Every finding on record at Camdenton Windsor Estates

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

Based on observation, interview, and record review, the facility staff failed to maintain professional standards of practice when staff failed to notify the physician and follow up with pharmacy when medications were unavailable for three (Resident #10, #12, and #201) out of three sampled residents. Facility staff failed to document the correct dose of medication for two (Resident #12 and #32) out of eight sampled residents. Staff failed to document the weight for one resident (Resident #40) weekly per physician orders. Staff failed to document weight and food intake for one resident (Resident #18) of one sampled resident with a history of significant weight loss. The facility census was 47. 1. Review of the facility's policies showed staff did not provide a policy for physicians orders. Review of the facility's telephone order policy, undated and the medication error policy, undated, showed the policies did not contain direction or guidance for unavailable or ommited medications. Review of the facility's condition change policy, undated, showed the policy did not contain direction or guidance for notification of the physician when medication is unavailable or omitted. 2. Review of Resident #10's Significant Change of Status Minimum Data Set (MDS), a federally mandated assessment tool, dated 03/03/25 showed the staff assessed the resident as cognitively intact. Review of the Physician Order Sheet (POS), dated April 2025, showed: -Fluticasone propionate (anti-inflammatory and hayfever medication) spray, 50 mircrograms (mcg) twice a day; -The order did not contain number of sprays or to which nostril; -The POS did not contain an order to allow the resident to self administer the medication. Review of the resident's Medication Administration Record (MAR), dated March 2025, showed staff documented the fluticasone was unavailable on 03/26/25-03/28/25, 03/30/25 and 03/31/25. Review of the resident's MAR, dated April 2025, showed staff documented the fluticasone was unavailable from 04/01/25 through 04/09/25. Review of the nurse notes, dated 03/01/25 through 04/09/25 showed staff did not document contact with the physician or the pharmacy when the resident did not recieve his/her medication. During an interview on 04/07/25 at 10:13 A.M., the resident said he/she had been out of his/her nasal spray for a long time now. He/She said that when at home he/she was taking two sprays to each nostril twice a day but at the facility they told her it was one spray to each nostril twice a day. He/She said he/she ran out of the medication and the pharmacy won't fill it because he/she ran out too soon. The resident said that the staff keep the medication in the medication cart but gives the spray to her to give it to him/herself. During interview on 04/09/25 at 10:08 A.M., Certified Medication Techinition (CMT) A said the resident's nasal spray has been sent off for refill but insurance has not refilled it. He/She said the resident knows he/she is only supposed to use one spray each nostril, but he/she says he/she needs two sprays and that's probably why insurance hasn't refilled it because its to soon. 3. Review of Resident #12's Quarterly MDS, dated [DATE] showed the staff assessed the resident as cognitively impaired. Review of the resident's POS, dated April 2025, showed and order for fluoxetine (an antidepressant) 10 milligrams (mg) once daily; Review of the resident's MAR, dated April 2025, showed staff documented the fluticasone was unavailable from 04/05/25 through 04/08/25. Review of the nurse notes, dated 03/01/25 through 04/09/25, showed staff did not document contact with the physician or the pharmacy when the resident did not recieve his/her medication. During interview on 04/09/25 at 10:08 A.M., CMT A said the resident's Fluoxetine has been ordered, but he/she is not sure why its not here yet. He/She said when medications aren't available for a few days he/she tells the evening CMT and that CMT will call pharmacy or let the charge nurse know. 4. Review of Resident #201's Admission MDS, dated [DATE], showed staff assessed the resident as cognitively intact and admitted on [DATE]. Review of the resident's POS, dated April 2025, showed a physician order on 03/21/25 for the following: -Alendronate (used to treat weak/thin bones) 35 mg weekly on Mondays; -Meloxicam (used to treat symptoms of arthritis) 15 mg daily; Review of the resident's MAR, dated March 2025, showed staff documented the following: -Alendronate as unavailable on 03/24/25 and 03/31/25; -Meloxicam as unavailable 03/21/25 through 03/31/25. Review of the resident's MAR, dated April 2025, showed staff documented the meloxicam as unavailable 04/01/25 through 04/08/25. Review of the nurse notes, dated 03/01/25 through 04/09/25, showed staff did not document contact with the physician or the pharmacy when the resident did not recieve his/her medication. 5. During an interview on 04/10/25 at 1:13 P.M., the Director of Nursing (DON) said when a medication is unavailable, the CMT is to write a note and let the DON know. If it is an over the counter (OTC) medication, he/she would go to a local store and pick it up. If the medication is a prescription, then the CMT can check the emergency supply and pull from that. If the medication is not in the emergency supply, the CMT is to notify the charge nurse. The resident should not go longer than a few days without the medication. The nurse should be calling the pharmacy to follow up and notify the DON and physician. Until yesterday, the CMT's were doing their own chart audits but now the nurse will be double checking with the CMT. He/She said he/she was not aware of the medications missing. Missing medication could cause harm or potentially death of a resident if missing. During an interview on 04/10/25 at 2:20 P.M., the Corporate Nurse said that staff should document the unavailable medication, notify the nurse, physician and DON of the medication and document any adverse effects of missing medications. During an interview on 04/10/25 at 2:20 P.M., the Administrator said CMT's should pull medications from the emergency supply if the medication is unavailable and would need to defer to nursing for the rest of the procedure. He/She said that the physician should be notified right away of any medication is out to avoid any adverse reactions. 6. Review of Resident #12's Significant Change MDS, dated [DATE], showed staff documented the resident diagnosis of Hypertension (high blood pressure). Review of the resident's POS, dated 02/10/25, showed an order for Diltiazem (medicine used to treat high blood pressure) 240 mg, one capsule daily. Observation on 04/08/25 at 8:55 A.M., showed CMT A administered Diltiazem 180mg to the resident. During an interview on 04/09/25 at 10:08 A.M., CMT A said the resident was previously on 180mg and the order must not have gotten followed through to get that changed and the correct card put in the medication cart. He/She said there is a lot of risks if the resident is not receiving the correct dosage of medication as prescribed depending on the medication. 7. Review of Resident #32's Admission MDS, dated [DATE], showed staff documented the resident diagnosis of Arthritis (a condition characterized by joint inflammation, causing pain, swelling, stiffness, and limited movement). Review of the resident's POS, dated 03/12/25, showed an order for Vitamin D3 (for bone and muscle strength, immune function, and healthy skin) 1,250 mcg, one tablet daily on Tuesday and Friday. Observation on 04/08/25 at 08:40 A.M., showed CMT A administered Vitamin D3 50mcg to the resident. During an interview on 04/09/25 at 10:08 A.M., CMT A said he/she noticed the incorrect dosage of Vitamin D3 was given after the observation. He/She said he/she was unsure how long the resident had been getting the incorrect dosage. During an interview on 04/10/25 at 1:35 P.M., the DON said staff should verify medication with the physician's order to ensure the correct dosage is given. He/She said there are a lot of risks to the residents regarding medication errors depending on the type of medication that was given incorrectly. 8. Review of the facility's Weight and Height Measurement policy, dated 03/2012, showed residents are weighed on admission and monthly unless ordered by the attending physician to monitor the resident's condition. 9. Review of Resident #40's Admission MDS, dated [DATE], showed staff assessed the resident as follows: -admitted [DATE]; -Cognitively intact; -Dependent on staff for mobility, and transfers. Review of the resident's POS, dated 03/2025, showed an order for weekly weights times four weeks. Once A Day on Mon. Review of the resident's care plan, reviewed/revised 03/29/25, showed weigh the resident weekly or as ordered by PCP (primary care physician). Review of the resident's medical record, dated 03/17/25 through 04/10/25, showed the record did not contain a weight for the resident. During an interview on 04/07/25 at 12:31 P.M., the resident said he/she has not been weighed since he/she arrived to the facility, because he/she has not got out of bed since admitted to the facility. During an interview on 04/10/25 at 11:07 A.M., Licensed Practial Nurse (LPN) D said facility policy is that residents are weighed on admit, weekly for four weeks, then monthly on the first of the month. He/She said the nurses and CNAs are responsible to obtain resident weights, but he/she is not sure if anyone is designated to verify all the monthly weights are obtained and documented. During an interview on 04/10/25 at 12:06 P.M., the MDS Coordinator said residents are weighed on admit, weekly for four weeks, then monthly, unless other directions such as daily. He/She said the charge nurse is responsible to tell the CNAs which residents need to be weighed, and the monthly weights should be obtained within the first five days of each month. During an interview on 04/10/25 at 2:58 P.M., Certififed Nurse Assistant (CNA) G said the CNAs are responsible to weigh residents when directed by the charge nurse at beginning of each shift, document the weight on paper and give to the nurse to calculate the difference between the resident and the chair they were weighed in. He/She said residents are weighed at different intervals such as monthly, weekly, or daily, and the nurse usually tells the CNAs who needs to be weighed and when. During an interview on 04/10/25 at 12:29 P.M., the DON said residents should be weighed on admit, weekly for four weeks, then monthly, and if ordered otherwise by physician. 10. Review of the facility's policy titled, Weight and Height Measurement, dated 03/2012, showed residents are weighed on admission and monthly unless ordered by the attending physician to monitor the resident's condition. 11. Review of Resident # 18's Significant Change in Status (SCSA) MDS, dated [DATE], showed staff assessed the resident as: -Mild cognitive impairment; -Received nutrition via tube feeding and a mechanically altered diet; -Received hospice care. Review of the resident's care plan, updated 3/18/25, showed the resident's goal is to maintain his/her current weight or possibly gain weight through the next assessment, and staff were directed: -Monitor and record weights as ordered by the physician, report weights to the resident; -Resident required nutrition through a feeding tube; -Resident can be expected to lose weight due to his/her terminal condition; -Resident at risk for altered nutritional status, chooses to have a pureed diet using a divided plate, follow diet recommendations as ordered. Review of the resident's progress notes, dated 03/04/25 through 03/31/25, showed: -On 03/14/25, the RD documented resident returned to facility on 03/12/25, received a puree diet supplemented with 90 cc Boost three times daily and enteral (tube) feeding, February 2025 weight 176 lbs, (a 1% loss in one month, and 2% loss in three months). Recommend weekly weights for four weeks to closely monitor with addition of enteral feeding, will continue to monitor and follow up as needed; -On 03/16/25, the RD documented recommend weekly weights for four weeks to closely monitor with addition of enteral feeding. Review of the resident's POS, dated 03/01/25 through 04/07/25, showed: -Weigh monthly unless otherwise indicated; -Boost 90 cc at meal pass due to weight loss/nutritional supplement with Meals, effective 11/11/24; -Jevity 1.5 Cal liquid, give 300 ml bolus three times a day after meals if less than 50% of meal consumed, effective 3/31/25. Review of the resident's electronic medical record (EMR), dated 04/09/25, did not contain documentation of weekly weights and did not contain documentation of the resident's daily food intake. During an interview on 04/08/25 at 2:38 P.M., LPN D said he/she thinks the Certified Nurses Aides (CNAs) document the resident's meal intake in the electronic chart, but they just tell the nurse if the resident ate his/her meal or not. During an interview on 04/09/25 at 12:35 P.M., CNA G said staff assist the resident with meals in the dining room and verbally tell the charge nurse how much the resident ate. He/She said the CNAs have not been instructed to document the resident's meal intake, and do not report his/her fluid intake because the resident has a feeding tube. During an interview on 04/10/25 at 11:07 A.M., LPN D said the resident had a feeding tube placed in March and should have at least one weight documented after his/her readmission in March. He/She said facility policy is residents are weighed on admit and the nurse and CNA are responsible to weigh residents as ordered. He/She said the DON is responsible to communicate recommendations from the RD to the nurses, and he/she was not aware the RD wanted the resident weighed weekly for four weeks after tube feeding started. During an interview on 04/10/25 at 12:06 P.M., the MDS Coordinator said charge nurse is responsible to tell the CNAs which residents need to be weighed, and the monthly weights should be obtained within the first five days of each month. He/She said the resident should have had a documented weight after admission in March. He/She said the DON follows up on recommendations from the RD. He/She said there was no system in place to document the resident's percentage of food intake. During an interview on 04/10/25 at 12:29 P.M., the DON said he/she expected staff to weigh the resident after he/she readmitted to the facility, and he/she probably should have been weighed weekly especially with the feeding peg tube. He/She said he/she is responsible to ensure the recommendations from the RD gets implemented, and just missed the weight recommendations on 03/14/25 and 03/16/25. He/She said there is not currently a charting system in place to document the resident's meal consumption. During an interview on 04/10/25 at 2:36 P.M., the administrator said each resident should be weighed on admit. He/She said the resident opted to have a feeding tube placed to enhance his/her weight, and staff should have obtained the resident's weight after he/she readmitted to the facility to monitor for any increased or decreased weight. He/She said the RD consults with residents monthly, sends his/her report to the administrator, who gives the report to the DON and dietary manager for follow up as recommended. He/She said there is not currently a charting system in place to document the resident's meal consumption, so he/she expects the CNA that assists the resident to eat to report the resident's food intake to the charge nurse after each meal. During an interview on 04/10/25 at 2:58 P.M., CNA G said the CNAs are responsible to weigh residents when directed by the charge nurse at beginning of each shift, document the weight on paper and give to the nurse to calculate the difference between the resident and the chair they were weighed in. He/She said residents are weighed at different intervals such as monthly, weekly, or daily, and the nurse usually tells the CNAs who needs to be weighed and when. During an interview on 04/11/25 at 9:03 A.M., the resident's physician said he/she would expect staff to weigh the resident when he/she readmitted to the facility to have a new baseline weight after the hospitalization and would expect staff to follow the RD's recommendations for additional weights for monitoring. 43327

Based on observation, interview, and record review, facility staff failed to ensure residents' environment remained free of accident hazards when staff failed to ensure resident's did not retain smoking materials while in the facility for six residents (Resident #10, #23, #26, #29, #34, and #40) out of six sampled residents as directed in the facility policy. The facility census was 46. 1. Review of the facility's Resident Smoking Policy, dated 12/2016, showed the policy will cover all types of smoking devices such as: -Cigarettes, tobacco, pipes, cigars (requiring matches or fire to light); -Electronic or vapor smoking replacement devices (require batteries that could cause resident damage); -Chewing tobacco; -Residents may not have or keep smoking materials in room, Smoking materials include; cigarettes, pipes, electronic or e-cigarettes, chewing tobacco, cigars, matches; -Smoking shall not be permitted in the living/sleeping area or inside the facility. Review of the facility's Admission Packet, Resident Rules and Regulations, showed residents may not retain matches or lighters. 2. Review of Resident #10's Significant Change of Status (SCSA) Minimum Data Set (MDS), a federally mandated assessment tool, dated 03/03/25, showed staff assessed the resident as cognitively intact and used tobacco. Observation on 04/08/25 at 11:35 A.M., showed the resident exit the facility to the designated smoke area. He/She removed a lighter from his/her walker and lit his/her cigarette. During an interview on 04/07/25 at 10:53 A.M., the resident said he/she goes in and out to smoke whenever he/she likes to. He/She said they are supposed to turn in their lighters after each break. 3. Review of Resident #23's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact. Observation on 4/07/25 at 11:38 A.M., showed the resident with one pack of cigarettes and lighter in coat pocket. During an interview on 04/07/25 at 11:38 A.M., the resident said he keeps his smoking material with him. He/She said he/she can go outside at any time to smoke. Observation on 04/09/25 at 1:16 P.M., showed the resident in his/her room with a vape (a device used for inhaling vapor containing nicotine and flavoring) in hand up by mouth. Resident covered vape and put in coat pocket. 4. Review of Resident #26's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact. Observation on 4/07/25 at 11:00 A.M., showed the resident had one electronic vape laying in nightstand next to bed and one pack of cigarettes in three drawer organizer in his/her room. During an interview on 04/07/25 at 11:00 A.M., resident said he/she vapes outside. He/She said he/she charges the vape when he/she comes inside from vaping. Resident said he/she charges the vape in his/her room with a charger connected to his/her laptop. He/She said from time to time he/she will smoke a cigarette, but usually vapes. Observation on 04/08/25 at 2:15 P.M., showed one electronic vape on nightstand and one pack of cigarettes in the drawer organizer in the resident's room. Observation on 04/09/25 at 8:38 A.M., showed one electronic vape laid on nightstand and one pack of cigarettes in the drawer organizer in the resident's room. 5. Review of Resident #29's Annual MDS, dated [DATE], showed staff assessed the resident as severe cognitive impairment and used tobacco. Observation on 04/07/25 at 11:55 A.M., showed the resident with a pack of cigarettes inside the cup holder attached to his/her wheelchair, as he/she propelled down the hallway to the dining room. Observation on 04/08/25 at 8:30 A.M., showed the resident in the dining room with a lighter and a pack of cigarettes inside the cup holder attached to his/her wheelchair. Observation 04/08/25 at 2:07 P.M., showed the resident in front of the nurses' station with a lighter and a pack of cigarettes inside the cup holder attached to his/her wheelchair. Observation on 04/09/25 at 8:23 A.M., showed the resident in the dining room with a lighter and a pack of cigarettes inside the cup holder attached to his/her wheelchair. During an interview on 04/10/25 at 11:04 A.M., Licensed Practical Nurse (LPN) D said the resident keeps his/her smoking materials with him/her. 6. Review of Resident #34's Admission MDS, dated [DATE], showed staff assessed the resident as cognitively intact and used tobacco. Review of the resident's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact. Observation on 04/08/25 at 11:35 A.M., showed the resident exit the facility to the smoke area. He/She removed a lighter from his/her jacket and lit his/her cigarette. During an interview on 04/07/25 at 11:18 A.M., the resident said he/she goes outside to smoke whenever he/she wants to. He/She said he/she does not turn in his/her smoking materials to include his/her lighter. 7. Review of Resident #40's Admission MDS, dated [DATE], showed staff assessed the resident as cognitively intact and current tobacco use. Observation on 04/07/25 at 12:30 P.M., showed the resident in bed with a vape on his/her bedside table. During an interview on 04/07/25 at 12:31 P.M., the resident said he/she does vape, but has not get out of bed since he/she admitted to the facility. The resident said they have to go outside to vape. Observation on 04/09/25 at 9:20 A.M., showed the resident in bed with a vape on his/her bedside table. 8. During an interview on 04/10/25 at 12:16 P.M., Certified Nurse Aide (CNA) G said all residents are independent smokers. He/She said residents are supposed to give their smoking materials back at the nurses station when they come back inside from smoking. He/She said this includes lighters, cigarettes, and electronic vapes. He/She said residents should only smoke or vape outside. He/She said residents should not charge vapes in their room. He/She said it is a fire hazard for the residents to keep smoking materials on themselves. During an interview on 04/10/25 at 12:06 P.M., LPN D said independent smokers are able to keep their smoking materials on them including their lighter and cigarettes. He/She said he/she is unaware of any residents who currently vape. He/She said he/she has not seen any chargers for vapes or has never been asked to charge a vape. During an interivew on 04/10/25 at 1:45 P.M., the Director of Nursing (DON) said residents are supposed to give smoking material back at the nurses station when they come back in from smoking. He/She said this includes cigarettes, lighters, and vapes. He/She said he/she was not aware that residents are keeping smoking materials on them or vaping inside the facility. He/She said this is a fire hazard for resident to keep smoking materials on them or charge vapes inside of room. He/She said it is all staff's responsibility to check if residents has smoking materials on them and if they find smoking materials staff should go to the charge nurse. During an interivew on 04/10/25 at 2:30 P.M., the administrator said smoking materials should be kept at the nurses station. He/She said this includes cigerattes, lighters, and vapes. He/She said he/she was absolutely not aware that residents are keeping smoking materials on themselves or that vapes were being charged in resident rooms. He/She said resident keeping smoking materials on themselves and charging vapes inside of rooms is a fire hazard. He/She said the residents are their own people and are aware of the policy when they were admitted and they should obey the policy. He/She said staff should monitor for smoking materials and if found they should be taken to the nurses station. 39644 43327 50422

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

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

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

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

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

Based on observation, interview and record review, facility staff failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections when staff failed to implement the Enhanced Barrier Precautions (EBP) Policy when they did not properly educate or alert staff of residents who required EBP during wound care for three (Resident #8, #18, and #19) of three sampled residents, failed to properly clean and disinfect glucometer (a device for monitoring blood sugars) and provide a barrier for the glucometer and insulin supplies for six residents (Resident #16, #17, #18, #21, #37, and #203) out of six sampled residents. Staff failed to perform proper hand hygiene during blood sugar checks and insulin administration for five residents (Resident # 16, #17, #18, #21, and #37) out of six sampled residents and failed to perform appropriate hand hygiene during toilet hygiene for two residents (resident #12 and #17) of three sampled resident and tracheostomy, catheter and feeding tube care for one (Resident #202) of one sampled resident in a manner to prevent the spread of infection. The facility census was 46. 1. Review of the facility's policy titled, Enhanced Barrier Precautions to Infection Control Guidance, dated 03/2024, showed the purpose is to prevent broader transmission of multidrug-resistance organisms (MDRO) and to help protect patients with chronic wounds and indwelling devices. EBP should be implemented for the period of their stay or until wounds have resolved or indwelling medical devices have been removed. Residents with a wound, regardless of their MDRO status, residents with an indwelling medical device including urinary catheter, feeding tube, tracheostomy/ventilator regardless of their MDRO status. Use EBP when providing high-contact resident care activities such as performing wound care, caring for or using an indwelling medical device. Gloves and gown are required when conducting high-contact resident care activities listed above. 2. Review of Resident #8's Quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 03/10/25, showed staff assessed the resident as cognitively intact, and had one venous ulcer (a wound on the leg or ankle caused by abnormal or damaged veins) present. Review of the resident's care plan, updated 04/01/25, showed: -EBP is required to be free from infections due to a wound; -An EBP identifier will be hung outside the resident's door to let staff know they need to utilize a gown, gloves when performing high-contact cares; -Staff will perform hand hygiene, put on Personal Protective Equipment (PPE), enter the room and perform necessary cares, remove PPE, perform hand hygiene, and exit the room taking all trash/linens with them. -Cleanse wound to Left outer ankle with wound cleanser and apply dry bordered dressing daily. Observation on 04/09/25 at 1:14 P.M., showed the resident's room did not contain a sign to alert staff on the use of EBP. Observation on 04/09/25 at 1:15 P.M., showed Licensed Practical Nurse (LPN) E provided wound care to the resident and did not wear a gown when he/she performed wound care to the resident's leg. During an interview on 04/09/25 at 1:40 P.M., LPN E said he/she did not think the resident required EBP precautions, and did not think he/she needed to wear a gown during wound care since the resident's wound was very tiny and without drainage. 3. Review of Resident #18's Significant Change MDS, dated [DATE], showed staff assessed the resident as moderate cognitive impairment, and uses a feeding tube for nutrition. Review of the resident's care plan, updated 04/01/25, showed: -EBP is required to be free from infections due to an opening in the resident's abdomen from a PEG tube (feeding tube placed directly into the stomach through the abdominal wall) placement; -An EBP identifier will be hung outside the resident's door to let staff know they need to utilize a gown, gloves when performing high-contact cares; -Staff will perform hand hygiene, put on PPE, enter the room and perform necessary cares, remove PPE, perform hand hygiene, and exit the room taking all trash/linens with them. -Cleanse area around PEG tube site with wound cleanser and apply split gauze dressing daily. Observation on 04/08/25 at 02:40 P.M., showed the resident's room did not contain a sign to alert staff on the use of EBP. Observation on 04/08/25 at 02:40 P.M., showed LPN D entered the resident room to assess and provide wound care to the residents PEG tube site on his/her abdomen. Observation showed the LPN did not wear a gown and provided the treatment. During an interview on 04/09/25 at 1:32 P.M., LPN D said there should be a sign on the resident's door to alert staff to use EBP and since the resident has a feeding tube. He/She said he/she should have worn a gown during the wound care to the resident's PEG tube site, but he/she did not think about it at the time. Observation on 04/09/25 at 9:15 A.M., showed the resident's room did not contain a sign to alert staff on the use of EBP. Observation on 04/09/25 at 9:16 A.M., showed LPN E entered the residents room to provide wound care. The LPN did not wear a gown when he/she provided wound care to the resident's PEG tube site. During an interview on 04/09/25 at 1:40 P.M., LPN E said there should be a sign on the resident's door to alert staff to use EBP since the resident has a feeding tube. LPN E said he/she should have worn gown when he/she provided wound care to the resident's PEG tube site, and he/she was not sure why he/she did not wear a gown. 4. Review of Resident #19's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact, and had one venous ulcer present. Review of the resident's care plan, updated 03/17/25, showed: -EBP is required to be free from infections due to a wound on the resident's left leg; -An EBP identifier will be hung outside the resident's door to let staff know they need to utilize a gown, gloves when performing high-contact cares; -Staff will perform hand hygiene, put on PPE, enter the room and perform necessary cares, remove PPE, perform hand hygiene, and exit the room taking all trash/linens with them. Observation on 04/09/25 at 9:22 A.M., showed a sign on the resident's door to alert staff to use EBP. Observation on 04/09/25 at 9:23 A.M., showed LPN E entered the residents room to provide wound care. The LPN did not wear a gown when he/she provided wound care to the resident's leg wound. During an interview on 04/09/25 at 1:40 P.M., LPN E said he/she was not sure why he/she did not wear a gown when he/she provided wound care to the resident's leg. 5. During an interview on 04/10/25 at 1:58 P.M., the Director of Nursing (DON) said he/she educated staff on residents who require the use of EBP, to wear gown and gloves when doing wound care for those residents and he/she expects all the nurses to use EBP when they provide care to a wound or device such as a PEG tube. The DON said he/she was responsible to ensure alert signs were placed on the door for resident #8 and #18. During an interview on 04/10/25 at 2:36 P.M., the administrator said if a resident required EBP, there should be a caution sign on the resident's door to alert staff. He/She said he/she expects staff to use EBP during wound care, the charge nurse to ensure the nurse aides use appropriate EBP, and the DON to ensure the nurses use appropriate EBP. 6. Review of the facility's Blood Glucometer Disinfecting policy, undated, showed staff were directed to: -Wash hands; -Put on gloves; -Provide a clean field in which to place the glucose meter (a paper towel works well for this); -Clean the blood glucose meter prior to using with approved wipes with 10% bleach or comparable product, place on clean field and let air dry according to manufacturer's directions. -Removed gloves; -Wash Hands. Review of the facility's Blood Glucose Monitoring policy, undated, showed staff were directed to place equipment on a clean surface (such as clean towel). 7. Review of Resident #16's medical record showed the resident admitted to the facility on [DATE] with a diagnosis of diabetes. Observation on 04/08/25 at 11:15 A.M., showed Certified Medication Technician (CMT) A did not perform hand hygiene, applied gloves, obtained a blood sample and placed the glucometer on top of the medication cart without a barrier. The CMT disposed the glucose strip, removed his/her gloves, and did not perform hand hygiene. CMT A drew up insulin from insulin vial and laid the open needle on top of medication cart without a barrier and did not perform hand hygiene. Observation showed CMT A applied gloves, administered insulin, removed gloves, cleaned glucose meter with an alcohol prep pad, and did not perform hand hygiene. 8. Review of Resident #17's medical record showed the resident admitted to the facility on [DATE] with a diagnosis of diabetes. Observation on 04/08/25 at 10:55 A.M., showed CMT A did not perform hand hygiene, applied gloves, obtained a blood sample and placed the glucometer on resident's bedside table without a barrier, disposed of the glucose strip, removed his/her gloves, cleaned the glucose meter with an alcohol prep pad, and did not perform hand hygiene. 9.Review of Resident #18's medical record showed the resident admitted to the facility on [DATE]. Observation on 04/08/25 at 10:45 A.M., showed CMT A did not perform hand hygiene, applied gloves, obtained a blood sample and placed the glucometer on residents' blankets without a barrier. Observation showed the CMT disposed of the glucose strip, removed his/her gloves, cleaned glucose meter with an alcohol prep pad. 10. Review of Resident #21's medical record showed the resident admitted to the facility on [DATE] with a diagnosis of diabetes. Observation on 04/08/25 at 10:58 A.M., showed CMT A did not perform hand hygiene, applied gloves, obtained blood sample and placed glucometer on the residents' blankets without a barrier. Observation showed CMT A disposed the glucose strip, removed gloves, and cleaned the glucose meter with an alcohol prep pad. CMT A drew up insulin from insulin vial and laid the open needle on top of medication cart without a barrier, did not perform hand hygiene, applied gloves, administered insulin, and removed gloves. 11.Review of Resident #37's medical record showed the resident admitted to the facility on [DATE] with a diagnosis of diabetes. Observation on 04/08/25 at 10:52 A.M., showed CMT A did not perform hand hygiene, applied gloves, obtained a blood sample and placed the glucometer on residents blankets without a barrier. Observation showed the CMT disposed of the glucose strip, removed his/her gloves, and cleaned glucose meter with an alcohol prep pad. 12. Review of Resident #203's medical record showed the resident admitted to the facility on [DATE] with a diagnosis of diabetes. Observation on 04/08/25 at 11:09 A.M., CMT A did not perform hand hygiene, drew up insulin from insulin vial and laid the open needle on top of medication cart without a barrier. Observation showed the CMT removed a medication pill from the container and placed into medication cup on top of medication cart. CMT A applied gloves, obtained blood sample and placed the glucometer on top of medication cart without a barrier. CMT A administered insulin, removed gloves, gave medication to resident, sanitized hands, removed glucose strip with a Kleenex and disposed of it. The CMT did not clean glucose meter. During an interview on 04/09/25 at 10:08 A.M., CMT A said he/she should have sanitized his/her hands more in between gloves changes. He/She said he/she shouldn't lay the glucometer down anywhere with blood on the strip due to risk of contamination and said the other CMT has mentioned that using a paper plate as a barrier is a good idea, but he/she just doesn't think about it. He/She said he/she was always taught to just use an alcohol prep wipe to clean the meter between residents and was never told differently. He/She said he/she shouldn't set an open needle on top of the medication care because of risk of contamination or an accidental needle stick. 13. During an interview on 04/10/25 at 1:41 P.M., the Director of Nursing (DON) said the glucometers should be cleaned with disinfecting wipes in the bottom of the medication cart. He/She said alcohol prep wipes are not acceptable cleaning method. He/She said laying the glucometer on residents' blankets or on top of unclean medication cart is not acceptable and there should be a barrier to prevent contamination. He/She said there should never be an open needle on top of medication cart due to risk of contamination or a needle stick. He/She said staff should be sanitizing or handing hands in between gloves changes. During an interview on 04/10/25 at 2:30 P.M., the administrator said he/she is unsure of the glucometer cleaning process. He/she said it is not acceptable to place an open needle on top of medication cart or lay the glucometer on residents blankets due to risk of blood borne pathogen and contamination. 14. Review of the facility's Handwashing policy, undated, showed the policy did not contain direction for when to perform hand hygiene. Review of the facility's Enteral feeding tube policy, undated, showed the policy did not contain direction for when to perform hand hygiene. Review of the facility's Perineal Care policy, undated, directed staff to perform perineal care, remove gloves, wash hands and position the resident. Review of the facility's Catheter care policy, undated showed staff are directed to: -Wash hands and apply gloves; -Change the position of the washcloth with each cleansing stroke; -Remove gloves and wash hands; -Position the resident; -Wash hands. 15. Review of Resident #12's Significant Change of Status (SCSA) MDS, dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -Dependent on staff for toilet and personal hygiene; -Required substantial or maximum assistance of staff for toilet transfers; -Diagnosis of stroke and renal failure. Observation on 04/09/25 at 08:50 A.M., showed Nurse Aide (NA) I and Certified Nurse Aide (CNA) H entered room to assist the resident and applied gloves. NA I and CNA H assisted the resident to the toilet. CNA H removed the soiled pants from the resident and NA I removed the soiled brief. With the same soiled gloves, CNA H placed clean pants on the resident and NA I places a clean brief on the resident. CNA H cleaned the resident's peri. With the same soiled glove NA I pulled up the residents clean brief and pants. With the same soiled gloves, CNA H handed the resident's hairbrush to NA I, NA I touched the wheelchair, the bed linens, placed a blanket on the resident's lap, and braided the residents hair. During an interview on 04/09/25 at 9:02 A.M., CNA H said staff should always wash their hands between dirty and clean stuff. He/She said he/she should have performed hand hygiene after removing the soiled pants and putting new clean pants on and before touching the resident's hairbrush. CNA H said hand hygiene would prevent the clean items from becoming dirty and just forgot. During an interview on 04/09/25 at 09:12 A.M., NA I said he/she has only been with the facility since January and currently in classes. He/She said that he/she didn't think about the need to change his/her gloves between touching the soiled brief and clean brief and before touching clean items in the room to include brushing the resident's hair. 16. Review of Resident #17's quarterly MDS, dated [DATE] showed staff assessed the resident as follows: -Cognitively Intact; -Dependent on staff for dressing and toileting hygiene; -Substantial/maximal assistance on staff for personal hygiene. Observation on 04/09/25 at 9:20 A.M., showed CNA C and NA B entered residents' room with gown and gloves on. CNA C removed residents soiled shorts. CNA C removed his/her gloves, did not perform hand hygiene and applied new gloves. CNA C provided peri care, removed his/her soiled gloves and applied new gloves. CNA C applied cream to buttock. With the same soiled gloves, CNA C placed a drawsheet underneath resident. NA B wiped bowel movement from residents' leg and lower back, and removed the soiled linens from the bed. With the same soiled gloves, NA B touched the residents' blankets, resident oxygen tubing and the bed remote. With the same soiled gloves, CNA C placed the resident's oxygen on. CNA C and NA B removed their gloves and gown, did not perform hand hygiene and walked out of the room. During an interview on 04/09/25 at 9:50 A.M., NA B said he/sheshould have changed gloves more often and washed her hands before touching blankets, oxygen tubing, or bed remote and before leaving the room. He/she said not washing hands is a risk for infection and contamination. During an interview on 04/09/25 at 10:08 A.M., CNA C said he/she should have changed his/her gloves more often and performed hand hygiene between glove changes. He/She said he/she should not have touched oxygen tubing with soiled gloves. He/She said he/she should have washed hands before leaving the room, but states that he/she knew he/she was going to the shower room afterwards. He/She said not performing hand hygiene is a risk of contamination. 17. Review of Resident #202's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -Dependent on staff for all care; -Had a tracheostomy (tube inserted into the windpipe for breathing); -Had a feeding tube (tube inserted into the stomach for hydration and artificial nutrition administration); -Had an indwelling catheter (tube inserted into the bladder to drain urine); -Diagnosis of traumatic brain injury. Observation on 04/08/25 at 02:09 P.M., showed LPN D enter the resident room to provide tracheostomy care, feeding tube care and catheter care. Observation showed the nurse set up a barrier and placed down supplies to perform tracheostomy care, applied sterile gloves, and provided tracjeostomy care. The LPN removed his/her gloves, applied clean gloves and applied a clean dressing to the tracheostomy site without performing hand hygiene. The LPN removed his/her gloves, gathered wet cloths and clean dressing for feeding tube care. The LPN did not wash his/her hands and applied gloves. The LPN used a wet cloth to wipe down the soiled feeding tube, used the same portion of the cloth over the same area of the tube multiple times and applied a clean dressing. The LPN removed his/her gloves, applied clean gloves, cleansed around the catheter site, cleansed the tubing with a warm cloth, used the same portion of the cloth over the same area multiple times, applied a clean dressing, and did not perform hand hygiene between catheter site cleaning and application of a clean dressing. During an interview on 04/08/25 at 2:31, LPN D said he/she did not wash or sanitize between glove changed because he/she did not want to risk touching his/her gown or ruin the clean field. He/She said he/she is aware he/she used the same portion of the wipe on the difficult areas to clean off the tubing, but moved to a clean portion once the difficult areas were clean. Hand hygiene helps decrease the risk of spreading infection and bacteria. 18. During an interview on 04/10/25 at 01:13 P.M., the DON said hand hygiene should be performed before care and after care, between glove changes, and between dirty and clean tasks. He/She said gloves are not to be considered a barrier that will prevent transmission of germs. He/She said gloves should be changed between different areas of the body. The DON said he/she does spot checks on the staff and interviews residents about staff performance. He/She did not know staff were performing inadequate hand hygiene during cares. During an interview on 04/10/25 at 02:20 P.M., the Administrator said he/she would expect staff to perform hand hygiene between glove changes, between dirty and clean tasks and when care is completed. He/She said staff are trained by electronic inservice company and monthly and tasks such as hand hygiene are monitored by the DON. He/She was not aware staff performed inappropriate hand hygiene during cares. 43327 50422

Based on observations, interview, and record review, facility staff failed to provide appropriate respiratory care and services, when they did not ensure oxygen delivery at the prescribed flow rate for one resident (Resident #6), and did not change oxygen tubing or properly clean and maintain oxygen concentrators for five (Resident #4, #6, #17, #19, and #26) out of five sampled residents. The facility census was 46. 1. Review of the facility's Oxygen Administration policy, undated, showed staff are directed as follows: -Set the flow meter to the rate ordered by the physician. -At regular intervals, check and clean oxygen equipment, masks, tubing and cannula. -Place cannula tubing in plastic bag attached to concentrator when tubing is not in use. -Change tubing per cleaning guidelines. 2. Review of Resident #4's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 04/01/25, showed staff assessed the resident as follows: -Mild cognitive impairment; -Required oxygen therapy; -Diagnosis of Chronic Obstructive Pulmonary Disease (COPD, a condition caused by damage to the airways or other parts of the lung). Review of the resident's physician order sheet (POS), dated 02/18/25, showed staff are directed to change the oxygen tube monthly on the first day of the month. Observation on 04/07/25 at 10:45 A.M., showed the resident in bed with oxygen via nasal cannula in place. Observation showed the oxygen tube dated 03/01/25. Observation on 04/08/25 at 3:00 P.M., showed the resident in bed with oxygen via nasal cannula in place. Observation showed the oxygen tube dated 03/01/25. 3. Review of Resident #6 admission MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment; -Diagnosis of Emphysema (a progressive, chronic lung disease characterized by the damage and enlargement of the tiny air sacs (alveoli) in the lungs, leading to reduced lung function and shortness of breath). Review of the resident's POS, dated 02/18/25, showed staff are directed to change the oxygen tube monthly on the first day of the month. Review of the resident's POS, dated 02/25/25, showed an order for Oxygen two Liters (L) per minute per nasal cannula continuous Observation on 04/07/25 at 10:00 A.M., showed the resident in bed with oxygen via nasal cannula in place. Observation showed the oxygen tube dated 03/01/25. Observation showed the resident's oxygen concentrator set at five liters per minute. Observation on 04/08/25 at 2:05 P.M., showed the resident in bed with oxygen via nasal cannula in place. Observation showed the oxygen tube dated 03/01/25. Observation showed the resident's oxygen concentrator set at five liters per minute. Observation on 04/09/25 at 2:00 P.M., showed the resident in bed with oxygen via nasal cannula in place. Observation showed the oxygen tube dated 03/01/25 and 04/08/25. Observation showed the resident's oxygen concentrator set at five liters per minute. Observation on 04/10/25 at 10:00 A.M., showed the resident in bed with oxygen via nasal cannula in place. Oxygen tubing dated 03/01/25 and 04/08/25. Observation showed the resident's oxygen concentrator set at five liters per minute. During an interview on 04/10/25 at 12:15 P.M., Licensed Practical Nurse (LPN) D said the nurse should check oxygen settings every shift. He/She said he/she was not sure why the resident's oxygen is set to five liters, and does not remember what it should be, but knows it's not to be that high. LPN D said there are many potential risks to the flow rate being too high, and it should be set for what the physician ordered. During an interview on 04/10/25 at 1:45 P.M., the Director of Nursing (DON) said every staff who walks into a room for a resident with continuous oxygen, is responsible to check the rate on the concentrator, aides can check and tell charge nurse if there is a concern. The DON said he/she is not sure why the residents oxygen is set at five liters, but it shouldn't be. The DON said if there was ever a need for a higher amount than ordered, staff should contact the doctor and document it. During an interview on 04/10/25 at 2:45 P.M., the administrator said the charge nurse is responsible to check the flow rate for oxygen. 4. Review of Resident #17's Annual MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Diagnosis COPD; -Required oxygen therapy. Review of the resident's POS, dated 02/18/25, showed staff are directed to change the oxygen tube monthly on the first day of the month. Observation on 04/07/25 at 10:42 A.M., showed the resident in bed with oxygen via nasal cannula in place. Observation showed the oxygen tube dated 03/01/25. Observation on 04/08/25 at 09:21 A.M., showed the resident in bed with oxygen via nasal cannula in place. Observation showed the oxygen tube dated 03/01/25. 5. Review of Resident #19's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact, received oxygen therapy and diagnosis of dependence on supplemental oxygen. Review of the resident's POS, dated 03/08/25 through 04/08/25, showed: -Change the oxygen tube monthly on the first Monday of the month; -Weekly concentrator cleaning. Special Instructions: Wipe down concentrator with disinfectant wipes allow to dry. Cleanse filter with soap and water and allow to dry. Observation on 04/07/25 at 10:50 A.M., showed the resident in bed with oxygen via nasal cannula in place. Observation showed the oxygen tube dated 03/01/25. Observation on 04/08/25 at 8:45 A.M., showed the resident in his/her wheelchair and received oxygen via nasal cannula from a portable oxygen tank. The oxygen tubing was undated. Observation on 04/08/25 at 2:13 P.M., showed the resident in bed with oxygen via nasal cannula in place. The oxygen tubing was undated, and the concentrator with scattered dried debris and dried brownish/red substance behind the flow rate display. Observation on 04/09/25 at 8:32 A.M., showed the oxygen concentrator with scattered debris and dried brownish/red substance behind the flow rate display, the black filter on the back covered with white debris and hair strands. Observation on 04/10/25 at 8:46 A.M., showed the oxygen concentrator with scattered debris and dried brownish/red substance behind the flow rate display, the black filter on the back covered with white debris and hair strands. During an interview on 04/09/25 at 08:36 A.M., the resident said the concentrator could use some cleaning. During an interview on 04/10/25 at 11:23 A.M., LPN D said the night shift nurse is responsible to change the resident's oxygen tubing per the schedule on the POS. He/She said the night nurse is also responsible to clean the concentrator, but he/she was unsure of the schedule. 6. Review of Resident #26's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Diagnosis COPD. Review of the resident's POS, dated 02/18/25, showed staff are directed to change the nebulizer tube monthly on the first day of the month. Observation on 04/07/25 at 10:44 A.M., showed nebulizer tube laid on the resident's nightstand and dated 03/01/25. Observation on 04/08/25 at 2:15 P.M., showed nebulizer tube laid on the resident's nightstand and dated 03/01/25. Observation on 04/09/25 at 08:30 A.M., showed nebulizer tube laid on the resident's nightstand and dated 03/01/25. During an interview on 04/10/25 at 12:06 P.M., LPN D said the night shift nurse is in charge of changing nebulizer tubing. He/She said he/she is not sure how often it is scheduled to change. He/She said he/she will change the tubing if he/she finds it on the floor or sees that it hasn't been changed in over a month. During an interview on 04/10/25 at 1:50 P.M., the DON said oxygen and nebulizer tubing should be changed at the beginning of the month by the night shift nurse. He/She said he/she asks the night nurse if its been done and just goes with that, but he/she said he/she should probably be checking it his/herself to ensure its being done. During an interview on 04/10/25 at 2:30 P.M., the administrator said oxygen and nebulizer tubing should be changed on the first day of the month by the night shift nurse. He/She said it is the DON's responsibility to ensure its getting done. 39644 50422

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

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

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

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

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

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

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

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

Based on interview and record review, facility staff failed to document the administration of the pneumococcal (lung inflammation caused by bacteria or viral infection) vaccine for six out of eight sampled residents (Resident #8, #14, #21, #25, #33, and #38). The facility census was 44. 1. Review of the Center for Disease Control (CDC) guidelines, dated 03/15/23, showed the following: -People age 65 or older who have no pneumococcal vaccines should receive 20 valent pneumococcal conjugate vaccine (PCV20) or 15 valent pneumococcal conjugate vaccine (PCV15), and then one year later pneumococcal polysaccharide vaccine (PPSV23); -People age 19 through 64 who have no pneumococcal vaccines should receive PCV20 or PCV1, and then one year later PPSV23. Review of the facility's Immunization policy, not dated, showed staff are directed to as follows: -Adults [AGE] years or older who have not already received a pneumococcal conjugate vaccine should receive either: -A single dose of PVC15 followed by a dose of PPSV23 one year later; -A single dose of PVC20, if a PCV20 is administered a dose of PPSV23 is not required; -Adults 19 through [AGE] years old who have not received a pneumococcal conjugate vaccine should receive either: -A single dose of PVC15 followed by a dose of PPSV23; -A single dose of PCV20, if PCV20 is administered a dose of PPSV23 is not indicated. 2. Review of Resident #8's medical record showed: -Resident age 85; -admitted to the facility on [DATE]; -Signed consent, dated 10/02/23, for all vaccines to be administered; -The record did not contain documentation staff offered or administered a pneumococcal vaccine. 3. Review of Resident #14's medical record showed: -Resident age 76; -admitted to the facility on [DATE]; -Signed consent, dated 10/02/23, for all vaccines to be administered; -The record did not contain documentation staff offered or administered a pneumococcal vaccine. 4. Review of Resident #21's medical record showed: -Resident age 81; -admitted to the facility on [DATE]; -Signed consent, dated 10/02/23, for all vaccines to be administered except the Covid (an infectious disease caused by a virus) vaccine; -The record did not contain documentation staff offered or administered a pneumococcal vaccine. 5. Review of Resident #25's medical record showed: -Resident age 62; -admitted to the facility on [DATE]; -Signed consent, dated 10/02/23 for all vaccines to be administered except the Covid vaccine; -The record did not contain documentation staff offered or administered a pneumococcal vaccine. Event History showed staff documented: -diagnosed with chest congestion on 12/13/23; -diagnosed with pneumonia on 12/23/23; Review of the Physician Order Sheet (POS) showed: -12/13/23: Levaquin (antibiotic) 500 milligrams (mg) daily for 10 days; -12/23/23: Doxycycline (antibiotic) 100 mg twice a day (BID) for 10 days. 6. Review of Resident #33's medical record showed: -Resident age 81; -admitted to the facility on [DATE]; -Signed consent, dated 09/26/23, for all vaccines to be administered; -The record did not contain documentation staff offered or administered a pneumococcal vaccine. 7. Review of Resident #38's medical record showed: -Resident age 79; -admitted to the facility on [DATE]; -Signed consent, dated 10/02/23, for all vaccines to be administered except the Covid vaccine; -The record did not contain documentation staff offered or administered a pneumococcal vaccine. Event History showed staff documented the resident had been diagnosed with a Upper Respiratory Infection (URI) on 03/09/24. Review of the POS showed: -03/09/24: Levaquin 500 mg daily for URI with stop date of 03/20/24; -03/09/24: Prednisone (steroid) 20 mg BID for URI with stop date of 3/20/24. 8. During an interview on 03/18/24 at 9:35 A.M., the Director of Nursing (DON) said he/she is the Infection Preventionist (IP) for the facility. The DON said any vaccines that have been given to the residents are recorded in the resident's chart. The DON said he/she ordered the pneumonia vaccines on 03/17/24 and they should arrive on 03/18/24. The DON said if a vaccine is not logged in the resident's chart, then it has not been given. During an interview on 03/19/24 at 9:10 A.M., the DON said the pneumonia vaccines had not arrived to the facility. The DON said he/she called the pharmacy to find out when the vaccines would be delivered and the pharmacy said it should be 03/19/24 or 03/20/24. During an interview on 03/20/24 at 8:00 A.M., the DON said the pharmacy emailed him/her and the pneumvaccines should be delivered on 03/21/24. The DON said there is a resident who is allergic to the vaccine, so he/she emailed the pharmacy to have them not send that dose. The DON said the pharmacy said they had just received the vaccine orders on 03/20/24 when the DON emailed about the allergy. The DON said he/she did not know why the pneumonia vaccines had not been ordered or given prior to 03/17/24. During an interview on 03/20/24 at 10:15 A.M., Licensed Practical Nurse (LPN) I said if something is not documented then it was not done. The LPN said the Business Office Manager (BOM) is responsible for obtaining vaccine consents or declination upon admission with the admission paperwork. LPN I said vaccines are given once they arrive from the pharmacy. The LPN said he/she or the DON would give the vaccines once they arrived from the pharmacy. During an interview on 03/20/24 at 11:05 A.M., the BOM said he/she completes the admission paperwork and obtains the vaccine consents or declinations upon admission with each resident. The BOM said he/she uploads the documents into the resident's chart. During an interview on 03/20/24 at 11:15 A.M., the DON said if something is not documented then it is not done. The DON said the BOM is responsible for obtaining the vaccine consent or declination up a resident's admission with the admission paperwork. Once the consent is obtained then the DON said he/she orders the appropriate vaccine from either the pharmacy or medical supplier. The DON said that either the charge nurse or him/her give the vaccines once they arrive to the facility. The DON said any vaccine that is given should be documented in the resident's chart. The DON said all consents should be followed. The DON said if vaccines are not given then the resident could have a potential outcome of an infection such as pneumonia, URI, influenza, or Covid. During an interview on 03/20/24 at 2:08 P.M., the administrator said that BOM is responsible for obtaining the vaccine consents or declinations with the resident's admission paperwork. The administrator said any vaccine not on hand is ordered from the pharmacy or medical supply company and once they arrive the charge nurse or DON is responsible for administration of the vaccine. The administrator said any vaccine given should be documented in the resident's chart and if something isn't documented then it is not done. documented in the resident's chart. The administrator said if something isn't documented then it was not done. During an interview on 03/28/24 at 8:30 A.M., the Medical Director (MD) said he/she is the only physician who covers the facility, and he/she sees all the residents in it. The Medical Director said he/she expects staff to give any vaccine the resident or responsible party signs consent for. The MD said he/she does not have an exact timeline for when the vaccine should be given once the consent is signed as the vaccines are not always easy to get from the supply company, however he/she said within a month of the consent being signed would be adequate. The MD said if a resident is admitted for short term rehab, for a couple of weeks for example, then he/she does not expect staff to administer the vaccine. The MD said any long-term care resident should get their vaccines given timely. Residents could have a potential outcome of URI or pneumonia if the pneumoccal vaccine is not given.

Based on observation, interview and record review facility staff failed to ensure pureed food items were reheated to proper temperatures. Facility staff failed to follow puree recipes. Facility staff failed to ensure hot foods were held at 140 degrees Fahrenheit F or greater during meal service. Facility staff failed to ensure hot food on room trays for three residents (Residents #27, #25, and #105) of three sampled residents were maintained at 120 F at the time the food was delivered and to ensure employees who delivered food to the residents in the rooms knew what the appropriate temperature should be at the time of service. The facility census was 44. 1. Review of the facility's policy titled Food Temperatures, dated April 2011, showed staff shall ensure food is at least 120 F. A test meal should be sent with the hall trays when there are food temperature complaints until the temperatures are at the appropriate levels. Record on Temperature Record of Test Trays form. 2. Review of Resident #27's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated 01/04/24, showed staff assessed the resident as follows: -Moderately impaired cognition; -Required set up assistance from staff for eating. Observation on 03/17/24 at 12:24 P.M., showed Nurse Aide (NA) F served the resident his/her hall tray. At time of service the resident's stuffing covered in turkey gravy temped at 118 F, the turkey and gravy temped at 114 F, and the green beans temped at 111 F. The NA left the room and did not offer to reheat the resident's food or get a new tray. During an interview on 03/17/24 at 12:29 P.M., the resident said the food could be warmer but he/she gets hall trays. 3. Review of Resident #25's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Required set up assistance from staff for eating. Observation 03/18/24 at 5:17 P.M., showed NA J served the resident his/her dinner tray in the resident's room. At the time of service the ham temped at 113 F. The NA did not take the tray to reheat, or get the resident a new tray. During and interview on 03/18/24 at 5:24 P.M., the NA said food is supposed to be 120 degrees when served to the resident. The NA said if the resident's food is under 120 degrees staff are supposed to ask resident if he/she wants a different tray. The NA said since it is just little under 120 degrees he/she leaves it up to the resident. The NA said the resident's food is probably cold because it is the last hall tray. During an interview on 03/17/24 at 4:23 P.M., the resident said the food isn't great. The resident said he/she eats in his/her room and the food is sometimes cold. Cold eggs are not good. 4. Review of Resident #105's Admission MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Required set up assistance from staff for eating. Observation on 03/19/24 at 5:16 P.M., showed Certified Nurse Aide (CNA) D served the resident his/her dinner tray in the resident's room. At time of service, the Tamale Pie with hamburger temped at 117 F. The NA left the room and did not reheat the resident's food. During an interview on 03/17/24 at 3:23 P.M., the resident said sometimes the food is good and sometime it is bad. The resident said the other day he/she got his/her baked potato and it was ice cold. The resident said another time he/she got cold turkey. During an interview on 03/20/24 at 9:14 A.M., Certified Nursing Assistant (CNA) A said he/she has never temped the meal trays. The CNA said the food should be 120 F for hall trays. The CNA said he/she has seen food served on the hall at less than 120 F but still over 100 F. The CNA said residents have complained about food temperatures in resident council meetings. During an interview on 03/20/24 at 9:34 A.M., Licensed Practical Nurse (LPN) I said he/she has no idea what the temperature of food should be when served to residents. The LPN said if the food is cold staff should take it back to the kitchen and get a new plate. During an interview on 03/20/24 at 11:15 A.M., the Director of Nursing (DON) said he/she does not know what the food temperature is supposed to be when served to residents. The DON said nursing staff deliver hall trays and they don't have thermometer. The DON said he/she is aware residents have complaints about cold food. The DON said if a resident's food is cold staff should take the tray back to the kitchen and reheat the food. 5. Review of the facility's policy titled Food Temperatures, dated April 2011, showed the Dietary Services manager or designee is responsible for seeing that all food is the proper serving temerpature(s) before trays are assembled. Review showed staff were directed to keep the temperature of hot foods no less than 140 F during meal service. Review of facility Food Preparation and Distribution policy, dated May 2015 showed: -Foods are prepared by methods that conserve nutritive value, flavor and appearance; -Recipes should be followed on each item prepared. Review of meatloaf and scalloped potatoes puree recipes showed cooks were directed to reheat both items to a minimum temperature of 165 F or higher for 15 seconds and hold at minimum temperature or higher for service. Review of pureed meatloaf, potatoes and corn recipes showed cooks were directed to follow hot holding temperature of 135 F or 140 F based on facility policy. Observation on 03/18/24 from 11:00 A.M. through 11:45 A.M., during lunch meal preparation, showed: -Cook P prepared pureed corn in a food processor and placed the pureed corn on the steam table for service. Observation showed Cook P did not check the temperature of the corn before placing it on the steam table. -Cook P used a spoon to remove meatloaf from the steam table and placed the meatloaf in a bowl. Cook P transferred the meatloaf from the bowl to a food processor and pureed the meatloaf. Cook P then transferred the pureed meatloaf to a pan on the steam table. Observation showed Cook P did not check the temperature of the meatloaf before it was placed on the steam table for service. -Cook P removed scalloped potatoes from the steam and place the potatoes in a bowl. Cook P transferred the potatoes from the bowl to a food processor. Cook P pureed the potatoes in the food processor and transferred the potatoes to a pan on the steam table. Observation showed Cook P did not check the temperature of the potaotes before they were placed on the steam table for service. Observation on 03/18/24 at 11:52 A.M., showed: -The temperature of the pureed meatloaf on the steam table was 124 F. -The temperature of the pureed scalloped potatoes was 130 F on the steamtable. -The temperature of the pureed bread was 112 F on the steam table. 6. Review of the pureed dinner roll recipe showed cooks were directed to prepare a slurry using bread product and water or milk. Cooks were also directed to process until smooth. Observation on 03/18/24 at 11:54 A.M., showed the pureed corn was runny in consistency and the pureed bread was thick in consistency. During an interview at on 03/18/24 at 12:08 P.M., Cook P said he/she pureed food items and placed the items on the steam table. Cook P said he/she checked food temperatures about 10 minutes after placing the food on the steam table and the temperature should be greater than140 degrees F. Cook P said he/she never reheated pureed items to 165 F and was not aware that pureed items should be reheated. Cook P said he/she never looked at the puree recipe instructions that indicated reheating to 165 F. Cook P said he/she did not follow recipes when preparing pureed food items. Cook P said a pureed item should be moist, soft and pudding like. Cook P said the corn was too runny and the bread was kind of thick. During an interview on 03/18/24 at 11:52 A.M., the Dietary Manager said the cook was responsible for ensuring all foods were prepared according to the recipes and at the correct consistencies. The dietary manger said the cook was responsible for ensuring proper food temperatures were met with cooking and holding food. The dietary manager said the corn was too runny and the pureed bread looked too thick. During an interview on 03/20/24 at 2:09 P.M., the administrator said food should be 140 F when served to residents. 45564

Based on observation, interview, and record review, the facility failed to keep harmful chemicals away from cognitively impaired residents. On 4/20/12, the Maintenance Director (MD) poured Ultra Delime (a clear, colorless, odorless liquid used to remove lime build-up) into a drinking glass, walked approximately two feet away, and turned his/her back on the glass. Resident #5 picked up the glass and drank the Ultra Delime while MD left it unattended. The resident was treated for [REDACTED]. In addition, the facility failed to implement changes to ensure residents did not have access to dangerous chemicals throughout the facility. Observations throughout the survey showed the shower rooms and janitor's closet containing hazardous chemicals were not locked. Additionally, facility staff failed to ensure one dependent randomly observed resident (Resident #19) had foot pedals on his/her wheelchair while staff wheeled the resident to his/her room, which resulted in the resident's feet caught under the wheelchair during transport. The facility census was 56. 1. Review of Resident #5's quarterly Minimum Data Set (MDS), a federally mandated assessment tool used to plan care, dated 1/20/12, showed staff assessed the resident as follows: -Moderately impaired cognitive abilities; -Utilized a wheelchair for ambulation. During tour of the facility, on 4/30/12, facility staff reported the resident had a [DIAGNOSES REDACTED]. Review of the resident's Physician order [REDACTED]. Review of the resident's Nurse's Notes, dated 4/20/12 at 12:00 P.M., showed staff documented they sent the resident to the emergency room that morning for treatment of [REDACTED].M. Review of the physician's Progress Note, dated 4/29/12, showed the resident's physician recorded the resident drank a hazardous chemical and was treated at the hospital. The physician recorded the chemical was "neutralized" and the resident returned to the facility. Review of the Material Safety Data Sheet (MSDS) for Ultra Delimer, the chemical the MD poured into the drinking glass, showed the following cautionary information: -If ingested could cause nausea, vomiting, diarrhea, erosion, burns to mouth and esophagus, abdominal pain, chest pain, shortness of breath, seizures, and death; -Hazardous ingredient: phosphoric acid; -Call physician immediately if ingested. During an interview on 5/2/12 at 2:18 P.M., the Director of Nursing (DON) said she was in a meeting on the date of the incident and the MD interrupted. The DON said the MD said he was deliming the sink in the dining room and the resident "rolled up" behind the MD to see what he was doing. The DON said the MD turned around and when he turned back around, the resident had the delimer in his/her hand and drank two or three ounces of it. The DON said staff reviewed the MSDS for Ultra Delimer, called poison control, called for an ambulance, and gave the resident water to drink as directed in the MSDS. The DON said the resident went to the hospital and returned approximately two hours later. During an interview on 05/02/12 at 2:22 P.M., the MD said he was removing lime from a sink in the main dining room. The MD poured delimer in a green plastic drinking glass because he did not want to carry the entire bottle around with him. The MD removed some parts containing a lime build-up from the sink and soaked the removed parts in the delimer in the drinking glass. After the MD removed the faucet parts from the drinking glass, he left the glass containing the delimer unattended. The MD said he walked about two feet away to the ice machine with his back turned to the drinking glass containing the delimer. The MD said he heard the resident say, "yuck, this is disgusting", and asked the resident what he/she drank. The resident held the empty drinking glass that the MD used to soak the faucet parts in the delimer. The MD said he immediately notified nursing staff that the resident drank the delimer, obtained the MSDS, called 911, and notified the DON and Administrator. 2. Observation on 4/30/12 at 7:00 P.M., showed the shower room on the Wisteria Way hall unlocked. Further observation showed one 32 ounce spray bottle labeled Classic Whirlpool Disinfectant Cleaner hooked on the grab bar of the shower stall. During this time staff were not in the shower room. Review of the container label showed the following hazardous components; Octyl-Decyl-Dimethyl Ammonium Chloride, Alkyl- Dimethyl Benzyl Ammonium Chloride, Dioctyl-Dimethyl Ammonium Chloride, Didecyl-Dimethyl Ammonium Chloride, and Ethyl alcohol. The hazardous potential health effects of the cleaner's chemical components included dizziness and headache if inhaled, gastrointestinal (stomach) irritation, disturbance, and pain if ingested, and redness, irritation, and burning if prolonged exposure to the skin occurred. Observation on 5/1/12 at 11:15 A.M., showed the shower room on the Wisteria Way hall remained unlocked. Further observation showed a one gallon container, and one 32 ounce spray bottle labeled Classic Whirlpool Disinfectant Cleaner on the bottom shelf of the shower room closet. At this time, the shower room was unsupervised by the staff, and was accessible to confused residents who could enter the shower room where potentially harmful chemicals were stored. Observation on 5/1/12 at 11:40 A.M., showed the shower room on the Wisteria Way hall remained unlocked. During this time, the Whirlpool Disinfectant Cleaner remained in the same location unsupervised and accessible to residents. Staff did not store harmful chemicals in a manner to prevent accidental ingestion and possible serious injury. During this time, residents walked in the hallway outside the shower room. Observation on 5/1/12 at 3:15 P.M., showed the shower room on the Wisteria Way hall to be unlocked. Further observation showed a one gallon container, and one 32 ounce spray bottle labeled Classic Whirlpool Disinfectant Cleaner on the bottom shelf of the shower room closet. At this time, the shower room was unsupervised by the staff, and was accessible to confused residents who could enter the shower room where potentially harmful chemicals were stored. 3. Observation on 5/2/12 at 2:00 P.M., showed the housekeeping closet door on Lilac Lane hall to be unlocked, unsupervised by the staff, and accessible to confused residents in the hallway. Further observation showed the following hazardous chemicals: -One gallon container of "TNT" tub and tile cleaner, which contained the following hazardous chemical components; Phosphoric Acid, Oxalic Acid, Nonylphhenoxypolyyethoxyethanol, and Quaternary Ammonium Chlorines. -One gallon of "Springtime" odor counteractant which contained the following hazardous chemical components; Nonylphhenoxypolyyethoxyethanol, Propylene Glycol, and Isopropanol. - One gallon container of glass cleaner concentrate, which contained the following hazardous chemical components; Isopropanol, Ammonium Hydroxide, and 2-Butoxyethanol. Record review of the Material Safety Data Sheets for these chemicals showed the chemicals could cause health hazards when exposure to the eyes, skin, when inhaled, or ingestion occurred. The dangers to health include redness, swelling, and burning when exposed to the eyes or the skin. Inhalation of these chemicals may cause damage to the respiratory (lungs) system, including dizziness headache and loss of coordination. Ingestion of these chemicals may cause nausea, vomiting diarrhea, stomach pain, and can also be fatal (causing death) if swallowed. During an interview on 5/2/12 at 1:50 P.M., NA G said the following: - There are residents who are confused and/or have wandering behaviors in the home. - Cleaners that are potentially harmful to the residents," should be locked up" when not being used by the staff. During an interview on 5/2/12 at 5:15 P.M., the DON said the following: - There are residents who are confused and/or have wandering behaviors in the home, some of these residents use the toilet in the Wisteria Way shower room. - Cleaners and chemicals that are potentially harmful to the residents should be locked up and out of the reach of the residents. - The chemicals used to clean the shower should be locked in a storage cabinet in the shower room. - The housekeeping closets should always be locked when unsupervised by the staff. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. A monitoring visit was completed on 05/04/12. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at this time. The Director of Nursing and/or the administrator inserviced staff regarding facility policies and procedures related to storage of hazardous chemicals and is ongoing until all staff are addressed. Staff installed automatic locks on closet doors containing hazardous chemicals. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. The severity of the deficiency was lowered to a D grid level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address the Class I violation. 4. Review of Resident #19's admission MDS, dated [DATE], showed staff assessed the resident as: - Severely impaired cognitive skills for daily decision making; - Requires extensive assistance of two or more staff with locomotion on the unit (how the resident moves between locations in his/her room and adjacent corridor, and how self sufficient the resident is in the wheelchair); - Requires limited assistance of two or more staff with locomotion off the unit (how the resident moves to and returns from off-unit locations, how the resident moves to and from distant areas, and how self sufficient the resident is in the wheelchair); - Uses a wheelchair; - Has Alzheimer's Disease; - fell in the month prior to admission. Record review of the resident's active medical record showed staff did not complete a comprehensive plan of care, which is used to inform and direct staff of the resident's care needs, within seven days of the completion of the admission MDS. Observation on 5/1/12 at 10:40 A.M., showed the resident seated in the wheelchair with his/her feet extended forward and above the floor. The resident's feet were suspended and not supported by any device. Observation showed nurse aide (NA) G wheeled the resident in the hall to his/her room. During this time, the resident's shoes caught on the floor and the resident lurched forward. Observation showed two unknown staff members approached the resident quickly and prevented him/her from falling out of the wheelchair. Observation showed the wheelchair did not have any foot pedals attached for the resident to place or rest his/her feet during forward movement. NA G then told the resident to "lift your feet" while NA G continued wheeling the resident to his/her room. Staff did not provide the resident with wheelchair foot pedals for proper placement of the resident's feet, to prevent avoidable accidents and possible injury. During an interview on 5/3/12 at 11:25 A.M., the DON said a resident who is unable to propel him/herself should have foot pedals on the wheelchair to rest his/her feet on during locomotion. The DON said the resident is unable to move him/herself in the wheelchair, and therefore should have foot pedals on the wheelchair. During an interview on 5/3/12 at 1:35 P.M., NA G said staff are directed to place foot pedals on wheelchairs before propelling residents. NA G said on 5/1/12, he/she was wheeling the resident to his/her room from the shower room. NA G said the foot pedals were not on the resident's chair in the shower room. NA G said normally the resident has foot pedals on his/her wheelchair or the resident holds his/her feet straight out while staff propel him/her. NA G said on 5/1/12 the resident put his/her feet down and almost fell out of the wheelchair. During an interview on 5/3/12 at 2:10 P.M., certified nurse assistant (CNA) E said staff are directed to put foot pedals on the wheelchairs of residents who cannot hold their feet up, or have a risk of dragging their feet. CNA E said the resident uses foot pedals on his/her wheelchair. 5. Record review of resident's #2's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated 3/26/12, showed staff assessed the resident as: - Severely impaired cognitive skills for daily decision-making; - Mildly depressed; - Required extensive assistance of two staff with transfers, ambulation, dressing, bathing, and personal hygiene; - Required assist of one with eating; - Incontinent of bowel and bladder; - Had fallen prior to and after admission; - Had sustained injuries as a result of fall(s) while living in the home. Review of the resident's admission care plan, dated 12/7/11, showed staff identified the resident as being at risk for falling. Review showed staff implemented the following interventions: - Re-orient the resident to surroundings and staff; - Personal alarm (PA) on bed; - Fall mat. Review of the resident's comprehensive Plan Of Care with a Fall Prevention Care Plan addendum dated 4/10/12 showed the staff identified the resident continued to have the problem of risk for falls, and implemented the following nursing interventions: - Observe the resident more closely; - Ensure the alarm pad is on; - Ensure assistive equipment is used appropriately; - Use a personal chair/bed alarm - 3/16/12. - Keep resident visible 3/27/12. Observation on 4/30/12 at 10:30 P.M., showed the resident in bed on his/her right side. During this time the resident did not have a fall mat at the side of his/her bed. Review of the nursing notes in the resident's active medical showed the staff documented the resident fell and sustained an injury (a cut to the head and bruising to the face and right eye) on 4/30/12 at approximately 10:40 P.M. During an interview on 5/2/12 at 4:00 A.M., CNA M said the following: - He/she works nights, and the resident seems to be more active during the night shift, because the resident's past occupation. - He/she said the resident takes medication that makes him/her need to go to the bathroom more during the night - The staff are responsible for ensuring the bed is in the lowest position, the bed alarm is in place, the fall mat is in place, and the resident is toileted every two hours and as needed. - CNA M said the night shift staff are directed to visually check the resident every 30 minutes. - CNA M and another CNA assisted Resident #2 to bed between 10:00 P.M. and 10:30 P.M. on 4/30/12. - The resident's bed alarm sounded at approximately 10:40 P.M.-11:00 P.M. - CNA M said staff had not checked on the resident since the resident was put in bed 15 minutes prior to the residents fall. - CNA M said he/she was the first staff person in the room, followed by licensed practical nurse (LPN) N. - The bed alarm was sounding, and the bed mat was partially under the resident's bed. Staff did not ensure the resident's fall mat was in the proper position when assisting the resident to bed on 4/30/12, as directed by the plan of care and to assist in preventing falls and possible injuries. During an interview on 5/2/12 at 4:30 A.M., LPN N said the following: -The resident seems to more active during the night shift. - The staff are responsible for ensuring the bed is in the lowest position, the bed alarm is in place, the fall mat is in place, the resident is toileted every two hours and as needed. - The resident's bed alarm sounded at approximately 10:40 P.M.-11:00 P.M. - LPN N said he/she was the second staff person in the room. - The bed alarm was sounding, and the bed mat was partially under the resident's bed. - The resident was assessed, and had a cut with facial bruising to the right eye. Emergency Medical Services (EMS) was called for transport to the hospital. - Documentation of the resident's fall was completed after taking care of the resident, and calling EMS for transport to the hospital. - LPN N said the nursing note's time may not be accurate in regards to the actual time the resident had fallen (4/30/12 not 5/1/12). Review of the EMS report showed the ambulance was called on 4/30/12 at 22:48 hours (10:48 P.M.), and arrived at the nursing home on 4/30 12 at 23:09 hours (11:09 P.M.). During an interview on 5/2/12 at 5:15 P.M., the DON said the following: - The home used both the admission care plan, and the comprehensive care plan with the fall prevention addendum to direct staff with the resident's care. - The resident worked at night in his/her past occupation, and often sleeps during the day, and is awake at night. - The staff are responsible to ensure all care plan interventions are followed to prevent the resident from future falls.

Based on interview and record review, the facility failed to obtain weekly [MEDICATION NAME] time (PT) and international normalized ratio (INR) (measures of how quickly the blood clots) laboratory samples for one resident (Resident #1) of five sampled residents to ensure they administered the correct dosage of [MEDICATION NAME] (blood thinner) to maintain therapeutic PT/INR levels. In addition, staff failed to notify the physician of the resident passing "tarry" stools (an indicator of [MEDICAL CONDITION]). Staff transferred the resident to the hospital for treatment of [REDACTED]. for blood transfusion) and Vitamin K (helps in blood clotting and prevention of bleeding) while hospitalized . The facility census was 46. 1. Review of Resident #1's hospital PT/INR report dated 01/08/11 showed the following: - PT 19.00 (therapeutic range is 10.81-13.09) - INR 2.42 (therapeutic range is 1.5-2.0) Review of the resident's admission physician's orders [REDACTED]. - [MEDICATION NAME] 5 milligrams (mg), one tablet on Tuesday, Thursday and Saturday; - [MEDICATION NAME] 2.5 mg, one tablet on Monday, Wednesday, Friday and Sunday. Review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Additional review of the resident's admission physician's orders [REDACTED]. Review of the resident's comprehensive Minimum Data Set (MDS), a federally mandated assessment tool, dated 01/15/11 showed staff assessed the resident with the following: - Confusion; - Required extensive assistance of staff for his/her Activities of Daily Living (ADL) including toilet use; - Occasionally incontinent of fecal material; - [DIAGNOSES REDACTED]. Review of the resident's medical record showed a Complete Blood Count laboratory report dated 01/17/11 which contained the following abnormalities: - Red blood cells 3.55 (normal is 4.5-6.3); - Hemoglobin 11.7 (normal is 14.0-18.0); - Hematocrit 34.2 (normal is 41.0-51.0). Review of the resident's medical record showed staff did not document ordering weekly PT/INR laboratory samples as directed by the resident's physician. Additional review showed the medical record did not contain any PT/INR laboratory reports. Review of the resident's vital signs including blood pressure, temperature, pulse and respirations dated 01/22/11 showed licensed staff recorded the following information: -During the 6:00 A.M. to 2:00 P.M. shift (no time), the resident's blood pressure was 124/58 (normal is approximately 120/80), temperature was 97.8 (normal is approximately 98.6), pulse was 85 (normal is approximately 60-100 beats per minute) respirations were 22 (normal is approximately 15-20 breaths per minute). - During the 2:00 P.M. to 10:00 P.M. shift (no time), the resident's blood pressure was 84/36, temperature was 96.8, pulse was 80 and respirations were 21. Review of the resident's nurses notes dated 01/22/11 at 10:28 P.M., showed licensed staff recorded the following information: - "Resident has had numerous black, tarry stools." Licensed staff did not document they notified the resident's physician of his/her tarry stools or low blood pressure. Review of the resident's nurses notes dated 01/23/11 at 3:00 P.M., showed licensed staff recorded the following: - "Resident transferred by EMS (emergency medical service) to local hospital. Oxygen saturation low, resident acute confusion. Blood pressure 110/40 - afebrile (without fever), blood sugar 179, pulse 120. Resident's skin was somewhat jaundiced (yellow in color), had four tarry stools yesterday." Review of the resident's hospital emergency department physician documentation dated 01/23/11 showed the emergency department physician recorded the staff transferred the resident to the hospital because of "respiratory difficulty and dark stools." Review of the resident's intensive care unit (ICU) physician documentation dated 01/23/11 showed the physician recorded the following information: "Acute or [MEDICAL CONDITION] most likely exacerbated by not only the prerenal azoturia (toxic condition associated with [MEDICAL CONDITION]) for an upper GI (gastrointestinal) hemorrhage (bleeding) but also significant intravascular volume depletion (dehydration). I will be transfusing not only fresh frozen plasma (FFP) but also two units of blood. Patient most likely has an upper gastrointestinal hemorrhage causing this dark maroon stools as indicated by the prerenal azoturia acute [MEDICAL CONDITION]. Additionally he/she has significantly elevated PT and INR is obviously a [MEDICATION NAME] coagulopathy (defect in the blood clotting mechanism) leading to hemorrhage. At time of my evaluation patient emergency department he/she has a large dark tarry stool." Review of the resident's hospital laboratory results dated [DATE] showed the following abnormalities: - Lipase (elevated lipase levels are often found in patients with [MEDICAL CONDITION]) 59 (normal is 14-51); - Blood Urea Nitrogen (BUN-measures normal renal function) 144 (normal is 8-26); - Creatinine (measures normal renal function) 3.9 (normal is 0.6-1.3); - Red Blood Count 2.53 (normal is 4.10-5.80); - Hemoglobin 8.5; - Hematocrit 25.2; - PT >100 seconds; - INR >9.40. Review of the resident's hospital discharge summary dated 02/03/11 showed the resident's hospital physician recorded the following information: - Admission Diagnoses: [REDACTED]. - Discharge Diagnoses: [REDACTED]. Additional review of the resident's discharge summary dated 02/03/11 showed the hospital physician recorded the following information: "The patient had transfusion of five fresh frozen plasma and three units of packed red blood cells." During an interview on 02/10/11 at 12:00 P.M., Licensed Practical Nurse (LPN) A said he/she could not find the results of the resident's weekly PT/INR. LPN A said "apparently" staff did not transcribe the resident's PT/INR orders onto laboratory requisitions and did not notify the laboratory of the weekly PT/INR orders. LPN A said when the physician ordered a laboratory test, the nurse filled out the necessary information onto the appropriate requisition, notified the laboratory of the scheduled laboratory test(s), then placed the requisition(s) into the laboratory requisition book. LPN A said the director of nursing audited the charts approximately once a month to ensure staff transcribed physicians' orders appropriately. LPN A said he/she was not aware of the resident passing "tarry" stools. During an interview on 02/10/11 at 12:10 P.M., Certified Nurse Assistant (CNA) B said he/she recalled the resident passing a tarry stool, but he/she did not remember who he/she reported it to or when it happened. During an interview on 02/14/11 at 3:20 P.M., CNA C said one to two days prior to the resident going to the hospital, the resident did pass a tarry stool but he/she did not remember who he/she reported this to. During an interview on 02/14/11 at 9:00 A.M., the Director of Nursing (DON) said she expected staff to follow physician's orders [REDACTED]. The DON said she audited the residents' medical records approximately every three days but did not check all the medical records. The DON said staff did not notify her of the resident passing tarry stools. The DON said anytime there was a new order, the nurse on duty and the oncoming nurse should make sure the orders "get done." MO 375