Every finding on record at Life Care Center of Sullivan

Based on observation, interviews, and record review, facility staff failed to provide care to meet the basic hygiene needs for five residents (Resident #2, #4, #5, #6, and #7) out of seven sampled residents who required assistance with Activities of Daily Living. The facility's census was 82. 1. Review of the facility's Activities of Daily Living (ADL) policy, revised 09/04/25, showed the residents will receive assistance as needed to complete ADLs. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review of the facility's shower schedule showed each resident is scheduled to be assisted with a bath/shower twice per week by facility staff. 2. Review of Resident #2''s Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Impairment to one side lower extremity (hip, knee, ankle, foot); -Required set-up assistance from staff for personal hygiene;-Required partial to moderate assistance from staff to shower/bathe. Review of the resident's care plan, dated 04/09/26, showed staff were directed to assist the resident with mobility and ADLs as needed. Review of the resident's electronic and paper shower records, dated 06/01/26 through 06/24/26, showed staff documented resident received a shower on 06/02/26, 06/04/26, 06/09/26, and 06/15/26. Observation on 06/24/26 at 10:44 A.M., showed the resident with long facial hair to his/her chin and upper lip. During an interview on 06/24/26 at 10:44 A.M., the resident said he/she is supposed to get two showers per week, but staff have only been offering one per week. He/She said he/she would like staff to shave his/her facial hair and has asked staff to shave him/her but they haven't, and if he/she had a razor he/she would shave the facial hairs him/herself. Observation on 06/24/26 at 1:47 P.M., showed the resident with long facial hair to his/her chin and upper lip. Observation on 06/25/26 at 10:04 A.M., showed the resident with long facial hair to his/her chin and upper lip During an interview on 06/25/26 at 10:04 A.M., the resident said staff assisted him/her with a shower the evening before but did not offer to shave or remove his/her facial hair. 3. Review of Resident #4''s admission MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Required partial/moderate assistance from staff with transfers;-Required substantial to maximum assistance from staff to shower/bathe. Review of the resident's care plan, dated 05/26/26, showed staff were directed to assist the resident with mobility and ADLs as needed. Review of the resident's electronic and paper shower records, dated 05/01/26 through 05/31/26, showed staff documented the resident received a shower on 05/11/26, 05/27/26, and one resident refusal on 05/04/26. Review of the resident's electronic and paper shower records, dated 06/01/26 through 06/24/26, showed staff documented the resident received a shower on 06/11/26. Observation on 06/24/26 at 10:58 A.M., showed the resident in bed with long greasy hair. Observation on 06/25/26 at 10:17 A.M., showed the resident in his/her wheelchair with long greasy hair. During an interview on 06/24/26 at 10:58 A.M., the resident said he/she was told staff would offer him/her a shower twice a week, but he/she has never received two showers in a week, and his/her last shower was about two weeks ago. He/She said not having a shower makes him/her feel crappy and his/her hair feels greasy. 3. Review of Resident #5''s Quarterly MDS, dated [DATE], showed staff assessed the resident as moderate cognitive impairment, and dependent on staff for personal hygiene, transfers, and to shower/bathe. Review of the resident's care plan, dated 05/26/26, showed staff were directed to assist the resident with mobility and ADLs as needed. Review of the resident's electronic and paper shower records, dated 05/01/26 through 05/31/26, showed staff documented the resident received a shower on 05/12/26 and 05/26/26. Review of the resident's electronic and paper shower records, dated 06/01/26 through 06/24/26, showed staff documented the resident received a shower on 06/01/26 and 06/09/26. Observation on 06/24/26 at 11:36 A.M., showed the resident in his/her wheelchair with long greasy hair and long fingernails. Observation on 06/24/26 at 2:30 P.M., showed the resident in his/her wheelchair with long greasy hair and long fingernails. Observation on 06/25/26 at 10:24 A.M., showed the resident in his/her wheelchair with long greasy hair and long fingernails. 4. Review of Resident #6''s Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact, and required substantial to maximum assistance from staff to shower/bathe. Review of the resident's care plan, dated 05/04/26, showed staff were directed the resident requires extensive/substantial assistance with bathing on shower days and as needed on request. Review of the resident's electronic and paper shower records, dated 05/01/26 through 05/31/26, showed staff documented the resident received a shower on 05/12/26, 05/29/26 and one resident refusal on 05/15/26. Review of the resident's electronic and paper shower records, dated 06/01/26 through 06/24/26, showed staff documented the resident received a shower on 06/09/26. Observation on 06/24/26 at 12:31 P.M., showed the resident in his/her wheelchair with greasy hair. During an interview on 06/24/26 at 12:34 P.M., the resident said he/she does not get a shower too often and he/she could use a shower. 5. Review of Resident #7''s Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact, and required substantial to maximum assistance from staff to shower/bathe. Review of the resident's care plan, dated 06/25/26, showed staff assessed the resident as totally dependent on one staff to provide bed bath, resident prefers Mondays and Thursdays. Review of the resident's electronic and paper shower records, dated 05/01/26 through 05/31/26, showed staff documented the resident received a shower on 05/09/26, 05/18/26 and 05/27/26. Review of the resident's electronic and paper shower records, dated 06/01/26 through 06/24/26, showed staff documented the resident received a shower on 06/02/26, 06/04/26 and 06/18/26. During an interview on 06/24/26 at 2:31 P.M., the resident said staff are supposed to assist him/her with a shower twice a week but have only been offering him/her a shower about once every two weeks and he/she had to beg staff a week ago to get a shower. He/She said he/she feels gross when he/she has to wait that long to get a shower. 6. During an interview on 06/24/26 at 1:12 P.M., Certified Nursing Assistant (CNA) D said the CNAs are supposed to offer each resident a shower twice per week or at least once a week per the shower schedule and document on the shower sheet and in the computer once completed. He/She said staff have been having difficulty keeping up with showers recently due to staffing. During an interview on 06/24/26 at 1:36 P.M., CNA E said the CNAs are supposed to offer the residents a shower twice a week per the shower schedule and chart on paper and the electronic chart once completed. He/She said the residents' showers are not getting done like they should because they've been busy, and the aides are just trying to keep the residents clean and dry. During an interview on 06/25/26 at 10:26 A.M., CNA F said the CNAs are supposed to offer the residents a shower twice a week per the shower schedule and as needed, and document on the shower sheet and in the computer once completed. He/She said staff are expected to wash hair, offer to shave facial hair and trim nails (if the resident is not diabetic). He/She said residents are not being assisted with showers because there are not enough staff at times to get it done. During an interview on 06/25/26 at 10:50 A.M., Registered Nurse (RN) C said staff are expected to offer the residents showers twice a week but staff don't always get them done due to low staffing. The RN said staff will try to complete the showers on the weekends when there is sometimes more help. During an interview on 06/25/26 at 2:27 P.M., the Director of Nursing (DON) said he/she expects the CNAs to offer residents a shower twice a week or at least once weekly, wash hair, trim nails, and shave shaved if needed, and document completed showers on paper and in the computer. The DON said the charge nurses are to provide oversight for the CNAs completing the showers, and he/she felt like showers not getting done had become more of an issue lately. During an interview on 06/25/26 at 3:17 P.M., the administrator said staff are expected to offer residents a shower twice a week, wash hair, trim nails, and shave females if needed. The administrator said he/she was not sure why staff were not offering showers to residents but he/she has had a few residents request a shower due to missed showers and ensured staff took care of it. Complaint# 3047789, 3047949, 3050202, 3052073

Based on observation, interviews and record review, facility staff failed to maintain professional standards of care, when staff failed to transcribe a wound treatment order from the hospital for one resident (Resident #1), and failed to document wound care and treatments as directed by the physician for three residents (Resident #1, #2, and #3) out of three sampled residents with wounds. The facility's census was 82.1. Review of the facility's Physician Orders policy, revised 02/11/26, showed the facility is to follow and carry out the orders of the prescriber in accordance with all applicable state and federal guidelines. Physician orders include medications and treatments. Review of the facility's Treatment Orders policy, revised 05/15/26, showed treatment orders are written per physician orders. The physician writes an order that includes the following: site of wound, name of cleanser, name of ointment, type of dressing and number of times to perform the treatment/duration of treatment. The physician order is followed, as are the manufacturer's instructions for use of each product ordered. 2. Review of Resident #1's Quarterly MDS, dated [DATE], showed staff assessed the resident as moderate cognitive impairment, and received applications of dressings to feet (with or without topical medications). Review of the resident's Physician Order Summary (POS), dated 06/01/26 through 06/15/26, showed a physician order directed staff to cleanse left heel with wound cleanser, pat dry, apply skin prep (a protective skin-protectant film) to peri wound, apply Santyl (medication to remove dead tissue from wounds) nickel thick to wound base, cut antibacterial foam dressing saturated in normal saline and apply to wound base, apply silicone foam bordered dressing daily and as needed if soiled or dislodged, stop date 06/16/26. Review of the resident's TAR, dated 06/01/26 through 06/15/26, showed the TAR did not contain documentation staff provided wound treatment as directed by the physician to the resident's left heel on 06/03/26, 06/05/26, 06/08/26, 06/12/26, and 06/14/26. During an interview on 06/24/26 at 2:02 P.M., Licensed Practical Nurse (LPN) A said he/she was new to the position, is now responsible to administer wound treatment to the resident's left leg Monday through Friday, and the charge nurse is responsible to do the treatment on the weekends. Review of the resident's Hospital Discharge Orders, dated 06/18/26, showed a physician order to change dressing to the resident's left leg daily, place 4x4's (gauze pads) over staples, place ABD padding (to absorb drainage and protect wounds) over the 4x4's, wrap with a sterile gauze, and wrap with ace bandage. Review of the resident's progress notes, dated 06/19/26 at 3:03 P.M., showed staff documented resident returned to facility yesterday evening, treatment not viewed due to no orders to change dressing noted or reported. Review of the resident's POS, dated 06/18/26 through 06/24/26, showed the POS did not contain orders for wound care to the resident's left leg. Review of the resident's TAR, dated 06/18/26 through 06/24/26, showed the TAR did not contain documentation of treatment orders or staff provided wound treatments to the resident's left leg. Observation on 06/25/26 at 1:22 P.M., showed staples to a wound on the resident's left leg. During an interview on 06/25/26 at 11:57 A.M., the administrator said the resident's wound treatment order was not transcribed to the POS or the TAR, but LPN A had documented the order in the wound assessment notes. He/She said if the order was not on the TAR, the nurses would not be prompted to administer the treatment. During an interview on 06/25/26 at 1:47 P.M., LPN A said the resident re-admitted with wound care order from his/her surgeon, and he/she transcribed the order to the resident's TAR but somehow the order got deleted. LPN A said if the treatment was not listed on the TAR, the nurses would not be prompted to administer the treatment to the resident's leg. During an interview on 06/25/26 at 2:27 P.M., the Director of Nursing (DON) said he/she expects the admission nurse to ensure treatment orders are entered on the POS, the wound nurse to follow up the next day to ensure the treatment orders were on the TAR, and he/she audits after a few days after. The DON said he/she completed an audit the day before and realized the resident's wound care order did not get transcribed to the POS and was not on the TAR. During an interview on 06/25/26 at 3:17 P.M., the administrator said he/she expects the nurse who admits the resident to enter the physician's orders and LPN A to follow up and ensure correct wound care orders are entered on the resident's POS and TAR. 3. Review of Resident #2's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact, and received surgical wound care. Review of the resident's POS, dated 06/01/26 through 06/24/26, showed a physician order directed staff to administer the following wound treatment to cleanse left lateral foot with wound cleanser, pat dry, apply skin prep to peri wound, apply betadine moistened gauze to base of wound with foam dressing daily and as needed every Monday, Wednesday and Friday, stop date 06/18/26. Review of the resident's TAR, dated 06/01/26 through 06/24/26, showed the TAR did not contain documentation staff provided wound treatment as directed by the physician to the resident's left foot on 06/03/26, 06/08/26, and 06/15/26. Review of the resident's progress notes, dated 06/01/26 through 06/24/26, showed the record did not contain documentation regarding the missed treatments. Observation on 06/24/26 at 10:44 A.M., showed the resident with a wound to his/her left foot. During an interview on 06/24/26 at 1:47 P.M., LPN A said he/she or the charge nurse is responsible to administer the physician ordered treatment to the resident's foot and document on the TAR once completed. He/She said if the nurse did not document on the TAR, the treatment probably was not administered that day. 4. Review of Resident #3's Significant Change MDS, dated [DATE], showed staff assessed the resident as cognitively intact, and received surgical wound care. Review of the resident's POS, dated 06/01/26 through 06/24/26, showed a physician order directed staff to cleanse left below knee amputation with wound cleanser, apply skin prep to peri wound, cut specialized black foam to fit inside of wound bed, peel adhesive drape front and back, sealing wound, then cut hole in middle of drape, apply suction pad, then cover with adhesive drape to completely seal wound, connect to suction vacuum pump set at 125 millimeter of mercury (mmHG) continuously on Monday, Wednesday, Friday, and as needed if air leak or dislodged. Review of the resident's TAR, dated 06/01/26 through 06/24/26, showed the TAR did not contain documentation staff provided wound treatment as directed by the physician to the resident's left leg on 06/12/26 and 06/15/26. Review of the resident's progress notes, dated 06/01/26 through 06/24/26, showed the record did not contain documentation regarding the missed treatments. During an interview on 06/25/26 at 1:47 P.M., LPN A said he/she is responsible for administering the treatment to the resident's left leg on Monday, Wednesday and Friday, and if he/she is not available, the DON completes the treatment. LPN A said if the TAR was not signed, the treatment probably did not get done. During an interview on 06/25/26 at 1:53 P.M., the resident said staff are supposed to change the dressing to his/her leg every two to three days, but staff have missed changing the dressing a few times. During an interview on 06/25/26 at 2:27 P.M., the DON said LPN A is responsible for administering the treatment to the resident's left leg and he/she will assist LPN A when needed. The DON said he/she was not aware of any missed treatments to the resident's left leg. Complaint# 3047789

Based on interviews and record review facility staff failed to obtain orders and complete assessments for one resident (Resident #1's) surgical wound which resulted in amputation of the right trans metatarsal (a partial foot amputation) The facility census was 67.1. Review of the facility's treatment order policy, reviewed 6/12/25, showed treatment orders are written per physician orders. If a resident has multiple wound sites, a complete and separate treatment order must be written for each site. The physician writes an order that includes the following: site of wound, name of cleanser, name of ointment, type of dressing and number of times to perform the treatment/duration of treatment.Review of the facility's Physician Orders, revised 2/11/26, showed a physician, physician assistant or nurse practitioner must provide orders for the resident's immediate care and ongoing care of the resident.2. Review of the resident's face sheet showed the resident admitted to the facility on [DATE].Review of the resident's hospital Discharge summary, dated [DATE], showed a diagnosis of gangrene (a serious, often life-threatening condition caused by tissue death). Review showed the summary did not contain orders for surgical wound care or for a follow up appointment.Review of the resident's physician order sheets, dated 4/10/26, showed the physician orders directed staff to have wound care provider evaluate and treat. Review showed the orders did not contain orders for surgical wound care or for follow up post operative appointment.Review of the residents Treatment Administration Record (TAR), dated 4/8/26 to 4/14/26, did not contain documentation of treatment orders or that staff provided treatments to the residents' surgical site.Review of the resident's nurses notes from 4/8/26 to 4/13/26 did not contain documentation staff assessed the residents dressing or surgical site. Review of the residents nurses notes, dated 4/14/26, showed staff documented family at bedside and concerned regarding resident's toe amputation site. Surgeon gave orders for residents to be sent to emergency room for further evaluation.Review of the resident's hospital discharge information, dated 4/22/26, showed podiatry consulted for worsened chronic right foot wound with tissue necrosis (he premature, irreversible death of cells and living tissue caused by external factors like infection, toxins, or trauma, often resulting from blocked blood flow) and a right trans metatarsal amputation was performed on 4/18/26.During an interview on 4/22/26 at 9:48 A.M., the administrator said the resident was admitted with an amputation of his/her toes and thought the order was to not change the dressing. He/She said the resident's family was at bedside on 4/14/26 and took the dressing off and sent a picture to the surgeon and he/she wrote an order for the resident to be sent to the emergency room. The administrator said the resident had more toes amputated at the hospital.During an interview on 4/22/26 at 10:26 A.M., the Director of Nursing (DON) said the resident admitted with amputation of the toes and the resident said the dressing was not to be removed until his/her follow up appointment. He/She said the family removed the dressing and the resident was sent to the hospital. He/She said the hospital had to take more toes or more of the foot and probably will end up taking more due to gangrene.During an interview on 4/22/26 at 12:12 P.M., Licensed Practical Nurse (LPN) C said he/she worked with the resident the day he/she was sent to the hospital, and he/she recommended the resident be sent because his/her foot looked like it was dying. He/She said he/she looked in the chart and there were no wounds or treatment orders. He/She said the admitting nurse documented the resident said not to touch the surgical site until he/she had a follow up with the surgeon.During an interview on 4/22/26 at 1:01 P.M., the DON said he/she could not find an order for the resident's treatment or an order to say the dressing should stay in place. He/She said her recollection was that is what the resident told the admitting nurse. During an interview on 4/22/26 at 1:06 P.M., LPN D said he/she documented the resident's bandage was to stay intact until he/she saw the surgeon for his/her follow up appointment because that was what he/she was told by the resident. He/She said the resident's hospital discharge paperwork did not contain treatment orders for the surgical site. He/She said the resident admitted on a Tuesday or Wednesday and said Thursday was the follow up, but the resident could not say if that was a day or two from then or a week. He/She said He/She passed the concern of the lack of wound orders to the oncoming nurse to get clarification and does not know what happened from there. LPN D said he/she did not notify the physician because he/she had passed everything on in report to the day charge and thought he/she would notify the physician to get direction.During an interview on 4/22/26 at 1:20 P.M., LPN C said he/she does not recall being asked to call to clarify the treatment orders for the resident, but he/she did not call the hospital, the original surgeon, or the wound care company to receive orders for the resident.During an interview 4/23/26 at 10:21 A.M., the Physician said the resident was a tough case because he/she and the facility had limited access to the resident's chart. He/She said the resident's amputation was completed by a private surgeon and then the resident was admitted to the facility from the local emergency room. He/She said he/she saw the resident on 4/10/26 and placed the order for wound care to evaluate and treat because there were no orders. He/She said he/she told the facility staff leaving the bandage for the weekend was acceptable because that is common for surgeons to request, depending on how long until the follow up. He/She said the facility should have followed up with wound care or tried to get in touch with the private surgeon to receive orders, He/She said in an ideal world, the facility would have orders by Monday 4/12/26 at the latest. He/She does not know why there was a lapse in wound care assessing the resident for that week.During an interview on 5/7/26 at 8:54 A.M., the DON said the resident was on the list to see the wound care plus nurse practitioner, but her case load had almost tripled because of the influx in new admits with wounds. He/She said wound care prioritized stage four wounds and wound vacs over surgical because the resident should have had a follow up with the surgeon.#2986607

Based on observation, interview and record review, the facility staff failed to serve food in accordance with the nutritionally calculated menus to one of one residents (Resident #40) who received a pureed diet and 10 residents who received mechanically altered diets. The facility census was 76.1. Review of the facility's policy titled Food Preparation, revised 04/29/25, showed the policy directed for the Director of Food and Nutrition Services to provide recipes and the recipes were to be followed by food service associates Review also showed the policy directed staff to prepare menu items in accordance with the menu, recipes and production sheets. 2. Review of the facility's lunch menus dated 03/17/26 (Week 4, Day 24), showed staff directed to provide the residents who received a pureed diet with a #10 (3.2 ounces (oz.)) scoop of pureed fish, and a #8 (four oz.) scoop of pureed seasoned beans. Observation on 03/17/26 at 12:30 P.M., showed [NAME] A served Resident #40 a #16 (two oz.) scoop of pureed fish (1.2 oz. less than directed by the menu) and a #16 scoop of beans (two oz. less than directed by the menu). 3. Review of the facility's lunch menus dated 03/17/26 (Week 4, Day 24), showed staff directed to provide the residents who received a mechanical soft diet with four oz. of cabbage or mixed vegetables and four oz. of soft potatoes.Observation on 03/17/26 at 12:30 P.M., showed [NAME] A served the 10 residents who received mechanical soft diets received a #12 (2.6 oz.) scoop of mechanically altered broccoli (1.4 oz. less than directed by the menus) and a #12 scoop of potatoes (1.4 oz. less than directed by the menus). 4. During an interview on 03/17/26 at 12:32 P.M., [NAME] A said he/she reviewed the menu portions and put the scoops on the serving line. The cook said pureed foods were served with a blue scoop, but he/she did not know what size the scoop was because he/she could not see the size on the scoop. The cook said he/she asked [NAME] B, who said the scoop sizes were okay. The cook said he/she had been trained on proper scoop sizes in the past. During an interview on 03/17/26 at 12:38 P.M., [NAME] B said he/she told [NAME] A it was okay to use blue scoops for the pureed items. The cook said he/she did not look closely at the menu or scoop size before he/she said the scoops were okay. During an interview on 03/17/2026 at 12:39 P.M., the Registered Dietician said he/she would expect staff to check the menus and verify the proper scoop sizes to be used before they serve residents. During an interview on 03/18/26 at 11:45 A.M., the Director of Food and Nutrition Services said he/she is responsible to ensure the cooks serve residents in accordance with the menus. The director said the cooks should look at the menus and verify the proper scoops to use before they serve the residents. The director said he/she just started two weeks ago so he/she did not know how much staff were trained and believed staff were confused about correct scoop sizes. During an interview on 03/19/26 at 11:15 A.M., the administrator said the residents should be served in accordance with the menus and the Director of Food and Nutrition Services is responsible to ensure the kitchen staff follow the menus and serve the correct portion sizes to the residents. The administrator said he/she did not know staff did not follow the menus.

Based on interview and record review, facility staff failed to educate and offer the Coronavirus disease 2019 (COVID-19) (a respiratory disease that can cause severe illness) vaccination for four residents (Resident #7, #10, #21 and #66) out of five sampled residents. The facility census was 76.1. Review of the facility's COVID-19 (SARS-CoV) Vaccination Program Policy for Residents, revised 11/25/25, showed the facility will educate residents or the resident representative regarding benefits and potential side effects associated with the Covid-19 vaccine and offer the vaccine unless it is medically contraindicated, or the resident has already been immunized. The resident's medical record includes documentation that indicates, at a minimum the following: -The resident or representative was provided education regarding the benefits and potential risks associated with COVID-19 vaccine; -Each dose of COVID-19 vaccine administered to the resident; -If the resident did not receive the Covid-19 vaccine due to medical contraindication or refusal. 2. Review of Resident 7's medical record showed he/she admitted to the facility on [DATE]. The record did not contain documentation the resident received education on the COVID-19 vaccine or had received or refused the vaccination. 3. Review of Resident #10's medical record showed the resident admitted to the facility on [DATE]. The record did not contain documentation the resident received education on the COVID-19 vaccine or had received or refused the vaccination. 4. Review of Resident #21's medical records showed he/she admitted to the facility on [DATE]. The record did not contain documentation the resident received education on the COVID-19 vaccine or had received or refused the vaccination. 5. Review of Resident #66's medical records showed he/she admitted to the facility on [DATE]. The record did not contain documentation the resident received education on the COVID-19 vaccine or had received or refused the vaccination. 6. During an interview on 03/18/26 at 9:35 A.M., the Infection Preventionist (IP) said he/she has been in the role for seven months and is responsible for managing the resident vaccination program. The IP said vaccination documentation for the past year could not be located. During an interview on 03/19/26 at 1:04 P.M., the administrator said the IP is responsible for implementing the resident vaccination program. The administrator said after the past IP left a few months ago staff discovered he/she did not comply with the vaccine policy and much of the paperwork had disappeared.

Based on observations, interview and record review, facility failed to conduct regular maintenance of all bedrails to identify areas of possible entrapment for 9 (Resident #1, #2, #5, #7, #9, #11, #12, #26, #70) of 11 sampled residents who used bed rails. The facility census was 76.1. Review of the facility's policy titled Bed Rails-Safe and Effective Use, dated 09/3/25, showed if bed rails are determined appropriate for use with a resident, a reassessment will be assessed at a minimum of quarterly or potentially with a change of condition utilizing the Evaluation for Use of Bed Rails form. When installing or maintaining bedrails, the Maintenance Department will follow the manufacturer's recommendations and specifications. 2. Review of Resident #1's admission Minimal Data Set (MDS), a federally mandated assessment tool, dated 02/6/26, showed staff assessed the resident as: -Cognitively intact; -Functional impairment on both sides; -Diagnosis of stroke; -Paraplegia (paralysis affecting the legs); Review of the resident's care plan, dated 06/3/24, showed use of one-quarter bedrail to aid in mobility. Review of the resident's medical record showed the record did not contain an entrapment assessment. Observation on 03/16/26 at 12:58 P.M., showed the resident in bed with bed rails raised on both sides. During an interview on 03/17/26, at 10:57 A.M., the resident said he/she used the bed rails to assist with bed mobility because his/her legs are paralyzed. 3. Review of Resident #2's admission MDS, dated [DATE], showed staff assessed the resident as cognitively impaired and restraints not used. Review of the resident's undated care plan documented use of bed rails. Observation on 03/16/26 11:13 A.M., showed the resident's bed with both bed rails in the upright position. The resident was not in the room. Review of the resident's medical record showed the record did not contain an entrapment assessment. 4. Review of Resident #5's Significant Change MDS, dated [DATE], showed staff assessed the resident as: -Moderately impaired cognition; -Mobility functions dependent or not assessed due to medical conditions or safety; -Diagnoses of debility and cardiorespiratory conditions; Review of the resident's care plan, dated 02/12/26, showed both quarter bed rails to aid in mobility. Review of the resident's medical record showed the record did not contain an entrapment assessment. Observation on 03/17/26 8:33 A.M., showed the resident in bed with raised bed rails on both sides. During an interview 03/17/20 8:35 A.M., the resident said he/she used the bed rails to assist with bed mobility. 5. Review of Resident #7's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Upper extremity impairment; -Uses a wheelchair; -Diagnoses of non-Alzheimer's dementia, Parkinson's disease and psychotic disorder; Review of the resident's care plan, dated 02/10/26, showed right side quarter bed rail to aid in bed mobility and safe transfers. Review of the medical record showed the record did not contain an entrapment assessment. Observation on 03/16/26 1:13 P.M., showed raised bed rails on both side of the resident's bed. The resident was not in the room. Observation on 03/17/26 8:33 A.M., showed the resident in bed with raised bed rails on both sides of the bed. During an interview at 03/17/26 11:32 A.M., the resident said he/she uses the bed rails to assist with bed mobility. 6. Review of Resident #9's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact and restraints not used. Review of the resident's undated care plan documented use of bed rails. Review of the resident's medical record showed the record did not contain an entrapment assessment. Observation on 03/16/26 12:00 P.M., showed bed rails raised on both sides of the resident's bed. The resident was not in the room. 7. Review of Resident #11's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact and restraints not used. Review of the resident's undated care plan documented use of bed rails. Review of the resident's medical record showed the record did not contain an entrapment assessment. Observation on 03/16/26 12:10 P.M., showed raised bed rails on both sides of the resident's bed. The resident was not in the room. 8. Review of Resident #12's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact and restraints not used. Review of the resident's care plan, revised 02/27/26, showed staff documented the resident uses a quarter bed rail to aid in mobility. Review of the resident's medical record showed the record did not contain an entrapment assessment. Observation on 03/16/26, at 9:00 A.M., showed the resident in bed, with bed rails in the upright position on both side of the bed. During an interview on 03/17/26, at 10:25 A.M., the resident said he/she uses the bed rails to assist with bed mobility. 9. Review of Resident #26's admission MDS, dated [DATE], showed staff assessed the resident as cognitively intact and restraints not used. Review of the resident's undated care plan documented use of bed rails. Review of the resident's medical record showed the record did not contain an entrapment assessment. Observation on 03/16/2026 12:20 P.M. showed the resident in bed with bed rails in the upright position on both side of the bed. 10. Review of Resident #70's Annual MDS, dated [DATE], showed staff assessed the resident as follows: -Did not assess resident's cognition level; -Independent with bed mobility; -Independent with transfers; Review of the resident's medical record showed the record did not contain an entrapment assessment. Observation on 03/16/26 at 12:00 P.M., showed the residents in bed with both bed rails in the upright position. The resident was not in the room early in the survey they were at dialysis. 11. During an interview on 03/18/26 at 1:15 P.M., the Maintenance Director said he/she is responsible for maintaining the bed rails, but at one point all bed rails were removed. As they were gradually re-installed it became very confusing to keep up with as beds are moved. The Maintenance Director said he/she does not have a schedule or process in place for bed rails maintenance. He/She said the Scheduler may have the completed documentation. During an interview on 03/18/26 at 1:22 P.M., the Scheduler said entrapment measurements have been completed, but the documentation disappeared while he/she was out sick for six months. During an interview on 03/19/26 at 1:04 P.M., the Administrator said bedrail measurements are done on admission, quarterly and as needed. The Administrator said it is the responsibility of the maintenance department to inspect the rails regularly to ensure proper function. The maintenance department receives a quarterly auto generated work order task in the computer for all bed rail inspections. The Administrator said the risk of not inspecting the bed rails is entrapment.

Based on observation, interview and record review, facility staff failed to provide timely treatment to one resident (Resident #1) when he/she sustained a burn injury to his/her right thigh on 06/02/25 from hot coffee and staff did not document any treatment interventions for the burn until 06/04/25. The facility's census was 67. 1. Review of the facility's policies showed the facility did not provide a policy for how to address a change in a resident's condition after a burn injury. 2. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 05/23/25, showed staff assessed the resident as moderate cognitive impairment, independent with eating, bed mobility, and transfers. Review of the resident's progress notes, dated 06/02/25 at 5:04 P.M., showed Licensed Practical Nurse (LPN) C documented the resident spilled hot coffee on his/her right leg, no blistering observed but there is a red blotchy area, will continue to monitor for skin changes. Staff did not document they administered any treatment to the resident's leg/thigh. Review of the resident's care plan, revised 06/03/25, showed the care plan did not contain interventions to direct staff on how to provide hot liquids to the resident or how to monitor the resident when hot liquids are provided. Review of the resident's progress notes, dated 06/03/25, did not contain documentation of the burn to the residents thigh. Review of the resident's progress notes, dated 06/04/25 at 12:20 P.M., showed staff documented the resident has reddened area to his/her right inner knee, and right thigh with two fluid-filled blisters, from a coffee spill two days prior, physician and resident representative notified, Silvadene (a topical antimicrobial medication used to prevent and treat infection in second and third-degree burns) applied to his/her right thigh. Review of the resident's shower sheet, dated 06/03/25, showed staff documented the resident refused his/her shower. Review of the resident's Physician's Order, dated 06/05/25, showed an order to apply Silvadene cream to right upper leg topically as needed for burn/blister twice daily. Review of the resident's Electronic Medical Record (EMR), dated 06/16/25, showed staff did not document they assessed the resident regarding his/her consumption of Hot Liquids. During an interview on 06/16/25 at 1:57 P.M., Certified Nursing Assistant (CNA) A said the resident drinks coffee all the time but he/she has not been assigned to him/her for a while. During an interview on 06/30/25 at 8:49 A.M., the Assistant Director of Nursing (ADON) said per LPN C's documentation on 06/02/25, he/she would not have expected LPN C to administer any treatment other than monitoring to the resident's skin after the burn. During an interview on 06/30/25 at 11:33 A.M., the resident's physician said after staff became aware of the burn, he/she would expect staff to apply a cool compress to the resident's thigh to cool the area down, monitor the area for any changes, and notify him/her by the next morning. He/She said he/she would have approved Silvadene treatment for use after the burn injury area had cooled. He/She said after staff notified him/her on 06/04/25, he/she approved treatment with Silvadene, directed NP F to assess the resident on 06/05/25, and the NP recommended to continue treatment with Silvadene and monitor. He/She said based on the NP's assessment and report on 06/05/25, the resident did not experience any ill-effects from the delay in treatment. During an interview on 06/30/25 at 1:44 P.M., CNA B said he/she served the resident coffee directly from the dining room as usual with his/her meal inside his/her room. He/She said he/she went to get milk and on his/her return to the room, he/she witnessed the resident pull the bedside table closer to him/her when the coffee spilled on his/her thigh and the resident yelled ow. The CNA said he/she immediately notified the nurse who assessed the resident. During an interview on 06/30/25 at 1:50 P.M., LPN C said one of the CNAs reported to him/her the resident spilled coffee on himself/herself, he/she assessed the resident's thigh with redness and the resident denied pain. He/She said he/she did not know how hot the coffee was. He/She said he/she did not initiate any treatment to the area and did not contact the physician for a treatment. MO00255369

Based on interview and record review, facility staff failed to notify the physician and resident representative in a timely manner of a change in condition, when one resident (Resident #1) spilled coffee on his/her thigh and resulted in a significant burn injury. The facility's census was 67. 1. Review of the facility's policies showed the facility did not provide a policy for when to notify the Physician/Resident Representative of an injury, or change in a resident's condition. Review of the facility's interact Signs and Symptoms guide (an electronic quality improvement communication tool designed to improve the identification, evaluation, and communication about changes in resident status), dated 2014, showed staff are directed to document an immediate entry for any burn other than a minor first degree burn with no significant pain, or a non-immediate entry for minor first degree burn in the past twenty-four hours. 2. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 05/23/25, showed staff assessed the resident as moderate cognitive impairment, independent with eating, bed mobility, and transfers. Review of the resident's progress notes, dated 06/02/25 at 5:04 P.M., showed Licensed Practical Nurse (LPN) C documented the resident spilled hot coffee on his/her right leg, no blistering observed but there is a red blotchy area, will continue to monitor for skin changes. Staff did not document they notified the physician or the resident's responsible party of the burn injury to the resident's right thigh. Review of the resident's progress notes, dated 06/04/25 at 12:20 P.M., showed staff documented the resident has reddened area to his/her right inner knee, and right thigh with two fluid-filled blisters, possibly from coffee spilled the day prior, physician and resident representative notified. During an interview on 06/30/25 at 8:43 A.M., the administrator said he/she would not have expected the nurse to contact the physician or the resident's responsible party after the burn occurred because it was a minor injury without significant pain. During an interview on 06/30/25 at 8:49 A.M., the Assistant Director of Nursing (ADON) said he/she would not have expected the nurse to contact the physician and the resident's responsible party after the burn occurred on 06/02/25 because it was a minor injury without significant pain. He/She said per LPN C's documentation on 06/02/25, he/she would not have expected LPN C to document an immediate interact entry either. During an interview on 06/30/25 at 11:33 A.M., the resident's physician said he/she would expect facility staff to notify him/her shortly after they became aware of the burn injury or within 24 hours. He/She said in this instance, he/she would have expected a notification from staff by the morning of 06/03/25. During an interview on 06/30/25 at 1:50 P.M., LPN C said he/she should have notified the resident's physician and resident representative of the burn on 06/02/25 but he/she got busy and forgot. He/She said he/she notified the resident's representative in-person the following day, and another nurse notified the physician. MO00255369

Based on observation, interview and record review, facility staff failed to review and revise comprehensive care plans to include interventions for one resident (Resident #1) after he/she sustained burns to his/her thigh from hot liquids, and smoking interventions for one resident (Resident #2) out of three sampled residents. The facility's census was 67. 1. Review of the facility's policy titled, Comprehensive Care Plans and Revisions, dated 09/11/24, showed staff are directed as follows: -A Comprehensive Care Plan must be reviewed and revised by the interdisciplinary team (IDT) after each assessment, including both the comprehensive and quarterly review assessments; -The facility should monitor the resident over time to help identify changes in the resident condition that may warrant an update to the person-centered plan of care; -When these changes occur, the facility should review and update the plan of care to reflect the changes to care delivery. 2. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 05/23/25, showed staff assessed the resident as moderate cognitive impairment and independent with eating. Review of the resident's nurse's notes, dated 06/04/25, showed staff documented the resident has reddened area to his/her right inner knee, and right thigh with two fluid-filled blisters, from a coffee spill the day prior, physician and resident representative notified, Silvadene (a topical antimicrobial medication used to prevent and treat infection in second and third-degree burns) applied to his/her right thigh. Review of the resident's care plan, revised 06/03/25, showed the care plan did not contain interventions for hot liquids and/or treatment of the burn to the resident's right thigh. During an interview on 06/16/25 at 12:55 P.M., the Assistant Director of Nursing (ADON) said the nurse should have updated the resident's care plan after the documented coffee spill/burn to the resident's thigh and should have also documented the incident under risk management via the electronic record so the IDT could follow up and ensure interventions were implemented. During an interview on 06/16/25 at 2:19 P.M., the interim Director of Nursing (DON) said the nurse should have added interventions to the resident's care plan after the coffee spill and he/she did not know the care plan was not updated. During an interview on 06/25/25 at 3:12 P.M. the Care Plan Coordinator said he/she was not aware the resident had sustained burns from hot liquids, and the nurse who documented the treatment and notification to the physician was responsible to either add interventions to the care plan or inform the IDT during daily rounds so the team could discuss and implement interventions. He/She said he/she was not sure why that was not done. 3. Review of Resident #2's Quarterly MDS, dated [DATE], showed staff assessed the resident as moderate cognitive impairment, and re-admitted to the facility on [DATE]. Review of the resident's nurse's notes, dated 05/21/25, showed staff documented the resident smokes and likes to attend all scheduled smoke breaks. Review of the resident's care plan, revised 06/06/25, showed the care plan did not contain interventions for smoking. Observation on 06/16/25 at 1:53 P.M., showed the resident outside smoking. During an interview on 06/16/25 at 12:55 P.M., the ADON said the resident smokes and his/her care plan should have interventions for smoking. During an interview on 06/25/25 at 3:12 P.M., the Care Plan Coordinator said the resident smokes, he/she was responsible to add interventions for smoking on the resident's quarterly care plan update but missed it. 4. During an interview on 06/16/25 at 12:55 P.M., the ADON said any nurse or other member of the IDT can update a resident's care plan with changes, and the Care Plan Coordinator is responsible to audit and update care plans at least quarterly or after an event. During an interview on 06/16/25 at 1:38 P.M., the administrator said any nurse or member of the IDT can update residents' care plan with changes. He/She said the Care Plan Coordinator is responsible to update care plans quarterly and in his/her absence, a regional nurse helps to ensure the care plans are up to date. He/She said direct care staff are expected to utilize residents' care plans to help with delivery of care. During an interview on 06/16/25 at 1:57 P.M., Certified Nursing Assistant (CNA) A said the nurses update residents' care plans, the CNAs access the care plans via the electronic point of care system and use the care plans to get information on a resident's specific care needs, how to transfer, and special precautions such as for smoking and hot liquids. During an interview on 06/25/25 at 3:12 P.M., the Care Plan Coordinator said he/she is responsible to update care plans at least quarterly and with changes when he/she is made aware. He/She said all nurses and members on the IDT can and are also responsible to update care plans with changes. MO00255369

Based on interview and record review, facility staff failed to ensure one resident (Resident #1) remained free from physical abuse when Resident #2 struck Resident #1 in the face. The facility census was 66. 1. Review of the facility's Abuse prevention policy, dated 6/17/24, showed it is the policy of this facility to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation. Identify, assess, and care plan for appropriate interventions and monitor residents with needs and behaviors which might lead to conflict or neglect such as verbally aggressive behaviors and physically aggressive behaviors. 2. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment tool, dated 1/13/25, showed staff assessed the resident as: -Cognitively intact; -Diagnoses of Alzheimer's and dementia; -No mood disorders or behaviors. Review of the resident's care plan, reviewed 3/16/25, showed staff assessed the resident at risk for changes in mood or behavior due to medical condition. Staff were directed to separate the resident from other residents if yelling occurs to avoid resident altercation. Review of the nurse's notes, dated 3/16/25 at 8:50 A.M., showed Registered Nurse (RN) A documented staff reported the resident in the hallway and Resident #2 approached him/her yelling. Resident #1 yelled back and Resident #2 slapped him/her. 3. Review of Resident #2's MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Diagnosis of Alzheimer's and unspecified mental disorder; -No mood disorders or behaviors. Review of the resident's care plan, dated 3/16/25, showed staff assessed the resident experienced behaviors. Staff are directed to separate resident from other residents if yelling occurs to avoid resident altercations and minimize potential for the resident's disruptive behaviors by offering tasks which divert attention. Review of the nurse's notes, dated 3/16/25 at 9:15 A.M., showed RN A charted the resident in the middle of the hallway yelling. Resident #1 yelled at Resident #2, and Resident #2 hit Resident #1. Residents were separated. Review of the nurse's notes, dated 3/20/25 at 8:21 A.M., showed LPN J charted he/she heard yelling at the nurses station. When he/she arrived at the nurses's station, Nurses Aide (NA) D saw Resident #2 slap Resident #1 twice in the face. 4. During an interview on 3/24/25 at 12:18 P.M., the administrator said the incident on 3/16/25 happened at the nurse's station between 200 hall and 400 hall when Resident #2 slapped Resident #1. He/She said staff separated the residents after the altercation but is unsure of what other interventions were put in place to keep Resident #1 safe from Resident #2. During an interview on 3/24/25 at 12:38 P.M., LPN B said the interventions put in place for the residents for their first altercation which occurred on 3/16/25 was to separate them. This was an isolated incident and staff were aware if Resident #2 became agitated he/she was to be redirected. He/She said the care plans were updated to reflect the behaviors. During an interview on 3/24/25 at 12:56 P.M., RN A said Resident #2 is always loud and shouts about smoking time. He/She said on 3/16/25 Resident #2 came up to the nurses station yelling When is it time to smoke and Resident #1 told Resident #2 to shut up. Resident #2 then slapped Resident #1 with an open hand to the face. He/She said staff immediately separated the residents and took Resident #2 to his room. RN A said he/she updated their care plan to move the residents away from each other if they started yelling to avoid an altercation. He/She is unaware of any other interventions put in place at the time to keep Resident #1 safe from Resident #2. During an interview on 3/24/25 at 1:13 P.M., NA D said he/she was present for the second altercation on 3/20/25 and saw Resident #2 as he/she went to hit Resident #1 in the face. NA D said Resident #2 struck Resident#1 twice in the face. He/She said the resident's were immediately separated and staff took Resident and placed him/her one on one until the ambulance arrived. During an interview on 3/24/25 at 1:28 P.M., Certified Nurse Aide (CNA) E said he/she was in a room providing care when the altercation occurred on 3/16/25. CNA E said he/she was not instructed to do anything following the incident to keep Resident #1 safe from Resident #2. During an interview on 3/24/25 at 1:38 P.M., RN C said he/she was not here for the incident but said staff were told to keep Resident #2 away from the nurse's station. During an interview on 3/24/25 at 1:46 P.M., CNA F said he/she was coming back from break on 3/16/25 and heard Resident #2 yelling and moving toward Resident #1. Resident #2 slapped Resident #1 in the face. CNA F said he/she immediately removed Resident #2 and took him/her back to his/her room to deescalate him/her. He/She is unaware of any interventions put in place to keep Resident #1 safe from Resident #2. During an interview on 3/24/25 at 2:09 P.M., CNA G said he/she was not aware of any interventions put in to place to keep Resident #1 safe from Resident #2. During an interview on 3/25/25 at 2:14 P.M., the Director of Nursing (DON) said he/she was made aware of the first altercation on 3/17/25 after the investigation had been started. He/She said staff separated the residents and were instructed to keep them apart to keep from having any more altercations. The DON said he/she is unsure of how the second altercation happened. During an interview on 3/27/25 at 3:30 P.M., LPN J said he/she was present for the altercation on 3/20/25. He/She did not witness it, but came up after Resident #2 had already made contact with Resident #1. He/She said staff separated the residents immediately and he/she took Resident #2 to the activity room. LPN J said he/she did not know of any interventions in place to keep Resident #1 safe from Resident #2. MO00251423

Based on observation, interview and record review, the facility staff failed to properly wash and sanitize soiled dishes to prevent cross-contamination. Facility staff failed to allow dishes to air dry prior to storage and use to prevent the growth of food-borne pathogens. Facility staff also failed to ensure waste containers in food preparation and utensil washing areas were covered when not in actual use. The facility census was 69. 1. Review of the facility's High-Temperature Dish Machine policy, dated 11/30/10, showed direction for the final sanitizing rinse temperature of the machine to be 180 degrees Fahrenheit (dF) and a booster heater is required to reach the 180 dF temperature for the rinse cycle. Review of the facility's Sanitation and Maintenance policy, dated 04/30/24, showed: -Food and Nutrition Services associates are to be trained in the proper use, cleaning and sanitation of all equipment and utensils; -Equipment of the type and in the amount necessary for the proper preparation, serving and storing of food and for proper dishwashing are provided and maintained in good working order; -Staff will be trained on how to operate the high temperature dish machine; -If the dish machine is not washing and sanitizing properly, disposable dinnerware will be used for meals and snacks until the issue has been resolved. Observation on 10/01/24 at 10:04 A.M., showed dietary staff washed dishes in the heat sanitizing mechanical dishwasher. Observation showed water leaked from the booster heater for the dishwasher and puddles of water on the floor around the heater. Observation on 10/02/24 at 2:20 P.M., showed the Dietary Manager (DM) washed dishes in the heat sanitizing mechanical dishwasher. Observation showed the gauges on the dishwasher showed the water temperature of the wash cycle measured 170 dF and the water temperature of the rinse cycle measured 118 dF during two cycles of the machine. Observation showed the heat booster for the dishwasher contained holes and water leaked from the heater and pooled onto the floor. During an interview on 10/02/24 at 2:39 P.M., the DM said the heat booster broke and started leaking about a month ago. The DM said he/she submitted a work order to the maintenance director and administrator at that time to get it fixed. The DM said the maintenance director tried to fix it shortly thereafter, but could not fix and they notified the administrator that they would need a new heater installed. The DM said he/she asks about the status of the repair to the booster heater about once a week in the department head morning meeting with the administrator. The DM said last week the administrator reported the corporation had finally approved for them to buy a new one, but he/she did not know if a new one had been ordered or of any other actions taken to repair the booster heater to day. The DM said the he/she did not know the water temperature for the rinse cycle should be 180 dF and he/she did not know the facility's policy on use of the dishwasher when it did not work as designed. During an interview on 10/04/24 at 1:26 P.M., the administrator said he/she knew the booster heater for the dishwasher in the kitchen was leaking and needed replaced. The administrator said they were working with the corporate office to get a new one, but a new or used booster heater had not been ordered or purchased and no other actions had been made to repair the booster heater to date. The administrator said if the dishwasher is not working as designed, then staff should wash dishes in the three-compartment sink. The administrator said he/she did not know that the water for the dishwasher did not reach the required temperature or that staff continued to use the dishwasher to wash dishes when it did not function properly. 2. Review of the facility's Sanitation and Maintenance policy, dated 04/30/24, showed the policy directed: -Food and Nutrition Services associates are to be trained in the proper use, cleaning and sanitation of all equipment and utensils; -All food grinders, choppers, slicers, mixers, et cetera should be cleaned, sanitized, dried and reassembled after each use; -A three-compartment sink, if available, will be utilized to wash, rinse and sanitize pots, pans and utensils effectively; -Sinks are to be filled as wash with detergent for washing, rinse with clean water to remove all soap residue and sanitize with an appropriate sanitizer using the guidelines noted by the manufacturer; -All items are to be air dried before storing. Observation on 10/02/24 from 10:52 A.M. to 10:58 A.M., showed [NAME] O washed the food processor in the three-compartment sink. Observation showed the cook washed the food processor with soapy water and then, without rinsing it in clean potable water, he/she placed the food processor into the sanitizing solution. Observation showed the cook removed the food processor from the sanitizing solution after 15 seconds to drain and then used the food processor while wet to grind prepared sweet and sour meatballs for service to residents at the lunch meal. Observation showed the cook then rinsed the food processor off with water in the food preparation sink and used the food processor while wet to grind a prepared beef patty for service at the lunch meal. Observation on 10/02/24 at 12:04 P.M., showed [NAME] R washed dishes at the three-compartment sink. Observation showed the cook washed the dishes in soapy water and then without rinsing with clean potable water, placed the dishes into the sanitizing solution. Observation on 10/02/24 at 12:07 P.M., showed [NAME] R washed the food processor in the three-compartment sink. Observation showed the cook washed the food processor with soapy water and then, without rinsing it in clean potable water, he/she placed the food processor into the sanitizing solution and then immediately removed to drain. Observation on 10/02/24 at 12:20 P.M., showed a quaternary ammonium (QUAT) sanitizer used for the sanitizing solution for the three-compartment sink. Observation of the sanitizer's product label, showed instruction to wash food contact surfaces thoroughly with detergent, follow with a clean potable water rinse and then expose all parts to a sanitizing solution with a concentration of 150-400 parts per million (ppm) for at least one minute. Observation on 10/02/24 at 12:26 P.M., showed [NAME] R emptied the QUAT sanitizing solution used in the three-compartment sink and refilled the sink with new QUAT sanitizing solution. Observation showed the cook washed soiled dishes in the three-compartment sink without checking the concentration of the sanitizing solution. Observation showed the cook washed the dishes in soapy water and then without rinsing with clean potable water, placed the dishes into the sanitizing solution and then immediately removed to drain. Observation showed, when tested with a QUAT test strip, the strip turned a deep aqua blue with a concentration greater than 500 ppm as indicated by the test kit's concentration comparison chart. During an interview on 10/02/24 at 12:26 P.M., [NAME] R said the concentration of the sanitizer solution should be 150 ppm. The cook said if the test strip turns blue it means the concentration of the sanitizer solution is greater than 500 ppm. Observation on 10/02/24 at 12:49 P.M., showed [NAME] O removed the dishes washed by [NAME] R from the three-compartment sink area and placed them in storage. Observation on 10/02/24 at 2:46 P.M., showed [NAME] R refilled the QUAT sanitizer solution in the three compartment sink and he/she washed soiled dishes in the three-compartment sink without checking the concentration of the sanitizing solution. Observation showed the cook washed the dishes in soapy water and then without rinsing with clean potable water, placed the dishes into the sanitizing solution and then immediately removed to drain. Observation showed, when tested with a QUAT test strip, the strip turned a deep aqua blue with a concentration greater than 500 ppm as indicated by the test kit's concentration comparison chart. During an interview on 10/02/24 at 2:47 P.M., [NAME] R said staff should check the concentration of the sanitizing solution each time they fill the sink and the concentration should measure 150 ppm. The cook said he/she did not check the concentration of the sanitizer after he/she filled the sink. The cook said the if the test strip turns blue it means the concentration of the solution is higher than it is supposed to be and it should not be used for dishwashing. The cook said he/she had worked at the facility for just over a year and the previous dietary manager trained him/her to wash dishes with soapy water, rinse them with sanitizing solution and then put them on the rack to drain and dry. The cook said he/she had not been told to allow the dishes to be in the sanitizer solution for any specific length of time and he/she had not read the instructions for use on the sanitizer used to make the solution. During an interview on 10/02/24 at 2:53 P.M., the DM said staff should check the concentration of the sanitizing solution when they fill the sink and the concentration of the solution should measure between 200 and 400 ppm. The DM said the previous DM trained all the staff, including him/her, to wash the dishes in the three-compartment sink with soapy water and rinse with the sanitizing solution. The DM said staff should leave the dishes in the sanitizing solution for two and on half minutes and all staff, except [NAME] O who had only worked at the facility for a month, should have been trained on these requirements. The DM said no one had ever told him/her that manually washed dishes should be rinsed with clean water between the soapy water and sanitizing solution. Observation on 10/04/24 at 12:45 P.M., showed Dietary Aide (DA) S filled the third compartment of the three-compartment sink with a QUAT sanitizing solution and then pre-scraped and rinsed soiled dishes in the mechanical dishwashing station. Observation showed, without washing the dishes with detergent, the DA placed the rinsed soiled dishes into the sanitizing solution at the three-compartment sink without checking the concentration of the sanitizing solution. Observation showed, when tested with a QUAT test strip, the strip turned a deep aqua blue with a concentration greater than 500 ppm as indicated by the test kit's concentration comparison chart. Observation on 10/04/24 at 12:53 P.M., showed DA S pre-scraped and rinsed soiled saucers and bowls in the mechanical dishwashing station and then, without washing with detergent, he/she placed the soiled dishes in sanitizing solution in the three-compartment sink. During an interview 10/04/24 at 12:54 P.M., DA S said he/she was told not to use the dishwasher to wash the dishes. The DA said the DM told him/her to rinse the dishes off in the mechanical dishwashing station and then put them in the sanitizing solution in the three-compartment sink. During an interview on 10/04/24 at 12:54 P.M., the DM said dishes should be washed with soap and rinsed before they are sanitized and he/she did not instruct the DA not to use the dishwasher. The DM said since the dishwasher was not hot enough to sanitize the dishes, he/she instructed the DA to wash the dishes in the dishwasher and then put them in the sanitizer at the three-compartment sink to sanitize them. During an interview on 10/04/24 at 1:26 P.M., the administrator said soiled dishes should be washed with soap, rinsed with clean water and then sanitized. The administrator said when dishes are washed at the three-compartment sink, staff should sanitize the dishes in the sanitizing solution for at least two minutes. The administrator said the concentration of the sanitizing solution used in the three compartment sink should be 200 to 400 ppm and staff should check the concentration of the solution before it is used. The administrator said staff are trained on all of these requirements. 3. Review of the facility's Sanitation and Maintenance policy, dated 04/30/24, showed the policy directed: -Food and Nutrition Services associates are to be trained in the proper use, cleaning and sanitation of all equipment and utensils; -All food grinders, choppers, slicers, mixers, et cetera should be cleaned, sanitized, dried and reassembled after each use; -All dishes, pots and pans must be air dried after sanitizing and should not be stored wet to prevent wet-nesting. Observation on 10/02/24 from 10:52 A.M. to 10:58 A.M., showed [NAME] O washed the food processor in the three-compartment sink and then used the food processor while wet to grind prepared sweet and sour meatballs for service to residents at the lunch meal. Observation showed the cook then rinsed the food processor off with water in the food preparation sink and used the food processor while wet to grind a prepared beef patty for service at the lunch meal. Observation on 10/02/24 at 11:44 A.M., showed six insulated plate warmers stacked together wet in the upright position on the plate lowerator. Observation showed the dietary staff used the wet stacked plate warmers for the service of room trays during the lunch meal. Observation on 10/04/24 12:42 PM, showed eight plastic cups stacked together wet on a tray on the storage rack. Observation on 10/04/24 at 12:50 P.M., showed [NAME] R removed a pan from clean side of the three-compartment sink while wet and stacked it on top of other pans in storage. During an interview on 10/04/24 at 12:52 P.M., [NAME] R said dishes should be dry before they are put away and he/she thought the pan was dry. During an interview on 10/04/24 at 12:52 P.M., the DM said all dishes should be air dried before they are used or put away and staff are trained on this requirement. During an interview on 10/04/24 at 1:26 P.M., the administrator said staff should allow dishes to air dry after they are washed and staff are trained on this requirement. 4. Review of the facility's Sanitation and Maintenance policy, dated 04/30/24, showed the policy did not contain direction to staff to cover waste containers in food preparation and storage areas when not in actual use. Observation on 10/02/24 at 11:41 A.M., showed the waste containers, which contained food and paper waste, in the mechanical dishwashing station and by the walk-in refrigerator uncovered and not in use by staff. Observation on 10/04/24 at 12:28 P.M., showed the waste containers, which contained food and paper waste, in the mechanical dishwashing station, by the walk-in refrigerator and by the DM's office uncovered and not in use by staff. During an interview on 10/04/24 at 1:05 P.M., the DM said waste containers should be covered at all times and staff have been trained on this requirement. The DM said he/she had not noticed that staff had left the waste containers uncovered. During an interview on 10/04/24 at 1:35 P.M., the administrator said waste containers should be covered at all times and staff are trained on this requirement.

Based on observation, interview, and record review, facility staff failed to maintain a clean, safe, comfortable, and homelike environment when staff failed to adequately clean and properly maintain three of the four shower rooms. The facility census was 69. 1. Review of the facility's policy titled Housekeeping General Policy, revised 06/12/24, showed it is the responsibility of the Executive Director through the Environmental Service Director to assure that Housekeeping Policies are implemented and followed. The facility must provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Housekeeping personnel are required to attend training classes. Review of the facility's policy titled Housekeeping Services, revised 06/04/24, showed the facility will provide a safe, clean, comfortable, and homelike environment. The facility must follow standard practices for cleaning and disinfection of surfaces and equipment in accordance with Center for Disease and Prevention (CDC) guidelines. The environmental services supervisor will maintain a schedule of cleaning and disinfection tasks, and the employee responsible for these tasks. Resident shower rooms: Clean and disinfect high touch surfaces after each resident use; Housekeeping will clean resident shower/bath area twice daily; Privacy curtains should be laundered routinely and when visibly soiled. Bathrooms and common areas, Clean and disinfect high touch areas at least twice daily; Clean low touch areas on a scheduled basis. 2. Observation on 10/02/24 at 2:45 P.M., showed the 100 hall shower room: -Vent over the toilet contained a thick layer of dust; -Vent over the entry door contained an unknown black substance; -Shower stall contained multiple areas of an unknown black substance; -The wall with cracked and missing tile. Observation on 10/03/24 at 10:08 A.M. showed the 100 hall shower room: -Vent over the toilet contained a thick layer of dust; -Vent over the entry door contained an unknown black substance; -Shower stall contained multiple areas of an unknown black substance; -Wall with cracked and missing tile. 3. Observation on 10/02/24 at 2:45 P.M., showed the 300 hall shower room: -Vent over the toilet contained a thick layer of dust; -Vent over the entry door contained an unknown black substance; -Shower stall contained multiple areas of an unknown black substance. Observation on 10/03/24 at 10:08 A.M., showed the 300 hall shower room: -Vent over the toilet contained a thick layer of dust; -Vent over the entry door contained an unknown black substance; -Shower stall contained multiple areas of an unknown black substance. 4. Observation on 10/02/24 at 2:45 P.M., showed the 400 hall shower room: -The vent over the toilet contained a thick layer of dust; -The vent over the entry door contained an unknown black substance; -The shower stall contained multiple areas of an unknown black substance; -The toilet contained multiple black stains. Observation on 10/03/24 at 10:08 A.M., showed the 400 hall shower room: -The vent over the toilet contained a thick layer of dust; -The vent over the entry door contained an unknown black substance; -The shower stall contained multiple areas of an unknown black substance; -The toilet contained multiple black stains. 5. Review of the maintenance request work logs, undated, showed it did not contain documentation of any shower room requests for work or concern. 6. During an interview on 10/03/24 at 10:25 A.M., Licensed Practical Nurse (LPN) B said staff use all four shower rooms LPN B said if staff find something broken, they are responsible to write it on a work order at the nurse's station. LPN B said maintenance is responsible to check the work orders daily. LPN B said he/she had not put any work orders on the board for the shower rooms. During an interview on 10/03/24 at 11:28 A.M., Nurse Assistant (NA) E said he/she is frequently assigned as the shower aide. NA said residents use all shower rooms. NA E said housekeeping is responsible to deep clean and mop the shower rooms. NA E said if staff notice something broken, they should fill out a work order, that maintenance checks daily. NA E said he/she had not put any work orders on the board for the shower rooms. During an interview on 10/03/24 at 11:34 A.M., Certified Nurse Assistant (CNA) D said he/she staff use all four shower rooms to toilet residents, but staff only shower residents in the 100 hall and 200 hall shower rooms. CNA D said the aide is responsible to clean and sanitize the shower chair, handrails, and shower stall after each use. CNA D said housekeeping is responsible to deep clean, refill supplies, and mop the shower rooms. CNA D said if staff notice something broken, they are responsible to write it on a work order hanging from a clipboard at the nurse's station. CNA D said maintenance is responsible to check the work orders daily. CNA D said he/she had not put any work orders on the board for the shower rooms. During an interview on 10/03/24 at 12:40 P.M., Housekeeper G said he/she did not know of a deep cleaning schedule for the shower rooms. Housekeeper G said he/she did not know the shower rooms had dirty vents or black substances on them. Housekeeper G said if staff notice something broken, they should fill out a work order. Housekeeper G said he/she had not filled out a work order for the shower rooms. During an interview on 10/03/24 at 2:10 P.M., the Housekeeping Supervisor said he/she is responsible to oversee and direct the housekeeping department. The housekeeping supervisor said housekeeping is responsible for cleaning the shower rooms daily including moping, cleaning the vents, replacing supplies, cleaning the toilets, showers, and sinks. The housekeeping supervisor said he/she does not have a deep cleaning schedule for the shower rooms and did not know he/she needed one. The housekeeping supervisor said staff use all four shower rooms. The housekeeping supervisor said he/she did know the shower rooms had black substances in them but did not know the vents were dirty. The housekeeping supervisor said if staff notice something broken, they should fill out a work order at the nurse's station, and maintenance is responsible to check the work orders daily. The housekeeping supervisor said he/she had not filled out any work orders for the shower rooms. During an interview on 10/03/24 at 2:30 P.M., the Maintenance Director said he/she does not have a deep cleaning schedule for the shower rooms and the housekeeping supervisor is responsible for that. The maintenance director said if staff find things needs fixed, they are responsible to log it on a work order at the nurses station. The maintenance director said he/she checks the maintenance log daily for work orders. and he/she did not know about the condition of the shower rooms. During an interview on 10/03/24 at 3:00 P.M., the administrator said housekeeping is responsible for cleaning shower rooms daily. The administrator said he/she expects housekeeping to have a deep cleaning schedule and follow it. The administrator said he/she did not know staff did not have a deep cleaning schedule and deep cleans were not being completed. The administrator said it is the housekeeping supervisor's responsibility to make a deep cleaning schedule and ensure the housekeeping staff follow it. The administrator said housekeeping is responsible to clean the shower rooms daily including the vents, sinks, toilets, shower stalls, and floors. The administrator said he/she did know the shower stalls had a black substance in them but did not know the vents were dirty. The administrator said if staff notice something broken, they are responsible to write it on a work order hanging from a clipboard at the nurse's station, and maintenance is responsible to check the work orders daily. The administrator said he/she had not put any work orders on the board for the shower rooms. The administrator said himself/herself and the housekeeping supervisor both scrubbed the areas with not much result made. The administrator said he/she didn't know what else to use to clean it off except the cleaner the facility had. The administrator said facility had just spent $80,000 on new flooring, so he/she said he/she did not want to ask for them to remodel the other three shower rooms.

Based on interview and record review, facility staff failed to document they provide restorative therapy for two residents (Resident #9 and #41). The facility census was 69. 1. Review of the facility's policy titled Restorative Nursing dated 11/30/23, showed staff are instructed to provide interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. This concept actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning. Restorative indicators may be identified by multiple disciplines utilizing various assessments, physician orders, progress notes, environmental factors, caregiver conversations, and another means of communication. Communicate the restorative care plan and care directives to other members of the interdisciplinary (IDT) team. The trained Certified Nurse Aide (CNA) will document provided techniques per the restorative care plan in the medical record. The licensed nurse will conduct an evaluation on a routine basis, to include progress towards goal and response to the program. Any changes will be documented in the medical record. The restorative care plan and care directive will be reviewed/revised as indicated. 2. Review of Resident #9's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 09/05/24, showed staff assessed the resident as: -Cognitively intact; -Required partial/moderate assistance to dress and undress the upper body; -Required substantial/maximal assistance to dress and undress the lower body; -Dependent on staff for Toileting; -Required substantial/maximal assistance to move from sitting to standing; -Required substantial/maximal assistance for toilet transfers; -Did not attempt to walk 10 feet. Review of the resident's occupational therapy discharge summary, dated 09/16/24, showed therapy assessed the resident: -Required partial/moderate assistance to dress and undress the lower body on 07/26/24; -Required partial/moderate assistance for toileting hygiene task on 08/20/24; -Required partial /moderate assistance for toilet transfers on 08/20/24; -A prognosis to maintain the current level of functioning with consistent staff follow-through. Review of the resident's medical record showed a referral for restorative nursing services, dated 09/16/24, instructed staff to: -Maintain cognitive skills allowing the resident to complete ADL's including upper body dressing, lower body dressing, toileting and toilet transfers with assist as needed; -Assist the resident with walking with a wheeled walker to tolerance approximately 50-100 feet. Review of the resident's care plan, dated 09/30/24, showed staff documented the resident required assistance with Activities of Daily Living (ADL's) (ADL's are tasks related to transfers, bed mobility, toileting, and eating) as needed to maintain or attain highest level of function; resident wishes to attain prior level of function; assist with mobility and ADL's as needed. The resident's medical record did not contain documentation the resident received restorative nursing services. During an interview on 10/04/24 at 4:23 P.M., the resident said he/she would like staff to work with him/her on walking and transfers. The resident said staff does not have time to help him/her and this takes away his/her abilities. 3. Review of Resident #41's medical record showed a referral for restorative nursing, dated 01/05/24, instructed staff to ambulate with wheeled walker to patient tolerance with wheelchair to follow; patient ambulates approximately 20 feet with the wheeled walker and utilize toilet for toileting needs; transfer to/from wheelchair with toilet using grab bars. Review of the resident's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Moderately cognitively impaired; -Required set-up assistance to dress and undress the upper body; -Required supervision/touching assistance to dress and undress the lower body; -Required supervision/touching assistance for toileting; -Required set-up assistance to move from sit to stand; -Required set-up assistance for toilet transfers; -Required set-up assistance to walk 50 feet with two turns. Review of the resident's occupational therapy discharge summary, dated 09/15/23, showed therapy assessed the resident: -Required contact guard/minimal assistance to dress and undress the lower body on 09/15/23; -Required maximal assistance for toileting hygiene task on 09/15/23; -Independent for toilet transfers on 09/15/23; -A prognosis to maintain the current level of functioning with consistent staff follow-through. Review of the resident's physical therapy discharge summary, dated 09/15/24, showed therapy assessed the resident: -Required contact guard assistance to transfer on 9/15/23; -Required contact guard assistance to walk 20-56 feet with a wheeled walker on 09/15/24. -A prognosis to maintain the current level of function with consistent staff follow-through. Review of the resident's care plan, dated 10/22/24, showed staff documented the resident required ADL Assistance as needed to maintain or attain highest level of function; resident wishes to attain prior level of function and walk 50 feet with two turns with supervision. The resident's medical record did not contain documentation the resident received restorative nursing services. During an interview on 10/04/24 at 4:19 P.M., the resident stated he/she had previously been able to walk and could still walk but no one will help him/her. The resident's spouse said he/she had been told therapy is paid to walk his/her spouse. 4. During interview on 10/03/24 at 11:15 A.M., the Rehabilitation Director said staff from the therapy department request restorative nursing for appropriate residents in order to maintain or improve function after therapy services end. The Rehabilitation Director said no restorative services had been provided and residents could have lost function. The Rehabilitation Director said recommendations for Residents #9 and #41 were not implemented. During an interview on 10/04/24 at 4:37 P.M., the Director of Nursing (DON) and administrator said at this time the facility does not have an active restorative nursing program. The DON said staff had not been hired and trained for this role. The administrator said restorative nursing should be provided for the residents to maintain or improve their functional mobility.

Based on observation, interview and record review, the facility staff failed to serve food in accordance with the nutritionally calculated recipes and menus to residents who received regular and easy to chew (EC) diets. The facility census was 69. 1. Review of the facility's Menus, Substitutions, and Alternatives policy, dated 04/30/24, showed Menus are planned in advance and are followed as written in order to meet the nutritional needs of the residents in accordance with established national guidelines. Residents with known dislikes of food and beverage items, who express refusal of the food served or request a different meal choice are offered a substitute of similar nutritive value. 2. Review of the facility menus dated 10/02/24 (Week 4, Day 25), showed the menus directed staff to serve one serving of sweet and sour meatballs, a #8 (four ounce) scoop of steamed rice, and a six ounce portion of Soup Da Jour at the lunch meal to residents who received regular diets. Review of the recipe for the sweet and sour meatballs, dated 03/20/24, showed the recipe directed staff to staff to serve 10 meatballs to make a three ounce edible portion when one half ounce meatballs are used in the preparation of the entree. Observation on 10/02/24 at 10:22 A.M., showed [NAME] O removed a case of meatballs from the walk-in freezer and used the meatballs to prepare the sweet and sour meatballs for service to the residents. Observation of the product label on the case showed the weight of each meatball as one half ounce. Observation on 10/02/24 during the lunch meal service which began at 11:36 A.M., showed [NAME] O served six sweet and sour meatballs (four less than directed by the menus), a #16 (two ounce) scoop of steamed rice (two ounces less than directed by the menus) and four ounces of Soup Da Jour (two ounces less than directed by the menus) to the residents who received regular diets. 3. Review of the facility menus dated 10/02/24 (Week 4, Day 25), showed the menus directed staff to serve a #8 scoop of steamed rice and a six ounce portion of Soup Da Jour at the lunch meal to residents who received EC diets. Observation on 10/02/24 during the lunch meal service which began at 11:36 A.M., showed [NAME] O served a #16 scoop of steamed rice (two ounces less than directed by the menus) and four ounces of Soup Da Jour (two ounces less than directed by the menus) to the residents who received EC diets. 4. During an interview on 10/02/24 at 11:36 A.M., [NAME] O said foods should be served in accordance with the menus. The cook said he/she reviewed the menus before the meal service, but did not know what the menu meant by one serving for the sweet and sour meatballs. The cook said he/she did not review the recipe when he/she prepared the sweet and sour meatballs. The cook said he/she did not realize that he/she had the wrong portion sizes for the meatballs, rice and soup. 5. During an interview on 10/04/24 at 1:01 P.M., the dietary manager (DM) said staff are trained to serve meals in accordance with the menus and recipes and they are expected to review them both during food preparation and before the meal service. 6. During an interview on 10/04/24 at 1:23 P.M., the administrator said staff should serve food in accordance with the recipes and menus and staff are trained on this requirement.

Based on interview and record review, facility staff failed to educate and offer the Covid-19 (a disease caused by a novel coronavirus) vaccination in accordance with current guidelines and policy for three (Residents #39, #57 and #61) of five sampled residents. The facility census was 69. 1. Review of the facility's policy Resident Vaccination, review dated 12/4/23, showed the facility in conjunction with the Public Health Authorities and CDC (Centers for Disease Control) guidelines will provide immunizations to older adults that are recommended and ordered by a physician once determined to be eligible and without contraindications. The facility should screen individuals prior to offering the COVID-19 vaccination to check for the following: Prior vaccination status; The presence of medical precautions and contraindication. Education must be provided to the resident and/or resident's responsible party regarding benefits and potential side effects of immunization. The resident or resident's representative has the opportunity to refuse immunizations. Review of the Centers for Disease Control (CDC) Interim Clinical Considerations for Use of COVID-19 Vaccines in the United States, dated September 6, 2024, recommends that people receive all recommended COVID-19 vaccine doses. Vaccination is especially important for people at highest risk of severe COVID-19, including people ages [AGE] years and older; people with underlying medical conditions, including immune compromise; and people living in long-term care facilities. 2. Review of Resident #39's medical record showed staff documented: -Most recent admitted [DATE]; -The record did not contain documentation the resident received education or had been offered the Covid-19 vaccine since 11/11/22. 3. Review of Resident #57's medical record showed staff documented: -Most recent admitted [DATE]; -The record did not contain documentation the resident received education about, refused or had been offered the Covid-19 vaccine. 4. Review of Resident #61's medical record showed: -Most recent admitted [DATE]; -The record did not contain documentation the resident received education about, refused or had been offered the Covid-19 vaccine since 11/11/22. 5. During an interview on 10/04/24 at 5:26 P.M., the Infection Preventionist (IP) stated residents are offered vaccinations each season and he/she does not know why the residents were missed and did not get offered the newest Covid-19 vaccines. During an interview on 10/4/24 at 4:37 P.M., the Director of Nursing (DON) said it is the responsibility of the Infection Preventionist to ensure vaccinations are provided to residents according to the season. During an interview on 10/4/24 at 4:37 P.M., the administrator said he/she expects the vaccination policy to be followed. It is the responsibility of the Infection Preventionist to manage the vaccine policy. The administrator said the residents had missed opportunities to receive Covid-19 vaccines.

Based on interview and record review, facility staff failed to ensure two Nurse Aides (NA)'s (NA M and NA N) of fourteen sampled completed the nurse aide training program within four months of his/her hire date. The facility census was 69. 1. Review of the facility's policy titled Nurse Aide Requirements, undated, showed the facility must not use any individual working in the facility as a nurse aide for more than four months, on a full-time basis. 2. Review of the facility's Active Payroll for September 2024 showed NA M with a hire date of 02/20/24, and NA N with a hire date of 01/11/24. 3. During an interview on 10/04/24 at 3:04 P.M., the Staffing Coordinator said NA M and NA N were scheduled to re-take the Certified Nurse Aide (CNA) test. The Staffing Coordinator said NA M and NA N were allowed to continue to work until they retook the test. During an interview on 10/04/24 at 4:00 P.M., NA M said he/she failed the CNA test. NA M said he/she is still doing the job of a CNA including providing all cares. NA M said he/she is not aware of any limitations and is doing the same duties as a CNA. During an interview on 10/04/24 at 3:04 P.M., the Staffing Coordinator said NA M and NA N are scheduled to re-take the CNA test. The Staffing Coordinator said NA M and NA N are allowed to continue working as NAs until they retake the test. During an interview on 10/04/24 at 4:37 P.M., the Director of Nursing (DON) said two of the NA's had not passed their CNA test and were given 90 days to retake the test. The DON said NA's had to be with a qualified staff member to provide residents hands-on care until proficient. During an interview on 10/17/24 at 8:14 A.M., the DON said NA M and NA N had completed competencies in all resident care areas, so were proficient and safe caring for residents without supervision. During an interview on 10/17/24 at 8:32 A.M., the administrator said NA's were allowed to perform resident care in all areas they had completed the competency checklists.

Based on observation, interview, and record review, facility staff failed to ensure the three most recent years of survey results were posted and readily accessible to residents, family members or representatives of residents. The facility census was 69. 1. Review of the facility's policy titled Availability of Survey Results, dated 05/23/19, showed results from the most recent state surveys must be available and easily accessible to the residents and family members within the facility. Place readily accessible. This is a place such as a lobby or other area frequented by most residents, visitors or other individual where individuals wishing to examine survey results do not have to ask to see them. 2. Observation on 10/01/24 at 9:43 A.M., showed the facility did not have a copy of the federal survey results accessible to the residents, family members, or representatives of residents. 3. Observation on 10/02/24 at 5:03 P.M., showed the facility did not have a copy of the federal survey results accessible to the residents, family members, or representatives of residents. 4. Observation on 10/03/24 at 7:46 A.M., showed the facility did not have a copy of the federal survey results accessible to the residents, family members, or representatives of residents. 5. During an interview on 10/04/24 at 3:35 P.M., the administrator said he/she did not realize the survey results needed to be available in an area accessible to residents and visitors. The administrator said he/she did not know why the survey results were kept in the Business Office. During an interview on 10/04/24 at 4:47 P.M., the Director of Nursing said he/she did not know the survey results needed to be out and available in the facility.

Based on observation and interview, facility staff failed to provide a clean, homelike and comfortable environment when staff failed to keep resident rooms and common areas clean and in good repair. The facility census was 69. 1. Review of the facility's policy titled, Resident Belongings and Home like Environment, reviewed 7/17/2023, showed it is the responsibility of all facility staff to create a homelike environment and promptly address any cleaning needs. Review of the facility's policy titled, Residents Rights , reviewed 10/6/2023, showed the resident has the right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and support for daily living safety. 2. Observation on 08/14/23 at 12:12 P.M., showed an approximate 12 inch (in) by (x) 12 in broken floor and wall tile in the dining room. Additional observation showed missing trim and chair railing in multiple places. Observations from 08/14/23 through 08/17/23, showed the bathroom wall in room [ROOM NUMBER] had been scraped and chipped. Further observation showed an exposed metal corner bead under the sheetrock. Observations from 08/14/23 at 11:00 A.M., through 08/17/23 at 4:00 P.M., showed the 100 and 300 hall had 19 S patterned gaps throughout the carpet. Further observation showed multiple large stains and discoloration on the carpets throughout the hallways, and strong odors. Observation on 08/17/23 at 3:39 P.M., showed room [ROOM NUMBER] with a hole in the door and scrapes to the bathroom door. Observations from 08/14/23 through 08/17/23, showed dark black stains on the floor at both nurse's stations. Observations from 08/14/23 through 08/17/23, showed multiple large stains and discolorations on the carpets throughout the hallway, and strong odors. Observations from 08/14/23 at 12:43 P.M. through 08/17/23 at 2:43 P.M., showed room [ROOM NUMBER] had large gouges in the sheet rock behind the bed and multiple stains on the walls. Further observation showed the base of the toilet and the bathroom trim had black stains. During an interview on 08/17/23 at 3:52 P.M., the Maintenance Director said if something is broken or damaged staff should fill out a work order or yellow sheet and put it in his/her mailbox, and give a copy to the administrator. He/She said housekeeping staff is all over the building and should help alert him/her to problem areas. He/She said all staff can report issues in common areas. The Maintenance Director said the large hole in the dining room wall, is due to a resident's wheelchair, and it has been fixed multiple times. He/She said at one time the facility had a floor tech to clean and maintain the floors, but he/she did not know if the budget allowed for the position anymore. He/She said the carpets are embarrassing, and have never looked so bad. He/She said staff does not have time to do anything, and the carpets are the main source of the bad odors. He/She said the snake pattern gaps in the carpet is from the way the company seamed it together. He/She said the carpets shrink and leave the gaps. Additionally, the Maintenance Director said he/she thinks the odors are absolutely coming from the old mattresses and poor perineal care. He/She said residents are left soiled because of the lack of staff. He/She said male residents urinate on the floor, and since it's a bodily fluid the nursing staff is supposed to clean it up and they do not have time. During an interview on 08/17/23 at 2:57 P.M., Housekeeping aide M said housekeeping is short staffed. He/She said there was two housekeepers yesterday for the entire building. He/She does not know when or how the carpets are cleaned. He/she said the housekeepers are not supposed to touch urine or feces because it is a bodily fluid, so it sits for a while sometimes because nursing is also short staffed. He/She said he/she has been asked to spray deodorizer because of the foul odors. During an interview on 08/17/23 at 2:38 P.M., Certified Nurse Aide (CNA) B said if something needs fixed staff should fill out a yellow slip and put it in the maintenance mailbox and give a copy to the administrator. The CNA said he/she has never seen anyone shampoo the carpets. He/She said he/she did not know how to clean bodily fluids out of the carpet, and the housekeeping department is short staffed, like all the other departments. The CNA said the foul odors in the building are from the furniture, bed, sheets, and carpets not being properly cleaned in a timely manner. He/She said the staff does their best but every shift is understaffed. During an interview on 08/17/23 at 2:16 P.M., Registered Nurse (RN) A said there are papers to fill out if something requires repairs. He/She said maintenance is responsible for making sure things get fixed and if it does not get done they can notify the administrator. During an interview on 8/17/23 at 2:21 P.M., Certified Medication Technician (CMT) G said staff should report broken or damaged items to their charge nurse and/or maintenance. The RN said staff should fill out a form and turn it in to maintenance. The RN said if the repairs are urgent staff should call maintenance. He/She said housekeeping is responsible for facility odors, and he/she had noticed the odors on the 400 hall. During an interview on 8/17/23 at 2:30 P.M., Licensed Practical Nurse (LPN) H said staff should fill out the maintenance repair log, and include the location of the damages. He/She said staff are to make a copy of the log sheet and turn it in to the administrator. LPN said he/she had noticed the odors but had not seen any broken or damaged walls, tiles, or equipment. During an interview on 8/17/23 at 3:00 P.M., the Administrator said if staff provides care like they are supposed to then the odors would be better. He/She said staff has deodorizer spray they can use as needed. He/she said the walls, stained carpets, and broken tiles should be repaired by maintenance. He/She said the carpet cleaner had been broken for about a month and staff had been using a small sport cleaner. The Administrator said he/she knows the tile around the nurses station is horrible but the night shift maintenance staff had not been trained to use the floor buffer. He/She said the housekeeping department is fully staffed, and if there is a mess or spill in the evening, the nursing staff should clean it up.

Based on interview and record review, facility staff failed to obtain labs in a timely manner for one resident (Resident #37), and failed to produce documentation for pharmacist recommended interventions for one resident (Resident #60). Additionally, staff failed to perform blood sugar tests in a manner to obtain an accurate reading for four residents (#17, #23, #30, and #32). The facility census was 69. 1. Review of the facility's policy titled, Laboratory services, dated 3/21/23, showed staff are directed to do the following: -The facility will ensure that laboratory services meet the needs of residents, that results are reported promptly to the ordering provider to address potential concerns and for disease prevention, provide for resident assessment, diagnoses, and treatment, and the facility is responsible for the quality and timeliness of services whether services are provided by the facility or an outside source; -The facility will ensure that laboratory reports are present in the residents' medical record and are dated. 2. Review of Resident #37's Annual MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Diagnoses of coronary artery disease, thyroid disease, arthritis, osteoporosis, stoke, anxiety and depression. Review of the resident's Pharmacist Consultation Report, dated 05/16/23, showed the resident had an elevated Thyroid Stimulating Hormone (TSH) laboratory value on 02/16/23, which resulted in an increase in Levothyroxine and a subsequent TSH laboratory order to recheck the value on 04/16/23. Further review showed the medical record did not contain a TSH level dated 04/16/23. The staff did not order the TSH lab until 06/06/23. During an interview on 08/17/23 at 2:16 P.M., Registered Nurse (RN) A said staff are expected to carry out lab orders and keep the orders in the accordion file so they know what labs need drawn on future days. During an interview on 08/17/23 at 05:00 P.M., the Interim Director of Nursing said labs should be obtained per physician or pharmacist orders. He/She does not know why the labs were not drawn. 3. Review of the facility's policy titled, Pharmacy Services and Medication Regimen Review, reviewed 8/25/22, showed staff are directed to the following: -The pharmacist must report any irregularities to the attending physician and the facility's Medical Director and Director of Nursing, and these reports must be acted upon; -The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the residents' medical record. 4. Review of Resident #60's quarterly MDS, 07/11/23, showed staff assessed the resident as: -Severe Cognitive Impairment; -Diagnoses of hip fracture, multiple traumas, renal failure, Alzheimer's disease and dementia. Review of the resident's pharmacy progress notes, dated 04/20/23 and 05/15/23, showed staff were directed to see consult sheet. Review of the facility's pharmacy consult book for April and May 2023 showed no pharmacy consults. Review of the facility's pharmacy consultant exit summary, dated June 2023, showed the pharmacist noted many consults and recommendations from May 2023 did not appear to be completed. Review of the resident's medical record showed no pharmacy consults for April or May 2023. During an interview on 08/16/23 at 3:27 P.M., the Administrator said the resident is on hospice and has been declining medications anyway, so it's just a special case why his/hers wasn't in there. During an interview on 08/16/23 at 03:32 P.M., Licensed Practical Nurse (LPN) P said all pharmacy consults and suggestions are normally in the residents' charts but nothing is normal anymore. He/She said there was no way to see what they were and if they were done if it is not in the chart. During an interview on 08/17/23 at 02:16 P.M., RN A said the pharmacy comes in and does a consult, the doctors agree or decline, the administrator or DON tell them if there was a change and they changed the orders. All the documentation should be in the facility's pharmacy consult book and in the residents' charts. 5. Review of the Assure Prism blood glucose monitoring system manual, not dated, showed the manual directed staff to do the following: -Wash hands and the sample site with soap and warm water; -Rinse and dry thoroughly; -If alcohol wipes were used, make sure the area was dry before taking blood sample. Residual alcohol may lead to inaccurate readings; -Obtain a blood sample using a lancing device. 6. Observation on 8/15/23 at 11:02 A.M., showed Licensed Practical Nurse (LPN) I entered Resident #23's room to check the resident's blood sugar. LPN I wiped the resident's arm with an alcohol pad, used a lancet to obtain a blood sample, and tested the resident's blood with the glucometer. LPN I did not wait for the alcohol to dry before obtaining the blood sample. LPN I exited the resident's room and then entered Resident #30's room to check the resident's blood sugar. LPN I wiped the resident's arm with an alcohol pad, used a lancet to obtain a blood sample, and tested the resident's blood with the glucometer. LPN I did not wait for the alcohol to dry before obtaining the blood sample. LPN I exited the resident's room and then entered Resident #17's room to check the resident's blood sugar. LPN I wiped the resident's arm with an alcohol pad, used a lancet to obtain a blood sample, and tested the resident's blood with the glucometer. LPN I did not wait for the alcohol to dry before obtaining the blood sample. LPN I exited the resident's room and then entered Resident #32's room to check the resident's blood sugar. LPN I wiped the resident's arm with an alcohol pad, used a lancet to obtain a blood sample, and tested the resident's blood with the glucometer. LPN I did not wait for the alcohol to before obtaining the blood sample. During an interview on 8/17/23 at 5:00 P.M., the Interim Director of Nursing said when checking blood sugars, staff should perform hand hygiene, apply gloves, insert the glucose strip into the glucometer, cleanse the resident's skin with an alcohol wipe, wait for the alcohol to dry, stick the resident with a lancet, wipe the first drop of blood with a 2 x 2 gauze pad, and obtain the blood sample.

Based on observation, interview, and record review, facility staff failed to ensure the resident's environment remained free of accident hazards when staff failed to properly store disposable razors in one of two shower rooms and left one resident (Resident #30) alone in the shower room with the disposable razors on the counter. Additionally, staff failed to properly propel five residents (Resident #33, #47, #55, #333, and one unidentified resident) in wheelchairs in a manner to prevent accidents. The facility census was 69. 1. Review of the facility's policy titled, Incident, dated 8/15/23, showed the facility to the best of its ability strives to provide an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. 2. Observation on 8/16/23 at 8:17 A.M., showed the spa room doors where left unlocked and unattended with an open box of disposable razors on the counter. Further observation showed four residents sat in wheel chairs alone in the hallway by the spa room doors. Observation on 8/17/23 at 10:39 A.M., showed the spa room doors where left unlocked and unattended with an open box of disposable razors on the counter and an unlocked cabinet with an open box of disposable razors. Further observation showed three residents sat in wheel chairs alone in the hallway by the spa room doors. 3. Review of Resident #30's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 4/13/23 showed staff assessed the resident as: -Diagnosis of Alzheimer's disease (A progressive disease that destroys memory and other important mental functions), dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), and epilepsy (A disorder in which nerve cell activity in the brain is disturbed, causing seizures). Observation on 8/17/23 at 3:20 P.M., showed the resident was left alone in the spa room with an open box of disposable razors on the counter. During an interview on 8/17/23 at 2:16 P.M., Registered Nurse (RN) A said razors should be locked up but right now the facility does not have a spa, it is just storage. During an interview on 8/17/23 at 2:21 P.M., Certified Medication Technician (CMT) G said disposable razors are kept in a locked box or cabinet away from residents or thrown away in the sharps container. He/She said the spa doors do not lock. During an interview on 8/17/23 at 2:30 P.M., Licensed Practical Nurse (LPN) H said disposable razors should be stored in a locked cabinet or room or if used they should be placed in the sharps box. Spa room does not lock but they have cabinets that do. Residents could cut themselves or harm others with the sharps. During an interview on 8/17/23 at 3:00 P.M., the Administrator said razors are kept locked in the central supply closet which has a door code, or in the clean utility rooms behind the nurse's station. After use staff expected to dispose of razors in the sharps container. She is not sure why they would not be locked up, but they should be. During an interview on 8/17/23 at 5:00 P.M., the Director of Nursing (DON) said disposable razors should be placed in the sharps container immediately after use. He/She said disposable razors should be stored out of reach of the resident in a locked cabinet. He/She said he/she is not sure if the spa room doors lock. He/She said they should lock and it is a safety concern if they do not lock. The DON said he/she was not aware of it. He/She said residents need to be supervised for in spa rooms at all times. 4. Review of the policies provided by the facility showed no policy for wheelchair safety. 5. Review of Resident #33's MDS, dated [DATE] showed staff assessed the resident as: -Severe cognitive impairment; -Required extensive assistance with locomotion on the unit; -Used a wheelchair; -Diagnoses of Alzheimer's disease, abnormal posture, difficulty walking, and generalized muscle weakness. Observation on 8/14/23 at 1:01 P.M., showed certified nurse aide (CNA) C propelled the resident in his/her wheelchair from the dining room, with foot pedals on. Further observation showed both of the resident's feet slid on the floor as he/she was propelled. Observation on 8/15/23 at 2:29 P.M., CNA B propelled the resident in his/her wheelchair down the 400 hall form, with foot pedals on. Further observation showed both of the resident's feet slid on the floor as he/she was propelled. 6. Review of Resident #47's Annual MDS, dated [DATE] showed staff assessed the resident as: -Cognitively intact; -Used a wheelchair; -Diagnoses of progressive neurological condition, Alzheimer's, dementia, Parkinson's, depression, psychotic disorder (not schizophrenia). Observation on 8/17/23 at 2:20 P.M., CNA B propelled the resident in his/her wheelchair from the shower to his/her room, without foot pedals. Further observation showed the resident's feet skimmed the floor, over 25 feet. 7. Review of Resident #55's admission MDS, dated [DATE], showed staff assessed the resident as: -Severely cognitively impaired; -Used a wheelchair; -Diagnoses of cancer, osteoporosis, hip fracture, dementia, malnutrition, depression. Observation on 8/15/23 at 7:35 A.M., the dietary manager propelled the resident in his/her wheelchair from the dining room, without foot pedals. Further observation showed the resident's left foot slid on the floor. 8. Review of Resident #333's medical record showed no MDS assessment. Observation on 8/15/23 at 9:20 A.M., CNA D propelled the resident in his/her wheelchair from the nurse's station to his/her room. Further observation showed the resident's feet drug under his/her foot pedals and did not rest on the pedals. 9. Observation on 8/14/23 at 12:12 P.M., CNA C propelled an unidentified resident from the dining room, without foot pedals. Further observation showed the resident's socks skimmed the floor. During an interview on 8/17/23 at 2:16 P.M., RN A said when propelling residents you must ensure their feet are on the pedals, if they don't have pedals and are cognitive then we will ask them to pick their feet up. During an interview on 8/17/23 at 2:38 P.M., CNA B said it is common sense to always use push pedals for safety. During an interview on 8/17/23 at 2:21 P.M., CMT G said wheel chair should be locked when getting residents up, foot pedals should be used when pushing residents, and feet should be on the pedals before pushing. CMT G said if resident's feet are not properly placed on the foot pedals before propelling the resident, they could break their ankles or injure their toes by having them dragged. During an interview on 8/17/23 at 2:30 P.M., LPN H said residents must have foot pedals on before propelling. He/She said feet should be properly placed on the pedals so that the resident does not become injured. He/She said residents could get abrasions or wounds to their feet, especially if they are not wearing foot wear. He/She said there are several residents who do not like to wear shoes or socks. During an interview on 8/17/23 at 3:00 P.M., the Administrator said residents should be propelled in their wheelchair with foot pedals. During an interview on 8/17/23 at 5:00 P.M., the Director of Nursing (DON) said he/she expected staff to always propel residents forward and never back ward, make sure residents have foot wear on, that they have foot pedals, and their feet are securely on the pedals. He/She said it is never appropriate for staff to propel a resident without foot pedals on. He/She said staff should not expect residents to be able to hold their feet up while propelling. He/She said the risk for not having foot pedals on or resident's feet firmly placed on foot pedals is a safety concern. He/She said feet can drag causing injury, feet can get caught and residents can be thrown from their chair. 47193