Every finding on record at Bella Vista Health Center

Based on interview and record review, the facility failed to administer medication as ordered for one of four sampled residents (1). As a result, Resident 1 was at increased risk of medication side effects.Findings: Per the facility's admission Record, Resident 1 was admitted to the facility on [DATE] with diagnoses to include fibromyalgia (a pain disorder). Per the facility's Medication Administration Record (MAR), dated April 2026, Resident 1 had an order for oxycodone (a pain medication) 10 milligram (mg) 1 tablet every six hours as needed for pain. On 4/4/26 at 12:24 P.M., Licensed Nurse (LN) 2 signed that he administered one tablet to Resident 1. Per the facility's Medication Count sheet for oxycodone 10mg, LN 2 signed out two tablets for Resident 1 on 4/4/26 at 12:24 P.M. On 4/17/26 at 4:22 P.M., a telephone interview was conducted with LN 2. LN 2 stated he did not remember why he signed out two tablets for Resident 1's 10mg oxycodone on 4/4/26. On 4/22/26 at 2:09 P.M., a telephone interview was conducted with the Director of Nursing (DON). The DON stated, on 4/4/26 LN 2 gave Resident 1 two tablets of oxycodone instead of one because he did not realize the order had changed. The DON further stated, that LN 2 should have read the order when administering the medication, and only given one tablet of oxycodone. Per the facility's undated policy, titled Medication Administration & Documentation Policy Medications must be administered according to physician orders, facility protocols, and professional standards of practice.

Based on observation, interview, and record review, the facility failed to ensure the dietary staff were competent on the ambient temperature (the temperature of the surrounding air, room temperature) food cool down process and cooked food cool down process for Time/Temperature Control for Safety Food (TCS- foods that can rapidly spoil and cause illness). These failures placed the facility's residents who consumed food prepared in the kitchen at risk of foodborne illness. Findings:According to the Federal Food and Drug Administration (FDA) Food Code 2017, Section 3-501.14 Cooling, Time/Temperature control for Safety Food shall be cooled within 4 hours to 5oC (degrees Celsius) (41oF) (degrees Fahrenheit) or less if prepared from ingredients at ambient temperature, such as .canned tuna.According to the FDA's online job aid titled Cooling Cooked Time/Temperature Control for Safety Foods and the FDA's Food Code: For Food Employees dated July 2024, indicated, .Bacteria or other pathogens that cause foodborne illness can grow rapidly on TCS foods when they are not cooled properly. The 'Temperature Danger Zone' is when food is most susceptible to pathogen growth- usually between 41 F and 135 F (5 C and 57 C). The amount of time food spends in this range needs to be minimized by proper cooling. Cooling typically occurs when: Leftovers are put into the refrigerator to be stored. After preparing hot foods, but before you intend to serve them. After preparing foods from room temperature that are not getting used immediately. The FDA Food Code requires a two-step cooling process for cooked TCS Food: 1. A two-hour rapid cool from 135 F to 70 F (57 C to 21 C) 2. Followed by a 4-hour window where foods must be cooled to 41 F or less (21 C to 5 C) This means that within two hours, the food must be cooled from cooking temperature (135 F) to 70 F in order to eliminate risk of pathogen growth. Over the next 4 hours the food must be cooled from 70 F to 41 F or less. Retrieved: www.fda.gov/retailfoodprotectionOn 9/28/25 at 7:48 A.M., an initial kitchen tour was conducted with Dietary Aid (DA) 1. During the kitchen tour, some hard-boiled eggs in a pot were observed on the stove. DA 1 stated some of the boiled eggs were served to a resident who requested them for breakfast and the leftovers were cooled down to make egg salad sandwiches for the residents. When DA 1 was asked about the cool down process and cool down logs for the boiled eggs, DA 1 reviewed a binder that contained a cool down log for macaroni salad and stated they did not have a cool down log for boiled eggs. During the dry storage tour, large canned tunas were observed on the shelves. The temperature in the dry storage room was 75.5 degrees F.During the inspection of the reach-in refrigerator, tuna salad sandwiches made on 9/27/25 were observed. When DA 1 was asked about the cool down process and cool down log for ambient temperature prepared food, DA 1 reviewed the cool down log and stated she only had entries for macaroni salad. DA 1 stated they did not have cool down logs for the ambient temperature prepared food. DA 1 stated the canned tunas were always kept in dry storage.On 9/30/25 at 10:19 A.M., an interview was conducted with the FSD and the Administrator (ADM). The kitchen findings were discussed with the FSD. The FSD stated the canned tuna and boiled eggs should have been cooled down properly and cool down logs kept since they were prepared later after being cooked and made starting at an ambient temperature. The FSD acknowledged cool down process was not being followed in the facility for tuna salad and leftover boiled eggs and stated the staff should have been trained on that. On 9/30/25 at 1:38 P.M., an interview was conducted with the Registered Dietitian Consultant (RDC). The kitchen findings were discussed with the RDC. The RDC stated she was not aware that the kitchen did not have ambient temperature prepared tuna salad and boiled egg cool down logs but there should have been a cool down process and cool down logs kept for those food items. The RDC stated following the cool down process was important because the food needs to reach safe temperatures within the safe timeline. A review of the facility's policy titled Kitchen Cool Down Policy revised unknown date, indicated, .Improper cooling is a leading cause of food borne illness and will not be permitted. Dietary staff are responsible for monitoring, documenting, and verifying proper cooling procedure.Dietary Supervisor reviews logs daily to ensure compliance.

Based on observation, interview and record review, the facility failed to ensure practices that mitigated the risk of resident food contamination were followed when: Fruit flies were observed flying around the kitchen. An open food thickener container was placed right next to the open trash can. A staff food cart was stored in the kitchen. An expired cream cheese was found in the walk-in refrigerator. Tuna salad sandwiches and hard-boiled eggs were not cooled down (a two-stage method for rapidly cooling food to prevent the growth of bacteria) properly. Washed dishes were stacked wet and with food residue on them. Washed coffee mugs had residue on them. Cooked chicken did not have a temperature taken before being plated and placed in the meal cart.These failures had the potential to cause foodborne illnesses among residents who received food from the kitchen.Findings: On 9/28/25 at 7:48 A.M., an initial kitchen tour was conducted with Dietary Aid (DA) 1. During the kitchen tour, some fruit flies were seen flying around where onions, potatoes, and bananas were stored in boxes under a prep table. DA1 stated the fruit flies could have entered through the exit screen door because the holes were large enough for them to pass through. DA1 stated the facility's protocol was to notify the Food Service Director (FSD) if pests were in the kitchen. Under the same prep table, an open trash can was observed next to an open food thickener container. DA1 stated both container's lids should have been closed to prevent cross-contamination.Next to the walk-in refrigerator, there was a cart with food, seasonings, condiments, and cooking equipment. DA 1 stated the food cart was for employee use. In the walk-in refrigerator, a container of cream cheese labeled Use By Date (indicates the last day a product is recommended for use) of 9/24/25 was found. DA 1 stated they followed the Use By Date, not the expiration date on the container from manufacturer. DA 1stated the cream cheese should have been thrown away. On the stove, some hard-boiled eggs in a pot were observed. DA 1 stated some of the eggs were served to a resident who requested them for breakfast and the leftovers were used to make egg salad sandwiches for residents. When asked about the cool down process and cool down log, DA 1 reviewed a binder that contained a cool down log for cooked macaroni. DA 1 stated they did not have a cool down process or cool down log for boiled eggs.In the reach-in refrigerator, tuna sandwiches made on 9/27/25 were observed. DA 1 reviewed cool down log which only had entries for macaroni salad and stated they do not have cool down process or cool down log for tuna sandwiches. DA 1 stated the canned tuna were always kept in the dry storage.During an observation of the dry storage room, cans of tuna were observed on a shelf. The temperature in the dry storage room was 75.5 degrees F. During the observation of the drying rack, about one hundred pitchers, four ice apple sauce cup containers, five food storage containers (1.5 Liters), and five quart containers were stacked wet. Two measuring cups were also observed with a thick clear residue on one of them. DA 1 stated wet stacked containers could grow mold and other organisms on them and that the dishes should have been fully dried before being stacked. DA 1 stated one of the measuring cups with the thick clear residue was not properly washed. Next to the beverage dispensers, there were two trays of approximately forty dry black coffee mugs with residue inside. One mug had red residue at the rim that resembled lipstick. DA 1 stated she would not want to use the mugs with residue on them if she were a resident. DA 1 stated she had a previous conversation with the dishwasher staff that the mugs were not washed to her expectations. On 9/29/25 at 11:40 A.M., an observation of lunch tray line was conducted. Several kitchen staff and the FSD were working in the kitchen to prepare lunch trays for the residents. After checking temperatures of food items on the steam table, the [NAME] started plating the food. The [NAME] checked a meal ticket of a resident who requested chicken and plated a piece of cooked chicken breast out of a metal container that was not on the steam table without checking its temperature. The FSD stated it was her expectation for the staff to have checked the temperature of the chicken before plating. On 9/30/25 at 10:19 A.M., an interview was conducted with the FSD and the Administrator (ADM). The kitchen findings were discussed with the FSD. The FSD stated the solid kitchen exit door should be kept shut to prevent fruit flies from entering the kitchen, The FSD stated no flies should be in the kitchen. The FSD stated the food thickener container and trash can should not be placed next to each other. The FSD also stated they should have their covers closed to prevent trash from falling into the thickener container. The FSD stated that the staff food cart should not have been kept inside the kitchen. The FSD stated the cream cheese beyond Use By Date should have been thrown away. The FSD stated the canned tuna and boiled eggs should have been cooled down properly and cool down logs kept since they were prepared ambient temperature (the temperature of the surrounding air, room temperature). The FSD stated the dishwasher staff skipped the air-drying process and took a short cut. The FSD stated stacked wet dishes and food containers could grow mold which could become an infection control risk. The FSD stated her expectation was to follow the proper protocol and use the mug brush to wash coffee mugs thoroughly. The FSD stated washed cooking or eating equipment should not have any food or lipstick residue on them. The FSD stated the cooked chicken temperature should have been taken before plating. On 9/30/25 at 1:38 P.M., an interview was conducted with the Registered Dietitian Consultant (RDC). The RDC stated it was important to eliminate fruit flies from the kitchen because they could carry bacteria. The RDC stated the food thickener container and trash can lids should be closed when not in active use. The RDC stated that the staff food cart should not be stored in the kitchen. The RDC stated she was not aware that the kitchen did not have ambient temperature prepared tuna and egg cool down logs but there should have been a cool down process and cool down logs kept for those food items. The RDC stated following the cool down process was important because the food needed to reach safe temperatures within the safe timeline. The RDC stated it was important to make sure wet dishes and equipment were dry to prevent bacterial growth on them. The RDC stated she expected no residue on washed coffee mugs and cooking equipment. The RDC stated all food should be checked for their core temperatures before plating. According to the Federal Food and Drug Administration (FDA) Food Code 2017, Section 3-501.14 Cooling, Time/Temperature control for Safety Food shall be cooled within 4 hours to 5oC (degrees Celsius) (41oF) (degrees Fahrenheit) or less if prepared from ingredients at ambient temperature, such as .canned tuna.According to the FDA's online job aid titled Cooling Cooked Time/Temperature Control for Safety Foods and the FDA's Food Code: For Food Employees dated July 2024, indicated, .Bacteria or other pathogens that cause foodborne illness can grow rapidly on TCS foods when they are not cooled properly. The 'Temperature Danger Zone' is when food is most susceptible to pathogen growth- usually between 41 F and 135 F (5 C and 57 C). The amount of time food spends in this range needs to be minimized by proper cooling. Cooling typically occurs when: Leftovers are put into the refrigerator to be stored. After preparing hot foods, but before you intend to serve them. After preparing foods from room temperature that are not getting used immediately. The FDA Food Code requires a two-step cooling process for cooked TCS Food: 1. A two-hour rapid cool from 135 F to 70 F (57 C to 21 C) 2. Followed by a 4-hour window where foods must be cooled to 41 F or less (21 C to 5 C) This means that within two hours, the food must be cooled from cooking temperature (135 F) to 70 F in order to eliminate risk of pathogen growth. Over the next 4 hours the food must be cooled from 70 F to 41 F or less. Retrieved: www.fda.gov/retailfoodprotection.A review of the facility's policy titled Kitchen Cool Down Policy revised unknown date, indicated, .Improper cooling is a leading cause of food borne illness and will not be permitted. Dietary staff are responsible for monitoring, documenting, and verifying proper cooling procedure.Dietary Supervisor reviews logs daily to ensure compliance.A review of the facility's policy titled Employee Personal Items and Food Storage in Dietary Services revised unknown date, indicated, .2. Staff food and beverages must be placed only in the employee break room refrigerator or other approved staff- designated food storge area. All personal food must be labeled with employee name and date. Items not labeled or expired will be discarded.A review of the facility's policy titled Kitchen Storage and Labeling Policy revised unknown date, indicated, .2. Leftovers.labeled and dated; discard within 72 hours unless frozen.A review of the facility's policy titled Dishwashing Policy revised unknown date, indicated, .Drying Dishes must be air dried in racks before stacking or storing.A review of the facility's policy titled Tray Line Food Temperature Policy revised unknown date, indicated, .1. Food temperatures must be taken before tray line begins.

Based on the observation, interview, and record review, the facility failed to ensure safe storage of resident food brought from outside of the facility when: Resident food was stored in the resident refrigerator for over 72 hours. Resident food containers were not properly labeled. The thermometer located in the resident food refrigerator was broken and the temperatures entered in the log were consistently over 41 degrees F (Fahrenheit). Staff food items were found in the designated resident refrigerator. The facility did not implement its policy titled Food Brought from Outside.As a result, the residents were at risk of consuming potentially contaminated food.Findings: On 09/28/25 at 12:13 P.M., an observation of the resident refrigerator and interview with Certified Nurse Assistant (CNA) 1 was conducted. CNA 1 stated the refrigerator located in the dining hall stored resident food brought from outside the facility. A temperature log and a sign with All items in this refrigerator must be dated and label [sic]. Open food good for 3 days only was observed on the outside of the refrigerator. The temperature log entries were greater than 41 degrees F 27 out of 28 days for A.M. shift and 24 out of 27 days for P.M. shift during the month of September 2025. CNA 1 opened the refrigerator and checked the temperature. CNA 1 stated the temperature was 50 degrees F which was warm. When asked who checked the temperature and food items inside the refrigerator, CNA 1 stated the checks were done by the kitchen staff. During the observation of the resident refrigerator contents, food items that did not have proper labeling were found: - A ketchup bottle with handwritten 12/21/24 and NOC on it.- A clear container with lemon wedges dated 9/28/25 without a resident's name.- A white container with a hard-boiled egg inside dated 9/23/25 with resident name. CNA 1 stated the staff labeled the received food items with the resident's name and date/time. CNA 1 stated all resident food items should have been properly labeled and thrown away according to the policy. CNA 1 also stated that the ketchup bottle was a staff food item, and it should not have been stored in the resident refrigerator. On 9/30/25 at 9:35 A.M., an interview with the Food Service Director (FSD) was conducted. The FSD stated Dietary Aids were expected to check the residents' refrigerator for the expiration date of food and to record the temperatures of the refrigerator daily. The FSD stated the logged temperatures were not in the right range and should have been kept between 36 to 41 degrees F. The FSD stated the Dietary Aids should have reported the temperatures to her when out of range. The FSD stated the thermometer inside the refrigerator was broken, therefore the temperatures entered on the log were wrong. Regarding the resident food items inappropriately labeled or left in the refrigerator for longer than three days, the FSD stated all resident food should have been clearly labeled with their names and date the food was received. The FSD also stated no staff food should have been kept in the resident refrigerator. On 9/30/25 at 10:13 A.M., an interview was conducted with the Dietary Aid (DA) 2. DA 2 stated she checked the refrigerator temperatures. DA 2 stated it was important to keep the refrigerator temperatures below 41 degrees F. DA 2 stated if the temperature was out of range, she would report it to the FSD and would throw away the food exceeding three days. DA 2 stated that if food did not have a proper label, it would also be thrown away. A review of the facility's policy titled Food Brought from Outside revised unknown date, indicated, .stored, and labeled properly to prevent foodborne illness and cross-contamination.All outside food must be consumed or discarded within safe timeframes.2. All food items must be: Labeled with resident's name, date, and time received.Foods not consumed within 72 hours (perishable) will be discarded.A review of the facility's policy titled Employee Personal Items and Food Storage in Dietary Services revised unknown date, indicated, .2. Staff food and beverages must be placed only in the employee break room refrigerator or other approved staff- designated food storge area. All personal food must be labeled with employee name and date. Items not labeled or expired will be discarded.A review of the facility's policy titled Kitchen Storage and Labeling Policy revised unknown date, indicated, .4.Staff personal food is stored only in employee breakroom refrigerator, not in kitchen prep or resident storage areas.

Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review Level II (PASARR II - an evaluation of the resident's psychiatric treatment requirements) was followed up on and completed for two of four residents (Resident 26 and 49) reviewed for PASARR.This failure had the potential for Resident 26 and Resident 49 to not receive necessary mental health care services in an appropriate healthcare setting.Findings:A review of Resident 26's admission Record indicated the resident was admitted to the facility on [DATE] with a diagnosis of schizophrenia, unspecified (a mental health condition that combines symptoms such as hallucinations and delusions), major depressive disorder (a mood disorder causing persistent feelings of sadness, hopelessness, and a loss of interest in activities), and bipolar disorder (a mental health disorder with mood swings). A review of Resident 26's Level I PASARR 1 screening from the Health Care Services dated 6/5/25, indicated the resident was positive for Serious Mental Illness (SMI).A review of Resident 26's Determination Report dated 6/5/25, indicated .the individual has a condition expected to require less than fifteen days of care in a nursing facility. No further evaluation is required at this time.A review of Resident 49's admission Record indicated the resident was admitted to facility on 7/23/25 with a diagnosis of schizophrenia disorder, unspecified.A review of Resident 49's Level I PASARR 1screening from the Health Care Services dated 7/22/25 indicated the resident was positive for Serious Mental Illness (SMI). A review of Resident 49's Determination Report dated 7/22/25, indicated .the individual has a condition expected to require less than fifteen days of care in a nursing facility. No further evaluation is required at this time.On 10/01/25 9:25 A.M., an interview and record review was conducted with Medical Record Director (MRD). The MRD stated she was responsible for reviewing, tracking, and submitting PASARR 1 screenings and following up on the residents' PASARR 1 in the facility. The MRD reviewed Resident 26's PASSR level 1 screening dated 6/5/25 which was positive for SMI. The MRD reviewed Resident 26's Determination Report dated 6/5/25 that indicated .the individual has a condition expected to require less than fifteen days of care in a nursing facility. No further evaluation is required at this time. The MRD stated Resident 26 had become a custodial resident on 6/22/25. The MRD then reviewed Resident 49's PASSR level 1 screening dated 7/22/25 which was positive for SMI. The MR reviewed Resident 49's Determination Report dated 7/22/25, that indicated .the individual has a condition expected to require less than fifteen days of care in a nursing facility. No further evaluation is required at this time. The MRD stated she should have followed up PASRR screening for PASRR level II for Resident 26 and Resident 49 after the residents stayed longer than fifteen days in the facility. On 11/17/25 at 2:35 P.M., an interview and record review was conducted with the Director of Nursing (DON). The DON stated it was important to follow up on the PASSR screenings for patient safety and care. The DON stated that the Medical Records Director should have followed up on Resident 26 and Resident 49 when they became permanent residents in the facility so that they would have been evaluated for PASRR level II screening. A review of the facility's policy and procedure titled, PASRR, undated indicated .No individual with a known or suspected serious mental illness (SMI), intellectual disability (ID), or related condition (RC) will be admitted to the facility without the required Level 1 screening, if indicated, a level II evaluation. The facility will ensure PASRR determinations are integrated into the care planning process.

Based on interview and record review, the facility failed to provide pharmaceutical services according to acceptable standards of practice when the documentation on the Controlled Drug Record (CDR an accounting of controlled medications, drugs with a high abuse potential) and the Medication Administration Record (MAR documentation in the medical record that a resident received a medication) did not reconcile for one of three randomly selected residents (Resident 14). This failure had the potential for drug diversion (illegal acquisition, misuse, or transfer of prescription medication for an unauthorized purpose) and/or inadequate pain management. Findings:A review of Resident 14's admission Record indicated he was admitted to facility on 2/8/25 with a diagnosis of surgical aftercare following surgery on the skin and subcutaneous tissue (fatty tissue).A review of Resident 14's order summary dated 8/27/25, indicated the resident was to receive Morphine Sulfate (medication used to treat pain) oral tablet 15 milligrams (mg) every four hours as needed for moderate to severe pain.On 9/29/2025 at 11:22 A.M., an interview and record review was conducted with Licensed Nurse (11). LN 11 stated it was important the controlled drug count to be correct for patient safety and for medications to be accounted for. LN11 reviewed Resident 14's CDR and MAR for September 2025 for Morphine 15 mg tablet on the following dates:On 9/9/25 at 3 P.M., Resident 14's Morphine 15 mg tablet was removed from storage and documented on the CDR, but not documented on the MAR.On 9/14/25 at 2 P.M., Resident 14's Morphine 15 mg tablet was removed from storage and documented on the CDR, but not documented on the MAR. On 9/18/25 at 6:30 A.M., Resident 14's Morphine 15 mg tablet was removed from storage and documented on the CDR, but not documented on the MAR.On 9/19/25 at 5:30 A.M., Resident 14's Morphine 15 mg tablet was removed from storage and documented on the CDR, but not documented on the MAR.On 9/24/25 at 7 A.M., Resident 14's Morphine 15 mg tablet was removed from storage and documented on the CDR, but not documented on the MAR.On 9/24/25 at 1 P.M., Resident 14's Morphine 15 mg tablet was removed from storage and documented on the CDR, but not documented on the MAR.On 9/27/25 at 3 P.M., Resident 14's Morphine 15 mg tablet was removed from storage and documented on the CDR, but not documented on the MAR. LN 11 stated Resident 14's Morphine 15 mg had been removed from storage and documented on the CDR, but he did not see it documented on the MAR. LN 11 stated CDR and MAR did not match and they should have. LN 11 stated documentation on the CDR and MAR should occur at the same time medication was given to the resident.On 10/01/25 at 9:01 A.M., an interview and record review was conducted with the Director of Nursing (DON). The DON reviewed Resident 14's CDR and MAR. The DON stated it was important to keep track of controlled medications for residents' comfort, pain management and to avoid potential drug diversion. The DON stated her expectation was for licensed nurses to check the residents' orders, dispense the controlled medication, administer the medication and then document. A review of facility's undated policy titled Medication Administration & Documentation Policy indicated .2. Document medication immediately after administration, never before. 3. Record each administration in narcotic log and MAR. Report discrepancies immediately to the DON and Administrator.

Based on interview and record review, the facility failed to provide outside dental resources and services in a timely manner for one resident (Resident 6). As a result, Resident 6 waited over 11 months to be evaluated for a new denture and was at risk for potential issues with the fitting of the new denture caused by the delay in receiving dental care and treatment. Findings:A review of Resident 6's admission Record indicated the resident was admitted to the facility on [DATE]. On 9/28/25 at 9:43 A.M., an interview was conducted with Resident 6. When the resident was asked if she had any issues with her care, she stated she was waiting for her teeth. On 9/30/25 at 9:11A.M., a joint interview and record review was conducted with the Social Services Director (SSD). The SSD reviewed Resident 6's Dental Progress Notes dated 10/31/24 and stated Resident 6 was waiting for a denture evaluation by a dentist from the newly approved dental program, because the resident insurance did not cover dentures. On 10/1/25 at 8:05 A.M., a joint interview and record review was conducted with the Charge Nurse (CN). The CN reviewed Resident 6's last Dental Progress Notes dated 10/24/25 and stated she requested a denture last year. On 10/1/25 at 10:29 A.M., a joint interview and record review was conducted with the SSD. The SSD reviewed Resident 6's clinical record and acknowledged that it had been a year since the resident requested a denture. The SSD stated this was a delay of care and the resident could have lost the ability to fit a denture in her mouth due to the length of the delay. On 11/17/25 at 2:53 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated that Resident 6's denture request should have been addressed using all the resources. The DON stated Resident 6 should have been evaluated for dentures and that a new denture should have been made within a few months of the resident's request. The DON stated the process should not have taken almost a year. A review of the facility's policy titled Ancillary referral revised unknown date, indicated, .maintain or improve their [residents] highest practicable physical.well-being.

Based on interview and review of the Centers for Disease Control and Prevention (CDC) publication titled, Infection Control Guidance: SARS-CoV-2 [COVID-19], the facility failed to ensure 161 of 162 facility staff with direct exposure to COVID-19 positive residents and who were required to wear N95 masks during a COVID-19 outbreak were fit tested to ensure a proper fit and seal of their N95 mask. Findings included: The CDC publication titled, Infection Control Guidance: SARS-CoV-2, dated 06/24/2024, revealed, This guidance applies to all U.S. settings where healthcare is delivered, including nursing homes and home health. The publication specified, Personal Protective Equipment -HCP [health care personnel] who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH [National Institute of Occupational Health and Safety]Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e. [id est, that is], goggles or a face shield that covers the front and sides of the face). -Respirators should be used in the context of a comprehensive respiratory protection program, which includes medical evaluations, fit testing and training in accordance with the Occupational Safety and Health Administration's (OSHA) Respiratory Protection standard. During an interview on 07/26/2024 at 10:16 AM, the Director of staff Development (DSD) stated she was also serving as the facility's Infection Preventionist (IP). The DSD stated the facility's most recent COVID-19 outbreak started on 06/21/2024, and their last positive result was on 07/10/2024. The IP said that during the outbreak, all staff wore N95 masks; however, the DSD indicated that despite arranging a certified fit tester, facility staff had not yet been fit tested . The DSD stated she was the only staff member that had been fit tested as of the time of the survey. The DSD said it was her understanding that fit testing was recommended but not required. During a follow-up interview on 07/26/2024 at 11:48 AM, the DSD stated that all staff working in the departments of nursing, management, housekeeping, maintenance, activities, and therapy went into the rooms of residents who were positive for COVID-19. She also stated laundry staff sorted the laundry coming from rooms with COVID-19 positive residents. During an interview on 07/26/2024 at 10:54 AM, the Director of Nursing (DON) said N95 mask fit testing was recommended but not required. The DON said the facility had arranged for staff to be fit tested , but it had not been completed yet. During an interview on 07/26/2024 at 10:56 AM, the Administrator said it was recommended that staff be fit tested for N95 masks. The Administrator said the facility arranged for fit testing, but the only staff member fit tested thus far was the DSD.

Based on record review, interview, and facility policy review, the facility failed to ensure a Level I Preadmission Screening and Resident Review (PASRR) accurately reflected the presence of a diagnosed mental disorder for 1 (Resident #44) of 5 residents reviewed for PASRR requirements. Findings included: An undated facility policy titled, Preadmission Screening and Resident Review revealed, Purpose: To ensure that all facility applicants are screened for mental illness and/or intellectual disability and to ensure coordination with the appropriate state agencies if indicated. The policy specified, II. The Facility, ensures that PASRR Level I is completed either by the transferring general acute care hospital (GACH), or by the Facility for all applicants, regardless of Payor source, prior to admission to determine if they have a serious mental illness (SMI) and/or intellectual disability, developmental disability or related condition(s) (ID/DD/RC). An Admission Record revealed the facility admitted Resident #44 on 06/04/2024. According to the Admission Record, the resident had a medical history that included a diagnosis of major depressive disorder, with an onset date of 06/04/2024. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/08/2024, revealed Resident #44 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had an active diagnosis of depression. Resident #44's care plan included a Focus area initiated on 06/05/2024, that indicated the resident exhibited negative mood/behaviors related to depression. A Focus area, initiated on 06/06/2024, indicated the resident received citalopram (an antidepressant medication) related to a diagnosis of mental illness, specifically depression. Resident #44's Preadmission Screening and Resident Review (PASRR) Level I Screening, dated 06/03/2024, revealed the resident's diagnosis of major depressive disorder was not reflected. The question related to whether the resident had a serious diagnosed mental disorder such as depressive disorder, anxiety disorder, panic disorder, schizophrenia/schizoaffective disorder, or symptoms of psychosis, delusions, and/or mood disturbance was answered no, resulting in a negative screening; thus, a Level II evaluation was not required. During an interview on 07/25/2024 at 10:54 AM, Medical Records (MR) Staff #1 stated that she was responsible for reviewing PASRRs completed by the hospital to make sure they were correct. MR Staff #1 said if a resident had a mental illness, it had to be reflected on their PASRR. MR Staff #1 said she was responsible for submitting another PASRR if the one completed by the hospital was not accurate and did not reflect all diagnoses. During an interview on 07/26/2024 at 10:00 AM, the Director of Nursing (DON) stated facility staff pulled PASRRs from the system but indicated they should be reviewing them for accuracy and updating them if needed. During an interview on 07/26/2024 at 10:55 AM, the Administrator stated she expected PASRRs to be complete and accurate.

Based on observation, interview, and facility policy review, the facility failed to ensure expired medications and/or biologicals were removed from 1 (Station 1) of 2 medication storage rooms and 1 of 1 central supply closet. Findings included: A facility policy titled, Storage of Medications, revised in 11/2020, indicated, The facility stores all drugs and biologicals in a safe, secure, and orderly manner. The policy specified, Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. An observation on 07/24/2024 at 12:07 PM of the medication storage room located on Station 1 revealed a Nozin Nasal Sanitizer with an expiration date of 03/2024. During an interview on 07/25/2024 at 12:09 PM, Registered Nurse (RN) #3 stated the Nozin Nasal Sanitizer was not supposed to be in the medication storage room, because it was expired. An observation on 07/24/2024 at 12:16 PM of the central supply closet revealed two boxes of Tucks (medicated pads) with an expiration date of 03/2024. During an interview on 07/25/2024 at 12:13 PM, the Director of Nursing (DON) said a routine check of stored medications should be conducted weekly. The DON said when expired medications were found, they should be discarded. The DON confirmed the Nozin Nasal Sanitizer and two boxes of Tucks should have been discarded prior to the survey. During an interview on 07/26/2024 at 10:57 AM, the Administrator said there should be no expired medications in any medication storage areas. The Administrator stated expired medications should be removed and disposed of.

Based on observation, interview, and record review, the facility failed to provide the necessary care and treatment to a resident's (1) identified skin issues (redness of the buttocks), for one of three sampled residents, when Resident 1's physician was not informed of the resident's skin condition during admission to the facility. The delayed care and treatment to Resident 1's skin issues had the potential to worsen Resident 1's skin condition. Findings: On 2/9/24, an unannounced onsite at the facility was conducted related to a complaint on quality of care. During a review of the facility's Admission Record, dated 12/31/23, the Admission Record indicated Resident 1 was admitted to the facility, with diagnoses which included generalized body weakness, dementia (inability to think, remember and reason), hemiplegia (paralysis that affect one side of the body), and hemiparesis (weakness or inability to move on one side of the body). During a review of Resident 1's minimum data set (MDS, an assessment tool), dated 1/2/24, indicated Resident 1's brief interview for mental status (BIMS, ability to recall) score was 7, which meant Resident 1's cognition was severely impaired. The functional abilities section of the MDS indicated Resident 1 required maximum assistance when repositioning in bed. During a review of Resident 1's undated acute care hospital (ACH) record, indicated Resident 1 had no skin issues [no rashes or ecchymosis - bruises]. During a review of Resident 1's skin measurement observation form completed by Licensed Nurse (LN) 1 dated 1/14/24, indicated LN 1 documented Resident 1 had moisture associated skin damage (MASD, caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate, mucus, saliva, and their contents) at the buttocks. During a review of Resident 1's Treatment Administration Record (TAR) for January 2024, indicated Resident 1 started receiving treatment of her buttocks on 1/2/24. During a joint observation of Resident 1 and an interview with Resident 1's personal caregiver (PC) on 2/9/24 at 12:13 P.M., PC stated she came to the facility every day. PC stated Resident 1 had some redness on her buttocks. PC opened Resident 1's incontinence brief and showed Resident 1's buttocks. Resident 1 had a red, open area at the buttocks, with dry flaky skin surrounding the open area. During a concurrent interview with LN 2 and a review of Resident 1's record on 2/9/24 at 4:17 P.M., LN 2 stated she admitted Resident 1 to the facility on [DATE]. LN 2 stated Resident 1 had redness on her groin and sacral area upon the initial skin assessment. LN 2 stated Resident 1 was diabetic and given her age was prone to skin issues. LN 2 stated if there was redness, there should be a barrier cream (protects the skin from external irritants) applied to the affected area. LN 2 stated she did not recall calling the physician. During a telephone interview with LN 1 on 2/15/24 at 11 A.M., LN 1 stated he did a thorough skin assessment on Resident 1 on 1/2/24 and noted Resident 1's skin redness of her buttocks and was assessed as MASD. LN 1 stated Resident 1 started getting treatment of her buttocks on 1/2/24. LN 1 stated the facility's policy was, Upon identifying the resident's skin issues, the LN has to inform the physician to get an order for the barrier cream or triad paste because you don't want the skin condition to get worse and try to treat it right away. During a telephone interview with the Director of Nursing (DON) on 2/15/24 at 2:40 P.M., the DON stated the expectation was if there were skin issues, the LNs should notify the doctor and have initiated the treatment because the skin condition could worsen overnight. During a review of the facility's policy titled, Prevention of Pressure Injuries, revised April 2020, the policy indicated, Purpose - The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors .Prevention .Skin Care .4. Use a barrier product to protect skin from moisture .Monitoring, I. Evaluate, report and document potential changes in the skin .

Based on staff interviews and review of the facility documents, the facility failed to ensure a safe discharge was provided for one of three sampled residents (1). As a result, Resident 1 was readmitted to the acute hospital. Findings: On 2/2/23 at 1:42 P.M., an unannounced onsite visit was conducted related to inappropriate discharge. On 2/2/23, Resident 1 ' s records was reviewed. Resident 1 was readmitted to the facility on [DATE], with diagnoses which included Parkinson ' s disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), per the facility ' s Admission Record. Resident 1's history and physical dated 11/22/22 was conducted. The physician documented, Resident 1 had the capacity to understand and make decisions. Resident 1 ' s discharge summary dated, 1/10/23 electronically signed by a licensed nurse (LN) 2 indicated, Resident went home alert and confused for HH [Home Health], PT [physical therapy], RT [sic] and RN [name of the home health agency] via wheelchair transportation and p/u [picked up] by ambulance . On 2/2/23 at 2:10 P.M., an interview with case manager (CM) 1 was conducted. CM 1 stated Resident 1 was admitted to the facility for physical, occupational, and speech therapy. CM 1 stated Resident 1 was discharged because his insurance determinedthat Resident 1 ' s condition had improved. CM 1 stated it was a planned discharged and that Resident 1 was discharged to a board and care. CM 1 also stated the licensed nurses (LNs) were responsible to get a discharge order from the physician. On 2/2/23 at 3:25 P.M., an interview with LN 1 was conducted. LN 1 stated Resident 1 was alert and oriented, and needed some assistance because of his Parkinson ' s. LN 1 stated he was not working the day Resident 1 was discharged from the facility. On 2/2/23 at 4:36 P.M., an interview with Physical Therapist (PT) 1 was conducted. PT 1 stated Resident 1 was discharged from the physical therapy because he had progressed and his insurance was exhausted. On 2/2/23 at 4:45 P.M., a concurrent interview and record review was conducted with the Director of Nursing (DON) and CM 1. The DON stated Resident 1 was seen by the attending physician on 1/5/23 and approved him to be discharged . However, the DON stated she did not find any discharge order for Resident 1. The DON stated the expectation was for LNs to obtain a discharge order from the physician to ensure resident's safety and a confirmation from the physician that the resident was ready to go home. The DON also stated the discharge summary was not detailed that should have included resident ' s progress, treatment rendered from the time of admission until his exit (discharge) including Resident 1 ' s safe discharge. A review of the facility ' s policy, titled Discharge Summary and Plan, revised December 2016, indicated, Policy Statement: Residents will be prepared in advance for discharge .When a resident ' s discharge is anticipated, a discharge summary .will be developed to assist the resident to adjust to his/her new living environment .2. The discharge summary will include recapitulation of the resident ' s stay at this facility .shall include a description of the resident ' s: .c. course of illness, treatment and/ or therapy since entering the facility .f. ability to perform activities of daily living .h. nutritional status and requirement .3. Nursing services is responsible for: a. obtaining orders for discharge or transfer, as well as the recommended discharge services .

Based on interview and record review, the facility failed to provide medical records for 1 sampled resident, Resident 1. As a result, Resident 1's Representative received the medical records four months after requested. Findings: Per the Admission Record, Resident 1 (R1) was admitted to the facility on [DATE] with diagnosis including Alzheimer's disease. On 7/13/22 at 10 A.M., R1's Resident Representative (RR2) stated, I requested my mom's medical records from the facility on 6/1/22. I attached the records request, the POA (Power of Attorney, a legally binding document that allows you to appoint someone to manage property, medical or financial matters) and my license to the email I sent. Review of R1's Admission Record, contact list listed RR2 as R1's Responsible Party, POA. RR2 was listed as R1's POA for care matters and financial affairs. On 1/25/23 at 12:54 P.M., during an interview with the Administrator (ADM), ADM stated, I received an email from (RR2) on 6/1/22. I forwarded it to our Director of Medical Records (DMR). DMR went on leave around that time. The ADM further stated, I did not know that (DMR) did not receive the email. On 1/25/23 at 1 P.M. an interview was conducted with RR2. RR2 stated, I did not receive the medical records until October 3, 2022. Review of the facility's policy titled, Access to Personal and Medical Records dated, May 2017 indicated .1. A resident may submit his/her request either orally or in writing for access to personal or medical information pertaining to him/her .3. If the format requested by the resident is not available, then the record will be provided in a form and format agreed to by the resident .5. The resident may obtain a copy of his or her personal or medical record within two business days of an oral or written request.

Based on observation, interview, and record review, the licensed nurses failed to follow a physician's order for intravenous (IV) antibiotics (used to treat a wide variety of infections) for one of two sampled residents (1). This failure resulted to missed seventeen doses of Resident 1's antibiotics and had the potential to worsen her ongoing infections. Findings: Resident 1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1's history and physical (H & P) dated, 1/11/21 indicated, she had the capacity to understand and make decisions. A review of Resident 1's minimum data set (MDS- an assessment tool), dated 1/17/21, indicated her brief interview for mental status (BIMS - a screen test to assist with identifying a resident's cognitive status) was 11 which meant her cognition was moderately impaired. On 2/2/21 at 3:18 P.M., a telephone interview with Resident 1 was conducted. Resident 1 stated she was admitted to the facility for IV antibiotic treatment every six hours because of a tooth infection. Resident 1 stated she was concerned because the antibiotics were not consistently given as ordered by the physician. On 2/4/21 at 2:52 P.M., an observation of Resident 1 was conducted in her room. Resident 1 was lying in bed with her eyed closed. An IV pole was placed on her bedside with no bag/treatment hanging. On 2/4/21, a review of Resident 1's physician orders and the medication administration record (MAR- a report that serves as a legal record of the drugs administered to a patient at a facility by a health care professional) was conducted. The physician's order dated 1/10/21, indicated, [MEDICATION(S)] - [MEDICATION(S)] Solution 3 (2-1) gram, use 3 grams IV every 6 hours for .Oropharyngeal/ dental infection for 4 weeks. The MAR for January and February 2021 indicated, there were no entries/initials on the dates and times of administration: - 1/12/21 - 6 in the morning (AM) - 1/13/21 - 6 AM and 12 noon (NN) - 1/14/21 - 12 midnight (MN), 6 AM, and 12 NN - 1/17/21 - 6 AM and 12 NN - 1/19/21 - 12 MN and 6 AM - 1/25/21 - 6 AM - 1/27/21 - 6 AM - 1/28/21 - 6 AM - 1/31/21 - 6 AM and 6 in the evening (PM) - 2/1/21 - 6 AM. There were total of 17 doses of antibiotic treatments not administered to Resident 1. On 2/4/21 at 3:08 P.M., an interview with Licensed Nurse (LN) 1 was conducted. LN 1 stated only registered nurses (RN) were allowed to administer the IV antibiotic treatments. On 2/4/21 at 3:48 P.M., a joint review of Resident 2's MAR, and an interview with RN 2 was conducted. RN 2 stated Resident 1 had an oral surgery and was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . RN 2 stated there were blank entries in Resident 1's MAR. RN 2 stated, I will tell the doctor to let him know that the resident missed it and they can reschedule so there was no skipped dose. RN 2 stated the goal of the treatment was to follow the physician's order for Resident 1's infection to get better. On 2/4/21 at 4:17 P.M., a joint review of Resident 1's MAR and an interview with the Director of Nursing (DON) was conducted. The DON stated the blank entries in Resident 1's MAR were missed doses of IV antibiotic treatments. The DON stated the RNs giving IV treatment should have documented/initialed the MAR to reflect it was administered. The DON stated if it was not documented, it was not given/done. A review of the facility's policy titled, Administering Medications, revised December 2012, indicated, Medications shall be administered in a safe and timely manner, and as prescribed .3. Medications must be administered in accordance with the orders, including any required time frame .

Based on interview and record review, the facility failed to report an alleged act of abuse that was reported by Resident 1. As a result, the allegation was not investigated by the abuse coordinator. This deficient practice had the potential to put other residents at risk for abuse. Findings: Per the Admission Record, Resident 1 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/19/21 at 11 A.M., during an interview, Resident 1 stated, On 2/8/21 I went out to the linen closet to get a towel so I could help clean my roommate. Resident 1 continued to say, The CNA was new and seemed overwhelmed with the poop and pee. Resident 1 further stated, While I was at the linen closet, the CNA yanked my arm where I had an IV (intravenous apparatus used to deliver liquid antibiotics). He said: Go back to your room! On 3/19/21 Resident 1's medical record titled, HPI (History of Present Illness), dated 1/17/21, was reviewed. The HPI indicated, Psychiatric: .Good judgement. Mental status: .Orientation: to time, place, and person. Memory: recent memory normal and remote memory normal. On 3/19/21 at 11:30 A.M., the social services director (SSD) and social services assistant (SS) were interviewed. The SSD stated, Resident 1 called the social services (SS) the day after she left the facility to let her know she was OK. The SS stated, Resident 1 called the facility on 2/9/21. She said she left because her IV antibiotic doses were finished and she was upset about an incident with the CNA the day before. Resident 1 said on 2/8/21, a CNA by the name of [NAME] grabbed her arm where the IV was. During the same interview, the SSD stated, We did not report the abuse allegations to the administrator because we could not identify who [NAME] was and Resident 1 left abruptly the next day. On 3/19/22 at 12:30 P.M., the administrator stated, This was an abuse allegation and I expected all my staff to report all allegations of abuse so they are investigated immediately. Review of the facility's policy titled, Abuse, no date, indicated, . Abuse Prevention; Procedure for Administration, 1. The Administrator will be this facility's designated Abuse Prevention Coordinator, and has the ability to delegate actions and tasks to other employees, such as the gathering of pertinent data, so that a timely resolution of an event and or alleged event will occur .Procedure for reporting and Investigating .1. The Department of Health is to be notified of actual or alleged abuse by telephone within 24 hours .Immediately to the Administrator and 2 hours if serious injury.

Based on interviews and record reviews, the facility failed to adequately monitor 1 of 3 sampled residents on prescribed narcotics, Resident 1. As a result, Resident 1 was found unresponsive, emergently transferred to an acute hospital where [MEDICATION(S)] (medication to reverse overdose of a narcotic) was used to revive him. Findings: Per the facesheet, Resident 1 was admitted on [DATE] for Acute Rhabdomyolysis (A breakdown of muscle tissue that releases a damaging protein in the blood stream) and [CONDITION(S)]. On [DATE], a review of the Emergency Department notes dated, [DATE] indicated, Pt BIBM (brought in by medic) from (name of facility) after being found unresponsive by staff .Pt is non-verbal upon assessment not responding to painful stimuli, malodorous wound with wound vac present. Pt not responding to painful stimuli, intermittent spontaneous movement, PERRL, gaze fixed forward, unable to perform full neuron as pt is not following commands, gag reflex intact some coughing .he was given [MEDICATION(S)] this woke him up Impression: .4. Opiate toxicity. On [DATE] a review of Resident 1's Order Summary Report indicated, the following pain medications were ordered by the physician on [DATE]: [MEDICATION(S)] [MEDICATION(S)] ER tablet Extended Release 15 MG (milligram) Give 1 tablet by mouth two times a day for pain. [MEDICATION(S)] Sulfate Tablet 15 MG Give 1 tablet by mouth every 4 hours as needed for mild pain. [MEDICATION(S)] Sulfate Tablet 15 MG Give 2 tablet by mouth every 4 hours as needed for severe pain. The physician ordered the following [MEDICATION(S)] [MEDICATION(S)] on [DATE]: [MEDICATION(S)] sulfate Tablet 15 MG. Give 1 tablet by mouth every 4 hours as needed for pain. NTE (not to exceed) 4 doses in 24 hours. Hold if RR (respiratory rate) < (less) 12 or Sedated. During an interview with license nurse (LN) 1 on [DATE] at 2 P.M., LN 1 stated, Resident 1 had pain in his legs. Pain level is assessed before we give the medication and 30 minutes to an hour after the medication is given. We document an E if the pain medication was effective. LN 1 further stated, When a drug is refused, we write a progress note. We would not give [MEDICATION(S)] if the resident was sleepy. Further review of the Order Summary Report indicated, an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Every shift. On [DATE] Review of the Medication Administration Records (MAR) indicated, the ROUTINE [MEDICATION(S)] [MEDICATION(S)] ER 15 MG was given twice a day, every day except for 2 doses. On [DATE] and [DATE] Resident 1 refused his 5 P.M. routine doses on both days. A review on [DATE] of the PRN (prescription taken as needed) [MEDICATION(S)] [MEDICATION(S)] MAR, indicated, PRN [MEDICATION(S)] [MEDICATION(S)] was administered, however, there were no documentations of non-pharmacological interventions recorded for the following days: On [DATE] at 10:50 AM- 15 MG tablet was given for pain rated 6 out of 10 on pain scale. There was no documentation to show non-pharmacological intervention was initiated. On [DATE] at 12:48 A.M., two [MEDICATION(S)] 15 MG tablets were given for pain rated 8 out of 10 on pain scale. No documentation to show non-pharmacological interventions were initiated. On [DATE] at 11:42 A.M., two [MEDICATION(S)] 15 MG tablets were given for pain rated 8 out of 10 on pain scale. No documentation to show non-pharmacological interventions were initiated. On [DATE] at 9 P.M., one [MEDICATION(S)] 15 MG tab was given for pain rated 3 out of 10 on pain scale. No documentation to show that non-pharmacological interventions were initiated. On [DATE] at 11:44 A.M., two [MEDICATION(S)] 15 MG tabs were given for pain rated 7 out of 10 on pain scale. No documentation to show non-pharmacological interventions were initiated. On [DATE] at 6:09 A.M., two [MEDICATION(S)] 15 MG tablets were given for pain rated 8 out of 10 on pain scale. No documentation to show non-pharmacological interventions were initiated. On [DATE] at 12 P.M., one [MEDICATION(S)] 15 MG tablet was given for pain rated 8 out of 10 on pain scale. No documentation to show that non-pharmacological interventions were initiated. On [DATE] at 9:41 P.M., two [MEDICATION(S)] 15 MG tablets were given for pain rated 8 out of 10 on pain scale. No documentation to show non-pharmacological interventions were initiated. On [DATE] at 5:30 A.M., one [MEDICATION(S)] 15 MG tablet was given for pain rated 7 out of 10 on pain scale. No documentation to show non-pharmacological interventions were initiated. On [DATE] at 7:41 P.M., one [MEDICATION(S)] 15 MG tablet was given for pain rated 8 out of 10 on pain scale. No documentation to show non-pharmacological interventions were initiated. On [DATE] at 10:31 A.M., one [MEDICATION(S)] 15 MG tablet was given for pain rated 7 out of 10 on pain scale. No documentation to show non-pharmacological interventions were initiated. On [DATE] at 1:18 P.M., two [MEDICATION(S)] 15 MG tablets were given for pain rated 6 out of 10 on pain scale. No notes were written to show non-pharmacological interventions were initiated. On [DATE] at 11:55 P.M., two [MEDICATION(S)] 15 MG tablets were given for pain rated 9 out of 10 on pain scale. No documentation to show non-pharmacological interventions were initiated. On [DATE], a review of the nurses progress notes revealed there were no nursing note entries for Resident 1 on a number of days. There were no reassessments for pain or related consequences 6 days in February, 14 days in March and 18 days in [DATE]. On [DATE] at 3 P.M., the Director of Staff Development (DSD) was interviewed. DSD stated, There should be a daily note by the LN in the progress notes. There should also be vital signs recorded. The DSD further stated, there should also be a weekly summary. On [DATE] at 4:05 P.M., during an interview with the DON, the DON stated she did not know why the nurses missed entering notes for Resident 1. The DON said it was her expectation that the nurses document an assessment of the residents pain daily in the progress notes or MAR. The DON further stated there should have been also nurse's weekly summary. The DON further stated, The vital signs are done daily and recorded daily for residents on controlled drugs to monitor for adverse effects. On [DATE], a document titled, Consultant Pharmacist's Medication Regimen Review dated [DATE] was reviewed. The document indicated, .Consider addition of routine vital monitoring while on routine opioids ie; RR (Respiration Rate) and sedation. On [DATE] the facility's document titled, Weights and Vital Summary was reviewed, it indicated: Blood pressure and Pulse were NOT recorded on the following days; February, 2021: 15, 16, 18, 21, 22, 23, 25, 27 March, 2021: 3, 4, 6, 7, 11, 13, 14, 15, 16, 18, 20, 21, 22, 25, 27, 29, 31 April, 2021: 1, 3, 4, 6, 8, 9, 11, 13, 14,17, 20, 22, 24, 26 Respiration Rates were NOT recorded on the following days: February, 2021: 15, 17, 18, 21, 22, 23,25, 26 27 March, 2021: 3, 4, 6, 7, 11, 13, 15, 16, 18, 20, 23, 25, 27, 29 April, 2021: 1, 2, 6, 8, 14, 17, 20, 22, 23, 24 On [DATE] at 3:50 P.M., during a concurrent interview and record review of a care plan titled, Focus Care plan: At risk for alteration in comfort related to episodes of pain secondary to Rhabdomyolysis, Diabetes Mellitus and multiple medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with the DON, the DON stated, There was no record that nursing followed up on the effectiveness of the care plan intervention. On [DATE] at 4 P.M., during a concurrent interview and record review with the DON, the DON stated, We did not have an IDT (Interdiciplinary team) meeting for Resident 1. The DON stated, We did not have an IDT meeting because Resident 1 was always sleeping. The DON further stated,We should have had the IDT. The doctor comes in once a month to do an assessment. According to the facility's policy titled, Pain- Clinical Protocol, dated [DATE], .Monitoring .Assessment and Recognition .2 The nursing staff will assess each individual for pain upon admission to the facility , at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain .The physician will order appropriate non-pharmacological and medication interventionist address the individual's pain .Monitoring .1. The staff will reassess the individual's pain unrelated consequences at regular-intervals; at least each shift for acute pain or significant changes in level of chronic pain and at least weekly in stable chronic pain. a. for example, review frequency and intensity of pain, ability to perform activities of daily living (ADLs), sleep pattern, mood, behavior, and participation in activities; .6. If pain is stable and the underlying cause is resolved or it is unclear whether a source of pain remains, the physician will consider a trial reduction or elimination of analgesic medication; for example, reduce the standing dose of an analgesic and see if there is any change in pain-related symptoms or use of PRN analgesics .a. The physician should document periodically why reduction of analgesics is not feasible. It should be more explicit than just assuming that the absence of pain symptoms implies the need for indefinite analgesic administration. Sometimes a trail tapering or discontinuation of analgesics is indicated to determine if current medications or doses are still needed. .

Based on observation, interview, and record review, the facility failed to ensure proper food handling practices, and sanitation requirements were met when: 1. Kitchen staff (KA 1) did not perform hand hygiene between kitchen tasks, and 2. Dishwashing racks (used for storing dinnerware, cups and glasses) were worn, and covered in a gray residue. These failures had the potential to cause the spread of food borne illness to residents in the facility. Findings: 1. On 1/26/22 at 8:20 A.M., an observation was conducted in the kitchen. KA 1 washed his hands, donned (put on) disposable gloves, opened the kitchen door, proceeded out of the kitchen, opened an outside door that led to the driveway at the side of the building, and walked outside. KA 1 came back inside the facility, with the gloves still on, opened the kitchen door and proceeded to the dirty side of the dishwashing section of the kitchen and began to wash the dirty pots and pans from breakfast preparation. KA 1 did not change gloves or wash his hands after he returned to the kitchen, and before he started to wash the dishes. On 1/26/22 at 8:35 A.M., a second observation was conducted in the dishwashing area of the kitchen. KA 1 washed his hands, donned disposable gloves, and proceeded to wash dirty dishes from breakfast service, on the dirty side of the kitchen counter (an area where unclean pots, pans, dishes, and utensils were placed before being washed). KA 1 moved from the dirty side of the counter to the clean side of the counter (where pots, pans, dishes, and utensils were placed after being sterilized in the dishwasher). KA 1 did not remove his gloves or wash his hands before moving from the dirty side to the clean side of the counter. KA 1 began to stack clean water jugs from the clean side of the counter onto a cart. KA 1 did not discard the dirty gloves before handling the clean water jugs. KA 1 moved back to the dirty side of the counter, touched the inside of the trash bin with one gloved hand, then placed both hands on the back pockets of his trousers. KA 1 did not change gloves or wash his hands between these actions. At 8:40 A.M., an interview was conducted with KA 1. KA 1 stated he had attended an in-service (training) on handwashing and sanitizing about a month ago. KA 1 stated he should have changed his gloves between the kitchen tasks. At 8:45 A.M., an interview was conducted with the DS. The DS stated it was important kitchen staff used correct hand hygiene techniques because of the risk of contamination between soiled and clean surfaces, and dirty and clean kitchen utensils and equipment. On 1/27/22 at 1:30 P.M., a record review was conducted. The facility policy, titled, Hand Washing Procedure, dated 2018, included .When Hands Need To Be Washed: 1. Before starting work in the kitchen 2. After handling soiled dishes and utensils .8. Touching trash can or lid . According to the facility's, Glove Use Policy, dated 2018, .When Gloves Need To Be Changed .2. Before beginning a different task . The Food and Nutrition Services In-Service, titled Handwashing, dated 1/11/22, indicated KA 1 attended the session. The Food and Nutrition Services In-Service, titled Glove Use, dated 12/1/21, indicated KA 1 attended the session. 2. On 1/26/22 at 8:25 A.M., an observation of the facility dishwashing racks was conducted. The dishwashing racks were used to store clean dishes, bowls and glasses. The racks looked worn and had a gray substance caked on the inside and outside of the racks. On 1/26/22 at 8:30 A.M., an interview was conducted with the DS. The DS stated the dishwashing racks were old and dirty. The DS stated the dishwashing racks needed to be replaced. According to the 2017 US Food and Drug Administration (FDA) Food Code, Section 4-101.11, titled Multiuse Characteristics. Materials that are used in the construction of utensils and food contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be: (A) Safe; (B) Durable, corrosion-resistant, and nonabsorbent; (C) Sufficient in weight and thickness to withstand repeated warewashing; (D) Finished to have a smooth, easily cleanable surface; and (E) Resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition .

Based on observation, interview, and record review, the facility failed to provide infection control standards of practice when; In the facility's designated Red Zone: 1a. CNA 6 and Maintenance (Mnt 6) staff was observed entering and exiting (clean to dirty area) the Red Zone not donning PPE (personal protective care equipment). 1b. A resident (Resident 58) was observed wandering the halls of the Red Zone without a mask. 1c. Social service (SS 6) staff member was observed exiting an isolation room and entering a clean room without performing handwashing. 1d. CNA 8 was observed entering an isolation room not donning PPEs. 2. During lunch meal service a CNA 7 did not perform handwashing when passing resident meal trays. 3. Urinary collection bags (a bag that collects uring draining from the body) and their attached dignity bags A fabic bag that covers the urine collection bag for privacy) were allowed to touch the floor for two of three residents (Residents 249, 250), reviewed for urinary catheter care and one unsampled resident (55). As a result, residents were at risk for cross contamination of pathogens. Findings: 1a. On 1/24/22 at 8:37 A.M., an observation was conducted of the facility designated Red Zone (covid unit) - Transmission Based Precautions. CNA 6 was observed entering and exiting (clean to dirty area) Red Zone and not donning (wearing/using) PPE. On 1/24/22 at 8:48 A.M., an interview was conducted with CNA 6. CNA 6 stated, she was assigned to work with the covid residents on this date. CNA 6 stated, she did not see the signage indicating Red Zone (covid unit) - Transmission Based precautions PPE, were to be used when entering this area. CNA 6 stated, she did not know she could not go from a clean zone (non-covid) area into the Red Zone (covid area) and back into a clean zone without using PPE. CNA 6 stated, I should have donned PPE when I entered the Red Zone. On 1/24/22 at 9:06 A.M., an observation was conducted outside the facility's designated Red Zone. Mnt 6 was observed entering and exiting (clean to dirty area) the Red Zone not donning PPE. On 1/24/22 at 9:18 A.M., an interview was conducted with Mnt 6 . Mnt 6 stated, he was doing a daily check of the temperature in the hallway of the Red Zone. Mnt 6 stated, he did not see the signage indicating the Red Zone. Mnt 6 stated, he did not know he could not go between the different designated areas of the hallway (clean/dirty/clean) without using PPE. Mnt 6 stated, I guess I should have worn PPE. On 1/27/22 at 9 A.M., an interview was conducted with the ICN. The ICN stated, staff have been educated regarding the use of PPE in the isolation areas, including the Red Zone. The ICN stated, all staff were expected to use PPE anythime they wer in the Red Zone and staff should not be crossing from a clean to dirty to clean area. ICN stated, this puts staff and residents at risk for cross contamination. ICN further stated, the staff were not following the facility's infection control policy and procedures. On 1/27/22 at 10:55 A.M., an interview was conducted with the DON. The DON stated, the staff were expected to follow the facility's infection control practices and they were not. According to the facility's policy titled, Infection Control Program, dated January 2022, .Education: .10. c. signs are used to alert staff / residents / visitors of transmission Based precautions . .Services: .12.e. Staff and residents shall use personal protective care equipment (PPE) according to established facility policy governing the use of PPEs . 1b. Resident 58 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/24/22 at 9:18 A.M., an observation of Resident 58 was conducted outside the facility designated Red Zone (covid unit). Resident 58 was diagnosed on [DATE] as being positive for covid by the facility surveillance (a systematic collection, analysis, and interpretation of infections) program. Resident 58 was observed on 1/24/22 at 9:42 A.M., 10:02 A.M., and 10:41 A.M., to be wheeling himself from his room into the hallway of the Red Zone without a mask on. On 1/24/22 at 5:33 P.M., an interview was conducted with CNA 6. CNA 6 stated, Resident 58 had issues with wandering into the halls, prior to being in isolation (covid unit) and Resident 58 does not like being in his room. CNA 6 further stated, Resident 58 needs to be re-directed back to his room frequently and is compliant with staff direction. On 1/25/22, a review of Resident 58's MDS (an assessment tool), 12/17/21, indicated a BIMS Score (Brief Inteview of Mental Status-a test for cognitive function) was 8 out of 15, indicating moderately impaired. A review of Resident 58's care plan, dated 9/15/21, list a goal of, .Resident will have fewer to no episodes of wandering . On 1/27/22 at 9 A.M., an interview was conducted with the ICN. The ICN stated, residents have been instructed in the use of face masks especially those in isolation rooms and the Red Zone. The ICN stated, all residents especially in the covid unit are expected to use face masks anytime they exit their room. The ICN stated, this puts staff and residents at risk for cross contamination. On 1/27/22 at 10:55A.M., an interview was conducted with the DON. The DON stated, the residents are expected to follow the facility infection control policy and procedure, to mitigate the risk of cross contamination. According to the facility's policy titled, Infection Control Program, dated January 2022, .Services: .12.e. Staff and residents shall use personal protective care equipment (PPE) according to established facility policy governing the use of PPEs . 1c. On 1/24/22 at 10:53 A.M., an observation was conducted of the hallway in nursing station Two. The Social Service staff (SS 6) was observed exiting an isolation room identified for droplet precautions and entering a non-isolation room across the hall without handwashing. On 1/24/22 at 10:56 A.M., an interview was conducted with SS 6. SS 6 stated, she was in a hurry because the resident across the hall had already called for her twice. SS 6 stated, I should have washed my hands after exiting the isolation room so I do not contaminate anyone. On 1/27/22 at 9 A.M., an interview was conducted with the ICN. The ICN stated, staff have been educated regarding handwashing. The ICN stated, all staff are expected to perform handwashing as per the standards of practice. The ICN stated, this puts staff and residents at risk for cross contamination. The ICN further stated, the staff were not following the facility infection control policy and procedure. On 1/27/22 at 10:55A.M., an interview was conducted with the DON. The DON stated, the staff are expected to follow the facility infection control policy and procedure regarding handwashing and they are not. According to the facility's policy titled, Infection Control Program, dated January 2022, .Hand Hygiene Protocol: .4. a. All staff shall follow hand hygiene practices consistent with accepted standards of practice 1d. On 1/27/22 at 3:27 P.M., an observation was conducted CNA 8 in the Red Zone (covid unit). CNA 8 was observed entering an isolation room without donning PPE. On 1/27/22 at 3:47 P.M., an interview was conducted with CNA 8. CNA 8 stated, she was assigned to work with the covid residents on this date. CNA 8 stated, she was entering the resident isolation room to answer a call light. CNA 8 stated, I should have donned PPE when I entered the resident isolation room, and I didn't. On 1/27/22 at 9 A.M., an interview was conducted with the ICN. The ICN stated, staff have been educated regarding the use of PPE in the isolation areas including the Red Zone. The ICN stated, all staff are expected to use PPEs (personal protective care equipment) anytime they are in the Red Zone (covid unit) especially when entering the resident rooms. The ICN stated, this puts staff and residents at risk for cross contamination. The ICN further stated, the staff are not following the facility infection control policy and procedure. On 1/27/22 at 10:55A.M., an interview was conducted with the DON. The DON stated, all staff are expected to follow the facility infection control policy and procedure, they are not. According to the facility's policy titled, Infection Control Program, dated January 2022, .Services: .12.e. Staff and residents shall use personal protective care equipment (PPE) according to established facility policy governing the use of PPEs . 2. On 1/25/22 at 11:53 A.M., an observation of lunch meal service was conducted in nursing station 2. CNA 7 was observed passing resident meal trays without performing handwashing between each tray pass. On 1/25/22 at 1:56 P.M., an interview was conducted with CNA 7. CNA 7 stated, he forgot about handwashing between each tray pass. CNA 7 stated, I should have washed my hands between each meal tray I passed so I do not contaminate anyone. On 1/27/22 at 9 A.M., an interview was conducted with the ICN. The ICN stated, staff have been educated regarding handwashing. The ICN stated, all staff are expected to perform handwashing as per the standards of practice. The ICN stated, this puts staff and residents at risk for cross contamination. The ICN further stated, the staff are not following the facility infection control policy and procedure. On 1/27/22 at 10:55 A.M., an interview was conducted with the DON. The DON stated, the staff are expected to follow the facility infection control policy and procedure regarding handwashing and they are not. According to the facility's policy titled, Infection Control Program, dated January 2022, .Hand Hygiene Protocol: .4. a. All staff shall follow hand hygiene practices consistent with accepted standards of practice 3a. Resident 55 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/24/22 at 9:36 A.M., an observation was conducted inside Resident 55's room. The urinary catheter bag was hanging from the left side of the bed frame, covered in a blue dignity bag. The bottom of the dignity bag was in contact with the floor. On 1/25/22 at 2:38 P.M., Resident 55 was observed eyes shut resting in bed. The urinary catheter bag was inside a blue dignity bag and hanging on the left side of the bed. The bottom of the blue dignity bag was in contact with the floor. On 1/25/22 Resident 55's clinical record was reviewed: The MDS (an assessment tool), dated 12/12/21, list a cognitive assessment score of 11, which indicated moderately impaired cognition. According to the physician orders, dated 1/24/22, foley (name brand) catheter care every shift for infection. According to the care plan, titled Foley catheter, dated 1/23/22, list a goal of, .Resident will show no signs/symptoms of urinary infection . 3b. Resident 249 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/25/22 at 2:35 PM an observation was conducted of Resident 249, while he was in bed. Resident 249 had been recently changed to a different room and his foley catheter bag was lying flat, directly on the floor, on the right side of the bed. The back side of the collection back was facing upwards, while the front side of the collection bag with its drainage port, was in direct contact with the floor. On 1/25/22, Resident 249's clinical record was reviewed: The MDS (an assessment tool), dated 11/20/21, list a cognitive assessment score of 8, indicating moderately impaired cognition. According to the physician orders, dated 1/18/22, foley catheter care every shift. According to the care plan, titled Foley catheter, dated 1/23/22, list a goal of, .Resident risk for [CONDITION(S)] (a serious blood infection) will be minimized/prevented via prompt recognition . 3c. Resident 250 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/25/22 at 12:28 P.M., and at 2:48 P.M., an observation was conducted of Resident 250 while he was in bed. The urinary catheter bag, within a blue dignity bag was placed on the right side of the bed frame. The bottom of the blue dignity bag was in contact with the floor. On 1/25/22, Resident 250's clinical record was reviewed: The MDS (an assessment tool), dated 11/20/21, list a cognitive assessment score of 11, indicating moderately impaired cognition. According to the physician orders, dated 1/24/22, foley catheter care every shift for infection control. According to the care plan, titled Foley catheter, dated 1/23/22, list a goal of, .Resident will show no signs/symptoms of urinary infection . On 1/26/22 at 8:02 A.M., an interview was conducted with CNA 2. CNA 2 stated urinary catheter bags should never be touching the floor for infection control purposes. CNA 2 stated if the collection bags or the dignity bags were in contact with the floor, bacteria could be easily transmitted up, from the floor to the bladder. On 1/26/22 at 8:08 A.M., an interview was conducted with LN 1. LN 1 stated catheter bags should never be in contact with the floor. LN 1 stated pathogens could be transmitted to the catheter and then the bladder, leading to infection. On 1/26/21 at 11:11 A.M., an interview was conducted with the DON. The DON stated all urinary catheters bags should always be kept off the floor. The DON stated it was a standard of infection control practice. On 1/27/22 at 10:22 A.M., an interview was conducted with the ICN. The ICN stated foley catheters bags should never be in contact with the floor, in order to stop the transmission of bacteria. According to the facility's policy titled, Catheter Care, Urinary, dated September 2014, .Infection Control: .2. b. Be sure the catheter tubing and drainage bag are kept off the floor .

Based on interview and record review, the facility failed to support four of seven residents (Residents 26, 47, 56, and 254), reviewed for resident rights, when their normal activity of smoking was not permitted. This failure resulted in Residents 26, 47, 56, and 254 to experience increased anxiety and anger. Findings: 1. Resident 26 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/26/22 at 4:05 P.M., an interview was conducted with Resident 26 in her room. Resident 26 stated about four weeks ago the facility staff told us the usual smokers could no longer go outside and smok, because the Covid virus (a highly contagious virus transported by air-particles) was in the building. Resident 26 stated she and other smokers were not in the Covid unit, so they did not understand why they could not continue to smoke. Resident 26 and others requested to have a meeting with the Administrator in Training (AIT-currently out on leave). Resident 26 stated three of the seven smokers were told by the AIT they could not smoke, because they would be blowing smoke out and spreading the infection. Resident 26 stated she argued they could distance themselves from each other. Resident 26 stated the AIT stated he would compromise, and allow them one cigarette break a day, instead of the usual three. Resident 26 stated, the one time a day never happened and she was mad because, he told them they could. Resident 26 stated the LNs offered her a nicotine patch, but she did not want one, she wanted to smoke. Resident 26 continued, stating the ADM said they could not smoke because they would have to transport resident's one at a time, down the elevator and they did not have the staff to do that. Resident 26 stated she was mad, because Covid infections cleared up in the building last week, and they still were not allowed to smoke. On 1/26/22, Resident 26's clinical record was reviewed: According to the facility's Smoking Observation Assessment, dated 11/1/21, the resident had no cognitive deficits and demonstrated clear understanding of the facility's smoking policy. According to care plan, titled, May Smoke Under Supervision, dated 11/1/21, listed, Reviewed with resident, designated smoking time and approved smoking area. 2. Resident 47 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/26/22 at 10:37 A.M., an observation and interview was conducted with Resident 47 in her room. Resident 47 stated she went to the hospital for pneumonia and returned to the facility on [DATE]. Resident 47 stated when she returned she was told by a nurse that she could not smoke, because there was Covid infections in the building. Resident 47 stated she did not have Covid and she had to ask the nurse for a nicotine patch. Resident 47 showed me the patch on the right side of her chest and stated she did not like it, because it made her skin itchy and irritated. Resident 47 continued, stating she wanted to be able to smoke and she did not like it when people told her she could not do the one thing she had been doing most of her life. On 1/26/22, Resident 47's clinical record was reviewed: According to the facility's Smoking Observation Assessment, dated 8/31/21, the resident had no cognitive deficit and demonstrated clear understanding of the facility's smoking policy. According to care plan, titled, May Smoke Under Supervision, dated 1/17/22, listed, Reviewed with resident, designated smoking time and approved smoking area. 3. Resident 48 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/25/22 at 11:18 A.M., an interview was conducted with Resident 48 in a common area. Resident 48 stated he has smoked for over [AGE] years. Resident 48 stated the last time he smoked was 2 weeks ago, and he was never told why he could no longer smoke. Resident 48 stated he was offered a smoking alternative, but he refused, and told the staff he wanted to be able to smoke. On 1/26/22, Resident 48's clinical record was reviewed: According to the facility's Smoking Observation Assessment, dated 10/2/21, the resident had no cognitive deficit and demonstrated clear understanding of the facility's smoking policy. According to care plan, titled, Smoking, dated 7/7/21, listed, Reviewed with resident, designated smoking time and approved smoking area. 4. Resident 56 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/26/22 at 2:34 P.M., an interview was conducted with Resident 56 in the center patio. Resident 56 stated she was told she could not smoke until Covid was over, because they did not have enough staff to monitor the smokers. Resident 56 stated she was offered a nicotine patch. Resident 56 stated she wanted to smoke and she should be allowed to smoke. Resident 56 stated not being allowed to smoke has made her anxious and irritable. On 1/26/22, Resident 56's clinical record was reviewed: According to the facility's Smoking Observation Assessment, dated 12/6/21, the resident had no cognitive deficit and demonstrated clear understanding of the facility's smoking policy. According to care plan, titled, May Smoke Under Supervision, dated 12/6/21, listed, Reviewed with resident, designated smoking time and approved smoking area. On 1/26/22 at 11:11 A.M., an interview was conducted with the DON. The DON stated the ADM decided to close the smoking area due to a Covid outbreak. The DON stated it was a resident's right to smoke however, the facility felt safety was more important with minimizing the Covid spread. The DON stated if the AIT told them they could smoke one time a day, he should have communicated that with the rest of staff, so a plan could have been formulated for transporting and supervising those residents who wanted to smoke. The AIT was not available for an interview. On 1/26/22 at 12:02 P.M., an interview was conducted with the ADM. The ADM stated all smoking breaks were stopped when the Covid outbreak occurred. The ADM stated she offered alternatives such as nicotine gum and patches. The ADM stated she told the resident's it was temporary. The ADM stated the facility just opened up this past weekend, because the virus was clearing out. The ADM stated they had not re-instated smoking yet, but they planned to provide smoking breaks. The ADM stated it would have been difficult to transport one resident at a time, in the elevator to the smoking section. Transporting residents to the smoking area would have taken all day. The ADM stated she explained to residents, it was a safety issue to minimize the outbreak of Covid, and she only did it as a safety precaution. The ADM was unaware the AIT had a meeting with some of the smoking residents and that he had told them they could smoke once a day. The ADM stated that would have been important for her to know. The ADM stated they did try at first to minimize the smoking breaks, but the outbreak got worst, so they had to squash it until the building cleared. According to the facility's policy, titled Resident Rights, dated December 2016, ,,,1. Federal and State laws guarantee certain basic rights to all residents in the facility. These rights include the resident's right to: .e. Self determination .h. be supported by the facility in exercising his or her rights .

Based on interview and record review, the facility failed to consistently offer snacks to five of six confidential residents (CR 1, CR 2, CR 3, CR 4, CR 5 ) and two unsampled residents (55, 90) reviewed for evening snacks. This failure had the potential for residents to experience hunger between meals. Findings: On 1/25/22 at 10:26 A.M., CR 1, CR 2, CR 3, and CR 4 stated they were never offered evening snack by staff. CR 1 and CR 3 stated they never knew snacks were available and yes, they would like to have something to eat at night, every once and a while. CR 2, and CR 4 stated they were aware they could get something, but they had to ask the staff when they wanted a snack. On 1/26/22 at 3:39 P.M., an interview was conducted with CR 5. CR 5 requested to remain anonymous. CR 5 stated she had been at the facility for almost a year and she had never been offered an evening snack. CR 5 stated she did not want a snack every night, but she would like to be asked. On 1/26/22 at 4 P.M., an interview was conducted with Resident 55. Resident 55 stated he used to be in another room and over there, he was offered evening snacks. Resident 55 stated since being in this new room for the past week, he had only been offered an evening snack once, which was last night. Resident 55 stated sometimes he does want something to eat before he goes to bed, and it would be nice to know it was offered and available. On 1/26/22 at 4:30 P.M., an interview was conducted with the RD. The RD stated it was important for staff to offer residents snacks between meals. The RD stated snacks helped prevent weight loss and it promoted a homelike environment. The RD stated the DS prepared snacks for designated residents, and unlabeled snacks for other residents, which were stored in the resident refrigerator for after hours. The RD stated the snacks routinely provided were fruit, sandwiches, pudding, ice cream, crackers and things like that. On 1/27/22 at 8:16 A.M., an interview was conducted with RNA 1. RNA 1 stated she worked both days and evening shifts. RNA 1 stated evening snacks were delivered to the nurses station around 7 P.M. RNA 1 stated the snacks at the nurse's station were labeled with specific resident names and were handed out to those residents. Other unlabeled snacks were stored in the resident refrigerator. RNA 1 stated if residents asked for something to eat during the evening or night shifts, she would get them a snack from the resident refrigerator. RNA 1 stated the refrigerated snacks were usually sandwiches, pudding, fruit, and crackers. On 1/27/22 at 8:29 A.M., an interview was conducted with LN 4. LN 4 stated he worked both day and evening shifts. LN 4 stated evening snacks arrived at each nursing station around 7 P.M., and were labeled with resident names and room numbers. LN 4 stated since the kitchen closes at night, a snack cooler is delivered to the nurses station, in case other residents wanted a snack at night. LN 4 stated the snack cooler was kept on a cart and residents could come request something if they got hungry. LN 4 stated they did not go around and ask each resident if they want something to eat, the residents needed to let the staff know they were hungry. On 1/27/22 at 8:56 A.M., an interview was conducted with CNA 4. CNA 4 stated she worked both the day and evening shifts. CNA 4 stated snacks arrived around 7 P.M. for designated residents and then there was a barrel with ice, that had unlabeled food for other residents. CNA 4 stated the CNAs were responsible for passing out the labeled snacks, and asking the other resident's if they wanted anything to eat. CNA 4 stated it was important to offer snacks to everyone, in order to help with nutrition, maintain blood sugars, and to make them comfortable until breakfast. CNA 4 stated she always asked her residents if they wanted anything to eat in the evening. On 1/27/22 at 10:30 A.M., an interview was conducted with Resident 90. Resident 90 stated he did not know he could have snacks during the day. Resident 90 stated no one offered him any snacks. Resident 90 stated he asked for something to eat one night around midnight, and then the staff brought him a snack. Resident 90 only recalled being given a snack one time while living in the facility. On 1/27/22 at 2:58 P.M., an interview was conducted with the DON. The DON stated she expected her staff to offer snacks to all resident's throughout the day and at evening time. The DON stated snacks were important because resident's got hungry and thirty between meals, and nutrition was very important. According to the facility's policy, titled Snacks (Between Meal and Bedtime), Serving, dated September 2010, .this procedure is to provide the resident with adequate nutrition Documentation: .1. The date and time the snack was served .7. If the resident refused the snack, the reason (s) why and the intervention taken .