Every finding on record at Cameron Nursing Center

Based on observations and interviews, the facility failed to maintain a clean, neat and orderly environment in the resident room [ROOM NUMBER] and shared resident restrooms for room numbers 201, 202, 203, and 204. restrooms. The facility census was 75. Review of the facility's undated Resident Rooms Cleaning policy showed:-Staff are to pick up any trash off the floors and counters, take out trash;-Look around room from ceiling down for cobwebs/dust, wipe off windowsills, night stands, dressers, TV stands, TVs and picture frames;-Use clean rag to wipe off door knobs and light switches, clean off counters beside and around sink, clean sink and faucet, clean mirror;-Sweep and mop floor, ring out mop pads, change mop x2 for each room, if there is a fall mat, clean/mop under the fall mat; -Clean bathroom, handrails, toilet, mop floor, wipe off walls.1. Observation of the resident restroom in room [ROOM NUMBER] on November 3, 2025, at 12:12 P.M., showed:-A dried, brown substance on the door frame, door and toilet tank; -A puddle of liquid on the floor next to the toilet; -The graduate (container used to measure urine) used to empty the catheter bag on top of the toilet tank, uncovered, with yellow liquid in the bottom of the graduate; -A strong smell of urine.2. Observation of the restroom shared between resident rooms #203 and #204 on November 3, 2025, at 12:45 P.M., showed:-A dried, brown substance on the toilet riser and toilet tank;-A puddle of liquid on the floor next to the toilet; -A strong smell of urine.3. Observation of the restroom shared between resident rooms #201 and #202, on November 3, 2025, at 12:19 P.M., showed:-Dried yellow substance on the toilet seat;-A strong smell of urine.4. During an interview on November 3, 2025 at 1:39 P.M., Housekeeper A stated:-When he/she cleaned the resident restrooms, he/she scrubbed the toilet, mopped the floor and behind the toilet, swept the floor. He/She also took a rag and wiped down the toilet seat, toilet tank, doors and other surfaces; -There should not be dried substances on any surface of the restroom or puddles on the floor. During an interview on November 3, 2025 at 1:37 P.M., Certified Nurses Assistant (CNA) A stated:-The resident bathrooms should be cleaned daily and if the staff see a restroom that needs attention, they should immediately tell the charge nurse or a member of housekeeping; -The graduate used when emptying a catheter bag should be rinsed after use. It is then supposed stored on the top of the toilet tank, covered. During an interview on November 3, 2025, at 1:45 P.M., Licensed Practical Nurse (LPN) A said:-The resident restrooms are cleaned daily by housekeeping staff;-If a resident, visitor or staff member sees a restroom needs to be cleaned, they should inform the charge nurse, housekeeping or Administrator; -After using the graduate to empty a catheter bag, the graduate should be rinsed then stored on the toilet tank, covered. During an interview on November 3, 2025 at 1:57 P.M., the Administrator said:-It is his/her expectation that the housekeeping staff follow the facility's policy when cleaning resident restrooms; -It is his/her expectation that resident restrooms are cleaned daily and as needed; -There should not be dried substances on the toilet, riser or any other surface;-There should not be a strong odor; -After staff use the graduate to empty a catheter bag, they should then rinse it out, and place it, covered on the toilet tank. Complaint 2655967

Based on observations and interviews, the facility failed to provide appropriate and adequate methods for residents to call for staff while the call light system is being repaired. Resident #1 experienced shortness of breath when being required to use a whistle to summon staff while the call system is malfunctioning. Other residents (Residents #2, #3, #4) experienced anxiety and emotional distress related to the call system not functioning. Facility census was 75. The facility did not provide a policy on the call light system.1.Review of Resident #1's electronic medical record on November 3, 2025 showed:-The resident has the diagnoses of acute and chronic congestive heart failure (CHF; a condition where the heart cannot pump blood effectively enough to meet the body's needs), chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breath), intervertebral disc degeneration (a condition where the intervertebral discs, which act as cushions between the vertebrae in the spine, gradually deteriorate over time), anemia (a condition where the intervertebral discs, which act as cushions between the vertebrae in the spine, gradually deteriorate over time), chronic respiratory failure, chronic respiratory failure (a condition where the lungs are unable to adequately exchange oxygen and carbon dioxide over a prolonged period), chronic pulmonary edema (a condition where fluid accumulates in the lungs over an extended period, leading to breathing difficulties), diabetes mellitus type 2 (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), chronic kidney disease (CKD, a progressive, irreversible condition where the kidneys are damaged and lose their ability to filter waste and fluids from the blood). Review of the resident's annual Minimum Data Set (MDS, a federally mandated assessment completed by staff) dated August 12, 2025, showed:-The resident had clear speech;-He/She was able to make him/herself understood;-He/She scored 15 on the Brief Interview for Mental Status (BIMS, a structured evaluation aimed at evaluating aspects of cognition in elderly residents), indicating no cognitive impairment;-He/She used a walker and wheelchair for mobility;-The resident required substantial assistance with bathing and moderate assistance with transferring.Review of the resident's comprehensive care plan, dated September 18, 2025, showed;-Interventions related to breathing treatments related to COPD;-Oxygen tank to remain by his/her chair at all times;-The resident was at risk for falls and had an actual fall with minor injury;-Activities of Daily Living (ADL) self-care performance deficit related weakness;-The resident has limited physical mobility related to weakness;-The resident was incontinent of bowel and bladder;- The resident had impaired visual function, shortness of breath, oxygen therapy related to CHF (oxygen as ordered, encourage or assist with ambulation, use portable oxygen tank as required).During an observation and interview on 11/3/25 at 1:02 P.M., Resident #1 said:-It has been two weeks that the call light system has not worked;-The call lights by the beds don't work, but the one in the bathroom does work; -The resident had the whistle on the bedside table next to her bed;-The resident also wears oxygen;-Resident #1 stated that two days ago, the resident needed staff assistance;-He/She blew the whistle for several minutes until he/she was very out of breath;-No staff came to assist the resident, so he/she had to walk to the bathroom and pull the call light next to the toilet; -The resident said that he/she was very short of breath while walking to the bathroom and very afraid he/she was going to fall; -The resident also stated that he/she was afraid that if he/she were to fall, no one would hear the whistle or hear him/her yelling and he/she would lay on the floor for a long time. 2. Review of Resident #2's electronic medical record on November 3, 2025 showed:-Diagnoses included: Diabetes mellitus type 2, dysphagia (difficulty swallowing), cognitive communication deficit (a difficulty with communication that's caused by an underlying issue with cognition), reduced mobility, Melas Syndrome (a rare genetic disorder that affects the mitochondria, the energy-producing organelles within cells), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing a significant impairment in daily life), anxiety disorder (GAD, a mental health disorder characterized by severe, ongoing anxiety that interferes with daily activities), heart disease (heart conditions that include diseased vessels, structural problems, and blood clots). Review of the resident's quarterly MDS, dated [DATE], showed:-The resident had highly impaired hearing and vision;-He/she scored 15 on the BIMS, indicated no cognitive impairment;-He/She required partial to moderate assistance with ADL's, including bathing, transfers and mobility;-The resident used a walker for mobility. Review of the resident's comprehensive care plan, dated April 14, 2025, showed:-Interventions related to difficulty hearing;-ADL self-care deficit related to activity intolerance/impaired balance/limited mobility;-Risk for falls related to balance problems. diagnoses of and medication for anxiety and depression. During an interview on November 3, 2025 at 12:45 P.M., Resident #2 stated:-It has been about 10 or 12 days that the call light system has not been working; -When asked where the resident's whistle was, he/she pointed out it was saying on the bedside table next to the resident's recliner; -The resident states that the call light system not working and having to use the whistles gives him/her anxiety;-He/She observed his/her roommate using the whistle to call for staff and no one has come;-Additionally, the resident has troubles with balance and fears if he/she fell and could not reach the whistle or is hurt and cannot blow the whistle, he/she will lay on the floor for a long time and no one will come help him/her. 3. Review of Resident #3's electronic medical record on November 3, 2025 showed:-Diagnoses included: Diabetes mellitus type 2, presence of left artificial hip joint, repeated falls, disorder of bone density and structure, dysphagia, tachycardia (faster than normal heart rate), cognitive communication deficit, intellectual disabilities. Review of the resident's quarterly MDS, dated [DATE], showed:-The resident had clear speech with adequate hearing and was able to make self understood and is able to understand others;-He/She scored 15 on the BIMS, indicated no cognitive impairment;-He/She used a walker and wheelchair for mobility;-The resident required partial to moderate assistance with ADLs, including dressing, bathing and personal hygiene. Review of the resident's comprehensive care plan, dated June 19, 2025, showed:-Interventions related to risk for falls related to unsteady gait;-The resident received respiratory therapy related to shortness of breath;-He/She had an ADL self-care performance deficit related to intellectual disabilities, altered cardiovascular status related to tachycardia, bladder incontinence.During an interview on November 3, 2025, at 12:19 P.M., Resident #3 said:-The call light system has not been working for about two weeks; -The facility gave him/her a whistle to use to call for staff; -When asked where the whistle was, Resident #3 responded he/she wasn't sure, but it was near his/her chair. Resident #3 then looked through a pile of belongings on the table beside his/her chair, and found the whistle underneath the pile. When asked how he/she would call for staff if the whistle wasn't within arm's reach, Resident #3 responded he/she would yell for staff and hope they hear, or would walk into the bathroom and use that call light; -Resident #3 stated that using the whistle or the bathroom call light to call for help causes him/her to be nervous;-If he/she needs help in the night and can't find the whistle, he/she would have to walk to the bathroom in the dark to use that call light;-This caused the resident to be afraid he/she would fall and possibly get hurt or lay on the ground for a long time until staff come by.4. Review of Resident #4's electronic medical record on November 3, 2025, showed:-Diagnoses included: Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), respiratory disorder, muscle weakness, dysphagia, malignant neoplasm of brain, major depressive disorder, seizures (a burst of uncontrolled electrical activity between brain cells (neurons, nerve cells) that causes temporary abnormalities in muscle tone or movements(stiffness, twitching or limpness), behaviors, sensations or states of awareness), cognitive communication deficit. Review of the resident's quarterly MDS, dated [DATE], showed:-The resident had adequate hearing, clear speech, and was usually able to make self understood and usually understands others;-He/She scored 13 on the BIMS, indicating minimal cognitive impairment;-He/She used a walker and wheelchair for mobility;-The resident required supervision for ADLs, including dressing, bathing and personal hygiene. Review of the resident's comprehensive care plan, dated June 26, 2025, showed:-Interventions related to impaired visual function, altered respiratory status/receiving respiratory therapy related to obstructive sleep apnea (a common sleep disorder characterized by repeated episodes of partial or complete blockage of the upper airway during sleep);-The resident had ADL self-care performance deficit related to Parkinson's disease and malignant neoplasm of the brain;-The resident was at risk for falls, bladder incontinence and seizure disorder.During an interview on November 3, 2025 at 12:25 P.M., Resident #4 said:-It has been two weeks that the call light system has not worked. The staff gave the resident and his/her roommate whistles to use to call the staff;-When asked where the resident's whistle was, he/she pointed out it was tied to the drawers next to the bed. When asked how he/she would call for staff if he/she could not reach the whistle, the resident stated he/she would yell until someone came; -Resident #4 said that a few days ago, he/she spilled water on the floor;-He/She used the whistle for several minutes but no staff came to assist;-The resident stated he/she then propelled his/her wheelchair into the hall and down to the nurses station to find some help to clean up the water;-The resident stated this made him/her feel frustrated and afraid that if he/she fell or got sick, no one would hear the whistle and come help. During an interview on November 3, 2025 at 1:37 P.M., Certified Nurses Assistant (CNA) A stated:-The staff gave the residents whistles and bells to call for staff while the call light system is not working;-Residents with breathing problems were supposed to be given bells; -The staff were instructed to do increased rounding on the hall where the call lights were not working;-He/She said the staff were rounding every two hours. During an interview on November 3, 2025 at 1:45 P.M., Licensed Practical Nurse (LPN) A said:-Residents were given whistles and bells to use to call for staff;-Residents who have any type of lung or breathing issue were supposed be given bells; -If residents cannot use the bell or whistle, they can use the call light in the bathroom to ring for staff; -A couple of residents have made comments to LPN A that not having the call light system made them anxious;-The staff have not received any instruction to do more frequent rounding; During an interview on November 3, 2025 at 1:57 P.M., the Administrator said:-It has been about two weeks the call light system has been malfunctioning;-Residents were given bells and whistles to use in place of the call lights; -Residents with breathing difficulties were supposed to be given bells; -It was his/her expectation that staff answer the bells and whistles just like they would call lights; -The staff have been instructed to do more frequently rounding;-They were not given a specific amount of time to do rounds, but to frequently walk the halls to monitor if residents need help; -The administrator has not received any reports of residents feeling anxious or any complaints of staff not responding to the bells or whistles. Complaint 2655967

Based on observation, interview, and record review, the facility failed to ensure the Dietary Manager (DM) had the appropriate competencies and skills sets to carry out the functions of the food and nutritional services. The facility census was 67. Review of the facility job description titled, Dietary Supervisor/Manager, revised December 2023, showed: -Responsible for supervising functions and personnel within the dietary department. Safely and efficiently provides nutritionally appropriate food to residents for the purpose of maintaining, and enhancing their overall health. Ensures the provision of quality food service and nutrition care in accordance with Federal, State, and Local regulations; -Upon admission and periodically thereafter, visits residents regarding menus, food service, food preferences, and dining information; -Ensures physician's orders are followed; -Performs quality audits of meals and tray lines to ensure attractive, palatable foods are served at correct temperatures; -Directs the ordering, delivery, storage, including labeling, and appropriate utilization of food supplies; -Maintains standards for food preparation and quality of food services; -Carries out responsibility for ordering, delivery, storage, including labeling, and appropriate utilization of food supplies; -Ensures meals are timely and accurate according to physician orders and resident food preferences; -Tests food to determine if it properly cooked, palatable, and at correct temperatures to meet resident needs; -Dietary services must be provided to residents according to their individual needs as determined by assessments and care plans; -Qualifications: -High school diploma; -Trained as a Certified Dietary Manager, Certified Food Protection Professional, or a Dietetic Technician; -Certification in food safety as required by state regulation; -Food service supervisory experience required; at least two years' experience in long term care preferred; -Follows food safety and sanitation guidelines per company policy and procedure and state and federal codes and regulations; -Performs regular audits of dietary services to ensure safe food handling; -Develops and ensures adherence to cleaning schedules and other tools needed to maintain sanitation and cleanliness of kitchen and other areas where food is stored and served. Facility provided, Dietary Supervisor's date of hire in his/her current position as 4/16/24. During an interview on 3/17/25 at 9:30 A.M., Dietary Manager said: -He/She had been acting dietary manager since last May; -He/She had not had a lot of training; -He/She did not have dietary management certification; -A lot of his/her training had been just figuring things out; During a follow up interview on 3/19/25 at 2:23 P.M., Dietary Manager said: -He/She had no dietary management or food supervisor certification; -He/She obtained serve safe certification on 8/7/19; -He/She had no training on creating therapeutic diets; -He/She struggled with budgeting food and supplies in kitchen; -He/She was still learning where he/she could order supplies and replace broken items and utensils; -He/She gets to end of month and had to try and stay under budget and did not order ground beef so had to switch his/her menu items; -He/She had issues with items needed for dietary menus being on hand or arriving on the truck deliveries. During an interview on 3/20/25 at 9:58 A.M., Registered Dietician said: -He/She expected the dietary manager to be certified, completed food service management education, or had experience in position of food service director. During an interview on 3/20/25 at 4:05 P.M., Administrator said: -He/She expected the facility dietary manager to have had education in food service management, had two years of experience in position as director of food service, or had completed a food safety management course.

Based on observation, record review, and interview the facility failed to prepare and serve food in accordance with professional standards for food service safety when staff did not practice sanitary hand washing skills, used hand sanitizer during meal preparation failed to wear proper hair coverings, did not dispose of expire food waste, did not label and date all foods, did not test dishwasher for proper sanitation before running dishes, properly sanitize all food preparation surfaces in the kitchen, and failed to maintain a clean and sanitary kitchen. The facility census was 67. 1. The Facility did not provide a policy on dietary handwashing, gloving, or sanitizer use. Review of facility policy, Safe Minimum Internal Temperature chart, undated, showed: -Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You can't see, smell or taste harmful bacterial that may cause illness. In every step of food preparation, follow the four guidelines to keep food safe: -Clean - wash hands and surfaces often. Review of facility policy, hand hygiene, revised ,d+[DATE], showed: -Facility staff must perform hand hygiene procedures in the following circumstances including but not limited too -After using bathroom -When soiled with visible dirt or debris -Before and after food preparation -Upon starting of the shift -After removing personal protective equipment. -Hand hygiene is always the final step after removing and disposing of personal protection equipment; -Use of gloves did not replace hand hygiene procedures; -Washing hands: Vigorously lather hands with soap and rub them together, creating friction to all surfaces, for at least twenty seconds under a moderate stream of running water, at a comfortable temperature. Rinse hands thoroughly under running water. Hold hands lower than wrists. Do not touch fingertips to inside of sink. Dry hands thoroughly with paper towels and then turn off faucets with a clean, dry paper towel. Discard towels into trash. During a continuous observation on [DATE] from 10:00 A.M.-11:10 A.M. showed: -10:12 A.M., Dietary manager entered kitchen, did not wash his/her hands and entered office; -10:14 A.M., Dietary Aide A entered kitchen, did not wash his/her hands; -10:17 A.M., Dietary Aide B loading dishwasher. He/She dipped his/her hands in red sanitizer bucket before removing clean trays from low-temp dishwasher. He/She did not wash his/her hands; -10:18 A.M., [NAME] A removed his/her gloves, did not wash his/her hands. Grabbed clean utensils off dishwasher and put them away; -10:20 A.M., Dietary Aide B used Comet to spray down 3-tiered cart, and then used a wash cloth from silverware tray that was sitting in liquid substance. He/She did not wash hands and stuck his/her fingers in red sanitizer bucket before removing clean trays from low-temp dishwasher; -10:23 A.M., Dietary Aide B loaded more dirty dishes into low temperature dishwasher. He/She then dipped his/her hands in sanitizer bucket before pulling clean dishes out of low temperature dishwasher; -10:25 A.M., Dietary Aide B wrote label for food item. Then removed dirty pitchers from dirty cart and placed in low-temperature dishwasher. He/She moved clean trays down line without washing his/her hands. Items were removed from dishwasher without washing his/her hands; -10:35 A.M., Dietary Aide B spraying three-tiered cart with Comet ,d+[DATE] bleach cleaner, obtained a wash cloth from the sanitizer bucket and used the wash cloth to wipe off the bottom shelf of cart, middle shelf, and followed by top shelf of cart. He/She did not wash hands and then proceeded to pull dishes out of clean side of dishwasher; -10:39 A.M. Dietary Aide A has not washed hands since entered kitchen at 10:14 A.M. -10:40 A.M. Dietary Aide A washed his/her hands for less than five seconds; -10:41 A.M. [NAME] A washed his/her hands, turned faucet off with bare hands, then dried his/her hands with paper towel; -10:43 A.M. Dietary Aide A placing silverware in paper sleeves; -10:46 A.M. [NAME] A applied gloves and temperature checked chicken nuggets. He/She then began preparing mechanical chicken strips by adding to robot coupe.; -10:53 A.M. [NAME] A added more chicken strips to robot coupe, hits pulsator, and said he/she was making the puree. Observed adding chicken broth. He/She then used hand sanitizer from cart, applied gloves, stirred, and added in more chicken broth to robot coupe. He/She then emptied pureed food into containers and placed in oven; -11:00 A.M. [NAME] A observed washing hands, turned faucet off with clean bare hands, and dried hands with paper towel. He/She then applied gloves, grabbed an alcohol wipe and cleaned thermometer; -11:01 A.M. [NAME] A removed gloves, used hand sanitizer, and applied new gloves. During a continuous observation on [DATE] from 7:33 A.M.-12:20 P.M. in the kitchen, showed: -7:35 A.M., [NAME] A applied gloves, cut open 2 8lb rolls of ground beef, placed in container, threw away trash, washed his/her hands and applied gloves. He/She then touched eggs, cracked into meatloaf, removed gloves, did not wash his/her hands, and applied new gloves. He/She then placed eggs in trash, pushed trash down and washed his/her hands. [NAME] A observed turning faucets off with his/her bare hands he/she had just washed and dried his/her hands with paper towel; -7:45 A.M., Dietary Manager washed his/her hands and applied gloves; -7:48 A.M. Dietary Manager removed gloves, washed his/her hands, gloves were applied, and he/she placed meatloaf into casserole pans to be cooked; -7:50 A.M. Dietary Manager said he/she wondered where cook A placed his/her hand sanitizer as there was a bottle of hand sanitizer up on shelf. He/She must have taken hand sanitizer with him/her. Dietary Manager then applied hand sanitizer and gloves; -7:53 A.M. Dietary Manager completed putting meatloaf in pan, removed his/her gloves, and went to wash his/her hands; -7:54 A.M., [NAME] A entered kitchen did not wash his/her hands, grabbed a serving spoon and exited the kitchen; -8:15 A.M., Dietary Manager observed sweeping floor. He/She then used healthcare wipes to wipe off surface of food preparation table behind stove. He/She did not wash his/her hands following sweeping to wiping down kitchen food preparation surface; -8:18 A.M. Dietary Manager loaded dirty dishes into low-temperature dishwasher, then used hand sanitizer at door on therapy side of kitchen that was mounted to wall. Dietary Manager then pulled clean dishes of the clean side of dishwasher; -8:19 A.M., Dietary Aide B entered kitchen, did not wash his/her hands and began applying gloves; -8:32 A.M., [NAME] A returned to kitchen, did not wash his/her hands and began adding items from food cart back to steam table; -8:36 A.M., [NAME] A washed his/her hands; -8:39 A.M., Dietary Aide B observed adding drinks to room tray carts and covering drinks with foil; -8:44 A.M., Dietary Aide B observed wearing same gloves applied at 8:19 A.M., threw trash away, gloves were removed and new gloves were applied. Discarded gloves were laid on stainless steel drink preparation table; -8:45 A.M., Dietary Manager cracked eggs into pan on stove where he/she was cooking turkey sausage and eggs. He/She then entered walk in cooler to obtain additional egg, and goes and uses hand sanitizer from wall; -8:47 A.M. Dietary Manager goes back into walk in cooler to get another egg, and cracks another egg into pan on stove. He/She did not wash hands; -8:48 A.M. Dietary Aide B exited kitchen with resident room breakfast trays; -8:49 A.M. Dietary Aide B re-entered kitchen and did not wash his/her hands. He/She continued with drink preparation wearing black gloves; -9:24 A.M. [NAME] A prepped red sanitizer bucket and took it over to dishwashing area; -9:31 A.M. [NAME] A wiping down steam table with washcloth; -9:32 A.M. [NAME] A observed washing his/her hands and turned faucet off with his/her bare hands; -9:33 A.M. [NAME] A removed meatloaf from oven, applied gloves, removed aluminum and plastic from top of meatloaf; -9:53 A.M. Dietary Manager entered kitchen, set items on counter, did not wash his/her hands; -9:59 A.M. Dietary Manager entered kitchen, did not wash his/her hands and entered cooler; -10:04 A.M. [NAME] A washed his/her hands and turned faucet off with his/her bare hands; -10:04 A.M. Dietary Aide B returned to kitchen did not wash his/her hands. Seen scratching his/her forehead and then added sweetener to a drink; -10:08 A.M. Dietary Aide C washed his/her hands, turned faucet off with his/her bare hands; -10:12 A.M. Dietary Aide C washed his/her hands, turned faucet of with his/her bare hands; -10:19 A.M. Dietary Manager entered kitchen, obtained coffee in a cup, did not wash his/her hands, exits kitchen with coffee in hand; -10:26 A.M. Dietary Aide B dipped his/her hands in red sanitizer bucket before pulling clean dishes off of dishwasher; -10:36 A.M. [NAME] A pulled meatloaf out of oven; -10:38 A.M. [NAME] A used hand sanitizer that was in his/her pocket; -10:41 A.M. [NAME] B entered kitchen, washed his/her hands, then turned water faucet handles off with bare hands; -10:44 A.M. [NAME] A washed his/her hands and turned faucet handles off with his/her bare hands; -10:56 A.M. [NAME] A washed his/her hands, faucet handle turned off with his/her bare hands; -10:57 A M. [NAME] B washed his/her hands, faucet handle turned off with his/her bare hands; -11:02 A.M. [NAME] A empties drain catch from three compartment sink, then removes gloves, and uses hand sanitizer from his/her pocket to sanitize his/her hands; -11:10 A.M. Dietary Aide C washed his/her hands and turned faucet handle off with his/her bare hands; -11:30 A.M. [NAME] A preparing creamed peas in robot coupe for puree diets; -11:32 A.M. [NAME] A placed robot coupe container in sink, removed gloves, used hand sanitizer, and applied new gloves. During an interview on [DATE] at 2:08 P.M., Dietary Aide B said: -He/She should wash his/her hands any time he/she changed gloves; -He/She did not wash his/her hands before pulling clean dishes off dishwasher; -He/She dipped his/her hands in red sanitizer buckets before pulling clean dishes out of dishwasher; -He/She had one day of training as facility dishwasher; -He/She had been working in kitchen for four years; -He/She did not really use hand sanitizer in kitchen. During an interview on [DATE] at 2:23 P.M., Dietary Manager said: -He/She expected hand washing or glove changing to occur every single time staff transitioned from a different job or left a task; -He/She expected staff to turn water on, wet hands, soap their hands, scrub up to six inches up arm, wash and rinse hands for thirty seconds, take a paper towel to wipe down their hands, and use a paper towel to turn off faucet hands; -It was not sanitary to turn faucet handles off with bare hands; -He/She expected staff to wash their hands upon entry into the kitchen; -He/She expected staff to keep glove use the same as washing hands with changing occurring after every new job, staff should wash their hands, dry them, and put on new gloves; -He/She indicated hand sanitizer could be used up to three times in between handwashing; -He/She only had one hand sanitizer station all the way over by double doors and sometimes it was easier to wash hands than to run over to the hand sanitizer station; -He/She felt it was appropriate for dishwasher to sanitize his/her hands in sanitizer solution prior to removing clean dishes from dishwasher; -He/She had corporate staff train staff they could use sanitizer bucket to sanitize their hands; -He/She did not test sanitation buckets for proper sanitation levels; -He/She chooses to use the hand sanitizer station when he/she sanitizes in between hand washing over the sanitizer bucket solution. During an interview on [DATE] at 2:47 P.M., [NAME] A said: -He/She was supposed to wash his/her hands between every task change, whenever he/she changed gloves; -He/She was told he/she could use hand sanitizer between hand washing; -It was not sanitary to turn off faucet handles with his/her bare hands; -He/She did use his/her bare hands to turn faucet handle off a few times that day. During an interview on [DATE] at 3:05 P.M., Dietary Aide C said: -Hands should be washed when he/she first entered kitchen, anytime he/she entered the kitchen, when he/she moved to different project, handled food carts; -He/She sometimes forgot to use paper towel to turn faucet handles off after washing his/her hands; -He/She should use paper towel to turn off faucet handles; -He/She should change his/her gloves regularly; -He/She did not always wash his/her hands when he/she swapped out gloves; -He/She did not use hand sanitizer in the kitchen. During an interview on [DATE] at 9:14 A.M, Dietary Aide A said: -He/She should wash hands when he/she entered kitchen, between tasks, prior to putting on gloves; -It was not sanitary to turn faucet handle off with bare hands; -He/She should turn off faucet handles with a paper towel; -He/She was not supposed to use hand sanitizer when working with food. During an interview on [DATE] at 9:58 A.M., Registered Dietician said: -He/She expected hand washing to be completed before shift, if staff take a break, anytime they leave the kitchen and come back into the kitchen to do work, every time they change tasks; -He/She expected staff to wash their hands if they were wearing gloves and took their gloves off, -He/She also expected staff to wash their hands anytime they touched their face, body, person, or cell phones; -He/She expected staff to use a paper towel to shut off faucet handles when washing their hands and it was not sanitary to use bare hands to shut off faucet handles; -He/She expected glove use to mirror handwashing, if staff left serving station they should apply new gloves before coming back to task; -He/She expected staff to wash their hands between going from dirty and clean side of dishwasher; -It was not appropriate for staff to stick their hands in sanitizer solution to sanitize their hands before pulling clean dishes off dishwasher. During an interview on [DATE] at 4:05 P.M., Administrator said: -He/She expected dietary staff to wash their hands; -He/She expected dietary staff to use a paper towel to turn off faucet handles and not use their bare hands during hand washing; -He/She expected that hand sanitizer not be used during food preparation; -He/She expected staff washing dishes to wash hands prior to removing clean dishes from dishwasher. 2. Review of facility policy, nutrition services personnel guidelines, revised [DATE], showed: -Hair must be fully covered with a hairnet or hair bonnet always within the department. Hairnet must be worn regardless of the amount of hair. -Facial hair is to be groomed, and mustache and beards are to be covered with hair restraint. -Only nutrition services department employees are allowed in the kitchen or food and supply storage areas. Other facility employees are not permitted in the department unless requested by the Dietary Manager. Observation on [DATE] at 9:37 A.M. showed Dietary Manager's beard cover was not covering all facial hair. [NAME] cover was resting below chin with Dietary Manager's goatee hanging out. Observation on [DATE] at 10:13 A.M. showed Maintenance Staff entered kitchen not wearing beard cover. He/She walked by stove to look at fire suppression system. Meal preparation was in process. Observation on [DATE] at 10:43 A.M. showed Dietary Manager came out of his/her office into kitchen and did not have beard cover covering facial hair. [NAME] cover was resting below his/her chin. Observation on [DATE] at 7:52 A.M. showed Admissions Coordinator exited dietary office into kitchen not wearing any hairnet. He/She walked directly through kitchen. Observation on [DATE] at 8:03 A.M. showed Director of Nursing (DON) entered kitchen, did not have hair net on, and walked through the kitchen to return a tray to dietary manager who was over at dishwasher. Observation on [DATE] at 8:29 A.M. showed Dietary Aide B had front part of hair hanging down in face. His/Her hairnet was not covering his/her hair. Dietary Aide was prepping drinks for breakfast hall trays. Observation on [DATE] at 9:32 A.M. showed CMT A entered kitchen to obtain coffee. He/She did not have hairnet on. During an interview on [DATE] at 2:08 P.M., Dietary Aide B said: -Hairnet must be worn at entry of kitchen; -Hairnet should cover all of his/her hair. During an interview on [DATE] at 2:23 P.M., Dietary Manager said: -He/She expected hairnets for everybody in kitchen; -When staff were going out in kitchen and working they had to have beard guard covering facial hair; -The beard guards should cover all the facial hair and not resting under chin; -He/She expected that staff's hair not be hanging out of hair nets. During an interview on [DATE] at 2:47 P.M., [NAME] A said: -Hairnets should be applied before entering the kitchen; -Beard coverings were kept in the office so it was not possible to apply beard coverings prior to entering the kitchen; -Beard coverings and hair nets should cover all hair. During an interview on [DATE] at 3:05 P.M., Dietary Aide C said: -Hairnets should be worn anytime he/she came into kitchen and be applied before he/she entered the kitchen; -Hairnets were located right outside kitchen door so staff could grab them before entering. During an interview on [DATE] at 9:14 A.M, Dietary Aide A said: -Hairnets should be applied before entering kitchen; -Hair should not be hanging out of hairnet. During an interview on [DATE] at 9:58 A.M., Registered Dietician said: -He/She expected hairnets and beard coverings to be worn at all times while in the kitchen and should be applied prior to entering the kitchen; -Hairnets and beard coverings should cover all hair and facial hair; -It was not appropriate for beard coverings to be resting below staffs chin. During an interview on [DATE] at 4:05 P.M., Administrator said: -He/She expected all hair to be covered for staff entering the kitchen; -It was not appropriate for beard covers to be resting below the chin with facial hair uncovered. 3. Facility did not provide a policy on labeling, dating, and disposal of expired food waste. Observation on [DATE] at 9:37 A.M. showed: -Opened and undated 18 ounce (oz) cinnamon, top of container had writing that was illegible; -Opened and outdated 12 oz poultry season, dated [DATE]; -Opened and outdated 14 oz cumin, dated [DATE]; -Opened and outdated 11 oz oregano, dated [DATE]; -Opened and outdated 5.5 dill weed, dated [DATE]; -Opened and outdated ground basil, dated [DATE]. Observation on [DATE] at 10:09 A.M. of refrigerator in main kitchen showed: -Opened and undated gallon of 2% milk; -Opened and undated 7lb 8oz chocolate syrup; -Sliced tomatoes in container, dated [DATE]; -Sliced lunch meat in container, unnamed, dated [DATE]; -Cooked chicken noodle soup dated [DATE]; -Pieces of ham in container, dated [DATE]; -Opened and undated 48 oz lemon juice; -Opened and undated 8.5 lb. mild salsa. Observation on [DATE] at 8:10 A.M. of refrigerator in main kitchen showed: -Potato soup in container, dated [DATE]; -Browning shredded lettuce, dated [DATE]; -Piece of ham in container, dated [DATE]; -Chocolate pudding in container, dated [DATE]; -Cooked chicken noodle soup dated [DATE]; -Opened and undated jar of picante sauce. During an interview on [DATE] at 2:08 P.M., Dietary Aide B said: -Items should be dated and labeled when opened; -When boxes arrive they should be opened and dated with opened date; -He/She dated and labeled anything stored in refrigerator. During an interview on [DATE] at 2:23 P.M., Dietary Manager said: -He/She expected dating and labeling to occur on any item that went into a container or was opened; -He/She expected the label to include the date it was opened and date it is to be thrown out; -He/She referred to signage on refrigerator on how long food items were good for; -He/She expected staff to throw out leftovers right away unless staff thought they could use them right away; -Spices could be kept for 1 year after opening. During an interview on [DATE] at 2:47 P.M., [NAME] A said: -He/She did not know how long spices could be maintained before needing to be thrown away; -Food that was prepared could be kept for three days; -He/She referred to the list on the refrigerator on how long other items could be kept and maintained; -Whatever cook got around to doing it was responsible for throwing out leftover food; -Dietary Manager would throw out leftovers when it got bad enough. During an interview on [DATE] at 3:05 P.M., Dietary Aide C said: -He/She should put a label on items write after he/she puts something in container or opens it; -All opened items should have a date on them; -Leftovers could be kept for three days; -Condiments and dressings could be kept longer than three days. During an interview on [DATE] at 9:14 A.M, Dietary Aide A said: -He/She should date and label items if he/she opens up item and places it in a container; -Most food is thrown away after three days; -He/She kept vegetables and pureed food; -They discussed labeling and dating food at last in-service; -All staff were responsible for throwing out leftovers. During an interview on [DATE] at 9:58 A.M., Registered Dietician said: -He/She expected foods to be dated and labeled; -He/She expected leftovers to be removed after three days; -Spices could be maintained for 1 year after date of opening. During an interview on [DATE] at 4:05 P.M., Administrator said: -He/She expected spices to be disposed of after one year from opening date; -He/She expected foods to be dated and labeled; -He/She expected leftovers to be disposed of within three days. 4. Facility did not provide a policy or manual on the low-temperature dishwasher sanitation use. Observation on [DATE] at 9:38 A.M. showed -Dishwashing machine racks were stored directly on floor; -Top of machine was covered in residue; -Cook A loaded dishwasher and started a load. During an interview on [DATE] at 9:38 A.M. [NAME] A said he/she did not know how to test the dishwasher. During an interview on [DATE] at 9:41 A.M. Dietary Manager said: -He/She did not know how to run a test strip on the low-temperature dishwasher to ensure it was running properly; -He/She could tell if dishwasher was running properly just by listening to the sound it made; -Staff were supposed to run a test strip every day but not at any certain time of day; -He/She had never been show how to properly test the dishwasher; -A lot of his/her training had been to just figure things out as he/she went; -He/She just had chemical guy out and he/she found that the dishwasher was running too much sanitizer and he/she turned the sanitizer down; Observation of low temperature dish machine log, dated [DATE], showed: -No entries were recorded on log for: -Breakfast: ,d+[DATE], ,d+[DATE], ,d+[DATE], and ,d+[DATE]; -Lunch: ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE],,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and ,d+[DATE]; -Dinner: ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and ,d+[DATE]. Observation of Dietary Manager running low temperature dishwasher on [DATE] at 9:45 A.M., showed: -Dietary Manager obtained hydrion test strips to test the low temperature dishwasher, compared strip to device showing it was at 150. Observation on [DATE] at 10:16 A.M. showed: -Dietary Aide B ran a test cycle of low temperature dishwasher with machine running at 124 degrees; -Dietary Aide B used different test strips than Dietary Manager had used at 9:45 A.M. observation; -Dietary Aide B stuck chlorine test strips; -He/She recorded the temperature and strip reading on the low temperature dish machine log During an interview on [DATE] at 10:16 A.M., Dietary Aide B said: -He/She had not tested the dishwasher machine yet today; -He/She had used the dishwasher off and on all morning to wash dishes; -He/She had worked in kitchen for four years. 5. Facility did not provide a policy on sanitizer use or cleaning of food preparation surfaces in kitchen. Observation on [DATE] at 10:16 A.M. showed Dietary Aide B prepared a red sanitizer bucket. Dietary Aide B stuck a hydrion strip (used in dietary sanitation by reacting with specific sanitizers and changing color, which is then compared to a color chart to determine the sanitizer solution's concentration) into the water. The hydrion test strip showed blue/green and compared to the chart on the strips container read the sanitation levels was 500 parts per million (PPM). During an interview on [DATE] at 10:16 A.M., Dietary Aide B said: -He/She did not normally test the sanitizer solution for proper sanitation; -He/She did not know why the buckets were not tested ; -He/She did not know why the test strip was darker than normal. Observation on [DATE] at 10:22 P.M. showed Dietary Aide B using a bottle of comet ,d+[DATE] with bleach to spray down a three-tiered food cart. He/She then dipped a wash cloth in solution in the silverware container and wiped down the carts. Washcloth was then placed in red sanitizer bucket. Dietary Aide B then dipped hands in red sanitizer bucket, and pulled clean dishes off the dishwasher and placed trays upside down on three tiered cart that was still observed to be wet. Review of directions for use, comet ,d+[DATE] with bleach, showed: -Shake well; -Spray ,d+[DATE] inches from the surface; -Let stand for 30 seconds or longer; -Wipe and rinse thoroughly with water. Review of safety data sheet, comet cleaner with bleach ,d+[DATE], revised [DATE], showed: -Restrictions on use: Do not mix with other cleaning products or chemicals as irritating fumes may be formed; -Wash hands thoroughly after handling. Observation on [DATE] at 8:00 A.M. in the kitchen showed the dietary manager wiped down kitchen preparation surface where meatloaf had just been prepared with a wash cloth from the green bucket. During an interview on [DATE] at 8:01 A.M. Dietary Manager said he/she generally tried to use the sanitizer wipes on the surface after he/she washed them down with detergent. Review of healthcare disinfecting wipes label showed: -Directions for use: Rinse food contact surfaces with clean, potable water after applying. Do not use to disinfect dishes, glassware, or utensils; -To clean, Deodorize or Disinfect: Remove pre-saturated wipe. Apply pre-saturated wipe to desired non-porous surface to e disinfected and must be wiped until visibly wet and remain visibly wet for the duration of contact time. A 2 minute contact time is required to kill the bacteria and viruses on the label. A 5 minute contact time is required to kill Serratia marcescens, Norwalk virus, feline calicivirus, and norovirus. For Sars-COV-s, treated surfaces must remain visibly wet for 1 minute; -To Clean: If surfaces are visibly dirty, clean first with another cloth before disinfecting. Discard used cloth in trash; -Precautionary statements: Hazards to humans and domestic animals. Causes moderate eye irritation. Avoid contact with skin, eyes or clothing. Wash thoroughly with soap and water after handling and before eating, drinking, chewing gum, using tobacco or using the toilet. Remove and wash contaminated clothing before use. Observation on [DATE] at 8:17 A.M. showed Dietary manager swept floor, did not wash his/her hands, then used healthcare wipes to wipe off surfaces to wipe off stainless steel food preparation table surface where meatloaf had been prepared. He/She then went and loaded dishes into dishwasher, used hand sanitizer at doorway, and pulled clean dishes off clean side of dishwasher. During an interview on [DATE] at 8:22 A.M., Dietary Manager said: -He/She delimed the dishwasher once a week; -The dishwasher was responsible for de-liming the dishwasher. Observation on [DATE] at 8:23 A.M. showed the low-temperature dishwasher had not been tested for the day. Observation on [DATE] at 9:24 A.M. showed [NAME] A added sanitizer to red bucket. He/She did not test sanitizer and placed bucket in dishwashing area. [NAME] A then seen wiping down steam table with a washcloth. Washcloth was then left out on steam table. Observation on [DATE] at 9:42 A.M. showed washcloth used to wipe steam table by [NAME] A remained laying on steam table. Observation on [DATE] at 10:20 A.M. showed Dietary Aide B filled out low temperature dishwasher log. Several loads of dishes had already been ran at time of testing. Observation on [DATE] at 10:45 A.M. showed [NAME] A used green detergent bucket to wipe off stainless steel food preparation surface where ingredients had been mixed for creamed peas. Surface was not wiped with sanitizer following detergent use. During an interview on [DATE] at 2:08 P.M., Dietary Aide B said: -He/She liked to use bleach cleaner to wipe down surfaces in kitchen; -He/She used the sanitizer solution to wash his/her hands before getting clean dishes off dishwasher; -He/She did not use sanitizer solution for anything else; -He/She did not use the healthcare wipes in kitchen; -He/She preferred to use the bleach spray to clean items. During an interview on [DATE] at 2:23 P.M., Dietary Manager said: -He/She did not test sanitizer solution buckets or log testing anywhere; -Sanitizer solutions were supposed to be changed every 2 hours; -The morning cook or Dietary Manager was responsible for changing sanitizer solution. During an interview on [DATE] at 2:47 P.M., [NAME] A said: -He/She used the green detergent buckets with the soap and then used the red sanitizer buckets; -He/She did not use spray chemicals; -He/She did use the healthcare disinfecting wipes; -He/She did not know if there was a surface time for the wipes proper use as he/she had not read the label; -The healthcare wipes in the kitchen were food safe wipes; -Dietary Manager indicated to him/her that they had not seen the wipes until corporate was in the building and ordered them; -He/She did not know who was responsible for de-liming the dishwasher; -Facility sometimes ran out of dishwashing chemicals; -Dishes were still ran through dishwasher even when we did not have chemicals for the machine. During an interview on [DATE] at 3:05 P.M., Dietary Aide C said: -He/She did not always have healthcare wipes; -He/She would use sanitizer solution buckets and a clean washcloth to wipe stuff down; -He/She preferred to use bleach wipes because they would get rid of Kool-Aid stains; -He/She did not usually use red sanitizer solution buckets in the dining room but instead would add sanitizer solution to the silverware buckets; -He/She placed a washcloth and sanitizer solution in the fourth compartment of the silverware holder and would use that to wipe things down in dining room. During an interview on [DATE] at 9:14 A.M, Dietary Aide A said: -He/She used sanitizer solution and a clean washcloth to wipe down food preparation surfaces in kitchen; -Sanitizer solution was tested every two hours; -He/She believed the dietary manager tested the sanitizer solution; -He/She washed dishes; -He/She tested the dishwasher by turning power button on and water was running through clean; -He/She would run a load through the dish washer by itself without anything in it; -He/She uses a test strip and look at thermometer and log the temperature on clipboard which had a log for the d

Based on interviews and record review, the facility failed to consider the views of resident council and act promptly upon grievances and recommendations made by the group when the facility failed to demonstrate their response to the council on follow up actions. This affected all the residents serving on the resident counsel and potentially other residents of the facility. The facility census was 67. Review of facility policy, Nursing Home Resident Rights, undated, showed residents can organize and participate in resident and family groups; Review of Resident Council Reports, showed: - 3/13/25 Issues brought up included bed sheets not being changed during shower days, staff not passing medications, and no fruit. There was no response from the facility to the resident council on past issues or grievances; - 3/6/25 Issues brought up included call lights not being answered quickly, food complaints, and wash clothes and hand towels not available. There was no response from the facility to the resident council on past issues or grievances; - 2/19/25 Issues brought up included vending machines prices too high, changing bandages during meal time, food suggestions, and a request for an internal survey of food likes by residents. There was no response from the facility to the resident council on past issues or grievances; - 2/13/25 Issues brought up included medications sitting on the bedside table, not picking up trash, coffee wanted early in the morning, no fresh fruit, and not knocking on door prior to entering resident's room. There was no response from the facility to the resident council on past issues or grievances; - 2/7/25 Issues brought up included night shift is noisy, food complaints and no fresh fruit. There was no response from the facility to the resident council on past issues or grievances; - 1/28/25 Issues brought up included improper transfers, roommate issues, more psychiatry services offered, running out of briefs, staff rudeness, and food temperatures. There was no response from the facility to the resident council on past issues or grievances; 1. During a group interview of the resident council on 3/19/25 at 9:57 A.M.: - Seven of seven residents said they were not presented with answers to the resident council issues and grievances from previous meetings and this creates distrust between the council and the facility staff and it's frustrating since they feel they are not being listened to or taken seriously; - One resident said that the Social Services person is in charge of grievances, but does not get back to the council to report on the results; During an interview on 3/19/25 at 1:10 P.M., Activities Director said: -The resident council does not get a copy of the minutes of each meeting that is held. -She or another staff member will take the notes and create the minutes of the meeting and turn it over to Social Services for action. -She does not know why they don't get a copy or how the process works on resolving the residents reported issues and concerns; During an interview on 3/19/25 at 1:40 P.M., Social Services Director said: - She did not know that the residents could have a copy of the minutes of each meeting; - All grievances or complaints that come from the resident council are identified to an individual resident and responses are given directly to that resident and no reports are made to the council on resolution or outcomes; During an interview on 3/20/25 at 4:00 P.M., Administrator said the resident council should be provided with resolutions or updated regarding the issues brought up by the council, in previous meetings.

Based on observation, record review and interview, the facility failed to ensure they informed residents of their rights periodically during the residents' stay both orally and in writing. This affected all residents at the facility. The facility census is 67. Review of facility Nursing Home Resident's Rights policy, undated, showed: - The law requires nursing homes to promote and protect the rights of each resident; - All residents have the right to be fully informed of the facility rules, regulations,and provided a written copy of the resident's rights; - The policy did not specifically indicate when these rights should be communicated with the residents. During a group interview on 3/19/25 at 9:57 A.M. seven of seven residents said: - They had not received education about their resident rights within the last year; - They were unable to identify their resident rights or know if they were being honored by the facility due to lack of education on the subject; Review of the previous resident council meeting minutes showed: - 3/13/25, no documentation that resident rights were reviewed; - 3/6/25, no documentation that resident rights were reviewed; - 2/19/25, no documentation that resident rights were reviewed; - 2/13/25, no documentation that resident rights were reviewed; - 2/7/25, no documentation that resident rights were reviewed; - 1/28/25, no documentation that resident rights were reviewed; During an interview on 3/19/25 at 1:10 P.M., the Activity Director said: -She facilitated resident council meetings; -She had not gone over resident rights during resident council meetings; During an interview on 3/19/25 at 1:40 P.M., the Social Services Director said the last time she remembered training for resident rights at the facility was about 13 months ago. During an interview on 3/20/25 at 4:00 P.M., the Administrator said residents should receive training on resident rights at least quarterly.

Based on observation and interview, the facility failed to protect the resident's rights when the facility did not provide training to the resident's regarding the State Long Term Care Ombudsman program or how to file a complaint with the State Survey Agency. This had the potential to affect the rights of all residents. The facility census was 67. Review of facility policy, Nursing Home Residents' Rights, undated, showed the resident has the right to be fully informed of contact information for the long-term care ombudsman program and the state survey agency; During a group interview on 3/19/25 at 9:57 A.M. the residents said: - Seven out of seven residents had not received training on the Ombudsman program or on how to contact the state to file a grievance; - Six of seven residents did not know what the Ombudsman position was or what their function entailed; - Five of seven residents could not identify where the Ombudsman poster was posted in the facility; - Seven of seven residents did not know how to file a complaint with the State of Missouri; During an interview on 3/19/25 at 1:40 P.M., Social Services Director said the last time she remembered training for the Ombudsman program or on contacting the State Agency to file a grievance was about 13 months ago; During an interview on 3/20/25 at 4:00 P.M., Administrator said: - No training is provided regarding the Ombudsman program because the Ombudsman comes into the facility monthly and talks to the residents. - There is a sign posted up front on how to contact the state agency to file a complaint and there is no training done on this topic.

Based on observations, interviews and record review, the facility failed to maintain a clean, comfortable, and homelike environment when the facility failed to maintain quiet noise levels during the night shift that affected five resident (Residents #27, #31, #43, #45, #58), failed to limit the use of the overhead paging system, which affected (Resident #43), failed to provide a room free of obstacles and homelike (Resident #5), and failed to maintain cleaning standards for showers and rooms (Residents #10, #24). This affected eight of 17 residents sampled. The facility census was 67. A policy for providing a homelike environment, housekeeping and maintenance of the facility was requested and not provided for review. Record review of resident council meeting notes showed: - 3/13/25 Dirty bed sheets not being changed on shower days; - 3/6/25 Dirty bed sheets not being changed on shower days; - 2/13/25 Staff being noisy during night shift, trash not being picked up; - 2/7/25 Staff being noisy during night shift; 1. Review of Resident #5's Annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/21/25, showed: - Cognitive skills intact; - Dependent on staff for toileting hygiene, showering, lower body dressing and chair/bed to chair transfers; - Uses a wheelchair for mobility; - Diagnoses included hypertension (high blood pressure), paraplegia (partial or complete paralysis of lower half of body), GERD (Gastroesophageal reflux disease, stomach disorder), diabetes (chronic insufficiency of insulin production), and hyperlipidemia (high cholesterol); During an observation of resident's room on 3/17/25 at 3:50 P.M., showed: - Floor sticky when walking on it. The door to the resident's room when opened hits the edge of Resident #5's bed. Resident #5 observed lying in bed on a low air loss mattress Staff was observed entering the room and hitting the edge of the bed with the door,due to the proximity of the bed to the door, and also walked into an electrical air pressure monitoring device for the mattress, causing it to dangle off the footboard of the bed. The staff member did not reattach the device to the footboard but instead left it hanging sideways with only one hanger attached and did not address the issue of the bed being hit by the door. During an interview on 3/17/25 at 3:52 P.M., resident said: - Due to his/her lack of mobility and amputated right leg the resident's bed will move a bit when staff reposition him/her while in the bed; - The door is constantly hitting the edge of the bed and it's quite annoying and wakes him/her up at night when staff comes in to check on him/her when he/she is sleeping. During an interview on 3/20/25 at 11:48 A.M., Resident #5's family member said: - The resident's room is too small for them to have their own TV with the way it is arranged and with the large bed installed. -The resident suffers because they don't have a clear view to the window, because the privacy curtain blocks the view. 2. Review of Resident #58's Annual MDS, dated [DATE], showed: - Cognitive skills intact; - Diagnoses included heart failure (heart cannot pump enough blood to meet the body's needs), renal insufficiency (kidney impairment), diabetes (chronic insufficiency of insulin production), and hyperlipidemia (high cholesterol); During an interview on 3/18/25 at 3:03 P.M.,the resident said the call light system at the nurses' station is very close to his/her room and every time a call light goes on it makes noise and will continue to make noise until the light is answered. The noise is loud enough for him/her to hear and it is very frustrating and annoying especially at night when he/she is trying to sleep. He/she has brought up the issue as a concern at resident council but nothing has been done about it; 3. Review of Resident #45's Significant Change MDS, dated [DATE], showed: - The resident has severe cognitive impairment; - Diagnoses included anemia (low level of red blood cells), hypertension (high blood pressure), hip fracture, Alzheimer's disease (progressive brain disorder), and Parkinson's disease (progressive neurological disorder); During an interview on 3/19/25 at 4:18 P.M., resident said he/she doesn't like loud noises at night and staff are loud at night when he/she is trying to sleep. He/she said the noise level is very annoying because it makes it hard for him/her to sleep. 4. Review of Resident #43's Quarterly MDS, dated [DATE], showed: - Cognitive skills intact; - Diagnoses included hypertension (high blood pressure), obstructive uropathy (urine flow is blocked in the urinary tract), diabetes (chronic insufficiency of insulin production), and depression; During an interview on 3/20/25 at 9:14 A.M., the resident said: - The overhead speaker is too loud and is very annoying because he/she has to stop talking each time it goes off and the other person can't hear what he/she is saying. At yesterday's resident council meeting, it was very frustrating because the overhead speaker went off at least 5 or 6 times over a 90 minute period. Last night the staff were singing during the night shift and it was bothersome and made it difficult for him/her to sleep. This noise level is loud quite often in the evenings during sleeping hours; During an observation on 3/17/25 at 10:40 A.M., showed room [ROOM NUMBER] refrigerator had food stains inside and on top of unit; During an observation on 3/18/25 at 11:11 A.M., showed room [ROOM NUMBER] had trash (paper and debris) on the ground not cleaned up; During an observation on 3/18/25 at 11:12 A.M., showed room [ROOM NUMBER] refrigerator remained unchanged, dirty with food stains inside and on top of refrigerator. During a continuous observation on 3/18/25 at 3:00 P.M. showed the overhead announcing system going off about 1 time every 15 minutes over a span of 90 minutes which was loud enough to stop all conversations going on in the Activities room. The announcements would notify staff members they had a phone call or requesting that a certain staff member report to a location within the facility; During an observation on 3/19/25 at 10:10 A.M. showed the North side nurses' station was asked how to contact the maintenance department so an interview could be conducted. The staff member at the desk did not pick up the phone next to them to call down to the maintenance office but instead paged two different maintenance staff members over the facility loudspeaker to come to the nurses' station immediately; During an interview on 3/19/25 at 10:15 A.M., the Maintenance Director said anyone of the staff can move a bed if it's in the way of the door. If staff need help they can contact Social Services and/or Maintenance department and it will be a joint effort to determine how to re-arrange the room best for the resident. During an observation on 3/19/25 at 2:15 P.M., of the North Shower Room showed: - Black debris on the floor in the shower and under the chair in the showering area; - Dirty wash clothes hanging from the handrails in the shower; - Overflowing trash can with half eaten pizza on a paper plate; - Toilet with dried feces inside the bowl; - Open chemical bottle of cleaning solution on the floor under the sink next to bagged up trash; - Therapeutic tub filled with coat hangers and PPE boxes; During an interview on 3/19/25 at 2:20 P.M., CNA E said: - The black chunks in the North shower room floor are most likely feces from a resident and the shower aide performing the shower should have cleaned it up after the resident was done with their shower. The overflowing trash can with half eaten pizza and bagged trash should have been cleaned up as well by the shower aide and staff are not allowed to eat in the shower room; - Housekeeping is responsible for cleaning the toilets and does the showers once daily; Record review of the housekeeping schedule showed the North shower room is deep cleaned by housekeeping once a week on Saturdays; During an interview on 3/20/25 at 4:00 P.M., Administrator and Director of Nursing (DON) said: - If an entrance door to a resident room is hitting a corner of the bed the room should be re-arranged and the issue brought up to the nursing staff then to housekeeping and maintenance departments; - Would expect that the overhead speaker in the facility should be used as infrequently as possible; - Staff should utilize the phone first to reach other staff members rather than going to the overhead intercom system first; - Resident refrigerators should be cleaned by housekeeping and it's done on a schedule; - Expectations are that showers are cleaned and sanitized between residents and it is expected that the shower aide would do this function; - Pizza should not be discarded in the shower room trash and the trash should not be overflowing. 47195 5. Review of Resident #10's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 2/18/25, showed: -Cognition severely impaired; -He/She had clear speech -He/She made self-understood and usually understood others; -He/She had no impairment to range of motion in upper and lower extremities; -He/She was dependent on a wheelchair; -He/She was dependent on staff for oral care, toileting, bathing, dressing, personal hygiene, and all mobility; -He/She required substantial/maximal assistance with eating; -Diagnoses included: stroke, depression, psychotic disorder, repeated falls, Review of care plan, revised 2/11/25, showed: -He/She had an activities of daily living self-care performance deficit due to dementia, impaired mobility, and history of frequently refusing a shower saying she had one already when she had not yet been showered; -He/She was dependent on assist of two staff with bed mobility; -He/She was dependent assistance of one staff for personal hygiene; -He/She was dependent with wheelchair for mobility; -He/She was incontinent of bowel and needed assistance with peri care when incontinence occurs. Observation on 3/18/25 at 1:15 P.M. showed resident was transferred by staff from his/her bed to his/her reclining wheelchair chair. A gel seat cushion was observed in residents chair with brown stains and feces on it. Staff placed resident in his/her mechanical sling directly on gel cushion with feces. Observation on 3/20/25 at 6:32 A.M. showed residents reclining chair was sitting outside resident's room in hallway with his/her gel seat cushion laying in seat of chair with brown discoloration and feces. 6. Review of Resident #24's Quarterly MDS, dated [DATE], showed: -Cognition moderately impaired; -He/She required partial to moderate assistance with toileting hygiene and bathing; -He/She was not on a urinary toileting program; -He/She was occasionally incontinent; -Diagnoses included: unsteadiness on feet, muscle wasting or atrophy, muscle weakness, Observation on 3/17/25 at 10:38 A.M. showed the resident's room flooring was sticky and feet stuck to the floor as attempted to walk across resident's side of the room. Observation on 3/19/25 at 11:56 A.M. showed the floor was sticky on resident's side of the bed and walking caused shoes to stick to the floor. During an interview on 3/18/25 at 8:55 A.M., Housekeeper A said: -Resident could not hold his/her bladder and was incontinent three to four times a day, urinating all over the floor; -Housekeeping staff go into resident's room three to four times a day to mop the floor due to resident's incontinence; -Resident's urine makes the floor sticky. 7. Review of Resident #27's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 1/8/25, showed: -He/She had clear speech; -Cognition moderately impaired; -Hearing minimally difficult; -He/She had clear speech; -Diagnoses included: Parkinson's disease , depression, difficulty in walking, unsteadiness on feet, weakness. Revise of care plan, revised 1/15/25, showed: -He/She was independent with bed mobility; -He/She had depression with major depressive disorder; During an interview on 3/17/25 at 11:12 A.M., Resident said: -Staff pass water at night when he/she was trying to sleep and it was loud; -Staff would talk really loud in the hallway at night when he/she was trying to sleep. Observation on 3/20/25 at 5:09 A.M., showed staff could be heard talking from conference room in room [ROOM NUMBER] and staff were down the hallway at nurses station across from rooms [ROOM NUMBERS]. Observation on 3/20/25 at 5:11 A.M., showed staff members yelling and then Licensed Practical Nurse (LPN) A was heard singing a repetitive song of 'I don't care what you want' and then a repetitive song of 'gobbly [NAME], gobbly goo, gobbly' from room [ROOM NUMBER] from down the hall across from room [ROOM NUMBER] and 409. Observation on 3/20/25 at 5:15 A.M., showed LPN A was seated at nurses station singing. During an interview on 3/20/25 at 5:16 A.M., LPN A said: -He/She was jamming out; -He/She had always been a signer but only when nobody was listening; -He/She hoped he/she was singing on key if they had been heard. 8. Review of Resident #31's Admission MDS, dated [DATE], showed: -Cognition intact; -He/She had clear speech; -He/She usually made self-understood others and had clear comprehension of others; -He/She had no impairment in upper or lower extremity range of motion; -He/She was dependent on walker and wheelchair; -He/She required supervision or touching assistance for mobility, toileting, bathing, lower body dressing; -He/She was independent with personal hygiene, and eating; -Diagnosis included diabetes, hyperlipidemia, seizure disorder, malnutrition, gastroenteritis During an interview on 3/17/25 at 2:09 P.M., Resident said: -Staff fill up his/her ice pitcher with ice and water between 2-3 A.M. when he/she was trying to sleep -He/She did not understand why staff refilled water pitchers at that hour; -Staff pushed open his/her door and wake him/her up during the night; -He/She thinks the staff could do this earlier in the evening or later in the morning to not disturb his/her sleep. Observation on 3/20/25 at 5:46 A.M. showed trash and soiled linen carts were wheeled down 300 hallway and were making loud noise as they were rolled through halls. Observation on 3/17/25 at 11:01 A.M. showed room [ROOM NUMBER] has crack in ceiling where paint is peeling away from surface of ceiling. During an interview on 3/20/25 at 4:05 P.M., Director of Nursing (DON) said: -He/She expected residents to be offered a quiet sleeping environment during the overnight hours; -He/She did not expect night shift to be singing and yelling down the halls during their shift while residents were sleeping. During an interview on 3/20/25 at 4:05 P.M., Administrator said: -He/She expected residents to be provided with a quiet sleeping environment; -He/She expected staff to not be singing and yelling during their shift causing residents to be awakened.

Based on observation, interview and record review the facility failed to develop and implement a comprehensive resident-centered care plan that met the needs of five residents (Resident #29, #36, #65, #62, and Resident #60). The care plans failed to identify changes in the resident's condition and did not address it in the plan of care for the staff interventions for side rails on Resident #60, did not address Infection prevention and enhanced barrier precautions for Residents #36, #62, and #65, and additionally did not address a resident's indwelling urinary catheter for one resident (Resident #29) This affected five of the 17 sampled residents. The facility census was 67. Review of the facility's Care Planning Policy, revised 6/2020., showed: - The purpose of a care plan is to develop a comprehensive patient centered care plan based on the individual needs of the resident. - In the event of changes in the resident needs or goals, these changes will be updated in the resident's plan of care. - Each care plan will help to ensure the resident attains or maintains their highest practicable physical, mental and psychosocial well being. - The Interdisciplinary team (IDT) will address changes to the care plan as dictated by changes in the resident's condition, and care. 1. Review of Resident #36's Quarterly MDS (Minimum Data Set) A federally mandated assessment, completed by facility staff, dated 1/9/25., showed: - Cognition severely impaired; - Diagnoses of: Wound Infection, yeast Infection, and stroke with right side paralysis; - Max assist of two for all activities of daily living (ADLS). Review of the resident's care plan, dated 2/28/25., showed: - No care planning regarding wound infection. - No care planning regarding yeast infection, or areas of concern. - Care plan states the resident has Covid 19 when the resident does not have an active Covid -19 illness. 2. Review of Resident #62's Quarterly MDS, completed on 3/5/25., showed: - Cognition was not intact. - No infections in the last 30 days. - Diagnoses included: Stroke, and Dementia - Assist of one for all ADLS. Review of the resident's care plan, last updated 6/2024, showed: - No care plan regarding a recent UTI (urinary tract infection) 3-9-25 - No care plan regarding a diagnoses of Shingles start date of 3-14-25 or the treatment interventions for staff. - No care plan regarding the resident having a rash. 3-14-25 3. Review of Resident #65's Significant Change MDS, dated [DATE]., showed: - Cognition not intact. - Dependent on staff for all ADLS. - Diagnoses: Pneumonia, and a Urinary Tract Infection (UTI) in the last 30 days Review of the resident's care plan, dated 2/2025., showed: - No care plan to address the resident's indwelling urinary catheter since start of catheter on 2/4/24. - Care plan states the resident is incontinent of urine, wears an incontinent brief and has re-occuring UTI. - Care plan does not address isolation precautions for the resident with an UTI and an indwelling urinary catheter. During an interview on 3-19-25 at 12:22 P.M., the MDS Coordinator said: - Wound infections, and any infections should be care planned. - Resident's with indwelling urinary catheters should be care planned. - The current needs or concerns regarding the resident should be care planned. - She completes the initial comprehensive care plans, but updates and changes are completed by the Director of Nursing (DON) or Assistant Director of Nursing (ADON) or Social Work for psychosocial needs. During an interview on 3/20/24 at 4:20 P.M., The Director of Nursing said: - Resident care plans should be updated to reflect the current needs of the residents - Resident's with urinary catheters should be care planned. - Resident's with infections should be care planned. - Resident's with shingles or rashes should be care planned. 47195 4. Review of Resident #60's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 2/27/25, showed: -Cognition moderately impaired; -He/She had clear speech; -He/She made self-understood and had clear comprehension of others; -He/She had no impairment to range of motion in upper or lower extremities; -He/She did not use bed rail; -Diagnoses included: memory deficit follow stroke, stroke (a medical emergency when blood flow to the brain is interrupted), lack of coordination, difficulty in walking, and legal blindness. Review of care plan, revised 3/10/25, showed: -Bed mobility was independent with turning and repositioning in bed; -He/She should have supervision or touching assistance for transfers. He/She required reminders to wait for assistance. -His/Her bed should be in low position with fall beds in place when he/she was in bed; -U-shaped cane rails were not care planned. Review of physician's orders, dated 3/18/25, showed and order with a start date of 1/23/25, left mobility bar to head of bed to allow resident to assist with bed mobility and transfers. Observation on 3/17/25 at 10:32 A.M. showed that resident had a u-shaped cane rail on the left side of his/her bed. Review of safety device evaluation, dated 1/22/25, showed: -He/She requested mobility bar for his/her bed; -He/She intended to use bar to improve turning from side to side, moving up and down in bed, holding self to one side, pulling self from laying to sitting position, improving balance during transfer, supporting self during transfer, exiting, entering, and transferring into bed more safely. Review of safety device consent, dated 1/22/25, showed: -He/She had mobility bar on left side of bed; -He/She consented to mobility bar on 1/22/25. During an interview on 3/20/25 at 8:39 A.M., MDS Coordinator said: -He/She was responsible for ensuring care plans were updated on all residents; -He/She expected residents with side rails to have the side rails included in their care planned; During an interview on 3/20/25 at 10:21 A.M., Certified Nurse Aide (CNA) E said: -Resident did her own thing with sitting up using the side rail; -He/She would hang on to the side rail as he/she walked beside the bed or would get in and out of bed. During an interview on 3/20/25 at 1:35 P.M., CNA D said the resident used side rails when he/she got changed, got his/herself in and out of their bed, and used side rails walking beside his/her bed. During an interview on 3/20/25 at 1:54 P.M., CNA B said the resident used his/her side rails for transfers and rolling. During an interview on 3/20/25 at 4:05 P.M., Director of Nursing (DON) said he/she expected side rails to be included in care plans. During an interview on 3/20/25 at 4:05 P.M., Administrator said he/she expected side rails to be included in care plans.

Based on record review and interview the facility failed to ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs, and that each resident and resident representative, if applicable, is involved in developing the care plan and making decisions about his or her care. This affected four residents (Resident #40, #65, #38, & #47) out of the 17 sampled residents. The facility census was 67. Review of the facility's Care Planning Policy, revised 6/2020., showed: - The purpose of a care plan is to develop a comprehensive patient centered care plan based on the individual needs of the resident. - In the event of changes in the resident needs or goals, these changes will be updated in the resident's plan of care. - Each care plan will help to ensure the resident attains or maintains their highest practicable physical, mental and psychosocial well being. - The Interdisciplinary team (IDT) will address changes to the care plan as dictated by changes in the resident's condition, and care. - Resident's and family should be invited and allowed to be part of the resident's care plan. 1. Review of Resident #65's Significant Change MDS, dated [DATE]., showed: - Cognition not intact. - Dependent on staff for all ADL'S. - Diagnoses: Pneumonia, and a Urinary Tract Infection (UTI) in the last 30 days. Review of the resident's care plan, dated 2/2025., showed: - No care plan to address the resident's indwelling urinary catheter since start of catheter on 2/4/24. - No care plan to address the resident's pneumonia or risk factors for pneumonia. - Care plan states the resident is incontinent of urine, and wears an incontinent brief and has re-occuring UTI. - Care plan does not address isolation precautions for the resident with an UTI and an indwelling urinary catheter. - Care plan states the resident is being treated for Covid. Resident did not have COVID in March of 2025. 50980 2. Review of Resident #40's Quarterly MDS, dated [DATE], showed: - Resident cognitive skills intact; - Substantial assistance from staff for toileting hygiene and bathing; - Dependent on staff for lower body dressing and footwear; - Partial assistance from staff for personal hygiene; - Diagnosis: hypertension (high blood pressure), neurogenic bladder (loss of bladder control); diabetes (chronic disease when body can't produce insulin), stroke, hemiplegia (weakness on one side of the body), asthma (chronic lung disease); Review of the resident's care plan conference, dated 12/5/24, showed: - Resident was notified of the care plan conference but did not attend; - Resident representative did not attend and there was no reason entered; During an interview on 3/17/25 at 11:01 A.M., resident said he/she did not remember ever being invited to a care plan meeting or participating in a meeting with staff to discuss his/her care plan; During an interview on 3/18/25 at 4:07 P.M., resident family member said: - He/she is the responsible party that is contacted for all issues related to the resident; - He/she has not been invited to attent a care plan meeting regarding the resident; 3. Review of Resident #38's Quarterly MDS, dated [DATE], showed: - Resident has moderate cognitive impairment; - Resident is independent for all activities for daily living (ADL's) and requires supervision for bathing; - Diagnosis: debility (physical weakness), heart failure, asthma, and respiratory failure (insufficient oxygen); Review of the resident's care plan conferences showed: - 9/9/24 resident declined to attend care plan meeting and that the family was notified of the care plan meeting and did not attend; - 12/12/24 resident declined to attend care plan meeting and resident representative was notified and choose not to attend; During an interview on 3/18/25 at 9:05 A.M., resident said he/she does not remember ever being invited to a care plan meeting or attending one in the past; During an interview on 3/18/25 at 4:07 P.M., resident family member said: - He/she is the responsible party for the reisdent and should be contacted for all issues related to the resident; - The last time he/she was contacted to attend a care plan meeting was the summer of 2024; 4. Review of Resident #47's Quarterly MDS, dated [DATE], showed: - Resident has severe cognitive impairment; - Resident requires staff supervision for oral hygiene, lower body dressing, and personal hygiene; - Resident requires moderate staff assistance for bathing and donning footwear; - Diagnosis: Non-traumatic brain dysfunction (brain damage), hypertension, and dementia (decline in cognitive abilities); Review of resident's care plan, revised 11/4/24, showed the resident wishes to stay at the facility long term and staff should discuss with resident and/or family guardian any concerns that they might have regarding long-term placement; During an interview on 3/20/25 at 11:30 A.M. resident said: - He/she has never been invited to a care plan meeting and he/she does not want to live in the facility long term. He/she does not know his/her discharge plan or how he/she can leave the facility, but his/her ultimate goal is to live on his/her own; - The resident never told staff that he/she wanted to live in the facility long term; During an interview on 3/19/25 at 10:25 A.M., Care Plan Coordinator said: - Residents and/or guardians are invited to care plan meetings and they try to hold them on Thursdays and they can be conducted via phone if the family member cannot make it into the facility; - Care plan meetings are held Quarterly or sooner if required due to a change in condition of the resident; During an interview on 3/19/25 at 11:20 A.M., Social Services Director said the facility invites the family members and residents to care plan meetings if they would like to attend; During an interview on 3-19-25 at 12:22 P.M., the MDS Coordinator said: - Wound infections, and any infections should be care planned. - Resident's with indwelling urinary catheters should be care planned. - The current needs or concerns regarding the resident should be care planned. - She completes the initial comprehensive care plans, but updates and changes are completed by the Director of Nursing (DON) or Assistant Director of Nursing (ADON) or Social Work for psychosocial needs. During an interview on 3/20/24 at 4:00 P.M., The Director of Nursing said: - Resident care plans should be updated to reflect the current needs of the residents - Resident's with urinary catheters should be care planned. - Resident's with infections should be care planned. - Resident's with shingles or rashes should be care planned. During an interview on 3/20/24 at 4:00 P.M., the Administrator said residents and/or family members/guardians should be included in care plan meetings.

Based on observation, interview and record review the facility failed to ensure the licensed staff maintained professional standards of quality in care and services according to accepted standards of clinical practice, when licensed staff did not follow through on known infections in the building by ensuring resident's with infections or those who were at risk for infections were identified, isolated appropriately and with proper posted signage outside the room. As well as ensuring that personal protective equipment was accessible and provided for staff to carry out care for the residents in the correct manor according to the infection. Additionally, this failure did not ensure ancillary staff or visitors who entered the resident's rooms were aware of the need for transmission based precautions. The facility additionally failed to offer and document yearly immunizations for four residents (Residents #9, #11, #41, #46). This had the potential to affect all residents in the building. The facility census was 67. Review of the facility's Infection prevention and control policy, undated., showed: - The infection preventionist coordinates the development and monitoring of the facility established infection control policies and procedures. - Reports information related to infection control to the administrator and the infection control committee. - Provides infection control related information to the nursing staff and physicians. - Consults on infection risks, and and prevention control strategies. - Provides education and training to staff regarding infection prevention and isolation. - Ensures infection surveillance and monitoring of infection control practices are in place. - Ensures access to isolation supplies, gowns, gloves, masks, etc, supplies are on hand and accessible for handling infectious wastes, blood, and body fluids. - Maintain on premises current CDC (Center for Disease Control), OSHA (Occupational Safety Heath Administration), and federal and state regulations guidelines and recommendations relative to infection control issues in healthcare facilities. - To ensure residents that require transmission based precautions are used when care for resident's with communicable diseases or transmittable infections, such as Varicella (Shingles), wound infections, infection related diarrhea-C-Diff (Clostridium-Difficile), Multi drug resistant organisms (MDRO) for Urinary Tract Infections (UTI). - To ensure residents who have MDRO, Indwelling devices such as urinary catheters, feeding tubes, vascular catheters-such as dialysis catheters, wounds, and unhealed pressure ulcers -should be placed on enhanced barrier precautions. - Ensure that the facility provides and maintains an effective disease prevention program by offering and administering preventative vaccines, such as Pneumococcal Vaccine, Influenza, and Covid-19 Vaccines. 1. Review of Resident #36's Quarterly MDS (Minimum Data Set) A federally mandated assessment, completed by facility staff, dated 1/9/25., showed: - Cognition severely impaired; - Diagnoses of: Wound Infection, yeast Infection, and stroke with right side paralysis; - Max assist of two for all activities of daily living (ADLS). Observation on 3/17/25 at 1:00P.M. showed the resident' was not on Enhanced Precautions for active infection and no PPE (personal protective equipment) available for staff outside the room. There was no isolation alert sign posted outside or inside the room. Observation on 3/19/25 at 2:00P.M. showed a green sign posted to the outside of the door that read-Stop, Please See The Nurse Before Entering. No type of isolation was posted. PPE holder on the door were empty. Observation on 3/20/25 at 9:35 A.M., showed an isolation sign posted on the resident's door that read Enhanced Barrier Precautions. Review of the resident's care plan, dated 2/28/25., showed: - No care planning regarding wound infection. - No care planning regarding yeast infection, or areas of yeast concern. Review of resident's nursing progress notes for the month of February 2025 showed: - Resident was positive for wound infection and had an active yeast infection, both receiving treatments by licensed staff. 2. Review of Resident #62's Quarterly MDS, completed on 3/5/25., showed: - Cognition was not intact. - No infections in the last 30 days. - Diagnoses included: Stroke, and Dementia - Assist of one for all ADL'S. Observation on 3/17/23 at 11:30 A.M. showed the resident lying in bed, without a room mate. Observation on 3/17/25 at 1:05P.M. showed the resident' was not on any transmission based isolation precautions for active infection and no PPE available for staff outside the room. There was no isolation alert sign posted outside or inside the room. Observation on 3/19/25 at 2:00P.M. showed a green sign posted to the outside of the door that read-Stop, Please See The Nurse Before Entering. No type of isolation was posted. PPE holder on the door were empty Review of the resident's care plan, last updated 6/2024, showed: - No care plan regarding a recent UTI (urinary tract infection) 3-9-25 - No care plan regarding a diagnoses of Shingles start date of 3-14-25 or the treatment interventions for staff. - No care plan regarding the resident having a rash. 3-14-25 Review of resident's nursing progress notes for the month of February 2025 showed: - The resident was currently receiving oral and topical medications for a diagnosis of Shingles. ( Herpes-Zoster. A contagious viral rash that requires specific isolation precautions to prevent the spread to others) 3. Review of Resident #65's Significant Change MDS, dated [DATE]., showed: - Cognition not intact. - Dependent on staff for all ADL'S. - Dependent of staff for tube feedings through a gastric feeding tube (a tube that is inserted through the abdominal wall into the stomach for nutrition). - Diagnoses: Pneumonia, and a Urinary Tract Infection (UTI) in the last 30 days. Observation on 3/17/25 at 1:15P.M. showed the resident was not on any transmission based isolation precautions for active infection and no PPE available for staff outside the room. There was no isolation alert sign posted outside or inside the room. Observation on 3/18/25 at 3:20 P.M showed the resident's tube feeding tubing and water bag tubing had not been changed out in the last 24 hours. Observation on 3/19/25 at 2:00P.M. showed a green sign posted to the outside of the door that read-Stop, Please See The Nurse Before Entering. No type of isolation was posted. PPE holder on the door were empty Observation on 3/20/25 at 9:35 A.M., showed an isolation sign posted on the resident's door that read Enhanced Barrier Precautions. Review of the resident's care plan, dated 2/2025., showed: - No care plan to address the resident's indwelling urinary catheter since start of catheter on 2/4/24. - Care plan states the resident is incontinent of urine, wears an incontinent brief and has re-occuring UTI. - Care plan does not address isolation precautions for the resident with an UTI and an indwelling urinary catheter. - The care plan states the resident as infection of the bowels- C-Diff. Review of resident's nursing progress notes for the month of February 2025 showed the resident had an active bowel infection and was being treated for C-Diff as well as a UTI. 4. Review of Resident #56's Admission MDS, dated [DATE]., showed: - Cognition not intact; - Diagnoses included: Kidney failure, Insulin dependent diabetic, and Hemodialysis (HD) recipient (The removal and cleaning of the blood, when the kidneys can no longer clean and filer the blood). Observation on 3/17/25 at 1:20 P.M., showed the resident was not on Enhanced Barrier Precautions, and no PPE available for staff outside the room. There was no isolation alert sign posted outside or inside the room. Observation on 3/20/24 at 12:20 P.M., showed the resident was not on Enhanced Barrier Precautions and no PPE. Review of the resident's care plan, dated 2/11/25., showed: - The resident had an (AV-Fistula) Arterial Venous Fistula implant ( An implant that provides direct access between an artery and a vein creating a larger, stronger blood vessel) for vascular access for HD access. - HD appointments scheduled as M,W,F chair time. Review of resident's nursing progress notes for the month of February 2025 showed the resident had an AV-Fistual and was being monitored every shift for changes. 52044 5.Review of Resident #11's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 01/23/25, showed: -Cognition moderately impaired; -He/She had clear speech with usually clear comprehension -He/She made self-understood and usually understood others; -He/She was dependent on a wheelchair but able to navigate chair herself; -He/She was mostly independent regarding oral care, toileting, bathing, dressing, personal hygiene, and mobility; -He/She required minimal assistance with eating -BIMS (Brief Interview of mental status) of 9 meaning moderate impairment. Review of Resident #11's Face Sheet showed: -Diagnoses included: Multiple Sclerosis (MS), a chronic, autoimmune disease that affects the centran nervous system (CNS), including the brain and spinal cord -A seizure disorder -Irregular heart rate called supraventricular tachycardia (SVT) -Hypertension or high blood pressure. Review of Resident #11's CarePlan dated 1/30/2025 showed no information regarding vaccinations or immunizations. Review of the Facility's Immunization record and Administration records on 03/19/25 10:00 A.M. for Resident #11 showed the last administered influenza vaccination was given on 10/18/23. No refusal was obtained and no administration for the influenza vaccination was given during the year of 2024. 6.Review of Resident #41's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 01/09/2025, showed: -Clear and normal conversation -Clear speech -BIMS of 14 meaning no impairment -No behaviors exhibited -Used wheelchair for mobility -Mostly Independent with ADLS, needing assistance with transfers and showers -Minimal assistance with meals Review of Resident #41's Face Sheet showed: -Anemia, when your blood produces a lower than normal amount of health red blood cells. -Orthostatic Hypotension, a condition where blood pressure drops significantly upon standing up from a sitting or lying position. -Renal Insufficiency, this occurs when the kidneys do not function properly. -Diabetes Mellitus, a chronic condition that affects how the body uses glucose (sugar) for energy. -Anxiety, a common mental health condition characterized by excessive worry, fear, and nervousness. -BiPolar disorder, a chronic mental health condition characterized by extreme shifts in mood, energy, and behavior. Review of Resident #41's CarePlan showed no information regarding vaccinations or immunizations. Review of the Facility's Immunization record and Administration records on 03/19/25 at 09:34 A.M. for Resident #41 showed the last administered influenza vaccination was given on 10/16/2023. No refusal was obtained and no administration for the influenza vaccination was given during the year of 2024 or 2025. 7. Review of Resident #46's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 01/17/2025, showed: -Minimal difficulty with hearing -Speech clear and comprehended communications -No Behaviors exhibited -Used a walker -Required set up for meals -Required supervision with oral hygiene -Required partial assistance with bathing -Participates in goal setting -BIMS of 7 meaning severe impairment Review of Resident #46's Face Sheet showed: -Non Traumatic brain dysfunction meaning abnormal brain functionality not due to trauma or injury -Hypertension, or high blood pressure -Dementia, or loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life Review of Resident #46's Care Plan showed no information regarding vaccinations or immunizations. Review of the Facility's Immunization record and Administration records on 03/19/25 at 10:30 A.M. for Resident #46 showed the last administered influenza vaccination was given on 10/18/2023. No refusal was obtained and no administration for the influenza vaccination was given during the year of 2024 or 2025. 8. Review of Resident #9s Discharge Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 03/05/25, showed: -BIMS 15, no impairment -No behaviors exhibited -Influenza vaccine received on 11/04/2024 Review of Resident #9's Face Sheet showed he/she was admitted on [DATE]. Review of Resident #9's CarePlan showed no information regarding vaccinations or immunizations. Review of the Facility's Immunization record and Administration records on 03/19/25 at 10:45 A.M. for Resident #9 showed the resident was ineligible due to the influenza vaccine already was administered in the fall of 2019 so it was not due. No refusal was obtained and vaccination was not documented in the eMAR as administered during the years of 2020, 2021, 2022, 2023, and 2024. During an interview on 3/18/25 at 10 :05 A.M the Infection Prevention Nurse said: -She was in charge of Infection Control and wound care for the building. -She was unable to provide the information regarding which resident's should be on isolation and what type. -She was not aware that there was no signage posted on the residents doors for those who should be on isolation. -She was not aware that resident's who had C-Diff, and Shingles were not on Transmission Based Precautions. -She was not aware of Enhanced Barrier Precautions or which resident's in the building met criteria for that Isolation type. -She was not aware that there was no PPE posted outside of or behind the doors of the rooms that should be on isolation. -They didn't have the correct signage to post outside of the resident's doors. -They had recently had Covid-19 in the building and were now short on PPE supplies. -She was aware of one resident had Shingles because she alerted two pregnant staff members in the building to not go in that resident's room. During an interview on 3/19/25 at 1:20 P.M the FNP (Family Nurse Practitioner) said: - He expected residents with transmissible infections to be placed on the correct isolation measures, with appropriate signage and PPE. - He ordered medication for Shingles and included the diagnoses of Shingles in the order, but now believes it was just a rash. -Residents should be offered immunizations yearly. During an interview on 3/20/25 at 4:15 P.M. the Director of Nursing said: - Residents with known transmissible infections should be placed on the appropriate types of isolation measures. - Resident with C-Diff should be on transmission based isolation precautions. - Residents with wounds, indwelling catheters, implanted devices should be on enhanced barrier precautions. - Residents with Shingles should be placed on transmission based isolation precautions. - PPE should be readily available to all staff providing care to residents. - Isolation signage should be posted so all staff and visitors know what type of PPE or precautions should be followed. - Every resident should be offered yearly immunizations for pneumonia, flu, and Covid-19.

Based on observation, record review, and interviews, the facility failed to ensure the correct installation, use, and maintenance of bed rails included assessing residents for risk of entrapment from bed rails prior to installation, ensure the bed's dimensions were appropriate for the resident's size and weight, and follow the manufacturers' recommendations and specifications for installing and maintaining bed rails. The facility also failed to include an evaluation of attempted alternatives prior to the installation or use of a bed rail on resident beds. This included three of 17 residents sampled (Resident #2, #27, and #60). The facility census was 67. Facility did not provide a policy on bed rails or entrapment. 1. Review of Resident #2's Quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 1/24/25, showed: -Cognition intact; -He/She had clear speech, was able to make self-understood and clearly comprehend others; -He/She had no impairment to range of motion on upper or lower extremities; -He/She was dependent on a wheelchair; -He/She required substantial or maximal assistance with upper body dressing; -He/She was dependent for lower body dressing, sit to lying transfers, chair to bed transfers, and tub transfers; -He/She did not use bed rail. -He/She required partial to moderate assistance rolling left and right; -Diagnoses included: diabetes, fracture, lack of coordination, dementia history of falling. Review of care plan, revised 3/11/22, showed: -He/She requested bilateral enabling devices to assist with turning, repositioning and bed mobility; -He/She would continue to utilize bilateral enabling device as indicated for bed mobility assistance over the next assessment period; -He/She would demonstrate ability to use safely use enabling devices for positioning, transfer, and bed mobility -Bilateral enabling devices consents signed and in resident's chart prior to placement of enabling devices. Consent to be renewed yearly; -Educate resident on risk and benefit of enabler device use; -Evaluation for use of enabling devices will be completed prior to placement of enabling devices and will be reviewed quarterly; -Physician order for bilateral enabling device use. Review of physician's orders, dated 3/18/25, showed an order dated 2/23/22 for bilateral positioning u-rails to the bed to assist the resident with bed mobility and transfers. Observation on 3/17/25 at 10:40 A.M. showed u-shaped cane rail on right side of residents bed. During an interview on 3/17/25 at 10:47 A.M., Resident said: -He/She fell last December and he/she had not done well since that time; -Staff had to get him/her up and down in a mechanical lift; -Side rails help him/her turn and reposition in his/her bed; -Prior to fall he/she had been able to get up and walk and go to bathroom independently. Review of safety device evaluation, dated 1/22/25, showed: -Resident requested device, mobility bar for bed; -Device would improve residents quality of life by turning side to side, moving up and down in bed, holding self to one side, pulling self from laying to sitting position, the device would not impede residents ability to independently perform activities of daily living (ADLS); -Ambulation status was non-ambulatory/wheelchair mobile with assist, non weight bearing, sitting balance: slides down, ADL's - requires total assist of one; -Physical limitations included a history of falls, vision status, adequate with glasses, orientation: Forgetful/short attention span, comprehension: follows directions, behaviors: no fears or anxieties expressed, medication therapy: currently taking antidepressants; -Risk and precautions: Resident, alternatives discussed with resident, -Safety device consent form signed: yes Review of electronic medical record showed: -Safety Device Evaluations were completed quarterly: -6/12/24, Score 5.0; -3/12/24, score 3.0 -2/3/24, score 3.0 -11/3/23, score 8.0 -8/2/23, score 11.0 -5/1/23, score 2.0 Review of safety device consent, dated 3/12/24, showed: -Consent was check marked yes, I do consent to safety device; -No signature found on document. During an interview on 3/20/25 at 10:21 A.M., Certified Nurse Aide (CNA) E said: -Resident was able to use side rails to roll themselves side to side; -He/She used to hold onto side rails during transfers, but resident was no longer ambulatory and now relied on mechanical lift. During an interview on 3/20/25 at 1:35 P.M., CNA D said: -The resident used side rails to help roll and pull self up in bed; -The resident is now a mechanical lift and no longer uses them to get in and out of bed. During an interview on 3/20/25 at 1:54 P.M., CNA B said: -The resident used side rails for rolling back and forth and pulling self up in bed; -The reisdent used side rails in the past to transfer self but the reisdent no longer was able to stand and no longer used the rails. 2. Review of Resident #27's Quarterly MDS, dated [DATE], showed: -He/She had clear speech; -Cognition moderately impaired; -He/She had no impairment to range of motion on upper or lower extremities; -He/She was dependent on walker or wheelchair for mobility; -He/She was independent with upper and lower body dressing, toileting, personal hygiene, and was independent with most mobility; -He/She did not use bed rail; -Diagnoses included: Parkinson's disease, aphasia (difficulty with talking), seizure disorder, depression, lack of coordination, difficulty in walking, unsteadiness on feet, weakness. Review of the residents care plan, revised 5/1/23, showed: -He/She required bilateral enabling devices to assist with turning, repositioning and bed mobility; -He/She would be educated on risk and benefit of enabler device use. -He/She would have evaluation completed prior to placement and quarterly of enabling devices; -Physician order obtained for enabler device use. Review of physician's orders, dated 3/19/25 showed: -Ordered 5/1/23, Bilateral mobility bars at head of bed to allow resident independence with bed mobility and assist with transfers. Also chooses to have left side of her bed against the wall. Observation on 3/17/25 at 11:15 A.M. showed resident had right two u-shaped cane rails on both sides of the bed. During an interview on 3/17/25 at 11:15 A.M., resident said he/she used the right side rail only to get up and position out of his/her bed. Review of safety device evaluation, dated 1/23/25, showed: -Device requested by resident and his/her responsible party; -Would improve resident's quality of life by aiding in turning side to side, moving up and down in bed, holding self to one side, pulling self from laying to sitting position, improving balance during transfer, supporting self during transfer, and entering, exiting, and transferring from bed more safely; -He/She ambulated with assist of one staff; -He/She was full weight bearing; -Education of risk and precautions were discussed with resident and responsible parties; -Safety device consent form was checked that it had been signed. Review of electronic medical record, dated 3/18/25, showed no safety device consent found or signature located. During an interview on 3/20/25 at 10:21 A.M., CNA E said the resident used his/her side rails for getting in and out of bed during transfers. During an interview on 3/20/25 at 1:35 P.M., CNA D said: -The resident used side rails to gets his/herself in and of bed; -The side rails were also used with his/her transfers. During an interview on 3/20/25 at 1:54 P.M., CNA B said: -The side rails helped the reisdent with mobility; -The reisdent used side rails for transfers. 3. Review of Resident #60's Quarterly MDS, dated [DATE], showed: -Cognition moderately impaired; -He/She had clear speech; -He/She made self-understood and had clear comprehension of others; -He/She had no impairment to range of motion in upper or lower extremities; -He/She did not use bed rail; -Diagnoses included: memory deficit follow stroke, stroke (a medical emergency when blood flow to the brain is interrupted), lack of coordination, difficulty in walking, and legal blindness. Review of care plan, revised 3/10/25, showed: -The resident was independent with turning and repositioning in bed; -The resident should have supervision or touching assistance for transfers. - The resident required reminders to wait for assistance. -The residents bed should be in low position with fall beds in place when he/she was in bed; -U-shaped cane rails were not care planned. Review of physician's orders, dated 3/18/25, showed an order with a start date of 1/23/25, for a left mobility bar to head of bed to allow resident to assist with bed mobility and transfers. Observation on 3/17/25 at 10:32 A.M. showed that resident had a u-shaped cane rail on the left side of his/her bed. Review of safety device evaluation, dated 1/22/25, showed: -He/She requested mobility bar for his/her bed; -He/She intended to use bar to improve turning from side to side, moving up and down in bed, holding self to one side, pulling self from laying to sitting position, improving balance during transfer, supporting self during transfer, exiting, entering, and transferring into bed more safely; -He/She ambulated with assist of one; -He/She was full weight bearing; -He/She had history of falls; -He/She was legally blind; -Education of risk and benefits were discussed with resident and resident representative. Review of safety device consent, dated 1/22/25, showed: -He/She had mobility bar on left side of bed; -He/She consented to mobility bar on 1/22/25; -His/Her responsible party consented on 1/22/25 at 2:08 P.M. via verbal phone consent. -No signed consent form found in electronic medical record for resident. During an interview on 3/20/25 at 10:21 A.M., CNA E said: -The resident did her own thing with sitting up using the side rail; -The reisdent would hold on to the side rail as he/she walked beside the bed or would get in and out of bed. During an interview on 3/20/25 at 1:35 P.M., CNA D said the resident used side rails when he/she got changed, got his/herself in and out of their bed, and used side rails walking beside his/her bed. During an interview on 3/20/25 at 1:54 P.M., CNA B said the resident used his/her side rails for transfers and rolling. During an interview on 3/20/25 at 5:43 A.M., Licensed Practical Nurse (LPN) B said: -He/She notified staff that resident wanted side rails put on; -He/She believed therapy assessed residents for the side rails to be placed; -Maintenance installed the side rails on the beds. During an interview on 3/20/25 at 8:20 A.M., Maintenance Director said: -Facility did not offer bed rails, they only offered assist rails; -He/She installed assist rails only after the Director of Nursing (DON) had completed his/her assessments and told him/her they could install the assist rails on resident's bed; -He/She did not have documentation when he/she installed side rails on resident beds; -He/She checked the facility maintenance tracking system log and did not keep installation requests or completions in this log; -He/She measured all four sides of the mattress including the head, foot, and between the rails; -He/She did not keep documentation of those measurements; -The DON kept all assist rail measurements and assessments documentation; -He/She completed measurements of assist rails when the assist rails were first installed; -He/She did not do regular measurements on assist rails of entrapment zones. During an interview on 3/20/25 at 8:50 A.M. DON said: -He/She completed assessments for side rails; -He/She obtained consent for side rails; -Residents would verbally ask him/her for side rails; -No staff were allowed to authorize side rails to be put on bed besides him/her; -He/She did not do measurements for areas or zones of entrapment; -He/She obtained verbal consent if resident could not sign for themselves; -He/She found that a lot of times resident's family requested the side rails; During an interview on 3/20/25 at 4:05 P.M., DON said he/she expected measurements to be taken to ensure there was no risk of entrapment when side rails were installed on beds. During an interview on 3/20/25 at 4:05 P.M., Administrator said he/she expected entrapment measurements to be taken on beds with side rails.

Based on observation and interviews, the facility failed to ensure staff served food to the residents that was palatable, attractive, and served at a safe and appetizing temperature to the residents when hot food was not served at an appetizing temperature to four of seventeen sampled residents (Resident #27, #32, #37, and #69). The facility failed to prepare dietary menus according to their recipes by not using recipe ingredients resulting in bland and tasteless food and the facility failed to serve dessert at appropriate holding temperature. The facility census was 67. Review of facility policy, food temperatures, revised 1/1/25, showed: -Foods prepared and served in the facility will be served at proper temperatures to ensure food safety. -At starting of meal services Hot Foods should be above 135 degrees Fahrenheit (F) and cold foods should be served below 41 degrees F; -Acceptable serving temperatures: -Cereal, gravy 135 degrees; -Meat, entrees, greater than 135 degrees; -Pureed foods, greater than 135 degrees; -Vegetables, Greater than 135 degrees -Hazardous salads, dessert, less than 41 degrees; -Pastries, cakes, less than 60 degrees; -Eggs, greater than 135 degrees; -If temperatures did not meet the required serving temperatures listed above, reheat the product or chill the product to the proper temperature. 1. Review of Resident #27's Quarterly Minimum Data Set, (MDS,a federally mandated assessment the facility staff complete), dated 1/8/25, showed: -He/She had clear speech; -Cognition moderately impaired; -He/She required set up or clean up assistance with eating; -He/She usually made self-understood and usually understood others; -Diagnoses included: Parkinson's disease without dyskinesia; aphasia, seizure disorder, depression, lack of coordination, dysphagia, abnormal posture, and weakness. Review of care plan, revised 2/12/24, showed he/she was independent with eating once meal was set up for him/her. During an interview on 3/17/25 at 11:14 A.M. Resident said sometimes his/her food was cold in the morning. During an interview on 3/18/25 at 8:53 A.M. Resident said his/her breakfast was cold that morning when it was served to his/her room. 2. Review of Resident #32's Quarterly MDS, dated [DATE], showed: -Cognition intact; -He/She made self-understood and had clear comprehension of others; -He/She required set up or clean up assistance with eating; -Diagnoses included diabetes (too much sugar in the blood) and malnutrition (condition that occurs when person did not receive enough nutrients or energy to meet their body's needs); Review of care plan, revised 10/5/24, showed he/she was independent with eating and preferred to eat in his/her room. During an interview on 3/17/25 at 11:37 A.M, Resident said: -Food was not seasoned; -He/She would get served chili with no chili seasoning in the chili; During an interview on 3/18/25 at 8:56 A.M., Resident said: -Facility meatloaf was tasteless; -He/She had not had meatloaf that did not have any seasoning added to it. 3. Review of Resident #37's annual minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 1/26/25, showed: -Cognition intact; -He/She had clear speech; -He/She made self-understood and usually understands or comprehends most conversation; -He/She had mechanically altered diet, therapeutic diet, and parenteral/IV feeding while a resident; -His/her average fluid intake per day by IV or tube feeding was 501 cc/day -Diagnoses included: diabetes, stroke, type 2 diabetes mellitus without complications, and dysphagia. Review of care plan, revised 1/13/25, showed he/she was able to eat independently after his/her tray was set-up. During an interview on 3/18/25 at 8:56 A.M., Resident said: -His/Her juice was warmer than his/her eggs; -Food was cold when it was served to his/her room. 4. Review of Resident #69's Admission MDS, dated [DATE], showed: -Cognition moderately impaired; -He/She made self-understood and had clear comprehension of others; -He/She required supervision or touching assistance with eating; -Diagnoses included malnutrition, chronic pain, oropharyngeal dysphagia (difficulty swallowing due to problems in the stage where food and liquids are moved from mouth to the upper esophagus). Review of care plan, revised 3/8/25, showed he/she required supervision assistance to eat with participation of one person. During an interview on 3/17/25 at 9:30 A.M., Resident said: -Food is cold when it gets to him/her; -He/She ate his/her meals served in their room. During an interview on 3/17/25 at 3:58 P.M., Resident's Representative said food is typically gel when it gets to his/her room. 5. Review of facility policy, menus, revised 1/1/25, showed: -Dietary manager will collaborate with the registered dietician to develop menus in advance. -Food served should adhere to written menu. Review of facility recipes: -Meatloaf with ketchup glaze showed: -16 and 1/4 pounds (lbs.) ground beef; -16 and 1/4 Eggs; -4 minced yellow onions; -1 quart and 1 tablespoon (Tbsp) plain bread crumbs; -1 lb and 8 ounces (oz) tomato paste; -1 cup and 1 teaspoon (tsp) Worcestershire sauce; -1 cup and 1 teaspoon minced garlic; -1/2 cup Italian seasoning; -1 Tbsp 1 tsp iodized salt; -1 Tbsp black ground pepper, -3 cups and 1 Tbsp Ketchup -Oven temperature 350 degrees - In mixer bowl, combine ground beef, egg, onion, bread crumbs, tomato paste, Worcestershire sauce, garlic, Italian seasoning, salt, and pepper; mix on low speed 2-3 minutes just until blended. Do not over mix. - Spray steam table pans with nonstick cooking spray. Place meat mixture into steam table pan and shape into equal loaves. - Bake 30 minutes; remove pans from oven. - Spread ketchup evenly on top of each meatloaf. Return to oven and bake 30-35 minutes or until desired internal temperature is reached. Final cooking temperature 155 degrees F or above for 17 seconds. Maintain holding 135 or above. - Allow meatloaf to rest 10 minutes, tented with foil, before slicing. Serve 3 oz slice per portion. -Creamy custard pie: -10 inch graham cracker pie crust; -1 quart liquid eggs; -1 lb., 8 oz sugar; -tsp salt -1 gallon milk; -2 Tbsp vanilla; -2 tsp. -Preheat oven to 350. - Place graham cracker crusts on sheet pans. - Beat eggs with sugar, salt, and vanilla until well combined and smooth. - Scald milk; cool slightly; - Add scalded milk to egg mixture slowly while whisking constantly to avoid scrambling eggs. - Pour mixture into pie shells. Approximate 3 cups per pie. - Sprinkle nutmeg evenly over tops of pies. - Bake 30 minutes or until a knife inserted halfway between the edge of pan and the center of the pie comes out clean and desired internal temperature is reached. Let cool. Cut each pie into 8 slices. Maintain holding 41 degrees F or below. During a continuous observation of kitchen preparation on 3/19/25 from 7:33 A.M.-12:20 P.M. showed: -7:33 A.M., Dietary manager said that he/she did meatloaf a little different because he/she did not use breadcrumbs but substituted oatmeal instead and did not use tomato paste due to facility having residents that could not tolerate tomato. It took him/her three hours to prepare meatloaf so they started preparing the meal early. -7:33 A M., [NAME] A started meatloaf preparation by placing 2-8lb rolls of ground beef in large metal container, then he/she cracked eggs into container, minced onions were observed already cut up an in measuring cup and were added to ground beef container; -Cook A indicated he/she had cut up 2 onions; -7:39 A.M. [NAME] A added quick oats to measuring cup and added to pan, and 1/2 cup of salt free seasoning added to pan; -7:41 A.M. [NAME] A began mixing meat loaf ingredients with gloved hands; -7:44 A.M., [NAME] A told dietary manager that he/she would need to take over the meatloaf preparation while he/she had to leave serve breakfast; -7:53 A.M., Dietary Manager observed placing meatloaf into two pans; -7:56 A.M., Dietary Manager placed meatloaf in oven; -7:57 A.M. Dietary manager said the first hour and thirty minutes the meatloaf went into the conventional oven; -7:58 A.M. Timer set on oven for thirty minutes; -Observation showed that recipe was not followed when no minced garlic, Italian seasoning, Worcestershire sauce, or tomato paste was added according to dietician menu recipe. -8:16 A.M., showed preparation tables behind stove had pie crusts on baking sheets covered with parchment papers; -8:32 A.M., [NAME] A returned to kitchen with food carts from dining room and placed breakfast containers onto steam table. [NAME] A then began serving up hall trays; -8:48 A.M., North hall tray left kitchen; -8:52 A.M., Food was not temperature checked since it had returned to kitchen and placed on steam table for room tray service; -9:00 A.M., Test tray left kitchen on 500 hall cart; -9:08 A.M. Test tray received and tested with Director of Nursing (DON) and Dietary Manager present: -Eggs were temperature checked at 112.4 degrees F, and were not at safe serving temperature; -biscuits and gravy temperature checked 116.6 degrees F, were not at safe serving temperature; -Sausage patty temperature checked 108 degrees F, were not at safe serving temperature; -Oatmeal temperature checked 138.5 degrees F; -9:31 A.M., Timer went off on oven, [NAME] A removed meatloaf from oven, meatloaf observed pink in color; -9:33 A.M., [NAME] A placed meatloaf from conventional oven to convection oven; -10:36 A.M. [NAME] A removed meatloaf out of convection oven and advised Dietary Manager meatloaf was not done and wanted to know what temperature he/she wanted convection oven at; -10:38 A.M. [NAME] A placed meatloaf back in oven; -10:42 A.M. Dietary manager told [NAME] B that he/she needed to take care of filling and whipped cream for the pies; -10:49 A.M. [NAME] A removed meatloaf from oven, removed foil, temperature checked first pan of meatloaf at 140.1 and still rising as cook A removed thermometer from pan and pan 2 was 160.6 degrees. [NAME] A stated he/she planned to add glaze and place back in oven. Review of recipe showed final cooking temperature was 155 or above for 17 seconds, meatloaf not temperature checked for 17 seconds; -11:07 A.M. [NAME] B obtains bowl from fridge of a white pie filling substance and started to fill pie crusts using a scoop; -11:18 A.M., [NAME] A temperature checked meat loaf, pan one tested 171 degrees F and pan two 169.2 degrees (2 hours and 22 minutes after initially placed in oven), meatloaf placed back in oven; -11:19 A.M., [NAME] B added cook whip to top of white pie filling mixture that was in each pie pan; -11:27 A.M., [NAME] A asking Dietary Manager how to apportion 3 oz of meatloaf per recipe as he/she did not know how to accurately proportion the meal per menu. Dietary Manager advised [NAME] to cut the meatloaf as he/she normally did as they could not measure proper portions due to not having a scale; -11:48 A.M., Meatloaf removed from oven and temperature checked at 189.9 degrees F. -11:53 A.M. Observation of pies showed pie filling was spreading off of crust, and whipped cream was running off top of pie crust; -12:00 P.M. [NAME] A said Dietary Manager pre-made the pie mixture that morning and he/she did not know if he/she followed a recipe; -12:14 P.M. [NAME] B pushes hot box out of kitchen to begin lunch service in dining room; -12:16 P.M. [NAME] B observed temperature checking food on steam table and custard pie; -12:26 P.M. First lunch tray served in dining room; -12:53 P.M. Test tray showed custard pie was above appropriate serving temperature at 66.7 degrees, the recipe indicated maintain holding at 41 degrees or below. Meatloaf taste tested was bland with little flavor and meat was dry. Custard pie was observed to be runny and not formed on the plate. During an interview on 3/19/25 at 2:23 P.M., Dietary Manager said: -He/She expected food to be temperature checked every meal and every food item as items are pulled from oven or stove and when it went on steam table; -He/She was aware of food temperatures being an issue especially with residents who received room trays and resided on far end of building; -Residents on 400 hall had especially had an issue with food temperatures; -After breakfast was served in main dining room it was returned to kitchen and placed back on steam table, food was not temperature checked again once it was back in kitchen and on steam table before serving room trays. -He/She sends a special food cart for resident #32 and #36 due to frequent complaints and makes their breakfast fresh; -Resident #69 complained about food being cold so we added his/her tray to same serving cart with Resident #32 and Resident #36; -He/She expected food to be served at a palatable temperature. During an interview on 3/19/25 at 2:47 P.M., [NAME] A said: -He/She temperature checked food when cooking and in dining room; -He/She did not temperature check food when it came back to kitchen before serving room trays at breakfast; -He/She was confused when making the meat loaf because he/she did not know how to measure out the ounces for the serving sizes as he/she normally just chopped up and had never weighed food before serving it; -He/She was aware of complaints about the taste of food regarding food tasting bland; -He/She was still working on seasoning; -He/She ordered new seasoning and just ordered salt-free seasoning; -He/She normally did not measure out ingredients or look at dietician recipe book; During an interview on 3/20/25 at 9:58 A.M., Registered Dietician said: -He/She expected food temperatures to be tested after the cooking process, before serving, and in the middle of meal service depending on how long the meal service takes; -He/She expected a test tray to be completed at end of meals to ensure appropriate temperatures of meal service; -He/She expected food to be served at appropriate temperatures and be palatable; -He/She expected staff to follow dietary recipes as were written. During an interview on 3/20/25 at 4:05 P.M., Administrator said: -He/She expected food to be served at a safe and appetizing serving temperature; -He/She expected dietary menu recipes to be followed.

Based on observation, interview, and record review the facility failed to ensure foods that were stored in resident personal refrigerators and freezers were monitored for safe and appropriate temperatures and discard potential spoiled contents to prevent the potential for food-borne illness. The facility census was 67. Facility did not provide a policy on food storage or resident room refrigerators. Review of facility policy, Food Brought in by Visitors, revised ,d+[DATE], showed: -Food may be brought to a resident by the family members, the resident's responsible party, or friends if the food is compatible with the attending physician's diet order; -Perishable food requiring refrigeration will be discarded after two hours at bedside, and if refrigerated it will then be labeled, dated, and discarded after 48 hours. Review of facility policy, food temperatures, revised [DATE], showed: -Foods prepared and served in the facility will be served at proper temperatures to ensure food safety; -Cold foods should be served below 41 degrees Fahrenheit (F). 1. Review of Resident #37's annual minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated [DATE], showed: -Cognition intact; -He/She had clear speech; -He/She made self-understood and usually understands or comprehends most conversation; -He/She required set up or clean up assistance with eating; -Diagnoses included: diabetes, dysphagia, reduced mobility, unsteadiness on feet, and dementia. Observation on [DATE] at 8:15 A.M. of Refrigerator/freezer unit in resident's room showed a log labeled November with only three dates entered with temperature readings. The log showed ,d+[DATE] was 10 degrees, 13th was 48 degrees, 14th 48 degrees, 15th 50 degrees. Observation of the thermometer in refrigerator read 44 degrees. No thermometer was located in the freezer of the unit. During an interview on [DATE] at 8:15 A.M., Resident said: -Staff do not check the temperature on the refrigerator; -He/She defrosted the refrigerator. 2. Review of Resident #32's Quarterly MDS, dated [DATE], showed: -Cognition intact; -He/She made self-understood and had clear comprehension of others; -He/She required set up or clean up assistance with eating; -Diagnoses included diabetes and malnutrition (condition that occurs when person did not receive enough nutrients or energy to meet their body's needs). Observation on [DATE] at 8:15 A.M. of mini refrigerator located on resident's bathroom sink vanity showed no thermometer in the unit. No temperature log found on unit. During an interview on [DATE] at 8:15 A.M. resident said: -He/She cleaned out his/her old food from refrigerator; -He/She kept salsa in the refrigerator for his/her eggs at breakfast. 3. Review of Resident #17's Quarterly MDS, dated [DATE], showed: -Cognition intact; -He/She had clear speech; -He/She made self-understood and had clear comprehension of others; -Diagnoses included: diabetes (too much sugar in the blood), repeated falls, need for assistance with personal care, weakness Observation on [DATE] at 8:25 A.M. showed resident had a temperature log hanging on outsize of refrigerator / freezer combination unit dated November. The log was filled out on nine dates including ,d+[DATE] -24 degrees, ,d+[DATE] - 22 degrees, ,d+[DATE] -22 degrees, ,d+[DATE] -20 degrees, ,d+[DATE] -18 degrees, ,d+[DATE] -20 degrees, ,d+[DATE] -20 degrees, and ,d+[DATE] -22 degrees. No thermometer found inside freezer portion of unit. Freezer showed it was covered in ice and ice was hanging outside and covering the inside top portion of refrigerator. During an interview on [DATE] at 8:25 A.M., Resident said staff did not check the refrigerator temperature. 4. Review of Resident #27's Quarterly MDS, dated [DATE], showed: -He/She had clear speech; -Cognition moderately impaired; -He/She had clear speech; -He/She usually made self-understood and usually understood others; -He/She required set up or clean up assistance with eating; -Diagnoses included: Parkinson's disease without dyskinesia; aphasia, seizure disorder, depression, lack of coordination, dysphagia, abnormal posture, difficulty in walking, unsteadiness on feet, weakness. Observation on [DATE] at 8:25 A.M. of refrigerator unit on his/her side of room showed there was a temperature log on outside of refrigerator labeled November. Temperature readings were documented on log on ,d+[DATE] at 40 degrees, ,d+[DATE] at 32 degrees, ,d+[DATE] at 35 degrees, ,d+[DATE] at 35 degrees, 13th at 40 degrees, 20th at 35 degrees, 22nd at 32 degrees, 29th at 38 degrees. The freezer of the unit was observed to be covered in ice with a very small open area to store food. The freezer had no thermometer in the unit. During an interview on [DATE] at 8:25 A.M., Resident said staff did not check temperatures on his/her refrigerator. 5. During an interview on [DATE] at 5:35 A.M., Licensed Practical Nurse (LPN) B said he/she did not know who was responsible for checking room refrigerator temperatures. During an interview on [DATE] at 10:34 A.M., Housekeeper C said aides were responsible for checking room refrigerator temperatures. During an interview on [DATE] at 1:35 P.M., Certified Nurse Aide (CNA) D said evening shift medication technicians were responsible for logging food temperatures on resident personal refrigerators in their rooms. During an interview on [DATE] at 1:54 P M. CNA B said resident's personal refrigerators were temperature checked by housekeeping. During an interview on [DATE] at 2:04 P.M., Dietary Manager said housekeeping was responsible for checking resident's personal room refrigerator temperatures. During an interview on [DATE] at 2:29 P.M., Director of Nursing (DON) said he/she thought day shift CNA's were responsible for temperature checking resident personal room refrigerators. During an interview on [DATE] at 4:05 P.M., Director of Nursing (DON) said he/she expected personal room refrigerators to be checked daily to ensure safe temperatures of resident foods. During an interview on [DATE] at 4:05 P.M., Administrator said: -He/She expected personal room refrigerators to be checked daily to ensure safe temperatures of resident foods; -He/She expected thermometers to be located in personal room refrigerators and freezers. -Housekeeping was responsible for checking temperatures in resident room refrigerators and also removing expired foods; -Personal room refrigerator temperatures were to be documented on forms located on the outside of refrigerators.

Based on observation, interview and record review the facility failed to ensure infection prevention measures were followed when the facility failed to properly dispose of contaminated personal protective equipment (PPE) for one resident (#52), failed to perform handwashing when serving multiple residents, failed to place four residents on enhanced barrier precautions (Residents #36, #56, #62, and #65), and failed to ensure housekeeping staff were properly trained in disinfection practices for infectious diseases. This affected 5 out of 12 sampled residents, The facility census was 27. Review of the facility's Infection prevention and control policy, undated., showed: - The infection preventionist coordinates the development and monitoring of the facility established infection control policies and procedures. - Reports information related to infection control to the administrator and the infection control committee. - Provides infection control related information to the nursing staff and physicians. - Consults on infection risks, and and prevention control strategies. - Provides education and training to staff regarding infection prevention and isolation. - Ensures infection surveillance and monitoring of infection control practices are in place. - Ensures access to isolation supplies, gowns, gloves, masks, etc, supplies are on hand and accessible for handling infectious wastes, blood, and body fluids. - Maintain on premises current CDC (Center for Disease Control), OSHA (Occupational Safety Heath Administration), and federal and state regulations guidelines and recommendations relative to infection control issues in healthcare facilities. - To ensure residents that require transmission based precautions are used when care for resident's with communicable diseases or transmittable infections, such as Varicella (Shingles), wound infections, infection related diarrhea-C-Diff (Clostridium-Difficile), Multi drug resistant organisms (MDRO) for Urinary Tract Infections (UTI). - To ensure residents who have MDRO, Indwelling devices such as urinary catheters, feeding tubes, vascular catheters-such as dialysis catheters, wounds, and unhealed pressure ulcers -should be placed on enhanced barrier precautions. - Ensure that the facility provides and maintains an effective disease prevention program by offering and administering preventative vaccines, such asPneumococcal Vaccine, Influenza, and Covid-19 Vaccines. 1.Review of Resident #52's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated, 1/10/25, showed: - Resident decision making cognitively intact; - Resident has an indwelling catheter; - Diagnosis: anemia (low level of red blood cells), hypertension (high blood pressure), neurogenic bladder (loss of bladder of control). During an observation on 3/17/25 at 8:30 A.M., showed Resident #52 has a catheter and his/her room is under Enhanced Barrier Protection (EBP) precautions which require gloves and a gown by staff when providing cares to the resident. During an observation on 3/19/25 at 8:40 A.M., showed CMT D entered resident #52's room in required Personal Protective Equipment (PPE) per EBP requirements. After providing cares staff member left the room without any PPE donned. A check of the resident's room showed the PPE discarded in an unmarked and unsealed plastic garbage bag in the trash can in the resident's bathroom which is shared by the resident's roommate. During an interview on 3/19/25 at 8:49 A.M., Resident #52 said that CMT D came into his/her room that morning and was wearing gloves and a gown while providing cares to the resident. He/she said that staff members don't normally wear a gown when entering his/her room. During an observation on 3/18/25 at 8:56 A.M., showed a staff member passing out trays on the 500 hall did not wash his/her hands between serving resident rooms. The staff member left a residents room, touched the outside of the door and grabbed the next tray and served the next resident room. During an observation on 3/19/25 at 8:17 A.M., showed the Activities Director pushed a coffee cart and stopped at a resident's room to prepare a beverage and serve the resident. Next the staff member went to two other resident rooms and served them as well inside of their rooms without washing hands between service; During an observation on 3/19/25 at 8:45 A.M., showed foot therapy staff donned PPE prior to entering an EBP room and provided cares. Upon entering staff member brought out the PPE in a plastic bag which was not sealed and had material protruding from the top of the bag. The staff member placed the bag on the cart they were using for cares and went to the next room to perform cares without properly sealing the trash bag with contaminated PPE. 46987 2. Review of Resident #36's Quarterly MDS (Minimum Data Set) A federally mandated assessment, completed by facility staff, dated 1/9/25., showed: - Cognition severely impaired; - Diagnoses of: Wound Infection, yeast Infection, and stroke with right side paralysis; - Max assist of two for all activities of daily living (ADLS). Observation on 3/17/25 at 1:00P.M. showed the resident' was not on Enhanced Precautions for active infection and no PPE (personal protective equipment) available for staff outside the room. There was no isolation alert sign posted outside or inside the room. Observation on 3/19/25 at 2:00P.M. showed a green sign posted to the outside of the door that read-Stop, Please See The Nurse Before Entering. No type of isolation was posted. PPE holder on the door were empty. Observation on 3/20/25 at 9:35 A.M., showed an isolation sign posted on the resident's door that read Enhanced Barrier Precautions. Review of the resident's care plan, dated 2/28/25., showed: - No care planning regarding wound infection. - No care planning regarding yeast infection, or areas of yeast concern. Review of the nursing progress notes for the month of February 2025 showed the resident was positive for wound infection and had an active yeast infection, both receiving treatments by licensed staff. 3. Review of Resident #62's Quarterly MDS, completed on 3/5/25., showed: - Cognition was not intact. - No infections in the last 30 days. - Diagnoses included: Stroke, and Dementia - Assist of one for all ADL'S. Observation on 3/17/23 at 11:30 A.M. showed the resident lying in bed, without a room mate. Observation on 3/17/25 at 1:05P.M. showed the resident' was not on any transmission based isolation precautions for active infection and no PPE available for staff outside the room. There was no isolation alert sign posted outside or inside the room. Observation on 3/19/25 at 2:00P.M. showed a green sign posted to the outside of the door that read-Stop, Please See The Nurse Before Entering. No type of isolation was posted. PPE holder on the door were empty Review of the resident's care plan, last updated 6/2024, showed: - No care plan regarding a recent UTI (urinary tract infection) 3-9-25 - No care plan regarding a diagnoses of Shingles start date of 3-14-25 or the treatment interventions for staff. - No care plan regarding the resident having a rash. 3-14-25 Review of resident's nursing progress notes for the month of February 2025 showed the resident was currently receiving oral and topical medications for a diagnosis of Shingles. ( Herpes-Zoster. A contagious viral rash that requires specific isolation precautions to prevent the spread to others) 4. Review of Resident #65's Significant Change MDS, dated [DATE]., showed: - Cognition not intact. - Dependent on staff for all ADL'S. - Dependent of staff for tube feedings through a gastric feeding tube (a tube that is inserted through the abdominal wall into the stomach for nutrition). - Diagnoses: Pneumonia, and a Urinary Tract Infection (UTI) in the last 30 days. Observation on 3/17/25 at 1:15P.M. showed the resident was not on any transmission based isolation precautions for active infection and no PPE available for staff outside the room. There was no isolation alert sign posted outside or inside the room. Observation on 3/18/25 at 3:20 P.M showed the resident's tube feeding tubing and water bag tubing had not been changed out in the last 24 hours. Observation on 3/19/25 at 2:00P.M. showed a green sign posted to the outside of the door that read-Stop, Please See The Nurse Before Entering. No type of isolation was posted. PPE holder on the door were empty Observation on 3/20/25 at 9:35 A.M., showed an isolation sign posted on the resident's door that read Enhanced Barrier Precautions. Review of the resident's care plan, dated 2/2025., showed: - No care plan to address the resident's indwelling urinary catheter since start of catheter on 2/4/24. - Care plan states the resident is incontinent of urine, wears an incontinent brief and has re-occuring UTI. - Care plan does not address isolation precautions for the resident with an UTI and an indwelling urinary catheter. - The care plan states the resident as infection of the bowels- C-Diff. Review of resident's nursing progress notes for the month of February 2025 showed the resident had an active bowel infection and was being treated for C-Diff as well as a UTI. 5. Review of Resident #56's Admission MDS, dated [DATE]., showed: - Cognition not intact; - Diagnoses included: Kidney failure, Insulin dependent diabetic, and Hemodialysis (HD) recipient (The removal and cleaning of the blood, when the kidneys can no longer clean and filer the blood). Observation on 3/17/25 at 1:20 P.M., showed the resident was not on Enhanced Barrier Precautions, and no PPE available for staff outside the room. There was no isolation alert sign posted outside or inside the room. Observation on 3/20/24 at 12:20 P.M., showed the resident was not on Enhanced Barrier Precautions and no PPE. Review of the resident's care plan, dated 2/11/25., showed: - The resident had an (AV-Fistula) Arterial Venous Fistula implant ( An implant that provides direct access between an artery and a vein creating a larger, stronger blood vessel) for vascular access for HD access. - HD appointments scheduled as M,W,F chair time. Review of resident's nursing progress notes for the month of February 2025 showed the resident had an AV-Fistual and was being monitored every shift for changes. During an interview on 3/18/25 at 10 :05 A.M the Infection Prevention Nurse said: -She was in charge of Infection Control and wound care for the building. -She was unable to provide the information regarding which resident's should be on isolation and what type. -She was not aware that there was no signage posted on the residents doors for those who should be on isolation. -She was not aware that resident's who had C-Diff, and Shingles were not on Transmission Based Precautions. -She was not aware of Enhanced Barrier Precautions or which resident's in the building met criteria for that Isolation type. -She was not aware that there was no PPE posted outside of or behind the doors of the rooms that should be on isolation. -They didn't have the correct signage to post outside of the resident's doors. -They had recently had Covid-19 in the building and were now short on PPE supplies. -She was aware of one resident had Shingles because she alerted two pregnant staff members in the building to not go in that resident's room. During an interview on 3/18/25 at 2:10 P.M. PT-Aide A., said: -Residents who should be on isolation, should have a sign telling staff know what type of isolation is needed and what type of PPE should be used. -He/She was not aware of which residents on the hall should be on isolation. During an interview on 3/19/25 at 8:30 A.M., LPC C said: - Resident's with infections like C-Diff should have isolation signs on the doors. - Was not sure if resident's with catheters or implanted devices should be on any type of isolation. - He/She was going to go look for isolation signs. - He/She was not aware of any resident with shingles in the building. 52043 6. During an interview on 03/18/25 at 9:00 A.M., Housekeeper B said: - He/she didn't know how to clean c-diff infected surfaces any differently than regular surfaces - He/she uses citric acid on rags for most cleaning. - When asked about a feces covered toilet observed yesterday,he/she stated housekeeping use the same liquid and towel combination and further stated they use that for all the cleaning and wiping down. During an interview on 03/18/25 at 9:31 A.M., Housekeeper A said: - He/she has not dealt with c-diff and doesn't believe they do anything different with cleaning for it. - If there is a large mess of stool or vomit on the ground, the CNA's clean it up then housekeeping comes in to sanitize and if on the floor we have mop stuff and other areas we wipe with the rag and liquid cleaner in the bucket. During an interview on 03/18/25 at 11:01 A.M., Floor Technician said: - He/she uses the GreenEx neutral all purpose cleaner for most cleaning - He/she had no idea what to do differently if dealing with c-diff or isolation room. During an interview on 03/20/25 at 9:30 A.M., LPN A said: - Nursing staff go over cleaning practices with housekeeping regarding infections and how to clean, but housekeeping boss isn't here now so there isn't consistency with how areas are cleaned. - Nursing let housekeeping know what needs wiped with bleach. During an interview on 03/18/25 at 10:14 A.M., Housekeeping Supervisor said: - He/she has been temporarily filling in for housekeeping and laundry since November. - The staff had one on one training and periodic training over cleaners and conditions. - The staff also had one on one with the lead housekeeper. - The main cleaner in Gen X (GreenEx) citric acid cleaner that they started using during covid. - We are not short handed on housekeepers with three full time and a floor tech. - Housekeeper A was pulled from floors due to them not being done well enough and placed in housekeeping. During an interview on 3/19/25 at 1:20 P.M the FNP (Family Nurse Practitioner) said: - He expected residents with transmissible infections to be placed on the correct isolation measures, with appropriate signage and PPE. - He ordered medication for Shingles and included the diagnoses of Shingles in the order, but now believes it was just a rash. During an interview on 3/20/25 at 4:15 P.M. the Director of Nursing said: - Residents with known transmissible infections should be placed on the appropriate types of isolation measures. - Resident with C-Diff should be on transmission based isolation precautions. - Residents with wounds, indwelling catheters, implanted devices should be on enhanced barrier precautions. - Residents with Shingles should be placed on transmission based isolation precautions. - PPE should be readily available to all staff providing care to residents. - Isolation signage should be posted so all staff and visitors know what type of PPE or precautions should be followed. - Housekeeping should know how to clean isolation rooms and what PPE. - Staff should done gown and gloves and hand wash prior to providing resident cares in a EBP room. - Staff should not discard PPE worn in an EPB room in trash bags that are not closed and sealed; - Staff should knock before entering rooms and sanitize hands before passing beverages; - PPE should not be stored on carts in unsealed trash bags that are going room to room.

Based on interview and record review, the facility failed to obtain signed immunization refusals, or administer the influenza vaccine to four residents (Resident's #41, #46, #11 & #9). This affected four of the 17 sampled Residents. The facility census was 67. Review of the facility's Infection prevention and control policy, undated., showed: - The infection preventionist coordinates the development and monitoring of the facility established infection control policies and procedures. - Reports information related to infection control to the administrator and the infection control committee. - Provides infection control related information to the nursing staff and physicians. - Consults on infection risks, and and prevention control strategies. - Provides education and training to staff regarding infection prevention and isolation. - Ensures infection surveillance and monitoring of infection control practices are in place. - Ensures access to isolation supplies, gowns, gloves, masks, etc, supplies are on hand and accessible for handling infectious wastes, blood, and body fluids. - Maintain on premises current CDC (Center for Disease Control), OSHA (Occupational Safety Heath Administration), and federal and state regulations guidelines and recommendations relative to infection control issues in healthcare facilities. - Ensure that the facility provides and maintains an effective disease prevention program by offering and administering preventative vaccines, such asPneumococcal Vaccine, Influenza, and Covid-19 Vaccines.Please place the facility's information here regarding immunizations/vaccinations here. Review of Resident #11's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 01/23/25, showed: -Cognition moderately impaired; -He/She had clear speech with usually clear comprehension -He/She made self-understood and usually understood others; -He/She was dependent on a wheelchair but able to navigate chair herself; -He/She was mostly independent regarding oral care, toileting, bathing, dressing, personal hygiene, and mobility; -He/She required minimal assistance with eating -BIMS (Brief Interview of mental status) of 9 meaning moderate impairment. Review of Resident #11's Face Sheet showed: -Diagnoses included: Multiple Sclerosis (MS), a chronic, autoimmune disease that affects the centran nervous system (CNS), including the brain and spinal cord -A seizure disorder -Irregular heart rate called supraventricular tachycardia (SVT) -Hypertension or high blood pressure. Review of Resident #11's CarePlan dated 1/30/2025 showed no information regarding vaccinations or immunizations. Review of the Facility's Immunization record and Administration records on 03/19/25 10:00 A.M. for Resident #11 showed the last administered influenza vaccination was given on 10/18/23. No refusal was obtained and no administration for the influenza vaccination was given during the year of 2024. Review of Resident #41's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 01/09/2025, showed: -Clear and normal conversation -Clear speech -BIMS of 14 meaning no impairment -No behaviors exhibited -Used wheelchair for mobility -Mostly Independent with ADLS, needing assistance with transfers and showers -Minimal assistance with meals Review of Resident #41's Face Sheet showed: -Anemia, when your blood produces a lower than normal amount of health red blood cells. -Orthostatic Hypotension, a condition where blood pressure drops significantly upon standing up from a sitting or lying position. -Renal Insufficiency, this occurs when the kidneys do not function properly. -Diabetes Mellitus, a chronic condition that affects how the body uses glucose (sugar) for energy. -Anxiety, a common mental health condition characterized by excessive worry, fear, and nervousness. -BiPolar disorder, a chronic mental health condition characterized by extreme shifts in mood, energy, and behavior. Review of Resident #41's CarePlan showed no information regarding vaccinations or immunizations. Review of the Facility's Immunization record and Administration records on 03/19/25 at 09:34 A.M. for Resident #41 showed the last administered influenza vaccination was given on 10/16/2023. No refusal was obtained and no administration for the influenza vaccination was given during the year of 2024 or 2025. Review of Resident #46's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 01/17/2025, showed: -Minimal difficulty with hearing -Speech clear and comprehended communications -No Behaviors exhibited -Used a walker -Required set up for meals -Required supervision with oral hygiene -Required partial assistance with bathing -Participates in goal setting -BIMS of 7 meaning severe impairment Review of Resident #46's Face Sheet showed: -Non Traumatic brain dysfunction meaning abnormal brain functionality not due to trauma or injury -Hypertension, or high blood pressure -Dementia, or loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life. Review of Resident #46's CarePlan showed no information regarding vaccinations or immunizations. Review of the Facility's Immunization record and Administration records on 03/19/25 at 10:30 A.M. for Resident #46 showed the last administered influenza vaccination was given on 10/18/2023. No refusal was obtained and no administration for the influenza vaccination was given during the year of 2024 or 2025. Review of Resident #9s Discharge Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 03/05/25, showed: -BIMS 15, no impairment -No behaviors exhibited -Influenza vaccine received on 11/04/2024 Review of Resident #9's Face Sheet showed the reisdent was admitted on [DATE]. Review of Resident #9's CarePlan showed no information regarding vaccinations or immunizations. Review of the Facility's Immunization record and Administration records on 03/19/25 at 10:45 A.M. for Resident #9 showed the resident was ineligible due to the influenza vaccine already was administered in the fall of 2019 so it was not due. No refusal was obtained and vaccination was not documented in the eMAR as administered during the years of 2020, 2021, 2022, 2023, and 2024. During an Interview with infection control nurse on 03/19/2025 at 11:00 A.M., reports online of influenza and Prevnar and covid vaccination records were reviewed. Did not administer or provide refusal documents to residents #41, #46, #11 & #9. During the exit interview with the DON and Administrator, they concurred that yearly vaccinations should be offered and then an order obtained before administering. If the resident refuses, a document is signed by resident refusing the vaccinations.

Based on observation, interview and record review, the facility failed to obtain signed refusals, or administer the Covid vaccine to four residents (Resident's #9, #11, #41, and & #46). This affected four of the 17 sampled Residents. The facility census was 67. Review of the facility's Infection prevention and control policy, undated., showed: - The infection preventionist coordinates the development and monitoring of the facility established infection control policies and procedures. - Reports information related to infection control to the administrator and the infection control committee. - Provides infection control related information to the nursing staff and physicians. - Consults on infection risks, and and prevention control strategies. - Provides education and training to staff regarding infection prevention and isolation. - Ensures infection surveillance and monitoring of infection control practices are in place. - Ensures access to isolation supplies, gowns, gloves, masks, etc, supplies are on hand and accessible for handling infectious wastes, blood, and body fluids. - Maintain on premises current CDC (Center for Disease Control), OSHA (Occupational Safety Heath Administration), and federal and state regulations guidelines and recommendations relative to infection control issues in healthcare facilities. - Ensure that the facility provides and maintains an effective disease prevention program by offering and administering preventative vaccines, such as Pneumococcal Vaccine, Influenza, and Covid-19 Vaccines. Please place the facility's information here regarding immunizations/vaccinations here. 1. Review of Resident #9s Discharge Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 03/05/25, showed: -BIMS (Brief Interview of mental status) of 15, meaning no impairment -No behaviors exhibited. Review of Resident #9's undated Care Plan showed no information regarding vaccinations or immunizations. Review of the Facility's Immunization record and Administration records on 03/19/25 at 10:25 A.M. for Resident #9., showed; the covid vaccination was never documented as given. No refusal was obtained and no administration for the covid vaccination was signed or documented on immunization record. Review of Resident #11's Quarterly MDS, dated [DATE], showed: -Cognition moderately impaired; -He/She had clear speech with usually clear comprehension -He/She made self-understood and usually understood others; -He/She was dependent on a wheelchair but able to navigate chair herself; -He/She was mostly independent regarding oral care, toileting, bathing, dressing, personal hygiene, and mobility; -He/She required minimal assistance with eating -BIMS of 9 (Brief Interview of mental status) of 9 meaning moderate impairment. Review of Resident #11's Face Sheet showed: -Diagnoses included: Multiple Sclerosis (MS), a chronic, autoimmune disease that affects the central nervous system (CNS), including the brain and spinal cord -A seizure disorder -Irregular heart rate called supraventricular tachycardia (SVT) -Hypertension or high blood pressure. Review of Resident CarePlan dated 1/30/2025 showed no information regarding vaccinations or immunizations. Review of the Facility's Immunization record and Administration records on 03/19/25 at 10:30 A.M. for Resident #11 showed; the last administered covid vaccination was given on 05/20/2022. No refusal was obtained and no administration for the covid vaccination was signed or documented during the year of 2023 or 2024. Review of Resident #41's Quarterly MDS, dated [DATE], showed: -Clear and normal conversation -Clear speech -BIMS of 14 -No behaviors exhibited -Used wheelchair for mobility -Mostly Independent with ADLS, needing assistance with transfers and showers -Minimal assistance with meals Review of Resident #41's Face Sheet showed: -Renal Insufficiency, this occurs when the kidneys do not function properly. -Diabetes Mellitus, a chronic condition that affects how the body uses glucose (sugar) for energy. Review of Resident #41's Care Plan showed no information regarding vaccinations or immunizations. Review of the Facility's Immunization record and Administration records on 03/19/25 at 10:45 A.M. for Resident #41 showed; the last administered covid vaccination was given on 10/30//2021. No refusal was obtained and no administration for the covid vaccination was signed or documented during the years of 2022, 2023 or 2024. Review of Resident #46's Quarterly MDS, dated [DATE], showed: -Minimal difficulty with hearing -Speech clear and comprehended communications -No Behaviors exhibited -Used a walker -Required set up for meals -Required supervision with oral hygiene -Required partial assistance with bathing -Participates in goal setting -BIMS of 7 meaning severe impairment Review of Resident #46's Face Sheet showed: -Non-Traumatic brain dysfunction meaning abnormal brain functionality not due to trauma or injury -Hypertension, or high blood pressure -Dementia, or loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life Review of Resident #46's Care Plan showed no information regarding vaccinations or immunizations Review of the Facility's Immunization record and Administration records on 03/19/25 at 10:55 A.M. for Resident #46 showed; the last administered covid vaccination was not documented. No refusal was obtained and no administration for the covid vaccination was signed or documented during the years of 2022, 2023 or 2024. During an Interview with infection control nurse on 03/19/2025 at 11:00 A.M., said online of immunization records were reviewed and said that covid vaccinations were not started for 2024-2025 yet. During the exit interview on 3/20/25 at 4:15 P.M. the DON and Administrator said, yearly vaccinations should be offered and then an order obtained before administering. If they refuse, a document is signed by resident refusing the vaccinations.

Based on observation, interviews, and record review the facility failed to ensure staff provided appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible when the facility staff failed to ensure proper catheter care of one of the 17 sampled residents (Resident #29). The facility census was 67. Review of the facility's Catheter - Care of Policy, dated 06/22, showed: - A resident, with or without a catheter, receives the appropriate care and services to prevent infections to the extent possible. - Collection bags should always be kept below the level of the bladder, including during transport, avoiding contact with the floor. - Take care to ensure the collection bag does not touch the floor at any time. 1. Review of Resident #29's most current MDS dated [DATE] showed: - Cognition not intact - Resident has indwelling urinary catheter - Requires staff assistance of 1-2 for all ADLS (acitivites of daily living) - Diagnoses: Alzheimer's disease, diabetes mellitus, high blood pressure, and urinary tract infection. Review of Resident #29's care plan dated 01/10/25 showed no plan regarding a catheter or direction for staff regarding catheter care. Review of the residents current physician order summary report dated 03/19/25 showed: - Catheter Output. Monitor for changes and/or signs and symptoms of infection such as (decreased output, dark urine, foul odor, red tinged, lower abdominal discomfort/swelling) every 8 hours for Cath Maintenance - Foley catheter care every shift and as needed every shift for cath maintenance. Observation on 03/18/25 at 1:54 P.M., showed CNA B entered Resident #29's room to perform catheter care. The catheter bag fell on to the floor while the aide emptied 400cc dark yellow urine from catheter into graduate. The bag was left on the floor while the aide emptied the graduate and washed his/her hands. The aide then locked brakes on wheelchair, applied gait belt, and attempted to get resident up and into bed and his/her foot touched the bag on floor. The resident was transferred back into his/her chair. CNA B left the room and got CNA F to assist him/her with care for the reisdent. While performing cares, CNA B wiped the inside of the reisdent's thigh and groin area and with same wipe, wiped the residents genitals and down the catheter tube. Observation on 03/18/25 at 3:04 P.M., showed CNA H entered Resident #29's room to get the resident up from the bed. CNA H slid the residents pants down over the catheter, unaware it was there, and had to remove the residents pants to run bag through residents pant leg. The catheter bag laid on floor as aide attempted to get resident up from bed. CNA A had to come in to help with cares. CNA A noticed the catheter bag on ground, picked it up and placed on his/her scrub pocket. Observation on 03/19/25 at 2:00 P.M., showed the resident in his/her wheelchair by the nurses station with very dark yellow urine in his/her catheter. Observation on 03/20/25 at 8:01 A.M., showed the resident being pushed up to dining room table with catheter bag dragging on floor under wheelchair. The resident was tugging at catheter tube coming out of his/her left pant leg. Observation on 03/20/25 at 8:49 A.M., showed CNA F pushing the resident back from dining room with the catheter bag dragging on floor under the wheelchair with what appears to be blood tinged urine and sediment in tubing. Observation on 03/20/25 at 2:00 P.M., showed the resident propelling his/her wheelchair in the hallway. The residents catheter bag dragging on floor and sediment in tubing. During an interview on 03/18/25 at 2:24 P.M., CNA B said: - Catheter care is provided every shift and as often as needed. - He/she wipes from the insertion of the catheter out to the end and cleans all folds. - If aides notice something wrong, like sediment or discoloration, they are to notify the nurse. During an interview on 03/20/25 at 9:03 A.M., LPN A said: - He/she would expect aides to report decreased urine flow, discharge, or sediment in catheter bags or tubing and to provide proper peri care - He/she would expect aides to keep catheter bag in a dignity bag and off the ground always - The aides usually use their pocket on their scrub pants to hold a catheter bag when providing cares. - He/she expects catheter care to be provided every two hours with peri care. During an interview on 03/20/25 at 4:25 P.M., Director of Nursing said: - Residents with a catheters should have a care plan. - He/she expects staff to keep catheter bags off the ground and from coming into contact with their feet. - He/she expects staff to report sediment or discoloration to the nurse.

Based on observation, interview, and record review the facility failed to recognize, evaluate, and address the hydration needs need of one and failed to offered sufficient fluid intake to maintain proper hydration and health for one of the 17 sampled residents (Resident #29). The facility census was 67. Review of the facility's Nutrition/Hydration Management policy dated 06/20 showed: -The purpose is to ensure that each resident maintains acceptable parameters of nutritional/hydration status such as body weight and protein levels, unless the resident's clinical condition demonstrates this is not possible based on the resident's comprehensive assessment. - A comprehensive care plan is developed by the interdisciplinary care team that addresses nutrition/hydration and an individualized nutrition/hydration management program based on individualized assessed need. 1. Review of Resident #29's most current (MDS) Minimum Data Set, a federally mandated assessment completed by facility staff, dated 01/10/25 showed: Resident has an activities of daily living (ADL) self-care performance deficit related to Alzheimer's disease and requires partial/moderate assistance with personal hygiene and substantial/maximal assistance with shower and bath. -Assist of 1-2 with all ADLS. -Resident has an indwelling urinary catheter. -Diagnoses of: Alzheimer's, Diabetes, High Blood Pressure, and UTI (urinary tract infection). Review of most current care plan, dated 01/10/25 showed no information about resident having a catheter and no care information for someone having a catheter. Had a history of UTI (Urinary tract infection) and fluids should be encouraged. Review of nursing progress notes for March 2025., showed the resident has a catheter and had recently completed antibiotics after testing positive for UTI. Output was documented on treatment administration record. No intake was noted. Observation on 03/18/25 at 1:54 P.M., showed CNA B empty 400cc dark yellow urine from catheter bag while performing catheter care. After providing the care asked resident if they needed anything else. Resident replied a glass of water would be nice but the aide did not seem to hear, exited room, and did not return with water. Observation on 03/18/25 at 2:24 P.M., showed CNA B, after interview outside resident room regarding fluids, not offer fluids to resident. Observation on 03/18/25 at 3:04 P.M., showed CNA H and CNA A get resident up from bed and change bedding. No one offered resident a drink until being told resident had mentioned being thirsty. Resident then wheeled into hallway by nurses station where they sat at least an hour with no fluids nearby nor any offered. Observation on 03/19/25 at 10:30 A.M., showed resident sitting in wheelchair by nurses station with a bedside table behind and to the right that doesn't seem to be noticed and no one has attempted to cue resident to drink. Observation on 03/19/25 at 1:30 P.M., showed resident wandering, in wheelchair, in hallway, eventually parking near nurses station with no fluids nearby and no one offering fluids. Observation on 03/19/25 at 2:00 P.M., showed resident has been sitting in wheelchair between halls with very dark urine in catheter tubing and no fluids offered. Finally pushed by an aide to nurses station, parked and left there with no fluids near or offered. Observation on 03/20/25 at 8:49 A.M., showed CNA F pushed resident back from breakfast, catheter bag dragging on floor and what appears to be blood and sediment in tubing. No fluids near or offered. During an interview on 03/18/25 at 8:27 A.M., spouse of the resident said: - He/she visits often and does not see staff offering or encouraging the reisdent to drink fluids. - He/she does not feel like the resident receives enough fluids and at his/her last visit the reisdent had blood in his/her catheter. - He/she had never observed the resident drink anything outside of the dining room. During an interview on 03/18/25 at 2:24 P.M., CNA B said: - Staff offer fluids at the start of shift then per request. - He/She does try to offer residents a drink when I he/she sets the cup down. During an interview on 03/20/25 at 10:08 A.M., LPN A said fluids should be offered every time staff go by the resident or by their room or at least every two hours. During an interview on 03/20/25 at 4:25 P.M., Director of Nursing said: - Staff should offer fluids to residents any time they are in the room. - The resident should have cold or room temperature water available.

Based on observation, interview and record review, the facility failed to store medications in a locked storage area to ensure medications were inaccessible to unauthorized staff and residents when medications were left at bedside for one resident (Resident #48) and when the medication cart was left unlocked and unattended. The facility census was 67. Review of facility policy, revised 8/2020, showed: -Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. -Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) are permitted to access medications. Medication rooms, carts, and medication supplies are locked when they are not attended by persons with authorized access. 1. Observation on 3/17/25 at 9:26 A.M. showed an unattended and unlocked medication cart was parked outside room [ROOM NUMBER]. The key was left hanging in the medication cart. Observation on 3/19/25 at 7:02 A.M. showed a medication cart was unattended and unlocked sitting outside of room [ROOM NUMBER]. At 7:05 A.M., Certified Medication Technician (CMT) A was observed exiting room [ROOM NUMBER] and returned to medication cart. During an interview on 3/20/25 at 5:24 A.M., CMT A said: -When he/she left his/her medication cart he/she should always lock the cart and lock his/her computer screen; -He/She left medication cart attended on 3/19/25. During an interview on 3/20/25 at 8:50 A.M., the Director of Nursing (DON) said he/she expected medication carts to be locked when they were not attended by staff. During an interview on 3/20/25 at 4:05 P.M., Administrator said he/she expected medication carts to be locked when unattended. 2. Review of Resident 48's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 1/13/25, showed: -Cognition moderately impaired; -He/She had no impairment to upper and lower extremity range of motion; -He/She was dependent on a walker; -He/She had clear speech; -He/She made self-understood and usually understands some or part of conversation with others; -Diagnoses included diabetes ,muscle weakness, difficulty in walking, unsteadiness on feet, weakness. Review of care plan, dated 1/20/25, showed: -He/She had impaired cognitive function/dementia; -Administer medications as ordered. Monitor/document for side effects and effectiveness; -Discuss concerns about confusion, disease process, nursing home placement with resident, family, caregivers; -Keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion; -Monitor/document/report PRN any changes in cognitive function; -Review medications and record possible causes of cognitive deficit: new medications or dosage increases; anticholinergics, opioids, benzodiazepines, recent discontinuation, omission or decrease in dose of benzodiazepines, drug interactions, errors or adverse drug reactions, drug toxicity -Resident understands consistent, simple, directive sentence. Review of physician's orders, dated 3/20/25, showed: -Started 8/8/24, Metformin HCL 1000mg tablet, give 1 tablet by mouth two times a day for Type 2 diabetes mellitus. Review of Medication Administration Record, dated March 2025, showed: -On dates 3/1/25-3/5/25, Metformin was administered at 0800; -On dates 3/6/25-3/20/25, Metformin was administered at 0700; -On dates 3/1/25-3/19/25, Metformin was administered at 1730. Observation on 3/17/25 at 11:31 A.M. showed resident was laying in his/her bed with family member present. Resident had a white round pill in a medicine cup on his/her bedside table. Resident was prompted to get up by his/her family member and resident indicated his/her stomach hurt and he/she did not feel good. Observation on 3/20/25 at 6:58 A.M. showed CMT C administering medications to Resident #48. Review of resident's medication bubble packs and medication bottles showed that resident received a white round pill, metformin 400mg, from a pill bottle that matched the pill that was found on resident's bedside table on 3/17/25. During an interview on 3/18/25 at 4:18 P.M., CMT B said: -There was nobody that self-administered their own medications on the 300 hall of the facility; -Leaving medicine in a pill cup at resident's bedside was not an allowed practice in facility; -He/She had not seen pills left on bedside tables in resident rooms; -Medications should never be left on bedside table residents; -Medications left at bedside would be considered a medication error because he/she would not know when and if that medication had been taken and would not be able to accurately advise of the time that medication taken if he/she did not observe the medication taken by the resident; -If he/she did not see the medication taken he/she could not assure the seven routes of medication administration were followed; -He/She would not allow medications to be left at bedside cause he could not assure the routes of medication passes -There were residents whom were confused that walked up and down halls of facility and who what was to prevent a confused resident from going into another residents room and taking that medication that could result in severe reactions or death of that resident; During an interview on 3/20/25 at 5:24 A.M., CMT A said: -Medications could not be left at bedside of residents; -There were no residents in the facility that self-administered their own medications. During an interview on 3/20/25 at 5:35 A.M., Licensed Practical Nurse (LPN) B said: -There was no residents on 300 hall who could have medications left at their bedside; -He/She had no residents that self-administered medications. During an interview on 3/20/25 at 8:50 A.M., the DON said: -He/She had a few residents in the facility that were allowed to have cough drops at bedside; -Medications should not be left at bedside in a pill cup unless they had physician's orders to self-administer medications; -Resident #48 should not have medications left on his/her bedside table. During an interview on 3/20/25 at 4:05 P.M., Administrator said he/she expected medications to be left at bedside only if a resident had a physician order to self-administer medications.

Based on observation, interviews, and record review, the licensed staff failed to assure staff followed their Abuse Prevention policy and procedure for one resident (Resident #1) who said a staff member hit him/her. Staff failed to inform the administrator, failed to make a report to the State agency, and failed to implement measures to prevent further potential abuse when they allowed that staff member to work the entire shift. The facility census was 72. Review of the facility's Abuse Prevention policy and procedure, dated 1/25/15, showed: - It is the policy of this Center to maintain the resident's right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of property. - To ensure the resident's rights are protected, by providing a method for the prevention, reporting, and investigation of any type of alleged resident abuse. - Supervision of staff to identify inappropriate behaviors, such as using derogatory language, rough handling, ignoring residents while giving care, directing residents, who need toileting assistance, to urinate or defecate in their beds. All staff will be trained to report any such observations to the appropriate department head or charge nurse who will then report to the administrator and director of nursing services. - Protection of residents during investigation includes the suspension of an employee pending the investigation. - Alleged violation and substantiated incidents will be reported to the State agency immediately and to all other agencies as required and in accordance with state law. - Allegations of abuse will be reported immediately to the Elder Abuse and Neglect Hotline. Review of the, undated, Preventing Resident Abuse, used to educate staff during orientation, showed: - You have an important role in providing a safe and comfortable environment for our residents. By being aware of the different types of abuse and reporting any signs of abuse, you ensure that our residents stay safe. By preventing and reporting abuse, you are upholding our values of integrity, [MEDICATION NAME], and respect. - Examples of verbal abuse may include, saying demeaning statements to a resident, humiliating or intimidating a resident, and punishing a resident when he/she does not do something as requested. - Examples of physical abuse may include punishing or slapping a resident, or hurting any part of the body intentionally. Review of Resident #1's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/28/15, showed: - Moderately impaired cognitive ability; - Usually understands others and usually makes self understood; - [DIAGNOSES REDACTED]. Review of the care plan, updated on 3/30/15, showed: - The resident usually made himself/herself understood and was usually able to understand others. The care plan directed staff to use simple words, allow enough time for the resident to respond, talk to the resident in a calm manner and soft tone of voice. - The resident's issues with impulse control continued to improve and directed staff to answer the resident's requests as soon as possible. - The resident had [DIAGNOSES REDACTED] (uncontrolled, awkward movements) and did not have full control of his/her extremities especially when upset. During an interview, on 4/6/15, at 9:35 A.M., the assistant director of nursing (ADON) said: - The facility used a "purple dot" to identify the certified nurse aide (CNA) required to stay if a CNA did not arrive for their shift. - She made out the staffs' schedules and placed a purple dot next to a CNA's name for each shift. - If a CNA called in for their assigned shift, the charge nurse asked for a volunteer, from the current shift, to work all or part of the shift. If no one volunteered, the charge nurse called CNAs to see if they wanted to work, all or part of the shift. If those CNAs did not want to work then the purple dot CNA must stay and work. During an interview, on 4/5/15, at 9:25 A.M., Registered Nurse (RN) A said: - The schedule showed CNA A worked the, 4/3/15, night shift and had the purple dot next to his/her name. - On 4/4/14, a day shift CNA called in sick; so CNA A had to stay and work the day shift. During an interview, on 4/6/15, at 10:35 A.M., the business office manager, said: - She worked as the management staff on 4/4/15. - She arrived a little after 7:00 A.M., made rounds of the residents' halls, and was in the dining room around 8:00 A.M. - She stayed at the facility until 11:00 A.M., and did not see or hear anything related to the resident's incident on 4/4/15. - She said no staff told her about the incident on 4/4/15. - She did not know anything about it until the administrator called her on 4/5/15. During an interview, on 4/5/15, at 11:35 A.M., CNA B said: - Yesterday (4/4/15), he/she was in the dining room during breakfast and it looked like Resident #1 had a [MEDICAL CONDITION]. - He/she did not know what happened but the resident's arms and legs were shaking and it took three staff to prevent him/her from falling out of the chair. During an interview, on 4/5/15, at 11:45 A.M., CNA C said: - The resident was alert and able to say what happened. - Yesterday (4/4/15), he/she was in the dining room during breakfast and Resident #1 started crying and shaking really bad, like a convulsion. - He/she thought the resident would fall out of the chair. Licensed Practical Nurse (LPN) A, LPN B and he/she ran to the resident to prevent him/her from falling. - Resident #1 cried and said "(CNA A's name) hit me, (CNA A's name) hit me" and continued to cry. During an interview, on 4/5/15, at 1:15 P.M., the administrator (Adm) said no staff told her anything about CNA A hitting the resident, on 4/4/15, until a few moments ago. During an interview, on 4/6/15, at 9:10 A.M., the resident said: - On Saturday (4/4/14), he/she was in the dining room and told CNA A that he/she spilt a drink. - CNA A hit him/her out of "meanness" on the back of the head then cursed him/her. The resident swung his/her arm to demonstrate the hit. He/she did not like CNA A hitting him/her. The resident cried got upset, and about passed out when CNA A hit him/her. - The resident said CNA A did not like him/her, was mean to him/her, and in the past pushed him/her against the bed side rails, out of meanness. - The resident said he/she was scared of CNA A and afraid that CNA A would hurt him/her worse. During an interview, on 4/5/15, at 1:50 P.M., CNA A said: - He/she worked the night shift on Friday (4/3/15) and had to stay and work that Saturday (4/4/15) because someone called in and he/she had the purple dot. - He/she took a resident to the dining room table behind Resident #1. - As he/she passed, Resident #1 said "(CNA A's first name), (CNA A's first name), I made a mess". CNA A walked to Resident #1 and "tapped (him/her) in the head," and said "I'm no Cinderella getting down on my hands and knees cleaning up no messes". CNA A raised his/her arm and made a quick wrist movement to demonstrate how he/she tapped the resident's head. CNA A said he/she then walked to the linen cart, got washcloths, and cleaned up the mess under the resident's chair. CNA A said he/she stood up, pointed at the resident and said "No more messes" and we all laughed. CNA A then left the dining room to get another resident up for breakfast. About three minutes later, LPN A entered and wanted to talk to him/her. LPN A asked if he/she had "just smacked" the resident in the head. CNA A said he/she demonstrated the same hand motion to show LPN A how he/she tapped the resident. LPN A said the resident was so upset he/she was "flopping" and trying to throw himself/herself out of the chair. CNA A went to the dining room, put his/her arm around the resident and said, "I'm very sorry if I upset you, I didn't mean to upset you". During an interview, on 4/5/15, at 2:40 P.M., LPN A said: - On 4/4/15 staff called him/her to the dining room. The resident was "freaking out", crying, shaking, upset, and would not answer staff. The resident did not speak for several minutes then said, CNA A hit him/her on the head and he/she did not like that. LPN A immediately went to find CNA A and if that was true. CNA A said he/she hit the resident in the back of the head and flicked his/her wrist. CNA A said he/she was joking and did not mean for it to come across as abuse. LPN A educated CNA A that any unwanted contact could be taken the wrong way. LPN A told RN A what CNA A said happened. RN A talked with residents at that table and nearby tables. During interviews, on 4/5/15, at 1:20 P.M., and 4/6/15, at 1:30 P.M., RN A said: - On 4/4/15 the resident was crying, in the dining room, when he/she asked the resident what was wrong the resident started kicking his/her legs. - LPN B came to help because the resident's face was red and he/she continued to kick his/her legs. The resident was upset and we thought he/she would fall out of the chair because he/she was so upset. He/she sent staff to get LPN A and told the staff to take the resident out of the dining room because he/she was so upset. RN A left to get a wheelchair because the resident was so upset he/she could not walk. The resident cried and kept rubbing his/her head and neck. When RN A returned with the wheelchair, the resident had stopped crying. RN A asked the resident what happened and the resident said he/she spilt a drink and CNA A hit him/her. RN A said the resident's neck was red, but he/she felt the resident caused the reddened area by rubbing it when he/she was so upset. RN A sent LPN A after CNA A; all of a sudden, CNA A entered and told the resident he/she was sorry, was just joking with the resident, and did not mean anything by it. The resident said okay. RN A said the resident regularly teased staff so it did not surprise him/her. What surprised RN A was that the resident took it "so bad". RN A felt that CNA A teased the resident about the spilt drink and gave the resident a friendly "buddy tap". RN A said it was not like abuse; not like CNA A punished the resident for the spilt drink. - RN A called the director of nursing (DON) then talked with residents at the table next to the resident. The residents said they did not see anything. He/she interviewed staff who said they were busy getting residents to the dining room and did not see anything. - Later, RN A went to the resident's room and the resident was excited about the outing with Family Member (FM) A on 4/5/15. The resident said he/she was okay and his/her neck was not red. - RN A asked if the resident was afraid of CNA A and he/she answered, no. RN A asked if the resident was okay with CNA A providing his/her care and he/she said, okay. RN A said the resident felt safe. - RN A said the resident kept asking if he/she was in trouble and appeared worried that he/she may not get to go out with FM A. - That evening (4/4/15), RN A call FM A, resident's guardian, and gave him/her a general idea of the incident and that staff would not work the rest of the weekend and the administrator would look into the incident further. During an interview, on 4/6/15, at 12:15 P.M., F.M. A said: - On 4/4/15 at about 6:00 P.M., RN A called and said at breakfast the resident spilt a drink and a CNA patted him/her on the back. RN A said the CNA was just joking with the resident when he/she patted him/her on the back. - Prior to admission to this facility, staff at another facility abused the resident. It was a very bad incident and staff turned the story around so that the resident got in trouble, instead of the staff. Ever since that incident the resident had a fear of being in trouble and definitely afraid staff would blame him/her. During an interview, on 4/6/15, at 1:10 P.M., CNA E said: - He/she worked on the resident's hall on 4/4/15 but stayed on the hall during breakfast. - Staff called for a wheelchair so he/she took a wheelchair to the dining room. - CNA A told him/her that he/she bumped the resident in the back of the head because he/she spilt the drink. - At lunchtime, on 4/4/15, the resident did not want to go to the dining room. The resident finally agreed to go to the dining room after he/she told resident he/she would stay in the dining room and watch over him/her. During an interview, on 4/6/15, at 9:35 A.M., the DON said: - On 4/4/15, RN A called her at 8:25 A.M., about the incident. She told RN A to start interviewing and find out what happened. - RN A called about 3:00 P.M., and about 4:00 P.M., to keep her informed. - She told RN A to interview the resident, CNA A, other staff, and residents. - She was not sure in which call she told RN A what to do but it all occurred on 4/4/15. - She did not know how many hours CNA A worked on 4/4/15. During an interview, on 4/6/15, at 2:55 P.M., the Adm, DON, and ADON said: - The DON said RN A did not tell her that CNA A worked the entire day shift. With the information that RN A provided in the 3:00 P.M., or 4:00 P.M., calls she felt it was not abuse. - The Adm said RN A told her yesterday (4/5/15) that he/she talked with the resident to make sure he/she felt safe. RN A did not feel that CNA A physically abused the resident and that it was just "horseplay" and it hurt the resident's feelings. If RN A felt CNA A abused the resident he/she would have sent CNA A home. It was inappropriate for CNA A to "tap" the resident. CNA A was "probably horsing around" but that was inappropriate. - The ADON said she educated staff on abuse and that hitting, slapping, punching, or any physical contact to inflict harm was physical abuse. - The Adm said the DON and RN A did not call her on 4/4/15 because they did not feel CNA A abused the resident. It was horseplay and no one meant to hurt anyone. - The DON said she talked with the resident yesterday (4/5/15) and he/she did not have any problems with CNA A. - The Adm said she and the DON interviewed the resident today. The Adm told the resident she needed him/her to be truthful with her; then asked, if anyone had been mean, abused him/her, or if he/she felt abused. At first, the resident said, no, no, then said, yes, and told her CNA D made him/her take a bath and he/she thought that was abuse. - The DON said today (4/6/15) she talked with the resident about Saturday (4/4/15) and he/she said CNA A tapped him/her of the back of the head, made him/her pass out, and fall to the floor. The resident said CNA A got in trouble and apologized. She asked if he/she was scared of CNA A and the resident said he/she was kind of scared of him, but not much. The resident said CNA A hit him/her out of meanness and he/she did not think CNA A was teasing him/her. The resident did not want CNA A to provide his/her care. The DON said when she prompted him/her about abuse the resident said he/she felt CNA A physically abused him/her. - RN A told her that CNA A had the purple dot but never said he/she worked the entire shift. - The ADON said that because of the miscommunication staff allowed CNA A to work the entire shift. During an interview, on 4/7/15, at 10:00 A.M., the Adm said she expected staff to notify her of all incidents. MO 8

Based on interview and record review, the facility failed to assure staff responded appropriately to one resident's (Resident #9's) change in condition. The resident complained of not being able to breathe, was not able to eat after staff gave insulin, developed low blood sugar and fell to the floor. The resident's condition was discovered when family visited. The resident required hospitalization for low blood sugar and pneumonia. The facility census was 76. 1. Review of the facility policy entitled Physician Notification of Change in Resident's Condition, dated November 2005, showed: - Change of Condition is defined as any sudden and marked adverse change in the resident's condition which is manifested by signs and symptoms different than usual denoting a new problem, complication or permanent change in status and requiring a medical assessment, coordination and consultation with the physician or physician extender and a change in the treatment plan. - It was the responsibility of the person observing the change to report that change to the licensed nurse. Review of Mayoclinic.org showed: - [DIAGNOSES REDACTED] is a condition characterized by an abnormally low blood sugar. Normal blood sugar is about 70 - 100 milligrams per deciliter or mg/dl. - Symptoms of [DIAGNOSES REDACTED] include confusion, sweating, shakiness and anxiety. - A cause of [DIAGNOSES REDACTED] in a person with diabetes mellitus who takes insulin or other medication and does not eat enough food at the time the medication begins to act. 2. Review of Resident #9's Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 11/07/13, showed: - Modified independence in cognitive skills for daily decision making. - Required limited assistance of one staff for bed mobility, transfers and to walk. - [DIAGNOSES REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] - Physician's orders to check the resident's blood sugar at 7:00 A.M. and to administer Humalog insulin (type of rapid acting insulin, it begins to lower the blood sugar quickly) per sliding scale according to the blood sugar results. - Registered Nurse (RN) A documented the resident's blood sugar at 7:00 A.M. was 162 and he/she administered 4 units of Humalog insulin. During an interview on 1/31/14, at 8:30 A.M., Registered Nurse (RN) A said: - He/she was the resident's charge nurse on the day shift on 1/18/14, and gave the resident his/her morning Humalog insulin at 8:00 A.M. or 8:15 A.M. - The resident ate in his/her room. - Hall trays came out from the kitchen around 7:45 A.M. to 8:15 A.M. - There is one aide to pass hall trays, and sometimes it might be later - around 9:00 A.M.- before staff serve hall trays. During an interview on 1/31/14, at 3:00 P.M., Certified Nurse Aide (CNA) F said: - He/she was assigned to the resident's hall on 1/18/14, on the day shift. - The kitchen delivered the trays to the hall around 7:45 A.M. - 7:50 A.M. - He/she thought he/she delivered the tray to the resident's room a few minutes after that, but said staff usually passed trays from 8:15 A.M. to 8:30 A.M. - The resident said he/she needed a breathing treatment first (before eating) because he/she was having trouble breathing. - CNA F set the tray down in the room and told the charge nurse the resident was having trouble breathing and the CMT that the resident could not eat until he/she received his/her breathing treatment. -He/she thought either the nurse or the CMT gave the resident a breathing treatment. During an interview on 1/31/14, at 8:30 A.M., Registered Nurse (RN) A said no one reported to him/her that the resident was having trouble breathing or asked to see the nurse. During an interview on 2/5/14, at 10:05 A.M., Certified Medication Technician (CMT) A said: - He/she remembered the resident demanded a breathing treatment that morning. - He/she administered the treatment per a nebulizer (machine that delivers medications in a fine mist to the respiratory tract through a face mask) and noted the resident's eyes "looked kind of wild." - He/she did not know if the resident was weak, sweaty or having breathing trouble. - He/she did not stay with the resident as he/she received the treatment because he/she had 8 - 10 other residents who received breathing treatments and was not able to stay with each one if they were capable of leaving it on. - He/she went back and checked on the resident once and then went back and removed the mask. - He/she did not remember if the resident had a tray or had eaten. - She did not notice if the resident had other symptoms. During an interview on 1/31/14, at 10:50 A.M., Licensed Speech Pathologist (LSP) A said on the morning of 1/18/14, a gentleman visitor stopped him/her in the hall and reported the resident was on the floor and he needed help. He/she saw the resident on the floor and got the nurse. Review of Nurses' Notes, dated 1/18/14, showed: - At 10:05 A.M. staff found the resident lying on the floor beside the bed. His/her face was flushed and sweaty. The resident was confused with mumbling speech. RN A tested the resident's blood sugar and the results were 21. - At 10:11 A.M. staff administered [MEDICATION NAME] (medication given by injection to raise blood sugar) one milligram by injection. - At 10:13 A.M. the resident's blood sugar was 22. - At 10:17 A.M. the resident's blood sugar was 29. - Between 10:20 A.M. and 10:25 A.M. staff gave the resident one tube of oral glucose gel (raises blood sugar) . - At 10:26 A.M. the resident's blood glucose was 41. - At 10:35 A.M. the resident's blood glucose was 46. - At 10:40 A.M. staff called the resident's physician and obtained orders. - At 10:50 A.M. the resident left the facility with EMS (emergency medical services) staff to go the hospital. During an interview on 1/31/14, at 8:30 A.M., RN A said: - He/she knew the resident should eat within 15 minutes after staff administered the insulin, but did not remember if the resident ate that morning. - He/she thought staff delivered the tray to the resident before 9:00 A.M. that morning, but did not know for sure. During and interview on 1/28/14, at 11:30 A.M., the resident's family member (FM) B said the resident told him/her of the the events on Saturday 1/18/14, as follows: - The nurse came in around 7:00 A.M. and gave the resident an insulin injection. - When staff brought the resident's breakfast, the resident told that staff person that he/she did not feel well and asked staff to set the tray aside and ask the nurse to come and check on him/her. - Staff left the room and no one came to check on him/her. - When another family member (FM D) arrived later, he/she found the resident on the floor. - The resident later told FM B that he/she was trying to get a wet washcloth because he/she felt so clammy and hot. During an interview on 1/28/14, at 12:00 P.M., FM C, (a third family member) said: - He/she came to the facility daily and staff usually delivered breakfast trays to the resident's room at 8:30 A.M. to 9:00 A.M. Today it was delivered at 8:45 A.M. - When he/she came to the facility on [DATE], he/she asked staff what time they delivered the breakfast tray and staff told him/her 9:00 A.M. - FM D arrived about 45 minutes later and found the resident on the floor. Review of the facility Report of Alleged Incident/Accident, dated 1/18/14, showed: - At 10:05 A.M. LSP A found the resident on the floor and got the nurse. - The resident's blood sugar was 21. - (The Director of Nurses (DON) wrote) Comments: Last blood sugar of the morning - 8:15 A.M. insulin given - hall tray 8:30 A.M. He/she ate a little bit, but not sure how much. Ate some oatmeal per RN A. During an interviews on 1/31/14, at 12:10 P.M. and 12:30 P.M., the DON said: - She investigated this incident by interviewing the charge nurse (RN A). - RN A said he/she gave the insulin at 8:15 A.M. and staff delivered the breakfast tray to the room at 8:30 A.M. RN A said the resident ate a few bites of breakfast. - She didn't interview the aide who delivered the breakfast tray. - She didn't know the resident's FM reported the breakfast was later than 8:30 A.M. - She didn't know the resident reported not feeling well to staff and asked for the nurse. Review of the hospital admitting history and physical, dated 1/18/14, showed the resident's chief complaint on admission to the hospital was [DIAGNOSES REDACTED] and fall. The history of present illness included: - Per history from the nursing home, family and EMS (emergency medical services) staff gave the patient insulin around 7:00 A.M. and was not fed until 9:00 A.M. - Patient became diaphoretic and stood up to get a towel to wash of his/her face and head and fell down. He/she did not lose consciousness. - EMS reportedly obtained a blood sugar reading of 46, began treatment and brought the patient to the emergency room . - Assessment showed [DIAGNOSES REDACTED] secondary to insulin use, diabetes mellitus, [MEDICAL CONDITIONS], anxiety disorder and others. Review of the hospital Physician's Progress Note, dated 1/22/14, showed assessment included shortness of air, likely [MEDICAL CONDITION] (inflammation of the large airways) vs developing pneumonia (lung infection).