Every finding on record at Oregon Care Center

Based on observation and interview the facility failed to prepare and serve food in accordance with professional standards of food service when the facility failed ensure the kitchen and dining room were in good repair. The facility census was 46.The facility did not provide the requested policy on repairs of the kitchen and dining room. 1.Observation on 12/02/25 at 12:23 P.M., showed:-A black substance on the wall behind sink in the dish area;-Five broken tiles and two missing tiles under the dishwasher;-The exit door leading into the dining room by the steam table with black stains along the edges and a black area around the door knob; -The doors to the dry storage with a brown substance and black stains on the bottom of the doors;-Seven broken floor tiles under and around the steam table;Observation of the dining room on 12/2/25 at 12:55 P.M., showed:-The cabinet under the sink in the dining room with missing paint and damaged wood on the bottom of it;-Black rings the size of basket balls on two ceiling tiles by the exit door;-Window blinds on all windows broken;-Eight dining room chairs with ripped seats and foam exposed.2.Review of Resident #13's Quarterly Minimum Data Set (MDS) a federally mandated assessment tool completed by facility staff, dated 9/03/25 showed:-The resident had no cognitive impairment;-Supervision with Activities of Daily Living (ADL)s;-Diagnoses included, diabetes, high blood pressure and anemia.Review of the resident's care plan dated 10/12/25 showed the resident required supervision with ADLs.During an interview on 12/3/25 at 1:45 P.M., Resident #13 said:-The broken chair's are uncomfortable to set in;-It would be nice to have blinds that are not broken to look at during meals.During an interview on 12/03/25 at 1:45 P.M., the Maintenance Supervisor said:-He is responsible for the repairs in the kitchen and dining room;-He said the kitchen and dining room should be in good repair;-He said the dining room chairs needed to be replaced because they were torn and uncomfortable;-He said he was trying to get the repairs completed but had not had time.During an interview the Administrator said:-She expected the kitchen and dinging room to be in good repair;-She expected the dinging room furniture to be in good repair and comfortable;-She expected the window blinds to be in good repair and clean;-The Maintenance supervisor is responsible for repairs to the kitchen and ding room.

Based on interview and record review, the facility failed to inform residents and/or their responsible parties, in advance of the risks and benefits of proposed care. When the facility failed to obtain written consent before beginning psychotropic medications (medications that affect the mind, emotions, and behavior) for two Residents (Resident #5, and Resident #7) of the 12 sampled residents. The facility census was 46. Review of the facilities Use of Psychotropic Medications policy, dated 5/9/25, showed: Prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medication in advance of such initiation or increase. 1. Review of Resident #5's Significant Change in Status Minimum Data Set (MDS) a federally mandated assessment tool completed by facility staff, dated 9/25/25, showed:The resident had a worsening change in behavior since the previous assessment;The resident had disorganized thinking that changed in severity;The resident had a diagnosis of: anxiety, depression, Schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions), and non-Alzheimer's Dementia.Review of the Resident's Care Plan, revised 9/23/25, showed:The resident was dependent on staff for meeting emotional, intellectual, social, and physical needs;The resident used anti-anxiety medication;The resident was on antipsychotic and antidepressant medication (medications used to treat mental health disorders and depression).Review of the Physician's Order Sheet, dated November 2025 through December 2025, showed:The resident's order for olanzapine 2.5mg (milligram) by mouth at bedtime (an antipsychotic medication) began on 3/5/25;The resident's order for bupropion 75mg by mouth in the morning (an antidepressant medication) began on 3/5/25;The resident's order for venlafaxine 150mg by mouth once a day (an antidepressant medication) began on 4/10/25;The resident's order for venlafaxine 75mg by mouth one time a day began on 4/10/25.Review of the residents medical record on 12/3/25 showed the facility did not have any record of a consent form for the resident regarding the use of psychotropic medications.2. Review of Resident #7's Quarterly MDS, dated [DATE], showed:The resident reentered the facility from an inpatient psychiatric facility;The resident had a diagnosis of: Depression, schizophrenia, and traumatic brain injury.Review of the Resident's care plan, revised 9/17/25, showed:The resident had a communication problem related to a traumatic brain injury;The resident used psychotropic medications related to schizophrenia and depression;The resident was dependent on staff for social, intellectual, emotional, and physical needs.Review of the Physician's Order Sheet, dated November 2025 through December 2025, showed:The resident's order for amitriptyline 100mg by mouth at bedtime (an antidepressant medication) began on 7/12/24;The resident's order for risperidone 2mg by mouth two times a day (an antipsychotic medication) began on 7/12/24;The resident's order for venlafaxine 75mg two capsules one time a day by mouth (an antidepressant medication) began on 11/20/24.Review of the residents medical record on 12/3/25 showed the facility did not have any record of a consent form for the resident regarding the use of psychotropic medications.During an interview on 12/04/2025 at 12:43 P.M. Licensed Practical Nurse (LPN) A said he/she was not sure when or if consents for psychotropic medications needed to be signed by the resident or the resident's responsible party. During an interview on 12/04/2025 at 12:43 P.M. the Director of Nursing (DON) said consents only need to be signed if a resident is started on a new medication or has a dosage change.During an interview on 12/04/2025 at 12:57 P.M. the DON said She should have interpreted the facilities policy as when the resident is initially admitted to the facility a consent needs to be signed for psychotropic medications. During an interview on 12/04/2025 at 12:57 P.M. the Administrator said she interpreted the policy wrong and consents for psychotropic medications should have been signed for all resident's or by their responsible party when admitted to the facility.

Based on observation and interview, the facility failed to maintain the resident's right to personal privacy and confidentiality of his or her personal and medical records when CMT (Certified Medication Technician) A walked away from the computer on the medication cart leaving confidential resident information open on the computer screen. This affected three (Resident #7, #16, and #32) of 12 sampled residents. The facility census was 46.Review of the Nursing Home Resident Right's policy, undated, showed: -Resident's have a right to privacy regarding personal, financial, and medical affairs;-Resident's have a right to privacy during treatment and care of personal needs. 1. Review of Resident #32's Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 10/19/25, showed:- The resident was taking diuretic (a medication that assists the body with getting rid of excess fluid and salt), hypoglycemic, and antiplatelet (medication that prevents blood clots from forming) medication;- The resident had a diagnosis of: mild cognitive impairment, primary hypertension (abnormally high blood pressure), and Type One Diabetes (a chronic condition where the pancreas does not make insulin). Review of the Resident's care plan, revised 9/11/25, showed:- The resident had an activities of daily living deficit due to limited mobility;- The resident was at risk for falls due to balance problems;- The resident had acute pain due to multiple rib fractures. Observation on 12/03/2025 at 4:10 P.M. showed CMT A left the computer screen on the medication cart open, unlocked, and visible to anyone who walked by the medication cart to view confidential information when he/she walked into the resident #32's room. 2. Review of Residents #16's Quarterly MDS, dated [DATE], showed:- The resident was taking anticoagulant (blood thinning medication) and antiplatelet (medication that prevent blood clots from forming) medications;- The resident had a diagnosis of: visual loss, hypertension, and heart failure. Review of the Resident's care plan, revised 11/11/25, showed:- The resident was dependent on staff for meeting emotional, intellectual, physical, and social needs;- The resident required assistance with activities of daily living due to blindness;- The resident had a communication problem related to a hearing deficit. Observation on 12/03/2025 at 4:25 P.M. showed CMT A left the computer screen on the medication cart open, unlocked, and visible to confidential information when he/she walked into the resident #16's room. 3. Review of Resident #7's Quarterly MDS, dated [DATE], showed:- The resident was taking antipsychotic, antidepressant, and anticoagulant medication;- The resident had a diagnosis of: traumatic brain injury, depression, and hypertension. Review of the Resident's care plan, revised 9/19/25, showed:- The resident was dependent on staff for meeting physical, emotional, and social needs;- The resident had an activity of daily living self-care performance deficit related to paralysis to the left side;- The resident had a communication deficit related to a traumatic brain injury. Observation on 12/03/2025 at 4:27 P.M. showed CMT A left the computer screen on the medication cart open, unlocked, and visible to confidential information when he/she went into the shower room. During an interview on 12/03/2025 at 5:03 P.M. CMT A said he/she knows not to leave the computer screen open with resident information visible when passing medications and should have closed the computer screen. During an interview on 12/04/2025 at 12:43 P.M. LPN A said the computer screen is not supposed to be left open when walking away from the medication cart, it either needs to be locked or on privacy mode. During an interview on 12/04/2025 at 12:57 P.M. the Director of Nursing (DON) said staff are not to leave the computer screen open with resident information visible when walking away from the medication cart. During an interview on 12/04/2025 at 12:57 P.M. the Administrator said she tells staff to minimize the computer screen or shut the laptop before walking away from the medication cart, it should not be left unattended.

Based on observation and interview the facility failed to provide a safe, comfortable and homelike environment. This affected all residents. The facility census was 46. Review of the facility's Safe and Homelike Environment Policy, dated 6/15/25 showed:-The facility will provide a safe, clean, comfortable and homelike environment;-Environment refers to any place in the facility that is frequented by residents, including dining areas and hallways.Review of the facility's Resident Environmental Quality Policy, dated 6/15/25 showed:-The facility shall be equipped and maintained to provide a safe, functional, and comfortable environment for the residents;-The facility will provide maintenance of the building to maintain a safe and homelike environment.Review of the facility's Handrails Policy, dated 6/15/25 showed routine maintenance on handrails will be completed by the maintenance department.Observation of the facility on 12/03/25 at 10:10 A.M., showed:-The base board heater between room [ROOM NUMBER] and room [ROOM NUMBER] was dented, bent out of shape and protruded into the hallway;-The base board heater between room [ROOM NUMBER] and 213 was dented, bent out of shape and protruded into the hallway;-The handrail on the right side of the hall outside the dining room was chipped and splintered when touched;- A piece of drywall was missing in the hall between room [ROOM NUMBER] and room [ROOM NUMBER];-The handrail between room [ROOM NUMBER] and 207 had missing paint and splintered when touched;-The handrail on the left side of the fire doors had missing paint and splintered when touched.During an interview on 12/03/25 at 12:58 P.M., the Maintenance Supervisor said:-He is responsible for the repairs to the walls, handrails and baseboard heaters in the facility;-All areas of the building should be in good repair;-He had not had time to complete the needed repairs.During an interview on 12/03/25 at 1:17 P.M., the Administrator said;-She expected all areas of the building to be in good repair;-She expected the maintenance department to complete these repairs.

Based on interview and record review the facility failed to maintain the resident's highest practicable level of physical, mental and psychosocial well-being that prevents or minimizes adverse consequences related to medication therapy to the extent possible, by providing oversight by a licensed pharmacist for three residents (Resident #5, #24, and #19) of the 12 sampled residents, when the facility to complete and follow the recommendations for a medication review. The facility census was 46.The facility did not provide the requested policy regarding Drug Regimen Reviews. Review of the facility's Gradual Dose Reduction of Psychotropic Drugs policy dated 6/6/25 showed that residents who use psychotropic drugs will receive gradual dose reductions unless clinically contraindicated. 1. Review of Resident #24's Quarterly Minimum Data Set (MDS) a federally mandated assessment tool completed by facility staff, dated 11/15/25 showed:-Severe cognitive impairment;-Antipsychotics administered to the resident;-Diagnoses included dementia and heart failure. Review of the resident's care plan dated 11/15/25 showed:-Impaired cognitive function related to dementia;-The resident received Seroquel (used to treat mental health conditions) for dementia. Review of the resident's medical record showed:- Physicians Order Sheet (POS) dated, 12/31/25 with an order for Seroquel 100 milligrams (mg) before bed with a start date of 9/19/25 with no diagnosis for use;-Review of the residents Medication Administration record dated (MAR), 12/31/25 with an order for Seroquel 100 mg give before bed, with no diagnosis for its use;-Consultant pharmacist recommendation dated 10/18/25 that showed the resident was receiving the antipsychotic agent Seroquel but lacked an allowable diagnosis to support its use;-No record that the physician had addressed the pharmacy recondensation was found. 2.Review of Resident #19's Quarterly MDS dated [DATE] showed:-No cognitive impairment;-Anticonvulsant medication administered;-Diagnoses included, seizure disorder, diabetes and depression. Review of the resident's care plan dated 9/15/25 showed:-The resident took medication for seizure disorder;-Obtain labs per physician's order and notify the physician of results. Review of the resident's medical record showed:-POS dated 12/31/25 with an order for Keppra (used to treat seizures) 750 mg two times daily;-The resident's MAR dated 12/31/25 with an order for Keppra 750 mg two times daily;-Pharmacy recommendation sheet dated 10/28/25 showed lab work is ordered but cannot be located in the medical record for a Keppra level on the next lab day and every three months;-No record that the physician had addressed the pharmacy recommendation was found;-No lab order for the Keppra level to be drawn was found;-No lab results for the Keppra level were found. 3. Review of Resident #5's Significant Change in Status Minimum Data Set (MDS) a federally mandated assessment tool completed by facility staff, dated 9/25/25, showed: The resident had impaired cognition and decision making; The resident had difficulty focusing during assessment that fluctuated; The resident had a diagnosis of non-Alzheimer's Dementia, anxiety, depression, and schizophrenia. Review of the Resident's care plan, revised 9/23/25, showed: The resident was dependent on staff for meeting physical, social, emotional, and intellectual needs; The resident used anti-anxiety medication; The resident used antipsychotic and antidepressant medication. Review of the Resident's Physician Order Sheet, dated November 2025 through December 2025, showed the resident's order for venlafaxine 75mg by mouth once a day began on 4/10/25 and the resident's order for venlafaxine 150mg by mouth once a day began on 4/10/25. Review of the Resident's Medication Regimen Review, dated 10/28/25, showed: The resident had been taking venlafaxine 225milligrams (mg) (150mg + 75mg) once daily since (an antidepressant medication) 4/10/24 without a gradual dose reduction; The pharmacist recommended an attempt of a gradual dose reduction to determine if the resident was on the lowest possible dose; The pharmacist requested a response with a reason why if the gradual dose reduction was not able to be completed; Did not show any documentation the information was sent to the physician or if the physician responded. During an interview on 12/3/25 at 9:18 A.M., the Director of Nursing (DON) said:-She is responsible for completing the pharmacy recommendations and getting them to the physician;-The recommendations should have been reviewed by the physician within 48 hours and any new orders followed;-Gradual dose reductions should be completed on residents who take psychotropic drugs unless it is contraindicated. During an interview on 12/3/25 at 10:09 A.M., the Administrator said:-Medication regimen reviews should be completed every month on all residents;-She expected the DON to ensure medication regime reviews were being completed ;-She expected the DON to ensure pharmacy recommendations to be addressed within 48 hours by the physician.

Based on observation and interview, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls when the facility failed to ensure that three bottles of lorazepam, a schedule IV medication (a controlled medication used to treat mood and behavior), was secured behind two locks. The facility census was 46. Review of the facilities Medication Storage policy, dated 5/9/25, showed: Schedule II drugs and back-up stock of schedule III, IV, and V medications are stored under double-lock and key. Observation of the medication room on 12/02/2025 at 4:17 P.M. showed:- Medication refrigerator that contained three bottles of liquid lorazepam was not locked;-The lock for the medication fridge was sitting on a counter in the medication room;- A piece of the locking mechanism on the fridge in the medication room was not attached to the fridge. During an interview on 12/02/2025 at 4:17 P.M. Certified Medication Technician (CMT) B said the lock for the fridge had been broken for awhile, not sure how long. During an interview on 12/02/2025 at 4:25 P.M. the Administrator said she was not aware that the lock for the fridge in the medication room was broken. During an interview on 12/02/2025 at 4:30 P.M. the Administrator said a piece of the locking mechanism was not attached to the fridge so the lock would not work. During an interview on 12/03/2025 at 5:03 P.M. CMT A said he/she did not know the lock on the fridge in the medication room was broken. During an interview on 12/04/2025 at 12:28 P.M. CMT C said he/she had heard that the lock was broken on the fridge in the medication room. During an interview on 12/04/2025 at 12:43 P.M. Licensed Practical Nurse (LPN) A said he/she was not sure how long the lock on the fridge in the medication room had been broken.

Based on interview and record review, the facility failed to complete a reassessment of the Level I preadmission screening resident review (PASARR) assessment (used to identify individuals with mental illness or intellectual/developmental disabilities completed before admission to the nursing facility and when a resident had a new diagnosis of a mental illness) for one (Resident #5) of the 12 sampled residents, when the resident had a new diagnosis of a serious mental illness. The facility census was 46. Review of the facilities Resident Assessment- Coordination with PASARR Program policy, dated 6/30/25, showed: Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. A negative Level I Screen permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later. 1. Review of Resident #5's Significant Change Minimum Data Set (MDS) a federally mandated assessment tool completed by facility staff, dated 9/25/25, showed:- The resident had disorganized thinking;- The resident had difficulty focusing attention;- The resident had a diagnosis of: Non-Alzheimer's Dementia, anxiety, depression, and schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, and emotional responsiveness). Review of the Resident's care plan, revised 9/17/25, showed:- The resident was dependent on staff for meeting physical, social, and emotional needs;- The resident used psychotropic medications related to mood disorder, schizoaffective disorder, and major depressive disorder;- The resident used anti-anxiety medications. Review of Resident #5's admission MDS, dated [DATE], showed: The resident did not have a diagnosis of schizophrenia at the time the admission MDS was completed. Review of the Resident's Level I PASARR, dated 8/19/21, showed: - The resident did not show any signs or symptoms of a major mental disorder;- The resident was not diagnosed as having a major mental disorder;- The resident did not qualify for a Level II Screening. Review of the resident's current Diagnosis Report, dated 12/4/25, showed: The resident had a diagnosis of schizoaffective disorder with an onset date on 3/28/25. During an interview on 12/04/2025 at 12:57 P.M. the Administrator said:- Resident #5 had a diagnosis of schizoaffective disorder since he/she was admitted when the initial level I PASARR was completed;- Some resident information did not transfer over in the charting system when the new company took over. - A new PASARR should have been completed.

Based on interviews and record review, the facility failed to protect the resident's right to be free from physical abuse when Resident #1 entered Resident #2's room and kicked Resident #2 in the shin resulting in pain and redness for Resident #1. The deficient practice affect one of four sampled residents. The facility census was 41. On 1/28/25, the Administrator was notified of the past noncompliance situation which occurred on 1/28/25. On 1/28/25, facility administration was notified of the incident, an investigation immediately began and corrective actions were implemented. The noncompliance was corrected on 1/30/25. Review of the facility's policy titled, Abuse and Neglect, revised 9/24, showed: - It is the policy of this facility to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/event in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person; - Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish; - Physical Abuse: Physical action within the definition of abuse, including, but not limited to, hitting, slapping, pinching, and kicking; - The home's administration will prohibit neglect, verbal, mental or physical abuse. Review of the facility's policy titled, Abuse and Neglect Procedure, revised 9/24, showed: - All new employees will receive in-service training pertaining to all aspects of abuse prohibition before working a shift; - All current employees will receive in-service training pertaining to all aspects of abuse prohibition at least annually; - Training will include: identification of potential victims of abuse or neglect, appropriate interventions to deal with aggressive and stubborn residents; - Administrative and licensed staff will be aware of potential situations of abuse during rounds and contact with staff, residents, and resident family members; - Protection: All residents will be immediately protected from harm, if another resident is the alleged perpetrator they shall immediately be assessed for treatment options; 1. Review of Resident #1's Admission Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 10/15/24, showed: - Resident has the diagnosis of hypertension (high blood pressure), diabetes (chronic disease when body can't produce insulin), thyroid disorder (a condition where the thyroid gland produces an abnormal amount of thyroid hormones), dementia (decline in cognitive abilities); - Resident scored seven on the BIMS (Brief Interview for Mental Status). This score indicates severe cognitive impairment; Review of Resident #1s comprehensive care plan, dated 10/22/24 showed: - Resident has an ADL self-care performance deficit due to dementia and limited mobility; - Resident uses a wheelchair for mobility and walker; - Resident is an elopement risk/wanderer and wanders aimlessly. Staff are to distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television and books; - Resident has potential to be physically aggressive due to dementia (revised 1/29/25); - Staff monitor/document/report as needed any incident of resident posing danger to self and others; (revised 1/28/25); - Staff anticipate and meet the resident's needs; - Resident uses psychotropic medications for dementia, staff monitor/record occurrence of behavior symptoms (wandering, violence/aggression towards staff/others). Record review of Resident #1s progress notes showed: - 1/13/25 resident had behaviors of yelling out for their family member; - 1/22/25 resident had behaviors of yelling for staff for assistance; - 1/25/25 resident had behaviors of yelling; Review of Resident #2s comprehensive care plan, dated 11/13/24 showed: - Resident is able to voice their concerns and their memory is good; - Resident is at risk for impaired skin integrity. Review of Resident #2's quarterly MDS, dated [DATE], showed: - Resident has the diagnosis of hypertension, coronary artery disease (condition in which the arteries that supply blood to the heart become narrowed or blocked), heart failure (heart cannot pump enough blood to meet the body's needs), renal insufficiency, depression; - Resident is cognitively intact. Review of the facility investigation, undated, showed events on 1/28/25: - Resident #2 reports that Resident #1 wheeled into his/her room and yelled at Resident #2 to leave the room; - Resident #1 then wheeled up to Resident #2 and kicked him/her in the shin; - Resident #2 stated that staff arrived and removed Resident #1 from the room; - Resident #2 had a reddened area to the shin and ice was applied by the nursing staff; - Nurse Aide (NA) A heard Resident #2 yelling and went immediately to intervene and remove Resident #1 from Resident #2's room; - Director of Nursing (DON) was immediately notified; - The kick was not witnessed by staff or any other residents; - Resident #1 could not remember the incident when asked about it after being removed from the room; - Interventions put in place: Stop sign barrier across the front of resident #2's doorway entrance held in place by Velcro, resident #1 place on 30 minute checks to monitor for location and needs, primary care physician contacted and ordered Depakote (a medication to treat behaviors) for resident #1 due to aggressive behavior; - Resident #2 assessed each day with no bruising, redness or skin issues noted; - Director of Nursing (DON) reports Resident #1 has been acutely ill for the last several weeks with influenza, pneumonia, and hypoglycemia. Resident was in the hospital the prior week and had been given Haldol (a strong medication typically used to treat behaviors. Upon readmission he/she demonstrated increased behaviors, such as yelling for help, exit seeking and falls. He/She has slowly been improving; - The investigation did not include dates. Review of in-service education, dated 1/30/25, showed staff were educated on Abuse and Neglect policy and reporting and Resident to resident altercations. During an interview on 2/6/25 at 10:00 A.M., the Resident #2 said: - Resident #1 entered his/her room and immediately yelled at him/her to leave. Resident #2, while in their wheelchair kicked Resident #1 in the shin and left the room with the help of staff. Resident #1 never said anything during the altercation; - The injury he/she received from Resident #1 hurt after that first day of when it occurred and he/she experienced pain; During an interview on 2/6/25 at 10:15 AM., Certified Medication Technician (CMT) A said: - He/She was present at the time of the incident and had spoken to Resident #1 after they were removed from Resident #2's room. Resident #1 could not recall the incident or kicking Resident #2 shortly after the incident; - Resident #2 said they were kicked in the shin and ice was applied to their leg as a precaution for swelling; - This type of behavior was uncharacteristic for Resident #1; - The Certified Nurses Aides (CNA)'s continue to complete 30 minute checks and the nurses continue hourly checks on Resident #1; - He/She has received staff education about abuse numerous times with the latest occurrence being 1/20/25; During an interview on 2/6/25 at 11:30 A.M., the Administrator said: -Although the incident was not witnessed by staff, the resident reported he/she had been kicked by a resident so the facility staff continued with the investigation and treated this incident as abuse. - On 1/28/25 physical assessment confirmed that there was redness on the residents shin; - On 1/28/25 she confirmed that interventions of 30 minute CNA checks were put in place for Resident #1, the primary physician had been contacted, an order obtained for Depakote for resident for behaviors and a stop sign barrier put in place for Resident #2's safety. - On 1/30/25 an in-service was conducted for all staff members regarding the Abuse and Neglect policy and reporting and resident to resident altercations. MO248688

Based on interview and record review, the facility failed to employ a qualified director of food and nutrition services. This deficient practice had the potential to affect 44 of 44 residents who received meals prepared in the facility's only kitchen. The facility census was 44. Findings include: Review of the list of the facility's Key Personnel provided by the facility revealed [Name of the Dietary Manager (DM)] as Dietary Manager. Review of the DM's Food Services Director Job Description, dated 07/01/23, revealed the education required for the position was, Certification as Dietary Manager- Association of Nutrition and Foodservice Professionals (ANFP). During an interview on 11/19/24 at 1:47 PM, the DM was asked if she was a Certified Dietary Manager (CDM) or qualified in another route. The DS stated, No, but she had been the dietary manager at the facility since July of 2023. The DM stated she had worked at the facility for ten years as a dietary aide. The DM stated she had planned to complete a dietary manager's course to become a CDM but had not taken a course study in food safety and management course yet. During an interview on 11/21/24 at 9:36 AM, the Registered Dietitian (RD) confirmed she was not full time. The RD stated she was on a consulting basis and was onsite monthly. The RD stated she was aware DM was not a qualified dietary manager. The RD stated she had recommended the DM to go through a course to become a CDM, and she would be her preceptor. The RD stated she had recommended the DM get her certification in a course in food safety and management; however, she was not sure if that had happened. The RD stated she conducted monthly oversite of the DM. During an interview on 11/21/24 at 12:19 PM, the Administrator confirmed the DM had not been in the management position for two years yet and had not completed a course that would provide the DM with the credentials she needed to meet the regulation.

Based on observation, interview, record review, and policy review, the facility failed to protect a resident's right to be free of physical abuse for one of two residents (Resident (R)16) reviewed for abuse out of a total sample of 15. This failure increased the risk of abuse towards residents. The facility census was 44. As a result of an Informal Dispute Resolution on 12/31/24, the deficiency was changed to past noncompliance, which began on 11/17/24. Upon discovery, the facility administration immediately conducted an investigation and corrective actions were implemented. The deficiency was corrected on 11/17/24. Findings include: Review of the facility's policy titled, Abuse and Neglect, revised 09/2024, revealed, . It is the policy of this home to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/event in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person . Review of R16's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) date of 10/18/24 and located in the MDS tab of the electronic medical record (EMR), revealed an admitted [DATE], a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderate cognitive impairment, no behaviors exhibited, and diagnoses of schizophrenia, flaccid hemiplegia affecting left nondominated side, and unspecified visual loss. Review of R16's Care Plan, revised 06/06/23 and located in the EMR under the Care Plan tab, revealed, . At times I will lash out verbally and/or physically towards my peers . An intervention included, . Anticipate the noise and crowds that may make me irritable or on edge. I have several triggers these include: 1. Not having a way out of a big group or a loud room. 2. Peers yelling at me. 3. Peers yelling at staff. 4. People blocking my way when I want to leave an area. If these triggers are not addressed as they occur, I may hit my peers or begin cursing at them . Review of R40's annual MDS, with an ARD date of 09/08/24 and located in the MDS tab of the EMR, revealed an admitted [DATE], a BIMS score of six out of 15, indicating severe cognitive impairment, no behaviors exhibited, and diagnoses Alzheimer's disease, depression, and heart failure. Review of R40's Care Plan, revised 11/19/24 and located in the EMR under the Care Plan tab, revealed, . The resident is/has potential to be physically aggressive r/t [related to] Dementia . An intervention included, . Encourage resident to sit in his normal spot in the dining room where he will not feel closed into an area . Review of R40's Incident Note, dated 11/17/24 and located in the EMR under the Progress Note tab, revealed, . This nurse walked into dining room this morning at 0720 and noted staff started to move towards table resident was standing by. Resident was standing in front of other resident yelling and swung right hand back and punched the other resident in the left side of temple(face) making his sunglasses come off. Staff moved other resident's motorized wheelchair back and away from resident and this nurse moved to stand in front of resident when resident started to try and attempt to go up to other resident again. This nurse attempted to calm resident down and attempted to help him get back to his room but resident continued to raise his voice and threatened this nurse. This nurse observed resident walk down to his room and slam door. Ambulance and sherrif's [sic] office notified and resident sent to [hospital name] for evaluation. NOC [night] shift nurse called report to ER [emergency room ] nurse [name] at 0825. Dr. [name] notified at 0840 . Review of the facility's investigation, dated 11/17/24, revealed, [R40] was sitting with his back to the wall at [R16]'s normal table in dining room. [R40]'s walker was sitting in [R16]'s normal seat. R16 went to move his walker and R40 began to cuss and yell at R16 as he stood and grabbed walker. This caused [R40] to be standing in front of [R16]. [R40] raised his right hand and struck [R16] in his left eye. This caused his ([R16]'s) sunglasses to fall to the floor.' '[R16] had sunglasses on and this resulted in a pin point scratch to the side of his face by his left eye. Resident denies pain with palpation. No bruising or swelling noted. [R16] denied any medical intervention.' Residents immediately separated. [R40] sent to his room. Room monitored to make sure staff knew his location. Sheriff deputy called to ensure safety in case [R40] came out of room. [R40] sent to [hospital name and location] for evaluation. [R40] started an Antibiotic on 11/16/24 for a UTI [urinary tract infection]. He has had symptoms of delusional behaviors in the last few days. On 11/18/24 at 11:27 AM, R40 was sitting in a chair in his room with a walker next to him. He was asked about the care and services he received at the facility. R40 stated he had no complaints, and he liked living at the facility. R40 stated he had not experienced any abuse, and he got along with the other residents in the facility. During an interview on 11/19/24 at 11:03 AM, the Administrator was asked where the facility was in their investigation. The Administrator confirmed the incident was reported timely within the two hours to the State Agency as required. The Administrator stated the incident occurred on 11/17/24 two days ago. The Administrator stated she was called on 11/17/24 about R40 hitting another resident. The Administrator stated staff immediately called Emergency Medical Services (EMS) and the police before she arrived. The Administrator stated staff separated R16 and R40 went voluntarily to his room to cool down. The Administrator stated R16 sustained a small scratch on his eye from the sunglasses he was wearing. The Administrator explained R40 was currently receiving an antibiotic for a urinary tract infection that may have impacted a change in his behavior. The Administrator stated that the police, and EMS were at the facility when the Administrator arrived and R40 was resting on his bed. The Administrator stated R40 reported the reason why he hit R16 was because R16 spoke profanities to him that were offensive but later admitted R16 did not say the profanities. The Administrator stated R40 agreed to go to the hospital. The Administrator stated R40 only stayed at the hospital for a few hours and was sent back to the facility. The Administrator stated when R40 returned, she asked him about his past, and R40 revealed some trauma he had experienced as a child and young adult. She stated R40 also admitted he was aware he had dementia, and his past goes through his head at times that cause him to become upset. The Administrator stated they discussed a plan to deal with these things when they happen and R40's seating was changed in the dining room. The Administrator stated the staff were educated on the new interventions that included R40 was to be seated in the dining room in an area that was open, and when R40 had a change in behavior, they were to ask him to stay in his room to gather himself and have the nurses talk with him so he can vocalize his feelings. The Administrator stated R40 started on an antidepressant 09/18/24, and R40 revealed with the medication came strange dreams. The Administrator stated R40's antidepressant was changed to another antidepressant, and he had received behavioral counseling weekly for the past year. The Administrator stated R40 was now being evaluated for post-traumatic stress disorder (PTSD) since this incident had revealed secrets to his past. She stated R40 had previous incidents that involved yelling and threatening other male residents but no physical contact, and staff continued to monitor him. On 11/19/24 at 12:12 PM, R40 was observed in the main dining room with an open space to walk. Another male resident accompanied R40 at the table, and no behavioral symptoms were exhibited. On 11/19/24 at 12:19 PM, R16 was awake in bed watching television. R16 was asked about the incident in the dining room on 11/17/24 involving R40. R16 stated he remembered his eye was hit and pointed to his left eye. R16 stated his eye did not hurt and he had no hard feelings towards R40. R16 stated he understands everyone has a bad day. No bruise or skin tear was observed on R16's left eye. During an interview on 11/20/24 at 3:16 PM, Certified Nurse Aide (CNA)1 stated she was at the facility working the day R16 moved R40's walker in the dining room and R40 hit R16. CNA1 stated R40 had never hit another resident in the one year she has worked at the facility. CNA1 confirmed she had received an in-service at the facility recently on abuse. During an interview on 11/20/24 at 4:02 PM, Licensed Practical Nurse (LPN)1 was asked if the facility had a plan to prevent a recurrence between R16 and R40. LPN1 stated staff do not have the residents sit by each other. LPN1 stated the staff conduct an ongoing assessment of both residents for agitation/mood. LPN1 stated R40 had felt trapped in the dining room on 11/17/24, and they now make sure R40 has space and does not feel trapped. LPN1 stated the incident on 11/17/24 was not R40's normal behavior. MO00245291

Based on observation, interview, and record review, the facility failed to 1.) ensure staff was knowledgeable of the proper usage of insulin pens for one of one resident (Resident (R) 20) who received insulin through an insulin pen. This failure had the potential to cause R20 to receive an incorrect dose of insulin, and 2.) failed to ensure physician orders recorded the volume of tube feeding formula to be provided for one of one resident (R41) reviewed for tube feedings out of a total sample of 15. This failure had the potential to cause unexpected weight changes and/or R41's nutritional needs to be unmet. The facility census was 44. Findings include: 1. Review of the Electronic Medical Record (EMR) for R20 under the Census tab revealed an admitted [DATE]. The EMR under the Diagnoses tab revealed diagnoses including diabetes. Review of the physician orders under the Orders tab in the EMR revealed a physician's order for Humalog insulin (a fast-acting insulin used to manage blood sugars levels in diabetic patients), six units. Review of the manufacturer's instructions for the Humalog insulin pen, provided by the facility, revealed that after the needle set is attached to the insulin pen, the administration dial is to be set to two units and activated to prime (remove the air from) the needle set with insulin prior to administering the ordered dose of insulin. Observation of Certified Medication Technician (CMT) 1 on 11/20/24 at 4:40 PM revealed CMT1 attached the needle set to the pen, set the administration dial to six units, and administered the insulin. She did not prime the needle set. Interview with CMT1 on 11/20/24 at 4:30 PM revealed CMT1 lacked knowledge of the need to prime the needle set to remove the air before administering the ordered dose of insulin to R20. An interview with the Director of Nursing (DON) on 11/20/24 at 4:30 PM revealed the lack of knowledge to prime the needle set, as directed by the manufacturer's instructions, prior to preparing and administering the physician's ordered dose of insulin to R20. 2. Review of the EMR for R41 under the Census tab revealed an admitted [DATE]. Review of the Diagnoses tab of the EMR revealed diagnoses including a stroke, swallowing disorder, and feeding tube (a tube placed through the wall of the abdomen into to stomach for supplemental feedings). Review of the EMR under Orders tab revealed an order for Isosource (a nutritionally complete tube feeding formula) three times during the night for nutritional support and weight loss prevention. The order did not record the volume of Isosource to be administered. Review of the Progress Notes tab of the EMR revealed that on 11/07/23, the consulting dietitian had requested the physician orders to be clarified to include the volume of Isosource to be administered with each feeding. An interview with the Administrator on 11/19/24 at 3:07 PM confirmed the physician orders lacked the volume of Isosource to be administered. An interview with the Registered Dietitian (RD) on 11/20/24 at 10:28 AM confirmed the physician orders for R41 lacked the volume of the Isosource to be administered. The RD confirmed they had asked for clarification on subsequent resident assessments for the last year and in five written assessment notes.

Based on observation, record review, and interview the facility failed to prepare and serve food in accordance with professional standards for food service safely when staff failed to maintain daily readings of refrigerator and freezer temperature logs, failed to follow proper hand washing practices, used hand sanitizer in food preparation, failed to change gloves between tasks, did not store plates and bowls inverted, did not sanitize thermometer dropped on floor, did not apply hair nets prior to entering kitchen, did not date and label spices, did not throw out expired spices, did not run food processor through dishwasher between uses, and did not maintain a clean and sanitary kitchen. The facility census was 46. 1. Review of facility policy, Food Safety and Sanitation, undated, showed: -Employees will wash their hands just before they start to work in the kitchen and after smoking, sneezing, using the restroom, handling poisonous compounds or dirty dishes, and touching face, hair, other people or surfaces or items with potential for contamination. Review of facility policy, Hand Washing, undated, showed: -Employees will wash hands as frequently as needed throughout the day using proper hand washing procedures. -When to wash hands: -After handling soiled equipment or utensils; -During food preparation, as often as necessary to remove soil or contamination and to prevent cross contamination when changing tasks; -When switching between working with raw food and working with ready to eat food. -Before donning disposable gloves for working with food and after gloves are removed. -After engaging in other activities that contaminate the hands. -How to wash hands: -Turn on the faucet using a paper towel to avoid contaminating the faucet. -Wet hands and forearms with warm water and apply an antibacterial soap. -Scrub well with soap and additional water as needed, scrubbing all areas thoroughly. Pay -Rinse thoroughly. -Dry hands with paper towel or use a hand blow dryer. -Use the paper towel to turn the faucet off and open the door if needed, and then discard it. -Food preparation and/or pot sinks will not be used for handwashing. Review of facility policy, Hand Antiseptic, undated, showed: -Hand antiseptic or antimicrobial gel used by staff as a hand dip or wash will be limited to situations that involve no direct contact with food by the bare hands. Hand antiseptic may be applied between washing hands twice before full hand washing must be completed. Hand antiseptic cannot be used in place of proper hand washing technique in food service setting. Review of facility policy, bare hand contact with food and use of plastic gloves: -Single use gloves will be worn when handling food directly with hands to assure that bacteria are not transferred from food handlers hands to food product being served. -Staff will use good hygienic practices and techniques with access to proper hand washing facilities. Antimicrobial or antiseptic gel is not used in place of proper hand washing techniques. -Gloved hands are considered a food contact surface that can get contaminated or soiled. If used, single use gloves shall be used for only one tasks, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operations. -Hands are to be washed when entering the kitchen and before putting on the single-use gloves and after removing single use gloves. -Gloves are just like hands. They get soiled. Anytime a contaminated surfaces is touched, the gloves must be changed and hands must be washed. -After handling garbage -After handling anything soiled. -After picking up any item from the floor -During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks -Wash hands after removing gloves. During an initial tour and observation in the kitchen on [DATE] at 9:25 A.M. showed: -Dietary Aide A going from clean and dirty side of dishwasher without washing his/her hands when he/she was observed putting away clean dishes after loading dirty dishes in dishwasher. Observation in the kitchen on [DATE] at 10:43 A.M. showed Dietary Aide A stuck hands in soapy water of the three compartment sink dish water, then stuck hands in second compartment of hot water, then dried his/her hands with paper towel. Observation in the kitchen on [DATE] at 10:59 A.M. showed [NAME] A wearing gloves took food processor container to dish room where he/she sprayed off container and stuck food processor on dish rack and pushed into dishwasher. He/She then pulled clean dishes from clean side of dishwasher without changing gloves or washing his/her hands. He/She then came out to handwashing sinks and washed his/her hands and then touched back of Dietary Aide B with clean hands. Observation in the kitchen on [DATE] at 11:18 A.M. showed Dietary Aide A left kitchen and went into dining room. When he/she re-entered kitchen he/she used hand sanitizer, applied gloves, and grabbed burger with gloved hands from box to place on griddle on stove. He/She then grabbed two more frozen burger patties to add to griddle. Observation in the kitchen on [DATE] at 11:20 A.M. showed Dietary Aide A was dishing up mandarin oranges wearing gloves. He/She then grabbed wash cloth and wiped off cart mandarin oranges was sitting on. He/She removed his/her gloves. He/She used hand sanitizer. He/She did not wash hands. He/She then applied gloves and went back to cooking hamburgers on the griddle. Observation in the kitchen on [DATE] at 11:28 A.M. showed [NAME] A dropped digital food temperature thermometer on the ground. He/She then picked up thermometer off the ground with his/her gloved hand. He/She did not wash hands or change gloves and continued serving food during lunch. Observation in the kitchen on [DATE] at 11:35 A.M. showed [NAME] A washing hands at handwashing sink. He/She turned off faucet with bare hands and then he/she dried hands with paper towel. Observation in the kitchen on [DATE] at 11:46 A.M. showed Dietary Aide A scrapping food off counter with his/her gloved hand, then threw trash away. He/She did not wash hands and went and served mandarin oranges and touched digital thermometer to temperature check grilled cheese. Observation in the kitchen on [DATE] at 12:01 P.M. showed [NAME] A washed his/her hands, dried hands with paper towel, and turned off faucet handle with his/her bare hands. During an interview on [DATE] at 12:21 P.M., Dietary Aide B said: -He/She should wash hands between each task; -Gloving occurred after washing hands; -He/She should change gloves when he/she changes materials or tasks; -He/She should wash hands when going from dirty side of dishwasher to clean side. During an interview on [DATE] at 1:29 P.M., [NAME] A said: -He/She should wash hands after tasks and between tasks; -It was not sanitary for him/her to turn faucet off with his/her bare hands; -He/She should wash his/her hands when going from dirty to clean side of dishwasher; -He/She did not wash hands today when he/she moved items from clean side of dishwasher to the side after loading dishwasher; -Gloves were to be applied when he/she started a task, after washing his/her hands, and every time he/she changed tasks he/she should wash his/her hands, During an interview on [DATE] at 1:43 P.M., Dietary Aide A said: -Handwashing should be completed when he/she entered the kitchen and between tasks; -He/She sometimes sticks hands in clean dish water, rinses them off with the spray thing, and then dries his/her hands with a hand towel, so he/she does not always wash them at the hand washing sink; -He/She applied gloves before he/she touched food; -He/She changed his/her gloves anytime he/she touched food, make drinks, between tasks; -It was okay for him/her to use hand sanitizer if he/she did not have time to wash his/her hands between tasks. During an interview on [DATE] at 1:52 P.M., Dietary Manager said: -Handwashing should occur by staff when they first enter kitchen, prior to gloving, between tasks; -He/She expected staff to use a paper towel to shut off faucet handles after washing their hands; -He/She expected staff to wash their hands after picking items up off the floor. During an interview on [DATE] at 2:04 P.M., Administrator said: -He/She expected staff to wash their hands when entering kitchen, between clean and dirty tasks, and after any contamination. 2. Review of facility policy, Cleaning Instructions: Food Preparation Appliances, undated, showed: -Small appliances (such as mixers and food processors) will be cleaned and sanitized after each use. -Rinse the parts with warm water and place in the dishwasher or sink. Clean, sanitize, and rinse following the guidelines for automatic or hand dish washing. Observation in the kitchen on [DATE] at 10:54 A.M. showed [NAME] A added stuffing to food processor and chicken broth. He/She then took food processor container into dish room, rinsed off with sprayer, did not run through dishwasher and returned food processor container to its base. During an interview on [DATE] at 1:29 P.M., [NAME] A said: -He/She should spray food processor out and run through dishwasher every time he/she completes a food item. During an interview on [DATE] at 1:52 P.M., Dietary Manager said: -He/She expected staff to run food processor through dishwasher or three compartment sink between each use. 3. Review of facility policy, Food Safety and Sanitation, undated, showed: -Refrigerated food is stored at or below 41 degrees Fahrenheit; -Frozen food is stored at a temperature that keeps them frozen solid. During an initial tour and observation in the kitchen on [DATE] at 8:42 A.M. showed: -The cooler temperature log had no entries on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and ,d+[DATE] on evening shift; -The freezer temperature log had no entries on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE] on evening shift; -The kitchen aid had mixed up a yellow food item sitting in the mixing bowl, the bowl had no cover, and there was no staff present in the kitchen. During an initial tour and observation in the kitchen on [DATE] at 8:42 A.M. showed: -Review of food temperature logs showed no cooking temperatures were taken on [DATE] During an interview on [DATE] at 12:21 P.M., Dietary Aide B said: -All staff are responsible for taking refrigerator and freezer temperatures; -Refrigerator and Freezer temperatures are recorded in the afternoon and morning shifts and recorded on log hanging outside the cooler doors. During an interview on [DATE] at 1:29 P.M., [NAME] A said: -The cook was responsible for testing the refrigerator and freezer temperatures and documenting on the log by the door. During an interview on [DATE] at 1:52 P.M., Dietary Manager said: -He/She expected staff to check and record refrigerator and freezer temperatures three times daily and document on paper outside the door of the cooler. During an interview on [DATE] at 2:04 P.M., Administrator said: -He/She expected all logs in the kitchen to be completed each shift. DATING AND LABELING OF FOOD/SPICES 4. Review of facility policy, Sanitation and Infection Control, undated showed: -When a food package is opened, the food item should be marked to indicate the open date. This date is used to determine when to discard the food. Review of facility handout, previous prime tags, showed: -Dating/labeling: marked with received by date, opened by date, and bulk food storage containers must have a date and label. During an initial tour and observation in the kitchen on [DATE] at 8:42 A.M. showed: Storage rack in main kitchen: -Undated and opened 18 ounce (oz) paprika; -Undated and opened 18 oz ground cinnamon; -Undated and opened 30 oz celery salt; -Undated and opened 14 oz cumin; -Undated and opened 26 oz iodized salt; -Undated and opened 16 oz garlic powder -Outdated [DATE] and opened ground nutmeg; -Undated and opened 2 oz bay leaves; -Undated and opened 12 oz. ground basil; -Undated and opened 12 oz Italian seasoning; -Outdated [DATE] and opened 20 oz lemon pepper; -Dated ,d+[DATE] with no year noted opened 6.25 oz Italian seasoning; -Outdated [DATE] and opened 12 oz ground thyme; -Undated and opened 40 oz seasoned salt; -Dated ,d+[DATE] with no year noted opened 20 oz fine onion powder; -Dated ,d+[DATE] with no year noted, opened 12 oz ground oregano; -Dated ,d+[DATE] with no year noted, opened 5.5 pound (lb) chili powder; -Dated ,d+[DATE] with no year noted, baking powder -Undated and opened 20 oz baking powder; -Undated and opened 16 oz cornstarch; -Dated opened on ,d+[DATE] with no year noted, plastic bag of parsley; -Opened with dated with two dates of ,d+[DATE] and also [DATE] date of baking cocoa; -Undated and opened 5oz hot sauce Dry storage room: -Undated and opened white sliced bread; -Undated and opened hamburger buns. During an interview on [DATE] at 12:21 P.M., Dietary Aide B said: -All food had to be dated and labeled; -Spices should be dated when they came in and then when they were opened; -He/She did not know how long spices could be kept once they were opened. During an interview on [DATE] at 1:29 P.M., [NAME] A said: -Food should be dated when opened; -Spices should be dated when opened; -He/She did not put years on spices when opening; -Spices should be thrown away after one year from date of opening. During an interview on [DATE] at 1:43 P.M., Dietary Aide A said: -Food should be dated and labeled as soon as it as opened; -He/She did not know how long spices could be kept from date they were opened. During an interview on [DATE] at 1:52 P.M., Dietary Manager said: -Food items should be dated when they are opened; -Spices could be maintained one year after opened or until the expiration date on the container but wasn't quite sure which was accurate. During an interview on [DATE] at 2:04 P.M., Administrator said: -He/She expected spices to be thrown out after one year 5. Review of facility policy, Food Safety and Sanitation, undated, showed: -Food stored in dry storage is placed on clean racks at least 6 inches above the floor. The room should be clean, dry and cool and between ,d+[DATE] degrees. Review of facility policy, Cleaning Dishes/Dish Machine: -All flatware, serving dishes, and cookware will be cleaned, rinsed, and sanitized after each use. The dish machines will be checked prior to meals to assure proper functioning and appropriate temperatures for cleaning and sanitizing. -Prior to use, verify proper temperatures and machine function. Confirm that soap and rinse dispensers are filled and have enough cleaning product for the shift. -The person loading dirty dishes will not handle the clean dishes unless they change into a clean apron and wash hands thoroughly before moving from dirty to clean dishes; -Low temperature dishwasher was temperature required 120 degrees F and 50 parts per million (PPM). Review of facility policy, cleaning dishes-manual dishwashing, showed: -Check sanitation sink frequently using a test strip to assure the level of sanitizing solution is appropriate. Review of facility policy, maintenance of dish machine, undated, showed: -The dish machine will be maintained to assure proper functioning. -Dish machine will be regularly cleaned and de-limed according to manufacturer's instructions. -The dish machine should be cleaned at least once per week. Review of facility policy, general sanitation of kitchen, undated, showed: -Food and nutrition services staff will maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule. -Cleaning and sanitation tasks for the kitchen will be outlined in a written cleaning schedule. -Tasks will be assigned to be the responsibility of specific positions. Review of facility policy, dry storage area, undated, showed: -Dry storage areas will be maintained to keep food safe and free of infestation or contamination. -Floors, walls, shelves, and other storage areas will be kept clean. -The store room will be cleaned on a regular basis. Floors will be swept and mopped at least weekly and more often as needed. During an initial tour and observation in the kitchen on [DATE] at 8:42 A.M. showed: -No sanitizer solution out in kitchen, red buckets observed empty; -Metal spice rack had a white plastic drawer container with cup lids with a spilled powdery and brown substance on top of container; -Metal rack of spices showed spilled powdery substances on all shelves; -Areas underneath the spice rack, shelves, deep fat fryer, and ovens had not been swept or mopped; -A 3 tiered metal cart sitting next to deep fat fryer had crumbs of food on each shelf surface; -Cleaning log on ice machine showed the log had not been completed since [DATE] -Dry storage room had large container of great northern beans and the lid was covered with white powdery substance; -Shelves in dry storage room covered with white powdery substance. During an initial tour and observation in the kitchen on [DATE] at 8:42 A.M. showed: -Dish racks that run through dishwasher were stored directly on the floor; -Dishwasher machine had substance of white powder and brown substance across the top of machine During an initial tour and observation in the kitchen on [DATE] at 8:42 A.M. showed: -The dish machine sanitation log showed there was blanks on the sanitation -[DATE] no entries at breakfast and lunch; -[DATE] no entries at breakfast -[DATE] no entries at supper; -[DATE] no entries at supper; -[DATE] no entries at breakfast and lunch -[DATE] no entries at breakfast and lunch; -[DATE] no entries at breakfast, lunch, or supper; -[DATE] no entries at breakfast, lunch, or supper; -[DATE] no entries at breakfast, lunch, or supper; -[DATE] no entries at supper; -[DATE] no entries at breakfast. Observation on [DATE] at 9:20 A.M. showed Dietary Aide A ran test strip at surveyor's request showing 50 parts per million (PPM) and 120 degrees. Dietary Aide had already ran several cycles of dishes. During an interview on [DATE] at 9:20 A.M., Dietary Aide A said: -He/She did not know when dishwashing machine was de-limed. -The dishwasher machine was tested twice a day; -He/She had not ran a test strip yet today to ensure dishwasher was running at appropriate sanitation levels and temperature; -He/She usually tested dishwasher when he/she first came in after running a cycle. Observation in the kitchen on [DATE] at 10:46 A.M. showed food truck arrived and unloading stacks of boxes and foods directly on floor outside of walk-in cooler. Observation in the kitchen on [DATE] at 11:06 A.M. showed Dietary Manager putting away food boxes. He/She lifted box of broccoli florets directly off floor and sat on food preparation table where Dietary Aide B was completing food preparation of cookies. Observation in the kitchen on [DATE] at 11:28 A.M. showed [NAME] A dropped digital food temperature thermometer on the ground. He/She then picked up thermometer off the ground with his/her gloved hand and placed on top of steam table. He/She did not wash hands or change gloves and continued serving food during lunch. Observation in the kitchen on [DATE] at 11:31 A.M. showed Dietary Aide A grabbed digital food thermometer that had just been on floor, did not sanitize thermometer and stuck thermometer directly into hamburger. Observation in the kitchen on [DATE] at 11:39 A.M. showed the lids of the cereal containers were covered with brown and black crumbs and food splatter. During an interview on [DATE] at 1:43 P.M., Dietary Aide A said: -It was not sanitary for items to be stored on the floor; During an interview on [DATE] at 12:21 P.M., Dietary Aide B said: -There was a cleaning routine in kitchen that included daily, weekly, and when you can get to it items; -Kitchen will have deep cleaning days after supper on an evening; -He/She did not know when the dishwasher was de-limed; -He/She should wash hands when going from dirty side of dishwasher to clean side. -Kitchen preparation surfaces should be cleaned with sanitizer water; -He/She prepared sanitizer water when he/she first arrived for his/her shift; -He/She tested sanitizer water when he/she first arrived, the test was not recorded; During an interview on [DATE] at 1:29 P.M., [NAME] A said: -Dishwasher should be tested before dishes are ran and documented on paper on dish room door; -Sanitizer water should be tested before dishes were ran and documented on paper posted on the bulletin board; -He/She de-limed dishwasher on Thursdays; -Floors were swept and mopped at night; -He/She did not know when shelves in kitchen and storage rooms were cleaned; -It was not sanitary to pick something up off the floor and continue serving foods; -The digital food thermometer should be sanitized between foods and after falling on the floor. During an interview on [DATE] at 1:43 P.M., Dietary Aide A said: -Deep cleaning of kitchen occurred on second shift; -The kitchen had a cleaning schedule that they followed for each shift to include weekly cleaning list; -He/She checked dishwasher for proper sanitation prior to doing lunch and supper dishes; During an interview on [DATE] at 1:52 P.M., Dietary Manager said: -De-liming of dishwasher was done once a week on Thursdays; -There should not be brown or powdery substances on top of the dishwasher; -Shelves should not have spilled substances; -He/She expected spills to be cleaned up immediately or when seen by staff; -Dishwasher should be tested for proper sanitation prior to running dishes to ensure the proper temperature and sanitization levels; -He/She expected staff to document testing of the dishwasher on paper posted on doorway to dish room; -He/She expected staff to test sanitizer solution prior to use; -He/she expected staff to switch out the dirty sanitizer water frequently; -He/She expected staff to clean up messes when they saw them; -He/She had a weekly cleaning schedule for staff to follow. During an interview on [DATE] at 2:04 P.M., Administrator said: -He/She expected staff to maintain a clean and sanitary kitchen; -He/She expected all logs in the kitchen to be completed each shift. 6. Facility did not provide policy on dish storage. Review of facility handout, previous prime tags, showed: -pots/pans must be properly stored upside down for proper drying technique. During an initial tour and observation in the kitchen on [DATE] at 8:42 A.M. showed: -Plates and bowls were stored upright. During an interview on [DATE] at 12:21 P.M., Dietary Aide B said: -Bowls and plates should be stored inverted. During an interview on [DATE] at 1:29 P.M., [NAME] A said: -Dishware should be stored upside down; -The cook was responsible for testing the refrigerator and freezer temperatures and documenting During an interview on [DATE] at 1:43 P.M., Dietary Aide A said: -Pitchers, bowls, and pans should be stored inverted; -He/She stored plates under the counters face up. During an interview on [DATE] at 1:52 P.M., Dietary Manager said: -He/She expected plates, bowls, pitchers to be stored inverted. 7. Review of facility policy, employee sanitary practices, undated, showed: -All employees will wear hair restraints (hairnet, hat, and/or beard restraint) to prevent hair from contacting exposed food. Observation on [DATE] at 8:44 A.M., showed Dietary Manager entered kitchen, went into dry storage room, then applied hair net. Observation on [DATE] at 8:56 A.M. showed Plant and Maintenance staff entered kitchen, did not have hair net on and entered dry storage room with bag of groceries. Observation on [DATE] at 10:56 A.M. showed Dietary Aide B entered kitchen, entered dry storage room and applied his/her hairnet. During an interview on [DATE] at 12:21 P.M., Dietary Aide B said: -He/She had to walk into dry storage room to apply hair nets; During an interview on [DATE] at 1:29 P.M., [NAME] A said: -Hairnet should be placed on head prior to washing hands. During an interview on [DATE] at 1:43 P.M., Dietary Aide A said: -He/She should apply hair net as soon as walked in door of kitchen. During an interview on [DATE] at 1:52 P.M., Dietary Manager said: -He/She expected staff to apply hair nets when they came into the dry storage room; -He/She tried to keep hairnets inside the kitchen by back door of storage room on shelves. During an interview on [DATE] at 2:04 P.M., Administrator said: -He/She expected staff to apply hair nets in the dry storage room. MO240734

Based on observation, interview, and record review, the facility failed to store medications in a locked storage area to ensure medications were inaccessible to unauthorized staff and residents, and when the medications were left in pill cups on the dining table for residents in the dining room (Resident #1 and #2) and when the facility failed to lock a medication cart. The facility census was 46. Review of facility policy, dated December 2016, showed: -Residents have right to self-administer medications if the interdisciplinary team had determined that it was clinically appropriate and safe for resident to do so. -If nursing team determined that a resident cannot safely self-administer medications, the nursing staff will administer the resident's medications. Review of facility policy, storage of medications, undated, showed: -Facility shall store all drugs and biologicals in a safe, secure, and order manner. -Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. 1. Review of Resident #1's annual minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 7/1/24, showed: -He/She was cognitively intact; -He/She was dependent on a wheelchair; -He/She had no impairment to upper or lower extremities; -He/She was independent with eating and oral care; -He/She received as needed pain medication; -He/She took antidepressant, anticoagulant, diuretic, opiod, -Diagnoses included: diabetes (too much sugar in the blood), high blood pressure, gastric esophageal reflux disorder (condition when stomach acid moves back up esophagus), Review of care plan, dated. 6/12/24 , showed: -Administer diabetic medication per doctor order; -Administer analgesic medication as ordered; -Give cardiac medications as ordered; -Give pain medication as needed; -Give medications as ordered; -Monitor/document side effects and effectiveness. Review of physician's orders, dated 8/21/24, showed: -Resident had no orders to self-administer medications; Review of electronic medical record showed: -No self-administration of medication assessment completed. Review of facility medication administration list, undated, showed: -If resident did not have a self administer order, staff must stay, administer, and observe resident. -Resident #1 staff was to administer their medications. Observation on 8/21/24 at 10:48 A.M. showed Certified Medication Technician (CMT) A took medication in a pill cup and sat down on resident's dining room table and left resident. Medications left in cup in front of resident. CMT A observed leaving dining room. During an interview on 8/21/24 at 1:07 P.M., Assistant Director of Nursing (ADON) said: -Resident did not self-administer his/her medications; During an interview on 8/21/24 at 2:20 P.M., CMT A said: -Resident #1 was very independent and he/she did not know he/she could not leave medications on table with resident; -He/She placed medications on the table in front of Resident #1 and walked out of dining room. 2. Review of Resident #2's quarterly MDS, dated [DATE], showed: -He/She had moderately intact cognition; -He/She was dependent on wheelchair; -He/She had no impairment to upper or lower extremities; -He/She took as needed pain medications; -He/She took antipsychotic, antidepressant, anticoagulant, and diuretic medications; -He/She required set up or clean up assistance with eating and oral care; -Diagnosis included: Chronic obstructive pulmonary disease (a condition making it difficult to breathe), diabetes, dementia (condition affecting the brain causing a decline in cognitive functioning such as thinking, remembering, and reasoning), depression, and anxiety. Review of care plan, dated 6/20/24, showed: -Administer medication per order and note changes may vary with labs; Review of physician's orders, dated 8/21/24, showed: -Resident had no orders to self-administer medications; Review of electronic medical record showed: -No self-administration of medication assessment completed. Observation on 8/21/24 at 10:48 A.M. showed CMT A took medication in a pill cup and sat down on resident's dining room table and left resident. Medications left in cup in front of resident. CMT A observed leaving dining room. Review of Resident administration list, undated, showed: -If resident did not have a self administer order, staff must stay, administer, and observe resident. -Resident #2, staff was to administer resident's medications. During an interview on 8/21/24 at 1:07 P.M., ADON said: -Resident #2 did not self-administer his/her medications; During an interview on 8/21/24 at 2:20 P.M., CMT A said: -Resident #2 was administered medication by him in dining room on 8/21/24; -He/She placed medications on table in front of Resident #2 and walked out of dining room; -Kitchen staff had been slow with meal service today; -He/She returned to resident after leaving dining room, and went to provide Resident #2 a drink, and ensure he/she took medication 3. Observation on 8/21/24 at 10:05 A.M. showed unlocked medication cart labeled north hall was sitting in lobby area outside of nurses station. Staff observed sitting with back to medication cart in office while sitting at computer. Observation on 8/21/24 at 10:27 A.M. showed unlocked medication cart labeled North hall was sitting outside of nurses station in lobby area of facility. No staff observed near medication cart. Observation on 8/21/24 at 1:07 P.M. showed unlocked medication cart labeled north hall was sitting outside of nurses station in lobby area of facility. Assistant Director of Nursing (ADON) was observed in nurses station sitting at computer away from cart. Observation on 8/21/24 at 1:21 P.M., showed unlocked medication cart labeled north hall was sitting outside of nurses station in lobby area of facility. No staff observed near cart. During an interview on 8/21/24 at 1:07 P.M., Assistant Director of Nursing said: -He/She expected the medication cart to be locked; -The medication cart contained creams, Band-Aid, and topical ointments; -It was not appropriate for staff administering medications to a resident to leave his/her medications sitting in front of them on dining room table and leave the dining room with pills still in their cups; -He/She expected staff administering medications to monitor the intake of the medications and not leave the room. During an interview on 8/21/24 at 3:18 P.M., Administrator said: -He/She expected medication carts to be left locked when staff was away from the cart; -It was not appropriate for staff administering medications to leave medications on the dining room table in front of resident and leave the dining room; -Staff were taught to chart medication administration after given medications to ensure medications were taken by residents. MO240734

Based on interview and record review, the facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day, seven days a week. The facility census was 47. The facility did not provide a policy regarding RN staffing. Review of facility staffing for May 2024 showed : -No RN scheduled for 5/18/2024 for eight consecutive hours. Review of facility staffing for June 2024 showed: -No RN scheduled for 6/1/24, 6/8/24, 6/24/24 for eight consecutive hours. Review of the facility staffing for July 2024 showed: -No RN scheduled for 7/4/24, 7/20/24, 7/26/24 for eight consecutive hours. During an interview on 8/2/24 at 2:22 P.M., the Administrator said: -He/She was aware there are days that the facility does not have RN coverage. -It is her expectation that the facility does have required and appropriate RN coverage.

Based on interview and record review, the facility failed to provide personal funds and a final accounting within thirty days upon discharge. This affected fourteen additionally sampled residents, (Resident #147, #148, #149, #150, #151, #152, #153, #154, #155, #156, #157, #158, and #159.) Facility census was 42. 1. Review of facility Refund Policy, undated, showed; -When a resident is discharged or expired, refunds to families or payments received shall be withheld for a period of 30 days. This policy was adopted due to the billing procedures of the companies that work with [NAME] Care Centers, INC. -All refunds will be based on the daily rate less supplies and charges used by the resident. Day of admission and not the day of discharge will be charged. Review of the facility policy Personal Fund Account, undated, showed; -This facility shall deposit any personal funds received from or on behalf of a resident in an account separate from the facilities funds. -Any money over $50.00 will be kept in an interest bearing account in the resident name through Resident Fund Management System and their banking institution. -Within 5 days of the discharge of a resident the facility will provide the resident, his/her designee, or guardian with an up to date accounting of the residents personal funds and return to the resident the balance of his/her funds. Upon the death of a resident the facility will provide to the fiduciary of the resident's estate all the resident personal funds. If no fiduciary makes a claim upon said funds the administrator shall contact the Department of Health and Senior Service. Upon the death of a resident, the operator shall contact the Department of Social Services, MO Healthnet Division, Third Party Liability Unit, to determine if the deceased resident is a MO Healthnet participant of aid, assistance, care, services, or if the resident has had moneys expended on his/her behalf by DSS. 2. Review of the facility's aging report, dated [DATE], showed the following residents had money in the facility's operating account: -Resident #147 discharged on [DATE]: with a balance of $170.51; -Resident #148 discharged on [DATE]: with a balance of $165.00; -Resident #149 discharged on [DATE]; with a balance of $972.13; -Resident #150 discharged on [DATE]; with a balance of $1,810.00; -Resident #151 discharged on [DATE]; with a balance of $718.30; -Resident #152 discharged on [DATE]; with a balance of $1,020.00; -Resident #153 discharged on [DATE]; with a balance of $4,482.44; -Resident #154 discharged on [DATE]; with a balance of $1,200.00; -Resident #155 discharged on [DATE]; with a balance of $160.33; -Resident #156 discharged on [DATE]; with a balance of $235.97; -Resident #157 without a discharge date ; with a balance of $1,100.03; -Resident #158 discharged on [DATE]; with a balance of $160.33; -Resident #159 discharged on [DATE]; with a balance of $996.40. 3. During an interview on [DATE] at 1:13 PM with the Business Office Manager (BOM) said: -She is behind in sending in for refunds. She is trying to clean up the report since. -Regarding resident #147 is the difference between hospice and facility and sending to [NAME] City. -Resident #149 who passed away is one that should be sent to the cooperate office to have refunds issued. -Resident #151 was private pay. That was at the beginning of outbreak and cooperate is checking into for the refund. -Resident #152 was sent a refund but not taken off the books. -Resident #153 was at the beginning of COVID and thought they were sent refunds so will send back to Medicaid. -Resident #154 was sent a refund and will come off the books this month. -Regarding resident #159 cooperate sent back to state to get credit from state. Continues to be waiting on a check. - The process for sending refunds is if resident is private pay she will submit a request for a refund to corporate. Corporate will make sure charges and payments are correct and check with Medicare part B coinsurance. Will ask if the family wants to use refund to offset any copays or corporate will send out the refund. She will send a Self-declaration to [NAME] City regarding any money returned. -She knows to send a refund when the resident is no longer at the facility or something in the report appears to be odd. Tries to send refund requests to corporate within two weeks after discharge. The goal is to get the request for refund to corporate by the 20th of every month. That's when the corporate office writes the checks. -The aging report is looked at monthly when balancing the control sheet. -The money for those residents who are on hospice with Medicare and/or Medicaid, she will complete a self-declaration form and send to [NAME] City. -She sends notice of death to [NAME] County. During an interview on [DATE] at 2:44 PM the Administrator said; -She expects when a resident expires a refund should be issued within 30 days. -Expects resident funds to be refunded from 30 days to six months after discharge. -The BOM would initiate requests to cooperate to have corporate write the refund check.

Based on record review and interviews, the facility failed to ensure they maintained a Department of Health and Senior Services (DHSS) approved surety bond in an amount to cover any loss of theft to residents' money held in the facility's Resident Trust Fund (RTF) account which affected all residents who had money held in their RTF account. The facility census was 42. Review of facility policy titled Policy for Surety Bond, undated, showed: -The Oregon Care Center will maintain Surety bond in accordance with State and Federal Regulations. The purpose of the surety bond is to guarantee that the facility will pay the resident (or the State on behalf of the resident) for losses occurring from any failure by the facility to hold, safeguard, manage, and account for the residents funds, i.e., losses occurring as a result of acts or errors of negligence, incompetence, or dishonesty. Review of the facilities approved surety bond, approved on 06/30/2020 showed an approved amount of $20,000.00. Review of the RTF worksheet, completed with the Business Office Manager (BOM), on 09/22/2022 showed: -The average monthly balance for the facility's interest bearing account of $21,129.67; -The approved bond amount for this average monthly balance (Grand Total rounded to the nearest thousand x 1.5 = required bond amount) should be at least $31, 500.00. During an interview on 09/22/22 at 10:15 AM the BOM said: -She knows that the current bond amount is $20,000 notarized on 6/30/2020. -Regarding how and/or who determines the bond amount, she says it is determined by the corporate office. Corporate usually looks at the bond amount when the census changes. - She will call corporate when she knows of obvious cues. She will monitor and send to corporate if she determines it is needed. -She routinely checks this once a year or with big changes to census. During an interview on 09/22/22 at 10:15 AM with the Administrator says; -She does not know about the surety bond.

Based on interviews and record review, the facility failed to ensure quarterly assessments were completed within 92 days following the previous assessment for two residents (Residents #1 and #4). Facility census was 42. Facility Policy Resident Assessment Instrument (RAI) Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff: -Quarterly Assessments must be completed at least every 92 days following the previous OBRA assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual changes in a resident's status are monitored. -Facilities may institute various processes to create the assessment schedules, however it is the responsibility of the MDS coordinator to ensure scheduling accuracy and timeliness. Late Assessments are considered unacceptable practice. 1. Review of Resident #1's MDS's showed: -Annual MDS completed on 1/20/22 -A quarterly MDS completed on 4/18/22. -No MDS since 4/18/22. 2. Review of Resident #4's MDS's showed: -A quarterly MDS completed on 5/9/22. -No MDS since 5/9/22. During an interview on 09/21/22 at 10:35 A.M. the Administrator said: -He/she and the Corporate nurse are covering MDS. -Resident #4's quarterly assessment is open but not completed yet. -Resident #1's quarterly assessment is not started yet. -He/she did not know why the system did not trigger an assessment for Resident #1 to be completed. -Part of the reason MDS's are behind is because they found several that had mistakes and were working to correct them. During an interview on 09/21/22 at 02:45 P.M. the Director of Nursing said: -He/she is not currently responsible for MDS's.

Based on observation, interviews, and record review, the facility failed to maintain accurate assessments to reflect resident statuses when antipsychotics were inaccurately coded for one resident (Resident #42), anticoagulants were not coded for one resident (Resident #12), ventilator and urinary tract infection ([CONDITION(S)]) were inaccurately coded for one resident (Resident #12), and restraints were inaccurately coded for one resident (Resident #17). Facility census was 42. Review of facility policy, Resident Assessment Instrument (RAI) Minimum Data Set (MDS) a federally mandated assessment instrument completed by staff, dated April 2022, showed: -Quarterly Assessments must be completed at least every 92 days following the previous OBRA assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual changes in a resident's status are monitored. -Facilities may institute various processes to create the assessment schedules, however it is the responsibility of the MDS coordinator to ensure scheduling accuracy and timeliness. -It is the responsibility of the DON to perform audits of existing MDS at least quarterly of a random sample of 10% of the residents in the facility. Audits should include at a minimum review of MDS for accuracy, documentation to support MDS, review of manuals for current manual use, review that team understands how to code MDS accurately. Outcomes of audit should be reported to the Quality Assessment and Assurance Committee. 1. Review of Resident #42's quarterly MDS, dated [DATE], showed antipsychotics coded. Review of physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 2. Review of Resident #12's quarterly MDS, dated [DATE], showed: -Ventilator coded. -[CONDITION(S)] (last 30 days) coded. -No anticoagulant coded. Review of physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -No ventilator orders, -No medications for an [CONDITION(S)] within 30 days of 6/6/22, -Order for [MEDICATION(S)] (blood thinner) 5 milligrams (mg) twice daily; start date 5/18/22 for [CONDITION(S)] (heart arrhythmia condition). Review of care plan updated 8-2022 showed: -No mention of an [CONDITION(S)]. -No mention of ventilator usage. -Medication monitoring [MEDICATION(S)] (blood thinner) 5 mg twice daily, [MEDICATION(S)] (blood thinner) 75 mg daily, monitor for bleeding and adverse reactions/side effects. Review of nurses notes showed: -No ventilator usage -No [CONDITION(S)] within 30 days of 6/6/22. Review of diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of the resident during survey from 9-19-22 to 9-22-22 showed no ventilator. During an interview on 09/20/22 at 08:44 A.M. Certified Nurse Aide (CNA) A said: -He/she has worked at the facility for 10 months and there has never been anyone with a ventilator. 3. Review of Resident #17's admission MDS, dated [DATE] showed: -Restraints coded. Review of physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Review of nurses notes showed no mention of restraints. Review of care plan updated 8-2022 showed no mention of restraints. Observation of the resident during survey from 9-19-22 to 9-22-22 showed no restraints. During an interview on 09/21/22 at 10:35 A.M. the Administrator said: -He/she and the Corporate nurse are covering MDS. -Resident #42 has never been on an antipsychotic. -Resident #17 has never had restraints. -Resident #12 has never been on a ventilator. -Anticoagulants should be coded on the MDS. -Resident #12 should have had anticoagulants coded on the MDS. -They had found several MDS mistakes and were working to correct them. During an interview on 09/21/22 at 02:45 P.M. the Director of Nursing said: -He/she is not currently responsible for MDS's or auditing MDS accuracy.

Based on observation and interviews, the facility failed to maintain medication storage when loose pills were found in the medication cart and expired medications found in the medication room. Facility census was 42. Review of facility policy, Policy for Medication Administration and Maintenance, not dated, did not address loose pills or expired medications. Observation and interview on 09/21/22 at 11:16 A.M. of the North Hall Cart showed and Certified Medication Technician (CMT) A said: -Three loose white pills in drawers. -He/she destroyed the loose pills. -He/she said the cart is checked every day. Observation and interview on 09/22/22 at 08:18 A.M. of the Medication Room showed and Licensed Practical Nurse (LPN) A said: -The medication room is checked monthly for outdates. -Two bottles of over the counter Vitamin D3 10 micrograms (mcg) unopened; expired 07/22. -One bottle of [MEDICATION(S)] 2 ( a supplement); expired 02/22. -One bottle of anti-diarrheal Loperamide 2 milligrams (mg); expired 03/22. -Resident #4's bottle of [MEDICATION(S)] (used for acid reflux) 40 mg; expired 08/22. -Resident #4's bottle of [MEDICATION(S)] 40 mg; expired 07/22. -An unknown resident's bottle of [MEDICATION(S)] 5 mg; expired 04/22. -An unknown resident's bottle of [MEDICATION(S)] 5 mg; expired 11/21. During an interview on 09/22/22 at 10:08 A.M. the Director of Nursing said: -Medication carts are checked everyday. -Pharmacy checks medications quarterly. -Loose pills should be destroyed. -Night shift is responsible for checking the medication room weekly.

Based on observation and interview, the facility failed to provide window's in resident rooms and other locations that were clear and homelike. This affected all residents in rooms where the window seals had leaked causing the panes to cloud up and residents were unable to clearly see the outside. This included residents in rooms 101, 102, 107, 108, 109, 110, 112, 113, 217 and 219. The Facility had a census of 43. 1. Observation on the Life Safety Code (LSC) tour of the facility on 7/9/19, between 9:30 A.M. and 5:00 P.M., showed the following rooms with cloudy windows: - Resident Rooms 101, 102, 107, 108, 109, 110, 112, 113, 217, 219; and the soiled utility room. During an interview on 7/10/19, at 10:30 A.M., Resident #18 said his/her windows were awful. He/she had tried to clean the windows multiple times but he/she cannot get them to come clean. He/she was [AGE] years old and should be able to enjoy watching the birds and seeing his/her plants. He/she spends a lot of time in his/her room and wanted to be able to see clearly out the windows. During an interview on 7/10/19, at 10:35 A.M., Resident #39, said he/she was unable to see out his/her windows. The windows had been cloudy since he/she moved in. It would be nice to see out the windows. During an interview on 7/10/19, at 10:38 A.M., Resident #16, said his/her windows are just awful! One needs to be able to see out of their windows. It has been way too long that the windows have been all clouded up. During an interview on 7/10/19, at 10:40 A.M., Resident #13, said he/she has towels stuffed at the bottom of his/her windows. Not only are his/her windows cloudy, they leak. When it rains, they have water coming into their room from the bottom of the windows. He/she also has cold or hot air coming through the windows which is another reason for the window being stuffed with towels. He/she spends almost all of his/her days in his/her room and all he/she can see when he/she looks out the window is a blur because of the cloudy window panes. During an interview on 7/10/19, at 10:45 A.M., the Maintenance Supervisor said they were aware of the cloudy windows. They had asked corporate for the funds to replace the cloudy windows but to date Corporate has not given approval so they can have the cloudy windows repaired or replaced.

Based on observation, interview and record review, the facility failed to assure staff followed appropriate safety measures for one resident (Resident #1) of three sampled residents, to avoid an accident. The director of nursing (DON) and assistant director of nursing (ADON) placed the resident on the toilet in the north central bath and left the resident alone, with no call light. After approximately one hour, the resident attempted to transfer him/herself to the wheelchair, fell and sustained a laceration and a swollen area on the back of his/her head. The facility census was 42. 1. Review of the Resident #1's fall risk assessment dated [DATE], showed staff assessed the resident with a total score of 16. A total score of 10 or above represented at high risk for falls. Review of the resident's Minimum Data Set (MDS), a federally mandated assessment instrument dated 6/23/10, showed the following: - [DIAGNOSES REDACTED]. - No short- or long-term memory problems. - Independent in cognitive skills for daily decision making. - Limited range of motion and partial loss of voluntary movement of arm/hand and leg/foot on one side. - Required extensive physical assistance two or more persons for transfers. Review of the resident's care plan, updated on 6/23/10, showed staff identified mobility as a problem for the resident. Staff were to transfer the resident with assist. A problem identified for safety and falls showed staff noted the resident had not fallen recently. Staff identified no approaches specifically to prevent falls. Staff identified the resident's goal was to remain fall and injury free. During interviews on 9/17/10 at 1:36 P.M. and 9/21/10 at 10:20 A.M., the resident said: - He/she had weakness in his/her left arm, hand, leg and foot, due to his/her stroke. - He/she used the toilet in the north central bath so staff had more room to assist him/her to the toilet. It had more room than the toilet room in his/her room. - He/she required the assistance of one staff to get on the toilet and two staff to assist him/her off the toilet and to help with repositioning his/her clothing. - On 9/5/10 at about 3:00 P.M. to 3:30 P.M., the DON and ADON assisted him/her onto the toilet, in the north central bathroom, then both left the room. During interviews on 9/21/10 at 1:30 P.M. and 3:00 PM, the ADON said: - On 9/5/10, all certified nurse aides (CNAs) scheduled to work the day shift "called in" (not able to work.) She and the DON came in and worked. - At the end of the shift, near 3:00 P.M., the DON asked her to help transfer the resident to the toilet. - After they transferred the resident onto the toilet in the north central bathroom, a CNA came to the door and asked for her. - She immediately turned, answered the aide and then left the room. During interviews on 9/21/10 at 2:35 P.M. and on 9/24/10 at 10:40 A.M., the DON said: - She and a CNA worked the resident's hall on 9/5/10 in the afternoon. - A little before 3:00 P.M., the resident asked to go the bathroom. - She asked the ADON for help. - The ADON transferred the resident onto the toilet and she assisted with lowering the resident's slacks. She did not give the resident the call light. - She left the room and went to the nurses' station. About 10-15 minutes later, she gave the oncoming shift CNAs "walking report" on residents on that hall. "Walking report" let the oncoming staff see the residents and let them know the condition of the residents for the day or if anything unusual or important had developed with the residents. - If residents was not in their room, staff usually told the oncoming staff where the they are. - She did not remember what she told the oncoming shift about Resident #1. She did not think she told them the resident was in the north central bath. - She thought the resident was out of the bathroom by that time. - She left the facility as soon as walking rounds were over, about 3:10 P.M. - She said she would expect direct care staff to give the resident the call light cord before leaving the room. During interviews on 9/17/10 at 1:36 P.M. and on 9/21/10 at 10:20 A.M., the resident said: - After the DON and ADON left, he/she realized they had not clipped the call light cord to his/her clothing. He/she saw the call light cord on the floor, but it was out of his/her reach. - He/she sat there a long time. No one came and he/she had no way to tell how long he/she had sat there, but it seemed like an hour or so. - He/she tried "hollering and beating on things", but no one heard. - He/she was not frightened, but "pretty uncomfortable" from sitting on the toilet so long. - He/she tried to transfer him/herself to the wheelchair and fell , hitting the back of his/her head on the sink. - He/she wound up on the floor and there was blood everywhere, because he/she took Coumadin (a medication which increased risk of bleeding.) - He/she continued to bang on the trash can, while lying on the floor. - He/she thought it might have been 20 minutes before Certified Medication Technician (CMT) A, heard him/her and came in the north central bath. Observation on 9/21/10 at 10:20 A.M., showed the resident had a nickel-sized firm, swollen area beside a crusted laceration, approximately one-half inch long, on the back of the resident's head. During an interview on 9/21/10 at 3:10 P.M., CMT A said: - He/she came to work at about 2:45 P.M. He/she received report on the other hall in the facility, not the resident's hall. - He/she had assisted a resident to bed and heard a tapping sound in the north central bathroom. - He/she was surprised he/she heard the sound, because he/she did not have his/her hearing aides in that day. - He/she looked went into the north central bathroom and found the resident on the floor. - He/she noted an area of blood under the resident's head, about one foot in diameter. - He/she stepped out in the hall and asked for a nurse "Stat" (immediately.) - Licensed Practical Nurse (LPN) A and other staff came to the bathroom. - The resident said, the DON and ADON put him/her on the toilet and did not give him/her the call light before they left the room. - The resident had a bump on his/her head and a cut that had bled. During an interview on 9/21/10 at 3:35 P.M., LPN A said: - He/she thought it was about 3:50 P.M. on 9/5/10, when CMT A came to her and told her the resident fell in the north central bathroom. - The resident lay on the floor in front of the sink. There was a smear of blood on the sink, blood splattered on the baseboard and about an eight inch circle of blood on the floor under the resident's head. - When he/she raised the resident's head, there was clotted blood in the resident's hair. - The resident said he/she shouldn't have tried to transfer him/herself without help, because he/she fell . - He/she assessed the resident, applied pressure to the resident's head to stop the bleeding and assisted to transfer the resident off the floor. During an interview on 9/21/10 at 12:55 P.M., the administrator said: - The DON and ADON told her they took the resident to the north central bathroom about 3:10 P.M. on 9/5/10. - She did not know if either told the oncoming shift the resident was in the north central bathroom. - She would have expected any staff to give the resident the call light before they left the resident. MO