Every finding on record at Good Samaritan Society - Pine River

Based on observation, interview and document review the facility failed to ensure appropriate hand hygiene was used during personal cares for 1 of 1 resident (R3) reviewed for activities of daily living (ADL's).Findings include:R3's quarterly Minimum Data Set (MDS) dated [DATE], identified R3 had severe cognitive impairment and diagnoses included dementia with mood disturbance, anxiety, and post-traumatic stress disorder (PTSD). R3 was always incontinent with bowel and bladder and was dependent on staff for activities of daily living (ADL's) including toileting and transfers.R3's care plan updated 2/16/26, identified R3 was non-ambulatory and required two staff and a total mechanical lift for transfers.During observation on 3/24/26 at 4:29 p.m., R3 was lying in bed while nursing assistant (NA)-A and NA-B were checking R3's brief. NA-A and NA-B were both wearing disposable gloves. NA-B assisted R3 to turn on his right side while NA-A cleaned feces from R3's skin with a disposable wipe and gloved hands. NA-A placed and fastened a clean brief on R3 and pulled up the R3's pants. NA-A failed to remove her dirty gloves after cleaning R3 and prior to assisting R3 with a clean brief and dressing. After R3 was fully dressed and ready for transfer NA-A removed the dirty gloves and washed her hands with soap and water in the bathroom.During interview on 3/24/26 at 4:45 p.m., NA-A stated she should have removed her dirty gloves and washed her hands right after cleaning feces from R3's skin. NA-A stated there was an increased risk of spreading bacteria when wearing dirty gloves and touching clean clothing and/or other surfaces.During interview on 3/24/26 at 7:23 p.m., the director of nursing (DON) stated staff should have removed their dirty gloves and washed their hands prior to completing any other tasks. Staff were instructed in orientation to always wash their hands after performing a dirty task including incontinence cares.The facilities Hand Hygiene policy reviewed 11/13/25, identified the purpose of the policy was to establish hand hygiene as the single most important factor in preventing the spread of disease-causing organisms to patients and personnel in healthcare settings. The policy defined hand hygiene as a general term that applied to either handwashing or applying hand sanitizer. The policy further identified staff were to perform hand hygiene during times including upon entering a room, before a clean task, after bodily fluid/glove removal, and upon exiting a room.

Based on observation, interview, and document review the facility failed to ensure the dishwasher rinse cycle reached or exceeded a tempurature to effectively sanitize dishes.This had the potential to affect 26 residents that consumed food from the kitchen. Findings include: On 2/2/25 at 11:31 a.m., an initial kitchen tour was completed with dietary aide (DA)-A. A single commercial dishwasher was observed along the wall. Two gauges were located on the top front of the dishwasher. One gauge was labeled wash, and the other was labeled rinse. DA-A stated she would run dishes through a cycle, then monitor and document the highest temperatures of the wash and rinse cycles. Staff documented the temperatures three times daily on the temperature log. DA-A stated the wash temperature was okay and reached a minimum of 160 degrees, but the minimum rinse temperature was supposed to be 180 degrees and the tempurare had been running low, ranging 173-178, since January 2025. DA-A stated she was unaware what the numbers meant and had not been given direction on what to do other than to document the numbers. The Dish Machine Temperature Log(s) were reviewed and identified the following: - January 1, 2025, through February 2, 2025, the dishwasher rinse temperature was recorded between 164 degrees and 176 degrees and reached the minimum of 180 degrees 4 times during the date range. - December 2024, identified 72 of 93 recorded dishwasher rinse temperatures were below 180 degrees when monitored for the three meals. - November 2024, identified 66 of 90 recorded dishwasher rinse temperatures were recorded below 180 degrees when monitored for the three meals. On 2/2/25 at 12:20 p.m., the dietary manager, (DM) stated during January 2025, the dishwasher had not been reaching the minimum rinse temperature and on 1/19/25, the repair man was contacted, and the thermostat was replaced. The dish machine was a hot water single machine and had a rinse brick for the sanitizer. Hot water flushed through a rinse brick and dissolved the appropriate amount of rinse needed to sanitize the dishes. DM stated the dishes were getting sanitized because the brick was getting smaller, and the dishes were hot when they came out. DM stated she had not rechecked the rinse temperature or the log after the repair man left, and thought the machine was functioning properly. DM stated she checked the rinse temperature on 1/31/25, and the temperature was above 180 degrees. DM informed the staff to continue checking the temperatures and if the rinse cycle went below 177 degrees to use the three-compartment sink process. DA stated she had not documented the observations or the discussions she had with the dietary staff. The DM was unable to identify the rinse cycle was supposed to reach a tempurature of 180 degrees F on the rinse cycle. The DM stated she was unaware how low the temperatures had gotten when she reviewed the tempurature logs. DM reviewed the February temperature log which indicated the final rinse temperatures of 172 through 174. DM stated she informed her staff to monitor the rinse temperatures and if the temps were below 177 degrees, then use the three compartment sinks. The infection control logs were reviewed from November through February and did not identfiy and gastrointestinal illness' and or outbreaks. Review of the service call summary forms identified the following: - 12/12/24: Regular Service Call - Rinse temperature of 178 degrees. - 1/13/25: Regular Service Call - Replaced temperature gauges that were not functioning properly. Rinse temperature before and after replacement at 180 degrees. - 2/3/25 Extra Service Request - Machine not hitting rinse temperature. Comments: Fixed stuck thermostat. A joint interview was completed with cook (CK)-A, DA-C and DA-B on 2/4/25 at 12:16 p.m CK-A stated she did not wash the dishes and prior to today was uncertain what the minimum rinse temperature should be. DA-C stated her primary role was washing dishes. DA-C stated she checked and documented the wash and rinse temperatures once per meal. DA-C stated she thought they had used the three compartment sink previously when the dish machine wasn't reaching minimum temperature. DA-C unable to remember the last time they used the three compartment sinks but thought it may have been in January 2025. DA-B stated she washed dishes one evening per week and checked the wash and rinse temperatures once during that meal. DA-B stated she wouldn't know what to do other than use the dishwasher, had not been directed to do anything differently and didn't know when they would use the three-compartment sinks. On 2/5/25 at 9:02 a.m., the maintenance/ ancillary services supervisor (MAINT) stated on 1/13/25, the dishwasher was not getting up to temperature. The repair mas was contacted and replaced the gauges. After that the dish machine was reaching temperature. Then on 2/2/25, DM reported the dish machine was not reaching temperature and contacted the repair man again. They came out on 2/3/25 and said the thermostat was stuck, they fixed it, and the dishwash machine had been reaching temperature since. The facility Warewashing-Mechanical and Manual - Food and Nutrition policy reviewed 3/25/24, identified warewashing as the means to clean and sanitize utensils and food-contact surfaces of equipment. The policy identified food and nutrition employees were to ensure food preparation equipment, dishes and utensils were effectively cleaned, sanitized to destroy potential disease carrying organisms, and stored in a protective manner. The policy identified staff were to follow manufacturers instructions for the specific dishwasher model for minimum temperatures for safe sanitization of dishes as well as complete the Food and Nutrition Competency Checklist for mechanical warewashing.

Based on observation, interview, and document review the facility failed to ensure dietary staff were educated on the required dishwasher tempuratures for 4 of 5 staff (cook (CK)-A, dietary aide (DA)-A, DA-B, DA-C, dietary manager (DM) who used the dishwasher. This had the potential to affect all 26 residents who consumed foods from the kitchen. Findings include: On 2/2/25 at 11:31 a.m., an initial kitchen tour was completed with dietary aide (DA)-A. A single commercial dishwasher was observed along the wall. Two gauges were located on the top front of the dishwasher. One gauge was labeled wash, and the other was labeled rinse. DA-A stated she would run dishes through a cycle, then monitor and document the highest temperatures of the wash and rinse cycles. Staff documented the temperatures three times daily on the temperature log. DA-A stated the wash temperature was okay and reached a minimum of 160 degrees, but the minimum rinse temperature was supposed to be 180 degrees and the tempurare had been running low, ranging 173-178, since January 2025. DA-A stated she was unaware what the numbers meant and had not been given direction on what to do other than to document the numbers. The Dish Machine Temperature Log(s) were reviewed and identified the following: - January 1, 2025, through February 2, 2025, the dishwasher rinse temperature was recorded between 164 degrees and 176 degrees and reached the minimum of 180 degrees 4 times during the date range. - December 2024, identified 72 of 93 recorded dishwasher rinse temperatures were below 180 degrees when monitored for the three meals. - November 2024, identified 66 of 90 recorded dishwasher rinse temperatures were recorded below 180 degrees when monitored for the three meals. On 2/2/25 at 12:20 p.m., the dietary manager, (DM) stated during January 2025, the dishwasher had not been reaching the minimum rinse temperature and on 1/19/25, the repair man was contacted, and the thermostat was replaced. The dish machine was a hot water single machine and had a rinse brick for the sanitizer. Hot water flushed through a rinse brick and dissolved the appropriate amount of rinse needed to sanitize the dishes. DM stated the dishes were getting sanitized because the brick was getting smaller, and the dishes were hot when they came out. DM stated she had not rechecked the rinse temperature or the log after the repair man left, and thought the machine was functioning properly. DM stated she checked the rinse temperature on 1/31/25, and the temperature was above 180 degrees. DM informed the staff to continue checking the temperatures and if the rinse cycle went below 177 degrees to use the three-compartment sink process. DA stated she had not documented the observations or the discussions she had with the dietary staff. The DM was unable to identify the rinse cycle was supposed to reach a tempurature of 180 degrees F on the rinse cycle. The DM stated she was unaware how low the temperatures had gotten when she reviewed the tempurature logs. DM reviewed the February temperature log which indicated the final rinse temperatures of 172 through 174. DM stated she informed her staff to monitor the rinse temperatures and if the temps were below 177 degrees, then use the three compartment sinks. On 2/4/25 at 12:16 p.m., DA-C stated her primary job was washing dishes. The final rinse temperature was checked three times daily, once at each meal. DA-C stated she ran dishes through the wash machine, monitored the gauges and documented the highest temperature reached during the wash and rinse cycles. DA-C stated she was uncertain if they used the three compartment sinks during the month of January because the tile was ripped up over by the sink and could not remember if they used the sinks during that time. - DA-B approached the conversation and stated she washed the dishes one evening shift per week and documented the highest wash and rinse temperature during the cycle. DA-B stated she had not been given direction of what to do if the rinse temperatures were below 180 degrees and had not known when they would use the three sinks unless the dishwasher was broken. On 2/4/25 at 1:34 p.m., the administrator stated she took the Basics of Food Safety in Long Term Care Facilities online training that the staff were required to take. The administrator stated the training did not specifically identify what temperature's the dishwasher needs to reach; however, the log does identify the minimum temperatures for rinsing. On 2/5/25 at 8:54 a.m., DM stated she was not aware of the facility Warewashing-Mechanical and Manual- Food and Nutrition policy or the Mechanical Ware Washing Food and Nutritional Competency Checklist included in the policy. DM stated the staff completed the Basics of Food Safety in Long Term Care Facilities online coarse although the course did not include information regarding the importance of appropriate wash and rinse temperatures for the dishwasher. DM stated competency checklists for all dietary staff were not completed. The undated ECOLab Dishmachine ES-2000HT manufacturer's instructions identified the sanitizing rinse water minimum temperature of 180 degrees. The facility Warewashing-Mechanical and Manual - Food and Nutrition policy reviewed 3/25/24, identified warewashing as the means to clean and sanitize utensils and food-contact surfaces of equipment. The policy identified food and nutrition employees were to ensure food preparation equipment, dishes and utensils were effectively cleaned, sanitized to destroy potential disease carrying organisms, and stored in a protective manner. The policy identified staff were to follow manufacturers instructions for the specific dishwasher model for minimum temperatures for safe sanitization of dishes as well as complete the Food and Nutrition Competency Checklist for mechanical warewashing.

Based on observation, interview, and document review, the facility failed to ensure the required nurse staffing information was consistently posted on a daily basis and failed to identify when the posting changed due to call ins. This had potential to affect all 26 residents along with staff and visitors who could wish to review this information. Findings include: During observation on 2/2/25 at 12:20 p.m., the staff in a clear hard plastic sleeve on the nurses' desk upon entrance to the facility. The staff posting form identified the facility name, date, census, shift and total hours for licensed practical nurse (LPN). nursing assistant (NA), registered nurse (RN) case manager, and RN. The posting for 2/2/25, identified a census of 26 (that was corrected from 27). The 6:00 am to 6:00 pm shift identified one NA but did not identify the total hours (hr) worked, one RN case manager for 11.5 hrs which is less than the 12-hour shift identified on the posting. The 6:00 a.m. to 2:30 p.m. shift identified one LPN for 8 hrs, one NA but did not identify the total hours worked. The 2:15 p.m. to 10 45 p.m. shift identified two NA's for a total of 4.25 hours which was not reflected of the shift, two RN's with no total hours identified. The 6:00 p.m. to 6:00 a.m. shift identified one NA for 11.5 hrs and one RN for 11.5 hours both of which were not the full 12 hours identified for the shift. Further, the posting failed to identify the staff hours worked due to call-ins, vacations and/or staff shortages. The working schedule for 2/2/25, identified from 6:00 a.m. to 2:30 p.m. there was one LPN and one NA, from 6:00 a.m. to 6:00 p.m. there was one RN and one NA, from 2:15 p.m. to 10:45 p.m. there was one RN, one LPN, and one NA, from 6:00 p.m. to 6:00 a.m. there was one RN and one NA. During observation on 2/3/25 at 4:11 p.m., the staff posting for 2/3/25, identified the facility name, date, census, shift and total hours for director of nursing (DON), health information management technician (HIM), LPN. NA, RN case manager, and supervisor ancillary services. The posting identified a census of 25 (corrected from 26.) The 6:00 am to 2:30 p.m. shift identified one LPN for a for 8 hrs, one NA without identifying the total hours worked. The 2:15 p.m. to 10:45 p.m. identified two NA's with a total of 4.25 hrs and two RN's without identifying the total hours worked. The 6:00p.m. to 6:00a.m. identified one NA for 11.5 hrs and one RN for 11.5 hours, the total hours worked did not match the shift. Further, the posting failed to identify the staff hours worked due to call-ins, vacations and/or staff shortages. The working schedule for 2/3/25, identified from 6:00 a.m. to 2:30 p.m. there was one LPN, one RN and two NAs, from 2:15 p.m. to 10:45 p.m. there were two LPNs and two NAs, from 10:30 p.m. to 7:00 a.m. there was one LPN and one NA. During observation on 2/4/25 at 11:13 a.m., the staff posting for 2/4/25, identified the facility name, date, census, shift and total hours for DON, HIM, LPN. NA, RN case manager, and supervisor ancillary services. The posting identified a census of 25 (corrected from 27). The 6:00 am to 2:30 p.m. shift identified one LPN for a for 8 hrs, two NA for a total of 16 hrs and one RN without identifying the total hours worked. The 8:00 a.m. to 4:30 p.m. shift identified the DON worked for 8hrs along with ) RN case managers for a total of 8 hrs. The 2:15 p.m. to 10:45 p.m. shift Identified one LPN for 8 hrs with a handwritten notation in the box 1 RN + without further information and two NA's for a total of 8 hrs. The 10:30 p.m. to 7:00 a.m. shift identified in the LPN box a zero with a line crossed through with a hand notations 1 RN without further information and one NA for a total of 4 hrs but did not identify what the shift worked for those 4 hrs. Further, the posting failed to identify the staff hours worked due to call-ins, vacations and/or staff shortages. The working schedule for 2/4/25, identified from 6:00 a.m. to 2:30 p.m. there was one LPN, one RN and two NA's from 2:15 p.m. to 10:45 p.m. there were two LPNs and two NAs, from 10:30 p.m. to 7:00 a.m. there was one LPN [10:30 p.m. to 3:00 a.m.] and one RN [from 3:00 a.m. to 7:30 a.m.] and one NA. During an interview on 2/4/25 at 12:07 p.m., the DON stated it was the staffing coordinator's responsibility to ensure the posting was available and updated as needed. DON stated when the staff coordinator was out it was her responsibility to ensure it was printed out of OnShift (a staff program for computer) and posted Once the posting was posted it should be updated as changes occur. On 2/2/25, the DON was working and stated she was responsible for the posting and did not update it with changes or call-ins, as she just did not have time. During an interview on 2/4/25 at 1:18 p.m., the staffing coordinator stated it was her responsibility to ensure the daily staff posting was done. If she was going to be gone or for the weekends, she made sure all the current information is in OnShift and print them off to be posted on the correct days. Some of the postings looked different as when they were printed from OnShift, sometimes the RN column was missing. The staffing coordinator did not know how to get it to show up. When the staffing daily posted, she always checks to ensure the census is updated on the form; however, if there were call ins or schedule changes, she did not update the staff posting during the day. The staffing coordinator was not aware the staff posting would need to be update and reflect the correct shift and hours The facility was always filling empty shift through the day. During an interview on 2/5/25, at 11:04 a.m., the administrator stated it was the expectation the daily staff posting would be accurate. The facility's Nurse Staff Daily Posting Requirements dated 12/2/24, identified it is important to keep the report updated by making staffing changes as they occur.

Based on interview and document review the facility filed to ensure timely reporting of allegations of abuse to the state agency (SA) for 2 of 3 residents (R2, R3) reviewed who alleged abuse at the facility. Findings include: R2's Admission Record indicated she admitted to the facility on [DATE], with diagnosis that included dementia and insomnia. R2's care plan 2/19/24, identified impaired cognitive function and a self care deficit. The care plan directed staff to assist R2 with toileting and transfers. Facility internal e-mail dated 3/30/24 at 12:56 a.m. from licensed practical nurse (LPN)-A sent an e-mail to the director of nursing (DON) that indicted R2 was yelling for help during the shift and stated she needed to use the bathroom. Nursing assistant (NA)-A offered to assist R2 and she refused to allow NA-A to help her pull her pants down. R2 came out of her room and reported NA-A was trying to take all her clothes off and would not let her out of the bathroom. NA-A attempted to assist R2 2-3 more times during the shift and she refused to let him help her. Sometime after the last time, NA-A tried to assist R2 she report to LPN-A that NA-A had groped her. R3's Admission Record indicated he admitted to the facility on [DATE], with diagnosis that included depression, stroke and anxiety. R3's care plan dated 3/4/24, identified impaired cognitive function and a self care deficit. The care plan directed staff to assist R3 with bed mobility, transfers and toileting. A report to the SA dated 4/2/24, indicated hospice social worker (SW)-A stopped by to check-in with R3's family member (FM). R3's FM told SW-A she believed R3 got molested or raped by staff. When asked why, FM gave the following report: I woke up to a lot of noise, it was about 1:00 a.m. He (R3) was all alone in his room when I checked on him. I woke him up to ask him are you okay? He replied yeah. I asked him what is wrong? He replied nothing. FM stated she looked under his covers and he was totally naked. During interview on 4/5/24 at 12:47 p.m., SW-A stated on 3/27/24, R3's family member (FM) reported to her she thought R3 had been assaulted the previous night. SW-A stated FM said she had gone to R3's room and he was naked so she thought he had been assaulted. SW-A stated she had reported the allegation to the facility on [DATE]. During interview on 4/5/24 at 1:13 p.m., the DON stated she tried to made a report to the SA after learning about the allegation but had trouble with the system. The DON stated she had not been told about the allegation until several hours after the allegation was made. The DON stated she had not reported the allegation regarding R3 to the SA because she knew the hospice SW was going to report so she did not think she had to make a report. Facility policy Abuse and Neglect- Rehab/Skilled, Therapy and Rehab dated 7/6/23, indicated if there is an allegation of abuse, it will be reported to the SA immediately but no more than two hours after the allegation is made.

Based on interview and document review, the facility failed to accurately code the Minimum Data Set (MDS) for 3 of 4 residents (R5, R21, R19) related to medications and 1 of 1 resident (R8) related to treatment who were reviewed for MDS accuracy. Findings include: R5's quarterly MDS dated [DATE], identified a diagnosis of Takotsubo syndrome (your heart's main blood-plumping chamber (the left ventricle) to change shape and get larger) and identified R5 was taking an anticoagulant (blood thinner which slows down body process of making a clot) medication. R5's November 2023 Medication Administration Record (MAR), identified R5 had not received an anticoagulant medication during the look back period of the MDS. R21's quarterly MDS dated [DATE], identified a diagnosis of atherosclerotic heart disease (buildup of fats, cholesterol, and other substances in and on the artery walls) and identified R21 was taking an anticoagulant medication. R21's December 2023 MAR, identified R21 had not received an anticoagulant medication during the lookback period of the MDS. 48109 R19's quarterly MDS dated [DATE], identified moderately impaired cognition and diagnoses of neurocognitive disorder with Lewy bodies (a progressive type of dementia affecting movement, thinking skills, mood, memory, and behavior), psychotic disorder with hallucinations due to known physiological disorder, major depressive disorder, and anxiety disorder. Section N of the MDS did not indicate antianxiety medication use during the assessment period. R19's physician order dated 9/12/23, identified Ativan (an antianxiety medication) 0.5 mg every evening for anxiety disorder. R19's December 2023 MAR identified Ativan was given to R19 every day of December including the MDS assessment period. R8's annual MDS dated [DATE], identified intact cognition and diagnoses of chronic obstructive pulmonary disease (COPD), acute and chronic respiratory failure. Section O identified no oxygen use during the assessment period. R8's physician orders dated 4/20/22, identified continuous oxygen at two liters per minute (LPM) via nasal cannula. R8's December 2023 MAR identified an order for oxygen at two LPM via nasal cannula continuously and was marked as given three times per day every day of December including the assessment period. During an interview on 1/7/24 at 1:32 p.m., R8 stated she wore oxygen at all times. During an interview on 1/09/24 at 12:07 p.m., registered nurse (RN)-A confirmed she completed the MDS' for R5 ,R8, R19, and R21. RN-A stated her process was to go through all the assessments, progress notes, nurse aid charting, and the MAR for what medications they had been taking during the assessment period. RN-A stated she had made an error on the residents MDS' and would be amending those. During an interview on 1/9/23 at 12:48 p.m., the administrator stated the expectation were the MDS were completed accurately. The Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) 3.0 User's Manual, dated October 2023, identified the intent of section N was to record the number of days, during the last seven days that any type of injection, insulin, and/or select medications were received by the resident. In addition, an Antipsychotic Medication Review has been included. Including this information will assist facilities to evaluate the use and management of these medications. Each aspect of antipsychotic medication use and management has important associations with the quality of life and quality of care of residents receiving these medications. The RAI manual identified the intent of the items in section O was to identify any special treatments, procedures, and programs that the resident received during the assessment reference period.

Based on interview and document review, the facility failed to offer and provide the most recent Centers for Disease Control (CDC) education in conjunction with their provider regarding the potential risks and benefits of the pneumococcal vaccine for 4 of 5 residents (R1, R7, R16, R22) reviewed for immunizations. This had the potential to affect all residents who were eligible for the pneumococcal booster. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 was [AGE] years old and had diagnoses of malnutrition and chronic kidney disease. R1's immunization record dated 1/9/24, identified R1 received the pneumococcal polysaccharide vaccine (PPSV23) on 6/25/12, and received the pneumococcal conjugated vaccine (PCV13) on 10/13/15. R1's medical record did not include evidence R1 or R1's representative received education regarding pneumococcal vaccine booster and there was no indication R1 was offered the pneumococcal vaccine in conjunction with their provider per CDC guidance. R7's quarterly MDS dated [DATE], identified R7 was [AGE] years old and had a diagnosis of Alzheimer's dementia. R7's immunization record dated 1/9/24, identified R7 received the PPSV23 on 11/11/00, and received the PCV13 on 2/23/17. R7's medical record did not include evidence R7 or R7's representative received education regarding pneumococcal vaccine booster and there was no indication R7 was offered the pneumococcal vaccine per in conjunction with their provider per CDC guidance. R16's annual MDS dated [DATE], identified R16 was [AGE] years old and had a diagnosis of Alzheimer's disease and weakness. R16's immunization record dated 1/9/24, identified R16 received the PPSV23 on 6/28/17, and received the PCV13 on 5/4/15. R16's medical record did not include evidence R16 or R16's representative received education regarding pneumococcal vaccine booster and there was no indication R16 was offered the pneumococcal vaccine in conjunction with their provider per CDC guidance. R22's admission MDS dated [DATE], identified R22 was [AGE] years old and had a diagnosis of chronic obstructive pulmonary disorder. R22's immunization record dated 1/9/24, identified R22 received the PPSV23 on 11/8/07, and received the PCV13 on 4/29/15. R22's medical record did not include evidence R22 or R22's representative received education regarding pneumococcal vaccine booster and there was no indication R22 was offered the pneumococcal vaccine conjunction with their provider per CDC guidance. During an interview on 1/9/24 at 1:36 p.m., the director of nursing (DON) stated the facility would review the residents' immunizations upon admit and once a year. She was aware of the PCV20 but was unaware of guidelines for offering the vaccination. DON would only offer the PCV20 if the resident did not have either the PPSV23 or the PCV13. The DON had not offered the PCV20 vaccination in the facility. It is important the residents remain current with their immunizations to protect their health. The facility's Immunizations/Vaccinations for Pneumococcal, Influenza, and COVID-19 policy dated 3/8/22, lacked guidance on administration of the PCV20 when the PPSV23 and PCV13 had been received.

Based on observation, interview and document review, the facility failed to assess, care plan, and obtain orders for 1 of 1 resident (R8) using a continuous positive airway pressure (CPAP) device. Findings include: R8's annual Minimum Data Set (MDS) dated [DATE], identified intact cognition and diagnoses of chronic obstructive pulmonary disease (COPD), acute and chronic respiratory failure. R8 needed assistance with bed mobility, transferring, eating and toilet use. R8's provider orders dated 4/20/22, did not identify orders for the use of a CPAP (a device that uses mild air pressure to keep breathing airways open while sleeping) machine. R8's care plan dated 4/21/22, did not indicate CPAP use. On 1/7/24 at 1:32 p.m., R8 stated the CPAP observed on R8's bed-side table was R8's and used it at night. During an interview on 1/8/24 at 4:04 p.m., licensed practical nurse (LPN)-A confirmed R8 wore a CPAP at night. During an interview on 1/9/24 at 7:49 a.m., LPN-B stated when R8 was ready for bed she would call the nurse and ask for the CPAP to be put on her. LPN-B confirmed there was not an order in the electronic health record to put the CPAP on R8. During an interview on 1/9/24 at 11:37 a.m., the director of nursing (DON) stated CPAP use would be in the resident's provider orders. The DON confirmed the order for putting on and taking off the CPAP was not currently on the MAR for R8. Their expectation would be that there was an order for when to put on and take off a CPAP and they needed to have orders for treatments being done so they made sure they were taking proper care of the resident. A facility policy, Physician/Practitioner Orders - Rehab/Skilled dated 3/29/23, identified the purpose was to provide individualized care to each resident by obtaining appropriate, accurate and timely physician/practitioner orders. A physician, physician's assistant, nurse practitioner or clinical nurse specialist must provide orders for the resident's immediate care consistent with the resident's present physical and mental status and needs. Required orders include treatments: a treatment will include the supporting reason (diagnosis/problem).

Based on observation, interview and document review, the facility failed ensure beard nets were worn when preparing resident meals, to prevent the spread of food born illness. This had the potential to affect all 27 residents who resided in the facility. Finding include: During observation on 4/17/23 at 11:19 a.m., cook (C)-A was assembling and temping food for lunch. C-A was wearing a surgical face mask and his beard protruded about 1.5 inches from the bottom of the face mask and the beard was hovering over the food. On 4/17/23 at 5:42 p.m., C-A was observed assembling food for the evening meal. C-A was wearing a surgical face mask and his beard protruded about 1.5 inches from the bottom of the face mask. During an interview on 4/17/23 at 6:16 p.m., C-A stated when preparing and assembling food it was important to have a beard net so hair did not end up the food. C-A worked for the facility for over two months never wore a beard net. To CA-A's knowledge there was no beard nets for use. During an interview on 4/19/23 at 12:27 p.m., the dietary manager (DM) stated it was her expectation for staff preparing and assembling food would wear the proper hair nets and beard nets. The DM was not aware of any beard nets in the facility since C-A was hired. During an interview on 4/19/23 at 12:58 p.m. the administrator stated staff preparing and assembling food should follow policy regarding employee hygiene with food services. Staff were expected to wear the proper hair restraints to ensure sanitary conditions. The facility policy for Employee Hygiene and Dress Code-Food and Nutrition Services dated 8/10/22, identified hair nets and beard nets are used when cooking, preparing, assembling food or ingredients. Hair was to be covered completely. The State Food Safety dated January 2023, identified facial hair could be a biological hazard. It could have several types of pathogens on it, including staphylococcus (bacteria that can cause infection) bacteria.

Based on interview and document review, the facility failed to ensure incidents of potential neglect were reported immediately, within two hours, to the State Agency (SA) for 1 of 3 residents (R1) reviewed for allegations of neglect of care. R1's Admission Record printed 4/22/22, indicated R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R1 required extensive assistance with all activities of daily living except for eating. R1's admission MDS section C, cognition was not assessed. R1's Care Area Assessment (CAA) dated 2/3/22, indicated R1 was at risk for falls. R1's care plan initiated 1/28/22, directed staff to assist R1 with activities of daily living (ADLs) including transfers, toileting, and personal cares. R1's care plan interventions included R1 was not to be left alone while using toilet due to [CONDITION(S)] episodes. On 4/18/22, at 1:55 p.m. a progress note indicated R1 had been found on her bathroom floor. R1 had been sent to the hospital due to R1 having pain and swelling in right leg. The progress notes further indicated R1 had been left unattended in the bathroom for approximately 30 min and R1's care plan had not been followed. Review of R1's medical record indicated R1 returned to the facility on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] On 4/21/22, at 3:05 p.m. an interview was conducted with the director of nursing (DON) and administrator. The DON verified R1 had been sent to the ED on 4/17/22, at approximately 12:30 p.m. due to injury from a fall as a result of R1 being left unattended while in the bathroom. The DON verified the incident had not been reported to the SA until 4/17/22, in the afternoon. The facility policy Abuse and Neglect-Rehab/Skilled, Therapy & Rehab revision date 3/31/21, directed that if there is an allegation of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, and/or there is serious bodily injury, then it will be reported immediately, but not later than two hours after the allegation is made.

Based on observation, interview and document review, the facility failed to ensure staff wore N95 respirators for new admissions who were not fully vaccinated from COVID-19 for 1 of 1 residents (R174) who was on a 14- day new admission quarantine. In addition, the facility failed to ensure all staff wore appropriate eye protection when in resident care areas as directed by the Centers for Disease Control (CDC). This had the potential to effect all 25 residents residing in the facility, along with staff and visitors. Findings include: N95 RESPIRATORS: R174's admission Minimum Data Set (MDS) dated [DATE], included a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R174's medical record did not identify R174 was having any signs or symptoms of COVID-19, nor did the record identify R174 was fully vaccinated from COVID-19. During observation on 10/12/21, at 6:39 p.m. a transmission-based precautions (TBP) cart outside was outside of R174's room. The TBP cart included gowns, gloves and surgical face masks but did not include any N95 respirators. On 10/13/21, at 8:29 a.m. the COVID-19 testing room was observed. There was a wired shelving unit with five shelves that contained approximately 80 boxes of N95 respirators with 10 to 20 respirators per box. During observation on 10/13/21, at 8:53 a.m. NA-A wore a surgical face mask with a face shield covering NA-A's eyes and face mask. NA-A put on a pink washable gown and gloves and carried bed linens into R174's room. NA-A did not wear an N95 respirator. On 10/13/21, 9:06 a.m. NA-A stated R174 was on TBP because R174 was a new admission and was not fully vaccinated against COVID-19. NA-A pointed to a sign on the TBP cart outside of R174's room and stated staff were to wear a gown, gloves, a surgical face mask and a face shield when they entered R174's room. The sign on the cart outside R174's room directed staff to wear gown, gloves, eye protection and surgical mask. The sign did not direct staff to wear a N95 respirator. On 10/13/21, at 11:38 a.m. physical therapy assistant (PTA)-A was observed seated face to face with R174 approximately 4 feet in front of R174. PTA-A was wearing a surgical face mask, face shield, gown and gloves. PTA-A stated R174 was a new admission and was on a 14-day quarantine. Staff were not required to wear an N95 respirator because R174 was not exposed to COVID-19. During interview on 10/13/21, at 12:46 p.m. NA-A stated staff would wear an N95 respirator when they entered a COVID-19 positive or suspected positive resident's room. R174 was on TBP because he was a new admission and was unvaccinated. NA-A stated staff did not wear an N-95 respirator in R174's room. During interview on 10/13/21, at 2:47 p.m. licensed practical nurse (LPN)-C stated R174 was on isolation precautions because he was a new admission and had not received a COVID-19 vaccination. Staff were expected to wear an N-95 respirator when they entered a COVID-19 positive resident's room. During interview on 10/14/21, at 12:01 p.m. the interim director of nursing (DON) stated the facility did not have a shortage of N95 respirators and would say the facility was in conventional status for N95 respirators. She was not aware of the requirement to wear an N95 respirator if the resident was on a new admission quarantine status and was not displaying any signs or symptoms of COVID-19. The facility provided COVID Standard Precautions sign dated 5/30/19, identified everyone entering needed to wear a gown, gloves and face protection. In addition, doctors and staff must wear appropriate mask, eye cover, gown and gloves if contact with body fluids was likely. The sign did not identify gowns, gloves, eye protection and N95 respirators needed to be worn at all times. The facility policy Emerging Threats-Acute Respiratory Syndromes Coronavirus (COVID)-Enterprise revised 10/7/21, identified the facility could implement practices allowing for reuse and extended PPE only when there was a limited supply. Further, the policy identified for suspected or confirmed COVID-19 the staff would wear a N95 respirator respirator and a surgical mask was acceptable if no N95 respirators were available. The CDC's Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes 9/10/21, identified all unvaccinated residents who are new admissions and readmissions should be placed in a 14-day quarantine, even if they have a negative test upon admission and an N95 respirator should be worn. The CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic dated 9/10/21, identified, health care personal (HCP) who enter the room of a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). The CDC's Strategies for Optimizing the Supply of N95 respirators dated 9/16/21, identified N95 respirators are the PPE most often used to control exposures to infectious pathogens transmitted via the airborne route, though their effectiveness is highly dependent upon proper fit and use. N95 respirators are intended to be used once and then properly disposed of and replaced with a new N95 respirator. The optimal way to prevent airborne transmission is to use a combination of interventions from across the hierarchy of controls, not just PPE alone. Applying a combination of controls can provide an additional degree of protection, even if one intervention fails or is not available EYE PROTECTION: On 10/13/21, at 7:16 a.m. LPN-E was standing at the medication cart setting up medications in the resident hallway. LPN-E was wearing prescription eye glasses with slide on plastic coverings on the bow of the glasses. The plastic created small gaps at the side and did not cover the eye area fully. LPN-E passed medications to multiple residents and multiple residents passed LPN-E in the hallway on the way to the dining room. LPN-E stated management instructed LPN-E they could use the eye shield coverings and was not aware the eye protection was not approved as personal protective (PPE) equipment. During observation on 10/13/21, at 1:23 p.m. environmental services (EVS) was using a large carpet sweeper to sweep carpet along the main resident hallway. EVS walked the entire length of the hallway with eye protection glasses on the top of his head. Residents were in the area. During observation on 10/14/21, at 11:24 a.m. EVS was standing in the resident hallway with his eye protection on top of his head and not covering his eyes. Residents were in the hallway. During interview on 10/14/21, at 11:25 a.m. EVS stated he had been wearing his eye protection on top of his head in the resident hallways as he thought that was an acceptable practice. During interview on 10/14/21, at 12:01 p.m. the interim DON stated approved eye protection (goggles or a faceshield) was to be worn in all resident care areas and especially when within six feet of other residents, to reduce the transmission of COVID-19. The facility policy Emerging Threats-Acute Respiratory Syndromes Coronavirus (COVID)-Enterprise revised 10/7/21, identified eye protection (e.g., face shields, goggles) must be morn for all close contact with suspected or confirmed cases of COVID-19 in routine outpatient, acute, care and long term care. Eye protection was also recommended to be worn with droplet or enhanced droplet precautions. Further eye protection that covers both the front and sides of the face would be used. The CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic dated 9/10/21, identified, health care personal (HCP) who enter the room of a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face).

Based on observation, interview and document review, the facility failed to ensure a resident toilet was clean for 1 of 1 residents (R1) reviewed who's family voiced concerns regarding an unclean toilet. Findings include: On 10/13/21, at 11:46 a.m. R1's family member (FM)-A stated R1's bathroom toilet was dirty. FM-A previously talked to staff about it and was still dirty today. The bathroom area was observed with FM-A. There was a dried unidentified substance around the bolt covers at the base of the toilet seat and in the frame mount (used to secure the toilet seat arm rests to the toilet) of R1's toilet. During interview on 10/14/21, at 8:33 a.m. the supervisor of ancillary services (SAS) stated housekeeping cleaned the the resident bathroom and toilets every day. Housekeeping staff had not received specific training for cleaning resident toilets. SAS expected staff to clean the resident toilet daily and thought staff knew how to clean the toilets. The facilities Environmental Cleaning Principles policy revised 12/16/20, indicated environmental cleaning played an important role in the infection control program, and the spread of infections from contaminated surfaces was significant and supported the need for good procedures and practices related to cleaning and disinfecting of surfaces. All staff should be aware of the general principles of environmental cleaning and safety.

Based on interview and document review, the facility failed to ensure incidents of potential abuse was thoroughly investigated to prevent further or ongoing abuse for 1 of 1 residents (R3) reviewed who had abuse allegations against a staff member. Findings include: R3's quarterly Minimum Data Set (MDS) dated [DATE], identified R3 had moderate cognitive impairment, required assistance with bed mobility, toileting and transfers and had not exhibited physical or verbal behaviors. R3's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The incident report submitted to the state agency (SA) on 10/6/21, at 4:09 p.m. indicated the incident occurred on 10/6/21. The report identified R3 had reported nursing assistant (NA)-C picked up his pillow off the floor and threw it in his face. The Investigation Status Report Summary submitted to the SA on 10/8/21, identified the facility was unable to substantiate the allegation of abuse; however the summary lacked interviews from other residents regarding potential staff to resident abuse. The facilities internal investigation notes identified FM-A reported the alleged abuse on 10/6/21. The notes indicated R3, FM-A, NA-C and licensed practical nurse (LPN)-D were interviewed and subsequently NA-C was placed on administrative leave pending further investigation. The documentation did not identify and other residents, other than R3, were interviewed regarding potential abuse by any staff member. During interview on 10/14/21, at 2:39 p.m. the interim director of nursing (DON) stated an abuse investigation would include interviews from the complainant, involved staff, and residents. If the concern involved a staff member, the specific staff member would be observed and depending on their work ethic, the facility may/may not interview more staff, families and/or other residents. Other residents were not interviewed because NA-C's observed interactions with residents and staff were positive and staff reported only good things regarding NA-C. The facilities Abuse and Neglect policy revised 12/23/20, indicated all incidents of alleged abuse were to be thoroughly investigated and staff were to prevent further potential abuse while the investigation was in process. The investigation may include interviewing employees, residents or other witnessed to the incident.

Based on observation, interview, and document review, the facility failed to implement identified interventions to minimize the risks for falls for 1 of 2 residents (R12) reviewed for falls. Findings include: R12's quarterly Minimum Data Set (MDS) dated [DATE], identified R12 had severe cognitive impairment and diagnoses which included dementia, anxiety disorder, spondylolisthesis (disorder of the spinal cord in which one vertebra slips onto the vertebra below it), chronic pain, lumbar spinal stenosis (condition where spinal column narrows and compresses the spinal cord), arthritis, and age-related [CONDITION(S)]. The MDS identified R12 required supervision with transfers, toilet use, walking in her room and locomotion on/off the unit and required limited assistance with walking in the corridor. Further, R12 had not experienced any falls since the previous assessment period. R12's care plan dated 6/8/21, identified R12 was at risk for falls related to severe lumbar stenosis, pain, arthritis, cognitive impairment, self-transfers, poor safety awareness, anxiety, incontinence, history of malnutrition, removed non-slip footwear on own, and impulsiveness as evidenced by a history of fall at previous skilled nursing facility attempting to throw self on floor and falls related to self-transfers. The care plan directed staff to implement interventions which included to ensure R12 wore appropriate, non-slip footwear when transferring, ambulating, or mobilizing in wheelchair, keep wheelchair next to bed when R12 was in bed, auto-lock brakes on wheelchair, and grip strips on floor next to bed, toilet, and sink. The care plan did not address grip strips in front of dressers. R12's incident report dated 10/4/21, identified at 6:11 a.m. R12 was found on the floor sitting on her buttocks next to the bed and had used the call light to alert staff. R12 stated she was at the end of the bed trying to get the dresser drawer open. R12's wheelchair was at the end of the bed in front of the dresser. R12 experienced a bruise and skin tear to her left knee and a laceration to her face. R12's Progress Note dated 10/4/21, identified the Falls committee reviewed R12's fall from 10/4/21 at 6:11 a.m. R12 was found sitting on the floor next to her bed and had used her call light to alert staff. R12 stated she had been at the end of the bed trying to get open the dresser drawer. R12's wheelchair was noted to be at the end of the bed near the dresser. R12 had apparently been sitting in the wheelchair, going through her dresser when she fell forward and then scooted herself over to the bed to use the call light. R12 was wearing gripper socks at the time of the fall. R12 was noted to frequently self-transfer and ambulate around her room without assistance or use of a walker. She did not remember staff's frequent reminders to call for assistance, instead did things on her own or refused staff assistance. Current fall interventions included: STOP signs in room. Keep wheelchair next to bed when in bed. Auto-lock brakes on wheelchair. Grip strips on floor next to bed, toilet, and sink. - The fall committee determined a new intervention to add grip strips to the floor in front of the dresser as R12 tended to stand at the dresser. They also determined to see if R12's room could be rearranged to have 2 short dressers in place of the one tall dresser to make it easier for her to look through the dresser. They also ordered a PT [physical therapy] screening, however felt as R12 had experienced no change in mobility, it was not likely she would require any therapy orders. No further fall interventions were identified. R12's Falls Tool dated 10/4/21, identified R12 was a medium risk for falls. During observation on 10/12/21, at 7:44 p.m. R1 was seated in a wheelchair in her room. The overhead lights were off, and a table lamp was on while R12 watched television. Non-slip strips noted on floor in front of bed and in front of the toilet. Two three-drawer dressers were positioned side by side on the wall under the television on the end of the bed; however, no non-slip strips noted to floor in front of the dressers. During observation on 10/13/21, at 9:47 a.m. R12 wheeled herself out of the bathroom in her room in her wheelchair. The wheelchair had auto-locking brakes. Non-slip strips were affixed to the floor in the bathroom and ran the length of the floor from in front of the toilet to in front of the sink. R12 was well groomed and wore slip-on loafers without socks. No non-slip strips were noted on the floor in front of the dressers in R12's room. During interview on 10/14/21 at 9:56 a.m. nursing assistant (NA)-E stated R12 required fall interventions such as auto-locking brakes on her wheelchair. She also checked on her every fifteen to thirty minutes as R12 liked to keep her door shut. R1 had skid strips next to her bed and in her bathroom and was not aware of placement of the skid strips anywhere else. During interview on 10/14/21, at 3:20 p.m. registered nursing (RN)-A stated the interdisciplinary team (IDT) met and reviewed resident falls to determine if any new interventions could be identified. She then documented a note regarding the review and ensured the care plan was updated and indicated this was usually done at the time of the IDT meeting. Care staff was then updated regarding the changes. Regarding R12's 10/14/21 fall, PT completed a screening and R12 had not met criteria for services. Her tall dresser was replaced with two short dressers. RN-A was not sure if the grip strips were supplied and stated these should have been documented in the maintenance book for the maintenance staff to apply to the floor. -At 3:25 p.m. R12's room was reviewed with RN-A and she stated the strips should be on the floor in front of R12's dresser and were not. During interview on 10/14/21, at 4:34 p.m. the interim director of nursing (DON) stated she would expect identified interventions to minimize falls be implemented. The Fall Prevention and Management - Rehab/Skilled, Therapy & Rehab policy dated 9/17/21, directed staff one of the purposes of the fall prevention and management program was to identify risk factors and implement interventions before a fall occurred. If a resident sustained a fall, the policy directed staff to update the care plan with any changes/new interventions and monitor the resident's condition and the effectiveness of the interventions.

Based on observation, interview and document review, the facility failed to ensure survey results were placed in a prominent place and contained or directed where to obtain the last three years of survey results. This had the potential to effect all 25 residents residing in the facility, along with family, visitors and staff. Findings include: During resident meeting on 10/13/21, at 10:38 a.m. R18 and R11 stated they did not know where the facility posted the survey results. During interview on 10/13/21, at 10:48 a.m. R6 stated she never noticed if the survey results were available and did not know where they are stored. On 10/14/21, at 9:48 a.m. licensed social worker (LSW) was asked where the facility survey results were kept for resident, family, visitors and staff to view. LSW walked over to the first nursing desk where there were a few binders on the edge of the desk, without labels on the binder edge. LSW pulled each binder out before identifying the survey results were in a white three ring binder. The front of the binder identified the facility survey results were in the binder; however, did not include the last three years of survey results from all abbreviated and recertification surveys. Further, the binder did not identify where to request the last three years of survey results. The binder contained the following survey results: - 9/9/20, from a focused infection control survey - 10/15/20, from a revisit survey - 2/3/21 - 2/4/21, from an abbreviated survey - 6/10/21, from an abbreviated survey - 9/8/21, from an abbreviated survey. During interview on 10/14/21, at 9:51 a.m. the administrator stated the administrator was responsible for placing the survey results in the binder and was likely missed due to staff turnover. The facility policy Posting Information- Social Services dated 12/22/20 identified All residents residing in the location have the right to be aware of certain location information concerning its operation, as well as their right of appeal and advocacy. It is the responsibility of the location to post this information in a visible place and keep it updated at all times. All postings must be legible and readable, and a magnifying glass needs to be available to assist those who are visually challenged. It is the responsibility of the social worker to keep abreast of what needs to be posted and post it accordingly. All information is to be accessible to all residents, whether ambulatory or in a wheelchair. The policy did not identify how many years of survey results were required to be available.

Based on interview and document review the facility failed to ensure written transfer notices were provided to the resident or resident representative and to the Long-Term Care Ombudsman following a facility-initiated transfer to the hospital for 2 of 2 residents (R23, R73) reviewed for hospitalization . This had the potential to affect all 25 residents residing in the facility. Findings include: R23's Progress Note dated 10/1/21, identified R23 was transferred to the hospital with weakness, confusion, labored breathing and wheezing and her representative was notified. The medical record lacked evidence written notice of the transfer was provided to R23 or her representative or Long-Term Care Ombudsman. R73's Progress Note dated 10/12/21, identified R73 was transferred to the hospital with shortness of breath and her representative had been notified and had approved a bed hold. The medical record lacked evidence written notice of the transfer was provided to R73 or her representative or Long-Term Care Ombudsman. During interview on 10/14/21, at 3:04 p.m. business office manager (BOM) stated she completed the transfer notice forms for R23 and R73 and scanned them into their medical records. She then opened R23's electronic record and displayed the completed form. However, BOM stated she only completed the form and scanned it into the record. She did not do anything else with the document. She had not provided the documents to the resident, resident representative, or to the Long- Term Care Ombudsman. During interview on 10/14/21, at 3:16 p.m. the health information manager (HIM) and registered nurse (RN)-A both stated they had not provided notices of transfer to either the resident, resident representative, or the Long-Term Care Ombudsman. HIM stated a previous director of nursing (DON), who no longer worked at the facility, changed the facility processes for transfer notices and the notices were not sent to the required individuals. The system was broken long enough that she could not remember the last time it was done. HIM provided a report which identified 14 residents were transferred to the hospital and/or the emergency department a total of 20 times since 7/1/21 and stated notices were not provided to the residents, representatives, or Long- Term Care Ombudsman for any of the identified facility-initiated transfers. During interview on 10/1421 at 4:31 p.m. the interim DON stated the facility should have notified the resident or resident representative and ombudsman regarding facility-initiated transfers as required. The Discharge and Transfer-Rehab/Skilled, Therapy & Rehab policy dated 12/29/20, identified when a resident was temporarily transferred on an emergency basis to an acute care center, this type of transfer was considered to be a facility-initiated transfer and a notice of transfer must be provided to the resident and resident representative as soon as practicable. Copies of notices for emergency transfers must also be sent to a representative of the Office of the State Long-Term Care Ombudsman, but they may be sent when practicable.

Based on observation, interview, and document review, the facility failed to implement recommended COVID-19 infection control procedures related to the use of gowns when in direct contact for 1 of 2 residents (R1) who was put on transmission based precautions due to exhibiting potential symptoms of COVID-19. This deficient practice had the potential to affect all 24 residents who resided in the facility and staff. Findings include: R1's Face Sheet printed 9/9/20, indicated R1's [DIAGNOSES REDACTED]. R1's care plan dated 8/19/20, indicated R1 required extensive assistance to complete activity of daily living tasks (ADLs). The care plan lacked indication R1 was on transmission based precautions related to COVID-19 symptoms. On 9/5/20, at 9:49 p.m. progress notes indicated R1 had symptoms of a dry cough. R1 placed on isolation for COVID-19 symptoms, and clinical monitoring was started. On 9/9/20 at 11:00 a.m. a personal protective equipment (PPE) cart was observed in the hallway next to R1's room. A droplet precautions sign on was on the top of the PPE cart, however, R1's door lacked any precaution signage. At 11:41 a.m. registered nurse (RN)-A was observed in the hallway, outside of R1's door, donning an isolation gown, in preparation of entering R1's room. RN-A stated R1 was on precautions because of symptoms of cough and upper respiratory infection. -At 12:40 p.m. nursing assistant (NA)-A was observed to enter R1's room to answer the call light. NA-A entered R1's room without donning an isolation gown. NA-A was in R1's room for one minute, then exited R1's room and walked across the hall to obtain a Hoyer (mechanical) lift. NA-A was overheard to request assistance from licensed practical nurse (LPN)-A. NA-A entered R1's room with the Hoyer lift. NA-A did not don a gown. LPN-A approached the PPE cart outside of R1's room, sanitized her hands with alcohol based hand rub (ABHR), donned an isolation gown, and entered R1's room. -At 12:46 LPN-A was observed to be in R1's doorway, doffing and disposing of her isolation gown and gloves in the garbage container in R1's room. LPN-A exited the room. NA-A exited R1's room directly behind LPN-A, however, was observed not to have an isolation gown on. Upon exiting R1's room, NA-A immediately entered the resident room next door to respond to a call light. -At 12:48 p.m. LPN-A stated she was aware R1 was on isolation precautions because of the sign on top of the PPE cart next to R1's room. LPN-A stated she was aware NA-A had not donned an isolation gown to enter R1's room, and verified NA-A should have been wearing an isolation gown because of cares they had just provided to R1. -At 12:55 p.m. NA-A was interviewed and stated she had used the Hoyer lift to assist R1 into her bed, and provided her with a bed pan with LPN-A's assistance. LPN-A stated R1 was currently on the bedpan, and they left the Hoyer lift in the room, so they could remove her off of the bedpan when she was done. NA-A stated she was aware R1 was on transmission based precautions, and she should have been wearing an isolation gown to provide care to R1, but had been in a hurry and had forgotten. NA-A stated she had made a mistake. On 9/9/20 at 4:30 p.m. in a joint interview, both the administrator and the director of nursing (DON) stated they would expect an isolation gown to be worn for direct patient care in the isolation rooms. The DON stated if assisting with direct cares, an isolation gown should be worn. The facility's policy Infection Prevention: Emerging Threats-Acute Respiratory Syndromes Coronavirus (COVID)-19 Enterprise dated 8/14/20, directed staff to isolate residents with suspected or positive COVID-19 to their room and post a droplet precaution sign on their door. The policy directed staff to limit only essential personnel to enter the room, wearing appropriate PPE. The policy indicated appropriate PPE to include gloves, gowns, eye protection and mask.

Based on observation, interview and document review, the facility failed to maintain the laundry room in a clean and sanitary condition. This had the potential to affect all 31 residents who resided in the facility. Findings include: On 11/7/19, at 10:31 a.m. during a tour of the laundry room with the facility administrator, the soiled laundry area was observed to have a two compartment sink. The faucet handles and the entire area around the faucet handles along the rear of the sink were noted to be covered in a white lime scale, ringed with green. The window in the soiled laundry room was entirely covered in a hazy grime with a thick covering of cobwebs noted in all four corners of the window. The floor was noted to be dirty with a grimy build up noted along the walls and in the corners of the room. The window in the clean laundry room, located behind the washing machines, was noted to be entirely covered in a thick layer of grime with thick, dust-covered cobwebs covering the entire window. A build up of grime was also noted on the floor and was more prominent along the edges and corner of the room. The administrator confirmed the rooms were in need of a good cleaning. On 11/7/19, at 11:22 a.m. housekeeper (HSK)-A verified she was doing laundry today in addition to her housekeeping duties. HSK-A stated she did not usually do the laundry, but was covering for someone who was on leave. HSK-A confirmed the laundry areas were not very clean and indicated the usual laundry staff did not do a good job of keeping it clean. HSK-A indicated she had emptied the garbage when she arrived that day as it had not been done. On 11/7/19, at 4:00 p.m. the administrator stated she was not sure who was responsible to clean the laundry areas. The administrator also stated the facility was working on a housekeeping performance improvement project and now realized the laundry areas also needed to be addressed. The adminstrator again confirmed the areas were dirty. The Laundry Room Policy dated (MONTH) (YEAR), indicated an important aspect of a laundry service program was the maintenance and use of the laundry room(s). Due to the bio-load (the amount of microorganisms on a contaminated object, surface, device, or instrument in a contaminated area) introduced into the soiled room/area and the necessity to maintain the clean laundry room/area to preserve the cleanliness of the laundered material, it was crucial that frequent cleaning, disinfecting and inspections of the laundry room occur. The policy directed to clean and disinfect folding tables/area, clean and soiled linen carts, laundry baskets and personal delivery carts at least daily, spot clean walls on a daily basis and all surfaces should be damp dusted with a disinfectant cleaner at least weekly.

Based on observation, interview and document review, failed to notify the physician regarding significant weight gain for 1 of 3 residents (R17) who received diuretics and had experienced rapid weight gain. Findings include: R17's [DIAGNOSES REDACTED]. R17's annual Minimum Data Set ((MDS) dated [DATE], indicated R17 had moderate cognitive impairment and required extensive to total assistance with all activities of daily living, except eating. The MDS further indicated R17 received diuretic medication daily. R17's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 9/27/19 indicated R17 received a diuretic to manage his heart failure. R17's undated Care Plan provided 1/7/19, indicated R17 had altered cardiovascular status related to hypertension, [MEDICAL CONDITION], heart failure, [MEDICAL CONDITION] as evidenced by [MEDICAL CONDITION], history of STEMI (ST-Elevation [MEDICAL CONDITION] Infarction is a very serious type of [MEDICAL CONDITION] during which one of the heart's major arteries (one of the arteries that supplies oxygen and nutrient-rich blood to the heart muscle) is blocked) with chest pain and shortness of breath. The Care Plan directed staff to monitor, document and report to health care provider changes in lung sounds on auscultation, [MEDICAL CONDITION], and changes in weight. The Care Plan also directed staff to apply Jobst stockings (a brand of compression stockings) to both legs, to be worn at all times except for bathing and cares to legs. Change daily with a.m. cares, lotion legs prior to application of stockings. (MONTH) be removed for up to two hours a day. R17's Medication Review Report dated 10/18/19, included the following orders: -weigh daily before breakfast. Contact MD (physician) for weight gain > 3 pounds (lbs) overnight or 5 lbs in a week related to fluid overload -[MEDICATION NAME] (diuretic), give 60 milligrams (mg) by mouth in the morning related to heart failure -[MEDICATION NAME] (diuretic) give 2.5 mg by mouth every Monday, Wednesday and Friday related to heart failure. On 11/6/19, at 10:15 a.m. nursing assistant (NA)-A and NA-B were observed to transfer R17 from the wheelchair to the bed via a mechanical lift. NA-A and NA-B prompted R17 to roll side to side and removed the lift sling and R17's pants. R17 observed to wear compression stockings to both legs. No extremity [MEDICAL CONDITION] observed. Review of R17's Weights and Vitals Summary from 8/1/19 to 11/7/19, revealed the following: -8/3/19: 283.4 via mechanical lift scale -8/7/19: 290.2 via mechanical lift scale (a gain of 6.8 lbs in 4 days) -9/1/19: 279 via mechanical lift scale -9/2/19: 284.4 via mechanical lift scale (a gain of 5.4 lbs in 1 day) -9/17/19: 268.2 via chair, wheelchair scale -9/18/19: 271.6 via chair, wheelchair scale (a gain of 3.4 lbs in 1 day) -9/20/19: 281.4 via chair, wheelchair scale (a gain of 9.8 lbs in 1 day) -10/17/19: 276 via chair, wheelchair scale -10/19/19: 286.7 via chair, wheelchair scale (a gain of 10 lbs in 2 days) -10/31/19: 276 via chair, wheelchair scale -11/1/19: 280.4 via chair, wheelchair scale (a gain of 4.4 lbs in 1 day) -11/2/19: 274.4 via chair, wheelchair scale -11/3/19: 279.4 via chair, wheelchair scale (a gain of 5 lbs in 1 day) R17's medical record lacked evidence the physician had been notified of the aforementioned weight gains, as ordered. On 11/7/19, at 3:29 p.m. the director of nursing (DPN) verified the weights as listed above and confirmed R17's physician had not been notified of the significant weight gains as ordered. The DON indicated the facility had been having problems with their scales and had recently purchased a new scale. However, DON verified even though they were having scale issues, the facility should still have notified physician. On 11/7/19, at 3:46 p.m. a message was left for R17's MD. On 11/8/19 at 8:02 a.m. MD returned call regarding R17. MD stated fortunately R17 had not had any adverse outcome from the weight gains reported and R17 had been stable and had not had any additional hospitalization related to his [MEDICAL CONDITION]. MD also stated he gave the parameter order for a reason and he expected the facility to notify him when a resident experienced these types of weight gains. MD indicated the facility had two different ways to contact him and he expected them to do so. MD also indicated he had spoken with the facility that morning to ensure his orders were followed. The Notification of Change policy dated (MONTH) (YEAR), indicated the facility must inform the resident, consult with the resident's physician and notify consistent with his or her authority the resident representative(s) when there was a significant change in the resident's physical, mental or psychosocial status.

Based on observation, interview and document review, the facility failed to ensure food temperature monitoring equipment was routinely calibrated to ensure accuracy in order to prevent potential food borne illness when used for serving potential hazardous food(s). In addition, the facility failed to ensure 1 of 1 meat slicer used in the main production kitchen was kept in a clean manner to reduce the risk of bacterial growth and associated foodborne illness. These findings had potential to affect all 31 residents residing in the facility and who received meals from the kitchen. Findings include: THERMOMETERS: On 3/19/19, at 11:47 a.m. the residents were observed in the dining room eating the noon meal. Meat loaf was served which was noted to be marbled with pink and brown color giving the meat an undercooked appearance. -At 11:52 a.m. the certified dietary manager (CDM) stated the temperature log indicated the meatloaf was 168 degrees Fahrenheit (F) when removed from the oven and was 155 degrees F when served. The CDM, stated the meatloaf had been in the steamtable since 11:00 a.m. The CDM removed a slice of meatloaf from the steamtable, temped it, and reported the temperature of the meatloaf was 132 degrees F. -At 12:05 p.m. the CDM stated he suspected his thermometers may have not been accurate when checking the meat temperature from the oven. The CDM stated the kitchen thermometers were calibrated every six months however, stated he had no documentation to show when the last calibration was completed. Although the facility experienced a gastrointestinal (GI) illness outbreak in (MONTH) 2019. On 3/19/19 at 12:46 p.m. the CDM placed two thermometers into a glass of ice water. One thermometer read 42 degrees. The second thermometer read 34 degrees. CDM verified the thermometer used to obtain the temperature of the meat on 3/19/19, was not accurate. On 3/19/19 12:54 p.m. CDM stated the facility did not have a policy and procedure related to checking the thermometer for accuracy or calibration. Facility Policy and Procedure for Food Thermometers, revision dated 7/2018, directed staff to calibrate thermometers on a weekly basis and ensure thermometers would be accurate to plus or minus 2 degrees Fahrenheit. MEAT SLICER: On 3/20/19 at 11:27 a.m. The sanitary tour was completed with the CDM. The meat slicer was observed to have food debris covering the blade housing of the machine. This debris was easily rubbed loose with light pressure. CDM verified all staff knew how to disassemble the slicer and clean it and were directed to clean it after every use. A policy related to the cleaning of the meat slicer was requested and none was provided.