Every finding on record at Riverdell Care Center

Based on observation, interview and record review, the facility staff failed to prepare and serve food in accordance with the nutritionally calculated recipes to all residents. The facility census was 47.1. Review of the facility's standardized recipe for spaghetti with meat sauce showed staff directed to use 12.5 pounds of ground beef for 50 servings of meat sauce. Observation on 05/27/26 during the lunch meal, showed [NAME] H served residents portions of spaghetti noodles and meat sauce combined. Observation showed the cook did not offer residents additional protein. During an interview on 05/27/26 at 12:31 P.M., [NAME] H said he/she prepared the spaghetti for the noon meal following the recipe for 50 servings. The cook said he/she used 10 pounds of beef to prepare 50 servings even though he/she knew the recipe called for 12.5 pounds. The cook said he/she used the beef that was thawed and did not know why he/she did not use the full amount called for in the recipe. 2. Review of the facility's standardized recipe for spaghetti with meat sauce showed staff directed to serve four ounces of spaghetti noodles and six ounces of meat sauce to the residents who received regular diets. Observation on 05/27/26 at 12:09 P.M., showed [NAME] H combined the spaghetti noodles and meat sauce in one steam table pan and served it to the residents. Observation showed [NAME] H served the residents who received regular diets a #6 (5.25 ounces) scoop of the combined spaghetti a meat sauce (4.75 ounces less than directed by the recipe). 3. Review of the facility's standardized recipe for spaghetti with meat sauce showed staff directed to serve residents who received pureed diets four ounces of pureed spaghetti noodles and a #6 scoop of pureed meat sauce. Observation on 05/27/26 at 11:00 A.M., showed [NAME] H added an unmeasured amount of combined spaghetti noodles and meat sauce to a food processor, blended it until smooth, and then transferred the pureed product into a pan and placed it on the stove. Observation on 05/27/26 at 12:23 P.M., showed [NAME] H served a #6 scoop of the pureed combined spaghetti noodles and meat sauce (four ounces less than directed by the recipe) to the residents who received pureed diets. During an interview on 05/27/26 at 12:31 P.M., [NAME] H said he/she always combines the spaghetti and meat sauce because the residents preferred it that way. The cook said he/she did not realize the recipe had separate portion sizes for the spaghetti noodles and the meat sauce. The cook said he/she did not know he/she underserved the residents. 4. During an interview on 05/28/26 at 2:45 P.M., the administrator said all cooks are responsible to prepare and serve food in accordance with the standardized recipes, which includes the portion sizes. The administrator said he/she did not know kitchen staff did not follow the recipes.

Based on observation, interview and record review, facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to clean a mechanical lift after use for three residents (Resident #14, #20, and #39). The census was 47.1. Review of the facility's Using a Mechanical Lifting Machine Policy, dated 2001 (no month), showed staff are to disinfect lift surfaces and wipe with a clean towel until dry. The policy did not contain guidance for when to cleanse the lift.2. Observation on 05/26/26 at 1:14 P.M., showed Certified Nurse Aide (CNA) E and the Assistant Director of Nursing (ADON) transferred Resident #14 from his/her wheelchair to the bed with the mechanical lift. Without cleansing the mechanical lift, the CNA and ADON transferred Resident #36, from his/her wheelchair to bed with the mechanical lift. During an interview on 05/26/26 at 2:24 P.M., CNA E said he/she did not clean the lift but thought the ADON did between residents. He/She said staff should clean the lift between residents to keep from spreading germs. 3. Observation on 05/27/26 at 10:02 A.M., showed CNA C and the Activity Director transferred Resident #20 from the wheelchair to the bed with the mechanical lift. Staff wheeled the lift to the storage room and did not clean the lift after use.During an interview on 05/27/26 at 10:45 A.M., CNA C said he/she did not clean the lift as he/she should have to prevent infection. He/She was in a hurry and nervous, just trying to get it done. 4. During an interview on 5/29/26 at 11:09 A.M., the DON said he/she expects staff to clean the lift between residents to maintain infection control. During an interview on 05/29/26 at 11:55 A.M., the Administrator said it would be nice if staff would clean the lifts between residents for infection control reasons. There are purple wipes available. He/She said he/she is not sure if it is being done.

Based on observation, interview and record review, facility staff failed to ensure four (Resident #8, #14, #17, #20) out of eight sampled residents who are unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene and grooming. The facility census was 47. 1. Review of the facility's policy titled Shaving the Resident, dated 2001, showed the purpose of shaving is to promote and to provide skin care. The policy did not contain direction or guidance for when to shave a resident. Review of the facility's policy titled Care of Fingernails/Toenails, dated 2001, showed the purpose of nailcare is to clean the nail bed, to keep nails trimmed, and to prevent infections. Nail care includes daily cleansing and regular trimming. Unless otherwise permitted, do not trim the nails of diabetic residents or residents with circulatory impairments. Review of the facility's policy titled Shower/Tub Bath, dated 2001, showed the purpose of bathing is to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. The policy did not contain direction or guidance for frequency of providing a bath/shower. 2. Review of Resident #8's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 02/24/26, showed staff assessed the resident as cognitively impaired and required substantial to maximal assistance of staff for personal hygiene. Review of the resident's care plan, dated 03/13/26, showed the resident needs ADL help and will resist care at times, staff is to provide for all ADLs, and the resident will be appropriately groomed and presentable. Review of the shower sheets, dated May 2026, showed staff documented nail care provided on 05/01/26. The shower sheets did not contain documentation that additional nail care had been provided or refused. Observation on 05/26/26 at 11:25 A.M., showed the resident with long, jagged fingernails with dark debris under the nail. Observation on 05/26/26 at 1:09 P.M., showed the resident with long, jagged fingernails with dark debris under the nail. The resident chewed on his/her nails. Observation on 05/27/26 at 11:28 A.M., showed the resident with long, jagged fingernails with dark debris under the nail. 3. Review of Resident #14's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively impaired, did not reject care, and dependent on staff for toileting, personal hygiene and showers. Review of the resident's care plan, dated 05/27/26, showed the resident required assistance from one to two staff for ADLs. Review of the shower sheets, dated May 2026, showed the sheets did not contain documentation that nail care had been provided or refused for the month. Observation on 05/26/26 at 11:43 A.M., showed the resident's fingernails long, jagged and with dark debris under the nail. Observation on 05/27/28 at 8:31 A.M., showed the resident's fingernails long, jagged and with dark debris under the nail. 4. Review of Resident #17's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact and required assistance with personal hygiene. Review of the resident's care plan, revised 01/02/26, showed the resident can be resistive with care such as showers, reapproach as needed, and document all refusals. The care plan does not address the residents' shaving and showering preferences. Review of the shower sheets, dated March through May 2026, showed staff did not document the resident had been shaved. Observation on 05/26/26 at 12:40 P.M., showed the resident with long chin hair and oily hair. Observation on 05/27/26 at 12:42 P.M., showed the resident with long chin hair and oily hair. Observation on 05/28/26 at 9:00 A.M., showed the resident with long chin hair and oily hair. Observation on 05/28/26 at 9:23 A.M., showed the resident with long chin hair and oily hair. During an interview on 05/29/26 at 12:00 P.M., the administrator said the resident should be shaved every time they are showered or bathed. Hair should be washed during every shower/bath or per the resident's preference. The administrator said the resident sometimes prefers the hairdresser to wash his/her hair at their appointments. If the resident's hair appears dirty or oily he/she would expect staff to ask the resident during showers if they wanted their hair washed. 5. Review of Resident #20's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively impaired, did not reject care and required substantial to maximal assistance with personal hygiene. Review of the resident's care plan, dated 02/25/26, showed needs assistance with ADL's but will express needs and wants. The care plan did not address the residents' facial hair preferences or nail care. Observation on 05/26/26 at 11:25 P.M., showed the resident in the dining room with long facial hair and long jagged fingernails with dark debris under the nail. Observation on 05/27/26 at 9:53 A.M., showed the resident's fingernails long, jagged and dark debris. Observation showed the resident with long facial hair. Observation on 05/28/26 at 9:08 A.M., the resident's fingernails long jagged and long facial hair. During an interview on 05/29/26 at 10:32 A.M., the Social Service Designee (SSD) the resident likes to be shaved most of the time, sometimes every other time if it's not long. 6. During an interview on 05/29/26 at 10:32 A.M., the SSD said staff are expected to take residents to the shower, give the shower washing their body and hair, then get them dressed in their room. When the residents get showers, they are supposed to be offered nail care and shaving. Residents with diabetes are provided nail care by the nurses and toenails by the podiatrist. Staff should trim fingernails when they are needed. During an interview on 05/29/26 at 10:46 A.M., the MDS Coordinator said staff should document resident refusals of care in the care plan and the care plan team should be updated. The MDS coordinator said nail care is expected and should not be listed on the care plan. During an interview on 05/29/26 at 11:09 A.M., the Director of Nursing (DON) said nail care and shaving should be done with each shower and refusals of showers should be documented in the electronic health record. If the resident is diabetic, nail clipping is done by the nurse and if not, the CNAs are responsible. If staff notice that a residents' nails are long and/or dirty they should soak them, clean them and trim them. If staff notice facial hair on residents that is unwanted, shaving should be provided. Shower sheets are turned into the DON when completed and if he/she did not get a sheet, the shower was not done. During an interview on 05/29/26 at 11:55 A.M., the administrator said CNAs should clip the fingernails of residents during showers unless the resident is a diabetic, then it would fall on the nurse. CNA's shave residents, at a minimum during showers or more often if the resident requests. The administrator said showers should be provided two times per week. He/She feels showers are not getting done due to low staffing.

Based on observation, interview and record review, facility staff failed to develop and implement a person-centered comprehensive care plan for five (Resident #2, #8, #14, #20 and #40) of twelve sampled residents. The facility census was 38. 1. Review of the facility's policy titled Comprehensive Care Plan dated May 2026, showed comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT). 2. Review of Resident #2's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 04/22/26, showed staff assessed the resident as cognitively impaired. Review of the resident's care plan, dated 05/26/26, showed the care plan did not contain use of signage above the resident's bed. Observation on 05/26/26 at 11:14 A.M., showed a sign hung on the wall above the resident's bed that read in the dining room for meals and one that showed transfer instructions. Observation on 05/27/26 at 8:27 A.M., showed the resident in his/her room by the bed in his/her wheelchair. A sign hung on the wall above the resident's bed that read in the dining room for meals and one that showed transfer instructions. Observation on 05/27/26 at 10:02 A.M., showed a sign hung on the wall above the resident's bed that read in the dining room for meals and one that showed transfer instructions. During an interview on 05/29/26 at 9:08 A.M., the MDS Coordinator said he/she is newer to the facility and still trying to get everything updated. The MDS Coordinator said signage over the bed should also be care planned but didn't think about it. The resident is cognitively impaired and does not have family to give consent. 3. Review of Resident #8's Annual MDS, dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -Felt it somewhat important to listen to music he/she enjoys, participate in activities with groups of people, go outside to get fresh air when the weather is good, and participate in religious services; -Required substantial to maximal assistance for personal hygiene. Review of the resident's care plan, dated 02/24/26, showed: -Needs assistance for ADLS; -Provide all ADLS; -The care plan did not include activities, bathing and nail care preferences and/or level of assistance needed. Observation on 05/26/26 at 1:09 P.M., showed the resident with long, jagged fingernails with dark debris under the nail. The resident chewed on his/her nails. Observation on 05/27/26 at 9:59 A.M., showed the resident fingernails long jagged and with dark debris under the nail. During an interview on 05/29/26 at 9:08 A.M, the MDS Coordinator said the resident likes to participate in activities and engage with his/her peers. He/She said activity participation should be a part of the care plan. He/she said nail care should be a part of the bathing process and would not normally be care planned. 4. Review of Resident #14's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -Had functional limitation in range of motion in all extremities; -Dependent on staff for bathing, dressing and personal hygiene. Review of the resident's care plan, dated 05/27/26, showed: -Unable to care for self; -Needs assistance to complete ADLs; -The care plan did not include fingernail or shower preferences. Observation on 05/26/26 at 11:43 A.M., showed the resident fingernails long jagged and with dark debris under the nail. Observation on 05/27/28 at 8:31 A.M., showed the resident fingernails long jagged and with dark debris under the nail. During an interview on 05/29/26 at 9:08 A.M, the MDS Coordinator said nail care should be a part of the bathing process and would not need to be care planned. 5. Review of Resident #20's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -Dependent on staff for bathing, toileting, and transfers; -Required substantial to maximal assistance for personal hygiene. Review of the residents' care plan, dated 01/22/26, showed: -Likes to go to activities, play bingo, and watch television; -Needs assistance with ADLS; -The care plan did not contain direction for bathing, facial hair and nail care preferences, or the use of a signage above the resident's bed. Observation 05/27/26 at 10:02 A.M., showed a sign hung above the resident's bed with a splint schedule and direction for wheelchair positioning. The resident's fingernails long, and he/she had long facial hair. During an interview on 05/29/26 at 10:46 A.M., the MDS Coordinator said ADL preferences for shaving, showers, and care should be on the care plan, but nail care would not necessarily be on the care plan as it is an expectation for staff to complete. Care plans should include all assistance the residents need. 6. Review of Resident #40's Annual MDS, dated [DATE], showed staff assessed the resident as: -Severely cognitively impaired; -Severely visually impaired; -Required set up or clean up assistance with meals. Review of the resident's care plan, revised 04/08/26, showed the resident is blind and his/her meals are served in divided plates to assist with independence. The care plan did not address the need for feeding assistance. Observation on 05/27/26 at 12:00 P.M. showed Certified Nurse Aide (CNA) I placed a non-divided plate with spaghetti, vegetables and bread, and a bowl of apple dessert in front of the resident. CNA I did not sit down with the resident. Observation on 05/27/26 at 12:05 P.M. showed the resident poked at his/her food and brought an empty fork to his/her mouth several times before he/she started to eat with his/her hands. Observation showed the resident ate with his/her hands and attempted to locate the utensils unsuccessfully. During an interview on 05/29/26 at 9:25 A.M., CNA I said the resident doesn't usually have trouble feeding himself/herself and he/she is surprised the resident is having trouble this week. CNA I said it sounds like the resident should be assisted at all times during meals. CNA I said he/she did not know the resident's meals should be served on a divided plate. During an interview on 05/19/26 at 11:30 A.M., the Director of Nursing (DON) said visually impaired residents should be assisted with meals and the assistance need should be on the care plan. The DON was not aware the resident was not being served on a divided plate. During an interview on 05/29/2026 at 11:54 A.M., the Administrator said he/she expects visually impaired residents to be assisted during meals according to their abilities. He/She said divided plates are available and have sections to separate food and should be on the care plan. The Administrator said everything that is resident-centered should be care planned and provided. 7. During an interview on 05/29/26 at 9:08 A.M., the MDS Coordinator said care plans are reviewed at least every 92 days and updated as needed. Care plans should include resident preferences and things specific to the residents. He/she said nail care and shaves should be a part of the bathing process and would not normally be care planned. He/She is newer to the facility and still trying to get everything updated. During an interview on 05/29/26 at 11:09 A.M., the DON said the overall care plan should include items like appetite, pain, overall care including showers, nail grooming, contractures and limited range of motion. Signage above resident beds should have family or resident approval prior to being hung. During an interview on 05/29/26 at 11:54 A.M., the administrator said the MDS Coordinator is responsible for overseeing the care plans. The care plans should be reviewed periodically and at a minimum quarterly. The care plans should include all the residents' preferences and anything that would benefit the care. All nursing staff have access to the care plans and changes can be put in the Electronic Health Record by the nursing staff as a quick alert that will go to the department managers and MDS Coordinator so care plans can be updated quickly. This process is a new integration, and staff are still being trained.

Based on observation, interview and record review, facility staff failed to provide assistance during meals for one resident (Resident #40) with visual impairment out of two sampled residents. The facility census was 54.1. Review of the facility policy titled Care of Visually Impaired Residents, dated 2001, showed staff are directed to describe the place setting and location of food on the plate according to the clock face (meat at 12:00, potato at 6:00, etc.) while dining.Review of the facility policy titled Meal Assistance, dated 2001, showed staff will serve trays and help residents who required assistance with meals. Residents who cannot feed themselves will be fed with attention to safety, dignity, comfort and dignity. Adaptive devices will be provided for residents who need or request them. 2. Review of Resident #40's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 04/07/26, showed staff assessed the resident as severely cognitively impaired, severely visually impaired and required set up or clean up assistance with meals.Review of the resident's care plan, revised 04/08/26, showed staff assessed the resident is blind and staff should serve meals in divided plates to assist with independence, let the resident know what he/she is eating and where food is placed. Observation on 05/27/26 at 12:00 P.M., showed the resident sat at a bedside table. Certified Nurse Assistant (CNA) I placed a non-divided plate of spaghetti, vegetables and bread, and a bowl of apple dessert in front of the resident. CNA I oriented the resident to the plated food, and did not sit down with the resident. Observation showed the resident poked at his/her food with a fork and brought an empty fork to his/her mouth several times before he/she started to eat with his/her hands. Observation showed the resident ate with his/her hands and attempted to locate the utensils unsuccessfully. Observation on 05/27/26 at 12:25 P.M., showed CNA I asked the resident if he/she wanted a napkin. The CNA did not assist the resident with his/her meal. Observation on 05/28/2026 at 11:36 A.M., showed the resident sat at a bedside table in his/her wheelchair. Staff placed a non-divided plate with a peanut butter and jelly sandwich, potatoes, fruit bowl and cake. Certified Medication Technician (CMT) F described the location of the food on the plate, location of utensils., coffee and punch. Observation showed CNA I sat down and assisted the resident, who frequently brought an empty spoon to his/her mouth. CNA I guided the coffee cup to the resident's mouth and helped him/her put food on his/her fork. The CNA fed the resident. At this same time, CNA I said, you are really hungry. The resident replied, it's the first I've eaten today. CNA I told the resident, I think you are doing pretty good. Observation showed CNA I stood up and went to help other residents. Observation showed the resident could not locate the utensils and ate with his/her hands. During an interview on 05/29/26 at 9:25 A.M., CNA I said the resident doesn't usually have trouble feeding himself/herself and he/she is surprised the resident is having trouble this week. CNA I said he/she did not realize the resident ate with his/her hands when not assisted. CNA I said it sounds like the resident should be assisted at all times during meals. CNA I said he/she did not know the resident's meals should be served on a divided plate. CNA I said staffing is short on the memory care unit, but a new CMT started a few days ago and helps, and the nurse is on the other side of the double doors if needed. He/She said it is a lot for one person at mealtime.During an interview on 05/19/26 at 11:30 A.M., the Director of Nursing (DON) said staffing has been tight. He/She said visually impaired residents should be assisted with meals and the assistance needs should be on the care plan. The DON was not aware that the residents' food was not served on a divided plate.During an interview on 05/29/2026 at 11:54 A.M., the administrator said he/she expects visually impaired residents to be assisted during meals according to their abilities. He/She said divided plates are available and have sections to separate food.

Based on observation, interview, and record review, facility staff failed to ensure medications were stored and labeled to facilitate consideration of precautions and safe administration of eye drops, inhalers, and nasal spray. The facility census was 47.1.Review of the facility's Storage of Medication Labeling and Storage Policy, dated 2001, showed:-The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manor;-If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items;-Multi-dose vials that have been opened or accessed are dated and discarded withing 28 days unless the manufacturer specifies a shorter or longer date for the open vial.Review of the facility's Discontinued Medications Policy, dated 2001 (no month), showed staff shall destroy discontinued medications or return them to the dispensing pharmacy in accordance with the facility policy.Review of the facility's Medication Administration Policy, dated 2001 (no month), showed when opening a multi-dose container, the date opened is recorded on the container.Review of the Federal Food and Drug Administration (FDA) package insert for:-Aplisol (tuberculin purified protein derivative, or Purified Protein Derivative (PPD)), dated November 2013 showed vials in use for more than 30 days should be discarded;-Tubersol (Tuberculin PPD), undated, showed a vial which has been entered and in use for 30 days should be discarded;-Teriparatide (hormone injection that stimulates bone formation), dated July 2006, showed to throw away the pen after 28 days, even if the pen is not completely empty;-Spriva (medication used to relax the airways), dated November 2007, showed a three month in-use expiration date from the date when the drug product cartridge is inserted into the device. 2. Observation on 05/26/26 at 10:06 A.M., showed the medication room contained:-One opened vial of Aplisol with an expiration date of 05/24/26;-One opened vial of Tubersol with an expiration date of 05/24/26;-Two unopened vials of Teriparatide with an expiration date of 05/01/26 and 05/05/26.During an interview on 05/26/26 at 10:15 A.M., Licensed Practical Nurse (LPN) B said thinks the Assistant Director of Nursing (ADON) checks the medication rooms for expired and outdated medication.During an interview on 05/26/26 at 10:20 A.M., the ADON said he/she is responsible for ensuring medications are not stored are expired, outdated or discontinued. He/She checks the medication room monthly and checked on 05/22/26. The ADON said he/she was unaware the medication room contained expired medication. 3. Observation on 05/26/26 at 10:25 A.M., showed a medication cart contained:-Three opened, undated bottles of Lantaprost eye drops (glaucoma medication);-Three undated and unlabeled individual teardrop shaped plastic vials;-Two opened, undated boxes of Spirva inhaler tablets;-Two opened undated, Albuterol inhaler;-One opened undated, Advair inhaler (prevents breathing difficulties);-One opened undated, Advair discus inhaler;-Four opened undated, Flonase nasal spray.During an interview on 05/26/26 at 10:32 A.M., Certified Medication Technician (CMT) G said he/she does not date eye drops, inhalers, nasal sprays or ear drops. He/she said once opened, most items are only good for 30 days. He/She said if the items are not dated when they are opened, staff would not know if the items were still safe to administer. He/She said he/she would assume that since the medications are scheduled, they would run out before they expire. The CMT said he/she thinks the ADON checks the cart for expired/discontinued medications.4. During an interview on 05/29/26 at 11:09 A.M., the Director of Nursing (DON) said medication storage and expired medications should be checked every week, but preferably daily. The night nurse is responsible for checking for expired medications. If medications are expired, staff are to place the expired medication cards in the cabinet in the medication room. During an interview on 05/29/26 at 11:55 A.M., the administrator said the CMT's should be checking and pulling expired medications and the ADON and DON should do periodic audits. When medications are opened, staff are expected to date the bottle, vial or box when opened to assist with monitoring for expiration of the drugs. He/She said most medication expires within 30 days of opening and would expect the medication to be pulled past that time. He/She said if the medication is not opened, the expiration date is the manufacturer labeled date.

Based on observation, interview and record review, facility staff failed to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (LD- a serious type of pneumonia (lung infection) caused by Legionella bacteria, which places all residents of the facility at risk of exposure which could lead to illness. Facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to position an indwelling catheter of one resident (Resident #11) out of two sampled residents off the floor. The facility census was 46 1. Review of the Centers for Medicare and Medicaid Services (CMS) Quality, Safety and Oversight (QSO) 17-30, dated 06/02/17 and revised on 07/06/18, showed: The bacterium Legionella can cause a serious type of pneumonia called LD in persons at risk. Those at risk include persons who are at least [AGE] years old, smokers, or those with underlying medical conditions such as chronic lung disease or immunosuppression. Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including hospitals and long-term care facilities. Transmission can occur via aerosols from devices such as showerheads, cooling towers, hot tubs, and decorative fountains. Facilities must have water management plans and documentation that, at a minimum, ensure each facility: -Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system; -Develops and implements a water management program that considers the ASHRAE industry standard and the CDC toolkit; -Specifies testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained. Review of the facility's Legionella Water Management Plan, reviewed 09/27/24, showed: -The plan introduction indicated the name of another facility; -The portion of the plan related to responsible personnel indicated the name of another facility; -The plan indicated maintenance personnel were to dismantle, clean and descale all showerheads and spray nozzles quarterly; -The water heaters will be flushed every six months; -The written description of the building water system indicated water entered the facility from a municipal water line from a town which is located more than 90 miles from the facility; -The written description of the building water system indicated the facility had three separate water systems, which consisted of six water heaters; -The plan table of contents indicated the plan contained a building water system flow diagram. Review showed the plan did not contain a flow diagram. Observation on 12/11/24 during the Life Safety Code tour showed the facility contained three water heaters. Observation showed two water heaters located in the mechanical room near the laundry room and one water heater in the 300-hall mechanical room. Review of the facility's Legionella control measures for the period of January 2024 through November 2024 showed the documentation did not include: -Semiannual water heater flushes; -Quarterly shower head and spray nozzle cleaning and descaling. During an interview on 12/12/24 at 10:50 A.M., the maintenance director said he/she was responsible for Legionella control in the facility. The maintenance director said the Legionella plan should include an accurate description of the facility water system. The maintenance director said he/she never cleaned shower heads because he/she thought staff cleaned them. The maintenance director said the facility contained three water heaters and he/she did not know why the Legionella plan indicated six water heaters. The maintenance director said he/she did not flush water heaters. The maintenance director said he/she reviewed the Legionella plan, but never read the plan thoroughly. During an interview on 12/12/24 at 11:40 A.M., the administrator said the Legionella Water Management plan was in place when he/she started. The administrator said he/she and maintenance staff were responsible for ensuring the Legionella plan was accurate and was followed. The administrator said the Legionella plan should have accurate facility water system descriptions. The administrator said he/she was not aware of all required components of a water management plan. 2. Review of the facility's Urinary Catheter Care policy, dated 2001, showed the policy did not contain direction for positioning of an indwelling catheter off the floor. 3. Review of Resident #11's MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Dependent on staff for toilet hygiene; -Used an indwelling catheter; -Diagnosis of stroke and urine retention. Observation on 12/10/24 at 10:27 A.M., showed the resident in bed. His/Her indwelling catheter on the floor. Observation on 12/11/24 at 09:05 A.M., showed the resident in bed. His/Her indwelling catheter on the floor. Observation on 12/12/24 at 09:03 A.M., showed the resident in bed. His/Her indwelling catheter on the floor. During an interview on 12/11/24 at 09:05 A.M., the resident said he/she has had the catheter a long time. He/She said the staff hook the catheter to the bed when he/she lays down. During an interview on 12/12/24 at 01:55 P.M., Certified Nursing Assistant (CNA) G said catheters should be hooked to the bed below the bladder and never touch the floor because the floor is dirty and could get bacteria inside the bag. During an interview on 12/13/24 at 08:15 A.M., the Assistant Director of Nursing (ADON) said catheter bags should be kept off the floor for infection control reasons. During an interview on 12/13/24 at 08:30 A.M., the Infection Preventionist said residents with catheters should be kept off the floor because the floor is dirty and could cause an infection. The Infection Preventionist said there is training for infection control and the DON and ADON complete staff competencies of pericare during actual resident care. During an interview on 12/13/24 at 09:15 A.M., the Administrator said catheters should not be laid on the bed or on the floor due to risk for infections. He/She said the DON is responsible to oversee the process. During an interview on 12/13/24 at 09:30 A.M., the DON said catheters should not be placed on the floor due to bacteria potential. He/She said there has not been catheter training lately and is his/her responsibility to ensure staff are following proper procedure. He/She said the ADON and DON complete daily hall checks.

Based on observation, interview and record review, facility staff failed to ensure the dish washer machine operated according to manufacturer's instructions in a manner adequate to prevent cross contamination of kitchen wares. The facility census was 46. 1. Review of the facility's Sanitization policy, revised November 2022, showed dishwashing machines are operated according to manufacturer's instructions. General recommendations for low temperature dishwashers (chemical sanitization) are wash temperature of 120 degrees Fahrenheit (F) and final rinse with 50 parts per million (ppm) hypochlorite (chlorine). Review of the facility's Dish Machine - PPM Sanitizer Record Logs for the period of 10/01/24 through 12/12/24 showed staff documented morning and afternoon machine temperatures of 98 degrees F on all days. Observation on 12/10/24 at 10:20 A.M., showed the front of the dish machine contained a label which indicated minimum wash and rinse temperatures of 120 degrees F. Observation on 12/10/24 at 11:06 A.M., showed Dietary Dish Aide M ran a food processor bowl, lid, and blade through the dish machine. Observation showed the maximum water temperature reached was 101 degrees F. Observation on 12/10/24 at 11:10 A.M., showed the Dietary Manager (DM) used a food processor to puree chicken and broth. Observation showed the DM rinsed the food processor parts, added the parts to a dish machine rack, and ran the items through the dish machine. Observation showed the maximum water temperature reached was 109 degrees F. Observation on 12/10/24 at 11:23 A.M., showed Dietary Dish Aide M ran a food processor bowl, lid, and blade through the dish machine. Observation showed the maximum water temperature reached was 102 degrees F. Observation on 12/10/24 at 12:20 P.M., showed Dietary Dish Aide M prewashed and ran a rack of dishes through the dish machine. Observation showed the maximum water temperature reached was 106 degrees F. Observation on 12/12/24 at 9:03 A.M., showed a test run of the dish machine indicated a maximum temperature of 104 degrees F. Observation showed the dish machine temperature gauge and a calibrated digital thermometer indicated the same temperature during the test run. During an interview on 12/12/24 9:01 A.M., Dietary Dish Aide M said he/she checked the dish machine water temperature in the morning and afternoon. He/She said the dish machine water temperature should be 98 to 100 degrees F. He/She said he/she documented water temperatures on the dish machine log. He/She said he/she was trained to check water temperatures and sanitizer concentrations by the previous DM. During an interview on 12/12/24 9:16 A.M., [NAME] L said the dish machine temperature usually ran around 98 degrees F. [NAME] L said the water temperature should be between 98 and 100 degrees F. [NAME] L said staff checked water temperatures daily and notified the vendor if there was a problem. [NAME] L said the vendor never said anything about the dish machine water temperature. During an interview on 12/12/24 at 9:12 A.M., the DM said he/she was responsible for making sure the dish machine operated correctly and staff were trained on proper use and function. The DM said he/she was not aware the dish machine water was not getting hot enough. The DM said he/she thought the water temperature should be 110 degrees F. During an interview on 12/12/24 at 10:50 A.M, the maintenance director said he/she used the dish machine temperature gauge to observe water temperatures. The maintenance director said the dish machine gauge never reached 120 degrees and that was okay because the machine used low temperature sanitizer chemicals. The maintenance director said he/she had read the instructional signage on the dish machine but he/she never thought about it. During an interview on 12/12/24 at 11:40 A.M., the administrator said the facility used a low temperature dish machine but he/she did not know the specific water temperature of the machine. The administrator said the DM was responsible for ensuring staff followed the dish machine manufacturer's instructions. The administrator said he/she was not aware the dish machine was not being operated in accordance with manufacturer's instructions.

Based on observation, interviews, and record review, the facility staff failed to propell two residents (Resident #7, and #44) when staff did not use wheelchair footrests. Facility staff failed to provide safe mechanical lift transfers for three residents (Resident #15, #21, and #33), and failed to store hazardous materials in a safe manner in one shower room, one dining room and one storage cabinet. The facility census was 46. 1. The facility did not provide a policy for wheelchair safety. 2. Review of Resident #7's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Independent wheelchair; -Diagnosis of cerebrovascular accident, bipolar, schizophrenia, and macular degeneration. Observation on [DATE] at 2:59 P.M., showed Certified Nurse Aid (CNA) E propelled the resident in a wheelchair from the nurses desk to the Physical Therapy room. Observation showed the wheelchair did not contain foot rests and the residents feet slid along the floor while being propelled. During an interview on [DATE] at 3:01 P.M., CNA E said he/she couldn't find the foot rests for the wheelchair and had to propel the resident without them. He/She said it is safer with footrests on the wheelchair. 3. Review of Resident #44's quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Substantial assistance wheelchair; -Diagnosis of dementia, and anxiety. Observation on [DATE] at 9:18 A.M., showed the administrator propelled the resident from the nurses desk to the resident's room. Observation showed the wheelchair did not contain footrests. Observation showed the residents foot on and off the floor while being propelled. 4. Review of the facility's Lifting Machine, Using a Mechanical policy, dated 2001, showed staff the purpose of the procedure is to establish the general principles of safe lifting using a mechanical lifting device it is not a substitute for manufacturer's training or instructions and make sure the lift is stable and locked. 5. Review of Resident #15's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Dependent on staff for all transfers; -Diagnosis of stroke. Observation on [DATE] at 01:05 P.M., showed NA D and CNA E transferred the resident from the wheelchair with a mechanical lift and the leg base of the lift open, NA D raised the resident from the wheelchair, closed the leg base, pushed the resident over the bed and lowered the resident onto the bed. During an interview on [DATE] at 01:43 P.M., NA D said the leg base should be open wide to keep the lift stable. NA D said when using a mechanical lift the legs should be open to the widest position for stability otherwise the lift could tip over. He/She said he/she did not think about it. 6. Review of Resident #21's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severely cognitively impaired; -Dependent on staff for all transfers; -Diagnosis of dementia. Observation on [DATE] at 10:43 A.M., showed License Practical Nurse (LPN) C and the housekeeping supervisor transfered the resident from the wheelchair with a mechanical lift and the leg base of the lift open. LPN C raised the resident from the wheelchair, closed the leg base, pushed the resident over the bed and lowered the resident onto the bed. During an interview on [DATE] at 08:15 A.M., LPN C said mechanical lift training is done by therapy and nursing at least every three to four months. He/She said staff should keep the leg base open during the transfer for stability but the room size makes it difficult. LPN C said the leg base should be kept open or the lift could go off balance and the resident could fall. 7. Review of Resident #33's quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Transfer total dependence; -Diagnosis of dementia. Observation on [DATE] at 10:00 A.M., showed CNA J and LPN C used a mechanical lift to transfer the from a wheelchair to a bed. LPN C operated the lift while CNA J steadied the resident. LPN C opened the legs of the mechanical lift and positioned it over the wheel chair. LPN C removed the wheelchair, closed the legs of the lift, pivoted the lift towards the bed, pushed the lift over the bed and lowered the resident. During an interview on [DATE] at 10:15 A.M., LPN C said the legs of the lift can not be opened because of the lack of space in the room. He/She said the legs should be open for stability and resident safety. 8. During an interview on [DATE] at 09:15 A.M., the Administrator said during mechanical lift transfers, staff should keep the leg base open for the stability of the machine. He/She said staff are trained on the operation of the lifts by the therapy department. The DON is responsible for the oversight of the nursing staff. During an interview on [DATE] at 09:30 A.M., the DON said for safety reasons, staff should keep the leg base open during transfers with a mechanical lift for better balance. He/She said staff are trained during on the floor assistance and observations. The DON said the ADON and DON do daily hall checks for issues. 9. The facility did not provide a policy for the storage of hazardous materials. Observation on [DATE] at 11:42 A.M., showed the 100 hall shower room unattended and door unlocked. Observation showed the shower room cabinet unlocked with an open disposable razor container. Observation showed staff were not present in the hallway by the unlocked door. Observation on [DATE] at 9:18 A.M.,showed the 100 hall shower room unattended and door unlocked. Observation showed the shower room cabinet unlocked with an open disposable razor container. Observation on [DATE] at 9:57 A.M., showed the 300 hall resident dining room contained two bottles of nail polish remover in a plastic bin. Observation showed unattended residents sat in the dining room. 10. During an interview on [DATE] at 1:52 P.M., CNA K said wheelchairs should have the footrest on before a resident is pushed because it could injure the resident without the footrest. Mechanical lifts should be closed during transfers. He/She said hazardous chemicals and razors should be locked to prevent resident access for their safety. During an interview on [DATE] at 1:43 P.M., LPN F said staff should not push residents in a wheelchair without the footrests on. There could be injuries if the footrests are not on the wheelchair. Mechanical lifts should be done with the legs spread to the widest position or a resident could be injured. All hazardous materials or razors should be locked when not in use. During an interview on [DATE] at 9:19 A.M., the Administrator said residents should not be pushed without the footrests on or they could be injured. The administrator said staff are educated on this wheelchair safety. He/She said all hazardous chemicals or razors should be locked for resident safety.

Based on observation, interview, and record review, facility staff failed to store medications in one out of two medication storage rooms in a safe and effective manner. The facility census was 46. 1. Review of the facility's policy titled Medication Labeling and Storage, dated February 2023, showed if the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. The nursing staff is responsible for maintaining medications storage and preparation areas in a clean, safe, and sanitary manner. 2. Observation on 12/11/24 at 10:17 A.M., showed the 100 hall medication storage room contained the following: -One bottle of Aspirin 325 milligram (mg) with an expiration date of 09/24; -One bottle of Magnesium Oxide 400 mg with an expiration date of 09/24; -Three bottles of Vitamin D 10 mg with an expiration date of 09/24; -One Diclofenac Sodium topical Gel 100 gram tube with an expiration date of 04/24. During an interview on 12/13/24 at 8:16 A.M., Certified Medication Technician (CMT) A said expired or damaged medication are returned to the pharmacy or destroyed. During an interview 12/13/24 at 8:34 A.M., Licensed Practical Nurse (LPN) B said the night shift nurse is responsible for monitoring the medication storage room. Expired medications should be returned to the pharmacy or destroyed by facility staff and then reordered. All nurses and CMT's are to check for medication issues. During an interview on 12/13/24 at 9:26 A.M., the administrator said the Director of Nursing (DON) and the CMT's are responsible for monitoring the medication storage room. There should not be any expired medications in the room because of the risk to resident's health. During an interview on 12/13/24 at 9:43 A.M., the DON said all nursing staff are responsible for medication storage and for checking for expired medications. The medications should be destroyed due to the risk to the residents if they received the expired medications.

Based on observation, interview and record review, facility staff failed to provide a comfortable and homelike environment for residents, when staff failed to maintain walls, ceilings, and floors. The facility census was 46. 1. Review of the facility's Homelike Environment policy, date February 2021, showed residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting to include a clean, sanitary, and orderly environment. 2. Observation on 12/10/24 at 10:30 A.M., showed resident occupied room [ROOM NUMBER]'s bathroom contained multiple areas of black stains in the tile around the toilet. Observation showed the tiles lifted from the floor. Observation on 12/10/24 at 11:10 A.M., showed resident occupied room [ROOM NUMBER]'s bathroom contained multiple areas of black stains in the tile around the toilet. Observation showed the tiles lifted from the floor. The wall by the sink with damaged sheetrock which exposed metal edges at the corner joint. 3. Observation on 12/10/24 at 10:39 A.M., showed resident occupied room [ROOM NUMBER]'s bathroom had a sticky dried yellow substance on the bathroom tile, and the room contained a strong odor. 4. Observation on 12/10/24 at 10:45 A.M., showed resident occupied room [ROOM NUMBER]'s bathroom tiles broken with exposed concrete below with sharp edges and had a strong odor. 5. Observation on 12/11/24 at 11:07 A.M., showed resident occupied room [ROOM NUMBER]'s ceiling near the window patched contained cracks, brown stains, and black material which protruded from a hole. 3. During an interview on 12/13/24 at 8:17 A.M. Certified Medication Technician A said if they see damage in the building there is a maintenance log to write it down. He/She said they also try to tell the Maintenance Director in person. During an interview on 12/13/24 at 8:22 A.M., Housekeeper I said he/she tells the housekeeping supervisor if damage is found. During an interview on 12/13/24 at 8:25 A.M., the Maintenance Director said he/she looks at the repair log to learn what repairs are need. Staff are to write the repair needs in the log. He/She said they were aware of the damage to walls and the flooring in the rooms. The maintenance director said he/she has been working around the building trying to keep up. During an interview on 12/13/24 at 9:27 A.M., the administrator said damage to the rooms could be a risk to residents. He/She said the facility has been too full to move residents when repairs are being done. The administrator said the Maintenance Director is responsible for making sure the repairs are finished.

Based on observation, interview and record review, facility staff failed to develop a comprehensive person-centered care plan for eleven residents (Resident #3, #25, #35, #37, #44, #45, #47, #23, #28, #31, #38) to ensure their medical and nursing needs were met. The facility census was 49. 1. Review of the facility's Care Planning - Interdisciplinary Team policy, dated September 2013, showed: -The care plan is based on the resident's comprehensive assessment and is developed by a care planning/interdisciplinary team; -The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the residents care plan. Review showed it did not contain direction for staff in regard to when the care plan should be updated when the resident's needs changed. 2. Review of Resident #3's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 9/24/22 showed staff assessed the resident as: -Severe Cognitive Impairment; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Totally dependent on one staff member for bed mobility, transfers, and toileting; -Had no impairment of Range of Motion (ROM) of extremities; -Bed rails not used. Review of the resident's care plan, dated 5/24/22, showed it did not contain strategies or interventions for the use of bed rails to maintain the resident's safety. Observation on 8/09/22 at 2:57 P.M., showed the resident's bed had bed rails up on both sides. Observation on 8/11/22 at 9:20 A.M., showed the resident's bed had bed rails up on both sides. Observation on 8/12/22 at 8:03 A.M., showed the resident's bed had bed rails up on both sides. During an interview on 8/12/22 at 3:05 P.M., Certified Nurse Aide (CNA) I said care plans were available to use, but were not needed to provide resident care. He/She said he/she did not know if bed rails were a part of the resident's care plan. During an interview on 8/12/22 at 3:16 P.M., CNA C said bed rail use should be listed in the care plan. He/She said he/she did not have access to care plans. He/She said the nursing staff informed him/her about the resident's preferences. During an interview on 8/12/22 at 3:17 P.M., the Assistant Director of Nursing (ADON) said he/she would expect bed rails to be on the resident's care plan and knew the resident had bed rails. During an interview on 8/12/22 at 3:38 P.M., the Director of Nursing (DON) said he/she expects positioning rails listed on a residents care plan if they are used. He/she said it's the MDS Coordinator's responsibility to update the care plans unless there is a new fall or telephone order. He/she said telephone orders are part of the care plan and reviewed nightly by the night nurses and reviewed the next day by the DON to ensure the interventions are appropriate and patient-centered. The DON said he/she was not aware bed rails were not on the care plan for this resident. During an interview on 8/12/22 at 3:55 P.M., Licensed Practical Nurse (LPN) E said he/she would expect bed rails to be addressed in the care plan. He/She said he/she was not aware the resident had a bed rail on one side of his/her bed. During an interview on 8/12/22 at 4:12 P.M., the MDS Coordinator said the care plans should address the use of bed rails. 3. Review of Resident #25's Admission MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Required extensive assistance from one staff member for dressing and personal hygiene; -Required limited assistance from one staff member for bed mobility, transfers, and toileting; -Has limited Range of Motion (ROM) to an upper extremity with an impairment on one side; -Bed rails not used. Review of the resident's care plan, dated 6/28/22, showed it did not contain strategies or interventions, for the use of bed rails, to maintain the resident's safety. Observation on 8/09/22 at 12:13 P.M., showed the resident's bed had one bed rail up. Observation on 8/11/22 at 8:15 A.M., showed the resident lay in bed with a bed rail up on one side. During an interview on 8/11/22 at 8:15 A.M., the resident said he/she used the bed rail to help with bed mobility. 4. Review of Resident #35's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Moderate cognitive impairment; -Required extensive assistance from one staff member for personal hygiene; -Did not reject care. Review of the resident's care plan, dated 5/17/22, showed it did not contain a comprehensive person-centered care plan to direct staff on how to care for the resident's facial hair or teeth. Observation on 8/9/22 at 11:55 A.M., showed the resident had facial hair on his/her upper lip and chin, brown bottom teeth, no upper teeth or dentures, and dark debris under his/her long fingernails. Observation on 8/10/22 at 8:39 A.M., showed the resident had facial hair on his/her upper lip and chin, brown bottom teeth, no upper teeth or dentures, and dark debris under his/her long fingernails. Observation on 8/11/22 at 9:50 A.M., showed the resident had brown bottom teeth, no upper teeth or dentures, and dark debris under his/her long fingernails. Observation on 8/12/22 at 4:40 P.M., showed the resident had brown bottom teeth, no upper teeth or dentures, and dark debris under his/her long fingernails. During an interview on 8/12/22 at 3:16 P.M., CNA C said he/she knew the resident did not have upper teeth. He/She said the resident did not complain about the missing teeth, or voice concerns regarding difficulty eating. He/She said the resident occasionally refused to allow staff to shave his/her face. He/She said the care plan should address dentures, facial hair preferences, and refusal of care. During an interview on 8/12/22 at 3:17 P.M., the ADON said hygiene preferences should be addressed in the care plan. He/She said he/she didn't know where the resident's dentures were. During an interview on 8/12/22 at 3:38 P.M., the DON said he/she expects nail care and shaving to be a part of a residents shower. The DON said refusals of care should be reported to the charge nurse to address at the time of refusal. During an interview on 8/12/22 at 3:55 P.M., LPN E said he/she would expect personal hygiene preferences addressed on the care plan. He/She said he/she knew the resident did not have top teeth, but said the resident requested soft foods at meals. During an interview on 8/12/22 at 4:12 P.M., The MDS Coordinator said he/she didn't know if facial hair preferences should be listed on the care plan. 5. Review of Resident #37's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Required total assistance from one staff member for personal hygiene; -Did not reject care. Review of the resident's care plan, dated 5/3/22, showed it did not contain a comprehensive person-centered care plan to direct staff how to care for the resident's facial hair. Observation on 8/11/22 at 8:04 A.M., showed the resident had facial hair on his/her chin. Observation on 8/10/22 at 8:07 A.M., showed the resident had facial hair on his/her chin. Observation on 8/12/22 at 4:36 P.M., showed the resident had facial hair on his/her chin and a yellow substance on his/her bottom lip. During an interview on 8/12/22 at 3:16 P.M., CNA C said facial hair preference should be listed on the resident's care plan. He/She said he/she would expect to see the resident's preferences listed, especially for those who are not able to voice what they want. He/She said he/she had never seen a care plan and didn't know if he/she had access. He/She said resident #37 does not refuse ADL care. 6. Review of Resident #45's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Moderate cognitive impairment; -Required total assistance from one staff member with personal hygiene; -Did not reject care. Review of the care plan, dated 5/19/22, showed it did not contain a comprehensive person-centered care plan to direct staff how to care for the resident's facial hair. Observation on 8/9/22 at 1:10 P.M., showed the resident had facial hair on his/her upper lip and chin. Observation on 8/10/22 at 8:42 A.M., showed the resident had facial hair on his/her upper lip and chin. Observation on 8/11/22 at 8:35 A.M., showed the resident had facial hair on his/her upper lip and chin. Observation on 8/12/22 at 4:45 P.M., showed the resident had facial hair on his/her upper lip and chin. During an interview on 8/12/22 at 3:16 P.M., CNA C said resident #45 refuses to be shaved at times. 7. Review of Resident #44's Five Day Scheduled MDS, dated [DATE], showed staff assessed the resident as: -Moderate cognitive impairment; -Received an antidepressant seven days out of the seven day look back period. Review of the resident's physician notes, undated, showed the physician documented a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan, dated 11/29/21, showed it did not contain direction for staff in regard to the residents use of the resident's antidepressant medication. During an interview on 8/12/22 at 3:17 P.M., the ADON said diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He/She said he/she didn't know the resident didn't and his/her use of an antidepressant addressed on the care plan. During an interview on 8/12/22 at 3:55 P.M., LPN E said he/she would expect a resident's pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He/She said he/she didn't know the resident's antidepressant use was not on care plan. During an interview on 8/12/22 at 4:12 P.M., the MDS Coordinator said the care plans should address anti-depressant medications. 8. Review of Resident #47's medical records showed staff assessed the resident as: -Cognitively intact; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Required extensive to total assistance with Activities of Daily Living (ADLs); -admitted on [DATE]. Review of resident's medical record showed it did not contain a smoking assessment. Review of the resident's care plan, dated 8/9/22 showed it did not contain a comprehensive person-centered strategies or interventions, for smoking, to maintain the resident's safety. During an interview on 8/12/22 at 3:17 P.M., the ADON said smoking should be addressed on the resident's care plan. He/She said he/she didn't know smoking was not addressed on the resident's care plan. During an interview on 8/12/22 at 3:38 P.M., the DON said the care plan should address smoking. He/She said he/she expects the MDS Coordinators to update the care plans, and he/she didn't know it was not addressed on the resident's care plan. During an interview on 8/12/22 at 3:55 P.M., LPN E said he/she would expect smoking to be on a resident's care plan. He/She said he/she didn't know smoking was not addressed on the resident's care plan. During an interview on 8/12/22 at 4:12 P.M., the MDS Coordinator said the care plans should address if the resident smokes. 9. Review of the facility's Wandering and Elopement policy, dated March 2019, showed: -The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents; -If a resident is identified as a risk for wandering, elopement, or other safety issues, the residents care plan will include strategies and interventions to maintain the resident's safety. 10. Review of Resident #23's Annual MDS, dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -Had disorganized thinking that comes and goes and changes in severity; -Wandered four to six days during the seven day look back period; -Had no change in behavioral symptoms since prior assessment; -Independent with locomotion in wheelchair; -Had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's Elopement risk assessment, dated 6/28/22, showed: -History of elopement while at home; -Cognitive impairment with poor decision-making skills; -Not a risk for elopement/wandering. Review of the resident's Nurses' Notes showed staff documented: -7/26/22: Resident with increased wandering and attempting to exit different doors and unable to express why he/she wants to leave or who he/she is looking for; -7/26/22: Resident continues to wander around facility in self-propelling wheelchair and in other residents rooms; -7/30/22: Resident self-propelling wheelchair around unit and went into several other resident rooms. Review of the resident's care plan, dated 6/28/22, showed it did not contain wandering/elopement strategies or interventions to maintain the resident's safety as directed in the policy. Observation on 8/11/22 at 7:59 A.M., showed the resident propelled his/her wheelchair near the nurse's station. Observation on 8/12/22 at 2:15 P.M., showed the resident propelled his/her wheelchair on the 200 hall. During an interview on 8/12/22 at 3:16 P.M., CNA C said the resident has attempted to elope from the facility and wanders in his/her wheelchair. He/She said wandering should be addressed in the care plan. During an interview on 8/12/22 at 3:17 P.M., the ADON said the resident has not tried to elope. He/She said the resident wanders in his/her wheelchair down the halls, and is not exiting seeking. He/She said he/she would try to redirect the resident and call for help if he/she tried to elope. During an interview on 8/12/22 at 3:38 P.M., the Director of Nursing (DON) said he/she expects wandering and elopement addressed in care plans. He/she said the resident has never tried to leave or elope, but does wander with purpose through the facility. During an interview on 8/12/22 at 3:55 P.M., LPN E said the resident has gone to the door but has not tried to go out or be exit seeking. He/She said the resident is looking for his/her family, who work at the facility. He/She said he/she would expect residents to have elopement and wandering addressed in their care plans. During an interview on 8/12/22 at 4:12 P.M., the MDS Coordinator said the care plans should address if a resident exhibits wandering behavior. 11. Review of the facility's Safety and Supervision of Resident Policy, dated July 2017, showed: -The facility strives to make the environment as free from accident hazards as possible with resident safety, supervision and assistance to prevent accidents a facility-wide priority; -Safety risks and environmental hazards are identified on an ongoing basis through incident/accident data; -An individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents; -Implementing interventions to reduce accident risks and hazards shall include documenting interventions, ensuring interventions are implemented, and assigning responsibility for carrying out interventions. 12. Review of Resident #28's Annual MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Had no behaviors; -Unsteady but able to reposition without assistance; -Used a walker for ambulation; -Required assistance from one staff member for transfers, ambulation, locomotion and toileting; -Had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Had no falls since previous MDS assessment. Review of the residents nursing notes, dated 8/8/22, at 2:45 A.M., showed staff documented: -Staff heard resident calling for help and noted resident sitting on buttock on floor at end of bed and leaning on left arm. Assessment revealed a one inch laceration to the left side of his/her forehead. Review of the residents care plan, dated 7/5/22, showed it did not contain documentation or new interventions in regard to the resident's fall on 8/8/22. Observation on 8/9/22 at 10:59 A.M., showed the resident's left forehead/brow had a hematoma (blood pooled under the skin), a laceration, and was bruised. The resident sat on the edge of his/her bed. During an interview on 8/10/22 at 8:32 A.M., the resident said he/she fell in his/her room and hit his/her head on the dresser. During an interview on 8/12/22 at 3:16 P.M., CNA C said the resident's care plan should be updated with a new intervention after each fall. During an interview on 8/12/22 at 3:38 P.M., the DON said the resident does not always wait for assistance. He/She said they are attempting to get the resident speech therapy to help with his/her cognition, but they are waiting on insurance approval. During an interview on 8/12/22 at 3:55 P.M., LPN E said the resident had a fall and he/she is not sure what interventions have been added. He/She said staff will be informed once the care plan has been updated. During an interview on 8/12/22 at 4:12 P.M., the MDS Coordinator said the care plans should address falls and any new interventions put in to place. 13. Review of Resident #31's Significant Change of Assessment MDS, dated [DATE], showed staff assessed the resident as: -Cognitively impaired: -Had behavioral symptoms not directed at others four to six days in the seven day look back period; -Required physical assistance from one staff member for bed mobility, transfers, and toileting; -Independent with locomotion; -Had unsteady balance when going from seated to standing; -Had no falls since last MDS Assessment; -Had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the residents nurse's notes showed staff documented: -8/3/22: Resident was observed in the bathroom beside the dining room. He/she had his/her pants down around the ankles and was sitting on the bathroom floor with the wheelchair at his/her side; -8/7/22: Resident with increased anxiety as evidenced by screaming for help trying to go out exit doors and into peers rooms with verbal redirection ineffective; -8/9/22: Resident slipped from the wheelchair to the floor onto back/buttocks. Review of the resident's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the residents care plan, dated 7/12/22, showed it did not contain direction for staff in regard to the resident's mechanical soft diet, interventions related to his/her falls on 8/3/22 or 8/9/22, or his/her exit seeking behaviors. During an interview on 8/12/22 at 3:16 P.M., CNA C said the resident receives a mechanical soft diet. He/She said staff sometimes assist him/her with eating and encourage him/her other times. He/She said the care plan should address the resident's diet, fall interventions and interventions for exit seeking behavior. During an interview on 8/12/22 at 3:17 P.M., the ADON said the resident can't use the bathroom by the dining area and staff keep him/her in visual sight. He/She said staff are to complete an elopement assessment upon admission and it should be on the care plan. He/She said he/she didn't know the resident's diet, but he/she sometimes assisted with meals and would expect the care plan to address the resident's diet and need for assistance. During an interview on 8/12/22 at 3:38 P.M., the DON said the MDS Coordinator is responsible for updating the care plans. He/she said all interventions should be followed up on the following day to ensure they are appropriate and person-centered. He/she said the resident has been moved into a room closer to the nurses station for closer observation. During an interview on 8/12/22 at 3:55 P.M., LPN E said the resident had a fall but he/she was not sure what the new interventions were. He/She said the care plan should be updated with a new intervention after each fall. He/She said he/she would expect elopement to be on the resident's care plan. He/She said the resident is on a mechanical soft diet and sometime receives assistance from staff with eating, and should be addressed in the care plan. During an interview on 8/12/22 at 4:12 P.M., the MDS Coordinator said the care plans should address if the resident received a special diet. 14. Review of the facility's End Stage Renal Disease, Care of a Resident with policy, dated September 2010, showed: -Residents with End Stage Renal Disease ([CONDITION(S)]) (longstanding disease of the kidneys leading to kidney failure) will be cared for according to currently recognized standards of care; -The resident's comprehensive care plan will reflect the resident's needs related to [CONDITION(S)]/[CONDITION(S)] care. 15. Review of Resident #38's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -Had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Required [CONDITION(S)] (process of removing excess water, solutes and toxins from the blood in people whose kidneys can no longer perform these functions). Review of the resident's POS, dated June 2022 through August 2022, showed they did not contain orders for [CONDITION(S)], including how often or duration of treatment, or access site care. Review of the resident's care plan, reviewed 7/18/22, showed: -5/16/22: [CONDITION(S)] discontinued; -5/24/22: [CONDITION(S)] as ordered; -8/8/22: [CONDITION(S)] resumed two days per week. Further review of the care plan showed it did not contain direction for staff in regard to who to contact with [CONDITION(S)] related concerns or complications, monitoring of risk factors and managing complications such as hemorrhage, access site infection, [CONDITION(S)] and to whom to report concerns, assessment and care of the access site, including the use of PPE as necessary and other infection control measures, and approach to administering medications before or after [CONDITION(S)] according to practitioner's orders. During an interview on 8/12/22 at 3:17 P.M., the ADON said he/she would expect the resident's care plan to address [CONDITION(S)]. He/She said the resident's [CONDITION(S)] sheet contains the resident's vitals and port placement check. He/She said he/she knows where the resident's port is due to report (nurse to nurse report) and skin assessments. During an interview on 8/12/22 at 3:38 P.M., the DON said he/she would expect [CONDITION(S)] to be addressed on the care plan. During an interview on 8/12/22 at 3:55 P.M., LPN E said he/she would expect for [CONDITION(S)] to be addressed on the resident's care plan. He/She knows how to care for the resident's port by nursing knowledge. This information is also passed on during shift change report. 16. During an interview on 8/12/22 at 3:16 P.M., CNA C said social services is responsible for updating the care plans. He/She said he/she was not sure how often the care plans were updated. During an interview on 8/12/22 at 3:55 P.M., LPN E said nurses can update the care plans, but the MDS coordinator is responsible for updating them monthly and with significant changes. During an interview on 8/12/22 at 4:12 P.M., the MDS Coordinator said the care plans are updated by the nursing staff, DON and himself/herself.

Based on observation, interview, and record review, facility staff failed to provide appropriate care and services to assist residents with Activities of Daily Living (ADLs) (everyday tasks), for four residents (Resident #33, #35, #37, and #45). The facility census was 49. 1. Review of the facility's Activities of Daily Living (ADLs), Supporting policy, dated [DATE], showed: -Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs); -Resident who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene; -Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming and oral care); -If residents with cognitive impairment or dementia (loss of cognitive functioning resulting in deceased ability to complete ADL's independently) resist care, staff will attempt to identity the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time, or having another staff member speak with the resident may be appropriate. 2. Review of Resident #33's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Required total assistance from one staff member for personal hygiene; -Did not reject care. Review of the resident's care plan, dated [DATE], showed staff documented the resident needed extensive to total assistance from staff with most ADLs. Observation on [DATE] at 1:53 P.M., showed the resident had long hair in his/her ears, and yellow dark debris under his/her long fingernails. Observation on [DATE] at 8:32 A.M., showed the resident had long hair in his/her ears, yellow dark debris under his/her long fingernails. Observation on [DATE] at 4:38 P.M., showed the resident had long hair in his/her ears, yellow dark debris under his/her long fingernails, and his/her second and third finger had a red substance under the entire nail. During an observation and interview on [DATE] at 4:38 P.M., the resident pointed to his/her ears and nodded when asked if he/she was pointing to hair in his/her ears. Additionally, when asked if the ear hair bothered him/her, the resident nodded. During an interview on [DATE] at 3:16 P.M., Certified Nurse Aide (CNA) C said the resident had declined showers, but no other ADLs. During an interview on [DATE] at 3:17 P.M., the Assistant Director of Nursing (ADON) said the resident refuses care often and it should be documented in the nurses' notes. During an interview on [DATE] at 3:38 P.M., the Director of Nursing (DON) said the resident's fingernails are stained but he/she should have this addressed in his/her plan of care. During an interview on [DATE] at 3:55 P.M., Licensed Practical Nurse (LPN) E said the resident refuses to have his/her nails trimmed and it should be documented in his/her nurses' notes. 3. Review of Resident #35's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Moderate cognitive impairment; -Required extensive assistance from one staff member for personal hygiene; -Did not reject care. Review of the resident's care plan, dated [DATE], showed it did not contain direction for staff related to the resident's facial hair preferences. Further review showed the resident required extensive assistance with his/her ADLs. Observation on [DATE] at 11:55 A.M., showed the resident had facial hair on his/her upper lip and chin, and brown bottom teeth. Further observation, showed he/she didn't have his/her upper teeth and had debris under his/her long fingernails. Observation on [DATE] at 8:39 A.M., showed the resident had facial hair on his/her upper lip and chin, and brown bottom teeth. Further observation, showed he/she didn't have his/her upper teeth and had debris under his/her long fingernails. Observation on [DATE] at 9:50 A.M., showed the resident had brown bottom teeth. Further observation, showed he/she didn't have his/her upper teeth and had debris under his/her long finger nails. Observation on [DATE] at 4:40 P.M., showed the resident had brown bottom teeth. Further observation, showed he/she didn't have his/her upper teeth and had debris under his/her long fingernails. During an interview on [DATE] at 3:16 P.M., CNA C said the resident doesn't refuse care. He/She said the resident brushes his/her teeth daily with assistance. He/She said he/she didn't know how often the resident sees a dentist and he/she had noticed the resident's upper teeth were missing, but did not ask about it. During an interview on [DATE] at 3:17 P.M., ADON said he/she hadn't noticed the resident's fingernails. He/She said the resident's upper dentures should be in his/her top drawer. During an interview on [DATE] at 3:38 P.M., the DON said he/she didn't know the resident had issues with his/her teeth. He/She said if he/she had known he/she would have arranged for dental services. He/she said he/she knew the resident was not wearing his/her upper dentures but the resident never complained about it. He/She said he/she expects the resident's nails clipped and facial hair removed during showers. 4. Review of Resident #37's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Required total assistance from one staff member for personal hygiene; -Did not reject care. Review of the resident's care plan, dated [DATE], showed staff documented the resident required extensive assistance with most ADL's. Further review showed it did not contain direction for staff in regard to the resident's facial hair preferences. Observation on [DATE] at 11:19 A.M., showed the resident had facial hair on his/her chin. Observation on [DATE] at 8:07A.M., showed the resident had facial hair on his/her chin. Observation on [DATE] at 8:04 A.M., showed the resident had facial hair on his/her chin. Observation on [DATE] at 4:36 P.M., showed the resident had facial hair on his/her chin and a yellow substance on his/her bottom lip. During an interview on [DATE] at 3:16 P.M., CNA C said the resident doesn't like to shower, but he/she doesn't refuse. He/She said the resident doesn't refuse to be shaved. During an interview on [DATE] at 3:17 P.M., ADON said he/she had not noticed the resident's facial hair. He/She said the resident refuses care. During an interview on [DATE] at 3:38 P.M., the DON said the resident can be challenging at times but he/she expects the CNA's to shave the resident during showers. 5. Review of Resident #45's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Moderate cognitive impairment; -Required total assistance from one staff member with personal hygiene; -Did not reject care. Review of the care plan, dated [DATE], showed it did not contain direction for staff related to the resident's facial hair or ADL care. Observation on [DATE] at 1:10 P.M., showed the resident had facial hair on his/her upper lip and chin. Observation on [DATE] at 8:42 A.M., showed the resident had facial hair on his/her upper lip and chin. Observation on [DATE] at 8:35 A.M., showed the resident had facial hair on his/her upper lip and chin. Observation on [DATE] at 4:45 P.M., showed the resident had facial hair on his/her upper lip and chin. During an interview on [DATE] at 3:16 P.M., CNA C said the resident had refused to have his/her facial hair shaved. He/She said he/she didn't know why. During an interview on [DATE] at 3:38 P.M., the DON said he/she expects staff to shave the resident during their shower. During an interview on [DATE] at 3:55 P.M., LPN E said he/she had noticed the resident's facial hair but had not had time to assist the resident. 6. During an interview on [DATE] at 3:16 P.M., CNA C said nail care and shaving should be completed when it's needed. He/She said staff should encourage resident's who refuse care, and follow up at a later time to try again. He/She said if a resident refuses it should be reported to the charge nurse. During an interview on [DATE] at 3:05 P.M., CNA I said residents' teeth should be brushed after meals. He/She said residents who are able to assist with cares should be encouraged or helped as needed and dependent residents should have their teeth brushed by the staff. He/She said if a resident refuses care he/she tries to encourage the resident, and if they still refuse, he/she said staff should try again. He/She said if the resident continued to refuse care, he/she would report it to the nurse. He/She said it is the aides' responsibility to provide care for residents' nails and to shave the residents. He/She said nail trimming and shaving should be completed during the resident shower. He/She said if he/she noticed a resident with long dirty fingernails or facial hair he/she would trim their nails or shave them. During an interview on [DATE] at 3:17 P.M., the ADON said the shower aides are supposed to shave the residents and trim their nails. He/She said the residents teeth should be brushed every morning, every evening, and after every meal. He/She said if a resident refused care staff are supposed to try another approach, or have another staff member try. He/She said refusals should be documented in nurses' notes. He/She said the Social Services Director (SSD) is responsible for scheduling dental appointments and said there had been a long wait for appointments. During an interview on [DATE] at 3:38 P.M., the DON said he/she expects the CNA's to complete shaves, and nail care during showers. He/She said staff should report dental issues to the nurses, who should then refer the resident to social services for follow-up and appointments. He/she said if a resident refused care it should be reported to the charge nurse so it can be addressed. During an interview on [DATE] at 3:55 P.M., LPN E said all nursing staff should help with shaves and nail trims. He/She said it should the resident should be checked for facial hair and the need for nail trims during their shower. He/She said resident's teeth should be brushed every morning, after each meal and before bed. He/She said he/she didn't know how often the residents saw the dentist. He/She said the SSD should make the appointments. He/She said if the resident refused care it should be documented in the nurses' notes.

Based on observation, interview and record review, facility staff failed to meet professional standards of quality and practice when they failed to provide consistent documentation in regard to residents' Advance Directives (a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) for four residents (Resident #3, #7, #30, and #43). Additionally, staff failed to obtain physician orders for [CONDITION(S)] (purification of blood, as a substitute for normal kidney function) for two residents (Resident #27 and #38), failed to follow physician orders for oxygen for one resident (Resident #47) and failed to provide consistent documentation in regard to diet orders for one resident (Resident #31). The facility census was 49. 1. Review of the facility's Do Not Resuscitate Order (DNR), (a type of advance directive in which a person states that healthcare providers should not perform cardiopulmonary resuscitation (CPR) if his or her heart or breathing stops) Policy, showed: -DNR orders must be signed by the resident's attending physician on the physician's order sheet (POS) maintained in the resident's medical record; -A DNR order form must be completed and signed by the attending physician and resident (or resident's legal surrogate, as permitted by state law) and placed in front of the resident's medical record; -The interdisciplinary care planning team will review advance directives with the resident during quarterly care planning sessions to determine if the resident wishes to make changes in such directives. Further review showed the facility did not have a policy for Advance Directives. 2. Review of Resident #3's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated [DATE], showed staff assessed the resident as: -Severely Cognitively Impaired; -Understood; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's POS, dated [DATE], showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the resident's medical record showed it did no contain a DNR order form per facility policy. 3. Review of Resident #7's Quarterly MDS, dated [DATE] showed staff assessed the resident as: -Severely Cognitively Impaired; -Usually Understood - difficulty communicating some words or finishing thoughts but is able if prompted or given time; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's medical record showed: -The current POS did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] -A DNR order form was in the front of the resident's medical record; -The resident's Care Plan dated [DATE] stated the resident wished to have orders for DNR. Review of the resident's POS, dated [DATE], showed it did not contain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the resident's care plan, dated [DATE], showed staff documented the resident had a DNR code status. 4. Review of Resident # 30's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Understood; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's POS, dated [DATE], showed it did not contain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the resident's care plan, dated [DATE], showed staff were directed the resident wished to be a full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive). During an interview on [DATE] at 3:07 P.M., the resident said he/she wanted to be a full code at this time. 5. Review of Resident #43's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Moderately Cognitively Impaired; -Understood, -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's POS, dated [DATE], showed it not contain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the resident's care plan, dated [DATE], showed staff were directed the resident wished to be a full code. During an interview on [DATE] at 3:17 P.M., the Assistant Director of Nursing (ADON) said a resident's code status should be listed at top of the POS. He/She said if a code status is not on the orders he/she would expect staff to clarify the code status with the physician and obtain an order. He/She said he/she didn't know some of the residents did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on [DATE] at 3:38 P.M., the Director of Nursing (DON) said advanced directives, including code status are reviewed on admission and quarterly during the care plan conferences with the resident and/or family, and with changes in resident status. He/she said all residents are considered a full code until a signed DNR physician's order is obtained. He/She said he/she didn't know resident #3, #7, #30 and #43 did not have code status orders. During an interview on [DATE] at 3:55 P.M., Licensed Practical Nurse (LPN) E said a resident's code status should be listed at the top of the POS. He/She said he/she didn't know some residents did not have orders for code status. 6. Review of the facility's End-Stage Renal Disease ([CONDITION(S)]) (a disease affecting kidney function) policy, dated [DATE] showed: -Residents with [CONDITION(S)] will be cared for according to currently recognized standards of practice; The policy did not contain direction for staff related to physician orders for access site care, scheduling of treatments including number and days per week, or timing and administration of medications, particularly those before and after [CONDITION(S)]. 7. Review of Resident #27's Significant Change in Status MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Receives [CONDITION(S)]. Review of the resident's current POS, showed it did not contain orders for [CONDITION(S)], access site care, or schedule including the number of treatments and days per week. 8. Review of Resident #38's Quarterly MDS, dated [DATE] showed staff assessed the resident as: -Moderately cognitively impaired; -Had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . -Receives [CONDITION(S)]. Review of the resident's POS, dated [DATE] through [DATE], showed it did not contain orders for [CONDITION(S)], access site care, or schedule including the number of treatments and days per week. During an interview on [DATE] at 3:17 P.M., the ADON said he/she would expect to see an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . He/She said he/she knows where the residents' ports are located due to the weekly skin assessments and nurse to nurse report. During an interview on [DATE] at 3:38 P.M., the DON said there should be a physician's order for [CONDITION(S)] and the nurses are responsible for obtaining them. He/she said he/she expects the night shift nurse to review new orders for accuracy and the DON to follow up the next day. He/she said resident #38's [CONDITION(S)] changed but there should have had an order. He/She said he/she didn't know resident #27 and #38 did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on [DATE] at 3:55 P.M., LPN E said a resident who receives [CONDITION(S)] should have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . He/she said he/she knew how to care for the residents from nursing knowledge and said staff know how to care for the residents through nurse to nurse report. He/She said he/she didn't know the residents didn't have orders for [CONDITION(S)]. 9. Review of the facility's Oxygen Administration Policy, revised [DATE], showed: -Verify that there is a physician's order for this procedure; -Review the physician's orders or facility protocol for oxygen administration. 10. Review of Resident #47's medical record showed staff assessed the resident as: -admitted [DATE]; -Cognitively intact; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Required extensive to total assistance from staff with Activities of Daily Living (ADL's); -Used oxygen. Review of the resident's POS, dated [DATE], showed: [DATE]: Oxygen at 4 Liters Per Minute (LPM) via nasal cannula (NC) as needed (PRN) for oxygen saturation (SpO2), (a measure of the amount of oxygen-carrying hemoglobin in the blood relative to the amount of hemoglobin not carrying oxygen) (SpO2) to stay above 90%. Observation on [DATE] at 12:42 P.M., showed the resident had his/her oxygen on at 5 LPM via NC. Observation on [DATE] at 3:23 P.M., showed the resident had his/her oxygen on at 5 LPM via NC. Observation on [DATE] at 8:25 A.M., showed the resident had his/her oxygen on at 5 LPM via NC. Observation on [DATE] at 1:05 P.M., showed the resident had his/her oxygen on at 5 LPM via NC. Observation on [DATE] at 9:53 A.M., showed the resident had his/her oxygen on at 5 LPM via NC. During an interview on [DATE] at 2:37 P.M., the resident said his/her oxygen has been set to 5 LPM since he/she was admitted . During an interview on [DATE] at 3:17 P.M., the ADON said residents should have orders for oxygen use and it's the nurses' job to make sure the order is followed. He/She said he/she didn't know the resident's oxygen was set to 5 LPM. During an interview on [DATE] at 3:38 P.M., the DON said nurses are expected to obtain orders for oxygen and the order should be followed. During an interview on [DATE] at 3:55 P.M., LPN E said residents on oxygen should have orders for its use, and nurses should ensure the resident receives the ordered amount. 11. Review of the facility's Food and Nutrition Services Policy, dated [DATE] showed: -Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident; -A resident-centered diet and nutrition plan will be based on the assessment of each resident's nutritional needs, food likes, dislikes and eating habits, as well as physical, functional, and psychosocial factors that affect eating nutritional intake and utilization. 12. Review of resident #31's the POS, dated [DATE] through [DATE], showed an order dated [DATE] to change the resident's diet order from Regular consistency to Mechanical Soft consistency related to difficulty chewing. Review of the physician orders, dated [DATE] through [DATE], showed they did not contain the change in diet from Regular Consistency to Mechanical Soft. During an interview on [DATE] at 3:38 P.M., the DON said the night shift nurse is responsible for checking new orders for accuracy. The DON said he/she is responsible for reviewing the orders the next day. He/she said he/she didn't know their was and order discrepancy. During an interview on [DATE] at 3:17 P.M., the ADON said he/she didn't know what the resident's diet order was. He/She said an order could be received and not carry over to the POS. During an interview on [DATE] at 3:55 P.M., LPN E said he/she didn't know what the resident's diet order was. He/She said it was not carried over to the most recent POS. 13. During an interview on [DATE] at 3:17 P.M., the ADON said all the nurses are responsible for obtaining and transcribing physician orders. He/She said he/she is responsible for reconciling orders obtained the previous day. He/She said the DON and MDS coordinator do the monthly change over and reconcile the orders. During an interview on [DATE] at 3:55 P.M., LPN E said nurses are responsible for obtaining physician orders and entering them into the charts. He/She said there is a folder for physician's orders so a 24 hour chart check can be completed. He/She said the MDS coordinator is responsible for reconciling the orders monthly.

Based on observation, interview, and record review, facility staff failed to ensure the residents' environment remained free of accident hazards when staff failed to properly store environmental hazards in the shower rooms and failed to properly propel seven residents (Resident #1, #23, # 28, #31, #39, #42 and #45) in wheelchairs in a manner to prevent accidents. The facility census was 49. 1. Review of the facility's Safety and Supervision of Residents Policy, dated July 2017, showed the care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. 2. Observation on 8/9/22 at 11:06 A.M., showed the 100 hall shower room unlocked and unattended. Further observation, showed an open and undated container of skin protectant sat on the back of the toilet. Additional observation, showed an open bottle of cleaner with bleach in an unlocked cabinet, with two unopened bottles, and a razor in an unlocked drawer. During an interview on 8/12/22 at 3:05 P.M., Certified Nurse Aide (CNA) I said he/she didn't know who was responsible for checking the shower rooms for accessible razors and chemicals. He/She said cabinets should be locked if they have razors or chemicals in them. During an interview on 8/12/22 at 3:38 P.M., the Administrator said he/she checked the shower rooms every morning for hazards. He/She said he/she expects razors, chemicals and creams to be in a locked up. He/she said it's everyone's responsibility to be mindful of hazards and lock things up. He/she said he/she did not know chemicals, and razors were not locked up. During an interview on 8/12/22 at 3:17 P.M., the Assistant Director of Nursing (ADON) said all staff are responsible for inspecting the shower rooms every day. He/She said razors should be kept locked in the room across from nurses station. He/She said razors are gathered with shower supplies, and should be disposed of in the shower room sharps container. During an interview on 8/12/22 at 3:55 P.M., Licensed Practical Nurse (LPN) E said the shower room should be checked by the house keepers every morning. He/She said it is everyone's responsibility to ensure all hazardous chemicals and razors are kept locked up. During an interview on 8/12/22 at 3:16 P.M., CNA C said shower rooms are inspected daily by staff. He/She said cabinet doors should be locked. 3. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 8/9/22, showed staff assessed the resident as: -Cognitively impaired; -Had disorganized thinking that comes and goes and changes in severity; -Dependent on one staff member for locomotion; -Uses a wheelchair; -Has diagnoses of [CONDITION(S)] (damage to the hearts major blood vessels), diabetes, and dementia (a group of thinking and social symptoms that interferes with daily functioning). Observation on 8/10/22 at 11:33 A.M., showed an unidentified staff member propelled the resident in his/her wheelchair from room his/her room to the dining room without foot pedals. The resident's feet were close to the floor. 4. Review of Resident #23's Annual MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Has diagnoses of dementia, anxiety, and [CONDITION(S)] (a mental disorder characterized by disconnection from reality); -Independent with locomotion on and off of the unit; -Had fluctuating disorganized thinking behaviors. Observation on 8/12/22 at 1:27 P.M., showed CNA C propelled the resident from the nurses station to room 102, approximately 40 feet, without foot pedals. 5. Review of Resident #28's Annual MDS, dated [DATE] showed staff assessed the resident as: -Cognitively intact; -Had diagnoses of non-traumatic [CONDITION(S)], [CONDITION(S)], hypertension, diabetes, arthritis, anxiety disorder, depression, and dementia; -Required limited assistance from one staff member for locomotion on and off of the unit; -Had no behaviors. Observation on 8/12/22 at 12:55 P.M., showed CNA H propelled the resident from the nurses station down the hallway to the resident's room, without foot pedals. 6. Review of Resident #31's Significant change MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Had diagnoses of dementia and anxiety; -Independent with locomotion on and off of the unit; -Had fluctuating inattention and disorganized thinking behaviors. Observation on 8/11/22 at 1:27 P.M., showed CNA C propelled the resident backwards in his/her wheelchair from the nurses station to his/her room, without foot pedals. Observation on 8/12/22 at 10:55 A.M., showed CNA C propelled the resident from the nurses station to the dining room without foot pedals. The resident's feet slid on the floor. Observation on 8/12/22 at 1:19 P.M., showed the ADON propelled the resident up 100 hall towards the nurses station, without foot pedals. 7. Review of Resident #39's Annual MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Required extensive assistance from one staff member for bed mobility; -Required total assistance from one staff member for transfers; -Uses a wheelchair. Observation on 8/11/22 at 12:46 P.M., showed an unidentified staff member propelled the resident without the use of foot pedals. 8. Review of Resident #42's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Had diagnoses of [CONDITION(S)] (loss in the center field of vision), Diverticulitis (Inflammation or infection in one or more small pouches in the digestive tract), and [CONDITION(S)] (urine can not drain through the urinary tract; -Independent with locomotion on and off of the unit; -Had fluctuating disorganized thinking behaviors present. Observation on 8/11/22 at 8:21 A.M., showed CNA C propelled the resident from the dining room to the resident's room without foot pedals. 9. Review of Resident #45's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Moderate cognitive impairment; -Required total assistance from two staff members with bed mobility and transfers; -Uses a wheelchair for mobility. Observation on 8/10/22 at 8:22 A.M., showed LPN A propelled the resident without the use of foot pedals. 10. During an interview on 8/12/22 at 3:05 P.M., CNA I said when staff push a resident in their wheelchair they should use foot pedals. He/She said staff should not pull residents backwards in their wheelchairs. During an interview on 8/12/22 at 3:17 P.M., the ADON said residents should not be propelled in their wheelchairs without foot pedals. He/She said a resident should never be pulled backwards in their wheelchair. During an interview on 8/12/22 at 3:16 P.M., CNA C said foot pedals should be placed on wheelchairs before staff propel a resident to ensure their safety. He/She said the resident should always be propelled forwards while in their wheelchairs. He/She said he/she has propelled a resident without foot pedals and has seen other staff do it as well. During an interview on 8/12/22 at 3:38 P.M., the Director of Nursing (DON) said he/she expects foot pedals to be placed on wheelchairs before staff propel any resident During an interview on 8/12/22 at 3:38 P.M.,The Administrator said if staff pull a resident backwards in a wheelchair, it's probably because there are not foot pedals on the chair. He/She said he/she expects staff to place foot pedals on wheelchairs before they propel residents. During an interview on 8/12/22 at 3:55 P.M., LPN E said resident's in wheelchairs should have foot pedals on, their hands and arm in their lap, and sit straight. He/She said staff should never propel a resident backward.

Surveyor: [NAME], [NAME] Based on observation, interview, and record review, facility staff failed to use hand hygiene and provide perineal care in a manner to reduce the risk of infection for two residents (Resident #19 and #40) and failed to provide wound care in a manner to reduce the risk of infection for one resident (Resident #47). The facility census was 49. 1. Review of the facility's Hand Hygiene Policy, revised August 2019, directed staff to: -Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: -When hands are visibly soiled; -Use an Alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: -Before and after direct contact with residents; -Before handling clean or soiled dressings, gauze pads, etc.; -Before moving from a contaminated body site to a clean body site during resident care; -After contact with blood or bodily fluids; -After handling used dressings, contaminated equipment, etc.; -After removing gloves. Review of the facility's Perineal Care Policy, revised February 2018, showed it did not contain direction for staff in regard to when to change gloves or proper cleansing wipe use. 2. Observation on 8/9/22 at 1:09 P.M., showed Certified Nurse Aide (CNA) F cleansed Resident #19's perineal area, removed his/her gloves, and reapplied new gloves, without hand hygiene. The CNA cleansed the resident's bottom, applied a clean brief and repositioned the resident, with the same soiled gloves on. Observation on 8/11/22 at 9:04 A.M., showed CNA C removed the resident's pants, and provided incontinence care. The CNA continued to wear the same soiled gloves and repositioned the resident. 3. Observation on 8/9/22 at 11:22 A.M., showed CNA F removed Resident #40's soiled brief, and touched the resident's legs with the same soiled gloves on. The CNA used the same wipe to wipe the resident multiple times, without using a different portion of the wipe. The CNA continued to wear the same soiled gloves and touched the resident's side. During an interview on 8/9/22 at 11:44 A.M., CNA F said staff are directed to perform hand hygiene before and after providing care, prior to going from a dirty to clean area, and before they exit a room. He/She did not think he/she missed a hand hygiene opportunity, or had used a wipe more than once. During an interview on 8/12/22 at 3: 55 P.M., Licensed Practical Nurse (LPN) E said staff are expected to perform hand hygiene before they apply gloves, when their gloves are soiled, when they move from a dirty to clean task, and before they leave the resident's room. During an interview on 8/12/22 at 3:17 P.M., the Assistant Director of Nursing (ADON) said staff should perform hand hygiene before and after direct resident contact, or if hands become soiled. He/She would expect staff to obtain a new wipe every time they wiped a resident. He/She would not expect staff to wipe a resident multiple times with the same wipe. He/She said staff should perform hand hygiene when they move for a dirty area to clean area. During an interview on 8/12/22 at 3:38 P.M., the Director of Nursing (DON) said he/she expects staff to wash or sanitize hands when they enter a room, when they remove their gloves, before they apply new gloves, and when they move from dirty to clean tasks. 4. Review of the facility's wound care policy, revised 6/2021, showed staff are instructed to: -Position the patient off affected area; -Gently cleanse area with Normal Saline (NS); -Apply Skin Prep (a liquid dressing that creates a clear barrier on the skin) to peri-wound (area of intact skin that surrounds a wound) and allow to dry (approximately 45 seconds); -For dry wounds apply one sixteenth (1/16) inch thick hydrogel and cover with cover dressing, change daily. Observation on 8/10/22 3:32 P.M., showed the ADON provided wound care to Resident #47's left heel. He/She cleansed the resident's peri-wound and then cleaned the wound bed (the open base of a wound) with the same soiled gauze. During an interview on 8/10/22 at 3:39 P.M., the ADON said he/she should not have used the same gauze to clean both areas due to cross contamination. During an interview on 8/12/22 at 3: 55 P.M., LPN E said staff are not expected to use the same gauze pad in the same area multiple times when they clean a wound. He/She said a new gauze pad should be used to prevent cross contamination. During an interview on 8/12/22 at 3:17 P.M., the ADON said staff should start cleansing a wound at the wound bed, and move outward. Staff should not go back over an area they have already cleansed with dirty gauze. During an interview on 8/12/22 at 3:38 P.M., the DON said wounds should be cleansed from the center of the wound outward. He/she said using the same gauze to clean the periwound and wound bed would cause the wound to be dirty.

Based on interview and record review, facility staff failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections during the coronavirus disease 2019 (COVID-19, an infectious disease caused by severe acute respiratory syndrome coronavirus 2 ([CONDITION(S)]-CoV-2)(the virus that causes COVID-19) pandemic when the facility failed to have an employee who tested positive for COVID-19 leave the facility in a timely manner to prevent further spread of the infection. The facility census was 39. Review of the Interim Infection Prevention and Control (IPC) Recommendations for Healthcare Personnel (HCP) during the COVID-19 Pandemic on the CDC website, updated 09/10/21, showed positive test results allow for identification and isolation of infected persons, as well as a case interview to identify and notify the case's close contacts of exposure and the need for quarantine. Any HCP who tests positive will be excluded from work from the initial positive [CONDITION(S)] diagnostic test until return to work criteria are met to include at least 10 day isolation period. Review of the facility's COVID-19 Testing and Return to Work Criteria for Healthcare Personnel Policy, undated, showed staff are directed as follows: -HCP who are confirmed as infected with [CONDITION(S)]-CoV-2 are restricted from work until at least 10 days have passed since positive test results; -At least 24 hours have passed since last fever without the use of fever-reducing medications; -Symptoms (e.g. cough, shortness of breath) have improved. Review of Certified Nurse Assistant (CNA) C's COVID-19 test results, dated 11/22/21, showed two separate tests were performed. The first test at 12:30 A.M. and the second at 1:30 A.M. with both test results positive for COVID-19. Review of CNA C's timecard, dated 11/22/21, showed CNA C clocked in to work at 5:45 P.M. on 11/21/21 for the night shift and clocked out at 6:15 A.M. at the end of his/her shift on 11/22/21. During an interview on 12/8/21 at 1:59 P.M., CNA A said the first person to test positive for COVID was CNA C and he/she was allowed to work the remainder of the shift after the positive results with a cough. During an interview on 12/13/21 at 1:30 P.M., CNA C said he/she had a cough when he/she came to work on 11/21/21, but thought it was because he/she smoked too much the night before. CNA C said the facility does COVID tests on Mondays, so he/she asked the nurse to do his/hers while at work so he/she didn't have to come back later in the day on 11/22/21 after he/she worked the night shift. The first nurse did one test at around 12:30 A.M. that was positive, then the second nurse who came on at 1:00 A.M. did a second test around 1:30 A.M. which was also positive. The nurse notified the administrator of the results and he/she informed CNA C his/her guidance was continue to work and just wear an N95 mask when he/she performs resident care. CNA C said the administrator came in that morning between 4:00 and 4:30 A.M., but went straight into the kitchen and he/she did not talk to him/her until around 6:00 A.M. at the end of the shift to ask what he/she should do now. CNA C said the administrator called him/her around 7:00 A.M. and told him/her to remain off the next 10 days. During an interview on 12/13/21 at 2:00 P.M., the administrator said he/she was informed of CNA C's positive test result by phone, but was unsure of the time. He/She directed staff to have CNA C wear an N95 mask and to perform a second test, because they had received inaccurate tests in the past, and that was their policy. He/She said no one ever called him/her back and he/she did not follow up on it. The administrator said, I was really out of it because I had worked a few doubles and had to be up early to work in the kitchen, but I should have followed up on it. The administrator said when he/she arrived to the facility around 4:00 A.M. CNA C was there, but he/she went on to the kitchen, and did not follow up on it then. The administrator said, I don't remember what time it was when CNA C came to the kitchen to ask what he/she should do, but he/she told him/her not to return to work for 10 days. MO 098 and MO 022

Based on observation, interview and record review, the facility failed to protect residents by not following acceptable infection control practices for 2019 Novel Coronavirus Disease (COVID-19), when the facility failed to implement infection control interventions for two residents that resided in the same room, (Resident #3 and #4), when Resident #4 tested positive for Covid-19, which put Resident #3 at an increased risk of contracting Covid-19 due to prolonged exposure, failed to wear required Personal Protective Equipment (PPE) for one resident (Resident #5), who was in quarantine, failed to remove gloves and perform hand hygiene before leaving resident rooms, and failed to decontaminate supplies after removing them from the resident's room and returning them to a clean surface or area. Furthermore, facility staff failed to place isolation supplies, signs to alert staff of isolation rooms, and/or signage that instructed healthcare personnel (HCP) of PPE requirements for one resident (Resident #5). The facility census was 45. 1. Review of the Centers for Disease Control (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel during the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 2/23/21, showed: - CDC recommends using additional infection prevention and control practices during the COVID-19 pandemic, along with standard practices recommended as a part of routine healthcare delivery to all patients; - Transmission from asymptomatic (without symptoms) or pre-symptomatic patients with [CONDITION(S)]-CoV-2 (COVID-19) infection can occur in healthcare settings, particularly in areas with moderate to substantial community transmission; - If admitted , place a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection in a single-person room with the door closed. The patient should have a dedicated bathroom; -HCP who enter the room of a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection should adhere to standard precautions (minimum infection prevention practices that apply to all patients) and use a National Institute of Occupational Safety and Health (NIOSH)-approved N95 (respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) or equivalent or higher-level respirator, gown, gloves, and eye protection; -PPE recommended when caring for a patient with suspected or confirmed COVID-19 include putting on an N95 respirator (or equivalent or higher-level respirator), eye protection (i.e., goggles or a face shield that covers the front and sides of the face), clean, non-sterile gloves, and a clean isolation gown upon entry into the patient room or care area; -Remove and discard gloves before leaving the patient room or care area, and immediately perform hand hygiene; -Remove and discard the gown in a dedicated container for waste or linen before leaving the patient room or care area. 2. Review of the facility's COVID-19 Policy and Procedure, undated, showed based on the identified risk for our frail elderly from the COVID-19 virus and the current American Healthcare Association (AHCA)/National Centers for Assisted Living (NCAL), Centers for Medicare and Medicaid Services (CMS) and CDC recommendations, aggressive infection control measure will be implemented to prevent introduction of the virus to residents, staff and visitors. The policy directed the staff as follows: -Develop an isolation plan and procedure for your specific facility; -Have an emergency plan in place for an area designated for isolation; -Maintain a pandemic coronavirus binder with emergency procedures available to staff; -Utilize the CMS Coronavirus (COVID-19) Toolkit; -Each facility's Infection Control Preventionist (ICP) will have the responsibility for ensuring proper isolation and other procedures are followed. Administration will validate ICP is utilizing current CDC recommendations and guidance; -Housekeeping is to follow HCSG guidelines specific for increased cleaning protocols; -ICP will remain aware of current CDC guidelines and of any occurrence of COVID-19 in their area; -A nursing home can accept a patient diagnosed with COVID-19 and still under transmission-based precautions for COVID-19 as long as it can follow CDC guidance for transmission-based precautions. If it cannot, it must wait until these precautions are discontinued. CDC has released Interim Guidance for Discontinuing Transmission-Based Precautions or In-Home Isolation for Persons with Laboratory-confirmed COVID-19. 3. Review of the facility's admission record showed Resident #3 and Resident #4 were admitted to the same room on 1/22/21. Review of Resident #3's individual COVID-19 test result sheet, dated 1/22/21 and 2/3/21, showed he/she tested negative for COVID-19. Review of Resident #4's individual COVID-19 test result sheets, dated 1/22/21, showed he/she was negative for COVID-19. Further review of the resident's individual COVID-19 test result sheets, dated 2/3/21, showed he/she tested positive for COVID-19. Review of the facility's COVID-19 testing surveillance sheet for all residents, dated 2/3/21, showed Resident #3 and Resident #4's test result box crossed out, and no results were documented. During an interview on 2/11/21 at 9:15 A.M., the MDS coordinator said he/she takes care of general infection control surveillance, and the administrator takes care of COVID surveillance. He/she said the facility had not had any COVID positive residents recently, and said they had tested the residents the last two weeks and they were all negative. He/she said on 1/22/21, the facility accepted residents from a different facility, who had tested negative prior to their admission. He/She said the transferred residents were tested for COVID after they were admitted , and one of the residents tested positive. Furthermore, he/she said the residents were in isolation for 10 days, and returned to their facility on 2/10/21. During an interview on 2/11/21 at 10:10 A.M., Certified Nursing Assistant (CNA) C said the facility had several residents on isolation recently for COVID. He/She said staff are supposed to wear gowns, N95 masks, face shields, and gloves when they take care of someone in isolation. He/She said either Resident #3 or Resident #4 had COVID. Furthermore, he/she said Resident #3 and #4 roomed together the entire time they were at the facility. Additionally, he/she said Resident #3 and #4 were only divided by a privacy curtain. During an interview on 2/11/21 at 11:00 A.M., CNA B said Resident #4 was positive for COVID while in the building. He/She said the staff wore full PPE with Resident #3 and #4. Additionally, he/she said Resident #3 and Resident #4 shared a room, with a privacy curtain between them. During an interview on 2/11/21 at 12:15 P.M., the MDS coordinator said maintenance did not divide Resident #3 and Resident #4's room with plastic. He/She said Resident #3 and Resident #4 were in a room together and only had plastic across the entrance door and a privacy curtain between them. Observation on 2/11/21 at 10:17 A.M., showed the room Resident #3 and Resident #4 shared had boards on the ceiling and down the wall at the entrance to the doorway and a privacy curtain between the two beds. During an interview on 2/17/21 at 11:20 A.M., the Administrator said Resident #3 and Resident #4 were tested for COVID using a point of care testing device on their day of admission. He/She said Resident #4 tested positive on, 2/3/21, and the residents were in isolation for 14 days. He/she said the residents were not tested on [DATE], because they were being discharged that day. He/she went on to say Resident #3 and Resident #4 were separated by plastic. He/she said they did not separate the residents because the facility did not have any place else to put them. During an interview on 2/18/21 at 3:00 P.M., the Maintenance Supervisor said he/she put plastic at the entrance door of Resident #3 and Resident #4's room. He/She said he/she never divided Resident #3 and Resident #4's room with plastic. 4. Review of Resident #5's Admission MDS, dated [DATE], showed the resident was admitted [DATE] from an acute care hospital. Review of the resident's immunization records showed the resident received his/her second COVID-19 vaccine two days prior to admission, on 2/2/21. Review of the facility's COVID-19 testing surveillance sheet for residents, dated 2/10/21, showed the resident's test result box was crossed out and no results were documented. During an interview on 2/11/21 at 9:15 A.M., the MDS coordinator said the resident was admitted on [DATE] and was in isolation due to being a new admission. He/she went on to say the resident's last day in isolation would be 2/15/21. Observation on 2/11/21 at 10:00 A.M., showed the door to the resident's room was open. A thick plastic divider hung from ceiling to floor approximately three and half feet inside the entrance of the door. There were no signs on the outside of the door indicating the resident was on isolation. Further observation, showed there was not an isolation cart containing PPE outside of the doorway. During an interview on 2/11/21 at 10:00 A.M., CNA D said staff wear masks, gloves, and gowns when they go in an isolation room, and the PPE should be set-up outside the resident's room. He/she said he/she guessed the resident was on isolation, because he/she had the plastic at his/her door. He/she said the room did not have gowns at the door. Furthermore, he/she said he/she did not know when the resident's 10 days of isolation was complete. Observation on 2/11/21 at 11:05 A.M., showed Housekeeper F entered the resident's room with gloves and a mask on, but no gown. A dry mop was propped against the wall outside of the resident's room in the hall. Housekeeper F then came out of the room with his/her same gloves and mask on, went to his/her cart, got a package of paper towels, and wrung out a wet rag from a bucket on the cart, again with the same gloves on, and then returned to the room. Further observation of the open bucket on the top of the cart showed it contained several rags and a scrubber with a handle. After approximately 15 minutes, Housekeeper F returned to his/her cart with the same gloved hands and four unidentified bottles of liquid. He/she hung the bottles on the inside of the trash receptacle on the cart, and returned to the resident's room with the dry mop, while he/she wore the same gloves. Further review of the bottles, showed two all-purpose cleaners, a water and bleach solution, and a window cleaner. Ten minutes later, with the same gloved hands, Housekeeper F swept dirt out into the hallway from the resident's room, swirled the mop in a circular motion in the hallway in front of the door, propped the dry mop against the wall in the hallway, took a broom and dust pan from the cart, swept up the dirt into a dust pan, put the dirt into the trash receptacle, on the cart, and propped the broom and dust pan against the wall next to the dry mop. Housekeeper F then, with the same dirty gloves, took the wet mop from the cart and reentered the resident's room. Housekeeper F returned to the cart with the mop with the same gloved hands, placed the mop in the mop bucket on the cart, and returned to the room to talk to the resident while he/she wore the same gloves. Housekeeper F then came out of the resident's room with the same gloves on, walked to the end of the hallway, pushed the code on the locked door to exit the hallway, and returned approximately one minute later with the same gloved hands. Observation showed Housekeeper F did not wear a gown any time he/she entered the resident's room, and did not change his/her gloves at any point while he/she cleaned the resident's room. During an interview on 2/11/21 at 11:55 A.M., Housekeeper F said he/she knows when someone is on quarantine because the charge nurse tells him/her in report. He/she said the resident was on isolation and staff were to wear gloves and masks when they went in the room. Additionally, he/she said staff could take cleaning supplies and equipment in resident's rooms, and bring them back out when they were in quarantine or isolation. He/she went on to say he/she hooked the bottles of disinfectant on the trash receptacle, because the door on the cart was broken. He/she said he/she changed his/her gloves when he/she came out of the resident's room. During an interview on 2/11/21 at 12:15 P.M., the MDS coordinator said staff should use masks, gloves, and gowns for isolation rooms and N95 masks if a resident is positive for COVID. Furthermore, he/she said he/she did not know why the resident did not have an isolation cart outside of his/her room. During an interview on 2/17/21 at 11:20 A.M., the Administrator said the resident did not have any test results on the COVID surveillance sheet for 2/10/21 because the resident had two COVID vaccinations and a negative COVID test result prior to admission. Furthermore, he/she said there should be PPE available outside an isolation room and staff should not come out of rooms with gloves on. He/She went on to say, bottles of disinfectant should not be hung on the inside of housekeeping cart trash receptacles. MO 505

Based on observation, record review and interview, facility staff failed to store food in a manner to protect it from potential contamination and outdated use. Facility staff failed to reseal and date opened food items. Facility staff also failed to ensure staff's personal food items and foods items brought in by visitors for residents were stored separately from the main facility food supply to prevent cross-contamination. The facility census was 48. 1. Review of the facility's Stock Storage policy dated 2004, showed the following: -leftover contents of cans and prepared foods shall be stored in covered, labeled and dated containers in refrigerators and/or freezers. 2. Review of the facility's Food from Family, Visitors, Community policy dated 2016, showed the following: -Food stored for residents should be labeled and dated appropriately, and discarded per safe food storage guidelines. A facility may choose to utilize a specific refrigerator or area of cooler for resident food. Observation on 12/03/19 at 10:40 A.M., showed the kitchen refrigerator contained salad dressing with an opened date of 07/10 and stock date 10/9/18. Additional observation showed the outside of the container of salad dressing with speckled material on it. 3. Observation on 12/03/19 at 10:55 P.M., showed the kitchen freezer with a package of fried okra dated 3/9/19 open to air, a package of country fried steak opened and undated, a package of uncooked chicken breast open to air and undated and a ham hock dated 11/18. During an interview at that time, the Dietary Manager (DM) said the ham hock was dated 11 of 2018. 4. Observation on 12/03/19 at 11:30 A.M., showed the refrigerator in the staff break room with resident and staff food in it. Additional observation showed the break room refrigerator did not contain a thermometer. Further observation showed dried liquid debris in the refrigerator and one gallon of fudge ice cream and one gallon of Neapolitan ice cream opened and undated. 5. Observation on 12/03/19 at 11:40 A.M., showed the following in the memory care unit refrigerator: -three large styrofoam cups filled with applesauce, covered with latex gloves, undated and unlabeled; -a plastic resealable bag which contained previously prepared pizza slices in a plastic bowl, undated and unlabeled; -a gray insulated cup which contained an unidentified liquid, a straw and a spoon, uncovered, undated and unlabeled; -a 16 oz energy drink unlabeled; -a metal tin which contained three slices of pie, undated and unlabeled; -a container of vegetable soup undated and unlabeled; -a plastic container of salad undated and unlabeled; -a 16 oz container of salad undated and unlabeled; -a bowl of sliced peaches uncovered, undated and unlabeled; -seven containers of strawberry flavored calorie supplement shakes. 6. Observation on 12/04/19 at 9:39 A.M., showed the kitchen freezer contained opened, undated and unlabeled waffles and cookie dough. 7. During an interview on 12/03/19 at 11:30 A.M., the Dietary Manager (DM) said he/she is responsible for cleaning the refrigerator, and staffing issues are interfering with the cleaning and labeling of items in the refrigerator. 8. During an interview on 12/03/19 at 11:45 A.M., Certified Nursing Assistant (CNA) A , said most of the food in the refrigerator belonged to Resident #98, because the resident's family brings him/her food and they put it in the refrigerator. The CNA said supplies for all residents on the unit and staff personal items are also stored in the refrigerator with the resident's personal food items. The CNA said he/she did not know who was responsible to clean the refrigerator and monitor the food storage. 9. During an interview on 12/04/19 at 2:11 P.M., the administrator said food should be stored covered, dated and, if it belongs to someone, it should have their name on it. The administrator said it is not acceptable to cover food containers with latex gloves. The administrator said resident personal food storage should be labeled with the resident's name and dated. The administrator said staff should store their food in the breakroom refrigerator and not in the kitchen or unit refrigerators. The administrator said the dietary supervisor is ultimately responsible to monitor everything food related, but the CNAs are responsible to monitor the unit refrigerators and the cooks are responsible for the other refrigerators. The administrator said staff should look at the refrigerators daily because they put snacks in there and he/she did not know why they allowed the refrigerators to look that way.

Based on observation, record review and interview, facility staff failed to store food in a manner to protect it from potential contamination and outdated use. Facility staff failed to reseal and date opened food items. Facility staff also failed to ensure staff's personal food items and foods items brought in by visitors for residents were stored separately from the main facility food supply to prevent cross-contamination. The facility census was 48. 1. Review of the facility's Stock Storage policy dated 2004, showed the following: -leftover contents of cans and prepared foods shall be stored in covered, labeled and dated containers in refrigerators and/or freezers. 2. Review of the facility's Food from Family, Visitors, Community policy dated (YEAR), showed the following: -Food stored for residents should be labeled and dated appropriately, and discarded per safe food storage guidelines. A facility may choose to utilize a specific refrigerator or area of cooler for resident food. Observation on 12/03/19 at 10:40 [NAME]M., showed the kitchen refrigerator contained salad dressing with an opened date of 07/10 and stock date 10/9/18. Additional observation showed the outside of the container of salad dressing with speckled material on it. 3. Observation on 12/03/19 at 10:55 P.M., showed the kitchen freezer with a package of fried okra dated 3/9/19 open to air, a package of country fried steak opened and undated, a package of uncooked chicken breast open to air and undated and a ham hock dated 11/18. During an interview at that time, the Dietary Manager (DM) said the ham hock was dated 11 of (YEAR). 4. Observation on 12/03/19 at 11:30 [NAME]M., showed the refrigerator in the staff break room with resident and staff food in it. Additional observation showed the break room refrigerator did not contain a thermometer. Further observation showed dried liquid debris in the refrigerator and one gallon of fudge ice cream and one gallon of Neapolitan ice cream opened and undated. 5. Observation on 12/03/19 at 11:40 [NAME]M., showed the following in the memory care unit refrigerator: -three large styrofoam cups filled with applesauce, covered with latex gloves, undated and unlabeled; -a plastic resealable bag which contained previously prepared pizza slices in a plastic bowl, undated and unlabeled; -a gray insulated cup which contained an unidentified liquid, a straw and a spoon, uncovered, undated and unlabeled; -a 16 oz energy drink unlabeled; -a metal tin which contained three slices of pie, undated and unlabeled; -a container of vegetable soup undated and unlabeled; -a plastic container of salad undated and unlabeled; -a 16 oz container of salad undated and unlabeled; -a bowl of sliced peaches uncovered, undated and unlabeled; -seven containers of strawberry flavored calorie supplement shakes. 6. Observation on 12/04/19 at 9:39 [NAME]M., showed the kitchen freezer contained opened, undated and unlabeled waffles and cookie dough. 7. During an interview on 12/03/19 at 11:30 [NAME]M., the Dietary Manager (DM) said he/she is responsible for cleaning the refrigerator, and staffing issues are interfering with the cleaning and labeling of items in the refrigerator. 8. During an interview on 12/03/19 at 11:45 [NAME]M., Certified Nursing Assistant (CNA) A , said most of the food in the refrigerator belonged to Resident #98, because the resident's family brings him/her food and they put it in the refrigerator. The CNA said supplies for all residents on the unit and staff personal items are also stored in the refrigerator with the resident's personal food items. The CNA said he/she did not know who was responsible to clean the refrigerator and monitor the food storage. 9. During an interview on 12/04/19 at 2:11 P.M., the administrator said food should be stored covered, dated and, if it belongs to someone, it should have their name on it. The administrator said it is not acceptable to cover food containers with latex gloves. The administrator said resident personal food storage should be labeled with the resident's name and dated. The administrator said staff should store their food in the breakroom refrigerator and not in the kitchen or unit refrigerators. The administrator said the dietary supervisor is ultimately responsible to monitor everything food related, but the CNAs are responsible to monitor the unit refrigerators and the cooks are responsible for the other refrigerators. The administrator said staff should look at the refrigerators daily because they put snacks in there and he/she did not know why they allowed the refrigerators to look that way.

Based on observation, record review and interview, the facility staff failed to prevent the development of a facility acquired pressure ulcer, failed to document descriptions, to include measurements, of the pressure ulcer in weekly pressure ulcer assessments to show on-going monitoring for improvement or decline of the pressure ulcer, and failed to provide the necessary treatment and services to promote healing of the resident's pressure ulcer for one (Resident #1) resident of two sampled residents. The facility census was 28. 1. Review of the facility's Pressure Ulcer Treatment Guidelines (undated) showed the policy directed staff to complete the following: - When eschar (death of a portion of tissue) is present, a pressure ulcer cannot be accurately staged until the eschar is removed; - Record all assessment data (for example, color, size, pain, drainage) when inspecting the wound; - Accurate staging of a closed unstageable pressure ulcer is impossible because the extent of tissue destruction is not apparent until the ulcer has opened; - Report information in accordance with professional standards of practice. 2. Review of Resident #1's admission nurses notes dated 02/18/11 at 4:00 P.M., showed licensed staff recorded the following information: - "Resident returned to the facility via van transport. Skin assessment done, no breakdown noted." Review of the resident's Braden Scale assessment (a form used to determine the resident's risk of developing a pressure ulcer) dated 02/18/11 showed licensed staff assessed the resident with a score of 18 (a score 15-18 showed him/her at mild risk for pressure ulcers). Record review of the resident's comprehensive Minimum Data Set, a federally mandated assessment tool, dated 02/23/11 showed staff assessed the resident with the following: - Alert and oriented; - Required extensive assistance of staff for his/her transfers, dressing and toilet use; - [DIAGNOSES REDACTED]. - Left above the knee amputation; - At risk of developing pressure ulcers; - (0) pressure ulcers on admission; - (0) venous and arterial ulcers. Review of the resident's plan of care dated 02/23/11 showed staff identified the resident at risk for skin breakdown and recorded the following information: - "The resident has a possible deep tissue injury on his/her right heel which appears as a blood blister." Additional review of the resident's care plans dated 02/23/11 showed staff planned the following interventions: - Monitor skin per weekly checks and follow wound/skin facility protocol; - Provide physician's treatments as ordered. - Notify physician of any skin problems; - Apply a pressure reducing mattress and pad in wheelchair. Additional review of the resident's nurses notes dated 02/28/11 at 6:20 P.M., showed licensed staff recorded the following information: - "Resident complained of pain in his/her right heel. Found what appears to be blood blister on outer aspect of right heel. Area measures 3.4 centimeter (cm) x 1.0 cm is dry, intact and tender to touch." Review of the resident's weekly pressure ulcer reports showed staff recorded the following information: -On 03/05/11: "Stage II" (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed) - Dark blue bruise, "blister like," 3.5 centimeters (cm) x 2.2 cm area to right heel. Skin intact. -On 03/11/11: Right heel, skin remains intact. Less purple today. No fluid to blister to right heel. 1.5 cm x 1.5 cm. -On 03/19/11: 3 cm x 1 cm blister - Nonfilled. Skin intact (right heel). -On 03/28/11: Right lower extremity - "Stage II" blister to heel. Skin intact. Fluid filled. Review of the resident's weekly pressure ulcer reports, dated after 03/19/11, showed licensed staff did not record the resident's weekly pressure ulcer wound description or measurements to show on-going monitoring for improvement or decline of the pressure ulcer. Review of the resident's physicians orders dated 04/11/11 showed the physician directed staff to provide the following: - Provolon boot (heel protector) to right heel at all times; - [MEDICATION NAME] spray (skin medication to treat pressure ulcers) to right heel twice daily. Review of the resident's treatment records showed staff transcribed the physician's orders [REDACTED]. Additional review showed licensed staff signed and circled their initials 04/11/11 through 04/18/11. Review of the back of the resident's treatment records dated 04/11/11 through 04/18/11 showed licensed staff recorded the [MEDICATION NAME] spray was "not available." During an interview on 04/28/11 at 1:45 P.M., Licensed Practical Nurse (LPN) A said when the resident's physician ordered [MEDICATION NAME] spray, the pharmacy informed the facility they could not deliver the [MEDICATION NAME] spray at that time because it was on "back order." LPN A said they notified the resident's physician who instructed the staff to use skin prep (helps to preserve skin integrity), ABD (thick absorbent gauze pad) and Kerlix (thick gauze treatment dressing) to the resident's right heel pressure ulcer until the [MEDICATION NAME] spray was available. Review of the resident's nurses notes dated 04/11/11 through 04/18/11 showed licensed staff did not record notifying the resident's physician of the [MEDICATION NAME] spray being "not available." Review of the resident's treatment records dated 04/11/11 through 04/18/11 showed licensed staff did not record applying skin prep, ABD pad and Kerlix to the resident's right heel pressure ulcer. During an interview on 04/28/11 at 2:30 P.M., LPN B said the resident's right heel open area was caused by pressure. LPN B said when the resident would sit in his/her wheelchair, he/she would press his/her right heel against the edge of the wheelchair foot rest which would then place pressure on the bottom of his/her right heel. LPN B said the staff instructed him/her to not place pressure on his/her right heel. During an interview on 05/03/11 at 10:30 A.M., Resident #1 said he/she did not know how he/she developed the pressure ulcer to his/her right heel. The resident said his/her right heel hurt when the nurses completed his/her right heel treatment. The resident said on a pain scale of 0-10, the pain can be a five. During an interview on 05/03/11 at 1:15 P.M., the Director of Nursing (DON) said when the resident's physician ordered the [MEDICATION NAME] spray, the pharmacy informed the facility that the resident's [MEDICATION NAME] spray was on "back order" and would be delivered to the facility as soon as it became available. The DON said the nurses did notify the physician who instructed them to use skin prep, ABD pad and Kerlix to the resident's right heel pressure ulcer until the pharmacy could deliver the [MEDICATION NAME] spray. Based on the National Pressure Ulcer Advisory Panel (NPUAP), Copyright NPUAP, 2007 Staging System, showed the following information: - Unstageable: "Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed." - Further description: "Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Observation on 05/03/11 at 2:30 P.M., showed the resident sat in his/her wheelchair in his/her room. Additional observation of the resident's right heel showed an approximate 3.5 cm x 1.0 cm pressure ulcer with dark brown edges and yellow slough (dead tissue separated from living tissue) which covered the entire wound bed with no odor or drainage. The surrounding skin was slightly red in appearance. Upon assessment of the resident's right heel pressure ulcer, the resident pulled back his/her right foot and said "that hurts." During an interview on 05/03/11 at 2:40 P.M., the DON said she had the resident's wound measurements somewhere, but could not find them at the moment. The DON said she "works the floor" so much that she did not have time to keep up with the wound reports as she should. During an interview on 05/03/11 at 2:40 P.M., the administrator said she expected the licensed staff to keep the weekly wound reports with measurements and wound descriptions current and up to date. The administrator said she expected the licensed staff to follow physicians orders. The administrator said if the licensed staff, for whatever reason, could not carry out the physicians orders, then they should notify the physician. The administrator said the DON has been "working the floor" quite a bit. MO 913