Every finding on record at Houston House

Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This had the potential to affect all residents. The facility census was 74.Review of the facility's policy titled, Food Receiving and Storage, revised November 2022, showed: - Dry foods and goods are handled and stored in a manner that maintains the integrity of the packaging until they are ready to use;- Food in designated dry storage areas are kept at least six inches (in.) off the floor (unless packaged for case lot handling, for example, dollies, pallets, racks and skids) and clear of sprinkler heads, sewage/waste disposal pipes and vents. Review of the facility's policy titled, Cleaning Rotation, dated November 2016, showed: - Items cleaned after each meal include can opener, small food preparation equipment (e.g. blender, food processor), slicer, kettles and utensils, mixers, cutting boards, worktables and counters, beverage tables, coffee urns, pots and pans, dishes, dining room tables and chairs;- Items cleaned daily include stove top and grill, kitchen and dining room floor, kitchen towels and cloths, toaster, microwave oven, mop and buckets, steam table, hand washing sink, food carts, pot and pan sink, and exterior of large appliances;- Items cleaned weekly include hoods, filters, trash barrels, garbage disposals, coffee machine, storerooms, drawers, cleaning closet, shelves, ovens, and cupboards;- Items cleaned monthly include refrigerators, freezers, ingredient bins, ice machines, food containers, and walls;- Items cleaned annually include ceilings and windows. 1. Observations on 03/30/26 at 10:50 A.M., 04/01/26 at 3:15 P.M., and 04/02/26 at 12:31 P.M., of the kitchen showed:- Four unlabeled clear plastic containers with bran flakes, crispy rice, and toasted oat rings; - The commercial gas range with an oily grime build-up around each burner, exterior surface, door handle, oven interior and scattered food debris on the floor beneath; - The floor, wall, and plumbing pipes below the dishwashing area counters and garbage disposal sink with scattered debris, an oily film, and a black substance;- The dishwasher hood vent interior with a buildup of gray dust;- The commercial dishwasher exterior with flaky white grime (dirt ingrained on the surface of something) build-up and scattered debris on the floor beneath;- The sink near the back door leaked onto the floor below the plastic drain while water flowed from the faucet; - One 4 in. x 12 in. ceiling diffuser (one of the few visible parts of an air conditioning system) with dust buildup and a brown substance on the front exterior surfaces near the back door;- One approximately 24 in. x 36 in. ceiling diffuser with dust buildup and a brown substance on the front exterior surfaces near the dietary office;- The 4-in. floor drain with a non-intact cover and black grime build-up inside near the food prep area. 2. Observation of the dry food storage area on 03/30/26 at 10:58 A.M., showed:- One 3-quart (qt.) dented can with green peas dated and received on 03/17/26;- One 3-qt. dented can with pumpkin dated and received on 11/18/25;- Five 50-ounce (oz.) dented cans with condensed tomato soup dated and received on 03/24/26;- Four 50-oz. dented cans with cream of celery soup dated and received on 01/20/26;- Three 50-oz. dented cans with cream of celery soup dated and received on 06/24/25;- One 50-oz. dented can with cream of chicken soup dated and received on 01/20/26;- One 28-oz. dented can with diced tomatoes and green chilies dated best by 06/30/27;- Two 4-in. x 12 in. ceiling diffusers with dust buildup and a brown substance on the front exterior surfaces near the food shelves;- Scattered food debris lay on the floor and along the walls below the food shelves. During an interview on 04/02/26 at 12:31 P.M., Dietary Aide (DA) M said he/she had been asked to clean below the dishwasher today due to the black substance. Part of the grime might be removed. Dented or rusted cans should be returned, and the dented cans should be placed in a cabinet until delivery day. All foods should have a label with a date, and they should be thrown out after three days. During an interview on 04/01/26 at 3:20 P.M., the Dietary Manager said there should not be cans sitting on the shelf that were dented. The kitchen sink leaked, and maintenance said the dietary staff caused the problem by bumping the sink. The canned goods should be checked by staff when the stock was put away and they should be moved to a cabinet in his/her office to get them off the shelf. During an interview on 04/02/26 at 1:41 P.M., the Maintenance Supervisor said he/she hadn't been asked about repairs. There was water damage in the smaller dishwashing area, and panels had been replaced on the outside wall and leaks had been fixed in the past. There was an assistant maintenance worker asked to work on the clogged floor drain in the kitchen and a new cover has been ordered. The vent over the dishwasher has not been cleaned. The ceiling vents were supposed to be cleaned last month but weren't. He/She had mentioned to the dietary manager that the area below the dishwasher should be free of the black substance, but he/she didn't think it had gotten done. During an interview on 04/02/26 at 1:30 P.M., the Administrator said the kitchen and the dining area should be kept in good repair and the ceiling vents should be clean. The floor in the kitchen should not have a black substance with signs of mold. The kitchen dry storage should not have dented cans on the shelves, and the cans should be removed when they were received and returned. MO2971042

Based on interview and record review, the facility failed to provide the bed hold fee on the bed-hold policy upon transfer to the hospital for five residents (Residents #3, #13, #20, #27, and #81), failed to include the name, address, or the telephone number of the Office of the State Long Term Care Ombudsmen (advocate for the resident in nursing facilities), mailing and email address for agency for protection and advocacy for residents with intellectual disabilities, and mailing, email address and telephone number for agency for protection and advocacy for residents with mental illness, within the transfer and discharge notices for six residents (Resident #1, #3, #13, #20, #27, and #81), and the facility failed to include the resident or responsible party's signature on the transfer/discharge form for one resident (Resident #27) out of six sampled residents. The facility also failed to provide a discharge summary to the resident which includes a recapitulation of the resident's stay, and a final summary of the resident's status for one resident (Resident #81) out of one sampled resident. The facility census was 74.Review of the facility's policy titled, Bed-Holds and Returns, revised October 2022, showed:- All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave);- Residents, regardless of payer source, are provided written notice about these policies at least twice, notice 1: well in advance of any transfer (e.g., in the admission packet); and notice 2: at the time of transfer (or, if the transfer was an emergency, within 24 hours);- The written bed-hold notices provided to the residents/representatives explain in detail the duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the facility; the reserve bed payment policy as indicated by the state plan (for Medicaid residents), the facility policy regarding bed-hold periods; the facility per-diem rate required to hold a bed (for non-Medicaid residents), or to hold a bed beyond the state bed-hold period (for Medicaid residents); and the facility return policy. Review of the facility's policy titled, Transfer or Discharge, revised March 2025, showed:- Once admitted to the facility, residents have the right to remain in the facility, transfers and discharges must meet specific criteria and require resident/representative notification, orientation, and documentation in the medical record;- When the facility transfers or discharges a resident, the following information is documented in the medical record and appropriate information is communicated to the receiving health care institution or provider, the basis for the transfer or discharge, that an appropriate notice was provided to the resident and/or legal representative, the date and time of the transfer or discharge, the new location of the resident, the mode of transportation, a summary of the resident's overall medical, physical, and mental condition, disposition of personal effects, disposition of medications, others as appropriate or as necessary, and the signature of the person recording the data in the medical record;- If the basis for the transfer or discharge is that the transfer or discharge is necessary for the resident's welfare, and the resident's needs cannot be met in the facility, the resident's physician (or provider) documents, the specific resident needs that cannot be met, the facility's attempt to meet those needs, and the receiving facility's service(s) that are available to meet those needs;- Upon notice of transfer or discharge, the resident is provided with a statement of his or her right to appeal the transfer or discharge, including the name, address, email, and telephone number of the entity which receives such requests, information about how to obtain, complete, and submit an appeal form, how to get assistance completing the appeal process; and the facility bed-hold policy. 1.Review of Resident #1's medical record showed:- admitted on [DATE];- Transferred to the hospital on [DATE]. Review of the residents' Notice of Resident Transfer or Discharge and Bed-Hold and Return Notification forms, dated 03/27/26, showed:- No documentation of the ombudsmen contact information, agency contact information responsible for protection and advocacy of individuals with developmental disabilities, and contact information for the agency for protection and advocacy of individuals with a mental disorder. 2. Review of Resident #3's medical record showed:- admitted on [DATE];- Transferred to the hospital on [DATE] and returned on 03/11/26. Review of the residents' Notice of Resident Transfer or Discharge and Bed-Hold and Return Notification forms, dated 02/05/26, showed:- No documentation of the daily bed hold rate;- No documentation of the ombudsmen contact information, agency contact information responsible for protection and advocacy of individuals with developmental disabilities, and contact information for the agency for protection and advocacy of individuals with a mental disorder. 3. Review of Resident #13's medical record showed:- admitted on [DATE];- Transferred to the hospital on [DATE] and returned on 02/20/26. Review of the residents' Notice of Resident Transfer or Discharge and Bed-Hold and Return Notification forms, dated 02/05/26, showed:- No documentation of the daily bed-hold rate;- No documentation of the ombudsmen contact information, agency contact information responsible for protection and advocacy of individuals with developmental disabilities, and contact information for the agency for protection and advocacy of individuals with a mental disorder. 4. Review of Resident #20's medical record showed:- admitted on [DATE];- Transferred to the hospital on [DATE] and returned on 03/14/26. Review of the residents' Notice of Resident Transfer or Discharge and Bed-Hold and Return Notification forms, dated 03/13/26, showed:- No documentation of the daily bed-hold rate;- No documentation of the ombudsmen contact information, agency contact information responsible for protection and advocacy of individuals with developmental disabilities, and contact information for the agency for protection and advocacy of individuals with a mental disorder. 5. Review of Resident #27's medical record showed:- admitted on [DATE];- Transferred to the hospital on [DATE], and returned on 12/03/25;- Transferred to the hospital on [DATE] and returned on 12/18/25. Review of the resident's Notice of Resident Transfer or Discharge and Bed-Hold Notice forms, dated 12/03/25 and 12/15/25, showed:- No documentation of the ombudsmen contact information, agency contact information responsible for protection and advocacy of individuals with developmental disabilities, and contact information for the agency for protection and advocacy of individuals with a mental disorder;- The resident wished to reserve his/her room;- No documentation of the daily bed-hold rate;- No resident or responsible party's signature. 6. Review of Resident #81's medical record showed:- admitted on [DATE];- Transferred to the hospital on [DATE] and returned on 02/19/26;- discharged to home on [DATE]; - No documentation the facility provided the written information to the resident and/or the resident's representative of the discharge summary to include the recapitulation of the stay and a final summary of the resident's status. Review of the residents' Notice of Resident Transfer or Discharge and Bed-Hold and Return Notification forms, dated 02/17/26, showed:- No documentation of the daily bed-hold rate;- No documentation of the ombudsmen contact information, agency contact information responsible for protection and advocacy of individuals with developmental disabilities, and contact information for the agency for protection and advocacy of individuals with a mental disorder. During an interview on 04/01/26 at 9:36 A.M., the Social Services Designee (SSD) said the bed-hold rate was $218, but the facility had never charged that amount. The residents were never charged for bed-holds even past the thirty days and he/she did not remember a resident being gone past thirty days. During an interview on 04/02/26 at 2:49 P.M., the Accounts Payable Secretary said he/she kept a binder with bed-holds and discharge notices. If the resident's representative or family was at the facility, he/she gave the notices to the resident. The bed-hold rate should be documented on the bed-hold forms. Copies were usually sent with the resident and it should have the appeal and the ombudsman contact information documented on it. If family was not in the facility when a resident went out, the notices were mailed. During an interview on 04/02/26 at 2:54 P.M., the Director of Nursing (DON) said the transfer and discharge notices and the bed-hold forms should have the appeals information and the ombudsman contact information on them. The ombudsman may not have been contacted yet, but there was a new system being set up for monthly contacts. The SSD should have information on the bed-hold rate for bed holds over thirty days. During an interview on 04/02/26 at 3:16 P.M., Registered Nurse (RN) H said nursing staff filled out the transfer and discharge notices and the Accounts Payable Secretary filled out the bed-hold rate on the forms. The appeal contact information should be on the form. During an interview on 04/02/26 at 3:32 P.M., the Administrator said the bed-hold rate should be displayed but not on the transfer or bed-hold forms because the residents or their family might get nervous about seeing the daily amount. The facility had never charged a bed-hold rate.

Based on interview and record review, the facility failed to document an accurate Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff) for two residents (Residents #13 and #47) out of 18 sampled residents. The facility census was 74. Review of the facility policy, Resident Assessments, dated October 2023, showed:- Information in the MDS assessments will consistently reflect information in the progress notes, plans of care, and resident observations/interviews. Review of the Resident Assessment Instrument (RAI) Manual, dated October 2025, showed:- H0300: Code 9, not rated: during the seven-day look-back period the resident had an indwelling bladder catheter (a sterile tube inserted into the bladder to drain urine) for the entire seven days. 1. Review of Resident #13's medical record showed:- admission date of 11/03/23;- Diagnoses of obstructive and reflux uropathy (conditions where urine flow is blocked or flows backward into the kidneys, causing swelling and potential kidney damage) and stroke. Review of the resident's physician's order sheet (POS), dated March 2026, showed:- An order for a urinary catheter, 16 French (Fr. - size of the catheter) with 5-30 milliliter (ml) balloon, change every 30 days and as needed (PRN) related to obstructive and reflux uropathy and as needed for occlusion or leakage, dated 02/26/26; - An order for urinary catheter care every shift and PRN, dated 02/26/26; - An order for a urinary catheter to change drainage bag every seven days on Sunday, dated 03/01/26. Review of the resident's significant change MDS assessment, dated 02/26/26, showed:- Did not utilize an indwelling urinary catheter;- Always incontinent of urine. 2. Review of Resident #47's medical record showed:- admission date of 01/18/26;- Diagnoses of unspecified dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning), unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance (a mental health condition that primarily affects your emotional state), and anxiety (constant fear and worry that is both intense and excessive). Review of the resident's quarterly MDS assessment, dated 12/08/26, showed:- Diagnosis of non-Alzheimer's dementia. Review of the resident's quarterly MDS assessment, dated 03/05/26, showed:- No diagnosis of non-Alzheimer's dementia. During an interview on 03/31/26 at 11:00 A.M., the MDS Coordinator said the MDS should be an accurate reflection of the resident to include the diagnosis and catheter. During an interview on 04/02/26 at 3:42 P.M., the Administrator and Director of Nursing (DON) said the MDS should indicate an accurate picture of the resident, such as if the resident had a catheter, it should have been selected.

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #13) out of two sampled residents had a completed hospice (care for the terminally ill with a life expectancy of six months or less) coordinated plan of care with all of the care required by the resident such as a urinary catheter (a sterile tube inserted into the bladder to drain urine) and wound care. The facility census was 74. Review of the facility's policy titled, Hospice Program, dated July 2017, showed:- Hospice services are available to residents at the end of life;- Coordinated care plans for residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by our facility;- The coordinated care plan will reflect the resident's palliative goals and objectives, palliative interventions, and medical treatment and diagnostic tests;- The coordinated care plan shall be revised and updated as necessary to reflect the resident's current status including: bowel and bladder care, symptom management, and skin integrity. 1. Review of Resident #13 's physician order sheet (POS), dated 03/30/26, showed:- An admission date of 11/03/23;- An order to admit to hospice for a diagnosis of heart failure (impaired heart function), dated 02/20/26;- An order for a urinary catheter, 16 French (Fr. - size of the catheter) with 5-30 milliliter (ml) balloon, change every 30 days and as needed (PRN) related to obstructive and reflux uropathy (conditions where urine flow is blocked or flows backward into the kidneys, causing swelling and potential kidney damage) and as PRN for occlusion (blockage) or leakage, dated 02/26/26; - An order for urinary catheter care every shift and PRN, dated 02/26/26; - An order for a urinary catheter to change drainage bag every seven days on Sunday, dated 03/01/26;- An order to clean the coccyx (tailbone) with hypochlorous acid (a powerful, non-toxic antimicrobial agent that cleanses wounds, reduces bacteria, and speeds up healing), pat dry, apply skin prep (protective barrier wipes) to the surrounding tissue, apply collagen powder (a topical dressing designed to accelerate healing in acute and chronic wounds by promoting tissue regeneration and providing a moist environment) to the wound bed and cover with a silicone bordered foam (a type of wound dressing) every three days and PRN, dated 03/09/26;- An order to clean the left lower extremity with wound cleanser, pat dry, cover with absorbent dressing (ABD - dressing used to keep wounds dry) pads and wrap with Kerlix (gauze bandage roll) daily, dated 03/18/26. Review of the resident's significant change Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 02/26/26, showed:- Severe cognitive impairment;- Always incontinent of bladder and bowel;- Had a pressure ulcer (localized damage to the skin and underlying soft tissue, usually over a bony prominence, caused by prolonged pressure, friction, or shear);- Received wound care;- Had no urinary catheter. Review of the resident's care plan, revised 02/27/26, showed:- Resident on hospice services related to end stage heart disease;- Resident has occlusion to the left lower leg that is inoperable with a pressure wound;- Resident has a pressure ulcer to the coccyx;- Resident has a urinary catheter. Review of resident's Hospice Coordinated Plan of Care, dated 02/28/26, showed:- Failed to address the urinary catheter with the specific urinary catheter orders, who was responsible for providing the supplies, and who was responsible for providing the urinary catheter care;- Failed to address the specific wound care treatments, who was responsible for providing the wound care supplies, and who was responsible for providing the wound care treatments. During an interview on 04/02/26 at 3:32 P.M., the Director of Nursing (DON) said the hospice coordinated plan of care should address catheter care, who would provide the care, who would provide the supplies, and anything personal to the resident's situation. The facility's care plan should reflect that as well. During an interview on 04/02/26 at 3:32 P.M., the Administrator said the hospice coordinated plan of care should be individually reflective of what care and equipment the resident received and indicate who was to be responsible for what.

Based on observation, interview, and record review, the facility failed to ensure placement of the urinary indwelling catheter (a sterile tube inserted into the bladder to drain urine) drainage bag and tubing was maintained for two residents (Residents #3 and #13) out of four sampled residents. The facility census was 74. Review of the facility's policy titled, Urinary Catheter Care, dated August 2022, showed:- The purpose of this procedure is to prevent urinary catheter associated complications;- Be sure the catheter tubing and drainage bag are kept off the floor. 1. Review of Resident #3's medical record showed:- admission date of 05/09/23;- Diagnosis of obstructive and reflux uropathy (conditions where urine flow is blocked or flows backward into the kidneys, causing swelling and potential kidney damage). Review of the resident's physician's order sheet (POS), dated March 2026, showed:- An order for a urinary catheter, 16 French (Fr. - size of the catheter) with 5-30 milliliter (ml) balloon, change every 30 days on the 11th and as needed (PRN) related to obstructive and reflux uropathy and as needed for occlusion or leakage, dated 003/22/26; - An order for urinary catheter care every shift and PRN, dated 03/19/26. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 03/19/26, showed:- Utilized a urinary catheter. Review of the resident's care plan, revised 03/19/26, showed:- Resident has a urinary catheter;- Provide urinary catheter care every shift and PRN;- Monitor urinary output every shift and document. Observation of the resident on 03/31/26, showed:- At 5:15 A.M., the resident lay in bed with his/her eyes closed, the catheter drainage bag hung on the bed frame with a dignity flap in place, and the bottom of the catheter drainage bag touched the floor;- At 6:01 A.M., Nurse Assistant (NA) A entered the resident's room and did not adjust the catheter drainage bag from touching the floor;- At 9:29 A.M., Certified Nurse Assistant (CNA) B picked up the catheter drainage bag and raised it higher than the resident's bladder level and placed it on the foot of the resident's bed with the foot of the bed elevated and the urine drained back towards the resident's bladder in the tubing. 2. Review of Resident #13's medical record showed:- admission date of 11/03/23;- Diagnosis of obstructive and reflux uropathy. Review of the resident's POS, dated March 2026, showed:- An order for a urinary catheter, 16 Fr. with 5-30 ml balloon, change every 30 days and PRN related to obstructive and reflux uropathy and PRN for occlusion or leakage, dated 02/26/26; - An order for urinary catheter care every shift and PRN, dated 02/26/26; - An order for a urinary catheter to change drainage bag every seven days on Sunday, dated 03/01/26. Review of the resident's significant change MDS, dated [DATE], showed:- Did not utilize an indwelling urinary catheter. Review of the resident's care plan, revised 02/27/26, showed:- Resident has a urinary catheter;- Provide urinary catheter care every shift and PRN;- Monitor urinary output every shift and document. Observation of the resident on 03/31/26, showed:- At 5:39 A.M., and 6:32 A.M., the resident lay in bed with his/her eyes closed, the catheter drainage bag lay on the floor with the valve side on the floor, and the privacy flap folded away from the drainage bag. One foot of the catheter drainage tubing with light colored urine lay on the floor;- At 9:11 A.M., CNA C picked up the catheter drainage bag, raised it higher than the resident's bladder level and placed it on the foot of the resident's bed, and the urine drained back towards the resident's bladder in the tubing; At 9:20 A.M., CNA C attempted to hang the catheter drainage bag on the bed frame, missed, and picked the catheter drainage bag up off the floor one minute later;- At 12:30 P.M., and 12:35 P.M., the resident lay in bed, the catheter drainage bag hung from the right side of the bed frame with a dignity flap in place, and the bottom of the catheter drainage bag touched the floor. During an interview on 03/31/26 at 2:30 P.M., CNA B and CNA C said catheter drainage bags should not be on the floor or above the level of the resident's bladder. During an interview on 04/02/26 at 3:04 P.M., Licensed Practical Nurse (LPN) G said the catheter drainage bag placement should be below the resident and it should not be on the floor even in a dignity bag. During an interview on 04/02/26 at 3:21 P.M., CNA F said catheter drainage bags should be above the floor and below the bladder and they should be in dignity bags. During an interview on 04/02/26 at 3:25 P.M., CNA E said there was a groove on the bed frame where a catheter drainage bag could be hung, and it should never be on the floor. During an interview on 04/02/26 at 3:32 P.M., the Director of Nursing (DON) and the Administrator said catheters were expected to remain below the level of the bladder and not on the floor. The catheter tubing should also not be on the floor.

Based on interview and record review, the facility failed to identify, assess, and provide supportive interventions for one resident (Resident #4) with a diagnosis of post-traumatic stress disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event) out of one sampled resident. The facility's census was 74. Review of the facility's policy titled, Trauma Informed Care and Culturally Competent Care, dated August 2022, showed:- Purpose is to address the needs of trauma survivors by minimizing triggers and/or re-traumatization;- Triggers are highly individualized;- Utilize the facility assessment;- Develop individualized care plans that address past trauma in collaboration with the resident and family, as appropriate;- Identify and decrease exposure to triggers that may re-traumatize the resident. 1. Review of Resident 4's medical record showed:- admission date of 03/11/26;- Diagnoses of PTSD and dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning). Review of the resident's April 2026 physician's order sheet (POS) showed:- An order for prazosin (a blood pressure medication also used to treat nightmares associated with PTSD) 1 milligram (mg) two capsules by mouth one time a day related to sleep terrors and give three capsules by mouth in the evening, dated 03/12/26. Review of the resident's Preadmission Screening and Resident Review (PASRR - a federal program to prevent inappropriate admission and retention of people with mental disabilities in nursing facilities), dated 04/02/26, showed:- Diagnosis of chronic PTSD. Review of the resident's Trauma Informed Care Assessment, dated 03/11/26, showed:- Experienced a traumatic event;- Had nightmares about the events in the last month;- Tried hard not to think about the events or went out of his/her way to avoid situations that reminded him/her of the events;- Constantly on guard, watchful, or easily startled. Review of the resident's care plan, dated 03/18/26, showed:- Did not address PTSD;- Did not address the resident's past trauma, any triggers that would cause the resident to have behaviors, and interventions. During an interview on 03/30/26 at 10:00 A.M., the resident's spouse said if the resident had a bad day, then all the steps of care the staff was providing needed to be explained. If there were too many people in the room, then the resident would make it known he/she needed everyone out. The spouse did not discuss the specifics of the resident's PTSD as the resident did not like to talk about it. During an interview on 04/02/26 at 3:42 P.M., the Director of Nursing (DON) and the Administrator said for any resident that had PTSD, it was expected that the care plan addressed the triggers and interventions.

Based on observation, interview, and record review, the facility failed to adhere to enhanced barrier precautions (EBP - precautions for use during high-contact resident care activities for residents infected with a multidrug-resistant organism (MDRO - microorganisms that are resistant to one or more classes of antimicrobial agents) or any resident who has a chronic wound and/or indwelling medical device) for two residents (Residents #13 and #25) when staff did not wear gowns to provide direct care and for one resident (Resident #25) during intravenous (IV - administer in the vein) medication administration out of six sampled residents. The facility also failed to use proper infection control techniques with hand hygiene and glove changes during incontinent care for six residents (Residents # 4, #5, #13, #25, #42, and #71) out of seven sampled residents, and during catheter (a flexible tube inserted into the bladder to drain urine) care for four residents (Residents #3, # 4, #13, and #42) out of four sampled residents. The facility census was 74.Review of the facility's policy titled, Handwashing/Hand Hygiene, revised 10/2023, showed:- Hand hygiene is indicated: a. immediately before touching a resident; b. before performing an aseptic task (for example, placing an indwelling device or handling an invasive medical device; c. after contact with blood, body fluids, or contaminated surfaces; d. after touching a resident; e. after touching a resident's environment; f. before moving from work on a soiled body site to a clean body site on the same resident; g. immediately after glove removal. Review of the facility's policy titled, Personal Protective Equipment (PPE) - Using Gloves, revised 09/2010, showed:- When gloves are indicated, use disposable single-use gloves;- Discard used gloves into the waste receptacle inside the room;- Use sterile gloves for invasive procedures to prevent contamination of the patient, and to decrease the risk of infection when changing dressing;- Use non-sterile gloves primarily to prevent contamination of the employee's hands when providing treatment or services to the patient and when cleaning contaminated surfaces;- Wash hands after removing gloves, (Note: Gloves do not replace handwashing);- Remove gloves before removing mask and gown and discard them into the designated waste receptacle inside the room. The facility did not provide a policy related to EBP. 1. Observation on 03/31/26 at 5:29 A.M., of Resident #13's and Resident #5's assessed need for incontinent care showed:- EBP signage on Resident #13's door;- Nurse Assistant (NA) A entered the resident's room, did not perform hand hygiene, and did not put on a gown and gloves;- NA A pulled back the resident's blanket, pulled the resident's brief away from the resident's body around the urinary catheter with his/her bare hands, and looked inside the brief;- NA A let go of the brief, did not perform hand hygiene, and put the blanket back over the resident with his/her bare hands;- NA A did not perform hand hygiene, exited Resident #13's room, entered Resident #5's room, did not perform hand hygiene, and did not put on gloves; - NA A pulled the resident's blanket back, unfastened the left side of the resident's brief, and lowered the brief away from the resident's body with his/her bare hands, and did not perform hand hygiene;- NA A looked inside the resident's brief, pulled the brief back into place, fastened the brief, and pulled the blanket back over the resident with his/her bare hands, did not perform hand hygiene, and exited the resident's room. 2. Observation of Resident #13's incontinent and catheter care on 03/31/26 at 6:53 A.M., showed:- EBP signage on the door;- Certified Nurse Assistant (CNA) C and CNA D put on a gown, performed hand hygiene, put on gloves, and entered the resident's room;- CNA C picked up the urinary catheter drainage bag off the floor where the bottom of the bag touched the floor and hung it on the bedframe. - CNA C performed hand hygiene and changed gloves;- CNA C cleaned the resident's front perineal area, cleaned the urinary catheter from the insertion site and down the catheter with the same area of the wipe twice, did not perform hand hygiene and did not change gloves; - CNA C cleaned the resident's buttocks, did not perform hand hygiene, changed gloves, touched the resident's bandaged black toes, placed pillows under the resident's left side, lifted the resident's legs and put a pillow under the resident's feet, and lowered the bed;- CNA C removed gloves, did not perform hand hygiene, took the trash bag out of the trash can, did not perform hand hygiene, and gave the resident a drink of water from a cup with his/her bare hands. 3. Observation on 03/31/26 at 7:22 A.M., of Resident #71's incontinent care showed:- EBP signage on the door; - CNA C and CNA D performed hand hygiene, put on gloves and gowns, and entered the room;- CNA C cleaned the resident's front perineal area, performed hand hygiene, and changed gloves;- CNA C cleaned fecal matter from the resident's gluteal cleft (the crease between the right and left buttock) and a dressing on the resident's coccyx (tailbone) was soiled with fecal matter;- CNA C attempted to remove the soiled dressing from the resident's coccyx (tailbone) and the gluteal fold (the horizontal skin crease that forms below the buttocks) when fecal matter got onto CNA C's left glove;- CNA C wiped the fecal matter off his/her left glove with a wipe, did not perform hand hygiene, did not change gloves, used a clean wipe to clean fecal matter from the gluteal cleft, did not change gloves, did not perform hand hygiene, picked up the wound cleanser spray bottle from the resident's nightstand, sprayed the dressing, removed the dressing, did not perform hand hygiene, and changed gloves;- CNA C cleaned fecal matter from the left inner buttock area, cleaned the wound areas, did not perform hand hygiene, changed gloves, cleaned fecal matter from the left lower buttock area, did not perform hand hygiene, and changed gloves;- CNA C retrieved a clean chuck pad (a disposable waterproof absorbent incontinence pad) from the dresser drawer, placed it under the resident, cleaned the left outer buttock area, removed the chuck pad soiled with fecal matter, did not perform hand hygiene, and did not change gloves;- CNA D cleaned fecal matter from the right gluteal cleft with a clean wipe, cleaned fecal matter from the right inner buttock with a clean wipe, folded the wipe in half and cleaned the inner half of the right buttock with the same area of the wipe 10 times to remove fecal matter from the buttock, did not perform hand hygiene, did not change gloves, obtained a clean wipe, cleaned the outer area of the right buttock area with the same area of the wipe three times, did not perform hand hygiene, and did not change gloves;- CNA D picked up the wipe package and handed it to CNA C. CNA C placed wipe package in the resident's top dresser drawer, removed the trash bag from the trash can, removed gown and gloves, did not perform hand hygiene, exited the resident's room, took the trash bag to the soiled utility room, and performed hand hygiene;- CNA D removed the trash bag from the bathroom trash, removed gown and gloves, did not perform hand hygiene, exited the resident's room, took the trash bag to the soiled utility room, touched the outside doorknob, placed the bags in the appropriate barrels with lids, and performed hand hygiene. 4. Observation on 03/31/26 at 8:27 A.M., of Resident #25's Hoyer (mechanical lift used to transfer residents from one position to another) lift transfer and incontinent care showed:- EBP signage on the door;- CNA C and CNA D performed hand hygiene, put on gloves, did not put on gowns, transferred the resident to the bed from the wheelchair via the Hoyer lift;- CNA D removed gloves, did not perform hand hygiene, exited the room to retrieve a Hoyer lift battery, reentered the room, did not perform hand hygiene, put on gloves, and did not put on a gown;- CNA D retrieved wipes from the package and gave CNA C a clean wipe;- CNA C used the wipe to clean the resident's front perineal area, changed gloves, and did not perform hand hygiene;- CNA D gave CNA C a clean wipe and CNA C cleaned fecal matter from the gluteal cleft;- CNA D gave CNA C a clean wipe and CNA C wiped the gluteal cleft;- CNA D gave CNA C a clean wipe, CNA C cleaned the buttock area, and removed the brief soiled with fecal matter;- CNA C and CNA D did not perform hand hygiene and changed gloves;- CNA C placed a clean brief under the resident;- CNA C and CNA D assisted the resident to turn, fastened the brief, and put pants on the resident;- CNA C removed gloves and did not perform hand hygiene; - CNA C and CNA D transferred the resident to the wheelchair via the Hoyer lift;- CNA C did not perform hand hygiene, exited the room with the Hoyer lift, and placed the Hoyer lift in a designated area down the hall from the resident's room;- CNA C reentered the room, performed hand hygiene, and did not put on gloves;- CNA D touched the bed linens, removed gloves, and performed hand hygiene;- CNA C removed the trash bag, did not perform hand hygiene, exited the room, took the trash bags to the soiled utility room, touched the outside doorknob, placed the bags in the appropriate barrels with lids, and performed hand hygiene. 5. Observation on 03/31/26 at 8:35 A.M., of Resident #42's incontinent and catheter care showed:- EBP signage on the door;- CNA I and CNA J put on gowns, entered the room, performed hand hygiene, and put on gloves;- CNA J cleaned the resident's groin area, did not perform hand hygiene, did not change gloves, cleaned the urinary catheter from the insertion site and down the catheter, did not perform hand hygiene, did not change gloves, and touched the resident's linens to cover the resident. 6. Observation on 03/31/26 at 8:46 A.M., Resident #25's medication administration showed:- EBP signage on the door;- LPN K performed hand hygiene, put on gloves, and did not put on a gown;- LPN K administered IV medication, removed gloves, and performed hand hygiene. 7. Observation on 03/31/26 at 9:11 A.M., of Resident #4's incontinent and catheter care showed:- EBP signage on the door;- CNA C cleaned the resident's perineal area, did not perform hand hygiene, did not change gloves, cleaned the resident's buttocks, did not perform hand hygiene, and changed gloves;- CNA C cleaned the urinary catheter from the insertion site and down the catheter with the same area of the wipe multiple times;- CNA B and CNA C removed gowns and gloves and performed hand hygiene. 8. Observation on 03/31/26 at 9:29 A.M., of Resident #3's catheter care showed- EBP signage on the door;- CNA C and CNA B put on a gown, performed hand hygiene, and put on gloves;- CNA C cleaned the resident's perineal area;- CNA C did not perform hand hygiene and did not change gloves;- CNA C cleaned the urinary catheter from the insertion site and down the catheter with the same area of the wipe twice;- CNA C did not perform hand hygiene, changed gloves, moved the resident's bed back against the wall, and covered the resident with his/her linens;- CNA C and CNA B removed gowns, gloves, and performed hand hygiene. During an interview on 04/02/26 at 3:12 P.M., Licensed Practical Nurse (LPN) L said during wound care and incontinent care, gloves should be changed between dirty to clean tasks. Staff should sanitize hands when entering a room, when leaving, in between care from dirty to clean tasks, and with glove changes. Staff should put on a gown during EBP transfers, perineal care, and to the toilet. During an interview on 04/02/26 at 3:16 P.M., Registered Nurse (RN) H said during wound care and incontinent care, gloves should be changed between dirty to clean tasks. Staff should sanitize hands when they enter a room, when leaving a room, in between care from dirty to clean tasks, and before glove changes. Staff should put a gown during EBP transfers, perineal care, and when assisting residents to toilet. During an interview on 04/02/26 at 3:21 P.M., CNA F said during incontinent care and wound care, gloves should be changed between dirty to clean tasks. Staff should sanitize hands between glove changes. A gown should be used during a transfer from a wheelchair to the bathroom for a resident on EBP. During an interview on 04/02/26 at 3:25 P.M., CNA E said gloves should be changed when they were visibly soiled and between dirty to clean tasks. Staff should sanitize hands between glove changes and before entering a room. Gowns should be used by staff during a transfer from a wheelchair to the restroom for a resident on EBP. During an interview on 04/02/26 at 3:32 P.M., the Director of Nursing (DON) and the Administrator said hand hygiene should be done when entering a resident's room. Staff should be sanitizing hands before using gloves and between glove changes. Staff should be changing gloves between dirty to clean tasks during care. The appropriate PPE should be used if exposed to any bodily fluids during wound care, catheter care, or incontinent care. The staff should use a gown in an EBP room before transferring a resident from a wheelchair to the bathroom. During a phone interview on 04/09/26 at 11:39 A.M., LPN K said EBP consisted of wearing a gown and gloves. EBP should be used when administering IV medications, and when providing care for a resident with an IV, wounds or catheters. Gloves should be changed and hand hygiene performed after contact with anything going from dirty to clean care, before and after any care, and between residents. He/She would expect hand hygiene to be performed and gloves to be used when checking a resident's brief for a need of incontinent care. When performing incontinent care, a new wipe should be used for each swipe and should not use the same area of the wipe multiple times. During a phone interview on 04/09/26 at 11:50 A.M., CNA D said EBP consisted of wearing PPE, such as gown and gloves, when providing care for residents with open wounds and catheters. Hand hygiene should be done when entering and exiting a resident's room, and in between residents. Hand hygiene should be performed and gloves changed when going from the front to the back areas during incontinent care, and any time needed in between. Wipes should be folded to a clean area with each swipe or get a new wipe each time. The same area of a wipe should not be used to continuously clean a resident. During a phone interview on 04/09/26 at 12:00 P.M., CNA C said EBP consisted of wearing a gown, gloves, and sometimes a face shield when providing care of residents with open wounds, catheters, and IVs. Hand hygiene should be performed before entering and when leaving a resident's room, and between residents and/or resident rooms. Hand hygiene should be performed and gloves changed when going from the front to the back areas during incontinent care and going from dirty to clean tasks.

Based on observation, interview, and record review, the facility failed to accurately code the Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, for one resident (Resident #55) out of 18 sampled residents. The facility census was 76. Review of the facility's policy titled, Certifying Accuracy of the Resident Assessment, revised November 2019, showed: - The information captured on the assessment reflects the status of the resident during the observation (look back) period for that assessment. 1. Review of Resident #55's medical record showed: - An admitted [DATE]; - Diagnoses of chronic inflammatory demyelinating polyneuritis (neurological disorder that affects peripheral nerves and nerve roots), polyneuropathy (peripheral nerve disorder that affects nerves throughput the body), paraplegia (paralysis affecting all or parts of lower part of body), muscle weakness, major depressive disorder (disorder that causes a persistent feeling of sadness or loss of interest), diabetes mellitus (DM - elevated levels of sugar in the blood), and anxiety (a feeling of fear, dread, and uneasiness); - Had post-traumatic stress disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event); - Care plan, last revised 01/24/25, addressed PTSD with triggers; - Brief Trauma Questionnaire, dated 11/03/23, showed PTSD with past therapies and coping methods. Review of the resident's annual MDS, dated [DATE], showed: - PTSD diagnosis not addressed. During an interview on 02/07/25 at 9:25 A.M., the MDS Coordinator said PTSD should have been addressed for Resident #55. If a resident had a diagnosis like diabetes that was not mentioned by the physician for 60 days, then he/she did not address the diagnosis on the MDS assessment. During an interview on 02/07/25 at 12:20 P.M., the Director of Nursing (DON) and Administrator said they would expect the MDS to accurately reflect the resident's condition and diagnoses at the time of the assessment. 49152

Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness when the facility failed to utilize pasteurized eggs to prepare fried eggs without a congealed yolk for seven residents (Residents #13, #42, #53, #54, #56, #57 and #63) out of 15 sampled residents. These practices had the potential to affect all residents. The facility census was 76. Review of the facility's policy titled, Hair Restraints, dated 2016, showed: - Staff shall wear hair restraints in all food production, dishwashing, and serving areas; - Hair restraints, hats, and/or beard guards shall be used to prevent hair from contacting exposed food. The facility did not provide a policy on the use of pasteurized (a process of food preservation in which packaged foods are treated with mild heat) eggs. 1. Observations on 02/04/25 at 11:20 A.M., and 02/07/25 at 10:58 A.M., of the kitchen showed: - Dietary Aide (DA) B served food from the steam table with hair partially unrestrained from the outside of a hairnet; - DA C prepared food with hair partially unrestrained from the outside of a hairnet; - An emptied disposable towel dispenser near the personal hygiene sink; - A 4 foot (ft.) section of vinyl baseboard peeled away from the wall behind the garbage disposal sink; - Six 4-inch (in.) x 12 in. ceiling diffusers (one of the few visible parts of an air conditioning system) with dust buildup and a brown substance on the front exterior surfaces near the food shelves and food preparation areas; - 14 1 ft. x 1 ft. vinyl floor tiles missing under the front food preparation counter along the wall. During an interview on 02/07/25 at 11:15 A.M., DA B said he/she tried to keep his/her hair under the hairnet and had been trained to keep hair restrained. During an interview on 02/07/25 at 11:20 A.M., DA C said he/she tried to keep his/her hair entirely under the hairnet and it was the expectation for dietary workers. During an interview on 02/07/25 at 11:25 A.M., the Dietary Manager (DM) said the dietary workers hair should be kept entirely inside of the hairnets. 2. Observations on 02/04/25 at 11:30 A.M., and 02/07/25 at 11:08 A.M., of the walk-in refrigerator showed: - No pasteurized shell eggs; - Six boxes with 15 dozen non-pasteurized eggs, dated 01/28/25; - One partially full box with non-pasteurized eggs, dated 01/14/25; - The refrigerator door gasket covered with a black substance; - The interior lower right front wall section near the door with an approximate 1 ft. diameter (dia.) hole in the thin metal surface layer with a 1 in. ice build-up; - The interior lower right side wall section with approximately 10 ft. by 1 ft. hole in the thin metal surface layer with a 1 in. ice build-up, 3. Observation of the dining room on 02/04/25 at 11:58 A.M., showed Resident #42 ate a partially full plate with three chopped yellow eggs prepared fried with an uncongealed (become liquid again or to thaw) yolk. During an interview on 02/04/25 at 11:20 A.M., DA A said the fried eggs were requested over easy and over medium by the residents. He/she had fried eggs this morning that were not well done for a resident and used unpasteurized shell eggs. There had been no training about only using pasteurized eggs. During an interview on 02/04/25 at 12:16 P.M., the DM said normally there were no less than twelve residents that order fried eggs. The eggs should be fried at least medium, but the resident this morning had runny, uncongealed yolks. The cooks were expected to use pasteurized eggs if they were going to be fried runny. They had not had the pasteurized eggs available since they ran out over one week ago, and the staff wanted to stick with the residents' choices on preparation of the fried eggs. During an interview on 02/04/25 at 12:35 P.M., DA B said he/she fried eggs over easy or over medium with the yolk a little runny this morning. He/She fried about 34 eggs in a skillet, but he/she wasn't sure how many residents were served the eggs. He/She was not trained to use only pasteurized eggs if they were to be fried a little runny. The eggs were taken from the partially full box with unpasteurized shell eggs, dated received on 01/28/25. A separate container with unpasteurized eggs was emptied this morning and the box had been removed from the kitchen. During an interview on 02/04/25 at 12:56 P.M., the Administrator said the policy for use of pasteurized eggs showed the residents should only be served fried eggs made from pasteurized eggs. The facility should only be ordering pasteurized eggs. The pasteurized eggs should have been used for the fried eggs today. There were several residents served eggs that were undercooked, the residents will be put on high awareness for the risk of food borne illness. The Director of Nursing (DON) had been made aware of the concern. During an interview on 02/06/25 at 8:37 A.M., the DON said she was aware the dietary department had served undercooked fried shell eggs that were non-pasteurized. They should not have been served undercooked and the residents were put on high awareness. The physician was contacted about the situation. The non-pasteurized eggs will be replaced with pasteurized shell eggs. The residents will only be served eggs that are cooked fully until we receive pasteurized eggs. During an interview on 02/04/25 at 01:25 P.M., Resident #13 said his/her eggs were served fried with a runny yolk this morning. During an interview on 02/04/25 at 1:30 P.M., Resident #63 said his/her fried eggs were received today and the yellow was still a little runny. Fried eggs had been served cold to his/her room about two weeks ago when the new cook started. He/She always ordered eggs fried over easy. During an interview on 02/07/25 at 11:22 A.M., Resident #56 said he/she was served fried eggs over easy this week on Tuesday, he/she prefers them that way, since then the eggs have been fried well done. During a group interview on 02/07/25 at 11:27 A.M., Residents #53, #54, and #57 said they were served eggs over easy and runny on Tuesday because that is their preference for fried eggs. They have been okay with having the eggs well done until the eggs are replaced with pasteurized eggs. 4. Observations of the dining room area on 02/07/24 at 10:58 A.M., showed: - Ice machine drain pipe not aligned over the floor drain and water dripped on the floor with one missing vinyl floor tile with scattered debris; - An 8 ft. wooden base cabinet with a damp black substance near the floor in the baseboard area; - The floor below dishwasher with scattered debris and a sticky film. During an interview on 02/07/25 at 11:30 A.M., the DM said issues with the walk-in refrigerator should be repaired. There should not be holes in the interior or ice buildup. The floors should be kept clean under appliances and ceiling vents should be clean and not have a brown substance. The floor should be in good repair and not have missing tiles. During an interview on 02/07/25 at 11:59 A.M., the Maintenance Director said he/she was aware of issues that were in need of repair including refrigeration, ventilation, and cabinetry, in the dining and kitchen areas. The damage will be repaired, and it should not be in that condition. The ice machine drain was adjusted so it didn't drip on the floor. The water caused damage to the wooden cabinet next to the ice machine and it will be repaired or replaced. The walk-in refrigerator should not have ice buildup or holes on the interior and it will need some repairs. The diffusers will be cleaned and repaired. During an interview on 02/07/25 at 12:45 P.M., the Administrator said the kitchen and dining area should be kept in good repair and the staff should be wearing hairnets that keep their hair fully restrained. The ceiling vents should be clean, the floor in the kitchen should not be missing tiles, and the dining room vanity will be repaired by the maintenance department. Maintenance would also need to look into repairing issues with the walk-in refrigerator.

Based on observation and interview, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This deficient practice had the potential to affect all residents. The facility census was 74. The facility did not provide a dietary policy. Observations on 12/11/23 at 11:07 A.M., of the kitchen showed: - The top of the commercial range covered in food debris and a buildup of a brown substance; - The front door panel and the handle of the commercial range covered with a brown sticky substance; - An air vent located on the ceiling located near the entrance door covered with a dark brown substance; - 10 ceiling fluorescent light fixtures with no covers. Observation on 12/11/23 at 11:10 A.M., of the dry storage room showed one 6 pound (lb.) dented can of fruit mix on the canned food rack. Observation on 12/13/23 at 8:22 A.M., of the walk-in refrigerator showed: - A large bag of several boiled eggs, not dated; - Six bowls of chocolate pudding covered with plastic wrap, not dated; - 13 glasses of juice, covered with plastic wrap, not dated; - 11 pieces of cake in a small storage box, not labeled or dated; - One 5 lb. bag of shredded cheese, opened and not dated; - One large bag of salad mixture, opened and not dated. Observation on 12/13/23 at 8:29 A.M., of the ice machine in residents' dining room showed two filters on the top portion of the ice machine with a build up of dust and debris. During an interview on 12/14/23 at 8:50 A.M., Dietary Aide (A) said if anything was opened and placed in the refrigerator, it should be labeled and dated at that time. During an interview on 12/14/23 at 8:56 A.M., the Dietary Manager (DM) said he/she would expect staff to pull any dented cans and send back to the supplier. Maintenance comes through and checks the vents. He/She was unsure who was responsible for the ice machine, but the kitchen staff did clean the filters. The light covers had been like that for years. He/She was aware the stove needed cleaned, it was on the weekly cleaning schedule, and should have been done already. Staff had been asked to clean the stove as scheduled. During an interview on 12/14/23 at 10:05 A.M., the Administrator said she expected the dietary staff to clean the stove on a weekly schedule. She was aware the stove was dirty and had told the staff to get it cleaned. The maintenance staff was responsible for checking the vents and things like that in the kitchen.

Based on observation, interview and record review, the facility failed to ensure staff treated residents with dignity and in a respectful manner by leaving two residents (Resident #69 and #225) out of nine sampled residents exposed during care. The census was 74. Review of the facility's policy titled Dignity, revised February 2022, showed: - Residents are treated with dignity and respect at all times; - Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. 1. Review of Resident #69's medical record showed: - admitted [DATE]; - Diagnoses of paraplegia (paralysis of the legs and lower body), general weakness, chronic inflammatory demyelinating polyneuropathy (CIDP) (a neurological disorder that involves progressive weakness and reduced senses in the arms and legs), neurogenic bladder (condition that results in lack of bladder control due to a brain, spinal cord or nerve problem), and sacral (the bottom of the spine, between the bottom of the lumbar spine and tailbone) decubitus (damage to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/15/23, showed: - Required substantial/maximal assist to totally dependent on staff for dressing, bed mobility, transfers, and toileting; - Had an indwelling urinary catheter; - Always incontinent of bowel. Observation of the resident on 12/13/23 at 3:39 P.M., showed: - The resident lay in bed; - Certified Nursing Assistant (CNA) D and CNA E entered the room to perform incontinent care, catheter care, and range of motion; - CNA D and CNA E did not pull the curtain or close the blind to the window; - Through the window, the outside courtyard and an exit door could be seen; - CNA D and CNA E failed to provide privacy during incontinent care, catheter care, and range of motion for the resident. Observation of the resident on 12/13/23 at 3:49 P.M., showed: - The resident lay in bed; - Licensed Practical Nurse (LPN) K entered the room to perform wound care; - LPN K did not pull the curtain or close the blind to the window; - Through the window, the outside courtyard and an exit door could be seen; - LPN K failed to provide privacy during wound care for the resident. During an interview on 12/14/23 at 9:30 A.M., LPN K said with any care, the window shade and/or curtain should be pulled. 2. Review Resident #225's medical record showed: - An admitted [DATE]; - Diagnoses of amputation of right first and second toes, type 2 diabetes mellitus (a disease in which the body's ability to produce or respond to the hormone insulin is impaired), generalized weakness, general pain, history of occluded right proximal superficial artery (a condition involving partial or complete blockage of blood flow through an artery that runs the length of the thigh), history of occluded right posterial (back) tibial artery (a condition involving partial or complete blockage of an artery that carries blood to the back compartment of the leg and plantar (sole) surface of the foot), depression, anxiety, and history of falls. Review of the resident's admission MDS, dated [DATE], showed: - Required substantial/maximal assist to totally dependent on staff for dressing, bed mobility, transfers, and toileting; - Frequently incontinent of bladder and bowel. Observation of the resident on 12/12/23 at 6:20 P.M., showed: - The resident lay in bed; - LPN R, CNA P, and CNA Q did not pull the curtain or close the door; - LPN R, CNA P, and CNA Q performed wound care for the resident; - The resident's abdomen was exposed and visible from the hallway; - LPN R, CNA P, and CNA Q failed to provide privacy during wound care for the resident. During an interview on 12/14/23 at 9:30 A.M., LPN K said with any care the window shade or curtain should be pulled. During an interview on 12/14/23 at 9:35 A.M., CNA F said all curtains, blinds and doors should be closed or pulled when care was provided for a resident. During an interview on 12/14/23 at 9:45 A.M., the Director of Nursing (DON) said with any care, the window shade, curtain, or door should be pulled or closed. 47445

Based on observation, interview and record review, the facility failed to complete ongoing re-evaluations for the continued need of a restraint (a device that limits a person's movement) for three residents (Residents #6, #30, and #46) out of three sampled residents. The facility census was 74. The facility failed to provide a restraint policy. 1. Review of Resident #6's medical record showed: - An admitted [DATE]; - Diagnoses of dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning), weakness, confusion, anemia (a condition in which the blood doesn't have enough healthy red blood cells), degenerative joint disease (a type of arthritis that occurs when flexible tissue at the ends of bones wears down), and difficulty walking; - Required assistance of one staff for toileting; - No documentation of a physician's order for a bed alarm; - No documentation of a restraint assessment. Review of the resident's quarterly Minimum Data Set (MDS) (a federally mandated assessment instrument completed by the facility staff), dated 09/18/23, showed: - Bed and chair alarms not used; - Wander guard (a roam alert that can trigger alarms and lock monitored doors to prevent the resident leaving unattended) used daily. Review of the resident's care plan, revised 09/25/23, showed: - The resident at risk for falls; - No documentation of a bed alarm as an intervention. Observations of the resident on 12/11/23 at 2:40 P.M., 12/12/23 at 3:21 P.M., and 12/13/23 at 4:13 P.M., showed: -The resident lay in bed with a bed alarm attached to a pad under his/her back; -The resident was unable to remove the bed alarm. 2. Review of Resident #30's medical record showed: - An admitted [DATE]; - Diagnoses of dementia, transient cerebral ischemic attack (TIA) (a neurologic deficit that produces stroke symptoms that resolve within 24 hours), essential tremor, and memory loss; - Required assistance of one to two staff for toileting; - No documentation of a physician's order for the bed and chair alarms; - No documentation of a restraint assessment. Review of the resident's quarterly MDS, dated [DATE], showed a bed and chair alarm used for the resident. Review of the resident's care plan, revised on 11/09/23, showed: - The resident at risk of falls and poor safety awareness; - An intervention of a chair and bed alarm, dated 02/10/23. Observations of the resident on 12/11/23 at 11:58 A.M., 12/12/23 at 9:50 A.M., 12/12/23 at 10:48 A.M., and 12/13/23 at 10:30 A.M., showed: - The resident sat in a wheelchair with a chair alarm attached to the back of the wheelchair and to a pressure pad under the resident's thighs and buttocks; - The resident was unable to remove the chair alarm. Observation of the resident on 12/12/23 at 10:57 A.M. showed: - The resident lay in bed with a bed alarm attached to a pad under his/her back; - The resident was unable to remove the bed alarm. 3. Review of Resident #46's medical record showed: - An admitted [DATE]; - Diagnoses of dementia, osteoporosis (a condition in which bones become weak and brittle), anxiety (intense, excessive and persistent worry and fear about everyday situations), depression (a mood disorder that causes persistent feeling of sadness and loss of interest) and insomnia (a common sleep disorder, including falling asleep, staying asleep or getting good quality sleep); - Required assistance of one staff for toileting; - No documentation of a physician's order for the bed and chair alarms; - No documentation of a restraint assessment. Review of the resident's quarterly MDS, dated [DATE], showed a bed and chair alarm used daily. Review of the resident's care plan, revised 11/07/23, showed: - The resident at risk for falls; - An intervention for bed and chair alarms, dated 02/14/23; Observations of the resident on 12/11/23 at 3:09 P.M., 12/12/23 at 9:09 A.M., 12/12/23 at 2:15 P.M., and 12/13/23 at 1:52 P.M., showed: - The resident sat in a wheelchair with a chair alarm attached to the back of the wheelchair and to a pressure pad under the resident's thighs and buttocks; - The resident was unable to remove the chair alarm. During an interview on 12/13/23 at 4:37 P.M., the Director of Nursing (DON) said she would not necessarily expect to see an order for a bed/chair alarm since they were considered nursing interventions. During an interview on 12/14/23 at 9:45 A.M., the DON said assessments or decision trees should be completed in order to show why the resident required an alarm and ensure it wasn't a restraint. 48532

Based on observation, interview, and record review, the facility failed to identify, assess and provide supportive interventions for two residents (Resident #69 and #70) with a diagnosis of post-traumatic stress disorder (PTSD) (a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event) out of two sampled residents. The facility's census was 74. The facility did not provide a PTSD policy. 1. Review of Resident #69's medical record showed: - Date of admission of 11/03/23; - Diagnosis of PTSD; - Trauma assessment dated [DATE] shows resident to trigger for PTSD. Review of the resident's Physician Order Sheet (POS), dated December 2023, showed: - An order for amitriptyline (an antidepressant medication) 25 milligram (mg) one tablet by mouth twice a day for depression, dated 11/03/23; - An order for Trazodone (an antidepressant medication) 50 mg one tablet at bedtime for insomnia (inability to sleep), dated 11/03/23. Review of the resident's care plan, dated 11/16/23 showed: - PTSD with interventions not addressed; - The resident's past trauma or any triggers that would cause the resident to experience behaviors not addressed; - Interventions for how the facility would address any behaviors if they occurred or how the facility would provide support to the resident not addressed. During an interview on 12/11/23 at 1:18 P.M., Resident #69 said he/she had PTSD from his/her past war time experiences. 2. Review of #70's medical record showed: - Date of admission 09/16/23; - Diagnoses of PTSD; - Review of Brief Trauma Questionnaire, dated 09/06/23, showed the resident triggered for PTSD; - Signed on 09/06/23 by the Social Services Director (SSD). Review of the resident's admission Minimum Data Set (MDS) (a federally mandated process for clinical assessment of all residents in certified nursing homes), dated 09/13/23, showed the resident with a diagnosis of PTSD. Review of the resident's Monthly Summary, dated 10/19/23, showed: - Little interest or pleasure in doing things; - Feeling or appearing down, depressed, or hopeless; - Trouble falling or staying asleep, or sleeping too much; - Moving/Speaking so slowly other people notice or being so fidgety or restless; - Being short-tempered, easily annoyed. Review of the resident's care plan, dated 09/19/23, showed: - PTSD with interventions not addressed; - The resident's past trauma or any triggers that would cause the resident to experience behaviors not addressed; - Interventions for how the facility would address any behaviors if they occurred or how the facility would provide support to the resident not addressed. During an interview on 12/11/23 at 4:25 P.M., Resident #70 said he/she had PTSD and had nightmares all the time about dead bodies in Vietnam. Observation of the resident on 12/11/23 at 4:25 P.M., showed the resident was tearful and anxious when he/she talked about Vietnam and and his/her nightmares. During an interview on 12/13/23 at 2:47 P.M., Licensed Practical Nurse (LPN) O said he/she would expect a resident's care plan to address PTSD. During an interview on 12/13/23 at 5:39 P.M., the Director of Nursing (DON) said it would depend on the level of PTSD if there would be psychiatry notes in a resident's medical record. Resident #70 was emotional at times. She would expect a diagnosis of PTSD to be addressed on a resident's care plan. 47445

Based on observation, interview, and record review, the facility failed to maintain adequate infection control practices to prevent the transmission of infection when staff demonstrated poor hand hygiene for eleven residents (Resident #17, #22, #30, #36, #43, #49, #50, #65, #69, #175 and #225) out of 12 sampled residents and one resident (Resident #15) outside the sample. The facility also failed to maintain adequate infection control practices during catheter (a tube inserted into the bladder to drain urine) care for two residents (Resident #36 and #69), emptying of the catheter drainage bag for one resident (Resident #69), and proper placement of a catheter drainage bag for one resident (Resident #36) out of three sampled residents. Review of the facility's policy titled,Handwashing/Hand Hygiene, dated August 2019, showed: - All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections; - All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors; - Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies; - Perform hand hygiene before applying non-sterile gloves; - Use an alcohol-based hand rub containing at least 62 percent (%) alcohol; or, alternatively, soap and water for the following situations: before and after direct contact with residents, before preparing or handling medications, before moving from a contaminated body site to a clean body site during resident care, after contact with a resident's intact skin, and before and after assisting a resident with meals. Review of the facility's policy titled, Personal Protective Equipment, dated September 2010, showed: - When gloves are indicated, use disposable single-use gloves; - Wash hands after removing gloves. 1. Observation on 12/12/23 at 11:50 A.M., of the feeding assistance provided for Resident #15 showed: - CNA F sat between Resident #15 and Resident #30 in the dining room; - CNA F altered picking up the spoon and drinks for Resident #15 and Resident #30 when offering bites of food and drinks to each resident; - CNA F used a spoon to bring a chip to Resident #30's mouth, then used his/her bare finger to push the chip into the resident's mouth; - CNA F used his/her bare fingers to hold down Resident #15's sandwich to cut it into smaller pieces; - CNA F altered between touching Resident #15's and Resident's #30's food and drinks while touching Resident #15's food with his/her bare hands and did not perform hand hygiene; - CNA F failed to use hand hygiene between feeding the residents and touched Resident #15's and Resident #30's food with his/her bare hands. 2. Observation of incontinent care provided for Resident #17 on 12/13/23 at 10:23 A.M., showed: - The resident lay in bed; - Certified Nurse Aid (CNA) G and CNA H did not perform hand hygiene and put on gloves; - CNA H cleaned the resident's front peri area and rolled the resident to his/her right side; - CNA H did not perform hand hygiene or remove his/her gloves, removed the incontinent pad from under the resident, placed a Hoyer lift (a mechanical lift) pad under the resident, and positioned the resident's pants; - CNA H did not perform hand hygiene or remove his/her gloves, and cleaned the resident's face with a wash cloth; - CNA H removed the gloves but did not perform hand hygiene; - CNA H failed to change gloves and perform hand hygiene during incontinent care. During an interview on 12/14/23 at 9:29 A.M., CNA H said when providing peri care, he/she should wash/sanitize his/her hands after taking off gloves. If gloves were soiled, he/she would change gloves. 3. Observation on 12/11/23 at 11:58 A.M., of the feeding assistance provided for Resident #30 showed: - Nurse Assistant (NA) M sat between Residents #30 and #15 in the dining room; - With his/her bare hand, NA M picked up Resident #30's grilled cheese and handed it to the resident twice; - With his/her bare hand, NA M picked up a chip and handed it to Resident #30; - NA M fed Resident #15 in between touching Resident #30's food with his/her bare hands and did not perform hand hygiene; - NA M failed to use hand hygiene between feeding the residents and touched Resident #30's food with his/her bare hands. Observation of incontinent care for Resident #30 on 12/12/23 at 11:30 A.M., showed: - CNA C and CNA D did not perform hand hygiene and put on gloves; - CNA C and CNA D transferred the resident from the wheelchair to the toilet; - CNA D removed the resident's urine soaked brief, CNA C grabbed it and handed it to CNA D; - Wearing the same gloves, CNA C tightened the gait belt (an assistive device used to help someone transfer) around the resident's waist, put a clean brief on the resident, held the resident's hands, and assisted the resident to stand; - CNA D removed the gloves, did not perform hand hygiene, and put on clean gloves; - CNA D performed incontinent care for the resident, removed the gloves, but did not perform hand hygiene; - Wearing the same gloves CNA C pulled the resident's clean brief and pants up; - Wearing the same gloves, CNA C assisted the resident back to the bed; - Wearing the same gloves, CNA C touched the resident's blanket, pillow and the resident's glasses when he/she removed them; - CNA C and CNA D failed to change gloves and perform hand hygiene during incontinent care. Review of the facility's policy titled, Catheters Insertion and Care, revised on August 2022, showed: - The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections (an infection in any part of the urinary system); - Empty the collection bag at least every eight hours using a separate, clean collection container for each resident. Avoid splashing, and prevent contact of the drainage spigot (a valve that keeps urine from draining out) with the nonsterile container; - Use aseptic technique (a collection of practices designed to avoid the introduction and transfer of germs and contaminants during medical processes) when handling or manipulating the drainage system; - Be sure the catheter tubing and drainage bag are kept off the floor; - Cleanse and rinse the catheter from the insertion site to approximately four inches outward. 4. Review of Resident #36's Physician order sheet (POS), dated 12/1/23, showed: - An order for a Foley (a type of indwelling catheter) catheter to drain via gravity with catheter care every shift, dated 8/26/23. Observations of the resident on 12/11/23 at 3:30 P.M., and 4:44 P.M., and 12/12/23 at 2:58 P.M., 4:00 P.M., 5:23 P.M., and 6:25 P.M., showed the resident's catheter drainage bag attached to the side pocket of the recliner with the bottom of the catheter drainage bag resting on the floor; - The facility failed to keep the catheter drainage bad from resting on the floor. 5. Observation of incontinent care provided for Resident #49 on 12/13/23 at 11:13 A.M., showed: - The resident lay in bed wearing a urine soaked brief; - CNA J, wearing gloves, cleaned the resident's front peri area and rolled the resident to his/her right side; - CNA J, wearing the same gloves, cleaned the resident's left hip, buttock and a small smear of fecal material from the resident; - CNA J removed his/her gloves, did not perform hand hygiene, and put on gloves; - CNA J placed a clean brief under the resident, then rolled the resident to his/her back and fastened the brief; - CNA J and CNA B repositioned the resident in his/her bed; - CNA J repositioned the resident's bed linens; - CNA J failed to change gloves and perform hand hygiene during incontinent care. 6. Observation of incontinent care provided for Resident #50 on 12/13/23 at 10:35 A.M., showed: - The resident lay in bed wearing a urine soaked brief; - CNA H touched the urine soaked brief with his/her gloved hand; - CNA G cleaned the resident's right hip, buttock and a large amount of fecal material from the resident; - CNA G removed the soiled brief; - Without removing the gloves or performing hand hygiene, CNA G positioned the clean brief under the resident; - CNA G and CNA H assisted the resident to his/her back; - CNA H cleaned the resident's front peri area and fastened the brief; - CNA G wearing the same gloves, touched the resident's clean clothes, the Hoyer lift, and the resident's hands; - CNA H removed the gloves, failed to perform hand hygiene, and removed the resident's bed linens with his/her bare hands; - CNA G and CNA H failed to change gloves and perform hand hygiene during incontinent care. 7. Observation of incontinent care performed for Resident #65 on 12/13/23 at 10:55 A.M., showed: - The resident lay in bed wearing a urine soaked brief; - CNA I, while wearing gloves, cleaned the resident's front peri area, then rolled the resident to his/her left side; - CNA I, wearing the same gloves, cleaned the resident's right hip, buttock and a small amount of fecal material from the resident; - CNA I removed his/her gloves, did not perform hand hygiene, and put on gloves; - CNA I placed the clean brief under the resident, rolled the resident to his/her back, fastened the brief and repositioned the resident's bed linens; - CNA I failed to change gloves and perform hand hygiene during incontinent care. 8. Observation of incontinent and catheter care performed for Resident #69 on 12/13/23 at 3:39 P.M., showed: - CNA D and CNA E did not perform hand hygiene and put on gloves; - CNA D cleaned the resident's front peri area; - CNA D performed catheter care and wiped toward the resident's catheter insertion site; - Wearing the same gloves, CNA D performed range of motion on both of the resident's legs. The resident's left leg had a bandage around the knee and one on the heel; - Wearing the same gloves, CNA D emptied the resident's catheter bag into a urinal with the drainage port freely hanging inside and touching the sides of the urinal; - CNA E rolled the resident onto his/her left side and CNA D performed incontinent care with fecal material on the resident's back peri area. The resident had a sacral (above the tailbone) wound not covered with a dressing; - CNA D, wearing the same soiled gloves, touched the resident's clean linens and thigh; - CNA D failed to change gloves and perform hand hygiene during incontinent and catheter care, and perform appropriate catheter care. 9. Observation of a medication pass on 12/13/23, showed: - At 5:26 P.M., Certified Medication Technician (CMT) N exited a resident's room without performing hand hygiene, and obtained medications for Resident #175; - At 5:29 P.M., CMT N administered medications to Resident #175 and did not perform hand hygiene after administering the medications; - At 5:30 P.M., CMT N obtained and administered medications for Resident #43 and did not perform hand hygiene after administering the medications; - At 5:34 P.M., CMT N obtained medications for Resident #22; - CMT N failed to perform hand hygiene before and after administering medications to residents. During an interview on 12/13/23 at 5:45 P.M., CMT N said he/she didn't perform hand hygiene between all of the residents' medication passes. Hand hygiene should be performed between residents and he/she usually did it but had been nervous. 10. Observation of incontinent care for Resident #225 on 12/14/23 at 9:18 A.M., showed: - The resident lay in bed; - CNA J cleaned the resident's front peri area and collected fecal material on his/her glove; - CNA J removed the gloves, failed to perform hand hygiene, and put on new gloves; - CNA J continued to clean the resident's front peri area, and collected fecal material on his/her gloves; - CNA J removed the gloves, sanitized his/her hands, and put on new gloves; - CNA J wiped fecal material down the catheter towards the insertion site; - Wearing the same gloves, CNA J retrieved a new wipe and cleaned down the resident's legs; - Wearing the same gloves, CNA J assisted the resident to to roll onto his/her right side, and removed the soiled sheet and the incontinent pad from the bed; - Wearing the same gloves, CNA J placed a clean sheet on the bed, wiped the soiled mattress with an incontinent wipe, and placed clean wipes on top of the clean sheet; - Wearing the same gloves, CNA J picked up the peri wash bottle, sprayed the resident's buttocks with the peri wash, and cleaned the resident's buttocks; - CNA J removed the gloves, sanitized his/her hands, and put on clean gloves; - Wearing the same gloves, CNA J folded a clean sheet and an incontinent pad, and placed them under the resident; - Wearing the same gloves, CNA J touched the resident's oxygen tubing; - CNA J removed the gloves, did not perform hand hygiene, and put on new gloves; - CNA J put a bottom sheet, a draw sheet, and an incontinent pad onto the bed with fecal material on the back of each of them; - Wearing the same gloves, CNA J touched the resident's right hand and body to assist the resident to roll onto his/her right side; - Wearing the same gloves, CNA J cleaned fecal material from the resident's buttocks; - Wearing the same gloves CNA J touched the peri wash bottle, assisted the resident to turn to his/her back, and cleaned the resident's front peri area; - Wearing the same gloves, CNA J cleaned the resident's thighs, and touched the resident's shoe; - CNA J removed the gloves, failed to perform hand hygiene, and with his/her bare hands placed a clean gown on the resident, tied and snapped the gown, touched the resident's oxygen tubing and placed the nasal cannula (a device that delivers extra oxygen through a tube to the nose) into the resident's nose, touched the package of wipes, closed the wipe lid, assisted the resident to reposition in the bed, touched the resident's pillow, and touched the resident's clean blanket when he/she unfolded it and placed it on the resident; - CNA J change gloves and perform hand hygiene during incontinent and catheter care, and perform appropriate catheter care. During an interview on 12/14/23 at 9:55 A.M., Registered Nurse (RN) L said hand hygiene should be done prior to entering a resident room. Gloves should be put on prior to performing peri care. Hand hygiene and gloves should be changed when going from dirty to clean care. Hand hygiene should be completed before moving to the next resident. During an interview on 12/14/23 at 9:30 A.M., Licensed Practical Nurse (LPN) K said hands should be washed/sanitized between glove changes. Glove changes should happen between clean and dirty care. Catheter care should be done from the insertion point down. Hands should be sanitized between residents when passing medications. Staff should not touch food with bare hands when feeding residents. During an interview on 12/14/23 at 9:35 A.M., CNA F said gloves should be changed between dirty and clean care. Hands should be sanitized between glove changes and catheter care should go from the insertion site and away. Food shouldn't be touched with bare hands. During an interview on 12/14/23 at 9:45 A.M., the Director of Nursing (DON) said hands should be washed/sanitized between glove changes. Glove changes should happen between clean and dirty care. Catheter care should be done from the insertion point and down. Hands should be sanitized between residents when passing medications. Staff should not touch food with their bare hands when feeding residents. During an interview on 12/14/23 at 10:05 A.M., CNA J said during incontinent care, he/she should wipe from front to back, using one wipe once and throw it away. If gloves were soiled, then the gloves should be changed. With catheter care, he/she should wipe from one side out, other side out, wipe in-between from front to back, then another wipe to clean the catheter from top to bottom. He/She should then change gloves, sanitize hands, put on new gloves, continue cleaning with a wipe, and changing gloves if soiled. Should sanitize hands with glove changes. If clean linens became soiled during the process, they would need to be replaced with new linens. He/She would expect a mattress to be disinfected if soiled. He/She would expect gloves not visibly soiled to be changed before touching other items in the room. 47445 48532

Based on interview and record review, the facility failed to reevaluate one resident (Resident #1), of seven sampled residents, for readmission to the facility when the resident was being discharged from the hospital after being sent for a psychological evaluation. The facility census was 74. Review of the facility's policy titled, Transferor Discharge, Facility-Initiated Policy, dated 10/2022, showed the following: -Once admitted to the facility, residents have the right to remain in the facility. Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notifications and orientation, and documentation as specified by this policy; -Facility initiated transfer or discharge means a transfer or discharge which the resident objects to, or did not originate through a resident's verbal or written request, and/or is not in alignment with the resident's stated goals for care and preferences; -A resident's declination of treatment is not grounds for discharge, unless the facility is unable to meet the needs of the resident or protect the health and safety of others. The facility will document that the resident or, if applicable, resident representative, received information regarding the risks of refusal of treatment and that staff conducted the appropriate assessment to determine if care plan revisions would allow the facility to meet the resident needs or protect the health and safety of others; -If discharge is initiated by the facility after an emergency transfer to the hospital, the reason for discharge is based on the resident's status at the time the resident seeks return to the facility (not at the time the resident was transferred to acute care); -If a resident exercises his or her right to appeal a transfer or discharge notice he or she will not be transferred or discharged while the appeal is pending, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility; -If the facility determines that the resident cannot return to the facility, the medical record will indicate that the facility made efforts to, ascertain an accurate status of the resident's condition, which can be accomplished via communication between hospital and facility staff and/or through visits by the facility staff to the hospital-find out from the hospital the treatments, medications, and services the facility would need to provide to meet the resident's needs upon returning to the facility. If the facility is unable to provide treatments, medications, and services needed, the facility may not be able to meet the residents needs and work with the hospital to ensure the resident's condition and needs are within the facility's scope of care, based on its facility assessment, prior to hospital discharge. 1. Review of Resident #1's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admitted [DATE] and readmitted [DATE]; -Diagnoses included autonomic neuropathy (damage to the nerves that control autonomic body functions), stress incontinence (sudden loss of urine), IBS (Irritable bowel syndrome), fatigue (feeling of constant exhaustion), S/P (Surgical) DEEP Brain Stimulator placement (surgical procedure in which electrodes are implanted in to certain brain areas), end of battery life of deep brain stimulator, difficulty walking, depression (persistent feeling of sadness or loss of interest), atherosclerosis of native coronary artery without angina pectoris (disease that starts when fats, cholesterols and other substances collect on the inner walls of the heart arteries), chronic low back pain, bipolar disorder (extreme mood swings), dementia (loss of memory and abstract thinking), anxiety (sudden feelings of intense fear or terror), and mood disorder (distorted emotional state or mood distorted or inconsistent with your circumstances). Review of the resident's care plan, dated 07/18/23. showed the following: -Cognitive loss, communication and dementia; -Extensive assist with all adult daily living skills; -Most medications have been discontinued because of refusals to take them; -Has become more combative and have had altercations with other resident resulting in need to be monitored frequently and staff to intervene if one happens; -Report any changes in mood or behavior. Send resident to the emergency room if resident is combative with other residents and notify Administrator and Director of Nursing (DON); -Frequent observation and place monitoring device on resident due to wandering. Review of the resident's nurse's note dated 05/16/23, at 4:15 P.M., showed the resident was transferred via staff and facility van to psychiatric hospital for psychological evaluation. Review of the resident's medical record showed on 05/17/23 the facility mailed a notice of discharge for emergency situation to the resident's family member by certified mail based on current condition. Review of the resident's social services' note, dated 05/23/23, showed the following: -SSD received notice the resident is set to discharge on 05/24/23; -The SSD informed the psychiatric hospital that he/she would verify that the decision to discharge was still what the medical director felt was the best in the safety of the residents in the facility. The hospital said they needed notification by 4:30 P.M.; -SSD called the hospital back to inform them the facility was standing by the decision to not bring the resident back to the facility. (The SSD did not document an assessment of the resident's current condition to determine if the resident could safely return to the facility.) Review of the resident's records, 05/24/23 to 07/17/23, staff did not document an assessment of the resident's current condition to determined if the resident could safely return to the facility. Review of the resident's nurse's note, dated 07/18/23, showed the following: -At 5:00 P.M., the resident arrived to facility via emergency medical services; -Resident alert to self, but stated he/she does not recognize some faces; -Code alert bracelet placed on left ankle; -Family member brought in medications and clothes for resident; -Resident refused nystop powder, became agitated at the nurse and acted like he/she was going to hit the nurse; -Resident did wander to unit 2 and was going in and out of rooms, staff redirected back to unit 1. During an interview on 08/01/23, at 12:10 P.M., Licensed Practical Nurse (LPN) A said he/she did not know if the resident was discharged or only sent out for a psych evaluation. During interviews on 08/01/23, at 12:20 P.M. and 1:52 P.M., LPN B said the following: -He/she hasn't dealt with an emergency discharge, but assumes it would be similar to a regular discharge; -When a resident discharges, staff do medication reconciliation, explain meds to the family, pass the discharge summary around to each department so they can fill out their part; -The resident was discharged due to an altercation, and sent out for a psych evaluation, -If the hospital called and wanted to send a resident back after the facility completed an emergency discharge, he/she would notify the DON and Administrator for direction. During interviews an on 08/01/23, at 12:20 P.M. and 1:52 P.M., LPN C said the following: -Haven't done an emergency discharge, with a regular discharge he/she makes copies of the resident's physician's order sheet, transfer sheet, any current labs and history and physical; -The resident was sent out for a psychological evaluation. He/she did not know if it was an emergency discharge. He/she did overhear that the facility didn't want to take the resident back and hoping they would find another place; -If the hospital called and wanted to send a resident back after the facility completed an emergency discharge, he/she would get a hold the DON or Administrator for direction. During interviews on 08/01/23, at 12:31 P.M. and 1:42 P.M., the Social Services Director (SSD) said the following: -When a resident is discharged they are given a notice. He/she is pretty sure this is done within 24 hours. The ombudsman and family are also notified. This is documented under the social services notes; -The resident was sent to a psychiatric hospital for an evaluation. After the resident was sent out, emergency discharge paperwork was done. He/she does not know why that was done; -If the hospital wants to send them back, would re-evaluate to see if facility could take the resident back and ask for records to see if they could return; -If facility sent an emergency discharge, the facility wouldn't be able to take a resident back if the hospital calls wanting to send them back. During an interview on 08/01/23, at 12:45 P.M., the DON said the following: -The administrator dealt with most of things regarding the resident; -We were concerned about the safety of other residents so the resident was sent to hospital for a psych evaluation. This was ordered by the facility physician; -The hospital doctor felt the behaviors were related to a UTI, so he/she wrote a script for an antibiotic; -When there's an emergency discharge, staff send papers with the resident, and certified letters are mailed to the family, and ombudsman in 30 days. The letters were mailed to the resident's family and the ombudsman; -The resident was sent to the psychiatric hospital for a psychological evaluation; -The resident is on a new medication that's a patch seems to be helpful and some better. During an interview on 08/01/23, at 1:00 P.M., the Administrator said the following: -Resident was sent to a psychiatric hospital for an evaluation due to behaviors; -Admin and the DON had a discussion after sending the resident and decided the best thing would be to do an emergency discharge. The facility physician was also involved; -Resident was sent to Lakeland on 05/16/23 due to facility could not meet the resident's needs and ensure safety of other residents; -Mailed the family and ombudsman a certified discharge letter and hand delivered to the physician. During an interview on 08/01/23, at 2:02 P.M., the Administrator and DON said the following: -If the hospital wants the resident to return to the facility staff would look at the documentation and go from there. They essentially do a reevaluation to determine if the resident is a fit to come back to the facility; -Staff had not seen the documentation on the resident. MO00221619

Based on interviews and record review, the facility failed to ensure all allegations of possible abuse were reported within two hours to the State Survey Agency (Department of Health and Senior Services - DHSS) when staff failed to report an allegation of abuse made by resident (Resident #1) that a staff member (Certified Nurse Aide (CNA A)) made threats to harm the resident. The facility census was 61. Record review of the facility's policy titled, Abuse Investigation and Reporting, revised July 2017, showed the following: -All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management; -An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but no later than two hours if the alleged violation involves abuse or has resulted in bodily serious bodily injury. 1. Record review of Resident #1's face sheet (admission data) showed the following: -admitted [DATE]; -Diagnoses included Type II diabetes (impairment in the way the body regulates and uses sugar), morbid obesity, legally blind, post traumatic stress disorder (PTSD - a mental health condition that's triggered by a terrifying event), traumatic brain injury (TBI - an injury that affects how the brain works), paraplegia (paralysis of the legs and lower body), and seizures (a sudden, uncontrolled burst of electrical activity in the brain). Record review of the resident's care plan, revised on 12/21/22, showed the following: -New below/above the knee amputation on right side; -Assisted to complete daily living activities of care; -The resident has potential for pain. Record review the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 12/29/22, showed the following: -Cognitively intact; -Verbal behavioral symptoms directed towards others and rejection of care; -Limited assist/one person for transfers, bed mobility, dressing, toileting, personal hygiene, and bathing. Record review of the resident's physician's progress note, dated 1/10/23, said the following: -Recently had a verbal confrontation with one of the staff members; -The resident said one of the staff members was being rude to him/her; -He/she has had a couple of issues like this since he/she has been in the facility; -At that point he/she refused any of his/her medications or the staff to come into his/her room; -It is difficult to fully understand what transpired between him/her and one of the staff at the nursing home; -Nursing management is interviewing all involved parties. Record review of the facility's investigation, dated 1/08/23, showed the facility completed an investigation of the allegation of verbal abuse. Record review of DHSS records showed the facility did not self-report the allegation of possible abuse. During an interview on 2/05/23, at 2:35 P.M., Certified Medication Tech (CMT) B said the following: -The resident told CMT B that CNA A was going to knock the resident out. CMT B was told this by the resident about three to four weeks ago and it had happened the night before; -The resident also told Registered Nurse (RN) H and he/she reported it to the Administrator and Director of Nursing (DON); -If the allegation the resident made is true, it would be considered verbal abuse; -When abuse is reported or witnessed, he/she tells the charge nurse first thing; -The abuse is to be reported to the state in two hours. During an interview on 2/05/23, at 3:25 P.M., CNA A said the following: -The resident made a comment to staff that he/she threatened the resident; -The resident told Licensed Practical Nurse (LPN) F that CNA A had threatened that if the resident didn't knock something off, CNA A was going to take him/her to the ground; -If a resident is threatened by staff, this would be verbal abuse; -If observe or resident reports abuse, would tell the charge nurse and write a statement. During an interview on 2/05/23, at 4:05 P.M., LPN F said the following: -The resident did not complain to him/her about CNA A, but rather told the night nurse that something had happened; -He/she was present during the time the alleged incident took place, but he/she did not hear anything; -The night nurse called the following day and said he/she had to make an incident report; -If abuse is reported, staff is to inform the Director of Nursing (DON) and Administrator, and begin the abuse forms; -Required to report to the state in two hours; -If a resident is threatened, would consider that abuse or dignity and respect. During an interview on 2/05/23, at 2:50 P.M., LPN E said the following: -The resident did not say CNA A had threatened him/her, but didn't want CNA A around him/her because they had words. The LPN did not know what that involved; -If a resident is threatened, that would be dignity and respect and could also be verbal abuse; -If the LPN seen or had abuse reported, he/she would tell DON; -The home has two hours to report suspected abuse to the state. During an interview on 2/05/23, at 2:40 P.M., Certified Med Tech (CMT) C said the following: -If abuse is reported or observed, he/she would tell the charge nurse; -If a staff member threatened to harm a resident, this would be considered verbal abuse or dignity and respect; -The home has one hour to report allegations of abuse to the state. During an interview on 2/05/23, at 2:40 P.M., CNA D said the following: -If abuse is reported or observed, he/she would tell the charge nurse; -If a staff member threatened to harm a resident, this would be considered verbal abuse or dignity and respect; -He/she Is not sure of the timeframes to report to the state, but needs to be immediately. During an interview on 2/05/23, at 3:53 P.M., Registered Nurse (RN) G said the following: -If staff threaten a resident, this would be verbal abuse and possibly dignity and respect too; -If abuse is reported staff have an abuse/neglect packet that's completed and investigate. Staff call the DON and Administrator so they can do their portion, the alleged perp is suspended; -Abuse should be reported to the state within two hours. During an interview on 2/06/23, at 1:15 P.M., RN H said the following: -He/she took the complaint of the incident from the resident; -The resident came to his/her desk on 01/07/23 or 01/08/23, complaining about CNA A; -The resident said CNA A had threatened to take the resident down. The resident said LPN F was present when this occurred; -The resident came back again 20 minutes later and changed his/her story and said LPN F wasn't present when the incident occurred; -The RN texted the Administrator and began the paperwork for investigating allegations of abuse; -When RN H has a report of abuse allegations, he/she notifies the Administrator and/or the DON; -They direct him/her to complete paperwork for the investigation and the DON does his/her part; -If staff said this to a resident, it would be verbal abuse or dignity and respect; -State should be notified of abuse allegations in 30 minutes. During an interview on 2/05/23, at 2:55 P.M., the Social Services Director (SSD) said the following: -If a resident is threatened, this would be considered verbal abuse or dignity/respect; -If a resident reports being threatened, he/she would go to his/her supervisor to notify them, visit with the staff and any witnesses; -The facility has two hours to notify state of any allegations of abuse. During an interview on 2/05/23, at 4:25 P.M., the DON said the following: -The incident involving the resident and CNA A was reported to the DON on 1/7/23 or 1/8/23; -The resident reported it to the day or night shift nurse and that nurse reported it to the DON; -DON requested the nurse complete an investigation, when the investigation was completed it was deemed no threat of harm; -The resident gave two different versions of the incident. One said he/she didn't stop this shit, CNA A was going to put the resident down, the next version just said put him/her down; -He/she feels like it's something that should have been reported to the state, but it was not reported. During an interview on 2/05/23, at 4:50 P.M., Administrator and DON said the following: -The incident involving the resident and CNA A was reported to RN H on 1/8/23, he/she then reported it to the DON, and the DON to the Administrator; -The resident said that CNA A was going to put him/her down; -If a staff did say to a resident to stop their shit or they're going to put them down, that would be verbal abuse and/or dignity and respect; -Did not call the state to report the incident; -Allegations of abuse should be reported to the state within two hours. MO00213579

Based on interview and record review, the facility failed to document following-up on physician orders in a timely manner when the physician ordered a referral for a stump sock (special sock worn over an amputation stump) and a knee brace for one resident (Resident #1). The facility census was 61. Record review showed the facility did not provide a policy regarding following physicians' orders. 1. Record review of Resident #1's face sheet (admission data) showed the following: -admitted [DATE]; -Diagnoses included Type II diabetes (impairment in the way the body regulates and uses sugar), morbid obesity, legally blind, post traumatic stress disorder (PTSD - a mental health condition that's triggered by a terrifying event), traumatic brain injury (TBI - an injury that affects how the brain works), paraplegia (paralysis of the legs and lower body), and seizures (a sudden, uncontrolled burst of electrical activity in the brain); -Resident discharged to home on 2/1/23. Record review of the resident's Physicians' Order Sheets (POS) showed the following: -An order, dated 12/07/22, to refer resident for a stump sock; -An order, dated 12/19/22, for knee hinged adjustable brace, monitor placement and skin daily. (What was the date of the order?) Record review of the resident's care plan, revised on 12/21/22, showed the following: -New below/above the knee amputation on right side; -Assisted to complete daily living activities of care; -The resident had potential for pain; -Observe for additional assistive devices as needed. Record review the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 12/29/22, showed the following: -Cognitively intact; -Verbal behavioral symptoms directed towards others and rejection of care; -Limited assist/one person for transfers, bed mobility, dressing, toileting, personal hygiene, and bathing. Record review of the resident's January 2023 Medication Administration Record (MAR) showed the following: -An order, dated 12/19/22, for left knee hinged adjustable brace in place, monitor placement and skin daily. Staff documented an X each day of the week (indicating the brace was not placed). Record review of the resident's Physicians' Order Sheets (POS) showed the following: -An order, dated 1/23/23, to give resident ACE wraps to do his/her own stump compression. Record review of the resident's January 2023 MAR showed the order for the resident ACE wrap was not added. Record review of resident's nurse practitioner's progress note, dated 1/06/23, showed the following: -Above knee amputation of right lower extremity. Resident continues to participate in physical therapy. Will check with Physical Therapy (PT) regarding stump shrinker. Record review of physician's progress note, dated 1/16/23, showed the following: -Chief complaint from resident is he/she is needing a compression sleeve for his/her right knee to eventually help him/her fit a prosthetic. He/she is also needing an adjustable knee brace for his/her left knee; -Resident is in need of a stump shrinking sleeve device. This is medically necessary to help him/her prepare for prosthetic device in the future; - Resident is also needing an adjustable knee brace for his/her left knee due to the new significant increase in activity and weight bearing on the left due to the loss of the right lower leg. Record review of the resident's January 2023 nurses' notes showed staff did not document that the referral for the stump sock had been followed-up on. During an interview on 2/05/23, at 2:50 P.M., Licensed Practical Nurse (LPN) E said the following: -The LPN doesn't think the resident wore a brace on his leg or a stump shrinker; -The facility ordered a hinge brace, but it hadn't come in before the resident left. Record review of the resident's medical record showed staff did not document ordering the resident's knee brace. During an interview on 2/05/23, at 2:55 P.M., the Social Services Director (SSD) said the following: -When the resident came to the facility orthopedics had not set up and appointment for a stump shrinker; -Residents are generally taken to a local town to be fitted for a strump shrinker; -The resident wasn't taken to the appointment as they were waiting for his/her stump to heal. During an interview on 2/05/23, at 3:53 P.M., Registered Nurse (RN) G said the following: -When a physician writes an order the nurse that's rounding with the physician would get a medical device if the facility has one on hand, the nurse would be responsible for communicating or initiation from the pharmacy or durable medical equipment supply; -Don't usually have long to wait, sometimes that also depends upon insurance; -If the resident requires a referral then the nurse would notify central services of the need for the equipment. Once the submission for the appointment has been completed social services does the appointments and he/she would become responsible; -If social services brings the resident back with an order, it's the nurse's responsibility to make sure that order gets completed. During an interview on 2/06/23, at 1:15 P.M., RN H said the following: -Never got the knee brace for the resident, that's why the X was on the MAR. The DON saw it and asked physical therapy and they said it's nursing; -Physician said the resident had a stump shrinker, but he/she never saw it; -There was an order on the treatment sheet for the stump shrinker, no one knew who ordered it; -Take a copy of the order and put in the Social Services Director's box or medical records; -Don't know who follows up on orders to make sure it's done. During an interview on 2/05/23, at 4:05 P.M., Licensed Practical Nurse (LPN) F said the following: -When the physician writes an order on the physician's order sheet, whoever takes the order would be responsible. If it's a phone order it would be that person. If it's an order while the physician is here, it would be the nurse rounding with the physician or the charge nurse; -A stump shrinker would need to be ordered through the pharmacy. The resident had an order for a stump shrinker, as far as he/she knew the resident did get the stump shrinker; -If a resident is referred to a doctor for something then social services sets up the appointments and they notify nursing of the appointments and those are added to the calendars at the nurses' stations; -Charge nurse should follow up to make sure the resident got the stump shrinker. During an interview on 2/05/23, at 4:25 P.M., the Director of Nursing said the following: -The resident came into the facility with a brace and he/she believes the resident was using it. From what therapy said, it didn't fit well; -The physician writes the order, the charge nurse makes a copy of the order, and it's put in the social services box; -The DON sent the order to the provider and information for an appointment. The provider requested additional information. He/she could not recall the date of this contact; -Physician's orders should be carried over to the MAR; -Social Services and charge nurse should follow up to make sure the appointment took place and the resident got the stump shrinker; -The DON was scheduling the appoint for both the stump shrinker and a new leg brace; -He/she believes this was around the end of January; -He/she said it's a long time to wait from 12/7/22 to the end of January to get an appointment for the stump shrinker and the leg brace; -Therapy does the stump shrinker sometimes, but since the resident was larger, PT said the resident would need to be fitted for one. During an interview on 2/05/23, at 4:50 P.M., the Administrator and DON said the following: -The physician writes an order for the resident, the nurse gets the order and goes over that with the charge nurse; -Social services sets up the appointment for the resident. If the resident comes back with an order, that's given back to the charge nurse and he/she follows through to make sure the order is filled; -Doesn't know if the order for the stump shrinker for the resident was followed through on, he/she doesn't think the resident ever got the stump shrinker; -There should be documentation on the attempts staff make to set up appointments. During an interview on 2/06/23, at 1:05 P.M., the resident's physician said the following: -He/she writes the order and the nurse takes care of it, they review, and fax to where it needs to go; -DON follows up on that and social services too; -If it takes a while to get a response from a referral, nursing should probably follow up. It can take anywhere from a week to three months to get an appointment scheduled; -The staff were using ace wraps temporarily because they knew the resident didn't have a strump shrinker so they did the best we could; -The resident did have a knee brace that didn't fit right so he/she needed a new one that was going to be done when he/she got the stump shrinker. MO00213579

Based on interview and record review the facility failed to ensure 100% of the staff had been fully vaccinated for COVID-19 (a highly contagious virus that causes serious illness or death) or granted a qualifying exemption as recognized by the Centers for Disease Control (CDC) when two facility staff members (Employee A and Employee B) had a medical exemption for a non-qualifying medical reason. In the four weeks prior to the onsite survey, 30 residents tested positive for COVID-19. The facility census was 52. Record review of the facility's policy titled COVID-19 Vaccine Policies and Procedures, dated 11/15/2021, showed the following information: -The purpose is to establish the process to comply with the Federal mandate that all staff are vaccinated against COVID-19 unless they have a medical or religious exemption to help reduce the risk resident and staff have of contracting and spreading COVID-19; -Staff is defined as all current staff, as well as any new staff, who provide care, treatment, or other services for the facility and/or its patients. -Under federal law, staff may be eligible for a medical or religious exemption, but must meet the criteria for the exemption to qualify; -Medical exemption: if the immunization is medically contraindicated, per CDC's Summary Document for Interim Clinical Considerations for Use for COVID-19 Vaccines Currently Authorized in the United States, staff may apply for a medical exemption or delay; -Please refer to Medical Exemption Form. Record review of the (undated) facility form titled, Request for Medical Exemption/Accommodation related to Covid 19 Vaccination showed the following information: -Medical exemptions/accommodations for the COVID-19 vaccine will be considered if the individual provides a written certification by a licensed, treating medical provider of one of the following: -The applicable Centers for Disease Control and Prevention contraindication for the COVID-19 vaccine; -The applicable contraindication found in the manufacturer's package insert for the COVID-10 vaccine; -Pregnancy-related condition that prevents the employee from getting the COVID-19 vaccine; -Other disability that prevents the employee from getting the COVID-19 vaccine. 1. Record review of the facility's COVID-19 Staff Vaccination Status for Providers forms provided on 3/30/2022, showed the following information: -Total staff of 62; -Staff with completed vaccination 34; -Staff with a granted (a qualifying medical or non-medical) exemption: 28; -Employee A listed as qualified medical exemption; -Employee B listed as qualified medical exemption and religious exemption. Record review of the facility provided list of residents with COVID-19 diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -In the prior four weeks, 30 residents with positive test results; -No residents had been hospitalized and no resident had passed away due to positive COVID test results. 2. Record review of the facility's medical exemption request for Employee A showed the following information: - Request for medical exemption form, dated 11/29/2021, completed by Employee A and medical provider showed the reason for the request due to long term lung issues; -Letter, dated 12/4/2021, showed the accommodation request had been approved for a medical accommodation and signed by the administrator. During an interview on 3/30/2022, at 10:42 A.M., Employee A said that he/she had requested a medical exemption for the COVID-19 vaccination. He/she filled out a form provided by the administrator and had his/her physician signature. Record review of the CDC Summary of Document for Interim Clinical Considerations, dated 3/7/22, showed the following: -The CDC did not recognize long term lung issues as a a reason to not receive a COVID-19 vaccination. 3. Record review of the facility's medical exemption request for Employee B showed the following information: -Request for medical exemption form, dated 11/29/2021, completed by Employee B and medical provider showed the reason for the request due to patient has [CONDITION(S)] condition and the vaccine could worsen the condition; -Letter, dated 12/6/2021, showed the accommodation request had been approved for a medical accommodation and signed by the administrator. Record review of the CDC Summary of Document for Interim Clinical Considerations, dated 3/7/22, showed the following: -The CDC did not recognize [CONDITION(S)] condition as a a reason to not receive a COVID-19 vaccination. 4. During an interview on 3/30/2022, at 12:59 P.M., the Administrator said she was responsible for approving medical and religious exemption requests. She approved the requests based on the staff member and their physician's request. She was not aware of the recognized clinical reasons for the contraindications to Covid 19 vaccines other than allergic reaction.

Based on record review and interview, the facility failed to ensure Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff) were completed a minimum of every three months for eight residents (Resident #1, Resident #6, Resident #12, Resident #18, Resident #19, Resident #189, Resident #190 and Resident #191). The facility census was 52. Record review of the facility's Resident Assessments policy, revised November 2019, showed the following: -A comprehensive assessment of every resident's needs is made at intervals designated by Omnibus Budget reconciliation Act (OBRA) and Prospective Payment System (PPS) requirements; -The Resident Assessment Coordinator is responsible for ensuring that the Interdisciplinary Team conducts timely and and appropriate residents assessments and reviews according to the following requirements; -Quarterly Assessment to be conducted not less frequently that three months following the most recent OBRA assessment of any type. 1. Record review of Resident #1's face sheet (admission data) showed the following: -admitted on [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's MDS assessments showed the following information: -Staff encoded a quarterly MDS assessment for the resident on 7/15/21 into the facility system, but had not completed the assessment. During an interview on 10/14/21, at 2:38 P.M., the MDS/Care Plan Coordinator said staff did not complete the resident's quarterly MDS assessments that were due on 7/15/21 and 10/14/21. 2. Record review of Resident #'6's face sheet showed the following: -admitted on [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's MDS assessments showed the following information: -Staff failed to complete the required quarterly due on 9/3/21. During an interview on 10/14/21, at 2:38 P.M., the MDS/Care Plan Coordinator said staff did not complete the resident's quarterly MDS assessment due on 9/3/21. 3. Record review of Resident #12's face sheet showed the following: -admitted on [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's MDS assessments showed the following information: -Staff failed to complete the resident's quarterly MDS due on 5/4/21; -Staff failed to complete the the resident's annual MDS assessment due on 8/17/21. During an interview on 10/14/21, at 2:38 P.M., the MDS/Care Plan Coordinator said staff did completed the resident's quarterly MDS assessment due on 5/4/21 and annual assessment due on 8/17/21. 4. Record review of Resident #18's face sheet showed the following: -admitted on [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's MDS assessments showed the following information: -Staff failed to complete the resident's quarterly MDS assessment due on 8/6/21. During an interview on 10/14/21, at 2:38 P.M., the MDS/Care Plan Coordinator said the resident's quarterly MDS assessment due on 8/6/21 was not completed. 5. Record review of Resident #19's face sheet showed the following: -admitted on [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's MDS assessments showed the following information: -Staff completed an admission MDS assessment on 5/11/21; -Staff did not complete the resident's quarterly MDS assessment due on 8/10/21. During an interview on 10/14/21, at 2:38 P.M., the MDS/Care Plan Coordinator said staff did not complete the resident's quarterly MDS assessment due on 8/10/21. 6. Record review of Resident #189's face sheet showed the following: -admitted on [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's MDS assessments showed the following information: -Staff completed a comprehensive MDS assessment on 01/29/21; -Staff did not complete the resident's quarterly MDS assessment due on 5/7/21 and 8/6/21. During an interview on 10/14/21, at 2:38 P.M., the MDS/Care Plan Coordinator said staff did not complete the resident's quarterly MDS assessments due on 5/7/21 and 8/6/21. 7. Record review of Resident #190's face sheet showed the following: -admitted on [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's MDS assessments showed the following information: -Staff completed a comprehensive MDS assessment on 2/1/21; -Staff did not complete the resident's quarterly MDS assessment due on 5/3/21 and 8/3/21. During interviews on 10/14/21, at 11:22 A.M. and 2:38 P.M., the MDS/Care Plan Coordinator said the staff did not complete the resident's quarterly MDS assessments due on 5/3/21 and 8/3/21. 8. Record review of Resident #191's face sheet showed the following: -admitted on [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's MDS assessments showed the following information: -Staff completed the resident's quarterly MDS assessment due on 11/20/20 and 2/19/21; -Staff did not complete the resident's quarterly MDS assessment due on 5/21/21; -Staff did not complete the resident's annual MDS assessment due on 7/28/21. During an interview on 10/14/21, at 2:38 P.M., the MDS/Care Plan Coordinator said staff did not complete the resident's quarterly MDS assessment, due on 5/21/21, and annual MDS assessment, due on 7/28/21. 9. During interviews on 10/14/21, at 11:22 A.M. and 2:38 P.M., the MDS/Care Plan Coordinator said the following: -She was the DON and MDS/Care Plan Coordinator for January 2021. She left the facility June 2021; -She returned to the facility as the MDS/Care Plan Coordinator the end of August 2021; -She had MDS assessments caught up until June 2021, before she left the facility; -The Assistant Director of Nursing (ADON) completed the MDS assessments 6/2021 to the end of 8/2021; -MDS assessments are late and not completed; -She submits the completed MDS assessments. 10. During interviews on 10/15/21, at 1:05 P.M., and on 10/19/21 at 2:38 P.M., the administrator said the following: -She took over as administrator in January 2021; -The prior MDS coordinator was interim and did three jobs; -The current MDS coordinator is behind on MDS assessments due to she worked the floor; -MDS assessments to be completed include quarterly and annual assessment; -MDS assessments are not completed and late. 11. During an interview on 10/15/21, at 1:23 P.M., the ADON said she was aware the MDS assessments were late and not completed. She had been in training for a couple of months and did not complete the MDS assessments.

Based on observation, interview, and record review, the facility failed to ensure a resident's choice of code status (the level of medical interventions a resident wishes to have if their heart or breathing stops) was clearly and consistently documented throughout the resident's medical record for three residents (Resident #7, Resident #21 and Resident #139). The facility census was 52. Record review of the facility's policy titled Advance Directives, revised ,d+[DATE], showed the following: -Advance directives will be respected in accordance with state law and facility policy; -Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive is he or she chooses to do so; -The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive; -Changes or revocations of a directive must be submitted in writing to the administrator. The administrator may require new documents if changes are extensive. The care plan team will be informed of such changes and/or revocations so that appropriate changes can be made in the resident assessment and care plan; -The Director of Nursing (DON) services or designee will notify the attending physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care;. 1. Record review of Resident #7's face sheet (admission data) showed the following: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's Outside the Hospital Do Not Resuscitate (DNR - do not attempt cardiopulmonary resuscitation (CPR - an emergency procedure that is performed when a person's heartbeat or breathing has stopped)) (OHDNR) form, dated [DATE], showed the following: -The resident's representative's signed the form; -The resident's physician's signed the form on [DATE]. Record review of the resident's care plan, dated [DATE], showed the following: -Code status of full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep alive). Record review of the resident's current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on [DATE], at 12:41 P.M., the administrator and DON said the resident's care plan should have been updated to show a DNR code status because of the change of code status by the representative. 2. Record review of Resident #21's face sheet showed the following: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's OHDNR form, dated [DATE], showed the following: -The resident's representative's signed the form; -The resident's physician's had not signed the form. Record review of the resident's care plan, dated [DATE], showed the following: -Code status full code; -See physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -Ensure code status is updated yearly or with a significant change in condition. Record review of the resident's [DATE] POS showed the resident's code status as full code. During an interview on [DATE], at 8:56 A.M., Registered Nurse (RN) D said the following: -The resident is full code; -The physician did not sign the DNR form; -The [DATE] POS has full code; -He/she is not sure of the resident's code status; -He/she said since the resident's representative signed the DNR on [DATE] he/she would assume the resident is DNR. 3. Record review of Resident #139's face sheet showed the following: -admitted on [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's OHDNR form, dated [DATE], showed the following: -The resident's representative's signed the form; -The resident's physician signed the form on [DATE]. Record review of the resident [DATE] and [DATE] POS showed staff marked out full code status and documented DNR. Record review of page one of the [DATE] and [DATE] POS showed the resident's code status as full code. Record review of the resident's care plan, updated [DATE], the resident's code status as full code. Record review of the resident's [DATE] POS showed the resident's code status as full code. During an interview on [DATE], at 9:37 A.M., the Social Service Director (SSD) said the resident's [DATE] POS showed full code and the DNR was signed [DATE] and the physician signed on [DATE]. 4. During an interview on [DATE], at 8:26 A.M., Certified Nurse Aide (CNA) O said the following: -He/she is unaware of where to find a resident's code status; -The facility used to have red stickers on resident charts for DNR code status; -He/she would get the nurse if he/she finds a resident unresponsive. 5. During an interview on [DATE], at 8:56 A.M., RN D said the following: -Staff find a resident's code status in the chart; -Staff should look at the first page of the POS to find a resident's code status; -The facility used to have colored stickers for code status; -The DNR should be under the legal document tab in the chart; -Nursing completes the DNR and after the resident or representative signs it, it should go to medical records; -He/she is unsure how the physician gets the DNR form to sign. 6. During an interview on [DATE], at 9:37 A.M., the SSD said the following: -She filed medical records until [DATE] when she became the SSD; -She asks the family, resident or durable power of attorney (DPOA) on admission of their code status; -She makes a copy of the signed DNR form and places the original DNR form in a folder for the physician to sign when he is at the facility once per week; -She puts the original DNR form in the resident's chart after the physician signs it; -The original DNR should be back in the chart after the physician has signed; -The nurse should document the code status on the POS the day the family or resident signs the form; -Staff should find the code status on the POS and the legal document section; -She is unsure of who puts the code status on the care plan; -The nurse should make code status changes on the revocation on the DNR form and update the POS and care plan if a resident/representative requests a code status change. 7. During an interview on [DATE], at 12:15 P.M., the MDS/Care Plan Coordinator said the following: -She reviews the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Code status should match throughout the residents' medical record. 8. During interviews on [DATE], at 11:55 A.M., and on [DATE], at 2:38 P.M., the Director of Nursing (DON) said the following: -Nurses should ask a resident's code status upon admission; -The DPOA or resident's representative signs the DNR form if the resident is unable to sign; -Staff should make a copy for the resident's chart and put the original form to medical records for the physician to sign; -Medical records brings the original form to the resident's medical record after the physician signs; -Code status should be on the POS and care plan; -She would expect a resident's code status to match throughout the resident's medical record. 9. During interviews on [DATE], at 11:55 A.M., and on [DATE], at 2:38 P.M., the administrator said the following: -Staff make a copy of the signed DNR and place it in the resident's chart and send the original form to medical record for the physician to sign; -Medical record staff should file the physician signed original DNR form in the resident's chart; -The resident's code status should be documented on the POS and care plan; -She would expect a resident's code status to match throughout the resident's medical record.