Every finding on record at Olive Branch Health and Rehabilitation Center

Based on observations, interview, and record review, the facility failed to ensure medications were stored securely for 10 of 15 residents observed. (Residents #2, #3, #4, #5, #6, #7, #8, #9, #10, #11)On 2/23/2026 at approximately 10:00 am, during a tour of the facility, medications were observed located on the bedside table in the rooms of Residents #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11. No staff were present in the rooms at the times observed.On 2/23/2026 at approximately 10:00 am, upon entering the room of Resident #8, the resident was observed seated in the room. A medication cup containing oral medication was noted on the bedside table. During the observation, Resident #7 picked up the medication cup and began taking the medications independently. No licensed nurse or staff member was present in the room at this time. Record review revealed no physician order authorizing self-administration of medication and no documented assessment of the resident's ability to safely self-administer medications for Resident #7.On 2/24/2026 at approximately 7:30 am, during a tour of the facility, medications were observed on the bedside table in the rooms of Resident #2, #3, #4, #5, #6, #7, #9. #10, and #11. No staff was present in the rooms at this time. On 2/24/2026 at approximately 1:00 pm, record reviews revealed no physician orders authorizing self administration of medication and no documented assessment of the resident's ability to safely self-administer medications for Residents #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11.On 2/24/2026 at approximately 8:00 am, Staff G, Registered Nurse, was observed during medication administration. The nurse followed standard medication administration practice. During the interview, Staff G mentioned medications are not to be left at bedside and residents must be observed swallowing all medications given in the presence of the nurse. She could not explain how the medications observed were left in the rooms

Based on observations and interviews, the facility failed to maintain posting of the daily staffing requirements at the beginning of the shift in a prominent place visible to residents and visitors for 2 of 4 days observed. The findings include: Upon tour of the facility on 4/6/25 and 4/7/25, there was no daily posting of the staff names in a prominent place for visitors and residents. On 4/7/25 at approximately 9:15 AM, an interview was conducted with the Staffing Coordinator, who indicated that she prints the staffing data to post daily on the counter behind the receptionist desk in the front lobby. The Staffing Coordinator further indicated that she lays it face up on the counter. When asked if the placement of the staffing posting is visible to residents and visitors, the staffing coordinator confirmed that placement would not be visible. She also stated that they used to keep it in a stand but they had stopped doing that for an unknown reason, but going forward it will be placed in the stand at the desk and will also place them at the nursing stations. On 4/7/25 at approximately 9:30 AM, an interview was conducted with the Administrator, who indicated that it was his expectation that the daily staffing requirement be placed in a stand up at the receptionist desk so that it would be visible to residents and visitors.

Based on observation, interviews, and policy review, the facility failed to ensure safe injection practices of intravenous medications by swabbing the rubber septum of the vial prior to accessing the medication for 1 of 12 residents sampled for medication administration. (Resident #71) The findings include: During a medication administration observation on 04/06/2025 at 1:03 pm, Staff A, a Registered Nurse (RN), administered Ertapenem (an antibiotic), 1 gram in 100 milliliters of normal saline, to Resident #71. The Ertapenam was contained in a glass vial with a rubber septum covered by a plastic cap. Staff A performed hand hygiene and popped the plastic cap off the vial using her bare hand. She then attached the vial to the 100 milliliter bag of normal saline without swabbing the rubber septum of the vial first. Staff A then administered the medication to Resident #71. In an interview afterwards, she acknowledged did not swab the top of the medication vial with alcohol before mixing with the bag of normal saline. In an interview on 4/06/25 at 3:16 PM, the Director of Nursing said the facility does not use multi-dose vials. During this interview, she was unable to recall if there was a policy which specifically included swabbing the rubber septum of the vial of medication with alcohol prior to accessing the medication and administering the medication. Review of the facility policy titled Parenterals/Intravenous Solutions dated October 2019 did not include language about wiping the rubber septum of a vial with alcohol swab prior to piercing the septum. The Centers for Disease Control and Prevention (CDC) Injection Safety Checklist dated February 7, 2024 and accessed on 04/06/2025 at 3:43PM included in the checklist The rubber septum on a medication vial is disinfected with alcohol prior to piercing.

Based on observation, resident interviews, and staff interview, the facility failed to provide a dining room to dine in for 1 out of 4 days observed. The findings include: A tour of the facility's dining area was conducted on Sunday, 4/06/25 at approximately 10:40AM. During this tour, the dining area was observed clean with dim lighting, and the tables were not set up to accommodate residents for lunch. An interview was conducted on 4/6/25 at approximately 12:15 PM, with the Certified Dietary Manager (CDM) concerning the fact that no one was eating in the dining room on Sunday during lunch. She stated that they were waiting for the facility to increase staffing for the weekend and that a plan is in the works. On 04/08/25 at approximately 11:25 AM, an interview was performed with Resident # 227 who was sitting at a dining room table reviewing the lunch menu to place an order. The resident stated, I have more options available here in the dining room then I do in my room. On Tuesday 04/08/25 at approximately 11:45AM, the dining area with was being used by about 15 residents throughout the dining area. Several dietary staff were tending to the resident's needs. On 04/09/25 at 11:00 AM, Dietician Tech C stated, I have been here since June 2022 and the dining room has not been open on the weekends as long as I have worked here. An interview was conducted on 4/09/25 at approximately 2:45PM, with the Administrator. The Administrator stated that the dining room was closed on the weekends due to short staffing, which was a result of the Center of Disease Control (CDC) COVID guidelines. However, it was shown that the CDC changed the guidelines 3 months ago. The Administrator stated that there was a meeting a couple of weeks ago to discuss the reopening of the dining room in two months. This would allow time to hire more staff, for the new food vendor to be in place, and new menus to be created.

Based on observations, interviews, and review of facility policy, the facility failed to maintain proper infection control for 1 of 3 residents sampled for COVID-19 isolation. (Resident #8) The findings include: A review of the electronic medical record for Resident #8 revealed an admitted [DATE]. Documentation revealed a diagnosis of COVID-19 dated 7/17/23. Further review revealed that the resident had orders for droplet isolation for 10 days, beginning on 7/17/23 and expiring on 7/27/23. On 7/24/23 at approximately 10:27 AM, an observation was made of Staff Member B, a housekeeper, exiting Resident #8's room. The only personal protection equipment (PPE) she was observed wearing was shoe protectors and a surgical mask. On the door of the room, a sign was posted for droplet precautions isolation, and an isolation cart noted outside the door of Resident #8's room. An interview was conducted with Staff B at this time. Staff B was asked if she donned a N95 mask while inside the room, she responded, no. Staff B stated that she was wearing a gown, shoe covers, eye wear and gloves, but that she did not see any N95 masks on the isolation cart so she did not put one on, just the surgical mask. When asked if it was the facility policy to wear a N95 mask while inside a COVID-19 isolation room, Staff B responded that it was. An isolation cart directly across the hall from Resident #8's room with a box of N95 masks located on the top of the cart was noted. When Staff B was asked why she did not use a N95 mask from the cart across the hall, she responded she did not think about that. On 7/24/23 at approximately 11:00 AM, an interview was conducted with the Director of Nursing (DON) concerning wearing the proper PPE for droplet isolation, the DON responded that it was her expectation for all staff to wear a N95 mask while in the droplet isolation room. A review of Policy titled Covid-19 Mitigation (May 2023), revealed, 1. Recommended routine infection prevention and control (IPC) practices for COVID-19. Under the section, Personal Protective Equipment (PPE), it states, HCP (health care personal) who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face).

Based on observations, record review and interview the facility failed to establish/maintain ongoing communication and collaboration with the [CONDITION(S)] facility, for 2 of 2 residents reviewed for [CONDITION(S)] services. (Residents #35 and #131). The findings include: Resident #35 A review of Resident #35 medical record was conducted which revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set, (MDS), dated [DATE] revealed Resident #35 received [CONDITION(S)] services. A review was conducted of Resident #35 paper chart, which failed to reveal [CONDITION(S)] communication forms, or [CONDITION(S)] treatment run sheets. An interview was conducted with Staff F, LPN, Supervisor on 8/23/22 at approximately 1:59 PM who stated the facility does not get the [CONDITION(S)] communication form back from the [CONDITION(S)] unit and stated she must call the [CONDITION(S)] facility to get the records faxed. Staff F, LPN stated the nurses should fill out the top of the [CONDITION(S)] communication form and send it to [CONDITION(S)] with the resident, then when the resident returns, the nurse should complete the bottom for the post treatment assessment, but further stated they are not getting the forms back. Staff F, LPN stated the nurses should take the vital signs and should assess the access site when the resident returns. A follow-up interview was conducted with Staff F, LPN, Supervisor on 8/24/22 at approximately 1:07 PM, who reviewed Resident #35 record and confirmed there were no [CONDITION(S)] communication form or [CONDITION(S)] treatment run sheets, and again stated the facility is having an ongoing problem receiving the communication from the [CONDITION(S)] center. A review of the outpatient [CONDITION(S)] services coordination agreement between the facility and [CONDITION(S)] unit, effective 6/1/18 was conducted. The agreement revealed under the subtitle, Mutual Obligations, both parties shall ensure that there is documented evidence of collaboration of care and communication between the Long-Term Care and End Stage Renal [CONDITION(S)] Unit. An interview was conducted with the DON and the Administrator on 8/25/22 at approximately 9:29 AM. The DON confirmed the facility has a difficult time receiving [CONDITION(S)] communication forms and confirmed the facility must call the [CONDITION(S)] unit in order to get the [CONDITION(S)] treatment run sheets. The DON stated unless there is someone at the [CONDITION(S)] center, they have a relationship with, they don't get the forms. The administrator was asked if management has intervened in resolving the communication concerns, and the administrator responded, what can we do, the residents need [CONDITION(S)]. The administrator stated the Registered Dietician can get weights because she has a relationship with the Registered Dietician. A telephone interview was conducted on 8/26/22 at approximately 10:05 AM with the Administrator of the [CONDITION(S)] center Resident #35 attends for treatment, who stated she has not seen any facility communication forms from the facility in a long while and further stated they are not allowed to complete the form. The administrator stated they can fax the [CONDITION(S)] treatment run sheet, but she has not had any requests for the documents. The administrator stated the dietician calls for weights, but she has not received any other calls. Resident #131 On 4/23/22 a record review was conducted for Resident #131. The resident receives hemodialysis treatments in the community on Mondays, Wednesdays and Fridays. The plan of care listed the intervention of communication between [CONDITION(S)] and facility to ensure the continuity of care. Returns with [CONDITION(S)] Transfer Form when returning to the facility. The record review showed there were only two [CONDITION(S)] Transforms. One for 8/1/22 and one for 8/19/22. On 8/24/22 at approximately 10:10 AM, an interview was conducted with Staff G, Registered Nurse and Assistant Director of Nursing, who stated there is an ongoing problem with dialyses not returning the forms. They have communicated with [CONDITION(S)] center to request the forms and are told they do not have to do that. A review of the policy Hemodialysis dated 1/2020 revealed the facility and the [CONDITION(S)] Center should maintain regular communication and should a change in condition occur before or during the [CONDITION(S)] treatment, the sending facility should communicate the changes in needs to the receiving facility.

Based on observation, interview, record review, and policy review the facility failed to review the Preadmission Screening and Resident Review (PASARR) for accuracy and update the form for 1 of 1 resident sampled for PASARR. (Resident #50). The findings include: On 8/22/22 at approximately 3:30 PM, an observation was made of Resident #50. She was noted to have limited cognitive, hearing, and verbal communication capabilities. A review of the admission record for Resident #50 revealed that she was admitted to the facility on [DATE] and had been diagnosed with an intellectual disability, developmental disorder of speech and language, a disorder of psychological development, anxiety disorder, and a mood disorder. The preadmission history completed at the hospital revealed that the resident had been residing at a group home for individuals with intellectual disabilities. A review of the PASARR form dated 5/26/22 was conducted. The form had a check in the box that indicated no diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Page 2 of the form had a check indicating that the resident had anxiety disorder. There is no check indicating any sort of intellectual disability. There was not a check in any box related to functional criteria. Additionally, there was no indication that the resident was currently receiving services for an intellectual disability. Section II of the PASARR form did not have any information indicating that Resident #50 had an intellectual disability. On 8/24/22 at approximately 2:10 PM, an interview was conducted with Staff Member V, Social Services. She was asked to explain the facility's process for reviewing PASARRs for accuracy. She explained that she does not do the PASARR'S that the Minimum Data Set (MDS) Department reviews them. If a PASARR does require a Level II, then she sets up the needed services. At this time, an interview was also conducted with Staff Member W, the Social Services Director, who explained that although she is new to her position, she believes that the MDS or admissions office reviews the PASARRs for accuracy. She reviewed Resident #50's PASARR and stated that it appeared to be incorrect based on Resident #50's reported history. On 8/24/22 at approximately 2:20 PM, a group interview was conducted with Nurse X, MDS Nurse, and the Director of the MDS Department. They explained that Staff Members S, Director of Community Relations, and Staff Member T, Admissions Coordinator, review the forms upon admission. After admission the PASARRs are reviewed by the social worker. The social services department notifies the MDS office when revisions are necessary. They explained that the MDS office only looks at the PASARRs when social services tells them to revise them. When a revision is necessary, the MDS office goes into the portal and completes the necessary revisions. Both staff members agreed that Resident #50's PASARR form was not accurate. On 8/24/22 at approximately 2:35 PM, a group interview was conducted with the Director of Community Relations and the Admissions Coordinator. They explained that the central admissions office gets the PASARRs when the hospital sends them, and that the MDS office should be checking them for accuracy. On 8/24/22 at approximately 3:00 PM, Nurse X, MDS Nurse, provided an amended PASARR form for Resident #50 with corrections indicating that the resident had an intellectual disability. 8/25/22 at approximately 9:00 AM, an interview was conducted with the Director of Central Admissions who confirmed that social services was responsible for reviewing the PASARR forms for accuracy. A review of the facility's Preadmission Screening (PASSAR/PASSR) policy was conducted. The policy states that a Level II PASSR must be completed if the individual has a primary or secondary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on record review, policy review and interview, the facility failed to obtain and document weekly weights as ordered by the physician for 1 of 2 residents reviewed for nutrition. (Resident #44) The findings include: Review of Resident #44's medical record revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Weigh prior to [CONDITION(S)], with a start date of 8/8/22. Review of the documented weights in the electronic medical record, (EMR), under the weights/vitals section was conducted on 8/23/22 which revealed the last weight documented was on 8/3/22. The documented weight was 85 pounds. There were no further weights documented. A review of the MAR (Medication Administration Record) revealed a check mark and staff initials on the scheduled days for weight, but no weights were documented. On 8/23/22 at approximately 1:40 PM an interview was conducted with Staff B, LPN, (Licensed Practical Nurse), who stated she does not know much about the nursing unit and was not sure when Resident #44 should be weighed. Staff B confirmed the weights should be in the EMR, and confirmed there was no weight book, or weights anywhere other than the EMR. On 8/23/22 at approximately 1:59 PM an interview was conducted with Staff F, LPN, supervisor, who stated the nurses should be documenting the weights in the EMR. Staff F, LPN stated Resident #44 has weights completed when she is at [CONDITION(S)], so the nurses would document those weights in the medical record. Staff F, LPN then stated the facility is having a difficult time getting the [CONDITION(S)] communication forms back from the [CONDITION(S)] centers and stated the communication forms or [CONDITION(S)] treatment records are filed in the resident's chart. Reviewed Resident #44 chart with Staff F. A [CONDITION(S)] communication form was found for 8/4/22 and for 8/13/22. There were no other communication forms in the record. Staff F, LPN stated she has to call the [CONDITION(S)] units to get the records. On 8/24/22 at approximately 9:39 AM an interview was conducted with the Registered Dietician who stated she recommended weekly weights for Resident #44, due the weight loss the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] #44. On 8/24/22 at approximately 11:56 AM an interview was conducted with the DON, (Director of Nursing) who revealed if there is an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/25/22 at approximately 9:29 AM a joint interview was conducted with the Administrator and the DON. The DON confirmed the facility is having a difficult time getting treatment documents from the [CONDITION(S)] units and stated sometimes they do not get the documents back for days to weeks. The Administrator stated the Registered Dietician was out the previous week, so they did not get weights from the [CONDITION(S)] unit. A review of the policy, Nutrition Protocol, no date, was conducted. The policy stated, all weights will be entered in the Electronic Medical Record on the MAR (Medication Administration Record) for daily/weekly weights or weight vital section in the EMR for admission/monthly weights. A review of the policy, hemodialysis, dated 1/2020 under section #10 revealed, The facility will utilize weights as provided by the [CONDITION(S)] Center to establish weights to be maintained in the resident's clinical record, unless otherwise indicated by physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, staff interview, record review and policy review, the facility failed to provide appropriate respiratory care by failing to change oxygen tubing at least weekly, failing to store respiratory equipment utilized for aerosol treatments in a clean container between uses, and failing to clean the filter on the oxygen concentrator for 1 of 2 sampled residents. (Resident #228) The findings include: On 8/22/22 at approximately 11:45 AM, Resident #228 was observed, she was receiving oxygen via nasal cannula at 3 liters per minute by way of an oxygen concentrator. The filter on the back of the concentrator was covered with a thick layer of a dusty substance. (Photographic evidence obtained). The nasal cannula did not have a date and there was no storage bag for the oxygen tubing at the bedside. Resident #228 also had a nebulizer machine at her bedside. The nebulizer tubing and the attached aerosol mouthpiece were stored in the top drawer of the bedside table uncovered. The nebulizer tubing was not dated, and no storage bag was available for the nebulizer mouthpiece or the tubing. On 8/24/22 at approximately 4:35 PM, an interview was conducted with Nurse K, Licensed Practical Nurse (LPN), who explained that normally oxygen and nebulizer tubing is changed weekly by central supply staff. She stated that the tubing should be stored in a bag and marked with the date the tubing was changed. She further stated that central supply staff also check and clean the filters on the oxygen concentrators. On 8/25/22 at approximately 10:00 AM, an interview was conducted with the facility's interim Director of Nursing (DON). She explained that central supply staff change the oxygen tubing once a week. A storage bag should be labeled, and the tubing should be stored in the bag. The DON agreed that the filter should have been cleaned and there should have been storage bags available for storage and to identify when the tubing had been changed. A review of the facility's Cleaning and Servicing Nebulizer procedure dated February 2016 was conducted. The procedure states that nebulizer mouthpiece should be rinsed with water and allowed to air dry on a paper towel and stored in an approved container between uses. The policy also states that tubing should be replaced weekly. A review of the [CONDITION(S)]/[CONDITION(S)] (bilevel positive airway pressure/continuous positive airway pressure) Devices/Non-Invasive Ventilation Devices procedure dated February 2016 was conducted. The procedure stated that washable filters should be cleaned once a week, more often if necessary. Tubing should be stored in an approved container between uses.

Based on observation, interview, record review and policy review, the facility failed to appropriately manage post-surgical pain for 1 of 1 resident sampled for pain management. (Resident #235) The findings include: On 8/24/22 at approximately 8:40 AM, an observation of Resident #235, during which he was grimacing in pain, restless, and tightly guarding his lower abdomen. He had difficulty moving up in the bed when Nurse H, Licensed Practical Nurse (LPN) tried to assist him up in the bed to take his medication. He complained of pain 10 on a 1-10 pain rating scale. Resident #235 said that the last dose of pain medication was given was about 1:00 AM, earlier that morning. He explained that he asked for pain mediation at about 4:00 AM and the nurse told him that he was out of the pain medication, and he has not had any medication since. At this time Nurse H, LPN explained that Resident #235 had run out of [MEDICATION(S)] on night shift. The Controlled Medication Utilization Record showed that the last dose of [MEDICATION(S)] 10 milligrams (MG) with Acetaminophen 325 MG had been signed out for Resident #235 on 8/24/22 at 1:14 AM, there were no more [MEDICATION(S)] 10 MG with Acetaminophen 325 MG tablets in stock to be taken after that dose was given. Nurse H, LPN went to the nurse communication book and retrieved an unsigned prescription for [MEDICATION(S)] 10 MG with Acetaminophen 325 MG tablet 1 tablet by mouth every 4 hours as needed. She explained that the new prescription had not yet been signed by a medical practitioner. At approximately 8:54 AM, Nurse H, LPN telephoned the medical provider and obtained an order to administer Acetaminophen 325 MG 2 tablets by mouth. She gave Resident #235 Acetaminophen (a non-narcotic pain reliever used to treat minor aches and pains) 325 MG 2 tablets by mouth. She explained to him that it would take a little time to obtain authorization from the medical provider and pharmacy before she could get the [MEDICATION(S)] 10 MG with Acetaminophen 325 MG, but she would bring it as soon as the process was complete. The surveyor asked Resident #235 if he could rate what his pain was earlier when he asked for pain medication at approximately 4:00 AM. The resident stated that his pain level was about an 8 on the 1-10 scale at that time. Nurse H, LPN forwarded the unsigned prescription to the medical provider for signature. She completed the Pharmacy Request for Removal of Schedule II to IV Medication from the emergency supply and faxed it to the pharmacy. At 9:23 AM, the pharmacy approved the faxed request. Resident #235 was given [MEDICATION(S)] 10 MG with Acetaminophen 325 MG 1 tablet by mouth for pain at approximately 9:30 AM. A review the resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's reported pain level was documented to be a 10 on a 1-10 scale at the time of administration. That dose of pain medication was documented to be effective on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan for Resident #235 stated that he was at risk for experiencing pain related to co-morbidities and recent surgery. The goal for Resident #235 was that he would verbalize relief from pain or show no signs or symptoms of pain as evidenced by facial expression or other non-verbal signs of pain. The listed action steps included that nurses should observe and document type, location, severity, and pattern of pain/discomfort and notify medical doctor (MD) or nurse practitioner (NP) of change. On 8/25/22 at approximately 10:15 AM, an interview was conducted with the Interim Director of Nursing. She was notified that Resident #235 did not receive pain medication after requesting pain medication on 8/24/22 at approximately 4:00 AM. The resident reported that he was told by Nurse R, LPN that he was out of medication. He did not receive pain medication until approximately 5.5 hours later, and approximately 8 hours after his last dose. The DON explained that the nurse should have called the medical provider and pharmacy to get authorization to administer pain medication to the resident and that the information should have been documented in the resident's record. A review of the facility's Pain Management Policy dated 3/2020 was conducted. The policy stated that if the resident's pain is not controlled by the current treatment regimen the practitioner should be notified. The policy also stated that patient's pain should be reassessed regularly. The Administration of Drugs policy updated 10/2019 stated that if a drug is withheld the physician should be notified.

Based on record review and interview, the facility failed to ensure the consultant pharmacist's recommendations were acknowledged with action to be taken to address the recommendation for 1 of 5 residents reviewed for drug regimen. (Resident #35) The findings include: A review of Resident #35 record revealed a diagnosis of [CONDITION(S)] with dependence on hemodialysis. A review of Resident #35 medication orders was conducted. The facility provided ordered medication Sevelamer and [MEDICATION(S)], both are [MEDICATION(S)] binders and [MEDICATION(S)] for appetite stimulation. A review of the consultant pharmacy recommendation dated 8/19/22 was conducted. The recommendation was related to Sevelamer and [MEDICATION(S)], the recommendation was to monitor labs every six months. The recommendation was signed by the Advanced Practice Register Nurse, (APRN), however, the APRN did not acknowledge whether to accept or decline the recommendation. A review of the recommendation dated 7/28/22 was conducted. The recommendation was related to [MEDICATION(S)] with a notation the medication has minimal effect on weight and is associated with adverse consequences. The recommendation was signed by the Advanced Practice Register Nurse, (APRN), however, the APRN did not acknowledge whether to accept or decline the recommendation. An interview was conducted with the Director of Nurses (DON) on 8/25/22 at 9:29 AM, who confirmed the two pharmacy consultant recommendation were not acknowledged with a decline or accept recommendations.

Based on interviews and record reviews, the facility failed to develop a process to ensure that Resident medications were ordered and administered in a timely manner for 1 of 3 residents sampled for administration of medication. The findings include: A record review for of the Order Summary Report for Resident #1 noted an order on 3/30/2022 for Hydralazine HCL Tablet 50 Mg (milligram) 1 tablet by mouth every 8 hours for hypertension. The order was scheduled on the Medication Administration Record to be administered at 6:00 AM, 2:00 PM and 10:00 PM. A review of the Medication Administration Record (MAR) for the administration of Hyrdralazine for the dates 4/17/2022 noted 2 consecutive doses (4/17/2022 at 6:00 AM and 4/17/2022 at 2:00 PM) were not administered. The reason documented for not administering the medication on those 4/17/2022 for the 6:00 AM dose medication not available. There was no reason documented for not administering the medication scheduled for 4/17/2022 at 2:00 PM. A record review for of the Order Summary Report for Resident #1 noted an order on 3/30/2022 for Minoxidil Tablet 2.5 mg give 2 tablet by mouth every 8 hours for hypertension. The order was scheduled on the Medication Administration Record to be administered at 6:00 AM, 2:00 PM and 10:00 PM. A review of the Medication Administration Record (MAR) for the administration of Minoxidil for the dates 4/17/2022 noted 4 consecutive doses (4/16/2022 at 2:00 PM, 4/16/2022 at 10:00 PM, 4/17/2022 at 6:00 PM, and 4/17/2022 at 2:00PM) were not administered. There was no documented reason for not administering the medication for the dose scheduled for 2:00 PM dose on 4/16/2022. The reason documented for not administering the medication on 4/16/2022 at 10:00 PM and 4/17/2022 at 6:00 AM was medication not available. There was no documented reason for not administering the medication for the dose scheduled for 2:00 PM on 4/17/2022. A record review of the Order Summary Report for Resident #1 noted an order on 3/30/2022 for Clonidine HCL Tablet 0.2mg give 1 tablet by mouth every 8 hours for hypertension. The order was scheduled on the Medication Administration Record to be administered at 6:00 AM, 2:00 PM and 10:00 PM. A review of the administration record for the administration of Clonidine HCL between the dates 4/16/2022 and 4/17/2022 noted 3 consecutive doses (4/16/2022 at 10:00 PM, 4/17/2022 at 6:00 AM and 4/17/2022 at 2:00 PM) were not administered. A review of the Medication Administration Record for the administration of Clonidine HCL between the dates of 4/25/2022 and 4/26/2022 noted 3 additional doses (4/25/2022 at 2:00 PM, 4/25/2022 at 10:00 PM and 4/26/2022 at 6:00 AM) were not administered. The reason documented for not administering the medication on 4/16/2022 at 10:00 PM and 4/17/2022 at 6:00 AM was medication not available. The reason documented on 4/17/2022 at 11:36 AM for not administering the 2:00 dose was Pharmacy will send. There was no follow up documentation of the dose being administered. The reason documented for not administering the 2:00 PM dose on 4/25/2022 was on order. The reason documented for not administering the 10:00 PM dose on 4/25/2022 was not available. The reason documented for not administering the 6:00 AM dose on 4/26/2022 was on order. A review of the Order Summary Report for Resident #1 noted an order on 4/8/2022 for Allopurinol Tablet Give 50 mg by mouth one time a day for gout. The order was scheduled on the Medication Administration Record to be administered at 8:00 AM. A review of the Medication Administration Record for Allopurinol on 4/25/2022 noted the dose was not administered. The reason documented for not administering the 8:00 AM dose on 4/25/2022 was on order. On 5/12/2022 at approximately 11:59 AM, an interview was conducted with Staff D, ADON during which she was shown the gaps in antihypertensive medication administration in the Medication Administration Record for Resident #1. She responded that those medications are in their breakout system in the medication dispensing system and that this was pure laziness. She said this would address this with staff.

Based on observations, interview, record review, and review of the facility policy, the facility failed to ensure staff who were exempted from the recommended COVID-19 vaccine took precautions to mitigate the transmission and spread of COVID-19. The facility failed to ensure employees wore the required Personal Protective Equipment (PPE) who were not up to date with all recommended COVID-19 vaccine doses. This failure had the potential to affect all residents and staff in the facility. Findings include: Review of the facility's policy titled, COVID-19 Vaccine Mandate for Staff, dated 03/11/22, revealed .ACCOMODATIONS FOR UNVACCINATED STAFF: Unvaccinated staff members with approved exemptions or approvals for delays must wear a facemask . (All staff must wear a facemask at this time due to our COVID-19 infection control guidelines.) Unvaccinated staff members with exemptions or approvals for delay in vaccination must continue wearing facemasks if the COVID infection control guidelines requiring masks use are removed . The policy did not specify what type of facemask unvaccinated staff were to wear. Observation and interview on 04/27/22 at 10:36 AM revealed Certified Nurse Aide (CNA) 3 was not vaccinated and had been granted a religious exemption. The CNA was wearing only a surgical mask. CNA3 stated she has been told she only needed to wear a surgical mask unless she was going into a COVID-19 room. The Director of Nursing (DON) was present and confirmed the observation of the CNA only wearing a surgical mask. Observation and interview on 04/27/22 at 10:39 AM revealed the Maintenance Director stated he was not vaccinated and had been approved for a religious exemption from the COVID-19 vaccination. The Maintenance Director was wearing only a surgical mask and stated that due to the religious exemption, he had to wear a surgical mask. The DON was present and confirmed the observation. During and observation and interview on 04/27/22 at 10:46 AM, CNA5 was observed in front of the South Main nurses' station wearing only a surgical mask. CNA5 stated she had been granted a religious exemption and had been told she had to wear a surgical mask at all times while she was in the building. The Assistant (ADON) was present during the observation and confirmed the CNA was wearing only a surgical mask. Review of the facility's untitled and undated staff matrix revealed CNA3, the Maintenance Director, and CNA5 were all identified as having been granted a religious exemption from the COVID-19 vaccination. Interview on 04/27/22 at 1:19 PM with the DON who was also the facility's Infection Preventionist (IP) revealed it was her expectation that staff who were unvaccinated and had an approved exemption would have a surgical mask on at all times while in the building. During an interview on 04/27/22 at 2:21 PM, the Administrator stated it was his expectation for nonvaccinated or exempt staff to wear a surgical mask at all times while they were in the building, while maintaining social distancing with other employees.

Based on observation, staff interview and policy review, the facility failed to ensure all medications were stored in locked compartments. The findings include: An observation of the B-2 hall physician office room was conducted on 6/14/21 at 1:53 PM. The room was unlocked and a yellow bag filled with prepackaged medications was observed on the floor in the corner behind the desk. The bag was labeled please return to pharmacy. Employee B (a Registered Nurse) returned to the room and stated it was her office. She stated she had gone to the restroom. She stated medications are usually stored in the medication room and these were brought to her from the other side of the building. Employee B confirmed she did not lock the door when she left the room and stated there was no key for the door. The facility policy for Storage of Medications (October 2019) was reviewed. Number 6 stated compartments containing drugs and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended. (Compartments include, but are not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.)

Based on observations, record review, staff interviews, and policy reviews the facility failed to implement infection control practices during resident care to prevent the development and transmission of disease and infections for 1 of 1 sampled residents on contact isolation (resident #26) and 1 of 2 observations of wound care (resident #33). The findings include: On 6/16/21 at 9:26 AM, employee A (certified nursing assistant) was observed to enter resident #26's room. Signage on resident #26's private room indicated the resident was on contact isolation and instructed staff must clean hands before entering and leaving the room, put on (don) gloves before room entry, put on gown before room entry. (Photographic evidence obtained) The employee failed to don a gown prior to entering the resident room. The employee was observed changing the linen on the resident's bed. Review of resident #26's record revealed a physician order dated 6/14/21 for contact isolation for ESBL (Extended Spectrum Beta-Lactamase) in urine. ESBL may be resistant to some antibiotics and most infections are spread by direct contact with an infected person's bodily fluids or by contact with contaminated equipment or environmental surfaces. An interview was conducted with employee A on 6/16/21 at 9:26 AM. Employee A stated resident #26 was currently on contact isolation. She stated staff are to don a gown and gloves before entering the room. She confirmed she made the resident's bed, to include removing soiled linen and forgot to put on a gown. Review of the facility policy for Isolation Precautions ( reveals for a resident on contact precautions clean gloves and gown should be worn when entering the room if you anticipate clothing will have substantial contact with the patient, environmental surfaces, or items in the patient's room, or if the resident is incontinent, has diarrhea, an [CONDITION(S)], a [CONDITION(S)], or wound drainage not contained by a dressing. On 6/15/2021 at approximately 2:00 PM, an observation was conducted of wound care for resident #33 with staff C, a Registered Nurse (RN). Staff C removed the soiled dressing, changed gloves from soiled to clean without performing hand hygiene in between. Staff C was also observed placing wound care scissors on a disposable barrier without cleaning the scissors. Staff C completed wound care and then placed the scissors back in a personal bag without cleaning them. On 6/15/2021 at approximately 2:30 PM, an interview was conducted with staff C, after she had completed the wound care for resident #33. When questioned if her scissors were cleaned prior to placing on the barrier, staff C stated she always cleaned her scissors prior to placing in bag. When questioned did she clean them after performing wound care and prior to placing them in her bag, staff C confirmed she did not. She was questioned about performing hand hygiene in between changing gloves staff C confirmed she did not wash her hands in between changing gloves. A review was conducted of the facility policy titled Dressings, Non-Sterile(April 2019) page 6 of 17 item 12 states pull glove over dressing and discard into appropriate receptacle, Item 13 states wash hands or sanitize hands with ABHR (alcohol based hand rub) if not visibly soiled. Item 14 states put on clean gloves.

Based on observations, interviews, record and policy reviews, the facility failed to report grievances for 2 of 4 residents sampled for grievances (#5 and #12). The findings include: A record review for resident #5 included the following note dated 6/1/2020 at 6:49PM, created by nurse H, a Registered Nurse (RN): Resident has had multiple complaints regarding evening meals, offered to warm coffee and tray for resident. Resident was not receptive and stated that she was speaking with her daughter about all of her concerns. Resident stated I am going to be taking legal action against this facility. Encouraged resident to speak with administration in regards to her concerns. A review of the facility grievance log did not contain any grievances regarding resident #5. On 10/20/2020 at approximately 8:25AM, an observation was made of the interaction between nurse B, a Licensed Practical Nurse (LPN) , and resident #12. Resident #12 told nurse B, LPN, he was very upset and had called for assistance to use the restroom over an hour ago. Nurse B, LPN, asked resident #12 if he requested assistance before or after breakfast trays were served. Resident #12 said it had nothing to do with breakfast and nurse B replied, when the trays are being passed we have to do that, we try to get you to the potty before or after. Nurse B, LPN informed resident #12 there were a couple more trays to be picked up from breakfast and then someone would be in and asked if there was something she could do to assist him immediately. Nurse B, LPN, informed resident #12 of the certified nurse assistant assigned to help him that day and resident #12 replied I don't want to include her in this, she's great, but I am not happy about waiting for over an hour. The others, they come and poke their head in and say they'll be back to help you and (made an exiting motion with his arm) off they go and you never see them again. On 10/20/2020 at approximately 10:49AM, an interview was conducted with Nurse B, LPN, concerning how nursing staff are to handle resident grievances. Nurse B stated If there is a grievance, I tell the supervisor and let them handle it. I haven't ever had to help a resident to fill out a grievance. I bring issues to the supervisor. On 10/20/2020 at approximately 11:10AM, an interview was conducted with the Staff member D, the Clinical Services Assistance Director for the south unit, during which she stated that there was a grievance report and staff were supposed to write down the concern, anybody can take the report, but usually the nurse or a supervisor does it. Staff member D demonstrated by showing a blank grievance report and explained how it was to be filled out and added staff are to fill it out and turn it in. A review of the grievance policy, dated December, 2016 indicated in the case of a verbal grievance, the person receiving the grievance will document the grievance on the Grievance Report. All Grievance Reports will be forwarded to the Grievance Officer for investigation initiation and follow through.

Based on interview and facility document review, the facility failed to ensure that all Immediate Reports submitted to the State Agency, were followed up with a 5-day report to include investigation and corrective action for 1 of 5 reviewed. (Resident #6) The findings include: A review was conducted of the facility's federal reported events for the current year which revealed that five reports had been submitted. Of these reports one (Resident #6) was an Immediate Report submitted on 03/02/2020 that failed to include the submission of a 5-day report that included the investigation of the event and the appropriate action taken. On 10/19/2020 at approximately 1:00 PM, an interview was conducted with the Administrator, who stated that he was responsible for submitting the federal reports. He was asked for the 5 day report for the event occurring on 03/02/2020 involving resident #6. The Administrator went to go look for the report and returned stating that it failed to be submitted. He presented documentation that the 5-day report was submitted on 10/19/2020. A review of the facility's Risk Management Abuse / Reporting Manual failed to address the submission of a 5-day report to the State Agency, following an investigation and corrective action.

Based on staff interview and employee file review the facility failed to ensure 2 of 2 sampled certified nursing assistants (employees C and D) had dementia training annually. The findings include: A review of two certified nursing assistant training files failed to find required dementia training annually. Employee C was hired 12/12/18 and Employee D was hired 5/7/18. The staff development registered nurse RN (Employee G) was interviewed on 1/9/2020 at 2:24 PM. She was asked to provide the dementia training for Employee C and Employee D. She said she would check. She returned at approximately 2:45 PM, and stated we do not had any dementia training in place annually for certified nursing assistants. Employee C and D and that the facility had no other training that could be found for dementia.

Based on observation, staff interviews and policy reviews, the facility failed to ensure staff prepare food under sanitary conditions during 1 of 2 observations of meal preparation. (Evening meal on 2/4/19) The findings include: Observation of meal preparation was conducted in the kitchen on 2/4/19 at approximately 6:38 PM. Employee A (dietary staff) was observed to be placing plates of food on food trays within a cart, covering the plates with a plastic lid, placing beverages on the trays and placing utensils on the trays. Employee A had long, dark hair with multiple braids to her waist and was not wearing a hair restraint. An interview was conducted with employee A at this time; she stated she was required to wear a hair restraint in the kitchen and it must have fell off. An interview was conducted with the employee B (dietary manager) on 2/6/19 at 7:46 AM. Employee B stated when staff are in the kitchen they are to wear a hair net. The facility policy for hair nets was reviewed. The policy stated per food code requirements, all associates who work in the dietary department with unpackaged food, clean equipment or utensils or food contact surfaces will wear proper hair restraints to prevent hair from contacting exposed food, clean equipment, utensils, linen and unwrapped single service and single use articles.

Based on observation, resident interview, staff interview and policy review the facility failed to ensure all medications were stored in locked compartments for 1 of 24 sampled residents. (resident #24) The findings include: Observation of resident #24's bathroom was conducted on 2/5/19 at 10:56 AM. A partial tube of [MEDICATION NAME]-[MEDICATION NAME] cream was observed on the sink counter. The resident stated the staff were aware the cream was in the bathroom and it was for a rash. An interview was conducted with employee C (Licensed Practical Nurse) on 2/6/19 at 11 AM. Employee C observed the cream on the sink counter and stated the cream should not be kept in the bathroom; it should be locked in the treatment cart. The facility policy for storage of medications was reviewed. The policy stated drugs and biologicals should be stored in a safe, secure, and orderly manner.