Every finding on record at Grandview Healthcare Center

Based on observation, interview and record review, facility staff failed to store food in a manner to prevent potential contamination and outdated use and use food in a first-in first out manner. Facility staff failed to perform hand hygiene as often as necessary using approved techniques to prevent cross-contamination. Facility staff failed to maintain kitchen equipment and surfaces in a clean and sanitary manner and ensure staff personal items were stored away from food storage and preparation areas. Facility staff failed to properly wash, sanitize and air-dry mechanically washed dishes to prevent cross-contamination and the growth of foodborne pathogens. Facility staff also failed to maintain a chemical sanitizer test kit to ensure the chemical sanitizer used in the mechanical dishwasher maintained the appropriate concentration. These failures have the potential to affect all residents. The facility census was 52.1. Review of the facility's policy titled Receiving and Storage of Food, undated, showed the dietary manager (DM) is responsible for receiving and storing food and nonfood items. Review showed the policy directed staff to follow the rule of First In, First Out, keep all foods in clean, undamaged wrappers or packages, and to reseal open boxes effectively. Review of the facility's policy titled Storage of Dry Food and Supplies, dated May 2015, showed metal or plastic containers with tight fitting covers, labeled top or side, must be use for storing opened products. Open boxes are to be effectively resealed. Bulk crackers, cereal, cookies, pasta, et cetera are to be stored and properly labeled in sealed containers. Food-grade plastic bags are to be tightly closed after being opened. Observation on 01/13/26 at 8:29 A.M., showed the cook's station contained: -An undated plastic bulk storage container which contained an undated bag of quick oats removed from its original packaging; Observation showed the bag inside the container opened to the air and a golf ball sized hole in the back side of the container; -An undated plastic bulk storage container which contained an opened and undated 25 pound bag of fish breading. Observation showed a delivery sticker on the bag dated 02/14/23 and the bag prevented the lid to the container from being sealed;-An undated plastic bulk storage container which contained an opened and undated 25 pound bag of flour;-An undated plastic bulk storage container which contained an opened and undated 50 pound bag of sugar;-An opened 57 ounce (oz.) container of instant mashed potatoes with a stock date of 12/29 and no opened date. Observation on 01/13/26 at 9:46 A.M., showed the dry goods pantry contained: -Three undated plastic storage containers of raisin bran cereal removed from its original packaging; -Two undated plastic storage containers of fruit whirls cereal removed from its original packaging;-Two undated plastic storage containers which contained honey nut toasted oats cereal removed from its original packaging;-An undated plastic storage container of crip rice cereal removed from its original packaging;-An opened and undated 10 pound box of graham crumbs;-An opened and undated one gallon bottle of red wine vinegar with use by date of 5/18/22;-An opened 32 oz. bag of light brown sugar with stock date of 7/31 and no opened date. Observation showed the contents of the bag hardened into small rock sized pieces; -An opened five pound bag of devil's food cake mix with a stock date of 7/31 and not dated when opened;-A 24 oz. box of quick grits opened to the air with stock date of 10/28 and not dated when opened; -An opened five pound bag of buttermilk pancake mix with stock date of 10/30 and not dated when opened;-An opened five pound bag of cornbread mix with a stock date of 11/20 and not dated when opened;-An opened five pound bag of devil's food cake mix with stock date of 12/12 and not dated when opened; -An opened 28 oz. bag of creamy wheat farina cereal with stock date of 12/14 and not dated when opened;-An opened 57 oz. container of instant mashed potatoes with a stock date of 12/29 not dated when opened;-An opened 35 oz. bag of honey nut toasted oats cereal with stock date of 1/8 and not dated when opened. During an interview on 01/3/26 at 10:50 A.M., the DM said food is dated when it enters the facility and anything that is opened should also be dated when it is opened so each item should have two dates on the package, except items removed from their original packages would only have the opened date. The DM said staff are expected to date any items leftover or made before they are put away in storage and ensure they are stored in sealed containers. The DM said the dates on the items identified in the dry goods pantry would be their stock dates and not their opened dates and he/she did not have a good reason as to why the food in the bulk containers and dry goods pantry were not dated and stored as required. The DM said staff would also be expected to discard any food items past their best by or use by dates. Observation on 01/13/26 at 12:14 P.M., showed the walk-in refrigerator contained: -An opened and undated five pound box of grated parmesan cheese;-An opened and undated five pound bag of shredded mozzarella cheese;-An opened 8.44 pound bottle of salsa with stock date of 12/18;-An opened and undated one gallon container of sweet pickle relish. Observation showed the delivery sticker on the container dated 06/05/25. Observation on 01/13/26 at 3:02 P.M., showed the walk-in freezer contained: -An opened and undated 40 oz. bag of corn;-An opened and undated bag of tater tots;-Two opened and undated bags of french fries;-An undated case of breadsticks opened to the air;-Three opened and undated bags of hashbrowns;-An opened and undated box of southern style biscuits;-An opened and undated bag of chicken tenders;-An opened and undated box of pork egg rolls. During an interview on 01/13/26 at 3:08 P.M., the DM said he/she is responsible to monitor food storage, and he/she looks in the refrigerator about every three days, but he/she does not really look around the other food storage areas. The DM said if he/she picks out a food item and notices it is not good, such as the hardened brown sugar, he/she would just throw it away and get a new one. The DM said staff should use all of one item before they open another of the same item so that food is used in a first-in, first-out manner. The DM said he/she had noticed multiple packages of the same item opened in the freezer, but he/she just had not had an opportunity to address it yet, since he/she had to work as the cook several days. The DM said if staff see something not stored properly, it should be corrected upon discovery, and he/she did not have a good reason as to why the food items were not stored correctly or used in first-in, first-out manner. During an interview on 01/13/26 at 3:34 P.M., the administrator said the DM is responsible to ensure food is stored appropriately and he/she should check it daily to ensure it not expired, stored in the appropriate place and properly sealed, labeled and dated. The administrator said if anything is not stored appropriately, it should be corrected at the time of discovery. The administrator said staff are expected to discard food items that are past their best by or use by dates and staff should use all of one food item before they open another like item to ensure food is used in a first-in, first-out manner. The administrator said staff are trained on proper food storage procedures upon hire during their orientation in the kitchen. 2. Review of the facility's policy titled Handwashing, dated May 2015, showed the policy directed staff to lather their hands with antiseptic soap, giving particular attention to the areas between fingers, around cuticles and under fingernails, and to turn the water off with a paper towel when they wash their hands. Review showed the policy did not contain direction to staff on when to perform hand hygiene or how long to lather their hands with soap when they wash their hands. Observation on 01/13/26 at 8:13 A.M., showed [NAME] M entered the kitchen and disposed of trash in the trash can by lifting the lid with his/her bare hand. Observation showed the cook then washed his/her hands at the handwashing sink and turned the faucet off with his/her bare hand before he/she dried his/her hands. Observation on 01/13/26 at 8:19 A.M., showed the DM entered the kitchen and, without performing hand hygiene, retrieved a metal food service pan to use for food service. Observation on 01/13/26 at 8:35 A.M., showed when Dietary Aide (DA) N washed his/her hands at the handwashing sink, he/she scrubbed his/her hands with soap for two seconds and turned the faucet off with his/her bare hand. Observation showed the DA then removed food service trays from the clean side of the mechanical dishwashing station and placed them on the food delivery cart. Observation on 01/13/26 at 8:54 A.M., showed DA N entered the kitchen and when he/she washed his/her hands at the handwashing sink, he/she scrubbed his/her hands with soap for two seconds and turned the faucet off with his/her bare hand. Observation showed the DA then put away dishes from the clean side of the mechanical dishwashing station. Observation on 01/13/26 at 8:56 A.M., showed when [NAME] M washed his/her hands at the handwashing sink, he/she scrubbed his/her hands with soap for seven seconds and turned the faucet off with his/her bare hand. Observation showed the cook then adjusted the glasses on his/her face and prepared drinks for service at the lunch meal. Observation on 01/13/26 at 9:10 A.M., showed when the DM washed his/her hands at the handwashing sink, he/she scrubbed his/her hands with soap for five seconds. Observation showed the DM then rolled a package of raw hamburger wrapped in plastic into a piece of aluminum foil and, without performing hand hygiene, tore off a piece of masking tape from the roll to date the hamburger, put the hamburger in the walk-in freezer and prepared food items for service at the lunch meal. Observation on 01/13/26 at 9:19 A.M., showed when the DM washed his/her hands at the handwashing sink, he/she scrubbed his/her hands with soap for five seconds. Observation showed the DM then continued to prepare food items for service at the lunch meal. Observation on 01/13/26 at 9:38 A.M., showed when DA N washed his/her hands at the handwashing sink, he/she scrubbed his/her hands with soap for two seconds and turned the faucet off with his/her bare hand. Observation showed the DA then put clean insulated dome plate covers onto the food service trays located on the food delivery cart. Observation on 01/13/26 at 10:33 A.M., showed the DM entered the kitchen and, without performing hand hygiene, picked up dishes from the clean side of the mechanical dishwashing station. During an interview on 01/13/26 at 10:33 A.M., the DM said he/she just came from the administrator's office and staff should wash their hands when they enter the kitchen. The DM said he/she did not think about the need to wash his/her hands when he/she entered the kitchen. During an interview on 01/13/26 at 3:16, the DM said staff should perform hand hygiene when they enter the kitchen, touch a trash can or anything that is dirty, which would include their glasses and raw meat. The DM said when staff wash their hands, they should scrub their hands with soap for at least 20 seconds and turn the faucet off with a towel and not their bare hand since the faucet is dirty. The DM said all staff are trained on proper hand hygiene upon hire. During an interview on 01/13/26 at 3:40 P.M., the administrator said staff should perform hand hygiene when they enter the kitchen, after they handle food and after they touch anything dirty, would include their glasses. The administrator said when staff wash their hands, they should scrub their hands with soap for at least 20 seconds and turn the faucet off with a paper towel, so they do not recontaminate their hands. The administrator said staff are trained on proper hand hygiene during orientation by their trainer and during routine hand hygiene in-services. 3. Review of the facility's policy titled Workspaces and Storage, dated May 2015, showed the policy provided direction to staff for the cleaning of drawers, vents, doors, walls, ceilings, light fixtures and switches. Review showed the policy did not contain direction to staff for the cleaning of other kitchen surfaces and equipment. Review of the facility's policy titled Handwashing, dated May 2015, showed the policy directed staff to store personal items in a designated area away from food preparation, service, and storage areas. Observation on 01/11/26 at 10:24 A.M., showed an excess of dried on food debris and liquid stains inside the reach-in refrigerator by the chest freezer. Observation on 01/11/26 at 10:24 A.M., showed an excess of hardened grease on the exterior of the two tabletop deep fat fryers and on the side of the range by the fryers. Observation on 01/13/26 at 8:22 A.M., showed an excess of dried on food debris and liquid stains inside the reach-in refrigerator by the chest freezer. Observation also showed an excess of paper trash and dirt on the floor behind the refrigerator and between the refrigerator and chest freezer. Observation on 01/13/26 at 8:23 A.M., showed an abundance of personal items stored on top of the chest freezer and an accumulation of pens, markers and paper trash on the floor behind the freezer. Observation on 01/13/26 at 8:29 A.M., showed an excess of hardened grease on the exterior of the two tabletop deep fat fryers and on the side of the range by the fryers. Observation also showed multiple french fries on the floor behind the fryers. During an interview on 01/13/26 at 9:18 A.M., the DM said the personal items on top of the chest freezer belonged to staff and he/she instructed the staff to store their personal items either in his/her office or on top of the freezer. The DM said he/she did not realize personal items should not be stored in food storage and preparation areas. The DM said the facility did not really have a routine cleaning schedule for staff to follow. The DM said he/she puts some things on his/her cleaning list to do, like cleaning the deep fat fryers, while he/she assigns other tasks to staff as needed. The DM said he/she knew there were things in the kitchen that needed to be cleaned, but he/she just had not been able to clean them yet due to having to work as the cook most of the time. During an interview on 01/13/26 at 3:47 P.M., the administrator said he/she did not have a policy related to the cleaning of all kitchen surfaces and equipment, all dietary staff are responsible to keep the kitchen clean and the DM should monitor that daily. The administrator said the cook should clean the deep fat fryers and range after each use and staff should clean equipment as well as sweep and mop the floors, which would include the areas behind and between equipment, daily and as needed. The administrator said he/she knew the DM often assigned cleaning tasks to the evening staff for completion, but the kitchen should have a cleaning schedule for the routine cleaning of the kitchen. The administrator also said staff should not store their personal items in the kitchen and he/she did not know the DM had told the staff they could store their personal items on the freezer. 4. Review of the facility's policy titled Dishwashing Temperatures, dated May 2015, showed the effective temperature range for chemical sanitizing machine listed as 75 dF to 120 dF. Review showed the policy directed staff to record the temperatures of the wash and rinse cycles daily, or as directed by the consultant dietician, for chemical sanitizing machines. Review showed the policy also directed staff to check the concentration of the chemical sanitizer with a test strip and log the concentration on the Dish Machine Temperature log. Review of the facility's policy titled Dishmachine, dated May 2015, showed the policy directed the staff to ensure the temperature of low temperature machines measured a minimum of 120 degrees Fahrenheit (dF) before washing the morning dishes and to document the temperature on the Dish Machine Temperature Log. Review showed the policy also directed staff to check the concentration of the chemical sanitizer with a test strip and log the concentration on the Dish Machine Temperature Log. Review of the facility's policy titled Dish Machine Temperature Log, dated May 2015, showed the policy directed staff to log the wash and rinse temperatures before washing dishes after each meal to ensure the wash and rinse temperatures are properly monitored and controlled. Review showed the policy also directed staff to record the sanitizer concentration for low temperature dish machines. Observation on 01/13/26 at 8:30 A.M., showed DA P washed soiled dishes in the chemical sanitizing mechanical dishwasher. Observation showed the water temperature for the wash and rinse cycles of the dishwasher measured 100 dF. Observation showed staff removed the dishes from the dishwasher from the clean side of the station upon completion of the dishwasher's cycle. Observation showed staff loaded another rack of soiled dishes into the dishwasher and the water temperature of the wash and rinse cycles measured 108 dF. Observation showed the kitchen did not contain a visible test kit to measure the concentration of the sanitizer used in the dishwasher and the Dish Machine Temperature Log which hung on the wall in area was dated August 2025. Review of the dishwasher manufacturer's instructions posted on the dishwasher, showed the water temperature of both the wash and rinse cycles to be a minimum of 120 dF. Review of the manufacturer's instruction for use on the label of the sodium hypochlorite sanitizer used in the dishwasher showed the minimum concentration for the sanitizer to be at 100 parts per million. Review showed the information did not contain instruction for the use of the product with a water temperature of less than 120 dF. During an interview on 01/13/26 at 8:35 A.M., DA P said he/she did not know what the required water temperature of the dishwasher should be, he/she had never checked the concentration of the sanitizer used in the machine and he/she had never seen a test kit to measure the concentration of the sanitizer. During an interview on 01/13/26 at 8:40 A.M., the DM said they switched chemical companies a couple of months ago. The DM said he/she was not present when they came to switch the dishwasher chemicals, but the company representative turned the water temperature down on the dishwasher and stated that the water temperature needed to be lower so it would not affect the effectiveness of the sanitizer. The DM said he/she did not put any Dish Machine Temperature Logs up after the company switched the chemicals since the dishwasher would not be at 120 dF. The DM said he/she did not have a test kit to measure the concentration of the sanitizer used in the dishwasher. The DM said they should have a sanitizer test kit, and he/she should have put a new Dish Machine Temperature Log up, but he/she did not have a good answer as to why he/she did not ensure those things were present. Review of an email to the administration from the facility's corporate purchasing coordinator, dated 01/14/26, showed the facility switched chemical companies and the new chemicals for the dishwasher were installed on 09/05/25. During an interview on 01/13/26 at 4:00 P.M., the administrator said the water temperature and concentration of the chemical sanitizer used in the dishwasher should be in accordance with the policies and staff should check the water temperature and sanitizer concentration each time they wash dishes and record the information on the log put out by the DM. The administrator said the kitchen should contain a test kit to measure sanitizer concentrations, but he/she could not recall if he/she had seen a test kit in the kitchen. The administrator said if the dishwasher is not working correctly, staff should notify maintenance and not continue to use the machine. The administrator said they were already using their current chemical company when he/she became the administrator in November 2025, and he/she did not know the water temperature of the dishwasher did not reach 120 dF or that the kitchen did not have a test kit for the sanitizer. 5. Review of the facility's policy titled Dishmachine, dated May 2015, showed the policy directed staff to allow all dishes to air-dry after they are washed in the mechanical dishwasher. Observation on 01/13/26 at 8:30 A.M., showed DA P removed cleansed plastic food service trays while wet from the mechanical dishwasher and placed them on the food delivery cart. Observation also showed 10 plastic food service trays, 10 insulated plate covers, and six insulated plate holders stacked together wet on the storage shelf on the clean side of the mechanical dishwashing station. Observation on 01/13/26 at 8:35 A.M., showed DA N removed cleansed plastic food service trays while wet from the clean side of the mechanical dishwashing station and placed them on the food delivery cart. Observation showed the DA then dried the trays with a cloth towel. Observation showed the DM in-serviced the DA to allow dishes to air-dry after they are washed. Observation on 01/13/26 at 8:54 A.M., showed DA P put the wet stacked insulated plate holders from the shelf onto the towel dried trays on the food delivery cart. Observation on 01/13/26 at 9:00 A.M., showed DA N removed cleansed food service pans while wet from the clean side of the mechanical dishwashing station and stacked them on top of the other pans on the storage shelf. During an interview on 01/13/26 at 9:00 A.M., DA N said dishes should be dry before they are put away and he/she thought the pans were dry. Observation on 01/13/26 at 9:25 A.M., showed [NAME] M used a cloth towel to dry cleansed dishes in the mechanical dishwashing station. During an interview on 01/13/26 at 3:20 P.M., the DM said dishes should be air-dried before they are put away. The DM said he/she does not train staff on putting the dishes away, but the DA who they work with during their orientation should train them to allow the dishes to air-dry. During an interview on 01/13/26 at 4:00 P.M., the administrator said staff should allow dishes to air-dry and staff are trained on that requirement. The administrator said the DM is responsible to ensure staff are trained on the requirements and routinely monitor the storage of dishes.

Based on record review and interview, facility staff failed to maintain an Antibiotic Stewardship Program (the monitoring for appropriate antibiotic use and effectiveness to improve outcomes and prevent development of antibiotic resistance). The facility census was 52. 1. Review of the facility's policy titled, Antibiotic Stewardship Champion Program, undated, showed:-The community will select an Antibiotic Stewardship Champion (ASC) who will be responsible for implementing and maintaining the Antibiotic Stewardship Champion Program;-Antibiotic usage will be reviewed during morning meeting, the resident's name, antibiotic, start date and location/type of infection will be listed on the white board for follow up until antibiotic is complete or repeat culture results are received;-Seventy-two hours after the start of antibiotics, a Time Out will be conducted: the resident's clinical record will be reviewed for the correct antibiotic, the correct length of time for the antibiotic prescribed, if any lab/culture results have been received, and any adverse reaction;-The Antibiotic Stewardship Champion will review the resident's Medication Administration Record (MAR) throughout the use of antibiotic to ensure administration of the antibiotic;-The ASC will also keep track of the location of infections throughout the facility monthly by highlighting the location of infections on a map of the facility. 2. Review of the Antibiotic Stewardship program, dated May 2025 to January 2026, did not contain documentation staff tracked antibiotics and infections in the facility.During an interview on 01/14/26 at 12:07 P.M., the Assistant Director of Nursing (ADON) said he/she has been working the floor a lot recently and has not had time to keep up with the antibiotic stewardship program. He/She said there is not another staff that is trained that could help while he/she is working the floor. He/She said its important to track infections and antibiotics in the facility to ensure residents are getting the prescribed antibiotic and to see if there is a way to prevent infections from occurring in the facility. During an interview on 01/14/26 at 3:42 P.M., the Director of Nursing (DON) said he/she is honestly unsure if the antibiotic stewardship program has been getting done because he/she has only worked at the facility since December 2025. During an interview on 01/14/26 at 4:24 P.M., the administrator said he/she was not aware that the antibiotic stewardship program had not been getting done. He/She said he/she was not sure who is responsible for completing the antibiotic stewardship program but will ensure the ADON is responsible moving forward.

Based on observation, interview, and record review, facility staff failed to review and revise the plan of care with changes in the residents' needs for six residents (Resident #2, #6, #7, #17, #22, and #27) out of 21 sampled residents. The facility census was 52.Review of the facility's policy titled Care Plan Comprehensive, undated, showed an individualized comprehensive care plan that includes measurable goals and time frames will be developed to meet the resident's highest practicable physical, mental, and psychosocial well-being. The comprehensive care plan will be based on a thorough assessment that includes but is not limited to the Minimum Data Set (MDS), a federally mandated assessment tool. A well-developed care plan will be oriented to preventing avoidable declines in functioning or functional levels, managing risk factors to the extent possible or indicating the limits of such interventions, applying current standards of practice in the care planning process, assessing and planning for care to meet the resident's medical, nursing, mental and psychosocial need, and addressing additional care planning areas that are relevant to meeting the resident's needs in the long-term care setting. The interdisciplinary care plan team is responsible for the periodic review and updating of care plans when a significant change in the resident's condition has occurred, at least quarterly, and when changes occur that impact the resident's care (i.e. change in diet, discontinuation of therapy, changes in care areas that do not require a significant change assessment).1. Review of Resident #2's Quarterly MDS, dated [DATE], showed staff assessed the resident as:-Severely cognitively impaired;-Weight of 158 pounds (lbs.);-Did not have weight loss;-Diagnoses of stroke, dementia with agitation, anxiety, depression, violent behavior, and stage three chronic kidney disease .Review of the resident's Physician Order Sheet (POS), dated January 2026, showed the physician directed staff as follows:-Diet: Level Six soft and bite sized (a diet for people with mild chewing difficulties, requiring foods that are soft, moist, and cut into small pieces), no fried foods, dated 03/22/25;-Boost Breeze Nutritional (food supplement, lactose-reduced) liquid, 120 milliliters (mL) three times a day, dated 05/01/25;-Super Cereal (a calorie-dense, fortified hot cereal enhanced with ingredients like cream, butter, milk, and sugar to combat unintended weight loss and malnutrition) at breakfast, dated 12/01/25;-Weight: Weekly until stable, on Monday, dated 12/01/25.Review of the resident's monthly weights showed the resident weight as follows:-On 08/01/25 weighed 155.4 lbs;-On 01/12/26, weighed 140.4 lbs a 9.65% loss.Review of the resident's care plan, dated 12/03/25, showed staff did not update the care plan to include the resident's recent weight loss, use of nutritional supplements, or change in frequency of weights.During an interview on 01/14/26 at 3:02 P.M., Certified Nurse Aide (CNA) A said the resident will spit his/her food out, like a behavior, but he/she will get the resident other things, like snacks throughout the day, and he/she did not know the resident had weight loss. The CNA said if he/she was aware the resident had weight loss, he/she would try to get him/her to eat more throughout the day.During an interview on 01/14/26 at 3:13 P.M., the MDS Coordinator said weight loss should be on the care plan, without interventions the resident could continue to lose weight, and the interventions are put in place to prevent and help regain some loss, and it should show supplements, food preferences, and assistance level needed with eating.3. Review of Resident #6's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Rarely/never understood;-Short and long-term memory problems;-Weight of 154 lbs.,-Did not have weight loss;-Received a mechanically altered diet (a diet that provides moist, soft-textured foods that are chopped, ground, or mashed for easier chewing and swallowing);-Dependent on staff for eating;-Diagnoses of anoxic brain damage (occurs when the brain receives no oxygen at all), diabetes, stroke, dementia, schizophrenia, gastroparesis (a chronic stomach condition in which the muscles in the stomach do not move food as they should for it to be digested), depression, and anxiety.Review of the resident's POS, dated January 2026, showed physician directed staff as follows:-Add yogurt yummy (a protein rich yogurt) with breakfast and lunch, twice a day A.M. and P.M., dated 10/01/25;-Diet: Level Six soft and bite size, dated 10/23/25;-Check weight weekly, on Monday, dated 11/17/25;-2.0 Supplement (a high-calorie, high-protein liquid nutritional drink) once daily, 90 milliliters (mL) once a day in the A.M., dated 11/18/25.Review of the resident's monthly weights showed staff documented the resident weight as:-On 08/01/25 weighed 179.2 lbs:-On 01/12/26, weighed 151.6 lbs. a 15.4% loss in five month.Review of the resident's care plan, dated 12/15/25, showed staff did not document the resident's recent significant weight loss, use of nutritional supplements, or change in frequency of weights.During an interview on 01/14/26 at 3:02 P.M., CNA A said staff feed the resident because his/her hands do not work. The CNA said he/she did not know the resident had lost weight. The CNA said if he/she was aware the resident had weight loss, he/she would try to get him/her to eat more throughout the day.During an interview on 01/14/26 at 3:13 P.M., the MDS Coordinator said weight loss should be on the care plan, without interventions the resident could continue to lose weight, and the interventions are in place to prevent and help regain some loss, and it should show supplements, food preferences, and assistance level needed with eating.During an interview on 01/14/26 at 4:05 P.M., the Director of Nursing (DON) said he/she often sits with the resident to assist with breakfast and lunch, and the resident will say no, no, and he/she has to encourage the resident to get him/her to eat.4. Review of Resident #7's admission MDS, dated [DATE], showed staff assessed the resident as cognitively intact.Review of the resident's care plan, dated 10/03/25, showed the care plan did not contain direction for the use of bed rails.Observation on 01/11/26 at 12:45 P.M., showed the resident in bed with the right grab bar in the upright position on the bed.Observation on 01/12/26 at 9:56 A.M., showed the resident in bed with the right grab bar in the upright position on the bed.Observation on 01/14/26 at 8:10 A.M., showed the resident in bed with the right grab bar in the upright position on the bed.During an interview on 01/14/26 at 3:13 P.M., the MDS Coordinator said if a resident used bedrails, it should be listed on the care plan.6. Review of Resident #17's Significant Change in Status Assessment (SCSA), dated 12/31/25, showed staff assessed the resident as:-Severely cognitively impaired;-Had delusions and behavioral symptoms not directed towards others daily;-Had identified symptoms that put the resident at risk for physical illness or injury;-Had significant interferences with participation in activities or social interaction;-Weight of 118 lbs.;-Did not have weight loss;-Dependent on staff for eating-Diagnoses of dementia with agitation, anxiety, and depression.Review of the resident's POS, dated January 2026, showed the physician orders as followed:-House supplement, dated 12/28/25;-Diet:Regular, dated 12/28/25;-Weight: weekly times four weeks, on Monday, dated 12/28/25.Review of the resident's monthly weights showed staff documented:-On 08/01/25, weighed 129.8 lbs:-On 01/12/2026, weighed 103.6 lbs. a 20.18% loss in five month.Review of the resident's care plan, dated 12/22/25, showed staff did not document the resident's significant weight loss, use of nutritional supplements, and change in frequency of weights.During an interview on 01/14/26 at 3:02 P.M., CNA A said it depends on the day, if staff can get the resident out of the merry walker (a walker/chair combination decided to provide stability and promote independent mobility for people with walking difficulties), then he/she will sit there and eat, but if the resident is sat down too early, then staff will have to feed the resident. The CNA said he/she did not know the resident had weight loss. The CNA said if he/she was aware the resident had weight loss, he/she would try to get him/her to eat more throughout the day.During an interview on 01/14/26 at 3:13 P.M., the MDS Coordinator said weight loss should be on the care plan, without interventions the resident could continue to lose weight, and the interventions are in place to prevent and help regain some loss, and it should show supplements, food preferences, and assistance level needed with eating.During an interview on 01/14/26 at 4:05 P.M., the DON said that staff will get the resident into the dining room chair from his/her merry walker, and he/she can feed himself/herself, but when the resident is ready to get up, he/she is ready and will not stay.7. Review of Resident #22's admission MDS, dated [DATE], showed staff assessed the resident as severely cognitively impaired with a diagnosis of Alzheimer's disease.Review of the resident's care plan, dated 11/12/25, showed staff did not document the resident's Alzheimer's diagnosis or include any interventions related to cognitive impairment. During an interview on 01/14/26 at 3:13 P.M., the MDS Coordinator said the resident should have his/her diagnosis of Alzheimer's/dementia on the care plan so that staff know what to do for the resident.8. Review of Resident #27's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively impaired, required substantial/maximal assistance to roll left to right, sit to lying position, and lying to sitting on side of bed.Review of the resident's care plan, dated 10/23/25, showed staff did not document direction for use of an assist bar on the bed.Observation on 01/11/26 at 11:35 A.M., showed the resident in bed with a left assist bar in the upright position on the bed. Observation on 01/12/26 at 9:05 A.M., showed the resident's bed had an assist bar on the left side in the upright position.Observation on 01/14/26 at 8:51 A.M., showed the resident's bed had an assist bar on the left side in the upright position.9. During an interview on 01/14/26 at 3:02 P.M., CNA A said he/she can look at care plans in the point of care (POC) care plan tab, and the care plan will say if a resident needs nutritional supplements, but the nurses also tells him/her that, so he/she does not have to look. CNA A said bed rails should be listed on the care plans for residents who use them, and if a resident has a diagnosis of dementia or Alzheimer's that should be on the care plan, so staff know how to take care of them.During an interview on 01/14/2026 at 3:13 P.M., the MDS Coordinator said he/she has worked at the facility for a couple of months and has never done MDS or care plans before, and he/she is trying to learn. The MDS coordinator said care plans should be updated with every change of condition, quarterly and annually.During an interview on 01/14/26 at 3:40 P.M., the DON said the MDS nurse is responsible to update the care plans. The DON said he/she expects the care plan to be individualized to fit the resident's needs. The DON said the care plan directs the resident's care. The DON said he/she would expect the care plan to have bed rails, weight loss and weight loss interventions, and frequency of weight checks. During an interview on 01/14/26 at 4:00 P.M., Administrator A said the MDS Coordinator is responsible to update the care plans quarterly and as needed with changes. Administrator A said he/she would expect the care plan to be individualized and reflect the resident's needs to direct staff on their cares. Administrator A said he/she would expect the care plan to have if a resident has bed rails, and the amount of assistance a resident need from staff. Additionally, the care plan should include nutritional supplements, weight changes with interventions and cognitive status. Administrator A said the facility has a morning meeting to discuss incidents or changes at that time. Administrator A said he/she expects the care plan to be updated if needed for those incidents or changes discussed.

Number of residents sampled:Number of residents cited:71.Review of the facility policy titled Event Investigation, undated, showed complete a Report of Event form as soon as possible whenever there is an unusual, unexpected and/or unintended event that is not consistent with the routine operation of the facility, the routine care of the resident and/or adversely effects or has the potential to adversely affect a resident. Examples of when a form should be completed include fall or person found on the floor. The charge nurse is responsible for completing the Report of Event form and forwarding to the Director of Nursing (DON) as soon as possible. When completing the form be certain to complete the form in full, leaving no blanks. Review of the facility policy titled Charting and Documentation, dated March 2015, showed for accidents/incidents the narrative documentation does not take the place of the Event Report form. Documentation pertaining to accidents or incidents involving residents should include: circumstances surrounding the accident or incident, where the accident or incident took place, date and time the accident or incident occurred, time the physician was notified as well as the time the physician responded, the date and time family was notified and by whom, the condition of the resident to include vital signs, disposition of the resident (i.e., transferred to hospital, put to bed, etc.), and all pertinent observations. Review of the facility policy titled Fall Event Instructional Flowsheet, undated, showed when a fall occurs, the charge nurse opens Fall Event and completes the short description, the charge nurse completes the event form details and the charge nurse enters initial vitals, progress note, and any orders and completes neuro-checks on paper form then scan and upload into resident documents. Review of the facility's Neurological Checks flowsheet, undated, showed neurological checks required for 72 hours post unwitnessed fall or head injury, to be completed every 15 minutes times four for the first hour, every 30 minutes times two for the second hour, every one-hour times two for the next two hours, and every shift for the next 72 hours. Review of the facility policy titled Wound Care and Treatment, undated, showed it is the purpose of this facility to prevent and treat all wounds. Prevention strategies include on-going skin assessment with weekly documentation of status. Review of the facility policy titled Weight and Height Measurement, undated, showed residents are weighed on admission and monthly unless otherwise ordered by the attending physician to monitor the resident's condition. 1. Review of Resident #2's Quarterly Minimum Data Set Assessment (MDS), a federally mandated assessment tool, dated 10/22/25, showed staff assessed the resident as:-Severely cognitively impaired; -Weight of 158 pounds (lbs.), -Did not have weight loss;-Diagnoses of stroke, dementia with agitation, anxiety, depression, and stage three chronic kidney disease (kidneys have moderate damage and are not filtering waste as effectively). Review of the resident's Physician Order Sheet (POS), dated January 2026, showed the physician directed staff on 12/01/25 to weigh the resident weekly until stable, on Monday.Review of the resident's weight documentation showed staff did not document the resident's weights for 12/01/25, 12/15/25, 12/22/25, and 01/05/26. During an interview on 01/14/2026 at 4:05 P.M., the Director of Nursing (DON) said he/she has started checking to make sure weights are being done for the resident. The DON did know why staff had obtained the weights. He/She had just started in mid-December as the DON. 2. Review of Resident #5's Quarterly MDS, dated [DATE], showed staff assessed the resident as:-Severely cognitively impaired;-Did not have behaviors or resist care,-At risk for skin breakdown;-Diagnoses of Schizophrenia, bipolar (mental health condition that causes extreme mood swings), malnutrition, venous insufficiency (occurs when veins don't allow the blood to flow back to the heart normally), and diabetes.Review of the resident's care plan, dated 05/21/25, showed staff documented the resident at risk for skin complications related to diabetes, and monitor skin per orders. Review of the resident's POS, dated 01/11/26, showed the physician directed staff to obtain weekly skin assessments on Friday during the day shift.Review of the resident's weekly skin assessments, dated 11/24/25 through 01/13/26, showed staff did not document a skin assessment on 11/24/25, 11/28/25, 12/5/25, 12/12/25, and 01/09/26. 3. Review of Resident #6's Quarterly MDS assessment, dated 12/16/25, showed staff assessed the resident as:-Rarely/never understood;-Weight of 154 lbs.;-Did not have weight loss-Received a mechanically altered diet (a diet that provides moist, soft-textured foods that are chopped, ground, or mashed for easier chewing and swallowing);-Diagnoses of anoxic brain damage (occurs when the brain receives no oxygen at all), diabetes, stroke, dementia, schizophrenia, gastroparesis (a chronic stomach condition in which the muscles in the stomach do not move food as they should for it to be digested), depression, and anxiety. Review of the resident's POS, dated January 2026, showed the physician directed staff to weigh the resident weekly, on Monday.Review of the resident's weight documentation showed staff failed to document weights for 11/17/25, 11/24/25, 12/1/25, 12/15/25, 12/22/25, 12/29/25, and 01/05/26. During an interview on 01/14/2026 at 4:05 P.M., the DON said he/she did not know the resident's weights were not being done weekly as ordered. 4. Review of Resident #15's Quarterly MDS, dated [DATE], showed staff assessed the resident as severely cognitively impaired, did not have behaviors or resist care, and had two or more falls since prior assessment.Review of the resident's progress note, dated 12/31/25, showed staff documented the resident had an unwitnessed fall without injury. The record did not contain a completed Event Report. Review of the resident's progress note, dated 01/08/26, showed staff documented the resident had an unwitnessed fall without injury. The medical record did not contain a completed event report or 11 of the 14 required neurological checks. 5. Review of Resident #16's admission MDS, dated [DATE], showed staff assessed the resident as:-Severely cognitively impaired;-Did not have behaviors or resist care;-Required assistance with Activities of Daily Living (ADLs);-At risk for falls. Review of the resident's care plan, dated 11/07/25, showed staff documented the resident at risk for falls and fell on [DATE]. Review of the resident's neurological checks showed staff did not document neurological checks after the resident had an unwitnessed fall on 11/19/26.During an interview on 01/13/26 at 1:00 P.M., the Assistant Director of Nursing (ADON) said he/she was the nurse on duty when the resident fell on [DATE]. The ADON said it was an unwitnessed fall, and he/she should have completed neurological checks on the resident. The ADON said he/she does not remember why he/she did not complete the neurological checks. The ADON said he/she should have completed the neurological checks per the facility policy. 6. Review of Resident #17's Significant Change in Status Assessment (SCSA), dated 12/31/25, showed staff assessed the resident as:-Severely cognitively impaired;-Weight of 118 lbs., -Did not have weight loss; -Had a fall since prior assessment, had two or more falls with no injury, had one fall with major injury;-Diagnoses of dementia with agitation, anxiety, and depression.Review of the resident's POS, dated January 2026, showed the physician directed staff to obtain weekly weight for four weeks, on Monday. Review of the resident's weight documentation showed staff did not document the resident's weights for 12/29/25 and 01/05/26. Review of the resident's progress notes showed staff documented the resident had an unwitnessed fall with minor injury on 10/26/25. The medical record did not contain an event report or 13 of the 14 required neurological checks. Review of the resident's progress notes showed staff documented the resident had an unwitnessed fall without injury on 10/28/25, 10/29/25, 11/19/25, and 11/29/25. The medical record did not contain a completed Event Report for the falls. During an interview on 01/14/2026 at 4:05 P.M., the DON said he/she did not know that the resident's weights were not being done and just found out. 7. Review of Resident #22's admission MDS, dated [DATE], showed staff assessed the resident as severely cognitively impaired and had two or more falls since admission/entry or prior assessment.Review of the resident's progress notes showed staff documented the resident had a witnessed fall with minor injury on 11/05/25. The record did not contain a completed Event Report. Review of the resident's progress notes showed staff documented the resident had an unwitnessed fall without injury on 11/09/25. The record did not contain a completed Event Report. 8. Review of Resident #29's Quarterly MDS, dated [DATE], showed staff assessed the resident as:-Cognitively intact;-Did not have behaviors or resist cares; -At risk for skin breakdown and has wounds;-Diagnoses of heart failure, cellulitis of lower limbs (bacterial infection of the skin), disorder of the subcutaneous tissue of the skin (disorder of the connective tissue and fat that connects the skin to muscle), lymphedema (localized swelling of a body part), chronic kidney disease and venous insufficiency. Review of the resident's POS, dated 01/11/26, showed an order to complete weekly skin assessments on Mondays.Review of the resident's weekly skin assessments, dated 11/24/25 through 01/13/26, showed staff did not document skin assessment on 11/24/25, 12/01/25, 12/08/25, 12/15/25, 12/29/25, and 01/05/26. 9. Review of Resident #31's Quarterly MDS, dated [DATE], showed staff assessed the resident as:-Severely cognitively impaired;-Weight of 113 lbs.;-Diagnosis of malnutrition or at risk for malnutrition, Review of the resident's POS, dated January 2026, showed an order for weekly weight, on Tuesdays.Review of the resident's weight documentation showed staff did not document weights for 10/28/25, 12/30/25, and 01/06/26. 10. Review of Resident #38's Quarterly MDS, dated [DATE], showed staff assessed the resident as:-Severely cognitively impaired;-Weight of 217 lbs.;-Did not have weight loss; -Diagnosis of malnutrition or at risk for malnutrition.Review of the resident's POS, dated January 2026, showed an order for monthly weights on the first of the month.Review of the resident's weight documentation showed staff did not document the resident weight for 10/01/25 and 01/01/26. 11. Review of Resident #51's Quarterly MDS, dated [DATE], showed staff assessed the resident as:-Cognitively intact;-Did not have behaviors or resist cares; -At risk for skin breakdown;-Diagnoses of spina bifida (a congenital condition in which part of the spinal cord and are exposed through a gap in the backbone, often causing paralysis of the lower limbs), incomplete paraplegia (inability to move the lower body parts), and end stage renal disease.Review of the resident's POS, dated 01/11/26, showed an order for weekly skin assessments every Thursday.Review of the resident's weekly skin assessments, dated 11/24/25 through 01/13/26, showed staff did not document a skin assessment on 11/27/25, 12/11/25, 12/25/25, and 01/01/26. 12. During an interview on 01/13/25 at 11:20 A.M., the DON said the facility fall policy is to be followed for all residents. The DON said the policy states if a resident has an unwitnessed fall or a fall with a head injury, neurological checks are to be completed every 15 minutes times four, every 30 minutes times two, every hour times two, and every shift for 72 hours. The DON said if a resident refuses to have the neurological checks completed, he/she expects the staff to document the refusal. The DON said an event report is to be completed by the charge nurse with each resident fall. The DON said he/she expects the event report and neurological checks to be filled out completely per facility policy. During an interview on 01/14/26 at 2:13 P.M., LPN C said the purpose of a physician's order is to direct staff how to care for a resident. LPN C said the charge nurse is responsible to enter and follow all physician's orders and the DON is responsible to oversee the charge nurse and ensure staff follow the orders. LPN C said if staff do not follow physician's orders it could be a detriment to the resident's wellbeing. LPN C said it is the charge nurse's responsibility to give the aides a list of weights needed to be completed each day. LPN C said the aides are responsible to obtain the weights and report those to the charge nurse. LPN C said it is the charge nurse's responsibility to enter the weights into the resident's chart. LPN C said if a resident refuses the charge nurse is expected to document the refusal. LPN C said the charge nurse is responsible to complete weekly skin assessments when they are due. LPN C said the skin assessment triggers on the treatment record and should be documented on a weekly skin assessment form. LPN C said he/she does not know why the skin assessments are not being completed weekly but said they should be. LPN C said if a resident has an unwitnessed fall or a fall with a head injury the charge nurse is responsible to document the fall correctly in the resident's medical record then complete neurological checks per the facility policy. LPN C said he/she does not know why the falls or neurological checks aren't documented correctly. LPN C said if something is not documented then it was not done.During an interview on 01/14/26 at 3:02 P.M., Certified Nurse Aide (CNA) A said CNA's or therapy staff obtain the weights for residents as directed by the nurses. The CNA said when he/she gets the resident's weights, he/she writes it on a form and then the nurse puts the weight in the computer. During an interview on 01/14/26 at 3:40 P.M., the DON said the purpose of a physician's order is to ensure staff provide appropriate care. The DON said he/she expects all staff to follow physician's orders. The DON said he/she expects staff to complete weekly skin assessments that are triggered in the system when due and the charge nurse is responsible to complete the assessment and document it in the resident's chart. The DON said weekly or daily weights should be completed per orders. The DON said the treatment record triggers the charge nurse to complete the weights as ordered. The DON said the charge nurse or aides are responsible to obtain the weights, and the charge nurse is responsible to document the weights in the resident chart. The DON said he/she is responsible to ensure the charge nurses and aides complete the weights per the orders. The DON said if something does not get documented there is not a way to know if it was completed. During an interview on 01/14/26 at 4:00 P.M., administrator A said the purpose of a physician's order is to direct resident care. Administrator A said the charge nurse is responsible to enter and to follow all physician's orders. Administrator A said the DON or ADON are responsible to ensure the charge nurses follow the physician's orders. Administrator A said weekly and daily weights should be completed per the orders. Administrator A said he/she expects staff to complete any weekly skin assessments as ordered by the physician. Administrator A said if something isn't documented it is not done.

Based on observation, interview, and record reviews, facility staff failed to ensure the residents' environment remained safe from hazards when staff failed to safely propel four residents (Resident #2, #15, #37, and #52) out of 21 sampled residents while in wheelchairs. Facility staff failed to store medication in a safe and effective manner when medication carts were left unlocked and unattended, and medication was left on top of the cart with residents close by. The facility census was 52. 1.Review of the facility's policy titled Wheelchair, Use of, undated, showed the policy did not address the use of foot pedals while propelling residents. 2. Review of Resident #2's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 10/22/25, showed staff assessed the resident with severe cognitive impairment, and required supervision or touch assist for wheelchair locomotion of 50 feet with two turns and wheeling 150 feet in wheelchair.Observation on 01/13/26 at 8:38 A.M., showed the Activity Director (AD) propelled the resident in his/her wheelchair without foot pedals. Observation showed the resident's feet drug the ground. Observation on 01/13/26 at 2:07 P.M., showed the Social Service Designee (SSD) propelled the resident in his/her wheelchair without foot pedals. Observation showed the resident's feet drug the ground. Observation on 01/14/26 at 7:28 A.M., showed Licensed Practical Nurse (LPN) C propelled the resident in his/her wheelchair without foot pedals. Observation showed the resident's feet drug the ground. Observation on 01/14/26 at 8:56 A.M., showed Certified Nurse Aide (CNA) K propelled the resident in his/her wheelchair without foot pedals. Observation showed the resident's feet drug the ground. During an interview on 01/14/26 at 1:37 P.M., CNA K said staff should not propel residents in their wheelchairs without foot pedals. He/She said residents could drag their feet, which could cause sores or for the resident to fall forward out of the chair. He/She said he/she is unsure why he/she did not check to make sure the resident's feet were on the pedals. Observation on 01/14/26 at 1:45 P.M., showed Licensed Practical Nurse (LPN) C propelled the resident around the nurse's station in his/her wheelchair. The wheelchair had foot pedals, but the resident's feet drug the floor. 2. Review of Resident #15's Quarterly MDS, dated [DATE], showed staff assessed the resident with severe cognitive impairment, and dependent on staff for wheelchair locomotion of 50 feet with two turns and wheeling 150 feet in wheelchair.Observation on 01/11/26 at 12:14 P.M., showed CNA A propelled the resident from the nurses' station to the dining room in his/her wheelchair. The wheelchair did not have foot pedals and the resident's feet drug the floor. 3. Review of Resident #37's admission MDS, dated [DATE], showed staff assessed the resident as cognitively intact, required substantial/maximal assistance for wheelchair locomotion of 50 feet with two turns, and dependent on staff for wheeling 150 feet in wheelchair.Observation on 01/11/26 at 11:50 A.M., showed Nurse Aide (NA) J propelled the resident from the hallway to the dining room in his/her wheelchair. The wheelchair did not have foot pedals and the residents right heel drug the floor. 4. Review of Resident #52's admission MDS, dated [DATE], showed staff assessed the resident as cognitively impaired, required partial/moderate assistance for wheelchair locomotion of 50 feet with two turns, and substantial/maximal assistance for wheeling 150 feet in wheelchair.Observation on 01/12/26 at 11:51 A.M., showed LPN C propelled the resident in his/her wheelchair with his/her feet in the foot pedals. Observation showed the resident foot would drop to the floor and stop the wheelchair. During an interview on 01/14/26 at 2:13 P.M., LPN C said he/she propelled the resident without foot pedals, but he/she thought it would be fine as he/she propelled the resident slowly. LPN C said he/she should have gotten the resident's foot pedals and put them on the wheelchair first. 5. During an interview on 01/14/26 at 1:34 P.M., NA J said residents should not be propelled in their wheelchairs without foot pedals. He/She said the resident could put their feet down and could fall forward out of the wheelchair. During an interview on 01/14/26 at 1:40 P.M., CNA A said staff should not propel residents in their wheelchairs without foot pedals. He/She said the resident could put their feet down which could cause them to flip out of wheelchair. During an interview on 01/14/26 at 1:43 P.M., the AD said if staff are propelling residents in their wheelchairs they should be using foot pedals. He/She said the resident could fall forward from the chair if foot pedals are not used. During an interview on 01/14/26 at 2:48 P.M., the MDS coordinator said staff are not supposed to propel residents in wheelchairs without foot pedals, because they could be injured. He/She said he/she does not remember pushing a resident without foot pedals, but if he/she did it may have been a short distance. During an interview on 01/14/26 at 3:10 P.M., CNA I said residents must have foot pedals on their wheelchairs when staff propel them. He/She said it's an accident risk and the resident could fall out of their wheelchair. During an interview on 01/14/26 at 2:13 P.M., LPN C said he/she has worked for the facility about two months, and he/she is not sure what the foot pedal policy is, but he/she said staff should ensure residents have foot pedals on their wheelchairs when propelling them. LPN C said if a resident doesn't have foot pedals it could lead to the resident getting an injury by rolling over their foot, or their foot getting trapped and falling out of his/her wheelchair. During an interview on 01/14/26 at 3:40 P.M., the Director of Nursing (DON) said he/she expects staff to ensure a resident has foot pedals on his/her wheelchair before propelling them. The DON said he/she educated staff on this recently. The DON said it is important to have the foot pedals on the resident's wheelchair to prevent injury. During an interview on 01/14/26 at 4:00 P.M., administrator A said he/she expects staff to ensure a resident has foot pedals on his/her wheelchair before propelling them. Administrator A said if a resident does not have foot pedals on his/her wheelchair they could drag feet and risk flipping forward out of their wheelchair and being injured. 6. Review of the facility's Medication Storage policy, undated, showed all medications for residents must be stored at or near the nurses' station in a locked cabinet, a locked medicine room, or one or more locked mobile medication carts. All mobile medication carts must be under visual control of the staff at all times when not stored safely and securely. An unattended medication cart must remain locked at all times, in the event the nurse is distracted from the task of passing medications by some unforeseen occurrence, the cart must be locked before leaving it or secured in a locked medication room. 7. Review of Resident #2's Quarterly MDS, dated [DATE], showed staff assessed the resident as severe cognitive impairment, required supervision or touch assist for wheelchair locomotion.Observation on 01/13/26 at 1:50 P.M., showed the 100/200/300 hallway medication cart sat unlocked and unattended at the nurses' station with residents nearby. Observation showed the resident pulled on the medication cart drawer handle to move his/her wheelchair around it. 8. Review of Resident #17's Significant Change in Status Assessment (SCSA), dated 12/31/25, showed staff assessed the resident as:-Severely cognitively impaired;-Had delusions and behavioral symptoms not directed towards others daily;-Had identified symptoms that put the resident at risk for physical illness or injury, and had significant interferences with participation in activities or social interactions;-Used a wheelchair for mobility;-Diagnoses of dementia with agitation, anxiety, and depression. Observation on 01/11/26 at 11:34 A.M., showed the resident wandered in his/her merry walker (a wheeled walker with a seat) through the hallways and around the nurses' station. Observation on 01/11/26 at 12:00 P.M., showed the resident wandered in his/her merry walker around the assisted dining room and into the lobby. Observation on 01/11/26 at 1:24 P.M., showed the 100/200/300 hall treatment cart sat unlocked and unattended by the nurses' station. Observation showed the resident by the cart. Observation on 01/11/26 at 3:17 P.M., showed the resident wandered throughout the 100/200/300 hallways and around the nurses' station. Observation at 01/12/26 at 8:27 A.M., showed the 100/200/300 treatment cart sat unattended and a cup of pink ointment sat on top of the cart. Observation showed the resident wandered nearby in his/her merry walker. Observation at 01/12/26 at 9:32 A.M., showed the 100/200/300 treatment cart sat unlocked and unattended with the resident nearby. Observation on 01/13/26 at 1:50 P.M., showed the 100/200/300 hall medication cart sat unlocked and unattended at the nurses' station with residents nearby. Observation showed the resident wandered nearby in his/her merry walker. Observation on 01/14/26 at 8:15 A.M., showed the 100/200/300 hall medication cart sat unlocked and unattended at the nurse's station. Observation showed the resident wandered nearby in his/her merry walker. During an interview on 01/11/26 at 11:34 A.M., Certified Medication Technician (CMT) D said the resident wanders frequently throughout the facility in his/her merry walker. 9. Observation on 01/12/26 at 8:05 A.M., showed the 100/200/300 hall medication cart and the 100/200/300 hall treatment cart sat unlocked and unattended at the nurses' station.Observation at 01/12/26 at 2:10 P.M., showed the 100/200/300 treatment cart sat unattended with a tube of Triamcinolone acetonide cream 0.5% (medication used to reduce inflammation, redness, itching, and swelling from skin) on top of the cart. Observation showed multiple residents nearby. 10. During an interview on 01/14/26 at 2:13 P.M., LPN C said medication carts and treatment carts should never be left unlocked and unattended. LPN C said medications and/or treatments should never be left on top of the cart unattended. LPN C said if a cart is left unlocked and unattended, or a medication and/or treatment is left on top of the cart unattended anyone could get into it, and it could potentially cause resident harm. LPN C said the nurse with the keys to the cart is responsible to keep it locked. LPN C said he/she did not realize he/she left the cart unlocked. LPN C said he/she should have ensured the carts were locked when unattended for resident safety. During an interview on 01/14/26 at 3:40 P.M., the DON said medication carts and treatment carts should never be left unlocked and unattended. The DON said the staff member who has the keys to the cart is responsible to ensure the cart is locked. The DON said this is to ensure resident safety and to prevent anyone from getting into it. The DON said medications and/or treatments should not be left on top of the cart unattended for resident safety. During an interview on 01/14/26 at 4:00 P.M., administrator A said the staff member with the keys to the cart is responsible to ensure it is always locked. Administrator A said staff should never leave a medication cart or treatment cart unlocked and unattended for resident safety. Administrator A said a medication and/or treatment should never be left on top of a cart unattended for resident safety and to prevent potential resident harm.

Based on observation, interview, and record review, facility staff failed to obtain consent for the use of bed rails and complete bed rails assessments for six residents (Resident #3, #7, #8, #27, #38, and #50) out of 21 sampled residents. The facility census was 52. 1. Review of the facility's policy titled Bed Rails, undated, showed:-Educate the resident/legal representative on the benefits and risks of bed rail use;-Once the bed rail observation is completed, the facility will print the observation and review associated risks and benefits with the resident and/or resident representative;-After the review is completed the resident and/or resident representative will sign the consent ling and the nurse will sign as well, once it is signed it will be uploaded into the resident's medical record.2. Review of Resident #3's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 10/30/25, showed staff assessed the resident as Cognitively intact and restraints not used.Review of the resident's care plan, revised 10/20/25, showed bilateral grab bars on the bed to assist with repositioning and transfers. Review of the resident's medical record showed staff documented a bed rail assessment on 05/05/25 but it did not contain a signed consent. Review showed the record did not contain a bed rail assessment or signed consent after 05/05/25. Observation on 01/11/26 at 1:30 P.M., showed the resident's bed with bilateral grab bars.Observation on 01/11/26 at 3:14 P.M., showed the resident in bed with both grab bars in the upright position on the bed.Observation on 01/12/26 at 2:22 P.M., showed the resident in bed with both grab bars in the upright position on the bed.Observation on 01/13/26 at 2:05 P.M., showed the resident in bed with both grab bars in the upright position on the bed. 3. Review of Resident #7's admission MDS, dated [DATE], showed staff assessed the resident as cognitively intact and restraints not used.Review of the resident's care plan, dated 10/03/25, showed the care plan did not contain direction for the use of grab bars. Review of the resident's medical record showed the medical record did not contain an informed consent for bed rail use, or a bed rail assessment. Observation on 01/11/26 at 12; 45 P.M., showed the resident in bed with the right grab bar in the upright position on the bed.Observation on 01/12/26 at 9:56 A.M., showed the resident in bed with the right grab bar in the upright position on the bed.Observation on 01/14/26 at 8:11 A.M., showed the resident in bed with the right grab bar in the upright position on the bed. 4. Review of Resident #8's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact and restraints not used.Review of the resident's care plan, revised 10/28/25, showed bilateral grab bars on the bed to assist with mobility.Review of the resident's medical record did not contain an informed consent for bed rail use, or a bed rail assessment. Observation on 01/11/26 at 11:26 A.M., showed the resident in bed with bilateral grab bars in the upright position on the bed.Observation on 01/12/26 at 8:09 A.M., showed the resident in bed with bilateral grab bars in the upright position on the bed.Observation on 01/13/26 at 2:00 P.M., showed the resident in bed with bilateral grab bars in the upright position on the bed.Observation on 01/14/26 at 8:05 A.M., and 11:12 A.M., showed the resident in bed with bilateral grab bars in the upright position on the bed. 5. Review of Resident #27's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively impaired, required substantial/maximal assistance to roll left to right, sit to lying position, and lying to sitting on side of bed.Review of the resident's care plan, revised 10/23/25, showed staff did not document direction for use of U-Bar on bed.Review of the resident's medical record showed the record did not contain an informed consent for bed rail use, or a bed rail assessment.Observation on 01/11/26 at 11:35 A.M., showed the resident in bed with a left assist bar in the upright position on the bed. Observation on 01/12/26 at 9:05 A.M., showed the resident's bed had an assist bar on the left side in the upright position. Observation on 01/14/26 at 8:51 A.M., showed the resident's bed had an assist bar on the left side in the upright position. 6. Review of Resident #38's Quarterly MDS, dated [DATE], showed staff assessed the resident as severely cognitively impaired, dependent on staff for rolling left to right, sit to lying position, and lying to sitting on side of bed.Review of the resident's care plan, revised 12/25/25, showed bilateral grab bars to assist staff with turning from side to side and repositions in bed.Review of resident's medical record showed staff documented a bed rail assessment on 06/30/25, the assessment did not contain a signed consent. Review showed staff did not document a further bed rail assessment or signed consent after 06/30/25.Observation on 1/11/26 at 2:40 P.M., showed the resident in bed with a grab bar in the upright position on the right side of the bed. Observation on 1/13/26 at 2:23 P.M., showed the resident in bed with a grab bar in the upright position on the right side of the bed.Observation on 1/14/26 at 2:53 P.M., showed the resident in bed with a grab bar in the upright position on the right side of the bed. 7. Review of Resident #50's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact, required supervision or touch assistance for rolling left to right, sitting to lying position, and lying to sitting on side of bed.Review of the resident's care plan, revised 12/25/25, showed bilateral grab bars to assist with self-repositioning and transfers in/out of bed.Review of resident's medical record showed staff documented a bed rail assessment on 05/13/25 but it did not contain a signed consent. Review showed no further bed rail assessment or signed consent after 05/13/25.Observation on 01/11/26 at 12:57 P.M., showed the resident in bed with assist bars in the upright position on both side of the bed.Observation on 01/12/26 at 8:25 A.M., showed the resident in bed with assist bars in the upright position on both side of the bed.Observation on 01/14/26 at 8:58 A.M., showed the resident in bed with assist bars in the upright position on both side of the bed. 8. During an interview on 01/14/26 at 2:13 P.M., Licensed Practical Nurse (LPN) C said he/she does not know who is responsible to obtain bed rail assessments consents for use. LPN C said he/she knows they should be completed prior to putting any assist bars on the residents' bed, but he/she does not know how often they should be updated after that. During an interview on 01/14/26 at 3:00 P.M., the maintenance staff said he/she is new, this is his/her first long-term care maintenance job, and he/she has only been at the facility for three weeks. The maintenance staff said he/she does not know who is responsible to obtain the bed rail consents. During an interview on 01/14/26 at 3:40 P.M., the Director of Nursing (DON) said he/she does not know who is responsible to obtain bed rail consents. The DON said the consent should be updated quarterly with the care plan review. The DON said the bed rail consent should be completed to ensure the resident and/or their responsible party are aware of the risks of using the bed rails, such as a resident getting stuck in one and possibly injured.During an interview on 01/14/26 at 4:00 P.M., the administrator said the charge nurse is responsible to obtain bed rail consents. The administrator said the bed rail consent should be completed quarterly. The administrator said if a consent has not been completed since October 2025, then the facility would be out of compliance.

Based on observation, interview, and record review, facility staff failed to remove and discard discontinued medication and improperly labeled medication from one of three medication carts and two of two medication rooms. The facility census was 52.1. Review of the facility's policy titled Injectables and Irrigating Solutions, undated, showed all multiple dose vials shall be dated and initialed upon opening. Once the seal is broken and punctured on Insulin, it shall be discarded after 28 days.Review of the facility's policy titled Medications, Storage of, undated showed all medications must be stored at or near the nurse's station in a locked cabinet, a locked medication room, or a locked mobile medication cart. No discontinued or outdated biologicals may be retained for use.2. Observation on 01/12/26 at 1:30 P.M., showed the supply room contained one bottle of Vitamin E 180 milligrams (mg) with an expiration date of 09/25.3. Observation on 01/12/26 at 1:30 P.M., showed the 100/200/300 medication room contained:-One opened vial of Tuberculosis (TB) solution open and undated; -One opened bottle of Lorazepam 2 mg/milliliter (ml) for Resident #59 in a cup not labeled by the pharmacy;-One opened bottle of Lorazepam 2 mg/milliliter (ml) for Resident #63 in a cup not labeled by the pharmacy.4. Observation on 01/12/26 at 1:30 P.M., showed the 100/300 hall medication cart contained:-One bottle of Mylanta with an expiration date of 07/25;-One bottle of Aspirin 325 mg with an expiration date of 10/25;-One Lispro Insulin pen open and undated;-One Lantus Insulin pen open and undated;-Two Lispro Insulin pens open and undated;-One Tresiba Insulin pen open and undated;-One Lantus Insulin pen open and undated;-One Aspart Insulin pen open and undated.5. During an interview on 01/12/26 at 2:10 P.M., Registered Nurse (RN) F said staff are expected to date medications when opened. RN F said all Insulin pens and TB solution should be dated when opened. RN F said the staff member who opens the medications is responsible to date the medication. RN F said he/she does not know why the medications were not dated when opened but should have been. RN F said all staff are expected to check expiration dates prior to administering medications to a resident. RN F said staff should never give a resident an expired medication. RN F said expired medications should be removed and destroyed when found. During an interview on 01/14/26 at 2:13 P.M., Licensed Practical Nurse (LPN) C said whoever opens a medication should date the medication. LPN C said all insulins and TB solutions should be dated when opened. LPN C said it is the responsibility of the staff member administering medications to check for the expiration date prior to administering the medication. LPN C said staff should never give a resident an expired medication. During an interview on 01/14/26 at 3:40 P.M., the Director of Nursing (DON) said he/she expects all insulins and TB solutions to be dated when opened. The DON said whoever opens the medication should date the medication. The DON said all staff administering medication should check the expiration dates prior to administration and should never administer expired medications. The DON said if a medication is expired staff are expected to remove it and properly destroy it. The DON said he/she was new to the position. During an interview on 01/14/26 at 4:00 P.M., Administrator A said whoever opens a medication should date the medication. Administrator A said he/she expects all insulins and TB solutions to be dated when opened. Administrator A said all staff administering medication should check the expiration date prior to administering a medication and should never give a resident an expired medication. Administrator A said if a medication is expired staff are expected to remove it and properly destroy it. Administrator A said he/she was new to the position.

Based on observation, interview, and record review, facility staff failed to use appropriate hand hygiene to prevent the spread of bacteria for two residents (Resident #14 and #13) out of two sampled residents. 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/or failed to have EBP signs posted for two residents (Resident #13 and #51) out of five sampled residents. Facility staff failed to ensure sanitary conditions for a urinary drainage bag (a container to hold urine) when staff failed to keep the container off the floor for one resident (Resident #16) out of two sampled residents. The Facility census was 52. 1. Review of the facility policy titled, Handwashing, undated, showed the policy did not contain direction for staff on when to wash hands while performing resident care.Review of the facility policy titled, Enhanced Barrier Precautions to Infection Control Guidance, dated March 2024, showed the purpose is to prevent broader transmission of Multidrug-resistant organisms (MDRO), a germ that is resistant to many antibiotics) and to help protect patients with chronic wounds and indwelling devices. EBP should be implemented for the period of their stay or until wounds have resolved or indwelling medical devices have been removed. Residents who require EBP are residents with an indwelling medical device including the following: central venous catheter, urinary catheter, feeding tube, tracheostomy, and residents with a wound, regardless of their MDRO status. Use EBP when providing high-contact resident care activities such as bathing/showering, transferring residents from one position to another, providing hygiene, changing bed linens, changing briefs or assisting with toileting, caring for or using an indwelling medical device, and performing wound care. Gloves and applying and removing of gown are required when conducting high-contact resident care activities that are listed above. The policy did not contain direction for EBP signage. 2. Observation on 01/12/26 at 8:31 A.M., showed Nurse Assistant (NA) J entered resident #14's room, did not wash his/her hands and applied gloves. The NA assisted the resident to bed, wiped the resident's face, removed his/her gloves, gave the resident a drink, and left the resident's room without washing his/her hands. During an interview on 01/13/26 at 9:27 A.M., NA J said he/she usually uses hand sanitizer before going in a resident room when exiting the room. He/She said he/she forgot to sanitize his/her hands before he/she left the room. He/She said not performing hand hygiene is an infection control issue. 3. Review of Resident #13's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool dated 10/31/25, showed staff assessed the resident with severe cognitive impairment and did not have an indwelling urinary catheter.Review of resident's medical record showed staff documented the resident returned from the hospital on [DATE] with a urinary catheter in place.Observation on 01/11/26 at 11:17 A.M., showed the resident in bed. A catheter bag hung on the side of the bed. The room did not have an EBP sign to alert staff of needed PPE.Observation on 01/12/26 at 8:26 A.M., showed the resident in bed. A catheter bag hung on the side of the bed. The room did not have an EBP sign to alert staff of needed PPE.Observation on 01/13/26 at 8:43 A.M., showed Certified Nurse Assistant (CNA) L and CNA A entered Resident #13's room to perform catheter care. CNA A did not wash hands before he/she applied gloves. Staff assisted the resident to bed. CNA L removed his/her gloves, did not wash hands, and put on a clean pair of gloves. CNA L performed frontal perineal care and catheter care, removed gloves, did not wash hands, reapplied a clean pair of gloves and performed posterior perineal care. CNA L and CAN A did not wear gowns during resident care. During an interview on 01/13/26 at 8:55 A.M., CNA L said he/she should have performed hand hygiene between gloves changes. He/She said he/she didn't think about it and didn't have any hand sanitizer handy at the time. The CNA said he/she should have followed EBP and worn a gown during the resident's care, but he/she did not. He/She said there is usually a sign on the door that alerts staff that a resident requires EBP. He/She said it's infection control concern not to use the appropriate PPE and not perform adequate hand hygiene. During an interview on 01/13/26 at 9:21 A.M., CNA A said he/she should have performed hand hygiene before he/she put gloves on. He/She said he/she realizes he/she should have worn a gown during care, but he/she did not think about it. He/She said there is usually an EBP sign on the door to alert staff. He/She said residents with wounds and catheters require EBP during cares. 4. Review of Resident #51's Annual MDS, dated [DATE], showed staff assessed the resident as cognitively intact, and does not receive dialysis (life-sustaining treatment for kidney failure that filters waste). Review of the resident's care plan, revised 10/29/25, showed staff documented the resident required dialysis three times a week, was at risk for infection due to a dialysis shunt (a surgically created connection between an artery and a vein, typically in the arm, designed to provide high-volume blood flow for effective dialysis), and did not contain direction for EBP.Review of the resident's POS, dated 01/11/26, showed and order dated 07/12/24 for dialysis on Monday, Wednesday and Friday. Observation on 01/11/26 at 11:30 A.M., showed the resident's room did not have EBP signage. Observation on 01/12/26 at 08:15 A.M., showed the resident's room did not have EBP signage. Observation on 01/13/26 at 8:13 A.M., showed the resident's room did not have EBP signage. Observation on 01/14/26 at 11:10 A.M., showed the resident's room did not have EBP signage. During an interview on 01/12/26 at 8:15 A.M., NA H said the resident was at dialysis. During an interview on 01/12/26 at 12:15 P.M., Licensed Practical Nurse (LPN) C said the resident goes to dialysis three times a week. During an interview on 01/14/26 at 2:13 P.M., LPN C said he/she has been at the facility a couple of months and has not had EBP training. LPN C said he/she does not know what EBP is used for. LPN C said he/she does not know who is responsible to place the EBP signs on resident doors. During an interview on 01/14/26 at 3:40 P.M., the Director of Nurse (DON) said it is the responsibility of the charge nurse, the Assistant Director of Nursing (ADON) and himself/herself to ensure EBP signs are placed on the doors of the residents who require EBP. The DON said EBP are for residents who have wounds, catheters, receive tube feeding, have a colostomy, and receive dialysis. The DON said the EBP signs should be used to direct staff when they need to use the precautions. The DON said if there is not a sign on the door the staff may not know what Personal Protective Equipment (PPE) is required. During an interview on 01/14/26 at 4:00 P.M., administrator A said the ADON is responsible to ensure the EBP signs are placed on the doors of the residents who require EBP. Administrator A said he/she was aware some of the residents who required EBP did not have signs on their doors. Administrator A said the ADON has been attempting to get the signs placed for those who require it but had not got them all placed yet. 5. Review of the facility policy titled, Catheter, emptying a urinary drainage bag, undated, directed staff to keep the drainage bag and tubing off the floor at all times to prevent contamination and damage. 6. Review of Resident #16's admission MDS, dated [DATE], showed staff assessed the resident with severe cognitive impairment and has an indwelling urinary catheter. Review of the resident's care plan, revised 12/02/25, showed the resident required an indwelling urinary catheter. Review of the resident's Physician's Order Sheet (POS), dated 01/11/26, showed:-11/06/25: Catheter care every shift;-12/05/25: Catheter change monthly on the 25th. Observation on 01/11/26 at 11:34 A.M., showed the resident in bed with his/her urinary catheter bag on the floor. Observation on 01/11/26 at 3:16 P.M., showed the resident in bed. The resident's urinary catheter bag hung on the side of the bed and touched the floor. Observation on 01/13/26 at 8:11 A.M., showed the resident in bed. The resident's urinary catheter bag hung on the side of the bed and touched the floor. Observation on 01/14/26 at 8:10 A.M., showed the resident in bed. The resident's urinary catheter bag hung on the side of the bed and touched the floor. During an interview on 01/14/26 at 2:13 P.M., LPN C said a catheter bag should never touch the floor. LPN C said if a catheter bag touches the floor, it can cause contamination and an infection. LPN C said he/she did not know the resident's catheter bag had touched the floor. LPN C said staff should ensure there is always a barrier between the catheter bag and the floor.During an interview on 01/14/26 at 3:40 P.M., the DON said a resident's catheter bag should never touch the floor. The DON said this could cause contamination of the bag which could lead to the resident getting an infection. The DON said staff should ensure there is always a barrier between the catheter bag and floor. During an interview on 01/14/26 at 4:00 P.M., Administrator A said a resident's catheter bag should never touch the floor. Administrator A said if a catheter bag touches the floor, it can cause a resident to get an infection due to contamination. Administrator A said he/she was not aware the catheter bag had touched the floor.

Based on observation, interview, and record review, facility staff failed to complete entrapment assessments for six residents (Resident #3, #7, #8, #27, #38, and #50) who used bed rails out of 21 sampled residents. The facility census was 52. 1. Review of the facility's policy titled Bed Rails, undated, showed when installing or maintaining bed rails, staff should follow manufacture's recommendations and specifications for applicable bed rails, mattresses, and bed frames. Staff will conduct regular inspections of all bedframes, mattress, and bed rails, to identify possible entrapment.2. Review of Resident #3's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 10/30/25, showed staff assessed the resident as cognitively intact and restraints not used.Review of the resident's care plan, revised 10/20/25, showed staff documented the resident to use bilateral grab bars on the bed to assist with repositioning and transfers. Review of the resident's medical record did not contain an entrapment assessment.Observation on 01/11/26 at 1:30 P.M., and 3:14 P.M., showed the resident's bed with bilateral grab bars.Observation on 01/12/26 at 2:22 P.M., showed the resident in bed with bilateral grab bars in the upright position on the bed.Observation on 01/13/26 at 2:05 P.M., showed the resident in bed with bilateral grab bars in the upright position on the bed. 3. Review of Resident #7's admission MDS, dated [DATE], showed staff assessed the resident as Cognitively intact and restraints not used.Review of the resident's care plan, dated 10/03/25, showed it did not contain direction for the use of grab bars. Review of the POS, dated 01/11/26, showed it did not contain orders for the use of grab bars. Review of the resident's medical record showed the record did not contain entrapment measurements. Observation on 01/11/26 at 12; 45 P.M., showed the resident in bed with the right grab bar in upright position on the bed.Observation on 01/12/26 at 9:56 A.M., showed the resident in bed with the right grab bar in upright position on the bed.Observation on 01/14/26 at 8:11 A.M., showed the resident in bed with the right grab bar in upright position on the bed.4. Review of Resident #8's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact and restraints not used.Review of the resident's care plan, revised 10/28/25, showed bilateral grab bars on the bed to assist with mobility.Review of the resident's medical record showed the record did not contain entrapment measurements. Observation on 01/11/26 at 11:26 A.M. and 3:15 P.M.,, showed the resident in bed with bilateral grab bars in the upright position on the bed.Observation on 01/12/26 at 8:09 A.M., and 11:35 A.M., showed the resident in bed with bilateral grab bars in the upright position on the bed.Observation on 01/13/26 at 8:09 A.M., and 2:00 P.M., showed the resident in bed with bilateral grab bars in the upright position on the bed.Observation on 01/14/26 at 8:05 A.M., and 11:12 A.M., showed the resident in bed with bilateral grab bars in the upright position on the bed.5. Review of Resident #27's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively impaired, required substantial/maximal assistance to roll left to right, sit to lying position, and lying to sitting on side of bed.Review of the resident's medical record showed the record did not contain entrapment measurements. Observation on 01/11/26 at 11:35 A.M., showed the resident in bed with a left assist bar in the upright position on the bed. Observation on 1/12/26 at 9:05 A.M., showed the resident's bed had an assist bar on the left side in the upright position. Observation on 01/14/26 at 8:51 A.M., showed the resident's bed had an assist bar on the left side in the upright position. 6. Review of Resident #38's Quarterly MDS, dated [DATE], showed staff assessed the resident as severely cognitively impaired, dependent on staff for rolling left to right, sit to lying position, and lying to sitting on side of bed.Review of the resident's care plan, revised 12/25/25, showed bilateral grab bars to assist staff with turning from side to side and repositions in bed.Review of the resident's medical record did not contain entrapment measurements. Observation on 1/11/26 at 2:40 P.M., showed the resident in bed with a grab bar in the upright position on the right side of the bed. Observation on 1/13/26 at 2:23 P.M., showed the resident in bed with a grab bar in the upright position on the right side of the bed.Observation on 1/14/26 at 2:53 P.M., showed the resident in bed with a grab bar in the upright position on the right side of the bed.7. Review of Resident #50's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact, required supervision or touch assistance for rolling left to right, sitting to lying position, and lying to sitting on side of bed.Review of the resident's care plan, revised 12/25/25, showed bilateral grab bars to assist with self-repositioning and transfers in/out of bed.Review of the resident's medical record showed the record did not contain entrapment measurements. Observation on 01/11/26 at 12:57 P.M., showed the resident in bed with assist bars in the upright position on both side of the bed.Observation on 01/12/26 at 8:25 A.M., showed the resident in bed with assist bars in the upright position on both side of the bed.Observation on 01/14/26 at 8:58 A.M., showed the resident in bed with assist bars in the upright position on both side of the bed.8. During an interview on 01/14/26 at 2:13 P.M., Licensed Practical Nurse (LPN) C said he/she does not know who is responsible to complete the entrapment measurements. LPN C said he/she knows they should be completed when staff initially put any grab bars on the residents' beds, but he/she does not know how often they should be updated. LPN C said if grab bars are not on the bed properly it could cause a resident to get hung in the rail and potentially cause the resident harm. During an interview on 01/14/26 at 3:00 P.M., the maintenance staff said he/she is new, this is his/her first long-term care maintenance job, and he/she has only been at the facility for three weeks. The maintenance staff said he/she does not know who is responsible to complete the entrapment measurements or when the measurements should be completed. He/She said he/she does not complete entrapment measurements when he/she installs the grab bars on the beds. During an interview on 01/14/26 at 3:40 P.M., the Director of Nursing (DON) said he/she does not know who is responsible to complete the bed rail entrapment measurements. The DON said the entrapment measurements should be updated he/she thinks quarterly with the care plan review. The DON said if entrapment measurements are not completed regularly, it could potentially lead to a resident getting stuck in the rail and injured. During an interview on 01/14/26 at 4:00 P.M., Administrator A said he/she does not know who is responsible to complete the entrapment measurements at this facility. Administrator A said the entrapment measurements should be completed and/or updated quarterly. Administrator A said if entrapment measurements have not been completed since October 2025, then the facility is out of compliance. Administrator A said if entrapment measurements are not completed timely a resident could potentially end up getting hung in a bed rail, possibly injured or even die.

Based on interviews and record review, facility staff failed to initiate and complete a thorough investigation of misappropriation of resident funds which affected one resident (Resident #64) of five sampled. The facility census was 52.1. Review of the facility's policy titled Abuse Prohibition Protocol Manual, undated, showed staff were directed to:-Resident has the right to be free from abuse, neglect, misappropriation of property, and exploitation; -Administrator or designee must report to the state survey agency no later than two hours after an allegation is made;-The facility must take the following actions in response to an alleged violation of abuse, neglect, exploitation, or mistreatment: -Thoroughly investigate the alleged violation; -Prevent further abuse, neglect, exploitation, or mistreatment from occurring while the investigation is in process; -Take appropriate corrective action as the result of the investigation findings.2. Review of Resident #64's Significant Change Minimum Data Set (MDS), a federally mandated assessment tool, dated 04/23/25, showed staff assessed the resident as cognitively intact. Review of the facility's prior abuse and neglect investigations did not contain documentation staff completed an investigation for the misappropriation. Review of Housekeeper O's employee file showed a hire date of 11/13/17 and termination date of 09/16/25. During an interview on 01/13/26 at 9:45 A.M., the detective said he/she had been notified by another officer that the resident's family had reported multiple fraudulent charges on the resident's credit card over an extended period. The detective said Housekeeper O was caught using the resident's credit card at a gas pump and then going inside the gas station and using his/her personal card inside. During an interview on 01/13/26 at 3:30 P.M., Administrator B said he/she worked at the facility until 10/15/25. Administrator B said the facility had not been made aware of any incidents with the resident's credit card until after the resident had been discharged . Administrator B said he/she started an investigation, but he/she did not know what happened to the investigation or if it had been finished. Administrator B said when he/she spoke to Housekeeper O and he/she denied making the fraudulent changes. During an interview on 01/14/26 at 4:00 P.M., Administrator A said he/she did not work at the facility at the time of the incident. Administrator A said he/she started at the facility on 11/03/25. Administrator A said he/she did not know anything about this incident or facility reported incident until the survey team started annual survey. Administrator A said if a report of misappropriation of a resident's money had been made to the facility, he/she would expect the Administrator to complete a detailed investigation, document the investigation, and keep the investigation at the facility. Administrator A said he/she would also expect a facility reported incident to be reported to DHSS timely. Administrator A said a detailed investigation should have been completed to determine if there were any other residents affected and to prevent other residents from being victims. Administrator A said he/she would have expected an all-staff in-service for abuse, neglect, and misappropriation completed at the time of the report as well. Administrator A said the facility discourages residents from keeping valuable in their rooms, and they do have a lock box in the BOM office for residents to lock items up. Complaint #2616438

Based on observation, interview, and record review, facility staff failed to provide care, to maintain personal hygiene and grooming for three residents (Resident #5, #16, and #46) out of 21 sampled. The facility census was 52.1. Review of the facility's policy titled Daily Care Needs, undated showed assist a resident to do as much of his/her care needs as possible. Encourage self-care when possible. 2. Review of Resident #5's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 12/02/25, showed staff assessed the resident with severe cognitive impairment, did not have behaviors or refuse care, and independent with all Activities of Daily Living (ADL's). Review of the resident's care plan, revised 05/21/25, showed staff were directed to monitor facial hair and remove as needed. Observation on 01/11/26 at 11:53 A.M., showed the resident with long facial hair. Observation on 01/12/26 at 8:07 A.M., showed the resident with long facial hair. Observation on 01/13/26 at 8:14 A.M., showed the resident with long facial hair. Observation on 01/14/26 at 8:04 A.M., and 11:14 A.M., showed the resident with long facial hair. 3. Review of Resident #16's admission MDS, dated [DATE], showed staff assessed the resident with severe cognitive impairment, did not have behaviors or refuse care, and required extensive assistance with hygiene, dressing and bathing.Review of the resident's care plan, dated 12/02/25, showed staff documented the resident required assistance from two staff for all ADL's and staff are to provide clean appropriate clothing daily. Observation on 01/11/26 at 11:34 A.M., showed the resident wore a grey sweatshirt and with long facial hair. Observation on 01/12/26 at 8:12 A.M., showed the resident wore the same grey sweatshirt as the day before and long facial hair. Observation on 01/13/26 at 8:11 A.M., and 1:54 P.M., showed the resident wore the same grey sweatshirt he/she had on two days prior and long facial hair. Observation on 01/14/26 at 8:10 A.M., and 11:09 A.M., showed the resident wore the same grey sweatshirt and long facial hair. 4. Review of Resident #46's Quarterly MDS, dated [DATE], showed staff assessed the resident with severe cognitive impairment, did not have behaviors and did not refuse care, independent with dressing and required moderate assistance for hygiene and bathing. Review of the resident's care plan, dated 09/26/25, showed the resident required supervision and assistance by staff for all ADLs. Provide clean appropriate clothing daily.Observation on 01/11/26 at 11:37 A.M., showed the resident wore a green sweatsuit and long facial hair. Observation on 01/12/26 at 8:10 A.M., and 1:30 P.M., showed the resident wore the same green sweatsuit as the day before and had long facial hair. Observation on 01/13/26 at 8:09 A.M., showed the resident wore the same green sweatsuit and had long facial hair. Observation on 01/14/26 at 8:07 A.M., showed the resident wore the same green sweatsuit for three days and had long facial hair. 5. During an interview on 01/14/26 at 2:13 P.M., Licensed Practical Nurse (LPN) C said the aides are responsible to assist the residents to change their clothes and shave. LPN C said the charge nurse is expected to ensure the aides complete the cares for each resident. LPN C said he/she expects a resident to be shaved with his/her shower and as needed. LPN C said he/she expects resident's clothes to be changed every day and as needed when soiled. LPN C said he/she was not aware the resident's clothes were not changed, and they had not been shaved. LPN C said if residents refuse cares another staff member should try and if the resident continues to refuse staff should document the refusals. During an interview on 01/14/26 at 3:40 P.M., the Director of Nursing (DON) said the aides are responsible to assist residents to change their clothes and shave. The DON said the charge nurse is responsible to ensure the aides complete the cares needed for each resident. The DON said he/she expects residents to change their clothes daily and as needed when soiled for their dignity. The DON said staff should assist residents to shave as needed, but especially with the resident's showers. The DON said he/she was not aware the resident's clothes were not changed nor were their faces not shaved The DON said if a resident refuse cares another staff member should make an attempted. The DON said if the resident continues to refuse, he/she expects the staff to document the refusal.During an interview on 01/14/26 at 4:00 P.M., Administrator A said he/she expects staff to assist residents to change their clothes daily and as needed when soiled. Administrator A said a resident should not wear the same clothes for more than one day. Administrator A said the aides are responsible to assist residents to shave when needed and the charge nurse is responsible to ensure the aides complete the care. Administrator A said he/she was not aware the resident's clothes were not changed nor were their faces not shaved Administrator A said if a resident refuse cares another staff member should make an attempted. Administrator A said if the resident continues to refuse, he/she expects the staff to document the refusal. Complaint#: 2652199, 2626155

Based on interview and record review, facility staff failed to provide professional standards of care for two residents (Residents #1 and #2) out of eight sampled residents, when staff failed to monitor and document residents' bowel movements, which resulted in Resident #1 being admitted to the hospital with a diagnosis of fecal impaction (a condition where a hard, dry mass of stool becomes stuck in the rectum or colon). The facility census was 48. The administrator was notified on 09/09/25 of past Non-Compliance which occurred on 08/15/25 when the administrator implemented new policies and procedures to ensure aides documented residents' bowel movements each shift, and licensed staff monitored residents' bowel movements daily. Staff were in-serviced on 8/15/25 regarding documentation and monitoring of residents' bowel movements. 1. Review of the facility's' Daily Care Needs policy, undated, showed staff are directed to determine if a resident has had a bowel movement each day. If the resident is confused, staff are to check the bowel records and determine if the resident needs a laxative or enema. If a resident has not had a bowel movement in three days, staff are directed to notify the charge nurse. 2. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 08/13/25, showed staff assessed the resident with impaired cognition and occasionally incontinent or bowel. Review of the resident's Care Plan, updated 07/11/25, showed staff assessed the resident at risk for constipation and dehydration. Review showed staff are directed to monitor the resident's intake and output every shift and report if the resident did not have bowel movement in two days to the charge nurse.Review of the resident's Physician's Order Sheet (POS), dated July 2025, showed the resident with a diagnosis of long-term use of an opiate analgesic (a pain-relieving medication, with the possible side effect of constipation). Review the POS showed orders for the following:-Docusate Sodium (a laxative) 100 milligrams (mg) one capsule daily for constipation;-Miralax (a laxative) 17 grams (gm) per dose 17 gm once a day for constipation;-Senna (a laxative) 8.6 mg one tablet every evening; -Bisacodyl suppository (a laxative) one suppository rectally daily as needed for constipation;-Milk of Magnesia (a laxative) 400 mg/5 ml 30 ml as needed for constipation. Review of the resident's Medication Administration Record (MAR), dated July 2025, showed the MAR did not contain documentation staff administered the resident's Bisacodyl or Milk of Magnesia. Review of the resident's vital sign sheet, dated 07/25/24 through 08/01/25, showed the vital signs sheet showed staff documented the last bowel movement the resident had on 07/24/25. Review of the resident's nurses' notes, dated 08/01/25 , showed Registered Nurse (RN) A documented the resident sent to the hospital for respiratory distress.Review of the hospital records, dated 08/01/25, showed a diagnosis of a stool impaction and a moderate amount of fecal matter present in the resident's colon. During an interview on 08/25/25 at 11:45 A.M., Certified Nurse Aide (CNA) E said he/she did not know when the resident last had a bowel movement. He/She said CNA's are responsible for monitoring residents' bowel movements every shift, and to document the information in the computer. He/She said he/she notifies licensed staff if a resident has not had a bowel movement in three days. During an interview on 08/29/25 at 9:38 A.M., RN A said staff notified him/her at approximately 8:00 A.M. on 8/01/25 the resident had a change in condition. He/She said no one notified him/her the resident had not had a bowel movement since 07/24/25. eating was declining, but so was everything else, and had been. Dr aware. During an interview on 08/29/25 at 10:00 A.M., CNA F said CNA's are responsible for documenting residents' bowel movements every shift. He/She said if a resident has not had a bowel movement in three days, they are supposed to notify the charge nurse. He/She said he/she did not know the resident had not had a bowel movement since 07/24/25, and staff did not report to him/her the resident was constipated. 3. Review of Resident #2's quarterly MDS, a federally mandated assessment tool, dated 08/13/25, showed staff assessed the resident as occasionally incontinent of bowels. Review of the resident's Care Plan, updated 07/23/25, showed staff assessed the resident at risk for constipation and dehydration. Review showed staff are directed to monitor the resident's bowel movements every shift and to report no bowel movement in two days to the nurse.Review of the resident's POS, dated July 2025, showed a diagnosis of constipation. Review showed physician's orders for the following:-Celexa 20 mg daily (an antidepressant, with the possible side effect of constipation) 10 mg one tablet daily;-Docusate Sodium 100 mg two capsules daily at bedtime;-Famotidine (an antihistamine, with the possible side effect of constipation) 10 mg every morning;-Bisacodyl suppository 10 mg one suppository rectally daily as needed for constipation;-Milk of Magnesia 400 mg/5 ml 30 ml as needed for constipation;-Miralax 17 gm/dose 17 gm daily as needed for constipation, Ondansetron (an antinausea meditation, with the possible side effect of constipation) 4 mg every eight hours as needed. Review of the resident's MAR, dated 07/01/25 through 07/31/25, showed it did not contain documentation that Bisacodyl, Milk of Magnesia, or Miralax had been administered from 07/01/31 through 0731/25. Review of the resident's vital records showed it did not documentation the resident had a bowel movement from 07/04/25 to 07/11/25 (seven days), from 07/13/25 to 07/21/25 (eight days) or from 07/22/25 to 08/02/25 (eleven days). During an interview on 08/25/25 at 11:30 A.M., Licensed Practical Nurse (LPN) B said CNA's should document residents' bowel movements each shift, and licensed staff should monitor to see if a resident has not had a bowel movement for three days. If a resident does not have a bowel movement for three days, licensed staff should administer as needed medications for constipation. He/She said the corporate nurse recently began printing reports for residents' bowel movement monitoring. He/She said if staff do not document monitoring a resident's bowel movement, then he/she would think staff did not monitor the resident's bowel movements. During an interview on 09/05/25 at 10:07 A.M., the administrator said CNA's are responsible for documenting residents' bowel movements in the electronic charting. He/She said he/she does not know why staff did not document bowel movements for Resident #1 or Resident #2. He/She said Certified Medication Technicians (CMT's) and licensed staff should monitor residents' bowel movements, and if a resident has not had a bowel movement in two days, they should administer as needed medications for constipation. He/She said approximately two weeks ago, the new MDS Coordinator showed staff how to add bowel movements to the Plan of Care documentation in the electronic medical records, which will not allow staff to document other care they performed until they document if the resident has had a bowel movement. During an interview on 09/05/25 at 11:35 A.M., CMT D said aides are responsible for documenting residents' bowel movements each day. He/She said if a resident does not have a bowel movement in three days, staff should administer an as needed medication for constipation. He/She said licensed staff are supposed to monitor residents' bowl movements and notify CMT's is a resident needs an as needed medication for constipation. Complaint # 2590452

Based on interview and record review, facility staff failed to transmit the required Minimum Data Sets (MDS), a federally mandated resident assessment completed by facility staff, for ten residents (Resident #2, #6, #11, #13, #18, #26, #32, #42, #44 and #53) of sixteen sampled residents. The facility census was 48. 1. Review of Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.18.11, dated October 2023, showed: -The CMS Long-Term Care Facility RAI User's Manual is the primary source of information for completing an MDS assessment; - All Medicare and/or Medicaid-certified nursing homes must transmit MDS data records to CMS' Internet Quality Improvement and Evaluation System (iQIES); -Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date (no later than 14 days from the resident's admitted and/or assessment reference date (ARD) plus seven days). All other MDS assessments must be submitted within 14 days of the MDS Completion Date; -A comprehensive or quarterly assessment is due every quarter unless the resident is no longer in the facility. There must be no more than 92 days between assessments. A comprehensive assessment is due every year unless the resident is no longer in the facility. There must be no more than 366 days between comprehensive assessments. Review of the facility's MDS and Care Planning Guidelines, dated October 2015, directed staff to use the most current CMS MDS Resident Assessment Instrument (RAI) Manual, any published interim RAI manual errata documents, and applicable federal guidelines as the authoritative guide for completion of MDS and care planning. 2. Review of Resident #2's MDS data in the Electronic Health Record (EHR), showed a quarterly MDS completion date of 06/05/24. Review showed the assessment was not transmitted as required within 14 days of completion. 3. Review of Resident #6's MDS data in the EHR, showed a quarterly MDS completion date of 06/10/24. Review showed the assessment was not transmitted as required within 14 days of completion. 4. Review of Resident #11's MDS data in the EHR, showed an annual MDS completion date of 05/17/24. Review showed the assessment was not transmitted as required within 14 days of completion. 5. Review of Resident #13's MDS data in the EHR, showed a Significant Change of Status (SCSA) comprehensive assessment completion date of 06/10/24. Review showed the assessment was not transmitted as required within 14 days of completion. 6. Review of Resident #18's MDS data in the EHR, showed an annual MDS completion date of 06/06/24. Review showed the assessment was not transmitted as required within 14 days of completion. 7. Review of Resident #26's MDS data in the EHR, showed a SCSA completion date of 06/07/24. Review showed the assessment was not transmitted as required within 14 days of completion. 8. Review of Resident #32's MDS data in the EHR, showed a SCSA completion date of 04/18/24. Review showed the assessment was not transmitted as required within 14 days of completion. 9. Review of Resident #42's MDS data in the EHR, showed a SCSA completion date of 05/29/24. Review showed the assessment was not transmitted as required within 14 days of completion. 10. Review of Resident #44's MDS data in the EHR, showed a quarterly MDS completion date of 06/20/24. Review showed the assessment was not transmitted as required within 14 days of completion. 11. Review of Resident #52's MDS data in the EHR, showed an admission MDS completion date of 05/27/24. Review showed the assessment was not transmitted as required within 14 days of completion. 12. During an interview on 07/11/24 at 2:00 P.M., the MDS Coordinator said he/she only completes the MDS. The Director of Nursing (DON) signs off and submits them. During an interview on 07/11/24 at 2:50 P.M., the DON said he/she is responsible for submitting the MDS data and does not have a back-up person. He/She said he/she submits the data every other week but took vacation twice in June and then just forgot. During an interview on 07/11/24 at 3:24 P.M., the administrator said he/she is not sure how often the MDS data should be submitted but is usually the responsibility of the DON. The administrator said they do not have a back-up person when the DON is unavailable. 42484 43327

Based on observation, interview, and record review, facility staff failed to create an environment respectful of the rights of each resident to make choices about significant aspects of their lives for one (Resident #12) of five sampled residents when staff failed to promote the resident's self determination through support of resident choices when staff failed to allow the resident the choice of independently going outside the facility. The facility census was 48. 1. Review of the facility's Nursing Home Residents' Rights policy, undated, showed the resident had the right to self determination including the choice of activities, the reasonable accommodation of needs and preferences, and participation in developing and implementing a person-centered plan of care incorporates personal and cultural preferences. 2. Review of Resident #12's quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 07/10/24, showed staff assessed the resident as follows: -Cognitively Intact; -Required total dependence for transfers; -Independent using a motorized wheelchair; -Diagnosis of multiple sclerosis and depression. Review of the resident's admission sheet shows the resident is his/her own legal representative. Review of the resident's care plan, dated 04/10/24, showed staff assessed the resident's preferred activity is to go across the street to the park in his/her motorized wheelchair. Review of the resident's medical record did not contain documentation the resident with safety concerns for his/her perferred activity to go across the street to the park. Review of the resident's smoking assessment, dated 07/10/24, showed staff assessed the resident as a safe smoker. During and interview on 07/10/24 at 10:59 A.M., the resident said he/she used to be able to independently go across the road to the park but recently was told they could no longer do so and this caused him/her stress. The resident said he/she is able to operate the wheelchair without problems and would use the cell phone to ask for help if needed. During an interview on 07/10/24 at 3:05 P.M., the resident's family member said he/she would like the resident to be able to go to the park because it helps him/her with depression and anxiety, and that is important for the quality of the resident's life. During an interview on 07/11/24 at 10:34 A.M., the Assistant Director of Nursing said the resident was found to be an unsafe smoker and started hitting things with their wheelchair causing the decision to made not allowing independent trips to the park. During an interview on 07/11/24 at 10:39 A.M., the MDS coordinator said staff had a care plan meeting to addressed using a smoking apron and not allowing the resident to go to the park unsupervised due to concerns it was a health risk and the resident said he/she did not want to be supervised going to the park. During an interview on 07/11/24 at 10:41 A.M., the administrator said the resident's unsupervised trips to the park were stopped due to concerns about the residents safety. During an interview on 07/11/24 at 2:00 P.M., Certified Nurse Aid (CNA) A said he/she would ask a charge nurse to see if a resident was independent and allowed to go to the park or outside on their own. He/She said they were not aware the resident could no longer go by themselves to the park. During an interview on 07/11/24 at 2:46 P.M., the Director of Nursing said a resident who is alert and orientated should be able to make their own choices but we were concerned for the resident's safety going across the road to the park alone.

Based on observation, interview and record review, facility staff failed to change and store oxygen tubing and/or clean oxygen concentrator filters in a manner to decrease the risk of the spread of infection for four (Resident #8, #25, #36, and #42) out of four sampled residents. The facility census was 48. 1. Review of the facility's Oxygen Administration policy, dated March 2015, showed: -At regular intervals, check and clean oxygen equipment, masks, tubing, and cannulas; -Change humidifier and tubing per cleaning guidelines; -At regular intervals, check liter flow contents of oxygen cylinder, fluid level in humidifier and access resident's respiration to determine further need for oxygen therapy. 2. Review of Resident #8's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 05/18/24 showed staff assessed the resident as: -Severely cognitively impaired; -Used oxygen. Review of the Physician Order Sheet (POS), dated July 2024, showed an order to change the oxygen tubing and humidity bottle monthly on the first, on the evening shift and to ensure the tubing and bottle is labeled. Observation on 07/09/24 at 11:08 A.M., showed the resident wore his/her oxygen via nasal cannula. The oxygen tubing did not contain a label with a date. Observation on 07/10/24 at 8:14 A.M., showed the resident with his/her oxygen on via nasal cannula. The oxygen tubing did not contain a label with a date. 3. Review of the Resident #25's annual MDS, dated [DATE], showed facility staff assessed the resident as follows: -Cognitively intact; -Received oxygen therapy; -Diagnoses respiratory failure. Review of the resident's POS for July 2024 showed the physican ordered oxygen three to five liters per minute (lpm) per nasal cannula, change oxygen tubing monthly and change nebulizer tubing monthly. Ensure tubing is dated. Observation on 07/09/24 at 11:41 A.M., showed the resident with his/her nasal cannula on dated 03/11 and the oxygen condenser filter covered with a white residue. Observation showed the resident's nebulizer tubing dated 11/8. Observation on 07/11/24 at 09:46 A.M., showed the resident with his/her nasal cannula on dated 03/11 and the oxygen condenser filter covered with a white residue. Observation showed the resident's nebulizer tubing dated 11/8. 4. Review of the Resident #36's Quarterly MDS, dated [DATE], showed facility assessed the resident as follows: -Cognitively intact; -Received oxygen therapy; -Diagnoses lung disease, and respiratory failure. Review of the resident's POS, dated July 2024, showed physician orders for oxygen two to five lpm per nasal cannula as needed for shortness of breath and Bilevel positive airway pressure ((BiPap) a device that helps with breathing) with a forced air pressure of 15/10 every night as tolerated. Observation on 07/09/24 at 12:00 P.M., showed the resident oxygen on per lasal cannula. Observation showed the tubing not date. Observation on 07/10/24 at 10:12 A.M., showed the resident oxygen on per lasal cannula. Observation showed the tubing not date. Observation on 07/11/24 at 9:41 A.M., the resident oxygen on per lasal cannula. Observation showed the tubing not date. During an interview on 07/10/24 at 10:12 A.M., the resident said he/she uses oxygen. 5. Review of Resident #42's Significant Change of Status MDS, dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -Used oxygen; -Diagnosis of heart failure and lung disease. Review of the resident's POS, dated July 2024, showed an order to change the oxygen tubing and humidity bottle monthly, first of the month, on the evening shift and to ensure the tubing and bottle is labeled. Observation on 07/09/24 at 11:42 A.M., showed the resident wore his/her oxygen via nasal cannula. The oxygen tubing did not contain a date and the humidifier bottle dated 06/01/24. Observation showed the filter on the machine was covered with a white substance. Observation on 07/10/24 at 08:13 A.M,showed the resident wore his/her oxygen via nasal cannula. The oxygen tubing did not contain a date and the humidifier bottle was dated 06/01/24. Observation showed the filter on the machine was covered with a white substance. 6. During an interview on 07/10/24 at 11:34 A.M., Licensed Practical Nurse (LPN) B said oxygen tubing should be changed monthly by nursing, and it is triggered by an order in the Treatment Administration Record (TAR). The tubing change is indicated in the TAR, and the tubing should be dated. LPN B said filters were not regularly cleaned. During a telephone interview on 07/11/24 at 2:50 P.M., the Director of Nursing (DON) said oxygen tubing should be labeled and dated when changed and should be changed monthly. He/She said nursing does not have a preventative maintenance for cleaning oxygen filters. The DON said it is his/her responsibility to ensure the tubing is being changed. During an interview on 07/11/24 at 03:24 P.M., the administrator said oxygen tubing should be changed on a regular basis, but he/she was not sure whether this is weekly or monthly. The administrator said the new tubing and new bag should be dated. If the tubing was marked with an earlier date, the tubing was not changed after that date. He/She said it was the responsibility of the charge nurse to ensure the tubing changes occurred as ordered. 43327

Based on interview and record review, facility staff failed to connect one resident's (Resident #1) nasal cannula tubing to the residents oxygen concentrator and failed to turn the oxygen concentrator on. The facility census was 53. 1. Review of the facility's oxygen administration policy, dated March 2015, showed when administering oxygen staff are directed to attach a face mask or cannula tubing to the humidifier and set the flow meter to the rate ordered by the physician. 2. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 11/30/23, showed staff assessed the resident as follows: -Severe Cognitive Impairment; -Dependent on staff to roll right or left in bed; -Dependent on staff to move from sitting to a lying position; -Atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), and dementia (a group of thinking and social symptoms that interferes with daily function); -Received oxygen therapy. Review of the resident's plan of care, dated 11/30/23, showed the plan of care did not contain direction for staff to provide oxygen therapy. Review of resident's physician orders, dated 6/30/23, showed an order for two to five liters of oxygen per minute per nasal cannula as needed. Review of resident's nurses notes, dated 12/10/23 at 3:37 P.M., showed the resident with diminished lung sounds and oxygen saturation at 55%. Review showed the nurses note did not contain documentation staff notified the resident's physician of the change in condition. During an interview on 1/10/24 at 2:59 P.M., Certified Nurse Assistant (CNA) A said he/she worked with the resident on 12/10/23 on the day shift, he/she last worked with the resident around 1:30 P.M. that day. and as far as he/she knew the resident's nasal cannula was on and connected to the oxygen concentrator. During a telephone interview on 1/10/24 at 3:10 P.M., the resident's attending physician said he expected staff to follow physician's orders to include for oxygen therapy. During an interview on 1/10/24 at 3:16 P.M., Licensed Practical Nurse (LPN) B said he/she was assigned to the resident's hall on the day shift of 12/10/23, and CNA A worked with the resident around 1:30 P.M., but at the end of the shift the resident was found with his nasal cannula tubing not connected to the concentrator and the concentrator was not turned on. He/She said they plugged the oxygen back up and turned it on to get the residents oxygen sats back up by utilizing the concentrator and portable tank. He/She at one point the resdient could remove the oxygen but was no longer strong enough to do so. During a telephone interview on 1/10/24 at 4:05 P.M., CNA C said he/she worked evening shift with the resident on 12/10/23 and he/she had came in around 3:00 P.M. for evening shift. CNA C said soon after the start of the shift while passing ice, he/she observed the resident with his/her nasal cannula on his/her face, without the tubing connected to the concentrator, and the oxygen concentrator was not turned on. During a telephone interview on 1/11/24 at 9:47 A.M., CNA A said I'm pretty sure I did hook the tubing back and turn on the concentrator. He/She said he/she did not know whether anyone else provided care after 1:30 P.M. to the resident or not. During a telephone interview on 1/11/24 at 10:15 A.M., the Director of Nursing (DON), said on 12/10/23 he/she was at the facility and the charge nurse reported to him/her that CNA A had removed the resident's nasal cannula tubing from the resident's portable oxygen tank but forgot to attach it to the resident's oxygen concentrator while working with the resident. He/She said the next day he/she spoke to CNA C who told him/her, he/she observed the resident's nasal cannula tubing not connected to the concentrator and didn't say anything about the concentrator not being turned on. During a telephone interview 1/11/24 at 11:26 A.M., LPN B said the resident would not have been able to pull his/her nasal cannula from the concentrator independently because he/she was too lethargic and sleepy. During a telephone interview on 1/11/24 at 3:17 P.M., the administrator said she expected staff to follow the physician's order for oxygen administration. She also said she expected staff to take the time to make sure residents' nasal cannula tubing is properly connected to the concentrator and flowing properly to the resident. MO00230021

Based on interview and record review, the facility staff failed to designate a person to serve as the Director of Food and Nutrition Services with the appropriate qualifications, when the facility did not employ a qualified dietitian or other clinically qualified nutrition professional full-time. The census was 61. 1. Review of the Dining Services Manager policy, dated April 2011, showed the dining services manager is delegated the administrative authority, responsibility and accountability necessary for carrying out the assigned duties which included supervision of personnel in the dietary department; planning, preparing and serving regular and modified diets to the residents; documenting in resident records for items such as care plans, progress notes, weight committee reports and minimum data set (MDS) assessments; and budget management. Review showed the minimum qualifications for the dining services manager listed as: -High school diploma or General Educational Development (GED) equivalent; -Two years of experience in a supervisory capacity of a hospital, skilled nursing care facility, or other medical facility; -Certified Dietary Manager if required by state regulations. Review of the dietary manager's (DM) personnel records, showed the DM previously employed as the DM of a skilled nursing facility from 04/08/19 to 01/26/22 and hired as the facility's DM with an effective date of 09/16/23. Review showed the records did not contain documentation of certification or other education required for the director of nutritional services position. During an interview on 09/19/23 at 10:00 A.M., the administrator said they just had a new dietary manager (DM) take over on 09/16/23. The administrator said the new DM had prior experience as a DM in a skilled nursing facility, but he/she did not have a degree or certification related to food service management and he/she had not completed or been enrolled in any other educational courses related to food safety and management. The administrator said the facility had a part-time consultant registered dietician and did not have any certified or clinically qualified nutritional staff employed full-time. During an interview on 09/19/23 at 11:25 A.M., the DM said he/she had been a DM for a different skilled nursing facility from 04/18/19 to February 2022 and became the DM for this facility on 09/16/23. The DM said he/she did not have a degree or certification related to food service management and he/she had not completed or been enrolled in any other educational courses related to food safety and management. The DM said the facility had a part-time consultant registered dietician and did not have any certified or clinically qualified nutritional staff employed full-time.

Based on observation, interview and record review, the facility staff failed to serve food in accordance with the nutritionally calculated menus and standardized recipes. Facility staff also failed to record substitutions made to the menus. 1. Review of the facility's Menus policy, dated May 2015, showed: -Menus will be dated and posted on the bulletin board in the kitchen; -Standardized recipes are available in the dietary department for foods on the menu; -A food substitute should be consistent with the usual and ordinary food item provided by the facility. All substitutes provide equal nutritional value; -When substitutions are made, changes are posted on the menu or substitution sheet. If an entire meal is substituted, for instance for a special function, the meal should be posted on the menu. If a single item is substituted because it is not available, it should be posted on the substitution sheet. 2. Review of the facility lunch menus dated 09/19/23 (Week 3, Day 17), showed the menus directed staff to provide the residents with pork loin, boiled potatoes, buttered spinach, a dinner with margarine and apple crisp. Review of the substitution log posted on the reach-in refrigerator, showed the last documented food substitution dated 02/14/23. During an interview on 09/19/23 at 10:38 A.M., the administrator said the food items for lunch would be pork loin, buttered noodles, turnip greens and coconut cream pie. The administrator said they did not have any canned potatoes to make the boiled potatoes and did not have any spinach. The administrator said the apple crisp was substituted with the coconut cream pie based on residents requests. The administrator said he/she contacted the facility's consultant registered dietician earlier that morning who approved of the substitutions and directed him/her to serve the portions of the substituted items at the same sizes listed on the menus. The administrator said substitutions should be recorded on the substitution log, but he/she did not do that. 3. Review of the resident meal tray tickets on 09/19/23 at 12:30 P.M., showed the diet types for all residents consisted of regular, Level 7 Easy to Chew (EC7) (a diet that includes normal everyday foods of soft/tender textures only that are developmentally and age appropriate), Level 6 Soft and Bite-Sized (SB6) (a diet in which food pieces are no greater than 15 millimeters in size for adults, is soft, tender and moist throughout with no separate thin liquid, can be can be mashed/broken down with pressure from fork, spoon or chopsticks and requires chewing before swallowing) and pureed. Review of the facility lunch menus dated 09/19/23 (Week 3, Day 17), showed the menus directed staff to provide the residents on regular and EC7 diets with a dinner roll and margarine. Further observation showed the menus directed the staff to provide the residents on SB6 and pureed diets with a #16 pureed dinner roll with margarine. Review of the facility's lunch meal choice papers (papers with the menu and available substitutions listed on them that are provided to the residents for them to choose what food items the want) for 09/19/23, showed the papers did not include the dinner roll with margarine or any other type of bread. Observations on 09/19/23 during the lunch meal service, showed staff did not prepare regular or pureed dinner rolls for service at the meal and staff did not offer the residents the dinner roll with margarine or any other type of bread. 4. Review of the facility lunch menus dated 09/19/23 (Week 3, Day 17), showed the menus directed staff to provide the residents on regular, EC7 and SB6 diets with one half cup of buttered spinach. During an interview on 09/19/23 at 10:38 A.M., the administrator said the residents would receive turnip greens because they did not have any spinach. The administrator said he/she contacted the facility's consultant registered dietician earlier that morning who approved of the substitution and directed him/her to serve the portion of the substituted item at the same size listed on the menus. Review of the facility's recipe for turnip greens, undated, showed the recipe directed staff to serve a #8 scoop (four ounces) portion of prepared turnip greens. Observation on 09/19/23 at 12:57 P.M., showed Dietary Aide (DA) N served the residents on regular, EC7 and SB6 diets in the north dining room with a #10 scoop (3.2 ounces) of turnip greens (less than directed by the menus and recipe). During an interview on 09/19/23 at 1:01 P.M., the DA said the turnip greens were to be served with #8 scoop, but he/she did not have the right scoop. The DA said he/she notified kitchen staff that he/she needed someone to bring him/her a #8 scoop, but no one brought on so he/she used the #10 scoop instead. The DA said if staff do not have the right scoop for service then they should go back to the kitchen and get the correct one. During an interview on 09/21/23 at 11:04 A.M., the dietary manager (DM) said staff should follow menus unless otherwise requested by the residents. The DM said substitutions should be recorded on the substitution log with the reason for substitution and all menu items should be served unless requested otherwise by the residents. The DM said when bread is on the menus, staff should offer the residents bread if it is not on the meal choice papers for them to choose and if staff don't have the right portion scoop for service they should get the right one from the kitchen before they serve. During an interview on 09/21/23 at 11:23 AM, the administrator said staff should follow the nutritionally calculated menus unless otherwise requested by residents. The administrator said the residents should receive all food items indicated by the menus in accordance with their specified diet types and if staff don't have the right scoop size for something then they should go get it from the kitchen and not use the wrong one. 42484

Based on observation, interview and record review, the facility staff failed to store food in a manner to prevent contamination and out-dated use. The facility staff failed to allow sanitized dishes to air dry prior to stacking in storage and use to prevent the growth of food-borne pathogens. The facility staff also failed to perform hand hygiene as often as necessary using approved techniques to prevent cross-contamination. The facility census was 61. 1. Review of the facility's Receiving and Storage of Food policy, dated [DATE], showed The Dining Services Manager is responsible for receiving and storing food and nonfood items. Review of the facility's Storage of Dry Food and Supplies policy, dated [DATE], showed the policy directed: -the dietary department to store dry food and supplies in accordance with facility guidelines and state regulations; -metal or plastic containers with tight fitting covers, labeled on the top or side, must be used for the storage of opened items and only National Sanitation Foundation (NSF) approved storage containers and food grade vinyl bags are to be used for food storage; -staff to reseal opened boxes effectively, properly label bulk food containers, and tightly close food-grade plastic bags after they are opened; -staff to date stock with the date of delivery; -that severely dented, rusted, leaking and bulging cans must be placed in a separate, labeled holding area for return to the distributor. Review of the facility's Safe Food Handling policy, dated [DATE] showed: -Dietary employees will follow safe food handling guidelines to prevent the spread of foodborne illness; -All food, including bulk items, should be tightly sealed with an identifying label and date; -Only containers approved by the National Sanitation Foundation (NSF) can be used for storage. Observations on [DATE] at 10:40 A.M., showed the dry goods pantry contained: -an opened and undated bag of sweetened coconut flakes; -eight undated plastic storage containers of fruit whirls, honey nut toasted oats, crisp rice, corn flakes and raisin bran cereals removed from original packages; -a 42 ounce (oz.) box of quick oats opened to the air, with stock date of ,d+[DATE], without an opened date; -an opened 35 oz. bag of sugar frosted cornflakes, with stock date of ,d+[DATE], without an opened date; -an opened 35 oz. bag of cornflakes, with stock date of ,d+[DATE], without an opened date; -an opened 35 oz. bag of honey nut toasted oats, with stock date of ,d+[DATE], without an opened date; -an opened and undated 25 pound bag of brown sugar; -an undated 25 pound box of long grain enriched parboiled rice opened to the air; -a 6.56 pound can of sliced carrots with large dent on lower left facing side stored on shelf with rest of canned food items. Observation on [DATE] at 11:35 A.M., showed an undated package of pork roast gravy mix opened to the air on the upper shelf of the cook's food preparation table. Observations on [DATE] at 11:42 A.M., showed the counter beneath food preparation sink contained: -a bulk container of food thickener, removed from original packaging, with a portion scoop buried inside the product. Further observation showed a handwritten label on the container which read exp ,d+[DATE] and the exterior of the container heavily soiled with dried food debris; -an undated bulk container of pureed bread mix removed from original container; -an opened and undated 25 pound bag of flour stored inside an undated bulk container. Further observation showed the exterior of container heavily soiled with dried food debris; -an opened and undated five pound container of peanut butter. Observations on [DATE] at 2:24 P.M., showed the walk-in refrigerator contained: -an opened and undated one gallon bottle of soy sauce; -an opened and undated 70 oz. bottle of picante sauce; -an opened and undated five pound carton of grated parmesan cheese; -an opened and undated five pound container of commercially prepared cucumber and onion salad; -an opened and undated five pound container of sour cream; -an opened and undated one gallon container of mayonnaise; -an opened and undated 32 oz. carton of scrambled egg mix. Observation on [DATE] at 7:15 A.M., showed an opened and undated 46 oz. carton of cranberry juice cocktail in the reach-in refrigerator. Observations on [DATE] 07:18 A.M., showed the dry goods pantry contained: -a 24 oz. box of quick grits, with a stock date of ,d+[DATE], without an opened date and opened to the air; -a 42 ounce (oz.) box of quick oats opened to the air, with stock date of ,d+[DATE], without an opened date; -an opened 35 oz. bag of sugar frosted cornflakes, with stock date of ,d+[DATE], without an opened date; -an opened 35 oz. bag of cornflakes, with stock date of ,d+[DATE], without an opened date; -an opened 35 oz. bag of crisp rice cereal, with a stock date of ,d+[DATE], without an opened date; -an opened 35 oz. bag of raisin bran, with stock date of ,d+[DATE], without an opened date; -an opened and undated 25 pound bag of brown sugar; -an undated 25 pound box of long grain enriched parboiled rice opened to the air; -a 6.56 pound can of sliced carrots with large dent on lower left facing side stored on shelf with rest of canned food items. Observations on [DATE] at 7:24 A.M., showed the counter beneath food preparation sink contained: -a bulk container of food thickener, removed from original packaging. Further observation showed a handwritten label on the container which read exp ,d+[DATE] and the exterior of the container heavily soiled with dried food debris; -an undated bulk container of pureed bread mix removed from original container; -an opened and undated 25 pound bag of flour stored inside an undated bulk container. Further observation showed the exterior of container heavily soiled with dried food debris; -an opened and undated five pound container of peanut butter. Observation on [DATE] at 7:26 A.M., showed the walk-in freezer contained: -an undated case of southern style biscuit dough opened to the air; -an undated case of country fried beef fritters opened to the air; -an undated case of chocolate chip cookie dough opened to the air; -an opened and undated plastic bag of six raw hamburger patties; -an undated plastic bag of sweet potato tots opened to the air; -an opened and undated plastic bag of shredded hashbrowns. During an interview on [DATE] at 10:57 A.M., the dietary manager (DM) said he/she is responsible to monitor for proper food storage daily when working, but he/she had not been able to do a good food storage check since he/she became the DM on [DATE]. The DM said staff should ensure that opened food items are labeled, dated, and sealed before they are put away. The DM said food items are dated when placed in stock, so opened food items should have two dates on them, the stock date and opened date. The DM said scoops should not be stored inside bulk containers of food, which would include the food thickener and staff should wipe down the bulk containers between cleanings which occurs when they are emptied. The DM said the handwritten label on the bulk container of food thickener would indicate that the product is expired and should not be in use by staff. The DM said dented cans should not be stored with the in-use supply of food and all dietary staff are trained on proper food storage requirements. During an interview on [DATE] at 11:17 A.M., the administrator said the DM is responsible to monitor for proper food storage daily when he/she is on duty and would be expected to make corrections and reeducate staff as needed. The administrator said opened food items should be sealed, dated with opened date, and labeled if not identifiable before they are put away. The administrator said scoops should not be left inside bulk containers of food and staff should clean the bulk containers when they are emptied and as needed. The administrator dented cans should be stored separately from the rest of the food supply and staff are trained on proper food storage requirements upon hire and as needed. 2. Review of the facility's Dishwashing policy, dated [DATE], showed the policy directed staff to allow washed items to thoroughly dry before they unload the racks or store the items. Observation on [DATE] at 11:13 A.M., showed DA Q removed the food processor from mechanical dishwasher while wet and returned it to the base in the upright position. Observation on [DATE] at 11:20 A.M., showed the interior of the food processor remained wet and the social services director (SSD) added five cups of prepared turnip greens to the wet food processor to prepare the pureed turnip greens for service to the residents at the lunch meal. Observation on [DATE] at 11:40 A.M., showed seven metal food preparation/service pans of various sizes stacked together wet on the storage shelf next to the handwashing sink. Observation on [DATE] at 2:12 P.M., showed showed DA Q removed four sanitized metal food preparation/service pans from the clean side of the mechanical dishwashing station while wet, stacked them together and placed them on the storage shelf by the handwashing sink. Observation on [DATE] at 2:56 P.M., showed DA Q stacked eight sanitized inner-lip plates on the counter in the upright position while wet. Observation on [DATE] at 7:13 A.M., showed six insulated plastic domed plate covers stacked together wet upside down on the rack above the clean side of the mechanical dishwashing station. Observation also showed two metal food preparation/service pans stacked together wet on the storage shelf by the handwashing sink. During an interview on [DATE] at 11:03 A.M., the DM said cleansed dishes should be air dried prior to stacking in storage and staff are trained on that requirement. During an interview on [DATE] at 11:21 A.M., the administrator said cleansed dishes should be air dried before they are put away and staff are trained on that requirement. 3. Review of the facility's Handwashing policy, dated [DATE], showed the policy directed staff to wet their hands and forearms with water, lather their hands with antiseptic soap, and wash their hands, giving particular attention to the areas between the fingers, around cuticles, and under their fingernails when they wash their hands. Review showed the policy did direct staff how long to scrub their hands with soap and when to wash their hands. Review of the facility's Dishwashing policy, dated [DATE], showed the policy directed staff to sanitize their hands properly before they pull racks of sanitized dishes from the clean side of the dishwasher. Review of the handwashing instruction sign posted above the kitchen handwashing sink, showed the sign directed staff to scrub their hands with soap for at least 30 seconds when they wash their hands. Observation on [DATE] at 10:35 A.M., showed the SSD washed his/her hands at the handwashing sink. Observation showed the SSD scrubbed his/her hands with soap for approximately five seconds before he/she rinsed and dried them. Observation showed the SSD then donned a pair of gloves and prepared coconut cream pies for service to the residents at the lunch meal. Observation on [DATE] at 12:49 P.M., showed DA Q touched his/her face multiple times and then passed food trays to residents at the lunch meal without performing hand hygiene before he/she passed the trays. Observation on [DATE] at 2:44 P.M., showed DA Q dropped sanitized insulated plate holders and covers on the floor, picked them up, put them in the mechanical dishwasher and, without performing hand hygiene, the DA then put away sanitized dishes from the clean side of the mechanical dishwashing station and sanitized pans from the clean side of the three-compartment sink. Observation on [DATE] at 2:56 P.M., showed DA Q washed soiled dishes in the mechanical dishwashing station and then, without performing hand hygiene, put away sanitized dishes from the clean side of the station. During an interview on [DATE] at 11:05 A.M., the DM said staff should wash their hands anytime they do something dirty, which would include after they pick up a dropped item off the floor, after they wash soiled dishes and after they touch their body. The DM said staff should scrub their hands with soap for at least 20 seconds when they wash their hands and all staff are trained on proper hand hygiene procedures. During an interview on [DATE] at 11:41 A.M., the administrator said staff should wash their hands anytime their hands become contaminated, which would include after they pick something up off of the floor, after they wash dirty dishes and after they touch their body. The administrator said staff should scrub their hands with soap for at least 30 seconds when they wash their hands and all staff are trained on proper hand hygiene procedures upon hire, annually and as needed.

Based on observation, interview and record review, the facility staff failed to properly contain waste and refuse to prevent the harboring and/or feeding of rodents and pests when the facility failed ensure indoor and outdoor waste containers remained covered when not in actual use. The facility census was 61. 1. Review of 2022 United States Food and Drug Administration Food Code, subsection 5-501.113 (Covering Receptacles), showed Receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered: (A) Inside the food establishment if the receptacles and units: (1) Contain food residue and are not in continuous use; or (2) After they are filled; and (B) With tight-fitting lids or doors if kept outside the food establishment. Observation on 09/19/23 at 10:00 A.M., showed two of four lids open on the outside dumpster which contained waste. Further observation showed Laundry Aide R placed trash in the open side of the dumpster and walked away without closing the lids. Observation on 09/19/23 from 11:25 A.M. to 12:26 P.M., showed the waste container in the mechanical dishwashing station, which contained food and paper waste, uncovered and the area unattended by staff. Observation on 09/21/23 at 6:30 A.M., showed two of four lids open on the outside dumpster which contained waste. Observation on 09/21/23 at 7:09 A.M., showed the waste container in the mechanical dishwashing station, which contained waste, uncovered and the kitchen unattended by staff. Further observation showed the administrator entered the kitchen and left without covering the waste container. Observation on 09/21/23 at 7:32 A.M., showed the waste container in the mechanical dishwashing station, which contained waste, remained uncovered and the kitchen unattended by staff. During an interview on 09/21/23 at 10:55 A.M., the dietary manager (DM) said waste containers should be covered at all times and staff are trained on this requirement. The DM said the staff who use the dumpster outside should make sure the lids are closed after use. During an interview on 09/21/23 at 11:16 A.M., the administrator said the facility did not have a policy for use and maintenance of waste containers. The administrator said waste containers should be covered when not in use and staff should be trained on that requirement during orientation. The administrator said everyone is responsible to ensure the outside dumpster remains covered and whomever puts trash in the dumpster should close the lids when they are done.

Based on observation, interview and record review, the facility staff failed to properly assess and care for a facility acquired pressure ulcer for one resident (Resident #5) of fifteen sampled residents. The facility staff also failed to identify and treat a pressure ulcer for one resident (Resident #9) of fifteen sampled residents and two (Resident #16 and #17) supplemental sample residents. The facility census was 65. 1. Review of the facility Wound Care and Treatment policy, dated 3/12, showed staff are to provide treatment to and document all treatments immediately after completion and apply barrier cream to residents after incontinent care. 2. Review of the Proper Notification policy, undated, showed staff are to contact the physician when a resident has a change in condition that warrants a professional opinion. Review also showed staff are to notify the resident's family of the resident's condition. Both notifications are to be documented in the nurses notes. 3. Review of the facility Pressure Ulcer Assessment tool, not dated, showed the following pressure wound assessment criteria: -Stage I-non-blanchable redness of a localized area; -Stage II-partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough; -Stage III-Full thickness tissue loss, subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough may be present, but does not obscure the wound bed. -Stage IV-Full thickness tissue loss with exposed bone, tendon, and/or muscle. Slough or eschar may be present. -Unstagable related to eschar-Eschar is dead or devitalized tissue that is hard or soft in texture, usually black, brown, or tan in color. Necrotic tissue and eschar are usually firmly adherent to the base, sides and edges of the wound 4. Review of Resident #5's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 4/16/14, showed the facility staff assessed the resident as follows: -Problems with short and long term memory; -No recall ability; -Inattention and disorganized thinking; -Extensive assistance of two staff for bed mobility; -Total dependence of two staff for transfers and toileting; -Total dependence of one staff for locomotion and hygiene; -Partial physical assistance of one staff member for bathing; -Extensive assistance of one staff member for eating; -Impaired range of motion to bilateral lower extremities; -Always incontinent of bowel and bladder; -Moderately hard of hearing; -Rarely understands or understood during communication; -Unclear speech; -At risk for skin breakdown; -No Stage I or higher pressure ulcers present. Review of the resident's care plan, dated 10/16/13, showed the facility staff are directed to care for the resident as follows: -Assistance of two staff members for transfers and Hoyer lift; -Assume an unhurried manner; -Examine skin during bathing for signs and symptoms of breakdown; -Report any breakdown to the charge nurse immediately; -Notify hospice of change in condition; -Shower/bath twice per week; -Toilet upon rising, before and after meals, at bedtime, and as needed; -Assist with oral care as needed; -Examine mouth for [MEDICAL CONDITION], sores, or excessive bleeding; -Monitor for skin breakdown and reddened areas during each toileting episode; -Assess skin status and pressure points for sign of breakdown every shift; -Heel protectors to be applied at bedtime as needed; -Moiety physician if breakdown occurs for treatment orders; -Report any red or open areas immediately to the charge nurse; -Reposition as needed several times each shift; -Monitor for reddened areas; -Skin assessment to be done on admission, quarterly, and with significant change assessments. Further review of the resident's care plan showed an update, dated 4/8/14, which showed the following: -New stage I (Stage I-non-blanchable redness of a localized area), right outer ankle; -Dark red area, intact skin. Further review of the resident's care plan updated 4/11/14, showed the following: -Dietary to give extra eggs; -Keep resident off of right side; -Alternate between back and left side positions; -Keep pressure off of right ankle. Review of the Resident Information Page, dated 4/16/14, showed staff were provided the following information to guide care: -Hi/Lo mat; -Grab bars x 2; -2 staff assist with Hoyer transfer; -Skin Risk, Braden, 13; -Not an elopement risk; -Falls risk 12; -Large briefs to be used. Observation on 4/22/14 at 3:10 P.M. showed the resident lay in bed on his/her right side with his/her right ankle on the mattress and heel protectors at the head of the bed. Observation on 4/23/14 at 3:57 P.M. showed the resident up in Broda (a specialized wheelchair for positioning) chair with dark area to right outer ankle. Review of the resident's Braden Scale, an assessment tool used to predict pressure sore risk, dated 4/7/14, showed the facility staff assessed the resident at a score of 13, which indicates moderate risk for pressure sore development. Review of the resident's physician's orders [REDACTED]. Review of the resident's Weekly Assessment, dated 4/21/14, showed the staff identified a pressure sore to the resident's left ankle with a treatment in place. Review of a Pressure Wound Report, dated 4/8/14, showed the facility staff assessed the wound as follows: -Stage I (Stage I-non-blanchable redness of a localized area); -Pressure Wound; -Right outer ankle; -New; -Length 1 centimeter (cm), width 0.5 cm, no depth; -Facility acquired; -Dark pressure area, skin intact, no fluid filled, redness to surrounding tissue; -Treatment-skin prep to right outer ankle three times per day. Review of a Pressure Wound Report, dated 4/15/14, showed the facility staff assessed the wound as follows: -Stage I (Stage I-non-blanchable redness of a localized area); -Pressure Wound; -Right outer ankle; -Prior length 1 cm, prior width 0.5 cm, prior depth less than 0.1 cm; -New length 1 cm, new width 0.5 cm, new depth less than 0.1 cm; -Facility acquired; -No redness to surrounding tissue, discolored area remains, not open, no fluid noted; -Treatment-skin prep to right outer ankle three times per day. Review of the Pressure Wound Report, dated 4/21/14, showed the facility staff assessed the wound as follows: -Stage I (Stage I-non-blanchable redness of a localized area); -Pressure Wound; -Right outer ankle; -Prior length 1 cm, prior width 0.5 cm, prior depth less than 0.1 cm; -New length 0.6 cm, new width 0.3 cm, new depth less than 0.1 cm; -Facility acquired; -Remains discolored, hard area, no redness to surrounding tissue. -Treatment-skin prep to right outer ankle three times per day. Observation on 4/23/14 at 4:50 P.M., showed a dark brown circular area surrounded by redness to the resident's right outer ankle. Observation on 4/23/14 at 4:55 P.M., showed LPN K provided the following wound description: -Dark brown area measured length-0.9 cm, width 0.4 cm; -Reddened surrounding tissue length-3.5 cm, width 2.5 cm. During an interview on 4/23/14 at 4:55 P.M., LPN K said the wound is a stage IV because the wound bed cannot be seen. He/She also said there is not a wound nurse, but he/she does not make decisions about wound stages. During an interview on 4/23/14 at 4:58 P.M., the DON said she looked at the resident's wound earlier in the day and it was a stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough). During an interview on 4/23/14 at 5:01 P.M., the DON said the resident's wound was dark and closed. She also said the wound could be a stage IV or unknown due to the dark spot in the middle of the wound. During an interview on 4/23/14 at 5:07 P.M. LPN K said the wound was not a stage IV, but was an unstageable wound according to the facility assessment tool. During an interview on 4/24/14 at 6:20 A.M. CNA H said if any redness, bruising, peeling, or other skin abnormality is found he/she would tell the charge nurse. He/She also said overnight he/she repositioned Resident #5 on his/her right side repeatedly. He/She said he/she does not look at care plans, but gets report on how to care for the residents, including Resident #5. 5. Review of Resident # 9's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff dated 2/08/14, showed staff assessed the resident as: - Severely impaired decision making skills; - Totally dependent for bed mobility, transfers, toileting and hygiene; - Extensive assistance for dressing; - Range of motion bilaterally lower extremities are impaired; - Suprapubic catheter; - Occasionally incontinent; - [DIAGNOSES REDACTED]. - Pressure ulcers, Contractures of joint, ankle/foot, [MEDICAL CONDITION]; - Risk for pressure ulcers; - One Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough), dated 1/28/14 with granulation. Review of the resident's plan of care, dated 4/10/14, showed staff are directed as follows: -Assess skin status and pressure points for signs of breakdown every shift; -Barrier cream applied with each episode of incontinence; -Notify Physician should breakdown occur for treatment orders; -Report any red or open areas immediately to charge nurse; -Reposition as needed several times each shift monitor for any reddened areas; Review of the Braden Scale (form used to assess pressure sore risk) dated 4/03/14, showed a score of 14 (12 or less is high risk). Review of the resident's Physician order [REDACTED]. -Ordered 9/29/13 [MEDICATION NAME] to sacral an coccyx area each shift until healed. -3/26/14 pressure ulcers healed. Review of the resident's Medication Administration Record [REDACTED]. Observation on 4/24/14 at 11:15 A.M., showed an unidentified Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough) on the top of the left upper thigh approximately the size of a pea. During an interview on 4/24/14 at 11:30 A.M., CNA F said the resident sits on a bed pan for a bowel movement and cannot feel when he/she is finished. The resident does not call staff when he/she is finished. Review of the resident's Treatment Administration Record (TAR), dated 4/04/14 to 5/03/14 showed: -[MEDICATION NAME] (barrier cream) topically to buttocks three times daily ordered 9/29/13; - 3/26/14 healed buttocks; -4/24/14 The surveyor found a Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough,) Left upper thigh pressure ulcer, pink 0.3 by 0.3 by less than 0.1; -Staff applied barrier cream, fax the physician. Review of the Comprehensive CNA Shower Review shows: - 4/17/14 Bed bath no open areas; - 4/19/14 Bed bath no open areas; - 4/22/14 Bed bath no open areas. Review of the Non-Decubitus Conditions Weekly assessment: - 4/04/14 [MEDICATION NAME] powder to perineal area; - 4/11/14 [MEDICATION NAME] to perineal area, [MEDICATION NAME] to sacral and coccyx; - 4/18/14 [MEDICATION NAME] to perineal area, [MEDICATION NAME] to sacral and coccyx no new open areas. Review of the Pressure Wound Report for three weeks consecutively 4/13/14, 4/15/14 and 4/21/14 showed the resident does not have any red areas or open wounds. 6. Review of Resident #16's MDS, a federally mandated assessment instrument completed by facility staff, dated 3/04/14, showed staff assessed the resident as: -Severely impaired decision making skills; -Extensive assistance with transfers, dressing,toileting and hygiene; -Range of motion is impaired bilaterally; -Frequently incontinent of bowel; -Always incontinent of bladder; -No pressure ulcers. Review of the resident's plan of care, dated 9/03/13, showed staff are directed as follows: -Monitor for skin breakdown and reddened areas during each toileting episode; -Provide brief and bed pads when needed; -Assess skin status and pressure points for signs of breakdown every shift; -Barrier cream applied with each episode of incontinence; -Notify Physician should breakdown occur for treatment orders; -Report any red or open areas immediately to charge nurse; -Reposition as needed several times each shift monitor for any reddened areas. Review of the Braden Scale dated 3/11/14, showed a score of 15 (12 or less is high risk). Review of the resident's Physician order [REDACTED]. -[MEDICATION NAME] (barrier cream) topically to buttocks three times daily ordered 1/30/14. Review of the resident's Medication Administration Record [REDACTED]. Review of the resident's Treatment Administration Record (TAR), dated 4/04/14 to 5/03/14, showed staff are directed to apply: -[MEDICATION NAME] (barrier cream) topically to buttocks three times daily ordered 1/30/14. Review of the Comprehensive CNA Shower Review shows: -4/14/14 No open areas or redness; -4/16/14 Pressure Ulcer, dark purple, complaint of pain; -4/16/14 Charge nurse rechecked sacral area no redness or open areas; -4/18/14 No open areas or redness; -4/21/14 No redness or open areas; -4/23/14 [MEDICATION NAME] to bottom for frequent breakdown skin intact peeling from old ? No redness. Review of the Non-Decubitus Conditions Weekly assessment shows: -4/07/14 Coccyx red [MEDICATION NAME] applied to coccyx; -4/21/14 [MEDICATION NAME] to buttocks. Review of the Pressure Wound Report for three weeks consecutively 4/13/14, 4/15/14 and 4/21/14 showed the resident did not have any red areas or open wounds. Observation on 4/24/14 at 7:25 A.M., showed an unidentified, red pea size open area, Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough), at the top of the left buttocks. Review of the resident's nursing notes dated 4/24/14, showed staff did not contact and update the physician of the new open area, or chart a Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough) pressure ulcer was found. During an interview on 4/24/14 at 7:10 A.M., CNA Q said the resident had a stage II pressure sore that had previously been a stage I (Stage I-non-blanchable redness of a localized area). During an interview on 4/24/14 at 7:46 A.M., CNA Q said he/she told the charge nurse two and a half weeks before about two stage I (Stage I-non-blanchable redness of a localized area) pressure sores on the residents buttocks/low back area. He/She then said he/she told the nurse one and a half weeks before the wounds were getting worse and opened. CNA Q said the charge nurse said he/she would chart the worsened wounds and inform staff to keep the resident off of his/her back. He/She also said the resident is on his/her back a lot. 7. Review of Resident # 17 quarterly MDS, dated [DATE], showed the facility staff assessed the resident as follows: -Cognitive score of 11, indicated moderately cognitively impaired; -Extensive assistance with bed mobility, transfers, hygiene and toileting; -At risk for the development of pressure sores; -No pressure sores present; -Frequently incontinent of bowel and bladder. Review of the resident's Care Plan, dated 9/11/13, showed the facility staff were directed to care for the resident as follows: -Assistance of two staff for activities of daily living (ADLs); -Concave mattress; -Examine skin during bathing for signs and symptoms of breakdown; -Report any breakdown to the nurse immediately; -Shower/bath 2 times per week; -Assess skin and pressure points for signs of breakdown every shift; -Barrier cream to be applied with each episode of incontinence; -Notify physician should breakdown occur for treatment orders; -Post incontinence cleaning and care provided by staff; -Report any red or open areas immediately to the charge nurse; -Reposition as needed several times each shift; -Monitor for any reddened areas; -Skin risk assessment to be done on admission, quarterly, and with significant change assessments. Further review of the care plan showed an update on 4/24/14, which showed the following: -Stage II Left buttock (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough); -Treatment to be initiated; -Keep off of left buttock; -Awaiting further orders. Observation on 4/24/14 at 10:05 A.M., showed the resident lay in bed on his/her back with the head of the bed elevated. Further observation showed no barrier cream on the resident's buttocks. Review of the resident's Weekly Assessment, dated 4/14/14, showed dry skin present. Review of the resident's Braden Scale, an assessment tool used to predict pressure sore risk, dated 4/3/14, showed the facility staff assessed the resident at a score of 18, which indicates a mild risk of pressure sore development. Review of a nurse's note, dated 4/24/14 at 10:45 A.M., showed the staff measured the wound as length 0.1 cm, width 0.1 cm, and depth less than 0.1 cm. Staff also charted the wound bed as red, surrounded by a white area. Review of the resident's POS, dated 4/4/14-5/3/14, showed no orders for wound care or preventative intervention. Review of the resident's Treatment Administration Record (TAR), dated 4/4/14-5/3/14, showed no orders for wound care or preventative intervention. 8. During an interview on 04/24/14 at 6:08 A.M., CNA A said when a skin issue is found, the CNA should report to the charge nurse. During an interview on 4/24/14 at 7:10 A.M., CNA Q said any skin issues he/she is not aware of should be reported to the nurse. He/She said examples of reportable skin issues are redness, warmth, scratches, and bruises, especially over bony areas. He/She said if a resident has a pressure sore, the resident should be turned and repositioned at least every two hours. He/She also said the charge nurse can be asked about specific care needs of residents. CNA Q said he/she knows there are care plans, but does not know where to find them and only has access to the Resident Information Page to guide care. During an interview on 04/24/14 at 9:26 A.M., Register Nurse (RN) P said the treatment nurse is responsible for measuring all skin wounds. The RN said skin wounds are measured reported on the weekly wound report. The weekly wound report is turned into the Director of Nursing (DON) by Wednesday of each week. The RN said he/she expects the CNA's to report immediately when they find a skin issue. The RN said the nurse is responsible to assess the wound and notify the resident's physician and obtain orders if needed. During an interview on 4/24/14 at 12:10 P.M. the administrator said residents' skin should be assessed daily. The CNA's should report any skin issues to the charge nurse, the nurse is to check the area and call the physician for treatment orders. The nurse should complete a skin assessment weekly on every resident. The ADON completes a weekly wound report to track reported wounds. She also said if the nurses feels the area is questionable the DON should assess. She also said she had no knowledge of a stage II pressure sore on Resident #16 and it must be very new. She said a CNA reported the area open "last week" but it was not at the time. She said she was told this morning about Resident #17's stage II pressure sore. She said she was not aware of a stage II pressure sore on Resident #9's thigh. During an interview on 4/24/14 at 12:10 P.M. the DON said the licensed nurses complete a yearly training about pressure wounds and the last inservice addressed wound staging. She also said she reviews the weekly wound reports, and that the staging of Resident #5's wound was "an error." She also said a new treatment was needed because skin prep is "not enough." She said the CNA's can get to the care plans and should know not to turn Resident #5 on his/her right side. She also said she had no knowledge of a stage II pressure sore on Resident #16 and it must be very new. She said a CNA reported the area open "last week" but it was not open at the time. She said she was told this morning about Resident # 17's stage II pressure sore. She said she was not aware of a stage II pressure sore on Resident #9's thigh.

Based on observation, interview, and record review, staff did not address one resident's (Resident #13) complaints of pain timely, did not report the resident's pain symptoms to the Physician, and did not administer the resident's PRN (as needed) pain relief medication to treat complaints and symptoms of increased pain. The facility census was 57. 1. Review of Resident # 13's Minimum Data Set (MDS), a federally mandated assessment instrument, dated 3/16/12, showed staff assessed the resident as follows: - Moderate cognitive impairment; - Required assistance from staff for transfers, walking, dressing, toilet use and personal hygiene; - Independent with eating with only setup help required; - Frequently incontinent of bladder and bowel; - Listed [DIAGNOSES REDACTED]. - [MEDICAL CONDITION]; - Staff did not document any information to show staff assessed the resident's oral/dental status. Review of the resident's comprehensive care plan, dated 12/19/11, showed staff identified the resident needs assistance with transfers, walking, dressing, grooming, personal hygiene, and bathing. Review showed staff did not identify pain as a problem area for the resident. Further, review showed staff were directed to provide the following interventions for the resident: - Encourage self-expression to ensure needs are met; - Monitor and document the resident's food intake; - Provide eating assistance if the resident becomes fatigued; - Staff set-up and prompts to consume meals as needed. Review of the resident's nurses note, dated 12/7/11, showed staff documented a dentist came to the facility to extract one of the resident's teeth. Review of the resident's nurses note, dated 5/12/12 at 5:00 P.M., showed staff documented the following: - The resident complained of tooth pain; - Staff left a message on an answering matching for a family member of the resident to notifying them of the resident's tooth pain; Review showed staff did not document the notification of a physician. Review showed staff did not document any pain interventions. Observation on 5/14/12 at 6:10 P.M., showed the resident sat at the dining room table with his/her right hand cupped on her right cheek and not eating any of his/her supper. The resident said he/she had a "very bad tooth ache" and was "not able to eat." Review of the resident's Intake and Output sheet, dated 5/14/12, showed staff documented the resident ate 50% of breakfast, 10% of lunch, and refused supper. Observation on 5/15/12 at 8:05 A.M., showed the resident sat at the dining room table with a plate of breakfast foods uneaten in front of him/her. The resident said his/her tooth "still hurts very badly." During an interview on 5/15/12 at 8:10 A.M., CMT Q said he/she was aware of the resident's tooth ache and the resident receives a scheduled pain medication. CMT Q said he/she administered pain medication for the resident. CMT Q said the resident has had tooth problems in the past and has seen a dentist that comes to the facility. CMT Q said the facility Social Worker was also aware and was making an appointment for the resident to see the dentist. Observation on 5/15/12 at 10:45 A.M., showed an unidentified staff member told LPN I the resident would not participate in restorative therapy because he/she said his/her "tooth hurt too bad." Observation during this time showed LPN I did not assess the resident or address the unidentified staff member's reports about the resident's complaints of tooth pain for at least 15 minutes. During this time LPN I remained at the nurses' station. Review of the resident's Intake and Output sheet, dated 5/15/12 staff documented the resident ate "bites" of breakfast and 25% of lunch. Further, review showed staff did not document any information about the resident's supper. Observation on 5/16/12 at 10:35 A.M., showed the resident said "I'm all mixed up right now, I have a toothache" while holding the right side of his/her face. Observation on 5/16/12 at 10:40 A.M., showed LPN O assessed the resident's pain. Observation on 5/16/12 at 10:50 A.M., showed the resident sat in a wheelchair holding the right side of his/her face. Observation on 5/16/12 at 11:30 A.M., showed the resident sat in the dining room and complained of tooth pain. During an interview on 5/16/12 at 11:35 A.M., LPN O said the resident does not have a dental appointment set up yet because he/she was unable to reach a family member for the resident to find out which dentist the family wants the resident to see. During an interview on 5/16/12 at 12:20 P.M., the Social Service Director said the following: - Today was the first time staff notified her about the resident's tooth pain; - The resident had "phantom tooth pain" in the past; - Staff think the resident's pain could be from allergies [REDACTED].; - Staff need to get ahold of of the resident's spouse to see if he/she wants the resident to see a dentist. Observation on 5/16/12 at 2:25 P.M., showed a dentist examined the resident in the hallway near the shower room. During an interview on 5/16/12 at 2:45 P.M., the Social Services Director said the following: - She contacted the dentist "today" and he came to the facility; - The dentist examined the resident's teeth and said the resident had a broken tooth with an exposed root, which was causing the resident's pain; - The dentist extracted the resident's broken right upper tooth. Review of the resident's nurses note, dated 5/16/12 at 2:30 P.M., showed staff documented a dentist came to the facility to pull the resident's tooth. Review of the resident's Intake and Output sheet, dated May 2012, showed for 5/16/12 staff documented the resident ate 10% of breakfast and 25% of lunch. Further, staff documented the resident ate 75% of supper. Review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review showed staff documented they administered only one dose of [MEDICATION NAME] to the resident, which was on 5/15/12 at 8:20 A.M.. Further, review showed staff documented the [MEDICATION NAME] was effective. Observation on 5/17/12 at 8:30 A.M., showed the resident ate all of his/her breakfast. During an interview on 5/17/12 at 2:00 P.M., CNA F said the following: - The resident complained of tooth pain for two weeks; - He/she told "several nurses" about the resident's tooth pain; - The resident told staff he/she did not want to go to meals because of the tooth pain. Review of the resident's nurses notes showed dated 5/1 through 5/14/12 showed staff did not record an assessment of resident's complaints of tooth pain or discomfort until 5/12/12 at 5:00 PM. During an interview on 5/17/12 at 2:30 P.M., LPN B said the following: - He/she knew about the resident's tooth pain on Monday (5/14/12); - This was the second episode of tooth pain the resident had; - He/she did not know if staff contacted the resident's physician about the resident's tooth pain; - He/she did not notify the resident's physician about the tooth pain because he/she received report from another nurse about the resident's pain, so he/she assumed the other nurse notified the resident's physician about the pain; - If the resident complained of tooth pain, staff should notify the resident's physician. -The resident's Physician was "out" this week so staff have not attempted to call and report the resident's tooth pain. LPN B did not assess the resident's complaints of tooth pain and did not contact the resident's physician and report the symptoms to inform the physician and seek treatment to relieve or address the resident's discomfort.

Based on observation, interview and record review, the facility failed to implement interventions and adequately supervise two residents (Resident # 2 and # 9) with a history of falls, resulting in multiple subarachnoid hemorrhages for one resident (Resident # 2) and a broken shoulder for one resident (Resident # 9). Further, the facility failed to provide a safe environment for the confused residents by leaving hazardous items accessible to the confused residents including: an unlocked housekeeping closet with multiple chemicals in it; an unlocked mechanical room with accessible wires; an open medication cart drawer which contained multiple medications; and unlocked shower room cabinets that contained razors and sharps. The facility census was 57. 1. Review of Resident # 2's Minimum Data Set (MDS),a federally mandated assessment instrument, dated 3/5/12 showed the facility staff assessed the resident as follows: - Severely impaired cognitive skills for daily decision making; - Impaired vision; -Requires extensive assistance from staff for bed mobility, transfers, dressing, eating and toilet use; - Totally dependant on staff for locomotion; -Always incontinent of bladder and bowel; - Listed [DIAGNOSES REDACTED]. - Weighed 88 pounds; - Used a wheelchair; - One fall, since admission or the prior MDS assessment, resulting in a minor injury; - One fall, since admission or the prior MDS assessment, resulting in a major injury. Review of the resident's comprehensive care plan, dated 3/14/11 , showed staff identified the resident had an unsteady gait, poor safety awareness, was at risk for injury from falls due to routine psychotropic medication, and had a history of [REDACTED]. - Monitor for acute illness and notify physician as needed; - One to two person assistance for transfers and ambulation; - Ensure call light is within reach and encourage the resident to call for help before attempting transfers; - Report all falls to the physician; - Offer the resident reassurance and attention from facility staff; - String alarm in place to alert staff of independent transfers; - Mat on each side of bed; - Bed in lowest position. Review of the resident's nurses note, dated 7/28/11 at 6:05 P.M., showed staff documented the following: - Staff found the resident laying on his/her back in another resident's room; - The resident told staff he/she was trying to go to bed; - No apparent injury noted; - Staff assisted the resident to his/her bed and placed a personal bed alarm under the resident. Review of the resident's comprehensive care plan, updated 7/28/11, showed staff updated the care plan to include the following: - At 6:05 P.M. staff found the resident lying on his/her back in another resident's room; - The resident's wheelchair was on it's side; - The resident was trying to get in bed and a bed alarm was in place and sounding; - Staff did not observe any injuries to the resident; - The resident's mental status was normal for the resident and the resident was very anxious and impulsive; - New intervention planned for staff to assist the resident to bed after meals. Review showed the CNA care book (used by nurse aides and contains directions for staff in assisting residents) did not contain any information to shows staff updated the book with direction for staff to assist the resident to bed after meals. Review of the resident's nurses note, dated 8/6/11 at 9:05 P.M., showed staff documented the following: - A Certified Nurses Aid (CNA) heard a personal bed alarm sounding; - When the CNA entered the resident's room he/she found the resident lying on the floor with his/her feet up in the air next to the resident's roommates bed; - The resident told staff he/she hit his/her head; - Staff did not observe any injuries to the resident. Review of the resident's comprehensive care plan, dated 3/14/11, showed staff updated the care plan on 8/6/11 to include the following: - A CNA heard a personal bed alarm sounding; - When the CNA entered the resident's room he/she found the resident lying on the floor with his/her feet up in the air next to the resident's roommates bed; - The resident told staff he/she hit his/her head; - Staff did not observe any injuries to the resident; - New intervention resulting from this fall was for staff to apply a string alarm to the resident and ensure it is on at all times. Review of the resident's nurses note, dated 1/17/12 at 10:30 A.M., showed staff documented the following: - The resident was screaming and climbing out of bed; - The resident was combative with staff and other residents; - Staff called the resident's physician and received an order for [REDACTED]. - Staff administered the Ativan to the resident and the resident "slightly calmed down." Review of the resident's Medication Administration Record (MAR), dated 1/4/12 through 2/3/12, showed staff documented an order for [REDACTED]. Review showed a staff member documented he/she administered PRN Ativan to the resident on 1/17/12 at 10:30 A.M.. Further, review showed staff did not document the administration of any other doses of PRN Ativan for 1/17/12. Review of the resident's nurses note, dated 1/17/12 at 6:50 P.M., showed staff documented the following: - The resident repeatedly leaned forward and scooted to the edge of the wheelchair; - CNAs repositioned the resident several times and walked away from the resident and the residents alarm sounded; - Staff found the resident laying on the floor on his/her left side; - A "significant amount of blood" dripped from the left side of the resident's head; - Staff called 911; - Staff called the resident's physician who gave an order for [REDACTED]. - The resident was cooperative and compliant with the Emergency Medical Technicians (EMTs) and the charge nurse; - EMTs placed a cervical collar on the resident and transported the resident to the hospital. Review of the resident's hospital nurses notes, dated 1/18/12 at 9:15 P.M., showed hospital staff documented the resident had the following injuries: - A laceration to the left temple; - Skin tear to the left hand; - Abrasion to the left elbow. Review of the resident's Critical Care Medicine History and Physical, dated 1/18/12 at 1:00 A.M., showed a hospital physician documented the resident was admitted to the hospital on [DATE] with multiple subarachnoid hemorrhages (bleeding) after falling from his/her wheelchair at the facility. Review of the resident's Physician's Progress Note, dated 1/20/12, showed the resident's physician documented the following: - The resident fell at the facility resulting in a large laceration and hospitalization ; - A computed tomography (CT) scan (uses X-rays to make detailed pictures of structures inside the body) completed at the hospital showed a subarachnoid hemorrhage involving most lobes of the brain; - The resident was kept under observation at the hospital and had no additional bleeding and was readmitted to the facility with hospice. Review of the resident's Hospice Admission Note, dated 1/19/12, showed a hospice nurse documented the resident's admitting [DIAGNOSES REDACTED]. Review of the resident's comprehensive care plan, dated 3/14/11, showed staff updated the care plan as a result of the fall on 1/17/12. Staff documented the following in the care plan: - On 1/17/12 at 6:20 P.M., the resident was at the nurses station and was very restless; - CNAs repositioned the resident and walked a couple of steps away and the resident leaned forward and hit his/her head on the floor; - The resident received two lacerations to the side of his/her head as a result of the fall; - Staff sent the resident to the hospital; - As a result of the fall on 1/17/12, staff implemented a new intervention of placing the resident in a Broda chair (A chair which provides comfort, pressure redistribution and positioning support; the chair can also tilt and recline to help keep the resident properly positioned in the chair, without needing to use physical restraints) while out of bed. Review of the resident's nurses note, dated 3/3/12 at 6:00 A.M., showed staff documented the following: - A Nurse Aid (NA) heard a fall alarm and went to the resident's room and found the resident laying on his/her left side on the floor and the resident's Broda chair flipped over; - The resident complained of left head pain, had a bruise to the left temple, and a golf ball sized hematoma (bruise) to the back of the left head; - Two staff persons assisted the resident back into the Broda chair and reclined the chair; - "Staff failed to recline the resident's Broda chair and the NA was educated on the importance of reclining the Broda chair. Review of the resident's comprehensive care plan, dated 3/14/11, showed staff updated the care plan as a result of the fall on 3/3/12 to include for staff to make sure to recline the resident's Broda chair at all times except for at the dinner table. Review of the Intake and Output book showed care sheets, undated, with information on them about the care each resident needs. Review of the care sheets showed staff did not document any information about needing to recline Resident #2's Broda chair. Observation on 5/14/12 at 5:05 P.M. showed the resident lay in bed awake without the personal alarm attached to the bed. During this time CNA C and CNA D entered the resident's room to provide incontinence care. The resident's string personal alarm remained unattached. Staff did not ensure the resident's bed alarm was attached and functioning properly while in bed to alert staff of the resident's attempts to rise unassisted and assist in preventing accidents and possible injuries. During an interview on 5/18/12 at 10:15 A.M., the Director of Nurses (DON) said the following: - She was unsure if the nursing staff on duty, at the time of the fall on 1/17/12, tried any other interventions with the resident besides repositioning to help the resident's restlessness, but if they had they should have charted it; - Nursing staff should always recline the resident's Broda chair, except for at meals. 2. Review of Resident # 9's MDS, dated [DATE], showed staff assessed the resident as follows: - Moderately impaired cognitive ability; - Severely impaired vision (no vision or sees only light, colors or shapes); - Required extensive assistance of two staff members for bed mobility, transfers, and toilet use; - Required extensive assistance of one staff member for locomotion, dressing, eating, and personal hygiene; - Had an upper and lower extremity impairment on one side; - Frequently incontinent of bladder; - Occasionally incontinent of bowel; - Had listed [DIAGNOSES REDACTED]. - One fall, since admission or the prior MDS assessment, resulting in a minor injury; - One fall, since admission or the prior MDS assessment, resulting in a major injury. Review of the resident's comprehensive care plan, dated 2/18/11, showed staff identified the resident was blind, had a history of [REDACTED]. The resident's care plan directed staff to do the following for the resident: - Offer the resident reassurance and attention from facility staff; - Provide a calm and predictable environment; - Keep call light with in reach of the resident and respond to the call light promptly; - Encourage the resident to call for help before attempting transfers; - Monitor gait and balance and provide assistance as needed; - Notify physician if need for skilled therapy arises; - Monitor for acute illness and notify physician as needed; - One to two staff person to assist with transfers; - Report all falls to physician; - Place a string alarm on the resident at all times to alert staff of the resident's attempts to transfer without assistance. Review of the resident's nurses note, dated 5/1/11, showed staff documented the following: - Staff observed the resident on the floor; - The resident told staff he/she slipped out of the wheel chair; - No apparent injuries. Review of the resident's comprehensive care plan, dated 2/18/11, showed after the fall on 5/1/11, staff implemented a new intervention for the resident to have shoes on when up in a wheelchair. Review of the nurses notes, dated 5/25/11 at 6:30 A.M., showed staff documented the following: - The resident told staff he/she sat on the side of the bed and tried to pull a blanket out from under him/her and slid off the bed; - The resident received two scratches from the fall. Review of the resident's comprehensive care plan, dated 2/18/11, showed after the fall on 5/25/11, staff implemented a new intervention to remind the resident not to sit on the edge of his/her bed and to call for assistance when removing things from the bed. Review of the nurses notes dated 10/3/11 at 3:30 A.M., showed staff documented the following: - The resident yelled out "Help, Help" and "I'm on the floor"; - Staff found the resident lying on his/her back next to his/her bed; - The resident told staff he/she was sitting on the side of the bed and fell off; - No apparent injuries. Review of the resident's comprehensive care plan, dated 2/18/11, showed as a result of the fall on 10/3/11 staff implemented a new intervention to place mats by the bed while the resident is in bed. Review of the nurses note dated 12/24/11 at 1:45 A.M., showed staff documented the following: - The resident yelled "Can I get some help please"; - Staff found the resident face down on the floor laying next to his/her bed; - The resident was unsure of what happened and told staff "I'm pretty sure I slipped off the bed"; - The resident complained of right shoulder pain and told staff he/she hit his/her head; - Staff ask the resident if he/she wanted to go to the hospital and the resident declined; - Staff did not document whether or not the fall mat staff implemented after the resident's last fall was in place or not; - Staff did not document whether or not the resident had his/her string alarm on at the time of the fall. Review of the nurses note dated 12/24/11 at 9:10 A.M., showed staff documented they called the resident's physician because the resident complained of "excruciating pain" to his/her right shoulder. The physician ordered a mobile x ray for the resident's right shoulder. Review of the resident's right should x ray, dated 12/24/11, showed an acute nondisplaced incomplete fracture of the humeral neck (broken right shoulder). Review of the resident's comprehensive care plan, dated 2/18/11, showed staff failed to implement any new fall prevention interventions as a result of the fall on 12/24/11. Review of the resident's nurses notes, dated 2/8/12., showed staff documented the following: - At 2:35 P.M., a CNA saw the resident fall forward out of chair to his/her right side; - The resident sustained [REDACTED]. - The resident complained of right shoulder pain and right elbow pain and staff notified the resident's physician of the fall and pain and the physician ordered a portable x ray of the resident's right elbow and ordered for staff to apply a seat belt to the resident's wheel chair for when the resident is up in the wheelchair; - The resident complained of right hip and right knee pain after the x ray of his/her shoulder was taken and staff called and notified the physician and received an order for [REDACTED]. - After the portable x rays of the resident's right hip and right knee were taken, staff received an order from the resident's physician to send the resident to the emergency room for pain management and a second x ray to the resident's right hip. Review of the resident's nurses note, dated 2/9/12, showed staff documented the following: - The resident returned from the emergency room at 2:15 A.M. - Hospital staff called a report to the facility and told the facility they were unable to find anything wrong with the resident and his discharge [DIAGNOSES REDACTED]. - The resident returned to the facility with new medication orders for pain. Review of the resident's comprehensive care plan, dated 2/18/11, showed staff updated the resident's care plan as a result of the fall on 2/8/12 to include a new fall intervention of a seatbelt to be on the resident when the resident is in the wheelchair. Review of the resident's nurses note, dated 4/21/12 at 9:30 A.M., showed staff documented the following: - Staff found the resident laying face down on the floor in his/her bedroom in front of a recliner; - The resident said he tried to kick out the foot rest of the recliner and fell forward to his/her left side; - The resident did not have any apparent injuries; - Staff did not document if the resident's string alarm sounded; - Intervention to prevent reoccurrence is to ensure string alarm on and functioning and to remind the resident to call for assistance. Review of the resident's comprehensive care plan, dated 2/16/12, showed staff failed to updated the resident's care plan , after the fall on 4/21/12, to include any new interventions to prevent falls. Review of the resident's nurses note, dated 4/22/12 at 3:35 A.M., showed staff documented the following: - Staff found the resident on the mat on the floor beside his/her bed; - The resident told staff he tried to get out of bed to "help a friend in need"; - The resident received no apparent injuries; - Staff did not document if the resident's string alarm sounded. Review of the resident's comprehensive care plan, dated 2/16/12, showed staff implemented a new interventions of a bed alarm and a chair alarm as a result of the fall on 4/22/12. Review of the Intake and Output book showed care sheets, undated, with information on them about the care each resident needs. Review of the care sheets showed staff are supposed to: - Use two staff to transfer the resident; - Fasten the resident's seatbelt when the resident is in the wheelchair; - Keep a string alarm on the resident at all times. During an interview on 5/18/12 at 10:25 A.M., the DON said the following: - The staff discontinued the resident's string alarm on 7/27/11 because it agitated the resident; - The staff implemented the string alarm, for the second time, for the resident after the resident's fall on 12/24/11, which resulted in a broken shoulder. Review of the resident's comprehensive care plan, dated 2/16/12, showed after staff discontinued the resident's string alarm on 7/27/11 they failed to document the discontinuation in the care plan and did not include any new fall prevention interventions to replace the string alarm to prevent the resident from falls and injuries. Observation on 5/15/12 at 6:10 A.M., showed the resident sitting in a wheelchair in his/her room with a blanket over his/her head. Observation showed staff had not fastened the resident's seatbelt and had not placed the resident's call light within reach. Observation on 5/15/12 at 6:50 A.M. showed the resident yelling "help me" from his room. LPN S entered the resident's room and found the resident slid partially down into his/her wheelchair. The resident's call light was attached to the bed rail but not within reach and the seat belt was not attached to the resident. Further observation showed the resident's buttocks slid off the seat of the wheelchair and his/her back laid against the seat of the wheelchair. At this time LPN S said he/she could not transfer the resident alone so he/he left the resident in this position and went to get help. The resident continued to yell, "help me" as LPN S left the room. Observation on 5/15/12 at 6:40 A.M., showed LPN S looking for another staff member to assist him/her with repositioning the resident. LPN S opened the door to room 403 where CNAs G and K, provided care to a resident. LPN S said "I need one of you". CNA K replied "It's going to be a minute". LPN S replied "I ain't got long" Resident # 9 "is starting to slide". Observation on 5/15//12 at 12:05 P.M., showed the resident called out for help. Observation showed CNA E entered the resident's room. Observation showed the resident slid partially out of his/her wheelchair. Observation showed staff had not fastened the seatbelt of the resident's wheelchair. Observation showed staff had not placed the resident's call light within reach. CNA E entered the resident's room and assisted the resident with repositioning in the wheelchair. Observation showed CNA E then fastened the seatbelt on the resident's wheelchair. Observation showed the resident told CNA E that he/she wanted to go to bed. Observation showed CNA E positioned the resident's wheelchair by his/her bed and unfasten the resident's seatbelt. Observation showed CNA E did not lock the resident's bed and wheelchair before he/she transferred the resident. Observation showed CNA E did not use a second person to assist with the transfer. Observation showed as CNA E lifted the resident out of the wheelchair, the wheelchair moved backwards. Observation showed after CNA E stood the resident up he/she turned the resident to sit him/her down in bed and the bed moved back as CNA E sat the resident down in the bed. Observation on 5/15/12 at 2:20 P.M., CNAs E and F stand the resident up from the toilet. Observation showed CNAs E and F sat the resident in the wheelchair. Observation showed CNAs E and F took the resident into his/her room and transferred the resident from the wheelchair to his/her bed. Observation showed CNAs E and F failed to place a gait belt around the resident to aid with safety. Observation on 5/16/12 at 8:20 A.M., showed the resident sat in a wheelchair in his/her room. Observation showed staff had not fastened the seatbelt around the resident and had not placed the resident's call light within reach. Observation on 5/16/12 at 2:25 P.M., showed the resident sat in his/her room in a wheelchair with the call light laying on his/her bed (not within reach). The resident yelled "Will somebody please give me a hand?" Observation showed two unidentified staff members walking by the nurses station (within hearing distance of the yelling resident). Observation showed the two staff members failed to assist the resident. The resident continued to yell for help. Observation on 5/16/12 at 2:30 P.M., showed the resident continued to sit in his/her room in a wheelchair with a call light laying on his/her bed (not within reach). The resident yelled "Help!" and continued to yell for help. Observation showed CNA E walked out of the shower room, by the nurses station (within hearing distance of the yelling resident), and into another residents room as Resident # 9 yelled for help. Observation showed LPN O outside of a shower room (within hearing distance of the yelling resident) by a medication cart assisting a resident. During this time other staff were not available in the area or did not assist the resident. Observation on 5/16/13 at 2:33 P.M., showed the resident continued to yell for help and no staff member had been to check on the resident since he/she started yelling at 2:25 P.M.. Observation showed the resident yelled "I need some help!" and CNA E walked by the nurses station and into the resident room. CNA E ask the resident what he/she needed and the resident said "I really need to go to the bathroom." CNA E told the resident he/she had to go get a second person to assist him/her to the toilet. Observation on 5/16/12 at 2:35 P.M., showed the resident continued to sit in his/her room in a wheelchair with a call light laying on his/her bed (not within reach). CNA E and LPN O entered the residents room and assisted the resident to the toilet. Observation on 5/17/12 at 8:15 A.M., showed CNA P wheeled the resident in a wheelchair to his/her room. Observation showed the resident ask to go to bed. Observation showed CNA P asked the resident if they needed another person to help transfer, or if one staff member to transfer the resident would be enough. Observation showed the resident said he/she though one staff member would be enough. Observation showed CNA P did not lock the resident's bed or wheelchair and tried to stand the resident up but was unable. Observation showed CNA P left the room. Observation showed CNA P and CNA F entered the residents room and CNA F locked the resident's wheelchair and bed and CNAs F and P transferred the resident to his/her bed. During an interview on 5/1712 at 8:20 A.M., the resident said he/she could not undue the seatbelt staff were suppose to place on him/her while in the wheelchair. During an interview on 5/17/12 at 8:25 A.M., CNA P said the resident use to be able to undue the seatbelt staff place on him/her but can no longer undue it. CNA P said staff should keep the resident's call light within the resident's reach when the resident is in his/her room. During an interview on 5/17/12 at 6:00 P.M., CNA D said the following: - The resident requires two staff persons for transfers; - Staff should ensure the seatbelt on the resident's wheelchair is fastened around the resident when he/she is in the wheelchair; - Staff should always make sure the resident's call light is within the resident's reach when the resident is sitting in his/her room; - Staff should always use a gait belt to transfer the resident; - Staff should ensure the resident's bed and wheelchair are locked before attempting to transfer the resident to/from the bed or wheelchair. During an interview on 5/17/12 at 2:30 P.M., LPN B said the following: - There should always be two staff to transfer the resident, that one staff member should never attempt to transfer the resident alone; - Staff should keep the resident's call light within the resident's reach when the resident is in his/her room; - Staff should always fasten the seatbelt around the resident when he/she is in the wheelchair to prevent him/her from slipping out; - Staff should use a gait belt when they transfer the resident; - Staff should lock the resident's bed and wheelchair before attempting to transfer him/her. During an interview on 5/18/12 at 10:15 A.M., the DON said the following: - Staff should transfer the resident with two staff and a gait belt; - Staff should lock the resident's bed and wheelchair prior to transfers; - If a resident yells for help, staff should immediately go check on that resident. 3. During an interview on 5/17/12 at 6:00 P.M., CNA D said there are care sheets in the front of each Intake and Output book which is what the CNAs look at to know what care to provide each resident. 4. During an interview on 5/17/12 at 2:30 P.M., LPN B said there are care sheets in the front of each Intake and Output book which is what the CNAs look at to know what care to provide each resident. 5. Observation on 5/14/12 at 12:25 P.M., showed the mechanical room door unlocked. Observation showed the room contained multiple electric cords and wires and was accessible to confused residents. Observation on 5/14/12 at 4:55 P.M., showed the housekeeping closet door unlocked and accessible to confused residents. Observation showed the closet contained multiple chemicals including: - A can of bug killer with a label which read "Hazardous to humans and domestic animals"; - A can of flying insect killer with a label which read "Hazardous to humans and domestic animals"; - A bottle of carpet spot remover with a label which read "Caution: Keep out of reach of children"; - A large container of odor eliminator with a label which read "Caution: Keep out of reach of children"; - A large container of tub and tile cleaner with a label which read "Caution: Keep out of reach of children"; - A large container of glass cleaner with a label which read "Caution: Keep out of reach of children"; - A large container of disinfectant with a label which read "Caution: Keep out of reach of children"; Further, observation showed five unidentified residents sitting within sight of the housekeeping closet with no staff in sight. Observation on 5/14/12 at 6:30 P.M., showed the cabinets were unlocked in the north side's shower room on the main hall, which contained disposable razors and a sharps container. Observation on 5/15/12 at 8:20 A.M., showed the mechanical room door continued to be unlocked. Observation showed the room contained multiple electric cords and wires and was accessible to confused residents. Observation on 5/15/12 at 8:20 A.M., showed the housekeeping closet door continued to be unlocked and accessible to confused residents. Observation showed the closet contained multiple chemicals including: - A can of bug killer with a label which read "Hazardous to humans and domestic animals"; - A can of flying insect killer with a label which read "Hazardous to humans and domestic animals"; - A bottle of carpet spot remover with a label which read "Caution: Keep out of reach of children"; - A large container of odor eliminator with a label which read "Caution: Keep out of reach of children"; - A large container of tub and tile cleaner with a label which read "Caution: Keep out of reach of children"; - A large container of glass cleaner with a label which read "Caution: Keep out of reach of children"; - A large container of disinfectant with a label which read "Caution: Keep out of reach of children". Observation on 5/16/12 at 6:00 P.M., showed the mechanical room door continued to be unlocked. Observation showed the room contained multiple electric cords and wires and was accessible to confused residents. Observation on 5/16/12 at 6:00 P.M., showed the housekeeping closet door continued to be unlocked and accessible to confused residents. Observation showed the closet contained multiple chemicals including: - A can of bug killer with a label which read "Hazardous to humans and domestic animals"; - A can of flying insect killer with a label which read "Hazardous to humans and domestic animals"; - A bottle of carpet spot remover with a label which read "Caution: Keep out of reach of children"; - A large container of odor eliminator with a label which read "Caution: Keep out of reach of children"; - A large container of tub and tile cleaner with a label which read "Caution: Keep out of reach of children"; - A large container of glass cleaner with a label which read "Caution: Keep out of reach of children"; - A large container of disinfectant with a label which read "Caution: Keep out of reach of children". Observation on 5/17/12 at 7:45 A.M., showed the mechanical room door continued to be unlocked. Observation showed the room contained multiple electric cords and wires and was accessible to confused residents. Observation on 5/17/12 at 7:45 A.M., showed the housekeeping closet door continued to be unlocked and accessible to confused residents. Observation showed the closet contained multiple chemicals including: - A can of bug killer with a label which read "Hazardous to humans and domestic animals"; - A can of flying insect killer with a label which read "Hazardous to humans and domestic animals"; - A bottle of carpet spot remover with a label which read "Caution: Keep out of reach of children"; - A large container of odor eliminator with a label which read "Caution: Keep out of reach of children"; - A large container of tub and tile cleaner with a label which read "Caution: Keep out of reach of children"; - A large container of glass cleaner with a label which read "Caution: Keep out of reach of children"; - A large container of disinfectant with a label which read "Caution: Keep out of reach of children". During an interview on 5/18/12 at 8:40 A.M., showed Housekeeper T said the housekeeping staff should always ensure the housekeeping closet door is locked after they open the door. During an interview on 5/17/12 at 2:30 P.M., LPN B said the following: - Staff should keep the housekeeping and mechanical closets locked because there are confused residents that occasionally wander; - He/she has never seen a resident attempt to get into the housekeeping or mechanical closets because they are always kept locked. 6. Observation on 5/15/12 at 6:40 A.M. showed LPN S administer