Every finding on record at Heritage Hall Nursing Center

Based on interview and record review facility staff failed to document treatments as ordered by the physician for four residents (Resident #1, #2, #3 and #4). The facility census was 40.1. Review of the facilities Wound Treatment Management policy, revised 11/07/25, showed the purpose of the policy is to promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Treatments will be documented on the Treatment Administration Record or in the electronic health record.2. Review of Resident #1's Quarterly Minimum Data Set, dated [DATE], a federally mandated assessment tool, showed staff assessed the resident with moderate cognitive impairment and diagnoses of gluteal cleft wound.Review of the resident's physician order sheet (POS), dated September 2025, showed staff were directed to administer Hydrocortisone External Cream 2.5 % one time a day and Dakins 0.25% solution (topical antimicrobial agent used to cleanse and disinfect wounds) twice a day.Review of the resident's Treatment Administration Record (TAR), dated September 2025, showed staff did not document they provided the resident Hydrocortisone External Cream 2.5 % (used for psoriasis treatment) on 09/06/25, 09/13/25 and 09/16/25 and Dakin's 0.25% solution, lightly pack wound with four-by-four gauze, cover with protective dressing on 09/23/25 as ordered.Review of the resident's TAR, dated October 2025, did not contain documentation staff completed the resident's treatments for Dakin's 0.25% solution, lightly pack wound with four by four gauze, cover with protective dressing on 10/04/25 and 10/11/25 as directed.3. Review of Resident #2's admission MDS, dated [DATE], showed staff assessed the residents as cognitively intact with diagnoses of right gluteus wound, and osteoarthritis.Review of the residents POS, dated September 2025, showed staff were directed to administer Voltaren (used for pain) External Gel 1% topical two times a day.Review of the resident's TAR, dated September 2025, showed staff did not contain document they provided the residents Voltaren External Gel 1% topical on 09/21/25 and 09/27/25 ordered.Review of the residents POS, dated October 2025, showed staff were directed to administer Voltaren External Gel 1% topical two times a day.Review of the resident's TAR, dated October 2025, showed staff did not document they provided the residents Voltaren External Gel 1% topical on on 10/11/25 as ordered.4. Review of Resident #3's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact with diagnoses of lymphedema, cellulitis, localized edema, and weakness.Review of the residents POS, dated September 2025, showed staff were directed to cleanse wound, pat dry, place Xeroform (sterile, non adherent gauze dressing) over any open wounds, cover with secondary dressing, wrap with gauze one time a day, apply ace wraps for edema two times a day, and Triamcinolone Acetonide (for rash treatment) External Cream 0.1 percent two times a day.Review of the resident's TAR, dated September 2025, did not contain documentation staff completed the resident's treatments wound cleanser, pat dry, place Xeroform over any open wounds, cover with secondary dressing, wrap with Kerlix for wound healing on 9/15/25 and 9/23/25 and ace wraps on 09/06/25, 09/13/25, 09/21/25 and 09/27/25, Triamcinolone Acetonide External Cream 0.1 percent on 09/15/25, 09/21/25, 09/23/25 and 09/27/25 as directed.Review of the residents POS, dated October 2025, showed staff were to apply ace wraps for edema two times a day, and Triamcinolone Acetonide External Cream 0.1 percent two times a day.Review of the resident's TAR, dated October 2025, did not contain documentation staff completed the resident's treatments as directed for Ace wraps on 10/11/25 and Triamcinolone Acetonide External Cream 0.1 percent on 10/08/25 as directed.During an interview on 11/06/25 at 10:23 A.M., the resident said he/she often does not get treatments on his/her legs even after he/she asks staff.5. Review of Resident #4's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact with diagnoses of stroke, edema, and wounds.Review of the residents POS, dated August 2025, showed staff were directed to apply ace wraps for edema and remove at bedtime one time a day.Review of the resident's TAR, dated August 2025, did not contain documentation staff completed the resident's treatments for ace wraps on 08/16/25 as directed.Review of the residents POS, dated September 2025, showed staff were directed to cleanse wound to the right foot great toe wound with wound cleanser, pat dry, and apply Sorbact (wound dressing) ribbon, gauze, and secure with tape one time a day and apply ace wraps for edema and remove at bed time one time a day.Review of the resident's TAR, dated September 2025 ,showed staff did not document they completed the resident's treatments for cleanse wound with wound cleaner, pat dry, and apply Sorbact ribbon, gauze, and secure with tape on 09/25/25 and ace wraps on 09/06/25, 09/13/25 and 09/27/25 as directed.Review of the residents POS, dated October 2025, showed staff were directed to apply ace wraps for edema and remove at bed time one time a day.Review of the resident's TAR, dated October 2025, showed staff did not document they completed the resident's treatments for ace wraps on 10/04/25 and 10/22/25 as directed.5. During an interview on 11/6/25 at 12:31 P.M., the administrator said all treatments are to be documented in the TAR in the facilities electronic health records program. He/She said if it's not documented then it wasn't done. He/She said he/she was not sure why treatments were not documented, and staff that have not documented should be written up for not following the policy.During an interview on 11/6/25 at 12:49 P.M., the Director of Nursing (DON) said he/she expects all treatments to be documented, if for some reason a treatment was not given, the expectation is to document why the treatment was not done. He/She said he/she does not know why staff are not documenting treatments. 2661490

Based on interview and record review, facility staff failed to implement appropriate infection control procedures to prevent the spread of communicable diseases when staff failed to screen seven staff (Certified Medication Technician (CMT) B, [NAME] D, Certified Nurse Aide (CNA) E, CNA F, Licensed Practical Nurse (LPN) G, Homemaker H and the Employee Experience Coordinator) out of 10 staff for tuberculosis (TB), a contagious, air-borne bacterial infection primarily affecting the lungs, in accordance with facility policy. The facility census was 38. 1. Review of the facility's policy titled TB Testing Policy, dated January 2025, showed: -It is the policy of this facility to follow current standards of practice, state regulations, Centers for Disease Control & Prevention (CDC) and Occupational Safety and Health Administration (OSHA) guidelines to prevent the transmission of TB;-Each employee and volunteer shall receive a tuberculin skin test (TST) in the two-step Mantoux method (a TB test where a small amount of purified protein derivative (PPD) solution is injected under the skin to detect exposure to the TB bacteria); -Within the state of Missouri, employees and volunteers working 10 or more hours per week shall receive a Mantoux PPD two-step TST within one month prior to starting employment at the facility; -If the initial test (first step) is zero to nine millimeters, the second test should be given within three to four weeks after employment begins;-The two-step performed within previous one month supported by documentation will be accepted, as well as previous positive test with screening or chest x-ray and/or written physician's statement to verify no active TB. 2. Review of CMT B's personnel records showed a hire and start date of 04/07/25. Review showed the records contained documentation of a negative two-step TST with the first step administered on 04/08/25 and the second step administered 05/08/25. Review of the records did not contain documentation of any additional TB testing. During an interview on 08/13/25 at 1:40 P.M., the Employee Experience Coordinator said he/she became responsible for employee TB testing in January 2025, and he/she keeps a log to track when employee's TB testing is due. He/She said staff should receive a two-step TST with the first step administered within one month prior to hire, the second within three weeks of their start date and both tests should be read 48 to 72 hours after administration. He/She said he/she would have been responsible for the CMT's TB testing and he/she did not have an answer as to why the CMT's TSTs were administered late. He/She said he/she could not provide any additional documentation of TB testing for the CMT. 3. Review of [NAME] D's personnel records showed a hire date of 11/14/24 and a start date of 11/19/24. Review showed the records contained documentation of a negative two-step TST with the first step administered on 11/19/24 and the second step administered on 12/17/24. Review of the records did not contain documentation of any additional TB testing. During an interview on 08/13/25 at 1:30 P.M., the Business Office Manager (BOM) said he/she had been responsible for employee TB testing prior to January 2025. Employees should receive a two-step TST with the first step being done within one month prior to hire, the second within three weeks of their start date and both tests should be read 48 to 72 hours after they are administered. The BOM said, when he/she oversaw employee TB testing, he/she would instruct the on-duty nurse to administer the employee's TST beginning on their hire date and give the nurse the TB testing form to complete and return to him/her when completed. The BOM said he/she did not track when the tests were administered, and he/she just overlooked that the cook's tests were not done on time. The BOM said he/she did not know why the cook's start date is listed as 11/19/24 instead of 11/14/24 and he/she could not provide any additional documentation of TB testing for the cook. 4. Review of CNA E's personnel records showed a hire and start date of 07/17/25. Review showed the records contained documentation of a negative one-step TST administered on 07/15/25. Review showed the records did not contain documentation of any additional TB testing. During an interview on 08/13/25 at 1:40 P.M., the Employee Experience Coordinator said he/she administered the CNA's second TST on 08/08/25, but he/she did not document the administration and all TST administration and results should be documented. He/She said he/she did not read the results of the CNA's second TST because the CNA works nights, so he/she did not know if the CNA had TB. He/She said he/she could not provide any additional documentation of TB testing for the CNA. 5. Review of CNA F's personnel records showed a hire date and start date of 02/21/25. Review showed the records contained documentation of a negative two-step TST with the first step administered on 02/22/25 and the second step administered on 03/05/25. Review of the records did not contain documentation of any additional TB testing. During an interview on 08/13/25 at 1:40 P.M., the Employee Experience Coordinator said he/she administered the CNA's first TST on 02/21/25 and at that time, he/she thought it was okay to administer the first TST on their start date but found out later that he/she was to administer the TST before they started work. He/She said he/she did not know why he/she documented that he/she administered the TST on 02/22/25 when he/she did it on 02/21/25 and the record should show the date it was administered. He/She said he/she could not provide any additional documentation of TB testing for the CNA. 6. Review of LPN G's personnel records showed a hire and start date of 11/11/24. Review showed the records contained documentation of a negative two-step TST with the first step administered on 11/11/24 and the second step administered on 12/20/24. Review of the records did not contain documentation of any additional TB testing. During an interview on 08/13/25 at 1:49 P.M., the BOM said he/she would have been responsible to have a nurse do the LPN's TB testing. The BOM said he/she did not know why the nurse administered the LPN's second step TST late and he/she just overlooked that it did not get done on time. The BOM said he/she could not provide any additional documentation of TB testing for the LPN. 7. Review of Homemaker H's personnel records showed a hire date and start date of 10/30/24. Review showed the records contained documentation of a negative two-step TST with the first step administered on 10/31/24 and the second step administered on 12/01/24. Review of the records did not contain documentation of any additional TB testing. During an interview on 08/13/25 at 1:43 P.M., the BOM said he/she would have been responsible to have a nurse do the homemaker's TB testing. The BOM said he/she did not know why the nurse administered the homemaker's TB tests late and he/she just overlooked that it did not get done on time. The BOM said he/she could not provide any additional documentation of TB testing for the homemaker. 8. Review of the Employee Experience Coordinator's personnel records showed a hire and start date of 01/06/25. Review showed the records contained documentation of a negative two-step TST with the first step administered on 01/06/25 and the second step administered on 02/11/25. Review showed the records did not contain documentation of any additional TB testing. During an interview on 08/13/25 at 1:16 P.M., Employee Experience Coordinator said he/she would have been responsible to ensure staff completed his/her TB testing on time, but he/she did not have an answer as to why staff administered his/her second step TST late. He/She said he/she could not provide any additional documentation of TB testing. 9. During an interview on 08/13/25 at 2:00 P.M., the administrator said the Employee Experience Coordinator is responsible for employee TB testing. The administrator said employees should have a two-step TST with the first step given prior to starting and the second step given within 30 days. The administrator said TSTs should be read 48 to 72 hours after administration and the staff who administer the tests should document when the tests are given. The administrator said the staff member responsible should develop his/her own system to track the TB tests to ensure they are done timely. The administrator said he/she does not review the TB testing records for new hires, he/she thought staff were testing the new hired staff in accordance with the policy and he/she did not know staff were not tested for TB as required. The administrator also said he/she did not know the second step TST had to be administered within three weeks after hire.

Based on interview, and record review, facility staff failed to maintain a system that assured full, complete, and separate accounting of each resident's personal funds to preclude the commingling of resident funds with facility funds for three residents (Residents #23, #49 and #50) out of 102 sampled residents. The facility census was 38. 1. Review of the facility's policy titled Resident Personal Fund, revised [DATE], showed: -If the resident chooses to deposit personal funds with the facility, upon written authorization of a resident, the facility must act as a fiduciary of the resident's funds and hold, safeguard, manage, and account for the personal funds of the resident deposited with the facility;-The facility will deposit any resident's personal funds in excess of $50 in an interest-bearing account (or accounts) separate from any of the facility's operating accounts, and will credit all interest earned on resident funds to that account;-The facility will establish and maintain a system that assures a full and complete and separate accounting, according to generally accepted accounting principles, of each resident's personal funds entrusted to the facility on the resident's behalf;-The system will preclude any commingling of resident funds with facility funds or with the funds of any person other than another resident;-Upon the discharge, eviction, or death of a resident with personal funds deposited with the facility, the facility will convey within 30 days the resident's funds and a final account of those funds to the resident, or in the case of death, the individual or probate jurisdiction administering the resident's estate, in accordance with state law. 2. Review of the facility's accounts receivable aging report, dated [DATE], showed Resident #23 with a current resident liability credit balance of $7961.30. Review of the resident's accounts receivable transaction report, dated [DATE] through [DATE], showed resident liability payments made to the resident's account as follows: -$876 on [DATE];-$584 on [DATE];-$4500 on [DATE];-$0.30 on [DATE];-$991 on [DATE]; -$1010 on [DATE];Total $7,961.30. Review of the resident's MO Healthnet Vendor Notice, dated [DATE], showed the resident with a zero dollar Medicaid surplus amount effective as of [DATE]. Review of the resident's MO Healthnet Vendor Notice, dated [DATE], showed the resident with a zero dollar Medicaid surplus amount effective for the months of February 2024 through [DATE]. During an interview on [DATE] at 8:30 A.M., the Business Office Manager (BOM) said he/she reviews the accounts receivable about every 30 days and if there is a credit balance he/she investigates the reason for the credit balance. The BOM said if the investigation shows the credit balance is the resident's money, then it should be refunded right away. The BOM said the resident's payer source was Medicaid pending until they received the Mo Healthnet Vendor Notices in [DATE] verifying that he/she had been approved for Medicaid effective as of February 2024 and the facility received payments from the resident's money for room and board during that time. The BOM said he/she kept the money in the operating account, because he/she wanted to verify that the resident did not have a surplus amount. The BOM said he/she emailed the family support division and his/her corporate representative on [DATE] regarding his/her concern about the resident's surplus amount, but he/she did not receive a response back about his/her concern and he/she had not followed up with anyone about it. The BOM said the $7961.30 belonged to the resident, there had not been any actions taken to date to refund the money to the resident and he/she did not have written authorization to hold the resident's money in the facility's operating account. 3. Review of the facility's accounts receivable aging report, dated [DATE], showed Resident #49 with a current private pay credit balance of $1367.50 and a discharge date of [DATE]. Review of the resident's medical records showed the resident discharged to home on [DATE]. Review of the resident's accounts receivable transaction report, dated [DATE] through [DATE], showed a private pay deposit of $1367.50 made to the resident's account on [DATE] which created a private pay credit balance of $1367.50. During an interview on [DATE] at 8:50 A.M., the BOM said the resident discharged to home on [DATE] and the resident's family made the $1367.50 payment without asking if the resident had a balance due. The BOM said the check was deposited to the facility operating account on [DATE] which created the credit balance and the $1367.50 belonged to the resident. The BOM said there had not been any actions taken to date to refund the money to the resident and he/she did not have written authorization to hold the resident's money in the facility's operating account. 4. Review of the facility's accounts receivable aging report, dated [DATE], showed Resident #50 with a current private pay credit balance of $2100 and a discharge date of [DATE]. Review of the resident's medical records showed the resident discharged to home on [DATE]. Review of the resident's accounts receivable transaction report, dated [DATE] through [DATE], showed in February 2025 the resident had a balance of $2110 due to the facility. Review showed a private pay deposit of $4210 made to the resident's account on [DATE] which left a private pay credit balance of $2100. Review of the resident's billing statement dated [DATE], showed the resident with a balance of $4210 due to the facility for room and board. During an interview on [DATE] at 8:55 A.M., the BOM said the resident discharged to home on [DATE]. The BOM said he/she got a call in February 2025 from the resident's lawyer who asked if the resident owed any money to the facility. The BOM said when he/she sent the [DATE] statement to the lawyer on [DATE], all of the adjustments to the resident's account had not been made so it showed the resident owed $4210. The BOM said the lawyer sent a check to pay the statement balance and the check was deposited to the operating account on [DATE] which left a private pay credit balance of $2100. The BOM said the $2100 belonged to the resident, there had not been any actions taken to date to refund the money to the resident and he/she did not have written authorization to hold the resident's money in the facility's operating account. 5. During an interview on [DATE] at 2:00 P.M., the administrator said the BOM is responsible for the resident funds and accounts receivable. The administrator said the BOM should review the accounts receivable at least once a week and if a resident has a credit balance, the BOM should contact the person responsible for the resident's money to notify them and refund the money. The administrator said funds that belong to a resident should be refunded within five days of discharge for living residents and within 30 days if deceased and when other actions need to occur like notifying of Medicaid funds. The administrator said he/she did not know about the resident credit balances or why the BOM did not refund the money and he/she could not provide any additional information about the resident credit balances held in the facility operating account.

Based on record review and interview, facility staff failed to document a complete and accurate Minimum Data Set (MDS), a federally mandated assessment tool, when staff did not accurately code medications administered for six residents (Resident #9, # 15, #26, #29, #30 and #39) out of 14 sampled residents. The facility census was 38.1. Review of the facility's policy titled MDS 3.0 Completion, dated 11/05/24, showed staff are directed to assess residents, using a comprehensive assessment process, to identify care needs and to develop an interdisciplinary care plan. According to federal regulations the facility conducts initially and periodically a comprehensive, accurate and standardized of each resident's functional compacity. When a resident's overall clinical status was not accurately represented on a submitted MDS, the facility staff have 14 days from the submission of the MDS, or identification of the error.2. Review of Resident #9's Significant Change MDS, dated [DATE], showed staff documented the resident received an anticoagulant (helps prevent blood clots). Review of the resident's Physician Order Sheet (POS), dated 08/25, showed an order for Clopidogrel Bisulfate (antiplatelet) 75 milligram (mg), give one tablet by mouth in the morning with start date of 03/27/25. 3. Review of Resident #15's Quarterly MDS, dated [DATE], showed staff documented the resident received antianxiety, antipsychotic and antidepressant medications.Review of the resident's POS, dated 08/25, showed the POS did not contain orders for an antipsychotic, antidepressant, or antianxiety medications.During an interview on 08/13/2025 at 1:58 P.M., the MDS Coordinator said he/she checks the resident's POS, to see if a resident receives psychotropic medications. The MDS Coordinator said the resident receives Aricept (acetylcholinesterase inhibitor) and he/she had been told the medication is psychotropic. The MDS Coordinator said the resident does not receive antipsychotic, antidepressant, or antianxiety medication. The MDS Coordinator said it is his/her error for marking those three drug classes on the resident's MDS, and he/she is responsible. During an interview on 08/14/2025 at 9:38 A.M., the Director of Nursing (DON) said the resident does not receive antipsychotic, antidepressant, or antianxiety medications. The DON said the resident's MDS is not accurate. 4. Review of Resident #26's Quarterly MDS, dated [DATE], showed staff documented the resident received an anticoagulant. Review of the resident's POS, dated 08/25, showed an order for Aspirin 81 mg with start date of 02/1/25. During an interview on 08/14/25 at 9:21 A.M., the MDS Coordinator said the resident receives Aspirin, which is an antiplatelet. 5. Review of Resident #29's Significant change MDS, dated [DATE], showed staff documented the resident received an anticoagulant.Review of the resident's POS, dated 08/25, showed an order for Aspirin 81 mg with start date of 06/19/25.During an interview on 08/14/25 at 9:21 A.M., the MDS Coordinator said the resident receives an antiplatelet medication, not an anticoagulant. The MDS Coordinator said the resident's MDS is not correct. 6. Review of Resident #30's Significant Change MDS, dated [DATE], showed staff documented the resident receives an anticoagulant.Review of the resident's POS, dated 08/25, showed an order for Aspirin 81 mg daily.During an interview on 08/14/2025 at 9:21 A.M., the MDS Coordinator said the resident receives Aspirin, not an anticoagulant, and the MDS shows anticoagulant therapy, so the MDS is not accurate. 7. Review of Resident #39's Quarterly MDS, dated [DATE], showed staff documented the resident received an anticoagulant.Review of the resident's POS, dated 08/25, showed an order for Aspirin 81 mg with start date of 10/08/24.During an interview on 08/14/2025 at 9:21 A.M., the MDS Coordinator said the resident receives Aspirin which is not an anticoagulant. The MDS Coordinator said on the resident's MDS is not accurate. 8. During an interview on 08/14/25 at 9:38 A.M., the DON said Aspirin is not an anticoagulant and should not be documented as one on the MDS. If aspirin is documented as an anticoagulant, then the MDS is not accurate. The DON said the corporate regional nurses review the MDS Coordinator's work. The DON said it is the responsibility of the regional nurses to ensure the MDS coordinator is completing the MDS accurately. During an interview on 08/14/25 at 10:50 A.M., the administrator said it is the responsibility of the MDS Coordinator to make sure MDS assessments are completed accurately. The administrator said the corporate nurses, oversee the MDS Coordinator's work on the MDS and review some of the assessments. The administrator said he/she is responsible to ensure the MDS Coordinator does his/her job correctly.

Based on observation, interview and record review, facility staff failed to properly contain waste and refuse to prevent the harboring and/or feeding of rodents and pests when the facility failed to ensure outdoor waste containers remained covered when not in actual use. This failure has the potential to affect all residents. The facility census was 38.1. Review of the facility provided policies from 08/11/25 through 08/14/25, showed did not contain a policy related to maintenance of outside waste containers. Review of the United States Food and Drug Administration Food Code, 2022 edition, 5-501.15, showed Receptacles and waste handling units for refuse, recyclables, and returnables used with materials containing food residue and used outside the food establishment shall be designed and constructed to have tight-fitting lids, doors, or covers. Observation on 08/11/25 at 12:30 P.M., showed the waste dumpster lids opened, and the waste dumpster contained waste. Observation on 08/12/25 at 2:30 P.M., showed Dietary Aide C disposed of waste in the outside waste dumpster and walked away without closing dumpster lids. During an interview on 08/12/25 at 2:30 P.M., the dietary manager said staff should close the lids on the dumpster after use and staff are trained on this requirement. Observation on 08/13/25 at 2:45 P.M., showed the waste dumpster lids opened, and the waste dumpster contained waste. Observation on 08/14/25 at 9:30 A.M., showed the waste dumpster lids opened, and the waste dumpster contained waste. During an interview on 08/14/25 at 9:30 A.M., the maintenance director said the lids on the dumpster should be closed when it is not in use. The maintenance director said he/she did not believe anyone had been assigned to monitor the dumpster and the staff who dispose of trash in it should close the lids after use. The maintenance director said he/she did not know if staff had been trained to close the lids on the dumpster after use. During an interview on 08/14/25 at 10:35 A.M., the administrator said all staff are responsible for the maintenance of the outside waste dumpster and staff should close the lids on the dumpster after use. The administrator said he/she did not believe that instruction to ensure the lids were closed on the dumpster was a part of any staff training program, so he/she did not know if they had been trained to close the lids.

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. This failure has the potential to affect all residents. The facility census was 87. 1. Review of the facility provided policies, showed the records did not contain a policy related to the qualifications for Director of Food and Nutrition Services. Review of the dietary manager's (DM) personnel records showed a hire date for the DM position listed as 04/20/23. Review showed a certificate of completion for a food protection manager course, which showed a start date of 02/21/24 and a completion date of 05/07/24. Review showed the records did not contain documentation of prior dietary manager experience in a nursing facility and certification or other education required for the director of nutritional services position. During an interview on 06/11/24 at 10:38 A.M., the DM said he/she had been the DM for about a year and he/she did not have prior experience as a dietary manager in a nursing facility and he/she did not have a degree or certification related to food service management. The DM said he/she completed a food protection manager course last month, but due to staffing issues, he/she missed his/her window to take the final exam for certification and would need to pay again to take the exam. The DM said he/she did not have an exam date schedule nor had he/she repaid for the exam yet and hoped to be able to pay to take the test again in two weeks when he/she got paid. The DM said the facility has a part-time consultant registered dietician (RD) that comes to the facility on ce a month and the facility did not have any certified or clinically qualified nutritional staff employed full-time. During an interview on 06/12/24 at 11:26 A.M., the administrator said the DM completed a food protection manager course and was waiting to take the final exam. The administrator said the DM did not report that he/she let the timeframe to take the final exam after his/her course expire due to staffing issues and needed to repurchase the exam to become certified. The administrator said the facility has a part-time consultant RD and they did not have any certified or clinically qualified nutritional staff employed full-time. During an interview on 06/12/24 at 12:54 P.M., the DM said he/she did not get enrolled in the manager's course until February because they did not know of the qualifications requirement for his/her position until January or February 2024. The DM said when they found out, they got with the RD about what they needed to do about it and it just took a little while to get him/her enrolled. During an interview on 06/12/24 at 1:09 P.M., the administrator said they did not get the DM enrolled in the course until February because they were not sure which course he/she needed to take. The administrator said they were going to enroll the DM into a certified dietary manager course, but knew they would need the oversight of the RD during that course and the RD got sick during that time and could only work from home. The administrator said when the facility had a mock survey in December 2023, he/she found out the DM could take a different course so they worked to get him/her enrolled in that course which they did in February 2024.

Based on observation, interview and record review, facility staff failed to thaw frozen meat using approved methods to prevent the growth of food-borne pathogens. Facility staff failed to store food in a manner to prevent contamination and out-dated use. Facility staff failed to reheat pureed food in accordance with the standardized recipes to prevent the growth of food-borne pathogens and potential for food-borne illness. These failures have the potential to affect all residents. The facility census was 41. 1. Review of the facility's Food Storage (Dry, Refrigerated and Frozen) policy, dated 2020, showed Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety. Review showed the policy did not contain instruction to staff on approved methods for thawing frozen foods. Observation on 06/11/24 from 9:50 A.M. to 11:09 A.M., showed a large frozen center cut pork loin sitting in food preparation sink with no water in the sink or running over pork loin. Observation also showed a box that contained five one pound packages of frozen sliced turkey deli meat on the countertop next to preparation sink. During an interview on 06/11/24 at 11:09 A.M., [NAME] A said he/she put the pork loin in the sink and sliced turkey on counter to thaw just before 9:50 A.M. The cook said the sliced turkey was to be used for dinner and he/she just had the pork loin in the sink to thaw so it can be cooked at another time. Observation on 06/11/24 at 11:54 A.M., showed the pork loin and sliced turkey deli slices in the food preparation sink with no water in the sink or water running over the food items. During an interview on 06/12/24 at 12:57 P.M., the dietary manager (DM) said frozen meat should be thawed in the refrigerator and he/she did not know why the cook placed the meat in the sink to thaw, because all dietary staff are trained on how to properly thaw frozen food. During an interview on 06/12/24 at 1:15 P.M., the administrator said staff should thaw frozen meat in the refrigerator on the bottom shelf and staff are trained on how to properly thaw frozen food. 2. Review of the facility's Food Storage (Dry, Refrigerated and Frozen) policy, dated 2020, showed: -Food shall be stored on shelves in a clean, dry area free from contaminants; -Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety; -Leftover contents of cans and prepared food will be stored in covered, labeled and dated containers in refrigerators and/or freezers. Observation on 06/11/24 at 9:50 A.M., showed the triple reach-in freezer in the aide's station contained opened and undated plastic bags of hashbrown patties, waffles, and sliced strawberries and an opened and undated box that contained multiple packages of croissant buns. Observation showed the top package of croissant buns in the box opened and undated. Observation also showed a bulk container of flour in the aide's station with a cup stored buried in the flour. Observation on 06/11/24 at 9:58 A.M., showed the reach-in refrigerator in the cook's station contained: -An opened and undated five pound container of sour cream; -An opened and undated 32 ounce (oz.) carton of liquid eggs; -An opened and undated 32 oz. bottle of lemon juice; -An opened and undated 32 oz. bottle of key lime juice; -An opened and undated 16 oz. bottle of Italian dressing; -An opened and undated seven oz. jar of [NAME] olives; -An opened and undated 24 oz. jar of kosher dill pickle spears; -An undated stack of white cheese slices wrapped in plastic film. Observation on 06/11/24 at 10:05 A.M., showed the cook's station contained: -An opened and undated 16 oz. container of cornstarch; -An undated box of baking soda opened to the air; -An undated and unlabeled plastic pitcher that contained an unidentifiable white powdered substance; -An opened and undated bag of corn chips. During an interview on 06/11/24 at 10:09 A.M., [NAME] A said staff use the baking soda for cooking and the white substance in the pitcher was potato flakes. The cook said opened food items should be dated and labeled and he/she did not know why they were not dated and labeled. Observation on 06/11/24 at 10:20 A.M., showed the dry goods storage pantry contained undated plastic containers of cornflakes, toasted oat o's and fruit [NAME] cereal removed from their original packaging. Observation also showed a box that contained five loaves of sliced bread wrapped in plastic sleeves stored on the floor in front of can rack. During an interview on 06/11/24 at 10:46 A.M., the DM said he/she is responsible to monitor food storage and he/she tries to do so every day when he/she is on duty. The DM said opened food items should be stored closed, labeled with what they are and dated with their opened date. The DM said staff should not leave scoops in the bulk food items and food should not be stored on the floor. The DM said all dietary staff are trained on proper food storage requirements and he/she did not know about the issues with the food storage. During an interview on 06/12/24 at 1:11 P.M., the administrator said opened food items should be labeled with what they are, dated with the date they are opened and stored sealed or in a covered container off the floor. The administrator said the DM is responsible to monitor the food storage several times a day when on duty and the dietary staff are trained on how to properly store food. 3. Review of the facility's Pureed Food Preparation policy, dated 2020, showed the policy directed staff to prepare pureed foods in accordance with standardized recipes to ensure quality, flavor, palatability, and maximum nutritive value and to heat pureed foods to a minimum of 165 degrees Fahrenheit ( F) before service. Review of the facility's standardized recipe for pureed tuna noodle casserole, undated, showed direction to staff to reheat the pureed casserole to an internal temperature to greater than 165 F for at least 15 seconds after made and to maintain the internal temperature at 135 F or above during service. During an interview on 06/11/24 at 11:15 A.M., [NAME] A said he/she prepares the pureed food items right before service so they will still be hot when served. Observation on 06/11/24 at 12:01 P.M., showed [NAME] A added prepared tuna noodle casserole and warm milk to the food processor and blended until smooth. Observation showed the cook scooped the pureed casserole into an insulated bowl and then, without checking the internal temperature, put a lid on the bowl, placed the bowl in the steamtable and walked away. Observation showed the internal temperature of the pureed tuna noodle casserole measured 100 F when the cook walked away. Observation on 06/11/24 at 12:27 P.M., showed [NAME] A placed the bowl of pureed tuna noodle casserole on a tray to be served to Resident #42 in his/her room without checking the internal temperature of the casserole. Observation showed the internal temperature of the pureed casserole measured 108 F at this time. During an interview on 06/11/24 at 12:38 P.M., [NAME] A said the internal temperature of hot pureed foods should be at least 140 F when put on the steamtable. The cook said he/she did not know what the temperature of the pureed casserole was when he/she put it on the steamtable because he/she did not take the temperature. The cook said he/she did not take the temperature of the pureed casserole because he/she did not think it cooled down that much when he/she made it. During an interview on 06/12/24 at 12:59 P.M., the DM said staff should check the internal temperature of pureed food items after they make them to make sure the hot pureed foods are at least 160 F before they are served. The DM said if a hot pureed food item is not 160 F after it is made then staff should reheat the item in the oven to an internal temperature of 160 F. The DM said dietary staff are trained on this requirement, so he/she did not know why the cook did not check the temperature of the pureed casserole. During an interview 06/12/24 at 1:17 P.M., the administrator said staff should check the internal temperature of pureed food when it is made and before it is served. The administrator said the internal temperature of hot pureed foods should be at least 165 F and if it is not, then staff should reheat it to 165 F. The administrator said dietary staff are trained on this requirement and he/she would expect the DM to periodically ask staff the requirements and check the internal temperatures to monitor for compliance.

Based on observation, interview, and record review, facility staff failed to ensure residents who are unable to complete their own Activities of Daily Living (ADLs) received necessary care and services to maintain good personal hygiene two residents (Resident #13 and #17) out of 14 sampled residents, when staff failed to assist with facial hair grooming, clothing changes and showers. The facility census was 41. 1. Review of the facility's policy titled Activities of Daily Living, dated 2023, showed care and services will be provided for the following ADL's: -Bathing, dressing, grooming, toileting and oral care; -Transfer and ambulation; -Eating to include meals and snacks; -A resident who is unable to carry out ADL's will receive the necessary services to maintain good nutrition, grooming, and personal or oral hygiene; -The facility will maintain individual objectives on the care plan. 2. Review of Resident #13's Admission Minimum Data Set (MDS), dated [DATE], showed staff assessed the resident as: -Moderate cognitive impairment; -Did not resist care; -Required moderate assistance from staff for hygiene, and dressing; -Required maximum assistance from staff for toileting, and bathing. Review of the resident's care plan, revised 05/08/24, showed staff were directed to: -Assist the resident with bed mobility, dressing, footwear, personal hygiene, and bathing; -Did not contain direction for refusal of care. Review of the facility's shower schedule, undated, showed the resident as scheduled for showers on Wednesday's and Saturday's. Review of the facility's shower documentation showed staff documented one shower given on 05/18/24. Review showed staff documented the resident refused a shower on 06/05/24. Observation on 06/11/24 at 10:16 A.M., showed the resident wore a green shirt and jeans. Observation on 06/12/24 at 7:15 A.M., showed the resident in bed and wore the same green shirt as the day before. Observation on 06/12/24 at 8:37 A.M., showed the resident in the hall and wore the same green shirt and jeans as the day before. Observation on 06/12/24 at 10:33 A.M., showed the resident in the dining room and wore the same green shirt and jeans. Observation on 06/13/24 at 7:55 A.M., showed the resident wore the same green shirt and jeans as the day before. Observation on 06/13/24 at 10:17 A.M., showed the resident wore the same green shirt and jeans. Observation on 06/13/24 at 12:01 P.M., showed the resident wore the same green shirt and jeans. Observation on 06/13/24 at 1:36 P.M., showed the resident wore the same green shirt. The shirt had a stain and food crumbs. Observation on 06/13/24 at 3:30 P.M., showed the resident sat in the hall and wore the same green shirt and jeans. Observation on 06/14/24 at 8:16 A.M., showed the resident wore the same green shirt and blue jeans on. Observation on 06/13/24 at 9:29 A.M., showed the resident wore the same green shirt and jeans. During an interview on 06/13/24 at 1:36 P.M., the resident said he/she needs help to change clothes. During an interview on 06/13/24 at 1:40 P.M., Certified Nurse Assistant (CNA) D said he/she worked the hall where the resident resided. CNA D said the resident needs assistance to change clothes, and with all his/her ADL care. CNA D said he/she is not sure why the resident had not had his/her clothes changed. 3. Review of Resident #17's Admission MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Did not resist care; -Required maximum assistance from staff for bathing, and dressing; -Dependent on staff for toileting, and hygiene. Review of the resident's care plan, revised 04/29/24, showed: -Resident received hospice services; -Resident has difficulty remembering and becomes easily confused; -Did not contain direction for ADL cares. Review of the facility's shower documentation showed it did not contain any documented showers provided by facility staff. Observation on 06/11/24 at 11:48 A.M., showed the resident sat in the dining room. Observation showed the resident wore a purple shirt and long facial hair. Observation on 06/12/24 at 7:42 A.M., showed the resident sat in the dining room. Observation showed the resident wore a purple shirt and long facial hair. Observation on 06/12/24 at 10:28 A.M., showed the resident long facial hair. Observation on 06/12/24 at 1:39 P.M., showed the resident wore an orange shirt and long facial hair. Observation on 06/13/24 at 7:55 A.M., showed the resident in bed with the same orange shirt on and long facial hair. Observation on 06/13/24 at 11:59 A.M., showed the resident in the dining room with the same orange shirt on and long facial hair. Observation on 06/13/24 at 1:39 P.M., showed the resident sat in the lobby. The resident wore the same orange shirt covered with food crumbs and had long facial hair. Observation on 06/13/24 at 2:10 P.M., showed the resident participated in an activity. The resident wore the same orange shirt covered with food crumbs and had long facial hair. During an interview on 06/12/24 at 12:40 P.M., Registered Nurse (RN) B said the resident is not on the facility shower list because he/she receives hospice services. RN B said resident's who are on hospice services get their showers from the hospice staff. During an interview on 06/12/24 at 3:55 P.M., the resident said he/she did not want to grow a beard. During an interview on 06/13/24 at 10:34 A.M., the Director of Nursing (DON) said if a resident receives hospice services the resident gets their scheduled shower by hospice staff twice a week. The DON said the facility staff only shower hospice residents as needed. The DON said all showers the facility staff provide are documented in the resident's chart. During an interview on 06/13/24 at 1:40 P.M., CNA D said he/she worked the hall where the resident resided. CNA D said the resident needs assistance to change clothes, shave, and with all his/her ADL care. CNA D said the resident is on hospice and hospice staff complete his/her showers, and shaves. CNA D said he/she is not sure why the resident's clothes had not been changed. 4. During an interview on 06/14/24 at 10:17 A.M., the Business Office Manager (BOM) said he/she was a Certified Medication Technician (CMT) and CNA. The BOM said he/she works the floor when the facility needs the assistance. The BOM said all residents are scheduled to get showers twice a week. The BOM said if a resident is on hospice the hospice staff does their scheduled showers and the facility staff only do them as needed. The BOM said hospice is an added entity for extra care and the facility is responsible to ensure a resident's care needs are met. The BOM said the CNA's are responsible to complete the showers assigned each day by the charge nurse. The BOM said he/she would expect staff to shave a resident with their shower and change their clothes. He/She said a resident should not wear the same clothes more than a day and staff should change them daily and as needed if soiled. During an interview on 06/14/24 at 10:20 A.M., CNA E said all residents are scheduled for showers twice a week and the CNA's are responsible to complete them. CNA E said if a resident is on hospice services the hospice staff completes their showers. CNA E said when staff give a shower they should provide nail care, shave the resident, and change their clothes. CNA E said a resident should have their clothes changed daily and as needed if they become soiled. During an interview on 06/14/24 at 10:33 A.M., RN B said residents are scheduled for showers twice a week. RN B said if a resident is on hospice services facility staff will give the resident a shower as needed, but hospice staff complete the scheduled showers. RN B said hospice is a supplemental care and the facility is responsible for the resident's cares. RN B said it is the charge nurse's responsibility to assign showers and the CNA's are responsible to complete them. RN B said he/she expects staff to change resident clothes and shave the resident when given a shower. RN B said residents should have their clothes changed daily and as needed if they become soiled. During an interview on 06/14/24 at 10:41 A.M., the Assistant Director of Nursing (ADON) said residents are offered showers twice a week and as needed. The ADON said if a resident is on hospice services facility staff will give the resident a shower as needed, but hospice staff complete the scheduled showers. The ADON said the CNAs are responsible to complete the showers and document them in the resident's chart. The ADON said he/she expects staff shave a resident, and change their clothes with each shower. The ADON said he/she expects staff to assist residents to change their clothes daily and as needed if they become soiled. During an interview on 06/14/24 at 10:41 A.M., the Director of Nursing (DON) said residents are scheduled for showers twice a week and as needed. The DON said if a resident is on hospice services facility staff will give the resident a shower as needed, but hospice staff complete the scheduled showers. The DON said the charge nurse is responsible to assign the showers each day. The DON said CNAs are responsible to complete the showers and document them in the resident's chart. The DON said he/she expects staff shave a resident, and change their clothes with each shower. The DON said the care plan should say how much care a resident needs for their ADL's The DON said he/she expects staff to assist residents to change their clothes daily and as needed if they become soiled. The DON said residents should not wear dirty clothes multiple days in a row. During an interview on 06/14/24 at 11:09 A.M., the Administrator said resident's are scheduled for showers twice a week and as needed. The Administrator said the CNA's are responsible to complete the showers and document them in the resident's chart. The Administrator said he/she expects staff to change a resident's clothes and shave a resident as needed with each shower. The Administrator said if a resident is on hospice services the facility staff only gives showers as needed and the hospice staff complete the scheduled showers. The Administrator said he/she expects residents to be assisted as needed for their ADL care and each resident's care plan should say how much care they need, and if the resident has behaviors such as refusing care. The Administrator said he/she expects staff to assist a dependent resident to change their clothes daily and as needed if they become soiled. The Administrator if a resident has a stain on their clothes or food staff should assist them to change their clothes.

Based on interview and record review, facility staff failed to provide residents with a written response to grievances. The facility census was 37. 1. Review of the facility's Resident and Family Grievances policy, dated 1/23/23, showed staff were directed as follows: - The grievance officer is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances; issuing written grievance decisions to the residents; and coordinating with state and federal agencies as necessary in light of specific allegations; - Upon request, the facility will give a copy of this grievance policy of the resident; - Evidence demonstrating the results of all grievances will be maintained for a period of no less than three years from the issuance of the grievance decision; - In accordance with the resident's right to obtain a written decision regarding his or her grievance, the grievance official will issue a written decision on the grievances to the resident or representative a the conclusion of the investigation. Review of the Resident Council minutes for January, February, and March 2023, showed staff did not document the residents received a written response to their grievances. During an interview on 3/22/23 at 1:46 P.M., the resident council said they do not receive written decisions regarding grievances expressed during the resident council meetings. During an interview on 3/24/23 at 8:11 A.M., the assistant director of nursing said they have grievance policy and a document that residents can fill out with their grievance. These are reviewed and given to the appropriate department to respond to. The staff will then discuss the response with the resident or the resident council. They do not give the resident or their representative a written response. During an interview on 3/24/23 at 8:22 A.M., the social services director said they have a grievance form that a resident or their family member can fill out. An investigation is done and at the conclusion they respond verbally to the resident or representative. They do not give a written response to the resident. During an interview on 3/24/23 at 8:30 A.M., the activity director said they talk to residents in person about grievances and forward these to department heads. They tell the residents in person the results and if they can resolve the grievance or not. The activity director said he/she did not think they gave the resident a written response to their grievance. During an interview on 3/24/23 at 8:40 A.M., the administrator said staff should take a grievance to the department head who then follows up on the grievance to investigate with the purpose of resolving the problem. They keep a form of the investigation in a binder and the results should also be given to the resident or family member.

Based on interview and record review, the facility failed to identify an appropriate discharge location in the 30 day discharge notice to meet the needs of two sampled residents (Residents' #1 and #3) of a sample of three residents the facility discharged from the facility. The facility census was 34. 1. Review of the facility's Transferor Discharge Policy Statement, revised December of 2016, showed Written Notices will be in writing and will contain all information required by state and federal law, rules, or regulations applicable to Medicaid or Medicare cases. In addition the form should state the effective date of the discharge or transfer and the location to which the resident is being discharged or transferred. 2. Review of Resident #1's Significant Change Minimum Data Set, dated dated [DATE], showed staff assessed the resident as follows: -Severely impaired cognition; -Required supervision and one person physical assistance for bed mobility, transfers, personal hygiene and locomotion on unit; -Required limited, one person physical assistance for dressing, toileting and bathing; -Always incontinent of bladder; -diagnosed with [CONDITION(S)], Hypertension ([CONDITION(S)]), [CONDITION(S)], [CONDITION(S)] and Dementia; -Disorganized thinking and inattention present, but fluctuates. Review of the resident's plan of care, revised 02/21/2022, showed staff assessed as follows: -Memory and decision making process not as reliable as it used to be, resident becomes confused and forgetful with any changes in environment or routines, resident may forget safety factors, so resident needs caregivers to help the resident stay safe as possible, the resident has issues with memory and is also frequently inappropriate. -Resident needs commonly used items to include the resident's call light within easy reach, resident needs to be reminded to ask for assistance when he/she needs it; -Resident is at risk for developing skin problems due to mobility and incontinence, it is important the caregivers reposition resident to help blood circulate and prevent problems; -Resident is incontinent of bowel and bladder, resident needs checked frequently to ensure he/she is dry and clean by a nursing assistant of one; -It is important for the nurse to keep track of resident's bowel movement, observe bowel records and ensure resident has bowel movement every three days; -Resident has wanderguard, resident is an elopement risk due to frequent exit seeking behaviors, resident needs someone with them at all times when resident goes outside. Review of the resident's 30 Day Discharge Notice, dated 03/17/2022, showed facility staff documented the resident's power of attorney's (POA) personal address as the location to which the resident will be discharged to. During an interview on 03/28/2022 at 8:18 A.M., the Social Service Director (SSD) said a 30-Day Discharge Notice had been sent out by certified mail on 03/17/2022 and the resident's discharge date is April 16th. The SSD said a referral package has been put together, but he/she is having issues finding a bed in a dementia Unit. The SSD said he/she had not contacted any facilities yet. The SSD said he/she thought the resident needed a secure unit for residents with dementia. During an interview on 03/28/2022 at 11:10 A.M., the Director of Nursing (DON) said the resident requires supervision with stand-by assistance. The DON said the facility had spoken with the resident's POA and explained the resident did not require skilled level care right now. The DON said the resident would be appropriate to live with his/her POA. During an interview on 03/28/2022 at 3:20 P.M., the resident's POA said he/she received a discharge notice for the resident. POA said the facility told him/her they would have to discharge the resident to the POA's home if payment isn't made. The POA said he/she would have to put the resident somewhere, because he/she could not care for the resident in his/her home. The POA said he/she could not personally deal with the resident's needs, and he/she thinks it would be unsafe for the resident to come to his/her home. The POA said he/she lived in a home with steps and the resident gets up and wanders at night, which would be pretty scary. During an interview on 04/01/2022 at 10:08 A.M., the resident's POA said no one from the facility ever assessed his/her home for placement of the resident. The POA said the facility staff never talked to him/her about sending the resident to his/her home, or he/she would have told them it is not an appropriate placement of care. The POA said he/she can not do it. During an interview on 04/01/2022 at 10:22 A.M., the DON said the facility did not assess the POA's home to ensure it is appropriate for the resident to discharge to. 3. Review of Resident #3's Quarterly MDS, dated [DATE], showed staff assessed resident as follows: -Moderately impaired cognition; -Required extensive, one person assistance with locomotion off and on unit; -Required extensive, two person assistance with bed mobility, dressing, toilet use and personal hygiene; -Totally dependent on two people for assistance with transfers; -Required two person assistance with bathing; -Always incontinence of bladder and frequently incontinent of bowel; -diagnosed with [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], Diabetes, [CONDITION(S)], Anxiety Disorder and Depression; -Weight of 349 pounds; -Received insulin injections, antipsychotic medications, anticoagulant, and a diuretic seven days of the of the look back period. Review of the resident's plan of care, revised 12/06/2021, showed staff assessed the resident as follows: -Resident is Diabetic, Nurse will need to check blood sugar and administer diabetic medication as ordered, if blood sugars are not within normal guidelines, the doctor will need to know so the doctor can decide if the resident's medications need to be adjusted; -Resident has a history of hiding medications, administer all medications and observe resident take medications, check resident's mouth afterwards to ensure medications are swallowed; -Resident has history of seizures and falls, if resident has [CONDITION(S)], place resident on side, maintain the resident's airway, maintain safe environment and notify the doctor of the resident's laboratory results as directed; -Resident's memory and decision making not reliable as it used to be, resident can become confused and forgetful with any change in resident's environment or routines. -Resident is at risk for developing skin issues, it is important for caregivers to reposition the resident frequently; -Resident requires physical assist of two person for bed mobility, dressing, personal hygiene, toileting and bathing, resident is also a two person with Hoyer (Mechanical lift device used to lift residents) for transfers; -Resident is incontinent of bowel and bladder, resident needs to be checked and toileted frequently; -It is important for nurse to keep track of bowel movements and review bowel movement records every three days; -Contact other level of care facility and/or skilled nursing facilities to determine if appropriate to meet resident's needs after rehabilitation; -Resident has remained in long term care due to level of function, resident would like to discharge home, but would need 24 hour care to do so. Review of the resident's 30-Day Discharge Notice to the resident, dated 03/17/2022, showed facility staff documented the resident's Durable Power of Attorney's (DPOA) personal address as the location to which the resident will be discharged . During an interview on 03/28/2022 at 8:18 A.M., the SSD said the resident will need skilled level of care. During an interview on 03/28/2022 at 11:10 A.M., the DON said the resident will require higher level of care, 24 hour care. The DON said he/she would recommend nursing home placement for the resident. During an interview on 03/30/2022 at 3:22 P.M., the resident's DPOA said it is his/her address on the discharge notice. The DPOA said he/she is [AGE] years old, he/she can not care for the resident in his/her home, the resident weighs between 350 and 400 pounds, and is in a wheelchair. The DPOA said he/she can barely care for himself/herself, how can he/she care for the resident? The DPOA said the facility staff have to use a hoyer lift to get the resident out of bed, how do they expect him/her to care for the resident? During an interview on 04/01/2022 at 10:14 A.M., the resident's DPOA said the facility never assessed his/her home for resident's care. The DPOA said the facility staff never asked him/her if he/she could care for the resident, or he/she would had told the facility, he/she couldn't. During an interview on 04/01/2022 at 10:22 A.M., the DON said facility staff did not assess the DPOA's home prior to discharge notice. The DON said the facility always knew the resident would need skilled level of care. The DON said, Honestly, I'm not sure why they put the DPOA's address on the discharge notice, it was the previous administrator who did the discharges. 4. During an interview on 03/28/2022 at 11:20 A.M., the Regional Nurse (RN) Consultant said he/she did not see in the regulation, where the address given on the discharge notice, had to be the address the resident would be discharged to. The RN said staff put POA's address, but would continue to make referral during the 30 days before discharge. The RN said he/she said she did not see in regulation where they had to have placement sent up for a resident before the facility gave a discharge notice. In the past the notice had been given and the resident does not always go to the address on the notice, because the facility would continue to make referral for placement of the resident during the 30 day period, before the facility discharged a resident. MO 895

Based on observation, interviews, and record review, the facility staff failed to perform hand hygiene appropriately when moving from a dirty task to a clean task. This failure had the potential to affect all residents who ate at the facility. The census was 29. 1. Review of the facility's Proper Hand Washing and Glove Use policy, dated 2020, showed: - All employees will use proper hand washing procedures and glove usage in accordance with state and federal sanitation guidelines; - All employees will wash hands upon entering the kitchen from any other location, after all breaks, and between all tasks; - Hand washing should occur at a minimum of every hour; - Employees will wash hands before and after handling foods, after touching any part of the uniform, face, or hair; - Hands are washed before donning gloves and after removing gloves; - When gloves must be changed, they are removed, hand washing procedure is followed, and a new pair of gloves is applied. Observation on 8/17/21 at 2:38 P.M., showed Cook F wore a face mask and adjusted the front of the facemask with his/her bare hand. Cook F did not perform hand hygiene after he/she touched his/her facemask and before he/she touched loaves of bread and various kitchen equipment. Observation on 8/18/21 at 9:50 A.M., showed Cook G prepared the lunch meal. Further observation showed Cook G removed his/her gloves, touched the trash can lid to discard gloves, and touched various kitchen equipment and utensils. He/she did not perform hand hygiene after removing gloves or touching the trash can and before touching kitchen equipment and utensils. Observation on 8/18/21 at 10:45 A.M, showed Cook G prepared the lunch meal. Further observations showed Cook G dropped the thermometer on the floor. He/she knelt down on the floor, with his/her hands on the floor, and picked up the thermometer. He/she did not perform hand hygiene afterhis/her hands were on the floor and before he/she continued to prepare the residents' lunch. Observation on 8/18/21 at 10:52 A.M., showed Cook G prepared the lunch meal. Further observation showed he/she dropped the oven mitts on the floor. Cook G picked up the oven mitts and placed them on the food service counter. He/she continued to use the oven mitts to transfer food from the oven to the steam table. He/she removed the oven mitts using his/her bare hand to the outside of the mitts, laid them on the food service counters, and continued to prepare the lunch meal. Cook G did not wash, sanitize, or replace the oven mitts after he/she dropped them on the floor. He/she did not sanitize the food service counters after contact with the soiled oven mitts. Cook G did not perform hand hygiene after removing the oven mitts and before touching various kitchen equipment and utensils. Observation on 8/18/21 at 10:57 A.M., showed Cook G washed a pot in the three compartment sink. He/she submerged his/her hands in the wash water and touched the faucet handles. Cook G continued to prepare the lunch meal. He/she did not perform hand hygiene when he/she moved from a dirty task to a clean task. During an interview on 8/18/21 at 1:40 P.M., the dietary manager was hired on 1/8/21, and he/she was not trained on the facility kitchen and food handling policies. The dietary manager said dietary staff were trained by the previous dietary manager, and they are familiar with the facility's policies. He/she said staff should perform hand hygiene when moving from a clean task to a dirty task, before and after putting on/taking off gloves, and whenever they come into the kitchen. The dietary manager said face masks, the floor, and the trash can are considered dirty, and staff should wash their hands immediately before moving to another task. He/she said staff are expected to remove and replace any food related items that touch the ground. During an interview on 8/18/21 at 3:35 P.M., the administrator said the dietary manager is responsible for ensuring food sanitation guidelines are followed, and he/she has been trained on the facility policies. The administrator said dietary staff are expected to perform hand hygiene when they enter/exit the kitchen, when moving from a dirty task to a clean task, and before and after putting on/taking off gloves. The administrator said staff should wash hands after touching their face masks, the trash can, and the floor. He/she said staff should immediately remove and replace any food related items that touch the floor.

Based on observation, interview, and record review, the facility staff failed to ensure a medication error rate of less than 5%. Out of 26 opportunities, two errors occurred, with two residents (Resident #10 and #14) resulting in a medication error rate of 7.69%. The facility census was 29. 1. Review of the facility's Medication Administration Policy, undated, showed weekly blood pressures should be taken on all anti-hypertensives unless physician has ordered holding and/or notification parameters for ordered medications. 2. Review of Resident #10's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 8/17/21 at 4:10 P.M., showed Licensed Practical Nurse (LPN) E did not assess the resident's blood pressure prior to the administration of the [MEDICATION(S)]. Review of the resident's medical record showed staff last documented the resident's blood pressure on 07/24/21. 3. Review of Resident #14's POS dated August 2021 showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 8/17/21 at 4:04 P.M., showed LPN E did not assess resident's blood pressure prior to the administration of the [MEDICATION(S)]. Review of the resident's medical record showed staff last documented the resident's blood pressure on 8/10/21. 4. During an interview on 8/17/21 at 4:15 P.M., LPN E said he/she was not sure why the resident's did not have their blood pressure checked prior to administration. He/She said they should check the blood pressure prior to administration if parameters are listed on the Medication Administration Record (MAR). During an interview on 8/18/21 at 11:35 A.M., Registered Nurse (RN) B, Charge Nurse, said blood pressures should be checked prior to administration when parameters are listed on the MAR. RN B also said the POS should be looked at as well to confirm if there are parameters listed that may not be on the MAR. During an interview on 8/18/21 at 11:50 A.M., the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) said blood pressure should be assessed prior to administering blood pressure medications, particularly when parameters are listed on the MAR and/or POS. They were not aware of the length of time that had elapsed since the last documented blood pressures for residents. They said per facility policy that each resident on anti-hypertensives should have blood pressure taken on a weekly basis, unless indicated otherwise by POS with orders for holding or parameters in place.

Based on observation, interview and record review, facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious organisms causing contaminants when staff failed to change or don new personal protective equipment, when staff would leave an identified COVID-19 positive resident's room and enter a negative COVID-19 resident's room to provide care. 29 of 33 residents have tested positive for COVID-19 so the facility considers the entire facility a covid positive area. The four negative residents are kept on the same hall as positive residents, but in separate rooms. The facility census was 33 1. Review of Center for Disease Control's (CDC) PPE guidance, dated November 4, 2020, showed the following guidance when working with the COVID-19 positive residents: Any reusable PPE must be properly cleaned, decontaminated, and maintained after and between uses. Facilities should have policies and procedures describing a recommended sequence for safely donning and doffing PPE; Disposable respirators and facemasks should be removed and discarded after exiting the patient's room or care area and closing the door; Reusable eye protection (e.g., goggles) must be cleaned and disinfected according to manufacturer's reprocessing instructions prior to re-use. Disposable eye protection should be discarded after use unless following protocols for extended use or reuse; Put on a clean isolation gown upon entry into the patient room or area. Change the gown if it becomes soiled. Remove and discard the gown in a dedicated container for waste or linen before leaving the patient room or care area. Disposable gowns should be discarded after use. Review of Center for Disease Control's (CDC) Preparing for COVID-19 in Nursing Homes guidance, updated November 20, 2020, showed: -Implement strategies to optimize current PPE supply even before shortages occur, including bundling resident care and treatment activities to minimize entries into resident rooms. Additional strategies might include: -Prioritizing gowns for activities where splashes and sprays are anticipated (including aerosol-generating procedures) and high-contact resident care activities that provide opportunities for transfer of pathogens to hands and clothing of HCP. -If extended use of gowns is implemented as part of crisis strategies, the same gown should not be worn when caring for different residents unless it is for the care of residents with confirmed COVID-19 who are cohorted in the same area of the facility and these residents are not known to have any co-infections (e.g., Clostridioides difficile). 2. Review of the facility's COVID-19 Preparedness and Response Guidelines, dated, 6/3/2020, showed staff are directed, when working with infected and isolation residents, to implement protocols for cohorting ill residents with dedicated healthcare professionals, as staffing and building allows. Review showed all protective equipment will be removed prior to leaving room and then the employee must exit room immediately. 3. Review of facility's untitled document, dated 12/1/2020, showed staff documented Resident #2's current status for COVID-19 as negative on 11/30/2020. Observation on 12/1/2020 at 11:45 A.M., showed the call light on for Resident #2. Observation showed certified nursing assistant (CNA) A, wearing full PPE to provide care for the 29 COVID-19 positive residents, responded to the call light. Outside the resident's door, the facility provided a supply of clean, disposable gowns. Observation showed the CNA placed a clean gown over his/her contaminated gown and entered the room of the resident. On exiting the room, the CNA removed the top gown in the the resident's room, which exposed the under PPE gown (gown the staff have been wearing all shift while working with COVID-19 positive residents), to the resident and possibly spreading virus. 4. Review of facility's untitled document, dated 12/1/2020, showed staff documented Resident #4's current status for COVID-19 as negative on 11/30/2020. Observation on 12/1/2020 at 11:56 A.M., showed CNA B had a gown, N-95 mask, face shield and shoe covers on to provide care for the facility's 29 COVID-19 positive residents. Observation showed the CNA took the noon meal cart and walked down the hall where the majority of residents were COVID-19 positive. Observation showed a supply of clean disposable gowns outside the resident's door. The CNA placed a clean disposable gown over the top of the PPE gown worn to provide care for COVID-19 residents. Observation showed the CNA entered Resident #4's room to deliver the meal tray. Observation showed the CNA remained in the resident's room to assist the resident with his/her meal. Prior to leaving the resident's room, the CNA removed the top gown, exposing the resident to the under PPE gown, worn to provide care for the COVID-19 residents, and possibly spreading [MEDICAL CONDITION]. During an interview on 12/1/2020 at 12:57 P.M., CNA B said because 29 of 33 residents have tested positive for COVID-19, all hallways are considered to be COVID-19 positive. Staff don full PPE when beginning work and wear the PPE for their full shift, unless it becomes soiled. The CNA said before entering the room of a resident negative for COVID-19, he/she is supposed to place a new gown over the PPE gown they had donned for the day, wash his/her hands, and put gloves on. The CNA said clean, disposable gowns are outside the room of each resident negative for COVID-19. Staff were instructed by the Director of Nursing (DON) to place a clean, disposable gown over the PPE gown they had been wearing for the day, before entering the negative resident's room. They have been instructed to discard the top gown before leaving the resident's room and place it in a designated container in the room. 5. Review of facility's untitled document, dated 12/1/2020, showed staff documented Resident #3's current status for COVID-19 as negative on 11/30/2020. Observation on 12/1/2020 at 12:03 P.M., showed the Social Service Director (SSD) walked down a COVID-19 positive hall wearing full PPE and carrying a resident's lunch tray. Further observation showed a supply of clean disposable gowns outside the resident's door. The SSD placed a clean gown over the PPE gown, worn on the COVID-19 positive hall, and he/she entered the room of a COVID-19 negative resident. Additional observation showed the SSD remained in the room, sat down, and assisted the resident with eating. During an interview on 12/1/2020 at 1:48 P.M., the SSD said the DON directed the staff to don a clean, disposable gown over the PPE gown worn when caring for COVID-19 positive residents, before entering a resident's room negative for COVID-19. 6. During an interview on 12/1/2020 at 2:20 P.M., the DON said staff working on the halls don PPE when beginning work because 29 of 33 residents have tested positive. The staff wear the PPE during their shift and would only change when soiled. When staff enter a COVID-19 negative resident's rooms, staff should cover the PPE gown with a clean, disposable gown kept outside the door of the negative resident's room. The DON said they received the direction to put the clean gown over the PPE gown from the medical director. During an interview on 12/1/2020 at 2:30 P.M., the administrator said the DON is the one who implemented the guidance to place clean gowns over the PPE gowns when staff enter a negative resident's room.

Based on interview and record review, facility staff failed to purchase a surety bond in an amount sufficient to assure security of all personal funds the facility holds. The facility census was 42. 1. Review of the resident trust fund account for Feburary 2019 through January 2020, showed an average monthly balance of $14,000, which requires a surety bond of $21,000. Review of the Department of Health and Senior Services (DHSS) database, showed the facility has an approved non-cancelable Escrow Agreement Account in the amount of $10,000.00. During an interview on 2/27/20 at 2:00 P.M., the Administrator and Business Office Manager (BOM) said they did not have proof of requesting an approval letter from the Department of Health and Senior Services in the required amount needed to be in complaince.

Based on observation, interview and record review, facility staff failed to use standardized recipes for the preparation of pureed food items and serve food items in accordance with the nutritionally calculated menus to all residents. The facility census was 46. 1. Review of Resident #7's Minimum Data Set (MDS), a federally mandated resident assessment, dated 09/14/18, showed staff assessed the resident with: -[DIAGNOSES REDACTED]. -problems with short and long-term memory; -severely impaired cognitive skills for daily decision making; -a mechanically altered diet. Review of the resident's meal tray card showed staff were directed to provide the resident with a pureed diet. Review of the facility menus, dated 12/06/18 (Day 33) showed staff were directed to provide the residents on pureed diets with the following food items and portion sizes for breakfast: -four ounces (oz.) of hot cereal or a #6 (5.3 oz.) scoop of pureed cold cereal; -a #16 (two oz.) scoop of pureed egg of choice; -a #20 (1.6 oz.) scoop of pureed breakfast meat; -a #20 scoop pureed breakfast bread; -one packet each of margarine and jelly. Observation on 12/06/18 at 6:41 A.M., showed one small pan of pureed food on the steamtable. During an interview on 12/06/18 at 6:41 A.M., Cook A said he/she pureed eggs, sausage, gravy, and bread all together to serve to the residents with pureed diets. The Cook said Cook B trained him/her when he/she started and that is how the cook told him/her to make breakfast for the residents with pureed diets on a daily basis. The cook said the residents with pureed diets are not offered choices at breakfast and he/she does not look at the recipes or menus for the breakfast meal. Observation on 12/06/18 during the breakfast meal beginning at 7:06 A.M., showed Cook A served the resident a six oz. scoop of oatmeal (two oz. more than directed by the menus) and a #8 (four oz.) scoop of the pureed egg, sausage, gravy and bread combination topped with a two oz. ladle of gravy. Observation of the resident's table menu, used by staff for the selection of food choices at each meal, showed the menu did not include the pureed combination and no food choices were marked by staff for the resident. During an interview on 12/06/18 at 7:28 A.M., Cook B said staff make a pureed casserole for the residents with pureed diets daily for breakfast. The cook said they did not have a recipe for the pureed casserole. The cook said staff never look at the breakfast menu because the residents can get anything they want for breakfast. The cook said he/she believed the residents with pureed diets liked the casserole and if they wanted something different they could ask for it. 2. Review of Resident #12's MDS dated [DATE], showed staff assessed the resident with: -[DIAGNOSES REDACTED].>-problems with short and long-term memory; -severely impaired cognitive skills for daily decision making; -a mechanically altered diet. Review of the resident's meal tray card showed staff were directed to provide the resident with a pureed diet. Review of the facility menus, dated 12/06/18 (Day 33) showed staff were directed to provide the residents on pureed diets with the following food items and portion sizes for breakfast: -four ounces (oz.) of hot cereal or a #6 (5.3 oz.) scoop of pureed cold cereal; -a #16 (two oz.) scoop of pureed egg of choice; -a #20 (1.6 oz.) scoop of pureed breakfast meat; -a #20 scoop pureed breakfast bread; -one packet each of margarine and jelly. Observation on 12/06/18 at 6:41 A.M., showed one small pan of pureed food on the steamtable. During an interview on 12/06/18 at 6:41 A.M., Cook A said he/she pureed eggs, sausage, gravy, and bread all together to serve to the residents with pureed diets. The Cook said Cook B trained him/her when he/she started and that is how the cook told him/her to make breakfast for the residents with pureed diets on a daily basis. The cook said the residents with pureed diets are not offered choices at breakfast and he/she does not look at the recipes or menus for the breakfast meal. Observation on 12/06/18 during the breakfast meal beginning at 7:06 A.M., showed Cook A served the resident a six oz. scoop of oatmeal (two oz. more than directed by the menus) and a #8 (four oz.) scoop of the pureed egg, sausage, gravy and bread combination topped with a two oz. ladle of gravy. Observation of the resident's table menu, used by staff for the selection of food choices at each meal, showed the menu did not include the pureed combination and no food choices were marked by staff for the resident. During an interview on 12/06/18 at 7:28 A.M., Cook B said staff make a pureed casserole for the residents with pureed diets daily for breakfast. The cook said they did not have a recipe for the pureed casserole. The cook said staff never look at the breakfast menu because the residents can get anything they want for breakfast. The cook said he/she believed the residents with pureed diets liked the casserole and if they wanted something different they could ask for it. 3. Review of Resident #27's MDS dated [DATE], showed staff assessed the resident with: -[DIAGNOSES REDACTED].>-a Brief Interview for Mental Status (BIMS) summary score of three (severe impairment) -a mechanically altered diet. Review of the resident's meal tray card showed staff were directed to provide the resident with a pureed diet. Review of the facility menus, dated 12/06/18 (Day 33) showed staff were directed to provide the residents on pureed diets with the following food items and portion sizes for breakfast: -four ounces (oz.) of hot cereal or a #6 (5.3 oz.) scoop of pureed cold cereal; -a #16 (two oz.) scoop of pureed egg of choice; -a #20 (1.6 oz.) scoop of pureed breakfast meat; -a #20 scoop pureed breakfast bread; -one packet each of margarine and jelly. Observation on 12/06/18 at 6:41 A.M., showed one small pan of pureed food on the steamtable. During an interview on 12/06/18 at 6:41 A.M., Cook A said he/she pureed eggs, sausage, gravy, and bread all together to serve to the residents with pureed diets. The Cook said Cook B trained him/her when he/she started and that is how the cook told him/her to make breakfast for the residents with pureed diets on a daily basis. The cook said the residents with pureed diets are not offered choices at breakfast and he/she does not look at the recipes or menus for the breakfast meal. Observation on 12/06/18 during the breakfast meal beginning at 7:06 A.M., showed Cook A served the resident a six oz. scoop of oatmeal (two oz. more than directed by the menus) and a #8 (four oz.) scoop of the pureed egg, sausage, gravy and bread combination topped with a two oz. ladle of gravy. Observation of the resident's table menu, used by staff for the selection of food choices at each meal, showed the menu did not include the pureed combination and no food choices were marked by staff for the resident. During an interview on 12/06/18 at 7:28 A.M., Cook B said staff make a pureed casserole for the residents with pureed diets daily for breakfast. The cook said they did not have a recipe for the pureed casserole. The cook said staff never look at the breakfast menu because the residents can get anything they want for breakfast. The cook said he/she believed the residents with pureed diets liked the casserole and if they wanted something different they could ask for it. 4. Review of Resident #33's MDS dated [DATE], showed staff assessed the resident with: -[DIAGNOSES REDACTED]. -a BIMS summary score of three (severe impairment); -a mechanically altered diet. Review of the resident's meal tray card showed staff were directed to provide the resident with a pureed diet. Review of the facility menus, dated 12/06/18 (Day 33) showed staff were directed to provide the residents on pureed diets with the following food items and portion sizes for breakfast: - four ounces (oz.) of hot cereal or a #6 (5.3 oz.) scoop of pureed cold cereal; -a #16 (two oz.) scoop of pureed egg of choice; -a #20 (1.6 oz.) scoop of pureed breakfast meat; -a #20 scoop pureed breakfast bread; -one packet each of margarine and jelly. Observation on 12/06/18 at 6:41 A.M., showed one small pan of pureed food on the steamtable. During an interview on 12/06/18 at 6:41 A.M., Cook A said he/she pureed eggs, sausage, gravy, and bread all together to serve to the residents with pureed diets. The Cook said Cook B trained him/her when he/she started and that is how the cook told him/her to make breakfast for the residents with pureed diets on a daily basis. The cook said the residents with pureed diets are not offered choices at breakfast and he/she does not look at the recipes or menus for the breakfast meal. Observation on 12/06/18 during the breakfast meal beginning at 7:06 A.M., showed Cook A served the resident a six oz. scoop of oatmeal (two oz. more than directed by the menus) and a #8 (four oz.) scoop of the pureed egg, sausage, gravy and bread combination topped with a two oz. ladle of gravy. Observation of the resident's table menu, used by staff for the selection of food choices at each meal, showed the menu did not include the pureed combination and no food choices were marked by staff for the resident. During an interview on 12/06/18 at 7:28 A.M., Cook B said staff make a pureed casserole for the residents with pureed diets daily for breakfast. The cook said they did not have a recipe for the pureed casserole. The cook said staff never look at the breakfast menu because the residents can get anything they want for breakfast. The cook said he/she believed the residents with pureed diets liked the casserole and if they wanted something different they could ask for it. 5. Review of the facility menus dated 12/06/18 (Day 33), showed staff were directed to provide the residents with mechanical soft diets four oz. of hot cereal or a #6 scoop of cold cereal and a #20 scoop of ground breakfast meet with gravy. During an interview on 12/06/18 at 6:41 A.M., Cook A said he/she does not look at the recipes or menus for the breakfast meal. Observation on 12/06/18 during the breakfast meal beginning at 7:06 A.M., showed Cook A served the residents with mechanical soft diets a six oz. scoop of hot cereal (two oz. more than directed by the menus) and a #12 (2.6 oz.) scoop of ground sausage with gravy (one oz. more than directed by the menus). During an interview on 12/06/18 at 7:28 A.M., Cook B said staff never look at the breakfast menu because the residents can get anything they want for breakfast. 6. Review of the facility menus dated 12/06/18 (Day 33), showed staff were directed to provide the residents with regular and consistent carbohydrate diets (CCHO) with a four oz. scoop of hot cereal or a #6 scoop of cold cereal. During an interview on 12/06/18 at 6:41 A.M., Cook A said he/she recipes or menus for the breakfast meal. Observation on 12/06/18 during the breakfast meal beginning at 7:06 A.M., showed Cook A served the residents with regular and CCHO diets six oz. of hot cereal (two oz. more than directed by the menus). During an interview on 12/06/18 at 7:28 A.M., Cook B said staff never look at the breakfast menu because the residents can get anything they want for breakfast. 7. During an interview on 12/06/18 at 7:40 A.M., the administrator said he/she would expect staff to prepared and serve meals in accordance with the recipes and menus. The administrator said he/she did not know dietary staff were combining all foods into one food item to serve to the residents with pureed diets. 8. During an interview on 12/06/18 at 9:39 A.M., the Dietary Manager (DM) said he/she did not know the cooks pureed all breakfast food items together to serve to residents with pureed diets. The DM said staff should have served the meal in accordance with the menus and not pureed all items together.

Based on observation, interview, and record review, the facility staff failed to ensure staff transferred resident's safely for three residents at risk for falls (Residents #13, #42, and #45). The census was 46. 1. Review of the facility's Use of Transfer Belt/Gait Belt policy, undated, showed the policy directs staff as follows: -Gait belts will be used when transferring resident's who are partially dependent, have some weight-bearing capacity and are cooperative with the transfer task; -More than one staff may be needed, always follow the resident's care plan; -Wrap the belt around the resident's waist and buckle securely in front; -Thread belt through buckles teeth, then double-lock it by looping it back through opening on the other side; -Place two or three fingers under the belt to check fit (belt should be snug but not too tight); -Position one hand on either side of the gait belt with underhand grip, and assist the resident to move forward until his/her feet are touching the floor; -Avoid pulling on the resident's shoulders; -Hold belt with underhand grasp; -For a pivot transfer, place one hand on each side of the buckle; -Ensure all wheels are locked and secure, if transfer involves a wheelchair place the chair at the foot of the bed facing forward or at a slight angle, position the small front caster wheels correctly, and assist elder to standing position, supporting knees and feet with staff member's legs and feet; -Provide only amount of assistance necessary; -Stand close to the resident during the transfer; -Assist the resident to a safe and comfortable position. 2. Review of Resident #13's quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 9/26/18, showed staff assessed the resident as follows: -Cognitively intact; -Requires limited physical assistance of one staff member for transfers; -Impairment of range of motion in one lower extremity; -Balance from seated to standing position and surface to surface transfers not steady, only able to stabilize with human assistance; -Use of a walker and a wheelchair; -The resident experienced a fall since the last assessment. Observation on 12/5/18, at 10:28 A.M., showed certified nurse assistant (CNA) C place the gait belt on the resident for a pivot transfer. The CNA put the gait belt on backwards. Additional observation showed staff did not tighten the belt and left it loose on the resident. 3. Review of Resident #42's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Required extensive physical assistance of two or more staff members for transfers; -Balance from seated to standing position and surface to surface transfers not steady, only able to stabilize with human assistance; -Use of a wheelchair; -The resident experienced two or more falls since the last assessment. Observation on 12/5/18, at 10:37 A.M., showed CNA D, and CNA E assist the resident with a pivot transfer. Additional observation showed CNA D lifted the resident with his/her arm under the resident's arm, applying pressure to the resident's under arm. During an interview on 12/5/18, at 10:37 A.M., CNA D said staff are not supposed to lift the resident's under their arms. 4. Review of Resident #45's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognition intact; -Required extensive physical assistance of one staff member for transfers; -Balance from seated to standing position and surface to surface transfers not steady, only able to stabilize with human assistance; -Use of a wheelchair. Observation on 12/6/18, at 9:42 A.M., showed CNA G assist the resident with a pivot transfer. CNA G placed the gait belt around the resident's chest area. The resident placed his/her arms around the CNA. Additional observation showed the gait belt slid up under the resident's arms during the transfer, and the CNA's arms placed pressure under the resident's arms. During an interview on 12/6/18, at 9:54 A.M., CNA G said staff are expected to use a gait belt during pivot transfers. He/She said he/she is not sure where the gait belt is supposed to be placed, I guess where it is most comfortable. He/She said staff are supposed to avoid placing pressure under the resident's arms, but the gait belt slid during the transfer. During an interview on 12/6/18, at 10:02 P.M., the resident said when staff put the gait belt around his/her waist it is more comfortable and doesn't pinch. He/She said it is uncomfortable if staff put weight on his/her shoulders because he/she has some arthritis. 5. During an interview on 12/07/18, at 12:54 P.M., the director of nursing (DON) said staff are expected to use a gait belt during pivot transfers. He/She said during the transfer the CNA's should assist the resident with the gait belt, and weight should not be placed under the resident's arms. He/She said he/she is not sure where the gait belt should be placed, but staff are expected to follow the policy.

Based on interview and record review, facility staff failed to screen new admissions for [MEDICAL CONDITION] (TB) as directed by the facility policy for three resident's (Resident #26, #29, and #38) out of five sampled residents. The facility census was 46. 1. Review of the facility Policy TB testing, dated (MONTH) (YEAR), directs the staff to: -Resident screening: Each resident shall receive a [MEDICATION NAME] skin test (TST); -The TST shall be administered within one month prior or within seven days of admission and thereafter under the CDC guidelines; -If the initial test (first step) TST is zero to nine millimeters, the second test should be given as soon as possible after one week of the first step being read as negative and up to three weeks; -Staff shall document in the resident's chart the site, any redness, [MEDICAL CONDITION], temperature, time and date of injection, site of administration, nurse administering, date of reading, size of induration in millimeters (mm) noting color, [MEDICAL CONDITION], and temperature, and the nurse reading administration site. 2. Review of Resident #26's entry Minimum Data Set (MDS), a federally mandated assessment tool used to plan care, dated 10/22/18, showed the resident admitted to the facility on [DATE]. Review of the resident's Immunization Record, dated 10/22/18, showed staff documented they administered the first step of TST on 10/22/18, negative zero mm. The documentation did not contain the date, time or the staff member that read the TST. Further review of the resident's record showed it did not contain documentation of the second TST test. 3. Review of Resident #29's entry MDS, dated [DATE], showed the resident admitted to the facility on [DATE]. Review of the resident's Immunization Record, dated 10/24/18, showed the staff documented first step of TST administered on 10/22/18, negative zero mm. The documentation did not contain the date or the staff member that read the TST. Further review of the resident's record showed it did not contain documentation of the second TST test. 4. Review of Resident #38's entry MDS, dated [DATE], showed the resident admitted to the facility on [DATE]. Review of the resident's Immunization Record, dated 9/18/18 (prior to the resident's admission), showed the staff documented the first step of TST administered on 9/18/18-historical, negative zero mm. The documentation did not contain the date or the staff member that read the TST. Further review of the resident's record showed it did not contain documentation of the second TST test. 5. During an interview on 12/06/18 1:18 P.M., licensed practical nurse (LPN) I said staff are expected to do a two step TST on residents when they are admitted . He/She said, We do one right after the resident is admitted , and do the second a week later usually. He/She said the electronic medical record does not have a place for staff to document the date, time or staff member that read the second step. During an interview on 12/06/18, at 3:24 P.M., the director of nursing (DON) said staff are expected to complete a two step TST on newly admitted resident's. He/She said the nurse initiating the TST on the above resident's put the order in incorrectly, so the system did not follow up to cue the staff to do the second TST. He/She said he/she does not know how or if Resident #38 received the first TST prior to admission and the nurse put it in as historical. He/She said the electronic medical record does not have a place for staff to document the date, time or staff member that read the second step.

Based on interview and record review, facility staff failed to obtain stop dates of 14 days or less on PRN (as needed) [MEDICAL CONDITION] medications (a chemical substance that changes brain function and results in alterations in perception, mood, consciousness or behavior), specify conditions present to administer the medications, and did not implement non pharmacological (medication) interventions to attempt prior to administration of the [MEDICAL CONDITION] medications for three residents ( Resident #38, #43 and #47) out 3 sampled residents. The facility staff also failed to attempt a gradual dose reduction (GDR), or document a clinical reason to justify the need to continue [MEDICAL CONDITION] medications for one resident (Resident #23). The facility census was 46. 1. Review of the facility's policy [MEDICAL CONDITION] Medication Monitoring, undated, showed the policy directs staff: -The facility will make every effort to comply with State and Federal regulations to the use of psychopharmacological medications in the facility to include regular review for continued need, appropriate dosage, side effects, risks and/or benefits. -The facility supports the appropriate use of psychopharmalogical medications that are therapeutic and enabling for residents suffering from mental illness while recognizing that the use of psychopharmalogical medications for dementia-related behaviors is inappropriate in most cases but rather the use of non-pharmacological interventions based on individual resident needs, preferences and routines is the most appropriate and first line treatment for [REDACTED]. -The facility supports the goal of determining the underlying cause of behavioral symptoms so the appropriate treatment of [REDACTED]. -The facility supports the goal of determining the underlying cause of residents having difficulty sleeping so the appropriate treatment of [REDACTED]. -Efforts to reduce dosage or discontinue of psychopharmacological medications will be ongoing, as appropriate, for the clinical situation. -Psychopharmacological medications will never be used for the purpose of discipline or convenience. -[MEDICAL CONDITION] medications include: anti-anxiety,/hypnotic, antipsychotic and antidepressant classes of drugs. -Physicians will document rationale and [DIAGNOSES REDACTED]. -attempt a gradual dose reduction (GDR) decrease or discontinue of [MEDICAL CONDITION] medications after no more than 3 months unless clinically contraindicated. Gradual dose reduction must be attempted for 2 separate quarters (with at lease one month between attempts).Gradual dose reduction must be attempted annually thereafter or as the resident's clinical condition warrants. The policy did not contain direction to staff on the use of PRN [MEDICAL CONDITION]. 2. Review of Resident #23's admission Minimum Data Set (MDS), a federally mandated assessment tool used to plan care, dated 1/12/18, showed staff assessed the resident as follows: -Cognitively intact; -The resident did not have signs or symptoms of depression, or behaviors; -Did not receive antianxiety, hypnotic, or diuretic medication. Review of the resident's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -The resident did not have signs or symptoms of depression, or behaviors; -Received antianxiety, hypnotic, and diuretic medication daily. Review of the resident's Physician's Order Sheets, dated 1/5/18-12/7/18, shows it directed staff to administer: -[MEDICATION NAME] 1 milligram (mg) two times daily for anxiety; -[MEDICATION NAME] HCL 50 mg at bedtime for [MEDICAL CONDITION]; -Duloxetine HCL 60 mg daily for depression. Review of the resident's Pharmacist Consultation Note, dated 8/31/18, showed the pharmacist recommended a dose reduction for the Trazadone and Duloxetine. Review of the resident's Pharmacy Consultation Note, dated 8/31/18, showed the physician documented a response dated 9/17/18, said not at this time, request again in six months. The physician's response did not contain a clinical reason or rationale the dosage reduction is not attempted. Review of the resident's Pharmacist Consultation Note, dated 10/31/18, showed the pharmacist recommended a dose reduction for the [MEDICATION NAME]. Review of the resident's Pharmacist Consultation Note, dated 10/31/18, showed the physician documented a response, undated, at this time we could try a decrease if the resident feels his/her symptoms are well controlled otherwise will plan to continue present dose and re-evaluate in three months. The resident's record did not contain any further documentation about the [MEDICATION NAME], or a clinical reason to continue the medication. 3. Review of resident #38's MDS, dated [DATE], showed staff assessed the resident as follows: -No cognitive impairment; -[DIAGNOSES REDACTED]. -No severe behaviors; -Extensive assistance with dressing and toileting. Review of the resident's Physician Orders (POS), dated 12/7/18, showed staff obtained a physician's order on 11/23/18 for [MEDICATION NAME] (an antianxiety medication) 0.5 mg by mouth every 12 hours as needed for agitation. The order did not contain a stop date of 14 days or less. 4. Review of Resident #43's MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -[DIAGNOSES REDACTED]. -No severe behaviors; -Two person assistance. Review of the resident's Physician Orders (POS), dated 12/7/18, showed staff obtained a physician's order on 11/16/18 for [MEDICATION NAME] (an antianxiety medication) 0.5 mg give 1 tablet by mouth every 24 hours as needed for anxiety for two weeks. The order did not contain a stop date of 14 days or less. 5. Review of Resident #47's admission MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -[DIAGNOSES REDACTED]. -The resident did not have signs or symptoms of depression, or behaviors; -Received antianxiety medications three out of seven days, and antidepressant medication daily. Review of the resident's Physician's Order Sheet, dated 11/16/18-12/3/18, showed it directed staff to administer [MEDICATION NAME] 0.25 mg every 24 hours as needed for anxiety. The physician's order did not contain a stop date of 14 days or less. 6. During an interview on 12/07/18, at 12:54 P.M. the director of nursing said staff are expected to obtain stop dates of 14 days for less for PRN antipsychotics. He/She said the physician should document a clinical reason why a GDR is not attempted. He/She is not sure why staff did not attempt the GDR.

Based on interview and record review, facility staff failed to follow physician orders, and notify the physician with blood glucose (sugar) results above the parameters set by the physician for two resident's (Resident #20, and #46) out of two sampled residents. The facility census was 46. 1. Review of the facility's policy Physician order [REDACTED]. -All medications will be administered as ordered by a health care professional authorized by the state to order medications; -Orders for medications will include: -Name and strength of medications; -Dosage and frequency of administration; -Route of administration; -Duration of administration; -Specific precautions or directions if needed; -Clinical rationale for order (indication/diagnosis). 2 Review of the facility's policy Medication Administration, undated, showed the policy directs staff to: -Administer all medications as ordered by a physician in a safe and sanitary manner; -Clinical staff will monitor each resident's response to medications by accounting for actual or potential adverse drug reactions, events, significant change, and medications errors through the appropriate specific policies and procedures. 3. Review of Resident #20's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 10/6/18, showed staff assessed the resident as follows: -Moderate cognitive impairment; -[DIAGNOSES REDACTED]. -Received insulin injections daily. Review of the resident's physician's orders [REDACTED]. -To obtain blood glucose before meals; -Administer [MEDICATION NAME] Solution Pen injector 100 units/milliliter (ml) per sliding scale if -blood glucose 151-200 administer 4 units; -201-300 administer 8 units; -301-350 administer 10 units; -351-400 administer 12 units; -401-450 administer 14 units; -451-500 administer 16 units; -greater than 500 call the physician. -Humalog (100 units/ml), inject 5 units in the morning; -Humalog 5 units in the afternoon; -Humalog 5 units in the evening; -[MEDICATION NAME] 28 units at bedtime. Review of the resident's Medication Administration Record [REDACTED] -10/1/18 at 5:00 P.M. to 6:00 P.M., blood glucose 513; -10/1/18 at bedtime, blood glucose 527; -10/7/18 at 5:00 P.M. to 6:00 P.M., blood glucose 600; -10/23/18 at 5:00 P.M. to 6:00 P.M., blood glucose 527; -11/13/18 at 5:00 P.M. to 6:00 P.M., blood glucose 576; -11/19/18 at 5:00 P.M. to 6:00 P.M., blood glucose 568; -Staff documented 4 times, the resident's blood glucose as more than 151, and staff did not document they administered the Humalog sliding scale in (MONTH) as ordered; -Staff documented 3 times, the resident's blood glucose as more than 151, and staff did not document they administered the Humalog sliding scale in (MONTH) as ordered; -Staff documented 2 times, the resident's scheduled Humalog as Insulin not required when routine insulin was scheduled to be administered, and the documentation did not show a reason why the insulin was not required in November. Review of the resident's care plan, last updated 4/9/18, showed it directs staff as follows: -The resident has a history of hospitalization s related to [DIAGNOSES REDACTED] (low blood sugar), and [MEDICAL CONDITION] (high blood sugar); -Monitor blood glucose before meals and as needed; -Monitor for symptoms of [DIAGNOSES REDACTED] and [MEDICAL CONDITION]; -Administer insulin and sliding scale as directed by the physician. Review of the resident's nurses notes, dated 10/1/18-12/7/18, showed staff documented on 11/13/18 at 4:44 P.M., the resident's blood glucose as 572. Additional review showed staff administered the required insulin, rechecked the resident's blood sugar level in 30 minutes and documented the blood glucose as 516. Further review showed staff did not document they notified the physician of the resident's blood glucose on 10/1/18, 10/7/18, 10/23/18, 11/13/18, or 11/19/18 as directed by the physician. 4. Review of Resident #46's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment; -[DIAGNOSES REDACTED].>-Received insulin injections daily. Review of the resident's physician's orders [REDACTED]. -To obtain blood glucose before meals; -Administer Humalog 100 units/milliliter (ml) per sliding scale if -blood glucose is less than 70 give snack or glucose tabs; -blood glucose greater than 140-180 administer 2 units; -181-240 administer 3 units; -241-300 administer 4 units; -301-350 administer 6 units; -351-400 administer 8 units; -greater than 400 administer 10 units and call the physician, and repeat blood glucose check in 30 minutes. -[MEDICATION NAME] 8 units at bedtime, hold if blood glucose less than 110. Review of the resident's MAR, dated 10/1/18-12/7/18, showed staff documented the following: -11/6/18 at 11:30 A.M., blood glucose 407; -11/6/18 at 4:04 P.M., blood glucose 407; -11/15/18 at 11:30 A.M., blood glucose 468; -11/15/18 at 4:32 P.M., blood glucose 468; -Staff documented 16 times, in November, the resident's blood glucose as less than 110 and they administered [MEDICATION NAME]; -Staff documented 3 times, in December, the resident's blood glucose as less than 100, and they administered [MEDICATION NAME]; -Staff documented 16 times, in November, the resident's blood glucose as more than 140, and staff did not document they administered the Humalog sliding scale as ordered; -Staff documented 2 times, in December, the resident's blood glucose as more than 140, and staff did not document they administered the Humalog sliding scale as ordered;. Review of the resident's nurses notes, dated 11/5/18-12/7/18, showed staff did not document they notified the physician of the high blood glucose, or the administration of [MEDICATION NAME] when the order directed staff to hold the insulin. 5. During an interview on 12/6/18, at 3:24 P.M., the director of nursing (DON) said staff are expected to follow the directions and administer all medications as ordered on the physician's orders [REDACTED]. During an interview on 12/7/18, at 11:00 A.M., registered nurse (RN) H said staff should follow the physician's orders [REDACTED]. [REDACTED].>During an interview on 12/7/18, at 12:54 P.M., the DON said he/she spoke with the nurse that did not notify the physician with the resident's blood glucose levels, and the nurse said he/she did not notify the physician because he/she did not want to get yelled at. During an interview on 12/17/18, at 11:38 A.M., the DON said that staff are expected to follow physician's orders [REDACTED]. He/She said Resident #46's [MEDICATION NAME] should have been clarified if staff were not certain if the dose should be held or administered. He/She said the sliding scale insulin for both resident's should be administered as ordered and staff are expected to document the administration of the sliding scale. He/She said he/she felt the order was confusing so he/she clarified the order.

Based on interview and record review, facility staff failed to complete a Comprehensive Significant Change Minimum Data Set for five residents (Resident #3, #20, #23, and #46) out of 12 sampled residents. The census was 46. 1. Review of the Resident Assessment Instrument (RAI) Manual, dated (MONTH) (YEAR), directs staff as follows: -Comprehensive Assessments are required comprehensive assessments include the completion of both the Minimum Data Set (MDS) and the Care Area Assessment (CAA) process, as well as care planning. Comprehensive assessments are completed upon admission, annually, and when a significant change in a resident's status has occurred or a significant correction to a prior comprehensive assessment is required. They consist of: -Admission Assessment -Annual Assessment -Significant Change in Status Assessment (SCSA) -Significant Correction to Prior Comprehensive Assessment A significant change is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting; 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/or revision of the care plan. A SCSA is appropriate when: - There is a determination that a significant change (either improvement or decline) in a resident's condition from his/her baseline has occurred as indicated by comparison of the resident's current status to the most recent comprehensive assessment and any subsequent Quarterly assessments; and - The resident's condition is not expected to return to baseline within two weeks. 2. Review of Resident #3's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 11/28/17, showed staff assessed the resident as follows: -Moderate cognitive impairment; -The resident does not have delusions; -Required limited physical assistance of one staff member for eating; -Required extensive physical assistance of one staff member for transfers, and hygiene; -Required extensive physical assistance of two or more staff members for bed mobility; -Ambulation did not occur; -Always incontinent of bowel and bladder; -Active discharge plan to return to the community. Review of the resident's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -The resident has delusions; -Required supervision and set up for eating; -Required limited physical assistance of one staff member for bed mobility, transfers, ambulation, and hygiene; -Frequently incontinent of bowel and bladder; -The resident does not have a discharge plan to return to the community. Further review showed staff did not complete a significant change MDS as directed by the RAI manual. 3. Review of Resident #20's annual MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Required limited physical assistance of one staff member for bed mobility, hygiene, and bathing -Required extensive physical assistance of one staff member for ambulation in his/her room and in the corridor, -The resident does not have functional limitation in range of motion; -Frequent incontinence of bladder and occasional incontinence of bowel; -No presence of pain; -Did not receive opioid medication. Review of the resident's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment; -Supervision and set up to ambulate in his/her room; -The resident did not ambulate in the corridor; -Required extensive physical assistance of one staff member for bed mobility, hygiene, and bathing -The resident has functional limitation in range of motion in one upper and one lower extremity; -Occasional incontinence of bladder and continent of bowel; -Presence of occasional moderate pain that limits his/her day to day activities; -Received opioid medication three out of seven days. Further review showed staff did not complete a significant change MDS as directed by the RAI manual. 4. Review of Resident #23's admission MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -[DIAGNOSES REDACTED]. -Independent with supervision for eating; -Required limited physical assistance of one staff member for ambulation, and hygiene; -Required limited physical assistance of two or more staff members for transfers, and toilet use; -Required extensive physical assistance of two or more staff members for bed mobility, dressing, and bathing; -Occasionally incontinent of bladder; -Did not receive antianxiety, hypnotic, or diuretic medication; -Received [MEDICAL CONDITION]/[MEDICAL CONDITION] while a resident. Review of the resident's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -[DIAGNOSES REDACTED]. -The resident did not have signs or symptoms of depression, or behaviors; -Required supervision and set up help for bed mobility, transfers, ambulation, dressing, eating, toilet use, hygiene, and bathing; -Frequently incontinent of bladder; -Falls since prior assessment; -Received antianxiety, hypnotic, and diuretic medication daily; -Did not receive [MEDICAL CONDITION]/[MEDICAL CONDITION] while a resident. Further review showed staff did not complete a significant change MDS as directed by the RAI manual. 5. Review of Resident #46's annual MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Required supervision and oversight with bed mobility, transfers, ambulation, dressing, toilet use, and hygiene; -Did not require the use of a wheelchair; -Occasional incontinence of bowel and bladder; -The resident did not experience shortness of breath. Review of the resident's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment; -Required limited physical assistance of one staff member for bed mobility, transfers, ambulation, and hygiene; -Required extensive physical assistance of one staff member for dressing, and toilet use; -Required the use of a wheelchair; -Frequent incontinence of bladder and continent of bowel; -The resident experienced shortness of breath on exertion and when lying flat. Further review showed staff did not complete a significant change MDS as directed by the RAI manual. 6. During an interview on 12/07/18, at 12:54 P.M., the director of nursing (DON) said the MDS coordinator (MDSC) is expected to complete a SCSA MDS as directed in the RAI manual. During an interview on 12/07/18, at 1:20 P.M., the MDSC said he/she is responsible to complete a SCSA on admission on to hospice services, and if the resident has a significant change in two areas of the MDS. He/She said he/she is new and is in training and he/she is not sure what has been done in the past.