Every finding on record at Gasconade Manor Nursing Home

Based on observation, interview, and record review, facility staff failed to use Enhanced Barrier Precautions (EBP) (an infection control practice that requires staff to wear Personal Protective Equipment (PPE) (gowns, gloves and/or eye protection), and failed to use appropriate hand hygiene and glove use for five residents (Residents #5, #6, #8, #34, and #42) out of 18 sampled while performing catheter care, wound care, and mechanical lift transfers. The facility census was 61. 1. Review of the facility policy titled Policy for Enhanced Barrier Precautions, dated 04/01/24, showed the facility will implement EBP beginning April 1, 2024, and EBP is designed to reduce the transmission of Multi-Drug-Resistant Organisms (MDROs), a germ that is resistant to many antibiotics, throughout the facility. Residents will be identified for EBP if they meet the following criteria: known infection or colonization with a resistant organism; indwelling medical devices including urinary catheter, central line, feeding tube, tracheostomy/ventilator; wounds including pressure ulcers, diabetic foot ulcers, unhealed surgical wounds and chronic venous stasis ulcers. Required used of gown and gloves during the following high-contact resident care activities: dressing, bathing/showering, transferring (in resident room, shower room, or Therapy gym), changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use, and wound care. Isolation caddies containing gowns, gloves, masks, and hand sanitizer will be placed on the back of the door in the rooms of residents requiring EBP; signage will be posted in applicable rooms to identify EBP implementation, care plans will be updated to reflect EBP requirements. Review of the facility policy titled Hand Hygiene Policy, dated 02/17/25, showed hand hygiene shall be performed after removing gloves; after handling soiled or used linens, dressing, bedpans, catheters or urinals; if moving from a contaminated body site to a clean body site during resident care; and after contact with an inanimate object in the immediate vicinity of the resident. Review of the facility policy titled Glove Use Policy/Procedure, dated 02/17/25, showed staff are to perform hand hygiene before putting on gloves; use a new pair of gloves for each resident task; remove gloves promptly after use and before touching clean surfaces. Review of the facility policy titled Catheter Care Policy, dated 02/17/25, showed while holding the catheter, clean three to four inches down the catheter tube; use a clean wash cloth, cleaning away from the urethra (body) with one stroke per section; use a new section of the wash cloth for each stroke; perform hand hygiene and ensure resident comfort, make sure the bed is low and locked, place call light within reach, and perform hand hygiene again. Review of the facility policy titled Wound Prevention and Care, dated 02/17/25, showed it did not address procedures for wound care treatments and dressing changes. 2. Review of Resident #5's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 06/27/25, showed staff assessed the resident as severe cognitive impairment, at risk for pressure ulcers, and had wounds. Review showed staff did not document an indwelling catheter. Review of the resident's care plan, dated 06/27/25, showed the resident had pressure ulcers. Review showed the care plan did not contain direction for an indwelling catheter. Review of the resident's Physician's Orders Sheet (POS), dated 07/28/25, showed orders for:-07/03/25: bilateral heel wounds, clean with cleanser, apply Xeroform gauze (a fine mesh gauze used for wound care), wrap and secure, change daily;-07/03/25: sacrum wound, clean with cleanser, apply Medi-honey (a medication for wound healing), Xeroform gauze, gauze, and cover with dressing to secure, change daily; -07/11/25: catheter care three times a day.Observation on 07/28/25 at 11:02 A.M., showed the resident's door did not contain a EBP signage. Observation showed the residents catheter hung below the resident's chair. Observation on 07/29/25 at 8:22 A.M showed the resident's door did not contain a EBP signage and PPE hung from the door. Observation on 07/30/25 at 9:20 A.M., showed the resident's door did not contain a EBP signage. Observation showed the resident catheter touched the floor. Certified Nurse Assistant (CNA) J and Registered Nurse (RN) F performed catheter care and did not wear a gown. Observation showed RN F knocked the resident's bedside table over and caused water to spill. Observation showed RN F cleaned up the water, changed his/her glove. Observation showed RN F touched the resident's catheter. Observation showed CNA J used peri-wash and a washcloth wiping the resident's groin and perineal area. Observation showed CNA J used the same portion of the washcloth to cleanse the catheter tubing. Observation showed both CNA J and RN F removed their soiled gloves and put clean gloves on. Observation showed the RN and CNA performed wound care, without gowns on. RN F removed a soiled dressing from the resident's sacral wound and did not change his/her gloves or wash his/her hands before he/she cleansed the wound or applied the clean dressing. Observation showed RN F changed his/her gloves, removed the residents foot protectors, reached into his/her fanny pack and got his/her scissors out, did not sanitize the scissors and cut the dressing off the residents left heel. The RN did not change his/her gloves or wash his/her hands after he/she removed the soiled dressing or before he/she applied the clean dressing to the resident's heel. With the same soiled gloves, the RN removed the soiled dressing, used the same scissors and reapplied a clean dressing. Observation showed RN F, removed his/her gloves, did not wash his/her hands, lowered the resident's bed, gathered trash and left the room. Observation on 07/31/25 at 8:00 A.M., showed the resident's door did not contain a EBP signage and PPE hung on the door. During an interview on 07/31/25 at 9:00 A.M., CNA J said staff should wash their hands before care, after care, and with any glove change. CNA J said when staff go from a dirty to a clean process, they should remove the dirty gloves, wash their hands, and put on clean gloves. CNA J said he/she should have used more than one washcloth to perform catheter care. CNA J said he/she was not aware he/she could fold the washcloth and use the clean portion. CNA J said he/she is not sure what EBP is or if he/she has had training regarding EBP. CNA J said he/she did not know he/she should have worn a gown to perform catheter care. CNA J said he/she does not know when he/she should wear a gown and gloves for EBP. CNA J said he/she assumes EBP is to help prevent germs from spreading. During an interview on 07/31/25 at 1:00 P.M., RN F said EBP is used for contact droplet, air droplet precautions and staff should use different PPE based on what communicable disease the resident has. RN F said he/she did not know there was a difference in EBP vs contact precautions. RN F said he/she has seen the signs for EBP on the doors but has not read them. RN F said EBP is required for a resident with a catheter, but he/she is not sure of other times EBP would be required. RN F said if a resident in on EBP staff should wear a gown and gloves while performing resident cares and transfers. RN F said he/she did not wear a gown while performing catheter care or wound care on the resident because she forgot. RN F said he/she has not gotten an EBP in-service, but said the purpose of EBP is to protect the resident from acquiring germs from staff. RN F said staff should wash their hands before care, after care, and with any glove change. RN F said when staff go from a dirty to a clean process, they should remove the dirty gloves, wash their hands, and put on clean gloves. RN F said the proper way to perform catheter care is for staff to wash their hands, apply gloves, and use a clean area of the washcloth or a clean washcloth with each swipe. RN F said staff should then remove their gloves and wash their hands or use hand sanitizer. RN F said the proper way to perform wound care is for staff to wash their hands, apply gloves, remove the soiled dressing, remove their soiled gloves, wash their hands, then apply clean gloves to finish the dressing. RN F said he/she realized after the wound care he/she did not change his/her gloves from dirty to clean, between the heel dressings, and did not wash his/her hands with glove changes or after the wound care. RN F said he/she should have done each of those things. RN F said he/she did not have hand sanitizer in his/her pocket and was not sure he/she could use a resident's sink to wash his/her hands. RN F said by not changing his/her gloves or performing hand hygiene he/she could have spread germs and contaminated the resident or caused an infection. During an interview on 07/31/25 at 2:30 P.M., Certified Medication Technician (CMT) K said he/she is responsible for keeping the PPE stocked and ensuring the residents have an EBP sign on their door when applicable. CMT K said the Assistant Director of Nursing (ADON) updates him/her weekly and tells him/her which residents require EBP precautions, and he/she goes to each resident's room to ensure the PPE is stocked and an EBP sign is on their door. CMT K said the resident has a catheter and wounds and should have an EBP sign on the door. CMT K said he/she does not know why the resident does not have an EBP sign on his/her door. 3. Review of Resident #6's Quarterly MDS, dated [DATE], showed staff documented the resident as cognitively intact, had a surgical wound, received applications of ointments/medications and applications of non-surgical dressing to wound. The resident is always incontinent of bowel and bladder.Review of the resident's POS, dated 07/24/25, showed an order to cleanse, apply betadine to pinpoint areas, cover with folded non-woven gauze, & tape, once a day.Review of the resident's progress note, dated 07/24/25, showed the ADON documented resident seen today on wound rounds by doctor for post-surgical lower thoracic areas. Observation on 07/30/25 at 1:37 P.M., showed the resident had an EBP sign posted on door. CNA Q, Nurse Aide (NA) R and CMT D entered the resident's room, did not apply gowns and transferred the resident with a mechanical lift to his/her wheelchair and then to his/her toilet. The CNA and CMT provided hands on assistance during the transfer. The NA pulled the resident's pants and brief down when lowered to the toilet. The three staff removed gloves, washed hands and exited the restroom, while the resident used the restroom. The CMT, CNA and NA reentered the restroom, washed hands, applied gloves and provided care without gowns on.During an interview on 07/30/25 at 2:00 P.M., NA R said EBP has to do with when residents are first admitted and are in isolation. The NA said for EBP, staff are supposed to wear a gown, gloves and mask. The NA said to his/her knowledge the resident is not on EBP, the sign was from when he/she went to hospital and had a wound on his/her back, but it is closed now. The NA said he/she would say staff forgot to take the EBP sign off the resident's door. The NA said he/she thinks the resident's wound is healed, but still has a dressing on it, but he/she never looks at it, so he/she does not know. The NA said he/she had gloves on during the transfer, he/she did not have a gown on. During an interview on 07/30/25 at 2:21 P.M., CMT D said he/she thinks the EBP sign should have been taken down. The CMT said if a resident is on EBP, staff are supposed to wear gloves, mask and gown. The CMT said he/she wore just the gloves with the resident. The CMT said the charge nurse will tell staff if a resident comes off EBP.During an interview on 07/30/25 at 2:53 P.M., the ADON said signs on the door of the resident's room, is how we let staff know what PPE to wear with a resident. Staff are supposed to wear gloves and gown if they are providing care. The ADON said the resident is on EBP because he/she has a pinpoint wound area from his/her wound vacuum. The ADON said the resident has an EBP sign on door, and he/she does not know why staff are not wearing the correct PPE, staff should be following the signage on the door. During an interview on 07/31/25 at 1:53 P.M., the administrator said staff should read the sign posted on the resident's door. The administrator said he/she would expect staff to wear EBP PPE if there is a sign posted on the resident's door. The administrator said the charge nurse and the Director of Nursing (DON) are responsible to make sure the staff are wearing the appropriate PPE. 4. Review of Resident #8's Quarterly MDS assessment, dated 06/17/25, showed staff assessed the resident as cognitively intact, had an indwelling urinary catheter, dependent on staff for toileting, diagnoses of non-traumatic spinal cord dysfunction, paraplegia (paralysis that affects all or part of the trunk, legs, and pelvic organs). Review of the resident's POS, dated July 2025, showed:-03/11/24 Cranberry capsule, 500 milligram (mg) once a day for urinary tract infection (UTI), an infection in any part of the urinary system;-01/22/25 Macrobid (antibiotic) capsule, 100 mg once a morning for UTI with no end date; -02/28/25 foley catheter care per facility policy three times a day, days, evenings, nights; -05/21/25 Catheter to prevent skin breakdown;-07/10/25 Change catheter monthly on the 28th; -07/28/25-08/03/25 Macrobid capsule, 100 mg once a day in the P.M. for UTI.During an interview on 07/29/25 at 10:49 A.M., the resident said he/she currently has a UTI and does have a catheter. Observation on 07/30/25 at 9:50 A.M., showed the resident's room with EBP sign on the door and PPE in the room. Observation on 07/30/25 at 10:28 A.M., showed CNA C and CNA B applied gowns and gloves in the resident's room. CNA C left the room to gather more supplies, removed gown and gloves, and used alcohol-based hand rub (ABHR); CNA C returned to room, applied a gown and gloves and did not perform hand hygiene. CNA C performed perineal care, with stool, removed his/her gown and gloves, did not perform hand hygiene and left the room. CNA C returned to room, performed hand hygiene, applied gown and gloves, and continued with perineal care. CNA C removed his/her soiled gloves and applied clean gloves without performing hand hygiene. CNA C used a wet washcloth and wiped repeatedly down the resident's catheter tubing with the same portion of the washcloth. CNA C and CNA B placed a clean brief on the resident, removed their gloves and gown, did not perform hand hygiene, applied clean gloves and transferred the resident with a mechanical lift without gowns on.During an interview on 07/31/25 at 9:47 A.M., CNA C said staff must wear gown and gloves for anyone that has a catheter, or he/she assumed if they have a colostomy or any kind of severe open areas like wounds. CNA C said if staff are providing care for anyone that has a catheter, they put the gown on as soon as they get in the room. He/She said staff are only supposed to wear gowns if they are messing with that area, like a catheter. CNA C said he/she did not think they had to wear a gown when transferring residents. CNA C said he/she should wear a gown and gloves, clean the area, and when done he/she would remove his/her gloves, wash his/her hands and then put on clean gloves. CNA C said he/she should have washed his/her hands between glove changes, but did not because there was very little soap, and there is no hand sanitizer in the room. He/she also said he/she should have folded the washcloth to a clean area during catheter care or even gotten a new washcloth. CNA C said he/she was not really taught how to use EBP, or when to wear gloves and gowns. During an interview on 07/31/25 at 12:44 P.M., CNA B said he/she really didn't know what EBP was or when he/she should use. He/She said it should probably be used if the resident has a catheter, wounds, or is sick. CNA B said he/she should wear gown and gloves, and sometimes a mask; and should wear it when changing a resident with a catheter, or if touching anywhere near wounds. CNA B said he/she did not think they had to wear gowns when transferring residents. He/she said staff should wash hands before and after working with residents and should wash hands between glove changes. CNA B said he/she received training around February of last, and did not realize he/she did not wash his/her hands after taking his/her gloves off. During an interview on 07/31/25 at 1:26 P.M, the ADON said staff should wash hands, apply gown and gloves, and when cleansing the catheter tubing should start at the opening then wipe down the tubing away from the body. He/she said the washcloth should be folded over to a clean area or a new one should be used when cleaning the tubing, staff should not wipe repeatedly in the same area with the same cloth.During an interview on 07/31/25 at 1:48 P.M., the administrator said staff should not use the same area of the washcloth when providing cares and should fold to a clean area or get a new washcloth, and staff should not wipe repeatedly up and down the tubing.5. Review of Resident #34's Quarterly MDS assessment, dated 05/20/25, showed staff assessed the resident as severely cognitively impaired, no unhealed pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure on the skin), and not at risk for developing pressure ulcers. Review of the resident's POS, dated July 2025, showed an order, dated 07/24/25, for coccyx and left buttock, cleanse, apply medi-honey (wound treatment), xeroform (dressing that covers your wound), gauze folded, and cover with dressing twice a day.Observation on 07/30/25 at 8:10 A.M., showed resident's room with an EBP sign on the door and PPE in the room. Observation on 07/30/25 at 1:25 P.M., showed RN F and CMT G entered the resident's room, put on gloves and did not put gowns on. RN F placed wound care supplies on the resident's bedside table without a barrier. RN F used his/her right gloved hand to remove the soiled dressing from the resident's buttocks wound, picked up the spray bottle of cleanser and sprayed the gauze in his/her left hand, then transferred the gauze to his/her right hand, wearing the same soiled gloves he/she used the gauze to cleanse the wound bed wiping in circular motions, and then with the same soiled gloves on, used dry gauze to dry the wound bed, placed xeroform, opened a tube of medi-honey and applied a small amount to his/her gloved fingers of the left hand. RN F used his/her gloved fingers and applied medi-honey to the wound bed, pulling the xeroform down with his/her soiled right gloved hand, and applied an island dressing. RN F did not wear a gown, remove gloves or perform hand hygiene through the process. Observation showed RN F removed his/her gloves, did not perform hand hygiene, pulled the resident's blanket up, and then left the room without performing hand hygieneDuring an interview on 07/31/25 at 1:00 P.M., RN F said he/she did not complete wound care appropriately, and he/she should have changed gloves and completed hand hygiene during the process, and he/she does not know why he/she did not do that. RN F said by not completing wound care with proper infection control techniques it could cause contamination and infection in the wound. RN F said gown and gloves should be worn for EBP, for any kind of patient care, if doing catheter care or wound care. RN F was not sure of what other activities would require the use of EBP. During an interview on 07/31/25 at 1:26 P.M., the ADON said staff should wash hands, apply gown and gloves, and after removing a soiled dressing should wash hands and apply new gloves; provide the treatment and new dressing, then remove gloves and wash hands again. He/she said it is not okay to do wound care that way.During an interview on 07/31/25 at 1:48 P.M., the Administrator said it would not be appropriate to do wound care without changing gloves from dirty to clean, or between different wounds and it could cause infection.6. Review of Resident #42's Quarterly MDS, dated [DATE], showed staff assessed the resident as severely cognitively impaired, had an indwelling catheter, and dependent on staff for toileting hygiene. Review of the resident's POS, dated July 2025, showed and order dated 03/11/25, for Indwelling catheter continuous for neuromuscular dysfunction of bladder (bladder dysfunction). Observation on 07/30/25 at 1:35 P.M., showed resident's room with an EBP sign on the door and PPE in the room. Observation on 07/30/25 at 1:35 P.M., showed RN F entered the resident's room, placed gloves on the nightstand, and unlocked the resident's bed to pull away from the wall. RN F applied gloves, wiped the groin area twice, folded the washcloth and then wiped down the tube away from the body repeatedly, without folding to a clean area or using a new washcloth. RN F with the same soiled gloves on touched the resident's blanket. RN F removed his/her gloves, placed a new trash bag in the trash can, lowered the resident's bed, touched the door, and left the room with the tied-up trash bag. RN F left the room without performing hand hygiene and placed the trash bag in the dirty linen room down the hallway. During an interview on 07/31/25 at 1:00 P.M., RN F said when doing catheter care, he/she should start closest to the body and wipe down the tubing, using a clean part of the washcloth each time, and he/she thought he/she had done that. RN F said if catheter care is not completed appropriately, it could cause an infection. RN F said he/she should have worn a gown and did not know why he/she did not wear one. RN F said hand hygiene should be done when going in and out of the room, after interacting with the resident, with catheter care, before and after wearing gloves, and when exiting the room. RN F said he/she did not think he/she could use the sink in the resident's room and was not sure if that was acceptable.7. During an interview on 07/31/25 at 1:26 P.M, the ADON said for catheter care staff should wash hands, apply gown and gloves, wipe the tubing away from the body, and always use a clean portion of the washcloth. Staff should not wipe repeatedly in the same area with the same cloth.During an interview on 07/31/25 at 1:48 P.M., the Administrator said staff should not use the same area of the washcloth to clean multiple areas when providing cares. During an interview on 7/30/25 at 3:22 P.M., the Infection Preventionist (IP) said the Director of Nursing (DON) or Human Resources (HR) conduct in-services, and he/she had compiled a list of education topics for EBP and handwashing in July. The IP said EBP is used for residents who are colonized with bacteria or have indwelling devices or wounds. He/she said the PPE worn should be gown and gloves, and sometimes face shields. He/She said the PPE is available and should worn during personal care, bed changes, catheter or device care, wound care, transfers, and any high contact care activities. The IP said hand hygiene should be completed in between residents, and before and after changing gloves. He/she said staff should be changing gloves and using hand hygiene when going from dirty to clean tasks, and in between dressing removal and wound treatments. The IP said staff should not use the same area of the washcloth repeatedly while cleansing catheter tubing. During an interview on 07/31/25 at 1:26 P.M., the ADON said in-services have gone out on infection control with the IP, a verbal explanation of the signs on the door and PPE. The ADON said he/she would expect staff to wear gowns and gloves for catheter care, wound care, and any device care. He/she said he/she did not know staff did not know when and how to do EBP, and if there is a sign on the door then they should do it. The ADON said hand hygiene should be done before and after glove changes, after removing old dressings, and in between different wound treatments. The ADON said staff should not touch anything with dirty gloves, that would be cross contamination and could cause more infection for wounds or catheters; and he/she really cannot say why staff are not doing it appropriately. The ADON said the charge nurse, DON, IP and himself/herself would be responsible for overseeing staff. During an interview on 07/31/25 at 1:48 P.M., the Administrator said EBP is a process, and he/she thinks with certain diagnoses the EBP gets put up, and all the PPE is there when staff enters the room. He/she said the DON and IP are responsible for overseeing EBP in the facility. The Administrator said there had been in-service education for EBP, recently in the last couple of months. He/she said it would be an infection risk for residents if staff did not wear the appropriate PPE. The Administrator said ultimately the DON and himself/herself were responsible for ensuring staff education. The Administrator said he/she was not sure if staff should use the resident bathroom sink because that could be an infection control issue.

Based on observation, interview, and record review, facility staff failed to conduct inspections of bedrails as a part of regular maintenance program for one resident (#57) and failed to remeasure and reassess all possible entrapment zones for three residents (Resident #2, #8, #9) out of 18 residents sampled. The facility census was 61. Based on observation, interview, and record review, facility staff failed to conduct inspections of bedrails as a part of regular maintenance program for one resident (#57) and failed to remeasure and reassess all possible entrapment zones for three residents (Resident #2, #8, #9) out of 18 residents sampled. The facility census was 61. 1. Review of the facility's policy titled Adaptive Equipment Assessment Policy and Procedures, undated, showed:-The purpose is to prevent, identify, and appropriately respond to entrapment hazards in beds and equipment used by residents;-Risk of using adaptive equipment is a resident may attempt to get out of bed unsafely resulting in injury or death;-Risk for entrapment resulting in injury or death;-All staff will be trained to recognize and mitigate entrapment risks and equipment will be regularly inspected to ensure safety.Review of the facility's bed manufacturer's recommendations titled Med [NAME] User Manual, undated, showed the bed mattress must be properly sized to meet the entrapment zone dimensional guidelines, and to refer to the Food and Drug Administration (FDA) guidelines for entrapment measurements. Review of the United States FDA guidelines document titled Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, dated 03/10/06, showed 413 people died as a result of entrapment events in the United States. Further review showed those among the most vulnerable for these entrapment type events are the elder patients and residents, especially those who are frail, confused, restless, or have uncontrolled body movements. Further review showed it identifies seven different potential, zones of entrapment should be measured regularly. This guidance characterizes the head, neck, and chest as key body parts that are at risk of entrapment. Review of the FDA document entitled, Guide to Bed Safety Rails in Hospitals, Nursing Homes and Home Health Care: The Facts, dated 12/11/17, shows the potential risk of bed rails may include:-Strangling, suffocating, bodily injury or death when patients or part of their body are caught between rails or between the bed rails and mattress;-More serious injuries from falls when patient climb over rails; -Skin bruising, cuts and scrapes; -Inducing agitated behavior when bed rails are used as a restraint; -Feeling isolated or unnecessarily restricted; -And preventing patients, who are able to get out of bed, from performing routine activities such as going to the bathroom or retrieving something from a closet. 2. Review of Resident #2's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 06/01/25, showed staff assessed the resident as cognitively intact, dependent on staff for bed mobility, and did not use bed rails. Review of the resident's care plan, revised 06/18/24, showed bed canes (a smaller bed rail) used for turning and repositioning. Review of the resident's Physician's Order Sheet (POS), dated 07/28/25, showed adaptive equipment bed canes for increased safety and independence with bed mobility and transfers.Review of the resident's medical record showed entrapment measurements completed on 06/18/24. Review showed the medical record did not contain additional measurements.Observation on 07/28/25 at 7:45 A.M., showed the resident's bed with bed canes in the upright position on both sides. Observation on 07/28/25 at 2:40 P.M., showed the resident in bed with bed canes in the upright position on both sides. Observation on 07/30/25 at 10:30 A.M., showed the resident in bed with bed canes in the upright position on both sides. Observation on 07/30/25 at 1:38 P.M., showed the resident in bed with bed canes in the upright position on both sides. Observation on 07/30/25 at 4:03 P.M., showed the resident in bed with bed canes in the upright position on both sides. Observation on 07/31/25 at 7:52 A.M., showed the resident in bed with bed canes in the upright position on both sides. 3. Review of Resident #8's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact, dependent for chair/bed to chair transfers, tub/shower transfers; and required substantial/maximum assist for rolling left/right in bed; and did not use bed rails. Review of the resident's care plan, dated 07/11/25, showed staff documented the resident used bed canes for turning, and repositioning. Review of the resident's POS, dated July 2025, showed an order dated 08/13/24 for bed canes to increase safety with bed mobility and transfers. Review of the resident's medical record showed entrapment measurements completed on 03/11/24. Review showed the medical record did not contain additional measurements. Observation on 07/28/25 at 3:34 P.M., showed the resident in bed with bed canes in the upright position on both sides. Observation on 07/29/25 at 10:49 A.M., showed the resident in bed with bed canes in the upright position on both sides. Observation on 07/30/25 at 9:50 A.M., showed the resident in bed with bed canes in the upright position on both sides. Observation on 07/30/25 at 10:28 A.M., showed the resident used his/her bed canes during care.Observation on 07/30/25 at 4:03 P.M., the resident in bed with bed canes in the upright position on both sides. Observation on 07/31/25 at 7:51 A.M., showed the resident in bed with bed canes in the upright position on both sides. 4. Review of Resident #9's Quarterly MDS, dated [DATE], showed staff assessed the resident as severe cognitive impairment, required maximum assistance for bed mobility, and did not use bed rails. Review of the resident's care plan, revised 07/21/25, showed bed canes used for turning and repositioning. Review of the resident's POS, dated 07/28/25, showed bed canes for increased safety and independence with bed mobility and transfers.Review of the resident's medical record showed entrapment measurements completed on 10/27/22. Review showed the medical record did not contain additional measurements. Observation on 07/28/25 at 11:14 A.M., showed the resident's bed had bed canes in the upright position on both sides. Observation on 07/29/25 at 8:50 A.M., showed the resident in bed with bed canes in the upright position on both sides. Observation on 07/29/25 at 2:33 P.M., showed the resident in bed with bed canes in the upright position on both sides. Observation on 07/30/25 at 10:32 A.M., showed the resident in bed with bed canes in the upright position on both sides. Observation on 07/31/25 at 12:46 P.M., showed the resident in bed with bed canes in the upright position on both sides. 5. Review of Resident #57's Quarterly MDS, dated [DATE], showed staff assessed the resident as severe cognitive impairment, required maximum assistance for bed mobility, and did not use bed rails. Review of the resident's care plan, revised 03/18/25, showed bed canes used for turning and repositioning. Review of the resident's POS, dated 07/28/25, showed bed canes for increased safety and independence with bed mobility and transfers.Review of the resident's medical record showed entrapment measurements not completed on 01/29/21. Review showed the medical record did not contain additional measurements. Observation on 07/28/25 at 11:12 A.M., showed the resident's bed had bed canes in the upright position on both sides. Observation on 07/29/25 at 7:45 A.M., showed the resident in bed with bed canes in the upright position on both sides. Observation on 07/29/25 at 7:45 A.M., showed the resident in bed with bed canes in the upright position on both sides. Observation on 07/30/25 at 9:05 A.M., showed the resident in bed with bed canes in the upright position on both sides. Observation on 07/30/25 at 1:37 P.M., showed the resident in bed with bed canes in the upright position on both sides. 6. During an interview on 07/31/25 at 8:25 A.M., the maintenance director said he/she is responsible to complete the entrapment measurements for all residents who use bed canes. The maintenance director said after the admission nurse and physical therapy determine if a resident needs bed canes, they let him/her know and he/she installs the bed canes and completes the entrapment measurements. The maintenance director said he/she only does the entrapment measurements upon resident admission or if a bed is changed. The maintenance director said he/she does not complete entrapment assessments as part of regular maintenance program because he/she was not aware he/she needed to. During an interview on 07/31/25 at 1:00 P.M., Registered Nurse (RN) F said he/she does not know who is responsible to complete entrapment measurements. RN F said the purpose of entrapment measurements is to ensure there are not big gaps which a resident could get stuck in and injured. During an interview on 07/31/25 at 1:25 P.M., the Assistance Director of Nursing (ADON) said maintenance is responsible to install the bed canes, but he/she does not know who is responsible to do the entrapment measurements or if they are updated regularly. The ADON said the purpose of entrapment measurements is to ensure there are not big gaps which a resident could get stuck in and injured. During an interview on 07/31/25 at 1:48 P.M., the Administrator said maintenance is responsible to install bed canes, complete the entrapment measurements, and maintain the beds. The Administrator said the entrapment measurements were not updated regularly. The Administrator said the entrapment measurements are only completed upon admission.

Based on record review and interview, facility staff failed implement the facility's policy by not checking the Employee Disqualification List (EDL) quarterly for six staff (Certified Nurse Aide (CNA) T, Housekeeper U, Licensed Practical Nurse (LPN) N, Dietary Aide (DA) V, Registered Nurse (RN) W and Certified Medication Technician (CMT) P) of 10 sampled staff. The facility census was 61.1. Review of the facility's policy titled Employee Disqualification List Protocol, dated 06/17/24, instructed staff to complete quarterly re-checks, they must review new EDL listings to ensure no current employees are disqualified. 2. Review of CNA T's employee file showed a quarterly EDL check had not been completed since his/her hire date of 02/15/25. 3. Review of Housekeeper U's employee file showed a quarterly EDL check had not been completed since his/her hire date of 09/03/24. 4. Review of LPN N's employee file showed a quarterly EDL check had not been completed since his/her hire date 10/24/24. 5. Review of DA V's employee file showed a quarterly EDL check had not been completed since his/her hire date of 07/25/24. 6. Review of RN W's employee file showed a quarterly EDL check had not been completed since his/her hire date of 09/03/24. 7. Review of CMT P's employee file showed a quarterly EDL check had not been completed since his/her hire date of 01/21/25 8. During an interview on 07/30/2025 at 12:01 P.M., Human Resources said he/she tries to check current staff against the EDL every four to six months, and he/she does not have a list he/she ran against the EDL. During an interview on 07/30/2025 at 2:45 P.M., Human Resources said he/she cannot find any of the quarterly EDL checks. He/She said he/she did not know staff had to be checked against the EDL every three months. During an interview on 07/31/2025 at 11:35 A.M., the administrator said Human Resources is responsible for running quarterly EDL checks. The administrator said EDL checks are ran before employment and then quarterly per facility policy. The administrator said he/she doesn't know why the checks had not been completed quarterly. The administrator said the EDL should be checked against all employees to ensure a staff member has not been added. The administrator said he/she is responsible to make sure Human Resources runs the quarterly EDL checks. The administrator said he/she assumed Human Resources was running them per policy.

Based on interview and record review, facility staff failed to provide written information to the resident and/or the resident's representative of the bed hold policy at the time of transfer to the hospital for three residents (Resident #6, #38, and #57) out of 17 residents sampled. The facility census was 61.1. Review of the facility's policy titled Bed Hold Policy, dated 10/17/23, showed in the event a resident leaves the facility for hospitalization, a charge will not be calculated with anticipated return. 2. Review of Resident #6's medical record showed staff documented the resident discharged from the facility on 04/04/25 to the hospital and returned on 04/10/25. The medical record did not contain documentation staff issued a bed hold upon discharge to the resident or the resident's responsible party, and did not notify the ombudsman of the transfer/discharge. 3. Review of Resident #38's medical record showed staff documented the resident discharged from the facility on 06/12/25 to the hospital and returned on 06/16/25. The medical record did not contain documentation that staff issued a bed hold upon discharge to the resident or the resident's responsible party, and did not notify the ombudsman of the transfer/discharge. 4. Review of Resident #57's medical record showed staff documented the resident discharged from the facility on 04/10/25 to the hospital and returned on 04/10/25. The medical record did not contain documentation that staff issued a bed hold upon discharge to the resident or the resident's responsible party, and did not notify the ombudsman of the transfer/discharge. 5. During an interview on 07/31/25 at 8:50 A.M., the Social Service Designee (SSD) said he/she is responsible to notify the Ombudsman of the facility's admissions and discharges, and he/she sends them monthly. The SSD said he/she does not send the hospital transfers to the Ombudsman, and he/she did not know he/she needed to. The SSD said the facility does not complete bed holds. During an interview on 07/31/25 at 1:00 P.M., Registered Nurse (RN) F said he/she does not know what a bed hold is and does not complete them when a resident is transferred to the hospital. RN F said he/she is responsible to complete a discharge transfer form and give to the receptionist to update the census. RN F said he/she sends a copy of the resident's face sheet and orders with the resident to the hospital and does not have the resident or responsible party sign any forms to hold the residents' bed. During an interview on 07/31/25 at 1:25 P.M., the Assistant Director of Nursing (ADON) said he/she does not know what a bed hold is. The ADON said when staff transfers a resident to the hospital, they send a copy of the residents' face sheet and orders. The ADON said the charge nurse is responsible to fill out a discharge transfer form and give it to the receptionist to update the census, but they do not complete a bed hold. During an interview on 07/31/25 at 1:48 P.M., the administrator said the facility does not do bed holds. The administrator said the SSD is responsible to notify the Ombudsman of the facility admissions and discharges. The administrator said the SSD does not notify the ombudsman of resident transfers and he/she did not know the ombudsman should be notified.

Based on observation, interview, and record review, facility staff failed to ensure multi-dose medications were dated when opened in one out of two medication storage carts. The facility census was 61.1. Review of the facility's policy titled Medication Protocol, undated, showed facility staff were directed daily to label/record date when stock medication is opened and check for expired medications.2. Observation on 07/28/25 at 10:28 A.M., showed the 200-hall medication cart contained:-One bottle of Sodium Chloride 1 gram (gm) (used for electrolyte replenisher) opened and undated;-One bottle of Fluticasone Propionate 500 micrograms (mcg) nasal spray (used for allergies) opened and undated;-One bottle of Equate eye itch relief drops, opened and undated;-One bottle of 0.25% Acetic Acid 1,000 milliliter (ml) bottle (used for urinary irrigation) opened and undated;-One bottle of ABC complete vitamin, opened and undated;-One bottle of Vitamin C 500 milligrams (mg, opened and undated;-One bottle of Vitamin D 2000 mg, opened and undated;-One bottle of Vitamin B12 500 mcg, opened and undated;-One bottle of Stool Softener 50 mg/8.6 mg (used for constipation), opened and undated;-One bottle of Gas-X 125 mg, opened and undated;-One bottle of Antacid, opened and undated;-One bottle of Clearlax (used for constipation), opened and undated.During an interview on 07/28/25 at 10:45 A.M., Certified Medication Technician (CMT) E said when staff opens a bottle of medication they are supposed to put the open date on the bottle. He/She said this is to include over the counter or stock medications, nasal sprays, eye drops, and solutions. He/She the importance is to make sure the medication is not expired. He/She said he/she was not aware of medications that did not have open dated on them.During an interview on 07/31/25 at 1:15 P.M., Registered Nurse (RN) F said the medication bottle should contain an open date. He/She said an open date is important to ensure the medication is not expired. He/She said the CMT's should check for open dates since they are using the carts.During an interview on 07/31/25 at 1:26 P.M. the Assistant Director of Nursing (ADON) said medication bottles should have an open date and should be initiated by the staff member who opens it. He/She said the CMT's should be putting the open dates on every bottle when opened. He/She said open dates should be checked every time the medication bottle is handled. He/She said it is important to have open dates because several medications expire after 30 days. He/She said the Charge nurses, Director of Nursing (DON), and ADON are responsible to ensure over the counter and stock medications have open dates. He/She said he/she did not know if a system was in place to check medications for open dates.During an interview on 07/31/25 at 2:05 P.M. the Administrator said medication bottles should be labeled with an open date. He/She said whoever opens the bottle is responsible for putting the open date on it. He/She said the Charge nurse and DON are responsible for ensuring open dates are put on medication bottles. He/She said he/she is unsure how often CMT's check, but it should be on a regular basis. He/She said the importance is to ensure medications are not expired.

Based on observation and interview, the facility staff failed to maintain the mechanical dishwasher in good repair to ensure dishes were effectively washed and sanitized to prevent cross-contamination. This failure has the potential to affect all residents. The facility census was 61. 1. Observation on 05/28/24 at 10:35 A.M., showed the Certified Dietary Manager (CDM) washed a rack of soiled cups in the chemical sanitizing mechanical dishwasher.Observation showed the CDM did not check the temperature of the dishwasher during the cycle. Observation showed the gauge of the dishwasher registered the water temperature during the wash cycle as 110 degrees Fahrenheit (dF) and the water temperature of the rinse cycle registered 112 dF. Observation showed when the dishwasher cycle finished, the CDM removed the rack of cups to the clean side of the station to dry and then loaded another rack of soiled dishes into the machine to wash. Observation showed the gauge of the dishwasher registered the temperature during the wash cycle as 110 dF and the rinse cycle as 112 dF. Observation of the manufacturer's instruction label on the dishwasher showed direction for the minimum water temperature to be 120 dF. During an interview on 05/28/24 at 10:37 A.M., the CDM said the temperature of the dishwasher should be at least 120 dF for the wash and rinse cycles and he/she did not know the machine did not reach 120 dF during the two cycles of dishes he/she washed in the machine. Observation on 05/29/24 at 7:20 A.M., showed dietary staff loaded a soiled sheet pan into the mechanical dishwasher, started the machine and walked away. Observation showed the dietary staff did not check the temperature of the water during the wash and rinse cycles of the machine. Observation showed the gauge on the dishwasher registered the water temperature of the wash cycle as 112 dF and the water temperature of the rinse cycle as 116 dF. Observations during a second run of the dishwasher, showed when tested with a calibrated metal stem-type thermometer, the water temperature of the wash cycle measured 112 dF and the gauge on the dishwasher registered the water temperature as 112 dF. Observation showed when tested with a calibrated metal stem-type thermometer, the water temperature of the subsequent rinse cycle measured 116 dF and the gauge on the dishwasher registered the water temperature as 116 dF. Observation showed the dietary staff returned to the kitchen, removed the sheet pan from the dishwasher and placed it on the clean side of the station to dry. Observation on 05/30/24 at 8:39 A.M., showed [NAME] F washed the soiled food processor in the mechanical dishwasher twice. Observations during a second run of the dishwasher, showed when tested with a calibrated metal stem-type thermometer, the water temperature of the wash cycle measured 112 dF and the gauge on the dishwasher registered the water temperature as 112 dF. Observation showed when tested with a calibrated metal stem-type thermometer, the water temperature of the subsequent rinse cycle measured 117 dF and the gauge on the dishwasher registered the water temperature as 117 dF. Observations showed the cook checked the water temperatures during the wash and rinse cycles of the machine when they measured less than 120 dF. Observation showed, when the dishwasher cycle finished, the cook removed the food processor from the machine to dry. During an interview on 05/30/24 at 8:40 A.M., [NAME] F said staff are supposed to check the water temperature first thing in the morning on the machine and the water temperature should be at least 120 dF. The cook said the water is always the hottest in the morning and it loses temperature throughout the day. Observation on 05/30/24 at 8:42 A.M., showed [NAME] F used the food processor to prepare pureed waffles for service to a resident at breakfast. During an interview on 05/30/24 at 8:53 A.M., the [NAME] F said if the dishwasher is not reaching the proper temperature then staff should not use it and wash the dishes another way. The cook said he/she knew the water temperature of the dishwasher did not reach 120 dF when he/she washed the food processor and he/she went ahead and used it anyway because he/she needed to get the pureed waffles out for breakfast. During an interview on 05/31/24 at 9:15 A.M., the CDM said the cooks are responsible to monitor the dishwasher water temperature on both shifts and the temperature should be at least 120 dF. The CDM said the water temperature of the dishwasher is not very hot first thing in the morning or after it sits for a while until it is used a few times and staff should check the temperature to make sure the machine is working appropriately before they use it to wash dishes. The CDM said if the dishwasher is not working correctly, staff should not use it and report the issue to him/her or the production manager for correction. The CDM said the facility did not have a policy for use and maintenance of the mechanical dishwasher, but staff are trained on proper use of the dishwasher upon hire. During an interview on 05/31/24 at 9:25 A.M., the administrator said the CDM and staff are responsible to monitor the condition of the dishwasher and check the water temperature of the machine before they use it to wash dishes to make sure it is right and they may need to run it a couple of times to get the temperature up properly. The administrator said the water temperature of the dishwasher should be close to 120 dF and staff have been trained on this requirement. The administrator said if staff have ran the dishwasher a few times and the water temperature is still not correct, then they should not use it and report it to the CDM or maintenance staff for repairs. 37131 FACILITY Kitchen 05/28/24 Initial Kitchen 10:35 A.M. Dishwasher, Cycle of cups already ran sitting to left of dishwasher drying. Dietary Manager (DM) [NAME] ran cycle on dishwasher for cups, wash cycle reached 110 F and Rinse cycle reached 112 F. DM did not check temp during cycle and moved cups on to dry an ran another load. Dishwasher washed at 110F again and Rinsed at 112F again at 10:37 A.M. DM not aware running cold as it is a low temp but minimum should be 120 F for rinse and wash cycle. Test strip showed chemical at 50 PPM. 10:44 A.M. Open to air 32 oz pack and sliced ham in white frigidaire refrigerator, undated. DM seen the ham as inspector seen it and said threw it away, said when in doubt throw it out. DM said we should always date and sill the food. 10:48 A.M. walk-in freezer and fridge have internal thermometers and temped good. 10:50 A.M. open 10 pound tube of hamburger, missing half tube wrapped in silifain on bottom shelf of [NAME] cooler with three full 10Ib tubes of hamburger in metal container. Half tube loosely covered and without open date. 10:53 A.M. walk-in fridge five 32oz. packages of thawed, sliced roast beef stored on third shelf up on left directly above open box with uncovered raw green peppers. 10:56 A.M. floor of [NAME] cooler has a lot of food debris and dried spills. Dry Storage: 10:59 A.M., 50 pound bag of oats stored on bottom shelf, top of bag torn open, no date and oats open to air and not covered.

Based on interview and record review, facility staff failed to provide an ongoing program of activities designed to meet the residents' interest on the weekends for two residents (#3 and #54) out of two sampled residents. The facility census was 61. 1. Review of the facilities policy titled, Resident acitvity policy, undated, states activities refer to an endeavor, other than routine Activities of Daily Living (ADLs) in which a resident participates that is intended to enhance his/her sense of well-being and to promote physical, cognitive, emotional health. The certified Activity Director (AD) completes an Activity Assessment within 72 hours of resident admission in order to implement an effective daily activity program meeting their physical, cognitive social, spiritual, educational, and recreational needs with options essential for preserving and enhancing resident's sense of well-being. 2. Review of the facilities Activity Calander, dated May 2024, showed: -Saturday, 05/04/2024, library, music room, pool table, streaming service in the activity oom and use gaming console; -Sunday, 05/05/2024, did not contain acitvities; -Saturday, 05/11/2024, library, music room, pool table, streaming service in the activity oom and use gaming console; -Sunday, 05/12/2024, National Nursing Home Week Radiant Memories- A Tribute to the Golden Ages of Radio; -Saturday, 05/18/2024, library, music room, pool table, streaming service in the activity oom and use gaming console; -Sunday, 05/19/2024, did not contain acitvities; -Saturday, 05/25/2024, library, music room, pool table, streaming service in the activity oom and use gaming console; -Sunday, 05/26/2024, did not contain acitvities. 3. During an interview on 05/29/24 at 3:39 P.M., Resident #3 said the facility does not have activities on the weekends. The resident said he/she would participate in activities on the weekends if they were offered. During an interview on 05/29/24 at 2:29 P.M., Resident #54 said the facility does not offer activities on Saturday and Sunday. The resident said he/she would attend activities on Saturday and Sunday if they were offered. During an interview on 05/30/24 at 3:45 P.M., Certified Medication Technician (CMT) D said he/she works every other weekend. The CMT said activities are not offered regularly on the weekends. The CMT said when nursing staff have time they will provide activities on their hall. The CMT said there are not scheduled activities on the weekends. During an interview on 05/30/24 at 3:55 P.M., Regisitered Nurse (RN) E said he/she works some weekends. The RN said he/she thinks there is church every now and then on Sundays but there are no scheduled activities on the weekends. During an interview on 05/30/24 at 4:02 P.M., Acounts Payable/Receptionist said he/she also assists with acitvities. He/She does not work weekends and rarely does the weekend have scheduled activities. He/She said the activities on the weekends are what the residents choose to do on their own. During an interview on 05/31/24 at 3:27 P.M., the Director of Nursing (DON) said weekend activities are resident choice, there are no scheduled activities. The DON said residents can do things such as color, play the gamin console, watch movies, play board games, or do puzzles. The DON said the nursing staff should be offering activities on the weekend. The DON said he/she is aware activities are not always getting done on the weekends, it is only being done when staff have the time. During an interview on 05/30/24 at 4:15 P.M., the administrator said activities are offered on the weekends by the nursing staff and usually involve going outside, games, or independent activities. The administrator said there is not a way for the residents to know what activities are offered on the weekend because they are not listed on the schedule.

Based on observation, interview, and record review, facility staff failed to ensure a medication error rate of less than 5% out of 25 opportunities observed, two errors occurred, resulting in a 8% error rate, which affected one resident (Residents #2) of 11 sampled residents. The facility census was 61. 1. Review of the facility's, Insulin Administration Policy, not dated, showed if using an insulin pen, prime needle with two units prior to dialing to the amount of insulin. Review of Resident #2's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 04/09/24, showed staff documented the resident diagnosis of Diabetes and received insulin injections seven days of the seven days in the look back period. Review of the resident's Physician Order Sheet (POS), dated 05/01/24, showed Humalog Kwik Pen (Insulin Lispro) 100 Units/milliliter (ml) per sliding scale three times a day. Review of the resident's Medication Administration Record (MAR), dated 05/01/24, showed staff documented the following medication administrations: -05/30/24, five units before lunch; -05/31/24, five units before breakfast. Observation on 05/30/24 at 11:37 A.M., showed Certified Medication Technician (CMT) C dialed the resident's Humalog Kwik Pen to five units and administered the insulin to the resident. The CMT did not prime the insulin pen prior to administration. Observation on 05/31/24 at 8:44 A.M., showed CMT A dialed the resident's Humalog Kwik Pen to five units and administered the insulin to the resident. The CMT did not prime the insulin pen prior to administration. During an interview on 05/31/24 at 11:44 A.M., CMT A said he/she should have primed the the insulin pen, that was his/her mistake. The CMT said he/she knows to prime the insulin pen, he/she just missed it. During an interview on 05/31/24 at 2:48 P.M., The Director of Nursing (DON) said staff should prime the insulin pen, he/she thinks two units. The DON said staff prime the needle to remove air. The DON said if staff did not prime the insulin pen, then the resident would not get the correct amount of insulin.

Based on observation, interview and record review, facility staff failed to post the required nurse staffing information in an easily accessible place for residents and visitors, and failed to include the required data in the posting. The facility census was 61. 1. Review of the facility's policy titled, Posted Nursing Data, dated 10/23/23, showed per state and federal guidelines, it is the policy of the facility that the day charge nurse post the following data on a daily basis located at the skilled nurses station area: Facility name, current date, census, number of Registered Nurses (RN), Licensed Piratical Nurses (LPN), and Certified Nurse Aides (CNA). Observation on 05/30/24 at 2:00 P.M., showed the nurse staff posting at the nurse's desk behind a locked door, not easily accessible to residents and visitors. Review showed the nurse posting did not contain the facility name, resident census, or the total hours worked for direct care nursing staff. Observation on 05/31/24 at 9:49 A.M., showed the nurse staff posting at the nurse's desk behind a locked door, not easily accessible to residents and visitors. Review showed the nurse posting did not contain the facility name, resident census, or the total hours worked for direct care nursing staff. During an interview on 05/31/24 at 10:49 A.M., RN B said the nurse staff posting is located behind the nurses desk. RN B said the night shift nurse fills the form out and it is always done when he/she arrives at the facility. RN B said there is no other staff posting in the building, and it is not accessible to residents and visitors when locked behind the nurses desk. The RN did not know what should be listed on the form. During an interview on 05/31/24 at 3:31 P.M., the Director of Nursing (DON) said the night shift charge nurse is responsible for filling out the nurse staff posting form. The DON said the form changed, and it did not include the required information. The DON said the form was moved behind the nurses station when the staffs first and last name was added. The DON said the form should be filled out per regulation. The DON said the form is not kept in an accessible area for residents and visitors. During an interview on 05/31/24 4:17 P.M., the administrator and assistant administrator said the nurse staff posting should include the date, facility name, census, the number of LPN's, RN's, CNA's and the total hours worked. The Administrator said there is a dry erase board outside the nurses station for it to be posted on. The posting should be accessible to visitors and family and should be filled out per the regulation.

Based on observation, interview and record review, the facility staff failed to store food in a manner to prevent potential contamination and out-dated use. Facility staff failed to use food in a first in-first out method when facility staff opened multiple containers of the same food item for use. Facility staff also failed to wear hair restraints to protect food and food-contact surfaces from potential contamination. The facility census was 60. 1. Review of the facility's Food Storage policy, dated 11/01/17, showed the policy directed staff to store food obtained for use by the facility for consumption by the residents properly in the kitchens and the refrigerators and freezers are to be maintained by the dietary staff. Review of the facility's Label and Dating policy, dated 11/01/17, showed Any food prepared and stored for later use or partially opened food items must be clearly identified. If the original packaging is not still intact the label must include what the product is and dated with day item produced. Items containing eggs, mayonnaise containing eggs, or fish products must be disposed of same day produced. All other food items must be stored and disposed of properly in direction of the Food code. Observation on 02/20/23 at 10:26 A.M., showed the main kitchen service area counter contained an opened and undated four pound jar of peanut butter and an opened and undated 12 ounce (oz.) container of powdered coffee creamer. Observation on 02/20/23 at 10:28 A.M., showed the black refrigerator in the main kitchen service area contained: -an opened and undated one gallon container of milk; -two opened and undated bottles of chocolate syrup; -an opened and undated bottle of caramel syrup; -an opened and undated bottle of strawberry syrup; -an opened and undated bottle of pancake syrup; -an opened and undated bottle of mustard; -an opened and undated bottle of grape jelly; -an opened and undated jar of grape jam. Observation on 02/20/23 at 10:36 A.M., showed the white refrigerator in the main kitchen contained: -an opened, undated and unlabeled [NAME] jar which contained an unidentifiable brown applesauce textured substance; -two opened and undated bottles of mustard; -three undated and unlabeled clear plastic cups with lids which contained an unidentifiable white and brown substance; -two opened and undated bottles chocolate syrup; -an opened and undated container of vegetable oil whipped spread; -a metal container which contained a cut onion opened to the air; -a cut tomato open to the air and undated; -six boiled eggs in plastic wrap undated; -an opened and undated two pound package of smoked ham in a plastic food storage container; -an undated bag of four boiled eggs opened to the air; -an undated plastic food storage container of white cheese slices. Observation on 02/20/23 at 10:37 A.M., showed the rack next to white refrigerator in the main kitchen contained: -four opened and undated bags of potato chips; -an opened and undated box of stir-fry rice noodles, opened to the air; -an undated bag of blueberry muffin mix in an undated plastic bag, opened to the air. Further observation showed a use by date of 11/16/22 printed on the muffin mix bag; -an opened and undated bottle of white chocolate flavoring with a hardened substance on the top of the bottle; -an undated bottle chocolate sauce opened to the air; -an undated bag of gluten free chocolate chip cookies opened to the air. Observation on 02/20/23 at 10:50 A.M., showed an opened and undated box of farina cereal on top of the microwave. Observation on 02/20/23 at 10:51 A.M., showed the white cabinet above the hot box contained: -two opened and undated one gallon bottles of vanilla flavoring; -two opened, undated and unlabeled [NAME] jars which contained an unidentifiable brown applesauce textured substance; -two opened and undated bottles cream of tartar; -a bag of yellow cake mix dated 6-30 opened to the air; -an opened and undated bag of graham cracker crumbs; -an opened and undated bag of cake mix; -an opened and undated bag of powdered sugar. During an interview on 02/20/23 at 11:29 A.M., the Certified Dietary Manager (CDM) said he/she could not identify the brown applesauce textured substance in the [NAME] jars and the jars should be labeled. Observation on 02/20/23 at 10:57 A.M., showed a sign posted on the reach-in refrigerator door that read STOP Please date and label everything. Further observation showed the reach-in refrigerator contained: -an undated plastic food storage container of white cheese slices; -an undated and unlabeled metal container covered with plastic wrap with contained an unidentifiable white sauce textured substance; -an opened and undated one gallon container of mayonnaise; -an opened and undated one gallon container of Caesar dressing; -an opened and undated one gallon container of soy sauce opened and undated; -an opened and undated one gallon bottle of Worcestershire sauce; -an opened and undated 6.5 pound container of sliced strawberries. Observation on 02/20/23 at 11:03 A.M., showed the walk-in cooler contained: -a box of raw bacon opened to the air; -an undated plastic resealable bag of sliced onions; -an undated plastic resealable bag of cabbage. Observation on 2/20/23 at 11:11 A.M., showed the walk-in freezer contained: -an undated and unlabeled plastic resealable bag of hamburger patties removed from their original packaging; -an undated and unlabeled bag of a unidentifiable meat crumbles; -a box of frozen pizza crust opened to the air. Observation on 02/20/23 at 11:40 A.M., showed the reach-in refrigerator in the rehabilitation unit contained: -an undated plastic bag of shredded carrots and a purple item; -an undated bag of celery opened to the air; -an opened and undated five pound bag of shredded cheese; -an undated plastic resealable bag of of cooked sausage. Observation on 02/20/23 at 11:46 A.M., showed the rehabilitation kitchen dry goods pantry contained: -an undated and unlabeled bag of an unidentifiable grain-like substance; -an undated metal bowl of broken pasta covered with plastic wrap undated; -a bag of tortilla chips opened to the air. Observation on 02/20/23 at 11:51 A.M., showed the rehabilitation kitchen reach-in freezer contained: -three large unlabeled and unidentifiable chunks of meat removed from their original packaging and wrapped in plastic wrap; -a box of biscuit dough opened to the air; -an opened and undated bag of dinner roll dough. Observation on 02/20/23 at 11:53 A.M., showed the rehabilitation kitchen food preparation area contained opened and undated plastic containers of dill weed, garlic, Italian seasoning, paprika, cumin rotisserie seasoning, onion power, basil leaves, ground ginger and pumpkin pie spice. Observation on 02/20/23 at 11:56 A.M., showed the rehabilitation kitchen serving area contained: -an opened and undated bag of tortilla chips; -an opened and undated jar of peanut butter; -an opened and undated jar of grape jelly; -an opened and undated bottle of pancake syrup. Observation on 02/20/23 at 12:05 P.M., showed the white refrigerator in the rehabilitation kitchen contained: -an opened and undated one gallon bottle of milk; -an opened and undated jar of grape jelly; -an opened and undated bottle of chocolate syrup; -an undated plastic cup of applesauce; -an open and unlabeled [NAME] jar which contained an unidentifiable brownish applesauce textured substance dated 1-14-23. Observation on 02/20/23 at 12:22 P.M., showed the white refrigerator in the 300 hall dining room contained: -three opened and undated bottles of mayonnaise; -four opened and undated bottles of ketchup; -an opened and undated bottle of mustard; -an opened and undated one gallon bottle of milk; -one bottle chocolate syrup opened and undated; -an opened and undated bottle of grape jelly; -an opened and undated container of vegetable oil spread opened and undated. Observation on 02/22/23 at 7:20 A.M., showed the combination freezer/refrigerator unit in the main kitchen contained: -an opened, undated and unlabeled one quart [NAME] jar which contained an unidentifiable brown applesauce textured substance; -an opened and undated 14 oz. bottle of ketchup; -an opened and undated 24 oz. bottle of caramel syrup; -three opened and undated 13 oz. bottles of mustard; -an opened and undated 11.5 oz. bottle of mayonnaise; -two undated bags of commercially prepared boiled eggs opened to the air; -two opened and undated 3.5 pound container of vegetable oil whipped spread. Observation also showed brown specks in product inside the containers; -an opened and undated 24 oz. jar of sliced dill pickles; -a small metal pan labeled as Mayo 2/21/23 partially covered with a steamtable lid that contained a utensil hole which exposed the contents to the air; -an small undated and unlabeled plastic parfait cup of an unidentifiable white and brown substance. During an interview on 02/22/23 at 7:41 A.M., Cook L said he/she could not identify the substance in the [NAME] jar and it should have been dated and labeled before staff put it into the refrigerator. The cook said he/she does not look in that refrigerator since it is storage for the servers and the servers are supposed to maintain it. Observations on 02/22/23 at 7:42 A.M., showed a bulk container of sugar dated 02/21/23 and a bulk container of flour dated 12-21 stored beneath the coffee counter. Observation showed measuring cups stored in the bulk containers with their handles buried in the products. Observation on 02/22/23 at 7:51 A.M., showed the cabinet above the hot box contained: -an opened five pound bag of pound cake mix dated 6/10/21. Observation showed the exterior of bag covered with cocoa powder; -a five pound bag of yellow cake mix dated 6-30 opened to the air; -a five pound bag of yellow cake mix dated 11-11 opened to the air; -an opened and undated five pound bag of graham cracker crumbs; -an opened and undated bag of white cake mix; -an opened and undated five pound bag of southern yellow cornbread; -an undated one gallon plastic resealable bag which contained an opened and undated bag of cocoa powder; -pearled Italian [NAME] opened to the air and dated 2-12. -an opened and undated one gallon bottle of imitation vanilla flavor. Observation showed the delivery sticker on the bottle dated 08/26/20; -an opened and undated one gallon bottle of imitation vanilla flavor. Observation showed the delivery sticker on the bottle dated 08/18/21; -an opened and undated two pound bag of powdered sugar. During an interview 02/22/23 at 7:58 A.M., Cook L said the date of the Italian [NAME] would be 02/12/22 not 02/12/23 since they had not used it yet this year. The cook said everyone is responsible to monitor food storage and he/she had not looked in the cabinet for a while. Observation on 02/22/23 at 8:06 A.M., showed the reach-in refrigerator by the hot box contained: -an opened and undated one gallon bottle of soy sauce; -an opened an d undated one gallon bottle of Worcestershire sauce; -an opened and undated 6.5 gallon plastic container of commercially sliced strawberries. Observation showed the lid of the container bulged which abruptly deflated when opened and the strawberries smelled fermented and sour. -an opened and undated 17.25 oz. jar of grape fruit spread. Observation showed the grape fruit spread appeared brown in color and the container had a best if used by dated of 05/27/22 printed on the label; -an opened and undated one quart [NAME] jar which contained an unidentifiable brown applesauce textured substance; -an opened and undated 24 oz bottle of caramel syrup; -an undated and unlabeled round plastic food storage container which contained an unidentifiable white greasy substance; -an opened and undated one gallon bottle of barbeque sauce; -an opened and undated one gallon bottle of horseradish flavored french salad dressing. Observation showed the delivery sticker dated 09/14/22; -an opened and undated one gallon bottle of creamy Caesar dressing. During an interview 02/22/23 at 8:10 AM the cook said the strawberries had been in the refrigerator since 02/14/23. Observation on 02/22/23 at 8:28 A.M., showed the rack by the combination freezer/refrigerator unit contained: -an undated 14 oz. box of stir-fry rice noodles opened to the air; -an undated 24 oz. box of gluten-free all purpose baking mix opened to the air; -a 24 oz. bag of gluten-free pancake mix, dated 09/13/22; -a one gallon plastic resealable bag dated 11/16/22, opened to the air. Observation showed the bag contained an opened and undated 20 oz. bag of oat flour; -an undated 16 oz. bottle of chocolate sauce opened to the air. Further observation showed the product label included instructions to refrigerate the product after opening; -an opened and undated 16 oz. bottle of white chocolate flavored sauce. Further observation showed the product label included instructions to refrigerate the product after opening. During an interview on 02/22/23 at 8:35 A.M., Cook L said if a product says to refrigerate after opening then staff should refrigerate the item after it is opened. The cook said all opened food items should be dated, labeled and sealed. Observation on 02/22/23 at 8:59 A.M., showed the storage cart in the cook's station contained: -an opened and undated five pound five oz. container of instant mashed potatoes; -an opened and undated one gallon bottle of white vinegar; -an opened and undated 16 oz. bag of marshmallows; -an opened and undated five pound bag of yellow cake mix; -an opened and undated one gallon container of soybean salad oil; -an undated 28 oz. bag of chicken flavored stuffing mix opened to the air. During an interview on 02/22/23 at 9:09 A.M., the CDM said opened food items should be sealed, dated and labeled. If a container says to refrigerate after opening staff should refrigerate the item after it is opened. The CDM said when their are multiple packages of items, staff should use the oldest package first. The CDM said staff should return any unused portions of opened food items to where they got them from and use all of one package before they open another package of the same item. The CDM said all staff are responsible to ensure food is stored appropriately and he/she usually checks food storage on truck days. The CDM said staff should also not store scoops in the bulk food bins and staff have been trained on these requirements multiple times. Observation on 02/22/23 at 9:55 A.M., showed the refrigerator in the rehabilitation kitchen contained: -an opened and undated 24 oz. bottle of chocolate syrup; -an opened and undated 12.7 oz. bottle of dill relish; -an opened and undated 14 oz. bottle of ketchup; -an opened and undated five oz. bottle of Tabasco sauce. Observation on 02/23/23 at 11:13 A.M., showed the refrigerator in the 300 hall dining room contained: -three opened and undated 14 oz. bottles of ketchup; -three opened and undated 11.5 oz. bottles of mayonnaise; -an opened and undated 12.75 oz. jar of sugar free grape jam; -an opened and undated 24 oz. bottle of sugar free pancake syrup; -an opened and undated 24 oz. bottle of pancake syrup; -an opened and undated 13 oz. bottle of yellow mustard; -an opened and undated 20 oz bottle of strawberry fruit spread with a best by date of 01/28/23 printed on the label; -an opened and undated 20 oz. bottle of grape jelly; -an opened and undated 3.5 pound container of vegetable oil whipped spread. Observation at this time also showed the dining room cabinets contained: -an opened and undated 40 oz. bottle of honey; -undated plastic storage containers of cornflakes, fruit whirls, toasted oat O's and crisp rice cereal removed form their original packaging; -a bag of crisp rice cereal dated 12-21 opened to the air. During an interview on 02/23/23 at 11:55 A.M., the Assistant Administrator said staff should label, date and seal opened food items and staff are trained to do so upon hire. The Assistant Administrator said staff should dispose of any unused food items passed the best by or use by date and if a food item says to refrigerate after opening, then staff should refrigerate it after they open it. The Assistant Administrator said staff should use food items in a first in-first out manner and use all of one container before they open another. The Assistant Administrator said the CDM is responsible to monitor food storage weekly and if something is found not in compliance, the CDM should throw the item away and reeducate staff. 2. Review of the facility's Hair Restraint policy, dated 11/01/17, showed proper hair restraints are required while serving and/or preparing food as well in serving areas. Hair restraints will be provided to all dietary staff. Hair restraints are designed to effectively keep hair from contacting exposed food and/or serving areas. In the event that an employee has facial hair a beard net must be worn. Observations on 02/22/23 from 7:20 A.M. to 9:18 A.M., showed Cook L and the CDM prepared and served food to the residents without the use of hair restraints for their facial hair. During an interview on 02/22/23 at 9:24 A.M. the CDM said staff are trained to wear hair restraints, which included facial hair restraints. The CDM said staff use to wear the facial hair restraints, but they stopped since they had to wear facemasks as a result of the pandemic and he/she thought the masks helped with that. The CDM said all hair should be restrained and he/she did not think about the facemasks not covering all of the staff's facial hair. During an interview 02/23/23 12:08 P.M., the Assistant Administrator said dietary staff should wear hair restraints when they prepare or serve food and the facility policy includes the use of facial hair restraints. The Assistant Administrator said staff are trained on the hair restraint policy and the CDM is responsible to monitor for the use of hair restraints. 45564

Based on observation, interview and record review, facility staff failed to provide the necessary care and services to maintain good personal hygiene for three sampled residents (Residents #4, #15, and #39) that were unable to perform their own activities of daily living (ADL), and failed to answer call lights in a timely manner for one resident (Resident #28). The facility census was 60. 1. Review of the facility's Bath and Shower policy, dated 10/10/22 showed: -It is the policy of the facility to allow residents their choice with their bath/shower regimen and schedule; -Resident are allowed to choose their preferred time of their bath/shower; -Residents will be bathed/showered minimally twice per week; -Residents have the right to request more showers/baths as they feel needed. 2. Review of Resident #4's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 12/7/22, showed staff assessed the resident as follows: -Severe cognitive impairment; -Required extensive assistance from two staff for transfers; -Required limited assistance from one person for personal hygiene; -Required one person physical assistance with bathing. Review of the resident's shower documents, from 1/1/23 through 2/23/23 showed staff documented the following regarding bathing assistance: - No bathing assistance between 1/1/23 and 1/24/23; - No bathing assistance between 1/26/23 and 1/31/23; - No bathing assistance between 2/1/23 and 2/7/23; - No bathing assistance between 2/9/23 and 2/22/23. Observation on 2/21/23 at 8:21 A.M., showed the resident's hair was unkempt and their fingernails had a brown substance under the nails. 3. Review of #15's Quarterly MDS dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -Required extensive assistance of two staff members for dressing, transfers and personal hygiene; -Did not have a bath in the lookback period (7 day period required to look back to complete the assessment); -Had no behaviors or rejection of care; -Had limited range of motion to one lower extremity; -Had diagnosis of hemiplegia (unable to move one side of body), and urinary incontinence. Review of the residents' Care Plan, dated 2/20/23 showed the record did not contain direction or guidance for the resident's shower preferences. Review of the resident's bath schedule, undated, showed staff should provide showers twice a week on Tuesday and Friday. Review of the resident's Point of Care ADL report, dated 1/1/23 through 1/14/23, showed staff documented they provided the resident one bath on 1/3/23 during the 14 day period. Review of the resident's Point of Care ADL report, dated 1/15/23 through 1/31/23, showed staff documented they provided the resident one bath on 1/10/23 during the 14 day period. Review of the resident's Point of Care ADL report, dated 2/1/23 through 2/22/23, showed staff documented they provided the resident one bath on 2/8/23 during the 22 day period. Observation on 2/20/23 at 10:41 A.M., showed the resident asked Certified Nurse Aide (CNA) K for a shower. CNA K told the resident, he/she could not have a shower because he/she was on isolation. Additionally, CNA K did not offer alternative ways to clean the resident. Observation on 2/20/23 at 3:00 P.M., showed the resident on isolation in his/her room. He/She had greasy hair, long dirty fingernails and long facial hair. During an interview on 2/20/23 at 3:00 P.M., the resident said he/she would like a shower but cannot have one because he/she is stuck in the room because of COVID. 4. Review of Resident #39's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Required extensive assistance from two staff for transfers; -Required extensive assistance from one person for personal hygiene; -Required one person physical assistance with bathing. Review of the resident's shower documents, from 1/1/23 through 2/23/23 showed staff documented the following regarding bathing assistance; - No bathing assistance between 1/2/23 and 1/5/23; - No bathing assistance between 1/6/23 and 1/8/23; - No bathing assistance between 1/9/23 and 1/12/23; - No bathing assistance between 1/13/23 and 1/16/23; - No bathing assistance between 1/17/23 and 1/19/23; - No bathing assistance between 1/20/23 and 1/23/23; - No bathing assistance between 1/24/23 and 1/26/23; - No bathing assistance between 1/28/23 and 1/31/23; - No bathing assistance between 2/2/23 and 2/13/23; - No bathing assistance between 2/15/23 and 2/22/23. 5. During an interview on 2/23/23 at 9:11 A.M., CNA F said residents who do not leave their rooms, such as those with COVID-19 would get a bed bath in their rooms and should be documented at the nurses station. He/She said all residents are scheduled for twice weekly baths with refusals documented at the nurses station in an aide book. CNA F said showers should include changing of clothing, shaving and nail care of the resident. He/She feels there is enough staff to meet the needs of the residents. During an interview on 2/23/23 at 9:19 A.M., Nurse Aide (NA) G said resident are supposed to get a shower twice a week and clothing changed at least daily including COVID-19 positive residents. He/She said COVID-19 positive residents cannot leave their room so they receive a bed bath, but isn't sure if it is documented anywhere. During an interview on 2/23/23 at 10:26 A.M., CNA D said residents receive showers twice a week if they want. He/She said some residents prefer only one per week and will sometimes refuse that. He/She said showers and refusals should be documented in the aide book kept on the hallway. He/She said the aides do work from a shower schedule to make sure they are completed. CNA D feels there is enough staff to meet the needs of the residents including receiving the showers as scheduled. During an interview on 2/23/23 at 10: 27 A.M., Certified Medication Technician A said residents receive two showers a week that is recorded in a shower book at the nurse desk. He/She said sometimes the residents only wish one bath per week and should be documented they refused the second bath. During an interview on 2/23/23 at 11:18 A.M., the Director of Nursing (DON) said residents who must stay in their rooms during isolation will need to take a bed bath and remain in their rooms. He/She said residents are showered at least weekly and per the resident's preference. The DON said refusals should be reported to the charge nurse and resident preferences should be in the plan of care. 6. Review of the facility's policies showed staff did not provide a policy for call lights. 7. Review of Resident #28's Admission MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Had no behaviors or rejection of care; -Dependent on two staff for bed mobility, transfers, dressing and toileting; -Dependent on one staff for personal hygiene; -Had diagnosis of quadriplegia (inability to move all four limbs). Review of the facility's call light report dated 2/15/23 through 2/22/23 showed the following call light response times: -2/18/23 at 8:03 A.M., room [ROOM NUMBER], 20:36 minutes; -2/18/23 at 10:59 P.M., room [ROOM NUMBER], 21:49 minutes; -2/19/23 at 7:48 A.M., room [ROOM NUMBER], 29:15 minutes; -2/19/23 at 9:18 P.M., room [ROOM NUMBER], 26:36 minutes; -2/19/23 at 11:47 P.M., room [ROOM NUMBER], 20:28 minutes; During an interview on 2/21/23 at 10:00 A.M., the resident said he/she has to wait a long time to be assisted with transfers, being changed, and assisted to eat by staff due to the staff struggling to respond if a timely manner. During an interview on 3/1/23 at 8:58 A.M., the Assistant Administrator said all staff are expected to answer call lights. He/She said call lights should be answered timely to meet the resident needs. 43327

Based on record review and interview, the facility staff failed to follow their policy to ensure they completed the required Nurse Aide (NA) Registry (a registry that is a list of individuals who had a previous incident involving abuse, neglect, or misappropriation of property) check in accordance with their policy prior to start date for 10 employees (Maintenance Worker L, Dietary Aid (DA) M, Housekeeping Aid N, Licensed Practical Nurse (LPN) O, LPN P, Certified Medical Technician (CMT) E, CMT A, Environmental Aid Q, NA R and Human Resource Director) out of 10 sampled employees. The facility census was 60. 1. Review of the facility's Abuse/Neglect policy, undated, showed: - The facility will not hire or maintain in employment a person with a history of abuse and will report any employee known to be abusive to the appropriate authorities; -The nurse aid registry will be checked prior to employment for each state where a nurse aid has shown to have worked, or has listed certification. Nurse aides will not be hired whose name is on any state abuse registry; -Verification of background checks, nurse aid registry checks, and reference checks will be maintained in the personnel file of each employee; A notation by facility staff member of telephone contacts for registry check and previous employer check would constitute verification. 2. Review of Maintenance worker L's personnel record showed: -The file did not contain documentation staff completed the NA Registry check. 3. Review of DA M's personnel record showed: -The file did not contain documentation staff completed the NA Registry check. 4. Review of Housekeeping Aid N's personnel record showed: -The file did not contain documentation staff completed the NA Registry check. 5. Review of LPN O's personnel record showed: -The file did not contain documentation staff completed the NA Registry check. 6. Review of LPN P's personnel record showed: -The file did not contain documentation staff completed the NA Registry check. 7. Review of CMT E's personnel record showed: -The file did not contain documentation staff completed the NA Registry check. 8. Review of CMT A's personnel record showed: -The file did not contain documentation staff completed the NA Registry check. 9. Review of EA Q's personnel record showed: -The file did not contain documentation staff completed the NA Registry check. 10. Review of NA R's personnel record showed: -The file did not contain documentation staff completed the NA Registry check. 11. Review of the Human Resource Director's personnel record showed: -The file did not contain documentation staff completed the NA Registry check. 12. During an interview on 2/23/22 at 8:20 A.M., the Human Resource Director said he/she knows the NA registry search should be done with each new hire but could not account for why personnel records did not contain a copy. During an interview on 2/23/23 at 8:33 A.M., with the Director of Nursing said background checks should be done on each employee including NA registry checks. During an interview on 2/23/23 at 8:57 A.M., with the Assistant Administrator said criminal background checks should be done with each employee and it should contain NA registry searches.

Based on observation, interview, and record review, facility staff failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections, when staff failed maintain a clean blood glucose meter (device used to obtain a blood sugar reading) between residents (Resident #15, #4, and #13). The facility census was 60. 1. Review of the facility's Blood Glucose Monitoring Device Care policy, undated, showed: -It is the mission of the facility to prevent transmission of pathogens through blood glucose monitoring devices; -Blood glucose monitoring devices must be disinfected by staff with hydrogen peroxide and/or Clorox wipes before and after each use; -Blood glucose monitoring devices are to be placed in a caddy and carried into the resident room; -The caddy is to be cleansed with hydrogen peroxide and/or Clorox wipes between resident's rooms; -If the caddy is placed on a hard surface, that area must be cleansed with hydrogen peroxide wipes after removal of caddy prior to leaving resident's room. Review of the CareSens N User Manual (the blood glucose monitoring device used by the facility), dated September 2015, showed: -Use a soft cloth or tissue to wipe the meter exterior. If necessary, dip the soft cloth or tissue in a small amount of alcohol; -Do not use any household and industrial cleansers that may cause irreparable damage to the meter. Review of the Centers for Disease Control (CDC)'s Infection Prevention during Blood Glucose Monitoring, dated March 2011, showed -Whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleansed and disinfected after every use, per manufacturer's instructions. If the manufacturer does not specify how the device should be cleaned and disinfected then is should not be shared; -Unsafe practices during assisted monitoring of blood glucose and insulin administration that have contributed to transmission of HBV or have put persons at risk for infection include using a blood glucose meter for more than one person without cleaning and disinfecting it in between uses and failing to change gloves and perform hand hygiene between finger stick procedures. 2. Observation on 2/22/23 at 11:00 A.M., showed CMT J entered Resident #15's room with a tote containing a vial of test strips, a sharps container, a medication cup filled with lancets (device used to poke the finger), a medication cup filled with pen needles (device used on an insulin pen), a medication cup holding the blood glucose meter and several alcohol pads. He/She sat the tote on the overbed table, removed the meter from the medication cup and placed the meter directly on the overbed table without a barrier. He/She obtained the blood sample and rested the meter back onto the overbed table and offered the resident some water. He/She removed the test strip with gloved hands and put it into the sharps container, removed his/her gloves, and washed his/her hands. He/She placed the blood glucose meter into the same medication cup on the tote, left the room and entered Resident #13's room without cleaning or disinfecting the blood glucose meter, tote or surface the tote sat on in Resident #15's room. 3. Observation and interview on 2/22/23 at 11:22 A.M., showed CMT J entered Resident #13's room sat the tote containing the blood glucose meter and supplies on the overbed table, and took the blood glucose meter from the medication cup used in Resident #15's room. When asked how often meters are cleansed, he/she stopped and said he/she better go clean it. He/she removed his/her gloves and washed his/her hands and went to the medication room after placing the meter back into the same medication cup. He/she did not cleanse the surface the tote sat on. Observation on 2/23/23 at 11:26 A.M., showed CMT J entered the medication room and sat the tote on the counter. He/she wiped the meter with a Clorox wipe and placed the meter back into the same medication cup. Observation on 2/23/23 at 11:28 A.M., showed CMT J entered Resident #13's room and sat the tote on the overbed table, placed the glucose meter on the overbed table after prepping it with a test strip without a barrier. He/She obtained the blood sample, removed the test strip with gloved hands, and placed the meter back into the same medication cup. Observation on 2/23/23 at 11:36 A.M., showed CMT J entered the medication room and sat the tote onto the counter. He/she wiped the blood glucose meter with a Clorox wipe and placed the meter back into the same dirty medication cup. 4. Observation on 2/23/23 at 11:40 A.M., showed CMT J entered Resident #4's room with the tote containing the glucose meter, lancet, alcohol pad and test strip and sat it on the overbed table. He/She took the meter from the medication cup, sat the meter on the resident's refrigerator, obtained a sample of blood, lay the meter on the resident's lap, removed his/her gloves and washed his/her hands, and placed the meter back into the medication cup on the tote. He/She left the room without disinfecting or cleaning the meter or surface the tote sat on. During an interview on 2/23/23 at 11:50 A.M., CMT J said normally blood glucose meters are cleaned between every 3-4 residents. He/She said, if he/she wasn't asked they would have checked Resident #13's blood sugar without cleaning the meter. He/She said staff just use Clorox wipes to clean the meters, but isn't sure if it's the right way or not. He/She said they should not put the meters back into a medication cup that had a used meter in it, and didn't think about it. CMT J said using a potentially dirty meter could spread germs. During an interview on 2/23/23 at 10:27 A.M., CMT A said staff are directed to clean the glucose meters with a bleach wipe after each resident so infection does not spread. During an interview on 2/23/23 at 10:38 A.M., LPN C said staff should clean the glucose meter with a bleach wipe after each resident. During an interview on 2/23/23 at 11:18 A.M., the DON said staff should take the glucose tote to the resident's room to obtain a glucose reading. He/She said staff should clean the meter and tote before leaving a resident's room. He/She said germs could spread if the equipment is not cleansed or disinfected between residents. 45564

Based on interview and record review, the facility failed to ensure one or more individuals completed specialized training in infection prevention and control (IPC) prior to assuming the role of infection preventionist (IP) for the facility's infection prevention and control program. The census was 60. 1. Review of the Centers for Disease Control and Prevention (CDC) website showed: -The Nursing Home Infection Preventionist Training course is designed for individuals responsible for infection prevention and control (IPC) programs in nursing homes; -The course is made up of 23 modules and sub-modules that can be completed in any order and over multiple sessions. Review of the IP's CDC training transcript showed three modules were completed in January 2022 and seven modules in May 2022. Further review showed no additional modules had been completed since May 2022. During an interview on 2/22/23 at 12:57 P.M., the IP said he/she started as the IP in May of 2022 and had completed the CDC online course. During an interview on 2/23/23 at 8:31 A.M., the Director of Nursing (DON) said he/she expected the IP to have his/her required training done, but did not know it was required before assuming the IP role. During an interview on 2/23/23 at 11:22 A.M., the Assistant Administrator said the IP training should be done in a timely manner - within the first year. The Assistant Administrator said he/she was not aware of training requirement before assuming IP role. He/She also said the facility did not have a policy covering IP qualifications.

Based on interview and record review, facility staff failed to maintain and follow current guidance and procedures for immunizations of residents against pneumococcal (infection caused by bacteria) pneumonia in accordance with national standards of practice for three (Residents #19, #40 and #47) of seven sampled residents. The facility also failed to ensure Resident #51 was offered the flu vaccine. The facility census was 61. 1. Review of the facility's Influenza/pneumococcal vaccination policy, last reviewed October 2022 showed: -All residents of the facility may receive an annual influenza vaccination and pneumococcal vaccination if needed, if not allergic to eggs and with resident or responsible party consent -Consent for vaccination(s) to be obtained on yearly basis and upon admission -Once resident has received either influenza or pneumococcal vaccination nursing staff will document regarding injection site and any adverse reactions for 24 hours. Review of the U.S. Department of Health and Human Services - Centers for Disease Control and Prevention (CDC), pneumococcal and influenza vaccine timing for adults, dated 4/01/2022, showed the following: -Four types of pneumonia vaccines are acceptable for adults [AGE] years or older. PCV13: 13-valent pneumococcal conjugate vaccine (Prevnar13), PCV15: 15-valent pneumococcal conjugate vaccine (Vaxneuvanc), PCV20: 20-valent pneumococcal conjugate vaccine (Prevnar20), and PPSV23: 23-valent pneumococcal polysaccharide vaccine (Pneumovax); -For those who previously received PPSV23 but who have not received any pneumococcal conjugate vaccine (e.g., PCV13, PCV15, PCV20) you may administer one dose of PCV15 or PCV20. -Regardless of which vaccine is used (PCV15 or PCV20): -The minimum interval is at least 1 year; -Their pneumococcal vaccinations are complete; -For those who have never received a pneumococcal vaccine or those with unknown vaccination history administer one dose of PCV15 or PCV20 2. Review of Resident #19's Significant Change Minimum Data Set (MDS), a federally mandated assessment instrument dated 2/20/23, showed facility staff assessed the resident as follows: -Cognitively intact; -The resident's pneumococcal vaccination is up to date. Review of the resident's medical record showed the resident received an unknown type of pneumonia vaccine on 9/01/21. The record did not contain documentation staff offered the second dose of the pneumonia vaccine. 3. Review of Resident #40's Quarterly MDS dated [DATE], showed facility staff assessed the resident as follows: -Severe cognitive impairment; -The resident's pneumococcal vaccination is up to date. Review of the resident's medical record showed the resident received the PPSV23 pneumonia vaccine on 10/01/2018. Further review showed a pneumonia consent form dated 9/15/21, annotated with the comment, not due received in 2018. 4. Review of Resident #47's Admission MDS dated [DATE] showed facility staff assessed the resident as follows: -Cognitively intact; -The resident's pneumococcal vaccination is up to date. Review of the resident's medical record showed the resident received a PPSV23 pneumonia vaccine on 11/13/17. The record did not contain documentation staff offered the second dose of the pneumonia vaccine. 5. Review of Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP) United States, 2022-23. Summary of Recommendations, dated 8-25-2022, showed: -ACIP recommends that adults aged [AGE] years or older preferentially receive any one of the following higher dose or adjuvanted (ingredient used in some vaccines that helps create a stronger immune response) influenza vaccines: quadrivalent (A vaccine that works by stimulating an immune response against four different antigens, such as four different viruses or other microorganisms) high-dose inactivated influenza vaccine (HD-IIV4), quadrivalent recombinant influenza vaccine (RIV4), or quadrivalent adjuvanted inactivated influenza vaccine (aIIV4). If none of these three vaccines is available at an opportunity for vaccine administration, then any other age appropriate influenza vaccine should be used. 6. Review of Resident #51's Annual MDS dated [DATE] showed facility staff assessed the resident as follows: -Cognitively intact; -Resident received this year's influenza vaccine outside of the facility. Review of the resident's medical record showed the resident received the influenza vaccine on 10/26/21. The record did not contain documentation the resident received or was offered an influenza vaccine for the current influenza season. 7. During an interview on 02/22/23 12:57 P.M., the Infection Preventionist said the Director of Nursing (DON) is responsible for resident immunizations. During an interview on 2/22/23 at 2:52 P.M., the DON said facility staff administer the Prevnar 13 and PPSV-23 pneumonia vaccines. The DON also said he/she did not have a facility policy for administering vaccines. The DON said Resident #51 does not have documentation of the current influenza vaccine, but he/she should. The DON also said he/she is responsible for resident influenza and pneumococcal vaccinations. During an interview on 2/23/23 at 11:22 A.M., The Assistant Administrator said the DON and charge nurses are responsible for resident immunizations. He/She said facility staff reviewed the resident population every year in the fall to see who needed influenza or pneumococcal vaccinations. The Assistant Administrator also said he/she was not familiar with pneumonia vaccine guidelines.

Based on interview and record review, facility staff failed to maintain evidence demonstrating the results of all grievances for a period of no less than three years. The facility census was 60. 1. Review of the facility's Grievance policy, undated, showed staff were directed as follows: - The grievance officer is responsible for ensuring that all grievances include; - The date the grievance was received; - A summary statement of the residents grievance; - The steps taken to investigate the grievance; - A summary of the pertinent findings or conclusions regarding the residents' concerns; - At statement as to whether the grievance was confirmed or not confirmed; - Any corrective action taken or to be taken by the facility as a result of the grievance; - The date the written decision was made. Review of facility records showed the record did not contain grievance reports for a period of no less than three years. During an interview on 2/21/23 at 10:00 A.M., the resident council members said they do not receive a written response or rationale to the grievances that are voiced and don't know what happens to their concerns. During an interview on 2/23/23 at 9:00 A.M., the Director of Nursing said grievances that are brought up by the resident council members and should be responded to by the activity director on a written form with rationale if needed. During an interview on 2/23/23 at 10:06 A.M., the Activity Director said he/she had a form a fill out with resident's grievances that he/she gave to the department heads. The response is told to the council verbally they do not give the resident council a written response. During an interview on 2/23/23 at 10:19 A.M. the Assistant Administrator said grievances should be investigated and then the grievance officer will take actions. The residents are told the results verbally and they do not give a written response.

Based on interview and record review, the facility failed to develop an antibiotic stewardship program and a system to monitor appropriate antibiotic use. The facility census was 60. 1. Review of the facility's Infection Control Program, undated, showed: -Infection Control Program includes: -Review of Monthly infection reports with corrective actions taken by facility if needed; -Antibiotic stewardship program. Review of the facility's Antibiotic Stewardship policy, undated showed: -The facility will implement and maintain an Antibiotic Stewardship Program with the mission to promote the appropriate use of antibiotics while optimizing the treatment of infections; -The facility Antibiotic Stewardship Program will incorporate all seven core elements including leadership, accountability, drug expertise, action to implement policies and practices, tracking measures, reporting data, education for physicians, nursing staff, residents and family about antibiotic resistance and opportunities for improvement; -The facility will have physicians, nursing, pharmacy and infection preventionist leads responsible for promoting and overseeing Antibiotic Stewardship Programs. As a team they will: -Review infections and monitor antibiotic usage and patterns of use; -Obtain and review antibiograms for institutional trends of resistance; -Compile and share report of antibiotic use, process measures and outcomes monthly; -A monthly Antibiotic Stewardship Program Tracking Report will be compiled and will include summaries of collected data and identify next action steps necessary. The monthly Antibiotic Stewardship tracking report will be discussed at a Quality Assurance Performance Improvement Meeting; -An annual Antibiotic Stewardship Policy tracking report will be developed and will include components of data summary, interpretation and next steps. During an interview on 2/22/23 at 12:57 P.M., the Infection Preventionist (IP) said he/she received a monthly antibiotic use report and he/she counted the number of residents on antibiotics and made sure the nurse had completed a 72 hour antibiotics timeout (reassessment of the continuing need and choice of antibiotics). The IP said he/she did not have a way of tracking antibiotic use over time and he/she did not look to see if facility staff could reduce antibiotic use. The IP also said he/she did not speak to the medical director or attend QA meetings and he/she had never heard of QA meetings. The IP said he/she had not reported anything to the DON or administrator because he/she did not find anything he/she felt worth reporting. The IP also said he/she did not have a policy on antibiotic use. During an interview on 2/22/23 at 2:52 P.M., the Director of Nursing (DON) said nursing staff did not use any screening tools to direct antibiotic use. The DON said the IP is responsible for the antibiotic stewardship program. During an interview on 2/23/23 at 8:35 A.M., the Medical Director said he/she discusses antibiotic stewardship and infections with facility staff but they do not track or trend infections or antibiotic use. During an interview on 2/23/23 at 11:22 A.M., the Assistant Administrator said the infection preventionist was responsible for the antibiotic stewardship program and he/she should be tracking antibiotic use and it should be reported to the DON. The Assistant Administrator said he/she would expect some type of antibiotic use tracking and would expect tracking of bacteria as well. He/She also said the IP had never brought antibiotic use or bacteria specific information to a QA meeting.

Based on observation, interview, and record review, the facility failed to maintain a system that assured a full and complete accounting of each resident's personal funds, for all residents that had funds entrusted to the facility on the resident's behalf. Staff failed to provide a description or written receipt for all transactions for two of five sampled residents (Resident #20 and #33) or their designees. The facility census was 60. 1. Review of the facility's policies showed staff did not provide a policy for resident funds. 2. Review of the Resident #20's monthly fund summary for November 2022 showed: -The resident had 50 dollars deposited in his/her envelope; -The resident had two envelope withdrawals totaling 50 dollars; -The summary did not provide dates for deposits or withdrawals; -The summary did not provide a description of the withdrawals. Review of the resident's monthly fund summary for December 2022 showed: -The resident had 50 dollars deposited in his/her envelope; -The resident had four envelope withdrawals totaling 50 dollars; -The summary did not provide dates for deposits or withdrawals; -The summary did not provide a description of the withdrawals. Review of the resident's monthly fund summary for January 2023 showed: -The resident had 50 dollars deposited in his/her envelope; -The resident had four envelope withdrawals totaling 50 dollars; -The summary did not provide dates for the deposits or withdrawals; -The summary did not indicate the nature of withdrawals. Review of the resident's Resident Trust Fund Monthly Reconciliation Statement showed a deposit of $50 dollars and expenses listed as $20, $10, $10, and$10. The statement did not provide dates or descriptions of expenses. 3. Review of the Resident #33's monthly fund summary for November 2022 showed: -The resident had 50 dollars deposited in his/her envelope; -The resident had three envelope withdrawals totaling 50 dollars; -The summary did not provide dates for deposits or withdrawals; -The summary did not provide a description of the withdrawals. Review of the resident monthly fund summary for December 2022 showed: -The resident had 50 dollars deposited in his/her envelope; -The resident had four envelope withdrawals totaling 50 dollars; -The summary did not provide dates for deposits or withdrawals; -The summary did not provide a description of the withdrawals. Review of the resident's monthly fund summary for January 2023 showed: -The resident had 50 dollars deposited in his/her envelope; -The resident had four envelope withdrawals totaling 50 dollars; -The summary did not provide dates for deposits or withdrawals; -The summary did not provide a description of the withdrawals. Review of the resident's Resident Trust Fund Monthly Reconciliation Statement showed a deposit of $50 dollars and expenses listed as $20, $10, $10, and $10. The statement did not provide dates or descriptions of expenses. Observation on 2/23/23 at 11:50 A.M., showed the resident's envelope showed the resident had a balance of $25 dollars. Further observation showed the envelope contained $35 dollars in cash. 4. During an interview on 2/23/22 at 11:45 A.M., the Patient Care Coordinator (PCC) said he/she did not keep receipts when residents received cash or when facility staff did shopping for residents. The PCC said he/she wrote deposit and withdrawal amounts on each residents' cash envelope and transferred the amounts to the monthly summary. The PCC also said he/she was not sure why Resident #33 had an extra 10 dollars in his/her envelope. During an interview on 2/23/23 at 2:15 P.M., the Assistant Administrator said the Patient Care Coordinator was responsible for resident funds and should keep receipts and descriptions for all transactions involving resident funds. The Administrator also said the facility did not have a policy for managing resident funds.

Based on observation, interview and record review, facility staff failed to post the telephone number for the Department of Health and Senior Services (DHSS) Adult Abuse and Neglect Hotline (used to report allegations of abuse and neglect) in a form and manner accessible to all residents and visitors on the rehabilitation unit. The facility census was 60. 1. Review of the policies provided by the facility showed they did not contain a policy for the required postings. Observations from 2/20/23 at 10:00 A.M. through 2/23/23 at 1:00 P.M., showed the facility did not post the name, address, and toll free telephone number for the Adult Abuse and Neglect Hotline in an accessible location for residents or visitors to use if needed on the rehabilitation unit. During an interview on 2/23/23 at 9:11 A.M., Certified Nurse Aide (CNA) F said he/she did not know if the Adult Abuse and Neglect Hotline information was posted anywhere in the facility for the residents. He/She did not know the number and said would not know what to do to find it. During an interview on 2/23/23 at 10:27 A.M., Certified Medication Technician (CMT) A said he/she is not sure where the number is posted, but would direct them to the nurse or their family for the information. He/She feels it should be posted around the facility so all residents could use it privately if they would want to. During an interview on 2/23/22 at 10:38 A.M., Licensed Practical Nurse (LPN) C said he/she is not sure where the abuse and neglect hotline number is but would google it if they needed to. He/She said it should be posted so all residents have access to it. During an interview on 3/1/23 at 8:58 A.M., the Assistant Administrator said the abuse and neglect hotline is posted near the dining room. Visitors, residents and staff have access to the number.

Based on observation, interview, and record review, facility staff failed to ensure the most recent survey results were posted and readily accessible to residents, family member or representatives of residents. This has the potential to affect all residents in the facility. The facility census was 60. 1. Review of the facility's Resident Rights policy showed the policy did not include information on survey results. Observation on 2/20/23 at 11:00 A.M., showed a table in the entrance of the facility with a sign pointing down with the words last years survey results printed on it. The table did not contain the survey results. Observation on 2/23/23 at 1:00 A.M., showed a table in the entrance of the facility with a sign pointing down with the words last years survey results printed on it. The table did not contain the survey results. During an interview on 2/21/23 at 10:00 A.M., the resident council said they did not know where the past survey results were posted. During an interview on 2/23/23 at 9:00 A.M., the Director Of Nursing said past survey results should be kept in binder in the activity room. During an interview on 2/23/23 at 10:19 A.M., the Activity Director said the survey results should be on the table in the front entrance, a resident has taken it and facility staff are unable to find it. During an interview on 2/23/23 at 10:30 A.M., the Assistant Administrator said the survey results book should be on the table in the front entrance but it has been lost.