Every finding on record at Meyer Care Center

Based on observation and interview, the facility failed to maintain the cleanliness of the walk-in cooler fans that had black debris buildup; maintain the floor behind and under equipment where debris had built up; maintain the cleanliness of the outside of the grease fryer and griddle; maintain the cleanliness of the ceiling above the pureed preparation area; cheese in the double door refrigerator was uncovered; salad was open in the walk-in cooler and failed to ensure sanitizer strips were being utilized and the ones readily available were not expired. The hot water pressure gauge was not working on the dish machine, and the facility had no way to test if the dishwasher was sanitizing the dishes properly. This practice potentially affected all 49 residents who ate food from the kitchen. The facility census was 49 residents. 1. Observation on 3/30/26 9:17 A.M., during the initial walk-through meal preparation showed:-Food debris behind and under equipment by the cook top and warmer area and behind the white refrigerator.-Fans in the walk-in cooler had black debris on them. -Cheese in the double door refrigerator was uncovered, and edges were starting to get hard.-Salad in a salad bag was open to the elements in the walk-in cooler. Observation on 4/1/26 from 9:04 A.M. to 12:00 P.M. during the lunch meal preparation showed:-The hot water pressure gauge was not working on the dish machine, and the facility had no way to test if the dishwasher was sanitizing the dishes properly. -The test strips to test sanitizer for the three-compartment sink and sanitizer bucket had expired.-Test strips were not being used to check the concentration of chlorine for soaking dishes. -Grease build up on the outside of the grease fryer.-Dried spilled food residue build up on the outside of the griddle. -The silver wall behind the griddle had food debris on it. -The ceiling above the puree preparation area had food splatters on it. During an interview on 4/1/26 at 12:00 P.M. the Food and Beverage Director (FBD) said:-The pressure gauge had been working and showed the tracked temperature log, but they did not have an alternative way to check the temperature. -He/She didn't know test strips could expire. -There was a daily checklist to make sure areas were being cleaned.-A deep clean behind and under equipment was completed every month. During an interview on 4/2/26 at 8:26 A.M. the FBD said:-He/She would look into getting a device to check the sanitizing temperature for the dish machine.-He/She had been looking into getting a new sanitizing company to come out and would make sure to have staff trained on using sanitizer strips.

Based on observation, interview and record review, the facility failed to ensure safe storage and labeling of bronchodilator medication (medication used to treat breathing disorders) to include date of opening and original packaging for one sampled resident (Resident #15) and one supplemental resident (Resident #31) out of 16 sampled residents and 8 supplemental residents; failed to ensure there were no expired medications in the medication room refrigerator and cabinets; failed to ensure insulin pens were dated, labeled, and properly stored; failed to ensure that expired medications were disposed of in two of two medication carts and two of two medication rooms; failure to segregate medications based on route of administration in order to prevent contamination and errors and failed to ensure proper defrosting was done in one out two medication storage rooms.A medication storage policy was requested but not provided by the facility. Review of the facility's undated Destruction of Unused Drugs policy showed:- All unused, contaminated, or expired prescription drugs shall be disposed of in accordance with state laws and regulations.-Unused, unwanted and non-returnable medications should be removed from their storage area and secured until destroyed.-The actual destruction of drugs conducted by our facility must be witnessed by the consultant pharmacist and one of the following individuals:An agent of the State Board of Pharmacy.The facility Administrator.The Director of Nursing (DON) services. -A Non-Controlled Medication Destruction Record must be maintained for all non-controlled drugs destroyed and such record must be verified by the consultant pharmacist. The following information shall be included on this record:The name and address of the facility.The name and license number of the consultant pharmacist.The date the medication was destroyed.The date the prescription was dispensed.The prescription or lot number of the medication.The name of the pharmacy dispensing the medication.The name, strength, and quantity of the medication being destroyed.The reason for destroying the medication.The method of destruction.The signature of the consultant pharmacist destroying the medications.The signature of the person(s) witnessing the destruction of the medications. -Our facility utilizes a waste disposal service or reverse distributor to destroy dangerous drugs and controlled substances. -The sealed container must be maintained in a secure area in the pharmacy or in a locked cabinet in the medication room until transferred to the waste disposal service or the reverse distributor by the consultant pharmacist, an agent of the state board of pharmacy, the facility administrator, or the director of nursing services. 1. Review of Resident #15's admission record showed he/she had diagnoses that included allergic rhinitis (an immune response to inhaled allergens like pollen or dander, causing nasal congestion, sneezing, runny nose, and itchy eyes). Review of the resident's Physician's Order Sheet (POS) dated March 2026 showed:-Albuterol Sulfate (a rapid-acting bronchodilator used as a rescue inhaler to treat or prevent bronchospasm in people with asthma and COPD) HFA Inhalation Aerosol Solution 108 (90 Base) microgram (MCG)/actuation (ACT) 2 puffs, inhale orally two times a day for allergies.-Fluticasone-Salmeterol (a prescription combination inhaler used for long-term maintenance of asthma and COPD) Inhalation Aerosol Powder Breath Activated 100-50 MCG/ACT (Fluticasone-Salmeterol) 1 puff inhale orally two times a day for allergies. Rinse mouth after each use. Observation on 4/1/26 at 9:40 A.M., of the 300 hall cart, with the Licensed Practical Nurse (LPN) A showed:-The resident had one fluticasone/salmeterol diskus 100/50 inhaler with the resident's name written on the medication and in the same compartment as oral medications without a date opened or in its original box/packaging.-One albuterol sulfate inhaler in the same compartment as oral medications without a date opened or in its original box/packaging. 2. Review of #31's admission record showed he/she had diagnoses that included:-Chronic obstructive pulmonary disease (a progressive, incurable lung disease that obstructs airflow and causes severe breathing difficulties, including chronic bronchitis and emphysema).-Chronic respiratory failure (where the lungs cannot adequately exchange oxygen and carbon dioxide, leading to low oxygen levels in the blood). Review of the resident's POS dated March 2026 showed Tiotropium Bromide (a long-acting, inhaled anticholinergic medication used for the daily, long-term maintenance treatment of COPD and asthma) Inhalation Aerosol Solution 2.5 MCG/ACT 1 puff inhale orally two times a day for COPD Rinse mouth after use. Observation on 4/1/26 at 9:40 A.M., of the 300-hall cart, with LPN A showed one Spiriva (Tiotropium Bromide) inhaler in the same compartment with oral medications, the resident's name and A.M/P.M. written on the medication and without a date opened or in its original box/packaging. 3. Observation on 4/1/26 at 9:45 A.M., of the 300-hall medication cart, with LPN A showed:-One bottle of Pataday (antihistamine drops that provide rapid, long-lasting relief from itchy, allergy-prone eyes) eye drops not labeled with a name and not in any packaging stored in the same compartment with topical creams.-Two tubes of Nystatin (a prescription antifungal medication used to treat cutaneous (skin) infections caused by Candida yeast (a type of fungus that commonly lives on the skin and inside the human body)) cream not labeled, packaged, or dated.-One tube of bacitracin (a topical antibiotic used to prevent infections in minor cuts, scrapes, and burns) that expired 10/2025.-19 hearing aid batteries that expired in August and September 2024.-Two unlabeled, undated white oblong pills in a medication cup.-One bottle of Nizoral shampoo and one bottle of beard oil in the same compartment with oral medications.-One bottle of Benzonatate (a prescription non-narcotic medication used to relieve coughs in adults and children over 10) capsules unlabeled and originally dispensed on 1/31/25 with no expiration date.--NOTE: One jug of drug buster (an eco-friendly, activated charcoal-based disposal system that neutralizes non-hazardous pharmaceuticals (pills, liquids, patches)) undated on shelf area in the nurse's station. During an interview on 4/1/26 at 10:45 A.M., LPN A said:-Expired batteries should not be in the cart and be given to maintenance for disposal.-There should not be any expired or discontinued medications in the cart.-Inhalers should be stored in their original bag or box.-He/She usually destroys expired and discontinued medications in drug buster jugs.-A waste sheet is filled out at the time of destruction as a record. 4. Observation on 4/1/26 at 10:59 A.M., of the 100/200 medication room with LPN A showed:-One bottle of stock Naproxen (a nonsteroidal anti-inflammatory drug (NSAID) used to treat mild to moderate pain, fever, inflammation, and stiffness) 220 milligram (mg) tablets that expired on 4/2025.-One bottle of stock Vitamin B12 (a synthetic or natural form of the essential nutrient cobalamin used to prevent or treat low vitamin B12 levels) that expired on 10/2024.-Four bottles of stock Melatonin (a supplement that is used for short-term insomnia, jet lag, and adjusting sleep schedules, generally helping people fall asleep slightly faster) 3 mg tablets expired on 1/2025.-Two bottles of stock Tylenol (an analgesic and antipyretic drug that treats mild-to-moderate pain and reduces fever) 500 mg caplets that expired on 2/2024.-In the refrigerator:--An excessive ice buildup in the freezer section of the refrigerator that needed defrosting.--Five Basalgar (a long-acting insulin used to control high blood sugar in adults with type 1 or type 2 diabetes) insulin pens that expired on 3/2025, for a resident that had passed away.--Three Tresiba (a long-acting basal insulin used to improve blood sugar control in adults) insulin pens that expired on 2/2026, for a resident that had passed away.-Three Levemir (a long-acting human insulin analog used to improve glycemic control in adults with diabetes) insulin pens that expired on 5/2025, for a resident that had passed away.--Three Humalog (a rapid-acting man-made insulin used to treat high blood sugar in adults with diabetes) insulin pens unlabeled and without dispense date.--One vial of insulin aspart (a rapid-acting man-made insulin used to treat high blood sugar in adults with diabetes) unlabeled and expired on 8/31/25.--Seven single dose Influenza (flu) vaccination injections that expired on 6/2025. During an interview on 4/1/26 at 11:22 A.M., LPN A said:-He/She was not sure who was responsible for auditing the medication room and discarding any expired medications.-Nursing staff usually kept all of the residents' medications including those they brought upon admission, until they leave or say that it is ok to destroy them. -The pharmacy usually audits narcotics and other prescription medications when they come to refill them and check inventory. -He/She was not sure how often this is done.-The pharmacy was not responsible for auditing the facility's medication rooms. During an interview on 4/1/26 at 11:53 A.M., LPN B said:-The pharmacy is responsible for auditing medication carts and pulling all expired medications.-He/She was not sure what the pharmacy's schedule was for auditing carts.-Usually, the nursing staff will use any medications brought in by residents upon admission, ideally, they would try to use those first unless otherwise requested by the family.-Nursing staff fills out a control/requisition form for medications being destroyed and places them in the drug buster. 5. Observation on 4/2/26 at 12:33 P.M., of the medication and treatment cart stored on the 300 hall with LPN B showed:-One bottle of Flonase nasal spray (a nasal spray used to treat nasal symptoms like congestion, sneezing, itching, and runny nose caused by allergies) unlabeled, undated, and without any packaging.-One opened stock bottle of Tylenol 500 mg expired on 2/2026.-One bottle of nitroglycerin (a medication used primarily to treat and prevent chest pain) tablets that expired on 7/2025.-Seven vials of Ceftriaxone (an antibiotic used to treat severe bacterial infections) 250 mg powder for injection discontinued on 3/11/26. During an interview on 4/2/26 at 12:48 P.M., LPN B said:-Eye drops and topical creams should not be stored together.-Expired medications should not be in the cart at any time.-He/She was not sure who was responsible for auditing and destroying medications in the medication room.-Medications could not be returned to the pharmacy for credit unless there is a pharmacy error and then only within a short window of time, he/she was not sure what it was exactly. During an interview on 4/2/26 at 2:22 P.M., the DON said:-In the past the Assistant Director of Nursing (ADON) or the Registered Nurse (RN) supervisor on the weekends did medication cart and room audits. -Nurses do it now but there is no schedule for doing so.-The nurses and ADON are responsible for making sure this were done and should be auditing them for sure.-He/She was not sure how often audits of the medication carts and medication room were done.-He/She had given education on this to nursing staff in March 2026.-There was not a current schedule for the cleaning/defrosting of the medication refrigerator.-The pharmacy was not responsible for cleaning out the medication carts or the medication room during the restock process.

Based on observation, interview, and record review, the facility failed to ensure that hot water temperatures were maintained at or below 120 F (degrees Fahrenheit) in the following rooms: resident rooms 308, 310, 309, 312, 311, 314, 317, 315, 319, 323. This practice potentially affected 18 residents who resided in those rooms. The facility census was 49 residents.1. Review of the facility's hot water temperature log showed the last time the facility documented hot water temperatures was 3/2/26. Observations with Maintenance Person B on 3/30/26, showed the following:-At 10:42 A.M., the hot water temperature in resident room [ROOM NUMBER] was 122.3 F.-At 10:49 A.M., the hot water temperature in resident room [ROOM NUMBER] was 122.3 F.-At 10:53 A.M., the hot water temperature in resident room [ROOM NUMBER] was 122.9 F. -At 10:58 A.M., the hot water temperature in resident room [ROOM NUMBER] was 122.9 F.-At 11:02 A.M., the thermostat for the hot water heater which served the 300 Hall was set at 125 F.-At 11:06 A.M., the hot water temperature in resident room [ROOM NUMBER] was 121.9 F. -At 12:22 P.M., the hot water temperature in resident room [ROOM NUMBER] was 122.0 F.-At 12:23 P.M., the hot water temperature in resident room [ROOM NUMBER] was 122.0 F (water in room [ROOM NUMBER] was running simultaneously as water in room [ROOM NUMBER]). -At 12:27 P.M., the hot water temperature in resident room [ROOM NUMBER] was 122.7 F.-At 12:28 P.M., the hot water temperature in resident room [ROOM NUMBER] was 122.9 F (water in room [ROOM NUMBER] was running simultaneously as water in room [ROOM NUMBER]).-At 12:39 P.M., the hot water temperature in resident room [ROOM NUMBER] was 121.6 F.-All temperatures were taken with a calibrated thermometer after the water ran for two minutes. 2. During an interview on 3/30/26 at 11:03 A.M., the Maintenance Assistant said he/she would have to turn down the hot water heater, and he/she has been trying to adjust it for the last two months. During a follow up interview on 3/31/26 at 9:23 A.M., the Maintenance Assistant said: -In the past, there was faulty wiring between the pilot light and the burner, because of that, the burner had faulty wiring. -In the past some of those rooms received cold water.-A heating and cooling company was called out and determined there was a break in the wire and repaired it. -For the past two months the thermostat for the heater has jumped around. -He/she had not taken any water temperatures since the first of the month. He/she did not let the water flow for two minutes before taking a reading.

Based on observation and interview, the facility failed to ensure there was negative airflow in the restrooms of resident occupied rooms [ROOM NUMBER] and in the soiled utility room on the service hall where the kitchen was located. This practice potentially affected three residents who resided on the 100 Hall. The facility census was 49 residents.**Note: Air flow was tested by holding one piece of tissue paper to the ceiling vent. If the paper was drawn to the vent, then negative air flow was present; if the paper fell, then negative airflow was absent. 1. Observation on 3/30/26, showed:-At 2:06 P.M., negative airflow was absent from the restroom of resident room [ROOM NUMBER].-At 2:10 P.M., negative airflow was absent from the restroom of resident room [ROOM NUMBER].-At 2:12 P.M., negative airflow was absent from the restroom of resident room [ROOM NUMBER].-At 2:16 P.M., negative airflow was absent from the soiled utility room on the service hall. During an interview on 4/2/26 at 1:31 P.M., the Maintenance Director said:-The reason why there was not any ventilation on the 100 Hall and in the soiled utility room was because the belt for the ventilation motor for that area of the facility was loose.-The belt turned the fan but the belt was so stretched out that the fan was not producing enough negative airflow.

Based on interview and record review, the facility failed to ensure that the Certified Nursing Assistants (CNAs) and Licensed Nursing Staff had the appropriate competencies and skills check off training to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being was completed annually and as needed. The facility census was 49 residents. Review of the facility's Competency Evaluation Policy copyright 2025, showed: -It is the policy of this facility to evaluate each employee to assure they meet appropriate competencies and skills for performing their job.-Definitions: Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual need to perform work roles or occupational functions successfully.-Policy Explanation and Compliance Guidelines:--The knowledge and skills required among staff to meet residents' needs are determined through the facility assessment process.--Evaluating competency of staff is accomplished through the facility's training program.--Initial competency is evaluated during the orientation process. --An employee remains on orientation until all competencies are verified.--Subsequent and/or annual competency is evaluated at a frequency determined by the facility assessment, evaluation of the training program, and/or job performance evaluations.--Checklists are used to document training and competency evaluations. 1. Review of the Facility's Assessment Report dated 4/2/26 showed:-Staff competencies completed depended on the acuity of the resident and the type of nursing resident care prescribed.-Nursing care included: activities of daily living (ADL), mobility and fall prevention injury, bowel and bladder needs, skin integrity, mental health and behavior, medication management, pain management, infection prevention and control, management of medical conditions, nutrition and hydration management, referrals to therapy, ostomy care, end of life care.-Care staffing needs were based on resident census and acuity, the resident required daily schedules for ADL's and activities that day. -All employee training available to facility staff included: resident rights & facility responsibilities; Abuse and neglect; Infection Control; Culture Change & Person-Centered Care; Required 12-hour ins-services; Dementia Care; Paid Feeding assistants; Identification and Communication of changes in resident Condition; Cultural Competency.Review of the facility employee training/clock hours binder dated 3/1/25 to 3/31/26 for the performance competency skill checks for five sampled staff members showed:-There were no annual performance competency skill checks for the five sampled staff. -The facility was not able to locate any documentation for the five sampled staff to show the completion of the performance competency skill checks.Review of the facility's employee annual training and performance competencies dated March 2025 to March 2026 showed:-Four of the five sampled staff did not have a performance competency skills check. -CNA A and CNA D did not have documentation of having completed orientation training and did not have a new hire performance competency skills check. -CNA B had no documentation of a performance competency skills check being completed. -CNA C had no documentation of a performance competency skills check being completed. -Licensed Practical Nurse (LPN) A had a performance competency skills check dated 10/23/24.--There was no documentation of an annual performance competency skills check completed in 2025 or from 1/1/26 to 4/1/2026.During an interview on 4/2/26 at 10:21 A.M., CNA A said.-The facility offered training monthly online with different topics each month. -He/She was not aware if he/she had completed a performance competency skills check during his/her employment at the facility. -Sometimes licensed staff watched or assisted with resident care and he/she would be educated on any resident care performance concerns. During an interview on 4/2/26 at 10:25 A.M. LPN B said:-He/She completed online training at least monthly to include dementia care, medication administration, abuse and neglect and infection control. -He/She was not sure when his/her last competency skills check was completed.-The facility offered skill performance checks at least annually.During an interview on 4/2/26 at 11:21 A.M., the Director of Nursing (DON) said: -He/She started as DON in September 2025. -The facility had scheduled upcoming staff competencies checks for 5/29/26 and 6/22/26.-He/She completed training for all staff. -He/She did not find additional staff training records or performance competency skills check documentation. -He/She would expect to have documentation of any staff performance competency skills check at least annually and as needed with resident care concerns.

Based on record review and interview, the facility failed to reconcile (a method of looking at monthly bank statements for the balance of the money in resident trust and subtracting any outstanding checks or payments) bank statements for the time span of March 2025 through February 2026 and failed to prevent a negative balance for one resident (Resident #15) out of three residents selected for the resident trust review. This practice affected five residents who allowed the facility to manage their funds within the resident trust. The facility census was 49 residents.Review of the facility's policy entitled Resident Personal Funds with a copyright date of 2025, showed in the Accounting and Records section:-The facility will establish and maintain a system that assures a full and complete and separate accounting, according to generally accepted accounting principles, of each resident's person funds entrusted to the facility on the resident's behalf. Review of the Medicaid resource Limit showed that limit was increased to $5909.25 in July 2025. 1. Review of the resident trust records dated between March 2025 through February 2026 showed:-The absence of bank statements for the months of March 2025 through February 2026.-The absence of monthly reconciled statements for the months of March 2025 through February 2026. 2. Review of Resident #15's account dated 10/24/23 through 3/5/26, showed the resident had a balance of negative $306.69. Review of Resident #15's resident Trust transactions showed surplus payments (a financial transfer representing excess funds, assets, or profits remaining after all liabilities, expenses, or debt obligations have been met) of the following:-A payment of $1,552.00 on 6/9/25.-A payment of $1,657.00 on 7/8/25. -A payment of $1,587.00 on 8/17/25. -The residents' balance never exceeded $3,887.16. 3. During an interview on 4/2/26 at 9:12 A.M., the Business Office Manager (BOM) said:-He/she did not get the bank statements. - The bank statements go to the Administrator.-He/she started this position in 2024. -He/she had not received training in resident trust and doing reconciliations.-He/she made payments for the residents' surplus for Resident #15 since 2025, because he/she thought the resident was over the resource limit (the amount of funds a resident was allowed to have while that resident received the assistance of Medicaid (Insurance program that provides free or low-cost health coverage to some low-income people, families and children, pregnant women, the elderly, and people with disabilities)). During an interview on 4/2/26 at 11:40 A.M., the Administrator said:-The BOM had access to the bank statements. -He/she provide education on to the BOM in 2024.-He/she expected the BOM to do the reconciliations. -The facility can partner with Entity A who does medical billing and they are versed in the regulations to assist with the reconciliations. During follow up written communication dated 4/6/26 at 11:04 A.M., the BOM wrote he/she:-Did not have any idea how much the resource limit in Missouri was.-He/she did not get notified of the resource limit.

Based on observation and interview, the facility failed to maintain four fans in the personal services shop, free from a heavy buildup of dust on the blades and the grates of the fans; failed to ensure the floors in resident rooms [ROOM NUMBERS] were in good repair; failed to maintain the stand-up lift in good repair; failed to maintain the ceilings, sprinkler heads, and light fixtures in the dining room and the therapy room, free from a buildup of dust. This practice potentially affected at least 25 residents who used or resided in those areas. The facility census was 49 residents.1. Observation on 3/30/26 at 10:12 A.M., showed a heavy buildup of dust on the blades and the grates (essential safety covers, usually made of metal or plastic, that protect fingers and cables from moving blades while maintaining airflow) of four fans in the personal services shop. During an interview on 3/31/26 at 10:24 A.M., the Housekeeping Supervisor said the housekeeping department did not clean the fans in the beauty shop, the beautician was supposed to clean the fans in the Personal Services' Shop. During an interview on 3/31/26 at 3:27 P.M., the Beautician said:-At some time in the past housekeeping used to clean the fans, but no one has communicated to him/her that it was his/her responsibility to clean the fans.-The fans have not been cleaned in quite some time. -The cleaning of the fans was not something that was discussed either. -He/she had been a beautician at the facility for 34 years. -He/she had no idea how to remove fans from the wall. 2. Observation with Maintenance Person B on 3/30/26 at 10:38 A.M., showed a 3 feet (ft.) long by 2 inches (in.) wide area of damaged flooring between the restroom and the living space in resident room [ROOM NUMBER]. Observation with Maintenance Person B on 3/30/26 at 10:58 A.M., showed two missing floor tiles under the bed on the left side (looking at the window perspective) in resident room [ROOM NUMBER]. 3. Observation on 3/30/26 at 12:32 P.M., showed one stand-up lift with a crack in the base of the lift in the lift storage room. During an interview on 3/30/26 at 12:34 P.M., Certified Nurse's Assistant (CNA) E said no one knew about the crack in the base of the lift. 4. Observation on 3/30/26 at 1:18 P.M., showed a heavy buildup of dust on the wooden girders (a long, thick piece of wood, metal or concrete, etc. that supports a roof, floor, bridge, or other large structure), with light fixtures and sprinkler heads in the Countryside Lane and [NAME] Meadows' dining rooms. During an interview on 3/30/26 at 1:21 P.M., the Housekeeping Supervisor said he/she:-Had never cleaned the sprinkler heads nor the wood girders in the Countryside Lane dining room.-Needed a longer tool to reach those high areas. 5. Observation on 3/30/26 at 1:03 P.M., showed the presence of dust on the wood girder and the sprinkler heads in the therapy area.During an interview on 3/31/26 at 10:21 A.M., the Housekeeping Supervisor said:-He/she had not cleaned the high ceiling in the therapy area until today.-The housekeeping department does not have a duster that is long enough to reach some of the high ceilings.

Based on interview and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases when the facility failed to ensure three sampled residents (Resident's #6, #9, and #28), out of five residents sampled during the review of the facility's infection prevention and control program, were offered and had documentation of refusal of the COVID-19 vaccine (a new disease caused by a novel (new) coronavirus) and education provided. The facility census was 49 residents.Review of the facility's undated COVID-19 Prevention, Response and Reporting policy showed:- The facility should offer resources and counseling to healthcare personnel, residents and visitors on theimportance of receiving the COVID-19 vaccine and staying up to date with all recommended COVID-19vaccine doses.-admission testing is at the discretion of the facility.-Residents who leave the facility for 24 hours or longer should generally be managed as anadmission. Review of the facility's undated General Immunization/Vaccination policy showed:-Residents, staff, and volunteer workers will be offered immunizations against infectious diseases as per current federal, state and local guidance.-Residents, staff, and volunteer workers will be screened prior to receiving any immunization to ensure eligibility for the specific vaccine(s).-Copies of the Vaccine Information Statement (VIS) or Emergency Use Authorization (EUA) will be given and explained to the staff member, volunteer, resident, or resident representative prior to receiving a specified vaccine(s).-The VIS or EUA, as appropriate, will be supplemented with visual presentations or oral explanations to assist vaccine recipients in understanding the benefits and potential side effects of the specified vaccine(s). Opportunity will be given for asking questions. -Staff, volunteer workers, residents or resident representatives will be required to sign a consent form prior to administration of the vaccine(s). The completed, signed, and dated record will be filed in the individual's medical record, or the staff or volunteer's medical file. -Residents, staff members, and volunteer workers retain the right to refuse immunizations. Mitigating interventions will be specified by the facility if such refusals occur (i.e., masking during influenza season, etc.).-The resident's medical record or staff/volunteer's medical file will include documentation that the staff, volunteer, resident and/or the resident's representative was provided education regarding the benefits and potential side effects of immunization(s), and that the resident received or did not receive the immunization(s) due to medical contraindication or refusal.-In case of lack of availability of the specified vaccine, or other issue with the availability leading to an inability to implement a specified immunization program, the facility will demonstrate:a. The vaccine has been ordered and the facility received either the vaccine or a confirmation of the order indicating that the vaccine has been shipped or that the product is not available but will be shipped when the supply is available.b. Plans are developed on how and when the vaccines are to be administered.c. Residents, staff and volunteers have been screened to determine how many and which individuals are eligible and wish to receive the vaccine; andd. Education regarding immunizations has been implemented. 1. Review of Resident #6's medical record showed:-No documentation of the resident's COVID vaccine status. -The resident had received education for the risks and benefits of the vaccine and wished to receive the vaccine as evidenced by a signed COVID vaccination directive dated 11/20/25. 2. Review of the Resident #9's medical record showed no documentation of the resident's COVID vaccine status or that the resident had received education for the risks and benefits of the vaccine since admission to the facility. 3. Review of Resident #28's medical record showed:-No documentation of the resident's COVID vaccine status or that the resident had received education for the risks and benefits of the vaccine since admission to the facility.-NOTE: the resident last received the vaccine on 11/07/22, there was no documentation of declination since. During an interview on 04/02/22 at 12:45 P.M., the Infection Control Preventionist (ICP) said:-All residents are offered the COVID vaccine upon admission and annually thereafter.-The administration, education, and acceptance or declination information should be located in the resident's admission packet and their electronic health record (EHR).-The nursing staff is responsible for making sure this is done. During an interview o 04/02/26 at 2:22 P.M., the Director of Nursing (DON) said:-He/She would expect all residents to be offered the COVID vaccine upon admission.-Usually, families will ask, and if not the facility will also ask family members if they want the vaccines administered.-A patient education and an acceptance/declination form should be signed and dated at the time of each vaccination offering and/or administration.-If resident's do not have an acceptance/declination form signed and dated on file, then the resident was not offered, did not receive education on and did not receive the vaccine.-Nurses are responsible for obtaining consent, education, administration, and documentation of all residents who are offered the Pneumococcal vaccine.-There are no possible negative outcomes for not receiving vaccines if wanted by the resident.

Based on interview and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases when the facility failed to provide a pneumococcal (pneumonia-lung inflammation caused by bacterial or viral infection) vaccine for three resident's (Resident #6, #9, and #28) out of five residents sampled during the review of the facilities infection prevention and control program. The facility census was 49 residents. Review of the facility's undated Pneumococcal vaccine policy showed:-It was the facility policy to offer residents and staff immunization against pneumococcal disease in accordance with current CDC guidelines and recommendations.-Each resident would be assessed for pneumococcal immunization upon admission. Self-report ofimmunization shall be accepted. Any additional efforts to obtain information shall be documented,including efforts to determine date of immunization or type of vaccine received.-Each resident will be offered a pneumococcal immunization unless it is medically contraindicated or ifthe resident had already been immunized. Following assessment for any medical contraindications,the immunization may be administered in accordance with physician-approved standing orders.-Prior to offering the pneumococcal immunization, each resident or the resident's representative willreceive education regarding the benefits and potential side effects of the immunization with theeducation documented in the clinical record.a. The individual receiving the immunization, or the resident representative, will be providedwith a copy of CDC's current vaccine information statement relative to that vaccine.b. If necessary, the vaccine information statement will be supplemented with visualpresentations or oral explanations to assist vaccine recipients in understanding.-The resident/representative retains the right to refuse the immunization. The facility will document inthe clinical record the reason for refusal or the medical contraindication of the immunization.-A consent form shall be signed prior to the administration of the vaccine and filed in the individual'smedical record.-A pneumococcal vaccination is recommended for adults who have certain chronic medical conditionsor other risk factors which may include:a. Alcoholismb. Cerebrospinal fluid leakc. Chronic heart disease, including CHF and cardiomyopathiesd. Chronic liver diseasee. Chronic lung disease, including COPD, emphysema and asthmaf. Chronic renal failureg. Cigarette smokingh. Cochlear implant1. Congenital or acquired aspleniaJ. Congenital or acquired immunodeficiencyi. (humoral) or T-lymphocyte deficiencyii. Complement deficiency, particularly Cl, C2, C3, or C4 deficiencyiii. Phagocytic disorder, excluding chronic granulomatous diseasek. Diabetes mellitus1. Generalized malignancym. HIV infectionn. Hodgkin diseasePneumococcal Vaccine (Series)o. Iatrogenic immunosuppression, including long-term systemic corticosteroids and radiationtherapyp. Leukemiaq. Lymphomar. Multiple myelomas. Nephrotic syndromet. Sickle cell disease or other hemoglobinopathiesu. Solid organ transplant-Pneumococcal vaccines are recommended for adults aged ~19 years and based on presence orabsence of underlying conditions.Adults 50 years or older:a. Routine vaccination:1. Administer PCV15, PCV20, or PCV21 for all adults 50 years or older who have neverreceived any pneumococcal conjugate vaccine or whose previous vaccination history isunknown. Review of the facility's undated General Immunization/Vaccination policy showed:-Residents, staff, and volunteer workers will be offered immunizations against infectious diseases as per current federal, state and local guidance.-Residents, staff, and volunteer workers will be screened prior to receiving any immunization to ensure eligibility for the specific vaccine(s).-Copies of the Vaccine Information Statement (VIS) or Emergency Use Authorization (EUA) will be given and explained to the staff member, volunteer, resident, or resident representative prior to receiving a specified vaccine(s).-The VIS or EUA, as appropriate, will be supplemented with visual presentations or oral explanations to assist vaccine recipients in understanding the benefits and potential side effects of the specified vaccine(s). Opportunity will be given for asking questions. -Staff, volunteer workers, residents or resident representatives will be required to sign a consent form prior to administration of the vaccine(s). The completed, signed, and dated record will be filed in the individual's medical record, or the staff or volunteer's medical file. -Residents, staff members, and volunteer workers retain the right to refuse immunizations. Mitigating interventions will be specified by the facility if such refusals occur (i.e., masking during influenza season, etc.).-The resident's medical record or staff/volunteer's medical file will include documentation that the staff, volunteer, resident and/or the resident's representative was provided education regarding the benefits and potential side effects of immunization(s), and that the resident received or did not receive the immunization(s) due to medical contraindication or refusal.-In case of lack of availability of the specified vaccine, or other issue with the availability leading to an inability to implement a specified immunization program, the facility will demonstrate:The vaccine has been ordered and the facility received either the vaccine or a confirmation of the order indicating that the vaccine has been shipped or that the product is not available but will be shipped when the supply is available.Plans are developed on how and when the vaccines are to be administered.Residents, staff and volunteers have been screened to determine how many and which individuals are eligible and wish to receive the vaccine; andEducation regarding immunizations has been implemented. 1. Review of Resident #6's face sheet showed that he/she had diagnoses that included:-Emphysema (a chronic, progressive lung disease, typically caused by long-term smoking or irritant exposure, that destroys the alveoli (air sacs) and reduces lung elasticity, causing severe shortness of breath and air trapping).-Chronic Obstructive Pulmonary Disease (COPD - a disease process that decreases the ability of the lungs to perform ventilation).-Cognitive communication deficit (a communication impairment caused by underlying cognitive issues like memory, attention, or executive dysfunction rather than language mechanics alone). Review of the resident's Physician Order Sheet (POS) dated March 2026 showed no physicians order to receive the Pneumococcal vaccine. Review of the resident's vaccine waiver/authorization form dated 11/20/25 showed:-The resident had been educated on the risks and benefits of the Pneumococcal vaccine.-The resident agreed to receive the Pneumococcal vaccine as evidenced by the form being signed and dated on 11/20/25. Review of the resident's immunization record, generated from the Electronic Health Record (EHR), showed the resident had refused the vaccine on 11/20/25 and there was no record of the vaccine being given. 2. Review of Resident #9's Face Sheet showed he/she had diagnoses that included:-Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses).-Sleep related hypoventilation (a disorder characterized by shallow or slow breathing during sleep, causing low oxygen causing low oxygen levels).-Cognitive communication deficit (a communication impairment caused by underlying cognitive issues like memory, attention, or executive dysfunction rather than language mechanics alone).-Heart failure (a chronic, progressive condition where the heart cannot pump enough blood to meet the body's needs).-Encounter for immunization. Review of the resident's POS dated March 2026 showed no physicians order to receive the Pneumococcal vaccine. Review of the residents' immunization record generated from the EHR showed:-The resident had received the Pneumococcal vaccine on 2/16/23.-There was no record of a signed and dated vaccine/waiver form indicating the resident had received education on the risks and benefits of the pneumococcal vaccine or that the vaccine was accepted or declined since that date. Review of the immunization documentation requested showed that:-The resident's Power of Attorney (POA-an agent to act on behalf of a principal for financial, legal, or medical matters) had written and submitted a letter dated 10/27/23 to the facility stating that he/she did not consent to all vaccines including Covid, Flu, and Pneumonia.-He/She was informed by the Director of Nursing (DON), that the resident had received a flu vaccine without his/her permission or consent. -He/She stated that they had previously requested to staff that the resident was not to receive a flu vaccine for that year, 2023. -He/She was not contacted for consent prior to the vaccine being given. -He/She stated under no circumstances was the resident to be given any vaccine without his/her permission and if permission was granted, it must be a consent form in writing.-Note: there was no record of any consent form for the pneumococcal vaccine since. 3. Resident # 28's Face Sheet showed he/she had diagnoses that included:-Type 2 Diabetes Mellitus (a chronic condition where the body resists insulin or fails to produce enough, causing high blood sugar).-Aphasia (inability (or impaired ability) to understand or produce speech, as a result of brain disease or damage).-Cognitive communication deficit.-Metabolic encephalopathy (a broad term for brain dysfunction caused by systemic chemical imbalances, such as organ failure, toxins, or infection, rather than direct head trauma).-Acute kidney failure (a sudden, often reversible loss of kidney function, differing from chronic end-stage renal disease). Review of the resident's POS dated March 2026 showed no physicians order to receive the Pneumococcal vaccine. Review of the residents' immunization record generated from the EHR showed:-There was no record of having received the pneumococcal vaccine upon admission (date of admission 4/26/22) or since.-There was no signed and dated vaccine waiver/authorization form showing education had been received on the risks and benefits of the pneumococcal vaccine and whether the resident had accepted or declined to receive it. During an interview on 4/2/26 at 12:45 P.M., the Infection Control Preventionist (ICP) said:-The pneumococcal vaccine should be offered to resident upon admission and then annually thereafter.-The administration, education, and acceptance or declination information should be located in the resident's admission packet and their EHR.-The nursing staff is responsible for making sure this is done. During an interview on 4/2/26 at 2:22 P.M, the Director of Nursing (DON) said:-He/She would expect all residents to be offered the pneumococcal vaccine upon admission.-Usually, families will ask, or the facility will also ask family members if they want the vaccines administered.-A patient education and an acceptance/declination form should be signed and dated at the time of each vaccination offering and/or administration.-If resident's do not have an acceptance/declination form signed and dated on file, then the resident was not offered, did not receive education on and did not receive the vaccine.-Nurses are responsible for obtaining consent, education, administration, and documentation of all residents who are offered the Pneumococcal vaccine.-There are no possible negative outcomes for not receiving vaccines if not wanted by the resident.

Based on observation, interview and record review, the facility failed to practice hand hygiene to prevent cross contamination during resident medication administration for five supplemental residents (Resident #12, Resident #19, Resident #31, Resident #36 and Resident #44) out of eight supplemental residents, failed to practice hand hygiene to prevent cross contamination during resident care for one sampled resident (Resident #28), failed to ensure proper sanitation of shared medical equipment before use, between residents and after use for one supplemental resident (Resident #36), failed to display the proper Enhanced Barrier Precaution (EBP-an infection control strategy for nursing homes, requiring gown and glove use during high-contact resident care to prevent the spread of multidrug-resistant organisms) signage; failed to ensure that the Personal Protection Equipment (PPE specialized gear-including helmets, gloves, masks, and goggles-designed to protect workers from physical, chemical, or biological hazards) basin in the resident's room was adequately stocked; and failed to ensure PPE were used during a transfer for one sampled resident (Resident #33) out of 16 sampled residents. The facility census was 49 residents.Review of the facility's undated Hand Hygiene Policy showed:-All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility.-Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR).-Alcohol-based hand rub with 60 to 95% alcohol is the preferred method for cleaning hands in most clinical situations. Wash hands with soap and water whenever they are visibly dirty, before eating, and after using the restroom.-The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves.-The policy contained a table that indicated that hand hygiene should be used under the following conditions:--When coming on duty.--Before applying and after removing PPE, including gloves.--Before handling or preparing medications. Review of the facility's Enhanced Barrier Precautions policy and procedure dated 2015, showed:- Enhanced barrier precautions refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO- are bacteria or other microorganisms, often called superbugs, that are resistant to at least three families of commonly used antibiotics) that employs targeted gown and gloves use during high contact resident care activities.-All staff receive training on enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precautions.-All staff receive training on high-risk activities and common organisms that require enhanced barrier precautions.-An order for enhanced barrier precautions will be obtained for residents with any of the following: Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO.-Make gowns and gloves available immediately near or outside of the resident's room. Note: face protection may also be needed if performing activity with risk of splash or spray.-PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room.-Ensure access to alcohol-based hand rub in every resident room (ideally both inside and outside of the room).-Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room.-High-contact resident care activities include dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, wound care: any skin opening requiring a dressing.-Enhanced barrier precautions should be followed outside the resident's room when performing transfers and assisting during bathing in a shared/common shower room. and when working with residents in the therapy gym, specifically when anticipating close physical contact while assisting with transfers and mobility.-Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. Review of the facility's Standard Precautions policy and Procedure dated 2025 showed:-All staff are to assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. Therefore, all staff shall adhere to Standard Precautions to prevent the spread of infection to residents, staff and visitors.-Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub.- Hygiene should be performed after touching blood, body fluids, secretions, excretions, contaminated items; before & after removing personal protective equipment (PPE-specialized clothing or gear worn by staff to create a barrier against infectious materials (blood, body fluids, respiratory secretions) and prevent the spread of infections between residents and staff. Essential PPE includes gloves, gowns, masks, respirators, and eye protection); between resident contacts; before meals and after using the restroom. 1. Observation of Resident #31 on 4/1/26 at 12:11 P.M., during medication administration with Licensed Practical Nurse (LPN) D showed:-LPN D performed hand hygiene, donned gloves and drew up 4 units of insulin in the insulin pen.-LPN D doffed gloves and donned new gloves without performing hand hygiene.-In the dining room, LPN D located resident, rubbing upper right forearm with an alcohol swab and injected the insulin.-After returning to the medication cart, LPN D doffed gloves and did not perform hand hygiene. 2. Observation of Resident #12 on 4/1/26 at 12:23 P.M., during a blood glucose (amount of sugar in the blood) check with LPN D showed:-LPN donned gloves without performing hand hygiene first.-Upon entering resident's room, swabbed area with alcohol, pricked finger, wiped blood drop and tested new blood drop. LPN returned to the cart and recorded the resident's blood glucose reading.-LPN D cleaned the glucometer with alcohol, doffed gloves, and performed hand hygiene. 3. Observation of Resident #19 on 4/1/26 at 1:26 P.M., during medication administration with LPN D showed:-LPN D donned gloves and prepared medications without performing hand hygiene first.-LPN D doffed gloves, did not perform hand hygiene, entered resident's room and donned gloves without performing hand hygiene first.-Medications were administered to the resident without issue.-LPN D doffed gloves and did not perform hand hygiene. 4. Observation of Resident #36 on 4/2/26 at 8:44 A.M., during medication administration with LPN A showed:-LPN A did not perform hand hygiene, entered resident's room to obtain the resident's blood pressure (the force of blood pushing against artery walls, measured in systolic (heart beating) and diastolic (resting) numbers) reading with a blood pressure wrist cuff that was shared medical equipment between the residents.-LPN A did not sanitize the blood pressure wrist cuff prior to using it on the resident or after use. 5. Observation of Resident #44 on 4/2/26 at 8:51 A.M., during medication administration with LPN A showed:-LPN A did not perform hand hygiene prior to preparing the resident's medications.-The resident took all medications without issue.-LPN A left the resident's room, touched several items on the cart and nurses' station, performed hand hygiene after sitting down at nurse's station. 6. Review of Resident #28's Face Sheet showed the resident was admitted with diagnoses including:-Stroke with paralysis on his/her right side, aphasia (a communication disorder resulting from damage to the brain's language centers, usually in the left hemisphere).-Hypertension (high blood pressure).-Seizures (a sudden, uncontrolled disruption in the brain's normal electrical activity, causing temporary changes in behavior, movement, feelings, or consciousness)-Kidney failure (occurs when kidneys lose the ability to sufficiently filter waste products from the blood)-Pain, muscle weakness, language disorder, restlessness and agitation. Review of the resident's quarterly Minimum Data Set (MDS, a federally mandated assessment tool to be completed by facility staff for care planning dated 1/19/26 showed the resident:-Had severely impaired cognition.-Was totally dependent on staff for bathing, dressing, transferring, mobility, toileting and used a wheelchair for ambulation.-Had limited range of motion on one side of his/her upper and lower extremities. Observation on 4/1/226 at 11:40 A.M., showed the resident was laying in his/her bed awake. Certified Nursing Assistant (CNA) B and CNA C came into the resident's room and informed him/her they were going to get the resident up for lunch. There was a full body mechanical lift that was already in the room. The following occurred:-Both CNA B and CNA C washed their hands and gloved. CNA B and CNA C removed the resident's soft boots and removed his/her brief.-CNA B began to clean the resident's perineal area wiping from front to back using one wipe per swipe. CNA C assisted by handing CNA B wipes and assisted with rolling the resident onto his/her side so CNA B could continue cleaning the resident.-CNA B finished cleaning the resident and discarded the soiled wipe and gloves. Without washing or sanitizing his/her hands, CNA B put on a new pair of gloves, obtained a clean brief and put the brief on the resident assisted by CNA C.-Both CNA B and CNA C assisted to put the resident's pants and footwear on. They rolled the resident to the side to put the sling under the resident and then de-gloved.-Both re-gloved and assisted to attach the sling to the lift and used the mechanical lift to transfer the resident to his/her positioning wheelchair.-After positioning the resident in his/her wheelchair, they both doffed and discarded their gloves.-CNA C pulled the resident's trash and then without washing or sanitizing his/her hands, he/she left the resident's room, taking the mechanical lift and trash out of the room.-CNA B took the resident out of the room then came back in and washed his/her hands. During an interview on 4/1/26 at 11:55 A.M., CNA B said:-They were supposed to wash their hands upon entering, whenever changing gloves between dirty to clean tasks and upon exiting the room.-He/she realized that he/she did not wash his/her hands after he/she cleaned the resident and discarded his/her gloves.-I realized that once I saw that my hands were soiled, I removed my gloves, but I should have washed my hands before I re-gloved.-They were always supposed to wash or sanitize their hands prior to or upon leaving the resident's room. 7. Record review of Resident #33's Face Sheet showed the resident was admitted with diagnoses including_-Arthritis (an inflammatory condition of the joints).-Hypertension-High cholesterol (a condition characterized by excessive levels of fatty substances (lipids) in the blood)-Atrial fibrillation (abnormal heart rhythm).-Anemia (low iron level). Observation and interview on 3/30/26 at 9:34 A.M., showed:-There was a sign on the resident's door showing the resident was on EBP. -The resident was sitting up in a chair in his/her room visiting with his/her spouse.-He/She said he/she was here for rehabilitation after back surgery and he/she had a wound on his/her back that was still being treated.-He/She said staff still had to assist him/her with most of his/her personal care due to limited mobility. Review of the resident's admission MDS dated [DATE], showed the resident:-Was alert, oriented and had no cognitive incapacity or behaviors.-Had no upper or lower extremity deficiency.-Used a walker and wheelchair for mobility-Needed moderate assistance for bathing, dressing, toileting, and transferring. Observation on 3/31/26 at 10:13 A.M., showed:-The resident's EBP sign was on the door with no PPE outside of the resident's room.-Upon entry, there was a grey box on a shelf with a box of gloves and blue gowns in it.-The Resident was sitting in a chair with his/her walker in front of him/her with his/her call light within reach.-His/Her spouse was sitting beside him/her and they were visiting with another friend/family in his/her room. Observation on 3/31/26 at 11:25 AM showed:-The resident was sitting in his/her recliner and nursing staff was in the resident's room (without wearing PPE) placed a gait belt around his/her waist and assisted the resident up into a standing position to his/her walker and assisted the resident as he/she walked with his/her walker out of his/her room and down the hallway to the group activity room. Observation on 4/1/26 at 9:27 A.M. showed the resident had EBP signage outside of room and a gray basin inside of room on the shelf that contained gowns and a box of gloves. During an interview on 3/31/26 at 11:31 A.M., LPN C said:-The resident was on EBP due to him/her having a very small surgical wound to his/her lower back that he/she was admitted with, which was infected, and the resident was taking antibiotics for.-He/She completed his/her treatment of antibiotics, but they were still treating the resident's surgical wound. 8. During an interview on 4/2/26 at 11:20 A.M., LPN B said:-Nursing staff can use hand sanitizer (instead of washing their hands) if their hands are not soiled.-Nursing staff should wash their hands or use hand sanitizer upon entering the resident's room, anytime they change their gloves and upon exiting the resident's room.-They should wash or sanitize their hands after cleaning the resident, before putting on a new pair of gloves and before performing a clean task.-Residents with wounds, catheters, surgical incisions, or any invasive tubing/treatment would be placed on enhanced barrier precautions.-When a resident is on enhanced barrier precautions, they place the EBP sign on the door and the resident's name plate would also have an orange sticker identifying to staff that they are on EBP.-At this facility they place the PPE in a basin inside of the room. Inside the basin would be the gowns and gloves and other protective equipment as needed.-They would expect the nursing staff to wear the PPE during actual care-wound care, catheter care-only if they are going to touch the area or skin and with any close contact with the resident. -If they were just transferring the resident without providing any care or they are not having any close contact with the resident's skin or catheter, wound etc., then they would not have to wear the PPE.-For example, if staff transferred a resident from their wheelchair to the recliner, they would not have to wear PPE because they are not having direct contact with the resident's skin or providing care. During an interview on 4/2/26 at 12:45 P.M., the Infection Control Preventionist (ICP) said:-EBP should be used for resident's with open wounds, wound vacs ( a portable medical device that uses continuous or intermittent suction to accelerate healing for complex, chronic, or surgical wounds) foley catheters (a flexible, indwelling tube inserted into the bladder to drain urine, secured by a small balloon, and used for urinary retention, surgery, or monitoring output), and tube feeding (delivers liquid nutrition directly into the stomach or small intestine via a tube for individuals unable to meet nutritional needs by mouth).-PPE should consist of gloves and gowns.-PPE should be kept in a basin the resident's room.-The ICP is initially responsible for maintaining and stocking PPE, then the nursing staff is responsible thereafter.-Training on EBP and PPE was done verbally in September 2025, the goal is to do them quarterly starting in April 2026.-EBP and PPE should be used during all resident hygiene, cares, and transfers. By not doing this it could cause the transfer of bacteria or infection. During an interview on 4/2/26 at 1:58 P.M., LPN A said:-EBP should be used for residents with open wounds, foley catheters, feeding tubes, colostomies (an alternative exit from the colon created to divert waste through a hole in the colon and through the wall of the abdomen), and any other openings on the body.-PPE should consist of gowns and gloves.-EBP and PPE supplies should be stored in a basin inside rooms, the ICP is responsible for this.-He/She would expect there to be signage outside the room of a resident who is on EBP.-He/She would expect to have to wear PPE when doing resident care, dressing, and hygiene cares. During an interview on 4/2/26 at 2:22 P.M., the Director of Nursing (DON) said:-Staff are trained on EBP during orientation and they have additional online training they are required to complete.-EBP should be used for residents who have catheter foleys, wounds, and IV (Intravenous (IV) therapy delivers fluids, medications, or nutrients directly into a vein for rapid absorption).-PPE should consist of gowns, gloves, masks, and face shields.-PPE should be stored either in a basin in the room or a cart outside of the room.-The ICP is responsible for making sure supplies are stocked for use.-He/She would expect that PPE be worn during resident care, transfers, and hygiene cares.-When this is not done it exposes the resident to infection.-Nursing staff should sanitize or wash their hands prior to entering the resident's room, between cares and upon exiting the resident's room.-They should wash their hands or sanitize between glove changes.-Hand hygiene should be performed whenever the staff's hands are soiled and between dirty and clean tasks.-If hand hygiene is not performed there is risk of infection.

Based on interview and record review, the facility failed to ensure five residents who authorized the facility to manage resident funds for them, had quick access to their resident trust account funds because the facility did not have a petty cash account for the residents who authorized the facility to manage their funds; and the facility failed to ensure two residents (Residents #15 and #38) or their legal representative authorized in writing a withdrawal of $100.00 from each of their accounts. This practice affected six residents who allowed the facility to manage their resident funds. The facility census was 49 residents.Review of the facility's policy entitled Resident Personal Funds with a copyright date of 2025 did not have a section which stated that the operator or other designated person shall use the personal funds of the resident exclusively for the use of the resident and only when authorized in writing by the resident, his/her designee, guardian and conservator, or conservator. 1. Review of a checking withdrawal statement dated 12/15/25 showed a bulk withdrawal of $400.00 from the resident trust account (to provide cash to multiple residents) and the absence of signatures from the residents or records of receipts given to residents. Review of the Petty Cash County sheet showed the facility Business Office Manager (BOM) signed the form to state the facility had no petty cash in the facility at the time of the survey. During an interview on 4/2/26 at 9:39 A.M., the BOM said:-The facility did not keep petty cash for the resident trust.- If a request for withdrawal of cash is made, he/she must go to the bank and complete a withdrawal slip and turn it in to the bank.-It depends on the time of day that a resident asks that they can get their requests fulfilled on that day. 2. Review of Resident #15's face sheet showed the resident had a Public Administrator as his/her Responsible Party. Review of Resident #15's account dated 10/24/23 through 3/5/26, showed a $100.00 withdrawal was made from the resident's account on 12/15/25 with no signatures. 3. Review of Resident #38's face sheet showed the resident had a Public Administrator as his/her Responsible Party. Review of Resident #38's account dated 6/8/23 through 3/5/26, showed a $100.00 withdrawal was made from the resident's account on 12/5/25 with no signutures. During an interview on 4/2/26 at 9:52 A.M., the BOM said he/she did not obtain signatures from Resident #15 or Resident #38, or their guardian for the withdrawals from their respective accounts. During a phone interview on 4/3/26 at 3:50 P.M., the Couty Public Administrator said:-He/she sent a limited amount of money every month to Residents #15 and Resident #38.- The residents could request those funds as they needed them. -The Public Administrator's Office received reports which detail how the resident's money was spent.-The facility has not contacted him/her about preapproval for withdrawals.

Based on observation, interview and record review, the facility failed to assess one resident (Resident #15) out of 16 sampled residents for a seatbelt in his/her wheelchair to determine if the seatbelt was a restraint or enabler. The facility failed to obtain a physician's order for it and there was no care plan showing the seatbelt was in place, whether it was a restraint or an enabler or how the facility staff monitored it. The facility census was 49 residents.Review of the facility's Restraint Free Environment policy and procedure dated 2025, showed it is the policy of this facility that each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of physical or chemical restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of such restraints. Procedure showed a Physical Restraint refers to any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Physical restraints may include but are not limited to.using devices in conjunction with a chair, such as trays, tables, cushions, bars or belts, that the resident cannot remove and prevents the resident from rising. Before a resident is physically restrained, the facility will determine the presence of a specific medical symptom that would require the use of restraints, and determine:-How the use of restraints would treat the medical symptom(s).-The length of time the restraint is anticipated to be used to treat the medical symptom(s), who may apply the restraint, and the time and frequency that the restraint will be released.-The type of direct monitoring and supervision that will be provided during use of the restraint.-How the resident will request staff assistance and how his/her needs will be met while the restraint is in place.-How to assist the resident in attaining or maintaining his or her highest practicable level of physical and psychosocial well-being.-Medical symptoms warranting the use of restraints should be documented in the resident's medical record. The resident's record needs to include documentation that less restrictive alternatives were attempted to treat the medical symptom but were ineffective, ongoing re-evaluation of the need for the restraint, and the effectiveness of the restraint in treating the medical symptom. The care plan should be updated accordingly to include the development and implementation of interventions, to address any risks related to the use of the restraint. 1. Review of Resident #15's Face Sheet showed the resident was admitted with diagnoses that included:-Diabetes (a metabolic disease). -Arthritis (an inflammatory condition of the joints).-Hypertension (HTN- high blood pressure)-Pain.-Muscle weakness.-Anemia (low iron).-Lack of coordination. Review of the resident's Occupational Therapy Plan of Treatment dated 3/22/24, showed:-The resident was referred to therapy due to receiving a new power wheelchair and required education and safety training for use for both the resident's safety and safety of residents and staff in the facility.-The resident treatments included wheelchair management training.-The goal was that the resident would increase his/her ability to self-propel safely in his/her power wheelchair, including management of the controls, manage on level and uneven surfaces and throughout the facility in order to facilitate his/her ability to live in an environment with the least amount of supervision and assistance and to safely use the power wheelchair around other residents and staff in the facility.-The resident had fair sitting balance (maintained balance unsupported without upper extremity support).-The resident was educated on resident safety and safety of staff and residents while using the power wheelchair. The resident had good coordination and was able to properly control the control of the wheelchair. The resident was independently able to use the power wheelchair around the facility without the assistance of staff.-There was no documentation that showed the power wheelchair had a seatbelt and there was no documentation showing the seatbelt was used during the assessment or that it was assessed as part of safety assessment during the resident's the use of the power wheelchair. The assessment did not show whether the seatbelt would be used, whether it was an assistive device or if it was a restraint (the resident's ability to release it was not documented). Review of the resident's Safety Device assessment dated [DATE] and 10/31/25 showed:-The device assessment showed areas to document the device used, rationale for the device, physician's orders, potential risks, potential benefits, whether the device prevented movement or access, and plan for use.-The device type documented showed the resident's bed was against the wall.-The symptom showed there was space between the bed against the wall.-There was no other device type documented on the form (such as a seatbelt).-The resident's seatbelt was not shown as a safety device or restraint. Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 1/24/26 showed the resident:-Was alert and oriented with some cognitive deficits.-Had no behavioral concerns.-Had lower extremity impairment on both sides of his/her body.-Used a wheelchair for mobility, had a motorized wheelchair and was able to use it independently.-Needed substantial assistance with bathing, dressing, toileting and moderate to substantial assistance with transfers.-Did not have a trunk or limb restraint. Review of the resident's Fall assessment dated [DATE], showed the resident:-Had no falls in the prior three months.-Had intermittent confusion.-Required assistance with transfer and elimination.-Was chairbound and required restraints.-The assessment did not show the resident had a seatbelt in his/her wheelchair. Review of the resident's Functional Abilities and Goals assessment dated [DATE], showed the resident:-Transferred with a full body mechanical lift with two staff providing assistance.-Had functional range of motion impairment on both sides of his/her lower extremities.-Used a wheelchair for mobility.-Independently used a motorized wheelchair.-The assessment did not show the resident had a seatbelt in his/her wheelchair and it did not show whether the seatbelt was or was not a restraint. There was no information showing how the staff monitored the resident's wearing of the seatbelt. Review of the resident's Safety Device assessment dated and signed on 2/5/26, showed:-The device assessment showed areas to document the device used, rationale for the device, physician's orders, potential risks, potential benefits, whether the device prevented movement or access, and plan for use.-The device type documented showed the resident's bed being against the wall.-The symptom showed there was space between the bed against the wall.-There was no other device type documented on the form (such as a seatbelt).-The resident's seat belt was not shown as a safety device or restraint. Review of the resident's Physician's Order Sheet (POS) dated 3/2026, showed there was no physician's orders for the resident's seatbelt in his/her wheelchair and whether it was to be monitored (released) or stating that the resident independently released it (showing it was not a restraint). Review of the resident's Care Plan dated 3/29/26, showed the resident was at risk for falls due to a history of falls, impaired cognitive and safety awareness, impaired mobility, and he/she had a behavior problem of running his/her electric wheelchair into other resident's walker related to ineffective coping skills. Interventions showed:-On 9/25/24 he/she slid out of his/her manual wheelchair to the foot pedals, with no injury. When his/her hair is done, attempt to remove him/her from the manual wheelchair to his/her bed or electric wheelchair. Remind him/her to use the call light to let staff know he/she is done. -Anticipate and meet the resident's needs.-Be sure his/her call light is within reach and encourage him/her to use it for assistance as needed. prompt response to all requests for assistance.-Encourage him/her to participate in activities that promote exercise, physical activity for strengthening and improved mobility.-Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in his/her wheelchair.-Administer medications as ordered. Monitor/document for side effects and effectiveness.-Caregivers to provided opportunity for positive interaction, attention. Stop and talk with him/her as passing by.-Educate the resident/family/caregivers on successful coping and interaction strategies.-Explain all procedures to the resident before starting and allow the resident time to adjust to changes. If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident.-Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Minimize potential for the resident's disruptive behaviors.-Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes.-Praise any indication of the resident's progress/improvement in behavior.-Provide a program of activities that is of interest and accommodates the resident's status.-The resident's care plan did not show that the resident wore a seatbelt in his/her electric wheelchair, and it did not show whether the resident's seat belt was an enabler/assistive device or a restraint. It did not show whether the resident was able to release the seatbelt independently or whether the resident needed assistance and there were no interventions showing how the facility was monitoring the resident since he/she had a seatbelt regardless of whether it was determined to be a restraint or an enabler/assistive device. Review of the resident's electronic medical record showed there was no documentation showing the resident was initially assessed for the use of a seatbelt to determine if it was a restraint or an enabler/assistive device. There was no documentation to show the seatbelt use was periodically re-assessed to determine if it continued to be a restraint or assistive device and how the facility would continue to monitor it and the resident's safety while using it. Observation on 3/30/26 at 10:05 A.M., showed the resident was dressed for the weather sitting up in his/her electric wheelchair watching television. The resident had a seatbelt in his/her wheelchair that was fastened at his/her waist. His/Her call light was on his/her bed and was within reach. He/She said that the staff got him/her up daily (and into his/her wheelchair) and they were accommodating. The resident then mobilized out of the room down the hallway. Observation and interview on 3/31/26 at 11:16 A.M., showed the resident was sitting up in his/her electric wheelchair watching television in his/her room with his/her call light available. His/Her seatbelt was fastened at his/her waist. The resident said:-He/She wore the seatbelt to keep him/her from falling out of his/her wheelchair.-He/She was able to remove it and put it on independently.-Having the seatbelt made him/her feel safer while up in his/her wheelchair.Observation showed the resident pushed the red button to release the seatbelt effectively. He/She then began trying to reconnect the seatbelt and had some difficulty due to range of motion limitations in his/her fingers, but he/she was able to eventually reconnect it with minimal assistance. During an interview on 4/1/26 at 12:32 P.M., Certified Nursing Assistant (CNA) C said:-He/She did not work with the resident as much, but the resident always wore a seatbelt when up in his/her wheelchair.-He/She did not know for sure if the resident could release the seatbelt himself/herself, and had not seen the resident release it, but thought the resident could release it independently. During an interview on 4/2/26 at 8:53 A.M. CNA B said:-The resident wore a seat belt in his/her electric wheelchair, and he/she was able to release it independently and upon command.-When they got the resident up in the morning, they placed the seatbelt on his/her lap and the resident fastened it and adjusted the strap to his/her comfort level.-When they laid him/her down, the resident unfastened the seatbelt prior to them transferring him/her to bed, the seatbelt was more of an assistive safety device, not a restraint.-He/She did not know if the resident was assessed for wearing the seat belt and did not know if the resident was re-assessed to ensure it remained an assistive device. During an interview on 4/2/26 at 10:05 A.M., Licensed Practical Nurse (LPN) A said:-The resident received the electric wheelchair while he/she was in rehabilitative therapy, and they assessed and obtained the electric wheelchair for the resident.-His/Her current electric wheelchair had the seatbelt for positioning and was not a restraint.-The resident was afraid of falling out of his/her wheelchair and wanted the seatbelt.-Therapy should have completed the initial assessment for the need for the seatbelt.-He/She has not completed any follow up assessments regarding the resident's seat belt or determining if she can/cannot release it independently.-He/She had not seen any further reassessments since the resident began wearing the seatbelt.-He/She has never seen the resident release the seatbelt.-The resident does not currently receive any rehabilitative services.-The resident's seatbelt was released after lunch (when he/she laid down) and whenever the nursing staff changed the resident or checked for incontinence.-They did not have a schedule showing when to release the seatbelt, but he/she did not believe the seatbelt was a restraint.-He/She did not see a physician's order for the resident's seatbelt or any instruction on releasing it or monitoring it.-There probably should be a physician's order for the resident to have the seatbelt and it should be in the resident's care plan.-(After looking at the resident's care plan), he/she did not see a care plan for the seatbelt as an assistive device or restraint.-At 10:28 A.M. he/she said he/she went to see the resident and asked him/her if he/she could remove his/her seatbelt it and the resident released the seatbelt. During an interview on 4/2/26 at 10:23 A.M., the Director of Rehabilitation said:-The rehabilitation department staff initiated obtaining the electric wheelchair for the resident and it had a seatbelt on it when it arrived.-Once they received the wheelchair, they assessed the resident regarding positioning and safety of use.-He/She did not remember specifically but thought they would have also evaluated the resident's ability to release the seat belt (to determine if it was a restraint or assistive safety device).-They did not currently treat the resident, and it had been a while (over a year) since they had provided any treatment to him/her.-They had not completed any further assessments of the resident or of the resident's seatbelt use while in his/her wheelchair. During an interview on 4/2/26 at 10:38 A.M., the Director of Rehabilitation said:-After looking at the resident's therapy documentation, they assessed the resident for the electric wheelchair, but his/her wheelchair came with the seatbelt already attached.-They did not assess the resident for the use of the seatbelt, but they did assess for positioning and his/her ability to use the electronic wheelchair safely.-The resident wore the seatbelt daily and was able to release it himself/herself.-The rehabilitative staff would not have continued to assess and monitor the resident's ability to use the seat belt once he/she was approved to use the electric wheelchair. During an interview on 4/2/26 at 2:22 P.M., the Director of Nursing (DON) said:-He/She did not know that the resident had a seatbelt.-They did not use restraints in the facility, so the seatbelt probably was not a restraint.-The seatbelt should be assessed prior to the resident using it and it should be re-assessed to ensure its being utilized properly and that there were no issues.-The assessment was to determine if the resident could release the seatbelt or not and how safe it was (the least restrictive).-It should be re-assessed quarterly to ensure the resident was able to release it or that it was still needed.-The nurses perform weekly skin assessments on the resident to ensure there were no problems with the resident's skin (from using the seatbelt).-He/She would not expect the seatbelt to be on the resident's POS if the seatbelt was not being utilized as a restraint and since they don't utilize restraints, they would not have a physician's order for it.-Its use should be on the resident's care plan.

Based on observation, interview, and record review, the facility failed to meet professional standards of practice when administering insulin (a hormone that regulates blood sugar), without priming the insulin pen with 2 units of insulin prior to drawing up the resident's prescribed dosage and injecting the insulin for one supplemental resident (Resident #31) out of 8 supplemental residents. The facility census was 49 residents.A policy was requested for insulin pen administration but not provided by the facility. 1. Review of Resident #31's admission Record showed he/she was diagnosed with Type 2 Diabetes Mellitus (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin). Review of the resident's Physician's Order Sheet (POS) dated April 2026 showed:-Insulin Lispro (a rapid-acting man-made insulin used to treat high blood sugar) 100 unit/ml--inject per sliding scale: 151-200=2; 201-250=4; 251-300=6; 301-350=8; 351-400=10, subcutaneously before meals and at bedtime. Observation on 4/4/26 at 12:13 P.M., during medication administration showed Licensed Practical Nurse (LPN) D, applied needle to insulin pen, drew up 4 units of insulin per sliding scale based on resident's blood sugar of 201, wiped resident's arm with alcohol swab and injected insulin into the resident's upper right arm. During an interview on 4/1/26 at 12:25 P.M., LPN D said he/she:-Had received in-service training on insulin administration with a pen three weeks ago that included instructions to prime the insulin pen with 2 units of insulin prior to drawing up the prescribed dose.-Should have primed the insulin pen with 2 units of insulin before use. During an interview on 4/2/26 at 2:22 P.M., the Director of Nursing (DON) said:-Nurses received training on insulin pen administration during a skills checkoff that included instruction on clean and priming prior to use around September of 2025.-He/She would expect for an insulin pen to be primed with 2 units of insulin prior to drawing up ordered dose and injecting.-If this is not done, you can't be sure that the pen is working correctly, and the resident may not receive the correct dose.

Based on observation, interview and record review, the facility failed to ensure hospice (end of life care) orders were complete and failed to update the resident's care plan to identify and include hospice services were provided for one sampled resident on hospice services (Resident #28) out of 13 sampled residents. The facility census was 49 residents. 1.Review of Resident #28's Face Sheet showed the resident was admitted with diagnoses that included:-Stroke with paralysis on his/her right side.-Aphasia (a communication disorder resulting from damage to the brain's language centers).-High blood pressure.-Seizures.-Pain.-Muscle weakness.-Communication deficit and language disorder.-Kidney failure.-Restlessness.-Agitation.Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 1/19/26, showed the resident:-Had severely impaired cognition.-Was totally dependent on staff for bathing, dressing, transferring, mobility, toileting and used a wheelchair for ambulation.-Had limited range of motion on one side of his/her upper and lower extremities.-Had chewing and swallowing problems, pocketing food-no significant weight loss noted.-Received hospice services.Review of the resident's care plan dated 1/19/26, showed the resident was at possible risk for spiritual distress related to end of life care on hospice for late-stage stroke effects. Interventions showed:-The resident would experience dignity at end of life.-Staff would consult clergy as needed.-Contact hospice with any change of condition or loss of life. -Determine the resident's religious affiliation.-Determine the resident's spiritual beliefs regarding death.-Encourage the resident/representative to verbalize needs or feelings.-Encourage the resident to continue to study spiritual beliefs.-Notify the resident's doctor of end of life when it occurred. -Notify hospice of new orders. -Provide options for spiritual activities to the resident.-The resident wished to participate in spiritual activities.-NOTE: The care plan did not describe the services hospice provided in conjunction with the services from the facility to ensure the coordination of palliative care of the resident was provided (outside of spiritual support). Review of the resident's Hospice Consent for Treatment document showed:-A treatment order was signed 10/11/24 with a primary diagnosis of stroke (terminal illness). -The recertification was completed on 1/6/26 for dates from 2/3/26 to 6/3/26.Review of the resident's Hospice Recertification Assessment document dated 1/11/26, showed the resident:-Needed total care, refused two out of three meals daily, required feeding and only ate 25 percent of the meal maximum.-Slept more throughout the day, required assistance to sit up and leaned to the right. -Had some contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to restricted joint mobility) to his/her right hand and hyperflexion (a condition where the neck is forced forward beyond its normal range of motion) in his/her neck. -Had temporal wasting (the loss of muscle mass and subcutaneous fat in the temple region, causing a sunken or hollow appearance of the forehead) and a sunken abdomen. -Had diminished lungs sounds and irregular heart sounds. -Continued to have a life expectancy of six months or less. Continued eligibility.Review of the resident's Physician's Order Sheet (POS) dated March 2026, showed physician's orders for:-Admit to hospice for late-stage stroke (start date10/11/24).-NOTE: The physician's orders did not show the hospice vendor or services provided.Review of resident's Hospice Coordinated Plan of Care showed the services hospice was providing to the resident included:-Hospice Nurse visits twice weekly (Tuesday/Friday).-Social Worker once monthly.-Chaplin once monthly.-Licensed Massage Therapist once monthly.-Certified Nursing Assistant visits twice weekly on Wednesday/Friday.Observation on 3/31/26 at 10:26 A.M., showed:-The resident was laying in his/her low bed on his/her back with his/her call light in reach. -His/Her eyes were closed and was resting comfortably. -There was a high-backed positioning wheelchair on the other side of the room across from his/her bed. -The resident showed no signs/symptoms of distress or discomfort.During an interview on 4/1/26 at 12:15 P.M., Licensed Practical Nurse (LPN) A said:-When a resident was referred to hospice services, the nurse obtained a physician's order for a hospice evaluation, and this would be on the resident's POS. -They also notified the resident and/or responsible party, who then decided which hospice provider they wanted then the nurse usually set up the evaluation with the chosen hospice.-Hospice then evaluated the resident and determined if they would admit the resident for hospice services and what diagnosis they were admitting the resident under. -The nurse then notified the physician and writes the order for hospice in the resident's POS showing at minimum, the name of the hospice that the resident will be under, the primary diagnosis and the date of the order. -He/She did not know how the care plan was documented but thought it should also show the hospice services and coordination of services with the facility.-They communicated verbally with the hospice nurse regarding the resident's care and any changes in care when the hospice nurse visited. -He/She documented a nursing note after speaking with the hospice nurse whenever there were changes or as needed but not with every hospice visit. -The facility nurse completed a monthly summary on everyone that received hospice services.-This resident had been on hospice for a long time, but he/she had not always been with the same hospice provider.During an interview on 4/2/26 at 2:22 P.M., the Director of Nursing (DON) said:-Hospice physician's orders should show the hospice the resident was accepted to and the diagnosis. -They had a separate physician's order for hospice to evaluate the resident that was also on the POS. -He/She did not know if it was the facility policy to add the diagnosis, but this was his/her expectation. -Hospice orders did not show the actual hospice services provided. -The resident's facility care plan should show that they were admitted to hospice, why they were admitted to hospice, the treatments and services the resident was receiving and the hospice interventions that they were coordinating with hospice on.-He/She expected the charge nurses to review the resident's physician's orders to ensure the hospice orders were complete. -He/She expected the MDS Coordinator to review the resident's care plan to ensure it included all the hospice interventions provided.-The interdisciplinary team also assisted with care planning for the resident.

Based on interview and record review, the facility failed to complete and document an incident report, make notifications according to the facility protocol and investigate the fall/ injury when one sampled resident (Resident #2) had a fall from his/her bed that resulted in increased pain and possible injury out of three sampled residents. The facility census was 39 residents. Based on interview and record review, the facility failed to complete and document an incident report, make notifications according to the facility protocol and investigate the fall/ injury when one sampled resident (Resident #2) had a fall from his/her bed that resulted in increased pain and possible injury out of three sampled residents. The facility census was 39 residents. Review of the facility's Fall Policy and Procedure revised 2025, showed It is the policy of this facility 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. The policy showed:-The risk assessment will be completed by the nurse or designee upon admission, quarterly, or when a significant change is identified.-The risk assessment will contain the following components: a. Identify environmental hazards and individual risks, including the need for supervision, b. Evaluate and analyze hazards and risks.-An At Risk for Falls care plan will be completed for each resident to address each item identified on the risk assessment and will be updated accordingly.-The At Risk for Falls care plan will include interventions, including adequate supervision, consistent with a resident's needs, goals, and current standards of practice in order to reduce the risk of an accident.-Monitor the effectiveness of the care plan interventions, and modify the interventions as necessary, in accordance with current standards of practice.-The policy did not show who should be notified when a fall occurs or how the nursing staff was expected to document the fall. 1.Review of Resident #2's Face Sheet showed the resident was admitted to the facility on [DATE] with diagnoses including high cholesterol, kidney disease, depression, anxiety disorder, heartburn, atrial fibrillation (irregular heartbeat), high blood pressure, and supraventricular tachycardia (fast heartrate). Review of the resident's Fall Risk assessment dated [DATE], showed the resident:-Was disoriented to person, place and time.-Had a history of falls within the last three months.-Was chair bound.-Had a fall risk score of 13 (a score of 10 or above was at high risk for falls). Review of the resident's Baseline Care Plan dated 2/9/26 showed the resident:Baseline Care Plan dated 2/9/26 showed the resident:-Needed one to two persons to assist with mobility and ambulation.-Needed one to two persons to assist with bathing, dressing, toileting, grooming.-Received psychotropic medications and pain medications-Had a history of falls and had falls prior to admission.-Was alert with cognitive impairment. Review of the resident's Pain assessment dated [DATE] showed:-The resident had pain and was able to communicate pain.-The resident's pain assessment site was his/her right knee.-His/her worse pain was a 5 (on a pain scale of zero to 10, 10 was severe pain).-Pain increased with activity and was relieved with repositioning, medication management, relaxation and warm compress placement.-Pain medication was needed at least daily.-The resident had no current pain.-The resident was satisfied with his/her current pain management. Review of the resident's Physician's Order Sheet (POS) dated 2/26 showed physician's orders for:-Tylenol 500 milligrams (mg) one tablet every 6 hours as needed for mild pain/fever (ordered 2/9/26).-Morphine Sulfate give 0.5 milliliters (ml) every hour as needed for mild pain/shortness of air (ordered 2/9/26).-Morphine Sulfate give 0.25 ml every hour as needed for mild pain/shortness of air (ordered 2/9/26).-Morphine Sulfate give 0.75 ml every hour as needed for moderate pain/ shortness of air (ordered 2/9/26).-Morphine Sulfate give 1ml every hour as needed for severe pain/shortness of air (ordered 2/9/26).-Oxycodone 5 mg four times daily for pain (ordered 2/9/26).-Hydroxyzine 25 mg every 8 hours as needed for anxiety (ordered 2/9/26)-Lorazepam give 0.5 ml every hour as needed for mild/moderate anxiety (ordered 2/9/26).-Lorazepam give 0.25 ml every hour as needed for mild anxiety (ordered 2/9/26).-Lorazepam give 0.75 ml every hour as needed for moderate anxiety (ordered 2/9/26).-Lorazepam give 1 ml every hour as needed for severe anxiety (ordered 2/9/26). Review of the resident's Nursing Notes showed:-2/9/26 the resident was admitted to the facility. Resident appears clean and well groomed. Resident is alert to self only. Speech is soft but clear. Has upper and lower dentures present upon admit. Regular diet with thin liquids. Mouth/lips appears clean, pink, moist. No glasses or hearing aids. Vision and hearing adequate. Lung sounds are clear. No cough or congestion noted. Oxygen was at 97 percent on room air. Resident is incontinent of bowel and bladder. Resident's buttocks and genital area clean and free from redness or breakdown. Skin is warm and dry. No open areas or sores. Right knee has a healed surgical incision. There was no redness, warmth, drainage, or sutures (stitches). Resident was unable to bear weight on lower extremities due to weakness. Full body mechanical lift was required for transfers. Hospice (end of life care) is also providing services and equipment such as low air loss mattress, padded specialized wheelchair, shower chair, and mechanical lift. Medications were reviewed with Hospice and his/her responsible party. Per hospice hydroxyzine (a medication used to treat anxiety) and Ativan ( a medication used to treat anxiety and sleeping disorders) for end-of-life comfort and care. The resident's primary care physician was notified of the resident's admission. The resident's vital signs (blood pressure, pulse respirations, temperature and oxygen level) were stable. The resident's call light was within reach. All nurse admission paperwork was reviewed with the resident's family member. The responsible party signed code status and all consents. Review of the resident's Behavior Note dated 2/10/26 showed:-After placing the resident in bed, the resident was trying to get out of bed. The resident would not use his/her call light at all. When nursing staff asked if he/she wanted to get back up in his/her recliner the resident would refuse. At one point nursing staff got the resident back up in his/her recliner to see if he/she would be more comfortable for the resident to relax and get some rest tonight. The resident continued to try and climb out of his/her recliner. Nursing staff placed the resident back in his/her bed and the nursing staff working on the unit sat in the resident's room and would only leave if a call light went off and the nurse was still in another resident room as well. When the nursing aide had to leave the resident's room, he/she returned to see the resident's lower extremities hanging off of the side of his/her bed and wiggling his/her hips trying to get out of bed. Finally, this nurse and aid got the resident up for the day and placed him/her in his/her specialized wheelchair. The resident was sitting up at the nursing station desk, has finally settled down and resting. Review of the resident's Functional Ability and Goals assessment dated [DATE] showed the resident:-Was dependent on staff for bathing, dressing, eating, transfers, mobility and toileting-Had limited range of motion in his/her lower extremities and used a wheelchair for mobility and did not walk. Review of the resident's Nursing Notes showed:-2/10/26 at 9:17 P.M., showed the resident's respirations were even and unlabored at rest, no oxygen needed. The resident had no cough or congestion. His/her skin was intact with no wounds or injuries noted. The resident was lying in bed with eyes closed and no signs/symptoms of pain or discomfort was noted. The resident spit medication back out after administering medication, was able to administer Ativan 0.5 ml to the resident for restlessness.-2/11/26 at 10:14 A.M., showed the resident remained on acute charting for admission. The resident was in his/her specialized wheelchair at the nurse's station. After breakfast the resident was agitated when staff put him/her in bed. Once he/she was placed in his/her wheelchair the resident relaxed and closed his/her eyes. He/she showed no signs of pain or discomfort. Hospice was present at this time.-2/13/26 at 12:24 P.M. showed when going in to take the resident's vital signs and give his/her medication, the resident appeared lethargic. The resident would open his/her eyes partially before rolling his/her eyes back and shutting them again. When trying to administer medications, the resident took the spoon in his/her mouth and just barely swallowed. The resident remained lethargic when the nurse tried to give a drink of water. The nurse took the resident's vital signs and noted his/her oxygen respirations were between 55 and 77 % on room air (normal is 96-100%). The nurse called the Hospice Licensed Practical Nurse (LPN) A, who was in the building. The nurse also noticed the resident's right wrist and hand were bent at the wall. The nurse noticed the resident was grimacing and this may have been why. The nurse documented he/she gently moved the resident's hand, and he/she let out a loud scream. The nurse informed Hospice LPN A of his/her observations. Roughly 5 minutes later, they went to make him/her more comfortable and noted that his/her right hand and right elbow was swollen, and his/her right wrist appeared bruised. It also was noted the arm to be in an awkward position. The nurse contacted the Director of Nursing (DON) and the DON directed him/her to order a 2 view x-ray of the resident's right elbow and right wrist. The nurse notified the resident's physician and the x-ray vendor. The resident's daughter was notified and was now at the resident's bedside. The x-ray vendor arrived and upon their arrival, the resident's responsible party declined to allow them to complete the x-ray because the resident's health status was consistently declining at this time. They notified the x-ray vendor, and they left the facility. The resident's responsible party and Hospice remained at the resident's bedside and Hospice LPN A ordered the hospice comfort cart (a hospice comfort cart is a mobile, curated cart, often managed by volunteers, designed to provide emotional and physical support to patients and families during end-of-life care. Stocked with items like snacks, toiletries, reading materials, and comfort items, it offers comfort and distraction to families, aiding them in staying bedside). Record review of the resident's medical record showed there was no nursing note documented on 2/12/26. There were no nursing notes showing the resident had an incident on 2/12/26 or on 2/13/26 that would have indicated any injury occurred during care or that a fall had occurred that could have caused an injury to the resident. Review of a facility email dated 2/13/26 showed:-The Assistant Director of Nursing (ADON) spoke with Agency LPN A who was the nurse who was on duty on night shift on 2/12/26 and worked directly with the resident.-Agency LPN A said during the night shift (on 2/12/26), the resident rolled out of bed onto his/her left side between midnight and 1:00 AM. -The resident was found lying on the mat next to his/her bed. -Agency LPN A completed a head-to-toe assessment and found no injuries and his/her range of motion was at baseline.-Agency LPN A said he/she and a Certified Nurse's Aide (CNA) used the full body mechanical lift to place the resident back into his/her bed.-Agency LPN A said he/she would never move the resident if there was indication that there was an injury to the resident (if something looked or felt broken).-Agency LPN A said he/she understood that he/she should have completed an incident report per policy and notified everyone, but he/she was being pulled several different directions to provide requested pain medications and to assist with answering call lights.-Agency LPN A said normally he/she would complete an incident report right away but must have spaced it out with everything else that was going on, but he/she would complete an incident report and make a note when he/she returned for his/her shift tonight. Review of the resident's Hospice Note dated 2/13/26 showed:-The Hospice Nurse arrived for a visit and LPN B came to report that the resident was having increased restlessness and pain.-The resident was laying on his/her right side appeared restless and was moaning.-The resident's right arm was bent at a 90-degree angle and his/her wrist was hanging off of the side of his/her bed and angled downward.-The resident had limited range of motion and pain. His/her right elbow to fingertips were cool to the touch and pedal pulse (rhythmic expansion of the artery) was present but weak. The resident had swelling throughout his/her right arm. There were no other injuries noted.-Facility staff reported that the night shift agency nurse said the resident had rolled out of bed early this morning and was found on the floor mat next to his/her bed.-Hospice was not notified.-The facility nurse reported the resident had scheduled Ativan and Oxycodone prior to Hospice arrival.-Pain assessment showed an estimated pain rating of 9 (on a pain scale of zero to 10, 10 was severe pain) based on a non-verbal pain assessment tool. Periods of labored breathing have been observed and may indicate distress caused by acute pain. Despite not being able to verbalize the presence of pain, the resident was making it clear throughout moans and groans that he/she was in significant discomfort and tightness in his/her jaw and grimace on his/her face indicated his/her pain was increased. The resident indicated pain at his/her right wrist. Despite the writer's attempts to offer vocal and tactile comfort, the resident's pain was too severe to be soothed, and a medication change was indicated for pain management. -A new order for Ativan 1 ml every 30 minutes for anxiety/restlessness and Morphine 1 ml every 30 minutes for pain/air hunger, until pain was under control. The writer documented he/she gave the resident Morphine three times while at the resident's bedside for pain control.-The facility Administrator and DON were aware of the situation.-Additional notes documented at 1:45 P.M., showed the Hospice nurse assessment showed the resident was not responsive to stimuli, had labored breathing that was irregular with shallow respirations. The nurse completed a non-verbal pain assessment and the resident's estimated pain level was at 2. The resident showed no audible signs of pain/discomfort, his/her facial expressions were calm, and his/her body language conveyed a sense of comfort and ease. The resident's pain seemed controlled. Review of the resident's Medical Record showed there was no documentation showing an incident report was completed regarding the resident's fall on 2/12/26 to include what occurred, the circumstances of the fall, when the resident was last seen prior to the fall, interventions that were in place prior to the fall, what immediate interventions were put in place after the fall, the nursing assessment of the resident (to include documentation of the resident's vital signs and neurological checks), notifications (physician, Hospice and responsible party). There was no documentation showing the facility investigated the injury after discovering that Agency LPN A acknowledged that the resident had a fall from bed on 2/12/26 and what the facility determined to be the root cause of the resident's injury after discovering the resident had an injury to his/her right wrist/elbow that was discovered on 2/13/26. Review of the resident's Coroner Report dated 2/16/26 (via facility email) showed:-He/She received a notification of the Hospice associated death of the resident on 2/13/26 at 7:35 P.M from Hospice.-Family Member A was concerned regarding the resident's death and potential of abuse/neglect while in the facility so additional information was gathered.- According to information provided by Family Member A, facility nursing staff and Hospice, the resident had a history of health issues, most recently a knee surgery, and was transferred to another skilled nursing facility where the resident exhibited severe pain, restlessness/agitation falls and continuing to deteriorate.-The resident was transferred to the current facility and Hospice was initiated for a diagnosis of heart disease, but the resident also had a current history of sepsis with ongoing dementia, prostate cancer, arthritis in the hip, knees and shoulders and aortic stenosis (heart valve failure).-According to information provided by the resident's family, facility nursing staff and Hospice the resident continued to deteriorate and on 2/13/26 when hospice evaluated the resident, the resident also appeared to have misalignment of his/her right wrist with severe pain with any manipulation. The facility and Hospice ordered an x-ray and the resident's daughter declined with concerns of potentially causing more pain. -Subsequent questioning by the facility found that the night nurse on 2/12/26 reported the resident was found to have fallen out of bed and was placed back in bed without any finding of injury and against protocol, the nurse made no notification to the facility administration, physician or family either at the time of the incident or afterwards.-At the resident's time of death, the Hospice nurse who was present did not observe redness, swelling or bruising on the resident's body and there was no evidence of head injury. There was no suggestion by any of the family or involved caretakers that there was a head injury observed on the resident.-The fall from a low mattress onto a mat in a resident who was not anticoagulated (did not take any medications used to thin the blood) with no evidence of a head injury was unlikely to cause a severe enough head injury to account for brain bleeding. The fall causing death was extremely improbable in the resident who was near death from multiple causes. Although lack of reporting the fall would seem to be inappropriate, it was an unfortunate incident at the end of life, which was otherwise appropriately managed with appropriate care given. An autopsy of the resident was not indicated. During a telephone interview on 2/17/26 at 2:25 P.M., Family Member A said:-The resident was admitted on [DATE] and was on Hospice and declining and needed total care. -On 2/12/26, Hospice LPN A called between 10:30 A.M. and 11:00 A.M., and said that the resident was declining rapidly, and he/she needed to come to the facility as soon as possible.-When he/she arrived at the facility at 11:30 A.M. Hospice LPN A said that the resident was in the dying process, but he/she also told him/her that the resident's arm looked broken, they had found his/her arm in a strange position, and it was disfigured. -He/She saw the resident's right arm/hand and it looked swollen and disfigured. -He/She called his/her friend who had visited the resident at around 6:00 A.M. on 2/13/26, and asked if he/she noticed anything and his/her friend said that when he/she asked Agency LPN A about how the resident was doing, Agency LPN A said that the resident may have fallen out of bed that night, but his/her friend did not see anything that indicated the resident was injured or in pain because he/she was asleep and it was dark in his/her room.-When he/she began asking the facility staff about what happened to the resident, the DON said that there was agency staff working on the night shift on 2/12/26 and the agency nurse did not document anything in the resident's medical record, but he/she had told the ADON that the resident had fallen out of bed.-The facility never notified him/her that the resident fell out of bed or that the resident's arm was swollen, disfigured or possibly broken. Hospice LPN A informed him/her of this.-While he/she was in the facility, the DON ordered an x-ray, but he/she contacted the Hospice physician, and he/she suggested not to put the resident through any more pain, and he/she agreed so he/she declined the x-ray for the resident. The Hospice physician ordered more pain medication to manage the resident's pain. -At 12:30 P.M. an executive at the facility (unknown name) said that they were going to complete a full investigation regarding the incident because Agency LPN A had not followed the facility protocol after the resident fell. -The resident passed away later that day, but he/she would like to get an x-ray of his/her arm to determine if it was actually broken.-He/She requested the resident's medical record, and the facility provided it, and he/she did not see where the nurse documented anything in the nursing notes regarding the resident falling or anything that lead up to him/her having any injury or broken arm. During an interview on 2/17/26 at 10:33 AM, the Administrator said:-The resident was a new admission and came in on Hospice services and was declining from the time he/she was admitted .-On the morning of 2/13/26, LPN B went in to check the resident, and saw the resident was lethargic. He/she initially observed the resident's arm when he/she went to give the resident's medication that morning, and there was no indication the resident had an injury until he/she moved the resident's arm, and the resident yelled out in pain.-After asking nursing staff, no one on the day shift knew why the resident was in pain or what had occurred to cause his/her pain.-They checked the resident's medical record and there was no documentation in his/her nursing notes on 2/12/26.-There was no documentation or indication that the resident had a fall or any incident the night or day before that would have caused an injury to the resident.-The day shift charge nurse told him/her that that he/she could potentially have an injury (on 2/13/26) and he/she spoke with the DON and ADON and neither were aware of an incident or fall that may have occurred so he/she instructed the ADON to contact Agency LPN A, who worked on the night of 2/12/26 to try to find out if the resident had expressed pain or whether he/she may have noticed anything different about the resident. -The ADON contacted Agency LPN A on 2/13/26 and this was when Agency LPN A said the resident had an unwitnessed fall from his/her bed and was found on the floor mat beside his/her bed that night during his/her shift (on 2/12/26).-Agency LPN A said he/she did complete a full body assessment and did not see any injury to the resident or any range of motion concerns. He/she said he/she and the Agency CNA A placed the resident back in bed. Agency LPN A did not document an incident report and did not make any notifications to the physician, responsible party, Hospice, himself/herself (Administrator) DON or ADON about the incident. -They notified Agency LPN A's agency that that they will no longer accept Agency LPN A back into their facility because he/she failed to follow the facility protocol for reporting the fall and completing the incident report and notifications. -They completed their own investigation on 2/13/26 and notified the physician who ordered an x-ray on the resident on the morning of 2/13/26.-The resident's daughter and Hospice LPN A were at the resident's bedside when the resident's responsible party declined the x-ray and chose to keep the resident comfortable instead.-They did not know if the resident's arm was actually broken because the x-ray was never completed per the responsible party's request.-The expectation was that Agency LPN A should have completed an incident report for the resident's fall, and he/she should have notified Hospice, herself/himself, the DON and physician on the day the resident was found on the floor mat. During a telephone interview on 2/17/26 at 3:41 P.M., Hospice LPN A said:-Since the resident arrived in the facility the resident had been declining very quickly.-He/She was having restlessness, agitation and was total care. The resident had pain due to a knee replacement and was receiving pain medication for that and for restlessness/agitation.-The resident was scheduled for two nursing visits weekly, but he/she was in the building every day in case the facility staff needed anything or whenever there were any changes concerning the resident or other residents on his/her caseload.-The facility was usually very good with notifying her of any changes with the resident and he/she thought the resident was receiving adequate care and medications while in the facility.-On 2/13/26, he/she was already in the building seeing another patient when LPN B contacted him/her to say he/she thought the resident was having increased restlessness and pain.-He/She went to complete an assessment on the resident and the resident was laying on his/her right side in bed. He/she noticed the resident had labored breathing and was lethargic. He/she also noticed his/her right arm was bent at a 90-degree angle with his/her wrist in a bent position and hanging off of the side of the bed.-He/She stated to LPN B that the resident was in an awkward position and asked if his/her arm had been like that and LPN B said it had been that way, but the resident had not been moved yet so she asked LPN B to notify the DON who came in and said that they needed to get an x-ray of the resident's arm.-He/She completed an assessment of the resident and noted that when he/she touched the resident on his/her right arm the resident would moan in pain.-He/She did not see any additional injuries on the resident and there was no indication of a head injury.-He/She never moved the resident, but he/she called the resident's responsible party and reported that the resident was declining rapidly (in the dying process), and his/her responsible party was already on the way to the facility and was there within 30 minutes.-The DON contacted the Agency LPN A to investigate what could have happened to the resident and that was when he/she was notified that Agency LPN A stated the resident fell out of bed on the night of 2/12/26. The DON notified him/her of what the agency said happened.-The DON received the order for the x-ray of the resident's hand/arm, but the resident's responsible party declined to have the x-ray completed.-He/She was not able to say if the resident's arm/wrist was broken because they did not have the x-ray results to show whether it was or not, but the resident did have increased pain, and they needed to increase his pain medication.-Hospice should have been notified as soon as the resident fell, and they were not notified by the facility until 2/13/26.-He/She began sitting with the resident at bedside on 2/13/26 from 10:30 A.M. until 1:30 P.M. and obtained an order to increase his/her pain medication (Morphine) to manage his/her increased pain. The resident continued to decline and at 1:30 P.M. he/she was relieved by another Hospice nurse who sat with the resident until he passed on 2/13/26.-He/She did not believe that the facility staff had been neglectful or were providing any poor care to the resident nor did he/she believe that the facility had abused the resident. During a telephone interview on 2/19/26 at 3:18 P.M., Agency LPN A said:-The resident had been declining and was having more restlessness and agitation leading up to 2/12/26. -He/She has worked at the facility several times and was the charge nurse on the night shift on 2/12/25 from 6:15 P.M. to about 7:30 A.M. on 2/13/26.-Around 12:50 A.M., Agency CNA A came in to tell him/her that the resident was on the floor.-When he/she saw the resident, he/she was laying partially on his/her back/side on the floor mat beside his/her bed. The resident was on a low bed in the lowest position.-The resident had a history of moving around in bed and he/she had been in the resident's room three times to check on the resident and twice he/she had to reposition him/her in bed.-When he/she saw the resident on the floor mat, he/she physically assessed the resident from head to toe and at that time the resident did not have any injuries and showed no signs of injury and did not vocalize or show signs of any pain.-He/She instructed Agency CNA A to get the sling for the full body lift and the lift. When Agency CNA A returned, they placed the sling under the resident, but they were unable to get the lift low enough to attach the sling to the lift so they could lift the resident. -He/She and Agency CNA A physically lifted the resident (with him/her at the foot of the sling and Agency CNA A at the head of the sling) and placed him/her back in bed.-At that time, the resident still showed no sign or symptom of injury or pain, and he/she did not yell out in pain or show any facial grimacing/crying that would indicate pain.-After the resident was in bed, he/she went to get narcotic pain medication for other residents and began assisting Agency CNA A with answering call lights. -He/She did not document a nursing note, write an incident report or make any notifications to the resident's physician, Hospice or responsible party regarding the resident's fall because he/she did not have time, and it was very busy that night.-He/She did not document the resident's vital signs after he/she fell.-The resident had no further incidents after he/she was back in bed, he/she did not have any observations afterward that indicated the resident was in increased pain or had any injuries. The resident remained in bed the rest of the night.-He/She told the charge nurse at shift change that the resident rolled out of his/her bed and that he/she did not have any injury before he/she left the facility at 7:30 A.M., but he/she still did not make a nursing note, incident report nor did he/she make any notifications to the resident's physician, Hospice or responsible party. He/she said he/she did not notify the Administrator, DON or ADON of the resident's fall before he/she left for the day.-Later on, that day, on 2/13/26 at around 11:00 A.M. the ADON called him/her and asked if the resident had shown any signs of increased pain. He/she told the ADON that the resident had rolled onto the floor mat out of bed during his/her shift and he/she had completed a head-to-toe assessment, and the resident did not have any injury or show signs/symptoms of pain or injury at that time. -He/She told the ADON that he/she had not notified the physician, responsible party or Hospice of the resident's fall. -He/She told the ADON that he/she would write the incident report and did so after his/her phone conversation with the ADON.-He/She was aware that he/she was supposed to document the incident report and write a nursing note documenting what happened, his/her assessment of the resident (to include vital signs) and notifications at the time of the incident or at sometime during his/her shift. During a telephone interview on 2/20/26 at 9:47 A.M. The DON said:-He/she was not notified of the resident's fall on 2/12/26 until around 12:00 P.M. on 2/13/26.-On 2/13/26, LPN B asked if he/she would come to assess the resident. -When he/she saw the resident he/she was in bed asleep and his/her right arm was laying on the bed, but it did not look to be swollen, bruised, disjointed and he/she did not notice anything that would have indicated that there was an injury.-Hospice LPN A was in the resident's room at this time and LPN B said when he/she moved the resident's arm, he/she grimaced in pain, so they were then trying to find out why he/she had pain there.-He/She spoke with the Hospice LPN A, and they decided to get an x-ray for the resident to check for a possible injury.-When they notified Family Member A, he/she did not want the x-ray completed and declined the x-ray twice.-They were trying to find out what could have created the pain to his/her arm/wrist, and he/she spoke with the day shift staff, and no one had any knowledge of anything that had happened to cause pain to his arm/wrist.-The ADON contacted Agency LPN A who had worked the night shift (on 2/12/26) and this was when they found out that the resident had rolled out of his/her bed onto the fall mat. -He/She was notified that Agency LPN A assessed the resident at the time and did not note any injury to the resident, the resident was put back into bed using the full body li

Based on interview and record review, the facility failed to inform one sampled resident (Resident #1) of transportation costs within the admission agreement out of seven sampled residents. The facility census was 53 residents. Review of the facility's policy titled Admissions dated from 2025 showed: -The facility would maintain an admissions policy governing admissions to the facility to ensure fair and impartial admission practices. -A nursing facility may charge a resident who was eligible for Medicaid for items and services the resident had requested and received only if: --That service was not defined in the State plan as nursing facility services (services required as part of the daily rate). --The facility informs the resident and the resident's representative in advance that the service was not covered to allow them to make an informed choice regarding the fee. --The resident's admission or continued stay was not conditioned on the resident's requesting and receiving that service. 1. Review of Resident #1's admission record showed he/she admitted to the facility on [DATE] with the following diagnoses: -Unspecified Fracture of his/her right femur. -Closed Fracture with Routine Healing. -Nondisplaced Fracture of Shaft of his/her left clavicle -Periprosthetic fracture around internal prosthetic to his/her right hip joint. Review of the resident's admission Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 5/29/24 showed: -The resident was under a Medicare covered stay. -The resident was cognitively intact. -The resident had recent surgery requiring active Skilled Nursing Facility (SNF) care. Review of a balance statement dated 6/30/24 showed the resident was billed 158.10 dollars for transportation that was completed on 6/17/24. Review of a balance statement dated 8/31/24 showed: -The resident was billed 144.10 dollars for transportation that was completed on 7/8/24. -The resident owed a total of 302.20 dollars for transportation during his/her stay at the facility. During an interview on 3/5/25 at 2:45 P.M. Family Member A said: -He/She was unaware that the facility had charged the resident for transportation. -He/She would not have had the facility take the resident to his/her doctor appointments if he/she had known about the cost. Review of a blank copy of the facility's admission agreement completed on 5/27/25 showed: -The resident or resident representative were to agree to pay the then-current rates of extra charges for the additional services, supplies, and/or equipment (SSE) that the resident or resident representative specifically requested and that are not included in the standard charge. -Residents and resident representatives were to refer to the Health Center Resident Handbook to determine whether an extra charge was or was not covered by Medicare and/or Medicaid. -A copy of the Health Center Resident Handbook was included with the other documents that were received by the residents or resident representatives at the time of receiving the admissions agreement. Review of a blank copy of the facility's resident admission packet completed on 5/27/25 showed transportation was an extra charge and the resident or resident representative would be billed by the facility for transportation. Review of the facility's Health Center Information Book completed on 5/27/25 showed transportation services and escort services would be billed directly. During an interview on 5/27/25 at 10:14 A.M. the Administrator said: -The resident had Medicare coverage. -Transportation billing information was included in the admission agreement. During an interview on 5/27/25 at 12:14 P.M. the Administrator said he/she could not find the resident's signed admission agreement. During an interview on 5/27/25 at 2:30 P.M. the Assistant Director of Nursing (ADON) said: -He/She was unsure if there was a time frame in which admission agreements needed to be completed. -The Social Services Designee (SSD) was responsible for completing admission agreements. -Once the admission agreement is signed by a resident or resident representative, the agreement would be uploaded into the resident's electronic medical record (EMR). -He/She was unable to find the resident's admission agreement in the resident's EMR. -Whenever a resident requested transportation, he/she would remind the resident or resident representative that there was a transportation fee. -He/She remembered having a conversation with the resident related to transportation fees, but that conversation was not related to a specific appointment. -He/She had not documented that conversation with the resident. During an interview on 5/27/25 at 2:46 P.M. the Administrator said: -The admission agreement needed to be signed by the resident or resident representative within the first week of admission to the facility. -Once the admission agreement was signed, a copy of the agreement would be uploaded into the resident's EMR. -The facility also kept the paper copy and it would be placed in the resident's medical record. -Residents and resident representatives were informed of the transportation fees when an appointment was requested, but nothing was signed to show the resident or resident representative was educated on the transportation fee. -The SSD was responsible for completing resident admission agreements. -He/She expected the SSD to have completed the resident's admission agreement. -He/She was unaware that the resident's admission agreement was not completed. -He/She was unsure why the resident's admission agreement had not been completed. During an interview on 5/27/25 at 2:57 P.M. the SSD said: -He/She was responsible for completing admission agreements. -There was not a designated time frame in which the admission agreements needed to be completed. -He/She would try to complete the admission agreement within the first couple of weeks that the resident was in the facility. -He/She was currently behind on completing admission agreements. -Once he/she completed an admission agreement then someone would upload it into the resident's EMR. -The paper copy of the signed admission agreement was also kept in medical charts. -He/She thought that an admission agreement was completed for the resident. -He/She was unsure of where the resident's admission agreement was if it was not found in the resident's EMR or medical chart. -The resident would have been able to sign the admission agreement himself/herself, so he/she was unsure of how it would not have been completed. -All additional charges, including transportation fees were included in the admission agreement. -To his/her knowledge there would be no other way for residents or resident representatives to know of the transportation fees outside of the admission agreement. -He/She thought there would not be an expectation for a resident or resident representative to pay for an extra charge or fee that they were not informed of. MO00250564

Based on observation, interview, and record review, the facility failed to follow appropriate infection control practices during incontinence care for one sampled resident (Resident #20) who was on Enhanced Barrier Precaution (EBP - refer to an infection control intervention designed to reduce transmission of multi--resistant organisms that employs targeted gown and glove use during high contact resident care activities), who was at risk for infection due to an open wound on his/her coccyx (tail bone) area; failed to perform adequate hand hygiene during medication administration for one sampled resident (Resident #6) and two supplemental residents (Resident's #33 and #47) out of 15 sampled residents and nine supplemental residents; failed to screen all employees for tuberculosis (TB-a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, and abnormal lung tissue and function) and maintain documentation of all employees' tuberculin screening, and to ensure the facility policy and procedures for TB screening was followed for three of ten sampled employees. The facility census was 53 residents. Review of the facility's undated Enhanced Barrier Precautions Policy copyright 2024 showed: -Implement enhance barrier precaution for the prevention of transmission of multidrug resistant organisms. -Implementation of EBP: making gowns and gloves available immediately near or outside the resident's room. -Personal Protective Equipment (PPE) for EBP is only necessary when performing high contact care activities and may not need to be donned prior to entering the resident room. -High contact resident care include but not limited to: transferring a resident, bathing, providing hygiene, changing briefs or toileting and wound care. -EBP should be used for the duration of the affected resident's stay in the facility or until resolution of the wound that placed the resident at higher risk. Review of the Center of Disease and Control (CDC), Center for Clinical Standards and Quality/Quality, Safety & Oversight Group, Ref: QSO-24-08-NH updated on 3/20/24 showed: -(EBP) recommendations now include use of EBP for residents with chronic wounds during high-contact resident care activities regardless of their multidrug-resistant organism status. -Enhanced Barrier Precautions require the use of gown and gloves only for high-contact resident care activities (unless otherwise indicated as part of Standard Precautions). they are intended to be in place for the duration of a resident's stay in the facility or until resolution of the wound that placed them at higher risk. Review of the facility's undated policy titled Hand Hygiene showed: -All staff would perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors; this applied to all staff working in all locations within the facility. -Hand Hygiene was a general term for cleaning hands by handwashing with soap and water or the use of anti-septic hand rub, also known as alcohol-based hand rub (ABHR). -Hand hygiene with soap and water was to be performed under the listed conditions, but not limited to: --Hands being visibly soiled. --Hands being soiled with blood or other bodily fluids. -Hand Hygiene with ABHR was to be performed under the listed conditions, but not limited to: --Between resident contacts. --After handling contaminated objects. --Before applying and after removing personal protective equipment (PPE), including gloves. --Before preparing or handling medications. -The use of gloves did not replace hand hygiene; if a task required gloves staff were to perform hand hygiene prior to donning gloves, and immediately after removing gloves. 1. Review of Resident #20's Physician Order Sheet (POS) dated 7/1/24 showed: -Cleanse areas to right buttocks and coccyx with hypochlorous acid (is a solution that helps clean wounds and prevent infections). Apply Calmoseptine ointment (is barrier cream commonly used to treat and prevent minor skin irritations) to both areas and cover with an abdominal pad (ABD, is an extra thick primary or secondary dressing designed to care for moderate to heavily draining wounds pad). Change daily and as needed for Wound care. -No physician order found related to the resident on EBP. Review of the resident's Significant Change Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 7/3/24, showed he/she: -Was severely cognitively impaired and had short term and long-term memory problems. -Had Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. It may also present as an intact or open/ruptured blister) Pressure Ulcer/wound (PU, localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). -Had Stage III (a full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) pressure ulcer/wound. -Was always incontinent of bowel and bladder. -Was dependent on facility staff for all cares. Review of the resident's care plan revised on 7/9/24 showed the resident: -Was at risk for skin breakdown related to incontinent of bowel and bladder, impaired mobility, weakness. The resident had an open area on his/her buttocks and on his/her coccyx at that time. -Interventions included: --A sign on door indicating the need for EBP. --Staff member was to wear gown and gloves when providing care for the resident. -Initiated on 7/9/24, the resident had a Stage II wound to his/her right buttock; refer to POS for current treatment. -Initiated on 7/9/24, the resident had a stage III wound to coccyx, refer to POS for current treatment. Observation on 7/14/24 at 10:14 P.M., the resident room showed: -Had signage on the door stating a resident in that room was on Enhanced Barrier Precautions. -Staff were to wear gown and gloves when providing direct contact care for the resident, including incontinent care and wound care. Observation on 7/16/24 at 9:15 A.M., of resident care showed: -The resident had EBP signage posted on the door. -Certified Nursing Assistant (CNA) A and CNA B entered the resident's room washed their hands and applied gloves. They did not wear PPE gown prior to transferring the resident or when providing incontinent care. -CNA A and CNA B transferred the resident with a Hoyer lift (a mechanical transfer device) from his/her chair to the bed. -While in bed CNA A and CNA B removed the resident's pants and briefs. -CNA A provided incontinent care for the resident while CNA B assisted in holding/positioning the resident on his/her left side for cares. -The resident did not have a dressing on his/her coccyx wound at the time of incontinent care. -The resident had an open area on his/her coccyx. The open area was like a slit in buttocks crack area about 1/2 inch or less in length with white outer edges and reddish pink inside. -The buttocks had irritation on both side of cheeks, a with few spots with shearing (peeling of skin) observed. -He/She also had a dime sized scabbed over area on his/her right knee. -CNA A said the charge nurse would provide wound care and treatment later that morning. During an interview on 7/16/24 at 1:09 P.M., CNA A said: -He/She was not aware the resident was on EBP. -He/She went to ask the nurse if the resident was on EBP. -CNA A was informed by the nurse the resident was on EBP. -He/She should have worn a gown during the resident's incontinent care. -He/She did not realize the resident had open wound area on his/her coccyx prior to care. -He/She did not see the EBP signage on the resident's door. -EBP would be used when a resident had the potential of infection due to wounds or other risk factors. During an interview on 7/15/24 at 12:36 P.M., Licensed Practical Nurse (LPN) B said: -The resident was on EBP for wounds. -The resident only has a small open area on coccyx. -He/She would expect CNAs and nurses to wear gown and gloves when providing incontinent care or wound care. During an interview on 7/17/24 at 10:22 A.M., CNA C said: -The resident was on EBP for wounds and required gowning and gloving with direct care. -He/She had not had any recent training related to EBP. During an interview on 7/17/24 at 12:14 P.M., CNA D said he/she would wear gloves and gown with any direct contact care for any resident on EBP. During an interview on 7/17/24 at 1:16 P.M., the Infection Control Preventionist said: -Enhanced Barrier Precaution would be used for those residents at risk for multi-drug resistant, to include residents with wounds. -For those residents on EBP, the PPE should be in the resident's room located in a drawer. -He/She would expect all care staff to wear gowns and gloves while providing incontinent care or other direct contact care for residents on EBP. -The resident was on EBP due to wounds. During an interview on 7/18/24 at 9:51 A.M., the Director of Nursing (DON) said: -Residents on EBP would be any resident with wounds and other risk factors. -Resident #20 was on EBP related to his/her wound. -He/She would expect nursing staff and care staff to wear PPE to include, gown and gloves when providing incontinent care or wound care for residents on EBP. -The Infection Control Preventionist would educate nursing staff and the facility nursing staff would educate CNAs or other care staff related to residents on EBP and what PPE required. -The resident on EBP should either have isolation cart outside room or staff can obtain gowns from the clean utility room. 46519 2. Review of an undated facility policy titled Nasal Spray Administration showed staff were to: -Wash hands thoroughly before beginning the procedure and don gloves. -Rinse the tip of the medication container in lukewarm water, and allow to dry. -Replace the cap. -Remove and discard gloves. Review of Resident #6's face sheet showed he/she admitted to the facility with the following diagnosis: -Age-Related Osteoporosis (a condition in which the bones become brittle and fragile from loss of tissue). -Nasal Congestion. Review of the resident's POS dated July 2024 showed an order for Calcitonin (Salmon) Nasal Spray Solution (used to treat bone loss in women with postmenopausal osteoporosis) 200 Units (U), one spray in alternating nostrils during the day shift. Observation on 7/16/24 at 9:27 A.M. of the resident's medication administration completed by LPN D showed: -He/She did not perform hand hygiene before dispensing the medication into the medication cup. -He/She grabbed gloves before entering the resident's room. -He/She did not perform hand hygiene upon entry to the resident's room. -He/She handed the medication cup to the resident and donned the gloves that were in his/her hands without performing hand hygiene prior to donning the gloves. -He/She then administered the nasal spray into the resident's left nostril. -He/She re-capped the nasal spray solution without cleaning the tip of the medication container. -He/She removed his/her gloves and exited the resident's room without performing hand hygiene. 3. Review of Resident #33's face sheet showed he/she admitted to the facility with the following diagnoses: -Right-Sided Heart Failure (when the heart's right ventricle is too weak to pump enough blood the lungs). -Gastro-Esophageal Reflux Disease (GERD- a digestive disease in which stomach acid or bile irritates the food pipe lining). -Vitamin Deficiency (a long-term lack of a vitamin). -Diarrhea, Unspecified. Observation on 7/16/24 at 9:36 A.M. of the resident's medication administration completed by LPN D showed: -He/She did not perform hand hygiene before dispensing the medication into the medication cup. -He/She did not perform hand hygiene upon entry into the resident's room. -He/She handed the medication cup to the resident, making contact with the resident's hand. -He/She then exited the resident's room without performing hand hygiene. 4. Review of Resident #47's face sheet showed he/she admitted to the facility with the following diagnoses: -Carcinoma in Situ of Rectum (a precancerous condition characterized by the presence of abnormal cells in the inner lining of the rectum). -Primary Hypertension (high blood pressure). -Chronic Kidney Failure (a long-standing kidney disease based on kidney damage or decreased kidney function for three or more months), Stage 3 (an indication of mild to moderate kidney damage). -Diarrhea, Unspecified. Observation on 7/16/24 at 9:49 A.M. of the resident's medication administration completed by LPN D showed: -He/She entered the resident's room without performing hand hygiene. -He/She checked the resident's blood pressure with a wrist cuff making contact with the resident's left arm and hand. -He/She exited the resident's room without performing hand hygiene. -He/She then started to dispense the resident's medication from the resident's medication strip pack. -He/She then knocked his/her pen to the floor and picked it up from the ground and continued to dispense the resident's medication into the medication cup without performing hand hygiene. -He/She then re-entered the resident's room without performing hand hygiene upon entry. -He/She then handed the medication cup to the resident, making contact with the resident's hand. -He/She then exited the resident's room and applied ABHR to his/her hands. During an interview on 7/16/24 at 10:04 A.M. LPN D said: -He/She had not realized that he/she had not performed hand hygiene in between residents during the medication pass. -He/She would normally perform hand hygiene in between each resident during medication pass. 5. During an interview on 7/16/24 at 11:20 A.M. LPN D said: -He/She had been nervous during the nasal spray administration and had not realized he/she had not performed hand hygiene during the procedure. -He/She knew that he/she had worn gloves during the procedure. -He/She should have used hand sanitizer (ABHR) after picking up the pen from the floor during Resident #47's medication pass. During an interview on 7/17/24 at 11:37 A.M. LPN C said: -Hand hygiene should be performed before and after each resident's medication pass, when entering and exiting resident rooms, and before and after any type of resident procedure is completed. -Gloves were not a substitute for hand hygiene. -The nurse had not performed hand hygiene appropriately during the medication pass and when administering the nasal spray. -He/She would have sanitized his/her hands after picking up an item that was dropped on the floor. During an interview on 7/18/24 at 8:22 A.M., the MDS Coordinator said: -Hand hygiene should be performed anytime a person feels it should be completed. -Hand hygiene should be performed before and after each resident's medication pass, before and after resident contact is made, and before and after using gloves. -Gloves were not a substitute for hand hygiene. -The nurse had not performed hand hygiene adequately during the medication pass. During an interview on 7/18/24 at 8:55 A.M., the Assistant Director of Nursing (ADON) said: -Staff should perform hand hygiene by washing their hands before starting medication pass. -Staff were to use ABHR between each resident during medication pass. -After three residents, staff needed to wash their hands before continuing the medication pass. -Gloves were not a substitute for hand hygiene. -The nurse had not performed hand hygiene correctly during the whole medication pass procedure. -The nurse should have washed his/her hands after picking up the pen from the floor. During an interview on 7/18/24 at 9:51 A.M., the DON said: -Hand hygiene should be performed before the start of medication pass and in between each resident. -Gloves were not a substitute for hand hygiene. -The nurse had not performed hand hygiene correctly during the whole medication pass procedure. -He/She would have expected the nurse to have washed his/her hands after picking up the pen off the floor, before continuing the medication pass. 50579 6. Review of an undated facility policy titled Insulin Pen showed staff were to: -Perform hand hygiene prior to the insulin administration. -Perform hand hygiene after the administration. 7. Review of Resident #157's POS showed orders for Humalog (a rapid acting insulin) four units subcutaneously (in fatty tissue via injection) three times per day. Observation on 7/16/24 at 10:47 A.M., showed Certified Medication Technician (CMT) A retrieved an insulin pen from the medication cart containing Humalog insulin. CMT A entered the resident's room without performing hand hygiene, donned gloves, applied a needle to the insulin pen, administered insulin and left the room without performing hand hygiene. 8. Review of Resident #156's the POS showed orders for Novolog (a rapid acting insulin) at a dose that was blood glucose level dependent (4 units for the resident's blood glucose at that time), three times per day. Observation on 7/16/24 at 10:52 A.M., showed CMT A returned to the medication cart, took out an insulin pen and applied the needle to the pen. CMT A, without washing or sanitizing his/her hands, donned gloves, cleansed an area on the resident's upper arm, administered the insulin and left the room without performing hand hygiene throughout the procedure. During an interview on 07/16/24 at 11:21 A.M., CMT A said he/she performed hand hygiene before and after each insulin administration. During an interview on 7/17/24 at 11:24 A.M., LPN A said hand hygiene must be performed before and after insulin administration because staff may come into contact with blood or other pathogens. During an interview on 7/18/24 at 9:50 A.M., the DON said he/she would expect staff to perform hand hygiene before and after insulin administration. 21003 9. Review of the facility's Infection Control policy and procedure updated 2024, showed direct care staff shall comply with physical examinations and immunization screening requirements upon employment and annually. Review of the following employee records showed there was no documentation showing these employees were given a two-step TB test upon hire or that there was documentation showing a previous TB test or X-ray to rule out TB had been completed prior to or upon employment: -Security A was hired on 10/21/23. Documentation showed the TB screening was not conducted until 4/13/24. There was no documentation showing the employee had a TB screening upon hire or provided documentation to rule out TB upon hire. -Housekeeper A was hired on 8/19/23. Documentation showed the TB screening was not conducted until 8/24/24. There was no documentation showing the employee had a TB screening upon hire or provided documentation to rule out TB upon hire. -Dietary Aide A was hired on 12/28/23. There was no documentation showing the employee had a 2 step TB test or provided documentation to rule out TB. This employee was no longer employed at the facility. During an interview on 7/18/24 at 8:38 A.M., the Human Resource Director said: -Some of the staff were hired under the former company and they were not completing the TB screenings correctly or timely. -He/She had been auditing employee files and making corrections but noticed there were several mistakes or missing information. -Regarding Housekeeper A, he/she thought the nurse mistakenly documented the year 2024 instead of 2023 on the 2 step TB form. -He/She did not know why Security A or Dietary Aide A was not completed upon hire but he/she was unable to find this documentation. During an interview on 7/18/24 at 9:51 A.M., the DON said: -Nursing completes employee TB testing and they try to complete it 3 days prior to hire. -The Human Resource Director tracks the TB tests and will bring the documentation to him/her so he/she can ensure they are completed correctly and timely. -He/She was aware that there were TB tests that were not done correctly under the prior owners and management and they were trying to correct those as they saw issues.

Based on observation and interview, the facility failed to maintain the baffle vents (metal vents which trap oil and grease that would make it into a kitchen's atmosphere by passing air through a series of interlocking baffles, because the oil gets stuck to the stainless steel or aluminum interior walls of the range hood (an open metal enclosure over cooking surfaces through which air is drawn in from the surrounding spaces to exhaust heat and grease, and to control the flow of rising hot air)) over the deep fat fryer free of a heavy buildup of grease; failed to maintain the floor behind the deep fat fryer free of a heavy buildup of grease; failed to maintain packages of zucchini sticks, breaded okra and frozen meat patties with a date and closed in the freezer; failed to maintain two cutting boards in an easily cleanable condition; failed to ensure the food processor was washed in a 3-step process between uses in processing different foods; failed to maintain the milk in the dining room at or close to 41 F (degrees Fahrenheit). This practice potentially affected all residents. The facility census was 53 residents. 1. Observations during the initial kitchen tour on 7/14/24 from 12:54 A.M. through 1:16 P.M., showed: -A buildup of grease on the baffle vents over the deep fat fryer. -A buildup of grease and cooking debris around the rim of the deep fat fryer. -Three packages of zucchini sticks, one package of breaded okra, one package of breaded chicken tenders and one package of frozen meat patties, which were not labeled with a date the packages were opened and the packages were not sealed. -The presence of red and brownish stains under one shelf which held meat. During an interview on 7/14/24 at 1:05 P.M., Dietary [NAME] (DC) A said: -He/She worked every other weekend and during the week. -Items in the freezer should all be sealed, labeled and dated and identified the packages of breaded okra, chicken tenders and frozen chicken were unsealed and unlabeled with a date they were opened. -They have ordered a solution to get the stains up but it had not come in yet. 2. Observations during the breakfast meal on 7/17/24 from 5:46 A.M. through 8:12 A.M., showed: -Two blue cutting boards not in an easily cleanable condition. -A buildup of grease on the baffle vents over the deep fat fryer. -A buildup of grease and cooking debris around the rim of the deep fat fryer. -DC A used the food processor to process and puree eggs and just rinsed the food processor instead of washing the food processor in a 3-step process (washing, rinsing and sanitizing). -DC A then used the food processor to process mechanical soft and pureed sausage. -DC A then only rinsed out the food processor -At 8:26 A.M., the milk in the bottle in the main dining room was 51.4 F During an interview on 7/17/24 at 8:29 A.M., the Dietary Director (DD) said he/she was not sure if the dietary staff had checked the temperature of the milk and the milk was not on ice. During interviews from 9:08 A.M. through 9:16 A.M., the DD said: -He/She had not conducted any in-services regarding the cutting boards since he/she has taken over. -The dietary staff were supposed to clean behind the deep fat fryer every two weeks. -He/She did not have the dietary staff to clean the baffle vents because he/she thought the range hood cleaning company cleaned the baffle vents. - He/She expected the dietary staff to do a three-step process or run the food processor through the dishwasher after each food is processed.

Based on interview and record review, the facility failed to provide sufficient proof of the Registered Nurse (RN) eight consecutive hours a day coverage during the Fiscal Year Quarter Two 2024 Payroll Based Journal (PBJ- a report that provides staffing dataset information submitted by nursing homes on a quarterly basis) for all the dates triggered within the quarter equaling 26 total days. This deficient practice had the potential to affect all residents within the facility. The facility census was 53 residents. Review of the facility's undated policy titled Nursing Services- Registered Nurse showed: -The intent of the policy was for the facility to comply with Registered Nurse staffing requirements. -The facility would utilize the services of a Registered Nurse for at least eight consecutive hours per day, seven days per week. -The facility was responsible for submitting timely and accurate staffing data through the CMS PBJ system. 1. Review of the PBJ Fiscal Year Quarter Two PBJ data report showed the facility had no RN coverage for the following dates: -Eight out of 31 days in January 2024: --1/6/24, 1/7/24, 1/13/24, 1/14/24, 1/20/24, 1/21/24, 1/27/24, 1/28/24, -Eight out of 29 days in February 2024: --2/3/24, 2/4/24, 2/10/24, 2/11/24, 2/17/24, 2/18/24, 2/24/24, 2/25/24. -Ten out of 31 days in March 2024: --3/2/24, 3/3/24, 3/9/24, 3/10/24, 3/16/24, 3/17/24, 3/23/24, 3/24/24, 3/30/24, 3/31/24. Review of a Daily Staffing Roster dated 1/6/24 and 1/7/24 showed no assigned RN coverage in the building. Review of a Payroll Detail Sheet dated 1/7/24 showed the Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) who was also an RN was in the building for 4.98 hours. Review of a Daily Staffing Roster dated 1/13/24 showed no assigned RN coverage in the building. Review of an undated RN Coverage Data Sheet showed the Director of Nursing (DON) was the assigned RN coverage for 1/13/24. Review of a Payroll Detail Sheet dated 1/13/24 showed the MDS Coordinator was in the building for 3.75 hours. Review of a Daily Staffing Roster dated 1/20/24 showed the MDS Coordinator was the assigned RN coverage in the building for that day. Review of a Payroll Detail Sheet dated 1/20/24 showed the MDS Coordinator had no work hours for that date. Review of a Daily Staffing Roster dated 1/21/24 showed the MDS Coordinator was the assigned RN coverage in the building for that day. Review of a Payroll Detail Sheet dated 1/21/24 showed the MDS Coordinator was in the building for four hours. Review of a Daily Staffing Roster dated 1/27/24 and 1/28/24 showed no assigned RN coverage in the building. Review of a Payroll Detail Sheet dated 1/28/24 showed the MDS Coordinator was in the building for four hours. Review of a Daily Staffing Roster dated 2/3/24 showed no assigned RN coverage in the building. Review of an undated RN Coverage Data Sheet showed the Director of Nursing (DON) was the assigned RN coverage for 2/3/24. Review of a Daily Staffing Roster dated 2/4/24 showed RN Supervisor A was the assigned RN coverage in the building. Review of a Payroll Data Sheet dated 2/4/24 showed RN Supervisor A had no work hours for that date. Review of an undated RN Coverage Data Sheet showed the DON was the assigned RN coverage for 2/4/24. Review of a Daily Staffing Roster dated 2/10/24 showed no assigned RN coverage in the building. Review of a Daily Staffing Roster dated 2/17/24 showed RN Supervisor A was the assigned RN coverage in the building. Review of an undated RN Coverage Data Sheet showed RN Supervisor A was the assigned RN coverage for 2/17/24. Review of a Payroll Data Sheet dated 2/17/24 showed RN Supervisor A was in the building for 1.37 hours. Review of a Daily Staffing Roster dated 2/18/24 showed no assigned RN coverage in the building. Review of a Payroll Data Sheet dated 2/18/24 showed the MDS Coordinator was in the building for three hours. Review of a Daily Staffing Roster dated 2/24/24 showed no assigned RN coverage in the building. Review of an undated RN Coverage Data Sheet showed the DON was the assigned RN coverage for 2/24/24. Review of a Daily Staffing Roster dated 2/25/24, 3/2/24, 3/3/24, and 3/9/24 showed no assigned RN coverage in the building. Review of a Payroll Data Sheet dated 3/9/24 showed the MDS Coordinator was in the building for four hours. Review of a Daily Staffing Roster dated 3/10/24 showed no assigned RN coverage in the building. Review of a Payroll Data Sheet dated 3/10/24 showed the MDS Coordinator was in the building for two hours. Review of a Daily Staffing Roster dated 3/16/24, 3/17/24, and 3/23/24 showed no assigned RN coverage in the building. Review of a Payroll Data Sheet dated 3/23/24 showed the MDS Coordinator was in the building for 5.45 hours. Review of a Daily Staffing Roster dated 3/24/24, 3/30/24, and 3/31/24 showed no assigned RN coverage in the building. During an interview on 7/14/24 at 11:56 A.M. the DON said: -From the end of last year into the springtime the facility lacked RN coverage. -He/She had started to work at the facility some time in February this year and provided most of the RN coverage. During an interview on 7/17/24 at 10:34 A.M. Certified Nursing Assistant (CNA) E said: -The RN coverage was usually marked on the Daily Staffing Roster. -The DON provided the RN coverage most of the time. During an interview on 7/17/24 at 1:40 A.M. Licensed Practical Nurse (LPN) C said: -The MDS Coordinator and the DON provided most of the RN coverage. -The RN coverage was usually marked on the posted staffing sheets, but the sheet would not indicate who was the assigned RN. -He/She had been aware that the building lacked RN coverage in the past and it seemed to improve once the DON started. During an interview on 7/18/24 at 8:25 A.M. the MDS Coordinator said: -He/She and the DON provided the RN coverage in the building. -Whenever he/she was the assigned RN, he/she would stay in the building for at least eight consecutive hours. -He/She was unsure how the facility would indicate the RN coverage hours provided by the DON on the PBJ report due to the DON being a salaried employee. During an interview on 7/18/24 at 9:01 A.M. the Assistant Director of Nursing (ADON) said: -The DON and the MDS Coordinator were the RN coverage for the building. -He/She was unsure how the facility would indicate the RN coverage hours provided by the DON on the PBJ report due to the DON being a salaried employee. During an interview on 7/18/24 at 9:36 P.M. the Administrator said: -He/She thought the PBJ data report for Fiscal Year Quarter Two was accurate and reflected the facilities actual RN coverage in the building. -The facility had gone through multiple staffing coordinators, and they would have been the ones to mark the RN coverage on the Daily Staffing Roster during that time frame.

Based on interview and record review, the facility failed to submit the required staffing data to the Payroll Based Journal (PBJ- a report that provides staffing dataset information submitted by nursing homes on a quarterly basis) for two of the last four quarters which had the potential to affect all residents. The facility census was 53 residents. Review of the facility's undated policy titled Payroll Based Journal showed: -It is the policy of the facility to electronically submit timely to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data in uniform format according to specifications established by CMS. -The facility would submit direct care staffing information on the schedule specified by CMS, but no less than quarterly. -The reporting deadlines included: --Fiscal Quarter One (October 1- December 31): [DATE]. --Fiscal Quarter Two (January 1- March 31): May 15. --Fiscal Quarter Three (April 1- June 30): August 14. --Fiscal Quarter Four (July 1- September 30): November 14. -Responsibilities for data submission included: --The Administrator, HR Director, and Director of Nursing were responsible for verifying accuracy of the staffing data that was submitted to CMS using various facility audit forms and/or payroll vendor reports. --The Business Office Manager was responsible for verifying the accuracy of census [NAME] and collaborating with the Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) for any needed corrections. --The Designated individual or vendor was responsible for submitting data and obtaining validation reports. --The Administrator was responsible for reviewing validation reports and ensuring that any needed corrections were made before the quarterly deadline. 1. Review of the Fiscal Year Quarter Three 2023 report showed the facility had failed to submit the required staffing data for the quarter. Review of the Fiscal Year Quarter Four 2024 report showed the facility failed to submit the required staffing data for the quarter. During an interview on 7/18/24 at 8:27 A.M. the MDS Coordinator said he/she thought the admissions nurse, or the Administrator were the staff responsible for submitting the PBJ data. During an interview on 7/18/24 at 9:00 A.M. the Assistant Director of Nursing (ADON) said he/she thought Human Resources, or the Administrator were the staff responsible for submitting the PBJ data. During an interview on 7/18/24 at 9:33 A.M. the Administrator said: -He/She was responsible for submitting the PBJ staffing data. -The previous management company had not let him/her submit the PBJ data and it was the responsibility of someone higher up then him/her to submit the data. -He/She would not have been the one responsible for the data submissions for Fiscal Year Quarter Three 2023 or Fiscal Year Quarter Four 2024.