accompanying the resident to hospital. 1. Review of Resident #11's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility 02/09/25; - The resident transferred to the hospital on [DATE] and returned to the facility 02/19/25; - The resident transferred to the hospital on [DATE] and returned to the facility 02/20/25; - A bed hold policy, dated 02/09/25 and signed by staff as the Resident/Representative with a notation Patient unable to sign; - A bed hold policy, dated 02/18/25 and signed by staff as the Resident/Representative; - A bed hold policy, dated 02/20/25 and signed by staff as the Resident/Representative; - No documentation that the resident or the resident's representative was informed in writing of the facility's bed hold policy at the time of transfer. 2. Review of Resident #21's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility 01/08/25; - A bed hold policy, dated 01/28/25 and signed by the Assistant Director of Nursing as the Resident/Representative with a notation Patient unable to sign; - No documentation that the resident or the resident's representative was informed in writing of the facility's bed hold policy at the time of transfer. 3. Review of Resident #22's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility 04/01/24; - The resident transferred to the hospital on [DATE] and returned to the facility 04/15/24; - The resident transferred to the hospital on [DATE] and returned to the facility 12/13/24; - The resident transferred to the hospital on [DATE] and returned to the facility 01/28/25; - A bed hold policy, dated 12/10/24 and signed by the Assistant Director of Nursing as the Resident/Representative with a notation Patient unable to sign; - No documentation that the resident or the resident's representative was informed in writing of the facility's bed hold policy at the time of transfer. 4. Review of Resident #33's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility the same day; - No documentation that the resident or the resident's representative was informed in writing of the facility's bed hold policy at the time of transfer. 5. Review of Resident #37's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility 02/22/25; - No documentation that the resident or the resident's representative was informed in writing of the facility's bed hold policy at the time of transfer. 6. Review of Resident #202's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility 10/10/24; - The resident transferred to the hospital on [DATE] and returned to the facility 02/21/25; - The resident transferred to the hospital on [DATE] and returned to the facility 02/28/25; - A bed hold policy, dated 09/28/24 and signed by staff as the Resident/Representative with a notation Patient unable to sign; - A bed hold policy, dated 02/11/25 and signed by staff as the Resident/Representative with a notation Patient unable to sign; - A bed hold policy, dated 02/28/25 and signed by staff as the Resident/Representative with a notation Patient unable to sign; - No documentation that the resident or the resident's representative was informed in writing of the facility's bed hold policy at the time of transfer. During an interview on 02/28/25 at 10:48 A.M., the Assistant Director of Nursing (ADON) said the floor nurses send a copy of the bed hold policy along with the transfer sheet to the hospital at the time of transfer. The families would be notified by phone. Staff have never sent anything in writing; they just call. She has signed the bed holds when the resident was unable to do so since she has worked here. During an interview on 02/28/25 at 4:45 P.M., the Administrator, Director of Nursing (DON) and ADON said they would expect bed hold policies to be given to residents or resident's representatives. The ADON said if the resident is unable to sign, staff sign the bed hold policy.

Based on interview and record review, the facility failed to update and revise care plans with specific interventions to meet individual needs for two residents (Resident #38 and #202) out of 12 sampled residents. The facility's census was 48. The facility did not provide a policy. 1. Review of Resident #38's medical record showed: - admitted [DATE]; - Diagnoses of chronic pain, anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life.) Review of the resident's care plan, revised 12/19/24, showed the resident is a smoker. During an interview on 02/25/25 at 2:49 P.M., the resident said he/she does not smoke anymore. During an interview on 02/27/25 at 2:30 P.M., the Director of Nursing said Resident #38 no longer smokes. The smoking assessments should be done quarterly with each Minimum Data Set (MDS - a federally-mandated assessment completed by the facility) assessment and the care plan updated as needed. 2. Review of Resident #202's medical record showed: - admitted [DATE]; - Diagnoses of heart failure (a condition where the heart doesn't pump blood as well as it should), absence of right leg below the knee, pneumonia (infection that inflames air sacs in one or both lungs, which may fill with fluid), chronic kidney disease, stage 5 (CKD-a longstanding disease of the kidneys leading to renal failure), end stage renal disease (a chronic condition where the kidneys have permanently lost their ability to function properly), dependence on renal dialysis (a medical procedure that removes waste products and excess fluid from the blood when the kidneys are unable to do so), and need for personal assistance with care; - A Physicians's order for dialysis three times per week on Monday, Wednesday, and Friday, dated, 10/11/24; - A Physician's order for bed cane rails for positioning, dated, 09/30/22; - A Physician's order for Apixaban (anticoagulant) 2.5 milligrams by mouth twice daily, dated 01/17/25. Review of the resident's care plan, revised 05/02/22, showed: - Resident used a bed cane rail on either side of the bed for positioning and transfers; - Resident receives an anticoagulant, with no bleeding precautions listed; - A diagnosis of CKD stage 4, and received dialysis on Monday, Wednesday, and Friday, but also has listed that he/she received dialysis on Tuesday, Thursday, and Saturday. Observations of the resident from 02/25/25 through 02/28/25 showed: - On 02/25/25 at 11:30 A.M. showed no bed cane rail on either side of the resident's bed; - On 02/26/25 at 9:30 A.M. showed no bed cane rail on either side of the resident's bed; - On 02/27/25 at 2:30 P.M. showed no bed cane rail on either side of the resident's bed; - On 02/28/25 at 4:00 P.M. showed no bed cane rail on either side of the resident's bed. During an interview on 02/26/25 at 2:00 P.M., the resident said he/she has not been using bed rails and that he/she goes to dialysis on Monday, Wednesday, and Friday. During an interview on 02/28/25 at 4:45 P.M., the Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON) collectively said they would expect care plans to be updated to reflect changes and the current condition of the resident. 46460 49754

Based on interview and record review, the facility failed to ensure that five nurse aides (NAs) completed a nurse aide training program within four months of his/her employment at the facility. This deficient practice had the potential to affect all residents. The facility's census was 48. Review of the facility's policy, Nurse Aide Training, dated 05/01/23, showed the policy did not address the requirement that nurse aides should be certified within four months of employment. 1. Review of Nurse Aide H's personnel file and schedule showed: - Hire date of 01/03/23; - Not currently enrolled in a Certified Nursing Assistant (CNA) class; - Scheduled to work day shift on 02/04/25, 02/05/25, 02/08/25, 02/09/25,02/13/25, 02/14/25, 02/18/25, 02/20/25, 02/22/25, 02/27/25, and 02/28/25; - The facility failed to ensure the NA was certified within four months of their employment. 2. Review of Nurse Aide I's personnel file and schedule showed: - Hire date of 11/17/23; - Not currently enrolled in a CNA class; - Scheduled to work day shift on 02/02/25, 02/03/25, 02/04/25, 02/09/25, 02/10/25, 02/11/25, 02/16/25, 02/17/25, 02/18/25, 02/23/25, 02/24/25, and 02/25/25; - The facility failed to ensure the NA was certified within four months of their employment. 3. Review of Nurse Aide J's personnel file and schedule showed: - Hire date of 01/10/24; - Not currently enrolled in a CNA class; - Scheduled to work day shift on 02/02/25, 02/03/25, 02/04/25, 02/09/25, 02/10/25, 02/11/25, 02/16/25, 02/17/25, 02/18/25, 02/23/25, 02/24/25, and 02/25/25; - The facility failed to ensure the NA was certified within four months of their employment. 4. Review of Nurse Aide K's personnel file and schedule showed: - Hire date of 02/12/24; - Not currently enrolled in a CNA class; - Scheduled to work day shift on 02/04/25, 02/12/25, 02/13/25, 02/17/25, 02/19/25, 02/21/25, and 02/25/25; - The facility failed to ensure the NA was certified within four months of their employment. 5. Review of Nurse Aide L's personnel file and schedule showed: - Hire date of 02/12/24; - Not currently enrolled in a CNA class; - Scheduled to work night shift on 02/01/25, 02/02/25, 02/07/25, 02/08/25, 02/09/25, 02/14/25, 02/15/25, 02/16/25, 02/21/25, 02/22/15, 02/23/25, and 02/28/25; - The facility failed to ensure the NA was certified within four months of their employment. During an interview on 02/28/25 at 11:00 A.M., the Assistant Director of Nursing (ADON) said that the facility does not offer CNA classes right now. They currently don't have a teacher. All the NAs are supposed to start CNA classes at another skilled nursing facility nearby the first week of March, starting on Wednesday. During an interview on 02/28/25 at 4:45 P.M., the Administrator, Director of Nursing (DON), and ADON said they would expect NAs to be certified within four months of hire.

Based on interview and record review, the facility failed to establish a system of records for the receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation of controlled medications to ensure nursing staff signed at the beginning and end of each shift. The facility failed to document the total number of narcotic drug cards counted for four of four narcotic count books checked. The facility's census was 48. Review of the facility's policy titled, Narcotic Count, revised 04/30/20, showed: - Purpose is to complete a physical inventory of narcotics at change of each shift by two licensed nurses, two Certified Medication Technicians (CMTs), or (any combination of) to identify discrepancies and need for reconciliation and accountability; to assure controlled drugs are handled, stored, and disposed of properly; and to assure proper record keeping for controlled drugs; - One licensed nurse or one CMT going off duty and one licensed nurse or one CMT coming on duty must count and justify accuracy of narcotics supply for each individual resident at the change of each shift; - Narcotic records are reconciled by a physical count of the remaining narcotic supply at the change of each shift by the oncoming and outgoing licensed nurse or CMT; - After the supply is counted and justified, each nurse or CMT must record the date and his/her signature verifying that the count is correct. 1. Review of the CMT narcotic count records on the short hall, dated January 1, 2025 through February 28, 2025, showed: - No signature and/or initials by the oncoming CMT on the shift verification of controlled substances count sheet for 51 shifts; - No signature and/or initials by the offgoing CMT on the shift verification of controlled substances count sheet for 52 shifts; - Total narcotic cards not documented on the card count verification form as counted by both oncoming and offgoing staff for 73 shifts. 2. Review of the CMT narcotic count records on the long hall, dated January 1, 2025 through February 28, 2025, showed: - No signature and/or initials by the oncoming CMT on the shift verification of controlled substances count sheet for 47 shifts; - No signature and/or initials by the offgoing CMT on the shift verification of controlled substances count sheet for 57 shifts; - Total narcotic cards not documented on the card count verification form as counted by both oncoming and offgoing staff for 82 shifts. 3. Review of the CMT narcotic count records on the [NAME] Wing 2 hall, dated January 1, 2025 through February 28, 2025, showed: - No signature and/or initials by the oncoming CMT on the shift verification of controlled substances count sheet for 53 shifts; - No signature and/or initials by the offgoing CMT on the shift verification of controlled substances count sheet for 53 shifts; - Total narcotic cards not documented on the card count verification form as counted by both oncoming and offgoing staff for 52 shifts. 4. Review of the nurse narcotic count records, dated January 1, 2025 through February 28, 2025, showed: - No signature and/or initials by the oncoming CMT on the shift verification of controlled substances count sheet for eight shifts; - No signature and/or initials by the offgoing CMT on the shift verification of controlled substances count sheet for eight shifts; - No documentation of total narcotic cards counted. During an interview on 02/27/25 at 2:00 P.M., Certified Medication Technician (CMT) M said he/she had already signed out for end of shift count even though the shift isn't over, and he/she understands that's probably not a good idea. During an interview on 02/27/25 at 2:05 P.M., CMT N said he/she had already signed out for end of shift count even though the shift isn't over. He/She just did it about 30 minutes ago because he/she knew the CMT for the next shift was here, but he/she thinks that's probably not a good idea to do that. During an interview on 02/27/25 at 3:24 P.M., CMT M said both the on coming and the off going nurse should sign the narcotic sheet and card count verification form at each shift change. During an interview on 02/28/25 at 4:45 P.M., the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) said they would expect on coming and off going staff to both sign the card count verification form and they shouldn't sign ahead of time prior to the end of their shift. The Administrator said she has a sign posted near the time clock that says Did you count? During an interview on 03/07/25 at 10:44 A.M., the Administrator said the nurses had not been doing a card count.

Based on observation, interview, and record review, the facility failed to maintain an error rate of less than five percent, when medications were administered. There were 29 opportunities with three errors made, for an error rate of 10.34%. This affected three residents (Resident #1, #9, and #31) outside of the 12 sampled residents, and had the potential to affect all residents. The facility's census was 48. The facility did not provide a policy. 1. Review of insulin aspart pen (insulin in a pen-type device) directions showed: - Remove cap; - Attach needle; - Prime pen by turning dose selector to select two units; - Press and hold button to make sure drop of insulin appears; - Select dose; - Give injection; - After dose counter reaches zero, count to six; - After injection, remove needle and place in sharps container. 2. Review of Fiasp insulin pen directions showed: - Pull pen cap straight off; - Select new needle, twist needle on till tight; - Turn the dose selector to select two units, press and hold the dose button until dose counter reaches zero; - Turn the dose selector to the number of units you need to inject, insert the needle into your skin and slowly count to six; - Pull the needle out of your skin, remove the needle from the pen and throw it away; - Replace the pen lid. 3. Review of Lantus insulin pen instructions showed: - Attach a new needle to the pen; - Select a dose of two units, hold the pen upright and press the injection button all the way in, ensure insulin comes out of the needle; - Select prescribed dose; - Stick needle into skin; - Press the injection button all the way in and slowly count to 10, then withdraw the needle; - Put the outer needle cap back on the needle and use it to unscrew the needle from the pen; - Dispose of the needle safely, put the cap back on the pen. 4. Observation on 02/27/25 at 11:05 A.M. showed: - Licensed Practical Nurse (LPN) F obtained the finger stick blood sugar (FSBS) for Resident #1; - LPN F obtained the insulin aspart pen from the medicine cart and adjusted the pen to the amount of insulin ordered; - LPN F did not prime the pen with two units of insulin per the manufacturer's directions prior to administering the ordered dose to the resident. 5. Observation on 02/27/25 at 11:10 A.M. showed: - LPN F obtained the FSBS for Resident #9; - LPN F obtained the Fiasp insulin pen from the medicine cart and adjusted the pen to the amount of insulin ordered; - LPN F did not prime the pen with two units of insulin per the manufacturer's directions prior to administering the ordered dose to the resident. 6. Observation on 02/27/25 at 11:25 A.M. showed: - LPN F obtained the FSBS for Resident #31; - LPN F obtained the Lantus insulin pen from the medicine cart and adjusted the pen to the amount of insulin ordered; - LPN F did not prime the pen with two units of insulin per the manufacturer's directions prior to administering the ordered dose to the resident. During an interview on 02/27/25 at 11:30 A.M., LPN F said he/she has never been shown to prime an insulin pen. During an interview on 02/28/25 at 4:45 P.M., the Administrator, Director of Nursing (DON) and the Assistant Director of Nursing (ADON), all collectively said they would expect the medication error rate to be less than 5%. They would also expect insulin pens to be primed per manufacturer's instructions.

Based on observation, interview, and record review, the facility failed to label and store medications in a safe and effective manner. This deficient practice affected one resident (Resident #202) out of 12 sampled residents and two residents (Resident #9 and #13) outside the sample and had the potential to affect all residents. The facility's census was 48. Review of the facility's policy titled, Medication Expiration Dates, dated [DATE], showed: - Purpose is to identify medication expiration dates and provide recommendations for disposal in accordance with manufacturer recommendations; - Medications and supplies that have reached their expiration date will be disposed of in accordance with facility policy; - The date of the opening should be noted on the medication package or container at the time of opening; - Specific manufacturer recommendations should be followed for storage and expiration of insulin; - Specific manufacturer recommendations for prescription medications and solutions will be followed based on specific time frames after opening - Tuberculosis PPD (Aplisol) vials 30 days. Review of the facility's policy titled, Medication Storage, dated [DATE], showed: - Purpose is to ensure that medications and biologicals are stored in a safe, secure storage and safe handling; - No discontinued, outdated, or deteriorated medications should be available for use in the facility. All such medications are destroyed per policy; - Medications requiring refrigeration should be stored in the refrigerator located in the drug room at the nurses' station. Please refer to package insert for specific temperature requirements of medication; - Vials must be dated upon opening and discarded within 30 days unless otherwise specified by manufacturer. Review of the package insert for Aplisol (a solution used in a skin test to help diagnose tuberculosis, a serious illness that mainly affects the lungs), updated [DATE], showed: - Do not freeze; - This product should be stored between 36 and 46 degrees Fahrenheit (F) and protected from light; - Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. Review of the package insert for NovoLog insulin (a hormone that helps the body use glucose for energy) pen, revised ,d+[DATE], showed to throw away all opened NovoLog vials after 28 days, even if they still have insulin left in them. Review of the package insert for Fiasp insulin pen, revised ,d+[DATE], showed the pen is to be thrown away after 28 days, even if it still has insulin left in it and the expiration date has not passed. Review of the package insert for Humalog (lispro) insulin, revised [DATE], showed to throw away the in-use Humalog Pen after 28 days, even if it still has insulin left in it. Review of the Food and Drug Administration website, www.fda.gov, showed according to the product labels from all three United States insulin manufacturers, it is recommended that insulin be stored in a refrigerator at approximately 36 degrees F to 46 degrees F. Observation on [DATE] at 11:15 A.M. of Resident #9's insulin administration showed Licensed Practical Nurse (LPN) F administered three units of Fiasp insulin from a pen opened on [DATE]. Observation on [DATE] at 1:45 P.M. of the medication refrigerator in the utility room behind the nurses station showed one vial of Aplisol with an opened date of [DATE]. During an interview on [DATE] at 1:45 P.M., LPN F said another LPN usually takes care of replacing the Aplisol when it is expired or out of date. Observation on [DATE] at 12:09 P.M. of the insulin pens in the top drawer of the treatment cart showed: - Resident #202's Novolog insulin pen with an opened date of [DATE] and a second Novolog insulin pen with an opened date of [DATE]; - Resident #9's Fiasp insulin pen with an opened date of [DATE]; - Resident #13's Humalog (lispro) insulin pen with an opened date of [DATE] and a Lantus insulin pen with no opened date. During an interview on [DATE] at 12:13 P.M., LPN F said they use these insulin pens for the residents. The overstock insulin is kept in the refrigerator in the utility room behind the nurses' station. Discarding the insulins that are past their date is kind of a team effort. We all kind of pitch in and do it. Another LPN may take care of it when he/she works Monday through Thursday. Review of the Vaccine Storage Temperature Log, dated [DATE] and February ,d+[DATE], 2025, showed: - Vaccine must be stored between 35 degrees F and 46 degrees F to maintain potency with 32 handwritten over 35, and 40 handwritten over 46; - Instructions to please put a check in the box that corresponds with the temperature, day of the month, and A.M. or P.M. for the temperature check. Then enter initials and the time monitored in the boxes at the top of the chart; - If the temperature is in the gray range (32 - 34 degrees F and 47 - 49 degrees F), store the vaccine under proper conditions as quickly as possible, call the vaccine manufacturer to determine whether the potency of the vaccines has been affected; - No temperature documented for [DATE] or [DATE]; - On ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], a documented temperature of 33 degrees F, which falls in the gray range; - On ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE] a documented temperature of 34 degrees F, which falls in the gray range; - On ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE] a documented temperature of 32 degrees F, which falls in the gray range; - On ,d+[DATE], a documented temperature of 31 degrees F; - On ,d+[DATE] P.M. shift, a documented temperature of 22 degrees F. Review of the Refrigerator Temperature Log, dated [DATE] to [DATE], showed: - Refrigerator temperature must be 45 degrees or below; - On ,d+[DATE], a documented temperature of 28 degrees F; - On ,d+[DATE], a documented temperature of 30 degrees F; - On ,d+[DATE], a documented temperature of 30 degrees F; - On ,d+[DATE], a documented temperature of 28 degrees F. During an interview on [DATE] at 2:15 P.M., the Director of Nursing (DON) and Assistant Director of Nursing (ADON) said the refrigerator just got replaced and that is why the temperature log starts just a few days ago. The old one was holding its temperature, but the knob was broken on it. The ADON said of the refrigerator temperature logs she provided, there are some holes in it, meaning some blanks where it wasn't filled out. During an interview on [DATE] at 4:15 P.M., LPN F said the midnight shift does refrigerator temperature checks. If the refrigerator temperature was out of range, he/she would tell the DON, and if not available, he/she would tell the Administrator. He/She isn't sure what the range should be. He/She doesn't pay much attention to that unless it feels warm when he/she sticks his/her hand in there. During an interview on [DATE] at 4:45 P.M., the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) said they would expect medications to be stored properly. Expired insulin pens and Aplisol are not to be used; they should be discarded. If the refrigerator temperatures are out of the 32 to 40 degrees F range, we would throw the medications away and replace the refrigerator. The night shift checks refrigerator temperatures or day shift if night shift didn't check. No staff has reported out of range temperatures to administration. During an interview on [DATE] at 1:26 P.M., the Administrator said the appropriate temperatures for the medication refrigerators are ,d+[DATE] degrees, and she is adding to the temperature log to inform the DON and/or ADON if temperature is below or above and to adjust the thermostat accordingly and recheck. When asked about the logs that were in use, both the log with the numbers handwritten over the numbers and also the log with the direction of a temperature of 45 degrees or below, the Administrator said staff would not know what to do.

Based on interview and record review, the facility failed to maintain quarterly Quality Assurance & Performance Improvement (QAPI) meetings with the required members. The facility's census was 48. Review of the facility's policy titled Quality Assurance and Improvement Program (QAPI), dated 05/31/24, showed: - The primary purpose of the QAPI program is to establish data-driven, facility-wide processes that improve the quality of care, quality of life, and clinical outcomes of our residents; - Members of facility management are accountable for QAPI efforts; - The QAPI Committee will include at minimum: the Administrator, Director of Nursing; Medical Director; Activities Director; Social Services Director; Dietary Manager; Housekeeping and Laundry Supervisor; Maintenance Director; additional facility staff; and contracted staff including Pharmacy Consultant, Dietician, and Rehab Director; - The committee shall maintain minutes of all regular and special meeting that include at least the following: the date committee met, start and adjourned time, and the names of the members present and absent; - The policy does not address the requirement of the Infection Preventionist (IP) as a committee member. 1. Review of the QAPI Meeting sign in sheet, dated 04/25/24 and provided by the Administrator, showed the following required members attended: - Administrator; - Director of Nursing; - Infection Preventionist; - At least two other staff members; - No record of the Medical Director attending. 2. Review of the QAPI Meeting sign in sheet, dated 07/17/24 and provided by the Administrator, showed the following required members attended: - Administrator; - Nurse Practitioner; - At least two other staff members; - No record of the Director of Nursing or Infection Preventionist attending. During an interview on 02/28/25 at 1:30 P.M., the Administrator said she would expect the required members to be present at all QAPI meetings.

Based on observation, interview, and record review, the facility failed to maintain infection control practices to prevent the development and transmission of infection when proper surveillance was not done. The facility failed to use a blood glucose monitor that could be disinfected and shared between residents for six residents (Resident #1, #9, #10, #13, #31, and # 202) out of six sampled residents. The facility's census was 48. 1. Review of the facility's Infection Control Policy, dated 04/10/19, showed: - Policies and procedures will be utilized as the standards of the Infection Prevention and Control Program (IPCP); - The IPCP will be driven by coordination, oversight, surveillance, data analysis, outbreak management, prevention of infection, immunization and monitoring; - The IPCP will be coordinated and overseen by the Director of Nursing (DON); - The IPCP committee will review surveillance data, and reporting data to determine potential issues or trends; - The outbreak management process will consist of determining the presence of an outbreak, managing the affected resident, preventing the spread to others, documenting information about the outbreak, reporting the information to appropriate public health, education, monitoring for reoccurrence, review after outbreak and updating policies and procedures as needed; - Prevention of infection and immunization included, but not limited to, education, screenings, appropriate isolations, identification of possible infections, widespread immunization and monitoring; - The committee will be made up of, but not limited to the DON, Administrator, Medical Director, Activities Director, Social Services Director, Dietary Manager, Housekeeping/Laundry Supervisor and additional staff as requested by the DON; - The IPCP committee will oversee implementation of infection control policies and assist department supervisors to ensure that they are implemented and followed; - The IPCP will meet at least quarterly and as needed between regular scheduled meetings. Review of the facility's Policy and Procedure, Cleaning and Disinfection of a Glucometer, dated 10/24, showed: - Policy: To provide guidelines to adequately clean and disinfect glucometer uses by multiple residents, in accordance with manufacturer recommendations; - All glucometers will be cleaned and disinfected using a 1:10 bleach (sodium hypochlorite) solution or commercially prepared EPA germicidal bleach wipe; - All glucometers that are shared among multiple residents will be thoroughly wiped with the disinfectant and allowed to air dry after every use and between each resident; - Cleaned and disinfected glucometers should be stored in approved containers in a clean location, such as a medication room or medication cart; - Cleaned and disinfected glucometers should not be stored in the pockets of scrubs, uniforms or lab jackets; - Isopropyl alcohol will not provide disinfection and is not recommended; - Procedure: Gather necessary equipment for procedure; - Perform hand hygiene and apply gloves; - Wipe all external surfaces, including top, bottom and sides, using the bleach solution or commercially prepared EPA germicidal wipe; avoid allowing the solution to penetrate the test strip and /or key code ports of the meter; - Ensure the meter remains wet for one minute and allow to air dry for an additional minute before using on the next resident; - If blood is visibly present on the meter, the procedure should be repeated a second time; - Discard soiled items in approved containers; - Remove gloves and perform hand hygiene. Review of the facility's Monthly Infection Log for December 2024 showed: - Six residents started on antibiotics; - No cultures performed; - One Urinary Tract Infection (UTI); - One Respiratory Infection (RI); - Two wound/skin infections; - Two sinus infections. Review of the facility's Infection Surveillance Monthly Report for December 2024 showed: - Six out of eight residents did not have signs and/or symptoms documented; - Five out of eight residents did not have documentation of the antibiotic ordered. Review of the facility's Monthly Infection Log for January 2025 showed: - Seventeen residents started on antibiotics; - Two cultures performed; - Eight UTIs; - Six respiratory infections; - One skin infection; - One Gastrointestinal Infection (GI); - One Clostridium difficile Colitis (C Diff-inflammation in the colon resulting from disruption of normal healthy bacteria in the colon, often from antibiotics). Review of the facility's Infection Surveillance Monthly Report for January 2025 showed: - Five out of 15 residents did not have signs and/or symptoms documented; - Seven out of 15 residents did not have documentation of the antibiotic ordered. During an interview on 02/28/25 at 12:52 P.M., the Administrator said since he/she had been at the facility for about one year, and they had not reviewed/updated the IPCP. He/She added that corporate would assist in this. During an interview on 02/28/25 at 12:53 P.M., the Director of Nursing (DON), who also served as the Infection Preventionist (IP), said the charge nurse will observe for signs and symptoms of an infection and talk to the nurse practitioner (NP), who is there twice a week, or physician to have them see the resident. The DON will add the antibiotic to the paper infection log. When an antibiotic is ordered in the electronic charting system, it will trigger for the Infection Prevention/Control (IPC) stop sign symbol to go up at the top of the screen. Staff hover over this and it will show suspected or confirmed. The infection is considered suspected until confirmed by diagnostics/labs or the physician. Once the physician confirms, it should show confirmed. He/She should be more vocal on assuring the NP and/or Physician order labs and cultures when indicated. The nurses are supposed to do an Infection Screen (under Assessments) when started on an antibiotic, then they should do an Antibiotic Timeout (under Assessments) three days later. Updates or whether the infection resolved or not are not documented on the tracking tool. The Administrator can run reports from the electronic charting system, and infections had been plotted on a facility map for the past three months on Tuesday, but that had not been done before. If several residents on a hall have the same type of infection, such as a UTI, it could be due to dehydration, but a root cause analysis had not been done to find out why infections are occurring, nor are the infections being tracked. 2. Review of the CareSens N blood glucose monitoring system user manual showed: - For single user/home use only; - Caring for the system, use a soft cloth or tissue to wipe the meter exterior; - If necessary, dip the soft cloth or tissue in a small amount of alcohol; - Do not use organic solvents such as benzene, acetone, or any household and industrial cleaners that may cause irreparable damage to the meter. Review of Microdot bleach wipe user guide, showed: - Use one or more wipes, as necessary to wet the surface sufficiently and thoroughly clean the surface; - To disinfect, the surface must remain wet for three minutes to achieve complete disinfection of pathogens listed on this label; - Allow surfaces to air dry. Observation on 02/27/25 at 11:05 A.M. showed: - Licensed Practical Nurse (LPN) F obtained Resident #10's fingerstick blood sugar (FSBS) using the CareSens N blood glucose monitor; - After obtaining the FSBS, LPN F wiped off the glucometer with a Microdot bleach wipe and placed the glucometer on top of a paper barrier on the nurse's medication cart; - LPN F failed to properly sanitize the glucometer. Observation on 02/27/25 at 11:10 A.M. showed: - LPN F obtained Resident #1's FSBS using the CareSens N blood glucose monitor; - After obtaining the FBS, LPN F wiped off the glucometer with a Microdot bleach wipe and placed the glucometer on top of a paper barrier on the nurse's medication cart; - LPN F failed to properly sanitize the glucometer. Observation on 02/27/25 at 11:15 A.M. showed: - LPN F obtained Resident #9's FSBS using the CareSens N blood glucose monitor; - After obtaining the FBS, LPN F wiped off the glucometer with a Microdot bleach wipe and placed the glucometer on top of a paper barrier on the nurse's medication cart; - LPN F failed to properly sanitize the glucometer. Observation on 02/27/25 at 11:20 A.M. showed: - LPN F obtained Resident #202's FSBS using the CareSens N blood glucose monitor; - After obtaining the FBS, LPN F wiped off the glucometer with a Microdot bleach wipe and placed the glucometer on top of a paper barrier on the nurse's medication cart; - LPN F failed to properly sanitize the glucometer. Observation on 02/27/25 at 11:25 A.M. showed: - LPN F obtained Resident #31's FSBS using the CareSens N blood glucose monitor; - After obtaining the FBS, LPN F wiped off the glucometer with a Microdot bleach wipe and placed the glucometer on top of a paper barrier on the nurse's medication cart; - LPN F failed to properly sanitize the glucometer. Observation on 02/27/25 at 11:30 A.M. showed: - LPN F obtained Resident #13's FSBS using the CareSens N blood glucose monitor; - After obtaining the FBS, LPN F wiped off the glucometer with a Microdot bleach wipe and placed the glucometer on top of a paper barrier on the nurse's medication cart; - LPN F failed to properly sanitize the glucometer. During an interview on 02/27/25 at 11:32 A.M., LPN F said to clean and sanitize a glucometer, he/she wipes the surface off with a Microdot bleach wipe. During an interview on 02/28/25 at 4:45 P.M., the Administrator said the facility should review the IPCP, at least annually and it should include standards, policies and procedures that are current, as well as an infection surveillance program. He/She would expect glucometers to be cleaned/sanitized per manufacturer's recommendations. 49754

Based on interview and record review, the facility failed to maintain an Infection Prevention and Control Program (IPCP) that included an effective antibiotic stewardship program. This deficient practice had the potential to affect all residents in the facility. The facility's census was 48. Review of the facility's Infection Control Policy, dated 04/10/19, showed: - Policies and procedures will be utilized as the standards of the IPCP; - The IPCP will be driven by coordination, oversight, surveillance, data analysis, outbreak management, prevention of infection, immunization, and monitoring; - The IPCP will be coordinated and overseen by the Director of Nursing (DON); - The IPCP committee will review surveillance data, and reporting data to determine potential issues or trends; - The outbreak management process will consist of determining the presence of an outbreak, managing the affected resident, preventing the spread to others, documenting information about the outbreak, reporting the information to appropriate public health, education, monitoring for reoccurrence, review after outbreak, and updating policies and procedures as needed; - Prevention of infection and immunization included, but not limited to, education, screenings, appropriate isolations, identification of possible infections, widespread immunization, and monitoring; - The committee will be made up of, but not limited to the DON, Administrator, Medical Director, Activities Director, Social Services Director, Dietary Manager, Housekeeping/Laundry Supervisor and additional staff as requested by the DON; - The IPCP committee will oversee implementation of infection control policies and assist department supervisors to ensure that they are implemented and followed; - The IPCP will meet at least quarterly and as needed between regular scheduled meetings. Review of the Antibiotic Stewardship Policy, last revised 03/24, showed: - Antimicrobial Stewardship (AMS) is a systematic approach to optimizing use of antimicrobials to reduce inappropriate use, improve patient outcomes and reduce adverse consequences of antimicrobials; - Staff will ensure microbiology guides therapy, when possible, indications should be evidence based, narrowest spectrum required, dosage appropriate, minimize duration, and tracking to assure correct antibiotic is prescribed; - Prescribers are responsible for complying with principles of good antimicrobial prescribing, documenting indication, and expected duration; - Nurses are responsible for ensuring antimicrobials are administered in accordance to the prescription and if therapeutic drug monitoring is required, ensure blood is sampled at appropriate time and result reviewed prior to administering next dose, or as specified by doctor or pharmacist; - The nurse will complete the Infection Screening Evaluation and Antibiotic Time Out Assessments in the electronic medical record, criteria form specific to individual's clinical symptoms and notify physician if meets specific criteria for antibiotic order; - The DON will put this information on the Infection Control Log; - Specific cultured organisms, when required, will also be logged on the Monthly Quality Assurance Infection Control Log; - The Quality Assurance Team will track and monitor appropriate use of the narrowest spectrum antibiotics and any trends related to microorganisms. 1. Review of the facility's Monthly Infection Log for December 2024 showed: - Six residents started on antibiotics; - No cultures performed; - One Urinary Tract Infection (UTI); - One Respiratory Infection (RI); - Two wound/skin infections; - Two sinus infections. Review of the Infection Tracking Log for December 2024, showed: - Two out of six residents did not have prescribed antibiotic documented; - Four out of six residents did not have signs or symptoms documented; - Six out of six residents did not have the date infection was resolved, or if resolved; - No documentation of organism for wounds or UTI diagnoses; - Four out of six residents did not have documentation that showed if appropriate antibiotic was ordered. Review of the facility's Infection Surveillance Monthly Report for December 2024 showed: - Six out of eight residents did not have signs and/or symptoms documented; - Five out of eight residents did not have documentation of the antibiotic ordered. 2. Review of the facility's Monthly Infection Log for January 2025 showed: - 17 residents started on antibiotics; - Two cultures performed; - Eight UTIs; - Six respiratory infections; - One skin infection; - One Gastrointestinal Infection (GI); - One Clostridium difficile Colitis (C Diff-inflammation in the colon resulting from disruption of normal healthy bacteria in the colon, often from antibiotics). Review of the Infection Tracking Log for January 2025 showed: - 17 out of 17 residents did not have the date infection was resolved, or if resolved; - No documentation of organism for wounds or UTI diagnoses; - One resident showed appropriate antibiotic was not ordered, with no other documentation; - One resident showed antibiotic changed in hospital; - Two residents had shortness of breath (SOB) documented as signs of infection; - 15 residents had no documentation that showed if appropriate antibiotic was ordered. Review of the facility's Infection Surveillance Monthly Report for January 2025 showed: - Five out of 15 residents did not have signs and/or symptoms documented; - Seven out of 15 residents did not have documentation of the antibiotic ordered. During an interview on 02/28/25 at 12:52 P.M., the Administrator said since he/she had been at the facility for about one year, and they had not reviewed/updated the IPCP program/policy. He/She added that corporate would assist in this. During an interview on 02/28/25 at 12:53 P.M., the Director of Nursing (DON), who also served as the Infection Preventionist (IP), said the charge nurse will observe for signs and symptoms of an infection and talk to the nurse practitioner (NP), who is there twice a week, or physician to have them see the resident. The DON will add the antibiotic to the paper infection log. When an antibiotic is ordered in the electronic charting system, it will trigger for the Infection Prevention/Control (IPC) stop sign symbol to go up at the top of the screen. Staff hover over this and it will show suspected or confirmed. The infection is considered suspected until confirmed by diagnostics/labs or the physician. Once the physician confirms, it should show confirmed. He/She should be more vocal on assuring the NP and/or Physician order labs and cultures when indicated. The nurses are supposed to do an Infection Screen (under Assessments) when started on an antibiotic then they should do an Antibiotic Timeout (under Assessments) three days later. Updates or whether the infection resolved or not are not documented on the tracking tool. The Administrator can run reports from the electronic charting system, and infections had been plotted on a facility map for the past three months on Tuesday, but that had not been done before. If several residents on a hall have the same type of infection, such as a UTI, it could be due to dehydration, but a root cause analysis had not been done to find out why infections are occurring nor are the infections being tracked. During an interview on 02/28/25 at 4:45 P.M., the Administrator, DON and Assistant Director of Nursing (ADON), collectively said they would expect the facility to have an on-going antibiotic stewardship program that includes documentation of the indication, dosage, duration, outcome of antibiotic use, proper diagnosis, labs and cultures if/when indicated. The Administrator said the facility should review the IPCP at least annually and it should include standards, policies and procedures that are current, as well as an infection surveillance program. 46460