Every finding on record at Rayville Nursing and Rehabilitation

Based on observations and interviews, the facility failed to maintain a safe, clean, comfortable and homelike environment for 2 (#12 and #45) of 2 residents reviewed for environment, and by having an area in the kitchen that was in need of repair. The failed practice was evidenced by having an air conditioner and a wheelchair that was in need of repair, and by having a part of the wall missing in the kitchen behind the three-compartment sink.Findings: On 08/18/2025 at 8:06 a.m., an initial tour of kitchen was conducted. Observation of the three compartment sink area revealed the wall behind the three compartment sink area was in need of repair. The wall tile above the three compartment sink was loose and there was a large hole in the wall beneath the three compartment sink. On 08/18/2025 at 8:10 a.m. an interview and observation with S4Dietary Manager confirmed the wall behind the three compartment sink was in need of repair. Resident #12 On 08/18/2025 at 1:32 p.m., and 08/19/2025 at 8:20 a.m., observations of Resident #12's air conditioning unit revealed the unit was missing the air diverting grill and needed to be repaired. On 08/19/2025 at 9:10 a.m., an observation of Resident #12's air conditioning unit with S4Maintenance Director confirmed the air diverting grill was missing and needed to be repaired. Resident #45 On 08/18/2025 at 12:44 p.m., an observation of Resident #45's wheelchair revealed the bilateral arm rests were cracked, and foam was exposed. On 08/19/2025 at 9:30 a.m. observation of Resident #45's wheelchair with S6Assistant Director of Nursing (ADON) confirmed the arm rests were cracked with foam exposed and the armrests needed to be replaced.

Based on observations, interviews, and record reviews, the facility failed to ensure an accurate assessment was completed for 3 (#2, #4, and #8) of 3 (#2, #4, and #8) residents reviewed for physical restraints. The failed practice was evidenced by Residents #4 and #8 having an inaccurate assessment related to the use of bed rails. Resident #2 had an an inaccurate assessment related to the use of bed rails and a pommel cushion. Findings: Resident #2 On 08/18/2025 at 9:00 a.m. and 08/19/2025 at 8:15 a.m., Resident #2 was observed lying in bed with bilateral 1/4 bed rails in the upright position. On 08/19/2025 at 9:50 a.m., Resident #2 was observed sitting in a high back manual wheelchair. There was a pommel cushion noted in the seat of the wheelchair. Record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus without complications, muscle wasting and atrophy, osteoarthritis left hip, abnormalities of gait and mobility, need assistance with personal care, generalized muscle weakness, end stage renal disease, dependence on renal dialysis, paroxysmal atrial fibrillation, and pain left hip. Review of admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 9 which indicated Resident #2 had moderate cognitive impairment for daily decision making. Further review revealed in section P (Restraints and Alarms), that Resident #2 had bed rails used daily as a physical restraint and other used daily in chair or out of bed as a physical restraint. Review of the August 2025 Physician Orders revealed the following active orders: Bilateral 1/4 side rails up x 2 to assist with bed mobility related to muscle weakness and osteoarthritis to left hip. Pommel cushion to wheelchair to improve posture and prevent from sliding forward. On 08/19/2025 at 2:25 p.m. an interview with S2Director of Nursing (DON) revealed Resident #2's bilateral 1/4 bed rails are used to assist Resident #2 with bed mobility. S2DON revealed Resident #2 had a pommel cushion in the seat of his wheel chair to improve posture and prevent him from sliding forward. S2DON revealed Resident #2 had part of his left hip removed and was not able to transfer or walk on his own. S2DON was informed the bed rails and the pommel cushion was coded as a physical restraint and she confirmed that was an inaccurate assessment. On 08/19/2025 at 2:30 p.m. S5MDS Coordinator revealed she coded the use of bed rails and the pommel cushion as a restraint in error. Resident #8 On 08/19/2025 at 8:05 a.m., Resident #8 was observed lying in bed with bilateral 1/4 bed rails in the up position. Record review revealed Resident #8 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, type 2 diabetes mellitus, atrial fibrillation, chronic systolic heart failure, hypertension, anemia, generalized muscle weakness, need for assistance with personal care, other abnormalities of gait and mobility, other lack of coordination, and primary generalized osteoarthritis. Review of quarterly MDS assessment dated [DATE] revealed BIMS score of 6 which indicated Resident #8 was severely cognitively impaired for daily decision making. Further review revealed in section P (Restraints and Alarms), that Resident #8 had bed rails used daily as a physical restraint. Review of the August 2025 Physician Orders revealed the following active order: Bilateral 1/4 side rails up x 2 to assist with bed mobility related to muscle weakness. On 08/19/2025 at 3:10 p.m., an interview with S2DON revealed Resident #8's bilateral 1/4 bed rails were used to assist with bed mobility. S2DON was informed the bed rails was coded as a physical restraint and she confirmed that was an inaccurate assessment. On 08/19/2025 at 3:15 p.m., an interview with S5MDS Coordinator revealed she coded the use of bed rails as a restraint in error. Resident #4 On 08/18/2025 at 11:52 a.m., Resident #4 was observed in bed with left side bed rail in the up position. On 08/19/2025 8:11 a.m., Resident #4 was observed in bed with left side bed rail in the up position. Review of quarterly MDS assessment dated [DATE] revealed in section P, (Restraints and Alarms) that Resident #4 had bed rails used daily as a physical restraint. Review of August 2025 orders revealed the following active order: Bed against wall for increased room mobility with left quarter bed rails up times one to aid in bed mobility secondary to muscle weakness. On 08/19/2025 12:58 p.m., an observation interview was conducted with S2DON in Resident #4`s room. S2DON reported the left upper bed rail was used only as an assistive device used to reposition. S2DON was informed the bed rail was coded as a physical restraint and she confirmed that was an inaccurate assessment. On 08/19/2025 2:29 p.m., an interview with S5MDS Coordinator revealed she coded the use of bed rails as a restraint in error.

Based on record reviews and interviews, the facility failed to implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet the resident's needs by not having documentation of meal percentage intakes for 1 (#55) of 3 (#2, #47 and #55) residents reviewed for nutrition. Findings: Review of the medical record for Resident #55 revealed an admission date of 08/02/2024. Resident #55 had diagnoses that included psychosis, muscle weakness, lack of coordination, anxiety, dysphagia, depression, and abnormal weight loss.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #55's Brief Interview for Mental Status (BIMS) score was 13 which indicated intact cognition for daily decision making. Further review of the MDS revealed the resident required setup assistance for eating, and Resident #55 had malnutrition and weight loss. Review of the current care plan revealed Resident #55 was at risk for weight loss related to poor appetite, monitor and record meal intake, and to administer medications as ordered. Further review of the care plan revealed the Certified Nursing Assistants (CNAs) were responsible for documenting the meal percentage intakes.Review of the medical record revealed no documented evidence of meal percentage intakes documented daily for July 2025. Further review of the record revealed no documented evidence of meal intake percentages documented for August 1, 2025 - August 14, 2025, August 18, 2025, August 19, 2025, and August 20, 2025.On 8/20/2025 at 10:15 a.m., interview with S8CNA whom worked with Resident #55 on 08/20/2025, revealed she had not documented meal intake percentages for Resident #55. On 08/20/2025 at 12:45 p.m., interview with S2Director of Nursing (DON) confirmed the CNAs were responsible for documenting meal intake percentages for Resident #55. Further interview with S2DON revealed there was no documentation of meal percentage intakes daily for Resident #55 for the month of July 2025 and the days listed above in August 2025.

Based on observations and interviews the facility failed to ensure each resident environment remains as free of accident hazards as is possible for 1 (#36) of 4 (#8, #10, #33, #36) residents reviewed for accident hazards. The facility failed to ensure the water temperature in Resident #36's bathroom was not greater than 120 degrees Fahrenheit. Findings:On 08/18/2025 at 10:45 a.m., an observation of Resident #36's bathroom sink revealed the water felt hot to surveyor touch. On 08/18/2025 at 11:13 a.m., an observation of S4Maintenance Director's check of the hot water temperature in Resident #36's bathroom sink revealed the temperature was 121 degrees Fahrenheit. Surveyor then checked the hot water temperature using his own thermometer revealed the temperature was 123.4 degrees Fahrenheit. S4Maintenance Director confirmed the water temperature in Resident #36's bathroom sink was greater than 120 degrees Fahrenheit. On 08/19/2025 at 4:30 p.m., S1Administrator was informed of hot water temperature greater than 120 degree in Resident #36's bathroom sink. S1Administrator confirmed the hot water in Resident #36's sink should not exceed 120 degrees.

Based on observation and record review the facility failed to provide care and services that is in accordance with physician's orders and facility policy for 1 (#35) of 1 resident reviewed for respiratory care by not ensuring the nebulizer and tubing were changed weekly. Findings:Review of the facility's policy and procedure on administering medications through a small volume (handheld) nebulizer dated October 2010 revealed the following:Steps in the procedure:30. Change equipment and tubing every seven days. Review of Resident #35's medical record revealed an admission date of 04/14/2025 with diagnoses that include hypertensive heart disease with heart failure, wheezing, and other specified diseases of upper respiratory tract. On 08/18/2025 at 9:25 a.m. and 08/19/2025 at 8:27 a.m., observations of Resident #35's room revealed nebulizer and tubing were being stored on bedside table in a bag dated 08/04. Further observation revealed that the nebulizer and tubing were not dated. On 08/19/2025 at 9:30 a.m., a record review of Resident #35's active August 2025 physician orders revealed an order to change nebulizer tubing every week on Thursdays. On 08/19/2025 at 9:50 a.m., an observation of Resident #35's nebulizer with S2Director of Nursing (DON) confirmed that the nebulizer and tubing were stored in a bag dated 08/04 and that the nebulizer and tubing were not dated.

Based on observations, record reviews, and interviews, the facility failed to ensure a resident who is unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for 4 (#17, #23, #29 and #44) of 6 (#17, #22, #23, #28, #29, #44) residents reviewed for Activities of Daily Living (ADL) care. The facility failed to ensure 1.) residents' fingernails were kept clean and trimmed for #17, #23, #29 and #44 , and 2. resident #23 received oral hygiene and grooming. Findings: Resident #44 Review of the medical record for resident #44 revealed diagnoses of hyperlipidemia, cerebral infarction, hemiplegia, hemiparesis, protein calorie malnutrition, hypertension, and cognitive communication deficit. Review of the care plan revealed a problem for self-care deficit and required assistance with activities of daily living, provide a whirlpool bath three times a week and bed bath on the other days, clean and check fingernails/toenails, and provide nail care weekly and as needed. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was independent with cognition for daily decision making and required moderate assistance with bathing and personal hygiene. On 07/30/2024 at 10:02 a.m. and on 07/31/2024 at 8:50 a.m., observations of resident #44 revealed his fingernails were long and were in need of trimming. On 07/31/2024 at 9:00 a.m., S2Director of Nursing (DON) observed resident #44's fingernails with the surveyor and confirmed his nails were long and needed to be trimmed. 32231 Resident #17 Review of the electronic health record revealed resident #17 was admitted to the facility on [DATE] with diagnoses including chronic diastolic (congestive) heart failure, pseudobulbar affect, disorientation, cognitive communication deficit, muscle weakness (generalized), lack of coordination, abnormalities of gait and mobility, dementia, and glaucoma. Review of the Significant Change MDS assessment dated [DATE] revealed resident #17 had a brief interview for mental status score of 05. A score of 00-07 indicated that resident #17 was severely cognitively impaired with daily decision making skills. Further review of the assessment revealed that resident #17 required supervision or touching assistance with eating. On 07/30/2024 at 10:15 a.m., an observation revealed resident #17 sitting in the common area. Further observation revealed resident #17 had food particles in between his teeth and his fingernails were dirty underneath the nail beds on both hands. On 07/30/2024 at 4:38 p.m., an observation revealed resident #17 sitting in the dining room. Further observation revealed resident #17 was holding a tuna sandwich with his bare hand, while feeding himself. The resident's fingernails on both hands remained dirty. S8Certified Nursing Assistant (CNA) and S9CNA were sitting at a table next to resident #17. They did not address resident #17's fingernails being dirty. On 07/30/2024 at 5:00 p.m., an observation revealed S10CNA assisting resident #17 to his room. S10CNA was notified of resident #23's fingernails being dirty. S10CNA confirmed that resident #17's fingernails were dirty and needed to be cleaned. On 07/31/2024 at 5:00 p.m., S1Administrator, S2DON, and S3Corporate Administrator were notified of resident #17 feeding himself while his fingernails were dirty. Resident #23 Review of the electronic health care record revealed resident #23 was admitted to the facility on [DATE] with diagnoses including, Pseudobular affect, muscle weakness (generalized), vascular dementia, and a cognitive communication deficit. Review of the annual MDS assessment dated [DATE] revealed that resident #23 had a brief interview for mental status score of 05 indicating that the resident had severe cognitive impairment with daily decision making skills. Review of the plan of care revealed resident #23 had a self-care deficit that required her to need assistance with activities of daily living including oral care. On 07/30/2024 at 9:42 a.m., an observation of resident #23 revealed her teeth looked un-brushed with old food particles observed in between the teeth, she had long white hairs observed on her chin and her fingernails were dirty underneath the nail beds of both hands with the nails untrimmed. On 07/30/2024 at 2:00 p.m., an observation of resident #23 revealed the resident had old food particles in between her teeth, the long hairs remained on her chin, and her fingernails remained dirty and untrimmed. On 07/31/2024 at 9:53 a.m., an observation of resident #23 revealed the resident had old food particles in between her teeth, the long hairs remained on her chin, and her fingernails remained dirty and untrimmed. On 07/31/2024 at 12:30 p.m., S2DON was notified of the observations of resident #23 having food particles in between her teeth, long chin hair, and dirty fingernails. An observation of resident #23 with S2DON revealed there was no tooth brush in the resident's room. S2DON confirmed that resident #23 needed her teeth brushed and the chin hairs removed. On 07/31/2024 at 5:00 p.m., S1Administrator, S5Corporate Administrator, and S2DON were notified of resident #23 having food particles between her teeth, long chin hair, and dirty, untrimmed fingernails. Resident #29 Review of the electronic health record revealed that resident #29 was admitted to the facility on [DATE] with diagnoses including major depressive disorder, muscle weakness (generalized), other abnormalities of gait and mobility, lack of coordination, and low back pain. On 07/31/2024 at 9:53 a.m., an observation revealed resident #29 lying in bed. Further observation revealed resident #29 had long hairs on her chin and her fingernails were untrimmed and dirty underneath the nail beds on both hands. On 07/31/2024 at 12:30 p.m., S2DON was notified of the observations of resident #29's fingernails being long, untrimmed, and dirty underneath the nailbeds. S2DON confirmed resident #29's fingernails needed to be cleaned and the hair on the resident's chin needed to be removed. On 07/31/2024 at 5:00 p.m., S1Administrator, S5Corporate Administrator, and S2DON were notified of the above findings.

Based on observations, interviews, and record reviews, the facility failed to provide, based on the comprehensive assessment, care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities for 4 (#1, #23, #29 and #43) of 5 (#1, #23, #29, #30, and #43) residents reviewed for activities. Findings: Resident #1 Review of the medical record for resident #1 revealed an admitted [DATE] with diagnoses including cystitis without hematuria, heart failure, ileus, muscle spasms, convulsions, reflux, aphasia, heart failure, anxiety, gastrostomy status, hypoglycemia, and quadriplegia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment for daily decision making. Review of the care plan revealed the resident had impaired thought processes/cognitive dysfunction related to aphasia, being understood or understanding others secondary to history of a brain injury. Further review of the care plan revealed the resident was at optimal level in activity attendance. The resident was bedbound and had a diagnosis of quadriplegia. The Activity Director was to visit the resident three times a week for in room activities such as reading and music. Review of the in room activity binder revealed there was no documented evidence of in room activities for resident #1 since February 2024. Observations of resident #1 during the survey dates of 07/29/2024 - 07/31/2024 revealed no in room activities were provided for the resident. On 07/31/2024 at 11:45 a.m., an interview with S3Activity Director (AD) revealed she had been employed with the facility for about a month and she had not been into resident #1's room to provide any in room activities. 32231 Resident #23 Review of the electronic health care record revealed resident #23 was admitted to the facility on [DATE] with diagnoses including, Pseudobulbar affect, muscle weakness (generalized), vascular dementia, and a cognitive communication deficit. Review of the annual MDS assessment dated [DATE] revealed resident #23 had a BIMS score of 5 indicating that he had severe cognitive impairment with daily decision making skills. Review of the plan of care revealed resident #23 had a self-care deficit that required her to need assistance with activities of daily living. Review of the in-room activities binder revealed there was no documented evidence of in-room activities provided to resident #23. Observations of resident #23 during the suvey dates of 07/29/2024 - 07/31/2024 revealed no in room activities were provided for the resident. On 07/31/2024 at 1:28 p.m., S3AD further revealed that she was supposed to visit with resident #23 three times a week. S3AD confirmed that she had not been consistently visiting in-room with resident #23 to offer the resident in-room activities. Resident #29 Review of the electronic health record revealed that resident #29 was admitted to the facility on [DATE] with diagnoses including major depressive disorder, muscle weakness (generalized), other abnormalities of gait and mobility, lack of coordination, and low back pain. Review of the record revealed that resident #29 was care planned for the potential for alteration in mood related to depression. The documented approaches included that resident #29 enjoyed staff visibility and talking with her. Review of the in-room activities binder revealed there was no documented evidence of in-room activities provided to resident #29. Observations of resident #29 during the suvey dates of 07/29/2024 - 07/31/2024 revealed no in room activities provided for the resident. On 07/31/2024 at 1:28 p.m., S3AD revealed that resident #29 did not like to go out her room for activities, but she did like to visit with staff, in her room. S3AD further revealed that she was supposed to visit with resident #29 three times a week. S3AD confirmed that she had not been consistently visiting in-room with resident #29 to offer the resident in-room activities. On 07/31/2024 at 5:00 p.m., S1Administrator, S5Corporate Administrator, and S2Director of Nursing were notified of the above findings. 41829 Resident #43 Record review revealed resident #43 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus without complication, hemiplegia following cerebral infarction affecting left non dominant side, unspecified dementia, dysphagia, cardiomegaly, contracture, cachexia, gastrostomy, generalized anxiety disorder, aphasia, restless agitation, and generalized muscle weakness. Review of the quarterly MDS assessment dated [DATE] revealed the BIMS was blank. Resident #43 was unable to complete BIMS due to severe cognitive impairment. Resident #43 was totally dependent on staff for all activities of daily living. Review of the care plan revealed the resident was at optimal level in activity attendance. The Activity Director (AD) was to visit the resident three times a week for in room activities such as reading and music. Review of the in room activity binder revealed there was no documented evidence of in room activities for resident #43. Observations of resident #43 during the survey dates 07/29/2024 - 07/31/2024 revealed no in room activities were provided for the resident. On 07/31/2024 at 1:22 p.m., an interview with S3AD revealed she started working at the facility one month ago. S3AD reported she had not provided any in room activities with resident #43.

Based on record reviews, observations, and interviews, the facility failed to ensure residents were assessed for the risk of entrapment from bed rails and received a written order from the physician for bed rails prior to installation for 6 (#1, #16, #17, #23, #29, and #30) of 6 (#1, #16, #17, #23, #29, and #30) residents reviewed for accident hazards. Findings: Review of the facility's policy for Physical Restraints, Side Rails (undated) revealed in part: Purpose The purposes of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms. General Guidelines 2. Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents. 3. An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's: c. Risk of entrapment from the use of side rails. Review of the facility's Physical Restraint Record of Informed Consent form (undated) revealed in part: I fully understand that should the use of a restraint be necessary, it will only be considered to treat a medical condition or symptom that endangers my physical safety or the safety of other residents and will: 2. Only to be used upon the written order of my attending physician. Resident #1 Review of the medical record for resident #1 revealed an admitted [DATE] with diagnoses including heart failure, ileus, muscle spasms, convulsions, aphasia, heart failure, anxiety, hypoglycemia, and quadriplegia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment skills for daily decision making. Further review of the MDS revealed resident #1 was dependent on staff for activities of daily living. During the survey dates of 07/29/2024 - 07/31/2024, observations of resident #1 revealed she was in the bed with quarter bed rails raised on both sides of the bed. Review of the July 2024 physician's orders revealed no order for the use of bed rails. Review of the care plan revealed resident #1 had impaired mobility due to the resident was bedbound and was a quadriplegic. The approaches were to turn and reposition, and to use a geo ultra max reactive pressure distribution mattress to the bed. Review of the Electronic Health Record (EHR) and paper chart revealed no documented evidence the facility assessed resident #1 for the risk of entrapment from bed rails prior to installation and there was not a physician's order obtained for bed rails. On 07/31/2024 at 5:00 p.m., an interview with S5Corporate Administrator, S2Director of Nursing (DON), and S1Administrator revealed there was no documented evidence of an assessment for the risk of entrapment and a physician's order for bed rails prior to the installation. 32231 Resident #17 Review of the electronic health record revealed resident #17 was admitted to the facility on [DATE] with diagnoses including chronic diastolic (congestive) heart failure, pseudobulbar affect, disorientation, abnormality of gait, lack of coordination, cognitive communication deficit, muscle weakness (generalized), lack of coordination, abnormalities of gait and mobility, dementia, and glaucoma. Review of the significant change MDS assessment dated [DATE] revealed resident #17 had a BIMS score of 5. A score of 00-07 indicated that resident #17 was severely cognitively impaired with daily decision making skills. Further review revealed resident #17 required substantial assistance from staff with activities of daily living including roll left and right, sit to lying, and chair/bed to chair transfer. During the survey dates of 07/29/2024 - 07/31/2024, observations revealed that resident #17 had quarter side rails on both sides of the bed that were raised at various times. Review of the July 2024 physician's orders revealed no order for the use of bed rails. Review of the electronic health record and paper chart revealed no documented evidence the facility assessed resident #17 for the risk of entrapment from bed rails prior to installation and there was not a physician's order obtained for side rails. On 07/31/2024 at 5:00 p.m., an interview with S5Corporate Administrator, S2DON, and S1Administrator revealed there was no documented evidence of an assessment for risk of entrapment, and a physician's order for bed rails prior to the installation. Resident #23 Review of the electronic health record revealed resident #23 was admitted to the facility on [DATE] with diagnoses including pseudobular affect, muscle weakness (generalized), vascular dementia, and cognitive communication deficit. Review of the annual MDS assessment dated [DATE] revealed that resident #23 had a BIMS score of 5 indicating that she had severe cognitive impairment with daily decision making skills. Review of the plan of care revealed resident #23 had a self-care deficit that required her to need assistance with activities of daily living. During the survey dates of 07/29/2024 - 07/31/2024 observations revealed that resident #23 was in the bed with quarter bed rails raised on both sides of the bed. Review of the July 2024 physician's orders revealed no order for the use of bed rails. Review of the electronic health record and paper chart revealed no documented evidence the facility assessed resident #23 for the risk of entrapment from bed rails prior to installation and there was not a physician's order obtained for bed rails. On 07/31/2024 at 5:00 p.m., an interview with S5Corporate Administrator, S2DON, and S1Administrator revealed there was no documented evidence of an assessment for risk of entrapment, and a physician's order for bed rails prior to the installation. Resident #29 Review of the electronic health record revealed that resident #29 was admitted to the facility on [DATE] with diagnoses including major depressive disorder, muscle weakness (generalized), other abnormalities of gait and mobility, other lack of coordination, and low back pain. Review of the quarterly MDS assessment dated [DATE] revealed resident #29 required supervision or touching assistance with bed mobility and transfers. During the survey dates of 07/29/2024 - 07/31/2024 observations of resident #29 revealed she was in the bed with quarter bed rails raised on both sides of the bed. Review of the July 2024 physician's orders revealed no order for the use of bed rails. Review of the electronic health record and paper chart revealed no documented evidence the facility assessed resident #29 for the risk of entrapment from bed rails prior to installation and there was not a physician's order obtained for bed rails. On 07/31/2024 at 5:00 p.m., an interview with S5Corporate Administrator, S2DON, and S1Administrator revealed there was no documented evidence of an assessment for the risk of entrapment, and a physician's order for bed rails prior to the installation. 43405 Resident #16 Review of the record for resident #16 revealed an admitted [DATE] with diagnoses including bipolar disorder, transient ischemic attack, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, major depressive disorder recurrent severe with psychotic symptoms, generalized anxiety disorder, falls, schizoaffective disorder bipolar type, and dementia in other diseases classified elsewhere unspecified severity without behavioral disturbance. Review of the quarterly MDS assessment dated [DATE] revealed a BIMS score of 3 indicating severe cognitve impairment. Review of the July 2024 physician's orders revealed no order for the use of bed rails. Review of the plan of care revealed resident #16 had a self-care deficit that required her to need assistance with activities of daily living. Observations on 07/29/2024 at 9:55 a.m. and 07/30/2024 at 8:55 a.m. of resident #16 revealed quarter bed rails were raised on both sides of the bed. Review of the electronic health record and paper chart revealed no documented evidence the facility assessed resident #16 for the risk of entrapment for bed rails prior to installation and there was not a physician's order obtained for bed rails. On 07/31/2024 at 5:00 p.m., an interview with S5Corporate Administrator, S2DON, and S1Administrator revealed there was no documented evidence of an assessment for risk of entrapment, and a physician's order for bed rails prior to the installation. Resident #30 Review of the record for resident #30 revealed an admitted [DATE] with diagnoses including cerebral atherosclerosis, insomnia, hypothyroidism, vascular dementia, unspecified convulsions, anxiety disorder, and dementia. Review of the July 2024 physician's orders revealed no orders for the use of bed rails. Review of the quarterly MDS dated [DATE] revealed a BIMS score of 99 indicating the facility was unable to determine resident #30's cognitive status. Review of the plan of care revealed resident #30 had a self-care deficit that required her to need assistance with activities of daily living. Observations of resident #30 on 07/29/2024 at 9:20 a.m. and 07/30/2024 at 9:10 a.m. revealed quarter bed rails were raised on both sides of the bed. Review of the electronic health record and paper chart revealed no documented evidence the facility assessed resident #30 for the risk of entrapment from bed rails prior to installation and there was not a physician's order obtained for bed rails. On 07/31/2024 at 5:00 p.m., an interview with S5Corporate Administrator, S2DON, and S1Administrator revealed there was no documented evidence of an assessment for risk of entrapment, and a physician's order for bed rails prior to the installation.

Based on observations and interviews, the facility failed to store, distribute, and serve food in accordance with professional standards with food service safety by: 1) having opened food items stored in the freezers, exposed to air and not being labeled with an opened date, 2) having dirt and grime buildup in the kitchen and 3) storing employee personal items in the food preparation area. Findings: On 07/29/2024 at 8:30 a.m., an observation of the kitchen with S11Dietary Manager (DM) revealed a small chest style freezer that contained five small cups of ice cream. The cups were turned over and/or partially turned on the side with the ice cream coming out of the cups and some of the cup lids stuck together. Further observation revealed one small pizza inside of a zip lock bag. The bag was not labeled with an opened date. S11DM confirmed the ice cream should have been removed from the freezer and the bag of pizza was not labeled with an opened date. There was an ice machine located next to a large food prep table. The outside lid of the ice machine was dirty. Further observation revealed a strip of old, thick grime buildup and a filter had a thin layer of dust buildup. Further observation of the ice machine revealed an area between the lid and the compressor that had a strip of grime buildup and dust on the machine's filter. Observation further revealed a large insulated drink container located to the side of the ice machine and next to the food prep table. S11DM confirmed the ice machine was dirty and needed be cleaned. She further confirmed the drink container belonged to a staff member and should not have been in the kitchen. Observation of the large walk-in freezer revealed the following: one ham wrapped in clear wrap and opened bags containing finger steaks, meat pies, hamburger patties, large link sausages, chicken bites, and fajita chicken. The bags were not labeled with an opened date. Observation of the kitchen further revealed a large three compartment sink located in the back of the kitchen. Further observation of the Polvinyl Chloride (PVC) pipes that were located underneath the 3 compartment sink revealed the pipes had a large amount of old grime and dust on them. The area containing the pipes was open and the PVC pipes were exposed for viewing. There was also a second three compartment sink that was located in the kitchen and next to the large dishwashing machine. There was a buildup of dust and grime on the flooring underneath the sink. Further observation of the area revealed approximately four to five long screws, a small packet of salt, and a black ring type object that were located in a pile of broken pieces of dirt and grime. S11Dietary Manager confirmed the kitchen needed to be cleaned, all opened food items should be labeled with an opened date, and employee personal items should not be stored in the kitchen. On 07/29/2024 at 9:41 a.m., after touring and observing the kitchen with S1Administrator and S12Maintenance Supervisor, they confirmed the kitchen needed to be cleaned. On 07/31/2024 at 5:00 p.m., S3Corporate Administrator was notified of the above findings.

Based on observations and interviews, the facility failed to maintain all mechanical equipment in safe operating condition by having: 1.) a microwave in the secured unit that contained rust and 2.) a deep fryer located in the kitchen that contained dust and grime. Findings: 1.) On 07/29/2024 at 9:20 a.m., an observation of the secured unit revealed a microwave was located in a cabinet in the day room and exposed rust was observed on the inside of the microwave. On 07/29/2024 at 2:30 p.m., an interview with S7Certifiied Nursing Assistant (CNA) that worked in the secured unit revealed that she used the microwave to reheat the residents' food when needed. On 07/30/2024 at 8:54 a.m., S2Director of Nursing (DON) observed the microwave with the surveyor and confirmed that the inside of the microwave contained rust and needed to be replaced. 32231 2.) On 07/29/2024 at 8:30 a.m., an observation revealed a large deep fryer centrally located in the kitchen. The fryer had a lower compartment that housed the gas piping system. Observation of the inner compartment revealed there was a buildup of dust and grime on a portion of the pipes. On 07/29/2024 at 8:41 a.m., S1Administrator and S12Maintenance Supervisor were notified of the dust and grime buildup on the pipes of the fryer. After an observation of the deep fryer, S1Administrator and S12Maintenance Supervisor confirmed the deep fryer was not in safe working condition and needed to be cleaned. On 07/31/2024 at 5:00 p.m., S5Corporate Administrator was notified of above findings.

Based on record review, observation, and interviews, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice by failing to administer eye drops as ordered for 1 (#32) of 1 (#32) residents reviewed for vision. Findings: Review of the medical record for resident #32 revealed an admitted [DATE] with diagnoses including chronic obstructive pulmonary disease, anorexia, lack of coordination, unspecified glaucoma, and heart disease. Review of the care plan revealed resident #32 had impaired vision related to glaucoma and to administer eye drops as prescribed. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) of 11, which indicated the resident had moderate cognitive impairment for daily decision making. On 07/29/2024 at 12:06 p.m., an interview with resident #32 revealed he had not received his eye drops today. Review of the July 2024 physician's orders revealed an order dated 01/01/2023 for Dorzolamide 2% eye drops and to apply 1 drop to both eyes three times a day. Review of the July 2024 Medication Administration Record (MAR) revealed there was no documented evidence that Dorzolamide 2% eye drops were administered on 07/26/2024, 07/28/2024 and 07/30/2024 at 2:00 p.m., and 07/28/2024 and 07/29/2024 at 6:00 a.m. On 07/30/2024 at 4:25 p.m., an interview with S6Licensed Practical Nurse (LPN) revealed the resident was out of the eye drops and she called the pharmacy today and they still have not sent the medication. On 07/30/2024 at 4:35 p.m., S2Director of Nursing (DON) was notified that resident #32 did not have the eye drops in the medication cart or medication room for administration. On 07/30/2024 at 4:45 p.m., an interview with S2DON revealed she called the pharmacy and they stated the medication was on back order and not available for the resident. S2DON confirmed resident #32's medication was not available for administration.

Based on record review, observations, and interviews, the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice and the comprehensive person-centered care plan for 1 (#42) of 2 (#10 and #42) residents reviewed for respiratory care. The facility failed to ensure resident #42 was administered oxygen via nasal cannula per the physician's orders. Findings: Review of the record for resident #42 revealed an admitted [DATE] with diagnoses including chronic heart failure, type 2 diabetes mellitus, chronic obstructive pulmonary disease, shortness of breath, anxiety disorder, paroxysmal atrial fibrillation, and cardiomyopathy. Review of the July 2024 physician's orders revealed an order dated 03/07/2023 for Oxygen at 4 Liters per nasal cannula continuously. Review of the July 2024 Medication Administration Record (MAR) revealed documentation that resident #42 received Oxygen at 4 Liters per nasal cannula on 07/29/2024 and 07/30/2024. Review of the record revealed a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 indicating no cognitive impairment. Review of the current care plan dated 03/01/2023 revealed the resident was at risk for shortness of breath and/or respiratory distress, chronic obstructive pulmonary disease, chronic sinusitis, COVID-19, and other variants. Further review of the care plan revealed an intervention for continuous Oxygen at 4 Liters per nasal cannula. Observations of resident #42 on 07/29/2024 at 8:55 a.m., 07/30/2024 at 8:40 a.m., and 07/31/2024 at 8:50 a.m. revealed resident #42 was not wearing oxygen per nasal cannula and there was no oxygen concentrator in the resident's room. An interview on 07/31/2024 at 8:50 a.m. with resident #42 revealed she had not been wearing oxygen and did not have an oxygen concentrator in her room. An interview on 07/31/2024 at 8:55 a.m. with S4Registered Nurse (RN) confirmed that resident #42 had a current physician's order for Oxygen at 4 Liters per nasal cannula continuously. S4RN further confirmed that there was no oxygen concentrator in the resident's room. An interview on 07/31/2024 at 9:00 a.m. with S2Director of Nursing (DON) confirmed resident #42 had a current order for Oxygen at 4 Liters per nasal cannula continuously. S2DON revealed the staff had documented administration of oxygen continuously on the July 2024 MAR on 07/29/2024 and 07/30/2024. S2DON further confirmed resident #42 did not receive oxygen on 07/29/2024 and 07/30/2024.

Based on observations, record reviews, and interviews, the facility failed to ensure that the resident's environment remains as free of accident hazards as is possible and each resident receives adequate supervision to prevent accidents for 2 (#35, #36) of 6 (#10, #19, #27, #31, #35, #36) sampled residents that were ambulatory with or without assistive devices, according to a list provided by S2Director of Nursing (DON). Findings: Resident #36: Record review revealed resident #36 was admitted to the facility on [DATE] with diagnoses including cerebrovascular disease, malignant neoplasm of unspecified part of bronchus or lung, secondary malignant neoplasm of brain, and cognitive communication deficit. Review of the Minimum Data Set (MDS) dated [DATE] revealed she had a Brief Interview for Mental Status (BIMS) score of 5, which indicated she was severely cognitively impaired. She required supervision for locomotion on unit. Further review of Section E: Behaviors revealed she was assessed to have wandering that occurred daily. Review of resident #36's nurse's note dated 07/15/2023 at 5:07 p.m. revealed the resident continues with confusion. Resident noted wandering in and out of other rooms. Review of resident #36's current care plan revealed the following areas of concerns were identified: 07/19/2023 - resident very confused at times and exhibits behaviors of wandering around room 07/19/2023 - resident at risk for falls related to abnormal gait mobility and interventions included visual checks every 2 hours (review of resident #36's record revealed no documentation the 2 hour visual checks were provided) 07/19/2023 - resident had impaired thought process On 08/21/2023 at 2:00 p.m., resident # 36 was observed ambulating independently. She was walking behind her wheelchair pushing it in the day area. The resident was alert with confusion noted and was only oriented to self. 18118 Resident #35 Review of the medical record for sampled resident #35 revealed diagnoses including dementia, osteoarthritis, and hypertension. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had moderate cognitive skills for daily decision making and was independent for bed mobility and transfers. Further review of Section E: Behaviors revealed he was assessed to have wandering that occurred 1 to 3 days. Review of the medical record revealed a care plan for dementia. Further review of the care plan revealed the resident will become confused at times and will forget or miss part of conversation. Review of the nurses' notes dated 06/13/2023 revealed the resident can be seen sitting outside visiting with other residents and the resident was a little confused at that time. Review of the medical record revealed a Patient Health Questionnaire was obtained on 06/12/2023. Further review revealed resident #35 wandered at times due to his confusion and he gets turned around and forgets where his room was located, and this behavior type occurred 1-3 days. On 08/22/2023 at 8:30 a.m. and 08/23/2023 at 9:50 a.m., observations of resident #35 revealed he was walking in the hallway to the smoking area. Environment Observations: On 08/21/2023 at 8:40 a.m., an observation revealed there was a biohazard storage closet on Hall A that was unlocked and contained 2 large red trash cans. Further observation revealed there were no staff monitoring the unlocked door. On 08/21/2023 at 9:45 a.m., observation of the biohazard storage closet on Hall A remained unlocked and contained 2 large red trash cans. Further observation revealed there were no staff monitoring this door. On 08/21/2023 at 11:30 a.m., the surveyors observed that the side exit door near laundry was unlocked. There was a wander guard pad to the left of door frame; however, it did not have any lights activated that would indicate it was working properly. Observation of the area right outside the door revealed the area was not enclosed and the highway in front of facility was nearby. Further observation revealed there were no staff monitoring the above area and any resident that was independent with ambulation could exit in and out through the door undetected. On 08/21/2023 at 2:55 p.m., the surveyors, S1Administrator, and S3Regional Administrator observed the side exit door near the laundry area. They confirmed the door was unlocked and both were unsure if the wander guard key pad was working and this could be a potential accident hazard. On 08/22/2023 at 8:05 a.m., observation of the biohazard storage closet on Hall A remained unlocked and contained 2 large red trash cans. Further observation revealed there were no staff monitoring this door. On 08/22/2023 at 8:10 a.m., an observation revealed the side exit door near laundry remained unlocked. There was a wander guard pad to the left of door frame; however, it did not have any lights activated that would indicate it was working properly. Further observation revealed there were no staff monitoring the above area and any resident that was independent with ambulation could exit in and out through the door undetected. On 08/23/2023 at 8:00 a.m., the biohazard storage closet on Hall A remained unlocked and contained 2 large red trash cans. Further observation revealed there were no staff monitoring this door. On 08/22/2023 at 2:30PM, S1Administrator, S2Director of Nursing (DON), and S3Regional Administrator were informed of the unlocked side exit door near laundry that was an accident hazard to any residents that were independent with ambulation and could exit in and out through the door undetected. On 08/23/2023 at 4:15 p.m. S2DON was informed that residents #35 and #36 were assessed as having wandering behaviors. S2DON confirmed resident #35 and #36 did ambulate throughout the building. On 08/23/2023 at 4:30 p.m., the surveyor informed S2DON of the Hall A biohazard door being left open multiple times during survey. She confirmed the door has an automatic key pad and should remain closed at all times.

Based on record reviews and interview, the facility failed to ensure there was a sufficient number of skilled licensed nurses to provide care and services to each resident's basic needs. The facility failed to have documented evidence of actual times that Licensed Nursing staff provided care to the residents from January 01, 2023 thru January 31, 2023. Findings: Review of the facility's PBJ (Payroll Based Journal) Staffing Data Report for Fiscal Year Quarter 2 2023 (January 1 to March 31) revealed the facility failed to have Licensed Nursing coverage 24 hours per days. Review of the daily hours form for the employees, provided by S3Regional Administrator, revealed the total number of hours worked per day. The form did not indicate the actual clock in and clock out times of the employees. On 08/23/2023 at 3:10 p.m., an interview with S3Regional Administrator revealed the facility was unable to provide the time cards to ensure the facility had Licensed Nursing coverage 24 hours per day. Further interview with S3Regional Administrator revealed the facility started using a different time clock system in February 2023 and they were unable to produce the timecards from January 2023.

Based on record review and interview, the facility failed to ensure a Registered Nurse (RN) was on duty for 8 consecutive hours per day for 7 days per week for 5 days during January 2023. Findings: Review of the facility's PBJ (Payroll Based Journal) Staffing Data Report for Fiscal Year Quarter 2 2023 (January 1 - March 31) revealed no RN (Registered Nurse) hours, and One Star Staffing Rating. Review of the daily hours form for the employees revealed the total number of hours worked per day. The form did not indicate the actual clock in and clock out times of the employees. On 08/23/2023 at 3:10 p.m., an interview with S3Regional Administrator revealed the facility was unable to provide the time cards to ensure 8 hours of RN coverage was provided 7 days a week for 01/01/2023, 01/07/2023, 01/08/2023, 01/14/2023, and 01/15/2023.

Based on record review and interview the facility failed to ensure the pharmacist must report any irregularities to the attending physician, the facility's medical director, and director of nursing, and these reports must be acted upon for 1 (#32) of 5 (#5, 10, 31, 32, and 149) residents reviewed for unnecessary medications. The pharmacist failed to address that resident #32 did not receive sliding scale insulin as ordered. Findings: Review of the medical record for resident #32 revealed an admitted [DATE] with diagnoses including peripheral vascular disease, atherosclerotic heart disease, hypertension, hyperlipidemia, hemiplegia, dysphagia, aphasia, anorexia, and diabetes mellitus. Review of the care plan dated 03/23/2023 revealed alteration in health maintenance related to diabetes. Monitor for signs and symptom of hyperglycemia every shift, monitor blood sugar levels as ordered, provide medications as ordered, and monitor for side effects. Review of the significant change Minimum Data Set (MDS) dated [DATE] revealed the resident had severe cognitive skills with daily decision making and required assistance with activities of daily living. Review of resident #32's August 2023 Physician Orders revealed an order dated 05/31/2023 for an accucheck before meals (AC) and at bedtime (HS) with a Humalog (insulin) Sliding Scale as follows: 0-150=0U (Units) 151-200=2U 201-250=4U 251-300=6U 301-350=8U 351-400=10U 401-450=12U >451=give 15U notify MD If <60 give orange juice (OJ) with 2 packs of sugar Recheck in 1 hr and notify physician (MD) Review of resident #32's July 2023 Medication Administration Record (MAR) revealed documentation the nurses failed to follow the above sliding scale parameters 13 times from 07/01/2023 - 07/31/2023 when resident #32's blood sugar level was 151 or greater. Review of the monthly medication regimen review verification log for August 2023 revealed the pharmacist did not address that resident #32 did not receive sliding scale insulin as ordered during July 2023. On 08/23/2023 at 12:45 p.m., an interview with S2Director of Nursing (DON) revealed there was no documented evidence that the pharmacist addressed the insulin not being given as ordered.

Based on record reviews and interviews, the facility failed to ensure that each resident's drug regimen was free from unnecessary drugs for 2 (#32, #149) of 5 (#5, #10, #31, #32, #149) sampled residents reviewed for unnecessary medications. The facility failed to ensure the nurses followed the residents' insulin sliding scale parameters as ordered. Findings: Resident 32: Review of the facility's policy for Administering Medications revised April 2019 revealed in part 4. Medications are administered in accordance with the prescriber orders, including any required time frame. Review of the medical record for resident #32 revealed an admitted [DATE] with diagnoses including peripheral vascular disease, atherosclerotic heart disease, hypertension, hyperlipidemia, hemiplegia, dysphagia, aphasia, anorexia, and diabetes mellitus. Review of the care plan dated 03/23/2023 revealed alteration in health maintenance related to diabetes. Monitor for signs and symptom so hyperglycemia every shift, monitor blood sugar levels as ordered, provide medications as ordered and monitor for side effects. Review of the significant change Minimum Data Set (MDS) dated [DATE] revealed the resident had severe cognitive skills for daily decision making and required assistance with activities of daily living. Review of resident #32's August 2023 Physician Orders revealed an order dated 05/31/2023 for an accucheck before meals (AC) and at bedtime (HS) with a Humalog (insulin) Sliding Scale as follows: 0-150=0U (units) 151-200=2U 201-250=4U 251-300=6U 301-350=8U 351-400=10U 401-450=12U >451=give 15U notify MD If <60 give orange juice (OJ) with 2 packs of sugar Recheck in 1 hr and notify physician (MD) Review of resident #32's July 2023 Medication Administration Record (MAR) revealed documentation that the nurses failed to follow the above sliding scale parameters 13 times from 07/01/2023 - 07/31/2023 when resident #32's blood sugar level was 151 or greater. Review of resident #32's August 2023 Medication Administration Record (MAR) revealed documentation that the nurses failed to follow the above sliding scale parameters 18 times from 08/01/2023 - 08/21/2023 when resident #32's blood sugar level was 151 or greater. Review of the medical record revealed no documented evidence that resident #32 received insulin as ordered per the sliding scale parameters. On 08/23/2023 at 12:00 p.m., an interview with S2Director of Nursing (DON) confirmed the nurses failed to follow resident # 32's Humalog Sliding Scale parameters as ordered. 22575 Resident #149: Record review revealed resident #149 was admitted to the facility on [DATE] with diagnoses including Type 2 diabetes, and cognitive communication deficit. Review of the 5 day Minimum Data Set, dated dated dated [DATE] revealed he had a Brief Interview for Mental Status (BIMS) of 15, which indicated he was not cognitively impaired. Further review revealed he required extensive to total assistance with all activities of daily living. Review of resident #149's August 2023 Physician Orders revealed an order dated 08/05/2023 for an accucheck before meals (AC) and at bedtime (HS) with a Humalog (insulin) Sliding Scale as follows: 0-150=0U 151-200=2U 201-250=4U 251-300=6U 301-350=8U 351-400=10U 401-450=12U >451=give 15U notify MD If <60 give orange juice (OJ) with 2 packs of sugar Recheck in 1 hr and notify physician (MD) Review of resident #149's August 2023 Medication Administration Record (MAR) revealed documentation that the nurses failed to follow the above sliding scale parameters. The following high blood glucose results were documented and there was no documentation the Humalog was given according to the above sliding scale parameters as ordered (total of 5 times from 08/06/2023-08/17/2023): 08/06/2023 - 8:00 p.m. (168) 08/07/2023 - 8:00 p.m. (157) 08/14/2023 - 4:00 p.m. (159); 8:00 p.m. (163) 08/17/2023 - 11:00 a.m. (191) Further review of resident #149's August 2023 MAR revealed documentation of the following resident #149's low blood glucose results and that the nurses failed to give orange juice with 2 packs of sugar and to recheck the blood glucose in 1 hour and notify the physician as ordered (total of 2 times from 08/14/2023-08/21/2023): 08/14/2023 - 6:00 a.m. (51) 08/21/2023 - 6:00 a.m. (56) Record review revealed there was no documentation indicating the reason resident #149 did not receive the Humalog or receive treatment for the low blood glucose results according to the sliding scale parameter as ordered. On 08/23/2023 at 1:30 p.m., an interview with S2 Director of Nursing (DON) confirmed the nurses failed to follow resident # 149's Humalog Sliding Scale parameters as ordered.

Based on observations and interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This deficient practice had the potential to affect the 44 residents that received meals prepared in the facility's kitchen. Findings: On 08/21/2023 at 8:10 a.m., an initial tour of the facility kitchen was conducted and the following items were located in the large storage room: 5 pound bag of grits was opened with no date opened and the bag was not sealed or placed in a closed container; 5 pound bag of self-rising flour was opened with no date opened, in a plastic container that was not sealed; sugar was stored in a large plastic bin and there were old sugar particles scattered on the top and was in need of cleaning; a dietary cart was dirty with old food particles/dust noted on all the shelves; and there were 3 loaves of bread and an opened package of Styrofoam plates stored on the shelves. Further observation of the kitchen during initial tour revealed the following: Large ice machine had dirt/grime build-up on the large filters on the back of the machine; microwave near the work prep area was dirty with old food splatters noted inside the microwave; and a large deep fryer had old grease and grime build up in the holding area underneath the fryer. On 08/21/2023 at 8:30 a.m., the surveyor observed the above areas in the kitchen with S5Dietary Manager. S5Dietary Manager confirmed the above areas were either not stored properly and/or in need of cleaning.

Based on observations and interviews, the facility failed to maintain an infection prevention and control program to provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections. This deficient practice had the potential to affect all 47 residents who currently received laundry services provided by the facility. Findings: On 08/21/2023 at 9:20 a.m., observation of the designated clean laundry room revealed a small table that was located in front of two large sections that contained multiple stacked shelves. The shelves contained various items that included in part, resident clothing, linens, therapy gait belts, sheep skins, heel protectors, lift pads. Further observation revealed there were two bibles located on the top shelf of one of the sections. The bibles were both dusty and one with a small dead spider on it. S7Laundry Worker was present during the observations and reported the section of shelves were designated for clean items only. There was a small table that was located in front of the sections of shelves. The table was dirty and had a dust buildup on the table top. Further observation revealed the following items that were located on top of and in direct contact with the table top: a disposable cup, ink pen, three fluid ounce spray bottle of aromatherapy fine fragrance mist, ten and one half ounce bottle of fragrance booster, opened roll of toilet paper, red cell phone power cord, six and one half ounce bottle of bath and body works body lotion, small stuffed animal, vase with an artificial yellow flower inside of the vase, electric clock that had a build-up of grime and dust, salt shaker, disposable glove, two tubes of clapstick, a power strip with two cell phone chargers plugged directly into the strip, cell phone power cord that was plugged into one of the cell phone chargers, and a ceramic vase that contained a pair of nail clippers, two tubes of chapstick, two small sticky note pads, disposable glove, white trash bag, and a large clip inside of the vase. All of the items were observed to be dirty with buildup of dust, grime, and /or both. There was an air conditioner unit in the window seal that was located directly above the table. Observation revealed there was a small ceramic shoe, large stapler, and glass globe sitting on the top of the air conditioner. The items had a buildup of dust and grime on them. Further observation revealed the air condition's vents were dirty and had a sticky buildup of an unknown substance and dust on them. Further observation revealed there were cracks in the window seals with a buildup of grime, dust, cob webs, dead insect, and a towel. During the observations, the air conditioner unit was powered on and blowing air inside of the designated clean laundry room where resident linens, clothing, sheepskins, lift pad, gait belts, heel protectors, and multiple other clean items were being stored on the shelves and available for resident use. There was a rolling chair to one side of the table. The chair had a buildup of grime and dust. There was a second rolling chair located on the opposite side of the table that also had a dust buildup on it and a feather pillow in the seat of the chair. Observation revealed the pillow did not have a pillow cover on it and there were two feathers observed on the outside of the pillow along with a sheet that had been partially draped with the remainder of the sheet hanging down to the floor. S7Laundry Worker confirmed the room designated as the clean laundry room was dirty and needed to be cleaned. On 08/21/2023 at 10:00 a.m., S1Administrator, S3Regional Administrator, S6Maintenance, Hskp, Laundry Spv. (Maintenance, Housekeeping, Laundry Supervisor) were notified of the findings during the observations in the laundry department. After completing an observation of the laundry room with S1Administrator, S3Regional Administrator, and S6Maintenance, Hskp, Laundry Spv, they confirmed the room designated as the clean laundry room was dirty and needed to be cleaned to prevent cross contamination. On 08/23/2023 at approximately 4:45 p.m., S2Director of Nursing confirmed that all 47 residents who currently resided in the facility received some type of laundry services provided by the facility which included at a [NAME], the resident's bed linens.

Based on observation, record review, and interview, the facility failed to ensure the resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident for 1 (#24) of 1 (#24) residents investigated for choices, by failing to ensure resident #24 received a whirlpool bath every Monday, Wednesday, and Friday, in accordance with resident #24's personal choices. Findings: Review of the electronic heath care record revealed resident #24 was readmitted to the facility on [DATE] with diagnoses including in part, cerebral infarction, chronic pulmonary edema, anxiety disorder, and heart disease. Review of the minimum quarterly assessment dated [DATE] revealed resident #24 required physical help in part of bathing activity with one person physical assist and that she had a brief interview for mental status score of 14. A score of 13-15 indicated resident #24 was cognitively intact regarding daily decision making. Review of the Care plan revealed care planning for: problem onset: 08/12/2023: Res will refuse baths at times very particular about what time she wants to bathe. Approaches included in part, assist with bathes 3 x's per week and as needed-CNA (Certified Nursing Assistant). On 08/23/2023 at 9:15 a.m., Observation revealed resident #24 sitting up in her wheelchair, inside of her room. During an interview, resident #24 reported that she was supposed to receive a whirlpool bath on Monday, Wednesday, and Friday, but she was lucky if she got a whirlpool bath once a week, because the whirlpool CNA would get pulled to work the floor at times. She further reported that she had notified S2DON (Director of Nursing) about not getting a whirlpool bath on her (resident #24) scheduled days. Review of the July 2023 CNA flowsheets revealed resident #24 had only received a whirlpool bath on the dates of Wednesday 07/05/2023 and Tuesday 07/18/2023. Further review revealed there was no further documentation of resident #24 receiving a whirlpool bath during the month of July 2023. Further review revealed there were two copies of the CNA flowsheets dated August 2023. Review of those flowsheets revealed they were both dated 08/16/2023 through 08/31/2023 with inconsistent documented entries on each of the sheets. Further review revealed there was no documentation on any of the three CNA flowsheets indicating the reason as to why resident #24 had not received a whirlpool bath three times a week on Monday, Wednesday, and Friday per resident #24's personal choice. On 08/23/2023 at 2:11 p.m., S9Whirlpool CNA confirmed that resident #24 was scheduled to receive a whirlpool bath three times weekly on Monday, Wednesday, and Friday. S9Whirlpool CNA was notified of the findings reviewed on the CNA flowsheets. After a review of the three CNA flowsheets was completed with S9Whirlpool CNA, she reported that she did not know why there were two CNA flowsheets for the month of August 2023. She confirmed the documentation of the August 2023 flowsheets was inconsistent, there was no documentation of resident #24 receiving a whirlpool bath on her scheduled days, and there was no documentation on the CNA flowsheets as to the reason why resident #14 did not receive a whirlpool bath as per resident #24's personal choice. On 08/23/2023 at 3:00 p.m., S2DON (Director of Nursing) was notified of the findings. After completing a review of the electronic health care record progress notes, medication administration records, and CNA flowsheets dated July 2023 and August 2023, S2DON confirmed there was no documentation to indicate the reason as to why resident #24 did not receive a whirlpool bath three times weekly, on Mondays, Wednesday, and Friday as per resident #24's personal choice. After the interview was completed, S1Administrator and S3Regional Administrator was notified of the findings.

Based on observation, record review, and interview the facility's administration failed to utilize its resources to ensure all staff were vaccinated for COVID-19 or had exemptions related to COVID-19; as well as ensuring those with exemptions were taking additional precautions when assigned to care for the residents in the facility. The deficient practice resulted in an immediate jeopardy situation on 07/25/2022 when the facility had 5 residents (#11, #19, #26, #35, and #88) that were COVID-19 positive, with 2 (#26 and #88) of the 5 (#11, #19, #26, #35, and #88) residents being hospitalized for COVID-19 within a 4 week period. The facility had 11(S9 CNA (Certified Nurse Aide), S10 LPN (Licensed Practical Nurse), S11 CNA, S12 CNA, S13 Dietary, S14 Ward Clerk, S15 CNA, S16 CNA, S17 Housekeeper, S18 Dietary, and S24 LPN) staff members either partially vaccinated or not vaccinated that were working and/or providing care and services to the residents in the facility. The facility' administration failed to ensure there was a contingency plan in place to address staff that were not fully vaccinated. S1 Administrator was notified of the Immediate Jeopardy situation on 08/10/2022 at 5:00PM. The Immediate Jeopardy was removed on 08/12/2022 at 3:00PM when the facility submitted an acceptable POR (Plan of Removal), which by record review, interview, and observations, the survey team verified was in progress of being implemented. The deficient practice continues at a potential for more than minimal harm for the remaining residents that reside in the facility. The POR read as follows: The following plan was started on 8/10/2022 and will be completed by 8/22/2022 unless otherwise stated in the plan. An in-service by S2 DON (Director of Nurses) held on day shift (starting 8/11/2022) & will continue until all staff have been instructed about receiving the COVID-19 vaccination or obtain exemption. Those staff that have only received one vaccination and/or is exempted must wear a KN95 &/or N95, during their working hours. This will be monitored by the IDT (Interdisciplinary Team) and/or designee daily time 4 weeks then 3 times a week times 4 weeks until compliance is met. The Administrator was in-serviced one on one with the Infection Control Nurse. Resident Affected: 1. Resident #11 - contracted COVID on 07/06/2022. Was placed on COVID Wing and Recovered 2. Resident #19 - contracted COVID on 07/06/2022. Was placed on COVID Wing and Recovered 3. Resident #88 - contracted COVID on 07/20/2022. Sent to ___ (local hospital) for treatment and returned on 07/28/2022. Remained positive via Abbott Rapid Test. Placed on COVID wing as a precaution. Returned to room on 07/30/2022 (recovered) 4. Resident #26 - contracted COVID on 07/21/2022. Sent to ___ (local hospital) for treatment and returned on 07/28/2022. Remained positive via Abbott Rapid Test. Placed on COVID wing as a precaution. Returned to room on 07/30/2022 (recovered) 5. Resident #35 - contracted COVID on 07/25/2022. Was placed on COVID Wing and Recovered Partial Vaccinated: 1. S15 CNA - received 2nd COVID-19 Vaccination on 08/12/2022 2. S14 Ward Clerk - received 2nd COVID-19 vaccination on 08/10/2022 3. S12 CNA - received 2nd COVID-19 vaccination on 08/10/2022 4. S13 Dietary - on 08/10/2022, was informed by S25 Dietary Manager to not return to work unless she has received 2nd COVID-19 vaccination and/or exemption is completed. This employee works on a PRN basis and has not worked in over a week, is not scheduled to come back to work until the weekend of the 27th. 5. S16 CNA - on 08/10/2022, was informed by S1 Administrator to not return to work unless she has received 2nd COVID-19 vaccination and/or exemption is completed 6. S24 LPN - 08/10/2022 medical exemption obtain. In-Service was conducted on 08/11/2022 (See in-service training report. Brief summary of discussion on topics. Discussed COVID-19 vaccination. (Proper mask usage such as KN95 or higher/respiratory hygiene and proper use, exemptions, temporary delays, & wearing of KN95 or higher. Expected completion of in-service will be done for all staff by 8/13/2022. A binder log will be started on 08/11/2022 and completed by 08/22/2022. The binder will include all staff including those who have received their 1st vaccination, those with exemptions & temporary delays. The Infection Preventionist and/or designee will ensure that an Infection Prevention and Control Program is put in place. The Infection Preventionist and/or designee will initiate a binder with all current employees's vaccination records and exemptions in order to meet CMS (Centers for Medicare/Medicaid Services) guidelines of 100%. This will be monitored by the Infection Control Nurse and/or designee in which will be overseen by the Administrator to ensure the binder stays updated and current. The Administrator will be monitored by other members of the IDT which includes the MDS (Minimum Data Set) Coordinator &/or DON. This will be done daily times 4 weeks, then 3 times a week until compliance is met. If compliance is not met disciplinary actions will be taken. If staff is non-compliant with mask wearing after 3 write-up that staff member will be suspended times one shift and once returned remains non-compliant that staff member will be terminated. Findings: Cross Reference F888. Review of the facility's COVID-19 Vaccination policy and procedure notice revealed: all new hires are required to show vaccination status upon hire; those who are unvaccinated have 30 days from date of hire to provide proof of receiving first vaccination or turn in an exemption form, failure to do so can result in exclusion from the schedule. The current recommendations for staff vaccination per CDC (Centers for Disease Control) include having had at least 1 COVID-19 vaccination prior to providing care to residents. The facility's current COVID-19 policy and procedure did not include a contingency plan for staff that are not fully vaccinated for COVID-19; including a deadline for staff to obtain vaccine, and actions taken if deadline was not met. The facility did not track and secure documentation for delayed staff vaccinations, or those given exemption forms to complete and had not be turned back in for approval. Review of the formulas for facility staff vaccination rate revealed a rate of 82% with 5 unvaccinated staff (S9 CNA (Certified Nurse Aide), S10 LPN (Licensed Practical Nurse), S11 CNA, S17 Housekeeper, and S18 Dietary) with no exemption/temporary delay, and 6 partially vaccinated staff (S12 CNA, S13 Dietary, S14 Ward Clerk, S15 CNA, S16 CNA, and S24 LPN) out of a total of 61 current employees as of 07/25/2022. An interview on 08/12/2022 at 8:40AM with S1 Administrator confirmed that the COVID-19 policies and procedures needed to be updated with current CDC guidelines for staff vaccination. She reported all staff should be vaccinated or have exemption before providing care and services to residents. She reported COVID-19 policies and procedures should include: monitoring, tracking, and securing documentation for COVID-19 staff vaccination for all staff, including temporary delays and exemptions. S1 Administrator also revealed the need to ensure facility's staff vaccination rate at 100% to be in compliance with requirements.

Based on interview and record review, the facility failed to ensure the Infection Preventionist established and maintained the Infection Prevention and Control Program by allowing COVID-19 unvaccinated and non-exempted staff to care for the residents. The Infection Preventionist also failed to ensure unvaccinated staff wore the proper PPE (personal protective equipment) and to ensure that staff had qualifying exemptions if they were not vaccinated. The deficient practice resulted in an immediate jeopardy situation on 07/25/2022 when the facility had 5 residents (#11, #19, #26, #35, and #88) that were COVID-19 positive, with 2 (#26 and #88) of the 5 (#11, #19, #26, #35, and #88) residents being hospitalized for COVID-19 within a 4 week period. The facility had 11(S9 CNA (Certified Nurse Aide), S10 LPN (Licensed Practical Nurse), S11 CNA, S12 CNA, S13 Dietary, S14 Ward Clerk, S15 CNA, S16 CNA, S17 Housekeeper, S18 Dietary, and S24 LPN) staff members, either partially vaccinated or not vaccinated that were working and/or providing care and services to the residents in the facility. The facility's Infection Preventionist failed to ensure that the Infection Prevention and Control Program had a system in place to address all staff were vaccinated or had exemptions for COVID-19; and that the system also included contingency plans with ways to take precautionary measures to minimize the COVID-19 exposure risk of all residents in the facility. The Immediate Jeopardy was removed on 08/12/2022 at 3:00PM, when the facility submitted an acceptable POR (Plan of Removal), which by record review, interview, and observations, the survey team verified was in progress of being implemented. The deficient practice continues at a potential for more than minimal harm for the remaining residents that reside in the facility. The POR reads as follows: The following plan was started on 08/10/2022 and will be completed by 08/22/2022 unless otherwise stated in the plan. The Infection Preventionist &/or designee will ensure unvaccinated staff and exemption staff wear KN95 &/or N95 while working with residents. 1. The Infection Preventionist &/or designee will ensure staff have qualifying exemptions. Resident Affected: 1. Resident #11- contracted COVID on 7/6/2022. Placed on COVID wing and recovered. 2. Resident #19- contracted COVID on 7/6/2022. Was placed on COVID wing and recovered. 3. Resident #88- contracted COVID on 7/20/2022. Sent to _____ local hospital for treatment and returned on 7/28/2022, remained positive via Abbott Rapid Test. Placed on COVID wing as a precaution. Returned to room on 7/30/2022 (recovered). 4. Resident #26- contracted COVID on 7/21/2022. Sent to ____ local hospital for treatment and returned on 7/28/2022, remained positive via Abbott Rapid Test. Placed on COVID wing as a precaution. Returned to room on 7/30/2022 (recovered). 5. Resident #35- contracted COVID on 7/25/2022. Was placed on COVID wing and recovered. Partial Vaccinated: 1. S15 CNA - received 2nd COVID-19 vaccination on 8/12/2022 2. S14 Ward Clerk- received 2nd COVID-19 vaccination on 8/10/2022 3. S12 CNA - received 2nd COVID-19 vaccination on 8/10/2022 4. S13 Dietary - on 8/10/2022, was informed by S25 Dietary Manager to not return to work unless she has received 2nd COVID-19 vaccination and/or exemption is completed. This employee works on a prn basis and has not worked in over a week. Is not scheduled to come back to work until the weekend of the 27th. 5. S16 CNA - on 8/10/2022, was informed by S1 Administrator to not return to work unless she has received 2nd COVID-19 vaccination and/or exemption is completed. 6. S24 LPN - obtained exemption on 8/10/2022. An in-service was conducted on 8/11/2022 (See in-service training report. Brief summary of discussion on topics. Discussed COVID-19 vaccination. (Proper mask usage such as KN95 or higher/respiratory hygiene and proper use, exemptions, temporary delays & wearing of KN95 or higher. Expected completed of in-service will be done for all staff by 8/13/2022. A binder log will be started on 8/11/2022 and completed by 8/22/2022. The binder will include all staff including those who have received their 1st COVID-19 vaccination, those with exemptions & temporary delays. (See Attachment) All residents have the potential to be affected. The Infection Preventionist &/or designee will ensure those staff that have only one vaccine and/or exemption wears a KN95 or higher masks. The Infection Preventionist and/or designee will ensure that Infection Prevention and Control Program is put into place. The Infection Preventionist and/or designee will initiate a binder with all current employee's vaccination records and/or ensure staff has an exemption in order to meet CMS Guidelines of 100% staff vaccination rate. RNRC (Rayville Nursing and Rehab Center) will ensure that all staff has received at least the 1st vaccination and/or exemption by 8/22/2022. No one will be hired at RNRC unless they have had their 1st COVID-19 vaccination &/or have an exemption. Anyone who has just received their 1st shot &/or has an exemption & currently employed will wear a KN95 or higher masks while working at RNRC. This will be implemented immediate. The Infection Preventionist (S3 LPN-Licensed Practical Nurse/Infection Preventionist) was counseled on 8/11/2022 by S1 Administrator in regards to failing to utilize the resources to ensure all staff were vaccinated for COVID-19; and those with exemptions were taking additional precautions when caring for residents, failure to develop policies related to staff vaccinations to include processes for tracking vaccination status, exemptions and implementation of additional precautions relate to those not fully vaccinated. S3 LPN/Infection Preventionist was also verbally counseled regarding failure to ensure that unvaccinated staff wore proper PPE & ensuring staff have qualifying exemptions. Counseled regarding ensuring all staff are vaccinated for COVID-19 or have an exemptions. Findings: Cross reference F888. Review of the COVID-19 Staff Vaccination Status Matrix for Providers that was provided by S3 LPN/Infection Preventionist revealed that the facility had 5 staff that were not vaccinated without exemption/delay, 6 staff that were partially vaccinated, and 9 staff that had granted exemptions. Review of the list of COVID positive residents from 07/11/2022 through 08/08/2022 revealed 5 (#11, 19, 26, 35, and 88) residents. An interview on 08/10/2022 at 10:50AM with S3 LPN/Infection Preventionist and S1 Administrator confirmed that the facility has 5 staff that were not vaccinated for COVID-19 and do not have an exemption or temporary delay; and 6 staff that are partially vaccinated. S3LPN/Infection Preventionist reported that these 11 staff are still working at the facility. S3LPN/Infection Preventionist reported that 2 (#26, #88) of 5 (#11, #19, #26, #35, and #88) residents that tested COVID positive in July 2022 were hospitalized in July 2022. An interview on 08/10/2022 at 11:45AM with S3LPN/Infection Preventionist and S1 Administrator confirmed that between 07/06/2022 through 07/25/2022 there had been an outbreak of COVID -19 that included 5 positive residents (#11, 19, 26, 35, and 88); with 2 (#26 and #88) of the 5 residents being hospitalized . The interview also verified that there were 5 staff (S9 CNA, S10 LPN, S11 CNA, S17 Housekeeper, and S18 Dietary) with no exemption/delays for COVID-19; and 6 staff (S12 CNA, S13 Dietary, S14 Ward Clerk, S15 CNA, S16 CNA, S24 LPN) with partial vaccinations for COVID-19 that were allowed to provide care and services to the residents in the facility. S3LPN/Infection Preventionist and S1 Administrator also stated that they had not ensured partially vaccinated, unvaccinated, and exempt staff took additional precautions while caring for the residents; and did not ensure that the partially vaccinated staff completed their COVID-19 vaccination within the allowable time frames according to CDC guidance.

Based on record review and interview, the facility failed to develop and implement policies and procedures that ensured all staff are fully vaccinated for COVID-19 or have a vaccine exemption in place regarding COVID-19. The facility had 11 out of 61 current staff members not fully vaccinated for COVID-19. The deficient practice resulted in an immediate jeopardy situation on 07/25/2022 when the facility had 5 residents (#11, #19, #26, #35, and #88) that were COVID-19 positive, with 2 (#26 and #88) of the 5 (#11, #19, #26, #35, and #88) residents being hospitalized for COVID-19 within a 4 week period. The facility had 11(S9 CNA (Certified Nurse Aide), S10 LPN (Licensed Practical Nurse), S11 CNA, S12 CNA, S13 Dietary, S14 Ward Clerk, S15 CNA, S16 CNA, S17 Housekeeper, S18 Dietary, and S24 LPN) staff members either partially vaccinated or not vaccinated that were working and/or providing care and services to the residents in the facility. The facility had no contingency plan to address staff that were not fully vaccinated. S1 Administrator was notified of the Immediate Jeopardy situation on 08/10/2022 at 5:00PM. The Immediate Jeopardy was removed on 08/12/2022 at 3:00PM when the facility submitted an acceptable POR (Plan of Removal), which by record review, interview, and observations, the survey team verified was in progress of being implemented. The deficient practice continues at a potential for more than minimal harm for the remaining residents that reside in the facility. The POR reads as follows: The following Plan was started on 08/10/2022 and will be completed by 08/22/2022 unless otherwise stated in the plan. By 08/22/2022, RNRC (Rayville Nursing and Rehabilitation Center) will ensure that all staff has received at least the 1st COVID-19 vaccination and /or exemption by 08/22/2022. No staff will be hired at RNRC unless they have had their 1st COVID-19 vaccination &/or have an exemption /or have a temporary delay. Anyone who has just received their 1st shot &/or has an exemption & currently employed will wear a KN95 or higher while working at RNRC. This will be implemented immediately. Resident Affected: 1. Resident #11 - contracted COVID on 07/06/2022. Was placed on COVID Wing and Recovered 2. Resident #19 - contracted COVID on 07/06/2022. Was placed on COVID Wing and Recovered 3. Resident #88 - contracted COVID on 07/20/2022. Sent to ___ (local hospital) for treatment and returned on 07/28/2022. Remained positive via Abbott Rapid Test. Placed on COVID wing as a precaution. Returned to room on 07/30/2022 (recovered) 4. Resident #26 - contracted COVID on 07/21/2022. Sent to ___ (local hospital) for treatment and returned on 07/28/2022. Remained positive via Abbott Rapid Test. Placed on COVID wing as a precaution. Returned to room on 07/30/2022 (recovered) 5. Resident #35 - contracted COVID on 07/25/2022. Was placed on COVID Wing and Recovered Partial Vaccinated: 1. S15 CNA - received 2nd COVID-19 Vaccination on 08/12/2022 2. S14 Ward Clerk - received 2nd COVID-19 vaccination on 08/10/2022 3. S12 CNA - received 2nd COVID-19 vaccination on 08/10/2022 4. S13 Dietary - on 08/10/2022, was informed by S25 Dietary Manager to not return to work unless she has received 2nd COVID-19 vaccination and/or exemption is completed. This employee works on a PRN basis and has not worked in over a week, is not scheduled to come back to work until the weekend of the 27th. 5. S16 CNA - on 08/10/2022, was informed by S1 Administrator to not return to work unless she has received 2nd COVID-19 vaccination and/or exemption is completed 6. S24 LPN - 08/10/2022 medical exemption obtained On 08/10/2022, reviewed and updated policy and procedure to reflect current CDC guidelines related to staff vaccination exemptions. In-Service was conducted on 08/11/2022 (See in-service training report, brief summary of discussion on topics. Discussed COVID-19 vaccination. (Proper mask usage such as KN95 or higher/respiratory hygiene and proper use, exemptions, temporary delays, & wearing of KN95 or higher. Expected completion of in-service will be done for all staff by 08/13/2022. A binder log will be started on 08/11/2022 and completed by 08/22/2022. The binder will include all staff including those who have received their 1st vaccination, those with exemptions, and temporary delays. Monitoring: This will be monitored by the infection control nurse and/or designee. This will be performed 3 times a week times 4 weeks, then weekly thereafter until compliance is met. If compliance is not met disciplinary actions will be taken. If continued compliance is not met, employee will be terminated. Findings: Review of the facility's COVID-19 Vaccination policy and procedure notice on 08/09/2022 revealed: all new hires are required to show vaccination status upon hire; those who are unvaccinated have 30 days from date of hire to provide proof of receiving first vaccination or turn in an exemption form, failure to do so can result in exclusion from the schedule. The current recommendations for staff vaccination per CDC (Centers for Disease Control) include having had at least 1 COVID-19 vaccination prior to providing care to residents. Review of the facility's current COVID-19 policy and procedure on 08/09/2022 at 12:00PM revealed it did not include a contingency plan for staff that are not fully vaccinated for COVID-19; including a deadline for staff to obtain vaccine, and actions taken if deadline was not met. The facility did not track and secure documentation for delayed staff vaccinations, or those given exemption forms to complete and had not been turned back in for approval. Review of the formulas for facility staff vaccination rate revealed a rate of 82% with 5 unvaccinated staff (S9 CNA, S10 LPN, S11 CNA, S17 Housekeeper, and S18 Dietary) with no exemption/temporary delay, and 6 partially vaccinated staff (S12 CNA, S13 Dietary, S14 Ward Clerk, S15 CNA, S16 CNA, and S24 LPN) out of a total of 61 current employees as of 07/25/2022 and remains current. On 08/11/2022 at 3:40PM an interview with S3 LPN/Infection Preventionist, confirmed that she had not completed a root cause analysis for the COVID-19 outbreak that occurred in July 2022. S3 LPN/Infection Preventionist also revealed at this time that she had not done in-services related to the most recent outbreak in July 2022, and stated that the COVID-19 policy and procedure had not been updated to address staff obtaining vaccinations timely, tracking and securing documentation of all staff vaccinations including temporary delays and exemptions, and a contingency plan for unvaccinated and partially vaccinated staff. Review of the COVID Positive Residents from 7-11-22 to 8-8-22 list provided by S3 LPN/Infection Preventionist on 08/09/2022 at 12:00PM revealed 5 residents (#26, #88, #11, #19, and #35) between 07/06/2022 and 07/25/2022 were COVID positive. This list included dates the residents tested positive, their course of treatment, and who had been their exposure risks. Resident #26 was admitted to the facility on [DATE]. Review of the 5 day MDS (Minimum Data Set) dated 06/02/2022 revealed a BIMS (Brief Interview of Mental Status) score of 15 indicating no cognitive impairment. Further review of the MDS revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #26 tested COVID positive on 07/21/2022, and was admitted to the local hospital for treatment on 07/21/2022 with symptoms of altered mental status, decreased appetite, and dehydration. Review of the COVID Positive Residents from 7-11-22 to 8-8-22 list revealed resident #26 was exposed per S27 Housekeeper who tested positive for COVID on 07/17/2022. Resident #88 was admitted to the facility on [DATE]. On 07/20/2022 resident #88 tested COVID positive on 07/20/2022 with the following signs and symptoms: nasal congestion, sore throat, cough, and fever. Resident #88 was admitted to the local hospital on 07/20/2022 for treatment. Review of the COVID Positive Residents from 7-11-22 to 8-8-22 list revealed resident #88 was exposed per S26 LPN who tested positive for COVID on 07/17/2022. Resident #11 was admitted to the facility on [DATE]. Review of the Quarterly MDS dated [DATE] revealed a BIMS score of 9 which indicates moderate cognitive impairment. Further review of the MDS revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #11 was residing on the secured care unit and tested COVID positive on 07/06/2022. Review of the COVID Positive Residents from 7-11-22 to 8-8-22 list revealed resident #11 was exposed per S23 CNA who tested positive for COVID on 07/04/2022 and worked the secured unit. Resident #19 was admitted to the facility on [DATE]. Review of the Annual MDS dated [DATE] revealed a BIMS score of 11 indicating moderate cognitive impairment. Further review of the MDS revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #19 was residing on the secured care unit and tested COVID positive on 07/06/2022. Review of the COVID Positive Residents from 7-11-22 to 8-8-22 list revealed resident #19 was exposed per S23 CNA who tested COVID positive on 07/04/2022 and worked the secured unit. Resident #35 was admitted to the facility on [DATE]. Review of the 5 day MDS dated [DATE] revealed a BIMS score of 15 indicating no cognitive impairment. Further review of the MDS revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #35 tested COVID positive on 07/25/2022. Review of the COVID Positive Residents from 7-11-22 to 8-8-22 list revealed resident #35 was exposed per S27 Housekeeper who tested COVID positive on 07/17/2022. Review of the COVID-19 Staff Vaccination Status for Providers provided by S3 LPN/Infection Preventionist revealed that the facility had 11 unvaccinated (S9 CNA, S10 LPN, S11 CNA, S12 CNA, S13 Dietary, S14 Ward Clerk, S15 CNA, S16 CNA, S17 Housekeeper, S18 Dietary, and S24 LPN) staff members either partially vaccinated or not vaccinated that were working or providing care or services to the residents in the facility. The list below consists of the 11 unvaccinated staff members along with their hire dates and disciplines from a list provided by S1 Administrator. S9 CNA was hired on 01/25/2022 and was not vaccinated with no exemption or temporary delay. Review of the COVID Positive Employees July 2022 list provided by S3 LPN/Infection Preventionist on 08/09/2022 at 12:00PM revealed S9 CNA tested COVID positive on 07/17/2022. S10 LPN was hired on 04/07/2021, and was listed as not vaccinated with no documentation of exemption or temporary delay. Review of the COVID Positive Employees July 2022 list provided by S3 LPN/Infection Preventionist on 08/09/2022 at 12:00PM revealed S10 LPN tested COVID positive on 07/13/2022. S11 CNA was hired on 07/16/2021, and was listed as not vaccinated with no documentation of exemption or temporary delay. S18 Dietary was hired on 04/05/2015, and was listed as not vaccinated with no documentation of exemption or temporary delay. S17 Housekeeper was hired on 01/25/2022, and was listed as not vaccinated with no documentation of exemption or temporary delay. S12 CNA was hired on 07/25/2019, and was listed as partially vaccinated. Review of the LINKS (Louisiana Immunization Network) Patient Vaccination Summary for S12 CNA revealed 1st COVID-19 vaccination was given on 12/01/2021. S13 Dietary was hired on 04/25/2022, and was listed as partially vaccinated. Review of the LINKS Patient Vaccination Summary for S13 Dietary revealed 1st COVID-19 vaccination was given on 11/05/2021. S14 Ward Clerk was hired on 10/22/2021, and was listed as partially vaccinated. Review of the LINKS Patient Vaccination Summary for S14 Ward Clerk revealed 1st COVID-19 vaccination was given on 07/06/2021. S15 CNA was hired on 01/14/2022, and was listed as partially vaccinated. Review of the LINKS Patient Vaccination Summary for S15 CNA revealed 1st COVID-19 vaccination was given on 12/30/2021. Interview with S15 CNA on 08/11/2022 at 4:00PM revealed she had received one dose of the COVID-19 vaccine and was scheduled to get her second dose of the vaccine tomorrow (08/12/2022). S16 CNA was hired on 07/17/2021, and was listed as partially vaccinated. Review of the LINKS Patient Vaccination Summary for S16 CNA revealed 1st COVID-19 vaccination was given on 12/02/2021. S24 LPN was hired on 01/13/2021, and was listed as partially vaccinated. Review of the LINKS Patient Vaccination Summary for S24 LPN revealed 1st COVID-19 vaccination was given on 12/09/2021. An interview on 08/10/2022 at 10:50AM with S3 LPN/Infection Preventionist revealed that the facility has 11 unvaccinated staff (S9 CNA, S10 LPN, S11 CNA, S12 CNA, S13 Dietary, S14 Ward Clerk, S15 CNA, S16 CNA, S17 Housekeeper, S18 Dietary, and S24 LPN) with no documented evidence of exemptions or temporary delays. S3 LPN/Infection Preventionist also confirmed that 5 (#11, #19, #26, #35, and #88) residents were COVID-19 positive, and 2 (#26 and # 88) residents were hospitalized for COVID-19 during the July 2022 outbreak beginning on 07/06/2022. An interview on 08/10/2022 at 10:50AM with S3 LPN/Infection Preventionist confirmed that the facility did not ensure all staff were vaccinated for COVID-19 or had exemption prior to caring for residents, and that there was no tracking and securing of the documentation for delayed staff vaccinations. S3 LPN/Infection Preventionist also confirmed that the facility's COVID-19 policy and procedure did not include current CDC guidelines for COVID-19 staff vaccination including a contingency plan for unvaccinated or partially vaccinated staff. An interview on 08/10/2022 at 10:50AM with S1 Administrator, confirmed that the facility did not develop and implement updated policies and procedures for COVID-19 staff vaccination that ensured all staff are fully vaccinated for COVID-19 or have a vaccine exemption in place regarding COVID-19.